Abstract Book 2005

Transcription

Abstract Book 2005

ABSTRACTS
11th Annual Conference
of the
British HIV Association [BHIVA]
with the
British Association for
Sexual Health and HIV [BASHH]
20–23 April 2005
Burlington Hotel · Dublin · Ireland
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CONTENTS
BHIVA and BASHH Committees …………………………………………………………………………………
…………………………………………………………………………
iii
………………………………………………………………………………………………………………………
1
Research Presentations: Summary
Oral Abstracts
Poster Abstracts
……………………………………………………………………………………………………………………
14
…………………………………………………………………………………………………………………
57
…………………………………………………………………………………………………………………………
61
Printed Abstracts
Author Index
ii
Abstract selection
The number of high-quality abstracts submitted for presentation at the Annual Conference of the British HIV
Association with the British Association for Sexual Health and HIV was overwhelming which made selection a
most difficult task. Thanks are due to the Joint BHIVA and BASHH Committees (see page ii) for all the time
and effort they put into this selection process. Unfortunately, due to time and space constraints, it has been
necessary to disappoint some potential presenters. The Committees hope this will not deter anyone from
submitting abstracts for future meetings.
Abstract citations
All abstracts accepted for both oral and poster presentation including printed abstracts will be published in
the supplement to the May issue of HIV Medicine, the BHIVA peer-reviewed journal. All published citations of
abstracts should be made to HIV Medicine and not to this conference book.
Prizes / Scholarships
There will be a conference prize for the best oral presentation and one for the best poster presentation.
Bristol-Myers Squibb Scholarships will be awarded to the five best abstract presentations. To qualify for a
scholarship, applicants must be of Junior Grade or under 35 years of age. Each scholarship is worth £1000.
BHIVA Science Scholarships are awarded to up to ten scientists studying for a PhD or MD. For those whose
abstracts are accepted for presentation (oral or poster), all registration fees, a contribution of a maximum of
£100 towards travel expenses and accommodation costs (maximum three nights at £60 per night) will be
paid for by BHIVA.
The Maggie Godley Memorial Prize will be awarded to the best abstract presented by a doctor who has
consultant status and who works in a district general/non teaching hospital in the UK.
i
BHIVA AND BASHH COMMITTEES
JOINT BHIVA/BASHH CONFERENCE COMMITTEE
Prof Brian Gazzard
Chair of Joint Committee
Dr Jane Anderson
BHIVA Honorary Secretary
Dr Jan Clarke
BASHH Treasurer
Dr Anna Maria Geretti BHIVA Executive Committee Member
Dr Margaret Johnson BHIVA Chair
Prof Fiona Mulcahy
BHIVA Invited Local Representative
Dr Rajul Patel
BASHH Education Committee Chair
Dr Anton Pozniak
BHIVA Executive Committee Member/
BASHH Board Member
Dr Angela Robinson
BASHH President
Prof Lorraine Sherr
BHIVA Invited Representative
Dr Helen Ward
BASHH Invited Representative
Dr Ian Williams
BHIVA Executive Commitee Member
Dr Janet Wilson
BASHH Conferences and
Communications Secretary
ORAL RESEARCH JUDGING PANEL
Dr Keith Aizen
Bristol-Myers Squibb Representative
POSTER RESEARCH JUDGING PANEL
Dr Colm Bergin
Dr Andrew Freedman BHIVA Executive Committee Member
Dr Gary Brook
BHIVA Executive Committee Member
Ms Vanessa Griffiths
BASHH Elected Representative
Dr Rachel Challenor
BASHH Elected Representative
Dr Ian Hitchcock
Bristol-Myers Squibb Representative
Dr Claudia Estcourt
BASHH Board Member
Dr Cathy Ison
Dr Ade Fakoya
BHIVA Executive Committee
Dr Frances Keane
BASHH Board Member
Dr Mark Pakianathan BASHH Board Member
Dr Adrian Palfreeman BHIVA Co-opted Representative
Prof Jonathan Ross
Dr Alan Tang
Dr Ann Sullivan
BHIVA Executive Committee Member
BHIVA COMMITTEE
Officers
Chair
Dr MA Johnson (Royal Free Hospital, London)
Hon Treasurer Dr EL Wilkins
(North Manchester General Hospital)
Hon Secretary Dr J Anderson
(Homerton University Hospital, London)
Executive members
Dr S Ash
Dr MG Brook
Dr A Fakoya
Dr M Fisher
Dr AR Freedman
Prof BG Gazzard
Dr AM Geretti
Dr C Leen
Dr NE Mackie
Dr AL Pozniak
Mrs D Robertson-Bell
Prof JD Ross
Dr C Skinner
Dr A Tang
Dr IG Williams
(Ealing Hospital, London)
(Central Middlesex Hospital, London)
(Newham General Hospital, London)
(Royal Sussex County Hospital, Brighton)
(Cardiff University School of Medicine)
(Chelsea and Westminster Hospital, London)
(Royal Free Hospital, London)
(Western General Hospital, Edinburgh)
(St Mary’s Hospital, London)
(Chelsea and Westminster Hospital, London)
(Whittall Street Clinic, Birmingham)
(Royal London Hospital, London)
(Royal Berkshire Hospital, Reading)
(Royal Free and UCMS, London)
Co-opted members
Prof S Lucas
Prof L Sherr
(Guy’s and St Thomas’ Hospital, London)
Co-opted representatives
Mr K Alcorn
(NAM)
Mr S Collins
(HIV i-Base)
Mr D Edmondson
(DHIVA)
Dr A Palfreeman
(MRC)
Ms N Perry
(NHIVNA)
Dr A Robinson
(BASHH)
Dr TG Tudor-Williams (CHIVA)
Mr BC West
(HIV Scotland)
Ms R Weston
(HIVPA)
ii
BASHH BOARD
Elected Officers and Representatives
Dr Angela Robinson President
Dr Simon Barton
Vice President
Dr Jan Clarke
Treasurer
Dr Keith Radcliffe
General Secretary
Dr Janet Wilson
Conferences and Communications
Secretary
Dr Immy Ahmed
Chair, Clinical Governance Committee
Dr Raj Patel
Chair, Education Committee
Dr Colm O’Mahony Past Chairman of AGUM
Dr Rachel Challenor Non-Consultant Career Grade
Representative
Ms Vanessa Griffiths Nurse/Health Advisor Representative
Dr Penny Goold
Doctors in Training Representative
Members
Dr George Kinghorn
Dr Stephen Dawson
Dr Mark Pakianathan
Dr Claudia Estcourt
Dr Francis Keane
Dr Phillip Kell
Sheffield
Slough
St George’s Hospital, London
St Bartholomew’s Hospital, London
Royal Cornwall Hospital, Truro
Archway Sexual Health Clinic, London
Co-opted Members
Dr Mark FitzGerald Chair of the Trustees
Dr Margaret Johnson BHIVA
Dr Alison Bigrigg
FFPRHC
RESEARCH PRESENTATIONS
THURSDAY 21 APRIL
0930–1030
Oral Research Presentations: Session 1
Epidemiology and partner management
– chlamydia and herpes
Chairs: Dr Raj Patel
Royal South Hampshire Hospital,
Southampton, UK
Dr Celia Skinner
Royal London Hospital, UK
0930–0940 Abstract 1
A decade of chlamydia in Leeds: comparative analysis
of demographic and geospatial risk factors at the
onset of chlamydia screening
AL Evans, Leeds General Infirmary, UK
Free availability of postal testing kits for chlamydia in
colleges of further education as an alternative to
nurse-led clinics: a prospective crossover intervention
trial
DJ Clutterbuck, Lothian Health Board, UK
The management of Chlamydia trachomatis in
genitourinary medicine clinics: a national audit in 2004
R Challenor, Derriford and Torbay Hospitals, Plymouth, UK
Compliance with novel ‘partner interventions’
amongst male sexual partners of women with
Chlamydia trachomatis
GR Scott, University of Edinburgh, UK
Comparison of virus culture and TaqMan real-time
polymerase chain reaction (PCR) for detection of
genital herpes simplex virus (HSV) infection
MK Malu, Whittall Street Clinic, Birmingham, UK
Do people with genital herpes tell their sexual
partners? The influence of stigma
J Bickford, Chelsea and Westminster Hospital, London, UK
1500–1600
Service delivery/women and children
Chairs: Dr Jane Anderson
Homerton University Hospital, London, UK
Dr Janet Wilson
Leeds General Infirmary, UK
Has young people's knowledge and use of
contraceptive services increased since the introduction
of the Teenage Pregnancy Strategy? Findings from the
Teenage Pregnancy Strategy Evaluation
RS French, Centre for Sexual Health and HIV Research,
Royal Free and UCMS, London, UK
Correlation of erectile dysfunction (ED) severity as
perceived by UK healthcare professionals compared to
the International Index of Erectile Function score (IIEF):
results from the Erectile Dysfunction Observational
Study (EDOS)
P Kell, Archway Sexual Health Clinic, London, UK
Antiretroviral therapy in a new public sector
antiretroviral treatment centre in Ghana: patients'
presentation and response
P Collini, Komfo Anokye Teaching Hospital HIV/AIDS Clinic,
Kumasi, Ghana
1530–1540 Abstract 10
Targeting points for further intervention: a review of
HIV-infected infants born in Ireland in the 5 years
following introduction of antenatal screening
W Ferguson, The Rotunda Hospital, Dublin, Ireland
1540–1550 Abstract 11
Evaluation of nelfinavir based mother-to-child
transmission regimens
S O’Dea, St James’ Hospital, Dublin, Ireland
1550–1600 Abstract 12
Increased psychosis in HIV-1-infected sub-Saharan
African immigrants
A Holmes, St. James’s Hospital, Dublin, Ireland
1620–1830
New infections, risk factors and early
treatment
Chairs: Dr Keith Radcliffe
Birmingham University Medical School, UK
Dr Ian Williams
1620–1630 Abstract 12a
Sexual behaviour and risk of ongoing transmission in
symptomatic patients attending genitourinary
medicine clinics
CH Mercer, Centre for Sexual Health and HIV Research,
1630–1640 Abstract 13
Overseas travel, high-risk sexual behaviour and STI
transmission risk among British adults: Results of a
national probability survey of sexual attitudes and
lifestyles
CH Mercer, Centre for Sexual Health and HIV Research,
1640–1650 Abstract 14
High risk sexual behaviour among London gay men:
no longer increasing?
J Elford, City University London, UK
iii
THURSDAY 21 APRIL
1650–1700 Abstract 15
Risk factors for the acquisition of HIV in individuals
known to have recently seroconverted
J Fox, Imperial College, London, UK
1750–1800 Abstract 21
Discordant responses to HAART in ARV naïve HIV
infected individuals
MY Tung, Chelsea and Westminster Hospital, London, UK
1700–1710 Abstract 16
A prospective study of post-exposure prophylaxis (PEP)
following non-occupational exposure to HIV in the UK
JE Blackham, Health Protection Agency Centre for
Infections, London, UK
1800–1810 Abstract 22
Discordant CD4 and viral load responses in patients
starting HAART in the UK Collaborative HIV Cohort
(CHIC) Study
RJC Gilson, Centre for Sexual Health and HIV Research,
Royal Free and UCMS, UK
1710–1720 Abstract 17
Trends in transmitted genotypic antiretroviral
resistance in primary versus longstanding HIV infection
K Aderogba, Brighton and Sussex University Hospitals, UK
1720–1730 Abstract 18
The longevity of HIV-specific CD4 T-helper responses
and clinical outcome following short course
antiretroviral therapy in primary HIV infection
J Fox, Imperial College, London, UK
1730–1740 Abstract 19
Late diagnosis and consequent short-term mortality of
individuals sexually infected with HIV: England and
Wales, 2002
TR Chadborn, Health Protection Agency Centre for
1740–1750 Abstract 20
Therapeutic vaccination with HIV-1 whole killed
vaccine is associated with immune modulation in
HAART-naïve, asymptomatic HIV-infected individuals
G Marchetti, University Milano, Italy
iv
1810–1820 Abstract 23
The effect of year of treatment and NA backbone on
durability of NNRTI based regimens
NT Annan, Chelsea and Westminster Hospital, London, UK
1820–1830 Abstract 24
Therapeutic drug monitoring (TDM) of efavirenz (EFV):
a tool to predict virologic outcome in HIV-patients on
first line once daily (OD) antiretroviral (ARV) therapy?
D Maitland, Chelsea and Westminster Hospital, London, UK
1830–1840 Abstract 24a
Predictors of current CD4+ T-cell response among
patients receiving subcutaneous recombinant
interleukin-2 in ESPRIT
H Nuwagaba-Birbonwoha, ESPRIT Research Group
FRIDAY 22 APRIL
0930–1030
Co-infections
Chairs: Dr Immy Ahmed
Nottingham City Hospital, UK
Dr Clifford Leen
Western General Hospital, Edinburgh, UK
0930–0940 Abstract 25
Evidence for sexual transmission of HCV in recent
epidemic in HIV-infected men in South-East England
M Danta, Royal Free and UCMS, London, UK
0940–0950 Abstract 26
Is the treatment of acute hepatitis C in HIV positive
individuals effective?
YC Gilleece, Chelsea and Westminster Hospital, London, UK
0950–1000 Abstract 27
Does nadir CD4 count in HIV-HCV co-infected patients
predict HCV treatment response to pegylated
interferon (p-IFN) and ribavirin (RBV)?
S Hopkins, Centre for Sexual Health and HIV Research,
1000–1010 Abstract 28
Hepatitis C infection is not associated with systemic
HIV-associated non-Hodgkin's lymphoma: a cohort
study
L Waters, Chelsea and Westminster Hospital, London, UK
1010–1020 Abstract 29
Inhibition of hepatitis B virus replication by small
interfering RNA expressed from viral vectors
M McClure, Imperial College London, UK
1020–1030 Abstract 30
Is there a relationship between Familial Mediterranean
Fever (FMF) host polymorphisms and paradoxical
reactions (PR) in tuberculosis (TB)?
A Dunleavy, Royal Brompton Hospital, London, UK
1050–1150
Management issues in HIV
Chairs: Dr Jan Clarke
Leeds General Infirmary, UK
Dr Ed Wilkins
North Manchester General Hospital, UK
1050–1100 Abstract 31
Identifying the key beliefs influencing uptake and
adherence to HAART: Final results of a 12-month
prospective, follow-up study
R Horne, University of Brighton and Royal Sussex County
Hospital, UK
1100–1110 Abstract 32
Stopping combination therapy whilst travelling: is
there a reason for great concern?
MA Schuhwerk, Mortimer Market Centre, London, UK
1110–1120 Abstract 33
Switching from a thymidine analogue to tenofovir
(TDF) achieves similar resolution of lipoatrophy and
better reduction in lipids than switching to abacavir
(ABC). Results of the RAVE study, a UK multi-centre
open-label randomised controlled trial
JD Cartledge, Mortimer Market Centre, London, UK
1120–1130 Abstract 34
3-dimensional surface laser scanning and psychological
assessment: objective evidence for the use of polylactic
acid implants in HIV-associated facial lipoatrophy
J Ong, Royal Free Hospital, London, UK
1130–1140 Abstract 35
What is the cost of switching an anti-retroviral therapy
(ART) from an HIV-centre perspective?
T Toward, Abbott Laboratories, UK,
1140–1150 Abstract 36
Extent of underdosage of antiretroviral therapy in
HIV-infected children
EN Menson, MRC Clinical Trials Unit, London, UK
1400–1500
New technologies and surveillance
Chairs: Dr Martin Fisher
Royal Sussex County Hospital, Brighton, UK
Dr Helen Ward
Imperial College School of Medicine,
London, UK
1400–1410 Abstract 37
Enhanced surveillance for lymphogranuloma venereum
(LGV) in England
CA Ison, Health Protection Agency Centre for Infections,
London, UK
1410–1420 Abstract 38
An outbreak of lymphogranuloma venereum in
London in 2004
M Hamill, Mortimer Market Centre, London, UK
1420–1430 Abstract 39
Syphilis outbreak in commercial street sex workers in
east London
N Lomax, Barts and The London NHS Trust, London, UK
1430–1440 Abstract 40
Syphilis PCR use for diagnosis of early syphilis audited
against routine serological testing
P Lewthwaite, North Manchester General Hospital, UK
1440–1450 Abstract 41
Opa-typing can subdivide NG-MAST sequence types of
Neisseria gonorrhoeae into epidemiological relevant
groups
AK Morris, Royal Infirmary of Edinburgh, UK
1450–1500 Abstract 42
HIV-1 antibody avidity testing to identify recent HIV
seroconverters
A Chawla, Royal Free and UCMS, London, UK
v
FRIDAY 22 APRIL
1620–1720
Late HIV infection
Chairs: Dr Rob Miller
Dr Anton Pozniak
Chelsea and Westminster Hospital, London,
UK
1620–1630 Abstract 43
No recent increase in mortality among HIV-diagnosed
individuals with long exposure to therapy: UK
1987–2004
TR Chadborn, Health Protection Agency Centre for
1630–1640 Abstract 44
How salvageable are the K65R and L74V mutations?
L Waters, Chelsea and Westminster Hospital, London, UK
vi
1640–1650 Abstract 45
Triple class antiretroviral agent resistance in a large UK
cohort – prevalence and risk factors for acquisition
R Jones, Chelsea and Westminster Hospital, London, UK
1650–1700 Abstract 46
Virological and clinical outcomes in patients with multi
(three)-class drug resistant (MDR) HIV in the UK
D Grover, Mortimer Market Centre, London, UK
1700–1710 Abstract 47
CD4 counts and the risk of lymphoma in individuals
with HIV in the UK
I Reeves, Brighton and Sussex University Hospitals, UK
1710–1720 Abstract 48
A prognostic model to predict survival in systemic AIDS
related non-Hodgkin's lymphoma
AM Young, Chelsea and Westminster Hospital, London, UK
11th
Oral Abstracts
O1
O3
A decade of chlamydia in Leeds: comparative analysis
of demographic and geospatial risk factors at the
onset of chlamydia screening
The management of Chlamydia trachomatis in
genitourinary medicine clinics: a national audit in
2004
AL Evans1, D Merrick2, EF Monteiro1, MH Wilcox1, CJN Lacey3
R Challenor1, S Pinsent1, S Chandramani2, N Theobald3, D Daniels4
1Leeds General Infirmary, 2Yorkshire and Humber Public Health
1GUM Department, Derriford Hospital, Plymouth, 2GUM Department,
Observatory, 3Hull York Medical School, University of York, UK
Objective: To compare the demographics of chlamydia in Leeds in
2003–2004 with 1994–1995.
Methods: Laboratory data for all chlamydia diagnoses in Leeds in
2003-2004 were compared to 1994–1995.
Results: For persons aged 15 to 54, total annualised positivity rates
increased 4-fold from 159.0/106 in 1994/5 by ELISA (95% CI 150.4 to
167.9) to 644.8/106 in 2003/4 by SDA (95% CI 627.4 to 662.5). This
increase was the same for both sexes; peak age groups remained 15–19
for women and 20–24 for men. Ethnicity data (Genitourinary Medicine
(GUM) diagnoses only) showed a persistent relative risk of 10 for black
as opposed to white ethnic groups. In 2003/4, GUM diagnosed 42% of
chlamydia positives compared with 80% in 1994/95. 51% were
diagnosed in the community: General Practice (39%), Contraceptive
services (7%) and Chlamydia Screening Project (5%). A positive female
was 4.5 times more likely than a positive male to be diagnosed in a
non-GUM setting. Analyses of setting-specific positivity rates and
geospatial distribution are underway.
Conclusions: Chlamydia continues to show a wide geospatial
distribution with increased risk in under-25s and black ethnic groups.
Women are now diagnosed mostly in community settings and efforts
will need to be concentrated on partner notification to reduce
transmission.
Manor Hospital, Walsall, 3John Hunter Clinic, Chelsea and Westminster
Hospital, London, 4Sexual Health Clinic, West Middlesex Hospital, UK
Aim: To undertake the first national audit of the management of
Chlamydia trachomatis in genitourinary medicine (GUM) clinics in the
UK.
Methods: A retrospective case note review. Non-Consultant Career
Grade Doctors working in GUM clinics were each asked to complete ten
data collection forms.
Results: One thousand six hundred and seventy forms were completed
(from 830 males and 840 females with chlamydia) during the audit
period of January to March 2004. Ninety nine per cent (1647) were
treated appropriately. Seventy six per cent (1261) were followed up, of
which 12% (154) required re-treatment. Seventy one per cent (1186)
were managed appropriately within four weeks and 942 partners (0.56
per index case) were managed satisfactorily within four weeks of the
initial partner notification interview. Partner notification outcomes
were significantly more successful when the index patient was
followed up (P <0.0001). Outcome standards were not associated with
age, gender or sexuality, but were significantly associated with
ethnicity (P <0.004).
Conclusion: GUM clinics are delivering high quality care and evidence
based national outcome standards are being met.
O2
O4
Free availability of postal testing kits for chlamydia
in colleges of further education as an alternative to
nurse-led clinics: a prospective crossover intervention
trial
Compliance with novel ‘partner interventions’
amongst male sexual partners of women with
Chlamydia trachomatis
DJ Clutterbuck, K Carrick-Anderson, K Allison, GR Scott, L McKay
Healthy Respect, Lothian Health Board, Lothian, UK
Three models of testing and treatment for chlamydial infection in
students attending four FE colleges in Lothian, SE Scotland were
compared in a prospective crossover intervention trial as part of the
'Healthy Respect' health demonstrator project. Part-time nurse-led
clinics were compared over two consecutive academic years with the
use of postal testing kits, distributed either under supervision by
trained non-healthcare staff or freely available from distribution
points. 316 tests for chlamydia were carried out, 65% in women and
35% in men. Chlamydia prevalence in those tested on site was the
same as that detected by postal testing (11.6% (14/121) vs 12.3%
(24/195), χ2=0.04; P>0.05). Treatment rate was 100% and contact
details were obtained in all cases. Free distribution of postal testing
kits generated a lower percentage return rate than supervised
distribution (15% (157/891) vs 25% (38/152), χ2=9.07; P =0.026) but
results in a greater number of students being tested. Although all
methods were successful in accessing men for testing, postal testing
kits carried no additional advantage over clinics. Free distribution of
postal testing kits detects a greater number of infections than
alternative models with comparable outcomes but reduced manpower
requirements.
A Johnstone, S Cameron, A Glasier, H Young, GR Scott
University of Edinburgh, Little France Drive, Edinburgh, UK
Aim: To explore novel approaches to partner notification and
treatment in view of suboptimal rates of contact tracing for chlamydia
(~25%) reported by Scottish GUM clinics.
Methods: Women diagnosed chlamydia-positive at either a hospital
gynaecology clinic (termination of unwanted pregnancy) or a
community family planning clinic, or a GUM clinic in Edinburgh, were
randomised to one of three strategies of partner intervention:
(i) contact tracing by a GUM health Adviser (ii) postal testing kit for
partner(s) to post urine sample for chlamydia testing, or (iii) patient
delivered partner medication (PDPM) whereby woman is given 1G of
azithromycin to give to sexual partner(s). Ethical Committee approval
was obtained.
Results: Thus far, 101 women have been recruited and randomised to:
33 contact tracing (33 partners), 33 postal testing (36 partners) and 35
PDPM (38 partners). There was no significant difference between
groups in terms of the percentage of partners known to have complied
with the intervention: 28% contact tracing, 28% postal testing and
32% PDPM.
Discussion: These preliminary results suggest that postal testing and
PDPM may be similar to standard contact tracing in terms of
proportion of sexual partners known to be tested/treated.
1
11th Annual Conference of the British HIV Association with the British Association for Sexual Health and HIV
O5
O7
Comparison of virus culture and TaqMan real-time
polymerase chain reaction (PCR) for detection of
genital herpes simplex virus (HSV) infection
Has young people's knowledge and use of
contraceptive services increased since the
introduction of the Teenage Pregnancy Strategy?
Findings from the Teenage Pregnancy Strategy
Evaluation
MK Malu1, R Cunningham2, J Northwood2, S Shaw3, JR Willcox2
1Whittall Street Clinic, Birmingham, 2Plymouth Hospitals NHS Trust,
Plymouth, 3Department of Statistics, University of Plymouth, Plymouth,
UK
Aim: To compare the detection rates of HSV with virus culture and
TaqMan PCR.
Methods: 134 patients with lesions suggestive of genital herpes
attending the GUM clinic in Plymouth were recruited in the study. Two
swabs were taken simultaneously by holding them together and sent
for virus culture and PCR.
Results:
Table: HSV detection by virus culture and PCR
Culture (n=134)
PCR (n =134)
HSV 1
29 (21.64%)
37 (27.61%)
HSV 2
25 (18.65%)
49 (36.56%)
Negative
74 (55.22%)
48 (35.82%)
Unable to perform test
6 (4.47%)
0 (0.0%)
Overall 40.29% and 64.17% of the specimens were positive for either
HSV 1 or 2 by culture and PCR respectively. Notably the yield was
higher with virus type 2 than type 1. There was no discrepancy in virus
type as determined by culture and PCR. There was no patient with PCR
negative but culture positive for the virus. There were 6 patients where
culture could not be done due to contamination, of which 2 were HSV
type 1, 2 were HSV type 2 and 2 were negative by PCR.
Conclusion: The PCR is significantly more sensitive in detecting HSV
(more sensitive for type 2 than type 1 virus) compared to culture.
RS French1, CH Mercer1, R Kane2, P Kingori1, JM Stephenson1,
K Lachowycz2, P Wilkinson2, K Wellings2
1Centre for Sexual Health and HIV Research, The Royal Free and
University College Medical School, London, 2London School of Hygiene
and Tropical Medicine, London, UK
Aim: To investigate young people’s knowledge and use of
contraceptive services over four years of the Teenage Pregnancy
Strategy.
Methods: Random location sample of young people aged 13–21 years
(n=8877) were surveyed using Computer Assisted Personal Interviews
between October 2000 and June 2004.
Results: 82% of young women and 69% of young men knew a place
they could visit for information about sex. Knowledge that
contraception is freely available has increased. However, the
proportion reporting they had obtained contraceptive advice prior first
sexual intercourse has declined over the last four years. The service
most frequently cited by young women for accessing supplies was
general practice (54%) and for young men was the commercial sector
(54%), but young men’s use of general practice and specialist
contraceptive services has increased. This was particularly evident in
local authorities rated as ‘high quality’ in terms of effort put into
sexual health services (Teenage Pregnancy Unit data). Young people
living in more deprived areas and those under 16 were more likely to
use designated young people’s services.
Conclusion: There has been some success in increasing knowledge and
use of services, but it may be too early to observe any positive changes
in outcomes.
O6
O8
Do people with genital herpes tell their sexual
partners? The influence of stigma
Correlation of erectile dysfunction (ED) severity as
perceived by UK healthcare professional compared to
the International Index of Erectile Function score
(IIEF): results from the Erectile Dysfunction
Observational Study (EDOS)
J Bickford, SE Barton, S Mandalia
Chelsea and Westminster Hospital, London, UK
Objectives: To assess the nature and effect of stigma on disclosure of
genital herpes diagnosis to sexual partners.
Methodology: Quantitative data regarding disclosure were collected
using a questionnaire survey which included the hospital anxiety and
depression scale captured on likert scales. In addition qualitative data
were collected on 10% of these subjects using semi-structured
interviews.
Results: Seventy-one patients responded to the questionnaire and the
in clinic response rate was 91%. The point prevalence of moderate to
severe anxiety in this sample was 32%. 54% discussed genital herpes
with all their sexual partners and 44% did so before first sexual
contact. Qualitative interview identified herpes related stigma
associated with non-disclosure of diagnosis to sexual partners.
Disclosure of diagnosis to sexual partners tended to occur within the
context of established relationships.
Conclusion: The reaction to a diagnosis of genital herpes and the
decision to disclose or not is influenced by cultural understanding of
the infection as well the value of the relationship in which the
disclosure may occur. Our study demonstrated that stigma is a barrier
to disclosure of genital herpes diagnosis. Management strategies
aimed at encouraging disclosure to sexual partners must address
stigma.
2
P Kell1, J Arellano2, M Noone2, A Riley3, S Kontodimas2
1Archway Sexual Health Clinic, London, 2Eli Lilly, UK, 3University of
Central Lancashire, Preston, UK
Introduction: EDOS is a pan-European, observational study assessing
effectiveness, satisfaction and treatment patterns of ED therapies.
Design and method: Patients initiating and changing treatment for ED
were recruited. All types of ED treatments were allowed. ED severity
was assessed using the IIEF-erectile function (EF) domain score and
physician's perception of severity according to the clinical history.
Results: In the UK 93 investigators enrolled 1,362 patients.
Investigators were GPs (84.4%) but also Urologists (4.4%), Andrologist
(2.2%), Sexual therapists (1%) and others (7.8%). The mean age was
57.2 years (range 18-86). 58% (n =782) of men had symptoms of ED
between 1 and 5 years. ED aetiology: organic -37%; psychogenic
–16%; mixed – 47%. Investigators rating of ED severity: 34% severe,
57% moderate, 8% mild. According to the IIEF-EF domain score*, 42%
of men had severe ED, 26% had moderate and 24 % had mild ED.
Moderate ED was the commonest categorisation of ED severity when
severity was assessed by investigators however within that category
patients with both severe and mild ED existed according to the IIEF
score.
Conclusion: Actual numbers of men with severe ED may be
under-reported without the use of tools such as the IIEF questionnaire.
*IIEF-EF domain score categories: Normal (26–30), Mild (17–25),
Moderate (11–16), Severe (1–10).
11th
Oral Abstracts
O9
O11
Antiretroviral therapy in a new public sector
antiretroviral treatment centre in Ghana: patients'
presentation and response
Evaluation of nelfinavir-based mother-to-child
transmission regimens
P Collini1, M Adjei1, K Torpey2, R Amenyah2, D Chadwick3,
G Bedu-Addo1
1Komfo Anokye Teaching Hospital HIV/AIDS Clinic, Kumasi, Ghana,
2Family Health International, Accra, Ghana, 3James Cook University
Hospital, Middlesbrough, UK
Objective: To review presentation of 200 patients and their response
after 6 months of antiretroviral therapy (ART) attending the new ARV
clinic in Komfo Anokye Teaching Hospital.
Methods: Prospective observational study of first 200 ART patients.
Results: Family Health International's START program in partnership
with the National AIDS Control Program / Ministry of Health and DFID
have scaled up the delivery of ART in Ghana. In its first year this clinic
enrolled 1738 patients and started over 600 on treatment. All received
2NRTI+1NNRTI except one (2NRTI+1PI). 188 were ART naïve. 128 had
a regime containing AZT (M=58), 21 later switched to d4T because of
anaemia. 71(M=25) started on d4T. Efavirenz was given to 101(M=71),
nevirapine to 95(M=11). No cases of nevirapine induced hepatitis were
recorded. 8 were switched from nevirapine to efavirenz on developing
tuberculosis. Mean (median) CD4 count increased by 166(158) from
125(123) cells/mm3 and weight increased from 50.7(50) to 58.0(58) Kg.
4 deaths were recorded. 15 patients defaulted follow up by more than
3 months. More than 80% of patients reported greater than 95%
adherence on every follow up visit over the period. Further data on this
cohort will be presented.
Conclusion: Effective and safe ART is achievable when scaling up.
S O’Dea1, F Mulcahy1, F Lyons1, H McDermott1, C Bergin1,
S Coughlan2
1GUIDE Clinic, St James Hospital, Dublin, 2National Virus Reference
Laboratory, University College Dublin, Ireland
Background: Sub-therapeutic levels of nelfinavir in pregnancy, at
standard dosing, have been reported. This study examines viral
response, resistance and outcome in a cohort of women receiving
combivir/nelfinavir(standard doses) in pregnancy.
Methods: 47 pregnant women with a pre-treatment CD4> 300×106/l
were prescribed combivir/nelfinavir in the 3rd trimester. All received at
least 6 weeks treatment (range 6–12, mean 11 weeks) and
discontinued post-partum. All women returned for genotypic
resistance testing after treatment cessation.
Results: Viral load at 36 weeks: 26/47[55%] <50cpm; 18/47[38%]
>50<1000cpm (mean 154cpm) and 3/47[6%] >1000cpm (mean
2160cpm). Mean pre-treatment VL 3,761cpm in <50 group versus
39,535cpm in >50 group. Adherence issues were identified in
4/26(15%) with 36 week VL<50cpm; 1/18(5.5%) with
VL>50<1000cpm and 1/3(33%) with VL> 1000cpm. No drug A/Es were
reported. No primary PI resistance mutations were identified after
treatment cessation. 1 baby acquired HIV (maternal VL<50cpm,
membranes ruptured >24hrs).
Conclusion: At standard nelfinavir dosing almost half the cohort failed
to achieve virological suppression <50cpm, suggesting that routine
TDM should be considered. Despite this, the absence of PI mutations
after treatment cessation suggests that short-term nelfinavir use may
not be detrimental to future maternal ART options.
O10
O12
Targeting points for further intervention: a review of
HIV infected infants born in Ireland in the 5 years
following introduction of antenatal screening
Increased psychosis in HIV-1-infected sub-Saharan
African immigrants
W Ferguson2, K Butler1,2,3, A Menon3 , M Goode1, L Barrett1,
A Walsh1, M Cafferkey2,3
1The Rainbow Clinic, National Centre for HIV Medicine in Children, Our
Lady’s Hospital for Sick Children, 3The Children's University Hospital
and 2The Rotunda Hospital, Dublin, Ireland
Aim: 'Opt-out' AN screening, in Ireland since Jan.'99, has 95%–99%
uptake. Vertical transmission rates are <2%. We sought to identify
intervention targets to reduce ongoing transmission.
Methods: HIV+ pregnant women are referred to the paediatric service.
Maternal and infant data are prospectively gathered.
Results: From 01/1999–12/2004, 11 infected infants were born. There
were 527 HIV+ pregnancies and 2 postnatal diagnoses. 2/11 infants
were born to the women diagnosed postnatally (1 pregnancy
seroconversion, 1 missed screening). Of the remaining 9, 4/9 women
who booked at (36 weeks received ≤3 weeks ART. 5/9 booked
<36 weeks; 1 received <1 week ART & delivered at 33 weeks. 4 received
>4 weeks ART (3 cART, 1 ZDV); adherence was poor in 1 (delivery VL
>10,000 copies/ml), 1 with undetectable VL had 24 hours ROM, in the
remaining 2 (1 ZDV monotherapy & delivery viral load <400 copies/ml,
1 cART from 20/40 & delivery VL 53 copies/ml), infant HIV-PCRs were
positive ≤5 days suggesting in-utero transmission. All 9 women &
infants received IP-ZDV and postnatal ART respectively (6 triple, 3
monotherapy).
Conclusion: There remain identifiable targets for intervention
(pre-conceptual screening, early booking, repeat tests for at-risk
women, adherence support). The problem of early in-utero transmission
remains.
A Holmes, S O’Dea, A O’Dwyer, F Mulcahy
St. James’s Hospital, Dublin, Ireland
Background: Psychiatric morbidity in HIV has been well documented in
western populations, but not in sub-Saharan African [SSA] immigrants.
Aim: To assess psychological morbidity in HIV positive SSAs, and
evaluate illness-related variables on presentation.
Method: Retrospective review of patient notes.
Results: Of a cohort of 324 [229 female, 95 male], 24 patients were
referred to the Department of Psychological Medicine. This referral rate
is 7.4%, compared to 5.9% [67/1138] in the non-SSA cohort. Diagnosis
of depression was associated with increasing HIV disease progression
and was made in 12 [50%] of patients, predominantly in females [75%,
18/24]. Psychosis was diagnosed in 5 [25%]; cases occurring within
three months of HIV diagnosis. 3 of these patients [60%] had an AIDS
defining illness. Anxiety and adjustment disorders accounted for
7 [29%]. Some cases were related to violence/sexual assault that had
resulted in HIV acquisition. Organic brain disease accounted for
2 referrals.
Conclusion: This study confirms the hypothesis that SSA immigrants
are at increased risk of psychological morbidity. The incidence of
psychotic illness was notably high. We believe that cultural beliefs and
the influence of immigration are important factors in both the rate and
type of psychological morbidity.
3
O12a
O14
Sexual behaviour and risk of ongoing transmission in
symptomatic patients attending genitourinary
medicine clinics
High-risk sexual behaviour among London gay men:
no longer increasing?
JA Cassell, CH Mercer, L Sutcliffe, MG Brook, E Jungmann, J Ross, G
Kinghorn, J Stephenson, A M Johnson on behalf of the PATSI
collaboration
Centre for Sexual Health and HIV Research, Department of Primary
Care and Population Sciences, Royal Free and University College
Medical School, University College London, London, UK
Background: Delayed access to services and sexual contact while
symptomatic may increase STI transmission.
Aim: To determine the extent of ongoing sexual contact in
symptomatic patients, whether symptoms influence sexual behaviour
at this time, and the impact of symptom resolution on health care
seeking.
Methods: A questionnaire was administered to approximately 8000
patients in 8 sexual health clinics and linked to preliminary clinical
data.
Results: 38.8% of men and 42.9% of women with acute symptomatic
STI continued sexual intercourse after symptoms began, by contrast
with 46.3% of men and 61.2% of women with no acute STI. Among
symptomatics, 7.7% of men and 0.7% of women had had more than
one sexual partner. Symptom duration was (7 days at clinic visit in
64.3% of men and 66.7% of women with an STI, of whom 22. 4% of
men, and 42.9% of women had self-treated. 22.4% of men and 36.7%
of women with STI would no longer seek care if symptoms resolved.
Conclusions: Our data reinforce the need for rapid access to diagnostic
and treatment services, for all patients and not just ‘high risk’ groups.
Health promotion should emphasize the need for individuals to seek
rapid care and cease sexual activity when an STI is suspected.
1City University London, 2Royal Free and University College Medical
School London, 3MRC Social and Public Health Sciences Unit, Glasgow,
UK
Aim: To examine changes in sexual behaviour among London gay men
between 1998–2004.
Methods: Nearly 5000 gay men using gyms in central London were
surveyed annually between 1998-2004 (range 498–834 per year,
response rate 50–60%). Information was collected on HIV status and
unprotected anal intercourse (UAI) in the previous 3 months. High risk
sexual behaviour was defined as UAI with a casual partner of unknown
or discordant HIV status.
Results: Of the 4934 men, 774 (15.7%) were HIV positive, 3099
(62.8%) were HIV negative, 1061 (21.5%) had never been tested for
HIV. Median age was 35 years. Between 1998–2001 the overall
percentage of men reporting high risk sexual behaviour with a casual
partner increased from 6.7% to 15.2% (P <0.001). Between
2001–2004, however, the percentage of men reporting high risk sexual
behaviour with a casual partner remained stable (annual figures,
15.2%, 15.5%, 16.1%, 14.7%, P =0.8). A similar pattern was seen for
HIV positive, negative and never-tested men when examined
separately.
Conclusion: The percentage of London gay men reporting high risk
sexual behaviour with a casual partner has remained stable since 2001,
although it increased significantly between 1998–2001. Addressing
this elevated level of risk will present a challenge for sexual health
promotion.
O13
O15
Overseas travel, high-risk sexual behaviour and STI
transmission risk among British adults: results of a
national probability survey of sexual attitudes and
lifestyles
Risk factors for the acquisition of HIV in individuals
known to have recently seroconverted
KA Fenton, CH Mercer, AM Johnson, AJ Copas, B Erens, K Wellings
Centre for Sexual Health and HIV Research Department of Primary
Medical School, University College London, Mortimer Market Centre,
London, UK
Aim: To identify factors associated with acquiring new sexual partners
while overseas.
Methods: National probability survey of 12,110 men and women aged
16–44 years, resident in Britain in 2000. Sociodemographic,
health-related, travel, sexual behaviour and attitudinal data collected
by computer-assisted-self-interviewing.
Results: 14.7% of men and 7.8% of women reported new sexual
partner(s) while abroad in the past 5 years. The mean (standard
deviation) number of new partnerships while abroad in this period was
significantly greater for men: 3.7 (12.8), than women: 2.0 (4.8). 49.5%
of new partners originated from the UK; 37.2% from other European
countries. Mixing was also assortative by country of birth, with
partners tending to be from the UK or, if not UK born, their own birth
region, than elsewhere. Reporting new partnerships abroad was
significantly associated with a range of demographic and risk
behaviours including younger age, non-married status, greater partner
numbers, paying for sex, same-sex partnerships, and unsafe sex in the
past 4 weeks.
Conclusion: Although travellers who have sex abroad select partners
from their own geographic regions, their higher prevalence of sexual
risk behaviours at home and abroad place them at greater risk and in
need of targeted sexual health promotion.
4
J Elford, G Bolding, M Davis, L Sherr1, G Hart2
J Fox, M McClure, J Weber, H Ward, S Fidler
Department of Medicine, Imperial College, London, UK
Background: People who have recently acquired HIV could play a key
role in onward transmission if they have unprotected sexual
intercourse (UPSI) with multiple partners whilst having a high viral
load and/or other sexually transmitted infections (STI).
Aims: To describe recent sexual behaviour in people who have recently
acquired HIV.
Methods: Cross sectional survey, 2002–4. Incident HIV was defined as
an evolving HIV antibody response, HIV PCR-DNA positive/ antibody
negative, and/or HIV antibody positive with a negative test within
6 months. A detailed sexual behaviour questionnaire was completed at
diagnosis.
Results: Five women and 50 men were recruited. Two of the women
reported casual sex in the previous 3 months, neither used condoms
consistently. 49 men were MSM; 19 reported sex for money; and 17
had UPSI with >10 casual partners in the preceding 3 months. Condom
use was inconsistent in 91% receptive and 93% insertive anal
intercourse with casual partners. High levels of recreational drug use
occurred. 2/55 viruses appeared phylogenetically related, (i.e. not a
sexual network). 14 had a concomitant STI at seroconversion.
Discussion: High-risk sexual activity is highly linked to those diagnosed
with incident HIV. Without immediate behaviour change onward
transmission in such individuals is likely.
11th
Oral Abstracts
O16
O18
A prospective study of post-exposure prophylaxis
(PEP) following non-occupational exposure to HIV in
the UK
The longevity of HIV-specific CD4 T-helper responses
and clinical outcome following short course
antiretroviral therapy in primary HIV infection
JE Blackham1, V Delpech1, P Benn2, BG Evans1 on behalf of the
NONOPEP project collaborative group.
1HIV and Sexually Transmitted Infections Department, Health
Protection Agency Centre for Infections, London, UK, 2Department of
Genitourinary Medicine, Mortimer Market Centre, Camden PCT,
London, UK
Aim: To describe recent trends in PEP use for non-occupational
exposures to HIV (NONOPEP), across 10 UK GUM/HIV clinics.
Methods: Individuals attending 10 GUM/HIV clinics receiving
NONOPEP between 11/2002 and 11/2004 were prospectively recruited.
Demographic, behavioural and clinical data were collected at baseline,
4–6 weeks, 3 and 6 months.
Results: 212 individuals have been recruited: 89% male, 74% men who
have sex with men (MSM), 79% of white ethnicity, average age 32
years (range 18-64). 91% received PEP following high-risk sexual
exposures, 22% with regular partners. 42/156 (27%) MSM and 13/22
(60%) women receiving PEP reported unprotected intercourse
(anal/vaginal respectively) with an HIV positive partner. All cases
received PEP in accordance with BASHH guidelines. Follow-up rates to
date are low: 4–6 weeks (57%); 3 months (35%); 6 months (28%). Of
the 128 followed-up: 86% completed the 4-week PEP course, 75%
adhered fully and 56% experienced mild-moderate side effects. During
the study period numbers prescribed NONOPEP increased by 98%
(range 60%–1400%); with the greatest increase occurring in London
(172%) in the later part of 2004.
Conclusions: The demand for NONOPEP is increasing, particularly in
London and among MSM. The reasons for low follow-up rates are
unclear and need to be addressed.
J Fox, T Scriba, A Oxenius, R Phillips, M McClure, K Porter, J Weber,
S Fidler
Department of Medicine, Imperial College, London, UK
Background: Antiretroviral treatment at HIV seroconversion has been
associated with the preservation of HIV-specific CD4+ T-cell responses
ordinarily lost without intervention. The longevity and clinical
relevance of this is unknown.
Aims: To compare the immunological outcome of receiving short
course ART (SCART) at Primary HIV (PHI) with rate of decline in CD4
count and this with a natural history cohort (CASCADE).
Methods: Seroconversion was identified by an evolving HIV antibody
response, HIV PCR-DNA positive/ antibody negative or HIV antibody
positive with negative test within 6 months. Patients were offered
SCART and followed monthly. HIV-specific CD4 T-cell frequencies were
determined by interferon-γ ELISPOT analysis.
Results: Of 105 subjects followed prospectively for 3 years, 90 chose
SCART at PHI. Longitudinal data on 16/105 subjects over 4 years,
showed 7/14 receiving SCART had maintained HIV-specific CD4+
T-helper responses compared to 1/2 who did not receive SCART. All
were CCR5 delta 32 negative. There was no relationship between
T-helper responses, CD4 count, and pVL. We report a more rapid decline
in CD4 count compared with CASCADE.
Discussion: Despite the preservation of HIV-specific CD4 T-helper
responses in 50% of treated seroconverters no correlation with CD4
count or clinical progression was observed.
O17
O19
Trends in transmitted genotypic antiretroviral
resistance in primary versus longstanding HIV
infection
Late diagnosis and consequent short-term mortality
of individuals sexually infected with HIV: England
and Wales, 2002
D Pao1, K Aderogba1, G Dean1, P Cane2, E Smit3, D Pillay4 and
M Fisher1
1Dept of GU Medicine, Brighton and Sussex University Hospitals, UK,
2Health Protection Agency, Porton Down, UK, 3Health Protection
Agency, Birmingham, UK, 4Health Protection Agency, Colindale, UK
Background: It is well recognised that a significant minority of
individuals with primary HIV infection (PHI) harbour transmitted
antiretroviral resistance (TAR). Whilst most clinicians perform
resistance testing in individuals diagnosed with PHI, only 6%
diagnosed with non-PHI were tested pre-treatment in the 2002/3
BHIVA audit, despite guidelines to the contrary.
Objectives: To compare trends in prevalence of genotypic TAR among
individuals diagnosed at PHI and non-PHI.
Methods: Analysis of TAR (including only major, significant mutations)
in 450 treatment-naïve individuals, classified as PHI or non-PHI by year
of diagnosis, from 2000–2004.
Results: Genotype results were available in 147/149 (99%) and
127/301 (42%) of the PHI and non-PHI group respectively. To account
for possible testing bias in non-PHI, re-analysis assuming no resistance
in those untested (58%) is shown(1).
2000
2001
2002
2003
2004
PHI
17%
21%
12%
15%
7%
Non-PHI (max)
14%
17%
9%
8%
15%
Non-PHI (min)(1) 12%
4%
3%
5%
10%
Conclusion: TAR remains of significant clinical importance despite
high levels of effective viral suppression. We demonstrate that rates
remain stable and furthermore are comparable in individuals diagnosed
at non-PHI as well as PHI. All new HIV diagnoses should have baseline
resistance testing performed irrespective of time since infection.
TR Chadborn, VC Delpech, K Sinka, BD Rice, BG Evans
HIV/STI Department, Health Protection Agency's Centre for Infections,
London, UK
Aims: To determine factors associated with late diagnosis of
individuals, sexually infected with HIV, and the impact this had on
short-term mortality.
Methods: Analysis of national HIV/AIDS case reports of new diagnoses
linked to CD4 cell counts from the CD4 Surveillance Scheme. Outcomes
were late diagnosis (CD4 <200 cells / mm3) and short-term mortality
(death within a year of diagnosis).
Results: 38% of 3,596 individuals sexually infected with HIV (with CD4
counts at diagnosis) were diagnosed late. Late diagnosis affected 26%
of homosexual men, 49% of heterosexual men and 40% of
heterosexual women (22% where diagnosis was antenatal). Late
diagnosis increased with age. Black Africans were diagnosed later than
white individuals (although not evident after stratifying by other
factors). There were 137 (2.6% of 5,200) deaths within a year of HIV
diagnosis. Short-term mortality was 6.2% for individuals diagnosed
late and 0.5% for others (excluding pregnant women for whom it was
0.4% overall). Early diagnosis could have markedly reduced short-term
mortality and all mortality in 2002.
Conclusions: Continued late diagnosis, particularly of older and
heterosexual individuals, means missed opportunities to start therapy
early and to prevent further transmission, and an approximate 10 times
higher risk of death within a year of diagnosis.s
5
O20
O22
Therapeutic vaccination with HIV-1 whole killed
vaccine is associated with immune modulation in
HAART-naïve, asymptomatic HIV-infected individuals
Discordant CD4 and viral load responses in patients
starting HAART in the UK Collaborative HIV Cohort
(CHIC) Study
A Gori1, D Trabattoni1, G Rizzardini2, R Maserati3, F Mazzotta4,
G Theofan5, DH Bray6, M Clerici1, G Marchetti
1University Milano, Milano, Italy, 2H di Circolo, Busto Arsizio, Italy,
3H S Matteo, Pavia, Italy, 4H SS Annunziata, Firenze, Italy, 5The
Immune Response Corp, Carlsbad, CA, United States, 6MRC, London, UK
Background: Use of agents increasing natural immune response to HIV
to delay initiation of antiretroviral therapy is being considered.
Immunogenicity of REMUNE®, a gp120-depleted, whole-killed HIV-1
vaccine consisting of HIV antigen in Incomplete Freund's Adjuvant
(IFA), was assessed in antiretroviral-naive HIV-1 infected subjects.
Methods: HAART-naïve asymptomatic subjects with HIV-1 RNA
10,000-40,000 copies/mL and CD4 400-800 cells/ul received three
injections of REMUNE® (N=19) IFA (n=11), or saline (n=10) at weeks
0, 12, and 24.
Results: Median absolute CD4 counts remained stable through week
28 in REMUNE(r) patients (baseline=534 cells/ul; week 28=560
cells/ul) but declined in both saline (baseline=497 cells/ul; week
28=388 cells/ul) and IFA (baseline=549 cells/ul; week 28=431 cells/ul)
treated subjects. Possible effect of REMUNE® on thymopoiesis was
evidenced by increases in naïve (CCR7+/RA+), central memory
(CCR7+/RA-) CD4 T cells, serum IL-7 and decrease in effector memory
(CCR7-/RA-) CD4 T cells in the REMUNE® group. These changes were
not observed in saline or IFA subjects. HIV specific CD8+
IL10-producing T cells (ICC) were diminished at week 28 in REMUNE®
patients.
Conclusions: Immunotherapy with REMUNE® may be associated with
changes in circulating lymphocytes phenotype and reduction of type 2
cytokines. Data from larger cohorts of patients is required to assess
clinical significance.
A Rider1, RJC Gilson1, A Copas1 and CA Sabin2, on behalf of the UK
CHIC Steering Committee
1Centre for Sexual Health and HIV Research, 2Department of Primary
Medical School , University College London, London, UK
Objectives: To examine the impact on survival and disease progression
of a discordant CD4:viral load (VL) response at 8 and 12 months after
starting HAART in the UK CHIC Study.
Methods: Patients with VL<50 copies/ml at 8m and 12m were divided
into those with a rise in CD4 from baseline of <100 (discordant
response) or >100cells/mm3 (non-discordant response). Incidence rate
ratios (IRR) for the effect of a discordant response on mortality and
AIDS were calculated using multiple Poisson regression.
Results: 6120 ART-naïve patients started HAART of whom 1205 had
baseline and follow-up CD4/VL data and VL<50 at 8m, and 1089 at
12m, of whom 494 (41%) and 351 (32%) had discordant responses
respectively. Discordant responses were associated with an increased
risk of death at 8m (6 deaths in the discordant group, 4 in the
non-discordant; IRR=2.23; 95% CI [0.63,7.89]) and 12m (7 vs. 4;
IRR=3.94 [1.15,13.46]), but a discordant response had little effect on
the incidence of AIDS (312 and 282 events from 8m and 12m
respectively).
Discussion: Many patients have sub-optimal increases in CD4 count
after starting HAART. Discordant responses at 12 and possibly 8
months may be associated with poorer outcome, although few deaths
were reported in this cohort study.
O21
O23
Discordant responses to HAART in ARV-naïve HIV
infected individuals
The effect of year of treatment and NA backbone on
durability of NNRTI-based regimens
MY Tung, AK Sullivan, S Mandalia, MR Nelson, BG Gazzard
St Stephen's Centre, Chelsea and Westminster Hospital, London, UK
Aim: Evaluate virological and immunological responses to HAART.
Methods: 12 month treatment outcome was defined as successful
(TS=VLBLD+>50CD4 cell rise), discordant immunological
response(DIR=VLBLD+<50CD4 cell rise), discordant virological
response(DVR=+VL+ >50CD4 cell rise) and failing (TF=+VL+<50CD4
cell rise). 24 month data and disease progression were obtained.
Results:
NT Annan, S Mandalia, M Bower, M Nelson, B Gazzard
Introduction: Several cohort studies have suggested increased potency
of efavirenz when compared with nevirapine but the 2NN study failed
to show this difference. Two possible confounding factors are year of
treatment and NA backbone. We evaluate the effect of these factors on
NNRTI based regimen success in a large prospectively collected cohort.
Methods: ART naïve individuals starting NNRTI with dual NA backbone
were identified between 1/1/1998–1/7/2004. Treatment failure was
defined as switch/discontinuation of NNRTI or documented virological
failure (2× VL>500 copies/ml).
Results: 994 patients were identified, 72.7% efavirenz and 27.3%
nevirapine. There were no significant differences in gender, age,
baseline VL or CD4 count. In univariate analysis, efavirenz was
associated with significantly greater virological success (p <0.001).
Multivariate analysis showed DDI/TFV(HR6.57, 95%CI 3.88–11.13) and
DDI/D4T (HR1.49, 95%CI 1.00–2.22) to be significant independent
predictors of failure. Univariate analyses showed the likelihood of
success to be almost two fold increase per year (HR1.96, 95%CI
1.81–2.13) since 1998. When controlling for NA backbone and
stratifying by year of therapy, there was no significant difference
between treatment with nevirapine or efavirenz.
Conclusion: We have shown in a large NNRTI-experienced cohort, that
although in univariate analysis efavirenz appears to have a higher
success rate, this is explained by differences in backbone and year. This
may explain differences between reported cohort studies and the 2NN
study.
Number(%)
Baseline CD4(cells/µL)
VL(copies/ml)
Rate of CD4 decline
preHAART
(cells/mL/month[95%CI])
24 month outcome N(%)
Disease Progression(%)
All
1141
175
71,138
TS
757(66.4)
157
88,792
9.7
[9.1–10.3]
DIR
186(16.3)
264
29,791
4.8
[3.7–6.0]
DVR
98(8.6)
151
101,818
9.5
[7.9–11.0]
TF
100(8.8)
225
67,091
4.7
[3.3–6.2]
755
6.3
548(72.6)*
4.6*
85(11.3)
8.9*
65(8.6)
4.2
57(7.5)
9.4
P=
<0.001
<0.001
<0.001
*<0.05
*0.02
Conclusions: 24.9% experience DR at 12 months, affected by age, CD4
count, VL and rate of CD4 decline. DIR and DVR have a good treatment
outcome at 24 months. <50 CD4 rise is more predictive of DP than a
positive VL.
6
11th
Oral Abstracts
O24
O25
Therapeutic drug monitoring (TDM) of efavirenz
(EFV): a tool to predict virologic outcome in
HIV-patients on first line once daily (OD)
antiretroviral (ARV) therapy?
Evidence for sexual transmission of HCV in recent
epidemic in HIV-infected men in South-East England
D Maitland1, M Boffito1, S Mandalia1, S Gibbons2, D Back2,
M Nelson1, B Gazzard1, G Moyle1
1Chelsea and Westminster Hospital, London, 2University of Liverpool,
UK
Aim: To investigate the usefulness of TDM of EFV in ARV-naïve patients
starting an OD regimen containing ddI/EFV and tenofovir (TDF) or 3TC.
Methods: EFV TDM was performed prospectively following ARV
initiation with blood samples collected at weeks 4 and 12.
Concentrations of EFV were determined by HPLC in plasma, samples
collected 10–15h post-evening-EFV dose. For samples >15h,
concentrations were back extrapolated to 12h by linear regression.
Results: Samples from 66 patients (9 females, median age 37years,
baseline median CD4+ and mean viral load 174cells/mm3 and
5.01log10-copies/ml) were analysed (n =132). Median EFV-[C] were
1569 (range 354-11611) and 1705 (466-13351)ng/ml week 4 and 12.
Among responders, 17 had at least one EFV-[C] lower than the
suggested effective-[C] (MEC) of 1000ng/ml. Of the 5 non-responders,
3 had EFV-[C]<1000ng/ml (despite 100% adherence assessed by
MEMSCAPS). Coefficient of variation in EFV-[C] was 90% at week 4
and 12. Subjects with higher (>1100ng/ml) EFV-[C] at week 4 and 12
were more likely to show virologic response (<50 copies/ml) at week 12
(p <0.001, ROC method).
Conclusion: Our prospective analysis confirms the association between
EFV-[C] and virologic response but with wide variability in EFV-[C],
suggesting a role for EFV TDM in naïve patients.
M Danta1, D Brown1, O Pybus6, M Nelson4, M Fisher5, C Sabin3,
S Bhagani2 for the HIV and Acute HCV (HAAC) group.
1Centre for Hepatology, 2Dept of HIV Medicine, 3Dept of Primary Care
and Population Sciences, Royal Free and University College Medical
School, 4Dept of HIV Medicine, Chelsea and Westminster Hospitals,
London, 5Dept of HIV Medicine, Brighton and Sussex University
Hospitals Trust, Brighton, 6Dept of Zoology, Oxford University, Oxford,
UK
Aims: To characterise the mode of acute HCV transmission in
HIV-infected individuals using linked molecular and clinical
epidemiological analysis.
Methods: Patients enrolled had a seroconversion to anti-HCV + and
positive HCV PCR within 9 months. The E1/E2 region of the HCV
genome from each patient's serum was amplified with RT-PCR and
sequenced. Using PAUP* software, a phylogenetic tree was constructed
from the amplified sequences, comparing them with unrelated E1/E2
sequences. A case-control study using a questionnaire instrument to
determine transmission factors was performed using HIV
mono-infected controls from each clinic's database, matching for age,
length of HIV infection and HAART.
Results: 90 HIV-positive homosexual males (mean age 36 yrs) with
acute HCV have been identified. Phylogenetic analysis of 55 E1/E2
sequences reveals multiple monophyletic clades signifying that several
independent HCV lineages (clades) are co-circulating in this
population. The largest clade involves 21 patients. Preliminary factors
identified more commonly in cases (n =23) vs controls (n=48) are:
unprotected receptive and insertive anal intercourse (P <0.001),
mucosally traumatic practices including fisting (P <0.001) and use of
sex toys (P<0.001), group sex (87% Vs 52.3%, P=0.01), and sexual
activity while feeling the effects of drugs (100% Vs 64%, P<0.003).
Conclusions: Mucosally traumatic sexual factors are significantly
associated with the recent transmission of HCV.
O24a
O26
Predictors of current CD4+ T-cell response among
patients receiving subcutaneous recombinant
interleukin-2 (RIL-2) in ESPRIT (evaluation of
subcutaneous Proleukin(r) in a randomized
international trial)
Is the treatment of acute hepatitis C in HIV-positive
individuals effective?
H Nuwagaba-Biribonwoha1, BJ Angus1,2, J Bebchuk3, A Babiker1,
B Cordwell1, F van Hooff1, L Hack1, Y Moraes1, B Gazzard4,
J Darbyshire1 on behalf of the ESPRIT Research Group
1Medical Research Council Clinical Trials Unit, London, UK, 2Nuffield
Department of Medicine, Oxford University, Oxford, UK, 3Division of
Biostatistics/CCBR, School of Public Health, University of Minnesota,
Minneapolis, USA, 4Chelsea and Westminster Hospital, London, UK
Aim: To examine predictors of current CD4+ response in patients on
the rIL-2 arm of ESPRIT.
Background: ESPRIT is an international, phase III, open-label,
randomized trial comparing the effects of subcutaneous rIL-2 and no
rIL-2 on disease progression and death in HIV-1 patients with absolute
CD4+ counts ≥300/µl at baseline who are taking combination
antiretroviral therapy (ART).
Methods: Baseline and rIL-2 cycling characteristics of patients
randomized to rIL-2 were analysed. Logistic regression determined the
independent predictors of CD4+ increase >200/µl above baseline at 35
median months of follow-up.
Results: Analysis was based on 1,977/1,998 (99%) of patients receiving
rIL-2. At their most recent follow-up examination, 876 (44%) had
CD4+ increase >200/µl while 1,101 (56%) had CD4+ increase ≤200/µl
from a median baseline CD4+ of 470/µl and 460/µl respectively. More
patients with CD4+ increase >200/µl had baseline viral load <50
copies/ml (83% versus 77%; OR=1.8, 95%CI 1.4–2.3, p <0.001); and
had completed (4 cycles of rIL-2 (67% versus 48%; OR=2.2, 95%CI
1.8–2.7, p<0.001). Age, duration of ART, nadir CD4+, baseline CD4+,
gender, and stage of HIV disease at baseline were not significantly
associated with CD4+ increase >200/µl above baseline. The results
were similar for the UK subset of patients.
Conclusion: More rIL-2 cycles and undetectable viral load at baseline
were associated with a better CD4+ response.
RE Browne, YC Gilleece, D Asboe, M Atkins, S Mandalia, M Bower,
BG Gazzard and MR Nelson
St Stephen’s Centre, Chelsea and Westminster Hospital, London, UK
Objective: To evaluate the effectiveness of treatment of acute hepatitis
C infection in HIV-1 positive individuals.
Design: Open label, prospective study.
Methods: Patients diagnosed with acute hepatitis C by positive HCV
antibody test had sequential HCV RNA levels measured at 0, 4, 12, 24,
32 and 48 weeks. If HCV RNA positive at 12 weeks patients were
offered pegylated interferon alpha-2b 1.5µg/Kg/week + weight
adjusted ribavirin for 24 weeks. Patients with increasing HCV RNA VL
were offered treatment earlier.
Results: 50 male homosexuals, mean age 37yrs, were identified: 44 via
newly abnormal LFT’s, 4 from sexual contact with HCV positive partner
and 2 at HIV seroconversion. 12 individuals became HCV RNA -ve
spontaneously. This was significantly associated with a high baseline
median CD4+ lymphocyte count (P =0.029), CD4+ lymphocyte count
>500 (P =0.017) and lower HCV RNA VL (P =0.017). 27 patients
accepted treatment, 16 (59%) of whom had a sustained virological
response (SVR). This was associated with a higher peak mean ALT
(P <0.001) but not with genotype.
Conclusions: SVR rates in HIV positive patients treated acutely for
hepatitis C are lower than in HIV negative subjects. A high percentage
of individuals seroconvert spontaneously.
7
8
O27
O29
Does nadir CD4 count in HIV-HCV co-infected
patients predict HCV treatment response to pegylated
interferon (p-IFN) and ribavirin (RBV)?
Inhibition of hepatitis B virus replication by small
interfering RNA expressed from viral vectors
J Turner1, S Hopkins2, T Mahungu2, R Johnstone1, RM Lascar1,3,
S Bhagani2, G Dusheiko, MA Johnson2, I Williams1,3, RJC Gilson1,3
1Centre for Sexual Health and HIV Research, Royal Free and University
College Medical School, 2Department of HIV Medicine, Royal Free
Hospital, 3Camden PCT, Mortimer Market Centre, London, UK, Centre
for Hepatology, Royal Free Hospital, London, UK
Introduction: Response rates of 26–46% have been reported to p-IFN
and RBV in HIV-HCV in published studies. None of these studies have
investigated the role of nadir CD4 count in predicting response.
Aim: to evaluate treatment outcomes and predictors of response,
particularly nadir CD4 counts
Methods: All HIV-HCV patients (n=59) who commenced treatment for
chronic HCV at two centres were included in this analysis. Baseline
demographics, HCV and HIV related factors were collated. Data was
entered and analysed on SPSSv10.0.
Results: Patients were predominantly male (86%), Caucasian (87%),
and on antiretrovirals (ARV) (69%). 32% were IVDU and 39% were
MSM. 44% were genotype 2/3. Median age was 40yrs, baseline CD4
count was 468x106/l and nadir CD4 count was 220×106/l. Median
baseline HCV-VL was 1.5X106IU/l. 56% had an end-of-treatmentresponse (Genotype (G) 1/4:33% & G2/3:86%) and 42% had a SVR
(G1/4:24%&G2/3:65%). Predictors of response were nadir CD4 count
(P =0.04) and genotype(P=0.008). No other factors predicted response
including age, sex, type of p-IFN (2A/2B) or duration of HCV therapy.
19% discontinued therapy.
Conclusion: This analysis demonstrates SVRs comparable to controlled
studies in HIV-HCV co-infected patients. In addition to genotype, nadir
CD4 predicted response to HCV therapy. This merits investigation in
larger datasets.
1Jefferiss Trust Laboratories, Wright-Fleming Institute, Imperial College
O28
O30
Hepatitis C infection is not associated with systemic
HIV-associated non-Hodgkin's lymphoma: a cohort
study
Is there a relationship between Familial
Mediterranean Fever (FMF) host polymorphisms and
paradoxical reactions (PR) in tuberculosis (TB)?
L Waters, J Stebbing, S Mandalia, AM Young, M Nelson, BG Gazzard,
M Bower
Departments of HIV Medicine and Oncology, The Chelsea and
Westminster Hospital, London, UK
Aim: HIV-associated immunosuppression increases the risk of
non-Hodgkin’s lymphoma (NHL). The hepatitis C virus (HCV) has been
implicated in the development of B cell lymphomas, and HCV is
common in HIV-infected individuals, we compared the incidence of
systemic NHL during HIV infection compared with HIV and HCV
co-infection.
Methods: Data were extracted from a prospectively collected database
for all patients entering our cohort in the HAART era. To compare
lymphoma risk in HIV mono-infected and co-infected individuals,
person years at risk (PYAR) was estimated from cohort entry to i) end
of study period, ii) NHL development, iii) last recorded visit or iv) date
of death. Data were analysed using the Genmod with loge link and
Poisson error distributions; all P values are two-sided. All NHL cases
were biopsy-proven and primary CNS lymphomas were excluded.
Results: Out of 5,832 individuals studied during the era of highly active
anti-retroviral therapy (HAART), 102 patients were diagnosed with
systemic NHL. The incidence of systemic NHL was 6.9/104 patient years
in co-infected individuals compared with 7.1/104 patient years if HIV
mono-infected (P =0.9).
Conclusion: In this immunocompromised patient population, there was
no association between HCV infection and an increased risk of
lymphoma.
A Dunleavy1, RAM Breen1, A Bybee2, S Hopkins1, PN Hawkins2,
M Lipman1
1Royal Free Hospital, London, 2The National Amyloid Centre, Royal Free
Hospital, London, UK
Aims: The inflammatory condition FMF is associated with
polymorphisms in the human pyrin gene. Its expression is upregulated
by cytokines similar to those implicated in TB related PR. We sought to
ascertain if patients with these polymorphisms are at an increased risk
of PR compared to HIV + subjects (known risk factor for PR).
Methods: MEFV exon 2 restriction length polymorphism for Q148 was
analysed in blood from subjects with active TB enrolled in a prospective
study of PR. Analysis was performed using SPSS 10.0.
Results: 42 subjects were assessed – 17 (41%) HIV+. (24%)
experienced PR. 9/42 (21%) expressed the Q148 mutation of which
4/10 (40%) had PR. 5/32 (16%) without PR were Q148 mutation+
(P =0.18). PR occurred in 5/17 (29%) HIV= and 5/25 (20%)
HIV-subjects (P=0.71). The odds ratio (OR) for developing PR with
Q148 was 3.6 (95%CI 0.40-7.0;P =0.48).
Conclusion: In our cohort PR appeared to be more strongly associated
with Q148 polymorphisms than HIV status. This requires confirmation
in a larger study.
M McClure1, MD Moore1, MJ McGarvey2, RA Russell1, BR Cullen3
London, UK, 2Hepatology, QEQM, Imperial College London, UK,
3Howard Hughes Medical Institute and Department of Molecular
Genetics and Microbiology, Duke University Medical Centre, Durham,
USA
Aim: To investigate the potential of RNA interference (RNAi) for the
treatment of Hepatitis B virus (HBV) infection.
Methods: An RNAi sequence active against the HBV surface antigen
(HBsAg) was expressed from a polymerase III expression cassette.
Therapeutic use of RNAi demands a suitable delivery system. Hence,
the expression cassette was inserted into two vector systems, one
based on the Prototype Foamy Virus (PFV), the other, Adeno-Associated
Virus (AAV). Both are non-pathogenic and capable of integration into
cellular DNA. The vectors containing the HBV targeted RNAi molecule
were introduced into a cell line stably expressing HBsAg (293T.HBs)
and one which secreted infectious HBV virions (HepG2.2.15).
Results: We identified an RNAi sequence active against HBsAg. Further,
we demonstrated knockdown of HBsAg by approximately 90%,
compared with controls in 293T.HBs cells transduced by
shRNA-encoding PFV and AAV vectors. This reduction has been
observed up to 5 months post-transduction in single cell clones. Both
vectors successfully inhibited HBsAg expression from HepG2.2.15 cells,
even in the presence of HBV replication.
Conclusions: This work is the first to demonstrate that delivery of RNAi
by viral vectors has therapeutic potential for chronic HBV infection and
establishes the ground work for the use of such vectors in vivo.
11th
Oral Abstracts
O31
O33
Identifying the key beliefs influencing uptake and
adherence to HAART: final results of a 12-month
prospective, follow-up study
Switching from a thymidine analogue to tenofovir
(TDF) achieves similar resolution of lipoatrophy and
better reduction in lipids than switching to abacavir
(ABC). Results of the RAVE study, a UK multi-centre
open-label randomised controlled trial
R Horne, V Cooper, G Gellaitry, M Fisher
Centre for Health Care Research, University of Brighton and Royal
Sussex County Hospital, Brighton, UK
Objective: To examine the utility of a necessity-concerns framework in
explaining uptake and adherence to HAART.
Methods: Patients attending Brighton clinics from 2000–2003 who
were not taking HAART were referred to this study by their HIV doctor.
Of 322 patients recruited, 153 were recommended HAART. Validated
questionnaires investigating beliefs about personal necessity of HAART
and concerns about adverse effects were completed following a
treatment offer. Those who subsequently accepted HAART (n =120)
were followed up after 1, 3, 6 and 12 months of treatment.
Results: Necessity (odds ratio (OR), 6.7; 95% Confidence Interval (CI),
2.5–18.0) and concerns (OR, 0.12; 95% CI, 0.03- 0.42) predicted uptake
independently of clinical variables. Adherence was initially high but
tailed off significantly by six months (P <0.001), and low adherence
was predicted by changes in beliefs about HAART over time. Further
analyses revealed how patients' perceptions of need and concerns
about HAART derived from their interpretation of symptoms and
personal beliefs about HIV that may conflict with the medical view.
Conclusion: This study has identified the key factors influencing
patients’ decisions about HAART and can inform the design of
evidence-based interventions to facilitate informed patient choice in
relation to HAART, with implications for clinical care.
JD Cartledge, G Moyle, C Sabin, M Johnson, E Wilkins, D Churchill,
P Hay, A Fakoya, M Murphy, G Scullard, C Leen, G Reilly (RAVE study
group)
Mortimer Market Centre, London, UK
Methods: 105 HIV+ adults with moderate/severe lipoatrophy and HIVRNA <50 on HAART containing d4T (n =71) or AZT (n=34) were
randomised to switch the thymidine analogue to open label ABC
300mg bd (n =52) or TDF 300mg od(n =53). Patients had to have no
documented resistance to ABC or TDF and/or no treatment history
suggestive of such resistance. Analyses were performed on an intentto-treat basis ignoring treatment changes
Results: Limb fat by DEXA was similar for the two groups at baseline.
Comparisons of results at baseline and at 48 weeks are given below.
Limb fat increased significantly in both groups (P <0.01) but with no
difference between the groups (P=0.36). CT scan showed reductions in
visceral fat and increases in subcutaneous fat that were similar for
both groups (P =0.32 & P=0.78 respectively). Viral load suppression was
similarly maintained by ABC and TDF(P =0.16). Ten patients
discontinued study drug, 1 on TDF, 9 on ABC (3 with hypersensitivity
reactions). Changes in cholesterol and LDL significantly favoured TDF
(P =0.01 & 0.05 respectively). A pre-planned subanalysis of response
according to thymidine analogue will be presented.
Conclusions: Switching from a thymidine analogue to tenofovir
achieves similar resolution of lipoatrophy, better reduction in lipids,
and fewer treatment discontinuations than switching to abacavir.
O32
O34
Stopping combination therapy whilst travelling: is
there a reason for great concern?
3-dimensional surface laser scanning and
psychological assessment: objective evidence for the
use of polylactic acid implants in HIV-associated
facial lipoatrophy
MA Schuhwerk1, J Richens2, M Prestage1, K Jones1, N De Esteban1,
RH Behrens3
1Mortimer Market Centre, Camden Primary Care Trust, 2Centre for
Sexual Health, University College Hospital, 3Hospital for Tropical
Diseases, University College Hospital, London, UK
Aim: To investigate whether stopping HAART during travelling is of
concern.
Methods: Questionnaire based survey of HIV positive individuals
attending the HIV outpatient clinic detailing history of travel.
Results: 12% (26/216) of individuals had stopped HAART whilst
travelling. 35% had a CD4 count of 200 or less. The regular HIV
physician was informed in 46% and only 30% had HIV inclusive travel
insurance. At the time of stopping 19 % were on a triple nucleoside,
44% a PI and 38% an NNRTI regimen. Individuals were twice more
likely to stop a PI regimen than an NNRTI regimen, 15% versus 7%.
65% had prior drug resistance. 50% reported ‘entering a country with
HIV restrictions’ as the main reason for stopping, 39 % ‘fear of being
found out’ and 23 % side-effects from tablets. Stopping had a clear
relationship to ethnic background: white 11%, Black 30%, Asian 0%.
31 % had to end their journey prematurely (versus 7 % who continued
HAART), 50% had to see a doctor abroad (versus 18 %) and 62%
needed to see a doctor on return (versus 27%).
Conclusion: A significant proportion stop HAART at low CD4 counts
and are at greatly increased risk of developing medical problems.
Development of drug resistance is a real concern.
J Ong, A Clarke, M Johnson, S Withey, P Butler
Departments of Plastic and Reconstructive Surgery, Clinical Psychology
and Infectious and HIV Medicine, The Royal Free Hospital Hampstead
NHS Trust, London, UK
HIV-associated lipoatrophy is a physical condition which is associated
with significant psychosocial morbidity. This study shows aesthetic and
psychological improvement with facial injections of Polylactic acid
(PLA) (NewFill(R)).
Methods: 50 patients with HIV-associated facial lipoatrophy had PLA
implants into their cheeks. All patients were assessed with
3 dimensional (3D) facial laser scanning, psychological questionnaires
(Derriford Appearance scale, HADS, Rosenberg self esteem scale) and
clinical photography and examination prior to treatment. All patients
received 4 or 5 sets of treatment. The first 30 patients had 3D scans
and clinical photographs before each treatment. All assessment
measures were repeated every 6 months until 1 year after treatment.
Results: Pre-treatment 3D laser scans were used as baseline (0mm).
Mean surface projection improvements were 0.8mm after 1 treatment,
1.4mm after 2 treatments, 1.8mm after 3 treatments, 2.3mm after 4
treatments and 2.6mm after 5 treatments. Post treatments scans at 6
months (2.8mm) and 12 months (2.8mm) showed persisting changes.
There were significant improvements in all Psychological and clinical
measures.
Conclusion: PLA implants improve the physical changes of
HIV-associated facial lipodystrophy. Physical and psychological
measures show objective improvements with treatment which persist
for a year following treatment.
9
10
O35
O37
What is the cost of switching an anti-retroviral
therapy (ART) from an HIV-centre perspective?
Enhanced surveillance for lymphogranuloma
venereum (LGV) in England
T Toward1,M Fisher2,G Scullard3,C De Souza3, P Hay4, A Adebiyi4,
F Pang1
1HE&OR, Medical Division, Abbott Laboratories, UK, 2Brighton &
Sussex University Hospitals, Brighton, 3St Mary's Hospital, London UK,
4St Georges' Hospital, London, UK
Aim: To estimate costs associated with switching an ART for reasons
of Virological-Failure or Modification (non Virological-Failure: i.e.
toxicity, non-adherence) in the UK setting.
Methods: Treatment-resource pathways associated with (i)
maintaining (VL<50copies/ml), or (ii) switching ART, were developed
from surveying staff at three HIV-centres (2 London, 1 outside London).
Direct resource costs for HIV-centre medical personnel (e.g. physician,
nurse, pharmacist, dietician) and laboratory tests (e.g. viral-load, CD4,
biochemistry, genotype, TDM) were included from an NHS perspective.
Total costs for each scenario (i and ii) were calculated from valuating
the resources consumed using representative NHS unit-costs. The
difference between these total costs was the cost of switching ART.
Further analyses investigated the impact of centre-specific costing and
costs over a one-year period. Costs for overheads, capital, lost ARTs,
concomitant treatment/investigations for Virological-Failure- or
Modification-related adverse events (e.g. diarrhoea, rash) were
excluded.
Results: The mean (lower-upper range) costs across 3 centres of
switching ART for Virological-Failure or Modification were
£787(£730–£889) or £534(£367–£618), respectively.
Conclusion: This is the first study to estimate the cost of switching ART
in the UK, a frequently overlooked element in costing HAART strategies.
This resource utilisation model provides a methodological framework
for HIV units to determine the cost impact of switching patients.
CA Ison, N Macdonald, IMC Martin, S Alexander, KA Fenton,
C Lowndes, H Ward on behalf of the LGV Incident Team
Health Protection Agency Centre for Infections, London, UK
Aim: To raise awareness and improve the diagnosis and surveillance of
LGV in England.
Methods: In October 2004 the Health Protection Agency (HPA)
launched an enhanced surveillance alert following outbreaks of LGV
among men who have sex with men (MSM) presenting with proctitis in
western Europe. Case definition is confirmation of C. trachomatis by
RT PCR in a rectal or urethral specimen and presence of an LGV serovar,
L1, L2 or L3 by genotyping. Clinicians provide additional clinical and
behavioural data on confirmed cases.
Results: By end Jan 2005, 29 cases of LGV were confirmed: 22 (76%)
from London and the remainder from major towns across the UK.
Epidemiological data for 19 cases confirmed: All 29 are MSM;
17 (89%) HIV positive; 18 reported anorectal symptoms; seven had
systemic symptoms; and two inguinal LGV symptoms. Concurrent STIs
were reported for 8/19(42%) patients and 4(21%) of whom were
hepatitis C antibody positive. Probable country of acquisition was
reported for 15 men, five identified mainland European countries, and
10 within the UK.
Conclusion: The HPA alert, Terence Higgins Trust publicity campaign,
and improved diagnostic tests, have increased community and
professional awareness about LGV, case ascertainment, and confirmed
in-country transmission of this rare disease.
O36
O38
Extent of underdosage of antiretroviral therapy in
HIV-infected children
An outbreak of lymphogranuloma venereum in
London in 2004
EN Menson, AS Walker, T Duong, K Doerholt, C Wells, M Sharland,
DM Gibb
MRC Clinical Trials Unit, London, UK
Aims: To explore the extent of, and contributing factors to,
underdosing of antiretroviral therapy (ART) drugs in children with HIV
infection in the UK and Ireland.
Methods: We evaluated ART doses prescribed to children aged 2–12
years in the Collaborative HIV Paediatric Study (CHIPS) (January
1997–December 2003, to be updated to November 2004). Underdosing
was defined relative to current recommended doses (CRD) in 2004
Paediatric European Network for the Treatment of AIDS (PENTA)
guidelines in order to evaluate ‘dosage-adequacy’ based on current
best evidence.
Results: The CHIPS cohort included 78% (757) of diagnosed
HIV-1-infected children; 73% had received ART drug(s). Children were
underdosed for 40.5% of their time on ART. Most commonly
underdosed ART drugs were efavirenz and nelfinavir. Prevalence of
underdosing reduced over calendar time, particularly for nelfinavir and
nevirapine, concordant with changes in prescription guidelines.
Accordingly, newer drugs such as kaletra were underdosed least.
Reasons for underdosing included failure to increase doses with
growth; limitations of drug formulations; rounding-down calculated
doses; and, for certain drugs, dosing using weight-bands or mg/kg for
dose calculations, rather than as recommended in prescription
guidelines.
Conclusions: Largely unwittingly, we have greatly underdosed
HIV-infected children on ART over the past 7 years.
M Hamill1, C Ison2, C Carder3, P Benn1, E Jungmann1, N MacDonald2,
P French1
1Department of Genitourinary Medicine, Mortimer Market Centre/
Archway Sexual Health Centre, Camden PCT, London, 2Sexually
Transmitted Bacteria Reference Laboratory, Health Protection Agency,
Centre for infections, Colindale, 3Department of Microbiology,
University College London Hospitals NHS Trust, London, UK
Introduction: Lymphogranuloma venereum (LGV), [Chlamydia
trachomatis (CT) – serovars L1–3] is rare in the UK. There has been a
recent resurgence of LGV (serovar L2) in Western Europe, with
outbreaks in several European cities among homosexual men (MSM);
who are predominantly HIV positive and many also co-infected with
hepatitis C (HCV).
Methods: All CT positive rectal samples identified by culture and
polymerase chain reaction (PCR) at UCLH during 2004 were genotyped
for presence of an LGV serovar and a clinical notes review was
undertaken.
Results: 20 CT positive samples were identified. So far, 10/15 samples
typed have been identified as LGV (L2). The earliest case of LGV
identified is from April 2004. All those with LGV were MSM, 9/10 lived
in London, age range 24–47 years, 9/10 were HIV positive, 2/10
co-infected with HCV and 9/10 had symptomatic proctitis. 1/10 had
inguinal lymphadenopathy and 1/10 reported constitutional symptoms
at diagnosis.
Discussion: Up to 18th January 2005 there were 23 confirmed cases of
LGV in the UK including 10 from our centre. Retrospective testing has
shown its presence in the UK since April 2004. Clinicians should be
aware of LGV in the UK population particularly its presentation as
proctitis among HIV positive MSM.
11th
Oral Abstracts
O39
O41
Syphilis outbreak in commercial street sex workers in
east London
Opa-typing can subdivide NG-MAST sequence types
of Neisseria gonorrhoeae into epidemiological relevant
groups
N Lomax, H Anderson, H Wheeler, B Goh
Barts and The London NHS Trust, London, UK
Background: An outbreak of infectious syphilis was identified in street
commercial sex workers (SCSWs) in Hackney, East London in early
2004.
Objective: To describe the epidemiology of the outbreak and measures
taken from April–December 2004.
Methods: A multidisciplinary team (MDT) based around an existing
outreach service provided a targeted service for STI screening and
treatment. SCSWs were identified at outreach or during drop-in
sessions. Meals were provided as an incentive for attending the GU
clinic with outreach workers.
Results: Of 24 SCSWs identified, 14 (58%) were found to have positive
treponemal serology (4 secondary, 6 early latent and 4 late latent
syphilis) Treatment was with either Benzathine penicillin (4),
azithromycin (3), doxycycline (2) or azithromycin and doxycycline (4).
Coexistent STIs were identified in 10 (42%). 92% used crack or heroin.
Discussion and Conclusions: Outbreak management in this population
is challenging: an MDT approach is crucial in identifying/treating
syphilis to prevent onward transmission. High prevalence of syphilis
was detected. Azithromycin was preferred by SCSWs; possible
resistance problems were minimised by addition of doxycycline. As
contact tracing is difficult, public awareness was heightened through
local newspaper articles. Real-time rapid syphilis tests (Abbotts) were
introduced to screen at source for SCSWs who decline attending GUM
clinics.
AK Morris, HM Palmer, H Young
Scottish Neisseria gonorrhoeae Reference Laboratory, Royal Infirmary
of Edinburgh, Edinburgh, UK
Aims: To opa-type all ciprofloxacin resistant (MIC≥ 1mg/l) and
intermediate resistant (MIC≥ 0.05 <1mg/l) isolates submitted to
SNGRL in 2002 that had a non-unique sequence type by NG-MAST. To
assess the concordance between opa and NG-MAST sequence types. To
determine if epidemiological information supports any subdivision of
NG-MAST sequence types resulting from opa-typing.
Methods: 74 isolates were opa-typed and the results compared with
NG-MAST sequence type and epidemiological data. These 74 isolates
were selected on the basis of NG-MAST sequence typing of 106
isolates with reduced susceptibility to ciprofloxacin (89 resistant and
17 intermediate resistant) submitted to SNGRL in 2002: there were
12 clusters containing 2–32 isolates each (74 isolates in total) and
32 unique sequence types.
Results: The 74 isolates were divided into 20 opa-types. Seven of the
NG-MAST sequence types were concordant with single opa-types, but
the remaining five sequence types (ST147, ST314, ST304, ST203, ST211)
were subdivided into 2–5 opa types. The largest NG-MAST cluster,
ST147, containing 32 isolates, could be subdivided into five opa-types.
Differences in patient sexual preference, and geographical location
were apparent for some of the opa-type subgroups.
Conclusions: Opa-typing can subdivide NG-MAST clusters into
subgroups, some of which are supported by epidemiological data.
O40
O42
Syphilis PCR use for diagnosis of early syphilis
audited against routine serological testing
HIV-1 antibody avidity testing to identify recent HIV
seroconverters
P Lewthwaite1, M Guiver2, A Turner2
1Infectious Diseases Unit North Manchester General Hospital,
2Manchester Medical Microbiol Partnership, Dept Clin Virology,
Manchester Royal Infirmary, Manchester, UK
The incidence of syphilis in the UK is increasing. Real-time Polymerase
Chain Reaction (PCR) assays were designed using gene targets used
with previously published PCR assays for the detection of syphilis we
audited the use of the PCR against routine serological testing. Swabs
taken from ano-genital or oral ulcers where either herpes or syphilis
was suspected and tested by syphilis PCR using both the Light Cycler
and Taqman assays. Samples were initially refrigerated at 4 degrees
centigrade and transferred to sterile 1.5ml tubes for storage at -80
degrees centigrade. Batches of samples were then tested. DNA was
extracted by Qiagen DNA extraction method. 135 samples from 111
patients were analyzed from July 2003–December 2004. In the
statistical analysis only one sample was analyzed per patient. 14
samples were PCR positive by both methods, 1 sample positive only by
Light cycler and 1 by Taqman assay only. In 2 samples which were PCR
positive, syphilis serology was positive but not felt to be consistent
with recent or active infection. Of the PCR negative samples 5 had
serology consistent with active or recent syphilis infection. Sensitivity
was 70.1% and specificity for both PCRs to be positive was 97.8%.
Given problems with conventional serological testing for syphilis PCR
provides a useful addition.
A Chawla, M Mirfenderesky, C Donnelly, M Raza, M Johnson, AM Geretti
Royal Free Hospital and Royal Free and University College Medical
School, London, UK
Objective: Antibody avidity, a measure of the tightness of antigenantibody fit, is low in early infection and increases as IgG responses
mature. Our aim was to determine whether the avidity index for HIV
antibodies can be used as a new serological marker to identify recent
seroconversion among newly diagnosed HIV-positive persons.
Methods: Serum samples were tested for HIV antibodies by manual EIA
(Ortho Diagnostics). Two aliquots were tested in parallel and in
duplicate or triplicate wells following either the standard EIA protocol
(=reference) or a modified protocol requiring an additional wash with
8M urea in PBS to dissociate low avidity antibodies (=test). The avidity
index was calculated by dividing the averaged reference optical density
(OD) value by the test averaged OD value.
Results: Among newly diagnosed HIV-positive persons, 17 patients had
a clinical history suggestive of a recent infection. Their median baseline
CD4 cell count was 620 cells/µL (range 520–1000). The serum samples
collected at the time of diagnosis showed an avidity index consistently
≤0.60 (median 0.40, range 0.2–0.60). Among the 17 patients, 9/17
showed reference OD values increasing from low to high in follow-up
samples, consistent with a recent infection; the remaining 8/17 had a
strongly positive reference EIA but were confirmed as recently infected
by Western blot. All 17 patients had detuned EIA result (STARHS)
consistent with infection acquired within the previous 5–6 months. The
avidity index was monitored in follow-up samples collected at various
time points after HIV diagnosis. Avidity increased over time and was
1.0 by day 30.
Conclusions: A HIV-1 avidity index =0.60 reliably identified HIV-1
infection acquired within the previous 30 days and was more sensitive
in identifying a recent infection than a low reactivity in the screening
EIA test.
11
O43
O45
No recent increase in mortality among HIV-diagnosed
individuals with long exposure to therapy:
UK 1987–2004
Triple class antiretroviral agent resistance in a large
UK cohort – prevalence and risk factors for
acquisition
TR Chadborn, VC Delpech, K Sinka, BG Evans
HIV/STI Department, Health Protection Agency's Centre for Infections,
London, UK
Aim: To determine whether mortality rates have increased in cohorts
of HIV infected individuals with long treatment exposure.
Methods: Analysis of national HIV surveillance data to examine
all-cause mortality rates of HIV-infected cohorts – grouped by year of
diagnosis. Mortality rates were calculated as the percentage of
HIV-diagnosed individuals that died within 0,1,2,etc. years of diagnosis
– approximated to calendar years.
Results: The number of deaths fell from 1,530 in 1995 to 409 in 2001
but is likely to exceed 500 for the first time since 1997 in 2003.
Mortality rates of cohorts diagnosed between 1987 and 1995 fell from
an average of 7.5% per year before 1996 to 2.1% in 1997 and then
continued to decline to 0.9% in 2002. Cohorts diagnosed between
1996 and 2002 experienced an average drop of 82% in mortality rates
from the year of diagnosis to the following year, and then a slow but
continued decline. There was no evidence of an increase in mortality
rates in recent years in any of the ‘year of diagnosis’ cohorts.
Conclusions: HAART dramatically cut mortality rates in 1996 and
continues to postpone death in individuals who were diagnosed with
HIV in the early 1990s and those newly diagnosed since 1996.
R Jones, S Mandalia, M Bower, M Nelson, B Gazzard
Department of HIV and GU Medicine, The Chelsea and Westminster
Introduction: Individuals harbouring triple class resistant virus
constitute one of the major treatment challenges of the HAART era.
This study examines the prevalence of triple class resistance and
factors influencing its acquisition
Methods: Patients with genotypic tests demonstrating resistance to
the three main antiretroviral classes were identified from a large
clinical database. Data were scrutinised to identify risk factors for
acquisition of triple class resistance.
Results: 7715 resistance tests from 3476 patients have been collected.
231(6.7%) individuals had triple class resistance defined as
≥3 mutations, constituting ≥1 mutation from NRTI, NNRTI and PI class
at any time point.170 (73.6%) had exposure to mono or dual agent
antiretroviral therapy in the pre-HAART era.16 patients (6.9%) had
documented
non-adherence.14(5.6%)
experienced
adverse
side-effects.5 patients(2.2%) underwent unstructured treatment
interruption.1(0.4%) had concurrent illness and 1 treatment naïve
individual (0.4%) had acquired a multi-resistant virus at the time of
seroconversion.
Conclusion: The need for salvage therapy is best prevented by limiting
acquisition of triple class resistance.Three class resistance exists at a
low level in our population. 73.6% of individuals received incompletely
suppressive therapy in the pre-HAART era.Non-adherence,
unstructured treatment interruption, side-effects eliciting
non-adherence, concurrent illness and acquisition of resistant virus
were all implicated in the development of multi-drug resistance.
O44
O46
How salvageable are the K65R and L74V mutations?
Virological and clinical outcomes in patients with
multi (three)-class drug resistant (MDR) HIV in the
UK
L Waters, S Mandalia, M Nelson, M Bower, BG Gazzard
Department of HIV Medicine, The Chelsea and Westminster Hospital,
London, UK
Aim: To investigate subsequent virological response to HAART in
patients with a K65R or L74V mutation.
Methods: Data were extracted for all patients entering our cohort
since January 2000. We identified all those with either mutation,
analysed subsequent HAART regimens and calculated % chance of viral
suppression (<50 copies/ml). Results are divided according to whether
subsequent therapy included ddI/ABC or TFV/3TC for individuals with
L74V/K65R respectively and whether or not therapy included a PI.
Results: 52 and 91 patients with K65R/L74V respectively had >6/12
follow-up. The numbers and percentage achieving undetectability with
first subsequent therapy are illustrated below.
NRTIs
PI-regimen
Non-PI
L74V
ABC
13/20 (65%)
11/21 (52.4%)
ddI
8/11 (72.7%)
2/7 (28.6%)
ABC/ddI
1/3 (33.3%)
0/4
No ABC or ddI 14/19 (73.7%)
1/6 (16.7%)
K65R
TFV
7/7 (100%)
1/3 (33.3%)
TFV/3TC
3/4 (75%)
No TFV
25/30 (83.3%)
4/8 (50%)
Conclusion: The K65R mutation appears to be highly salvageable with
a PI-based regimen, whether or not the backbone includes TFV, and less
so with non-PI HAART. There is a trend for less success salvaging the
L74V whether or not this includes a PI.
12
D Grover1, L Allen3, D Pillay1,3,4, H Green2, A Copas3, S Forsyth1,
SG Edwards1 on behalf of the UK Collaborative Group on HIV Drug
Resistance and UK Collaborative HIV Cohort Study (UK CHIC)
1Mortimer Market Centre, 3UCL, 4HPA, 2Medical Research Council
Clinical Trials Unit, London, UK
Aim: To evaluate predictors of survival and virological response in
patients with MDR HIV in the UK HIV Drug Resistance Database.
Methods: Poisson and linear regression were used to determine factors
associated with survival and HIV viral load (VL) response 24-48 weeks
after MDR diagnosis.
Results: 628 patients; 85.3% males; median age 43 years; median CD4
and VL at MDR diagnosis 238 cells/mm3 and 4.15 log10 copies/ml;
median number of any inactive drugs 12; median time on ART 4.5
years. There were 54 deaths after MDR diagnosis (median follow-up
23.9 months). Estimated probability of death was 3%, 8% and 13% by
12, 24 and 36 months respectively. 250 patients changed regimen after
MDR diagnosis. In adjusted analysis, higher VL and lower CD4 at MDR
diagnosis were significantly associated with increased risk of death
(P =0.03, <0.001). Change in regimen and lower number of inactive
drugs were significantly (P <0.01) associated with a decreased risk of
death. In patients changing therapy after MDR, genotypic sensitivity
score of the new regimen was significantly associated with decrease in
VL after 24 weeks, (P =0.02) but not the risk of death (P =0.11).
Conclusion: Active management of patients with MDR HIV-1 is
associated with delayed time to death, and resistance test guided
therapy confers virological benefit.
11th
Oral Abstracts
O47
O48
CD4 counts and the risk of lymphoma in individuals
with HIV in the UK
A prognostic model to predict survival in systemic
aids related non-Hodgkin's lymphoma
I Reeves1, M Fisher, T Hill, C Sabin, on behalf of the UK Collaborative
HIV Cohort (CHIC) Steering Committee
1Brighton and Sussex University Hospitals, Brighton, UK
Aim: To describe the incidence of and risk factors for lymphoma in the
HAART era in the UK CHIC Study.
Method: Poisson regression analyses determined the associations
between lymphoma and the following variables: sex, exposure,
ethnicity, viral load, current and nadir CD4 count, receipt of HAART.
Results: 106/13729 (0.8%) patients had lymphoma (59 NHL, Burketts,
immunoblastic or equivalent, 23 primary cerebral and 24 type
unknown). At lymphoma diagnosis, patients were aged from 25–73
(median 38) years, had a median CD4 count of 169 cells/mm3, and 52
(49.1%) had received HAART. 80 (75%) were homo/bisexual with 76
(72%) white and 13 (12%) black African. Compared to individuals with
a CD4>500 cells/mm3, the rate was highest in those with a current
CD4<50 cells/mm3 (relative rate 9.46, 95% CI: 3.4, 26.1, P =0.0001)
and decreased as the CD4 count increased. The trend with nadir CD4
count was similar. There were no significant relationships with sex,
exposure, ethnicity, age or previous HAART. After adjusting for the
most recent CD4 count, the nadir count was not significantly
associated with the risk of lymphoma.
Conclusion: The risk of lymphoma is increased at low CD4 counts,
although the nadir CD4 does not contribute further to this risk.
AM Young, J Stebbing, T Dhillon, T Newsom-Davis, C Thirlwell,
T Powles, S Mandalia, M Nelson, B Gazzard, M Bower
The Chelsea and Westminster Hospital, London, UK
Background: The established International Prognostic Index (IPI) for
lymphomas has not included patients with systemic AIDS-related non
Hodgkin's lymphoma (ARL). As this remains an important cause of
morbidity and mortality in individuals infected with the human
immunodeficiency virus (HIV), we wished to establish the most
appropriate prognostic index for use in these patients.
Methods: Multivariate analyses of 215 patients with ARL were used to
examine criteria for survival. Cox's proportional hazards regression
analysis determined the prognostic significance of clinico-pathological
variables.
Results: In multivariate analyses of the entire cohort, CD4 count, prior
AIDS diagnosis, Burkitt’s lymphoma and IPI risk group were significant
variables. Regression modelling for patients diagnosed in the era of
HAART reveals 2 independent predictors of mortality: IPI risk group and
CD4 count. These identified four risk strata with one year survivals of
82%, 47%, 20% and 15%.
Conclusions: For patients with ARL in the era of HAART, an accurate
prognostic score can be established by combining the IPI with
CD4 count. As patients presenting with ARL and a low CD4 count have
a poor prognosis, this can be used to guide therapeutic options.
13
P1
■
Improving access and managing patient flow in a
busy inner city, sexual health clinic
■
V Griffiths, I Ahmed-Jushuf
Presenting on behalf of the Six-Sigma Group: S Barton, S Bhaduri,
C Bowman, E Carlin, S Dawson, P Greenhouse, TC Harry, M Kingston,
E Morgan, C O’Mahony, J Ross, M Weir
Background: Patients wishing to access GUM clinics have endured
long waiting times due to excess demand. Follow-up:new case ratio
has dropped from 2.2:1 in 1990 to 1.3:1 in 2003.
Method: 12 Centres formed a project team to challenge current
practice and seek ways of reducing the ratio. Using the six-sigma
management tool, the team identified opportunities for reducing the
ratio. Six-sigma uses a 5-stage process ‘DMAIC‘: Define-MeasureAnalyse-Improve-Control. All follow-up patients attending the
12 centres during 19–23.04.2004 were analysed against a set
proforma.
Results: Group base line ratio was 0.7:1 (p <0.02). 3 main reasons were
identified where further reduction was deemed possible: results policy,
Chlamydia/non-gonococcal urethritis and warts. Aim was to reduce by
80% in each of the three areas; a potential group mean of 0.47 was
identified as a target to work towards. Groups mean ratio was
0.5:1–(31.12.2004)
Conclusion: The follow-up:new ratio can be significantly reduced thus
releasing much needed capacity. The six-sigma management tool
ensures that patient processes, which contribute to the ratio, are
properly evaluated and opportunities for improvement identified. It
also ensures that effective controls are in place to ensure that the
quality of care is not compromised. The completion date for the project
is March 2005. Final data will be available at the conference.
P3
■
Turning the tide – effectively managing increasing
demand for GU services
Experience with the Test not Talk (TNT) clinic for
asymptomatic men
M Ottewill, G Dean, E Collins, D Williams
Department of GU Medicine, Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
Background: Since the late 1990s GUM services have witnessed
unprecedented increases in demand due to rising STI rates, changes in
sexual behaviour and greater public awareness. The situation has been
exacerbated by attempts to meet Sexual Health Strategy targets within
constrained resources. Without compromising quality of clinical care,
we modernised services within existing resources.
Methods: Following multidisciplinary consultation, service provision
changes were implemented: redesign of appointment system, using an
advanced access model, prioritising symptomatic patients; improving
laboratory/clinic IT links to facilitate ‘no-news is good-news’ results
system (including HIV results); introducing telephone follow-up for
NSU/chlamydia;
increased
use
of
text-messaging
for
results/recall/appointment reminders.
Results: There was a reduction in follow-up to new-episode ratio from
2.11 in 2001 to 0.86 in 2004. Between 2001 and 2004 chlamydia
diagnoses increased by 89%, and syphilis by 455%. HIV testing rates
improved: 93% patients offered a test in 2004 with uptake of 65%,
compared to 76% and 48% respectively in 2001.
Conclusion: By reconfiguring services the need for follow-up
appointments declined, whilst maintaining access for symptomatic
patients. Patient and staff satisfaction improved, with reduced waiting
times and predictable workload. These modernisation efforts increased
efficiency without compromising quality of care, although additional
resources are required to address asymptomatic disease.
D Martin, J Barter, R Pittrof
Department of Reproductive and Sexual Health GUM, Town Clinic,
Enfield Primary Care Trust, Enfield, UK
Aim: Evaluation of a screening clinic for asymptomatic men.
Methods: Audit of the first year of TNT services.
Process: The receptionists asked male patients calling for an
appointment: ‘Do you just want a check up or do you have symptoms’.
Check up only patients were offered a TNT appointment. In the clinic
patients received written information, a symptom/risk self-assessment
questionnaire saw a nurse and were offered first void urine
(gonorrhoea-culture, chlamydia-SDA) and blood tests (syphilis-EIA,
HIV-EIA). Symptomatic, high risk patients or patients who want to talk
were referred to the next GUM clinic. Results were communicated by
letter or phone.
Results: 39 clinic sessions were offered and 337 of 468 possible
appointments were made. Of the 303 men who attended (median age
of 23) 264 were new to our service, 161 classified themselves as white
UK and 257 as asymptomatic. Symptoms and risk factors
acknowledged were: genital pain:10, dysuria:10, urethral discharge:0,
skin problems:18, MSM:10, IVDU:2, >1 partner in the last
3 months:118.
248 underwent full STI/HIV screening and 22 new STI diagnoses were
(chlamydia:20, gonorrhoea:1, late latent syphilis:1). All patients with
STIs were effectively treated.
Conclusion: Screening by receptionists identified patients suitable for
a high volume, and low cost screening.
Large Poster
14
■
Releasing capacity through reduction in follow-ups
M Brady1, D Crates1, G Miflin2
1Caldecot Centre, King’s College Hospital, London, 2South East London
Strategic Health Authority, London, UK
Background: Rates of STIs and GUM attendances continue to rise.
Novel ways of improving access and quality are needed. We report the
impact of changes to service delivery on patient flow and transit times.
Methods: Detailed demand and capacity analyses were performed. We
undertook process mapping to better understand our system with a
view to improving patient flow. We designed a ‘Slot System’ to spread
demand throughout the day. The service remains ‘walk-in’ but each day
is divided into hourly slots and a fixed number of patients are seen
each hour. Activity and patient transit times were recorded throughout.
Data was analysed using run (SPC) charts and control (I or xMR) charts.
Results: Patient attendances have remained stable. Mean transit time
decreased from 1hr 38 minutes (upper control limit (UCL) 3hrs
48 minutes) to 1 hr 13 minutes (UCL 2hrs 56). The proportion of
patients waiting more than 4 hours reduced by 90%.
Conclusion: Improvements to service have been measurable. We have
established that better analysis and management techniques can have
as large an impact as simply spending resources on more of the same.
Continued work to reduce waiting and transit times will further
improve service quality with the ultimate aim of reducing local sexual
ill-health.
P2
P2a
■
Standard Poster
●
11th
P4
Poster Abstracts
■
P6
■
Do GUM patients want chaperones?
HIV workload and patient complexity ratings
M Osmond1, C Newey1, D Mercey2, E Jungmann3, S Edwards1
1Mortimer Market Centre, Camden PCT, 2Centre for Sexual Health and
HIV Research UCL, 3Archway Sexual Health Clinic, Camden PCT,
London, UK
Background: The GMC and Royal Colleges recommend that we offer
chaperones to all patients for intimate examinations. Only 10% of
genitourinary medicine (GUM) clinics have a policy regarding
chaperones. The policy in the 2 clinics studied is to offer each patient
a chaperone before their examination. Little data is available from the
patient perspective.
Aim: To identify patients’ wishes concerning offer and provision of
chaperones in a GUM clinic.
Methods: Anonymous questionnaire given to patients after their
examination at two GUM clinics in London.
Results: 600 questionnaires were completed. Results of 336 showed:
mean age 29 (range 16–61), M:F 51%:49%. 158 (47%) were offered a
chaperone at this visit, of whom 20 (12%) said yes, 128 (80%) declined
(8% no response). 167 (50%) weren’t offered a chaperone, of whom
143 (80%) didn't want to be offered one. 12% (40) of respondents said
they would like a chaperone at their next visit. The patients preferred
method of being offered a chaperone was to be asked during the
consultation (48%,55/114). Full results will be presented at the
conference.
Conclusion: This study shows the majority of patients do not want a
chaperone, but if offered one, this should be during the consultation.
HR Gumley, N Rees, CA Sabin, D Ransom, M Youle, MA Johnson
Royal Free Hospital, Royal Free and UCL Medical School, London, UK
Aim: To investigate changes in HIV activity between 2000 and 2003
and introduce a patient complexity model to monitor HIV casemix and
outcomes.
Methods: Identified patients seen at a single centre between 1/1/2000
and 31/12/2003.
Results: The number of patients increased by 35% from 1524 in 2000,
to 2057 in 2003. Total outpatient visits increased by 53% from 13,637
in 2000, to 20,808 in 2003 and the mean number of visits per patient
increased from 8.95 to 10.12. Day case visits decreased by 6% while
inpatient visits increased by 19%. Plotting actual data against
predictions from the 1999 York report indicated that actual patient
population and outpatient activity are much increased on previous
expectations. Non-complex patients increased by 47% from 1146 in
2000, to 1682 in 2003 and patients of varying complexity increased by
15% from 338 in 2000, to 389 in 2003.
Conclusion: Rising patient numbers have led to a huge increase in
workload. Activity/casemix trends among Trusts must be monitored on
a regular and comparable basis so that we can be better prepared for
future growth and diversity as well as the changing commissioning
needs of Trusts for the particular cohort of patients for whom they
provide care.
P5
P7
■
Finding out what primary care wants from GUM and
delivering it
DJ Clutterbuck, M Sutherland, N Harrison, C Thomson, J Donald,
Edinburgh GUM CLIP team, Edinburgh GUM GP Liaison Group
Lothian University Hospitals, Edinburgh, UK
Aim: To support primary care delivery of STI services according to GPs’
requirements.
Methods: Questionnaire survey to prioritise interventions deliverable
with existing resources.
Results: A brief questionnaire was sent to each of 709 GP principals
and practice nurses (PNs) in 127 practices in Lothian in October 2003.
Overall return rate was 58%. At least one questionnaire was returned
from 95 practices (75%). To improve STI care 42% prioritised improving
existing services, 36% developing peripheral services and 18%
improving support for GPs. Changes that GPs and PNs thought would
most help them to manage STIs and refer appropriately were an STI
management protocol, a telephone helpline, and a website. A GP
liaison group was formed and developed and published an STI
management protocol as its first priority, with a navigable web-based
version launched in November 2004. The protocol directed GPs to a
helpline that was incorporated into the existing nurse triage service.
Other findings are guiding the further development of STI services.
■
HIV admissions in a south London teaching hospital
M Aboud, S Hussain, L Collins, N Larbalastier, B Peters, R Kulasegaram
Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
Introduction: The incidence of HIV is rising in the UK with 63,000 cases
reported by the end of 2003. About 14,300 cases are estimated to be
unaware of their diagnosis. Despite improved testing and effective
treatment, new and known HIV patients still present with advanced
disease or AIDS-defining illnesses (ADI’s). We aim to describe the
admission demographics at our inner city unit.
Methods: We conducted a retrospective analysis of 140 admissions at
St Thomas’ Hospital from September 2003 to September 2004. Data on
age, sex, ethnicity, length of stay, new versus old diagnosis, CD4 count,
viral load (VL), ADI's and bacterial infections were collected and
analysed on Microsoft Access.
Results: 70% of all patients were male, 39% white, 39% black (91%
of these African). 30% of all patients were new HIV diagnoses. Of
these, 80% had a CD4 Count <200, 40% a CD4 count <50, 52% a VL
>100000, 64% an ADI. 52% of all cases were already on HAART. Of
these, 52% had a detectable VL, 43% a CD4 <200, and 25% an ADI.
Discussion: Our study showed that a significant proportion of HIV
admissions are late presenters with preventable morbidity. Improved
testing and public awareness remain a priority.
15
P8
●
Are we a happy lot? Evaluation of a walk-in GU
service
J Dhar, J Watt, A Needham
Department of GU Medicine, University Hospitals of Leicester NHS
Trust, Leicester, UK
Background: GU clinics nationally have experienced dramatic
increases in clinic attendances and strategies for managing demand
and access are constantly being explored. Prior to March 2003 the
clinic offered a walk in service in the mornings and appointments only
in the afternoon, but this had to be reviewed in view of perceived
imbalance between a.m./p.m. sessions, high DNA rates in the
afternoon, loss of lunchtime educational and training opportunities by
over-running a.m. sessions. In April 2003 walk in service was extended
to the afternoons with appointments late morning and in the late
afternoon.
Discussion: A pre and post-implementation patient and staff
satisfaction exercise was undertaken in March 2003 and in June 2003,
which indicated that the new system benefited staff and patients.
Satisfaction rates were up by 15–20% for both groups. Details of this
will be presented. However, since 2003 an increase of 5% has been
observed. The impact of this further increase on patient and staff
satisfaction has been evaluated.
Conclusion: Increase in demand with no corresponding growth in
resources has precipitated a considerable decrease in the satisfaction
levels for both staff and patients, and will be discussed. Walk in STI
service, though a viable option, needs adequate long-term resources.
P9
16
●
P9a
●
Recognising the potential of non-registered nurses to
increase capacity – another phase in modernising
GUM Services
V Griffiths, S Butler, I Ahmed-Jushuf
Department of GU Medicine, Nottingham City Hospital, Nottingham,
UK
Aim: To identify a ‘New’ way of screening for asymptomatic men. To
evaluate the feasibility of using non-registered clinicians to deliver a
fast-track ‘mini-screening’ service.
Method: All male ‘walk-in’ patients between August-October 2004
were given a leaflet explaining suitability for ‘mini-screen’, as well as
information regarding tests and procedures. Mini-screen comprised of
a first catch urine for chlamydia (BD-Probetest) and serological tests
for syphilis and HIV. Screening was undertaken by trained
non-registered nurses using a standard proforma. All positive
diagnoses followed-up as per clinic policy.
Results: 58 patients opted for ‘mini-screen’, (49%) had previously
attended. 51 eligible, 7 referred back to clinician. 49/51(96%)
consented for syphilis and HIV serology, all negative. 8 (16%)
chlamydia positive, all successfully recalled, and one contact per index
case treated. All documentation had been completed correctly.
Mini-screen patients spend less time in the clinic as compared to other
walk-ins (38:140min).
Conclusion: Rapid STI screening is feasible within GUM for
asymptomatic patients. This service is comparable to the
chlamydia-screening programme – indeed more value added as
patients get offered tests for syphilis and HIV. Rapid screening services
improve the ‘patients process’, and releases capacity of registered
clinicians to see symptomatic patients.
P10
●
Does a closed appointment system improve access?
I’m OK
S Bhaduri, C Minton, M Mann
Sexual Health Service, South Worcestershire Primary Care Trust, UK
Introduction: Patients attending all GU clinics were recently asked to
complete a HPA survey regarding time taken to obtain an appointment.
In North Worcestershire (where routine appointments can only be
made 48 hours in advance), the result was 43% of patients could
obtain an appointment within 48 hours (West Midlands average was
28%). Is this figure anomalous or does it reflect genuine access?
Methods: Telephone calls were logged over a 3 month period recording
whether a routine appointment was offered or not available.
Results: On average 143 calls regarding appointments were logged per
week (range 113–166). 47% (range 38–57%) of callers/week were able
to make routine appointments, 44% (range 27-59%) were unable to
book and were asked to ring again (20% of these were male). 9% were
offered appointments but declined attendance at time offered.
Conclusion: Call analysis correlated with the HPA survey results
suggesting the closed 48 hour booking system may genuinely improve
access although further research is required in this area.
P Handy, J Richards
Dept of Genito-Urinary Medicine, Newcastle General Hospital,
Newcastle, UK
Objective: To provide earlier access to asymptomatic patients for
sexual health screening
Method: Currently those who are asymptomatic but wish to check
their sexual health may have to wait for up to 3 weeks for an
appointment. An audit of attendees at our clinic found that about 50%
were asymptomatic patients. Whilst a triage system is in place for
those who are symptomatic or have been in contact with an infection,
we recognised that nothing existed for the asymptomatic worried as
well. A weekly ‘I’m OK’ nurse led clinic designed to see only
asymptomatic patients was funded by the PCT allowing 35 walk in
slots. Tests for chlamydia, gonorrhoea, HIV, syphilis were taken, no
microscopy was performed. Signs or symptoms of infection resulted in
the patient being referred to a normal clinic session. Results were
available by phone after 1 week. Those found to have an infection are
asked to return to a normal clinic.
Results: Over initial two-month period overall asymptomatic
chlamydia infection rate of 10%. Other infections found include HIV,
syphilis, gonorrhoea.
Conclusion: Popular with patients. Encourages attendance. Enables
rapid detection of asymptomatic infection.
11th
P11
Poster Abstracts
●
P13
●
Improving access – Blush and create a new website
(www.gumnewcastle.nhs.uk)
Results by text – preferred by patients, transforming
work patterns
RS Pattman and R Hackett
Department of Genitourinary Medicine, Newcastle upon Tyne, UK
Aim: To use non-recurrent Department of Health (DoH) funding to
improve service access.
Methods: Commercial website redesign to provide information on:
infections both by condition and symptoms (novel ‘self-diagnosis’
format) supported by graphic images; 'normal' genital variants;
prevention – top ten tips, condom use, importance of partner
notification; local UK clinics (via a link - www.playingsafely.co.uk). Also
interaction with questions and answer section, guidelines/information
leaflets for general practitioners, a fun section (games and e-cards
linked to the site), staff section, password protected (with image and
PowerPoint libraries). The site had to be: easy to update and monitor;
compliant with NHS guidance and also attractive to the casual
browser; accessible to the disabled.
Results: The site was built using Curo. A cartoon figure, ‘Blush’, and
‘Sex is – …’ rotating banner headlines were produced to promote the
site and our service. Clinic staff produced the information for the site
and ‘Mates’ provided the condom use images. The site was launched in
October by Newcastle Falcons Rugby Football Club and was supported
by representation from the Sexual Health Unit, DoH amid local
publicity. Further detail and information on feedback/usage will be
presented.
J Clarke1, Y Taylor1, PJR Harkin2
1Leeds General Infirmary, 2Leeds University School of Medicine, Leeds,
UK
A city centre GU Medicine clinic changed the methods of sending
results to patients following an initial patient questionnaire indicating
that 85% of attenders had access to a text phone. Patients were
encouraged to book a text message for results. One of two standard
messages were sent: a negative text or a request to call the clinic.
Options for results by letter, in person or by ringing a nurse telephone
clinic were also available. The text service started in August 2004. A
further patient questionnaire was performed to assess the acceptability
of texting and other methods. 278 out of 300 questionnaires (93%
response rate) were completed by new and rebook attenders. 80% of
respondents agreed that results by text were acceptable, and 91%
wanted contact for all results, positive or negative.
Method available
Considered best way of contact
Text patient
44%
Ring into nurse clinic
32%
Letter home
26%
Face to face with staff
25%
A review of the impact at December 2004 revealed over 250 texts sent
per month. A reduction of over 60% in nurse-led telephone clinics
workload freed clinical staff to develop new screening services.
Secretaries saw an 85% reduction in results letter requests. The text
messaging results service was acceptable to patients, released nursing
time into clinic, and has modernised the approach to patient care.
P12
P14
●
Time to use text appointment reminders in
genitourinary medicine (GUM) clinics
CE Cohen, S Mandalia, AM Waters, AK Sullivan
John Hunter Clinic, Chelsea and Westminster Hospital, London, UK
Aim: To determine patient preferences for GUM appointment
reminders.
Methods: 350 questionnaires were distributed to consecutive GUM
attendees.
Results: The response rate was 87%, 156 (52%) were female and the
median age was 27 years (range 14–73). 268 (88%) patients
considered appointment reminders a good idea. Reminders via text
message were the most preferred option [203 (67%)] followed by
phone call [105 (35%)], e-mail [81 (27%)] and letter [72 (24%)]. There
was no association with age or gender. 254 (84%) considered
automated voicemail reminders to mobiles as acceptable. Younger
patients were significantly more accepting of voicemail reminders to
their mobiles compared to either home or work (p =0.026)*. 301 (99%)
preferred reminders 1–7 days in advance, 2–3 days being most popular
[119 (39%)]. 99 (33%) patients preferred morning reminders, 52 (17%)
afternoon, 48 (16%) evening, and 20% did not mind. 208 (68%) were
accepting of reminders at weekends and 178 (59%) on public holidays.
No association with age or gender was found.
Conclusion: Our clinic patients favoured reminder-texts to mobile
phones, 2–3 days before appointments. Pilots in other specialties
reduced DNA rates by 38%. We plan to pilot this service for chronic
problem clinics, to reduce the high non-attendance rate.
*χ2 test
DNA-did not attend
●
Mobile phone text messaging to give results to
patients in a district general hospital genitourinary
medicine clinic
O McQuillan, R Hewart, E Morgan
Bolton Centre for Sexual Health, Bolton, UK
Aim: To assess efficiency of and patient satisfaction with giving results
by text message in the setting of a busy DGH GUM clinic. No formal
assessment of text messaging results service has been carried out
before.
Methods: For one month patients who received results by text message
were asked to give a score out of 5 for level of satisfaction.
Results: 373 results were text messaged to patients who were assessed
as low risk of having an STI who had attended our GUM clinic.
329(88.3%) results were negative which were texted in an average
time of 9.78 days so these patients did not need to phone or attend the
clinic again. 125(37.9%) of these texted back and gave an average
satisfaction score of 4.63/5. 44(11.7%) results were positive (C4a/ B1/
C10a/A4/E1A) and appointments were sent out in an average of 9.75
days, out of which 23(52%) attended the department. 18(78.2%) of
these gave an average satisfaction score as 4.62/5. 1 negative result
went to the wrong phone number due to this being recorded
incorrectly in the notes.
Conclusion: Text messages are a safe way to give results and deliver a
high level of patient and staff satisfaction.
17
P15
●
FEA Keane1, S Gray2, J Tilbury3, N Saulsbury1
1Department of Genito-urinary medicine, Royal Cornwall Hospital,
Truro, 2Lowe Lemon Street Surgery, Truro, 3The Health Centre, Haye
Road, Callington, Cornwall, UK
The National Strategy for Sexual Health describes services for patients
at their General practice (level 1, essential) in enhanced
community-delivered services (level 2) and in specialised services
(level 3). General Practitioners have subsequently disputed that all level
1 services described in the Department of Health Sexual Health
Commissioning Toolkit (CT) document are essential. The New GMS
Contract is inconsistent with the National Strategy, designating Sexual
Health as a National Enhanced Service. To date, the discrepancies
between the National strategy and GMS contract have not been
resolved at national level. This has contributed to delayed strategy
implementation.
In order to overcome this impasse locally, GPs and GU consultants met
to scrutinize each service element described in the CT and agree its
assignment to essential, additional, enhanced or specialised level. This
document, subsequently endorsed by the Local Medical Committee,
will be displayed. It has enabled the local Sexual Health Advisory Board
to place business plans before the Primary Care Trusts’ Professional
Executive Committees towards development of enhanced Sexual
Health Services.
This is the first time, to our knowledge, that such a formal agreement
has been reached, allowing real progress to be made in implementation
of the National Sexual Health Strategy in Cornwall.
●
The need of men’s health clinics
C O'Connor1, M O'Connor2, J Byrne2, H Myles2, S O'Connor2,
S O’Shea2
1GU/STD clinics Regional Hospital, Limerick, Ireland, 2Medical School,
University College, Cork, Ireland
Introduction: Men’s health issues include the commonest cancer
(testicular) (TC) in young men (15–40 years). It has doubled in the last
20 years. Mortality =8%. The project investigates the need for services.
Methods: A cross-sectional self-administered anonymous
questionnaire survey on 400 consecutive men >18 at a Regional
Hospital (OPD) and a university campus (Unit) was done. Consent was
obtained and information and contact details were given.
Results: Response rate 336/400 (84%)
Table: Some findings of study
OPD
Unit
Total
(200)
(200)
(400)
Mean age
48
22
34
Aware age category TC (%)
31%
49%
41%
Examined by Dr for TC (%)
19%
15%
17%
Knew someone with TC
23%
30%
28%
Who would consult with lump: GP (%) 91%
89%
90%
STI clinic (%) 6%
7%
6%
Attended an GU/STD clinic (%)
7%
13%
9%
Treated for STI
8%
3%
5%
Men’s Health Clinic wanted (%)
84%
70%
76%
Conclusion: 76% desired a male specific health clinic. Death rates are
higher here than internationally (8% v 2%). Outside of GP, STI clinics
are the preference site for consultation. In view of HIV being an
increased risk factor for TC it seems appropriate that Sexual Health
Clinics should add Men's Clinics.
18
●
Overcoming the barriers to GP involvement in the
diagnosis and management of HIV infection
The National Sexual Health Strategy and the New
General Practitioners' contract: poles apart or
reconcilable?
P16
P17
A Bailey1, M Fisher1, R Barker2, G Dean1
1Brighton and Sussex University Hospitals Trust, 2Brighton University,
Brighton, UK
Background: As HIV care becomes more complex and encompasses
cardiovascular and metabolic disorders, GPs need to play an increasing
role in co-management. In conjunction with local GPs we established
a primary care focused interactive two day course based upon the STIF
model.
Methods: Attendees completed questionnaires before and after to
assess current involvement in HIV care and confidence in
co-management. Additionally, quantitative assessment of effect using
laboratory data on numbers of HIV tests was performed.
Results: Of 46 participants, 16 were GPs of whom 7 had >20 HIV+
patients. Barriers to HIV testing identified most frequently were lacking
knowledge about HIV and support services. After the course, all
reported increased confidence in managing non-HIV related issues and
HIV testing, with 13/16 more confident in managing HIV-related
problems. Although HIV testing rates were unchanged after the course,
some individuals did increase their testing rates with 3 new positive
diagnoses made post-course.
Conclusions: A primary care focused course can enhance the role of
GPs in co-management and may help reduce levels of undiagnosed
HIV.
P18
●
Issues impacting on HIV service uptake by Africans in
the UK
F Burns1, A M Johnson2, J Nazroo3, KA Fenton1,4
1Centre for Sexually Health and HIV Research, Mortimer Market
Centre, UCL, 2Department of Primary Care and Population Sciences,
Royal Free and University College Medical School, 3Department of
Epidemiology and Public Health, UCL, 4Health Protection Agency,
London, UK
Background: In Britain Africans with HIV access health services late in
the course of their HIV disease compared to non-Africans. The factors
behind late presentation are not yet fully understood. We wanted to
identify the key issues affecting utilisation of HIV services in order to
develop a questionnaire and topic guide for future research on this
topic.
Aim: To identify key issues affecting the utilisation of HIV services by
Africans in Britain.
Methods: Semi-structured interviews were conducted with key
informants with extensive experience working with African
communities, HIV and sexual health.
Results: Eleven interviews were conducted. Respondents felt there was
high HIV awareness within African communities in the UK but this did
not translate into perception of individual risk. Rumour, myth and the
media perpetuate fear and misunderstanding about transmission and
health services. Health is a low priority, and preventive medicine an
alien concept for many Africans. Ignorance around entitlement to care
and unfamiliarity with the NHS hinder access. Health services have not
yet effectively engaged with African men.
Conclusions: HIV remains a much feared and stigmatised disease in
African communities in the UK. More involvement from the African
communities in the planning and implementation of health services is
needed.
11th
P19
Poster Abstracts
●
P21
●
The use of general practitioners amongst HIV-positive
patients
The role of the sexual health advisor (SHA) in a
hospital-based HIV service
D Robertson-Bell, S Madge, CJ Smith, MA Johnson and Nursing and
Medical Staff of the Ian Charleson Day Centre
Royal Free Hospital and Medical School, London, UK
Background: With the introduction of HAART, the care of HIV patients
has moved from acute care to the management of a chronic condition.
The Royal Free operates an emergency clinic which caters for a variety
of conditions, including non-HIV-related.
Method: 149 patients at the emergency clinic and 93 who attended
out-patient’s clinic completed a self-administered questionnaire on GP
use.
Results: 186 (77%) were male, 50 (21%) Black African and 161 (67%)
White. The median age was 38 years. 200/242 (83%) had GPs. Women
were more likely to have a GP (96% of women, 79% men;p=0.0019),
but there were no differences according to ethnicity, age, or routine
appointment. 32/42 (76%) of those who did not have a GP felt the
Royal Free met their health needs, and 20 (48%) felt their GP could not
meet their health needs.
Of those with a GP, 128/200 (64%) have informed their GP of their HIV
status. 137/200 (69%) had seen their GP in the last year. 40/70 (57%)
who have not told their GP they are HIV-positive were worried about
confidentiality in the practice
Conclusions: Although many HIV-positive patients have GPs, a
proportion remains unaware of their patient's HIV status.
P Anderson, M Murcie, A Winter, R Fox
The Infection Tropical Medicine and Counselling Service, The Brownlee
Centre, Gartnavel General Hospital, Glasgow, UK
Problem: No routine sexual health screening done in our HIV clinic;
cohort of 587 HIV positive clients seen regularly between Genitourinary
Medicine (GUM) and Infectious Disease (ID). Rise in local syphilis
numbers. Unknown partner notification outcomes for HIV.
Intervention: SHA employed in January 2003, to assess sexual health
needs of our clients. Aim is to review all patients at least annually by
Sexual Health Advisor (SHA) within their routine outpatient clinic
appointment for HIV, 71% of PN outcomes for April–June 03 were
verifiable. Syphilis testing offered quarterly, data to 31st December
2004
Outcomes
Sexual Health Assessment
483 (82%) of cohort
Referred to GUM for STI screening
223(46% of assessed)
Seen at GUM for STI screening
193 (86% of referred)
STI testing at HIV unit
19 (4%)
STI's diagnosed (n =52)
69 (11% of 483 assessed)
(27% of 193 who tested)
STI Diagnosis: 69 chlamydia 20 (29%), gonorrhoea 10 (15%), HSV 14
(20%), PID 1 (1%), genital warts 24 (35%). Syphilis: 17 (routine
testing).
Conclusion: SHA has increased uptake of STI tests and GUM
attendance, yielding a significant number of diagnosis of STIs on this
positive population. On going Audit to identify reasons for clients not
seeing SHA.
P20
P22
●
A treatment advice clinic (TAC) for patients
attending an HIV outpatient clinic: how does it
operate and what do patients think?
C Griffiths1, K Miles1,2, D Aldam2, D Cornforth2, J Minton3,
S Edwards2, I Williams1,2
1Centre for Sexual Health and HIV Research, UCL, 2Mortimer Market
Centre, Camden PCT, 3University College London Hospitals NHS
Foundation Trust, London, UK
Background: Mortimer Market Centre provides care for over 1300
patients on HAART and approximately 20 patients start therapy each
month. TAC offers appointments to patients advised to start/change
therapy. Anecdotal evidence suggests TAC is beneficial. We evaluated
the practicalities, performance and outcomes of the TAC service to
determine patient benefit.
Methods: Qualitative and quantitative data were collected through 20
consultation observations, 20 patient interviews, database analyses
and 100 retrospective case note reviews.
Results: Patients referred to TAC from their routine doctor will see one
of two research nurses, two consultants or a pharmacist, for a onehour booked session. Care pathway analysis revealed that though
sessions were similar across treatment advisors, follow-up care varied
depending on the approach and capacity of the advisor. It was felt that
follow-up should be standardised and routinely offered to all patients
initiating therapy. Patients outlined many benefits: appointment
length, observing tablets to describe options, tailoring regimen to
lifestyle, and telephone follow-up/support. Patients felt these factors
helped improve adherence. Differences in clinical outcomes between
TAC and non-TAC patients could not be determined.
Conclusions: Although evidence that TAC improves clinical outcomes
is unavailable, there are clear benefits at the individual level suggesting
investment in TAC is worthwhile.
●
BRASH: assessing the first year of a new service
C Ashton, E Stephens, H Mitchell
Mortimer Market Centre, London, UK
Aim: To review the first year of the BRASH (Bloomsbury Reproductive
and Sexual Health) Service for HIV-positive individuals attending a
central London HIV treatment centre
Background: The BRASH service was set up in response to a
demonstrated need for one-stop provision of sexual and reproductive
healthcare for HIV-positive individuals in their treatment centre.
Methods: Retrospective computer and notes review of all BRASH clinic
attendances.
Results: 36 clinics ran in the first year of the service, with a total of
180 appointments available of which 106 were booked. There was a
13% DNA rate, leaving 93 visits. 82 sets of notes were reviewed, 53
were new patients and 29 follow-ups. Equal numbers attended for
advice on contraception (32%) as did for pregnancy planning (30%).
4 patients attended for advice on unplanned pregnancy, 1 opted to
continue and 3 requested referral for termination. 6% attended for
infertility and 4% to discuss sperm washing.
Conclusions: There was a good uptake of a new service specifically
designed to meet the reproductive and sexual health needs of an
HIV-positive individuals attending their treatment centre.
19
P23
■
CD4 cell count and starting ART: trends in six UK
centres 1997-2002
W Stöhr1, D Dunn1, K Porter1, C Sabin2 on behalf of UK CHIC Study
1MRC Clinical Trials Unit, 2Department of Primary Care and Population
Sciences, Royal Free and UC Medical School, London, UK
Aim: BHIVA and other treatment guidelines have become progressively
more conservative in their recommendations on when to initiate
antiretroviral therapy (ART). We examined the extent to which this has
been followed in routine clinical practice in the six centres
participating in the UK Collaborative HIV Cohort (UK CHIC) Study,
which covers around one-third of all patients in the UK.
Methods: Each CD4 measurement between 1997 and 2002 was
classified as resulting or not resulting in ART initiation, defined as
within 3 months of sampling and before the next measurement. The
probability of initiating ART was then estimated for each combination
of individual calendar year and CD4 level (<200, 200–350, 351–500,
>500 cells/mm3).
Results: 6277 patients were included, of whom 3004 (48%) started
ART. Between 1997 and 2002, the probability of starting ART following
a CD4 count between 200–350 cells/mm3 gradually decreased from
34% to 16%, and from 15% to 4% at counts of 351–500 cells/mm3.
Preliminary analyses using longitudinal methods confirmed this trend.
Conclusion: There was a trend of deferring ART, which reflected
changing BHIVA and other treatment guidelines. Further analyses are
planned to examine the role of viral load and selected demographic
factors on the initiation of HAART.
P24
■
What is the clinical significance of sustained
low-level viraemia (SLLV) in patients on HAART?
P Easterbrook1, L Bansi2, CA Sabin2, T Welz on behalf of the UK
Collaborative HIV Cohort (CHIC) Study
1GKT School of Medicine, London, 2Royal Free and University College
Medical School, London, UK
Background: The clinical significance and management implications of
sustained low-level viraemia (SLLV) in patients on HAART remain
poorly defined. We aimed to determine the incidence, virological- and
immunological consequences of SLLV in a large cohort of patients
receiving HAART.
Methods: The UK CHIC is an observational cohort of 16,593
HIV-infected individuals from 6 clinical centres in the UK. SLLV was
defined as a viral load (VL) between 500–10,000 copies/ml for
=6 months in patients who initially attained an undetectable VL (=500
copies/ml) on 2 consecutive occasions following initiation of HAART
(n=6509).
Results: 270/6509 (4%) patients developed SLLV which was sustained
for a median of 10.3 months (IQR=7.5, 15.5). Treatment was changed
in 45% of cases. The median CD4 count at start of SLLV was 355
copies/ml (220, 500) with no significant change during SLLV. In 116
patients (43%) the VL increased to >10, 000; 127 patients (47%)
regained an undetectable VL; and 27 patients (10%) had ongoing SLLV
at the end of follow-up [median duration: 13.0 months (9.6, 18.0)].
3 patients developed an AIDS event
Conclusion: A small proportion of patients on HAART have SLLV with
no adverse immunological or virological consequences. The impact on
the development of drug resistance need to be further evaluated.
20
P25
■
Long and strong: experience of first line therapy with
nevirapine (NVP) in a cohort of antiretroviral (ART)
naive HIV-positive patients
AA Benzie1, NE Mackie1, CA Sabin2, RJ Weston1, J Walsh1
1Jefferiss Wing, St Mary’s Hospital, 2Department of Primary Care and
Population Sciences, Royal Free and University College Medical School,
London, UK
Background: Concerns about potency and hepatotoxicity continue to
influence prescribing of Nevirapine (NVP). We re-analysed and updated
durability and tolerability data from a previous cohort analysis in
HAART-naive patients who commenced a NVP-containing regimen.
Methods: Case note review. Kaplan-Meier methods were used to
assess time to virological failure (viral loads >500 copies/mL on two
consecutive occasions) and time to significant liver abnormality.
Patients who stopped NVP and lost to follow up were considered as
failures, but not those who switched an NRTI backbone for toxicity.
Results: 287 patients were included in the analysis. The median (range)
baseline CD4 count and HIV-1 RNA were 200 (0–821) cells/µL and
54,494 (202–500,000) copies/mL. The median (range) follow up was 39
(1–76) months. 49 patients were lost to follow up. 34/287 (12%)
experienced virological failure, 24/287 (8%) discontinued due to
toxicity, hepatotoxicity occurred in only 4/287 (1.4%). 25/287 (9%) of
patients chose to discontinue therapy.
Conclusion: This is the first cohort study providing long term durability
and tolerability data in ART-naive patients commenced on NVP.
Beyond the first six weeks, there was no significant hepatotoxicity
related to NVP.
P26
■
The impact of fosamprenavir and lopinavir/r drug
levels on virological outcome in patients on these
drugs in combination
C Slater1, S Castelino2, S McCormick2, C Tong3, R Kulasegaram1
1Department of Genitourinary Medicine, 2Department of Pharmacy,
3Department of Virology, St Thomas’ Hospital, London, UK
Background: Fosamprenavir and lopinavir/r interact producing reduced
drug levels compared to single PI therapy. We reviewed our cohort on
this combination to see if their drug level had an impact on virological
outcome.
Method: Case notes were reviewed. Data was collected on sex, age,
ethnicity, CDC stage, antiretroviral history, drug history, CD4, viral load
(VL) and trough concentration (Ctrough) results from therapeutic drug
monitoring (TDM) for patients on fosamprenavir 700mg bd +
lopinavir/r 3bd + ritonavir 100mg bd (T1, N=20) and those on
fosamprenavir 1400mg bd + lopinavir/r 3bd (T2, N=12).
Results: 85% on T1 had TDM, 17.6% had Ctrough< estimated minimum
Ctrough (EMCtrough); 66.6% with Ctrough<EMCtrough responded
virologically vs. 85.7% with Ctrough >EMCtrough. 83.3% on T2 had TDM,
20% with Ctrough<EMCtrough; 50% Ctrough <EMCtrough responded
virologically vs. 62.5% with Ctrough >EMCtrough. All virological failures
in both treatment groups had low lopinavir levels but adequate
fosamprenavir levels. 82.4% on T1 responded virologically vs. 60% on
T2. (p>0.05 for all comparisons.)
Discussion: Greater virological failure is associated with low drug
levels, but this did not reach statistical significance and will be
compounded by adherence. From this small review, we would
recommend T1. Lopinavir levels appear key in determining response.
11th
P27
Poster Abstracts
■
P29
■
Double-boosted protease treatment using atazanavir
and lopinavir/ritonavir
The effect of proton pump inhibitors on protease
inhibitor plasma concentrations in the clinical setting
J Ballinger, L Swaden, S Bhagani, M Tyrer, M Youle, MA Johnson
Royal Free Centre for HIV Medicine, London, UK
Background: Atazanavir (ATV) is a relatively new protease inhibitor (PI)
drug and there is little data on its use combined with other PIs. We
wanted to examine the efficacy of using it in combination with
lopinavir/ritonavir (LOP/r) in treatment-experienced patients.
Methods and Results: From our database we identified 23 patients
who received HAART containing ATV and LOP/r. Most recent viral load
(VL) and CD4 count and those at time of first receiving this
combination were noted. Median CD4 count at start of this
combination was 494. Most recent median CD4 count was 522. 15/23
(65%) patients had a VL <50copies/ml on starting the combination and
22/23 (97%) had a VL <50copies/ml at end of study. The patient group
were generally heavily pre-treated with 16/23 (70%) having received
greater than 4 previous treatment combinations. Therapeutic drug
monitoring was performed on 7 occasions for ATV and 3 occasions for
LOP/r. All TDM results were within the therapeutic range for both
drugs.
Conclusion: Treatment with this double-boosted PI combination is
effective in patients pre-treated with multiple combinations.
SE Gibbons, DJ Back, SH Khoo
Department of Pharmacology and Therapeutics, University of Liverpool,
UK
Background: Recent reports indicate that coadministration of proton
pump inhibitors (PPI) with atazanavir (BMS, Dear Healthcare Provider
Letter, December 2004) or fosamprenavir (Ford SL et al, Antimicrob
Agents Chemother, 2004, 49, 467–469) can decrease protease inhibitor
plasma concentrations. The PPI interaction in the clinical setting was
examined using requests received by the Liverpool TDM Service.
Methods: A retrospective analysis was performed on trough samples
from adults receiving lansoprazole or omeprazole in ritonavir-boosted,
twice-daily amprenavir/fosamprenavir (APV) or once-daily atazanavir
(ATV) containing regimens. Plasma concentrations were compared to
samples obtained during a similar time period from patients reported
as not receiving a PPI.
Results: No difference in median plasma concentrations of either APV
or ATV was noted in patients receiving a PPI. The proportion below
target (APV 400 ng/ml, ATV 100 ng/ml) was not different between the
groups for either drug.
Conclusions: These data highlight the limitations of a pre-selected,
diverse cohort for investigating potential drug interactions. Only
carefully designed pharmacokinetic studies can address these issues.
P28
■
P30
■
Safety and efficacy of atazanavir with low dose
ritonavir in a clinic population
Tipranavir (Tip)/T-20 containing salvage regime in
highly treatment experienced HIV-infected patients
SF Forsyth1, DM Mullan1,2, MA Schuhwerk1, A Copas2, SG Edwards1,
IG Williams1,2
1Mortimer Market Centre, Camden PCT, 2Centre for Sexual Health and
HIV Research, Royal Free and University College London Medical
School, London, UK
Aim: To describe the use and outcome of Atazanavir/ritonavir (ATZ/r)
in a HIV clinic population.
Methods: Retrospective case series of all patients starting ATZ/r
between 26/01/04 and 31/10/04, follow-up to be extended. Data
collected using a standardised proforma.
Results: 102 patients identified, 88 male: median (range) age 42
(20,73) years. Median prior antiretroviral therapy (ART): 6.4 (0–15.3)
years. 6 were ART naive, 23 PI naive, 28 single PI, 51 multiple
PI-experienced. Median follow-up: 135 (0,331) days. 12 (11.8%)
discontinued ATZ/r: 4 jaundice, 5 depressed mood, 4 other. Of those
with a detectable viral load at baseline (N=35), 19 (54%) had VL<50 at
12 weeks, median CD4 count rise 100×106/l (-140,830). Of those
starting ATV/r with VL<50 copies/ml, none experienced viralogical
failure. 14 (19%) had total cholesterol (TC) >6.5 mmol/l at baseline and
5 (8%) at week 12. Mean fall (95%CI) in TC in patients switching
therapy :-0.43(–0.76,–0.09)mmol/l at 3 months, p =0.012. Median
(range) total bilirubin at baseline: 9 (2,71) umol/l, rise by 12 weeks: 15
(–18,98) p <0.001. 61% patients with ART associated diarrhoea at
baseline reported improvement.
Conclusions: ATZ/r was well tolerated in this clinic population and
associated with significant falls in plasma cholesterol, resolution of
diarrhoea in patients switching therapy. Severe mood change was seen
in some patients.
U Kalidindi, M Lechelt, C Skinner, M Murphy, Y Gilleece, G Baily,
C Loveday, C Orkin
Barts and The London NHS Trust, London, UK
Aim: to assess efficacy, safety and tolerability of Tipranavir/T-20
containing regimes in a clinic cohort.
Methods: Review of triple drug class experienced clinic patients who
had failed previous Protease Inhibitor (PI) containing regimes and were
receiving Tipranavir/T-20 with optimised nucleoside analogue (NA)
backbone for a minimum of 3 months.
Results: 10 patients (9 male, 1 female) were identified. Median age 48
(range 35–61). 6 Caucasian and 4 Black African. Median time since
diagnosis was 13 years (range 3–19), nadir CD4 16 (1–146) and the
median number of prior ARV combinations 11 (6-13). 9 patients
showed triple class resistance. Median exposure to Tipranavir/T-20 was
7 months (4–15).
Pre Tip/T-20 3 months
6 months
9 months
(N=9)
CD4 (median)
45
101 (N=9
91 (N=8) 127 (N=3)
VL log (median)
5.05
2.90 (N=8)
2.48 (N=6) 70 (N=1)
1 log ↓
66% (6/9)
83% (5/6)
VL<400
44% (4/9)
83% (5/6) 67% (2/3)
No grade 3/4 toxicities for lipids or LFTs were observed during the study
time. All patients continue on therapy.
Conclusion: Tipranavir/T20 containing regimes with optimised
nucleoside/nucleotide backbone is successful in highly treatment
experienced HIV-infected patients. It is acceptable and well tolerated.
21
P31
■
T20 use in the UK: is it optimal?
N Perry on behalf of the T20 National audit Group
Department of HIV/GUM, Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
Aim: To compare UK prescribing of T20 and response with known
predictive factors for treatment success in the TORO studies.
Method: UK wide audit of patients receiving T20.
Results: 61 patients from 11 centres. Median time on ARVs was
85 months (range 15–152) with 12 (3–29) prior agents. At starting T20
(‘baseline’) median CD4 was 84 (range 4–456) and viral load 4.7log
(0–6log). 24 patients had a baseline CD4 count >100cells; 30 had a
viral load ≤5log, and 20 had ≤10 previous ARVs at baseline. Only
7 patients met all 3 predictive factors for success. Resistance data and
genotypic sensitivity score will be presented. The median CD4 count
rise and viral load drop in the whole group was 40 cells and 1.4 log
respectively. The probability of achieving either a VL<400 copies was
greater in those with all 3 predictive values (86% vs 0%; p=0.0001)
with a trend for <50 copies (14% vs 0%; ns). 10 (16%) patients
discontinued. 46% of patients reported no injection site reactions.
Conclusion: Despite the majority of patients initiating T20 in an
unfavourable setting, reasonable responses were seen and T20 was well
tolerated. T20 may perform better if use is optimised.
P32
■
Natural killer cell function and KIR receptor
expression in HIV long term non-progression
A Holmes1, G O’Connor2, F Mulcahy1, C Gardiner2
1St James Hospital Dublin, Ireland, 2Trinity College Dublin, Dublin,
Ireland
Aim: Investigation of NK cell function and KIR receptor expression in
HIV long-term non-progressors (LTNP).
Method: NK cell cytotoxicity of 8 control, 6 HIV-infected and 10 HIV
LTNP (defined by viral load and CD4+ count) individuals was measured
using a standard 4-hour 51Cr release assay. PBMCs were stained with
anti-CD16, anti-CD56 and anti-CD3 antibodies to identify NK cell
subsets. NK cell receptor expression was examined by flow cytometry.
Results: NK cell cytotoxicity was decreased in all HIV patients relative
to controls [previously reported]. Cytotoxicity was increased in HIV
LTNPs relative to HIV progressors (P=0.01), although it did not reach
control levels. Whilst the percentage of NK cells (CD56+ and/or CD16+
lymphocytes) was similar in all groups, expansion of CD16+CD56-, a
subset that shows poor cytotoxicity, was increased in both HIV groups.
The percentage of NK cells expressing KIR receptors was decreased in
HIV progressors; levels on NK cells of HIV LTNP patients were similar to
control values. KIR expression on T-cells was increased in HIV patients
relative to controls, especially in LTNPs, possibly reflecting chronic
activation of a T-cell subset.
Conclusion: LTNPs maintain NK cytotoxicity relative to HIV regular
progressors, suggesting a role for NK cells in HIV control.
22
P33
■
Efavirenz concentrations resulting from
co-administration of rifampicin with either 600 or
800 mg efavirenz
S Gibbons, L Almond, D Back, S Khoo
University of Liverpool, Liverpool, UK
Aims: Current guidelines recommend increasing the efavirenz dose
from 600 to 800 mg q.d. when co-administering with rifampicin.
However, recent studies suggest that the standard efavirenz dose is
adequate when given with rifampicin (Pedral-Sampio et al., 2004; Patel
et al. 2004). This retrospective survey of the Liverpool TDM dataset
(1999–2004) compared efavirenz plasma concentrations in adult
patients taking rifampicin with either 600 or 800 mg efavirenz.
Methods: Data from samples taken between 8–16 hours post-dose
were analysed. Patients considered to be non-adherent (concentrations
<100ng/ml) were excluded. Data were analysed using Mann
Whitney-U and Fisher’s Exact statistical tests.
Results: There was no difference in efavirenz concentrations between
patients taking 600 (n=20) or 800 mg (n=125) efavirenz (median 2543
vs. 2698 ng/ml; p=0.78). The percentage of patients taking 600 mg
efavirenz with concentrations below the considered minimum effective
concentration (1000 ng/ml) was not different from those taking
800 mg [4.8% vs. 10.0%; OR=0.45 (95%CI 0.07-4.97) p=0.30].
Likewise, there was no difference in the proportion of patients with
high (>4000 ng/ml) efavirenz concentrations [30.4% vs. 40.0%;
OR=0.66 (95% CI 0.23–2.01), p=0.40].
Conclusion: There was marked interpatient variability and the datasets
were unequal. However, efavirenz concentrations were comparable
irrespective of dose given.
P34
■
Clinical experience with atazanavir
P Holmes, M Tung, M Nelson, M Bower, BG Gazzard
Methods: A prospective review describing the results of treatment with
atazanavir (ATZ) at 6 months of therapy
Results: As of 1/6/04, 241 individuals received ATZ, 231 ritonavir
boosted, 10 ATZ alone. 89 protease inhibitor (PI) naive, 47 single PI
experienced and 105 multiple (PI) experienced. Reason for utilization
were virological failure (126) and switch, VL <50 (115). Reasons for
switch, adverse drug reaction (78), adherence (9), end of trial (28). ATZ
was switched for Kaletra (34), saquinavir/ritonavir (22), other PI (14),
NRTIs (3), efavirenz (38), nevirapine (2). In patient switching therapy,
at week 24 89% VL<50, 94%<500 by ITT and 94%<50, 99%<500 by
OT. CD4 increment 98 cells. In virologically failing individuals, mean VL
decrease -1.94 log in PI experienced, -2.12 log in PI naive.
PI Naive
PI Experienced
OTT
ITT
OTT
ITT
<500
92%
76%
93%
79%
<50
84%
69%
72%
64%
CD4↑
+165
–
+124
–
Hypercholesterolaemia rate (>6.5 mmol/L) decreased from 15% to 9%.
Mean bilirubin rise was 24 mmol/L. 4 individuals stopped therapy due
to jaundice. 6 individuals with virological failure in whom pre/post
therapy resistance tests were available, showed no new protease
mutations.
Conclusions: ATZ may be successfully utilized on PI naive and PI
experienced individuals requiring switch of antiviral agents.
11th
P35
Poster Abstracts
●
Single agent switching to tenofovir – a retrospective
analysis
TJ Barber, BC De Souza
Imperial College of Science, Technology and Medicine,
St Mary’s Hospital, London, UK
Aim: To audit single agent switching to Tenofovir in combination
therapy in HIV patients.
Methods: We identified patients prescribed Tenofovir
(1/10/2003–31/03/2004),
through
our
database.
Naive
prescriptions/switching following virological failure were excluded.
Results: Of 27 eligible patients, 1 was excluded due to virological
failure (switched back to Stavudine). 26 patients remained – 20 (77%)
male. Agents switched: Zidovudine (17; 65%), Stavudine (7), Abacavir
(1), Didanosine (1). Reasons for switch: lipodystrophy/fat loss (17), nail
discolouration (1), raised serum lipids (1), lipodystrophy concern (1),
peripheral neuropathy (1), neutropaenia (1). No reason for switch
recorded: 4 patients. Regime simplification was not cited as a reason
for switch in this sample. Mean serum Hb at baseline was 14.01g/dL.
Mean serum haemoglobin and random cholesterol six-month post
switch were not significantly different to baseline (p=0.43 and p=0.36).
Six months after switching, 8/17 lipodystrophy patients showed
subjective improvement (7/8 objective); 9/17 no worsening. The patient
with raised serum lipids improved (t0 T Chol = 11.20mmol/L; t6 T Chol
= 6.23mmol/L). The patient with peripheral neuropathy also improved
subjectively.
Conclusions: Data in our cohort suggests that switching to Tenofovir
is clinically beneficial in the management/stabilisation of patients with
lipodystrophy. Longer follow up would be valuable.
This audit was made possible thanks to an unrestricted educational
grant from Gilead Sciences.
P36
●
Boosted atazanavir use in an intravenous drug user
cohort
S Chew, J Kieran, C Bergin, F Mulcahy
Department of Genitourinary Medicine and Infectious Diseases,
St. James's Hospital, Dublin, Ireland
Introduction: Atazanavir (ATZ) is the first once-daily (OD) protease
inhibitor for the treatment of human immunodeficiency virus type 1
infection and was first prescribed at our service in September 2003,
soon after it received FDA approval. Due to its OD dosing, it is favoured
when choosing an ART regime for an intravenous drug user (IVDU) to
maximize compliance.
Aims: The aim of this audit is to analyse HIV positive IVDU attending
our clinic to determine: The proportion receiving a boosted ATV
containing regimen as their first ART regimen versus salvage regimen;
Compliance at the end of the follow up period; The effect of boosted
ATV containing ART regimen on CD4 and HIV viral load (VL); The
frequency of hyperbilirubinemia due to ATV and its severity.
Method: A retrospective chart analysis of patients attending our HIV
clinic and receiving a boosted ATV containing ART regime from
September 2003 to October 2004. These patients were followed up for
3 months from the date of ATV commencement. Data was also
cross-referenced with pharmacy records.
Results: There were a total of 67 patients who received ATV during the
specified period. Of these, 45/67 (67.1%) were IVDU. 11/45 were on
their first ART regimen, 14/45 had received more than 2 previous ART
regimes. After 3 months, only 33/45 (73.3%) were still compliant with
the boosted ATV containing ART regimen. The rest were either lost to
follow up or still attending the clinic, but non-compliant with
treatment.
P37
●
The use of atazanavir/ritonavir as part of a once daily
antiretroviral therapy regime in intravenous drug
users
N Chew
St James’s Hospital, Dublin, Ireland
Aim: The aim of this study is to evaluate efficacy, adherence,
tolerability and hyperbilirubinemia in an atazanavir (ATV) containing
antiretroviral (ART) regimen.
Methods: All patients who commenced an ATV containing ART regimen
between October 2003 to October 2004 were included in this
prospective study. Adherence was measured by cross-referencing with
pharmacy records. Symptoms of methadone withdrawal were
monitored regularly by the drug treatment centre and at each HIV
clinic visit. Week 12 data is presented.
Results: 45 patients were included in this study. 33/45 (73.3%) were
fully adherent to ART. On the basis of on treatment analysis, the mean
increase in CD4 count was 101.2 cells/mm3 and 19/33 (57.6%) had
VL<50 cpm. Of the remaining 14 patients who still had detectable VL,
13/14 had a 2 to 4 log reduction in VL. On intention to treat analysis,
42.2% of patients had VL<50 cpm. There were no cases of methadone
withdrawal clinically. 10/33 (30.3%) of patients developed
hyperbilirubinemia, none requiring discontinuation of ATV.
Conclusion: Atazanavir is a favourable option in an ART regime for an
IVDU to facilitate once daily directly observed therapy.
P38
●
Clinical experience with atazanavir
M Natha1, M Pakianathan1,2, T Sadiq1, B Marett1
1South West London HIV and GUM Clinical Services Network Heath
Clinic, Mayday University Hospital, 2Courtyard Clinic, St Georges
Purpose of study: Boosted Atazanavir (ATZ/r) has been licensed in
Europe since 2004 for the management of treatment experienced HIV
positive patients. In the 045 study which demonstrated similar efficacy
between ATV/r and boosted lopinavir, the number of patients assigned
to the boosted atazanavir was relatively small (n=120). Additional data
on the outcomes of patients taking boosted atazanavir will aid in
informing future clinical practice.
Methods: Ongoing, prospective, observational study on patients
receiving ATV/RTV 300/100 mg daily as part of combination
antiretroviral therapy (CART). Parameters assessed include HIV RNA,
CD4 cell count, and safety (including lipids).
Results: Available to 48 weeks. Table 1 describes the demographic and
clinical baseline characteristics of patients.
Baseline characteristics
n =40
(at starting or switching to Atazanavir/r)
Median age
38
Ethnicity %
White
30
Black African
65
Other
5
Proportion treatment experienced
40 (100%)
Median CD4 (cells/mm3
229
Baseline viral load <50 copies/ml
17 (43%)
Median bilirubin change µmol/L
+32
Conclusions: ATZ/r was well tolerated and there were no
discontinuations. Expected elevations in serum bilirubin were observed.
Most patients commencing an ATZ/r containing regimen achieved viral
suppression to <400 copies/ml at 48 weeks follow-up.
23
P39
●
Audit of concomitant protease inhibitor and proton
pump inhibitor use
ML Schmid, MC Bailey, MH Snow
Department of Infection and Tropical Medicine, Newcastle General
Hospital, Newcastle, UK
Aim: Following recent interaction warning of atazanavir (ATV) and
omeprazole we audited our cohort to identify if concomitant protease
inhibitor (PI) and proton pump inhibitor (PPI) use had a negative effect
on HIV +ve patients.
Methods: Retrospective case note review and prospective PI
therapeutic drug monitoring (TDM) in a regional North-East HIV
cohort.
Results: 11 episodes of longer-term concurrent PI/PPI treatment in
10/450 HIV+ve were identified: 9 episodes used lansoprazole,
2 omeprazole whilst on various PI regimens. No concurrent ATV or
ATVr/omeprazole prescription was identified. 1 patient had viral load
increase whilst on omeprazole/SQVandRTV which was attributed to
viral resistance development. Rest of patients did not have any
negative change in their viral loads. Patients on current PI/PPI
treatment had TDM requested. Of those 2 patients on ATV or ATVr and
PPI (lansoprazole) had TDM which were within therapeutic levels.
Conclusion: No patient was on potentially dangerous ATV and
omeprazole. However patients on ATV or ATVr/lansoprazole
combination did not have reduced ATV levels. Patients on boosted or
unboosted ATV requiring acid suppression may be safer to use PPIs with
limited interaction like lansoprazole.
P40
●
Atazanavir and acid suppressants – are doctors and
patients aware?
E Davies, K McCormick, C Ruddy, Y Mullens, M Bower, B Gazzard,
M Nelson
Aim: To investigate the incidence of co-administration of atazanavir
and proton pump inhibitors or H2 antagonists in a clinic cohort.
Methods: A prospective survey of patients who consecutively attended
the clinic pharmacy, established on atazanavir. Patients were
questioned as to whether they were currently taking a PPI/H2
antagonist, whether it was prescribed by their doctor, purchased over
the counter (OTC) and if they were aware of the potential problem with
co-administration of these medications and atazanavir.
Results: 68 patients were surveyed. 15 were currently taking PPIs or H2
antagonists. 14 of these (93%) had purchased the drug OTC. Only 53%
of patients stated that they were aware of any guidance on the
co-administration of these agents with atazanavir.
Conclusion: Despite the fact that all patients attending our clinic are
counselled regarding drug interaction issues and issued with written
information when initiating atazanavir, this survey demonstrates that
repeated reinforcement of such information is required at each visit.
Conversely, only 1 patient had received their PPI/H2 antagonist via
prescription which suggests that clinicians/HIV pharmacists seem to be
well informed of the data.
24
P41
●
Effectiveness of tipranavir in a clinic cohort
A Abbara, A Bhuya, L Davies, M Bower, R Popat, M Nelson,
BG Gazzard
Aim: Tipranavir is the first non-peptidic protease inhibitor, and is
active against both wildtype and multiple PI resistant HIV-1. It’s
position in the HIV armamentarium remains unclear, with many
physicians utilizing this drug only in late stage salvage.
Methods: Retrospective note review
Results: Ritonavir boosted tipranavir has been utilized in 10 patients at
our unit. 8 male and 2 female. 8 patients received this drug following
virological failure of protease inhibitor therapy, one for intensification,
one had HIV-2. Patients were extensively pre-treated having received
a mean of 5.4 NRTIs, 1.4 NNRTIs and 2.9 PIs. 4 received T20. In
8 individuals with virological failure, 7 had 5–8 PI mutations, one
greater than 8 PI mutations. Of 8 individuals with a viral load
quantifiable above 500 copies, 2 individuals achieved a viral load fall
greater than 1 log within 6 months of therapy, and one individual a
viral load below 500 copies. In both individuals who achieved a viral
load fall greater than 1 log, the number of active drugs other than
tipranavir in the regimen was 2, compared with no other active drugs
in all 6 individuals who did not achieve this endpoint.
Conclusion: Tipranavir when used as very late therapy with no other
agents is a non-successful therapeutic approach. Individuals with other
active agents available respond.
P41a
●
A sensitive case
B Killingley, MA Johnson
Royal Free Centre for HIV Medicine, London, UK
A 34 year old Afro-Caribbean lady was diagnosed with HIV in June
2004, CD4 = 231 (26%). On 16/07/04, in Zambia, she was commenced
on Trimune bd (Stavudine 30mg, Lamivudine 150mg and Nevirapine
200mg) after a lead in period with nevirapine alone. She presented to
our centre on 18/08/04 with fever, abdominal pain and diarrhoea and
3 days later facial oedema and a maculopapular rash were seen. This
progressed to a bullous and then blistering rash with involvement of
mucous membranes.
A diagnosis of Toxic Epidermal Necrolysis was confirmed on skin biopsy
and in association with an acute hepatitis, a hypersensitivity reaction
to Nevirapine was presumed. Drugs were withdrawn, she received
human immunoglobulin and had a long and complicated recovery.
The pathogenesis of Nevirapine hypersensitivity is probably immune
mediated. There is a spectrum of severity, the incidence of Stevens
Johnson syndrome is 0.3-1%. Risk is multifactorial and has been linked
to female sex, CD4 count >250, Afro-Caribbean race and an HLA
association. Toxicogenomic studies are underway and may identify
other markers.
Specific treatment options are limited, although intravenous
immunoglobulin has been used with some success.
This case highlights the importance of drug toxicity in HIV disease.
11th
P42
Poster Abstracts
■
P44
■
Prevalence of genital infections in a cohort of
HIV-positive pregnant women
Kaletra in pregnancy – experience of a north London
teaching hospital
C Brookings, R Browne, P Ratcliffe, W Khan, DA Hawkins
Aim: To investigate the prevalence of genital infections in a cohort of
HIV positive pregnant women.
Methods: All HIV positive pregnant women are offered a vaginal
examination and screen for infections at 16–18 weeks and at 32
weeks. The screens are predominantly done in the 'Splash' clinic; a
service based in the HIV clinic, run by a specialist GUM nurse.
Retrospective clinical data from this service was analysed.
Results: 42 out of 55 women agreed to screening between May 2003
and December 2004. Median age was 33 (range 19–41) and median
CD4 was 318 (range 86–713). 8 were newly diagnosed with HIV. 19
women had two screens and the rest one. 22 women had infections
detected; candida (8), bacterial vaginosis (7), chlamydia (1),
B-haemolytic streptococcus (1), genital warts (1), bacterial vaginosis
and candida (1), HSV and candida (1), genital warts and HSV (1). One
woman had bacterial vaginosis and candida initially and candida alone
on second screen.
Conclusion: Genital infections in pregnant women are associated with
adverse pregnancy outcomes (miscarriage, preterm delivery and infant
infections). The prevalence of genital infections was 52 per 100
women. We recommend that all HIV positive pregnant women should
be routinely screened.
U Harrisson, S Shah, H Montgomery, S Madge, S Kinloch, M Tyrer,
H Evans, Johnson M
Royal Free Hospital Hampstead NHS Trust, Ian Charleson Day Centre,
London, UK
Introduction: HAART may increase the risk of premature delivery.
Kaletra is often used during pregnancy, yet little is known of its effects
on pregnancy complications.
Methods: We retrospectively investigated pregnancy outcome, HIV
factors and routine blood results of women receiving Kaletra during
pregnancy between 2002–2004.
Results: Of 35 HIV+ve women, 11(31%) used Kaletra during pregnancy,
6 received it prior to conception and 9 were black-African.
Pre-pregnancy median CD4 counts and viral loads in patients
commencing Kaletra during pregnancy and those using Kaletra prior to
pregnancy were 478cells/mm3 and 6050copies/ml, and 499cells/mm3
and <50copies/ml respectively. 9/11 were admitted prior to planned
caesarean section (CS), 4 were in labour, 3 had SROM, 2 suffered
placental abruptions and 1 had HELLP. Additionally, 8 had emergency
CS, 1 had spontaneous vaginal delivery and 2 had elective CS. Median
gestation at delivery was 37+2 (excluding 1 emergency CS at 27wks).
Median ALT was 13IU/l and AST 20IU/l. Viral loads <50copies/ml were
seen in 9 women at delivery. Mean birth weight was 2765.5g
(excluding 1 born at 27wks); 3 were admitted to neonatal ICU. All
babies remain HIV-negative with no abnormalities.
Conclusion: Kaletra is a viable choice for HIV+ve pregnant women but
additional monitoring during the 3rd trimester is recommended.
P43
P45
■
■
Potential clinical importance of altered nelfinavir
pharmacokinetics in pregnancy
Outcomes of planned vaginal delivery of HIV-positive
women managed in a multi-disciplinary setting
C Bell1, C Slater2, A DeRuiter2, H Noble3, G Taylor1
1St Mary’s Hospital, 2Guys and St Thomas’s, 3Newham General
Aim: Nelfinavir is widely prescribed in pregnancy but PK studies have
shown reduced nelfinavir and M8 concentrations in pregnant women.
We sought to determine whether these changes might impact on the
antiviral effect of nelfinavir-containing HAART, using the initial rate of
viral decay in treatment naive patients as a surrogate marker.
Method: Pregnant and non-pregnant women commencing either
nelfinavir or nevirapine, with AZT/3TC were identified retrospectively.
The crude rate of viral decay was determined from pre-treatment and
temporally comparable first on-treatment viral loads and compared for
significance using t-test.
Results: 39 pregnant (nevirapine n=17, nelfinavir n=22) and
27 non-pregnant women (22 and 5) were identified. Viral t1⁄2 in
pregnant women taking nelfinavir was prolonged compared with
non-pregnant women (4.15 v 2.94 days p 0.03). No significant
difference was seen by pregnant state with nevirapine (2.1 v 1.75 days
p 0.18). HIV decay at 2 weeks was significantly prolonged in the
pregnant nelfinavir group compared with nevirapine (3.02 v 1.94 days
p = 0.004).
Conclusion: Although the study's small, retrospective and limited by
relatively late first on-treatment viral load sampling the reduced rate
of viral decay in pregnant women taking a nelfinavir-containing
regimen suggest that the PK data are of clinical importance.
R Browne1, EGH Lyall1,2, Z Penn1, W Khan1, DA Hawkins1
1Chelsea and Westminster Hospital, 2St Mary’s Hospital, London, UK
Aim: To investigate the management and outcomes of HIV positive
women having planned vaginal deliveries.
Methods: Women with or expected to have viral loads of
<50 copies/ml at 36 weeks are offered the option of a vaginal delivery
provided there are no obstetric contraindications. Analysis of case
notes and computerised data on this cohort was performed.
Results: Between January 1999 and December 2004, 24 women (total
141) planned to deliver vaginally had 32 infants; 7 had >1 pregnancy.
The proportion of the total infants born vaginally statistically
significantly increased. With HAART all women achieved viral load
<50 copies/ml =6 weeks prior to labour. Five women had an emergency
caesarean section after the onset of labour due to failure to progress
and one woman had a planned caesarean section after a rebound in
viral load just prior to delivery. The median length of labour in the rest
was 5 hours and 23 minutes. The median infant gestational age and
birth weight was 39 weeks (IQR 37–39), and 2.9kg (IQR 2.6–3.2)
respectively. There has been no HIV transmission to date.
Conclusion: Women with viral loads of <50 copies/ml at 36 weeks
should be offered the option of a planned vaginal delivery with optimal
intra-partum care and senior review in labour.
25
P46
■
HIV infection results in body fat redistribution
M Boothby, G Gilleran, N Crabtree, H Jaleel, M Shahmanesh
University Hospitals Birmingham Foundation Trust, Birmingham, UK
Background: Lipodystrophy is seen in some HIV infected patients
receiving antiretroviral therapy. Peripheral lipoatrophy has been
reported in some HIV treatment naive patients. To our knowledge there
have not been any comparisons with HIV negative controls.
Aims: Cross sectional study to measure body fat distribution by DEXA
scan in HIV infected treatment naive patients and HIV negative
controls
Methods: Whole-body DEXA scans and fasting plasma lipids and
glucose were performed in 25 HIV infected treatment naive patients
(20 male) and 15 control subjects (8 male). Peripheral fat (arms plus
legs), trunk fat and lean mass were expressed as g/height (cm). Ethical
committee approval was obtained. Comparison between groups was by
Chi-Squared test and Man Whitney test.
Results: There were no differences in age, sex and ethnicity, LDL
cholesterol, triglyceride, and glucose between the groups. Serum HDL
cholesterol was significantly lower in the HIV infected persons (table 1)
as was total cholesterol. While BMI and lean mass was similar between
the two groups, HIV infected patients had a greater lean mass/height
and a significantly reduced limb fat/height but not total fat/height or
trunk fat/height (table 1).
Controls
HIV treatment Naive P value
Age
32 (23–40)
34 (29–38)
0.41
Total cholesterol
5.10 (4.20–5.50)
4.30 (3.38–4.78) 0.012
LDL cholesterol
2.41 (2.20–3.48)
2.53 (1.92–2.92) 0.62
HDL cholesterol mmol/l 1.7 (1.5–2.2
1.0 (0.9–1.2)
<0.001
BMI kgm2
24.1 (20–27.2)
23.8 (21.4–25.2) 0.62
Median +/– interquartile range
Conclusion: Compared to control subject, HIV infected patients who
are not on antiretroviral treatment have approximately 2.5 kg (28%)
loss of limb fat compared to HIV negative controls.
P47
■
Decreased incidence of lipoatrophy in a group of
HIV-positive people taking HAART (highly active
antiretroviral therapy) without stavudine assessed by
anthropometry measurements and reported
self–perceptions of body shape changes
C Taylor, V Pribram, C Hodgson, R Goncalves, P Easterbrook
King’s College Hospital, London, UK
Aim: To assess fat redistribution occurrence in the current therapeutic
era.
Method: An observational study comparing morphological changes
before HAART and 12–36 months post HAART using anthropometry
and standardised questionnaire.
Results: This treatment naive group (n=74) enrolled 6/2000-11/2002
consisted of 42% women, 51% black Africans, 19% black Caribbeans,
30% Caucasians, with mean age 37.5 (SD=/–8.3) mean nadir CD4
173.2 (SD+/-139). Ninety-three percent of nucleoside analogues used
were zidovudine, lamivudine, emtricitabine, abacavir; non-nucleosides
used consisted of efavirenz (83%), nevirapine (17%). Four percent of
prescribed drugs were protease inhibitors (PIs). Anthropometry,
consistent with reported patient perceptions, showed statistically
significant increases in weight (p=.000), waist circumference (p=. 018),
suprailiac (p=.047) indicating increased subcutaneous adipose tissue,
mid-upper arm (p=.008), and hip circumference (p=.023). This trend
was strongest among women, black Africans and with CD4 nadir <200.
Improvements were reported for facial wasting from pre-treatment
levels, particularly among over 35s (p=.034). There were no statistically
significant increases in LDL cholesterol, reported thinning of legs,
buttocks, or increased vein prominence.
Conclusion: Unlike stavudine containing HAART regimes, these results
demonstrate an absence of lipoatrophy but high incidence of increased
abdominal girth despite very limited PI use. Increased waist size may
largely be due to substantial weight gain on HAART in this population.
26
P48
■
Experience of the use of statins and fibrates in
patients receiving highly active antiretroviral therapy
(HAART) in the Edinburgh HIV Cohort
WI Beadles, CLS Leen, X Recabarron, R Lessells
Regional Infectious Diseases Unit, Western General Hospital,
Edinburgh, UK
Background: Our objective was to assess the indications for
commencing lipid lowering agents and their efficacy and tolerability.
Methods: Medical notes were reviewed for patients on HAART and a
lipid lowering agents.
Results: There were 330 patients on HAART, of whom 29 were on a
statin, 2 a fibrate and 2 both. 7 patients had diabetes, 7 ischaemic
heart disease, 5 peripheral vascular disease and 2 cerebral vascular
disease. 10 year risk of a major coronary event was calculated for
patients at time of commencing statin/ fibrate: 6= <10%, 8= 10–20%,
8= >20%, 1= >30%, 8= insufficient data. 1 patient had a possible
statin related rash; there were no cases of myositis or hepatotoxicity.
26% of patients had >30% decrease in cholesterol at 6 months. Of
patients <30% change in cholesterol, 43% (10/23) had their statin
increased or a fibrate added and of these 20% (2/10) had >30%
decrease in cholesterol at 6 months.
Conclusions: The threshold for commencing patients in this cohort on
a lipid lowering agent maybe lower than in the general population.
Statins and fibrates were well tolerated. Further guidance is needed to
help in the management of those patients who have poor response to
these agents.
P49
■
Long-term efficacy and safety of injectable poly-Llactic acid for the correction of facial lipoatrophy
SE Barton, GJ Moyle, L Lysakova, S Brown
Department of HIV Medicine, Chelsea and Westminster Hospital,
London, UK
Objective: To evaluate the long-term safety and efficacy of injectable
poly-L-lactic acid (PLLA) for the correction of HIV-associated facial
lipoatrophy (LA).
Methods: This was a randomised, open-label, comparative,
single-centre study of Immediate (Weeks 0, 2 and 4) or Delayed
(Weeks 12, 14 and 16) PLLA treatment, administered as three sessions
of bilateral injections into the deep dermis above the buccal fat pad.
Efficacy was evaluated at the Recall Visit (12–18 months post final
study assessment) using visual analogue scales (VAS) to record patient
satisfaction, and by the Hospital Anxiety and Depression Scale (HADS).
All adverse events (AEs) were recorded.
Results: Twenty-seven of 30 patients returned for the Recall Visit.
Significant improvements over baseline in VAS scores for facial
appearance were sustained to the Recall Visit in both groups (p<0.05
and p<0.001). Improving trends in HADS scores were also noted. One
case of injection-site induration and 9 cases of injection-site nodules
were noted the Recall Visit, none of which were serious or severe.
Conclusions: Physical and psychological benefits of PLLA are sustained
over at least 18 months. Delayed AEs are neither serious nor severe and
include mild nodularity at the treatment site.
11th
P50
Poster Abstracts
■
P52
■
Nucleoside reverse transcriptase inhibitors
(NRTI)-related hepatic fibrosis and decompensated
portal hypertension
The prevalence of canonical resistance mutations in
naive HIV-1 infected patients is low and did not
increase over the time period of 2000 to 2003
JA Garcia-Garcia, S Bhagani1, A Quaglia, M Tyrer, MA Johnson,
G Slapak
Royal Free Hospital, London, UK, 1Hospital Universitario de Valme,
Seville, Spain
Aim: We report three cases of advanced hepatic fibrosis in HIV-positive
patients on highly active antiretroviral therapy without any other
aetiology of liver disease.
Results: Three patients presented to our centre with variceal bleeding.
Prolonged previous therapy with stavudine and didanosine were
involved in all cases (median 5.6 years). Two patients had also taken
hydroxyurea. Mild transaminitis and lipodystrophy was previously
noted in all the patients. Other recognisable aetiologies of liver disease
were not seen on liver biopsies or evident from laboratory tests or past
medical histories. All denied alcohol intake. They had well-controlled
HIV disease (CD4 count higher than 250 cells/mm3 and viral load less
than 1000 copies/mL in all the cases). Variceal bleeding were treated
initially with band-ligation and then prophylactic banding as well as
nonselective betablockade. Antiretrovirals were changed to nucleoside
sparing regimens. Liver transplantation is being considered.
Conclusion: Prolonged NRTI therapy may lead to progressive hepatic
fibrosis, probably as a result of mitochondrial toxicity and
non-alcoholic steatohepatitis. Clinicians should be aware of the risk of
significant liver disease in patients with lipodystrophy, prolonged
current or previous NRTI-use and even a moderate transaminitis. These
patients should be offered early evaluation for fibrosis and portal
hypertension.
H Price, R Jones, S Mandalia, M Bower, M Nelson, B Gazzard
London, UK
Background: Recent studies have suggested that the transmission of
drug resistant virus following primary HIV infection is increasing. This
study examines the prevalence of mutations in an ARV naive
population from 2000–2003 at the Chelsea and Westminster Hospital.
Methods: Since 2000 all patients naive to therapy have had a
resistance test performed on the first stored blood sample available.
Significant mutations were identified using IAS criteria. Individuals
with VL<500 were excluded from the analysis.
Results: The prevalence of mutations in each of the 3 classes of ARVs
has been 10% over each of the last four years. (χ2 for trend analysis
p=0.5.
P51
P53
■
Conclusion: Acquisition of drug resistant HIV-1 has been constant over
the last four years.
■
Thyroid dysfunction amongst HIV-infected patients:
HIV or HAART?
How common is the K65R mutation in clinical
practice?
S. Pren, A Scourfield, J Smythe, M Stefanovic, R Jones, S Mandalia,
AK Sullivan, MR Nelson, BG Gazzard
Aim: To evaluate the prevalence of thyroid disease in our HIV cohort
and to assess the possible role of HAART.
Methods: We reviewed the case notes of all patients prescribed thyroid
medication between April 1995–June 2004. Patients with known
thyroid disease were excluded Routine screening of thyroid function
was subsequently performed from August–November 2004.
Results: Of 35 patients, 3 had thyroid disease pre-HAART. 72% were
male, 84% White Caucasian and mean age was 43.1 years. Median
(IQR) CD4: 228(156-325) incidence/10000 patient years (95%CI).
E Harte, P Tilston, E Wilkins, A Bonington, J Vilar, E Dunbar, S Clarke
North Manchester General Hospital, Manchester, UK
Background: There is little data on the emergence of K65R in routine
clinical settings, where there is widespread prescribing of Tenofovir
(TDF) to both ART naive and experienced patients.
Methods: A retrospective review was carried out on patients who
acquired the K65R mutation over a 6 year period.
Results: Since the availability of TDF, 350 patients have received this
medication, with 27 patients developing the K65R mutation.
Twenty-five patients (93%) were ART experienced with a mean of four
prior combinations, including prior exposure to thymidine analogues
(TA). Two patients were ART naive. At the time of the emergence of
K65R, twenty-five patients were not receiving any TA. Both patients
who were receiving a TA were poorly compliant. In addition to K65R,
other mutations included: 7 × M184V, 11 × Y181C, 11 × K103N,
4 × Y115F, 2 × K219E, 3 × D67N. Twenty-four patients (88%) had no
TAMs, and two patients had a single TAM, one patient with two TAMs.
Conclusion: These data demonstrate that the emergence of the K65R
mutation is not as common as perhaps thought from the clinical trial
setting. The data also provides further evidence of the negative
correlation between K65R and the presence of TAMs.
Conclusion: The results indicate a significant prevalence of thyroid
disease in HIV positive patients on HAART. Thyroid antibody production
in some patients suggests an association with immune restoration
following HAART. Thyroid disease was not linked to any class of ART.
27
P54
■
Which antiretroviral regimens drive the K65R and
L74V mutations?
L Waters, S Mandalia, M Nelson, M Bower, BG Gazzard
Department of HIV Medicine, The Chelsea and Westminster Hospital,
London, UK
Aim: To investigate which antiretrovirals drive the K65R and L74V
mutations.
Methods: Data were extracted for all patients entering our cohort
since January 2000. We identified all those with either mutation,
analysed preceding HAART regimens and calculated risk per 100PY of
exposure to various combinations of TFV, ddI and ABC.
Results: 81 and 129 patients with available drug history developed
K65R/L74V respectively. The numbers of patients (rate per 100PY) are
expressed below.
Conclusion: K65R is driven mainly by TFV/ddI +/-ABC (particularly with
NRTI -only regimens). PIs appear to be protective. L74V is
predominantly driven by ddI/ABC or ddI/TFV; although numbers are
small, PIs don't appear to confer protection.
P55
28
■
P56
■
The presence of a single canonical NNRTI resistance
mutation in naive HIV-1 infected patients reduces
the proportion achieving virological success when
starting NNRTI-based regimens
H Price, R Jones, S Mandalia, M Bower, M Nelson, B Gazzard
London, UK
Aim: There is a 10% prevalence of resistance mutations in plasma
samples from antiretroviral (ARV) naive patients. This study examines
whether this influences the result of treatment.
Methods: Between 2000 and 2003, 808 patients had a resistance test
retrospectively performed on a stored sample taken prior to initiating
therapy with either a PI-based regimen, an NNRTI-based regimen or
nucleoside analogues only. The proportion of patients who were
virologically undetectable within six months was assessed.
Results:
N
Rx PI
Rx NN
Rx NA only
PI mutation
28
5 ex 6
17 ex 19
2 ex 3
NNRTI mutation
49
13 ex 15
19 ex 31
2 ex 3
Multiple mutations
27
4 ex 9
8 ex 14
3 ex 4
No mutations
704
98 ex 155 397 ex 506 29 ex 43
Conclusion: More than half the patients treated with NNRTI regimens
responded despite pre-existing resistance although response to a PI
containing regimen was better.
P57
●
Do the mutations M046I and I047A confer resistance
to Kaletra?
Nevirapine use in pregnant HIV-positive women – is
it the end? (Experience of a provincial centre)
M Stevanovic, H Price, R Jones, S Mandalia, M Bower, M Nelson, B
Gazzard
Department of HIV and GU Medicine, The Chelsea and Westminster
Introduction: In HAART experienced patients, protease inhibitor (PI)
resistance constitutes a major treatment challenge. Kaletra, the
formulation of lopinavir and ritonavir, has significant antiretroviral
potency often maintaining antiviral activity where other PI regimens
have failed. Recent data have suggested that the mutations M046I and
I047A may confer resistance to Kaletra.
Methods: All individuals with genotypic resistance tests demonstrating
M046I and I047A were identified from a large, prospectively collected
clinical database. Data were scrutinised to identify treatment history
and immunological outcomes in each of the individuals.
Results: A total of 7715 resistance tests pertaining to 3476 patients
have been collected at this institution. 104 individuals harboured
M046I, I047A or both. Of these, 7 (6.7%) individuals had previous
exposure to Kaletra as part of their antiretroviral regimen. 52
individuals were exposed to Kaletra following resistance testing. Of
these, 33 (63.5%) maintained an undetectable viral load whilst
prescribed a Kaletra containing HAART regimen.
Conclusion: Prior exposure to Kaletra is not required in the
development of the mutations M046I and I047A. Presence of these
mutations does not adversely affect virological response to Kaletra
therapy as part of an HAART regimen.
C Chapman, J Dhar
Department of GU Medicine, University Hospitals of Leicester NHS
Trust, Leicester, UK
Background: Since 1997 Nevirapine (NVP) has been used as
monotherapy and combination in HAART to prevent mother to child
transmission in HIV disease. Concerns about its use in patients with a
relatively intact CD4 count prompted a ‘Dear Doctors’ letter in February
2004.
Aim: To review the use of NVP in pregnant females, and assess the
incidence of adverse events in our cohort. To explore the impact, if any,
on the prescribing practices post February 2004.
Method: The case notes of all HIV positive pregnant women between
January 2000–December 2004 were reviewed.
Results: During this period the total number of pregnancies
documented were 90, which included 5 miscarriages, 2 terminations
and 1 stillbirth. Of the 82 pregnancies the majority were of Black
African origin. 51 (57%) patients received NVP as combination therapy.
4 (7%) in this group developed side effects requiring hospitalisation,
including a case of toxic epidermal necrolysis. Data will be presented
indicating a shift from the recommended guidelines for the
management of pregnant HIV positive women in our area post February
2004.
11th
P58
Poster Abstracts
●
P60
●
Experience of delivering women with HIV in an inner
city London hospital 1994–2002
Tenofovir-associated renal dysfunction – can we
predict it?
M Parisaei1, J Anderson2, KJ Erskine1
E Devitt, E Wallace, M Bryne, WG Powderly, G Sheehan
Department of Infectious Diseases, Mater Misericordiae Hospital,
Dublin, Ireland
Aim: To review cases of tenofovir (TDF) associated renal dysfunction
within our cohort and to see if there are any predictors of this adverse
outcome.
Methods: A review of all patients attending an urban HIV unit who
have received TDF as part of combination antiretroviral therapy. Cases
that have developed renal dysfunction (creatinine clearance
<50ml/min) were identified and further evaluated.
Results: 101 patients have been prescribed TDF. Three cases of renal
dysfunction were identified. Mean CD4 starting TDF was 171. Elevation
in serum creatinine from baseline occurred in all cases.
Hypophosphataemia occurred in one. The cases had a baseline
creatinine clearance of 120, 71 and 85 ml/min. The latter two had
significant co-morbidities including diabetes mellitus, hypertension
and liver disease. 2/3 cases required hospitalisation and
discontinuation of TDF with return towards baseline of renal
parameters. 2/3 cases died, neither death was felt to be solely due to
renal dysfunction.
Conclusion: The contribution of tenofovir to renal dysfunction is
controversial. Although elevated creatinine was not seen in clinical
trials, TDF has been linked with renal tubular dysfunction in several
case reports. Our cases highlight the possibility of developing renal
dysfunction while on TDF, but also indicate the potential contribution
of other co-morbidities.
1Department of Obstetrics and 2Sexual Health, Homerton University
Hospital NHS Foundation Trust, London, UK
Objective: To compare pregnancy outcomes of women with and
without HIV.
Design: Retrospective review of pregnancy and outcomes 1994-2002.
Setting: Inner City London Hospital, UK (Homerton University Hospital)
Results: A total of 82 deliveries were studied in 88 women with HIV.
Compared to the general antenatal population these women were
more likely to be black African with inadequate housing and only 65%
spoke English as a first language. However there were few intercurrent
medical or antenatal complications except previous history of
depression. 81% were delivered by caesarean section. There was one
vertical transmission in this period. 95 % of the women with HIV had
an uneventful postnatal period.
Conclusion: Based on our observations there is room for optimism
about the obstetric course and outcome of pregnancy in women with
HIV in a multidisciplinary setting.
P59
●
P61
●
HAART to heart. Where do DHIVA diets fit into
BHIVA guidelines?
Toxic levels of efavirenz (EFV) two weeks after
stopping therapy
A Culkin1, C Stradling2, on behalf of DHIVA3
1Northwick Park Hospital, Harrow, 2Birmingham Heartlands Hospital,
3Dietitians in HIV/AIDS Group of the British Dietetic Association, UK
Background: The BHIVA Treatment Guidelines for HIV infected adults
(2003) state that all newly diagnosed patients should have baseline
bloods including a lipid profile and glucose level. The aim was to audit
the guidelines and subsequent action taken on abnormal levels.
Methods: An audit form was devised and the case notes of 70 patients,
diagnosed with HIV since 2003, from 7 centres in England were
reviewed.
Results: Baseline cholesterol, triglyceride and glucose were recorded in
68 (97%), 67(96%) and 61(87%) respectively, of patients studied.
23(34%) cholesterol, 20 (30%) triglyceride and 8 (13%) glucose levels
were raised. Only 9 patients with raised levels were repeated fasting.
18 (25%) patients were referred to the dietician, of whom 6 were given
appropriate lipid advice (Mediterranean diet, omega 3 fats, fruit and
vegetables, increased activity levels), and a further 6 were found to
have normal levels when repeated fasting. 6 patients were
appropriately referred for other reasons including PEG feeding,
nephrotic syndrome and weight reduction. None of the patients were
prescribed lipid lowering medication.
Conclusion: Clinics are measuring baseline bloods to identify patients
who may be at risk of lipodystrophy. In most cases, referrals to
dieticians are made and the assessment of CHD risk factors may
warrant further dietetic input.
G Crowe1, SH Khoo2
1Princess Alexandra Hospital, Harlow, Essex, 2University of Liverpool,
Liverpool, UK
Introduction: We present a 40 year old HIV positive African woman
who developed toxic levels of EFV which persisted for more than 2
weeks after stopping therapy.
Case Report: A 40 year old Zambian woman was diagnosed HIV
positive in June 2004. Baseline viral load (VL) and CD4 were 22,121
copies per ml and 34 × 106 per litre respectively. Antiretroviral therapy
was commenced with Zidovudine, Lamivudine and EFV along with
Septrin for PCP prophylaxis. Two months later she complained of
weakness, nausea, vomiting and shortness of breath, and further
investigations revealed pulmonary tuberculosis. She was commenced
on Rifampicin, Isoniazid, Ethambutol, Pyrazinamide and Pyridoxine,
and her EFV was increased from 600 mgs to 800 mgs daily. Two weeks
later therapeutic drug monitoring (TDM) was carried out which
revealed an EFV trough level of 27,499 ng/ml. There were no
neurological symptoms or signs at this stage. Her EFV was decreased to
600 mgs per day and a further TDM was carried out two weeks later.
This showed a level of 44,463 ng/ml and EFV was stopped. At this stage
she appeared vague, confused, was unsteady on her feet, walked with
a broad based gait and exhibited dysdiadokokinesis. An MRI of brain
was normal. Repeat TDM levels over the following two weeks showed
a slow decrease in levels.
Conclusions: EFV levels rose to toxic concentrations despite
co-administration with Rifampicin which is known to increase EFV
metabolism. Levels fell slowly and were still in the toxic range more
than two weeks after stopping therapy. Neurological toxicity was not
noted until levels above 27,000 ng/ml were reached. TDM was vital to
enable correct management. Further genetic investigations to
sequence the CYP2B6 gene are being undertaken.
29
P62
30
●
P64
●
The snail’s progress: a case report of schistosomiasis
in the era of HAART
Opsoclonus-myoclonus syndrome following the
initiation of HAART
S de Silva1, J Walsh2, M Brown3
1Mortimer Market Centre, Camden Primary Care Trust,
2St Mary’s Hospital, London, 3London School of Hygiene and Tropical
Medicine, London, UK
We describe a 36 year old man from South Africa, diagnosed with HIV
infection in 1990. Following initiation of HAART in November 2002, his
CD4 count increased from 190 × 106/l to 230 × 106/l in 4 weeks. At 6
weeks he presented with vomiting, abdominal pain and diarrhoea.
Attributing these symptoms to his medication, he stopped his HAART,
with prompt symptomatic improvement. The gastrointestinal
symptoms recurred 3 weeks after re-initiation of HAART. During the
following 2 years his symptoms forced him to stop treatment on
5 occasions – each time demonstrating the temporal association
between HAART and these GI symptoms. Following extensive
investigations, colonic histology demonstrated numerous granulomas
containing ova of Schistosoma mansoni. Schistosoma antibody ELISA
was positive at level 4. He was successfully treated with praziquantel.
Schistosomiasis is the second most prevalent tropical disease, with
approximately 120 million people worldwide symptomatic and 600
million at risk. Schistosoma eggs are highly immunogenic. Granuloma
formation leads to fibrosis causing long-term damage. This patient
probably acquired S. mansoni many years previously, but only
experienced symptoms following initiation of HAART. This immune
reconstitution appears to have resulted in an acute inflammatory
response to his chronic infection. This phenomenon is likely to take on
further significance with the increasing availability of antiretroviral
medication in the tropics.
J Hutchinson1,3, AS Pym1, RWH Walker2, PA Brex2, S El Gadi3
1Departments of Infection and Immunity and 2Neurology,
St Bartholomews and the Royal London Hospitals, and 3Departments
of Sexual Health, Homerton University Hospital, London, UK
Opsoclonus-mycoclonus
syndrome
(OMS)
is
a
rare
neuro-ophthalmological disorder usually considered to be either a
paraneoplastic or post-infectious condition. We report a case of OMS
in a 36-year-old HIV positive Caucasian woman. She presented with a
week's history of dizziness progressing to an unsteady gait, shaking and
vomiting. On neurological examination she was found to have
opsoclonus, myoclonus of the arms and neck and truncal ataxia, the 3
hallmarks of OMS. Her CD4 count at presentation was 193 having risen
from a nadir of 1 five months previously when she had reinitiated
HAART after a three-year interruption. During this time she had been
treated for Pneumocystis carinii pneumonia, salmonella septicaemia
and cytomegalovirus infection. Extensive investigation failed to
identify an associated neoplasm or precipitating infection. Her
condition was not initially improved by clonazepam, sodium valproate
or a 5-day course of intravenous immunoglobulin. Nevertheless she
made a gradual and eventually almost full recovery over two months.
OMS is thought to be immune mediated. The appearance of the
condition following a rapid and steep rise in CD4 count suggests OMS
could be a rare manifestation of Immune Reconstitution Inflammatory
Syndrome (IRIS).
P63
P65
●
■
HAART improves outcome from HIV-associated TTP
Plastic specula: can we ease the passage?
S Roedling, RF Miller, M Scully, H Cohen, R Starke, SJ Machin,
SG Edwards
Department of Genitourinary Medicine, Mortimer Market Centre,
Department of Haematology, University College Hospital, Royal Free
and University College Medical School, UCL, London, UK
Introduction: TTP is a rare cause of thrombocytopenia in HIV infection
but incidence is up to 40 times higher than in the general population.
It is due to deficiency of von Willebrand factor –cleaving protease
(vWF-cp) activity. Standard treatment is plasma exchange (PE).
Pre-HAART TTP appeared to be more common in those with advanced
disease and had a poor prognosis.
Aim: Describe clinical presentation, laboratory data, treatment and
outcome in the era of HAART.
Methods: Case note review.
Results: 9 patients identified, 5 not known HIV+. All black African
heterosexuals, 8 female. HAART was started in the first week of (PE)
treatment of TTP and reduced the number of PE needed. 8/9 alive, all
survived acute TTP. Longest survival 51⁄2 years to date. Relapse
occurred in 2/2 patients who stopped HAART compared to 0/7 who
continued. Both recovered following re-initiation of PE and HAART.
vWF-cp levels were low at diagnosis in all patients and, in 4, increased
as CD4 improved and HIV viral load fell.
Conclusions: We highlight the importance of HIV testing all patients
presenting with TTP. Treatment with plasma exchange and HAART is
associated with a high rate of complete remission. Relapse occurs if
HAART is stopped.
L Kozakis, J Vuddamalay, P Munday
Watford General Hospital, Vicarage Road, Watford, UK
Aim: To investigate the effects of lubricating gel on the culture of
Neisseria gonorrhoeae, and on Chlamydia trachomatis Strand
Displacement Assay (SDA).
Introduction: With the increased use of disposable plastic specula, a
common problem is friction on insertion. The perceived wisdom is that
specula should be used without lubrication other than water; however
this does not appear to be robustly evidence based.
Method: We looked at the effect of Aquagel on the culture of
N. gonorrhoeae on 3 standard laboratory media. Varying dilutions of
N. gonorrhoeae were created by taking different numbers of colonies
and emulsifying them in 30 microliters of gel. They were then plated
and incubated in the standard way and read after 48 hours. We also
added 100 microliters of gel to the Chlamydia trachomaits SDA
positive and negative controls, and ran the test as normal.
Results: There was found to be no inhibition of growth of
N. gonorrhoeae by Aquagel at any concentration. The positive and
negative chlamydia controls were also unaffected by the addition of
gel.
Conclusion: We feel that the clinician should now feel more confident
that if a difficult examination requires the use of a lubricant, the test
results will not be compromised.
11th
Poster Abstracts
P66
P68
Withdrawn as requested.
Comparison of the sensitivity and acceptability of
meatal swabs with endourethral swabs for Chlamydia
trachomatis NAAT testing in men
■
B Elawad, KN Sankar and CF Dickson
Department of Genitourinary Medicine, Newcastle upon Tyne, UK
Aim: Accuracy and patient acceptability of meatal swabs compared to
endourethral swabs for detecting Chlamydia trachomatis.
Method: 100 symptomatic men or chlamydia contacts recruited. Using
standard urethral swabs meatal and endourethral swabs were collected
and tested using Roche PCR C. trachomatis assay. Men completed
questionnaire indicating swab causing least discomfort and time last
urinated. C. trachomatis is diagnosed if both or either swabs tested
positive
Results: 36 men had positive meatal and urethral chlamydia swabs and
4 had positive urethral swabs only. Both methods scored 100%
specificity. The sensitivity of meatal swab was 90.0% (95%
CI 80.7%–100%) and urethral swabs 100%. 93% of men considered
meatal sampling caused the least discomfort. No difference between
the sensitivity of meatal swabs in symptomatic and asymptomatic
chlamydia positive men. No relationship between the time of last
urination and meatal swab sensitivity.
Conclusion: Meatal swabs are more acceptable to men than
endourethral swabs. Meatal swabs achieved high sensitivity, but the
low lower 95% C.I. makes it unsatisfactory alternative to endourethral
sampling. Meatal swabs may have place when endourethral swab is not
tolerated and urine specimen unavailable. Design of a specific meatal
swab may improve sensitivity. Additional assessment examining
acceptability of self-collected swabs would be of value.
P67
■
A comparison of self-taken vulvo-vaginal and
cervical samples for the diagnosis of Chlamydia
trachomatis infection by PCR
R Bendall1, FEA Keane2, N Saulsbury2, L Haddon2
1Department of Medical Microbiology, Royal Cornwall Hospital Trust,
Truro, 2Department of Genito-urinary Medicine, RCHT, Truro, UK
Background: The National Chlamydia Screening programme
commenced in Cornwall in April 03 for under 25 year olds in
Genito-urinary Medicine (GUM) and community venues, using Roche
COBAS PCR diagnostics. Initially, urine samples were obtained in
community sites and endocervical samples in GUM clinics. However,
the rate of inhibitory results from female urines was unacceptably high
(8%) and the positivity rate lower than from other anatomical sites. In
January 04 self-taken vulvo-vaginal swabs became the preferred
community collection specimen. We compared self-taken
vulvo-vaginal and cervical samples for the diagnosis of C. trachomatis
in GUM.
Methods: Women under the age of 25 were invited to obtain their own
vulvo-vaginal sample initially, an endocervial sample was obtained
during examination and the results compared.
Results. 333 women participated. The positivity rates for the
2 sampling sites are shown below.
Vulvo/vag positive Vulvo/vag negative
Cervical positive
51
2
53 (91.4%)
Cervical negative
5
275
280
56 (96.6%)
277
15.3% of samples tested were positive at both sites, 15.9% from the
cervical site were positive compared to 16.8% vulvo-vaginal samples.
There is no significant difference between positivity rates in cervical
and vulvo-vaginal samples.
Conclusion: Self-taken vulvo-vaginal samples are an acceptable
alternative to cervical samples for C. trachomatis diagnosis.
P69
■
Why we do not review NGU more than once?
T Theobald1, C O'Connor2, F Berkt3
1Medicine Rostock Medical School, Germany, 2GU/STD clinics Regional
Hospital, Limerick Ireland, 3Frankfurt Medical School, Germany
Background: Increasing workloads in GUM clinics necessitates
re-evaluation of work practices. A recent articlei states that 34% of
clinics in UK do not require male patients with NSU re-attend. A review
of literature showed paucity of evidence for either practice. Traditional
practice was evaluated.
Methods: Retrospective analysis of 1010 patients was done by
reviewing files of men with non-gonococccal urethritis (NGU).
Evaluated were: causative agents (chlamydia, anaerobes), cure rate at
each review, sexual intercourse following treatment. Treatment policy
is per UK guidelines. Retesting was done 3 weeks after therapy2.
Results: 1010/1922 (52.5%) had NGU. Age range was 16.5-63 years.
(mean=27.7). 25% had chlamydia (mean age=26.4) while 27% grew
anaerobes.
Table 1: Reviews
Conclusions: 1. Between 50% and 65% resolved at each review.
2. Chlamydia trachomatis was present in 25% and anaerobes in 27%.
3. Significant differences in cure rate was found between those who
had and had not sexual intercourse following treatment (p<.0005).
31
P70
■
Prevalence of genital infection in women attending
prior to termination of pregnancy (TOP)
32
■
Outbreak of gonorrhoea linked to internet use among
men who have sex with men
G Crowe, F Chhibber, S Amin
Princess Alexandra Hospital NHS Trust, Essex, UK
Background: Pelvic inflammatory disease occurs in up to 10% of
women undergoing TOP and it is recommended that these women are
screened for sexually transmitted infections (STIs) or given prophylactic
antibiotics. In our area all patients are seen within the Department of
Sexual Health (DOSH), offered a full STI screen including HIV, given
prophylactic antibiotics and followed up if positive. We examine the
prevalence of genital infections and HIV in this group.
Methods: The notes of women attending for TOP between 1st January
2004 and 31st December 2004 were analysed.
Results: Of 370 women who attended, 7 deferred their TOP and
therefore 363 were offered screening, of whom 351 (96.7%) accepted.
One hundred and sixty one infections were detected including
28 chlamydia infections, 6 cases of genital warts, and 1 molluscum
contagiosum (MC). Of 355 women who accepted screening for HIV,
1 was positive. STIs were commonest in those aged 16–25 of whom
12% had chlamydia and 2.8% had warts or MC. All 28 patients with
chlamydia were treated and recalled; 21 reattended of whom
1 required retreatment. Nine brought partners of whom 2 were also
positive, and 7 others were known to have been treated elsewhere.
Conclusions: Women seeking TOP will accept screening for STIs and
HIV, and have a high prevalence (9.9%) of these infections. Follow-up
of positive patients is assisted by the screening process being carried
out within DOSH but despite this only 75% of those requiring
follow-up, attended. We intend to pilot a dedicated telephone followup clinic within the TOP service to try and address this need.
P71
P72
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CA Ison1, A Rea2, SA Collins2, IMC Martin1, N Bilek3, BG Spratt3
1Health Protection Agency Centre for Infections, Colindale, London,
2Department of Genitourinary Medicine, Lincoln County Hospital,
3Department of Infectious Disease Epidemiology, Imperial College
London, London, UK
Aim: To investigate an increase in numbers of cases of gonorrhoea
among men who have sex with men (MSM) where sexual contact had
been arranged through internet chat rooms or cruising in a rural part
of England between July and September 2000.
Methods: Case notes for all gonococcal diagnoses were reviewed using
KC60 coding. Standard clinic operating procedures were followed to
guide contact tracing and partner notification activity and contact
network maps were constructed. A molecular method (NG-MAST) was
used to genotype all available gonococcal isolates.
Results: Epidemiological data were available for 41 patients, and
typing results for 38. Seven clusters of linked patients, predominately
among MSMs, were identified. Each cluster included multiple sexual
partners many of whom were unidentified or untraceable. Molecular
typing confirmed all known epidemiological links. There was evidence
of contact through internet chat rooms in two of these clusters, (the
largest cluster of 18) and of cruising in an additional two clusters.
Conclusion: Acquisition of gonorrhoea and onward transmission
within a rural town occurred through contact initiated via the internet
or cruising, which has public health implications since they involve a
high frequency of anonymous sexual contact and mixing of individuals
from a wide geographical area.
P73
■
How molecular tests for gonorrhoea infection fit into
a modernised genitourinary medicine service
Getting it right the first time: an audit of
gonorrhoea management in a high prevalence area
C Ryan, G Kudesia, GR Kinghorn
Sheffield Teaching Hospitals Trust, Sheffield, UK
Background: The BD ProbeTec ET Strand Displacement Assay (SDA) test
for gonorrhoea (and chlamydia) is reliable, acceptable, and increases
laboratory efficiency. However it neither provides immediate results
nor antimicrobial sensitivity data.
Method: To establish a clinical protocol for optimal test use, a
retrospective audit was performed in 1587 consecutive patients
(736 males, 851 females) attending the GUM clinic in Sheffield. The
case records of 54 patients who tested positive for gonorrhoea
(27 males, 27 females) were further reviewed to determine the
presence of risk factors for gonorrhoea.
Results: All 27 positive males and 23 (85%) of 27 positive females had
at least one risk factor for gonorrhoea. The 4 females without risk
factors represented 15% of the gonorrhoea positive group, but only
0.47% of the tested women. Symptoms were the commonest risk
factor and occurred in 93% males and 55% females.
Discussion: Gonorrhoea screening by SDA alone, using the chlamydia
screening sample, is feasible for the majority of asymptomatic GUM
patients. Assessment of specific risk factors in the routine patient
history identifies those in whom additional tests for microscopy and
culture should be taken. Only a few women missed by risk factor
assessment require repeat examination and additional culture tests
prior to treatment.
I Reeves, M Tenant-Flowers
Aim: To audit the management of gonorrhoea in an area of high
prevalence in light of the current revision of guidelines and rising
anti-microbial resistance.
Method: A retrospective audit of all gonorrhoea diagnoses over a
three-month period. Case notes were reviewed and data collected
regarding demographics, site of infection, antibiotic sensitivity,
treatment and outcome.
Results: There were 144 diagnoses: 93 men and 51 women. Black
patients accounted for 69% of infections. All women and 92% men
were heterosexual. Thirteen infections were resistant to initial
antibiotic treatment. In three of these cases, patients (all male) did not
re-attend despite being recalled, effectively receiving azithromycin
only. Two men receiving azithromycin for NSU did not re-attend for
gonorrhoea treatment. Test of cure (TOC) was done in 67% cases. DNA
rates for TOC were 35% men and 19% women. There were 6 positive
TOC’s: 5 had evidence/high clinical suspicion of re-infection. Treatment
of contacts was 0.24 per male patient and 0.52 per female.
Conclusions: This audit supports doubt over the utility of TOC and
highlights the importance of appropriate initial therapy and sensitivity
testing. Attempts to address the issues raised in this audit include:
targeted patient information, maintaining open-access clinics and
educating local GPs.
11th
P74
Poster Abstracts
■
■
The syphilis outbreak in Northern Ireland
Change from microscopy and culture to gonorrhoea
strand displacement assay – is there an impact on
clinical care?
C Slater3, M Hawkins3, D Lewis3, E Fox1, J Klein2
1Department of GUM, 2Department of Microbiology,
3St Thomas’ Hospital, London, UK, St Thomas’ Hospital, London, UK
Aim: Strand displacement assay (SDA) is now our screening test for
gonorrhoea, with microscopy reserved for cases of high gonorrhoea
probability and culture as confirmation. We assessed the impact of this
change on clinical care.
Methods: Case note review of 249 patients with gonorrhoea pre (OP,
n=141) and post protocol change (NP, n=108). Data collected: sex, age,
ethnicity, sexuality, symptoms, gonorrhoea SDA, microscopy and
culture results, time to treatment and complications. Gold standard
= positive gonorrhoea culture (gonorrhoea contacts presumed true
positive SDA).
Results: Men – SDA sensitivity 98%, positive predictive value (PPV)
100%. Percentage treated on day 1 was no different (75.5% NP vs OP
76%).
Women – SDA sensitivity 100%, PPV 91.5%, false positive SDA 9.3%.
SDA 100% PPV in higher risk women (SDA, microscopy and culture at
presentation). Women treated day 1: NP vs OP – 41.8% vs 45.4%
overall, 59% vs 60.9% asymptomatic; median time to treatment 25 vs
20 days; delayed treatment and subsequent PID 0% vs 5.6%. p>0.05
for all comparisons.
Discussion: Use of SDA with selective microscopy and culture has not
compromised patient care. The impact of false positive tests is difficult
to quantify and positive gonorrhoea SDA results should always be
confirmed by culture.
P75
P76
■
C Emerson, A Lynch, S Gray, C Cunningham, RD Maw
Royal Victoria Hospital, Belfast, Ireland
Background: The resurgence of syphilis has been well reported, with
notable outbreaks in Brighton, Manchester, London and Dublin,
predominately among men who have sex with men (MSM). We report
here a similar outbreak in Northern Ireland.
Methods: Case notes were reviewed from 1st July 2000 to 31 March
2004 of all GUM clinic attendees to identify those who met the agreed
criteria for primary, secondary or early latent syphilis. An outbreak
control team was established to improve surveillance and partner
notification.
Results: 96 individuals were diagnosed with syphilis, 83 were MSM. 16
indicated a contact in Dublin as likely source. 20 were identified
through contact tracing. 4 had more than 1 episode of infection. Most
(64) had 1 or 2 partners in the previous 3 months. 10 cases were HIV
positive (8 aware of status).
Conclusion: Initially the contacts were mostly from Dublin, as the
outbreak gained momentum syphilis was contracted within Northern
Ireland. The cohort was not generally associated with high number of
sexual contacts, multiple anonymous partners or specific locations. The
challenge is to educate both patients and health care professionals as
to sexual health issues, specifically the risk associated with casual oral
sex by MSM.
P77
■
Syphilis outbreak in Walsall: epidemiology and
lessons for control and prevention
Syphilis in Nottingham - predominantly a
heterosexual disease
A Joseph1, M Pallan2, S Chandramani1, I Morrall1
1Department of Genitourinary Medicine, Manor Hospital, Walsall,
2Directorate of Public Health, Primary Care Trust, Walsall, UK
Aim: Review the epidemiology of the recent outbreak of syphilis and
assess the risk taking behaviour among men who have sex with men
(MSM).
Methods: Syphilis cases diagnosed at the department of genitourinary
medicine (GUM) and at outreach screening at a sauna and a public
house during a 12 month period beginning September 2003 were
reviewed. Risk taking behaviour was assessed using a standardised
questionnaire among men attending the sauna.
Results: Fifty IgM positive cases were diagnosed. Of the 39 males,
27 had acquired syphilis through heterosexual contact. Four cases were
referred through outreach screening. Twenty-nine men and 4 women
had primary syphilis while 11 patients were asymptomatic. Four
heterosexual men reported commercial sex workers (CSW) as contacts.
Six patients were HIV antibody positive of whom 2 seroconverted
subsequently. Questionnaires were completed by 163 men, of whom
76% described themselves as MSM. Half the men reported having
2–5 sexual partners in the past month and 12% over 10 partners.
Unprotected anal sex and oral sex was reported by 64% and 98%
respectively in the past month. GUM services have never been used by
35% but 73% said they would use a service in the community such as
the sauna. While 37% assumed that they were HIV negative, 53%
assumed that their last sexual partner was HIV negative.
Conclusion: Syphilis outbreak was occurring in two separate settings.
Targeted multifaceted outreach programmes to include community
venues and CSW's are necessary to combat further spread.
K Ponnusamy, P Goold, C J Bignell, C A Bowman
Department of Genitourinary medicine, Nottingham City Hospital,
Nottingham, UK
Aim: To describe the epidemiology and clinical features of the ongoing
outbreak of infectious syphilis.
Method: Case-note review of all patients diagnosed with infectious
syphilis between December 2002 and December 2004. Enhanced
partner notification was implemented to identify network connections.
Results: Ninety-seven cases of infectious syphilis were diagnosed.
Sixty-two cases were in men, of whom 46 (74.2%) were heterosexual.
3 gay men were HIV positive. Twelve men reported paying for sex. 9 of
the 35 (25.7%) women were commercial sex workers (CSW). Six
women were pregnant. A genital lesion was present in 70 cases (72.%)
at presentation. Skin signs were present in eighty-four (86.5 %). 21 of
68 (30.8 %) genital ulcers were painful or tender. Inguinal
lymphadenopathy was prominent in 38 male cases. 24 of the 38
dark-ground (DG) examinations performed were positive. 5 men were
DG positive VDRL negative at presentation. In 67 cases (69 %) the
diagnosis of syphilis was only established on receipt of serology results.
Conclusions: Heterosexual transmission accounted for 83.5% of the
cases in this local outbreak. Diagnosis relied heavily on serology despite
the high prevalence of clinical signs. Close collaboration with local
prostitute outreach project (POW) resulted in enhanced screening of
CSWs.
33
P78
■
UK national audit of early syphilis management
H McClean, D Daniels, C Carne, P Bunting, R Miller on behalf of the
National Audit Group of British Association for Sexual Health And
HIV, Royal Society of Medicine, London, UK
A national audit of 781 early syphilis cases presenting during 2002–03
in UK genitourinary medicine clinics was conducted in late 2004,
organised through the Regional Audit Groups. Data were aggregated by
Region, allowing practice in Regions to be compared to the UK national
guidelines and national averages.
An EIA test was used to diagnose 89% of cases (regional range
18–100%) with highly variable use of other tests. A pre-treatment
non-treponemal test (NTT) was obtained for 94% (50–100%). Uptake
of HIV testing was 77% (69-94%). Overall, 67% of treatments were
injected, with equal use of benzathine (50%, 0-97%) and procaine
penicillin G (50%, 3–100%). Doxycycline comprised 85% (0–100%) of
oral treatments. About 4% were not, or not known to be, treated.
Treatment completion was recorded for 88% (71–100), resolution of
lesions for 74% (40-96%), and a fourfold decline in NTT for 54%
(37–70%). Only 35% (12–56%) had a negative NTT recorded at one
year, mainly explained by non-attendance and other reasons. Contact
tracing was provided for 87% (57–97%), and identified 997 traceable
contacts of whom 511 (ratio 0.51, 0.26–0.70) were seen, and 215 (42%
3–73%) had syphilis.
Individual NHS Trust data aggregated by Regions were provided to
Chairs of Regional Audit Groups.
P79
■
■
Topical 5% imiquimod cream in the management of
anogenital warts unresponsive to four weeks of
standard treatment
K Aderogba, I Fernie, I Samuel
Caldecot Centre, Kings College Hospital, London, UK
Aim: To investigate the efficacy of topical 5% imiquimod cream in
treating anogenital warts in cases non-responsive to 4 weeks of
cryotherapy and /or topical podophyllotoxin solution.
Method: A prospective study using self applied topical 5% imiquimod
cream 3 times weekly for 16 weeks, or resolution, whichever was
sooner. Partial response assessed as equal or >50% reduction in wart
area, poor response <50%.
Results: 61 patients recruited, 42 males and 19 females of which 16/42
and 11/19 were Afro-Caribbean respectively. Mean age 33. 8/42 males
and 4/19 females were HIV positive. Amongst the males 18/42 (43%)
had perianal warts alone. In the women 10/19 (52%) had vulval warts
alone. Complete clearance rates were 34/61 (56%) of which 20/42
(48%) was male and 14/19 (74%) female. Median time to complete
response was 4 weeks (range 1–18). 11/61 (18%) showed partial
clearance with a median of 16 weeks use (range 8-26). 16/61 (26%) a
poor response with a median 16 weeks use (range 4–22). Adverse
events were observed in 11/61 (18%) and most commonly mild. One
male experienced a severe reaction.
Conclusion: 5% imiquimod cream demonstrated good efficacy and
was well tolerated. Complete responses were better in females with no
ethnic differences observed.
P81
●
Women and men with herpes simplex (HSV) – telling
a new partner and the impact on sexual relationships
Should all confirmed cases of Chlamydia trachomatis
be referred to a genitourinary medicine (GUM) clinic?
M Nicholson1, L Waters2, S Barton2
A Davies, A Chiganze, H Birley
Department of Genitourinary Medicine, Cardiff Royal Infirmary,
Cardiff, UK
Aim: To assess the initial management of patients with confirmed
chlamydia infection subsequently referred to GUM and to identify any
benefits of referral.
Methods: Notes of 100 consecutive cases of Chlamydia trachomatis
referred in from elsewhere (mainly general practice) in 2003 were hand
searched. Treatment and contact tracing prior to referral, additional
diagnoses made in GUM and number of further contacts identified,
notified and treated as a result of referral were noted.
Results: Prior to referral 67% received appropriate treatment, 4%
received inappropriate treatment and 24% received no treatment. 57%
had at least one contact notified and 32% had at least one contact
treated. In GUM clinic 53 additional contacts were identified. 34% of
the clients referred had further contacts notified and 16% had further
contacts treated. On referral 68% were already chlamydia –ve. 7% had
an additional STI and 36% an additional non-STI diagnosis made.
Conclusions: The majority of cases of chlamydia infection can be
adequately managed in primary care and routine referral to GUM may
therefore not be justified.
1Herpes Viruses Association, London, 2Department of GU Medicine,
Aim: To assess the experiences of females and males with genital HSV
when telling new partners and the outcomes of divulging this
information.
Method: The Herpes Viruses Association (HVA) sent a postal
questionnaire to all their members, including questions on their
experience of the impact of HSV on their relationships and their
partners' attitude.
Results: 200 individuals, 148 women, 52 men, responded. 39 females
reported 39 rejections in 116 experiences when divulging their HSV
status, 1/2.9 episodes. 12 men experienced rejection (19 times in 61),
1/3.2 divulgences. 107 people had never been rejected when telling
169 partners (52% and 55% of women and men respectively).
Non-disclosure was reported by 14 women and 8 men, a
non-significant difference. Non-disclosing men tend to be more
recently infected. Most individuals reported having sex since their
diagnosis and positive attitudes from their partners with a small
proportion experiencing denial, judgemental or punitive attitudes.
When asked if herpes simplex is more of a physical or emotional
problem, both sexes find it more of an emotional problem.
Conclusion: Most individuals with genital HSV infection divulge this
information to new partners and the majority experienced positive
responses. There is a trend for non-disclosure amongst the recently
diagnosed.
34
P80
11th
P81a
Poster Abstracts
●
Test > Text > Treatment: text messaging service
(TMS) improves the time to treatment of Chlamydia
trachomatis infection and reduces the cost of result
provision
P83
●
Chlamydial conjunctivitis resulting from direct
ejaculation into the eye
AS Menon-Johansson, F McNaught, S Mandalia, AK Sullivan
John Hunter Clinic, Chelsea and Westminster Hospital, London, UK
Aim: To assess the impact of TMS on time to treatment for genital
Chlamydia trachomatis (CT) infection and result provision.
Methods: Time from testing to diagnosis and treatment for patients
with CT infection receiving results via text message (TG) was compared
to a sex and age matched standard recall group (SG, n=21) over a six
month period. Providing results in person, by phone and by text
message were calculated to take 12, 4 and 1.5 minutes respectively.
Economic calculations were based on a staff rate of £13/hr.
Results: Of 952 text messages sent, 28 were for untreated CT. The
mean number of days (standard deviation) to diagnosis was
significantly shorter in TG vs SG; 7.9 (3.6) vs 11.2 (4.7), p < 0.001. The
median time to treatment was 8.5 days (range 4–27 days) for TG vs
15.0 (range 7–35) for SG, p = 0.005. By month 6, 46.9 less hours were
required to provide equivalent result numbers (69.0hrs vs 115.9hrs for
month 1) with a saving of £609/month.
Conclusions: Patients with genital CT infection are diagnosed and
receive treatment sooner since the introduction of TMS. Significant
savings in costs and staff time were seen following the introduction of
this service.
S Rackstraw, ND Viswalingam, BT Goh
Diagnostic Clinic, Moorfields Eye Hospital, London, UK
Background: The majority of cases of chlamydial conjunctivitis are
thought to result from autoinoculation by the patient of infected
genital secretions from themselves or their sexual partners. We noted
that some patients had developed symptoms following direct
ejaculation into the affected eye.
Methods: Retrospective casenote review of chlamydial conjunctivitis
seen at the Diagnostic Clinic from 1995–2004, looking for a history of
direct ejaculation into the eye.
Results: 4 cases of chlamydial conjunctivitis following ejaculation of
semen directly into the eye were identified. The duration of onset of
the eye symptoms was from 1 to 4 weeks, compared to experimental
models where symptoms developed 2–19 days following inoculation of
the organism. In only one case was chlamydia detected in the genital
tract. In 3 cases, there was no evidence of genital chlamydial infection;
the sources of the eye infection being either from infected genital
material of their sexual partners transferred by hands to the eyes, or
more likely from direct ejaculate inoculation.
Conclusion: Chlamydial conjunctivitis can result from direct
ejaculation into the eyes. This mode of transmission may
underestimated as a history of ejaculation into the conjunctiva is not
normally asked for.
P82
P84
●
Prevalence of chlamydia in patients attending for
termination of pregnancy
S Bhaduri, C Minton, M Mann
Sexual Health Service, South Worcestershire Primary Care Trust, UK
Introduction: Patients undergoing a Termination of Pregnancy (TOP)
are routinely screened and prophylactically treated for chlamydia
pre-operatively to prevent post operative salpingitis.
Is the prevalence of chlamydia in this population higher than those
attending GU clinics?
Methods: GU and TOP case notes were analysed retrospectively over 1
year for diagnoses of chlamydia (via PCR) with respect to age of
attendees.
Results: 2540 tests were done in GUM, 14.3% were positive. 369 tests
were done pre TOP, 8.13% were positive. Age specific incidences were
similar apart from 2 groups– a) patients less than age16 (GUM 9/55
were positive for chlamydia compared to TOP where 3/113 were
positive, p<0.01) and b) those aged 30 and over (GUM 50/746 were
positive compared to TOP 0/103, p<0.01), where a higher incidence was
seen in GUM patients in both age groups.
Conclusion: In view of the lower incidence of chlamydia in TOP
attendees, particularly in attendees over 30 years of age, further work
is required to look at the cost effectiveness of chlamydia screening in
TOP in this older age group.
●
Microscopic cervicitis, will you treat?
R Moussa
Ipswich Hospital, Ipswich, Suffolk, UK
Background: Microscopic cervicitis is a controversial topic in GUM
diagnosis and management.
Objective: To evaluate the clinical significance of microscopic cervicitis
in the diagnosis of STIs.
Methods: 437 female patients attended the GUM clinic 1/5/04-30/6/04
and were examined. Of these, 105 were diagnosed as cervicitis as they
had 10+ pus cells/HPF on cervical microscopy.
Results: Of these 105 patients, 88 were coded as C4H and 17 as C4A
when laboratory results available. [5 of those coded ac C4A were
contacts of chlamydia (2), Gonorrhoea (1) and NSU (2)]. Another 6 were
chlamydia positive with no cervicitis. Results of contacts of all female
C4H patients will be shown. Also, details of co-existing infections.
Conclusion: 105 female patients were treated for microscopic
cervicitis from a total of 437 patients examined, i.e. 24% of female
clinic attenders. In this study, chlamydia was diagnosed nearly 3 time
as often in patients with cervicitis (17), as those without (6). With the
increase in GUM attenders and the increased number of STIs
diagnosed, how should we manage cervicitis? Is treating and contact
tracing a waste of resources, or is it an opportunity for preventing PID
and tubal infertility?
35
P85
●
Lymphogranuloma venerum in HIV-positive
homosexual men: is an outbreak emerging in
London?
●
MK Malu, KW Radcliffe
Whittall Street Clinic, Birmingham, UK
Aim: To compare the outcome of management of gonorrhoea by test
of cure with telephonic follow-up.
Methods: Data was collected from the case notes of patients with
gonorrhoea managed between April and September 2003 using test of
cure, and cases managed between April and September 2004 by
telephonic follow-up.
Results: Patients was similar in terms of age, sex, sexual orientation in
both the groups, but ethnic mix was different. There were more whites
(30.3% vs 19.8%, p=0.004), less blacks (43.9% vs 56.5%, p= 0.003) and
less other ethnic groups (12.9% vs 21.6%, p=0.007) in the telephonic
follow-up phase than the test of cure phase.
Conclusion: Outcome of management of cases of gonorrhoea with
telephonic follow-up is satisfactory and a step in right direction
towards the modernization of GUM services.
P88
●
The demography of gonorrhoea in Wales – an
analysis from the GRASP study
Gonorrhoea treatment response after change to
treatment guidelines
CM Davies1, D Thomas2, M Lyons2, H Birley3, R Das4, E Rudd5, C Ison6
M Tung1, A Kingston1, L Low1, T Annan1, B Azadian2, AK Sullivan1
1Department of Genitourinary Medicine, 2Department of Microbiology,
Aim: To assess the clinical and microbiological response to treatment
of gonorrhoea following the change in national treatment guidelines
for first line antibiotic therapy to cefixime or ceftriaxone, and to
identify any cases of cephalosporin resistance.
Methods: Antibiotic sensitivities and clinical data were collected for all
culture positive gonorrhoea infections identified over a four month
period in three genitourinary medicine clinics.
Results: 198 cases were identified. Patients’ mean age was 31.2 years,
174 (88%) were men, 112 (64%) were MSM. 83 cases (42%) were
treated with cefixime, 78 (39%) with ceftriaxone, and 28 (14%) with
ciprofloxacin. The incidence of chlamydia co-infection was 12%; 18
(75%) cases in men, 10 (56%) heterosexual. No isolates demonstrated
resistance to cephalosporins, 11% were ciprofloxacin resistant, 6%
penicillin resistant and 4% resistant to both penicillin and quinolones.
140 patients (70%) returned for follow-up, 134 (96%) were
successfully treated becoming asymptomatic with a negative test of
cure. 3 cases (2%) had positive gonococcal cultures following
treatment, with no evidence of antibiotic resistance. Cause for
treatment failure was unprotected intercourse with an untreated
partner.
Conclusion: The use of cefixime or ceftriaxone for uncomplicated
gonorrhoea infection is effective clinically and microbiologically with
no cases of treatment failure.
1Cardiff Royal Infirmary, Wales, 2NPHS CDSC Wales, 3Cardiff Royal
Infirmary, Wales, 4Royal Gwent Hospital, Wales, 5Communicable
Disease Surveillance Centre, 6Centre for Infections, Health Protection
Agency, London, UK
Introduction: New cases of uncomplicated gonorrhoea seen at GUM
clinics in England (reported on form KC60) decreased by 5% between
2002 and 2003. In Wales the number of cases diagnosed by GUM
clinics increased by 29%. Welsh laboratory reports from Cardiff and
Newport indicate a further increase in 2004. This report examines the
increase in gonorrhoea seen in Wales (2000-2003) using data from
GRASP (the sentinel surveillance system for gonococcal resistance to
antimicrobials). Data from Cardiff GUM clinic includes 2004.
Results: The figures confirm a rise in the number of cases of
gonorrhoea in Wales since 2001. The number of patients diagnosed
with gonorrhoea from ethnic minorities in Wales (7% in 2003) is
remarkably low when compared to data from all centres across England
and Wales. Data from Cardiff demonstrate a 55% increase in the
number of cases of gonorrhoea from 2003 to 2004. The increase occurs
in all groups, the largest increase being in heterosexual males. The
distribution of diagnosis in homosexual males (40% and 38% in Cardiff
in 2003 and 2004 respectively) is notably high.
Conclusion: Gonorrhoea cases have continued to increase in contrast
to national data, highlighting the necessity of local surveillance to
inform public health.
36
●
Telephonic follow-up of gonorrhoea: a step in the
right direction
NT Annan1, J Dunning1, NA Smith1, K McLean1, B Azadian1,
N MacDonald2, C Ison2, M Nelson1
1Chelsea and Westminster Hospital, London, 2Health Protection
Agency, Colindale, UK
Introduction: Recent outbreaks of Chlamydia trachomatis L2 genotype
have been reported amongst gay men in Western Europe.
Lymphogranuloma venerum (LGV) is associated with transmission of
HIV infection.
Case report: We report the cases of five HIV positive men presenting
to our clinics between November 2004 and January 2005. All presented
with proctitis and 40% with perianal ulceration following unprotected
passive anal sex. Four had sexual contacts outside the UK (Italy,
Germany and Madeira). Three patients were antiretroviral (ART) naive
and two were ART experienced with viral loads <50 copies/Molalla
cases had positive rectal chlamydia nucleic acid amplification tests for
Chlamydia trachomatis of the L2 genotype. All cases were successively
treated with doxycycline. Three cases had concurrent rectal gonorrhoea
and were treated with Ceftriaxone.
Conclusion: Given the outbreaks in Western Europe and the number of
cases presenting to our clinic in recent months we conclude that
increased awareness among clinicians is essential to facilitate early
diagnosis, treatment and prevent onward transmission of both LGV and
HIV. Close collaboration between clinic staff and those in microbiology
has been vital.
P86
P87
11th
P89
Poster Abstracts
●
High rates of Neisseria gonorrhoea contacts abroad
reduced partner notification
P91
●
Men with herpes simplex (HSV) - treatment and
information satisfaction survey
M Nicholson1, L Waters2, S Barton2
R Buckley, P O’Grady, A Wyer, F Mulcahy
GUIDE Clinic, St James’s Hospital, Ireland
Background: National guidelines for gonorrhoea recommend that at
least 0.6 sexual partners should be verified as having been
satisfactorily managed within four weeks. Previous studies carried out
at this clinic have shown that partner notification for heterosexuals is
significantly higher than for MSM.
Method: A prospective study was undertaken comparing the
effectiveness of partner notification of casual partners of
heterosexuals and MSM.
Results: 42 index patients with GC had casual partners. (19 MSM, 20
heterosexual males and 3 heterosexual females) Heterosexuals
documented 42 casual partners over the previous three-month. MSM
documented 34 partners but 18% of MSM failed to quantify the
number of partners. Partner notification for casual partners was (0.24)
and (0.04) for heterosexuals and MSM respectively. 76% (32/42) of
heterosexual casual partners were non-contactable. Analysis of the
barriers to partner notification indicated 86% (26/32) of
non-contactable partners of heterosexuals were abroad, 77% (20/26)
Asia. 14% of casual partners in Ireland were uncontactable. MSM who
indicated their casual partners were uncontactable met their partner in
Ireland.
Conclusion: This review concurs with previous findings, however more
recently partner notification in heterosexuals is reduced secondary to
significant sexual contact outside country of residence.
Aim: To assess levels of patient satisfaction with the management of
their first episode of genital HSV.
Method: The Herpes Viruses Association (HVA) performed a detailed
postal questionnaire of all their male members. Individuals were asked
to detail their waiting time, first-episode management, treatment
success and satisfaction with the information provided.
Results: 51 men responded (mean age 46.4, mean time since diagnosis
11.6 years). 41 were diagnosed in a GU clinic with an average delay
(within the last 3 years) of 2.6 days, a figure that has not changed
significantly over time. The majority received aciclovir tablets or no
specific therapy; oral therapy yielded the highest satisfaction scores.
The levels of satisfaction regarding information varied with a trend for
patients to be less satisfied with information from their GP as opposed
to GU clinic staff. 10/15 received no written information from their GP
compared with 2/26 in a GU clinic.
Conclusion: Male patients attending GU services with a first episode of
genital HSV are seen within 3 days. Oral aciclovir, the commonest
therapy, led to high satisfaction scores. Even within specialist services
a number remain unsatisfied with the information supplied and the
provision of written information by GP services was poor.
P90
P92
●
Syphilis causes eye disease – a case series
M Gupta1, R Ellks1, S Al Alabri2, C Murphy3, D Edrisinghe4, Al Pearce3,
M Bradley1, NJ Beeching2
1Department of Genitourinary Medicine, 2Tropical and Infection
Diseases, 3Ophthalmology, Royal Liverpool University Hospital and
4Department of GUM Countess of Chester Hospital, Cheshire, UK
Introduction: Co-infection with HIV alters the course, clinical
presentation and serological findings of syphilis. A rapidly progressing
ocular problem may be the presenting feature of either. We present a
series of 5 cases of ocular syphilis seen in 2004.
Findings: All patients were male. Four were homosexuals. All presented
with blurring of vision and were referred after there had been no
response to standard ophthalmological treatment for uveitis. All had
strongly positive syphilis serology. Three subsequently tested positive
for HIV. The clinical presentation ranged from retinitis to anterior
uveitis and will be illustrated. They responded to high dose intravenous
penicillin/ceftriaxone/doxycycline, with steroid cover for first 48 hours
to prevent Jarisch-Herxheimer reaction.
Discussion: Syphilis is becoming more common and ophthalmic
involvement would be expected in 5–10% of patients. There are no
pathognomic ocular findings of syphilis. A differential diagnosis
includes infection, granulomatous and autoimmune disease.
Ophthalmic involvement of syphilis should be considered as
neurosyphilis and treated early with high dose intravenous penicillin.
Conclusion: Ocular manifestations of syphilis are likely to become
more common and may be severe. Syphilis should be considered in the
differential diagnoses of ocular inflammation, as delay in treatment
can lead to permanent visual loss.
1Herpes Viruses Association, London, 2Department of GU Medicine,
●
A 5-year study of the trends in incidence and
management of Trichomonas vaginalis
A Ezeokoli, M Nathan
Department of Sexual Health, Homerton University Hospital NHS
Foundation Trust, London, UK
Aim: To identify the incidence and management trends of
trichomoniasis in a busy inner city clinic over a 5-year period.
Results: Over a five year period, the incidence of Trichomonas vaginalis
was 40.4–55.8 per 1000 new women attending. The majority of cases
were in the 21–30 age group. The predominant symptom was vaginal
discharge (59.7-68%) and 20-25% of patients were asymptomatic and
diagnosed through screening. Wet film microscopy within the
department enabled the diagnosis in 76.2–87.2%. Culture alone
enabled the diagnosis in further 10-14%. 25% of patients had a
concomitant sexually transmitted disease (gonorrhoea 2.7%,
chlamydia 14.7%, syphilis 4%). Most patients (92–96.6%) were treated
with a single dose (2g) or a five day course (400mg bid) of
metronidazole. In 1999, 51% of patients attended for follow-up
appointments compared to 56% in 2003. 44.4-52% of patients had a
negative test at follow up.10–16% had recurrence within a year.
Contact tracing was initiated at the time of diagnosis in 77.3%.
Information regarding partner treatment was available for 18.7–23.6%
of patients.
Conclusion: Trichomonas vaginalis remains a significant sexually
transmitted disease in our locality which also has a high prevalence of
HIV infection.
37
P93
●
The changing face of STIs in pregnancy in Limerick,
Ireland over 15 years
C O’Connor, J Clancy
GU/STD Clinic, Regional Hospital, Limerick, Ireland
Background: Regional meeting of clinicians requested ‘STIs in
pregnancy’ be discussed at next meeting.
Methods: Files of pregnant women and post partum to 6 weeks were
manually searched (1987–2002) and audited.
Findings: 5%(217) were pregnant of which 21%(47) attended
immediately post partum. 102/217(47%) were seen 2000–2002 of
which 38(37%) were non nationals.
Attendance:
Conclusion: A large increase in foreign nationals is noted. Even in the
most distal clinics increased clinical awareness of less common
diagnoses and co-operation is essential to help prevent congenital
transmission of preventable diseases.
P94
38
■
P95
■
Similar high frequency of detection of PPD-specific
CD4+ lymphocytes in broncho-alveolar lavage in HIV
positive and negative patients with active TB
RAM Breen, K Dheda, JP Dilworth, I Cropley, M Beckles, MA Johnson,
G Janossy, MCI Lipman
Departments of Thoracic and HIV Medicine, Royal Free Hospital,
London, UK
Introduction: In HIV-infected individuals diagnostic difficulties
frequently lead to delays in TB treatment. Lung-derived CD4+
lymphocytes producing interferon-gamma (IFN-γ) in response to PPD
have been demonstrated at high frequencies in HIV negative TB
patients. This assay may have diagnostic utility. We sought to
investigate its performance in HIV-infected individuals.
Methods: Broncho-alveolar lavage (BAL) was performed on patients
with various respiratory conditions. BAL was incubated overnight with
PPD or no antigen and CD4 lymphocytes producing IFN-γ measured by
flow cytometry.
Results: BAL from 33 HIV positive individuals with a median blood CD4
count of 131 cells/µl (6-661 cells/µl) was analysed and compared to
BAL from 64 HIV negative individuals. Median frequency of PPD
response for culture-confirmed TB were: HIV+ 7.13% (n=15;
0.00–67.11%) versus HIV- 13.94% (n=19; 0.12-79.32%). Median TB
culture negative response: HIV+ 0.01% (n=18; 0.00-16.12%); HIV0.67% (n=45; 0.00–45.66%). Frequency of PPD response was similar at
high and low blood CD4 counts in the HIV-infected population.
Conclusion: A similar high frequency of CD4+ lung lymphocyte
responses to PPD are demonstrated in HIV positive and negative
subjects, even in the presence of marked CD4 lymphopenia. This lungorientated, rapid immunological technique may have diagnostic utility
in all patients with TB.
P96
■
Immune reconstitution inflammatory syndrome
(IRIS)-associated Kaposi sarcoma
Hepatitis B vaccine service: staying on top of the
audit cycle
C Thirlwell, AM Young, T Newsom-Davis, T Dhillon, T Powles,
S Mandalia, M Nelson, B Gazzard, M Bower
Background: Starting HAART occasionally reactivates indolent
infections, a phenomenon known as immune reconstitution
inflammatory syndrome (IRIS). We have identified a similar paradoxical
deterioration in Kaposi sarcoma (KS) on starting HAART.
Methods: Since 1996, 300 patients were diagnosed for the first time
with KS; 239 patients were HAART naive, and 150 were treated with
HAART alone. We examined the clincopathological details and clinical
course of these patients.
Results: Ten of the 150 naive patients developed rapid clinical
progression of KS within 2 months of starting HAART. All 10 patients
developed new KS lesions and progression of established lesions.
Moreover, the rate of progression of KS accelerated during this period
compared to prior to starting HAART. There were no differences in
KS stage or visceral involvement between the 10 who developed IRIS
KS and the 140 who did not. Patients who developed IRIS KS had a
higher CD4 count at start of HAART (median 335/mm3 vs 121/mm3 :
p=0.028) but no difference in HIV viral load (median 295K/mm3 vs
171K/mm3 : p=0.35).
Conclusion: Patients with KS who start HAART may be at risk of IRIS
progression of KS
AS Menon-Johansson, K Coyne, A Rajkumar, P Randell, A McOwan
Chelsea and Westminster Healthcare, London, UK
Aim: To assess the impact of audit recommendations on the Hepatitis
B vaccine (HepBvax) service.
Methods: The delivery of the first and third dose of HepBvax to all
eligible MSM was audited across four clinics on four occasions.
Recommendations were made and implemented after each audit. The
Sexual Health Strategy targets of 80% and 50% for the 1st and 3rd
HepBvax dose became effective at the end of 2004.
Results:
In 2004, 27% of eligible MSM requested to wait for serology results
prior to vaccination. However, almost half of these individuals did not
return.
Conclusions: Clear audit recommendations to modernizing service
delivery have improved vaccine uptake over three audit cycles.
Introducing POCT could capture those patients who currently defer
vaccine until their serology result is known.
11th
P97
Poster Abstracts
■
Does hepatitis B ultra-rapid vaccination work in HIVpositive people? A comparative study of HIV-positive
and HIV-negative vaccine recipients
L Rubinstein, G King, MG Brook
Central Middlesex Hospital, London, UK
Aim: To assess ultra-rapid hepatitis B vaccination in HIV+ and
HIV-patients.
Methods: A retrospective analysis of individuals prescribed the
ultra-rapid vaccination regimen (0,1,3 weeks) in 2004 who had
post-vaccine antibody levels.
Results: 22 HIV+ and 34 HIV- individuals met the entry criteria. There
was an excess of women (13/22, 59% vs 9/34, 26% p= 0.02) and black
people (16/22,73% vs 5/34,15% p<0.001) in the HIV+ vaccinees.
Response rate (anti-HBs >10iu/l) was lower in the HIV+ individuals
(11/22, 50% vs 30/34, 88% p=0.004) although this response is similar
to longer vaccination schedules. Approximately equal numbers of
patients actually received three injections either during >2 months
(‘rapid’) or <2 months (-ultra-rapid’). The differences between HIV+
and HIV- remained for ultra-rapid (8/12, 67% vs 16/17 94% n.s.) and
rapid recipients (3/10, 30% vs 14/17, 82% p=0.01). Ultra-rapid
achieved better results than rapid vaccination in the HIV+ (8/12, 67%
vs 3/10, 30% n.s). This difference is explained by CD4 count: 7/8 (88%)
and 3/3 (100%) ultra-rapid and rapid responders but only 1/4 (25%)
and 3/7 (43%) non-responders had a CD4 count >350 cells/mm3.
Conclusion: Ultra-rapid vaccination of HIV+ people seems to be as
effective as longer schedules in terms of early antibody response.
P98
■
Comparison of two accelerated hepatitis B
vaccination schedules – completion and immune
response
RK Ellks, H Sugunendran
Royal Liverpool University Hospital, Liverpool, UK
Introduction: It is accepted that the two accelerated vaccination
schedules for hepatitis B are equally efficacious. This study was
designed to compare vaccinations at 0,7,21 days (schedule-A) and
0,1,2 months (schedule-B) examining completion rate of course and
the development of adequate immunity i.e. hepatitis B surface
antibody (anti-HBs) >10IU/L at two months after the third vaccine.
Method: A retrospective analysis of 264 patient records.
Results: Schedule-A 140 patients, (86males). Schedule-B 124 patients,
(87 males). The groups were equally matched for age, immune status
and indication for vaccination. 73% of schedule-A completed
vaccination compared with 64% schedule-B (not significant (NS)).
Anti-HBs was checked in 61% of schedule-A compared with 70%
schedule-B (NS). Schedule-A had 60% anti-HBs >10IU/L compared
with 76% in schedule-B (significant p=0.055).
Conclusion: This study shows that the two schedules have no
significant difference in completion rates, and no significant difference
in attendance for antibody check. The anti-HBs response is
significantly lower with the 0,7,21 vaccine. The widespread use of this
schedule should now be reconsidered.
P99
■
Prevalence of hepatitis C in urban sexually
transmitted infections (STI) clinic for men who have
sex with men (MSM): is screening necessary and is it
cost effective?
G Courtney1, L Jones2, M Crean2, S Keating1
1Gay Men’s Health Project, Dublin, 2Virus Reference Laboratory, UCD,
Dublin, Ireland
Background: Outbreaks of HepC in MSM, especially those with HIV
co-infection have recently been reported. This study reports the
prevalence of HepC in a community based screening programme and
evaluates its cost-effectiveness.
Methods: From Jan–Dec 04 all MSM attending a community based
MSM Sexual Health Clinic were screened for Hepatitis C Abs by Ortho
EIA assay. Positive tests were confirmed by RIBA.
Results: 1258 MSM were screened, 1389 tests performed. 28 men
tested positive for HIV. 2 men screened + for HepC; 1 positive by Ortho
EIA, but not confirmed on RIBA3, was reported negative. The only
confirmed positive case was in a man who had a previous sexual
partner who was an IVDU. HepC PCR was +, HIV1/2 ab negative. The
prevalence rate was 0.07%. The cost of screening for the year was
19,737 euro, personnel costs not included.
Conclusion: The prevalence of Hepatitis C in HIV negative MSM is low
even in the context of a recent local syphilis epidemic and rising rate
of HIV in this population. Generalised screening is not cost effective in
this population however targeted testing in those with a sexual history
identifying increased risk (IVDU/ partner IVDU) and in HIV+ cases
remains important.
P100
■
Treatment and outcomes of HCV treatment in
HIV-HCV co-infected patients 2001–2004
J Lambourne, G Farrell, H McDermott, S Woods, C Bergin, F Mulcahy
GUIDE department, St James’s Hospital, Dublin, Ireland
Background: With the use of HAART increasing morbidity/mortality
from HCV mediated end stage liver disease in HIV populations is
recognised. Pegylated interferon and ribavirin (PEG/RBV) use has been
associated with an increased sustained virological response (SVR).
Objective: To identify primary and secondary treatment outcomes of
HCV treatment.
Results: Demographics: 89% male, 63% IVDU, 27% haemophiliac, 42%
genotype 1/4, 58% genotype 2/3, 55% on HAART, mean CD4
507×10^6/l. 62 patients commenced PEG/RBV. 54 completed
treatment with an end of treatment response of 37/54 (69%)
[genotype 1/4=6/19 (32%) and genotype 2/3= 31/35 (89%)]. 46
reached 6/12 post treatment. SVR seen in 28/46 (61%) [genotype
1/4=4/16 (25%) and genotype 2/3=24/30 (80%)].
OT analysis: SVR seen in 27/42 (64%) (genotype 1/4=4/15 (27%) and
genotype 2/3= 23/27 (85%). 11/62 discontinued treatment because of
psychiatric morbidity (n=4), sustained significant CD4 decline (n=1),
non-treatment related death (n=2). Two patients required dose
reduction, 14 received haematological support (erythropoetin 9,
transfusion 2, GC-SF 6).
Conclusions: SVR rates compare favourably to mono-infected data.
Increased awareness of HCV treatment toxicities, use of supportive
growth factors to enable use of full dose HCV therapies and knowledge
of HAART interactions enable favourable therapeutic outcomes.
39
P101
■
Treatment outcomes of hepatitis C intervention with
pegylated interferon and ribavirin in hepatitis C/HIV
co-infected haemophiliacs
J Kieran, J Lambourne, G Farrell, S Chew, C Bergin, F Mulcahy, B
White, B Nolan
St James’ Hospital, Dublin, Ireland
Aim: To examine the primary and secondary outcomes of hepatitis C
treatment in co-infected haemophiliacs.
Method: In 2001 an open-label treatment study was commenced. All
patients were initially treated with 24 weeks of pegylated interferon
and ribavirin; those with genotype 1/4 infection received a further
24 weeks of treatment providing they were HCV-PCR negative. Primary
endpoints were HCV-PCR negative at the end of treatment (EOT) and
at 6 months post completion of treatment i.e. sustained viral response
(SVR). Secondary outcomes were discontinuation or dose reduction due
to adverse drug reactions, need for haematological support and
interactions with HAART. 62 patients have received treatment, 17 of
whom are haemophiliac.
Results: Of 17 patients, 10 had genotype 1/4 disease and 7 had
genotype 2/3. 83% were HCV-PCR negative at EOT (100% genotype
2/3, 60% of genotype 1/4). Overall SVR is 53% (genotype 2/3;86%).
18% were non-responders, all genotype 1. No patient required dose
reduction or had interactions with their HAART. There was one case of
thyroiditis and 17% required haematological support to maintain full
dose therapy.
Conclusion: Pegylated interferon and ribavirin is an effective and well
tolerated treatment in co-infected haemophiliacs.
P102
■
Use of pegylated interferon-alpha (peg-IFN) with or
without ribavirin in the treatment of acute HCV in
HIV-positive individuals
M Danta1*, JM Turner2*, R Johnstone2, RM Lascar2,3, MA Johnson4
GM Dusheiko1, IG Williams2,3, RJC Gilson2,3, S Bhagani4
1Centre for Hepatology, Royal Free Hospital, London, 2Centre for
Sexual Health and HIV Research, Royal Free and University College
Medical School, 3Camden Primary Care Trust, The Mortimer Market
Centre, London, 4Department of HIV Medicine, Royal Free Hospital,
London, UK
*Joint first authors
Aims: To describe the virological outcomes of two different treatment
strategies for acute HCV infection in HIV infected individuals.
Method: HIV-positive individuals presenting with acute HCV infection
at two centres were offered treatment but with different standard
regimens. At centre 1 all individuals persistently positive for HCV RNA
by reverse transcriptase polymerase chain reaction (PCR) 12 weeks
after presentation were offered peg-IFN alpha 2b (1.5 µg/kg) and
ribavirin (>10.6 mg/kg) for 48 weeks. At centre 2 individuals were
offered immediate treatment with peg-IFN alpha 2a or 2b for
24 weeks. Ribavirin (800mg/d) was added in individuals still positive for
HCV RNA at week 12.
Results: Baseline characteristics were similar in individuals at centre 1
(n=24) and centre 2 (n=15); mean age (35.7 Vs 36.3 years), CD4 count
(583 Vs 515 cells/ml), HIV viral loads (30% Vs 20% <50copies), HCV
genotype 1 or 4 (83% Vs 87%), and ALT (177 Vs 362IU/ml). Sustained
clearance rates were available in 23 patients and were significantly
better at centre 1 (60%) than centre 2 (8%) p<0.001. Side effect
profiles were similar.
Conclusions: The optimal treatment schedule for acute HCV in HIV
co-infection is not known but our experience suggests that peg-IFN
alone has poor efficacy.
40
P103
■
HCV-specific T-cell responses of acutely HCV infected
individuals with and without HIV
M Danta1*, N Semmo3*, J Northfield3, D Brown1, G Dusheiko1,
P Fabris4, S Bhagani2, P Klenerman3
1Centre for Hepatology, 2Department of HIV Medicine, Royal Free and
University College Medical School, London, 3Nuffield Department of
Clinical Medicine, Peter Medawar Building, University of Oxford,
Oxford, UK, 4Department of Infectious Diseases and Tropical Medicine,
S Bortolo Hospital, Vicenza, Italy
*Joint first authors
Aims: To assess HCV-specific T-cell responses and serum cytokines in
HIV-positive and HIV-negative individuals with acute HCV infection.
Methods: Frozen PBMCs and serum from multiple time points in the
acute phase of HCV infection from a cohort of HIV-positive individuals
in London and an Italian cohort of HCV mono-infected individuals were
used. HCV-specific T-cell responses were assessed using an IFN-γ
ELISpot for HCV core derived peptides (20mers overlapping by 10aa)
and HCV recombinant non-structural proteins (NS3-5). Serum
cytokines were analysed using cytokine bead array and FACS analysis.
Results: HIV-positive individuals (n=12, all male, mean age 33, mean
CD4 714 cells/ml) were compared with 10 HCV mono-infected (n=10,
6 male, mean age 40) individuals. Comparison of IFN-( ELISpots for
NS3-5 proteins revealed significantly reduced responses in
HIV-positive vs. HIV-negative individuals (1/10 vs. 5/7, p=0.034). No
difference was seen for the core peptides (3/10 vs. 5/7, p=ns). In
HIV-positive individuals cytokines (pg/ml) compared at peak ALT and
>2 months post-peak ALT revealed significant late increases in: INF-γ
(108.9±34.5 vs. 154.5±32.7, p<0.01), TNF (7.7±2.9 vs. 10.9±2.3,
p<0.01) and IL-2 (3.3±0.4 vs. 3.6±0.4, p<0.01).
Conclusions: Failure of early immunological control of HCV in
HIV-positive individuals is supported by the lack of breadth of the CD4
responses to the non-structural proteins and late elevation of
cytokines.
P104
●
Hepatitis C (HCV) screening: what should
genitourinary medicine be doing?
PM Williams, A Edwards
Harrison Department, Radcliffe Infirmary, Oxford Department of GUM,
UK
Objective: To improve the effectiveness of HCV screening in GUM.
Method: The indications for tests requested over a six month period
were audited against national guidelines. Reasons for inappropriate
testing, and risk factors for all diagnosed HCV cases were determined.
Risk factors for all HCV cases over four years were also collected. The
guidelines were modified to limit testing to: All IDU; Long-term sexual
contacts of known HCV positive individuals; All HIV positive patients at
initial diagnosis. This was implemented and the audit repeated.
Results: 174 tests for HCV were requested over the initial six months.
62% complied with national guidelines. 50% of inappropriate tests
were sexual contacts of IDU. We identified 10 new cases, 8 were IDU
and 1 HIV positive. No patient who is thought to have acquired HIV
heterosexually from someone of WHO pattern 2 origin and who denied
intravenous drug use (29 patients) was co-infected with HCV. 90% of
cases of HCV diagnosed over four years were IDU. Implementing
modified guidelines resulted in 50% fewer requests, 9 new cases, all
IDU.
Conclusion: Using our modified guidelines we would not miss cases of
HCV and we reduced unnecessary requests by 50%.
11th
P105
Poster Abstracts
●
P107
●
HIV-associated T-cell non-Hodgkin lymphoma
Pulmonary Kaposi sarcoma in era of HAART
T Powles, T Dhillon, AM Young, C Thirlwell, T Newsom-Davis,
M Nelson, B Gazzard, M Bower
Background: T-cell non-Hodgkin’s lymphoma (T-NHL) accounts for
<10% NHL and has only recently been found to have an increased
incidence in HIV+ people. The management of HIV-associated T-NHL is
uncertain.
Methods: Since 1986 we have managed 317 HIV+ patients with
lymphoma including 62 primary cerebral NHL, 24 Hodgkin's disease,
and 231 systemic NHL. We compared the clinicopathological features
and outcomes of patients with systemic T-NHL and B-NHL.
Results: We identified 10 patients with T-NHL. There were no
significant differences in gender (χ2 p=0.57), age (MW p=0.16), prior
AIDS defining illness (χ2 p=0.43), NHL stage (χ2 p=0.28), CD4 cell
count (MW p=0.25) or HIV-1 viral load (MW p=0.62) at NHL diagnosis.
Aggressive NHL is classified using the International Prognostic Index;
there was no difference in the distribution of IPI scores (χ2 p=0.33).
There is no difference in overall survival (log rank p=0.40). The 2 year
overall survival is 32% (95%CI: 27-39%0 for B-cell NHL and 46%
(95%CI: 14-78%) for T-cell NHL.
Conclusion: There were no differences in immunological parameters or
survival duration between patients with T-NHL and B-NHL. We suggest
that aggressive T-NHL could be included as an AIDS defining
malignancy along with high grade B-NHL.
T Newsom-Davis, T Dhillon, AM Young, T Powles, C Thirlwell,
M Nelson, M Bower
Background: The survival following a diagnosis of Kaposi sarcoma (KS)
has improved dramatically since the introduction of HAART.
Methods: Since 1996, 301 patients have been diagnosed for the first
time with KS, including 26 with pulmonary KS (pKS). The
clinicopathological features and outcome of patients with pKS are
compared with those without pulmonary involvement.
Results: Patients with pKS were more often female (all black Africans)
(15% vs 4% χ2 p=0.006) and were younger (mean age 36 vs 39 MW
p=0.02). They had lower CD4 cell counts (median 33/mm3 vs 128/mm3
MW p=0.009) but similar HIV plasma viral loads (MW p=0.8). All
patients were treated with chemotherapy and HAART. The 5 year
overall survival for patients with pKS is 49% (95%CI: 24–74%)
compared to 82% (95%CI: 77–87%) for KS patients without
pulmonary involvement (log rank p<0.0001).
Conclusion: The median survival for pKS is 1.6 years in this cohort
which compares favourably with quoted rates of 3–10 months from the
pre-HAART era. However, the prognosis of pKS remains poor and is
significantly worse than for KS without lung involvement.
P106
P108
●
●
Hodgkin’s disease in the era of HAART – single
institution experience
No cardiotoxicity observed with liposomal
anthracyclines for Kaposi sarcoma
T Powles, C Thirlwell, AM Young, T Newsom-Davis, T Dhillon,
S Holmes, P Nelson, B Gazzard, M Bower
Background: Although not AIDS defining, Hodgkin's disease (HD)
occurs at increased frequency in the HIV+ population and was
previously associated with a poor outcome.
Methods: We reviewed our experience of HD since 1996 when HAART
was introduced into routine clinical care.
Results: We have treated 17 patients (16 male) for HIV associated HD.
The mean age is 42 years and 4 (24%) had a prior AIDS defining illness.
At diagnosis, the median CD4 count was 175/mm3 (range 49–661) and
11 (65%) were on HAART of whom 7 (64%) had an undetectable HIV
viral load. Most had advanced HD at presentation: 10 (59%) had stage
IV disease, 14 (82%) had B symptoms and 8 (47%) had bone marrow
involvement. This compares to values of 15%, 40% and <5% in the
general population with HD. All patients were treated with
combination chemotherapy. One patient was treated at relapse with
high dose chemotherapy and autologous stem cell transplantation. The
actuarial 2 year survival is 79% (95%CI: 58–100%). Four patients have
died, 2 from HD and 2 from other causes.
Conclusion: Even in the HAART era, patients with HD present with
advanced stage disease, however the survival for these patients is
improving with aggressive therapeutic strategies.
T Dhillon, AM Young, C Thirlwell, T Newsom-Davis, R Jones,
MR Nelson, BG Gazzard, M Bower
Background: Anthracyclines are associated with cumulative
cardiotoxicity due to free radical peroxidation of cardiolipids in
myocytes. Cardiotoxicity is characterised by dilated cardiomyopathy.
The recommended maximum lifetime cumulative dosages of
non-liposomal anthracyclines are 450 mg/m2 for doxorubicin and 600
mg/m2 for daunorubicin.
Method: We measured the lifetime cumulative dosages of liposomal
anthracyclines delivered to patients with AIDS-Kaposi sarcoma
(AIDS-KS) and the incidence of clinically significant cardiac failure.
Results: We have treated 93 patients with AIDS-KS (90 male, 2 female,
1 gender reassignment) whose mean age is 39 years (range 24–62)
with liposomal anthracyclines. Liposomal anthracyclines were the first
line systemic chemotherapy for 78 (84%). Fifty eight patients were
treated with liposomal daunorubicin (Daunoxome), 30 with pegylated
liposomal doxorubicin (Caelyx) and 5 with both. The median
cumulative doses received were 120mg/m2 (range 20–520) for
liposomal daunorubicin and 240mg/m2 (range 80-760) for pegylated
liposomal doxorubicin. The maximum cumulative dosage delivered to a
single patient was 640 mg/m2 liposomal daunorubicin plus 160 mg/m2
pegylated liposomal doxorubicin. The actuarial 5 year survival from
commencing liposomal anthracycline chemotherapy is 73% (95%
confidence interval: 61-85%).
Conclusion: We have observed no clinically significant episodes of
cardiotoxicity amongst this cohort of patients despite high cumulative
dosages of liposomal anthracyclines.
41
P109
●
Clinicopathological features of 12 cases of
HIV-associated multicentric Castleman's disease
H Dharmana, A Roy, AM Young, S Cox, M Nelson, BG Gazzard,
M Bower
Background: The diagnosis of HIV-associated multicentric Castleman’s
disease (MCD) is often delayed due to non-specific clinical findings.
Methods: We examined the clinical features of 12 patients with MCD
diagnosed or treated at our institution.
Results: The mean age was 39 years (range 31-49) and 11 were male.
Five (42%) had prior AIDS defining illness and 8 (67%) had cutaneous
KS. All had lymphadenopathy and PUO and 10 /11 splenomegally
(1 prior splenectomy for ITP). Two (17%) had effusions and 5 (42%)
pulmonary infiltrates. The median symptom duration was 5 months
(range 2–24). At presentation 11 (92%) were anaemic (Hb<10g/dl),
8 (67%) thrombocytopenic (Plt<100×109/l). 9/10 had polyclonal
gammaglobulinaemia (median IgG 29 g/l, range 5–59, normal range
5–16) and all had low albumin (<35g/l). The median CD4 count was
197/mm3 (range 65–1429), CD8 was 881/mm3 (range 310–5661) and
CD19 was 228/mm3 (range 8-554). Only 2 had undetectable HIV-1
viraemia, although 8 were on HAART at MCD diagnosis. Three (25%)
also had plasmablastic microlymphoma associated with MCD. Seven
patients have died and the median survival is 6 months.
Conclusion: The rather non-specific clinicopathological features at
presentation may account for the prolonged duration of symptoms
prior to diagnosis of MCD.
P110
●
Under-reporting of tuberculosis among HIV-infected
individuals diagnosed in the UK
V Delpech1, J Forde1, M Lipman2, D Antoine3, B Evans1
1HIV/STI and 3Respiratory Departments, CDSC, Centre for Infection,
Health Protection Agency, London, 2Department of Respiratory
Medicine, Royal Free Hospital, London, UK
Background: HIV is fuelling the TB epidemic in high HIV prevalence
populations. Both infections are on the increase in the UK with over
6000 new diagnoses of each reported per year. We reviewed national
trends and matched cases of AIDS with TB at diagnosis to the national
TB database to assess under-reporting.
Results: The proportion (and number) of AIDS cases with TB at initial
diagnosis increased from <5% (59/1577) in 1992 to 30% (233/766) in
2003. TB has drawn level with PCP as the most common initial AIDS
defining illness. 88% of black-Africans diagnosed with AIDS presented
with tuberculosis in 2003 (compared to 2.3% of MSM). Almost 40% of
AIDS cases with TB at initial diagnosis reported (1998-2001) could not
be matched to the TB surveillance system, ranging from 36% in 1998
to 42% in 2001.
Conclusions: TB is now a leading cause of HIV related morbidity in the
UK. High co-infections among black-African individuals reflect the
high prevalence of HIV and TB in their country of origin. Although
estimates are subject to matching limitations, the high proportion of
under-reporting of tuberculosis among HIV individuals is concerning
and warrants further investigation.
42
P111
●
Virological outcome for individuals with
HIV/tuberculosis co-infection receiving highly active
antiretroviral therapy
RAM Breen1, RF Miller2, T Gorsuch3, A Schwenk3, J Ballinger1, l
Swaden1, CJ Smith2, MA Johnson1, MCI Lipman1
1Departments of Thoracic and HIV Medicine, Royal Free Hospital,
2Department of Primary Care and Population Sciences, Royal Free and
University College Medical School, 3Department of HIV Medicine,
North Middlesex Hospital, London, UK
Aim: To describe the virological response to HAART in TB/HIV patients.
Methods: Retrospective case-note review of 115 consecutive
individuals with HIV/TB co-infection.
Results: At TB diagnosis, patients had a median CD4 count 132 cells/uL
(3–1200); viral load 365,000 copies/mL (50–750,000). TB treatment
was rifamycin-based in 113/115. 84/115 (73%) patients received
HAART during TB treatment (1/3 were on this at TB diagnosis). Time
from anti-TB therapy to starting HAART if HAART naive:
<2 weeks=12/59 subjects (20%); 3–4 weeks=7/59 (12%); 5–8
weeks=22/59 (37%); 9-16 weeks=12/59 (20%); 17-24 weeks=6/59
(10%). 18 different HAART regimens were prescribed: PI containing
n=26; NNRTI containing n=45; triple NRTI n=13. 69/84 (82%) achieved
a viral load <50 copies/ml by the end of TB treatment, similar to our
non-TB HAART treated individuals. Viral load response was not related
to specific regimen type. 5/15 who did not achieve <50 copies/ml had
a >2 log fall in HIV load and were felt to be responding slowly; giving
a total response of 74/84 (88%). 10/15 had a <1 log fall in HIV load.
Conclusions: Good virological responses are seen in the majority of our
cohort, demonstrating that anti-tuberculosis and anti-retroviral
therapy can be successfully combined.
P112
●
Intravenous pentamidine is inferior to trimethoprimsulphamethoxazole for treatment of Pneumocystis
jirovecii pneumonia (PCP)
J Helweg-Larsen, T Benfield, C Atzori, RF Miller
University College London, London, UK
Background: Trimethoprim-sulphamethoxazole (TMP-SMX) is first-line
treatment for (PCP). Few data are available to guide choice of
second-line treatment for patients who fail or who are intolerant of
first-line therapy.
Methods: Treatment data and outcome from 1145 episodes of
HIV-associated PCP (1035 patients) presenting between January 1989
and June 2004 were analysed to identify if specific treatment was
associated with 3-month mortality. Patients were from Copenhagen
(555), London (375) and Milan (215).
Results: First-line therapy was TMP-SMX in 928, IV pentamidine (PENT)
in 82, clindamycin/primaquine (C+P) in 67 and ‘Other‘ (dapsone/TMP),
atovaquone or inhaled PENT) in 65. Outcomes for first-line treatment
[response rate/treatment switch for toxicity/switch for treatment
failure/mortality at 3 months] were TMP-SMX: 78%, 17%, 5%, 14%; IV
PENT: 53%, 27%, 20%, 19%; C+P: 56%, 26%, 18%, 16%: 'Other' 57%,
12%, 31%, 3%. For patients receiving second-line treatment
multivariate Cox regression analysis of risk of death (95% CI) at
3 months was IV PENT = 3.2 (2.2-4.6), C+P = 1.1 (0.6-1.8), ‘Other’ = 0.7
(0.3–1.4).
Conclusion: Compared to TMP-SMX treatment of PCP with IV PENT has
a 3.2-fold risk of death at 3 months, which is due to its inferior efficacy
as first and second-line therapy.
11th
P112a
Poster Abstracts
●
Simultaneous pulmonary and extrapulmonary
infection with multiple strains of Mycobacterium
tuberculosis in an immunocompromised patient:
a case report
●
Contact tracing by HIV genotypic resistance test
results
J Lambourne1, N Gibbons2, J Keane3, C Bergin1
1Department of Genitourinary Medicine and Infectious Diseases,
2Department of Medical Microbiology, 3Department of Respiratory
Medicine St James’s Hospital, Dublin, Ireland
We present a case of disseminated Mycobacterium tuberculosis (MTB)
infection involving multiple MTB strains in a 28-year-old Vietnamese
patient co-infected with HIV and hepatitis C. The patient presented
with cough, sputum and constitutional upset. Pan-sensitive MTB was
isolated from blood, urine, pleural and cerebrospinal fluid.
Bronchioalveolar lavage fluid grew both pan-sensitive and
Isoniazid-resistant MTB indicating mixed infection with multiple
strains within a single anatomic compartment.
Three months following presentation, while on treatment with
rifampicin, ethambutol and pyrazinamide, the patient began to
complain of increasing headache, nausea and vomiting and recurrent
falls. Examination revealed marked ataxa and sustained nystagmus on
both left and right gaze. Neuroimaging revealed leptomeningeal
tuberculous disease and multiple parenchymatous tuberculomas with
obstructive hydrocephalus. MTB isolated from CSF at this time was
resistant to rifampicin. Genetic analysis identified this isolate as
identical to the original pan-sensitive isolates implying the
development of rifampicin resistance while on therapy.
Cases of mixed infection are increasingly recognised and it appears
that co-infecting strains of MTB are not necessarily equally distributed
between pulmonary and extra-pulmonary sites. This highlights the
importance of culture and sensitivity testing and isolate identification
of all samples obtained from distinct sites in patients with MTB
infection.
P112b
P112c
●
C Kamutasa, OE Williams, S McAndrew, H Bailey
Ysbyty Glan Clwyd Hospital, North Wales, UK
Introduction: Genotypic resistance testing is now recommended
before starting HAART in HIV disease. The results can accurately
identify the source of infection when more than one contact exists.
Case summary: A 38-year-old Caucasian heterosexual male tested
positive with multi-drug resistant HIV clade C. His current partner is a
married HIV-positive African woman with wild-type clade C virus,
undetectable on Trizivir since 2002. Genotyping prompted revelation of
former partner, another African female who died of AIDS in 2001 while
on third HAART regime of d4T/ddl/Kaletra. HIV genotypes were closely
related for the index patient deceased female and her ex-husband,
strongly suggesting the same source.
RT mutations D67N, T215S/F, G190S, A98G and PR mutation M63I
were common to the female and index patients while the two males
shared the RT mutations: G109S/G/A, K101/3E/K/R, V35T, E36A, T39E,
K173E, Q174R, D177E, Q207E and R211K and PR mutations: M36I,
I93L, L93L.
A conscious decision was made not to reveal the link.
Discussion: HIV genotyping allows the correct choice of HAART. Using
the results for contact tracing is debatable, particularly with the recent
criminalisation of non-disclosure of HIV status.
Conclusion: Genotypic resistance test results enabled accurate contact
tracing in a seemingly unrelated cluster.
P112d
●
A case of prolonged immune reconstitution
inflammatory syndrome
Case report: HIV and seronegative arthropathy and
role of methotrexate
EJ Morris, EF Monteiro
Leeds General Infirmary, Leeds, UK
IRIS is a common complication of the treatment of HIV and TB.
Symptomatic treatment with steroids is suggested. Leukotriene
receptor anatagonists exert broad anti-inflammatory effects and may
benefit in refractory cases.
Case report: A 41 year old Kenyan man presented with gross cervical
lymphadenopathy. He was HIV positive with a CD4 of 18. Lymph node
biopsy confirmed tuberculosis fully sensitive to antimicrobials.
Quadruple therapy with pyridoxine was commenced. ART was started
two weeks after TB treatment. He continued to have intermittent
pyrexia, increasing lymphadenopathy and persistently raised
inflammatory markers. High dose prednisolone and later intravenous
hydrocortisone showed no clinical benefit. He required weekly cervical
lymph node aspiration and later developed fistulae. Aspirate fluid
remained culture negative. Adherence to all therapy was excellent. CD4
count was 59 @ four months. Montelukast was trailed at this stage.
Two weeks later, lymphadenopathy had improved and CRP had
decreased significantly. He required no further drainage.
However, he deteriorated five weeks later with leg pain and restricted
movement. Massive psoas and abdominal abscesses were found and
over 1 litre of pus drained (culture negative). Since drainage of the
abscesses he has continued to improve.
IRIS can be prolonged and difficult to manage. Montelukast may have
a role in its management.
RAM Varma, M Nathan
Homerton Hospital, London, UK
Introduction: The effects of methotrexate on patients with HIV are not
well known. We report a case of a man with a relatively high CD4
count, not requiring treatment with HAART, displaying evidence of
immune failure while on methotrexate.
Case presentation: We describe the case of a 48 year old British
Caucasian gay man who presented with a 2 year history of lower limb
synovitis requiring recurrent steroid injections; he became
progressively more debilitated. Initially tested negative for HIV. He also
complained of early morning back pain for a number of years and HLA
B27 confirmed clinical suspicion of Ankylosing Spondylitis (AS).
Repeated HIV testing 2 years after initial presentation confirmed HIV
with CD4 count 622 cells/µl (25%) and 41,400 viral load HIV-1 RNA
copies/ml.
Initial results suggested that HAART should be withheld. Escalating
doses of methotrexate have coincided with evidence of impaired T cell
function manifest as widespread Molluscum and violatious lesions on
his 1st MTP joint. Biopsy confirmed Kaposis sarcoma (KS). His
arthropathy remains difficult to control; however he now has an AIDS
illness requiring treatment with HAART.
Discussion: The effects of steroid use in patients with HIV is
established as a risk for the development of opportunistic infection and
KS. The effects of methotrexate are not as clear and there is very little
literature of the interaction between HIV and AS.
43
P112e
●
A case of optic perineuritis
A Checkley, P Hay
St George’s Hospital, London, UK
A 46-year-old man presented with a 2-month history of headaches,
visual obscurations and night sweats. On examination he had
widespread lymphadenopathy, a maculo-papular rash and optic disc
oedema. Visual acuity and fields were normal. CT brain was also
normal, and lumbar puncture revealed a normal opening pressure, with
protein 1.3g/l, 94 white cells/(µl (100% lymphocytes) and glucose
2.7/5.6 mmol/l (CSF/plasma). HIV serology was positive, with a CD4
count of 260 x109/l. Syphilis serology was also positive, with the
following titres: RPR 1 in 2 and TPPA >1/1280 (plasma), and TPPA
1/320 and a positive RPR (CSF). A diagnosis was made of
meningovascular syphilis with optic perineuritis.
Syphilitic optic perineuritis is characterised by optic disc oedema with
normal visual acuity, pupillary responses and intracranial pressures,
and normal visual fields except for an enlarged blind spot. It is a rare
manifestation of neurosyphilis, thought to represent an extension of
basal meningeal inflammation to the optic nerve sheaths. It is
differentiated from papilloedema by a normal CSF opening pressure,
and from papillitis by normal visual acuity and pupillary responses. It
has also been described in meningococcal meningitis, viral
meningoencephalitis, rickettsial infections and sarcoidosis.
P113
■
Expedited partner therapy (ExPT): is it feasible and
acceptable to sexual health clinic attenders in the
UK?
L Sutcliffe1, J Cassell1, C S Estcourt1,2, JL Chapman2, G Brook3
1Department of Primary Care and Population Sciences, Royal Free and
University Medical School, University College London, 2Centre for
Infectious Disease, ICMS, Queen Mary University of London, 3Patrick
Clements Sexual Health Clinic, Central Middlesex Hospital, London, UK
Aim: To explore acceptability and feasibility of a range of options for
rapid treatment of sexual partners of clinic attenders diagnosed with
acute sexually transmitted infections (STIs), including treatment
without clinic attendance (ExPT).
Methods: Exploratory, qualitative, cross-sectional pilot study, using
semi-structured, audiotaped interviews, which were thematically
analysed.
Participants: Purposive sample of 41 patients representing a range of
demographic variables and risk factors within an outer London sexual
health clinic.
Results: Preliminary analysis suggests that clinic users find ExPT a
highly acceptable method of partner notification. Both
patient-delivered therapy and collection of therapy from community
pharmacies are feasible and acceptable options. Users perceived a high
degree of motivation to attend clinic for subsequent HIV testing after
ExPT. Further detailed analysis will include: preferred methods of
communication with partners; communication with partners by mobile
phone whilst index is attending, and issues surrounding primary and
non-primary partners.
Conclusion: Many sexual health services are unable to meet current
targets for partner notification for acute STIs. We believe that
innovative models of partner management including patient delivered
therapy, using modern communication technology, should be
evaluated. We present detailed patient consultation data addressing
feasibility and acceptability of expedited partner therapy in a high risk
population.
44
P113a
■
What potential do patients presenting to primary
care hold for effective STI control interventions?
JA Cassell, L Sutcliffe, C H Mercer, MG Brook, E Jungmann, J Ross,
GR Kinghorn, J Stephenson, A M Johnson on behalf of the PATSI
collaboration.
Centre for Sexual Health Research, Department of Primary Care and
Population Sciences, University College London, London, UK
Background: There is evidence that up to 40% of new patients in
genitourinary medicine clinics seek care in general practice first. This
may have an impact on transmission and cure rates.
Aims: To compare sexual behaviour, health care seeking behaviour and
extent of symptoms between clinic attenders who did, and did not,
approach primary care first.
Methods: A questionnaire was administered to approximately 8000
patients in 8 sexual health clinics and linked to clinical data.
Results: 22.5% of males and 48.0% of females with an STI had first
sought care elsewhere, of which 76.0% of males and 76.5% of females
had approached primary care. Males first approaching primary care
were more likely to report 2 or more partners while symptomatic than
those attending clinic directly (P=0.03). Symptom duration was
≥7 days in 85.1% of those first approaching primary care, and 62.8%
in others (P0.01) – the association held for males and females.
Conclusions: Patients with high risk sexual behaviour often refer
themselves to primary care, rather than to specialist sexual health
services. Expedited treatment is required for such patients, since
attendance at primary care delays definitive treatment, and some
patients may fall ‘through the net’ between services.
P114
■
Yeah but, no but, yeah but … What information are
young Britons getting about sexual health?
V Lee, K Walsh, E Foley
Department of GU Medicine, Southampton University Hospitals NHS
Trust, Southampton, UK
Background: The numbers of sexually transmitted infections (STI's)
diagnosed in the UK continues to increase, with the highest reported
rates in young sexually active persons. Many young women rely on the
media including womens’ magazines for information about sexual
health, and is a commonly cited reason why a young woman presents
for STI screening.
Aims: To determine the quantity and quality of information about sex
and sexual health, in particular STI's in young womens’ magazines sold
in the UK.
Method: This is a prospective study since November 2004. Womens’
magazines which target 14–21 year-olds were reviewed for articles
concerning sex and sexual health. This study examined the article type,
the authors’ professional qualifications, and the accuracy of the
content.
Results: Of the 77 journals reviewed to date, 90% carried articles
about sex but only 14% had articles on STI's. In all cases the factual
content was correct. The types of infections reviewed, article type
authorship will be discussed.
Conclusion: Although information about sexual health is common in
young womens' magazines, there is far less information about STI’s.
With the increasing awareness for asymptomatic screening magazines
may provide a good vehicle in which to disseminate more information
about STI’s.
11th
P115
Poster Abstracts
■
Designed by young people for young people:
description and review of a specialist sexual health
clinic in Hammersmith and Fulham
■
A description of the sexual risk behaviours of college
students when they travel abroad
CE Cohen, NA Smith, S Bennett, J Marshall, S Mandalia, KA McLean
Chelsea and Westminster Healthcare NHS Trust, West London Centre
for Sexual Health, London, UK
Aims: To determine the rates of sexually transmitted infections (STIs)
and pregnancy in young people attending a specialised sexual health
clinic, ‘Cont@ct 2’, at the WLCSH, from its inauguration in June
2001–December 2003. To describe this unique service designed by
young people.
Methods: Data was collected prospectively for all Cont@ct 2
attendees, and was analysed using SAS statistical package.
Results: There were 1312 attendances from 734 patients, aged
13.6–21.5 years (mean, 17.7). Most were female [572 (77.9%)], 263
(35.8%) were white, and 335 (45.6%) of varying Black ethnicities. The
rate of infection with chlamydia was 16.7% (95/572) amongst females,
and 17.3% (28/162) amongst males. The rate of infection with
gonorrhoea was 5.4% (31/572) and 7.4% (12/162) respectively. There
were 378 attendances for contraception. The pregnancy rate was 7.5%
(43/572), 25 (57.8%) amongst girls of Black ethnicities. Eight (18.6%)
had concurrent STIs at diagnosis. Thirty termination of pregnancy
referrals were made for 29 girls.
Conclusion: This open-access clinic, operating after school hours, with
different registration facilities in a separate clinic area, has found high
rates of STIs and teenage pregnancy. The increasing numbers of yearly
attendances, testifies to the success of our approach and necessity to
expand this service.
P116
P117
■
A review of a nurse-led sexually transmitted
infection screening service, including laboratory
provision, in a young person's clinic after 9 months
K Jones, B Beeching, C Jones, M Devine, J Davies, P Roberts, C Bates
Royal Liverpool and Broadgreen University Hospital, Liverpool Brook
Centre, Liverpool, UK
Aim: To review the outcome and acceptability of sexually transmitted
infection (STI) screening in the setting of a young persons
contraceptive service.
Methods: Records of all clients who attended a GUM clinic at Liverpool
Brook Centre were reviewed.
Results: During the first nine months of this new service 666
appointments were attended; 576 (86.5%) were first attendee’s, 10
(1.5%) were re-registered clients and 80 attended for follow up. 544
(92.8%) clients received a full screen which in 222 (37.9%) was
negative. HIV testing was offered to 560 (95.6%) clients of whom 213
(37.2%) accepted. A partner notification audit of clients seen during
the first six months was carried out; 60.7% of known contacts
attended for testing and/or treatment. 61 (93.8%) clients from a
random sample of 65 completed a client satisfaction questionnaire. A
high degree of satisfaction was expressed regarding both premises and
staff attitudes.
Conclusion: A nurse led STI screening service, including laboratory
provision, in a community setting is acceptable to clients. More than
96% of clients seen were managed within the service. Evidence of
infection was found in 444 (62.1%); achieved rates of HIV tests offered
and contacts traced fell within national targets (DH 2002, SSHA 2004).
R Buckley, F Mulcahy
GUIDE Clinic, St James’s Hospital, Dublin, Ireland
Background: The number of students travelling abroad is increasing
yearly. This study raises the issues of the sexual ‘risk behaviour’ among
college students when they travel abroad.
Method: A quantitative study was conducted among undergraduate
students. 385 students were invited to participate, yielding a 78%
response rate.
Results: 30% had casual sex while abroad. Exploring this group showed
35% had unprotected sex, more males than females. 62% who had
casual sex abroad travelled with the intention of having sex, 86% were
male. Casual sex was more common among single people however;
unprotected casual sex was more common with those who were
already in an existing relationship at home. The time during sexual
intercourse in which a condom was put on varied from before genital
contact to after some penetration, increasing risk for sexually
transmitted infections. 98% of the college students were under the
influence of alcohol and 79% felt they drank excessively. Perception of
risks is lower than behaviour suggests.
Conclusion: Many perceive their risk as lower than their behaviour
suggests. Addressing this behaviour requires a health promotion
campaign challenging how holidays are promoted and addressing the
influence of alcohol and drugs on sexual health and correct use of
condoms.
P118
■
Sex work practices and condom use in female sex
workers in Sydney
J Fox1, RL Tideman1, S Gilmore1, C Marks1, I van Beek2, A Mindel1
1Department of Medicine, Imperial College, London, 2Sexually
Transmitted Infections Research Centre, The University of Sydney,
Westmead Hospital, Westmead, Australia
Objective: To determine sex work practices, sexual behaviour and
predictors of condom use among sex workers (SWs) in Sydney.
Methods: Female SWs were recruited from two sexual health centres
in Sydney. Participants completed a self-administered questionnaire
covering demographic, sexual and reproductive characteristics and sex
work practices. The association of each variable with condom use was
assessed.
Results: 148 International (born in Asia) and 141 Local SWs (born in
Australia, New Zealand or the UK) were recruited. 54% of International
SWs and 21% Local SWs had worked outside Australia (p=0.001). Local
SWs saw more clients per shift (p=0.002), but International SWs
worked more shifts per week (p=0.001). Local SWs had more
non-paying partners in their lifetime than International SWs (p=0.001).
International SWs used condoms less consistently at work but more
consistently with non-paying partners (=0.01) than Local SWs (0.001).
On multivariate analysis, inconsistent condom use was associated with
speaking Thai (p<0.001) or Chinese (p<0.001) and previous sex work in
Thailand (p=0.02).
Conclusions: International SWs used condoms less consistently than
Local SWs. Speaking Thai or Chinese and previous sex work in Thailand
were the only independent variables showing an association with
inconsistent condom use. Condom use with non-paying partners was
poor.
45
P119
■
Heterosexual men and women are less likely to use
the internet to look for sex than gay men
■
Is advice on condom use from HIV clinic staff
associated with sexual risk behaviour among
HIV-positive gay men?
J Elford1, G Bolding1, M Davis1, L Sherr2, G Hart3
UK
Aim: To examine the extent to which heterosexual men, women and
gay men use the Internet to look for sexual partners.
Methods: Heterosexual men, women and gay men attending a London
HIV testing clinic in 2002–2003 were asked to complete a
questionnaire concerning their use of the Internet for seeking sexual
partners.
Results: 331 heterosexual men (median age 30 years), 330
heterosexual women (28 years) and 319 gay men (32 years) were
included in the analysis (response rate 75%). The majority of
respondents were white, employed, had a higher education and had
access to the Internet at home or at work. Nearly half the gay men
(43%) had used the Internet to look for sex in the previous 12 months
compared with 10% of heterosexual men and 5% of heterosexual
women (p<0.001). Rates of high risk sexual behaviour were elevated
among those who used the Internet to look for sex (gay men,
25% v 12%, p<0.001; heterosexual men, 39% v 25%, p=0.2;
heterosexual women, 38% v 17%, p=0.1).
Conclusion: While heterosexual men and women are less likely to use
the Internet to look for sexual partners than gay men, those who do so
may be at elevated risk for STI.
G Bolding1, M Davis1, LL Sherr2, G Hart3, J Elford1
UK
Aim: To examine whether advice on condom use from HIV clinic staff
(in relation to HIV cross infection or undetectable viral load) is
associated with sexual behaviour among HIV positive gay men.
Methods: HIV positive gay men attending a London HIV outpatient
clinic in 2002–2003 were asked to complete a self administered
questionnaire (n=483, response 72%).
Results: Two-thirds of respondents (n=319) said they had discussed
HIV cross-infection with clinic staff and had been advised to always
use condoms for anal sex with another HIV positive man. The
remainder had not discussed it. There was no association between
discussing this with clinic staff and reporting unprotected anal
intercourse (UAI) with another HIV positive man (13% v 13%, p=1.0).
Two-thirds (n=304) said they had discussed HIV transmission risk when
their viral load was undetectable and had been advised to always use
condoms to avoid passing on HIV. There was no association between
discussing this with clinic staff and UAI with a partner of unknown or
discordant HIV status (26% v 23%, p=0.5).
Conclusions: Two-thirds of respondents had been advised by HIV clinic
staff to use condoms in specific situations but there was no association
between receiving this advice and their sexual behaviour.
P120
P122
■
Sexual behaviour of HIV-positive men who have sex
with men with gonorrhoea
C Newey, E Jungmann
Mortimer Market Centre, Camden PCT, London, UK
Backgound: Bacterial sexually transmitted infections (STIs) are
important risk factors for the transmission and acquisition of HIV,
together with increasing reports of unprotected anal intercourse (UAI)
with casual partners of unknown or discordant HIV status. This may
explain the sustained high incidence of HIV in men who have sex with
men (MSM).
Aim: To determine the sexual behaviour of HIV positive MSM with
gonorrhoea and estimate the risk of onward transmission of HIV.
Methods: Retrospective case note review of HIV positive patients with
gonorrhoea at a large HIV outpatient centre in London (01/04–09/04).
Results: 139 patients with gonorrhoea were identified. Preliminary
results of 61 patients showed the total number of partners recorded for
the preceding 4 weeks was 127 (1–4). Of these, 35% were known to be
HIV positive, 50% were of unknown or discordant HIV status 15%
missing. 70 (55%) were casual partners. 54% of episodes were UAI.
Median viral load was 165756 (200–1680700 copies/ml). Full results
will be presented at the conference.
Conclusion: This study shows the potentially high risk of onward
transmission of HIV in MSM with gonorrhoea and the need to offer
repeat screening for HIV to HIV negative MSM with gonorrhoea.
46
P121
■
Surveillance data on HIV and other sexually
transmitted infections (STIs) in the UK in 2003: can
we reach targets set in the National Strategy for
Sexual Health and HIV?
V Delpech, K Sinka, C Lowndes, J Parry, B Evans, N Gill on behalf of
the HIV/STI Department
CDSC, Centre for Infection, Health Protection Agency, London, UK
Aim: Current national surveillance data on the intersecting epidemics
of HIV and other STIs in the UK will be presented within the context of
targets of Sexual Health Strategy to reduce the undiagnosed
prevalence and transmission of STIs and HIV.
Results: Of the estimated 53 000 people living HIV in 2003, 27% were
undiagnosed. New diagnoses continued to rise among heterosexual
men and women born in sub-Saharan Africa, most acquiring their
infection abroad. Sustained high level of new diagnoses in MSM may
be partly explained by improved testing (uptake of 47% among MSM
attending GUM clinics in 1998 cf 64% in 2003). However, increases in
HIV incidence (3.7% of MSM attending GUM clinics in 2003) are of
concern. Antenatal HIV screening uptake is now high: >90% of HIV
infected women are diagnosed prior to delivery. Prevalence among
pregnant women born in the UK remains stable (0.03%). STI trends are
difficult to interpret but indicate limited progress in curtailing the
epidemic. Compared to 2002, chlamydial diagnoses increased by 8%;
genital warts 2%; syphilis 28% in men and 32% in women (cf a 4%
decline in gonorrhoea). STIs remain particularly high among young
people, MSM and ethnic minority groups.
11th
P123
Poster Abstracts
■
Is there a heterosexual epidemic of HIV in the UK?
PJ White, GP Garnett
Imperial College, London, UK
Aim: The annual number of new HIV diagnoses in heterosexuals in the
UK has increased rapidly in recent years, accompanied by increases in
reported risk behaviour and in the incidence of other
sexually-transmitted infections. However most of these
newly-diagnosed HIV infections were acquired outside the UK. We
examine whether there is a self-sustaining HIV epidemic – with
continued onward transmission leading to a potential explosion of
cases – occurring in heterosexuals in the UK.
Methods: We compare annual numbers of new UK-acquired
heterosexual HIV cases with the UK prevalence of HIV in heterosexuals,
to calculate the average annual number of new infections per
prevalent infection. This number must exceed a threshold value for
there to be sustained transmission. Since diagnoses reflect past
incidence of infection, sensitivity to the delay between infection and
diagnosis is examined.
Results: The average annual number of new infections per prevalent
infection is currently too low for there to be a self-sustaining UK
epidemic. However, of concern is the increase in this rate over time,
consistent with reported increasing risk behaviour.
Discussion: The evidence does not indicate a heterosexual HIV
epidemic currently occurring in the UK. However, transmission rates
are increasing and there is no room for complacency.
P124
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The use of geographical information software (GIS)
in sexually transmitted infections mapping
R Arms, A Wright, MR Pakianathan
Courtyard Clinic, St Georges Hospital, London, UK
Objectives: To explore the use of GIS to assess access to genitourinary
medicine (GUM) clinics according to ward of residence and to identify
areas of high sexually transmitted infection (STI) incidence.
Methods: Data from patients aged 15–29, living within a predefined
area, attending a GUM clinic from July 2003-2004 were analysed.
Attendance rates were calculated using census data. Ethno
demographic characteristics were compared between patients testing
positive for a non-viral STI (chlamydia, gonorrhoea, or syphilis) and
those attending for other reasons. Mapping was performed using ARC
GIS ©software.
Results: Of the 7442 patients identified, 749 (10.1%) were diagnosed
with a non-viral STI. Those with non-viral STIs were more likely to be
of black ethnicity (39.5% c.f 26.4%) [p≤0.001], particularly those with
gonorrhoea (63.4% vs. 26.4%) [p≤0.001] or be male (47.9% c.f
37.9%)[p≤0.001]. GIS software demonstrated that the highest rates of
attendance were from wards in close proximity to the clinic. High
disease incidence areas were also clearly demonstrated.
Conclusions: GIS is a useful in mapping access patterns of populations
to GUM services. It may also have a role in identifying ‘hotspots’ of
disease, thus assisting in targeted disease control initiatives. GIS maps
will be presented at the meeting.
P125
■
STISS: developing a national web-based STI coding
system in Scotland
AJ Winter1, C Thompson2 on behalf of the STISS steering group
1Sandyford Initiative, Glasgow, 2Department of GU Medicine,
Edinburgh Royal Infirmary, Edinburgh, UK
Problem: By 2002 Scottish GUM clinic ISD(D)5 (KC60 equivalent) data
collection was 3 years behind due to combination of failing
stand-alone IT systems, delays in processing paper-based returns and
lack of prioritisation by NHS trusts.
Intervention: A Scottish Executive-funded STI epidemiology working
group recommended adoption of centralized web-based data
collection. The STISS (STI Surveillance Scotland) system was developed
by Information Services of National Services Scotland. All clinics were
given NHS-net-enabled computers; diagnostic codes were revised to
introduce service codes, yielding denominator data. Key advantages
include: real-time secure data collection; real-time validation,
enhancing data completeness and accuracy; context-sensitive help;
flexible revisions to codes; scaleability to any number of locations with
minimum site visits.
Outcome: Web-based coding went live on 22/04/04. By 31/12/04,
11812 records had been submitted from 16 sites, with 60% of clinics
in Scotland participating. New mandatory service records were
complete for every record. Chlamydia positivity rate was 11.9% in
women, 13.3% in men. HIV test uptake rate 51.9% overall, 47.3% in
those with acute STI.
Conclusion: The new STISS system has greatly improved data
collection and quality and allows timeous reporting of STI trends and
positivity rates.
P126
■
Follow-up to establish the probable route of
infection for individuals diagnosed with HIV between
1997 and 2003 in England, Wales and N Ireland
VL Gilbart, KJ Sinka, RD Smith, S Dougan, BG Evans
The Health Protection Agency’s Centre for Infections, Colindale,
London, UK
Introduction: Understanding the epidemiology of HIV infection in the
UK requires establishing the transmission route for as many as possible
of those diagnosed. The national surveillance process includes
standardised follow-up of all cases where the likely transmission route
cannot be determined from the case report.
Methods: The route of infection categorisations of cases with
diagnosed HIV infection were compared before and after follow-up for
reports received between January 1997 and December 2003 by
examining the up-dated data as it stood at the end of 2004. The
contribution of this to the overall understanding of HIV infection in the
UK was evaluated.
Results: 10,911 reports required following up between 1997 and 2003.
At the end of 2004 full allocation to one of the established
transmission route categories was achieved for 9,205, 181 had been
closed unresolved and for 1,487 follow-up was continuing. Of those
allocated to a category, most were infected heterosexually and the
follow-up ascertained that the majority of these infections occurred
abroad. Thirty-eight cases which did not fall into one of the four main
transmission routes were identified.
Conclusion: Detailed follow-up provides a more complete
understanding of the changing epidemic in the UK, information
fundamental to the appropriate targeting of prevention efforts.
47
P127
■
Late presentation of HIV infection - more evidence
of health inequalities?
S Kegg, S Mitchell, J Russell
Queen Elizabeth Hospital, London, UK
Aim: To investigate determinants of late presentation of HIV
(CD4<200).
Methods: Notes review of all new diagnoses of HIV infection in 2004.
Results: 84 adults were newly diagnosed HIV antibody positive in our
centre in 2004. Late presentation was defined by baseline CD4<200.
No significant differences in baseline CD4 count were observed
between males and females, although black African men were
significantly more likely than black African women to present with
advanced disease (p=0.024). Moreover, no significant differences were
seen in baseline CD4 count between black African women testing as
part of the antenatal screening programme compared to those testing
in the GUM clinic setting. Predictably, individuals testing positive as inpatients had significantly worse CD4 counts than those electively
testing in the GUM clinic (p=0.007). A higher proportion of antenatal
diagnoses had well-preserved CD4 counts compared to those testing in
GUM clinic (p=0.037). Duration of stay in the UK at time of diagnosis
had no impact on baseline CD4 count.
Conclusion: Black African men remain a difficult to reach group for
early elective HIV testing. The impression that seeking HIV care drives
migration from high prevalence/resource-poor countries would appear
to be a largely false one.
P129
●
Patient preferences for partner notification
A Apoola1, KW Radcliffe2, S Das3, V Robshaw1, G Gilleran2,
M Kumari3, M Boothby2, R Rajakumar1
1Derbyshire Royal Infirmary, Derby, 2Whittall Street Clinic,
Birmingham, 3Coventry and Warwickshire Hospital, Coventry, UK
Aim: To identify patient preferences for notification of sexual contacts.
Methods: A questionnaire survey of 2500 patients attending the
Genito-Urinary clinics at the participating sites.
Results: An interim analysis of the first 1239 respondents is presented.
The median age was 24 years (range 13–69). The index patient's ratings
of the methods of contacting a sexual partner if they are found to have
a sexually transmitted infection are as follows:
Conclusions: Provider referral is less acceptable to patients than
patient referral for partner notification*. Notifying contacts through a
letter seems to be more acceptable than phoning, text messaging or
email**.
P128
P130
Withdrawn as requested
Who fails to attend following contact tracing?
●
R Finch1, G Bell2, KE Rogstad2
1Sheffield University School of Medicine, 2Department of
Genitourinary Medicine, Sheffield, UK
Aim: To identify the characteristics of contacts of chlamydia who fail
to attend following provider referral.
Methods: 217 (151 M; 66 F) heterosexual contacts of chlamydia
notified by a health adviser in 2003 from a provincial city GUM were
classified according to attendance, age, gender, ethnicity and
deprivation score. Postcodes were 'deprived' if below the 20th centile
on the Index of Multiple Deprivation Super Output Area Levels. C2
analysis was carried out using Epi Info.
Results: 70.9 % of males attended, v 80.3 % females (p=0.20); 74/107
(69.2%) ‘deprived’ attended v 86/110 (78.2%) less deprived (p=0.18);
65/97 (67.0%) under 20 attended v 95/120(79.2%) over 20s (p=0.06).
For ethnicity, differences in attendance patterns were highly
significant: 135/157 (86%) of whites compared with only 19/33 (56%)
of non-whites (p=0.0004).
Conclusions: Poorer outcomes for provider referral are strongly
associated with non-white ethnicity, and young age is almost
statistically significant; there is a trend for association with male
gender and poverty. This gives a useful insight into which populations
find access to sexual health services most difficult, and where other
control strategies (e.g. screening programmes) may be targeted most
effectively.
48
11th
P131
Poster Abstracts
●
P133
●
Stakeholder perspectives on delivering sex and
relationships education (SRE) in Tower Hamlets
Psychological and psychosexual impact of HIV
infection in an older population
T Fernandez, J Chapman, C Estcourt
St Bartholomews and The London, QMW, London, UK
Introduction: Sexpression, a Medical Student International Network
initiative is a voluntary, student led society at Bart's and The London
medical school. Set up in Tower Hamlets, Sexpression identified a need
for targeted, culturally specific Sex and Relationships Education (SRE)
in this ethnically diverse community. Working with the PCT and sexual
health services, Sexpression recruits and trains medical students to
deliver SRE to young people. Trained medical students will provide
informal interactive teaching to young people, thus supporting local
agencies and schools in the community. Sexpression highlights the
need for developing culturally sensitive and relevant SRE in line with
the needs of the local community.
Aim: Determine stakeholder perceptions of SRE delivery in Tower
Hamlets. Determine stakeholders views on the role of Sexpression
within context of SRE delivery as a community initiative.
Methods: Semi-structured interviews with a cross section of
stakeholders including teachers, nurses, youth workers, community
leaders, sexual health services managers, parents centre manager,
department of education.
Results: Qualitative inductive thematic analysis will be presented using
data from the semistructured interviews. The results include themes
about consumer involvement, cultural sensitivity, and educational
content.
Conclusion: Data highlights that consumer involvement is crucial for
organisational and personnel development of delivery plans for SRE.
S Delamere , F Mulcahy, S Clarke
Genito-Urinary and Infectious Diseases Clinic (GUIDE), St James’s
Hospital, Dublin, Ireland
Background: As people become older their sexual habits change. This
study is looking at how this affects sexual habits of HIV positive
patients. A total of 27 patients aged 60 years and over (Males =23,
Females =4) attend the HIV Clinic.
Aim: The aim of this study is to identify the psychological and
psychosexual impact of a HIV diagnosis in an older patient cohort.
Methodology: A mini-mental assessment and a detailed structured
questionnaire was performed on the first sequential twelve patients
aged 60 years and over. This recorded demographic information,
previous medical history, psychological aspects of their diagnosis and
the psychosexual impact of a HIV diagnosis.
Results: Twelve patients were interviewed (male 9, female 3) mean age
69 years (Range 62–81 years) Risk factor for HIV acquisition was
Heterosexual (5) Bisexual (6) Blood transfusion (1). Mini-mental
assessment scores ranged from 22–30. (Normal range 25–30).
Following their diagnosis, 50% of patients described a new onset of
insomnia, 33% of patients described significant anxiety symptoms.
Prior to diagnosis nine patients enjoyed sexual intercourse, one enjoyed
sex post diagnosis, eight patients no longer had sex because of HIV,
four patients described new onset of erectile dysfunction post
diagnosis.
Conclusion: This study demonstrates a significant morbidity associated
with the aging HIV population.
P132
P134
●
One-stop shop versus collaborative integration: what
is the way forward?
RS French1, C Fenton1, M Gerressu1, A Graham2, D Gray2,
C Salisbury2, J Coast2, S Hollinghurst2, A Robinson1, K Miles1,
CH Mercer1, K Rogstad3, J Stephenson1
1Centre for Sexual Health and HIV Research, The Mortimer Market
Centre, University College London, London, 2Department of
Community-Based Medicine, University of Bristol, Bristol, 3Dept of
GUM, Royal Hallamshire Hospital, Sheffield and Chesterfield and North
Derbyshire Royal Hospital, UK
Aim: To examine models of integrated and/or one-stop shop (OSS)
sexual health services (including general practice, mainstream
specialist services and designated young people's services), exploring
their relative strengths and weaknesses.
Methods: Literature review, interviews with key-informants involved in
developing the UK's National Strategy for Sexual Health and HIV
(n=11), and site observations at services taking part in the national
OSS evaluation.
Results: Contraceptive and genito-urinary medicine issues are closely
related. However, there is no agreement about what it means to have
integrated services, about which services should be integrated or where
integration should happen. There are concerns OSSs will result in
over-centralisation, precluding the continuation of stand-alone and
satellite services. OSS models are potentially more user-focused, but
the stigma that surrounds sexual health services may create an access
barrier. From staff perspectives, the highlights are greater career
opportunities and increased responsibility, while the downsides are
concerns OSSs will result in loss of expertise and professional status.
Parallel services are expensive and limited resources often mean there
are reduced opening hours, however data on cost-effectiveness is
contradictory.
Conclusion: Despite a policy commitment to developing OSS services,
the evidence gap around the impact and appropriateness of this
approach is substantial.
●
Did the ‘Brazilian’ kill the pubic louse?
NR Armstrong, JD Wilson
Department of Genitourinary Medicine, The General Infirmary at Leeds,
Leeds, UK
Background: Anecdotes suggest a recent reduction in cases of pubic
lice despite increasing patient numbers and increasing prevalence rates
of other sexually transmitted infections (STIs). The aim was to
determine the prevalence rates of pubic lice between 1997 and 2003,
and compare these with rates of gonorrhoea and chlamydia over the
same period.
Methods: Annual cases of pubic lice, gonorrhoea and chlamydia were
obtained for 1997 to 2003. Prevalence rates were calculated by
dividing these figures by new patient numbers.
Results: The prevalence rates were:
Year
GC
CT
Public lice
1997
1.7%
9.4%
0.41%
1998
1.3%
11.1%
0.43%
1999
1.6%
12.3%
0.39%
2000
2.8%
12.8%
0.25%
2001
2.6%
12.2%
0.27%
2002
3.8%
13.2%
0.30%
2003
3.5%
12.0%
0.17%
Comparing 2003 with 1997 there was a significant drop in prevalence
of pubic lice (OR 0.41; 95%CI 0.23–0.70) whereas there was a
significant increase in gonorrhoea (OR 2.18; 1.86-3.48) and chlamydia
(OR 1.31; 1.21–1.43).
Conclusion: Sexual behaviour changes cannot account for this
discordant pattern of STIs so there must be another explanation. The
drop in pubic lice in women was around 2000 and coincided with the
introduction of new trends in pubic hair removal. Full breakdown of the
figures will be presented and correlated with pubic hair removal
practices.
49
P135
■
■
Characteristics of patients declining an HIV test in a
genitourinary medicine clinic
KNOW4SURE – a community-based rapid HIV point
of care test (POCT) clinic
J Zhou1, R Webb2, S Ghosh1 ST Sadiq2, MR Pakianathan1
Medical School, London, UK
Aim: To determine the characteristics of patients who decline HIV
testing in a GUM clinic since the introduction of a routine testing
policy.
Methods: Retrospective case notes analysis of patients declining HIV
testing compared to those accepting over a three-month period in
2004. Demographic characteristics, risk behaviour and KC60 diagnostic
codes were compared.
Results: Of a total of 1996 patients who were offered HIV testing, 797
(39.9%) declined the test. A random sample of 220 (103 accepting, 117
declining) was analysed further. Factors associated with an increased
likelihood of accepting an HIV test included same sex relationships for
men (odds ratio [OR] 5.01, confidence interval [CI] 1.72 to 14.60) and
a discernible HIV risk factor ( OR 9, CI 2.40 to 5.07). Declining testing
was not association with gender, a concurrent STI diagnosis or having
tested previously. However, 20% of patients declining the test had
identified risk factors for HIV infection.
Conclusions: A routine testing policy for HIV within GUM clinics does
not guarantee universal uptake. While patients perceived to be at risk
are more likely to test, a significant proportion of patients with risk
factors continue to decline testing. Further detailed analysis will be
presented at the meeting.
R Mugezi1, A Barrat1, A Wilkinson3 A Waters1, A McOwan2,
AK Sullivan1
1John Hunter Clinic, London, 1,2Chelsea and Westminster Hospital,
London, 3Terence Higgins Trust, Lighthouse West London, London, UK
Aim: To evaluate an outreach, rapid HIV POCT clinic.
Method: We reviewed the case records of all attendees to a
community-based, weekday evening clinic offering a maximum of
10 tests per session.
Results: 626 individuals attended over 21 months, 73% men, 30%
MSM, 0.5% IVDU. The mean age was 31.7 years, and 23% were from
BME communities. 96% of responders indicated a preference for
evening/Saturday clinics, 87% preferred a walk-in service. 55% had
tested before, mean 2.1. 9% were expecting a positive test result, and
26% admitted to high level worry regarding HIV. The availability of a
rapid test influenced the decision to test for 96%. Identified risks
included unprotected intercourse; 52% vaginal, 16% anal and 16%
oral. 60% had a partner of unknown HIV status and 6% a known HIV+
partner. 597 tests were performed, 22 (3.7%) were positive. Recent
increase in number of tests and staff has resulted in 30% increased
attendance.
Conclusion: A large proportion of individuals testing were at low risk
for HIV, reflected in the relatively low diagnosis rate. Current
interventions are underway to increase the attendance of individuals at
higher risk. Rapid testing and 'out of hours' services are preferred.
P136
P138
1Courtyard Clinic, St George’s Hospital, London, 2St George’s Hospital
■
Do differences in access to GUM clinics or HIV
testing behaviour of African men and women
account for the high proportion of women testing
HIV-positive in the UK?
K Bond, I Begum, EF Fox
Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
Background: In 2003, 59% of new UK HIV diagnoses were acquired
through heterosexual sex, and 65% of these were women,
predominantly from Africa. We aimed to determine if this could be due
to higher uptake of HIV tests in African women than men, through
increased access to our GUM clinic, or being offered or accepting a test
more often than men.
Methods: All African-born new patients of Black African ethnicity
attending between January and June 2004 were reviewed to determine
if an HIV test was offered and accepted. Data collected on sex, age,
sexuality, presenting complaint and STI diagnosis, was analysed using
Chi squared.
Results: 234 men and 190 women attended. 95.5% men and 94.6%
women were offered an HIV test (p=0.813) and 73.8% men and 72.8%
women accepted (p=0.906). 12 men and 12 women tested positive
(p=0.517). Asymptomatic patients were significantly more likely to
accept an HIV test than symptomatic patients (p=0.009).
Discussion: Women and men were equally likely to be offered and
accept an HIV test in our clinic. More men than women attended. This
study did not demonstrate that greater testing of women than men in
GUM accounts for the high proportion of new infections in women.
50
P137
■
Acceptability of voluntary HIV testing among NHS
staff: results from a questionnaire-based survey
M Hamill1,2, S Murphy2
1Patrick Clements Clinic, Central Middlesex Hospital, London, 2Jefferiss
Wing, St Mary’s Hospital, London, UK
Background: Numbers of healthcare workers from high endemnicity
areas employed by the NHS are increasing. The DoH has guidelines for
the responsibilities of HIV infected staff but none for universal
voluntary testing of healthcare workers.
Aims: To assess the acceptability of voluntary HIV testing for NHS
staff.
Methods: Anonymous questionnaire to staff at a London DGH.
Results: Of the first 69 respondents: 75.4% were female, 23.3% male,
1.4% no data available (NDA). Ethnicity: 11.6% black British, 30.4%
white British, 8.7% Asian British, 5.8% Caribbean, 11.6% African,
11.6% Asian, 2.9% black other, 13% white other and 4.3% NDA.
38% were nurses, 19% doctors, 16% clerical/administrative, 7%
healthcare assistants, 20% other. 92.4% understood the terms
HIV/AIDS, NDA 5.8%. 39% had a previous HIV test. None were known
HIV positive. 42% worked in areas offering routine HIV testing, 55%
did not, NDA 3%. 62% would consider having an HIV test, 38% would not.
Of the 62%, reasons given were:
Of the 38%, reasons given were:
11th
P139
Poster Abstracts
■
Effects of restrictions to HIV-positive people
travelling to the USA
P141
■
Non disclosure of HIV-positive status
M Mahto, E Wilkins
North Manchester General Hospital, Manchester, UK
Background: The USA bans entry to non-citizens with HIV unless they
obtain a waiver visa.
Aim: To establish how many people with HIV infection travelled to the
USA, whether they were aware of the travel restriction, whether they
travelled with a waiver visa and medical insurance, how they managed
with their HAART and their feelings towards the ban.
Design: Cross sectional study, using a structured self-completion
questionnaire.
Results: 408 questionnaires were returned (73%). 99 (24%) had
travelled to the USA since testing positive of whom 83% took out
medical insurance, 64% were aware of the waiver visa, and 76% were
on HAART. Of those taking HAART, 10% posted their medicines before
travel, 47% took their drugs on time, 32% took a doctors letter, and
16% were searched. Only 5% of patients obtained a waiver visa before
travel with 9% discontinuing their medication before entering the USA.
Many patients reported negative practical and emotional experiences
resulting from the travel restrictions.
Conclusion: The majority of HIV patients travel without the waiver
visa, many with insufficient planning and advice; in nearly 10% of
patients, this led to discontinuation of therapy without medical advice.
N NÌ Rathaille, S Flynn, J Herbst, O Halvey, E O'Donoghue, F Mulcahy
St James Hospital, Dublin, Ireland
Objectives: To examine the social and demographic status of patients
who have reported sexual contacts without disclosure.
Methods: From Jun 04–Nov 04 patients were interviewed in depth by
medical social workers (MSW) to establish patterns of non-disclosure
and thereby facilitate contact tracing.
Results: 22 HIV+ heterosexuals, (9 male, 13 female) of whom 5 (23%)
identified their source of infection as IVDU, were interviewed. 18 had
received post-test counselling. 16 (73%) reported being in a
relationship >6 months, (4 married, 7 co-habiting.) 17 denied any
casual sexual contacts. 12 report to be sexually active, 10 of these
reporting regular condom use. 14 partner contact details were
withheld. In 11 cases, disclosure occurred within the first 6 months of
strategic disclosure intervention. The majority of disclosures were
undertaken by patients (n = 9). 1 by a third party and 1 through
anonymous contact tracing. 11 have yet to disclose and work is
ongoing. Factors impeding disclosure include fear of relationship
breakdown (n = 14) and domestic violence (n= 5).
Conclusion: This research revealed a complex and broad range of
difficulties around the issue of disclosure. This may necessitate a
considered, individualised approach when working on disclosure issues
and the need for further research.
P140
P142
■
What impact can an HIV conference have on the lives
of people living with HIV?
B Evans
On behalf of the four Changing Tomorrow conference partners:
National AIDS Trust; National Long-Term Survivors Group, Positively
Women, UK Coalition of People Living with HIV and AIDS, UK
Aim: To investigate whether Changing Tomorrow had an impact on the
lives of participants.
Methods: 208 pre-conference questionnaires completed, an
independently assessed evaluation of the conference and
post-conference questionnaires.
Pre-conference findings: Only 5% of participants said they were in
poor health. 70% were taking HIV treatment, however 85% worry
about long-term effects. A further 9% are put off as a result. 70% were
satisfied with both their treatment and experiences of health care. Only
6% were unhappy with their specialist HIV care. White people rated
their understanding of the NHS higher and had more confidence to get
involved. A disproportionate number of heterosexual men were not
satisfied with many aspects of their life. Most participants had told
somebody about their HIV status, only 13% receiving a negative
reaction.
Conference evaluation findings: 65% felt more confident about
disclosure. 97% stated intentions to take further action (involvement
in the NHS, being proactive about health, increasing levels of
optimism).
Post-conference findings: analysis of post-conference questionnaires
identified actions taken by participants and changes in attitudes and
behaviour; 44% were less worried about the long-term effects of HIV
medication; moderate levels of involvement had increased by over
40%; 51% were more satisfied with the overall quality of their life;
46% were eating more healthily.
Conclusion: Changing Tomorrow had a significant impact on the lives
of participants living with HIV.
●
HIV opt-out increases the offer and uptake of HIV
tests in patients at low risk for HIV (LRP) in a
genitourinary medicine (GUM) clinic
H Price, I Thompson, J Birchall, C Newey, E Musgrave, F Smith, AM
Waters, AK Sullivan
Department of Genitourinary Medicine, Chelsea and Westminster
Aim: To evaluate the effect of introducing HIV opt-out testing for
patients assessed as LRP on test offer and uptake rates in the John
Hunter Clinic (JHC).
Methods: The case notes of 100 consecutive new attendees at 3 clinics
(JHC,C2,C3) were reviewed before (T1) and after (T2) the introduction
of HIV opt-out testing in JHC.
Results: The notes of 600 patients were reviewed, 319 were male, 23%
MSM, mean age was 29.4 years. The offer of HIV tests rose in JHC vs
C2+3 (88 to 94% vs 85 to 83%, p<0.001). The number of LRP offered
a test increased in JHC T1 vs T2: 64 vs 80%, p=0.012. The number of
tests performed increased in JHC vs 2+3, for all patients 70 vs 56%,
p=0.045, for LRP 72 vs 52% p=0.003. Of LRP in JHC offered a test,
uptake did not change, 77%.
Conclusion: The introduction of HIV opt-out for low HIV risk patients
increased the number of HIV tests offered and performed. The increase
in LRP uptake appears to be due to increased offer rather than
increased proportion accepting the offer, suggesting this was not
influenced by a change in staff input beyond the opt out process.
51
P143
●
HIV testing and the sexual health strategy: are we
‘targeting’ the right people?
52
●
Successful implementation of a new HIV testing
service in an inner-city primary care practice
I Reeves, M Poulton, M Tenant-Flowers
Aim: To investigate whether national targets for HIV testing are being
achieved and whether those at high risk test.
Method: A retrospective audit of patients attending for an STI screen
during one week with collection of risk data.
Results: The notes of 333 patients were reviewed. New patients: 95%
offered HIV testing with 57% uptake. Of 125 re-attending patients
45% tested for HIV: 44% not offered and 50% declining a test had
never tested. All 11 gay men and one female commercial sex worker
accepted a test. Black patients were significantly less likely to test than
White patients when attending for a first screen (p = 0.016). This
relationship remained significant only for Black Caribbean patients
amongst all Black ethnic groups. The testing uptake for those reporting
>1 or 1 or 0 sexual partners in the previous three months was not
significantly different. Overall 33% of those diagnosed with an STI also
had an HIV test.
Conclusions: National strategy targets for HIV testing can be achieved
but do not necessarily result in uptake of testing amongst those at high
risk. Further work is needed to identify ways to increase uptake in
certain groups. Sensitive, non-invasive testing may offer a solution.
P144
P145
●
R Bickersteth1, A Benhene Poku2, SGG Sekweyama2, B Bailey1, EF Fox1
1Guy's and St Thomas’ NHS Foundation Trust, 2Trafalgar General
Practice, Southwark, London, UK
Background: The national strategy for sexual health and HIV supports
outreach services to target risk groups with high rates of undiagnosed
HIV. We started a weekly community HIV testing service in Southwark,
incorporated into the new patient health check, targeted at the African
population. It is run by practice nurses following training by the STI
Management in Primary Care Project, supported by the community
health adviser.
Methods: All new patients registering with the practice are offered HIV
testing. Data was collected on age, ethnicity, country of birth,
acceptance of HIV test, HIV result and attendance for results from the
first 3 months of the service, 2004. One year data will be presented.
Results: 6 women and 11 men attended. 8/17(47%) were Africans and
2/17(12%) Jamaican. 16/17(94%) had not tested for HIV previously. All
attendees accepted an HIV test following pre-test discussion.
2/17(12%) patients tested HIV +ve. 12/17(71%) DNA’d their result
appointment.
Discussion: It is possible to set up an HIV testing service in
collaboration with primary care colleagues, which successfully targets
at-risk individuals who have not previously tested for HIV. Given the
high DNA rate for results, alternative methods of informing patients of
their results should be considered.
P146
●
Bridging the gap – reducing undiagnosed HIV
infection through targeted training in non-specialist
settings
Uptake of HIV test is enhanced by a special
post-carnival 'KNOW4SURE' clinic offering rapid HIV
point of care testing (POCT)
J Roberts, M Ottewill, G Dean, DR Churchill, M Fisher
Claude Nicol Centre, Royal Sussex County Hospital, Brighton, UK
Background: Late diagnosis of HIV is associated with poorer outcome
to treatment. Many ‘late presenters’ have previously received care by
specialities without HIV being recognised. To attempt to reduce such
late diagnosis we constructed an interactive training package on HIV
testing with individualised case studies for each speciality.
Methods: Questionnaires were completed to determine attitudes and
barriers to HIV testing. HIV testing patterns were measured for
3 monthly periods both prior to and after the training package and any
positive diagnoses were noted.
Results: 6 specialities undertook the course, totalling 57 participants.
54% had previously performed an HIV test. Commonest barriers were
uncertainty regarding testing procedure, concern about raising patient
anxiety and giving a positive result. Confidence in testing increased
from 17.5% to 47.3% after the course. HIV tests performed during 3
month periods before and after the course was essentially unchanged
(20 vs 19). However 3 new HIV diagnoses were made, in the postcourse period. A further 18 patients were referred to GUM for testing,
of which 3 tested positive.
Conclusions: A focused course improves confidence in HIV testing and
targeted referral to GUM. It has minimal effect on testing frequency
but may assist in identifying a small number of infections.
R Mugezi1, A Wilkinson3, U Kalidini2, R Betourney1, A Waters1,
J Anderson2, AK Sullivan1
1John Hunter Clinic, Chelsea and Westminster Hospital, 2Homerton
University Hospital NHS Foundation Trust, 3Terence Higgins Trust,
Lighthouse West, London, UK
Aims: To evaluate the effect of providing specific event-related HIV
testing clinics following targeted promotion at a community event, and
the effect of offering rapid HIV testing at one of the clinics.
Method: Two one-off HIV testing clinics were held following
promotion to Black and Minority Ethnic (BME) communities at the
Notting Hill Carnival. A Saturday clinic offering rapid HIV POCT was
held at the Lighthouse West London (KNOW4SURE) and a Thursday
evening clinic offering standard HIV testing was held at the Homerton
Hospital (HH).
Results: 17 people attended KNOW4SURE, none attended HH. Eight
were male, 14 heterosexual and the mean age was 32.1 years. 73%
identified themselves as being BME, compared to 24% of those
attending the regular weekly ‘KNOW4SURE’ Monday evening clinics
held at the same location (p<0.001). 10/10 (100%) attendees preferred
evening or weekend clinics. 12/13 (92%) were influenced by the
availability of one hour testing and 7/13 (54%) would not have tested
had it not been available.
Conclusion: Promotion of an event specific clinic increased the
proportion of individuals from a target population attending. The
availability of rapid HIV POCT appears to influence testing behaviour.
11th
P147
Poster Abstracts
●
P149
●
Unusual mode of transmission of HIV
The complexity of travelling with HAART
C Emerson, C Cunningham, SP Quah
Royal Victoria Hospital, Belfast, UK
We report an unusual case of HIV transmission that would be missed
by traditional assessment of risk.
A 39 year old Caucasian man developed flu like illness with symptoms
of lethargy and weakness, August 2002. Persistent lymphadenopathy
lead to HIV being considered January 2003. A subsequent HIV test was
positive. He has one lifetime female Caucasian partner. He had no past
history of blood transfusions or IVDU. Of note his 37 year old brother
had contracted HIV in Botswana via heterosexual contact two years
previous. He was on HAART (combivir and nevaripine) and had a CD4
350 (16%) with viral load 4800 (log 3.68). A bloody fight had occurred
between them July 2002. Post exposure prophylaxis was not
considered. To determine if this was the mode of transmission
phylogenetic analysis was undertaken. Analysis of the pol gene region
indicated that samples from both brothers belonged to the subtype
C clade of HIV-1, and that the sequences were closely related to one
another. We present this subject to highlight the importance of careful
history taking. Exposure risk data is extremely useful in helping counsel
patients prior to HIV testing but as this case illustrates must not be
used in a rigid way.
MA Schuhwerk1, J Richens2, H Wyss1, L Kirkpatrick1, C Ashton1,
RH Behrens3
1Mortimer Market Centre, Camden Primary Care Trust, 2Centre for
Sexual Health, University College Hospital, 3Hospital for Tropical
Diseases, University College Hospital, London, UK
Aim: To investigate the issues of antiretroviral therapy in the context
of foreign travel
Methods: Retrospective questionnaire based survey of HIV positive
individuals attending the Bloomsbury HIV outpatient clinic.
Results: 72% (n=216) of study participants were on HAART, 4% had
started therapy less than 4 weeks prior to travelling and 8% less than
3 months. 5% were on a triple nucleoside, 26% on a PI, 64% on an
NNRTI and 5% on a PI/NNRTI regimen. 12% stopped HAART for the
duration of their holiday. 26% reported side-effects to HAART prior to
travelling, 8% had worsening and 2% new side-effects during their
trip. 81% reported no change in adherence, 11% worse and 8% better
adherence to medication whilst travelling. 14% reported storage
problems and 15% were searched and questioned at border entry point.
Nobody had been refused entry. 38% of patients travelling were
unaware of potential drug interactions.
Transport to destination: 81% carried medication in their
hand-luggage, 32% in their suitcase, 6% mailed HAART to their
destination. Individuals used a variety of ways to adapt to time zone
changes.
Conclusion: Travelling on HAART has many complex issues and needs
appropriate discussion with the HIV positive individual.
P148
P150
●
Non-disclosure of previously known HIV
seropositivity in patients newly diagnosed with HIV
infection
M Natha1, A Newell1, M Pakianathan1,2
South West London HIV and GUM Clinical Services Network,
1Heath Clinic, Mayday University Hospital, Croydon, 2Courtyard Clinic,
St George’s Hospital, London, UK
We present a case series of five individuals who had previously been
diagnosed with HIV, who then re-presented for HIV antibody testing
and subsequent treatment without disclosing their HIV positive status.
All patients were of African origin. Reasons for non-disclosure included
fear of discrimination, immigration worries and concerns as to how
they may be treated. Non-disclosure can lead to failure to recognise
pre-existing antiretroviral drug resistance and toxicities, failure to
address relevant social problems and inappropriate antenatal
treatment increasing the risk of mother-to-child-transmission.
Antiretroviral resistance already documented in several sub-saharan
African countries is likely to increase with expanded access to
treatment. Clinical clues such as a raised mean cell volume and
lipodystrophic morphology raised suspicion in our cases. Deranged lipid
profiles or pigmentation are other indicators. The supposition that
patients with low viral loads may have a non-B clade viral subtype may
not always be accurate. Therapeutic drug monitoring and genotypic
resistance testing can also be useful. Three out of our five cases had
extensive multi-class resistance. In all cases, disclosure occurred after
multiple clinic attendances. Clinicians should consider the possibility of
HIV status non-disclosure and previous exposure to antiretrovirals
when seeing newly diagnosed patients with HIV.
●
How accurately do patients with HIV know their viral
load and CD4 cell count?
G Bolding1, M Davis1, L Sherr2, G Hart3, J Elford1
UK
Aim: To examine how accurately HIV positive gay men recall their most
recent CD4 cell count and viral load test result.
Methods: 523 HIV positive gay men (72% response rate) attending a
London HIV outpatient clinic in 2002–2003 completed a self
administered questionnaire in which they reported their last CD4 cell
count and viral load test result. Self-reported data were compared with
corresponding data abstracted from patient records.
Results: Four out of five men said they knew the result of their last CD4
cell count (404/519, 78%) or viral load test (428/518, 83%). Half the
men (51%) who said they knew their last CD4 cell count correctly
reported it to within 50 cells/mm 3. The remainder under- or
over-estimated their CD4 cell count by more than 50 cells/mm3 (27%,
21% respectively). Most men who knew their viral load test result
correctly reported it as being detectable or undetectable; 95% of the
269 men with a laboratory-confirmed undetectable viral load, and 91%
of the 126 men with a laboratory-confirmed detectable viral load
correctly reported this.
Conclusion: Most HIV positive gay men correctly reported whether
their viral load was detectable or not and half knew their CD4 cell
count to within 50 cells/mm3.
53
P151
●
Diagnostic value of bone marrow (BM) sampling in
HIV-infected patients in the era of HAART
MJ Llewelyn, M Noursadeghi, A Dogan, SG Edwards, RF Miller
University College London, London, UK
Aim: To assess the diagnostic value of BM sampling in investigation of
HIV infected patients since availability of HAART.
Results: 114 consecutive patients underwent BM sampling between
1999 and 2004. BM aspirates were normal or non-diagnostic, apart
from lymphoma in one and mycobacterial infection in two patients;
culture identified mycobacterial infection in nine. BM trephine had a
diagnostic yield of 26.1 % in patients with fever and cytopaenia
[mycobacteriosis in 13.9 %, lymphoma in 6.2 %, Castleman disease in
3 %, 'drug effect' in 3 %], a yield of 20 % in patients with fever, but
no cytopaenia [mycobacteriosis in each case] and a yield of 19.1 % in
patients with cytopaenia in the absence of fever [lymphoma in 4.8 %
and ‘drug effect’ in 14.3 %]. For investigation/staging of lymphoma
diagnostic yield was 36%. Diagnostic yield from BM sampling was
30.2% in patients receiving HAART and 22.5% in those not receiving
HAART. BM sampling was of most diagnostic value in patients where
fever and cytopaenia coexisted in the absence of localizing signs of
infection, and in the staging/investigation of lymphoma.
Conclusions: BM sampling continues to have a diagnostic utility in HIV
infected patients in the era of HAART.
P152
●
Vitamin D deficiency in HIV-seropositive individuals
AJ Tunbridge, E Ronan, S Naylor, DH Dockrell, SC Metcalf
Department of Infection and Tropical Medicine, Royal Hallamshire
Hospital, Sheffield, UK
Background: Vitamin D levels are associated with immune system
differentiation and function. Nutritional deficiencies are common in
HIV sero-positive individuals. Little information is however available on
the incidence of Vitamin D deficiency in HIV sero-positive individuals
or its impact on immune function.
Methods: Vitamin D levels (assayed by immunoassay), basic
demographic data, CD4 T-lymphocyte counts and HIV viral loads
obtained at the same visit were recorded for 43 sero-positive
individuals.
Results: 63% were male and the median age was 39 (range 23–63).
The median CD4 T-lymphocyte count was 363 (range19–1127) with 8
(19%) of individuals having a CD4 count < 200 cells. 27 (63%) of
individuals were receiving HAART with a low or undetectable viral load.
The median Vitamin D level was 38.3 (range 11.9–124.8 nmol/L).
According to local guidelines one individual (2.3%) had severe vitamin
D deficiency (<15nmol/L) and 11 (25.3%) had mild deficiency (15–30
nmol/L). The median CD4 counts in the deficient group was
311(19–663) vs. 416 (131–1127) in the non-deficient group. This
represented a weakly positive (r=0.17) but not significant correlation.
Conclusions: Mild vitamin D deficiency is common in HIV positive
individuals and shows a weakly positive correlation with CD4
T-lymphocyte numbers.
54
P153
●
HIV infection and sexually transmitted infections
among persons with insecure immigration or seeking
asylum in the UK
V Lee1, E Foley1, R Patel1, JM Tobin2
1Department of GU Medicine, Southampton University Hospitals NHS
Trust, 2Department of GU Medicine, St Mary’s Hospital, Portsmouth, UK
Background: Recently over 30% of new HIV infections diagnosed in
the UK are in those born outside this country. An increasing work load
in GU Medicine clinics arises from individuals with insecure
immigration or seeking asylum.
Aim: To determine the prevalence of HIV infection and other STI’s in an
immigration removal centre in the UK.
Method: From April 2004 a sexual health screening clinic was
established in a male immigration removal centre.
Results: To date 99 individuals have attended, representing 15% of the
total inmates. The majority (74%) were from African countries and the
mean age was 29 years. 16% had previously had a negative HIV
antibody test. 40% admitted to sexual intercourse with a UK national.
During the study 4 new HIV, 3 latent syphilis, 2 gonorrhoea and
1 chlamydia infections have been diagnosed.
Conclusion: A small proportion of the group were diagnosed HIV
antibody positive, yet its prevalence (4%) is higher than that of the
general population in the UK. A smaller number of STI’s were diagnosed
yet in all cases these were asymptomatic. In view of this higher level
of serious infection targeted screening services should be made
available at an early stage to this group.
P154
■
Five years of non-occupational post-exposure
prophylaxis (NONOPEP) in a south London teaching
hospital
S Day, A Mears, K Bond, R Kulasegaram
Harrison Wing, St Thomas' Hospital, London, UK
Aim: An observational study of non-occupational post-exposure
prophylaxis (NONOPEP) prescription.
Methods: Data was collected from NONOPEP recipients managed in a
South London Genitourinary clinic between 1st Jan 2000 and 1st Dec
2004.
Results: 101 patients received NONOPEP. These were predominantly
white (81%), homosexual (57%) and male (82%), of median age 33yrs
(range 20 to 65yrs). 44% initially attended Casualty. 33% prescriptions
were given during the last six months alone. Exposure type was usually
sexual intercourse (75%) [anal(56/76), vaginal(18/76)]. 74% sexual
exposures received NONOPEP in accordance with BASHH guidelines.
91% sexual acts were consensual of whom 68% knew their source.
Antiretroviral therapy and HIV viral load of ‘known’ sources was
reported in 43% and 29% respectively. 88% received
combivir/nelfinavir. 45% completed the course. Side effects were
experienced by 56% and were the predominant reason for therapy
discontinuation. Median ‘exposure to NONOPEP’ time was 19.5hrs. No
patients seroconverted although, only 46% attended for 3m/6m HIV
testing. 75% received baseline HIV testing. Baseline screening
identified one patient infected with Hepatitis C.
Conclusion: NONOPEP prescription has increased in the last six months
possibly due to enhanced public awareness. NONOPEP is prescribed
following predominantly ‘high-risk’ exposures with recommended
combinations. Follow up attendance rates are poor.
11th
P155
Poster Abstracts
■
Impact of BASHH guidelines upon PEP provision
following sexual exposure to HIV
■
STI self-treatment, STI prophylaxis and auto-PEP
A Beattie, S Roedling, SG Edwards, P Benn
Department of Genitourinary Medicine, Mortimer Market Centre,
Camden PCT, London, UK
Background: BASHH guidelines for post exposure prophylaxis (PEP)
following sexual exposure to HIV outlines when PEP is recommended
(R), should be considered (C) or not recommended (NR).
Aim: To establish whether introduction of the guidelines has
influenced prescribing practice.
Methods: Retrospective case note review of individuals requesting PEP
pre- (21/3/03-20/3/04) and post-introduction of the BASHH guidelines
(17/7/04–31/12/04). Demographics, exposure characteristics and
clinical data were collected. Prescribing practice was classified: 1/R,
2/C or 3/NR according to the guidelines.
Results: Pre-guidelines 97 individuals requested PEP, of which 51/97
(52.5%) followed sexual exposure. 48/51 (94.1%) started PEP: 40/48
(83.3%) were classified as R, 5/48 (10.4%) as C and 3/48 (6.25%) as
NR. Following introduction of guidelines 100 individuals requested PEP
of which 80 followed sexual exposure. Data were available for 69.
62/69 (89.8%) started PEP: 52/62 (83.8%) were classified as R, 8/62
(12.9%) as C and 2/62 (3.2%) as NR. Overall only 5/110 (4.5%) who
received PEP were classified as NR.
Conclusions: The majority of PEP is issued within guidelines and since
their introduction prescribing practice appears unchanged at MMC.
Practice may be most influenced by these guidelines outside GUM
settings or where prior demand has been low.
P156
P157
■
Impact of raising awareness of post exposure
prophylaxis for HIV infection following sexual
exposure
S Roedling1, I Reeves2, A Beattie1, S Edwards1, A Copas1, M Fisher2,
P Benn1
1Department of Genitourinary Medicine, Mortimer Market Centre,
Camden PCT, London, 2Claude Nicol Centre, Brighton and Sussex
University Hospitals NHS Trust, Brighton, UK
Background: Terrence Higgins Trust launched a campaign promoting
awareness of post exposure prophylaxis (PEP) following sexual
exposure to HIV in July 2004.
Aims: Determine the campaign's impact upon demand for PEP in two
GUM clinics.
Methods: Retrospective case notes review of individuals requesting
PEP in 2004. Comparisons between demographics, clinical data,
exposure characteristics and campaign awareness pre- and post
campaign were made.
Results: 216 individuals requested PEP (165 MMC, 51 Brighton). Data
were available for 196/216 (90.7%). The proportion following sexual
exposure significantly increased after the campaign (pre- 49/89
(55.1%), post- 90/127 (70.9%) (p=0.025)). 126/139 (90.6%)
commenced PEP following sexual exposure. There was a trend towards
more men reporting unprotected anal intercourse (UPAI) with a partner
of unknown HIV status (11/24 (45.8%) pre- and 41/72 (56.9%)
post-campaign (p=0.48). The campaign was cited by 30.7%. Mean time
to initiation of PEP was unchanged (30.4 vs 31.5 hours) and completion
rates poor (47.8% vs 48.8%) pre- and post-campaign respectively.
Attendances for PEP following sexual exposure at MMC have increased
significantly since 1997 (8 in 1997 to 121 in 2004 p<0.001).
Conclusion: Post-campaign demand for PEP following sexual exposure
has significantly increased. Time to initiation and completion rates
remain unchanged.
A Menon-Johansson
Aim: To determine the extent of self-initiated treatment and
prophylaxis for STI and partner initiated HIV post-exposure prophylaxis
(PEP)
Methods: Anonymous questionnaires were given to 150 consecutive
patients in two inner London clinics.
Results: A 70% response rate (n = 105) was obtained in the GU clinic.
Of these individuals 55% were male, 24% described themselves as
homosexual/bisexual, 5% were HIV positive and 49% had a previous
STI. Ten percent reported treatment outside the healthcare setting and
another 5% self-initiated antibiotics as STI prophylaxis. GP treatment
was reported in 11%. In the HIV clinic, a response rate of 64% (n = 96)
was obtained. Of these individuals 93% were male, 84% described
themselves as homosexual/bisexual and 84% had a previous STI. Three
percent reported STI treatment outside the healthcare setting and
another 6% self-initiated STI prophylaxis. STI treatment outside the
GUM setting (by GP or HIV physician) occurred in 26%. Three
respondents reported giving anti-retroviral treatment to a partner as
HIV prophylaxis ('auto-PEP') without medical supervision.
Conclusions: STI self-treatment and prophylaxis is reported by a
significant proportion of clinic attendees. Further research, especially
in the community, is required to determine the full extent and
implications of this practice.
P158
■
Experience in providing technical assistance to the
ARV Roll-Out Program in Kwa-Zulu Natal (KZN),
South Africa: The Kings College-Nelson Mandela
University Partnership
S Barrett1, L Campbell2, C Ball1, R Pawinski3, K Moshal4,
P Easterbrook1
1Kings College Hospital, London, 2Post Shepstone Hospital, Kwa-Zulu
Natal, South Africa, 3Nelson Mandela Medical School, Durban, South
Africa, 4Great Ormond Street Hospital, London, UK
Background: In 2004, one of the largest Anti-retroviral (ARV) roll-out
programmes worldwide was initiated in Kwa-Zulu Natal (KZN). A key
challenge is the shortage of health care workers (HCW) trained in ARV
use. We have established an institutional partnership to provide ARV
training to participating sites. We report our initial experience and
evaluation of ARV roll-out at one of the 12 nodal roll-out sites – Port
Shepstone Hospital (PSH).
Methods: The initial Kings College programme has been led by a
consultant team and an SPR on a ten week attachment to PSH, liaison
with LC at PSH and RP in Durban.
Results: Between 08/04 and 12/04 160 patients started ARVs at PSH.
Key achievements included the introduction of structured and
standardized approaches for initial visits and monitoring; strategies for
improving clinic access for infected HCWs; an audit of reasons for
drop-out of the ARV training programme; and optimising Ol treatment
protocols. 7 HCWs at PSH have been trained in ARV use through
tutorials, lectures and direct clinical supervision.
Conclusions: The partnership has contributed to improvements in both
clinical care and streamlining of clinic operational procedures at PSH.
We plan to extend to additional sites in 2005.
55
P159
■
■
Why do HIV-positive patients drop out of ARC access
programmes? Experience from a newly established
ARV clinic in Kwa-Zulu Natal (KZN), South Africa
Reaching the parts free ARVs do not reach: a
sustainable UK sponsorship programme for staff with
HIV in a Tanzanian hospital
S Barrett1, L Campbell2, R Pawinski3, T Welz1 P Easterbrook1
J Meadway, K Collins
Medicines for Muheza, Essex, UK, Hospitali Teule, Muheza, Tanga
Region, Tanzania
Aim: To establish a programme at a district hospital in Tanzania to
provide HIV positive staff with antiretroviral (ARV) treatment whilst
government programmes are not supplying free ARVs.
Background and Method: Muheza Hospital serves a rural population
of 280,000 in north east Tanzania. The UK charity Medicines for
Muheza (MforM) provides up to 9% of the annual hospital income. In
2001 there was a death every month from HIV amongst the 316 staff
and in 2002 a programme for ARVs began with new regular donors
sponsoring individual staff through MforM. Treatment follows WHO
guidelines using generic ARVs.
Results: 25 patients entered the programme, of whom two died of
advanced HIV after a short time, and two more are not on ARVs.
Twenty-one staff are on ARVs, 15 on stavudine, lamivudine and
nevirapine (Triomune) and 6 on zidovudine and lamivudine (Duovir)
with efavirenz. Three are temporarily off work because of tuberculosis
and 18 are well and working. Staff morale has improved, and HIV
stigma has decreased. Free ARVs remain unavailable, but the success of
the scheme encourages recruitment of new donors in the UK to keep
pace with entrants to the programme.
Conclusion: A sustainable ARV programme has provided great benefit
to hospital staff. Expertise in HIV management, monitoring, dispensing,
and adherence support have been developed in readiness for an
extensive programme when free ARVs become available.
1Kings College Hospital, London, UK, 2Post Shepstone Hospital,
Kwa-Zulu Natal, South Africa, 3Nelson Mandela Medical School,
Durban, South Africa
Background and Aims: Eligibility criteria for Antiretroviral therapy
(ARV) in the newly established KZN government ARV programme
include: CD4 count <200 copies/ml, disclosure of HIV status, and
completion of 3 HIV/ARV educational sessions. We aimed to identify
factors associated with drop-out during pre-treatment education at a
district hospital.
Methods: We retrospectively analysed the log of patients referred for
ARVs and completing 3 training modules between 09/04 and 11/04.
Results: 173 patients were referred. 118 (69%) were female. Mean CD4
count and age at first visit were 196 (SD 133) and 31.8yrs (SD 9.2). 64
(37%) had CD4 count >200. 173 patients completed module 1, 147
(85%) module 2, and 129 (75%) module 3. Univariate analysis showed
no association between drop-out and gender or CD4 count. However,
patients aged 20-30yrs were less likely to drop out (7%) than those
younger (30%) or older (27%) (p=0.018). 3 patients died during
training.
Conclusions: One-quarter of patients referred for treatment did not
complete the prerequisite training and were therefore ineligible for
ARVs. Young adults were least likely to drop out. Qualitative interviews
are in progress to further explore reasons for drop-out. Preliminary
data suggest travel distance and transport money as obstacles to
attendance.
P160
■
Why are HIV-infected care workers reluctant to
attend an ARV clinic? Experience from the Port
Shepstone Hospital Rollout Programme in Kwa-Zulu
Natal, South Africa
S Barrett1, L Campbell2, R Pawinski3, P Easterbrook1
1Kings College Hospital, London, UK, 2Post Shepstone Hospital,
Kwa-Zulu Natal, South Africa, 3Nelson Mandela Medical School,
Durban, South Africa
Background and Aims: HIV seroprevalence in Kwa-Zulu Natal (KZN) is
36% and 16% among health care workers (HCW). A dedicated ARV
clinic was established at Port Shepstone Hospital (PSH) in 08/04, where
an estimated 200 HIV-infected HCWs work. By 11/04 only 2 staff had
presented for ARVs. We investigated the reasons for reluctance of staff
to attend the ARV clinic, and identified strategies to improve
attendance.
Methods: A confidential, anonymous 20-item questionnaire available
in English and Zulu, was randomly distributed to 200 HCWs at PSH.
Results: The response rate was 79%. The main reasons given for
non-attendance were: concerns about confidentiality and
stigmatisation (75%); lack of awareness of their HIV status (56%);
unaware of the existence of the clinic (44%); and poor knowledge
about the benefits of ARVs (54%). Motivating factors for staff to
attend were the ability to see ARV physicians privately (73%), the
provision of an off site (58%) and out of hours clinic (34%).
Conclusions: Concerns about confidentiality remain a key barrier to
improving HCW access to ARV therapy. Strategies in progress at PSH
include a staff education programme on the benefits of ARVs and
knowing your HIV status, and the establishment of an off-site clinic.
56
P161
11th
Printed Abstracts
PA1
PA3
Clinical nurse specialist led GUM service for
HIV-positive men
Review of cases referred to genitourinary medicine by
community paediatrics/forensic medical examiner
Y Dass, C Bell, C Marfo, J Walsh
The Jefferiss Wing, St Mary’s Hospital, London, UK
Introduction: Evidence suggests high rates of STIs in HIV positive men.
A nurse practitioner led clinic was established in June 2004 to improve
GUM screening access, opportunities to discuss safer sex, PEP and
ensure adequate hepatitis A & B vaccinations.
Method: 125 HIV positive men attended this clinic between
June–August 2004. Retrospective data was collected from 66 notes
using a specially designed audit tool.
Results: The clinic was utilised mainly by 125 HIV positive men, who
were mainly white (n = 40) and homosexual (n = 61). Mean CD4 541;
34 men were on antiretroviral therapy. 14 men had received STI
screening in the last year. The average number of sexual partners in the
preceding 3 months was 13 range 1–450. 30 men had an STI diagnosed
requiring treatment including gonorrhoea (12), early syphilis (2) and
epidemiological treatment for syphilis (2). None of the men audited
used condoms for anal sex. Safer sex was discussed with all men.
Previous studies indicate HIV positive men prefer a GUM service within
their HIV centre. This new service was introduced to reflect this finding.
During this review the service was well utilised, the high rates of
infection reflect a continuing need for this service.
C Thompson
NHS Lothian, University Hospitals Division, Lothian, UK
Introduction: This department has a dedicated clinic (SA) for adult
victims of sexual assault for STI screening but STI screening in children
has traditionally been undertaken on an ad-hoc basis. Links with local
Forensic Medical Examiners (FME) and Community Paediatricians (CP)
have been strengthened to facilitate referral of younger patients for
appropriate screening. Pre-pubertal children, usually with chronic
rather than acute sexual abuse, were seen at the SCAN (suspected child
abuse and neglect) clinic run by CP, in a co-ordinated ‘one-stop shop’
approach, with FME, video-colposcopy and STI screening. Post-pubertal
youngsters, particularly those disclosing an acute assault, were seen in
the SA clinic, having already had a two doctor forensic medical
examination. The case load for CP/FME referrals from 1/4/03–31/3/04
was reviewed by retrospective case record examination.
Results: Nineteen (5 boys, 14 girls) were referred. Eight (4 boys) aged
1–13 were seen at SCAN. Eleven (one boy) aged 12–14 were seen at
SA. Two girls (1 and 3) had vulval erythema and genital warts
respectively with no suggestion of abuse. Fifteen (4 boys) alleged
non-consensual sexual intercourse (SI) in whom no STI were detected.
Conclusion: Awareness of STI risk in SCAN patients allows
co-ordinated and comprehensive examination and appropriate
screening.
PA2
PA4
The epidemiology, clinical features, and diagnosis of
women with trichomoniasis in a south London sexual
health clinic: 2003–2004
Audit of child protection issues in under 15 year olds
attending a department of genitourinary medicine
M Natha1, J Watson1, C Fernandez2
1Department of Genitourinary Medicine, 2Department of Clinical Audit,
Mayday University Hospital, Croydon, UK
Aims: To determine the clinical presentation and management of
female genitourinary medicine clinic attendees with Trichomonas
vaginalis infection.
Methods: A retrospective case notes review was undertaken of all
cases of T. vaginalis infection diagnosed in females in a 12 month
period between January 2003 and December 2003 (n=155). Descriptive
features of these patients were collated.
Results: The incidence of T. vaginalis infection was 3.0% in 2003. The
mean age of patients was 28.8 years. Black Caribbean and Black
African women were over-represented. Overall, patients were more
likely to be symptomatic at presentation (78.1%) and have vaginal
discharge as their presenting symptom (87%). 19% had co-existing
chlamydia infection and 7% had co-existing gonorrhoea infection.
There were 2 new HIV diagnoses. Culture improved diagnosis,
identifying an additional 10% of cases. Contact tracing was initiated
in 81.3% of cases. There was one ‘true’ treatment failure.
Conclusions: The mean age of 28.8 years is lower than that quoted in
other studies. Most patients were symptomatic at presentation. The
rate of co-infection with chlamydia was high, we should consider
giving empirical treatment for chlamydia in patients diagnosed with
T. vaginalis infection. Routine test of cure could be stopped.
C Thompson
NHS Lothian, University Hospitals Division, Lothian, UK
Introduction: More young people under the age of 16 years are
sexually active, with consequent child protection issues. This
department's policy is for all attendees under 16 to be seen by a Health
Adviser (HA) to highlight any child protection concerns. This was
audited by retrospective case-note review for those aged <15 years,
attending 1/4/03–31/3/04.
Results: Thirty-six people aged <15 were seen; 6/36 were excluded
(not sexually active). Eleven, (one boy, 10 girls) aged 12–14, were seen
at the dedicated sexual assault clinic; all were referred by the police
with child protection team (CPT) involvement. Nineteen (2 boys,
17 girls) were seen at routine clinics; one girl aged 13, 18/19 aged 14.
Two girls reported non-consensual sexual intercourse (SI) when drunk.
Of 17 (15 girls) admitting consensual SI, partners were aged <16 in 12,
16–17 in 3, 22 in one and unknown in one. HA saw 16/19 attending
routine clinics; 3/19 were already known to CPT. A responsible adult
(carer/parent) was identified in 11/19; of the seven admitting
consensual SI without an identified responsible adult, all had partners
<16; all were deemed Fraser competent.
Conclusion: No cases of un-addressed child protection concerns were
identified in patients aged <15 years.
57
PA5
PA7
Kaposi’s sarcoma progressing during pregnancy – lack
of suppression by hCG
Reception triage in the HIV emergency clinic
B Gazzard, C Thirlwell, L Waters, T Powles, M Nelson, M Bower
Background: HIV associated KS is rarer in women. The pregnancy
associated hormone human chorionic gonadotropin (hCG) induces
apoptosis of HIV associated KS cells in vitro and in mouse xenograft
models.
Methods: Since 1986 1137 HIV+ patients have been diagnosed with KS
including 18 women (1 gender reassignment). Two presented during
pregnancy. The clinicopathological features and clinical course of these
patients were examined.
Results: The clinical features are shown and in both cases there was a
disease progression during the third trimester. Following delivery one
woman had spontaneous regression of disease whilst another required
radiotherapy.
Conclusions: We report two cases of KS presenting and progressing
during pregnancy when hCG levels are extremely high. This contradicts
two previously reported cases where spontaneous remissions of KS
during pregnancy where observed. Moreover this observation
contradicts the laboratory findings of KS response to hCG.
PA6
PA8
Switching to once daily antiretroviral therapy
Hypertrophic herpes simplex genitalis in HIV-1
infection
L McDonald, R Arjoonsingh, M Chikohora, MG Brook
Central Middlesex Hospital, London, UK
Aim: To assess the uptake of the offer of once daily HAART on patients
already established on HAART.
Methods: A retrospective analysis of 78 consecutive individuals who
had been assessed for once daily therapy.
Results: 33 individuals were not offered the switch: 22 because of the
inability to construct an o.d. regimen, 4 due to pregnancy and 11 due
to other clinical reasons. 45 individuals were offered a switch to once
daily HAART of whom 35 (78%) accepted. Of the 10 who declined 4
(40%) were afraid of the consequences and the other 6 (60%) were
happy with their current regimen. 10/35 (29%) switched for clinical
reasons on the advice of the clinician. The reasons given by the other
patients for accepting a switch were: increased convenience (9, 26%)
and reduced pill burden (17, 49%). The patients who switched for
non-clinical reasons had previously received 1–11 (median 3) regimens.
The commonest nucleoside backbones were abacavir/3TC (8, 23%) and
tenofovir/3TC (6, 17%). Nevirapine (15, 43%), boosted Atazanavir (10,
29%) and efavirenz (8, 23%) were the commonest third agents.
Conclusion: A high proportion of patients who are suitable for o.d.
therapy will decide to change if offered the choice.
58
M Raychaudhuri, M Poulton, M Solmon
King’s College Hospital, Caldecot Centre, London, UK
Background: HIV patients were attending the HIV Emergency Clinic
with issues that could be appropriately dealt by someone other than
the doctor. Alteration in this service could potentially improve care if
patients were seen by appropriate staff.
Aim: To assess the appropriate use of walk in clinics.
Method: We audited attendances over 1 week prospectively. Data
collected included reason for attendance, if considered appropriate and
who else could have dealt with the problem. Data was re-audited after
5 months.
Results: Only 45% attendances were deemed appropriate and 41%
patients could have been dealt by other members of staff. A
questionnaire was developed for use at reception to help redirect
individuals walking in to appropriate members of staff or outside
agencies. In addition posters and leaflets were produced to advise
patients of the appropriate use of the emergency clinic. On re-auditing,
54% attendances to the clinic were deemed appropriate and only 18%
of patients could have been dealt with by someone other than the
doctor.
Conclusion: Reception triage has been helpful in improving the
appropriate use of the HIV emergency service. Further work is planned
to develop nurse triage and encourage increased use of GP services.
A Holmes, M McMenamin, C Bergin, F Mulcahy
St. James’s Hospital, Dublin, Ireland
Aim: Description of 3 cases of Hypertrophic Herpes Simplex Genitalis
[HSV] in HIV 1 infected patients.
Cases: One 30yo Congolese man. 3-year history of HIV, on
antiretroviral therapy [ART], viral load [VL] <50cpm, CD4 >400 × 106/l.
Recurrent genital ulceration despite Valacyclovir prophylaxis. He
developed multiple disfiguring hypertrophic lesions of the penis and
perineum. No response to Foscarnet or Cidofovir. TK mutation negative.
Excellent response to Thalidomide/ Valacyclovir combination.
2: 48 year old Rwandan woman. 7-year diagnosis of HIV, VL<50cpm on
ART. CD4 count <200 × 106/l. Dapsone as PCP prophylaxis. Recurrent
HSV 2 initially responded to episodic Valacyclovir, but progressed to
hypertrophic lesions. No response to Cidofovir; relapse within weeks of
Foscarnet. Trials of Valgancyclovir and Thalidomide unsuccessful.
Histology at vulvectomy: VIN 3
3: 34-year-old Ugandan woman. 2-year diagnosis of HIV, on ART with
a CD4 > 500 × 106/l.Genital ulceration treated episodically with
Valacyclovir; culture negative. Developed hypertrophic labial and
perineal lesions.
Histology: Marked lymphocytic, plasmacytic and eosinophilic infiltrates
and immunohistochemistry positive for HSV.
Discussion: Hypertrophic HSV is unusual, even in the setting of HIV
[3/1200 in our cohort, all African], difficult to treat, and may
predispose to dysplastic changes.
11th
Printed Abstracts
PA9
PA11
Acceptability of the role of Advanced Nurse
Practitioner (Sexual Health): A comparison study
with the Senior House Officer (SHO) on patients
attending for sexual health screening in the
Genito-Urinary and Infectious Diseases Clinic
(GUIDE), St James Hospital, Dublin
Recurrent cryptococcal meningitis in a HIV positive
man despite HAART and induction/maintenance
therapy. Can CD4 counts mislead?
S Delamere, G Courtney, V Wong
GUIDE Clinic, St James Hospital, Dublin
Background: The role of the Advanced Nurse Practitioner (Sexual
Health) was initially proposed and developed in 1997 following the
increasing incidence of sexually transmitted infections (STI’s) both
locally and nationally.
Aim: The aim of this study is to demonstrate that patients are receiving
equally satisfactory care from the ANP (Sexual Health) as they are from
the SHO.
Methodology: A quantitative approach was employed, by
administering an anonymous questionnaire, designed to measure the
satisfaction with the service.
Results: Overall 90% response rate, 97% from patients seen by the
ANP and 83% from patients seen by the SHO. Results were favourable
from both groups. Higher scores measuring information given to
patients on ‘what to do should difficulties with treatment arise’, ANP
(76%) and SHO (60%), and on what to do 'should a recurrence of
problem occur' ANP (81%) and SHO (57%), were seen in the ANP
group. A higher number of patients were referred to the Health Advisor
and Counsellor by the SHO, demonstrating the breadth of the
professional remit of the ANP.
Conclusion: In this sexual health clinic, the investigation has shown
that patients are equally satisfied with the care provided by the ANP as
they are with that offered by the SHO.
C Cunningham, C Emerson, RD Maw
A 55 year old HIV positive Caucasian man was admitted in July 2002
with increasing headache, nausea and vomiting. CD4 count 280
cells/mm3, on HAART (Trizivir) and viral load undetectable. He had
cranial nerve palsies and a small midbrain lesion on CT scanning. Blood
cultures identified Cryptococcus neoformans var. neoformans. Therapy:
2 weeks of I.V. Ambisome and Flucytosine. He had worsening visual
acuity. CT Brain showed ventricular dilatation and opening pressure on
lumbar puncture was 46cms/H2O, therefore a ventriculoperitoneal
shunt was inserted. CSF culture was negative for fungal growth. He
was discharged on Fluconazole 400mg. In October 2002 he was
readmitted with recurrent symptoms despite treatment adherence. CD4
count 100 cells/mm3, CSF was positive for Cryptococcal Ag and culture.
He received induction and maintenance therapy as before, CSF samples
at 2 and 4 weeks were clear. In July 2004 he presented with arm
weakness, confusion and seizures. CD4 count 200 cells/mm3, Serum
and CSF cryptococcal Ag positive, MRI Brain showed focal lesions.
Therapy: I.V. Ambisome for 3 weeks (with marked clinical
improvement). On discharge CSF Ag titre 1:2, culture negative and
continued maintenance therapy of Fluconazole 400mg. He remains
well with quarterly CSF surveillance. Interestingly viral loads were
undetectable throughout.
PA10
PA12
A review of service delivery in a community-based
HIV service: 1989-2004
HIV-associated pulmonary arterial hypertension
(PAH)
S Dawson, N Desmond, C Woods, C Cornish, B Brett, F Hawkins
The Garden Clinic, Upton Hospital, Berkshire, UK
The HIV service started in a community based Genitourinary Medicine
(GUM) setting in 1988 becoming part of an holistic Sexual Health
Service in 1993. There have been major changes in the epidemiology of
the cohort (586) over 15 years. Responsive to patients' needs, audits of
practice were carried out leading to specific service developments. HIV
sexual health clinics were established focussing on pre-conceptual
counselling, contraception, cytology and STI screening. Increased
recruitment of women required the development of a Family clinic, an
antenatal clinic and a postnatal clinic, facilitated by the availability of
clinicians working within the integrated service. The full range of
antiretroviral therapies, resistance testing and therapeutic drug
monitoring was available. Treatment outcome audits showed
equivalence to figures from clinics within teaching hospital or DGH
settings. Close collaboration from the local DGH, three miles distant,
led to the development of paediatric and obstetric protocols. Antenatal
testing (96%) and the prevention of vertical transmission (0/40) have
been very successful. There has been less success in providing robust
in-patient medical management.
Conclusion: This review shows that the vast majority of HIV care can
be provided from such a community base should clinicians with the
interest and skills wish to develop it.
C Cunningham, C Emerson, RD Maw
A 44-year-old Caucasian woman with no prior history of cardiorespiratory disease presented in March ’04 with increasing dyspnoea,
dry cough and lethargy. Her oxygen saturation was normal but she was
tachypnoeic and had a loud P2 and pan-systolic murmur. A V/Q scan,
high-resolution CT scan, CT pulmonary arteriogram and Echo showed
elevated right ventricular systolic pressure (RVSP=85mmHg) and a
dilated right ventricle (end-diastolic diameter RVEDD=47mm). Cardiac
catheterisation confirmed PAH. Epoprostenol (prostacyclin analogue)
infusion during the procedure produced no significant fall in
pulmonary arterial pressure. On six-minute walk testing she covered
93m with no desaturation. Her husband originated from Zimbabwe,
therefore both were tested and found to be HIV-positive. Her baseline
CD4 180 cells/mm3 with viral load 7,900 copies/ml. She commenced
HAART (Combivir and Efavirenz) and Bosentan (endothelin receptor
antagonist) at 62.5mg bd for 4 weeks, 125mg bd thereafter with
monthly LFT checks and TDM for Efavirenz.
On repeat six-min walk testing at 2 months she covered 186m with no
desaturation. Most recent Echo revealed a RVSP 61mmHg, RVEDD 43
mm. This case illustrates that combination treatment with HAART and
Bosentan may significantly improve functional and haemodynamic
parameters in a disease previously considered to have a uniformly poor
prognosis.
59
PA13
PA15
Diagnosing hepatitis C (HCV): an opportunity lost?
Audit of sexually transmitted infections (STI),
Hepatitis B (HBV) and Hepatitis C (HCV) monitoring
in HIV positive patients
H Wankowska
Department of Sexual Health, Ipswich Hospital NHS Trust, Suffolk, UK
Aim: To see if unsuspected cases of HCV are missed in a G-U Medicine
clinic in a District General Hospital.
Method: HCV tests were offered to all New Episode (New=N and
Rebook=R) patients, opting for an HIV test. (01/01/2004–31/03/2004).
Previously, HCV tests were offered only to patients with a ‘risk’ history,
(injecting drug use, HIV positive etc.). Initial test, ELISA antibody (a/b)
(ortho eci on vitros). Confirmation, ELISA a/b (biorad). RNA, PCR (artus).
Results: Total New Episodes=1622. (N=845+R=777). Total HIV tests,
(S2+P1A)=833; HIV offered, (P1B)=489. Total HCV tests=700. Initial
test: 14 non-negative=7 reactive+7 intermediate. (None HIV positive).
Confirmation: 7 reactive=5 positives+1 intermediate+1 negative; 7
intermediates=7 negatives.
RNA: Of 5 a/b positives; RNA=3 positives+2 negatives; (a/b
intermediate & a/b negative=RNA negative). HIV positives:=3 (All
negative HCV). 5 patients = Hepatitis C positive. All 5 had given ‘risk’
history. 1= ‘possible HCV’ (No ‘risk’ history). (All 6 referred
Gastroenterology.)
8 = ‘HCV Negative’ (No ‘risk’ history); advised.
Conclusions: In this clinic, no definite cases of HCV, would have been
missed if tests were offered only to patients with ‘risk’ history. A
patien’'s history is an excellent guide to risk of HCV.
References:
Hepatitis C Strategy for England, Department of Health, August 2002.
Wankowska, H. A Year in Prison, Poster Presentation, BASHH, Bath,
2004.
PA14
Audit of virological and immunological outcome of a
patient group on treatment with Tenofovir (TDF) and
didanosine (ddI) plus Efavirenz (EFV) or Nevirapine
(NVP)
K Forbes, M Murphy, C Skinner, G Baily, Y Gilleece, C Orkin
Bart’s and London NHS Trust, The Royal London Hospital, Whitechapel,
London
Aim: To audit efficacy of ddI+ TDF + EFV/NVP-containing regimes in
clinic population following reports of suboptimal CD4 and Viral load
(VL) responses in HIV infected individuals.
Methods: Clinical audit of individuals identified on the above regimes.
Results: 12 individuals identified: 8 male, 4 female. Median age:
41.5 years (32–70). 10 received EFV, 2 NVP. 3 groups: 3 were naïve, 9
had received prior HAART: 5/9 had been switched for lipodystrophy (S),
4/9 started on this regime after a treatment interruption (TI). Median
time on therapy: 9.5 months (2–33). Median baseline VL: 2425
copies/ml (<50–136,000). Median baseline CD4 count: 257 cells/mm3
(38–529). At 3 months 10 were suppressed on treatment. 2
experienced virological failure: 1 naïve and 1 TI. The naïve patient had
mutations: 211K 98S 135T 179D 190C 190S. At 6 months (n=8) all
remained suppressed. At 9 months (n=6) 5 remained suppressed. At 12
months (n=3) all remained suppressed. At 15 months another (S) had
virological failure. Median CD4 count increase (? CD4) at 3 months was
40 (–786–419) and at 6 months was 32.5 (-281-388).
Conclusion: 3 individuals on ddI+ TDF + EFV/NVP-containing regimes
experienced virological failure and the ? CD4 was small.
60
M Pammi, IH Ahmed, K Mian, A Ahmed
Nottingham City Hospital, Nottingham, UK
Aim: To monitor STI & HBV/HCV status in all the HIV positive patients
attending GUM clinic in Nottingham between September2003 and
October2004.
Audit standard: All HIV positive patients should be offered sexual
health screen yearly and HBV/HCV status identified and vaccinated as
appropriate.
Methods: Retrospective case note audit was performed. Demographic,
epidemiological and clinical data were collected.
Results: 100 case notes analysed.49% patients had STI screen in the
last one year and among them 49% had at least one STD diagnosed.
Syphilis testing was done in 54%.
The reasons for no STI screen: 37% not offered; 29% not sexually
active; 22% not indicated. HBV status assessed in 91%, 44% were
susceptible but only 15% were vaccinated. 75% were screened for
HCV, 9% had HCV coinfection.
Conclusion: We are not achieving the standard for STI screening in
sexually active HIV+ patients. In patients who were screened a
significant proportion of STI were identified. Although majority were
screened for HBV/HCV, a significant proportion of them were not
appropriately vaccinated. STI screen must be offered at least once a
year and HBV vaccination should be offered in those who are
susceptible.
Author Index
Abbara A
Aboud M
Adebiyi A
Aderogba K
Adjei M
Ahmed A
Ahmed IH
Ahmed-Jushuf I
Al Alabri S
Aldam D
Alexander S
Allen L
Allison K
Almond L
Amenyah R
Amin S
Anderson H
Anderson J
Anderson P
Annan NT
Annan T
Antoine D
Apoola A
Arellano J
Arjoonsingh R
Arms R
Armstrong NR
Asboe D
Ashton C
Atkins M
Atzori C
Azadian B
P41
P7
O35
O17, P80
O9
PA15
PA15
P2a, P9a
P90
P20
O37
O46
O2
P33
O9
P70
O39
P58, P146
P21
O23, P85
P88
P110
P129
O8
PA6
P124
P134
O26
P22, P149
O26
P112
P85, P88
Back D
Bailey A
Bailey B
Bailey J
Bailey MC
Baily G
Ball C
Ballinger J
Bansi L
Barber TJ
Barker R
Barrat A
Barrett L
Barrett S
Barter J
Barton S
Barton SE
Bates C
Beadles WI
Beattie A
Beckles M
Bedu-Addo G
Beeching B
Beeching NJ
Begum I
Behrens RH
Bell C
Bell G
Bendall R
Benfield T
Benhene Poku A
Benn P
Bennett S
Benzie AA
Bergin C
O24, P29, P33
P17
P145
P112c
P39
P30, PA14
P158
P27, P111
P24
P35
P17
P137
O10
P158, P159, P160
P3
P2a, P79, P91
O6, P49
P116
P48
P155, P156
P95
O9
P116
P90
P136
O32, P149
P43, PA1
P130
P67
P112
P145
O16, O38, P155, P156
P115
P25
O11, P36, P100, P101,
P112a, PA8
P69
P146
P2a, P9, P82
O25, O27, P27, P50,
P102, P103
P41
P145
O6
P77
P72
P142
P81, P86
O16
O23
Berkt F
Betourney R
Bhaduri S
Bhagani S
Bhuya A
Bickersteth R
Bickford J
Bignell CJ
Bilek N
Birchall J
Birley H
Blackham JE
Boer M
Boffito M
Bolding G
Bond K
Bonington A
Boothby M
Bower M
Bowman C
Bradley M
Brady M
Brays DH
Breen R
Brett B
Brex PA
Brook G
Brook MG
Brookings C
Brown D
Brown M
Brown S
Browne R
Bryne M
Buckley R
Bunting P
Burns F
Butler K
Butler P
Butler S
Bybee A
Byrne J
Cafferkey M
Cameron S
Campbell L
Cane P
Carder C
Carlin E
Carne C
Carrick-Anderson K
Cartledge JD
Cassell J
Castelino S
Chadborn TR
Chadwick D
Challenor R
Chandramani S
Chapman C
Chapman J
Chawla A
Checkley A
Chew N
Chew S
Chibber F
Chiganze A
Chikohora M
Chirlwell C
Churchill D
Clancy J
Clarke A
Clarke J
Clarke S
Clerici M
Clutterbuck DJ
Coast J
Cohen CE
Cohen H
Collini P
Collins E
Collins K
Collins L
Collins SA
Cooper V
Copas A
Cornforth D
Cornish C
Coughlan S
Courtney G
Cox S
Coyne K
O24
O14, P119, P121, P150
P136, P154
P53
P46, P129
O26, O28, O44, O45,
O48, P34, P40, P41,
P52, P54, P55, P56,
P94, P105, P106, P107,
P108, P109, PA5
P2a, P77
P90
P1
O20
O30, P95, P111
PA10
P64
P113
O12a, P97, P113a, PA6
P42
O25, P103
P62
P49
O26, P42, P45
P60
P89, P117
P78
P18
O10
O34
P9a
O30
P16
O10
O4
P158, P159, P160
O17
O38
P2a
P78
O2
O33
O12a, P113, P113a
P26
O19, O43
O9
O3
O3, P75
P57
P113, P131
O42
P112e
P37
P36, P101
P70
P81
PA6
P107
O33, P144
P93
O34
P13
P53, P134
O20
O2, P5
P132
P12, P115
P63
O9
P2
P161
P7
P72
O31
O13, O22, O46, P28,
P156
P20
PA10
O11
P99, PA9
P109
P96
Crabtree N
Crates D
Crean M
Cropley I
Crowe G
Culkin A
Cullen BR
Cunningham C
Cunningham R
P46
P1
P99
P95
P61, P70
P59
O29
P76, P147, PA11, PA12
O5
Daniels D
Danta M
Das R
Das S
Dass Y
Davies A
Davies M
Davies E
Davies J
Davies L
Davis M
Dawkins DA
Dawson S
Day S
De Esteban N
De Silva S
De Souza BC
De Souza C
Dean G
Delamere S
Delpech V
O3, P78
O25, P102, P103
P86
P129
PA1
P81
P86
P40
P116
P41
O14, P119, P121, P150
P42
P2a, PA10
P154
O32
P62
P35
O35
O17, P2, P17, P144
P133, PA9
O16, O19, O43, P110,
P122
P43
PA10
P116
P60
P8, P57
P109
P95
O48, P94, P105, P106,
P107, P108
P68
P95
P152
O12
P151
P5
O42
P126
P53
O30
P23
P85
O12
O27, P102, P103
DeRuiter A
Desmond N
Devine M
Devitt E
Dhar J
Dharmana H
Dheda K
Dhillon T
Dickson CF
Dilworth JP
Dockrell DH
Doerholt K
Dogan A
Donald J
Donnelly C
Dougan S
Dunbar E
Dunleavy A
Dunn D
Dunning J
Duong T
Dusheiko G
Easterbrook P
Evans H
Ezeokoli A
P24, P47, P158, P159,
P160
P90
P104
O46, P4, P20, P28,
P63, P151, P155, P156
P64
P68
O14, P119, P121, P150
P90, P98
P76, P147, PA11, PA12
O13
P58
P113, P131
O1
O16, O19, O43, P110,
P122, P126, P140
P44
P92
Fakoya A
Farrell G
Fenton C
Fenton KA
Ferguson W
Fernandez C
O33
P100, P101
P132
O13, O37, P18
O10
PA2
Edrisinghe D
Edwards A
Edwards S
El Gadia S
Elawad B
Elford J
Ellks RK
Emerson C
Erens B
Erskine KJ
Estcourt C
Evans AL
Evans B
61
Fernandez T
Fernie I
Fidler S
Finch R
Fisher M
Flynn S
Foley E
Forbes K
Forde J
Forsyth S
Fox E
Fox J
Fox R
French P
French RS
Garcia-Garcia JA
Gardiner C
Garnett GP
Gazzard BG
62
P131
P80
O15, O18
P130
O17, O25, O31, O35,
O47, P17, P144, P156
P141
P114, P153
PA14
P110
O46, P28
P74, 136, P145
O15, O18, P118
P21
O38
O7, P132
Gellaitry G
Geretti AM
Gerressu M
Ghosh S
Gibb DM
Gibbons N
Gibbons S
Gilbart VL
Gill N
Gilleece Y
Gilleran G
Gilmore S
Gilson RJC
Glasier A
Goh B
Goncalves R
Goode M
Goold P
Gorsuch T
Graham A
Gray D
Gray S
Green H
Greenhouse P
Griffiths C
Griffiths V
Grover D
Guiver M
Gumley HR
Gupta M
P50
P32
P123
O21, O23, O24, O26,
O28, O44, O45, O48,
P34, P40, P41, P42,
P45, P51, P52, P54,
P55, P56, P94, P105,
P106, P107, P108,
P109, PA5
O31
O42
P132
P135
O12
P112a
O24, P29, P33
P126
P122
O26, P30, PA14
P46, P129
P118
O22, O27, P102
O4
O39, P83
P47
O10
P77
P111
P132
P132
P15, P76
O46
P2a
P20
P2a, P9a
O46
O40
P6
P90
Hackett R
Haddon L
Halvey O
Hamill M
Handy P
Harkin PJP
Harrison N
Harrisson U
Harry TC
Hart G
Harte E
Hawkins DA
Hawkins F
Hawkins M
Hawkins PN
Hay P
Helweg-Larsen J
Herbst J
Hewart R
Hill T
Hodgson C
Hollinghurst S
Holmes A
Holmes P
Holmes S
P11
P67
P141
O38, P138
P10
P13
P5
P44
P2a
O14, P119, P121, P150
P53
P45
PA10
P74
O30
O33, O35, P112e
P112
P141
P14
O47
P47
P132
O36, P32, PA8
P34
P106
Hopkins S
Horne R
Hussain S
Hutchinson J
O27, O30
O31
P7
P64
Ison C
O37, O38, P72, P85,
P86
Jaleel H
Janoosy G
Johnson AM
Johnson M
P46
P95
O12a, O13, P113a, P18
O27, O33, O34, O42,
P6, P19, P27, P41a,
P44, P50, P95, P102,
P111
O4
O27, P102
P116
O32, P116
P99
O44, O45
P51, P52, P55, P56,
P108
P75
O12a, O38, P113a, P4,
P120
Johnstone A
Johnstone R
Jones C
Jones K
Jones L
Jones R
Jones R
Joseph A
Jungmann E
Kalidindi I
Kalidini U
Kamutasa C
Kane R
Keane FEA
Keane J
Keating S
Kegg S
Kell P
Khan W
Khoo S
Kieran J
Killingley B
King G
Kinghorn GR
Kinghorn H
Kingori P
Kingston A
Kingston M
Kinloch S
Kirkpatrick L
Klein J
Klenerman P
Kontodimas S
Kozakis L
Kudesia G
Kulasegaram R
Kumari M
P30
P146
P112c
O7
P15, P67
P112a
P99
P127
O8
P42, P45
P29, P33, P61
P36, P101
P41a
P97
P71, P113a
O12a
O7
P88
P2a
P44
P149
P74
P103
O8
P65
P71
P7, P26, P154
P129
Lacey CJN
Lachowycz K
Lambourne J
Larbalastier N
Lascar RM
Lechelt M
Lee V
Leen C
Lessells R
Lewis D
Lewthwaite P
Lipman M
Llewelyn MJ
Lomax N
Loveday C
Low L
Lowndes C
Lyall EGH
Lynch A
Lyons F
Lyons M
Lysakova L
O1
O7
P100, P101, P112a
P7
O27, P102
P30
P114, P153
O33, P48
P48
P74
O40
O30, P110, P95, P111
P151
O39
P30
P88
O37, P122
P44
P76
O11
P86
P49
MacDonald N
Machin SJ
Mackie NE
O37, O38, P85
P63
P25
Madge S
Mahto M
Mahungu T
Maitland D
Malu MK
Mandalia S
Mann M
Marchetti D
Marfo C
Marks C
Marshall J
Martin D
Martin IMC
Maserati R
Maw RD
Mazzotta F
McAndrew S
McClean H
McClure M
McCormick K
McCormick S
McDermott H
McDonald L
McGarvey MJ
McKay L
McLean K
McMenamin M
McOwan A
McQuillan O
Meadway J
Mears A
Menon A
Menon-Johansson A
Menson EH
Mercer CH
Mercey D
Metcalf SC
Mian K
Miflin G
Miles K
Miller RF
Mindel A
Minton C
Mirfenderesky M
Mitchell H
Mitchell S
Monteiro EF
Montgomery H
Moore MD
Morgan E
Morrall I
Morris AK
Morris EJ
Moshal K
Moussa R
Moyle G
Mugezi R
Mulcahy F
Mullan DM
Mullens Y
Munday P
Murcie N
Murphy C
Murphy M
Murphy S
Musgrave E
Myles H
Natha M
Nathan M
Naylor S
Nazroo J
Needham A
Nelson M
P19, P44
P139
O27
O24
O5, P87
O6, O21, O23, O24,
O26, O28, O44, O45,
O48, P12, P51, P52,
P54, P55, P56, P94,
P115
P9, P82
O20
PA1
P118
P115
P3
O37, P72
O20
P76, PA11, PA12
O20
P112c
P78
O15, O18, O29
P40
P26
O11, P100
PA6
O29
O2
P85, P115
PA8
P96, P137
P14
P161
P154
O10
P96, P157
O12
O7, O12a, O13, P113a,
P132
O1, P4
P152
PA15
P1
P20, P132
P63, P78, P111, P112,
P151
P118
P9, P20, P82
O42
P22
P127
O1, P112b
P44
O29
P2a, P14
P75
O41
P112b
P158
P84
O24, O33, P49
P137, P146
O11, O36, P32, P36,
P89, P100, P101, P117,
P133, P141, PA8
P28
P40
P65
P21
P90
O33, P30, PA14
P138
P142
P16
P38, P148, PA2
P92, P112d
P152
P18
P8
O21, O23, O24, O25,
O26, O28, O44, O45,
Author Index
Ni Rathaille N
Nicholson M
Noble H
Nolan B
Noone M
Northfield J
Northwood J
Noursadeghi M
O48, P34, P41, P51,
P52, P54, P55, P56,
P85, P94, P105, P107,
P108, P109, PA5
P40, P106
P148
P4, P120, P142
O48, P94, P105, P106,
P107, P108
P141
P79, P91
P43
P101
O8
P103
O5
P151
O’Connor C
O’Connor G
O’Connor M
O’Connor S
O’Dea S
O’Donoghue E
O’Dwyer A
O’Grady P
O’Mahony C
O’Shea S
Ong J
Orkin C
Osmond M
Ottewill M
Oxenius A
P16, P69, P93
P32
P16
P16
O11, O36
P141
O36
P89
P2a
P16
O34
P30, PA14
P4
P2, P144
O18
Pabris P
Pakianathan M
Pallan M
Palmer HM
Pammi M
Pang F
Pao D
Parisaei M
Parry J
Patel R
Pattman RS
Pawinski R
Pearce AI
Penn Z
Perry N
Peters B
Phillips R
Pillay D
Pinsent S
Pittrof R
Ponnusamy K
Popat R
Porter K
Poulton M
Powderly WG
Powles T
Pren S
Prestage M
Pribram V
Price H
Pybus O
Pym AS
P103
P38, P124, P135, P148
P75
O41
PA15
O35
O17
P58
P122
P153
P11
P158, P159, P160
P90
P44
P31
P7
O18
O17, O46
O3
P3
P77
P41
O18, P23
P143, PA7
P60
O48, P94, P105, P106,
P107, PA5
P51
O32
P47
P52, P55, P56, P142
O25
P64
Quaglia A
Quah SP
P50
P147
Rackstraw S
Radcliffe KW
Rajakumar R
Rajkumar A
Randell A
Ransom D
Ratcliffe P
Raychaudhuri M
Raza M
Rea A
Recabarron X
P83
P87, P129
P129
P96
P96
P6
P42
PA7
O42
P72
P48
Nelson P
Newell S
Newey C
Newsom-Davis T
Rees N
Reeves I
Reilly G
Rice BD
Richards J
Richens J
Rider A
Riley A
Rizzardini G
Roberts J
Roberts P
Robertson-Bell D
Robinson A
Robshaw V
Roedling S
Rogstad K
Ronan E
Ross J
Roy A
Rubinstein L
Rudd E
Ruddy C
Russell J
Russell RA
Ryan C
P6
O47, P73, P143, P156
O33
O19
P10
O32, P149
O22
O8
O20
P144
P116
P19
P132
P129
P63, P155, P156
P130, P132
P152
O12a, P2a, P113a
P109
P97
P86
P40
P127
O29
P71
Sabin C
Sutcliffe L
Sutherland M
Swaden L
O22, O25, O33, O47,
P6, P23, P24, P25
P135
P38
P132
P80
P68
P15, P67
P39
O32, P28, P149
P111
O2, O4
P51
O18
O33, O35
P63
P145
P103
P44
P46
O12
O5
P60
O14, P50, P119, P121
O19, O43, P122, P126
P30, PA14
P50
P26, P43, P74
O17
P19, P111
P142
P85, P115
P126
P51
P39
PA7
P72
P63
O28, O48
P51
P22
O7, O12a, P113a, P132
P55
P23
P59
P98
O21, P12, P88, P51,
P137, P142, P146
O12a, P 113, P113a
P5
P27, P111
Taylor C
Taylor G
Taylor Y
Tenant-Flowers M
Theobald N
P47
P43
P13
P73, P143
O3, P69
Sadiq ST
Sadiq T
Salisbury S
Samuel I
Sankar KN
Saulsbury N
Schmid ML
Schuhwerk MA
Schwenka A
Scott GR
Scourfield A
Scriba T
Scullard G
Scully M
Sekweyama SGG
Semmo N
Shah S
Shahmanesh M
Sharland M
Shaw S
Sheehan G
Sherr L
Sinka K
Skinner C
Slapak G
Slater C
Smit E
Smith CJ
Smith F
Smith NA
Smith RD
Smythe J
Snow MH
Solmon M
Spratt BG
Starke R
Stebbing J
Stefanovic M
Stephens E
Stephenson J
Stevanovic M
Stöhr W
Stradling C
Sugunendran H
Sullivan AK
Theofan G
Thirlwell C
Thomas D
Thompson C
Thompson C
Thompson I
Thomson C
Tideman RL
Tilbury J
Tilston P
Tobin JM
Tong C
Torpey K
Toward D
Trabattoni D
Tunbridge AJ
Tung M
Turner A
Turner J
Tyrer M
O20
O48, P94, P105, P106,
P108, PA5
P86
P125
PA3, PA4
P142
P5
P118
P15
P53
0P153
P26
O9
O35
O20
P152
O21, P34, P88
O40
O27, P102
P27, P44, P50
Van Beek I
Varma R
Vilar J
Viswalingam ND
Vuddamalay J
P118
P112d
P53
P83
P65
Walker AS
Walker RWH
Wallace E
Walsh A
Walsh J
Walsh K
Wankowska H
Ward H
Waters A
Waters L
O12
P64
P60
O10
P25, P62, PA1
P114
PA13
O15, O37
P12, P137, P142, P146
O28, O44, P54, P79,
P91, PA5
PA2
P8
P135
O15, O18
P2a
O7, O13
O12
P24, P159
P25
O39
P101
P123
O1
O33, P53, P139
P137, P146
O7
O5
P2
O27, P20, P28, P102
P112c
P104
P134
P21, P125
O34
PA9
PA10
P100
P124
P89
P149
Watson J
Watt J
Webb R
Weber J
Weir M
Wellings K
Wells C
Welz T
Weston RJ
Wheeler H
White B
White PJ
Wilcox MH
Wilkins E
Wilkinson A
Wilkinson P
Willcox JR
Williams D
Williams I
Williams OE
Williams PM
Wilson JD
Winter A
Withey S
Wong V
Woods C
Woods S
Wright A
Wyer A
Wyss H
Youle M
Young AM
Young H
Young Y
P6, P27
O28, O48, P94, P105,
P106, P107, P108, P109
O41
O4
Zhou J
P135
63

Abstract Book 2005

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