Emergence of Acquired HIV-1 Drug Resistance Almost Stopped in Switzerland: A 15-Year Prospective Cohort Analysis

BACKGROUND

Drug resistance is a major barrier to successful antiretroviral treatment (ART). Therefore, it is important to monitor time trends at a population level.

METHODS

We included 11 084 ART-experienced patients from the Swiss HIV Cohort Study (SHCS) between 1999 and 2013. The SHCS is highly representative and includes 72% of patients receiving ART in Switzerland. Drug resistance was defined as the presence of ≥1 major mutation in a genotypic resistance test. To estimate the prevalence of drug resistance, data for patients with no resistance test was imputed based on the patient's risk of harboring drug-resistant viruses.

RESULTS

The emergence of new drug resistance mutations declined dramatically from 401 to 23 patients between 1999 and 2013. The upper estimated prevalence limit of drug resistance among ART-experienced patients decreased from 57.0% in 1999 to 37.1% in 2013. The prevalence of 3-class resistance decreased from 9.0% to 4.4% and was always <0.4% for patients who initiated ART after 2006. Most patients actively participating in the SHCS in 2013 with drug-resistant viruses initiated ART before 1999 (59.8%). Nevertheless, in 2013, 94.5% of patients who initiated ART before 1999 had good remaining treatment options based on Stanford algorithm.

CONCLUSIONS

Human immunodeficiency virus type 1 drug resistance among ART-experienced patients in Switzerland is a well-controlled relic from the era before combination ART. Emergence of drug resistance can be virtually stopped with new potent therapies and close monitoring.

High Quality of Diabetes Care Based Upon Individualised Treatment Goals - A Cross Sectional Study in 4784 Patients in Germany

OBJECTIVE

Recent guidelines recommend an individualized approach towards patients with diabetes mellitus. Data of a programme dealing with quality of diabetes care, "Diabetes TÜV" of the Deutsche BKK was reappraised in the light of recent evidence applying these recommendations.

PATIENTS AND METHODS

Data originates from a population-based study in primary diabetes care in Germany. Patients with diabetes mellitus insured by the Deutsche BKK were invited to participate. From 2000 to 2004 data of 4 784 patients participated. Double or multiple visits were not included. HbA1c was analysed in 0.5% categories and in age groups below and above 70 years. HbA1c was DCCT adjusted.

RESULTS

A total of 368 patients with diabetes mellitus type 1 (DM1) (42% women, HbA1c 54 mmol/mol (7.1%), BP 136/79 mmHg) and 4 416 patients with diabetes type 2 (DM2) (44% women, HbA1c 48.6 mmol/mol (6.6%), BP 142/81 mmHg) were included.). An HbA1c of 53 mmol/mol (7%) or less was found in 70%, less than 64 mmol/mol (8%) in 87% of all patients, and higher than 86 mmol/mol (10%) in 2.8%. The detailed analysis shows that an HbA1c of <=47.6 mmol/mol (6.5%) is achieved of 38% of people with DM1 and 56% with DM2, an HbA1c <=66 mmol/mol (8.0%) of 79% and 88%, respectively.The mean systolic blood pressure (BP) was 142 mmHg, the diastolic BP was 81 mmHg. Systolic BP increased with age (systolic BP: < 50 years 131 mmHg; 50-70 years 142 mmHg; > 70 years 144 mmHg/diastolic BP: < 50 years 81 mmHg; 50-70 years 82 mmHg; > 70 years 80 mmHg). Using WHO grading, BP is mainly mildly elevated (grade 1: 41% (n=1942); grade 2, 17% (n=820) grade 3 6% (n=281). In 10 patients (0.2%) HbA1c above 86 mmol/mol (10.0%) coincides with a BP WHO grade 3.

CONCLUSIONS

In recent years new evidence is available regarding treatment targets. The reappraisal of a cross sectional study of a quality assurance programme of a German health insurance in a differentiated way demonstrates that more than 2/3 of the people with diabetes mellitus meet their specific goals. Only very few patients are at imminent risk due to bad glycaemic control and high blood pressure. Old patients may be at risk of overtreatment. Strategies aiming at adapting pharmacological interventions in older patients must be conceived.

Long-term Outcomes in Steroid-refractory Ulcerative Colitis Treated with Tacrolimus Alone or in Combination with Purine Analogues

BACKGROUND AND AIMS

Tacrolimus is recommended for the treatment of steroid-refractory ulcerative colitis (UC). Concomitantly started purine analogues (PAs) are used for the maintenance of remission, though their therapeutic relevance remains uncertain. Here we studied the role of PAs in the long-term outcome of steroid-refractory UC after tacrolimus treatment.

METHODS

In five centres, charts of tacrolimus-treated UC patients with a steroid-refractory moderate to severe course were reviewed. Long-term efficacy was determined by colectomy rates and clinical remission in cases of colectomy-free survival for 3 months.

RESULTS

We identified 156 patients (median age 34 years) with a median Lichtiger score of 12 (4-17) and pancolitis (E3) in 65% (101). The Kaplan-Meier curve for colectomy-free survival after month 3 showed a benefit in the PA group (p = 0.02). In patients treated with PA clinical remission was achieved in 82% (65/79) vs 67% (39/58) in those not treated with PA (p = 0.02). Time to colectomy was 2 years (median, 0.7-5.8) in the PA group and 0.8 years (0.3-4.7) in the group not treated with PAs (p = 0.02). Time to relapse was 1.2 years (median, 0.3-6.2) in patients with PA treatment and 0.5 years (0.3-3.9) in those without PA treatment (p = 0.05). Overall, clinical remission was achieved in 67% (104/156) of patients. Colectomy was performed in 29% (45/156) 0.5 years (median, 0.04-5.79) after initiation of tacrolimus. Ten (6%) patients had to stop tacrolimus due to adverse events and two (without PA treatment) died.

CONCLUSIONS

Our study supports the efficacy of tacrolimus in steroid-refractory UC. Purine analogues appear to be beneficial for the long-term outcome of these patients.

Yeast-derived biosynthesis of silver/silver chloride nanoparticles and their antiproliferative activity against bacteria

Here, we provided the first evidence of Ag/AgCl-nanoparticles production in yeast strains fromin vitrocultures.

HIV-1 Transmission During Recent Infection and During Treatment Interruptions as Major Drivers of New Infections in the Swiss HIV Cohort Study

BACKGROUND

Reducing the fraction of transmissions during recent human immunodeficiency virus (HIV) infection is essential for the population-level success of "treatment as prevention".

METHODS

A phylogenetic tree was constructed with 19 604 Swiss sequences and 90 994 non-Swiss background sequences. Swiss transmission pairs were identified using 104 combinations of genetic distance (1%-2.5%) and bootstrap (50%-100%) thresholds, to examine the effect of those criteria. Monophyletic pairs were classified as recent or chronic transmission based on the time interval between estimated seroconversion dates. Logistic regression with adjustment for clinical and demographic characteristics was used to identify risk factors associated with transmission during recent or chronic infection.

FINDINGS

Seroconversion dates were estimated for 4079 patients on the phylogeny, and comprised between 71 (distance, 1%; bootstrap, 100%) to 378 transmission pairs (distance, 2.5%; bootstrap, 50%). We found that 43.7% (range, 41%-56%) of the transmissions occurred during the first year of infection. Stricter phylogenetic definition of transmission pairs was associated with higher recent-phase transmission fraction. Chronic-phase viral load area under the curve (adjusted odds ratio, 3; 95% confidence interval, 1.64-5.48) and time to antiretroviral therapy (ART) start (adjusted odds ratio 1.4/y; 1.11-1.77) were associated with chronic-phase transmission as opposed to recent transmission. Importantly, at least 14% of the chronic-phase transmission events occurred after the transmitter had interrupted ART.

CONCLUSIONS

We demonstrate a high fraction of transmission during recent HIV infection but also chronic transmissions after interruption of ART in Switzerland. Both represent key issues for treatment as prevention and underline the importance of early diagnosis and of early and continuous treatment.

Strong Impact of Smoking on Multimorbidity and Cardiovascular Risk Among Human Immunodeficiency Virus-Infected Individuals in Comparison With the General Population

AIDS-associated morbidity has diminished due to excellent viral control. Multimorbidity are more prevalent and incident in Swiss HIV-positive persons compared to HIV-negative controls. However, smoking, but not HIV status, had a strong impact on cardiovascular risk and multimorbidity.

Background. Although acquired immune deficiency syndrome-associated morbidity has diminished due to excellent viral control, multimorbidity may be increasing among human immunodeficiency virus (HIV)-infected persons compared with the general population.

Methods. We assessed the prevalence of comorbidities and multimorbidity in participants of the Swiss HIV Cohort Study (SHCS) compared with the population-based CoLaus study and the primary care-based FIRE (Family Medicine ICPC-Research using Electronic Medical Records) records. The incidence of the respective endpoints were assessed among SHCS and CoLaus participants. Poisson regression models were adjusted for age, sex, body mass index, and smoking.

Results. Overall, 74 291 participants contributed data to prevalence analyses (3230 HIV-infected; 71 061 controls). In CoLaus, FIRE, and SHCS, multimorbidity was present among 26%, 13%, and 27% of participants. Compared with nonsmoking individuals from CoLaus, the incidence of cardiovascular disease was elevated among smoking individuals but independent of HIV status (HIV-negative smoking: incidence rate ratio [IRR] = 1.7, 95% confidence interval [CI] = 1.2–2.5; HIV-positive smoking: IRR = 1.7, 95% CI = 1.1–2.6; HIV-positive nonsmoking: IRR = 0.79, 95% CI = 0.44–1.4). Compared with nonsmoking HIV-negative persons, multivariable Poisson regression identified associations of HIV infection with hypertension (nonsmoking: IRR = 1.9, 95% CI = 1.5–2.4; smoking: IRR = 2.0, 95% CI = 1.6–2.4), kidney (nonsmoking: IRR = 2.7, 95% CI = 1.9–3.8; smoking: IRR = 2.6, 95% CI = 1.9–3.6), and liver disease (nonsmoking: IRR = 1.8, 95% CI = 1.4–2.4; smoking: IRR = 1.7, 95% CI = 1.4–2.2). No evidence was found for an association of HIV-infection or smoking with diabetes mellitus.

Conclusions. Multimorbidity is more prevalent and incident in HIV-positive compared with HIV-negative individuals. Smoking, but not HIV status, has a strong impact on cardiovascular risk and multimorbidity.

Healthcare utilization of people with type 2 diabetes in Germany: an analysis based on health insurance data

AIMS

This population-based study assesses the healthcare utilization of people with Type 2 diabetes by analysing routine data from Allgemeine Orts-Krankenkasse (AOK), the largest statutory health insurance provider in Germany.

METHODS

Anonymized billing data from all AOK-insured persons with at least one day of insurance during the evaluation year 2010 were analysed. Treatment and cost data from all areas of inpatient and outpatient care were available, as was information regarding patient age and sex. International Classification of Diseases (ICD-10) diagnosis and Anatomical Therapeutic Chemical (ATC) classification were used to identify 2.7 million insured persons with diabetes.

RESULTS

The age- and sex-standardized prevalence of Type 2 diabetes was 9.8%. Of those patients identified, 33.9% had at least one diabetes-related complication and 83.0% had a diagnosis of hypertension. Almost two-thirds (63.1%) received antihyperglycaemic medication. Metformin and sulfonylurea were prescribed most often; medications without proof of benefit in endpoint studies were prescribed much less frequently. People without diabetes were admitted to hospital only half as often as those with Type 2 diabetes. The projected total expenditure in Germany for all people with Type 2 diabetes amounted to approximately €33.3 billion in 2010.

CONCLUSIONS

This study shows an increase in both the prevalence of diabetes and treatment costs. The majority of people with Type 2 diabetes were aged 70 years or older. One third of this group has diabetes-related complications. Antihyperglycaemic medications without proof of benefit in endpoint studies were prescribed much less frequently than drugs with proof of benefit.

Postprandial self-monitoring of urine glucose reflects glycaemic control in people with relatively well controlled Type 2 diabetes mellitus not treated with insulin: a retrospective cohort study

AIM

To analyse the association of self-monitoring of urine glucose with HbA1c concentration in people with Type 2 diabetes not treated with insulin.

METHODS

We studied the association of postprandial self-monitored urine glucose with HbA1c concentrations in 264 people with Type 2 diabetes (mean age 62.4 years, time since diagnosis of diabetes 6.8 years and HbA1c 50 mmol/l). All patients took part in a diabetes treatment and teaching programme. HbA1c values were adjusted according to the Diabetes Control and Complication Trial.

RESULTS

The mean ( ± sd) HbA1c concentration for the patients with constant negative urine glucose tests (56.1% of patients) was 46 ( ± 6) mmol/mol [6.4 ( ± 0.6)%]. This was significantly lower than in patients with < 50% positive urine glucose tests (33.3% of patients): mean ( ± sd) HbA1c was 53 ( ± 8) mmol/mol [7.0( ± 0.7)%] and also lower than in patients with ≥50% positive tests (10.6% of patients): mean ( ± sd) HbA1c of 57 ( ± 8) mmol/mol [7.4 ( ± 0.7)%]; P < 0.001. There was a significant correlation between the urine glucose test results and HbA1c (r = 0.416; P < 0.001).

CONCLUSION

HbA1c concentrations were observed to be in the near-normal range for people with Type 2 diabetes not receiving insulin treatment who were negative for postprandial glucosuria. Urine glucose self-monitoring is a cheap and effective method to determine the quality of glucose control.

People with type 2 diabetes on premixed insulin therapy: how is the daily insulin dose partitioned and are there effects on the metabolic control?

AIM

To investigate the correctness of the recommendation for dose distribution in premixed insulin therapy, with two thirds of daily insulin dose before breakfast and one third of daily insulin dose before dinner.

METHODS

The individual insulin dose distribution and metabolic control of people with Type 2 diabetes treated with premixed insulin therapy were studied in a cross sectional study involving 199 patients in a university outpatient department and 2 general practices in 2010.

RESULTS

All 199 patients were treated with premixed human insulin. The mean pre-breakfast dose was 57% (min. 32%, max. 83%) and the mean pre-dinner dose 43% (17-67%) of the total daily insulin. A pre-breakfast dose of exactly two thirds of total daily insulin was used by 6.5% (n=13), about two thirds, i. e., 60-70%, was injected by 27.6% of the patients. The diurnal insulin distribution<60%, 60% up to 70% and > 70% pre-breakfast insulin did not make any difference in HbA1c, which was 7.3% (56 mmol/mol) each.

CONCLUSION

The quite common recommendation in German and Austrian medical textbooks, that premixed insulin therapy should consists of a dose distribution with two thirds before breakfast and one third before dinner, is not observed in daily practice. Diurnal insulin dose distribution and HbA1c are not associated in this cohort. Novelty statement: The circadian insulin dose distribution of 2/3 before breakfast and 1/3 before dinner could not be confirmed for patients with diabetes type 2 and conventional insulin therapy. No correlation between metabolic control and insulin circadian insulin dose distribution was detected.

Increases in Condomless Sex in the Swiss HIV Cohort Study

Condomless sex is a key driver of sexually transmitted diseases. In this study, we assess the long-term changes (2000-2013) of the occurrence of condomless sex among human immunodeficiency virus (HIV)-infected individuals enrolled in the Swiss HIV Cohort study. The frequencies with which HIV-infected individuals reported condomless sex were either stable or only weakly increasing for 2000-2008. For 2008-2013, these rates increased significantly for stable relationships among heterosexuals and men who have sex with men (MSM) and for occasional relationships among MSM. Our results highlight the increasing public health challenge posed by condomless sex and show that condomless sex has been increasing even in the most recent years.

Complete evaluation of adrenal tumours in a tertiary care institution in Thuringia, Germany

INTRODUCTION AND OBJECTIVE

Adrenal tumours, mainly incidentalomas, are an increasingly common clinical and diagnostic challenge. The aim of the present study was the retrospective evaluation of all patients with adrenal tumours treated in our university department from 1.1.1999-31.12.2013 PATIENTS AND METHODS: 187 patients (108 females: 79 males, mean age 57.7 years) were found to have adrenal tumours in our institution during the study period. All patients underwent basic and, when indicated, advanced analytical testing for hormonal activity. Tumours were classified according to patients' gender, age at diagnosis, tumour localization and size, as well as benignity and malignancy when postinterventional histopathological examination was conducted.

RESULTS

134 (71.7%) patients had non-hormone secreting tumours, 17 (9.1%) pheochromocytoma, 13 (7.0%) Conn-syndrome, 13 (7.0%) adrenal Cushing's disease, 1 congenital adrenal hyperplasia and 2 sexual hormone-secreting tumours. 7 (3.7%) tumours could not be definitively classified due to unclear or marginal test-results. Cushing's disease was more prevalent in females (11 females: 2 males). 163 (87.2% of the total cohort) tumours were unilateral [95 (50.8%) left; 68 (36.4%) right] and 24 (12.8%) were bilateral. Tumour size was <3 cm in 109 (58.3%), 3-6 cm in 63 (33.7%) and >6 cm in 15 (8.0%) patients. 60 (32.1%) patients underwent adrenalectomy, thereof 88.9% of the patients with hormonally active tumours, while 8 (4.3%) were evaluated with ultrasound-guided biopsy. Malignancy was confirmed in 10 individuals (5.3%; 3 non-functioning tumours, 3 pheochromocytomas, 2 Cushing's patients and 2 sexual-hormone secreting tumours), while 2 surgical specimens with histopathological diagnosis of pheochromocytoma showed signs of malignant changes. Benignity was histopathologically confirmed in 55 patients.

CONCLUSIONS

The prevalence of detected adrenal tumours is rising due to widely available and applied abdominal imaging procedures. The vast majority of them are benign, of small size (<3 cm) and hormonally inactive. Adrenalectomy is the therapeutic method of choice in big and/or confirmed hormone-secreting tumours.

The wingless-related integration site-5a/secreted frizzled-related protein-5 system is dysregulated in human sepsis

Sepsis and type 2 diabetes exhibit insulin resistance as a common phenotype. In type 2 diabetes we and others have recently provided evidence that alterations of the proinflammatory wingless-related integration site (wnt)-5a/anti-inflammatory secreted frizzled-related protein (sFRP)-5 system are involved in the pathogenesis of insulin resistance. The aim of the present study was to investigate whether this novel cytokine system is dysregulated in human sepsis, which may indicate a potential mechanism linking inflammation to metabolism. In this single-centre prospective observational study, critically ill adult septic patients were examined and proinflammatory wnt5a and wnt5a inhibitor sFRP5 were measured in serum samples by enzyme-linked immunosorbent assay (ELISA) at admission to the intensive care unit (ICU) and 5 days later. Sixty sepsis patients were included, and 30 healthy individuals served as controls. Wnt5a levels were found to be increased significantly in septic patients compared to healthy controls (2·21 ± 0·33 versus 0·32 ± 0·03 ng/ml, P < 0·0001). In contrast, sFRP5 was not altered significantly in septic patients (19·72 ± 3·06 versus 17·48 ± 6·38 ng/ml, P = 0·07). On admission to the ICU, wnt5a levels exhibited a significant positive correlation with the leucocyte count (rs  = 0·3797, P = 0·004). Interestingly, in patients recovering from sepsis, wnt5a levels declined significantly within 5 days (2·17 ± 0·38-1·03 ± 0·28 ng/ml, P < 0·01). In contrast, if sepsis was worsening, wnt5a levels increased in the same time-period by trend (2·34 ± 0·59-3·25 ± 1·02 ng/ml, P > 0·05). sFRP5 levels did not change significantly throughout the study period. The wnt5a/sFRP5 system is altered in human sepsis and might therefore be of interest for future studies on molecular pathophysiology of this common human disease.

Incident Hepatitis C Virus Infections in the Swiss HIV Cohort Study: Changes in Treatment Uptake and Outcomes Between 1991 and 2013

Background.  The hepatitis C virus (HCV) epidemic is evolving rapidly in patients infected with human immunodeficiency virus (HIV). We aimed to describe changes in treatment uptake and outcomes of incident HCV infections before and after 2006, the time-point at which major changes in HCV epidemic became apparent. Methods.  We included all adults with an incident HCV infection before June 2012 in the Swiss HIV Cohort Study, a prospective nationwide representative cohort of individuals infected with HIV. We assessed the following outcomes by time period: the proportion of patients starting an HCV therapy, the proportion of treated patients achieving a sustained virological response (SVR), and the proportion of patients with persistent HCV infection during follow-up. Results.  Of 193 patients with an HCV seroconversion, 106 were diagnosed before and 87 after January 2006. The proportion of men who have sex with men increased from 24% before to 85% after 2006 (P < .001). Hepatitis C virus treatment uptake increased from 33% before 2006 to 77% after 2006 (P < .001). Treatment was started during early infection in 22% of patients before and 91% after 2006 (P < .001). An SVR was achieved in 78% and 29% (P = .01) of patients treated during early and chronic HCV infection. The probability of having a detectable viral load 5 years after diagnosis was 0.67 (95% confidence interval [CI], 0.58-0.77) in the group diagnosed before 2006 and 0.24 (95% CI, 0.16-0.35) in the other group (P < .001). Conclusions.  In recent years, increased uptake and earlier initiation of HCV therapy among patients with incident infections significantly reduced the proportion of patients with replicating HCV.

Use of snacks in insulin-treated people with diabetes mellitus and association with HbA1c , weight and quality of life: a cross sectional study

AIM

Insulin therapies with prandial injections offer the possibility to skip snacks or omit meals. It is unclear how many people with insulin-treated diabetes mellitus eat snacks and whether they snack for their own comfort or only on the recommendation of healthcare professionals.

METHODS

In 2004, 163 consecutive people with insulin-treated diabetes seen in a university outpatient department were interviewed regarding their diet and degree of satisfaction with their meals. Fifty-five had Type 1 diabetes [age 47 years; diabetes duration 18 years; BMI 27 kg/m(2) ; HbA1c 62 mmol/mol (7.8%)], 53 had Type 2 diabetes with biphasic insulin therapy [age 68 years; diabetes duration 17 years; BMI 31 kg/m(2) ; HbA1c 60 mmol/mol (7.6%)] and 55 had Type 2 diabetes with prandial insulin therapy [age 60 years; diabetes duration 16 years; BMI 33 kg/m(2) ; HbA1c 59 mmol/mol (7.6%)].

RESULTS

Eighty per cent of those with Type 1 diabetes ate snacks, together with 77% of the Type 2 diabetes/biphasic group and 62% of the Type 2 diabetes/prandial group. Most participants (91% Type 1 diabetes, 88% Type 2 diabetes/biphasic group, 82% Type 2 diabetes/prandial group) liked to have snacks. The time at which they ate snacks was the same for both diabetes types. There were no differences between participants with Type 1 diabetes who snacked and those who did not in terms of age (P = 0.350), BMI (P = 0.368), HbA1c (P = 0.257) and time since diagnosis (P = 0.846). Participants with Type 2 diabetes who ate snacks were older than those who did not (biphasic: P = 0.006; prandial: P = 0.008). There were no differences in terms of BMI (biphasic: P = 0.731; prandial: P = 0.393), HbA1c (biphasic: P = 0.747; prandial: P = 0.616) and time since diagnosis (biphasic: P = 0.06; prandial: P = 0.620).

CONCLUSIONS

Most people with insulin-treated diabetes eat snacks voluntarily and not because of physicians' instructions. There were no correlations between the use of snacks and HbA1c , BMI and time since diagnosis, except that the participants with Type 2 diabetes who ate snacks were older.

Molecular profiling of myeloid progenitor cells in multi-mutated advanced systemic mastocytosis identifies KIT D816V as a distinct and late event

To explore the molecular profile and its prognostic implication in systemic mastocytosis (SM), we analyzed the mutation status of granulocyte-macrophage colony-forming progenitor cells (CFU-GM) in patients with KIT D816V(+) indolent SM (ISM, n=4), smoldering SM (SSM, n=2), aggressive SM (ASM, n=1), SM with associated clonal hematologic non-mast cell lineage disorder (SM-AHNMD, n=5) and ASM-AHNMD (n=7). All patients with (A)SM-AHNMD (n=12) carried 1-4 (median 3) additional mutations in 11 genes tested, most frequently TET2, SRSF2, ASXL1, CBL and EZH2. In multi-mutated (A)SM-AHNMD, KIT D816V(+) single-cell-derived CFU-GM colonies were identified in 8/12 patients (median 60%, range 0-95). Additional mutations were identified in CFU-GM colonies in all patients, and logical hierarchy analysis indicated that mutations in TET2, SRSF2 and ASXL1 preceded KIT D816V. In ISM/SSM, no additional mutations were detected and CFU-GM colonies were exclusively KIT D816V(-). These data indicate that (a) (A)SM-AHNMD is a multi-mutated neoplasm, (b) mutations in TET2, SRSF2 or ASXL1 precede KIT D816V in ASM-AHNMD,

Obesity Trends and Body Mass Index Changes After Starting Antiretroviral Treatment: The Swiss HIV Cohort Study

BACKGROUND

The factors that contribute to increasing obesity rates in human immunodeficiency virus (HIV)-positive persons and to body mass index (BMI) increase that typically occurs after starting antiretroviral therapy (ART) are incompletely characterized.

METHODS

We describe BMI trends in the entire Swiss HIV Cohort Study (SHCS) population and investigate the effects of demographics, HIV-related factors, and ART on BMI change in participants with data available before and 4 years after first starting ART.

RESULTS

In the SHCS, overweight/obesity prevalence increased from 13% in 1990 (n = 1641) to 38% in 2012 (n = 8150). In the participants starting ART (n = 1601), mean BMI increase was 0.92 kg/m(2) per year (95% confidence interval, .83-1.0) during year 0-1 and 0.31 kg/m(2) per year (0.29-0.34) during years 1-4. In multivariable analyses, annualized BMI change during year 0-1 was associated with older age (0.15 [0.06-0.24] kg/m(2)) and CD4 nadir <199 cells/µL compared to nadir >350 (P < .001). Annualized BMI change during years 1-4 was associated with CD4 nadir <100 cells/µL compared to nadir >350 (P = .001) and black compared to white ethnicity (0.28 [0.16-0.37] kg/m(2)). Individual ART combinations differed little in their contribution to BMI change.

CONCLUSIONS

Increasing obesity rates in the SHCS over time occurred at the same time as aging of the SHCS population, demographic changes, earlier ART start, and increasingly widespread ART coverage. Body mass index increase after ART start was typically biphasic, the BMI increase in year 0-1 being as large as the increase in years 1-4 combined. The effect of ART regimen on BMI change was limited.