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BACKGROUND: HIV-1 is a highly diverse virus; subtypes may exhibit differences in rates of transmission, disease progression, neurotoxicity, antiretroviral treatment failure profiles and accuracy of viral load measurements. To date, the HIV epidemic in Canada and the rest of the developed world has been largely due to subtype B; however, shifts in subtype epidemiology could have significant implications.OBJECTIVE: To determine whether there has been an increase in HIV subtype diversity in southern Alberta, Canada.METHODS: All 2358 patients receiving any HIV care between December 31, 2001 and December 31, 2010 were included in a retrospective analysis of subtype prevalence and incidence. In an indexed analysis, subtype trends from 1994 to 2010 were also evaluated.RESULTS: Between 2001 and 2010, the prevalence of non-B HIV subtypes in patients with a known subtype increased from 7% to 24%. In 2010, the most prevalent non-B subtypes were C (65%), A (11%), CRF02_AG (9.7%), CRF01_AE (4.9%), D (3.9%), G (2.9%) and CRF06_cpx (1.5%). In the indexed analysis, there was an overall proportional increase in non-B subtypes of 2.3% per year. The year-over-year increase in the prevalence of patients infected with a nonsubtype B virus increased from 13% from 1995 to 2002 to 27% from 2003 to 2010 (P=0.01). Incident non-B subtype cases increased from 9.6% to 32.4% over these time periods.CONCLUSIONS: This recent and dramatic shift in HIV strain diversity in Canada is unprecedented and may have important public health, research and clinical consequences.

BACKGROUND: The numbers and demographics of HIV-positive patients in care between 2003 and 2007 in the prairie provinces were examined.METHODS: Estimates of HIV-positive patients presenting to care between 2003 and 2007 were obtained from four clinic registries in Manitoba, Saskatchewan and southern Alberta. Detailed data were collected from clinical records of new patients in 2007.RESULTS: By the end of December 2007, 2263 HIV-positive persons were in care in Manitoba, Saskatchewan and southern Alberta. Males and females accounted for 1674 (74.0%) and 589 of the cases, respectively. Overall, there was a 12% increase per year in new HIV cases to care between 2003 and 2007 (P=0.026), with the rate of increase for males being 60% higher than for females over this time period (P=0.002). In 2007, there were 222 new HIV cases to care (37.4% female). Heterosexual contact was the most common HIV risk, but diversity was seen across sites with frequent injection drug use and men who have sex with men risk in Saskatchewan and southern Alberta, respectively. The Aboriginal population remains heavily over-represented, with approximately 36.0% of new cases being Aboriginal. Late presentation was common across all care sites, with 35.1% of cases presenting with CD4 counts of less than 200 cells/mm3.DISCUSSION: Heterosexual risk is the most common risk reported for HIV acquisition, but injection drug use risk remains significant in Saskatchewan. Aboriginals are over-represented at all sites, and in Saskatchewan accounted for the majority of new cases seen. In contrast to national trends, numbers of new and late diagnoses are increasing in the praire provinces, and this has significant treatment implications and potential public health consequences. Further efforts need to be made to facilitate earlier testing and linkage to care.

Pneumocystis jiroveci pneumonia uncommonly presents with pulmonary nodules and granulomatous inflammation. An unusual case of granulomatous P jiroveci pneumonia in an HIV patient with a CD4+ lymphocyte count of greater than 200 cells/mm3, occurring in the context of immune reconstitution with highly active antiretroviral therapy, is described. The case highlights the importance of establishing this diagnosis to institute appropriate therapy.

Since 1999, Cryptococcus gattii has been identified as a primary pathogen on Vancouver Island in British Columbia, and it has resulted in infection of both people and animals living in that area. A previously healthy 45-year-old female resident of Alberta developed C gattii infection 11 months after travelling to an endemic region of Vancouver Island. A case of an immunocompetent patient, with an atypically long incubation time, who presented with subacute meningitis secondary to disseminated pulmonary cryptococcosis is presented. The present report highlights the need for clinical vigilance in treating patients presenting with atypical pulmonary infections or meningitis who have been holiday travellers to endemic areas of Vancouver Island.

Efavirenz is a potent antiretroviral agent used in combination with other antiretroviral agents as part of highly active antiretroviral therapy. Efavirenz is generally well tolerated because the majority of its adverse effects are self-limiting, with central nervous symptoms and rash being the most frequent. In routine practice, the discontinuation rate of efavirenz due to adverse effects appears higher than that described in clinical trials. To minimize early treatment interruption and maximize the benefit of long term viral suppression that can be achieved with efavirenz therapy, health care providers and patients have identified that there is a need for information, education about and practical tools for the management of efavirenz-related side effects. To this end, a panel of experts in the care of HIV patients consisting of primary care physicians, infectious disease specialists, psychiatrists and pharmacists was convened. Through the evaluation of current literature and discussion among the group, the panel arrived at consensus recommendations. The present report outlines general management recommendations that apply to adverse effects related to efavirenz initiation, as well as specific management strategies for central nervous system symptoms such as agitation, sleep disturbances, dreams, dizziness, impaired concentration and depression. It is hoped that these practical recommendations will aid clinicians in minimizing and improving patient tolerance of side effects, thereby achieving improved adherence and patient outcomes.

Extraintestinal infections of Clostridium difficile are rare and often associated with underlying disorders. A case of empyema caused by aspiration of C difficile in a patient with carcinoid syndrome and C difficile colitis is described.

OBJECTIVE: To determine the incidence of human immunodeficiency virus (HIV) associated non-Hodgkin’s lymphoma (NHL) in a cohort of patients from a distinct geographic region (southern Alberta). The type and location of NHL as well as how it affected the survival of these patients was examined.PATIENTS AND METHODS: The Southern Alberta HIV Clinic in Calgary serves all of southern Alberta, which has an estimated population of one million. The clinic has provided primary care for 1086 patients from January 1983 to August 1995. Data were obtained by reviewing the clinic’s database and patients’ charts.RESULTS: Over a 12-year period, 39 cases of NHL were diagnosed in a group of 1086 HIV-infected patients. Presentation of NHL was at an extranodal site in all but four cases, with the most common sites being the bowel and central nervous system. The mean CD4 count on presentation with NHL was 143.4±37.4×106/L (range 1 to 1219×106/L). Mean survival was 1.25±0.25 years with a range from 0 (diagnosed on autopsy) to 6.45 years. Patients with a CD4 count of less than 200×106/L and/or diagnosed with an AIDS-defining illness before development of NHL had significantly reduced survival (0.85 years versus 2.48 years, P<0.02 and 0.57 years versus 2.09 years, P<0.001, respectively). Patients who presented with NHL involving either nodes alone or central nervous system had significantly decreased survival (0.28 years and 0.29 years, respectively, P<0.05). Patients with NHL involving the gastrointestinal tract had a longer mean survival than those with NHL elsewhere (P<0.05). All but seven cases received therapy for NHL including chemotherapy, radiotherapy, surgery or combined therapy. Fifteen patients (47% of treated) achieved a complete response that led to improved survival (P<0.01). Patients tolerated surgery, chemotherapy and radiotherapy well and no deaths were due to NHL therapy.CONCLUSIONS: These data suggest that development of NHL in HIV is associated with reduced survival, and that survival is predominantly determined by CD4 count and site of involvement at the time of diagnosis of NHL.

Since the first report of human infection with Pneumocystis carinii in 1942, cases of pneumonia due to this opportunistic pathogen have become increasingly common. Animal studies and clinical observations show that a significant depletion or dysfunction of T helper lymphocytes predisposes to clinical disease. Individuals with damaged T helper cells secondary to malignancies (eg, Hodgkin’s lymphoma), drugs (eg, cyclosporine, steroids), or certain infections (eg, human immunodeficiency virus) are at particular risk. Serological studies suggest that disease is most often secondary to the reactivation of an asymptomatic infection, usually acquired during childhood. Increasing shortness of breath, a nonproductive cough and hypoxia often preceded by several weeks of lethargy, fever and weight loss are the classical features of P carinii pneumonia in acquired immune deficiency syndrome. Bronchoalveolar lavage is usually the optimal diagnostic test. Immunofluorescent staining on liquified sputum induced by nebulized saline appears to be a promising and noninvasive test. Early empiric therapy with trimethoprim-sulphamethoxazole (trimethoprim 5 mg-sulphamethoxazole 25 mg/kg/day every 6 h) or intravenous pentamidine (4 mg/kg/day) for 21 days is usually effective, but infection is not eradicated, and clinical disease is likely to recur. Prophylaxis using aerosolized pentamidine reduces the risk of pulmonary disease but can predispose to extrapulmonary infection. Improved in vitro and in vivo models of human pneumocystis infection would significantly increase understanding of the molecular biology of the organism, the pathogenesis of disease, and the optimal therapeutic regimens.

OBJECTIVE: To determine the prevalence of exposure to cytomegalovirus (CMV), Toxoplasma gondii, syphilis, hepatitis B virus (HBV) and hepatitis C virus (HCV) in a large, well characterized, regional population presenting for human immunodeficency virus (HIV) care.DESIGN: Demographic and serological data compiled prospectively in a relational database used for routine patient care. Results were analyzed for statistically significant trends within demographic subpopulations known to be at risk of such infections.PATIENTS AND SETTING: A total of 1274 persons with documented HIV infection in southern Alberta have sought medical care since 1985. Serological status to CMV, T gondii, syphilis, HBV and HCV infections were routinely requested as part of the initial assessment. All patients with serological results available were included in the analysis.RESULTS: CMV infection was found in 84.1% of patients. A lower prevalence of CMV infection in those under 30 yeasr old (P<0.001), intravenous drug users (IVDUs) (P=0.001) and in patients with transfusion-acquired HIV (P<0.001) was seen. T gondii seropositivity was found in 10.6% of patients, with an increased risk of seropositivity in those born outside of Canada (P<0.001). Syphilis seropositivity was present in 5.1% of patients, with a higher prevalence in gay males (P=0.1). HBV carrier status was noted in 8.0% of patients, with males having an increased risk (P=0.025). Since 1990, there has been a 17.6% prevalence of HCV, predominantly in IVDUs (P<0.001).CONCLUSION: Seroprevalence to common pathogens in HIV disease varies significantly among subpopulations, necessitating individual testing.