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Lee CY, Lin YP, Lin CY, Chen TC, Kuo SH, Lo SH, Wang SF, Lu PL. Trends and the associated factors of optimal immunological response and virological response in late anti-retroviral therapy initiation HIV cases in Taiwan from 2009 to 2020. J Infect Public Health 2024; 17:339-348. [PMID: 38194765 DOI: 10.1016/j.jiph.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/22/2023] [Accepted: 12/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Late cART initiation (CD4 count ≤200 cells/μL or AIDS-defining opportunistic illnesses [AOIs] at cART initiation) impedes CD4 count recovery and virologic suppression after cART initiation. However, studies to evaluate trends of and modifiable factors for optimal immunological response (IR) and virological response (VR) in people living with HIV (PLWH) with late cART initiation with the current HIV treatment strategies are limited. METHODS We retrospectively identified 475 PLWH with late cART initiation in 2009-2020. Patients were grouped based on the presence of IR (CD4 count ≥200 cells/μL) or VR (plasma viral load [PVL] ≤ 50 copies/mL) within 18 months after cART initiation (403 [84.8%] IR(+) and 72 [15.2%] IR(-); 422 [88.8%] VR(+) and 53 [11.2%] VR(-)). We used Joinpoint regression to identify IR (+) and VR(+) proportion changes. RESULTS From 2009 to 2020, the proportion of IR(+) patients remained unchanged (75% to 90%, P = 0.102), whereas that of VR(+) patients increased significantly (75% to 95%, P = 0.007). No join point was identified for either IR(+) or VR(+), and the annual percentage change was 0.56% (nonsignificant) and 1.35% (significant) for IR(+) and VR(+), respectively. Compared to IR(-) patients, IR(+) patients were more likely to have a higher pre-cART PVL, to start with a first-line INSTI-based regimen, or to start cART within 14 days of HIV diagnosis but were less likely to have chronic kidney disease, composite AOIs, or a lower pre-cART CD4 count. Compared to VR(-) patients, VR(+) patients were more likely to start a single-tablet regimen but were less likely to have a higher pre-cART PVL. CONCLUSIONS Our study identified several modifiable factors for optimal IR (rapid cART initiation and INSTI-based regimen initiation) and for optimal VR (STR initiation) among late initiators, which may guide early treatment modifications to reduce their AIDS-defining event incidence and mortality.
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Affiliation(s)
- Chun-Yuan Lee
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC; M.Sc. Program in Tropical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Yi-Pei Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC; M.Sc. Program in Tropical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Chun-Yu Lin
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| | - Tun-Chieh Chen
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Shin-Huei Kuo
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Shih-Hao Lo
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Sheng-Fan Wang
- Center for Tropical Medicine and Infectious Disease, Kaohsiung Medical University, Kaohsiung, Taiwan , ROC; Department of Medical Laboratory Science and Biotechnology, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Po-Liang Lu
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC; School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Taiwan, ROC.
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Impact of opioid substitution therapy on the HIV prevention benefit of antiretroviral therapy for people who inject drugs. AIDS 2017; 31:1181-1190. [PMID: 28323752 DOI: 10.1097/qad.0000000000001458] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A recent meta-analysis suggested that opioid substitution therapy (OST) increased uptake of antiretroviral treatment (ART) and HIV viral suppression. We modelled whether OST could improve the HIV prevention benefit achieved by ART among people who inject drugs (PWID). METHODS We modelled how introducing OST could improve the coverage of ART across a PWID population for different baseline ART coverage levels. Using existing data on how yearly HIV-transmission risk is related to HIV plasma viral load, changes in the level of viral suppression across the population were used to project the relative reduction in yearly HIV-transmission risk achieved by ART, with or without OST, compared with if there was no ART - defined here as the prevention effectiveness of ART. RESULTS Owing to OST use increasing the chance of being on ART and achieving viral suppression if on ART, the prevention effectiveness of ART for PWID on OST (compared with PWID not on OST) increases by 44, 31, or 20% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively. Improvements in the population-level prevention effectiveness of ART are also achieved across all PWID, compared with if OST was not introduced. For instance, if OST is introduced at 40% coverage, the population-level prevention effectiveness of ART could increase by 27, 20, or 13% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively. CONCLUSION OST could improve the HIV prevention benefit of ART; supporting strategies that aim to concurrently scale-up OST with ART.
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Bello KJ, Mesner O, O'Bryan TA, Won SH, Lalani T, Ganesan A, Agan BK, Okulicz JF. Factors associated with 10 years of continuous viral load suppression on HAART. BMC Infect Dis 2016; 16:351. [PMID: 27449671 PMCID: PMC4957300 DOI: 10.1186/s12879-016-1677-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 06/09/2016] [Indexed: 12/03/2022] Open
Abstract
Background The principal goal of HAART is sustained viral load (VL) suppression resulting in immune reconstitution and improved HIV outcomes. We studied the factors associated with 10 years of continuous VL suppression on HAART in the US Military HIV Natural History Study. Methods Participants with continuous VL suppression (CS, n = 149) were compared to those who did not have continuous viral load suppression (NCS, n = 127) for ≥10 years on HAART. Factors associated with >10 years of VL suppression were evaluated by multivariate logistic regression. Additionally, association between CS and CD4 reconstitution was analyzed with a mixed effects model. Results Compared to NCS participants, a lower proportion of CS participants started HAART in the early HAART era (66 vs 90 %, for years 1996–1999; p < 0.001) and had less antiretroviral use prior to HAART (37 vs 83 %; p < 0.001). At initial HAART, the median CD4 cell count was higher and VL was lower for CS compared to NCS participants (375 cells/uL [256, 499] vs 261 cells/uL [146, 400]; p < 0.001 and 4.4 log10 copies/mL [3.5, 4.9] vs 4.5 log10 copies/mL [3.8, 5.0]; p = 0.048, respectively). New AIDS events were lower during HAART (5 vs 13 %; p = 0.032) and post-HAART CD4 trajectories were greater for the CS compared to NCS group. Factors negatively associated with ≥10 years of VL suppression included log10 VL at first HAART (OR 0.61, 95 % CI 0.4, 0.92; p = 0.020) and antiretroviral use prior to HAART (OR 0.16, 95 % CI 0.06, 0.38; p < .001). Conclusions Sustained VL suppression is a key to long-term health in HIV-infected patients, as demonstrated by the lower proportion of AIDS events observed 10 years after HAART initiation. The current use of more potent and well-tolerated regimens may mitigate the negative factors of pre-HAART VL and prior ARV use encountered by treatment initiated in the early HAART era.
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Affiliation(s)
- Kathryn J Bello
- Internal Medicine Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, 78234, TX, USA
| | - Octavio Mesner
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Thomas A O'Bryan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, 78234, TX, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Seung Hyun Won
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Naval Medical Center, 620 John Paul Jones Circle, Portsmouth, 23708, VA, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Infectious Disease Service, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, 20889, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Brian K Agan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Jason F Okulicz
- Internal Medicine Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, 78234, TX, USA. .,Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA. .,Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, 78234, TX, USA.
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Patterson S, Cescon A, Samji H, Cui Z, Yip B, Lepik KJ, Moore D, Lima VD, Nosyk B, Harrigan PR, Montaner JSG, Shannon K, Wood E, Hogg RS. Cohort Profile: HAART Observational Medical Evaluation and Research (HOMER) cohort. Int J Epidemiol 2015; 44:58-67. [PMID: 24639444 PMCID: PMC4339756 DOI: 10.1093/ije/dyu046] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 11/13/2022] Open
Abstract
Since 1986, antiretroviral therapy (ART) has been available free of charge to individuals living with HIV in British Columbia (BC), Canada, through the BC Centre of Excellence in HIV/AIDS (BC-CfE) Drug Treatment Program (DTP). The Highly Active Antiretroviral Therapy (HAART) Observational Medical Evaluation and Research (HOMER) cohort was established in 1996 to maintain a prospective record of clinical measurements and medication profiles of a subset of DTP participants initiating HAART in BC. This unique cohort provides a comprehensive data source to investigate mortality, prognostic factors and treatment response among people living with HIV in BC from the inception of HAART. Currently over 5000 individuals are enrolled in the HOMER cohort. Data captured include socio-demographic characteristics (e.g. sex, age, ethnicity, health authority), clinical variables (e.g. CD4 cell count, plasma HIV viral load, AIDS-defining illness, hepatitis C co-infection, mortality) and treatment variables (e.g. HAART regimens, date of treatment initiation, treatment interruptions, adherence data, resistance testing). Research findings from the HOMER cohort have featured in numerous high-impact peer-reviewed journals. The HOMER cohort collaborates with other HIV cohorts on both national and international scales to answer complex HIV-specific research questions, and welcomes input from external investigators regarding potential research proposals or future collaborations. For further information please contact the principal investigator, Dr Robert Hogg (robert_hogg@sfu.ca).
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Affiliation(s)
- Sophie Patterson
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Angela Cescon
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hasina Samji
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Zishan Cui
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Benita Yip
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Katherine J Lepik
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - David Moore
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Viviane D Lima
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - P Richard Harrigan
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kate Shannon
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada and Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Burchard PR, Abou Tayoun AN, Scherer A, Tsongalis GJ. A rapid RT-PCR assay for the detection of HIV-1 in human plasma specimens. Exp Mol Pathol 2014; 97:111-5. [PMID: 24945443 DOI: 10.1016/j.yexmp.2014.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The CDC estimates that there are currently over 1million people living with human immunodeficiency virus (HIV-1) in the United States, with new cases increasing by approximately 50,000 each year. HIV-1 consists of four distinct groups: the major M group, and the rare N, O, and P groups, each comprising of various subtypes. Without proper care, HIV-1 can lead to cardiovascular, kidney, and liver diseases, cancer, and rapid progression into acquired immune deficiency syndrome (AIDS). Here, we describe a novel, rapid, and highly sensitive assay for the detection of HIV-1 using intercalating dye based RT-PCR and melt curve analysis. MATERIALS AND METHODS We designed an RT-PCR assay for the detection of the major M subtypes in addition to the rare (O, N, and P) HIV-1 groups, as well as an extraction/RT-PCR control, using melt curve analysis. Viral RNA was extracted using the automated Qiagen EZ1 robotic system (Qiagen, Valencia, CA). To establish the limit of detection (LOD) for this assay, we diluted the AcroMetrix HIV-1 panel (LifeTechnologies, Grand Island, NY) to concentrations ranging from 25 to 500 copies/ml. Armored RNA BCR/ABL b3/a2 (Asuragen, Austin, Texas) was used as our extraction and RT-PCR control. Specificity and accuracy were assessed by testing plasma specimens from 48 anonymized patients negative for HIV-1. RESULTS This assay has a turnaround time of less than 2.5h and has a limit of detection of 50 copies/ml of plasma. Our assay also demonstrated 100% concordance with 53 previously quantified plasma patient specimens, including 48 negative samples and 5 positive samples. HIV-1 and our extraction/RT-PCR control were consistently identified at 79 °C and 82.5 °C, respectively. CONCLUSIONS We developed a comprehensive, easy to use assay for the detection of HIV-1 in human plasma. Our assay combines a rapid and cost-effective method for molecular diagnostics with the versatility necessary for widespread laboratory use. These performance characteristics make this HIV-1 detection assay highly suitable for use in a clinical laboratory.
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Affiliation(s)
- Paul R Burchard
- Department of Pathology, Geisel School of Medicine at Dartmouth, Hanover, NH, United States; Dartmouth Hitchcock Medical Center and Norris Cotton Cancer Center, Lebanon, NH, United States
| | - Ahmad N Abou Tayoun
- Department of Pathology, Geisel School of Medicine at Dartmouth, Hanover, NH, United States; Dartmouth Hitchcock Medical Center and Norris Cotton Cancer Center, Lebanon, NH, United States
| | - Axel Scherer
- Department of Electrical Engineering, California Institute of Technology, Pasadena, CA, United States
| | - Gregory J Tsongalis
- Department of Pathology, Geisel School of Medicine at Dartmouth, Hanover, NH, United States; Dartmouth Hitchcock Medical Center and Norris Cotton Cancer Center, Lebanon, NH, United States.
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Boufassa F, Lechenadec J, Meyer L, Costagliola D, Hunt PW, Pereyra F, Deeks S, Pancino G, Taulera O, Lichterfeld M, Delobel P, Saez-Cirion A, Lambotte O. Blunted response to combination antiretroviral therapy in HIV elite controllers: an international HIV controller collaboration. PLoS One 2014; 9:e85516. [PMID: 24465584 PMCID: PMC3894966 DOI: 10.1371/journal.pone.0085516] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 11/27/2013] [Indexed: 11/19/2022] Open
Abstract
Objective HIV “elite controllers” (ECs) spontaneously control viral load, but some eventually require combination antiretroviral treatment (cART), due to a loss of viral control or a decline in CD4 T-cell counts. Here we studied the CD4 T-cell count dynamics after cART initiation among 34 ECs followed in U.S. and European cohorts, by comparison with chronically viremic patients (VIRs). Methods ECs were defined as patients with at least ≥5 viral load (VL) measurements below 400 copies/mL during at least a 5-year period despite never receiving ART and were selected from the French ANRS CO18 cohort, the U.S. SCOPE cohort, the International HIV Controllers study and the European CASCADE collaboration. VIRs were selected from the ANRS COPANA cohort of recently-diagnosed (<1 year) ART-naïve HIV-1-infected adults. CD4 T-cell count dynamics after cART initiation in both groups were modelled with piecewise mixed linear models. Results After cART initiation, CD4 T-cell counts showed a biphasic rise in VIRs with: an initial rapid increase during the first 3 months (+0.63/month), followed by +0.19/month. This first rapid phase was not observed in ECs, in whom the CD4Tc count increased steadily, at a rate similar to that of the second phase observed in VIRs. After cART initiation at a CD4 T-cell count of 300/mm3, the estimated mean CD4 T-cell gain during the first 12 months was 139/mm3 in VIRs and 80/mm3 in ECs (p = 0.048). Conclusions cART increases CD4 T-cell counts in elite controllers, albeit less markedly than in other patients.
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Affiliation(s)
- Faroudy Boufassa
- Inserm, CESP Centre for research in Epidemiology and Population Health, Epidemiology of HIV and STI Team, le Kremlin-Bicêtre, France
- Univ Paris-Sud, Le Kremlin Bicêtre, France
- * E-mail:
| | | | - Laurence Meyer
- Inserm, CESP Centre for research in Epidemiology and Population Health, Epidemiology of HIV and STI Team, le Kremlin-Bicêtre, France
- Univ Paris-Sud, Le Kremlin Bicêtre, France
- AP-HP, Service de Santé Publique, Hôpital de Bicêtre, le Kremlin Bicêtre, France
| | | | - Peter W. Hunt
- Laboratory Medicine, Departments of Medicine, Epidemiology, and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Florencia Pereyra
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard University, Cambridge, Massachusetts, United States of America
| | - Steve Deeks
- Laboratory Medicine, Departments of Medicine, Epidemiology, and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Gianfranco Pancino
- Institut Pasteur, Unité de Régulation des Infections Rétrovirales, Paris, France
| | | | - Mathias Lichterfeld
- Infectious Disease Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Pierre Delobel
- Service des Maladies Infectieuses et Tropicales, Hôpital Purpan, Toulouse, France
- INSERM, Toulouse, France
| | - Asier Saez-Cirion
- Institut Pasteur, Unité de Régulation des Infections Rétrovirales, Paris, France
| | - Olivier Lambotte
- AP-HP, Service de Médecine Interne, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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Berhan A, Berhan Y. Virologic response to tipranavir-ritonavir or darunavir-ritonavir based regimens in antiretroviral therapy experienced HIV-1 patients: a meta-analysis and meta-regression of randomized controlled clinical trials. PLoS One 2013; 8:e60814. [PMID: 23593314 PMCID: PMC3617230 DOI: 10.1371/journal.pone.0060814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 03/02/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The development of tipranavir and darunavir, second generation non-peptidic HIV protease inhibitors, with marked improved resistance profiles, has opened a new perspective on the treatment of antiretroviral therapy (ART) experienced HIV patients with poor viral load control. The aim of this study was to determine the virologic response in ART experienced patients to tipranavir-ritonavir and darunavir-ritonavir based regimens. METHODS AND FINDINGS A computer based literature search was conducted in the databases of HINARI (Health InterNetwork Access to Research Initiative), Medline and Cochrane library. Meta-analysis was performed by including randomized controlled studies that were conducted in ART experienced patients with plasma viral load above 1,000 copies HIV RNA/ml. The odds ratios and 95% confidence intervals (CI) for viral loads of <50 copies and <400 copies HIV RNA/ml at the end of the intervention were determined by the random effects model. Meta-regression, sensitivity analysis and funnel plots were done. The number of HIV-1 patients who were on either a tipranavir-ritonavir or darunavir-ritonavir based regimen and achieved viral load less than 50 copies HIV RNA/ml was significantly higher (overall OR = 3.4; 95% CI, 2.61-4.52) than the number of HIV-1 patients who were on investigator selected boosted comparator HIV-1 protease inhibitors (CPIs-ritonavir). Similarly, the number of patients with viral load less than 400 copies HIV RNA/ml was significantly higher in either the tipranavir-ritonavir or darunavir-ritonavir based regimen treated group (overall OR = 3.0; 95% CI, 2.15-4.11). Meta-regression showed that the viral load reduction was independent of baseline viral load, baseline CD4 count and duration of tipranavir-ritonavir or darunavir-ritonavir based regimen. CONCLUSIONS Tipranavir and darunavir based regimens were more effective in patients who were ART experienced and had poor viral load control. Further studies are required to determine their consistent viral load suppression effect as the duration of treatment is more prolonged.
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Affiliation(s)
- Asres Berhan
- Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
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Tang YW, Ou CY. Past, present and future molecular diagnosis and characterization of human immunodeficiency virus infections. Emerg Microbes Infect 2012; 1:e19. [PMID: 26038427 PMCID: PMC3630918 DOI: 10.1038/emi.2012.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 05/08/2012] [Accepted: 05/21/2012] [Indexed: 12/31/2022]
Abstract
Substantive and significant advances have been made in the last two decades in the characterization of human immunodeficiency virus (HIV) infections using molecular techniques. These advances include the use of real-time measurements, isothermal amplification, the inclusion of internal quality assurance protocols, device miniaturization and the automation of specimen processing. The result has been a significant increase in the availability of results to a high level of accuracy and quality. Molecular assays are currently widely used for diagnostics, antiretroviral monitoring and drug resistance characterization in developed countries. Simple and cost-effective point-of-care versions are also being vigorously developed with the eventual goal of providing timely healthcare services to patients residing in remote areas and those in resource-constrained countries. In this review, we discuss the evolution of these molecular technologies, not only in the context of the virus, but also in the context of tests focused on human genomics and transcriptomics.
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Affiliation(s)
- Yi-Wei Tang
- Memorial Sloan-Kettering Cancer Center , New York, NY 10065, USA
| | - Chin-Yih Ou
- Centers for Disease Control and Prevention , Atlanta, GA 30333, USA
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Decline of CD4⁺ T-cell count before start of therapy and immunological response to treatment in antiretroviral-naive individuals. AIDS 2011; 25:1041-9. [PMID: 21412128 DOI: 10.1097/qad.0b013e3283463ec5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Treatment guidelines recommend initiation of therapy for individuals experiencing rapid CD4 cell decline. It is not known, however, whether the rate of CD4 cell decline before combination antiretroviral therapy (cART) is related to immunological response following cART. METHODS We estimated precART and postcART CD4 cell slopes by mixed models and categorized patients into two groups according to whether estimated precART slopes were above or below the 75th percentile. We compared immunological responses of the two groups through both mixed models and survival techniques. Models were stratified by CD4 cell at baseline, adjusted for HIV RNA, age, sex, HIV transmission group, year of seroconversion, initiation during primary infection, hepatitis C virus and hepatitis B virus serostatus, and cART class. RESULTS Of 2038 eligible patients, 1531 and 507 experienced median (interquartile range) precART CD4 cell slope of −105 (−471 to −61) and −42 (−62 to −80) cells/μl, respectively, over 2 years. After adjusting for potential confounders, individuals with shallower decline experienced a slower rate of CD4 cell recovery following cART initiation of +9.5 [95% confidence interval (CI) +6.6 to +12.2] compared to +13.9 (+13.0 to +14.8) cells/μl per month among those with steeper precART decline (P < 0.001). After stratifying by the baseline CD4 cell count, the adjusted relative hazard of an increase from baseline of more than 50 cells/μl was 0.70 (95% CI 0.62−0.79) for those with a shallower vs. steeper precART decline. CONCLUSION Findings highlight the existence of a subgroup of individuals with shallower precART CD4 cell decline who experience poorer CD4 cell increases after cART; new studies in this group may provide information to optimize responses to therapy.
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Vella V, Govender T, Dlamini SS, Moodley I, David V, Taylor M, Jinabhai CC. Cost-effectiveness of staff and workload profiles in retaining patients on antiretroviral therapy in KwaZulu-Natal, South Africa. AIDS Care 2011; 23:1146-53. [DOI: 10.1080/09540121.2011.554517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Venanzio Vella
- a Italian Cooperation, Department of Health , KwaZulu-Natal , South Africa
| | | | | | - Indres Moodley
- c Director Health Outcomes Research Unit, Department of Public Health Medicine, Nelson R Mandela School of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Verona David
- d Department of Public Health Medicine, Nelson R Mandela School of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Myra Taylor
- d Department of Public Health Medicine, Nelson R Mandela School of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Champaklal C. Jinabhai
- d Department of Public Health Medicine, Nelson R Mandela School of Medicine , University of KwaZulu-Natal , Durban , South Africa
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Sahali S, Carcelain G, Goujard C, Delfraissy JF, Ghosn J. [Enhancing immune restoration in human immunodeficiency virus infection]. Rev Med Interne 2011; 32:425-31. [PMID: 21440340 DOI: 10.1016/j.revmed.2011.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 11/22/2010] [Accepted: 02/07/2011] [Indexed: 11/17/2022]
Abstract
The primary objective of antiretroviral therapy has recently evolved from a virologic endpoint towards the achievement of normal CD4T cell count (greater than 500/mm(3)) to avoid progression to AIDS. This shift in the primary objective is supported by many clinical and epidemiological studies. Recent data have shown that HIV-infected adults with a CD4T cell count greater than 500cells/mm(3) on long-term combination antiretroviral therapy reach same mortality rates as the general population. However, less than 50% of patients receiving long-term suppressive antiretroviral combination reach such a CD4T cell level. New antiretroviral strategies to improve immune reconstitution, such as specific or non-specific immune-based therapy on one hand and the use of novel antiretroviral drugs from new classes on the other hand are currently under investigation. Here we review several current strategies that may improve immune reconstitution, keeping in mind that the best way to reach normal CD4T cell count is an early treatment initiation.
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Affiliation(s)
- S Sahali
- AP-HP, service de médecine interne et maladies infectieuses, CHU de Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
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12
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Gianotti N, Galli L, Zazzi M, Ghisetti V, Bonora S, Micheli V, Meraviglia P, Corsi P, Bruzzone B, Menzo S, Di Giambenedetto S, De Luca A, Filice G, Penco G, Castagna A. No pol mutation is associated independently with the lack of immune recovery in patients infected with HIV and failing antiretroviral therapy. J Med Virol 2011; 83:391-8. [PMID: 21264858 DOI: 10.1002/jmv.21989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
An investigation was undertaken to determine whether specific pol mutations hinder long-term immune recovery regardless of virological response. In total, 826 patients with >50 HIV RNA copies/ml, who underwent genotypic resistance testing between 1 January 2000 and 31 December 2003 after >3 years of antiretroviral treatment, and were followed up for >3 years after genotypic resistance testing, were analyzed retrospectively. The outcome of the study was the lack of immune recovery after >3 years of follow-up, defined as a slope by linear regression <0. The viremia detectability ratio was defined as the number of HIV RNA values of >50 copies/ml divided by the number of HIV RNA measurements during follow-up. Logistic regression was used for univariable and multivariable analysis. Median (Q1, Q3) values at baseline were the following: age 40 (37, 45) years, years on antiretroviral therapy 4.45 (3.65, 5.47), HIV RNA 3.91 (3.39, 4.53) log(10) copies/ml, CD4+ T-cell 358 (211, 524)/µl. After 3.13 years of follow-up, 375 patients (45.4%) showed a lack of immune recovery. The risk of lack of immune recovery increased independently with increasing baseline CD4+ counts (OR=1.104 per 50-cell increase, 95% CI=1.069-1.142, P<0.0001), increasing viremia detectability ratio during follow-up (OR=1.145 per 0.1-unit increase, 95% CI=1.093-1.202, P<0.0001), and with earlier calendar years of resistance testing (overall effect: P=0.0007). In conclusion, no pol mutation is associated independently with the lack of immune recovery.
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Affiliation(s)
- Nicola Gianotti
- Department of Infectious Diseases, IRCCS San Raffaele, Milan, Italy.
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Retrospective study on the critical factors for retaining patients on antiretroviral therapy in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr 2010; 55:109-16. [PMID: 20595904 DOI: 10.1097/qai.0b013e3181e7744e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze the critical factors favoring the retention of patients under antiretroviral therapy (ART) in KwaZulu-Natal (KZN), South Africa. DESIGN AND METHODS This retrospective study was based on the review of a representative sample of patients who began ART between March 2004 and May 2006 in 32 public sector sites and were followed up to July 1, 2007. Extended Cox proportional hazard models were used to identify the factors which significantly influenced treatment retention during the first 2 years of treatment. Kaplan-Meyer provided the probabilities of remaining on ART if these factors were present. RESULTS The 2835 sampled patients corresponded to about 10% of the universe of patients under ART in the 32 sites; 929 (33%) were males, and the median age of the sampled patients was 34 (interquartile range: 28-41). The analysis identified factors that significantly decreased the probability of remaining on ART. Patients' risk factors were initial CD4 <100 cells per microliter, lack of a telephone contact number, and being male. Sites' risk factors were the presence of a part time (PT) versus a full time (FT) senior professional nurse, a PT versus FT doctor, and intakes of 200 or more new patients per doctor per year. The probability of remaining on ART declined significantly for each increasing level of workload, but having a FT versus a PT doctor made a significant difference only for level of workload of 200 or more new patients per year. CONCLUSIONS The analysis has identified the conditions influencing retention of ART patients in KZN. This has provided a method to estimate absorption capacity of the ART delivery sites, which is of added value for a sustainable expansion of the ART coverage.
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Immune activation, apoptosis, and Treg activity are associated with persistently reduced CD4+ T-cell counts during antiretroviral therapy. AIDS 2010; 24:1991-2000. [PMID: 20651586 DOI: 10.1097/qad.0b013e32833c93ce] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Persistently reduced CD4(+) T-lymphocyte counts in the face of undetectable HIV viremia are seen in a sizable percentage of HIV-infected patients undergoing antiretroviral therapy (ART). We analyzed the immune correlates of this phenomenon. MATERIALS AND METHODS Sixty-seven HIV-infected patients with undetectable viremia (<50 copies/microl) after more than 7 years of ART were enrolled in the study and divided into two groups (CD4 cell counts >500 cells/microl or <500 cells/microl). Duration of HIV infection (>16 years) was comparable. Peripheral blood mononuclear cell were stimulated with gag+env or with cytomegalovirus peptides. Activated T cells (Ki67(+)), Treg lymphocytes (CD4(+)/CD25high/Foxp3+), divided into naive and activated cells based on PD1 expression, interleukin (IL)-10 and transforming growth factor (TGF)-beta production, annexin V, activation of caspases 8 and 9, Toll-like receptor (TLR)2 and TLR4 expression on immune cells, and plasma lipopolysaccharide (LPS) concentration were analyzed. RESULTS CD4(+)/Ki67(+) T cells; plasma LPS; total, naive, and activated Treg; TLR2-expressing and TLR4-expressing Treg; IL-10 production; and early and late apoptotic CD4 T cells, were significantly increased in patients with undetectable viremia and CD4 cell counts less than 500 cells/microl after more than 7 years of ART. As previously shown, CD4 nadir were also lower in these individuals. Immune activation, LPS concentration, Treg, and degree of apoptosis were negatively correlated with CD4 cell counts. CONCLUSION Lack of CD4 recovery in individuals in whom ART suppresses HIV replication is associated with complex immune alterations. Immune activation, likely driven by altered gut permeability and resulting in augmented Treg activity could play a pivotal role in this process.
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Moore DM, Harris R, Lima V, Hogg B, May M, Yip B, Justice A, Mocroft A, Reiss P, Lampe F, Chêne G, Costagliola D, Elzi L, Mugavero MJ, Monforte AD, Sabin C, Podzamczer D, Fätkenheuer G, Staszewski S, Gill J, Sterne JAC. Effect of baseline CD4 cell counts on the clinical significance of short-term immunologic response to antiretroviral therapy in individuals with virologic suppression. J Acquir Immune Defic Syndr 2009; 52:357-63. [PMID: 19668084 PMCID: PMC3032437 DOI: 10.1097/qai.0b013e3181b62933] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Achieving virologic suppression is a clear therapeutic goal for patients receiving combination antiretroviral therapy (cART). However, the effects of immunologic responses, whether measured as CD4 count changes from baseline or CD4 counts at follow-up, in patients with virologic suppression, have not been clearly established. METHODS Treatment-naive individuals aged > or =16 years, who initiated cART between 1998 and 2005 in participating cohorts of the ART Cohort Collaboration and achieved viral load < or =400 copies per milliliter 6 months after cART initiation, were included. We used Cox models to examine associations of CD4 change from baseline to 6 months, and absolute CD4 counts at 6 months, with subsequent rates of mortality and AIDS. Analyses were stratified by baseline CD4 count. RESULTS Among 23,679 eligible participants, the median increase in CD4 count at 6 months, and the implications of these increases for subsequent mortality and AIDS, varied with baseline CD4 count. Mortality hazard ratios for increases of 0-50 cells per microliter, compared with >100 cells per microliter, were 1.87 (95% confidence interval: 1.28 to 2.73), 1.60 (1.13 to 2.28), 0.98 (0.58 to 1.65) and 1.24 (0.70 to 2.18) in participants with baseline CD4 cell count <50, 50-199, 200-349 and > or =350 cells per microliter, respectively. In contrast, hazard ratios for mortality or AIDS associated with absolute CD4 cell counts at 6 months were similar across all but the highest baseline CD4 cell count strata. CONCLUSION It is not possible to derive thresholds for change in CD4 count that define an adequate immunologic response in individuals receiving cART. Absolute CD4 counts at 6 months are a more useful measure of immunologic response and subsequent prognosis.
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Affiliation(s)
- David M Moore
- Division of Epidemiology and Population Health, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada.
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16
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Gilson RJC, Man SL, Copas A, Rider A, Forsyth S, Hill T, Bansi L, Porter K, Gazzard B, Orkin C, Pillay D, Schwenk A, Johnson M, Easterbook P, Walsh J, Fisher M, Leen C, Anderson J, Sabin CA. Discordant responses on starting highly active antiretroviral therapy: suboptimal CD4 increases despite early viral suppression in the UK Collaborative HIV Cohort (UK CHIC) Study. HIV Med 2009; 11:152-60. [PMID: 19732175 DOI: 10.1111/j.1468-1293.2009.00755.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Patients starting highly active antiretroviral therapy (HAART) may have a suboptimal CD4 increase despite rapid virological suppression. The frequency and the significance for patient care of this discordant response are uncertain. This study was designed to determine the incidence of a discordant response at two time-points, soon after 6 months and at 12 months, and to determine the relationship with clinical outcomes. METHODS Data obtained in the UK Collaborative HIV Cohort Study were analysed. A total of 2584 treatment-naïve patients starting HAART with HIV viral load (VL) > 1000 HIV-1 RNA copies/mL at baseline and < 50 copies/mL within 6 months were included in the analysis. Patients were classified at either 6-10 (midpoint 8) months or 10-14 (midpoint 12) months as having a discordant (CD4 count increase < 100 cells/microL from baseline) or concordant response (CD4 count increase >or= 100 cells/microL). RESULTS Discordant responses occurred in 32.1% of patients at 8 months and in 24.2% at 12 months; 35% of those discordant at 8 months were concordant at 12 months. A discordant response was associated with older age, lower baseline VL, and (at 12 months) higher baseline CD4 cell count. In a multivariate analysis it was associated with an increased risk of death, more strongly at 12 months [incidence rate ratio (IRR) 3.35, 95% confidence interval (CI) 1.73-6.47, P < 0.001] than at 8 months (IRR 2.08, 95% CI 1.19-3.64, P = 0.010), but not with new AIDS events. CONCLUSIONS Discordant responders have a worse outcome, but assessment at 12 months may be preferred, given the number of 'slow' responders. Management strategies to improve outcomes for discordant responders need to be investigated.
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Affiliation(s)
- R J C Gilson
- Centre for Sexual Health and HIV Research, Research Department of Infection & Population Health, University College London, The Mortimer Market Centre, Camden Primary Care Trust, London, UK.
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Increased reporting of detectable plasma HIV-1 RNA levels at the critical threshold of 50 copies per milliliter with the Taqman assay in comparison to the Amplicor assay. J Acquir Immune Defic Syndr 2009; 51:3-6. [PMID: 19247185 DOI: 10.1097/qai.0b013e31819e721b] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the application of the new COBAS Ampliprep Taqman HIV-1 assay in comparison with the COBAS HIV-1 Ampliprep AMPLICOR MONITOR ultrasensitive assay version 1.5, with a particular focus on the most clinically relevant region near the lower limit of quantification. METHODS Scatterplots and the Bland-Altman plot were used to inspect the degree of agreement between the 2 assays when tested on samples from the British Columbia Centre for Excellence in HIV/AIDS monitoring and evaluation system. Consistency of clinically applicable values at low HIV-1 RNA copy number was assessed from samples from individuals with previously undetectable Amplicor results. RESULTS Despite general agreement of these assays over a wide dynamic range, the Taqman assay resulted in a nearly 2-fold increase (from 3.6% to 6.9%) in the number of patients experiencing a plasma HIV-1 RNA level >50 copies per milliliter after being suppressed to levels <50 copies per milliliter consistently during the previous year (P < 0.01). In addition, rare discrepancies between the 2 assays were observed to be as high as 0.7 log10 copies per milliliter. The kappa statistic was 0.19, indicating only slight agreement at the critical threshold of 50 HIV RNA copies per milliliter, with 43% of undetectable samples in the Amplicor assay testing detectable in the Taqman assay (median 70 copies/mL; interquartile range 60-83 copies/mL). CONCLUSIONS The increased frequency of detectable plasma HIV-1 RNA levels at the threshold of 50 copies per milliliter with the new Taqman assay has important implications for highly active antiretroviral therapy monitoring. Until there is clinical evidence that patients with detectable HIV by the Taqman assay (but undetectable HIV with Amplicor) have differential outcomes, it is unclear whether the Taqman assay is appropriate for routine management of HIV-1 therapy, and caution is required in the interpretation of low-level viremia by the Taqman assay until a clinical validation of a new cutoff is performed.
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Increased frequency of HIV-1 viral load blip rate observed after switching from Roche Cobas Amplicor to Cobas Taqman assay. J Acquir Immune Defic Syndr 2009; 51:364-5. [PMID: 19553776 DOI: 10.1097/qai.0b013e3181aa13b3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-term patterns in CD4 response are determined by an interaction between baseline CD4 cell count, viral load, and time: The Asia Pacific HIV Observational Database (APHOD). J Acquir Immune Defic Syndr 2009; 50:513-20. [PMID: 19408354 DOI: 10.1097/qai.0b013e31819906d3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Random effects models were used to explore how the shape of CD4 cell count responses after commencing combination antiretroviral therapy (cART) develop over time and, in particular, the role of baseline and follow-up covariates. METHODS Patients in Asia Pacific HIV Observational Database who first commenced cART after January 1, 1997, and who had a baseline CD4 cell count and viral load measure and at least 1 follow-up measure between 6 and 24 months, were included. CD4 cell counts were determined at every 6-month period after the commencement of cART for up to 6 years. RESULTS A total of 1638 patients fulfilled the inclusion criteria with a median follow-up time of 58 months. Lower post-cART mean CD4 cell counts were found to be associated with increasing age (P < 0.001), pre-cART hepatitis C coinfection (P = 0.038), prior AIDS (P = 0.019), baseline viral load < or equal to 100,000 copies per milliliter (P < 0.001), and the Asia Pacific region compared with Australia (P = 0.005). A highly significant 3-way interaction between the effects of time, baseline CD4 cell count, and post-cART viral burden (P < 0.0001) was demonstrated. Higher long-term mean CD4 cell counts were associated with lower baseline CD4 cell count and consistently undetectable viral loads. Among patients with consistently detectable viral load, CD4 cell counts seemed to converge for all baseline CD4 levels. CONCLUSIONS Our analysis suggest that the long-term shape of post-cART CD4 cell count changes depends only on a 3-way interaction between baseline CD4 cell count, viral load response, and time.
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Rebeiro PF, Kheshti A, Bebawy SS, Stinnette SE, Erdem H, Tang YW, Sterling TR, Raffanti SP, D'Aquila RT. Increased detectability of plasma HIV-1 RNA after introduction of a new assay and altered specimen-processing procedures. Clin Infect Dis 2008; 47:1354-7. [PMID: 18922071 DOI: 10.1086/592693] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
After changes to assay and specimen-processing methods, plasma human immunodeficiency virus type 1 (HIV-1) RNA was frequently detectable in patients who previously had well-suppressed HIV-1 RNA levels. This artifact is attributable to shipping frozen plasma in primary plasma preparation tubes and is not caused by the HIV-1 RNA detection assay; it can be avoided by shipping plasma in a secondary tube.
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Affiliation(s)
- Peter F Rebeiro
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-2582, USA
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Khanna N, Opravil M, Furrer H, Cavassini M, Vernazza P, Bernasconi E, Weber R, Hirschel B, Battegay M, Kaufmann G. CD4+T Cell Count Recovery in HIV Type 1–Infected Patients Is Independent of Class of Antiretroviral Therapy. Clin Infect Dis 2008; 47:1093-101. [DOI: 10.1086/592113] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Fielden SJ, Rusch ML, Levy AR, Yip B, Wood E, Harrigan RP, Goldstone I, Guillemi S, Montaner JS, Hogg RS. Predicting hospitalization among HIV-infected antiretroviral naïve patients starting HAART: Determining clinical markers and exploring social pathways. AIDS Care 2008; 20:297-303. [DOI: 10.1080/09540120701561296] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Sarah J. Fielden
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
- b Department of Interdisciplinary Studies , University of British Columbia , US
| | - Melanie L.A. Rusch
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
- c Department of Health Care and Epidemiology , University of British Columbia , US
- d Division of International Health & Cross-Cultural Medicine , University of California , San Diego , CA , US
| | - Adrian R. Levy
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
- c Department of Health Care and Epidemiology , University of British Columbia , US
| | - Benita Yip
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
| | - Evan Wood
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
- e Department of Medicine , University of British Columbia , US
| | - Richard P. Harrigan
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
- e Department of Medicine , University of British Columbia , US
| | - Irene Goldstone
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
- f School of Nursing , University of British Columbia , US
| | - Silvia Guillemi
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
| | - Julio S. Montaner
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
- e Department of Medicine , University of British Columbia , US
| | - Robert S. Hogg
- a B.C. Centre for Excellence in HIV/AIDS , Vancouver , BC , US
- g Faculty of Health Science , Simon Fraser University , Burnaby , BC , US
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Anderson AML, Kosinski AS, Bartlett JA. Decreasing CD4 + T-cell Count During Suppressed or Low-Level Viraemia in Patients with HIV Infection. Antivir Ther 2007. [DOI: 10.1177/135965350701200712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Suboptimal improvement in CD4+ T-cell count is not uncommon in HIV-infected patients with suppressed plasma HIV RNA levels, and a decrease in CD4+T-cell count in patients with suppressed or low-level viraemia has been observed. Methods Our objectives were to identify the prevalence of decreasing CD4+ T-cell counts during suppressed or low-level viraemia, to determine the frequency of clinical events during and immediately after such decreases, and to examine for associations with individual variables. A matched case-control study was undertaken using the Duke Infectious Diseases Clinic database ( n=3,949). Cases had at least two consecutive significant decreases in either CD4+ absolute count or CD4+ percentage, while also having plasma HIV RNA levels <1,000 copies/ml. Results The prevalence of decreasing CD4+ T-cell counts during suppressed or low-level viraemia was 1.22%. Only three HIV-associated clinical events occurred. The majority of cases had an increase in the CD4+ T-cell count immediately following the study period. The use of either zidovudine or stavudine was weakly associated with decreasing CD4+ T-cell counts in a multivariable analysis, but this association was not present in cases with only a decrease in CD4+ T-cell percentage. Conclusions Decreasing CD4+ T-cell counts during suppressed or low-level viraemia are rare, typically transient, and not associated with an increase in HIV-associated clinical events.
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Affiliation(s)
- Albert ML Anderson
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Centre, Durham, NC, USA
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics and Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC, USA
| | - John A Bartlett
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Centre, Durham, NC, USA
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Gras L, Kesselring AM, Griffin JT, van Sighem AI, Fraser C, Ghani AC, Miedema F, Reiss P, Lange JMA, de Wolf F. CD4 cell counts of 800 cells/mm3 or greater after 7 years of highly active antiretroviral therapy are feasible in most patients starting with 350 cells/mm3 or greater. J Acquir Immune Defic Syndr 2007; 45:183-92. [PMID: 17414934 DOI: 10.1097/qai.0b013e31804d685b] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE CD4 cell count changes in therapy-naive patients were investigated during 7 years of highly active antiretroviral therapy (HAART) in an observational cohort. METHODS Three endpoints were studied: (1) time to >or=800 CD4 cells/mm in 5299 therapy-naive patients starting HAART, (2) CD4 cell count changes during 7 years of uninterrupted HAART in a subset of 544 patients, and (3) reaching a plateau in CD4 cell restoration after 5 years of HAART in 366 virologically suppressed patients. RESULTS Among patients with <50, 50 to 200, 200 to 350, 350 to 500, and >or=500 CD4 cells/mm at baseline, respectively, 20%, 26%, 46%, 73%, and 87% reached >or=800 CD4 cells/mm within 7 years of starting HAART. Periods with HIV RNA levels >500 copies/mL and age >or=50 years were associated with lesser increases in CD4 cell counts between 6 months and 7 years. Having reached >or=800 CD4 cells/mm at 5 years, age >or=50 years, and >or=1 HIV RNA measurement >1000 copies/mL between 5 and 7 years were associated with a plateau in CD4 cell restoration. CONCLUSIONS Restoration to CD4 cell counts >or=800 cells/mm is feasible within 7 years of HAART in most HIV-infected patients starting with >or=350 cells/mm and achieving sufficient suppression of viral replication. Particularly in patients >or=50 years of age, it may be beneficial to start earlier than current guidelines recommend.
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Affiliation(s)
- Luuk Gras
- HIV Monitoring Foundation, Amsterdam, The Netherlands.
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Hogg RS, Bangsberg DR, Lima VD, Alexander C, Bonner S, Yip B, Wood E, Dong WWY, Montaner JSG, Harrigan PR. Emergence of drug resistance is associated with an increased risk of death among patients first starting HAART. PLoS Med 2006; 3:e356. [PMID: 16984218 PMCID: PMC1569883 DOI: 10.1371/journal.pmed.0030356] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Accepted: 06/14/2006] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The impact of the emergence of drug-resistance mutations on mortality is not well characterized in antiretroviral-naïve patients first starting highly active antiretroviral therapy (HAART). Patients may be able to sustain immunologic function with resistant virus, and there is limited evidence that reduced sensitivity to antiretrovirals leads to rapid disease progression or death. We undertook the present analysis to characterize the determinants of mortality in a prospective cohort study with a median of nearly 5 y of follow-up. The objective of this study was to determine the impact of the emergence of drug-resistance mutations on survival among persons initiating HAART. METHODS AND FINDINGS Participants were antiretroviral therapy naïve at entry and initiated triple combination antiretroviral therapy between August 1, 1996, and September 30, 1999. Marginal structural modeling was used to address potential confounding between time-dependent variables in the Cox proportional hazard regression models. In this analysis resistance to any class of drug was considered as a binary time-dependent exposure to the risk of death, controlling for the effect of other time-dependent confounders. We also considered each separate class of mutation as a binary time-dependent exposure, while controlling for the presence/absence of other mutations. A total of 207 deaths were identified among 1,138 participants over the follow-up period, with an all cause mortality rate of 18.2%. Among the 679 patients with HIV-drug-resistance genotyping done before initiating HAART, HIV-drug resistance to any class was observed in 53 (7.8%) of the patients. During follow-up, HIV-drug resistance to any class was observed in 302 (26.5%) participants. Emergence of any resistance was associated with mortality (hazard ratio: 1.75 [95% confidence interval: 1.27, 2.43]). When we considered each class of resistance separately, persons who exhibited resistance to non-nucleoside reverse transcriptase inhibitors had the highest risk: mortality rates were 3.02 times higher (95% confidence interval: 1.99, 4.57) for these patients than for those who did not exhibit this type of resistance. CONCLUSIONS We demonstrated that emergence of resistance to non-nucleoside reverse transcriptase inhibitors was associated with a greater risk of subsequent death than was emergence of protease inhibitor resistance. Future research is needed to identify the particular subpopulations of men and women at greatest risk and to elucidate the impact of resistance over a longer follow-up period.
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Affiliation(s)
- Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada.
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Bisson GP, Gross R, Strom JB, Rollins C, Bellamy S, Weinstein R, Friedman H, Dickinson D, Frank I, Strom BL, Gaolathe T, Ndwapi N. Diagnostic accuracy of CD4 cell count increase for virologic response after initiating highly active antiretroviral therapy. AIDS 2006; 20:1613-9. [PMID: 16868442 DOI: 10.1097/01.aids.0000238407.00874.dc] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To derive and internally validate a clinical prediction rule for virologic response based on CD4 cell count increase after initiation of HAART in a resource-limited setting. DESIGN AND METHODS A retrospective cohort study at two HIV care clinics in Gaborone, Botswana. The participants were previously treatment-naive HIV-1-infected individuals initiating HAART. The main outcome measure was a plasma HIV-1 RNA level (viral load) < or = 400 copies/ml (i.e. undetectable) 6 months after initiating HAART. RESULTS The ability of CD4 cell count increase to predict an undetectable viral load was significantly better in those with baseline CD4 cell counts < or = 100 cells/microl [area under the ROC curve (AUC), 0.78; 95% confidence interval (CI), 0.67-0.89; versus AUC, 0.60; 95% CI, 0.48-0.71; P = 0.018]. The sensitivity, specificity, and positive and negative predictive values of a CD4 cell count increase of > or = 50 cells/microl for an undetectable viral load in those with baseline CD4 cell counts < or = 100 cells/microl were 93.1, 61.3, 92.5 and 63.3%, respectively. Alternatively, these values were 47.8, 87.1, 95.0 and 24.5%, respectively, if a increase in CD4 cell count of > or = 150 cells/microl was used. CONCLUSIONS CD4 cell count increase after initiating HAART has only moderate discriminative ability in identifying patients with an undetectable viral load, and the predictive ability is higher [corrected] in patients with lower baseline CD4 cell counts. Although HIV treatment programs in resource-constrained settings could consider the use of CD4 cell count increases to triage viral load testing, more accurate approaches to monitoring virologic failure are urgently needed.
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Affiliation(s)
- Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania19104-6021, USA.
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Moore DM, Hogg RS, Chan K, Tyndall M, Yip B, Montaner JSG. Disease progression in patients with virological suppression in response to HAART is associated with the degree of immunological response. AIDS 2006; 20:371-7. [PMID: 16439870 DOI: 10.1097/01.aids.0000196180.11293.9a] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if immunological response is associated with disease progression in patients with virological suppression after initiating HAART. DESIGN A cohort study of 1084 treatment-naive participants in the British Columbia HIV/AIDS Drug Treatment Program who had achieved viral loads < 500 copies/ml at 3-9 months after initiating triple-drug therapy. METHODS Cox proportional hazards was used to model the association with disease progression of baseline variables, change in CD4 cell counts and CD4 cell count strata at 6 months. Logistic regression analysis was used to examine associations with two definitions of poor immunological response. RESULTS Patients were followed for a median of 51.4 months. In univariate analyses, increases in CD4 cell counts of < 25 cells/microl and absolute CD4 cell counts of < 200 cells/microl were associated with an increased risk of death or new AIDS events. Two mulitivariate models, one including baseline CD4 cell count and change in CD4 cell count from baseline and the other including only absolute CD4 cell counts at 6 months, were found to predict disease progression in this setting. Increases in CD4 cell count of < 25 cells/microl were associated with increasing age and inversely associated with low baseline CD4 cell counts, high baseline viral loads and good adherence to therapy. CD4 cell counts of < 200 cells/microl at 6 months were associated with low baseline CD4 cell counts and having AIDS at baseline. CONCLUSION Patients with virological suppression are still at risk for HIV disease progression if adequate immunological responses are not achieved.
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Affiliation(s)
- David M Moore
- BC Centre for Excellence in HIV/AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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Moore DM, Hogg RS, Yip B, Wood E, Tyndall M, Braitstein P, Montaner JSG. Discordant immunologic and virologic responses to highly active antiretroviral therapy are associated with increased mortality and poor adherence to therapy. J Acquir Immune Defic Syndr 2005; 40:288-93. [PMID: 16249702 DOI: 10.1097/01.qai.0000182847.38098.d1] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the independent association of discordant virologic and immunologic responses to highly active antiretroviral therapy (HAART) with mortality. METHODS A population-based study of 1527 treatment-naive individuals initiating HAART used Cox proportional hazards modeling to determine the independent association of treatment response at 3 to 9 months with nonaccidental mortality. Logistic regression was used to examine associations with discordant responses. RESULTS Viral load (VL)/CD4 discordant responses were seen in 235 (15.4%) of subjects, and VL/CD4 responses were seen in 179 (11.7%) of subjects. In adjusted Cox regression models, discordant responses were found to be independently associated with an increased risk of mortality (VL/CD4: relative hazard [RH] = 1.87, 95% confidence interval [CI]: 1.15 to 3.04; VL/CD4: RH = 2.47, 95% CI: 1.54 to 3.95). VL/CD4 discordance was found to be associated with increasing age, baseline HIV RNA load <100,000 copies/mL, baseline CD4 counts <50 cells/muL, the use of lamivudine (3TC)/zidovudine (ZDV), and poor adherence to therapy. VL/CD4 discordance was associated with younger age; injection drug use; baseline HIV RNA load >100,000 copies/mL; the use of 3TC/ZDV, didanosine (ddI)/3TC, or ddI/stavudine; and poor adherence to therapy. CONCLUSION Discordant responses are independently associated with an increased risk of mortality and are, in turn, associated with poor adherence to therapy.
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Affiliation(s)
- David M Moore
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, British Columbia, Canada V6Z 1Y6.
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Molina-Pinelo S, Leal M, Soriano-Sarabia N, Gutiérrez S, Fernandez G, Muñoz-Fernández MA, Lissen E, Vallejo A. Prevalence and factors involved in discordant responses to highly active antiretroviral treatment in a closely followed cohort of treatment-naïve HIV-infected patients. J Clin Virol 2005; 33:110-115. [PMID: 15952251 DOI: 10.1016/j.jcv.2004.09.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The prevalence and the factors involved in discordant responses to highly active antiretroviral therapy were analysed in a closely followed cohort of 51 naïve HIV-infected patients at 48 weeks. A complete treatment response was considered as an increase in CD4 cell count of >or=50 cells/mm3 with a >or=1 log10 decrease in viral load or viral suppression. Virologic response (<50 CD4+ cells/mm3 increase) and immune response (<1 log10 decrease in viral load) were observed in 15.7% and 5.8% of the patients, respectively. We demonstrated that the prevalence of virologic response decreased at week 72 and disappeared after 96 weeks of treatment. This slower response did not correlate with protease inhibitor-based (PI-based) regimens or HCV coinfection. On the other hand, immune response in our cohort could be easily attributable to a simple mechanism, i.e. irregular treatment compliance.
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Affiliation(s)
- Sonia Molina-Pinelo
- Viral Hepatitis and AIDS Study Group, Department of Internal Medicine, Unidad de Investigación, Hospital Universitario Virgen del Rocío, Seville, Spain
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Jaafar A, Massip P, Sandres-Sauné K, Souyris C, Pasquier C, Aquilina C, Izopet J. HIV therapy after treatment interruption in patients with multiple failure and more than 200 CD4+T lymphocyte count. J Med Virol 2004; 74:8-15. [PMID: 15258962 DOI: 10.1002/jmv.20139] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The aim of the study was to investigate the safety and efficacy of a salvage therapy initiated after interrupting treatment in patients with virological failure and more than 200 CD4(+) T lymphocyte count. In this prospective study, 77 patients who received failing regimens had stopped completely all medication for 3 months before starting an optimised regimen consisting of 3-5 drugs. Patients were tested for HIV resistance before and after treatment interruption. Discontinuation of therapy for 3 months was associated with a median increase in HIV RNA of 1.1 log(10), a median decrease in CD4(+) T cell count of 136 x 10(6)/L and five clinical events related to HIV, but no AIDS-defining event. Eighty-seven percent of patients showed a shift from a drug resistant genotype to a wild-type genotype based on the major resistance mutations. Forty-seven percent of patients with a genotype shift reached fewer than 200 HIV RNA copies/ml of plasma 6 and 12 months after treatment resumption whereas none of those without a genotype shift did so (P = 0.03). However, the genotypic shift was not associated with a sustained virological response by multivariate analysis. The use of a new therapeutic class of compound in the salvage regimen was the only predictor of the sustained virological response. Salvage therapy with 3-5 drugs after interrupting treatment for 3 months can be a safe and effective strategy provided the HIV disease is not too advanced. Randomised trials in this population are needed to assess the clinical benefit of this strategy.
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Affiliation(s)
- Acil Jaafar
- Laboratoire de Virologie, Hôpital Purpan, CHU Toulouse, Toulouse Cédex, France
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CD4+ T-Cell Gain With Nonnucleoside or Protease Inhibitors: Convenience May Not Always Be The Most Convenient:Reply. J Acquir Immune Defic Syndr 2004. [DOI: 10.1097/00126334-200406010-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wood E, Hogg RS, Yip B, Harrigan PR, O'Shaughnessy MV, Montaner JSG. The impact of adherence on CD4 cell count responses among HIV-infected patients. J Acquir Immune Defic Syndr 2004; 35:261-8. [PMID: 15076240 DOI: 10.1097/00126334-200403010-00006] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There have been concerns that irreversible immune damage may result if highly active antiretroviral therapy (HAART) is initiated after the CD4 cell count declines to below 350 cells/microL; however, the role of antiretroviral adherence on CD4 cell count responses has not been well evaluated. METHODS We evaluated CD4 cell count responses of 1522 antiretroviral-naive patients initiating HAART who were stratified by baseline CD4 cell count (<50, 50-199, and >or=200 cells/microL) and adherence. RESULTS Among patients starting HAART with <50 cells/microL, during the fifth 15-week period after the initiation of HAART, absolute CD4 cell counts were 200 cells/microL (interquartile range [IQR]: 130-290) for adherent patients versus 60 cells/microL (IQR: 10-130) for nonadherent patients. Similarly, among patients starting HAART with 50 to 199 cells/microL, during the fifth 15-week period after the initiation of HAART, absolute CD4 cell counts were 300 cells/microL (IQR: 180-390) versus 125 cells/microL (IQR: 40-210) for nonadherent patients. In Cox regression analyses, adherence was the strongest independent predictor of the time to a gain of >or=50 cells/microL from baseline (relative hazard [RH] = 2.88, 95% confidence interval [CI]: 2.46-3.37). Among patients with baseline CD4 cell counts <200 cells/microL, adherence was the strongest independent predictor of the time to a CD4 cell count >200 cells/microL (RH = 4.85, 95% CI: 3.15-7.47). CONCLUSIONS These data demonstrate that substantial CD4 gains are possible among highly advanced adherent patients and should contribute to the ongoing debate over the optimal time to initiate HAART.
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Affiliation(s)
- Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada
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Kaufmann GR, Khanna N, Weber R, Perrin L, Furrer H, Cavassini M, Ledergerber B, Vernazza P, Bernasconi E, Rickenbach M, Hirschel B, Battegay M, Bachmann S, Battegay M, Bernasconi E, Bucher H, Burgisser P, Cattacin S, Egger M, Erb P, Fierz W, Fischer M, Flepp M, Fontana A, Francioli P, Furrer HJ, Gorgievski M, Gunthard H, Hirschel B, Kaiser L, Kind C, Klimkait T, Ledergerber B, Lauper U, Opravil M, Paccaud F, Pantaleo G, Perrin L, Piffaretti C, Rickenbach M, Rudin C, Schupbach J, Speck R, Telenti A, Trkola A, Vernazza P, Weber R, Yerly S. Long-Term Virological Response to Multiple Sequential Regimens of Highly Active Antiretroviral Therapy for HIV Infection. Antivir Ther 2004. [DOI: 10.1177/135965350400900212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Information about the virological response to sequential highly active antiretroviral therapy (HAART) for HIV infection is limited. The virological response to four consecutive therapies was evaluated in the Swiss HIV Cohort. Design Retrospective analysis in an observational cohort. Methods 1140 individuals receiving uninterrupted HAART for 4.8 ±0.6 years were included. The virological response was classified as success (<400 copies/ml), low-level (LF: 400–5000 copies/ml) or high-level failure (HF: >5000 copies/ml). Potential determinants of the virological response, including patient demographics, treatment history and virological response to previous HAART regimens were analysed using survival and logistic regression analyses. Results 40.1% failed virologically on the first (22.0% LF; 18.1% HF), 35.1% on the second (14.2% LF; 20.9% HF), 34.2% on the third (9.9% LF; 24.3% HF) and 32.7% on the fourth HAART regimen (9% LF; 23.7% HF). Nucleoside pre-treatment (OR: 2.34; 95% CI: 1.67–3.29) and low baseline CD4 T-cell count (OR: 0.79/100 cells rise; 95% CI: 0.72–0.88) increased the risk of HF on the first HAART. Virological failure on HAART with HIV-1 RNA levels exceeding 1000 copies/ml predicted a poor virological response to subsequent HAART regimens. A switch from a protease inhibitor- to a non-nucleoside reverse transcriptase inhibitor-containing regimen significantly reduced the risk of HF. Multiple switches of HAART did not affect the recovery of CD4 T lymphocytes. Conclusion Multiple sequential HAART regimens do not per se reduce the likelihood of long-term virological suppression and immunological recovery. However, early virological failure increases significantly the risk of subsequent unfavourable virological responses. The choice of a potent initial antiretroviral drug regimen is therefore critical. This study has been presented in part at the 10th Conference on Retroviruses & Opportunistic Infections. Boston, Mass., USA, 2003. Abstract #571.
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Affiliation(s)
| | - Gilbert R Kaufmann
- Division of Infectious Diseases, University Hospital, Basel, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases, University Hospital, Basel, Switzerland
| | - Rainer Weber
- Division of Infectious Diseases, University Hospital Zurich, Zurich, Switzerland
| | - Luc Perrin
- Division of Infectious Diseases and Laboratory of Virology, University Hospital, Geneva, Switzerland
| | - Hansjakob Furrer
- Division of Infectious Diseases, University Hospital, Berne, Switzerland
| | - Matthias Cavassini
- Division of Infectious Diseases, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Bruno Ledergerber
- Division of Infectious Diseases, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Vernazza
- Department of Internal Medicine, Cantonal Hospital, St.Gallen, Switzerland
| | - Enos Bernasconi
- Department of Internal Medicine, Regional Hospital, Lugano, Switzerland
| | - Martin Rickenbach
- Co-ordination and Data Center of the Swiss HIV Cohort Study, University of Lausanne, Lausanne, Switzerland
| | - Bernard Hirschel
- Division of Infectious Diseases and Laboratory of Virology, University Hospital, Geneva, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases, University Hospital, Basel, Switzerland
| | - S Bachmann
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - M Battegay
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - E Bernasconi
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - H Bucher
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - Ph Burgisser
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - S Cattacin
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - M Egger
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - P Erb
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - W Fierz
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - M Fischer
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - M Flepp
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - A Fontana
- Centre Hospitalier Universitaire Vaudois, Lausanne
| | - P Francioli
- Centre Hospitalier Universitaire Vaudois, Lausanne
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Tomasoni LR, Patroni A, Torti C, Paraninfo G, Gargiulo F, Quiros-Roldan E, Uccelli MC, Airò P, Tinelli C, Carosi G, Castelli F. Predictors of long-term immunological outcome in rebounding patients on protease inhibitor-based HAART after initial successful virologic suppression: implications for timing to switch. HIV CLINICAL TRIALS 2004; 4:311-23. [PMID: 14583847 DOI: 10.1310/fgmf-y0ly-dmx8-371v] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess predictive factors of long-term immune restoration in patients who started protease inhibitor (PI)-based HAART and experienced virological rebound after initial complete success. METHOD A retrospective longitudinal analysis of all HIV-infected patients who started their first PI-based HAART and reached viral load below 500 copies/mL was carried out in a large academic center in Italy. Patients were classified either as complete virologic responder (CR) or rebounders (REB) when confirmed plasma viremia was detected thereafter. Immunological outcome was the area under the curve (AUC) of the absolute CD4+ cell count change since the 8th month after treatment initiation (CD4+ T-cell AUC). Association between baseline characteristics, virological outcome, and CD4+ T-cell AUC was assessed by univariate and multivariate analysis. RESULTS There were 374 patients who were included in the study. Mean follow-up was 30.2 months. There were 226/374 patients (60.4%) who remained CR while 148/374 (39.6%) presented at least one rebound (REB). Among REB patients, complete viral suppression was regained in 15/42 (35.7%) and 50/106 (47.1%) patients who underwent therapy changes or not, respectively. When multiple linear regression was carried out, previous nucleoside reverse transcriptase inhibitor (NRTI) experience and baseline CD4+ cell count below 350 cells/muL did not impair long-term immune restoration. The occurrence of rebound, its duration (> 18 months), and its magnitude (peak of viral load > 10,000 copies/mL) were independent negative prognostic factors. CONCLUSION The occurrence of viral rebound is independently associated with significantly impaired long-term immunological restoration. The magnitude of viral rebound (< 10,000 copies/mL) and its duration (< 18 months) may be useful to identify those rebounding patients who may still profit from maintaining the current failing therapy if a more aggressive approach may be expected to be deleterious for tolerability reasons or lack of options.
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Affiliation(s)
- L R Tomasoni
- Institute for Infectious and Tropical Diseases, University of Brescia, Italy
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Choremi-Papadopoulou H, Tsalimalma K, Dafni U, Dimitracopoulou A, Kordossis T. Limited long-term naive CD4+ T cell reconstitution in patients experiencing viral load rebounds during HAART. J Med Virol 2004; 73:235-43. [PMID: 15122798 DOI: 10.1002/jmv.20081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Long-term (3.5 years) immune reconstitution in relation to viral load response was determined. Plasma HIV-1 RNA was suppressed in 40 patients (full responders) up to 42 months, and 17 patients achieved partial response. The measurements of CD4(+) and CD8(+) T lymphocyte subsets (CD45RA, CD45RACD62L, CD45RO, CD28, CD38) were carried out by flow cytometry. Full responders had a significant increase of CD4(+) and all CD4(+) T subsets both up to 6 and from 6 to 42 months, while the increase for partial responders was only up to 6 months. By 6 months, higher slopes were observed in full versus partial responders in the % of CD28 on CD4(+) and the % of CD4(+) memory subset and in both naïve and memory CD4(+) subsets from 6 to 42 months. The percentage of CD8(+) and its subsets was decreased significantly in full responders both up to 6 and from 6 to 42 months (except for an increase in the CD8(+)CD45RA(+) CD62L(+) cells), while in partial responders this decrease was only up to 6 months. Lower slopes were observed in full versus partial responders from 6 to 42 months in the percentages of CD8(+), CD8(+)CD45RO(+), CD8(+)CD28(-), and CD8(+)CD38(+) T cells. In conclusion, full responders have a stronger long-term naive CD4(+) T cell subset reconstitution than partial responders.
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Wood E, Hogg RS, Heath KV, de la Rosa R, Lee N, Yip B, O'Shaughnessy MVO, Montaner JSG. Provider bias in the selection of non-nucleoside reverse transcriptase inhibitor and protease inhibitor-based highly active antiretroviral therapy and HIV treatment outcomes in observational studies. AIDS 2003; 17:2629-34. [PMID: 14685057 DOI: 10.1097/00002030-200312050-00010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the characteristics of patients prescribed non-nucleoside reverse transcriptase inhibitors (NNRTI) and protease inhibitors (PI), and evaluate treatment outcomes in a setting in which nevirapine has been preferentially recommended since 1998. METHODS A population-based analysis of antiretroviral-naive adults who started highly active antiretroviral therapy (HAART) between 1 August 1996 and 31 July 2000, and who were followed until 31 March 2002. We compared baseline characteristics, and evaluated virological responses and mortality. RESULTS Overall, 439 patients (28.8%) started HAART with NNRTI (94.1% used nevirapine), 100 (6.6%) used a double PI, and 983 (64.6%) used a single PI-based regimen. Substantial differences were observed between the baseline clinical characteristics of these populations. In adjusted analyses, in comparison with single PI therapy, only the use of NNRTI was associated with more rapid HIV-RNA suppression [relative hazard (RH) 1.42; 95% confidence interval (CI) 1.22-1.65; P < 0.001]. A total of 204 deaths were identified in the study population [42 (9.6%) NNRTI; 11 (11%) double PI; 151 (15.4%) single PI, respectively]. In adjusted analysis, NNRTI (RH 1.01; 95% CI 0.71-1.45) and double PI-based HAART (RH 0.74; 95% CI 0.40-1.39) had similar mortality rates to the single PI reference category. CONCLUSION NNRTI use was associated with more rapid virological suppression, whereas similar rates of rebound and mortality were found. Nevertheless, major baseline differences existed between patients prescribed the various initial regimens. As such, it is likely that similar selection factors may explain why our findings contrast with several non-randomized studies showing worse clinical outcomes of patients prescribed nevirapine.
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Affiliation(s)
- Evan Wood
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, Canada
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Abgrall S, Duval X, Joly V, Descamps D, Matheron S, Costagliola D. Clinical and Immunologic Outcome in Patients with Human Immunodeficiency Virus Infection, According to Virologic Efficacy in the Year after Virus Undetectability, during Antiretroviral Therapy. Clin Infect Dis 2003; 37:1517-26. [PMID: 14614675 DOI: 10.1086/379070] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2003] [Accepted: 07/01/2003] [Indexed: 11/03/2022] Open
Abstract
To evaluate factors associated with durable viral suppression (DVS), low viral rebound (virus load of 500-5000 copies/mL), and high viral rebound (virus load above 5000 copies/mL), we studied 3736 patients who achieved an undetectable virus load (i.e., <500 copies/mL) while receiving an initial highly active antiretroviral therapy regimen containing a protease inhibitor (PI). A total of 2636 patients (71%) had DVS, 387 (10%) had low viral rebound, and 713 (19%) had high viral rebound. Factors associated with DVS were antiretroviral-naive status, choice of PI (indinavir or boosted PI), lower virus load and higher CD4+ cell count, shorter duration of therapy (<6 months), and larger CD4+ cell increment until an undetectable virus load was attained. These factors (except for receipt of indinavir) were also associated with low versus high viral rebound. Compared with patients with DVS, patients with high viral rebound were more likely to experience clinical failure (adjusted hazard ratio [aHR], 1.71; 95% confidence interval [CI], 0.97-3.02) and immunologic failure (aHR, 1.57; 95% CI, 1.34-1.83), and patients with low viral rebound were as likely to experience these types of failure (aHR for clinical failure, 1.18 [95% CI, 0.48-2.92]; aHR for immunologic failure, 1.07 [95% CI, 0.87-1.32]), suggesting that a low viral rebound while receiving HAART that contains a PI has no significant consequence on midterm clinical outcome.
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Affiliation(s)
- Sophie Abgrall
- Equipe mixte INSERM 0214, Hôpital Pitié Salpêtrière, Paris, France.
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Wood E, Montaner JSG, Bangsberg DR, Tyndall MW, Strathdee SA, O'Shaughnessy MV, Hogg RS. Expanding access to HIV antiretroviral therapy among marginalized populations in the developed world. AIDS 2003; 17:2419-27. [PMID: 14600512 DOI: 10.1097/00002030-200311210-00003] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kousignian I, Abgrall S, Duval X, Descamps D, Matheron S, Costagliola D. Modeling the time course of CD4 T-lymphocyte counts according to the level of virologic rebound in HIV-1-infected patients on highly active antiretroviral therapy. J Acquir Immune Defic Syndr 2003; 34:50-7. [PMID: 14501793 DOI: 10.1097/00126334-200309010-00007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To study the influence of the level of virologic rebound during combination antiretroviral therapy on the time course of the CD4 count. METHODS Between January 1997 and December 1999, we enrolled 3736 patients from the French Hospital HIV Database who had an undetectable viral load on a first course of highly active antiretroviral therapy (HAART). Four levels of virologic rebound were defined on the basis of viral load values during the year following initial undetectability on HAART: group 1, all viral loads <500 copies/mL; group 2, all viral loads <5000 copies/mL; group 3, all viral loads <10,000 copies/mL; and group 4, at least 1 viral load >10,000 copies/mL. We developed a continuous time-homogeneous Markov process with 5 reversible stages defined by CD4 count intervals. RESULTS CD4 counts increased continuously over time in each group. The smaller the virologic rebound, the stronger was the increase in the CD4 count (P < 0.0001). The mean CD4 cell count increments between months 2 and 6 were 26, 20, 11, and 2 cells/mm3 in groups 1, 2, 3, and 4, respectively. The rate of gain fell after month 6 and was almost nil in group 4. CONCLUSION After achieving an undetectable viral load on HAART, immunologic reconstitution is possible whatever the subsequent level of viral replication, except among patients with high-level rebound, meaning that in patients with a long history of antiretroviral therapy and a reduced choice of antiretroviral drugs due to acquisition of resistances, delay in antiretroviral therapy switch can be possible in patients with low or intermediate rebound.
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Ormaasen V, Bruun JN, Sandvik L, Holberg-Petersen M, Gaarder PI. Prognostic value of changes in CD4 count and HIV RNA during the first six months on highly active antiretroviral therapy in chronic human immunodeficiency virus infection. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2003; 35:383-8. [PMID: 12953949 DOI: 10.1080/00365540310009716] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to evaluate the prognostic value of changes in CD4 counts and human immunodeficiency virus (HIV) RNA following 6 months of highly active antiretroviral therapy (HAART) in chronic HIV-1 infection. 148 treatment-naive patients treated with 2 nucleoside analogue reverse transcriptase inhibitors (NRTIs) + at least 1 protease inhibitor or non-NRTI for at least 180 d were included. Mean follow-up time after 6 months on HAART was 758 d. The patients were divided into 2 groups based on the increase in CD4 count (deltaCD4) from therapy initiation: groups A (n = 37, deltaCD4 < 0.052 x 10(9)/l) and B (n = 111, deltaCD4 > or = 0.052 x 10(9)/l). Patients were also stratified according to achievement of HIV RNA < 400 copies/ml (n = 122) or > or = 400 copies/ml (n = 26). Endpoints were the occurrence of subsequent HIV-related disease (CDC category B or C) or death after 6 months on HAART. Subjects in group A had an increased risk of HIV-related disease compared with group B when adjusted for CD4 count at initiation of therapy [adjusted risk ratio (RR) 2.62, 95% confidence interval (95% CI) 1.07-6.40]. Viral load > or = copies/ml versus reaching viral suppression < 400 copies/ml was associated with an increased risk of HIV-related disease only in patients with deltaCD4 < 0.052 x 10(9)/l (RR 4.20, 95% CI 1.05-16.9). Thus, this study indicates that patients with no or a small increase in CD4 counts after 6 months of HAART and low CD4 levels at initiation of therapy have an increased risk of HIV-related disease.
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Affiliation(s)
- Vidar Ormaasen
- Department of Infectious Diseases, Ullevål University Hospital, Oslo, Norway.
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Hunt PW, Deeks SG, Rodriguez B, Valdez H, Shade SB, Abrams DI, Kitahata MM, Krone M, Neilands TB, Brand RJ, Lederman MM, Martin JN. Continued CD4 cell count increases in HIV-infected adults experiencing 4 years of viral suppression on antiretroviral therapy. AIDS 2003; 17:1907-15. [PMID: 12960823 DOI: 10.1097/00002030-200309050-00009] [Citation(s) in RCA: 209] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the extent to which HIV-infected patients, including those with advanced immunodeficiency, can reverse peripheral CD4 T-cell depletion while maintaining long-term viral suppression on highly active antiretroviral therapy. DESIGN Cohort study. PARTICIPANTS Four-hundred and twenty-three HIV-infected patients who initiated HAART prior to 1998 and achieved a viral load </= 1000 copies/ml by 48 weeks were evaluated for up to 4 years or until plasma HIV RNA levels increased to > 1000 copies/ml. MAIN OUTCOME MEASURE CD4 count changes. RESULTS Among patients who maintained plasma HIV RNA levels </= 1000 copies/ml, CD4 counts continued to increase through year 4 of HAART. In the last year examined, from year 3 to 4 of HAART, mean CD4 count gains were +89 x 10(6), +86 x 10(6), +95 x 10(6), and +88 x 10(6)/l in patients with pre-therapy CD4 counts of < 50 x 10(6), 50 x 10(6)-199 x 10(6), 200 x 10(6)-349 x 10(6), and >/= 350 x 10(6)/l, respectively (all gains were significantly greater than zero; P < 0.05). Among those with a pre-therapy CD4 count of < 50 x 10(6)/l, 88% achieved a CD4 cell count of >/= 200 x 10(6)/l and 59% achieved a count of >/= 350 x 10(6)/l by year 4. Factors associated with increased CD4 cell count gains from month 3 to year 4 included lower pre-therapy CD4 cell count, younger age, female sex, and infrequent low-level viremia (versus sustained undetectable viremia). CONCLUSIONS Most patients who achieve and maintain viral suppression on HAART continue to experience CD4 T-cell gains through 4 years of therapy. The immune system's capacity for CD4 T lymphocyte restoration is not limited by low pre-therapy CD4 counts.
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Affiliation(s)
- Peter W Hunt
- Positive Health Program, San Francisco General Hospital, University of California, San Francisco, California, USA
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Thiébaut R, Jacqmin-Gadda H, Leport C, Katlama C, Costagliola D, Le Moing V, Morlat P, Chêne G. Bivariate longitudinal model for the analysis of the evolution of HIV RNA and CD4 cell count in HIV infection taking into account left censoring of HIV RNA measures. J Biopharm Stat 2003; 13:271-82. [PMID: 12729394 DOI: 10.1081/bip-120019271] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We present a bivariate linear mixed model taking into account censored measures of the response variable due to lower quantification limit of the assays. It allows an estimate of the correlation between the two response variables and takes into account this correlation for the estimation of other model parameters. This model was applied in a large cohort study (APROCO Cohort) to study the evolution under antiretroviral treatment of the two major biomarkers of the progression of Human Immunodeficiency Virus (HIV) infection: plasma HIV RNA and CD4+ T lymphocytes cell count. In a sample of 929 patients who started an highly active antiretroviral therapy, we illustrate the superiority in terms of likelihood of a bivariate model compared to two univariate models and the impact of taking into account the left-censoring of HIV-RNA. Moreover, interpretation of the model parameters allows confirmation of correlation between these two markers throughout the whole follow-up and the continuous decrease of plasma HIV RNA on average. Despite some limitations (distribution assumption, ignorance of missingness process), such a model appeared to be very useful to correctly describe the current evolution of important biomarkers in HIV infection.
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Affiliation(s)
- Rodolphe Thiébaut
- INSERM EMI 0338, Institut de Santé Publique d'Epidémiologie et de Développement (ISPED), Université Victor Segalen Bordeaux 2, Bordeaux, France
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Izopet J, Souyris C, Sandres-Sauné K, Puissant B, Obadia M, Pasquier C, Puel J, Blancher A, Massip P. Virological and immunological effects of salvage therapy following treatment interruption and a shift in HIV-1 resistance genotype. J Med Virol 2002; 68:305-10. [PMID: 12226815 DOI: 10.1002/jmv.10204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The circulating human immunodeficiency virus type 1 (HIV-1) population of patients in whom many prior therapy regimens have failed often undergo a shift from a drug-resistant virus to a wild-type virus following interruption of treatment. This study analyses the virological and immunological effects of salvage therapy following treatment interruption and a shift from a drug-resistance genotype. Twenty-one HIV-1 infected patients who had genotype reversion by population-based sequencing after 3 months of treatment interruption were given a new salvage regimen consisting of 3-5 drugs selected according to their treatment history. Seven (33%) of 21 patients who had fewer than 200 HIV-1 RNA copies/ml until month 12 were defined as virological responders. Four patients were transient responders and 10 were nonresponders. The virological responders were more frequently CDC group A and had higher CD4 + T lymphocyte counts at the time of treatment resumption. The peripheral blood T CD4 + and T CD8 + lymphocyte populations of the patients declined significantly during treatment interruption. Only virological responders showed significant increases in their CD4 + T lymphocyte count 12 months after treatment resumption and these counts rapidly returned to pre-interruption baseline values in most of these patients. Treatment interruption could be useful for optimising salvage therapy for patients previously given many failing regimens. However, controlled trials are needed to assess the clinical benefit of this strategy.
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Affiliation(s)
- Jacques Izopet
- Laboratoire de Virologie, Hôpital Purpan, CHU Toulouse, Place du Dr Baylac, Toulouse, France.
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Easterbrook PJ, Ives N, Waters A, Mullen J, O'Shea S, Peters B, Gazzard BG. The natural history and clinical significance of intermittent viraemia in patients with initial viral suppression to < 400 copies/ml. AIDS 2002; 16:1521-7. [PMID: 12131190 DOI: 10.1097/00002030-200207260-00009] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To determine the prevalence and prognostic significance of intermittent viraemia (IV) in patients who attained an undetectable viral load (VL) < 400 copies/ml within 6 months on highly active antiretroviral therapy (HAART). METHODS Retrospective analysis of viral load rebound > or = 400 copies/ml and CD4 cell counts rise for 765 patients followed for > or = 12 months following initial VL undetectability, comparing the 226 (29.5%) who maintained an undetectable VL for > 1 year from initiation of HAART and 122 (15.9%) who had one or more episodes of IV. Genotypic resistance was evaluated at the time of the first episode of IV > or = 2000 copies/ml. RESULTS Patients with IV had a threefold higher rate of sustained virological rebound [hazards ratio (HR), 3.15; 95% confidence interval (CI), 1.72-5.77; P < 0.001). For patients with and without IV, the Kaplan-Meier estimates at 24 and 36 months after initiation of HAART were 19.3% (95% CI, 8.9-21.5) versus 7.7% (95% CI, 4.5-13.0) and 31.6% (95% CI, 21.8-44.2) versus 12.9% (95% CI, 7.5-21.5), respectively (P < 0.001). The median CD4 cell count rise at 18 and 24 months was significantly lower in those with IV than in those without: 138 [interquartile range (IQR), 58-221] versus 224 x 10(6) cells/l (IQR, 119-357) (P = 0.0001) and 200 (IQR, 89-294) versus 260 x 10(6) cells/l (IQR, 125-384) (P = 0.003), respectively. In a subgroup of 16 patients, genotypic resistance mutations were found in the reverse transcriptase gene for five (31%) and in the protease gene in one. A probable contributing factor/event was identified for most patients with IV, such as poor adherence (42.6%), intercurrent infection (26.2%) or drug interaction (6.8%). CONCLUSIONS Patients with IV > 400 copies/ml are three times more likely to experience sustained viral rebound and to have an impaired CD4 cell rise relative to those who maintain undetectable VL. This supports the adoption of a more pro-active approach to treatment intensification and the need for caution with structured treatment interruptions.
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Affiliation(s)
- Philippa J Easterbrook
- Department of HIV/GUM, Guy's, King's and St Thomas' School of Medicine, King's College Hospital, London, UK
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Wood E, Hogg RS, Yip B, Tyndall MW, Sherlock CH, Harrigan RP, O'Shaughnessy MV, Montaner JSG. "Discordant" increases in CD4 cell count relative to plasma viral load in a closely followed cohort of patients initiating antiretroviral therapy. J Acquir Immune Defic Syndr 2002; 30:159-66. [PMID: 12045678 DOI: 10.1097/00042560-200206010-00004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In HIV-positive persons receiving antiretroviral therapy, CD4 cell responses are associated with optimal suppression of viral replication. However, increases in CD4 cell counts in the absence of viral suppression have been reported. We characterized plasma viral load (pVL) and CD4 cell count increases in closely followed patients to evaluate determinants and the prevalence of CD4 cell responses at a populational level. METHODS All HIV-positive patients in the province of British Columbia, Canada, who were antiretroviral naive and initiated therapy between August 1996 and May 1998 were eligible for the study. The selection criteria were that patients had to have CD4 cell counts and pVLs measured at baseline and at least once during eight 16-week periods after the initiation of therapy. We characterized CD4 cell responses and sought patients who had a "discordant" increase at 1 year, which was defined as an increase in CD4 cell count of >or=50/mm3 with a <1 log10 decrease in pVL. We also evaluated adherence and antiretroviral use. RESULTS Overall, when baseline and 1-year pVLs and CD4 cell counts were compared, 6.2% of patients had CD4 cell count increases without pVL decreases of >or=1 log10. However, when all pVLs before 1 year were considered, 92% of the discordant increases could be attributed to prior transient or partial viral suppression. Furthermore, although substantial increases in CD4 cell counts were observed in transient virologic responders, the cumulative number of antiretroviral agents used by this group was significantly higher than that used by full virologic responders (p <.001). CONCLUSIONS Our results demonstrate that virtually all CD4 cell count increases can be attributed to transient or partial pVL suppression. Unmeasured pVL suppression likely explains discordant responses that have been previously reported. Similarities between transient and full virologic responders also appear to be time limited and are often associated with greater cumulative use of antiretroviral therapy by transient virologic responders.
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Affiliation(s)
- Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada
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Montaner JS, Harris M. Management of HIV-infected Patients with Multidrug-resistant Virus. Curr Infect Dis Rep 2002; 4:259-265. [PMID: 12015920 DOI: 10.1007/s11908-002-0089-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Heavily pretreated HIV-infected patients with multidrug-resistant virus remain a clinical challenge to the treating physician. While the goal of therapy in such patients is still controversial, sustained immunologic and clinical benefit have only been demonstrated with complete suppression of plasma viral load below detectable levels. Expert use of resistance testing may help in the selection of the salvage regimen, and monitoring of plasma drug levels may help optimize the potency and tolerability, especially of complex, multiple drug regimens where adherence remains a critical determinant of treatment outcome. The potential roles of newer agents, adjuvants, treatment interruptions, and immune-based therapies remain under investigation.
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Affiliation(s)
- Julio S.G. Montaner
- University of British Columbia/St. Paul's Hospital, 667-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
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Jacobson LP, Phair JP, Yamashita TE. Virologic and Immunologic Response to Highly Active Antiretroviral Therapy. Curr Infect Dis Rep 2002; 4:88-96. [PMID: 11853662 DOI: 10.1007/s11908-002-0072-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Highly active antiretroviral therapy (HAART) delays clinical progression to AIDS by suppressing viral replication, allowing the immune system to reconstitute. These virologic and immunologic consequences do not occur uniformly among HAART users; markers of HIV disease stage at the time of HAART initiation are critical determinants of the progression while under HAART. In this paper, we review studies describing the heterogeneous virologic and immunologic progression following the initiation of HAART, and update findings obtained in the Multicenter AIDS Cohort Study that show that CD4 cell count and history of antiretroviral therapy at the time of initiation are independent determinants of response.
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Affiliation(s)
- Lisa P. Jacobson
- Room E7006, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
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Potential Adverse Effects of Structured Therapeutic Interruptions on the Pool of HIV-Infected Cells. J Acquir Immune Defic Syndr 2001. [DOI: 10.1097/00126334-200110010-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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