Recomendaciones de Gesida/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana (actualización febrero de 2009)

Virological efficacy of PI monotherapy for HIV-1 in clinical practice

BACKGROUND

Clinical trials of PI monotherapy indicate that most participants maintain viral suppression and emergent protease resistance is rare. However, outcomes among patients receiving PI monotherapy for clinical reasons, such as toxicity or adherence issues, are less well studied.

METHODS

An observational study of patients attending an HIV treatment centre in London, UK, who had received PI monotherapy between 2004 and 2013, was conducted using prospectively collected clinical data and genotypic resistance reports. Survival analysis techniques were used to examine the times to virological failure and treatment discontinuation.

RESULTS

Ninety-five patients had PI monotherapy treatment for a median duration of 126 weeks. Virological failure occurred during 64% of episodes and 8% of patients developed emergent protease mutations. We estimate failure occurs in half of episodes within 2 years following initiation. Where PI monotherapy was continued following virological failure, 68% of patients achieved viral re-suppression. Despite a high incidence of virological failure, many patients continued PI monotherapy and 79% of episodes were ongoing at the end of the study. The type of PI used, the presence of baseline protease mutations and the plasma HIV RNA at initiation did not have a significant impact on treatment outcomes.

CONCLUSIONS

There was a higher incidence of virological failure and emerging resistance in our UK clinical setting than described in PI monotherapy clinical trials and other European observational studies. Despite this, many patients continued PI monotherapy and regained viral suppression, indicating this strategy remains a viable option in certain individuals following careful clinical evaluation.

Clinical outcomes of patients infected with HIV through use of injected drugs compared to patients infected through sexual transmission: late presentation, delayed anti-retroviral treatment and higher mortality

AIMS

To compare patients who acquired HIV infection through use of injected drugs (HIV-IDU) with patients who acquired HIV by sexual transmission (HIV-ST) in terms of late presentation (LP), delay in anti-retroviral treatment (ART) initiation, virological and immunological response to ART, mortality and progression to AIDS.

DESIGN

Prospective multi-centre cohort study of HIV-infected subjects naive to ART at entry (Cohort of the Spanish HIV Research Network: CoRIS).

SETTING

Thirty-one centres from the Spanish public health-care system.

PARTICIPANTS

A total of 9355 patients were included (1064 HIV-IDU and 8291 HIV-ST) during 2004-13.

MEASUREMENTS

We compared LP (defined as presentation for care with a CD4 cell count < 350/μl and/or AIDS-defining illness), delayed ART initiation (defined as initiating treatment more than 6 months after the date when treatment was indicated by the guidelines, or not initiating treatment at all when it was indicated), virological and immunological response to ART (defined as viral load < 50 HIV-1 RNA copies/ml and a CD4 count increase of at least 100 cells/μl, respectively, after 1 year of treatment), mortality and progression to AIDS in HIV-IDU and HIV-ST.

FINDINGS

Compared with HIV-ST, HIV-IDU had higher risk of LP [odds ratio (OR) = 1.76; 95% confidence interval (CI) = 1.41-2.18], delayed ART initiation (OR 1.87; 95% CI = 1.46-2.40) and higher mortality [hazard ratio (HR) = 1.43; 95% CI = 1.03-2.01] and risk of progression to AIDS [subhazard ratio (SHR) = 1.68; 95% CI = 1.29-2.18]. Virological suppression due to ART was lower in HIV-IDU than in patients with HIV-ST only among patients without hepatitis C virus (HCV) infection [adjusted OR (aOR) = 0.59; 95% CI = 0.36-0.95]; among patients with HCV infection, virological suppression due to ART did not show significant differences between HIV-IDU and HIV-ST. There were no significant differences in immunological response after adjusting by HCV (aOR = 0.74; 95% CI = 0.52-1.06).

CONCLUSIONS

In Spain, patients who acquire HIV infection through use of injected drugs appear to have a higher risk of late presentation, delayed initiation of anti-retroviral treatment and progression to AIDS and death than patients who acquire HIV by sexual transmission.

Effectiveness of Ritonavir-Boosted Protease Inhibitor Monotherapy in Clinical Practice Even with Previous Virological Failures to Protease Inhibitor-Based Regimens

BACKGROUND AND OBJECTIVE

Significant controversy still exists about ritonavir-boosted protease inhibitor monotherapy (mtPI/rtv) as a simplification strategy that is used up to now to treat patients that have not experienced previous virological failure (VF) while on protease inhibitor (PI) -based regimens. We have evaluated the effectiveness of two mtPI/rtv regimens in an actual clinical practice setting, including patients that had experienced previous VF with PI-based regimens.

METHODS

This retrospective study analyzed 1060 HIV-infected patients with undetectable viremia that were switched to lopinavir/ritonavir or darunavir/ritonavir monotherapy. In cases in which the patient had previously experienced VF while on a PI-based regimen, the lack of major HIV protease resistance mutations to lopinavir or darunavir, respectively, was mandatory. The primary endpoint of this study was the percentage of participants with virological suppression after 96 weeks according to intention-to-treat analysis (non-complete/missing = failure).

RESULTS

A total of 1060 patients were analyzed, including 205 with previous VF while on PI-based regimens, 90 of whom were on complex therapies due to extensive resistance. The rates of treatment effectiveness (intention-to-treat analysis) and virological efficacy (on-treatment analysis) at week 96 were 79.3% (CI95, 76.8-81.8) and 91.5% (CI95, 89.6-93.4), respectively. No relationships were found between VF and earlier VF while on PI-based regimens, the presence of major or minor protease resistance mutations, the previous time on viral suppression, CD4+ T-cell nadir, and HCV-coinfection. Genotypic resistance tests were available in 49 out of the 74 patients with VFs and only four patients presented new major protease resistance mutations.

CONCLUSION

Switching to mtPI/rtv achieves sustained virological control in most patients, even in those with previous VF on PI-based regimens as long as no major resistance mutations are present for the administered drug.

Mortality, Causes of Death and Associated Factors Relate to a Large HIV Population-Based Cohort

INTRODUCTION

Antiretroviral therapy has led to a decrease in HIV-related mortality and to the emergence of non-AIDS defining diseases as competing causes of death. This study estimates the HIV mortality rate and their risk factors with regard to different causes in a large city from January 2001 to June 2013.

MATERIALS AND METHODS

We followed-up 3137 newly diagnosed HIV non-AIDS cases. Causes of death were classified as HIV-related, non-HIV-related and external. We examined the effect of risk factors on survival using mortality rates, Kaplan-Meier plots and Cox models. Finally, we estimated survival for each main cause of death groups through Fine and Gray models.

MORTALITY RESULTS

182 deaths were found [14.0/1000 person-years of follow-up (py); 95% confidence interval (CI):12.0-16.1/1000 py], 81.3% of them had a known cause of death. Mortality rate by HIV-related causes and non-HIV-related causes was the same (4.9/1000 py; CI:3.7-6.1/1000 py), external was lower [1.7/1000 py; (1.0-2.4/1000 py)].

SURVIVAL RESULTS

Kaplan-Meier estimate showed worse survival in intravenous drug user (IDU) and heterosexuals than in men having sex with men (MSM). Factors associated with HIV-related causes of death include: IDU male (subHazard Ratio (sHR):3.2; CI:1.5-7.0) and <200 CD4 at diagnosis (sHR:2.7; CI:1.3-5.7) versus ≥500 CD4. Factors associated with non-HIV-related causes of death include: ageing (sHR:1.5; CI:1.4-1.7) and heterosexual female (sHR:2.8; CI:1.1-7.3) versus MSM. Factors associated with external causes of death were IDU male (sHR:28.7; CI:6.7-123.2) and heterosexual male (sHR:11.8; CI:2.5-56.4) versus MSM.

CONCLUSION AND RECOMMENDATION

There are important differences in survival among transmission groups. Improved treatment is especially necessary in IDUs and heterosexual males.

Association between IL7R polymorphisms and severe liver disease in HIV/HCV coinfected patients: a cross-sectional study

BACKGROUND

Interleukin-7 (IL-7) is a critical factor for T cell development and for maintaining and restoring homeostasis of mature T cells. Polymorphisms at α-chain of the IL-7 receptor (IL7R or CD127) gene are related to evolution of HIV-infection, but there are no data concerning the evolution of hepatitis C virus (HCV) infection. The aim of this study was to analyze the association between IL7R polymorphisms and severe liver disease in HCV/HIV coinfected patients.

METHODS

We performed a cross-sectional study in 220 naïve patients who underwent a liver biopsy. IL7R polymorphisms (rs6897932, rs987106 and rs3194051) were genotyped using the GoldenGate(®) assay. The outcome variables were: (a) liver biopsy: advanced fibrosis (F ≥ 3), severe activity grade (A3); (b) non-invasive indexes: advanced fibrosis (APRI ≥1.5 and FIB-4 ≥3.25). Logistic regression analysis was used to investigate the association between IL7R polymorphisms and outcome variables. This test gives the differences between groups and the odds ratio (OR) for liver disease.

RESULTS

Patients with rs6897932 CC genotype had higher likelihood of having A3 than patients with rs6897932 CT/TT (adjusted odds ratio (aOR) = 4.16; p = 0.026). Patients with rs987106 TT genotype had higher odds of having F ≥ 3 (aOR = 3.09; p = 0.009) than rs987106 AA/AT carriers. Finally, patients with rs3194051 AA genotype had higher odds of having severe liver fibrosis (F ≥ 3; APRI ≥1.5, and FIB4 ≥3.25) than patients with rs3194051 AG/GG genotype [aOR = 2.73 (p = 0.010); aOR = 2.52 (p = 0.029); and aOR = 4.01 (p = 0.027); respectively]. The CTA haplotype (comprised of rs6897932, rs987106, and rs3194051) carriers had higher odds of having F ≥ 3 (aOR = 1.85; p = 0.012), APRI ≥1.5 (aOR = 1.94; p = 0.023), and FIB4 ≥3.25 (aOR = 2.47; p = 0.024). Conversely, the CAG haplotype carriers had lower odds of having F ≥ 3 (aOR = 0.48; p = 0.011), APRI ≥1.5 (aOR = 0.48; p = 0.029), and FIB4 ≥3.25 (aOR = 0.29; p = 0.010).

CONCLUSIONS

The presence of IL7R polymorphisms seems to be related to severe liver disease in HIV/HCV coinfected patients, because patients with unfavorable IL7R genotypes (rs6897932 CC, rs987106 TT, and rs3194051AA) had a worse prognosis of CHC.

rs7903146 polymorphism at transcription factor 7 like 2 gene is associated with total cholesterol and lipoprotein profile in HIV/hepatitis C virus-coinfected patients

Transcription factor 7 like 2 (TCF7L2) rs7903146 polymorphism has been associated with metabolic disturbance and cardiovascular disease. The aim of this study was to analyze the association between TCF7L2 rs7903146 polymorphism and potential disturbances on the lipid profile in human immunodeficiency virus (HIV)/hepatitis C virus (HCV)-coinfected patients. We performed a cross-sectional study on 263 HIV/HVC-coinfected patients. TCF7L2 polymorphism was genotyped by GoldenGate assay. The analysis was performed by linear and logistic regression under a dominant model of inheritance. The variables analyzed were total cholesterol (TC), high-density lipoprotein (HDL-C), low-density lipoprotein (LDL-C), non-HDL-C, and triglycerides. Patients harboring the rs7903146 TT/TC genotype showed a diminished concentration of TC (p=0.003), LDL-C (p=0.004), HDL-C (p=0.012), and non-HDL-C (p=0.013), a lower percentage of TC≥200 mg/dl (p=0.038), and a higher percentage of HDL≤40 mg/dl (p=0.023). In addition, we observed that rs7903146 was differently related to fasting serum lipid levels according to the HCV-genotype (HCV-GT). With regard to HCV-GT1 patients, the rs7903146 TT/TC genotype was associated with lower levels of HDL-C [adjusted arithmetic mean ratio (aAMR)=0.91; p=0.049] and an elevated percentage of patients with HDL-C≤40 mg/dl [adjusted odds ratio (aOR)=3.26; p=0.003]. For HCV-GT3 patients, the rs7903146 TT/TC genotype was associated with lower serum values of TC (aAMR=0.81; p=0.037), LDL-C (aAMR=0.67; p=0.001), and non-HDL-C (aAMR=0.75; p=0.002) and a reduced percentage of TC≥200 mg/dl (aOR=0.089; p=0.037). In conclusion, the TCF7L2 rs7903146 TT/TC genotype was associated with lower levels of TC, LDL, and HDL in HCV-GT3 patients, and lower levels of HDL-C in HCV-GT1 patients, suggesting a role in cardiovascular disease and a potential use as a biomarker in HIV/HCV-coinfected patients.

TLR3 polymorphisms are associated with virologic response to hepatitis C virus (HCV) treatment in HIV/HCV coinfected patients

BACKGROUND

Toll-like receptor-3 (TLR3) is a cellular receptor that may recognize double-stranded RNA (dsRNA) from viruses, resulting in production of proinflammatory cytokines and interferons, which are important for the adaptive immune response.

OBJECTIVES

To analyze the association between Toll-like receptor-3 (TLR3) polymorphisms (rs3775291 and rs13126816) and virologic response to pegylated interferon-alpha plus ribavirin (pegIFNα/RBV) therapy in HIV/HCV coinfected patients.

STUDY DESIGN

We performed a retrospective study in 321 naïve patients treated with pegIFNα/RBV. Genotyping was performed by using the GoldenGate(®) assay with VeraCode(®). The outcome variables were early virologic response (EVR) and sustained virologic response (SVR).

RESULTS

In a multivariate analysis, rs3775291 A allele decreased the likelihood of achieving EVR (aOR = 0.20; p = 0.018) and SVR (aOR = 0.38; p = 0.024). Regarding rs13126816, the percentage of EVR decreased with each minor A allele (p = 0.034) in HCV-GT2/3 patients, although no significant association was obtained in the multivariate analysis (p = 0.076). Regarding TLR3 haplotypes (comprised of rs3775291 and rs13126816), GT2/3 patients with AA haplotype had decreased odds of achieving EVR (p = 0.030), whereas GG haplotype increased the likelihood (p = 0.018). Regarding SVR, GG haplotype carriers had increased odds of achieving SVR (p = 0.019, p = 0.043 and p = 0.070 for all, GT2/3 and GT1/4 patients, respectively). Besides, GT1/4 patients with GA haplotype had lower odds of achieving SVR (p = 0.039).

CONCLUSIONS

Our study shows the first evidence that two TLR3 polymorphisms (rs3775291 and rs13126816) seem to be related to the HCV therapy response in HCV/HIV coinfected patients.

[Barriers to ART initiation in HIV infected subjects and with treatment indication in Spain. Why don't they start their treatment? Bridgap Study]

INTRODUCTION

In Spain, HIV treatment guidelines are well known and generally followed. However, in some patients there are no plans to initiate ART despite having treatment indications. The current barriers to ART initiation are presented.

METHODS

A cross-sectional survey including every HIV infected patient in care in 19 hospitals across Spain in 2012, with ≥1 indication to start ART according to 2011 national treatment guidelines, who had not been scheduled for ART initiation. Reasons for deferring treatment were categorized as follows (non-exclusive categories): a) The physician thinks the indication is not absolute and prefers to defer it; b) The patient does not want to start it; c) The physician thinks ART must be started, but there is some limitation to starting it, and d) The patient has undetectable viral load in absence of ART.

RESULTS

A total of 256 patients, out of 784 originally planned, were included. The large majority (84%) were male, median age 39 years, 57% MSM, 24% heterosexuals, and 16% IDUs. Median time since HIV diagnosis was 3 years, median CD4 count, 501 cells/mm3, median viral load 4.4 log copies/ml. Main ART indications were: CD4 count <500 cells/mm(3), 48%; having an uninfected sexual partner, 28%, and hepatitis C coinfection, 23%. Barriers due to, the physician, 55%; the patient, 28%; other limitations, 23%; and undetectable viral load, 6%.

CONCLUSIONS

The majority of subjects with ART indication were on it. The most frequent barriers among those who did not receive it were physician-related, suggesting that the relevance of the conditions that indicate ART may need reinforcing.

Association between IL7RA polymorphisms and the successful therapy against HCV in HIV/HCV-coinfected patients

Interleukin-7 (IL-7) is a critical factor in maintaining or inducing effective antiviral CD4+ and CD8+ T-cell responses. The aim of this study was to examine the association of interleukin-7 receptor-α (IL7RA) polymorphisms with a sustained virologic response (SVR) after hepatitis C virus (HCV) therapy with pegylated interferon-alpha plus ribavirin (pegIFNα/ribavirin) in 177 human immunodeficiency virus (HIV)/HCV-coinfected patients. We performed a retrospective study in 177 naïve patients who started HCV treatment. The IL7RA rs6897932, rs987106, and rs3194051 polymorphisms were genotyped by the GoldenGate® assay. An SVR was defined as undetectable HCV viral load through 24 weeks after the end of HCV treatment. The highest SVR rate was found in patients with the rs6897932 CC (p = 0.029) and rs3194051 GG (p = 0.002) genotypes, and HCV genotypes 2/3 (GT2/3) infected patients with the rs987106 AA genotype (p = 0.048). Additionally, carriers of the rs3194051 GG genotype had a higher likelihood of achieving an SVR [adjusted odds ratio (aOR) = 5.32; 95 % confidence interval (CI) = 1.07-26.94; p = 0.040] than patients with the rs3194051 AA/AG genotype, while rs6897932 CC (aOR = 0.63; p = 0.205) and rs987106 AA (aOR = 0.60; p = 0.213) were not significant. Moreover, three major haplotypes were found: 46.6 % for CTA, 32.4 % for CAG, and 20.7 % for TAA haplotypes. Patients infected with GT2/3 and carriers of the CTA haplotype had lower odds of achieving an SVR (aOR = 0.08; p = 0.004) and the CAG haplotype (favorable alleles) had higher odds of achieving an SVR than other haplotypes (aOR = 21.96; p < 0.001). IL7RA polymorphisms seem to play a significant role in the virological response to pegIFNα/ribavirin therapy in HIV/HCV-coinfected patients, in particular among patients infected with HCV GT2/3.

CXCL9, CXCL10 and CXCL11 polymorphisms are associated with sustained virologic response in HIV/HCV-coinfected patients

BACKGROUND

The CXCL9, CXCL10 and CXCL11 (CXCL9-11) chemokines play a critical role in eradication of hepatitis C virus (HCV), although HCV-specific immunity often fails to eradicate the HCV, allowing the chronicity of hepatitis C.

OBJECTIVE

To examine the association between CXCL9-11 polymorphisms and the sustained virological response (SVR) following hepatitis C virus (HCV) therapy with pegylated-interferon-alpha plus ribavirin in HIV/HCV-coinfected patients.

STUDY DESIGN

We performed a retrospective study in 176 naïve patients who started HCV treatment. The CXCL9 rs10336, CXCL10 rs3921 and CXCL11 rs4619915 polymorphisms were genotyped by GoldenGate(®) assay. Genetic data were analyzed under recessive inheritance model. The SVR was defined as undetectable HCV viremia through 24 weeks after the end of HCV treatment.

RESULTS

In the intention-to-treat analysis, the SVR rate was higher in HCV genotype 1/4 (GT1/4) patients carrying rs10336 TT (p=0.042), rs3921 GG (p=0.021), and rs4619915 AA (p=0.024) genotypes; and they had higher likelihood of achieving SVR (adjusted odds ratio (aOR)=3.26 (p=0.038), aOR=4.21 (p=0.019), and aOR=4.08 (p=0.022), respectively). For CXCL haplotype analysis (CXCL9/rs10336, CXCL10/rs3921, and CXCL11/rs4619915), the TGA haplotype (favorable alleles) had better odds of achieving SVR than the CCG haplotype (unfavorable alleles) in GT1/4patients (OR=2.69; p=0.003). No significant results were found in GT2/3 patients. Moreover, similar results were obtained in the on-treatment analysis.

CONCLUSIONS

The presence of homozygous for the minor allele of CXCL9 rs10336, CXCL10 rs3921 and CXCL11 rs4619915 was related to higher likelihoods of achieving the HCV clearance after pegIFNα/ribavirin therapy in HIV infected patients coinfected with HCV GT1/4.

[Characteristics of a cohort of pregnant women with human immunodeficiency virus infection]

BACKGROUND

Mother-to-child transmission (MTCT) during pregnancy, delivery or breastfeeding, is the main route of HIV infection in children. Strategies aimed at promoting the health of HIV infected pregnant women and MTCT prevention have reduced transmission to below 2%. This paper presents the clinical and epidemiological features of a cohort from Madrid and compares foreign-born with Spanish-born women.

METHOD

Retrospective, observational and descriptive study on HIV infected pregnant women from South Madrid (n=70) and their offspring (n=78) who were born during the study period from August 1992 to January 2010.

RESULTS

Most pregnant women were infected by heterosexual transmission (51%). Most Spanish-born women (66%) were diagnosed before pregnancy (81%), while foreign-born women (34%) were diagnosed during pregnancy (70%). Foreign-born women had less obstetric check-ups (67%) than Spanish-born women (97%). The MTCT rate was 1.3% during the last ten years.

CONCLUSIONS

Heterosexual transmission is the primary mode of acquisition of HIV infection both for Spanish-born and foreign-born pregnant women. However, the HIV infection was diagnosed earlier in Spanish-born women. There were no differences in the effectiveness of antiretroviral therapy as a preventive measure against MTCT when it is started at an early stage.

[Development and validation of a prediction model to identify HIV+ patients with drug-related problems. A prediction study]

OBJECTIVE

To develop and validate a prediction model for the detection of drug-related problems (DRP) in patients on antiretroviral treatment during their regular monitoring in Pharmaceutical Care Clinics before dispensing drugs. MEHOD: Open multicentre prospective study. HIV patients with and without DRP were included. Demographic, clinical and pharmacotherapy variables (related and unrelated to antiretroviral treatment) were included in the model design. To find prognostic factors for DRP, a binary logistic regression model was created after performing a univariate analysis that identified independent variables related to DRP these variables were introduced in the multivariate model for the final selection. Model validity was determined by the shrinkage method and the discriminatory power by Harrell's C-index.

RESULTS

733 patients were included. The variables "adherence", "prescription of drugs needing dosage adjustment", and "total number of drugs prescribed (apart from the antiretroviral treatment)" were independently related to the appearance of DRP. Probabilities predicted by the model, customising the coefficients using the uniform shrinkage method, showed a R(2)=0.962 for the construction sample and a R(2)=0.872 for the validation sample. The discriminatory capacity of the model was 0.816 for the construction sample and 0.779 for the validation sample.

CONCLUSIONS

The developed and validated model enables detection of patients on antiretroviral treatment who are at a higher risk for experiencing a DRP. The prediction variables employed are commonly used in patient's pharmacotherapy record, allowing the model to be used in routine clinical practice.

[Pharmaceutical intervention on the therapeutic adherence in patients with chronic renal disease]

OBJECTIVES

To assess the therapeutic adherence in patients with stage 3-5 chronic renal disease (CRD), and evaluate whether pharmaceutical intervention improves medication adherence.

MATERIAL AND METHODS

A prospective uncontrolled before-after study (July 2008-March 2009) was carried out in the Pharmaceutical Care Unit of a tertiary hospital. Polymedicated patients >65 years with stage 3-5 CRD, and on treatment with erythropoietin. Infowin(®) program was used to provide written information during the interviews with patients, who signed the informed consent. The Haynes-Sackett and Morisky-Green questionnaires were used to assess the therapeutic adherence.

RESULTS

Of a total of 103 candidates, we asked 94 patients to participate, of whom 53 agreed; women 60.4%, mean age: 76.8 ± 6.9 years.

EXCLUSION CRITERIA

refusal to participate (19.5%), non-appearance of patient or usual caregiver (70.7%), and institutionalised patients (9.8%). Average number of drugs per patient: 10.8 ± 2.97. A total of 88.7% had no difficulty in taking medication (Haynes-Sackett) and 73.6% were considered compliant (Morisky-Green). Differences were observed when comparing both methods (P=.036). Patients with difficulty in taking medication were less compliant (45.6%). The Morisky-Green questionnaire was used for a second time on 78.6% of unreliable patients, and obtained a 45.5% increase in compliance, increasing the overall compliance to 87.8% (P=.00003). Fifty-two drug-related problems (DRP) were detected.

CONCLUSIONS

The initial compliance of patients with stage 3-5 CRD was was noteworthy. However, after pharmaceutical intervention there was a statistically significant improvement in adherence to therapy.

Indications for the use of next-generation antiretroviral drugs in current clinical practice

OBJECTIVE

To describe the indications for use, in medical practice, of next-generation antiretroviral drugs (NGA): darunavir, raltegravir, maraviroc and etravirine.

METHOD

An observational, transversal and descriptive study conducted in adult patients who have started to receive a NGA between May 2008 and April 2009. The variables associated with the use of NGA were defined as follows: a) Variables related to efficacy: resistance confirmed by geno/phenotype tests or potencial resistance as a result of extensive exposure to antiretroviral agents, and/or severe immunological deterioration (CD4 less than 200 cells/mcl). b) Variables related to safety: prior toxicity to classic antiretroviral drugs and/or comorbidity which compromises their use. c) Combined efficacy and safety variable (main variable): prioritizing the variables which were detected, the patients were classified into three groups: multiresistant geno/phenotype (multi-G/P), multiresistant as a result of treatment history and other situations. Data was obtained from electronic medical records, laboratory tests, and records of interviews and drugs dispensed by the Pharmacy Service.

RESULTS

Seventy three patients, 40% of whom had an undetectable viral load and 38.4% who showed severe immunological deterioration, were included in the study. Multi-G/P occurred in 45% and multiresistance as a result of treatment history was found in 33% of patients. Patients classified as belonging to the "other situations" category were characterized by having a greater viral load and a poorer immunological status. In 90% of the patients without multi-G/P two or more variables associated with the use of NGA were detected.

DISCUSSION

The medical reality of using NGA shows that they play a role in clinical situations which are very different, specific and difficult to manage.

[Meta-analysis of the effectiveness of the strategy of monotherapy with boosted protease inhibitors in HIV+ patients]

INTRODUCTION

The objective of this study is to analyse the available evidence regarding the effectiveness of the strategy of induction maintenance with boosted protease inhibitors with ritonavir in adult HIV patients as compared to conventional treatment.

METHODS

We performed a meta-analysis of randomised controlled trials in HIV patients to compare the efficacy of a monotherapy strategy of boosted protease inhibitors as compared with conventional antiretroviral therapy. The literature search was conducted in PubMed, EMBASE (September 1999-September 2009) and in conference abstracts of the last 5 years. The Odds Ratio of treatment failure and their 95% confidence intervals were calculated. To combine the results of individual studies selected, a fixed effects model based on the Mantel-Haenszel method or random effects was used, depending on whether or not the results were heterogeneous.

RESULTS

Initially a total of 1510 publications were found, of which just 8 studies met the criteria for inclusion in the meta-analysis. The combined Odds Ratio of the 8 studies is 1.39 (95% CI 1.02-1.90) for the treatment group with conventional antiretroviral treatment, but with a confidence interval close to the limits of statistical non-significance.

CONCLUSION

The results of the combined effectiveness analysis in the meta-analysis found no significant differences between the conventional strategy and monotherapy. This strategy is considered recommended (level A evidence) in patients with no history of previous failure of protease inhibitor, with undetectable plasma viral load and signs or symptoms of nucleoside/nucleotide toxicity.

[Analysis of the duration of and reasons for changing the first combination of antiretroviral therapy]

OBJECTIVE

To determine the duration of and reasons behind changing the various combinations of drugs used for the initiation of antiretroviral treatment in naïve patients.

METHODS

A retrospective observational study that included all patients with HIV infection who started antiretroviral therapy in a high-tech university reference hospital during the period from 1 January 2003 and 31 December 2005. Patients were followed until 31 December 2008. To estimate the cumulative probability of discontinuation the Kaplan-Meier method was used.

RESULTS

A total of 441 patients were included. The average duration of the first treatment was 384 (interquartile interval 84-1290) days. The regimen based on non-nucleoside reverse transcriptase inhibitors and those that included as nucleosides abacavir or tenofovir in combination with lamivudine or emtricitabine showed a significantly longer duration than the rest. The main reasons for termination were the side effects, although in a lesser percentage than that obtained in previous studies. No associations were found between the rest of the characteristics of the patients or of the treatment and the risk of termination.

DISCUSSION

Although the duration of the first antiretroviral treatment remains short, currently fewer changes are made due to side effects and due to loss to follow-up. The reasons may be better tolerance and less complexity. However, more studies are needed to determine the benefits of one regimen or another, and to be able to generalise the results.

[The role of the hospital pharmacist in the prevention, treatment and management of the side effects associated with antiretroviral treatment]

At present, the side effects associated with antiretroviral treatment are the main reasons for discontinuation of this kind of therapy, both in clinical trials and in regular clinical practise. On the other hand, due to the change of direction that our profession has suffered in recent years, we face the need to establish a different relationship with the patient, achieving direct and effective Pharmaceutical Care within a framework of shared responsibility for therapeutic results. Pharmacist interventions should be aimed at improving the quality of life of patients, which can only be achieved with a multidisciplinary approach and individualised and adjusted to new patterns of toxicity of the drugs currently used. The pharmacist who does this work must know how to interpret these side effects, giving accurate information to the patient about both pharmacological and non-pharmacological treatment and correct pharmaceutical follow-up which clearly sets forth the criteria for referral to medical appointments. The aim of this paper is to establish baselines so that the hospital pharmacist can perform clearly and uniformly in the prevention, identification and management of major side effects: gastrointestinal, cardiovascular, dermatological, at the central nervous system and kidney level, associated with antiretroviral therapy.

[AIDS Study Group/Spanish AIDS Plan consensus document on antiretroviral therapy in adults with human immunodeficiency virus infection (updated January 2010)]

OBJECTIVE

This consensus document is an update of antiretroviral therapy recommendations for adult patients with human immunodeficiency virus infection.

METHODS

To formulate these recommendations a panel made up of members of the Grupo de Estudio de Sida (Gesida, AIDS Study Group) and the Plan Nacional sobre el Sida (PNS, Spanish AIDS Plan) reviewed the advances in the current understanding of the pathophysiology of human immunodeficiency virus (HIV) infection, the efficacy and safety of clinical trials, and cohort and pharmacokinetic studies published in biomedical journals or presented at scientific meetings. Three levels of evidence were defined according to the data source: randomized studies (level A), cohort or case-control studies (level B), and expert opinion (level C). The decision to recommend, consider or not to recommend ART was established in each situation.

RESULTS

Currently, the treatment of choice for chronic HIV infection is the combination of three drugs of two different classes, including 2 nucleosides or nucleotide analogs (NRTI) plus 1 non-nucleoside (NNRTI) or 1 boosted protease inhibitor (PI/r), but other combinations are possible. Initiation of ART is recommended in patients with symptomatic HIV infection. In asymptomatic patients, initiation of ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: 1) therapy should be started in patients with CD4 counts below 350 cells/microl; 2) When CD4 counts are between 350 and 500 cells/microl, therapy should be started in case of cirrhosis, chronic hepatitis C, high cardiovascular risk, HIV nephropathy, HIV viral load above 100,000 copies/ml, proportion of CD4 cells under 14%, and in people aged over 55; 3) Therapy should be deferred when CD4 are above 500 cells/microl, but could be considered if any of previous considerations concurs. Treatment should be initiated in case of hepatitis B requiring treatment and should be considered for reduce sexual transmission. The objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after ART failures but undetectable viral loads maybe possible with the new drugs even in highly drug experienced patients. Genotype studies are useful in these situations. Drug toxicity of ART therapy is losing importance as benefits exceed adverse effects. Criteria for antiretroviral treatment in acute infection, pregnancy and post-exposure prophylaxis are mentioned as well as the management of HIV co-infection with hepatitis B or C.

CONCLUSIONS

CD4 cells counts, viral load and patient co-morbidities are the most important reference factors to consider when initiating ART in asymptomatic patients. The large number of available drugs, the increased sensitivity of tests to monitor viral load, and the ability to determine viral resistance is leading to a more individualized therapy approach in order to achieve undetectable viral load under any circumstances.

The future of antiretroviral therapy: challenges and needs

The introduction of combination antiretroviral therapy (cART) has substantially modified the natural history of HIV infection. At the beginning of the cART era the objective was focused on HIV-1-associated mortality and morbidity, but as this objective was accomplished other issues emerged, including toxicity, resistance and compliance with treatment. Moreover, the participation of other disease mechanisms, such as proinflammatory activity, in the so-called non-AIDS events is becoming increasingly important. To overcome these issues, therapeutic options have dramatically expanded, which has made the management of HIV-1-infected patients increasingly complex. The intense changes seen raise the question of what will be the future of HIV infection and its treatment. A projection into the future may help to reflect on current limitations, needs and research priorities, to optimize patient care. To debate on this topic a group of 38 experts has initiated The HIV 2020 Project, with the aim of reflecting on the future of HIV infection and identifying the needs that should be the attention of research in different areas. This document summarizes the group's conclusions on the future of antiretroviral treatment, presented as 20 relevant questions. Each question includes the current status of the topic and our vision for the future.

[Lopinavir/ritonavir monotherapy as a simplification strategy in the treatment of HIV-1 infection]

Simplification of triple antiretroviral therapy to lopinavir/ritonavir (LPV/r) monotherapy in patients with well-controlled viremia for prolonged periods (more than 6 months) without prior failure with a protease inhibitor has been proposed as a strategy that could reduce the toxicity and costs of antiretroviral therapy in the long term while also preserving other therapeutic options. The results of several studies are currently available, some of which had a large number of patients and follow-up of up to 4 years. These studies indicate that this strategy is safe and efficacious, thus allowing its clinical use when indicated. This strategy may be especially useful in reducing the costs of treatment in countries with scarce economic resources. The role of LPV/r monotherapy in the prevention and management of lipodystrophy and in improving the selection of patients with an optimal risk-benefit ratio remains to be defined.

[Lopinavir/ritonavir monotherapy. Possible indications]

Monotherapy with LPV/r maintains blocked viral replication when used as a simplification strategy from antiretroviral therapy with a boosted protease inhibitor and two nucleoside analogs in patients with an undetectable viral load for at least 6 months. This simplification strategy can be recommended to patients in these circumstances and who are able to maintain near perfect adherence. As recommended by the GESIDA guidelines, LPV/r monotherapy could be offered to patients with undetectable viral loads but who show symptoms or laboratory abnormalities attributable to nucleoside analog toxicity, or co-morbidities such as liver disease or nephropathy; LPV/r monotherapy could also be offered to patients who simply wish to take a lower number of pills. This strategy reduces treatment toxicity and costs, without jeopardizing the patient's future.

[Pharmacoeconomic aspects of lopinavir/ritonavir monotherapy]

The present article briefly reviews the main types of pharmacoeconomic analyses that evaluate the costs associated with HIV infection and the efficiency of antiretroviral therapy in general. The results of several pharmacoeconomic analyses applied to the selection of antiretroviral drugs in distinct clinical scenarios are also presented. Finally, we analyze the advantages, in terms of efficiency, of lopinavir/ritonavir as induction-maintenance therapy, both in terms of saving the direct costs of treatment and in possibly reducing the costs due to the management of the adverse effects of nucleoside analogs.

Differences in resistance mutations among HIV-1 non-subtype B infections: a systematic review of evidence (1996-2008)

Ninety percent of HIV-1-infected people worldwide harbour non-subtype B variants of HIV-1. Yet knowledge of resistance mutations in non-B HIV-1 and their clinical relevance is limited. Although a few reviews, editorials and perspectives have been published alluding to this lack of data among non-B subtypes, no systematic review has been performed to date.With this in mind, we conducted a systematic review (1996-2008) of all published studies performed on the basis of non-subtype B HIV-1 infections treated with antiretroviral drugs that reported genotype resistance tests. Using an established search string, 50 studies were deemed relevant for this review.These studies reported genotyping data from non-B HIV-1 infections that had been treated with either reverse transcriptase inhibitors or protease inhibitors. While most major resistance mutations in subtype B were also found in non-B subtypes, a few novel mutations in non-B subtypes were recognized. The main differences are reflected in the discoveries that: (i) the non-nucleoside reverse transcriptase inhibitor resistance mutation, V106M, has been seen in subtype C and CRF01_AE, but not in subtype B, (ii) the protease inhibitor mutations L89I/V have been reported in C, F and G subtypes, but not in B, (iii) a nelfinavir selected non-D30N containing pathway predominated in CRF01_AE and CRF02_AG, while the emergence of D30N is favoured in subtypes B and D, (iv) studies on thymidine analog-treated subtype C infections from South Africa, Botswana and Malawi have reported a higher frequency of the K65R resistance mutation than that typically seen with subtype B.Additionally, some substitutions that seem to impact non-B viruses differentially are: reverse transcriptase mutations G196E, A98G/S, and V75M; and protease mutations M89I/V and I93L.Polymorphisms that were common in non-B subtypes and that may contribute to resistance tended to persist or become more frequent after drug exposure. Some, but not all, are recognized as minor resistance mutations in B subtypes. These observed differences in resistance pathways may impact cross-resistance and the selection of second-line regimens with protease inhibitors. Attention to newer drug combinations, as well as baseline genotyping of non-B isolates, in well-designed longitudinal studies with long duration of follow up are needed.

[Tenofovir DF in rescue regimens]

As with other nucleoside analogues, tenofovir (TDF) can be affected by several mutations in the reverse transcriptase gene. Most nucleoside analogue mutations (NAMs) are not induced specifically by TDF, although they can affect the activity of this drug. The impact of thymidine analogue mutations (TAMs) on tenofovir varies and, as with the remaining nucleoside analogue reverse transcriptase inhibitors, largely depends on the type and number present. Thus, the greater the number of TAMs, and the greater the number of type 1 TAMs, the more TDF activity will be affected. The 41L and 210W mutations have the greatest effect. The incidence of the 65R mutation was slight before the clinical introduction of TDF. This mutation was selected by treatments with zalcitabine monotherapy. However, after TDF came on to the market, the 65R mutation began to be more frequently reported and is currently the signature mutation of this drug. TDF has been shown to be safe and effective in patients with prior virological failure and resistance mutations in the reverse transcriptase gene. In these patients, the presence of the 41L and 210W mutations is associated with a worse response to rescue therapy containing TDF. In contrast, the presence of type 2 TAMs (67N, 70R and 219Q/E/N) has little effect on TDF activity in these patients. Importantly, in TDF therapy, the presence of the 184V mutation is associated with a more favorable virologic response than the absence of this mutation, with any of the distinct combinations of mutations present.

[Safety of atazanavir in patients with HIV and hepatitis B and/or C virus coinfection]

Atazanavir is a protease inhibitor indicated, in combination with other antiretrovirals, as an initial treatment of HIV infection or in previously treated patients. Antiretroviral treatment based on atazanavir has been associated with a low incidence of hepatotoxicity, both in Clinical Trials as well as in cohort studies. However, the finding of hyperbilirubinaemia has been common in these studies, although it usually does not involve withdrawing the treatment. In patients co-infected with hepatitis B or C, the level of virological response to does not appear to be affected and the incidence of adverse effects, except the higher incidence of hepatotoxicity, is no higher than in non-coinfected subjects. The incidence of severe hepatotoxicity (grade 3-4) in patients coinfected by HIV and HVC who receive drug combinations that contain atazanavir is 6%. Atazanavir has a favourable tolerance and safety profile in patients coinfected with hepatitis virus even in the presence of significant fibrosis. The lower association of atazanavir with the development of insulin resistance, a fact that has been associated with increasing the progression to hepatic fibrosis and lower treatment response rates, could be an added benefit of the use atazanavir in coinfected patients and could serve as an additional argument for its use in these patients.