Initial suboptimal CD4 reconstitution with antiretroviral therapy despite full viral suppression in a cohort of HIV-infected patients in Senegal

How to properly define immunological nonresponse to antiretroviral therapy in people living with HIV? an integrative review

In recent decades, significant progress has been made in understanding the mechanisms underlying human immunodeficiency virus (HIV) infection and its treatment. Antiretroviral therapy (ART) has notable improved the life expectancy and quality of life for people living with HIV (PLHIV) by suppressing viral replication and promoting CD4+ T-cell recovery. However, despite its efficacy, approximately 10-40% of ART-treated PLHIV with virological suppression (<50 RNA copies/mL) do not achieve adequate immunological reconstitution. These PLHIV, classified as immunological non-responders (INR), experience higher morbidity and mortality rates compared to those with satisfactory immune reconstitution, known as immunological responders (IR). Various studies have explored the mechanisms contributing to immunological nonresponse, yet a major challenge remains: the lack of a standardized definition of immunological response and nonresponse across studies. Currently, definitions are inconsistent, limiting comparability between studies. This review proposes a clear and adequate classification for IR and INR PLHIV to support future advancements in understanding immunological recovery and improving the quality of life for ART-treated PLHIV.

Suboptimal Immune Recovery and Associated Factors Among People Living with HIV/AIDS on Second-line Antiretroviral Therapy in Central China: A Retrospective Cohort Study

BACKGROUND

The introduction and scale-up of antiretroviral therapy (ART) have contributed to significantly improved patients with acquired immune deficiency syndrome (AIDS) quality of life and prolongs their survival. This has occurred by suppressing viral replication and recovering the CD4 cell count. However, some patients do not normalize their CD4 cell count, despite suppression of the viral load (VL). Patients with suboptimal immune recovery (SIR), as defined by a viral load(VL) < 400 copies/ml with a CD4 cell count of<200cells/μl, after ART initiation, exhibit severe immune dysfunction and have a higher risk of AIDS and non-AIDS events. In recent years, People living with HIV/AIDS (PLWHA) with first-line ART failure began to gradually switch to second-line ART. This study aimed to examine the prevalence and factors affecting SIR among people living with HIV/AIDS (PLWHA) who switch to second-line ART in rural China.

METHODS

A 1-year retrospective cohort study was conducted among PLWHA who switched to second-line ART between January 2009 and December 2018. All patients with a viral load(VL) < 400 copies/ml after 1 year of second-line ART were included. SIR was defined as a CD4 cell count <200 cells/μl and a viral load(VL) <400 copies/ml after 1 year of second-line ART. The data collected from medical records were analyzed by univariate and multivariate analyses.

RESULTS

A total of 5294 PLWHA met the inclusion criteria, 24 died, and 1152 were lost to follow-up after 1 year of second-line ART. Among 4118 PLWHA who were followed up, 3039 with a viral load(VL) <400 copies/ml had their data analyzed, and the prevalence of SIR was 13.1%. The patients' mean age at recruitment was 47.6±8.1 years and 45.3% were men. A total of 30.7% of patients were HIV-positive for >8 years and 88.2% were receiving ART before starting second-line ART for >3 years. The mean CD4 cell count was 354.8±238.2 cells/μl. A multivariable analysis showed that male sex, single status (unmarried or divorced), and a low CD4 cell count were risk factors for SIR among PLWHA with second-line ART.

CONCLUSIONS

The prevalence of SIR among PLWHA who switched to second-line ART in this retrospective cohort study is lower than that in most other studies. Several factors associated with SIR include male sex, marital status, and CD4 cell count levels in PLWHA. This article is protected by copyright. All rights reserved.

Polymorphisms in TNF-α/TNFR1 pathway genes are associated with CD4+ T cells recovery in HIV-1-infected individuals on antiretroviral therapy

BACKGROUND

Antiretroviral therapy (ART) is an important hallmark of HIV-1 treatment, enabling viral load suppression to undetectable levels and CD4+ T cells recovery. However, some individuals do not recover the CD4+ T cell count to normal levels, despite viral suppression. We hypothesize that variation in genes involved in extrinsic apoptosis pathways may influence interindividual immune recovery during ART.

METHODS

We assessed clinic-epidemiological variables, and the allelic/genotypic distribution of functional single nucleotide polymorphisms in genes involved in extrinsic apoptosis pathways (TNFRSF1A: rs1800692, rs767455; TNFAIP3: rs2270926; NFKBIA: rs8904; TNF-α: rs1800629) and their relationship with immune recovery in ART treated (one year) HIV-1-infected individuals. We enrolled 155 HIV-1 infected individuals, 102 showing immunological success and 53 with immunological failure.

RESULTS

Through univariate analysis, we observed that the male sex (60.4%, p=0.002) showed higher median of age at treatment onset (34.8 years, p=0.034) and higher time until virological suppression (6 months, p=0.035), both risk factors for immune failure. Survival analysis revealed that individuals who started ART treatment with T CD4+ cells count <200 cells/mm3 took a longer time to immunological recovery (median time = 27 months, p=0.029). ART containing zidovudine (AZT) also was associated with immune recovery in univariate e multivariate analysis. Variants in TNFRSF1A (rs767455: T, TT; rs1800692-rs767455: T-T combination) and NFKBIA (rs8904: A) genes associated with immune failure, while NFKBIA (rs8904: GA) and TNF-α (rs1800629: GA), with CD4+ T cells recovery.

CONCLUSIONS

Clinic-epidemiological and variants in genes involved in extrinsic apoptosis pathways might influence the CD4+ T cells immune recovery.

Definition of Immunological Nonresponse to Antiretroviral Therapy: A Systematic Review

BACKGROUND

Terms and criteria to classify people living with HIV on antiretroviral therapy who fail to achieve satisfactory CD4 T-cell counts are heterogeneous, and need revision and summarization.

METHODS

We performed a systematic review of PubMed original research articles containing a set of predefined terms, published in English between January 2009 and September 2018. The search retrieved initially 1360 studies, of which 103 were eligible. The representative terminology and criteria were extracted and analyzed.

RESULTS

Twenty-two terms and 73 criteria to define the condition were identified. The most frequent term was "immunological nonresponders" and the most frequent criterion was "CD4 T-cell count <350 cells/µL after ≥24 months of virologic suppression." Most criteria use CD4+ T-cell counts as a surrogate, either as an absolute value or as a change after a defined period of time [corrected]. Distinct values and time points were used. Only 9 of the 73 criteria were used by more than one independent research team. Herein we propose 2 criteria that could help to reach a consensus.

CONCLUSIONS

The high disparity in terms and criteria here reported precludes data aggregation and progression of the knowledge on this condition, because it renders impossible to compare data from different studies. This review will foster the discussion of terms and criteria to achieve a consensual definition.

The risk factors for suboptimal CD4 recovery in HIV infected population: an observational and retrospective study in Shanghai, China

Although the initiation of antiretroviral therapy (ART) has promoted the reconstitution of CD4+ T-cell count in the HIV infected population, not all patients can achieve the normalization of their immunologic functions. We analysed the variables associated with immunologic recovery, which is commonly regarded as the increase of CD4 to 350 cell/μL after a year of ART. We collected data from 3,485 patients attending a university-based HIV clinic from June 2005 to July 2014 in Shanghai, China. Logistic regression test was performed to analyse the risk factors for suboptimal CD4+ recovery following yearlong ART. The CD4+ T-cell of 723 participants (41.5% of the 1744 subjects) showed more than 350 cell/μL after one year of ART. Compared with baseline CD4 > 350 cell/μL, patients with baseline CD4 ≤ 200 cell/μL or 200 < CD4 ≤ 350 cell/μL were 42.6, 4.5 times more likely to be incomplete CD4 recovery, respectively. The risk of suboptimal immunologic recovery among patients with regimen including AZT or d4T were 2.1, 2.4 times higher compared with TDF, respectively. In our study, between optimal CD4 recovery group and suboptimal recovery group, there were no significant differences in age, gender, marital status, transmission routes, WHO stage, and CD4 recovery rates. As for the dynamic CD4 change, we found the CD4 recovery rates were 49.9% and 61.8% in the second and third year of ART, respectively. Patients who had a low level of CD4+ T-cell count (< 200 cell/μL) during the initiation of ART exhibited more difficulties recovering to a normal level. Furthermore, the regimen, including AZT or d4T, was not beneficial to CD4 recovery. So, more efforts should be made to guarantee the early diagnosis and timely treatment for HIV/AIDS patients, and simultaneously optimize antiretroviral therapy.

Discordant Immune Response with Antiretroviral Therapy in HIV-1: A Systematic Review of Clinical Outcomes

Background

A discordant immune response (DIR) is a failure to satisfactorily increase CD4 counts on ART despite successful virological control. Literature on the clinical effects of DIR has not been systematically evaluated. We aimed to summarise the risk of mortality, AIDS and serious non-AIDS events associated with DIR with a systematic review.

Methods

The protocol is registered with the Centre for Review Dissemination, University of York (registration number CRD42014010821). Included studies investigated the effect of DIR on mortality, AIDS, or serious non-AIDS events in cohort studies or cohorts contained in arms of randomised controlled trials for adults aged 16 years or older. DIR was classified as a suboptimal CD4 count (as defined by the study) despite virological suppression following at least 6 months of ART. We systematically searched PubMed, Embase, and the Cochrane Library to December 2015. Risk of bias was assessed using the Cochrane tool for assessing risk of bias in cohort studies. Two authors applied inclusion criteria and one author extracted data. Risk ratios were calculated for each clinical outcome reported.

Results

Of 20 studies that met the inclusion criteria, 14 different definitions of DIR were used. Risk ratios for mortality in patients with and without DIR ranged between 1.00 (95% CI 0.26 to 3.92) and 4.29 (95% CI 1.96 to 9.38) with the majority of studies reporting a 2 to 3 fold increase in risk.

Conclusions

DIR is associated with a marked increase in mortality in most studies but definitions vary widely. We propose a standardised definition to aid the development of management options for DIR.