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

12th World AIDS Conference

Abstracts 42405-42409 855

42405 The effectiveness of hepatitis B vaccine in the
HIV-infected patient
MaryAnn Zwiebel', J. Jacobs2, S. Merrick2, S. Ferrando2, B. Boyle2. 1133
William Street Williston Park, New York 11596; 2The New York Hospital-Cornell
Medical New York NY, USA
Background: HIV-associated immunosuppression has a significant impact on the
immunologic and clinical course of Hepatitis B virus (HBV) infections. Accordingly,
the Centers for Disease Control (CDC) currently recommends that all HIV-infected
individuals who do not have serologic evidence of immunity should receive the
HBV vaccine. Studies to date have shown that HIV+ patients have a decreased
response to the vaccine and accelerated loss of detectable antibodies. This study
was undertaken to determine the overall response rate to the HBV vaccine and if
CD4 cell count could be utilized to predict those patients likely to respond.
Method: The study was conducted at The Center for Special Studies of The
New York Hospital-Cornell Medical Center. The Center provides care for over
1,000 HIV+ patients. A retrospective chart review was completed of all HBV
surface antibody (HBVsAb) negative patients who had completed the vaccine
series following the CDC protocol and received routine care at the Center from
1991 to 1997. HBVsAb was determined using the RIA method with a cutoff >200
count per minute being a positive convertor.
Results: 33 of 67 (49%) patients completed HBV vaccination following CDC
protocol. 12 (36%) seroconverted to HBVsAb+, 21 (64%) did not. At time of
vaccine completion, the mean CD4 of seroconvertors was 389 (range 11-560)
and of nonconvertors 294 (range 14-658). The difference was not statistically
significant.
Conclusions: Health care providers should educate their patients regarding
the importance of HBV vaccination and carefully monitor for vaccine completion.
Given the poor and unpredictable response to the vaccine, post-vaccination HBVsAb testing should be considered in all vaccinated patients and a standard part
of HIV clinical care should include educating patients regarding ways to avoid
HBV infection, including safer sex practices, using clean needles and avoidance
of body fluids.
42406 HIV telephone consulting service for health care
providers: Data from six years' experience
Petra Liljestrand', R.H. Goldsmidt2, K.B. Balano2, J. Legg2, B. Dong2,
N. Birnbauh2, W. Zizzo2. CPAT SF General Hospital Bldg 80 Ward 83 San
Francisco CA 64110; 2University of San Francisco CA, USA
Objectives: To provide expert telephone consultation to HIV/AIDS primary care
clinicians nationwide.
Methods: The National HIV Telephone Consultation Service ("Warmline"), a
toll-free hotline funded by the Health Resources and Services Administration to
provide consultation and support to primary care providers involved in HIV care
was started in 1991. Located at San Francisco General Hospital, the Warmline is
staffed by a multidisciplinary faculty of physicians, pharmacists, and nurses.
Results: Between 9/1/91 and 8/31/97, 18,977 calls were received. The majority
of callers were physicians (41%) or nurses (22%), with 1/4 calling from rural areas.
Callers had varied HIV experience; 50% cared for fewer than 4 HIV+ patients,
while 13% cared for more than 50 patients at the time of their first call. Most questions were patient-specific and concerned patients with AIDS; 67% of patients
had a CD4 count of 200 or less. Questions focused on the clinical management
of conditions and symptoms (66%) (e.g., Pneumocystis carinii pneumonia, CMV,
MAC), transmission and prevention (11%), and counseling and testing (5%). Drug
regimen questions, particularly combination antiretroviral therapy (e.g., indications, dosing, availability) have recently increased markedly. Caller evaluations
average 4.7 (5-point Likert scale), and 1/3 of callers make multiple calls to the
service, yet continuous outreach/advertising is necessary. Successful strategies
include word of mouth (27% of callers), other Federal hotlines (25%), and publications (19%). The amount of time spent on each call varies greatly, the majority
(43%) requiring 6-15 minutes. Complex calls (18%) typically require 30 minutes
or more, and frequently (26% of all calls) a multidisciplinary staff involvement.
Conclusion: This service has effectively met the clinical consultation and education needs of HIV-providers for six years. Data collected have been useful in
identifying providers' educational needs. Changes over time in utilization patterns,
caller demographics, and the nature of questions will be presented.
S42407 Serum y-globulin level as a predictor of HIV infection in
perinatally exposed children
Marinella Della Negra, W. Queiroz2, Y.C. Lian2, A.P.V. Gomes2, S.R. Pimentel2,
M.A.O. Goes2. 1Rua Pamplona 356 11 Andar; 2lnst. Infect. Emilio Ribas Sao
Paolo, Brazil
Objective: The aim of this study was to analyze the probability of having a
presumptive HIV infection diagnosis before 18 months of age, through serum
quantitative y-globulin test, once in developing countries tests like PCR, P24

antigen or HIV culture are not easily available.
Methods: One hundred and nine HIV seropositive, vertically exposed children,
asymptomatic, aged between 0 to 18 months (mean = 9.6 ~ 4.2 mo.) were
followed in our service. All of these children had blood samples collected for
serum protein electrophoresis assay as well as HIV serology until the age of 18
months (ELISA + Western blot). The values of serum y-globulin were analyzed
(Reference levels between 0.85 to 1.46 g/dL). None of this children were receiving
any drug therapy. Mann Whitney test was used for statistical analysis.

Results: Seventy (64.2%) were male and 39 (35.8%) were female. Forty
nine (45.0%) had their HIV infection serologically confirmed after the age of 18
months and 60 (55.0%) seroreverted. The mean values for y-globulin among
the seroreverters subjects was 0.995 g/dL (SD + 0.519) while the mean values
found among the HIV infected children was 2.573 g/dL (SD ~ 1.062) and this
difference was statistically significant (p = 0.000). Ten percent of the seroreverters
and 89.8% of the HIV infected children showed y-globulin values above 1.5 g/dL.
When analyzing y-globulin values higher than 1.9 g/dL, 91.9% of the children
were HIV infected and this percentage can reach 100% with y-globulin values
higher than 3.1 g/dL.
Conclusions: Serum y-globulin titers may be useful for the presumptive diagnosis of HIV infection in HIV seropositive, vertically exposed children under
18 months of age, when more sophisticated tests are not available, helping the
management and medical decisions. Greater cohorts may establish the actual
predictive value of this test.
42408 Integration of peer education into HIV care in a clinic
setting
Jeff Maskovsky, J. Shull, J. Davids. Philadelphia Fight 1233 Locust St.
Philadelphia, PA 19107, USA
Issue: The successful integration of peer education into HIV care in a clinic
setting requires innovative interventions at the client, staff and institutional level.
Project: Given the demonstrated power of peer education in delivering information to HIV positive people, an intervention using peer educators in a newly
established HIV clinic was developed. The clinic's target population was uninsured individuals living with HIV, most of whom are low-income people of color.
Two African American peer educators (PEs) from the same demographic group
were hired to work alongside a white nurse practitioner, an African American
physician, and several interns as part of a treatment team. PEs were available
to counsel clients on a voluntary basis about a range of issues including safer
sex, relationship issues, doctor/patient communication, and selection of, and adherence, to antiviral therapy. They escorted patients to other sites for x-rays and
other diagnostic or ancillary care. A number of training interventions with staff,
peer educators and administrative personnel were developed to facilitate better
integration of the peer educators into the clinic setting.
Results: PEs became a vital part of the treatment team. PEs were also effective in ensuring patient retention through follow-up calls. The introduction of PEs
required significant adjustments in work role expectations by other staff. Health
care practitioners who were not used to working with PEs lacked communications
skills needed to work successfully with PEs (a situation exacerbated by racial and
cultural differences); supervisory responsibilities over the PEs were unclear and
not always welcomed by staff whose main concerns were client care; and PEs
had difficulty meeting the professional expectations of other staff. Supervisory
training for staff, professional development training for PEs, and the adjustment
of administrative procedures reduced tensions produced by the introduction of
PEs into the clinic setting.
Lessons Learned: Clinics must be willing to spend considerable time problem-solving and developing new procedures to effectively integrate PEs into the
treatment team.
42409 A collaborative approach to HIV primary care education
in smaller centres
Robert Throop1, Alex Klein2, K. Logue3, B. Merkley3, A.R. Rachlis4, J. Tipping5,
S. Facca6, P. Madden6. 1HIV Health Evaluation Unit, Sunnybrook HSC 2075
Bayview Ave. Rm. G315, Toronto; 2Champ Toronto ON; 3Private Practice
Toronto ON; 4Sunnybrook Health Science Centre Toronto ON; 5 University of
Toronto Toronto ON; 6Merck Frosst Toronto ON, Canada
Issue: Traditional approaches to HIV primary care education focus on the cities at
the centres of the epidemic. To extend education outside of these cities, barriers
of distance, patient density and anonymity must be overcome.
Project: In the spring of 1995, Merck Frosst Canada approached the Canadian
HIV AIDS Mentorship Program (CHAMP) to develop a physician education model
for use with HIV primary care in Canada. The model uses an experienced HIV primary care physician and an infectious diseases specialist to guide small groups
of physicians through a set of cases designed to introduce the basics of HIV
primary care in the age of highly active antiretroviral therapies. The goal of the
program is to develop physician mutual support groups in smaller communities
throughout the country, building a network of physicians interested in learning
more about HIV and improving.
Results: The program operates in 4 phases: case development, facilitator training workshops, regional organization, and local physician workshops. Three cases
and accompanying education manuals were develop by the authors. A national
panel of 25 facilitators and specialists were trained in the workshop technique
in November 1995. Working with local AIDS service organizations and specialty
clinics across Canada, CHAMP develops local lists of HIV-involved physicians,
sends out invitations, and books participants. Pharmaceutical industry represen
tatives handle local arrangements and host meetings. By December 1997, 8
groups (24-hour meetings) have met run across Canada and more are planned
for the coming year. Summary results of participant evaluations are presented.
Lessons Learned: (1) Interest by local physicians is intense bu limited; (2)
regional accreditation by medical college improves in enrolment; (3) appropriateness of cases depends on types of support services available in the region; (4)
including nonmedical health care providers helps build local network of services.