Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

832 Abstracts 42254-42295

12th World AIDS Conference

445* / 42291 Assessment of eligibility for antiretroviral therapy
among HIV-infected patients attending selected
outpatient clinics in Abidjan, C6te d'lvoire
Gaston Djomand1, J. Nkengasong2, M. Sassan-Morokro2, R.A. Ekpini2,
P.D. Ghys3, 0. Tossou2, C. Maurice2, S. Konate4, T.H. Roels5, A.E. Greenberg5,
S.Z. Wiktor5. 101 BP 1712, Abidjan 01; 2Projet Retro-CI, Abidjan; 4National
Blood Transfussion Center Abidjan, Cote d'lvoire; 3 Institute of Tropical Medicine,
Antwerp, Belgium; 5Center for Disease Control and Prevention Atlanta, USA
Background: In 1998, up to 3,000 HIV-infected persons in C6te d'lvoire are scheduled to receive antiretroviral (ARV) therapy as a part of a UNAIDS-sponsored
pilot program. Treatment guidelines have been established but no information is
available on the proportion of patients who will meet the recommended biologic
eligibility criteria of plasma viral load (VL) >10,000 copies/ml or VL < 10,000
copies/ml but CD4 < 500/t/1.
Methods: Questionnaire data, physical examination and blood samples for
CD4 count and HIV plasma viral load were obtained from HIV-infected patients
attending several outpatient clinics in Abidjan including a prenatal clinic (n =
48), a confidential STD clinic for female sex workers (n = 50), a follow-up clinic
for HIV-Infected former blood donors (n = 36) and an ambulatory tuberculosis
treatment center (n = 50). Clinical disease staging was assessed by the WHO
criteria, CD4 lymphocytes enumerated by flow cytometry and plasma viral load
quantified by the Amplicor Monitor assay (Roche).
Results: Pregnant women Former blood donors Sex Workers TB patients
Pregnant Former Sex TB
women blood donors Workers patients
(n = 48) (n = 36) (n = 50) (n = 50)
% VL 10,000 copies/mL 35 47 26 66
% VL < 10,000 copies/mL but CD4 < 500/pIl 16 33 40 16
% eligible for ARV therapy 52 80 66 82
% eligible and asymptomatic 23 36 14 0
(WHO stage 1)
Conclusion: A majority of HIV-infected patients attending selected outpatient
clinics in Abidjan would be potentially eligible for ARV therapy. Since a significant
proportion of these patients are asymptomatic, the WHO clinical staging system
can not be used to reliably define patient eligibility.
42292 US Public Health Service Expert Panel on clinical
practices: A public-private partnership with worldwide
internet access
Eric Goosby1, A. Macher2, A. Fauci3, J. Bartlett4, S. Stanley3, E. Daniels5,
M. Smith6. 1200 Independence Ave SW Room 736-E, Washington DC 20201;
2 U. S. Public Health Service, Rockville, MD; 3 U.S. Public Health Service,
Bethesda, MD; 4Johns Hopkins Hospital, Baltimore; 5U.S. Public Health Service,
Washington DC; 6Henry J. Kaiser Family Foundation, Menlo Park, CA, USA
Issue: Ever-evolving research findings require ongoing review and interpretation
by experts in the public and private sector who will develop updated practical
antiretroviral treatment guidelines.
Project: The panel on clinical practices is a 3-year public-private partnership
convened in December 1996 by the Office of HIV Policy/Department of Health
and Human Services, and the Henry J. Kaiser Family Foundation. The panel's
mission is to provide comprehensive descriptions of HIV clinical practices and
recommendations for treatment options to practitioners, patients and payers. This
multidisciplinary panel includes persons living with HIV/AIDS.
Results: In June 1997 the panel produced draft guidelines for the use of
antiretroviral agents; these were entered onto the worldwide internet for public
comment during a 30-day review period. Over 30,000 accessed the guidelines
through the internet and over 600 comments were submitted. Revised guidelines
were entered onto the internet November 1997. Thereafter the panel convenes
monthly to review new data; updated recommendations are entered directly onto
the internet. The panel is also serving to review and endorse HIV guidelines
regarding prophylaxis of opportunistic infections; management of tuberculous
infection and disease; pediatric, maternal and vertical transmission issues; and,
occupational exposure prophylaxis.
Conclusion: The US Public Health Service is successfully interacting with the
private sector and the worldwide internet to produce practical clinical antiretroviral
treatment guidelines. Updated recommendations are entered onto the internet on
an ongoing basis for immediate worldwide access.
42293 From guidelines to clinical reality: Doctors' and patients'
view of health care and treatment in HIV
Christine Koppt, S. Lang1, A. Iten1, H.J. Furrert, J. Von Overbeck1
H.R. Wicker2. 1HIV-Sprechstunde Med. Pol., Inselspital 3010 Bern; 2lnstitut Fuer
Ethnologie, Universitaet Bern, Bern, Switzerland

Objectives: Using concepts from Medical Anthropology, the Swiss study investigates explanatory models of HIV in asymptomatic HIV long-term survivors (LTS),
medical doctors (MD) and complementary therapists (CT) and their impact on
health care and treatment choices. Based on the evaluation, a model for improved
health care in HIV will be developed.
Methods: Phase 1) Semi-structured interviews were lead with LTS (n = 11),
their MDs (n = 11) and CTs (n = 7), then transcribed and coded for evaluation.

Phase 2) Structured questionnaires were developed based on the interview evaluation, mailed to LTS (n = 55), MDs (n = 807), and CTs (n = 751), and statistically
evaluated.
Results: Preliminary evaluation showed that a vast majority of the LTS did not
use antiviral therapy (AT) despite being in medical care and having laboratory
values that suggest treatment according to the Swiss guidelines. Evaluation of
the interviews revealed: A) Structural reasons: LTS: Reluctance against structuring the daily routine in accordance with AT. MDs: Missing systems to ensure
regular follow-up visits lead to delayed/irregular control of HIV. Implementing AT
may involve difficulties in collaboration between GPs and specialized centers.
B) Cognitive reasons: Doubts concerning AT (long-term efficacy, side effects,
number of pills, long-term adherence) amongst LTS and MDs. C) Role/identity
conflicts: LTS: AT means handing over responsibility to an outside agent and
thus becoming dependent. It is related to a sick role that seems inadequate for
asymptomatic persons and questions strategies of controlling HIV through personal action (lifestyle/coping). MDs: Conflicts concerning the role of the doctor;
patient advocacy and doctor-patient interaction in decision-making may be valued
higher than implementing guidelines.
Conclusions: Reasons against the usage of antiviral therapies are common
amongst HIV-positive persons as well as medical doctors. On both sides they
include structural problems, doubts concerning therapies, as well as role and identity conflicts related to prescribing/taking therapies. Quantitative data, including
the usage of antiviral therapies outside the Swiss HIV Cohort Study, is presented
at the conference.
S42294 Changes in treatment strategies among HIV-positive gay
men
Garrett Prestage1, S. Knox2, S. Kippay2, D. Campbell2, A. Grulich1, P. van de
Ven2, D.A. Cooper3. National Centre in HIV Epidemiology, 376 Victoria St
Darlinghurst NSW 2010; 2National Centre in HIV Social Research, Sydney;
3National Centre in HIV Epi & Clinic Res, Sydney, Australia
Research Question: What changes have there been in the use of treatments
among HIV-positive gay men in recent years?
Methods: SMASH is a cohort study of 1143 gay men, including 257 HIV-positive gay men. Annual interview and clinical data collected from these men since
1993 were used.
Results: Use of anti-retrovirals (ARVs) declined from about half the men in
1993 (55%) to about a third (38%) in early 1996. At the outset about half the
men (47%) taking ARVs were on monotherapy. There was a dramatic increase
in ARV treatment use during 1996, particularly later in the year. By early 1997
over two thirds (71%) were taking ARVs, mainly as triple combination therapy
(57%). Prior to late 1996 use of ARVs was mainly correlated with being in poor
health. This relationship was non-existent by early 1997. Men with lower CD4
counts, however, tended to be more likely to use ARVs. During 1993 about 44% of
positive men were using complementary ('alternative') therapies, provided by an
alternative health care practitioner. In early 1997 use of these therapies dropped
sharply to 23%.
Conclusion: HIV-positive gay men in Sydney alter their treatment regimes
over time, often in response to changing information and community beliefs. Until
mid-1996 feeling unwell was an important factor in treatment decisions but this
has become less important. Since combination therapies have been viewed as
appropriate treatment options for all positive men, alternative therapies have been
used less widely.
42295 The development of Canada's largest HIV patient
treatment information database
Jo-Ann Mayo-Millar, D. Hettiiarachuchi, R. Palmer, A. Rachlis, M. Doswell. HIV
Health Evaluation Unit, Sunnybrokhsc 2075 Bayview Ave. Room G318, Toronto,
Canada
Issues: The Ontario Ministry of Health subsidizes several antiretroviral medications. This established a need to monitor the use and distribution of these
medications while ensuring confidentiality and timely, cost effective drug access
for a large patient population servicing a geographical area of 412,582 square
miles.
Project: The Ontario Drug Distribution and Monitoring Program (ODDMP) was
created to provide province-wide drug distribution and monitoring; establish a
centralized location for patient enrollment and follow-up; provide information on
antiretroviral access and distribution for physicians, pharmacists and other health
care providers.
Results: ODDMP designed centralized drug purchasing/distribution, a computerized patient information system (data collection/entry) and a communication
network involving numerous stakeholders. The program currently monitors twelve
antiretroviral medications, three of which are distributed by ODDMP. As of February 1998, the program had registered 10,800 patients (80% of all people receiving
antiretrovirals in Ontario), 1,300 physicians and over 200 pharmacies. In 1997
ODDW shipped over 50,000 bottles of medications to over 90 pharmacies in

Ontario. In its first decade the ODDMP has created Canada's largest patient
database of HIV treatment information.
Lessons Learned: ODDMP gained valuable knowledge and experience related to the monitoring of ongoing drug use/distribution; organization, collection
and management of data; confidentiality and security. The information collected
by ODDMP provides an important resource for HIV research in Ontario, as well
as vital distribution information for pharmaceutical companies.