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Yuan Z, Yang X, Hu Z, Gao Y, Yan P, Zheng F, Hong K, Cen K, Mai Y, Bai Y, Guo Y, Zhou J. Investigating the impact of inflammatory response-related genes on renal fibrosis diagnosis: a machine learning-based study with experimental validation. J Biomol Struct Dyn 2024:1-13. [PMID: 38381715 DOI: 10.1080/07391102.2024.2317992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Renal fibrosis plays a crucial role in the progression of renal diseases, yet the lack of effective diagnostic markers poses challenges in scientific and clinical practices. In this study, we employed machine learning techniques to identify potential biomarkers for renal fibrosis. Utilizing two datasets from the GEO database, we applied LASSO, SVM-RFE and RF algorithms to screen for differentially expressed genes related to inflammatory responses between the renal fibrosis group and the control group. As a result, we identified four genes (CCL5, IFITM1, RIPK2, and TNFAIP6) as promising diagnostic indicators for renal fibrosis. These genes were further validated through in vivo experiments and immunohistochemistry, demonstrating their utility as reliable markers for assessing renal fibrosis. Additionally, we conducted a comprehensive analysis to explore the relationship between these candidate biomarkers, immunity, and drug sensitivity. Integrating these findings, we developed a nomogram with a high discriminative ability, achieving a concordance index of 0.933, enabling the prediction of disease risk in patients with renal fibrosis. Overall, our study presents a predictive model for renal fibrosis and highlights the significance of four potential biomarkers, facilitating clinical diagnosis and personalized treatment. This finding presents valuable insights for advancing precision medicine approaches in the management of renal fibrosis.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Ziwei Yuan
- Department of Endocrinology, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Xuejia Yang
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zujian Hu
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yuanyuan Gao
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Penghua Yan
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fan Zheng
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Kai Hong
- Department of General Surgery, Ningbo First Hospital, Ningbo, China
| | - Kenan Cen
- Department of General Surgery, Ningbo First Hospital, Ningbo, China
| | - Yifeng Mai
- Department of General Surgery, Ningbo First Hospital, Ningbo, China
| | - Yongheng Bai
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yangyang Guo
- Department of General Surgery, Ningbo First Hospital, Ningbo, China
| | - Jingzong Zhou
- Department of Endocrinology, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Taizhou, Zhejiang, China
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Villa G, Owusu D, Smith C, Azumah M, Abdullahi A, Phillips S, Sayeed L, Austin H, Chadwick D, Phillips RO, Geretti AM. Liver steatosis and fibrosis in people with human immunodeficiency virus in West Africa and the relationship with hepatitis B virus coinfection. Hepatol Commun 2022; 6:3036-3051. [PMID: 36103301 PMCID: PMC9592782 DOI: 10.1002/hep4.2000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/17/2022] [Accepted: 04/06/2022] [Indexed: 12/14/2022] Open
Abstract
There is a heavy burden of liver disease in West Africa. While the role of hepatitis B virus (HBV) infection is well recognized, less is known about the contributing role of liver steatosis and how the two interact in the context of human immunodeficiency virus (HIV) infection. Adults with HIV in Ghana underwent FibroScan measurements to determine prevalence of liver steatosis (expressed as controlled attenuation parameter [CAP]) and fibrosis (expressed as liver stiffness [LS]). We explored contributing factors in linear regression models, including demographics, lifestyle characteristics, medical history, HIV and HBV status, and measurements of metabolic syndrome. Among 329 adults (72.3% women; median age, 47 years), 322 (97.9%) were on antiretroviral therapy (median duration, 8.9 years). CD4 counts were preserved (median, 619 cells/mm3 ); plasma HIV RNA was fully suppressed in 162 (50.3%) of the treated participants. Cigarette smoking, excessive alcohol consumption, and use of traditional or herbal remedies were uncommon (6.1%, 1.8%, 3.3%, respectively). Largely undiagnosed metabolic syndrome was detected in 87 (26.4%) participants. We obtained readings indicative of ≥S2 steatosis and ≥F2 fibrosis in 43 (13.1%) and 55 (16.7%) participants, respectively. Higher CAP values were associated with metabolic syndrome and longer prior stavudine exposure. Higher LS values were associated with male sex, higher HIV RNA, and higher CAP values. Relative to people without HBV, those with HBV (n = 90) had a similar prevalence of ≥S2 steatosis but a higher prevalence of ≥F2 fibrosis (36.7% vs. 9.2%, p < 0.0001) and concomitant ≥S2 steatosis and ≥F2 fibrosis (9.1% vs. 1.3%, p < 0.001). Conclusion: Both HBV and liver steatosis pose a threat to long-term liver health among people with HIV in West Africa. Urgently required interventions include improving HIV suppression and diagnosing and managing determinants of the metabolic syndrome.
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Affiliation(s)
- Giovanni Villa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Dorcas Owusu
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Colette Smith
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, UK
| | - Marilyn Azumah
- Department of Internal Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Adam Abdullahi
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Suzannah Phillips
- Department of Biochemistry, Liverpool Clinical Laboratories, Liverpool University Hospitals National Health Service Foundation Trust, Liverpool, UK
| | - Laila Sayeed
- Centre for Clinical Infection, James Cook University Hospital, Middlesbrough, UK
| | - Harrison Austin
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - David Chadwick
- Centre for Clinical Infection, James Cook University Hospital, Middlesbrough, UK
| | - Richard Odame Phillips
- Department of Medicine, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anna Maria Geretti
- Department of Infectious Diseases, Fondazione PTV and University of Rome Tor Vergata, Rome, Italy.,Department of Infectious Diseases, School of Immunity and Microbial Sciences, King's College London, London, UK
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Impact of HIV-1 Infection on the Natural Progress of an Anti-HCV Positive Population in an Impoverished Village in China from 2009 to 2017. Viruses 2022; 14:v14081621. [PMID: 35893687 PMCID: PMC9330172 DOI: 10.3390/v14081621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 12/02/2022] Open
Abstract
Our study aimed to determine the impact of HIV coinfection on the natural progression of liver disease in treatment-naive HCV-infected patients. From 2009 to 2017, we tracked non-invasive markers of liver fibrosis and end-stage liver disease (ESLD)-associated mortality among HCV mono-infected and HIV/HCV coinfected patients in an impoverished village in China. The study cohort consisted of 355 HBsAg-negative and anti-HCV (+) or anti-HIV (+) patients recruited in July 2009, 164 of whom were diagnosed with HIV-1 infection. The surviving patients were re-evaluated in August 2017. During the follow-up, the disease status, liver biochemical, and non-invasive indicators of liver fibrosis (APRI and FIB-4) were measured. The transaminases ALT and AST were significantly higher in HIV-positive HCV resolvers (HIV+ HCVr) than in HIV-negative HCV resolvers (HCVr) (p = 0.019 and p < 0.0001, respectively). APRI and FIB-4 scores of HIV-positive chronic HCV carriers (HIV+ HCVc) were significantly higher than in HIV-negative chronic HCV carriers (HCVc) (p < 0.001). Similarly, APRI and FIB-4 scores were higher in the HIV+ HCVr group than in the HCVr group (ps < 0.001). From 2009 to 2017, the levels of ALT (p = 0.006), AST (p = 0.003), APRI (p = 0.015), and FIB-4 (p = 0.025) were significantly elevated in the HIV/HCV coinfected patients with CD4+ T counts below 500 cells/l. ESLD-related mortality was significantly greater in HIV/HCV-infected cases than in HCV mono-infected patients (73.3% vs. 31.3%, p = 0.009) among patients (n = 45) who died between 2009 and 2017 during follow-up. These findings suggest a higher risk of ESLD-related death and rapid progression of liver fibrosis in HIV/HCV coinfected individuals compared with HCV mono-infected patients. During HIV/HCV coinfection, HIV infection may aggravate HCV-associated liver injury.
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Kirkegaard-Klitbo DM, Bendtsen F, Lundgren J, de Knegt RJ, Kofoed KF, Nielsen SD, Benfield T. Increased Prevalence of Liver Fibrosis in People Living With Human Immunodeficiency Virus Without Viral Hepatitis Compared to Population Controls. J Infect Dis 2020; 224:443-452. [PMID: 33320268 DOI: 10.1093/infdis/jiaa763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver fibrosis is associated with poor liver-related outcomes and mortality. People with human immunodeficiency virus (PWH) may be at increased risk. We aimed to estimate the prevalence and factors associated with liver fibrosis in PWH compared to population controls. METHODS This was a cross-sectional cohort study comparing 342 PWH with 2190 population controls aged 50-70 years.Transient elastography was performed and elevated liver stiffness measurement (LSM) defined as 7.6 kPa as a proxy for significant liver fibrosis. Adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) were computed by logistic regression. RESULTS The prevalence of elevated LSM was higher in PWH than in uninfected controls (12% vs 7%; P < .01). Human immunodeficiency virus (HIV) infection was independently associated with elevated LSM. In multivariate analysis, elevated LSM was associated with HIV (aOR, 1.84 [95% CI, 1.17-2.88]; P < .01); higher age (per decade: aOR, 3.34 [95% CI, 1.81-6.18]; P < .01); alanine aminotransferase (ALT) (per 10 IU/L: aOR, 1.25 [95% CI, 1.05-1.49]; P < .01); body mass index (BMI) (per 1 kg/m2: aOR, 1.17 [95% CI, 1.05-1.29]; P < .01), and previous exposure to didanosine (per year: aOR, 2.26 [95% CI, 1.01-5.06]; P = .04). CONCLUSIONS The prevalence of elevated LSM was higher in PWH compared to population controls. Higher age, BMI, ALT, previous exposure to didanosine, and positive HIV status were independently associated with higher odds of elevated LSM.
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Affiliation(s)
| | - Flemming Bendtsen
- Gastrounit, Medical Division, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Lundgren
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre of Excellence for Health, Immunity and Infections, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Klaus Fuglsang Kofoed
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Susanne Dam Nielsen
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Viro-immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Etiology and Severity of Liver Disease in HIV-Positive Patients With Suspected NAFLD: Lessons From a Cohort With Available Liver Biopsies. J Acquir Immune Defic Syndr 2019; 80:474-480. [PMID: 30807482 DOI: 10.1097/qai.0000000000001942] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Spectrum of liver injury among HIV-positive people is wide; in particular, prevalence of nonalcoholic fatty liver disease (NAFLD) seems to be higher compared with HIV-negative people. METHODS We retrospectively evaluated all liver biopsies performed at Royal Free Hospital from 2000 to 2017 in HIV monoinfected patients with abnormal transaminases, to assess the underlying cause of liver disease and to characterize the extent of fibrosis. We furthermore evaluated the diagnostic accuracy of FIB4 and FibroScan as noninvasive tools for fibrosis assessment. RESULTS Ninety-seven patients were included. Most common histological findings were NAFLD (28%), nonspecific changes (26%), and normal histology (13%). Twenty percent of the patients had significant fibrosis and 11% had advanced fibrosis. FIB4, at a cutoff of 1.3, had a specificity of 82% and negative predictive value (NPV) of 95% for exclusion of advanced fibrosis. FibroScan was available in 28% patients and 33% had a liver stiffness ≥7.5 kPa. FibroScan showed a specificity of 77% and NPV of 94% for exclusion of significant fibrosis. Among patients with NAFLD (n = 27), 18% had advanced fibrosis, whereas the majority (56%) did not have any fibrosis. The NPV of FIB4 for advanced fibrosis in these patients was 93%. CONCLUSIONS Among HIV-positive patients with elevated transaminases, a surprisingly high number of patients had nonsignificant changes or even normal histological findings. The prevalence of NAFLD was lower than reported in other series. Use of noninvasive tools with a high NPV for significant fibrosis can help reduce the number of required biopsies.
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Nherera B, Mhandire K, Nyazika TK, Makura A, Musarurwa C, Mapondera PT, Stray-Pedersen B, Matarira HT. Comparison of non-invasive methods of assessing liver fibrosis in combination ART-experienced Zimbabweans. South Afr J HIV Med 2019. [DOI: 10.4102/sajhivmed.v20i1.844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: The prevalence of morbidity and mortality associated with liver disease among HIV-infected individuals on combination antiretroviral therapy (ART) is high. Early screening of liver disease is essential, as it provides an opportunity for successful treatment. Hence, there is a need for reliable, inexpensive and non-invasive early markers of hepatic damage.Objectives: Non-invasive algorithms are available for assessing the extent of liver fibrosis as markers of ongoing inflammatory damage. This study compared the use of the FibroTest, Fibrosis-4 (FIB-4) index, APRI test and AST:ALT ratio in assessing liver fibrosis in combination ART-experienced individuals.Methods: In a comparative cross-sectional study, 79 participants between the ages of 8 and 62 years were recruited. The performance of each fibrosis algorithm was determined using established cut-off scores for clinically significant liver fibrosis.Results: The prevalence of liver fibrosis as determined by the FibroTest, FIB-4 index, APRI test and AST: ALT ratio were 19.0%, 21.5%, 12.7% and 79.7%, respectively. For individual biomarkers, A-2M concentration (p < 0.001) and AST activity (p = 0.003) remained significantly elevated in participants with fibrosis than those without as defined by FibroTest and APRI test, respectively, after adjustments for multiple comparisons.Conclusion: Our data demonstrate a high prevalence of asymptomatic liver fibrosis among combination ART-experienced individuals in Zimbabwe, and this warrants adequate monitoring of liver fibrosis in individuals on ART. Discordance of fibrosis results among the algorithms and individual biomarkers and calls for further work in identifying optimal biomarkers for detection of asymptomatic fibrosis.Keywords: Liver fibrosis; Non-invasive methods; Biomarkers; Combination anti-retroviral therapy; Zimbabwe.
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Dharan NJ, Neuhaus J, Rockstroh JK, Peters L, Gordin F, Arenas‐Pinto A, Emerson C, Marks K, Hidalgo J, Sarmento‐Castro R, Stephan C, Kumarasamy N, Emery S, Matthews GV. Benefit of Early versus Deferred Antiretroviral Therapy on Progression of Liver Fibrosis among People with HIV in the START Randomized Trial. Hepatology 2019; 69:1135-1150. [PMID: 30298608 PMCID: PMC6393919 DOI: 10.1002/hep.30296] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/12/2018] [Indexed: 12/16/2022]
Abstract
The role of antiretroviral therapy (ART) in reducing or contributing to liver fibrosis in persons with human immunodeficiency virus (HIV) is unclear. We evaluated participants in the Strategic Timing of AntiRetroviral Treatment (START) trial for liver fibrosis using the AST to Platelet Ratio Index (APRI) and Fibrosis-4 Index (FIB-4), and assessed for a benefit of early versus delayed ART on liver fibrosis progression. ART-naïve persons with high CD4 counts (>500 cells/µL) from 222 clinical sites in 35 countries were randomized to receive ART either at study enrollment (immediate treatment arm) or when their CD4 count fell below 350 cells/µL (deferred treatment arm). The following outcomes were evaluated: fibrosis (APRI > 0.5 or FIB-4 > 1.45), significant fibrosis (APRI > 1.5 or FIB-4 > 3.25), hepatic flare, and resolution of elevated APRI and FIB-4 scores. Of the 4,684 enrolled into the START study, 104 did not have APRI or FIB-4 results and were excluded. Among 4,580 participants (2,273 immediate treatment; 2,307 deferred treatment), the median age was 36 years, 26.9% were female, and 30.4% were black. Three percent had an alcoholism or substance abuse history, 6.4% had hepatitis B and/or C, and 1.1% had significant fibrosis at baseline. The median CD4 count was 651, and 5.3% had HIV RNA ≤ 200. Immediate arm participants were at lower risk of developing increased fibrosis scores than deferred arm participants (hazard ratio [HR] = 0.66; 95% confidence interval [CI] = 0.57-0.78; P < 0.001) and more likely to have resolution of elevated baseline scores (HR 1.6; 95% CI 1.3-1.9; P < 0.001). Conclusions: Significant liver fibrosis was rare among ART-naïve HIV-positive persons with high CD4 counts. Our findings suggest a benefit of early ART in preventing the development of liver fibrosis.
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Affiliation(s)
| | | | | | - Lars Peters
- CHIP, Department of Infectious DiseaseRigshospitaletCopenhagenDenmark
| | | | | | | | - Kristen Marks
- Weill Medical College of Cornell UniversityNew YorkNY
| | | | | | | | | | - Sean Emery
- Kirby InstituteUNSW SydneySydneyAustralia,Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
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Sherman KE, Peters MG, Thomas D. Human immunodeficiency virus and liver disease: A comprehensive update. Hepatol Commun 2017; 1:987-1001. [PMID: 30838978 PMCID: PMC5721407 DOI: 10.1002/hep4.1112] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/29/2017] [Accepted: 09/19/2017] [Indexed: 12/16/2022] Open
Abstract
Among persons living with human immunodeficiency virus (HIV) infection, liver disease remains a major cause of morbidity and mortality. While the etiologies are varied and often overlapping in the individual patient, the underlying mechanisms, including oxidative stress, direct activation of stellate cells, HIV interaction with hepatocytes, and bacterial translocation with systemic immune activation, seem to be unifying characteristics. Early and fully suppressive HIV antiretroviral therapy is a mainstay of management either before or concurrent with treatment of etiologic cofactors, including hepatitis C virus, hepatitis B virus, and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis. Significant barriers to care that still exist include liver disease recognition, appropriate linkage to care, ongoing substance abuse, and psychiatric comorbidities in the HIV-infected population. Emerging issues in these patients include acute and chronic hepatitis E, underreported hepatitis D, and a rising incidence of hepatocellular carcinoma. (Hepatology Communications 2017;1:987-1001).
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9
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Effect of coinfection with hepatitis C virus on survival of individuals with HIV-1 infection. Curr Opin HIV AIDS 2017; 11:521-526. [PMID: 27716732 DOI: 10.1097/coh.0000000000000292] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Hepatitis C virus (HCV) coinfection is a common and an important comorbidity in HIV infection. We review current trends in mortality and the potential for early combination antiretroviral therapy (cART) and HCV therapy to improve survival in coinfected patients. RECENT FINDINGS HIV/HCV coinfection increases risk of death from all causes, and from liver disease and harmful drug use in particular. There is growing evidence for a direct role of HIV in liver fibrogenesis and for cART to decrease the risk of dying from liver disease in coinfected persons. Sustained virologic responses after HCV treatment greatly impact mortality by reducing rates of hepatic decompensation, hepatocellular carcinoma and death from liver-related and nonliver-related causes by at least 50%, but treatment uptake has been low so far. Recent epidemiologic studies do suggest that liver-related mortality is declining in recent calendar periods; however, methodological limitations of currently available studies are important. SUMMARY Early cART and wider HCV treatment have the potential to markedly reduce HCV-related mortality and thus increase survival overall for HIV-infected populations. However, HCV treatment will need to be greatly scaled up. Given the complex nature of the populations affected, future studies will need to be carefully designed and controlled to rigorously evaluate the impact of these revolutionary therapies on survival.
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Liver Fibrosis and Hepatitis B Coinfection among ART Naïve HIV-Infected Patients at a Tertiary Level Hospital in Northwestern Tanzania: A Cross-Sectional Study. J Trop Med 2017; 2017:5629130. [PMID: 28828009 PMCID: PMC5554579 DOI: 10.1155/2017/5629130] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/11/2017] [Accepted: 06/22/2017] [Indexed: 12/16/2022] Open
Abstract
Background Liver fibrosis which is a common complication of chronic hepatitis B infection is rarely diagnosed in low-resource countries due to limited capacity to perform biopsy studies. Data on the utilization of noninvasive techniques which are feasible for diagnosis of liver fibrosis in these settings among HIV-infected patients is scarce. The objective of this study was to establish the magnitude of liver fibrosis by using both aspartate-aminotransferase-to-platelets ratio and fibrosis-4 scores with associated hepatitis B coinfection among antiretroviral therapy naïve HIV-infected patients. Methods We reviewed data of 743 adult patients attending HIV clinic with available hepatitis B surface antigen test results. Baseline clinical information was recorded and aspartate-aminotransferase-to-platelet ratio and fibrosis-4 scores were calculated. The cut-off values of 1.5 and 3.25 were used for diagnosis of significant fibrosis by aspartate-aminotransferase-to-platelets ratio and fibrosis-4 scores, respectively. Results The prevalence of liver fibrosis was 3.5% when aspartate-aminotransferase-to-platelet score was used and 4.6% with fibrosis-4 score and they were both significantly higher among patients with hepatitis B coinfection. Younger patients with HIV advanced disease and elevated liver transaminases had increased risk of having hepatitis B coinfection. Conclusion A remarkable number of HIV-infected patients present with liver fibrosis, predominantly those with hepatitis B infection.
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Parisi SG, Basso M, Mengoli C, Scaggiante R, Andreis S, Franzetti MM, Cattelan AM, Zago D, Cruciani M, Andreoni M, Piovesan S, Palù G, Alberti A. Liver stiffness is not associated with short- and long-term plasma HIV RNA replication in immunocompetent patients with HIV infection and with HIV/HCV coinfection. Ann Gastroenterol 2017; 30:534-541. [PMID: 28845109 PMCID: PMC5566774 DOI: 10.20524/aog.2017.0175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/06/2017] [Indexed: 12/24/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) may be directly responsible for liver damage but there are contrasting data regarding the influence of detectable plasma viremia. We analyzed the influence of plasma HIV RNA (pHIV) detectability and of other clinical and viro-immunological variables on liver stiffness (LS) measurement in adult immunocompetent HIV-monoinfected patients and in patients coinfected with hepatitis C virus (HCV). Methods Logistic regression analysis was performed using the value of LS>7.1 kPa as the dependent variable. A linear regression model was applied using LS measurement after log10 transformation (lkpa) as the dependent variable and we analyzed the predicted values versus the observed lkpa values; pHIV was classified as detectable or undetectable in the 12- and 36-month study periods before LS measurement. Results We studied 251 patients (178 with HIV monoinfection), most of whom were on antiviral treatment; 36-month study time was available for 154 subjects. The mean CD4+ cell count was 634 cells/mm3 in HIV-monoinfected patients and 606 cells/mm3 in coinfected patients. No difference in LS was found between patients with detectable or undetectable pHIV in either the 12- or the 36-month study period before transient elastography. The mean LS was higher in HIV/HCV coinfected patients (P<0.0001) than in the HIV-monoinfected subjects; lkpa was positively correlated with HCV coinfection (P<0.0001) and aspartate aminotransferase levels (P<0.0001). Detectable pHIV failed to reach significance. Eight HIV-monoinfected patients had a predicted LS measurement lower than the observed one, while eight patients had the opposite result. Conclusion LS was not correlated with ongoing HIV replication during the 12- and 36-month study periods in immunocompetent HIV-monoinfected and HIV/HCV-coinfected patients.
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Affiliation(s)
- Saverio Giuseppe Parisi
- Department of Molecular Medicine, University of Padova, Padova (Saverio Giuseppe Parisi, Monica Basso, Carlo Mengoli, Samantha Andreis, Daniela Zago, Sara Piovesan, Giorgio Palù, Alfredo Alberti), Italy
| | - Monica Basso
- Department of Molecular Medicine, University of Padova, Padova (Saverio Giuseppe Parisi, Monica Basso, Carlo Mengoli, Samantha Andreis, Daniela Zago, Sara Piovesan, Giorgio Palù, Alfredo Alberti), Italy
| | - Carlo Mengoli
- Department of Molecular Medicine, University of Padova, Padova (Saverio Giuseppe Parisi, Monica Basso, Carlo Mengoli, Samantha Andreis, Daniela Zago, Sara Piovesan, Giorgio Palù, Alfredo Alberti), Italy
| | - Renzo Scaggiante
- Infectious Disease Unit, Padova Hospital, Padova (Renzo Scaggiante, Marzia Maria Franzetti, Anna Maria Cattelan), Italy
| | - Samantha Andreis
- Department of Molecular Medicine, University of Padova, Padova (Saverio Giuseppe Parisi, Monica Basso, Carlo Mengoli, Samantha Andreis, Daniela Zago, Sara Piovesan, Giorgio Palù, Alfredo Alberti), Italy
| | - Marzia Maria Franzetti
- Infectious Disease Unit, Padova Hospital, Padova (Renzo Scaggiante, Marzia Maria Franzetti, Anna Maria Cattelan), Italy
| | - Anna Maria Cattelan
- Infectious Disease Unit, Padova Hospital, Padova (Renzo Scaggiante, Marzia Maria Franzetti, Anna Maria Cattelan), Italy
| | - Daniela Zago
- Department of Molecular Medicine, University of Padova, Padova (Saverio Giuseppe Parisi, Monica Basso, Carlo Mengoli, Samantha Andreis, Daniela Zago, Sara Piovesan, Giorgio Palù, Alfredo Alberti), Italy
| | - Mario Cruciani
- Center of Diffusive Diseases, ULSS 20, Verona (Mario Cruciani), Italy
| | - Massimo Andreoni
- Clinical Infectious Diseases, Tor Vergata University of Rome, Rome (Massimo Andreoni), Italy
| | - Sara Piovesan
- Department of Molecular Medicine, University of Padova, Padova (Saverio Giuseppe Parisi, Monica Basso, Carlo Mengoli, Samantha Andreis, Daniela Zago, Sara Piovesan, Giorgio Palù, Alfredo Alberti), Italy
| | - Giorgio Palù
- Department of Molecular Medicine, University of Padova, Padova (Saverio Giuseppe Parisi, Monica Basso, Carlo Mengoli, Samantha Andreis, Daniela Zago, Sara Piovesan, Giorgio Palù, Alfredo Alberti), Italy
| | - Alfredo Alberti
- Department of Molecular Medicine, University of Padova, Padova (Saverio Giuseppe Parisi, Monica Basso, Carlo Mengoli, Samantha Andreis, Daniela Zago, Sara Piovesan, Giorgio Palù, Alfredo Alberti), Italy
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12
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Anderson M, Gaseitsiwe S, Moyo S, Thami KP, Mohammed T, Setlhare D, Sebunya TK, Powell EA, Makhema J, Blackard JT, Marlink R, Essex M, Musonda RM. Slow CD4 + T-Cell Recovery in Human Immunodeficiency Virus/Hepatitis B Virus-Coinfected Patients Initiating Truvada-Based Combination Antiretroviral Therapy in Botswana. Open Forum Infect Dis 2016; 3:ofw140. [PMID: 27800524 PMCID: PMC5084712 DOI: 10.1093/ofid/ofw140] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 06/21/2016] [Indexed: 12/21/2022] Open
Abstract
Background. Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) coinfection has emerged as an important cause of morbidity and mortality. We determined the response to Truvada-based first-line combination antiretroviral therapy (cART) in HIV/HBV-coinfected verus HIV-monoinfected patients in Botswana. Methods. Hepatitis B virus surface antigen (HBsAg), HBV e antigen (HBeAg), and HBV deoxyribonucleic acid (DNA) load were determined from baseline and follow-up visits in a longitudinal cART cohort of Truvada-based regimen. We assessed predictors of HBV serostatus and viral suppression (undetectable HBV DNA) using logistic regression techniques. Results. Of 300 participants, 28 were HBsAg positive, giving an HIV/HBV prevalence of 9.3% (95% confidence interval [CI], 6.3–13.2), and 5 of these, 17.9% (95% CI, 6.1–36.9), were HBeAg positive. There was a reduced CD4+ T-cell gain in HIV/HBV-coinfected compared with HIV-monoinfected patients. Hepatitis B virus surface antigen and HBeAg loss was 38% and 60%, respectively, at 24 months post-cART initiation. The HBV DNA suppression rates increased with time on cART from 54% to 75% in 6 and 24 months, respectively. Conclusions. Human immunodeficiency virus/HBV coinfection negatively affected immunologic recovery compared with HIV-1C monoinfection. Hepatitis B virus screening before cART initiation could help improve HBV/HIV treatment outcomes and help determine treatment options when there is a need to switch regimens.
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Affiliation(s)
- Motswedi Anderson
- Botswana Harvard AIDS Institute Partnership; Department of Biological Sciences, University of Botswana, Gaborone
| | - Simani Gaseitsiwe
- Botswana Harvard AIDS Institute Partnership; Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership; Division of Medical Virology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | | | - Terence Mohammed
- Botswana Harvard AIDS Institute Partnership; Department of Biological Sciences, University of Botswana, Gaborone
| | | | - Theresa K Sebunya
- Department of Biological Sciences , University of Botswana , Gaborone
| | | | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership; Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - Richard Marlink
- Botswana Harvard AIDS Institute Partnership; Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Max Essex
- Botswana Harvard AIDS Institute Partnership; Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Rosemary M Musonda
- Botswana Harvard AIDS Institute Partnership; Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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13
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Lui G, Wong VWS, Wong GLH, Chu WCW, Wong CK, Yung IMH, Wong RYK, Yeung SL, Yeung DKW, Cheung CSK, Chan HY, Chan HLY, Lee N. Liver fibrosis and fatty liver in Asian HIV-infected patients. Aliment Pharmacol Ther 2016; 44:411-21. [PMID: 27301337 DOI: 10.1111/apt.13702] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 03/29/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Little is known about the importance of liver fibrosis and fatty liver in HIV-monoinfected individuals without hepatitis virus co-infection, particularly among the Asian population. AIM To evaluate prevalence and risk factors for liver fibrosis and fatty liver in Asian HIV-monoinfected individuals. METHODS Eighty asymptomatic HIV-monoinfected individuals (tested negative for HBV/HCV) were compared with 160 matched HIV-uninfected healthy controls. Transient elastography and proton-magnetic resonance spectroscopy ((1) H-MRS) were performed to measure liver stiffness and hepatic steatosis respectively. Blood samples were analysed for metabolic profiles and markers of steatohepatitis (e.g. cytokeratin-18). RESULTS All HIV-infected individuals (mean ± s.d. age 54 ± 11 years, male 93%, Chinese 94%; diagnosis median duration 8 (IQR 4-13 years) were stable on anti-retrovirals (PI-based 58.7%, NNRTI-based 25.0% integrase-inhibitors 16.3%); diabetes, dyslipidaemia, and metabolic syndrome were common. Fatty liver disease was detected in 28.7%. There was significantly higher degree of liver stiffness [4.9 (IQR 4.1-6.2) kPa vs. 4.2 (IQR 3.6-5.0) kPa, P < 0.001], and greater proportions developed significant fibrosis (7.0 kPa, 14.3% vs. 3.1%, P = 0.001) and cirrhosis (10.3 kPa, 5.2% vs. 0.6%, P = 0.040) compared with controls. HIV infection was an independent risk factor for significant fibrosis (adjusted OR 4.00, 95% CI 1.29-12.41, P = 0.016). HIV-infected individuals with fatty liver had excessive liver stiffness and fibrosis. Two cases of asymptomatic hepatocellular carcinoma were detected. CONCLUSIONS HIV-monoinfected patients are at risk for liver fibrosis and cirrhosis. HIV-related mechanisms and fatty liver disease may play important roles. Screening and intervention to prevent severe outcomes should be considered.
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Affiliation(s)
- G Lui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - V W-S Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - G L-H Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - W C-W Chu
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Hong Kong
| | - C-K Wong
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong
| | - I M H Yung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - R Y K Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - S-L Yeung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - D K-W Yeung
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Hong Kong
| | - C S K Cheung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - H-Y Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - H L-Y Chan
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - N Lee
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.,Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong
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14
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Bilal U, Lau B, Lazo M, McCaul ME, Hutton HE, Sulkowski MS, Moore RD, Chander G. Interaction Between Alcohol Consumption Patterns, Antiretroviral Therapy Type, and Liver Fibrosis in Persons Living with HIV. AIDS Patient Care STDS 2016; 30:200-7. [PMID: 27158847 DOI: 10.1089/apc.2016.0010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
We examined the longitudinal association between alcohol use and liver fibrosis, measured by FIB-4 Score, among HIV-infected individuals by (1) antiretroviral therapy (ART) class, and (2) the presence of hepatitis C (HCV) co-infection. This was a prospective cohort study of 550 individuals in the Johns Hopkins HIV Clinical Cohort initiating ART between 2000 and 2012. The relationship between alcohol consumption (defined using NIAAA categories of non-, moderate, and hazardous drinkers) and liver fibrosis (FIB-4 score) by ART class was assessed using linear mixed effects models. Additionally, we examined whether the presence of HCV modified and whether viral load mediated the relationship between alcohol use and liver fibrosis. Overall, FIB-4 levels were 15.6% higher in hazardous drinkers compared to moderate drinkers (p = 0.025) after adjusting by age, sex, and race. Hazardous drinkers on PI-based regimens had FIB-4 scores 26.9% higher than moderate drinkers (p = 0.015). However, there was no difference in FIB-4 levels between hazardous drinkers on non-PI-based regimens compared to moderate drinkers (1.83% versus moderate drinkers, p = 0.848). There was no significant difference in FIB-4 between nondrinkers and moderate drinkers, irrespective of ART regimen. These associations were not modified by HCV status or mediated by viral load changes. Individuals with hazardous alcohol consumption and on PI-based regimens had significantly increased liver fibrosis, as measured by the FIB-4. These data suggest that providers should consider level of alcohol consumption when choosing an ART regimen to minimize detrimental effects on the liver.
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Affiliation(s)
- Usama Bilal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mariana Lazo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary E. McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Heidi E. Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark S. Sulkowski
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard D. Moore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geetanjali Chander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Prevalence of hepatitis B and C viruses in HIV-positive patients in China: a cross-sectional study. J Int AIDS Soc 2016; 19:20659. [PMID: 26979535 PMCID: PMC4793284 DOI: 10.7448/ias.19.1.20659] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 01/06/2016] [Accepted: 02/16/2016] [Indexed: 12/26/2022] Open
Abstract
Introduction Liver disease related to hepatitis B (HBV) and hepatitis C (HCV) may temper the success of antiretroviral therapy (ART) in China. Limited data exist on their prevalence in HIV-positive Chinese. A multi-centre, cross-sectional study was carried out to determine the prevalence and disease characteristics of HBV and HCV co-infection in HIV-positive patients across 12 provinces. Methods HIV-positive ART-naïve patients were recruited from two parent cohorts established during November 2008–January 2010 and August 2012–September 2014. Hepatitis B surface antigen (HBsAg), hepatitis B e antigen and HCV antibody (anti-HCV) status were retrieved from parent databases at the visit prior to ART initiation. HBV DNA was then determined in HBsAg+ patients. HCV RNA was quantified in anti-HCV+ patients. Aspartate aminotransferase-to-platelet ratio index (APRI) and the fibrosis-4 (FIB4) were calculated. Chi-square test, Kruskal–Wallis test and logistic regression were used for statistical analysis, as appropriate. Results Of 1944 HIV-positive patients, 186 (9.5%) were HIV–HBV co-infected and 161 (8.3%) were HIV–HCV co-infected. The highest HIV–HBV prevalence (14.5%) was in Eastern China while the highest HIV–HCV prevalence was in the Central region (28.2%). HIV–HBV patients had lower median CD4 + T cell count (205 cells/μL) than either HIV monoinfected (242 cells/μL, P=0.01) or HIV–HCV patients (274 cells/μL, P=0.001). Moderate-to-significant liver disease was present in >65% of the HIV–HCV, ~35% of the HIV–HBV and ~20% of the HIV monoinfected patients. Independent associations with moderate-to-significant liver disease based on APRI included HBV (Odds ratio, OR 2.37, P < 0.001), HCV (OR 9.64, P<0.001), CD4 count≤200 cells/μL (OR 2.55, P<0.001) and age ≥30 years (OR 1.80, P=0.001). Conclusions HBV and HCV prevalence is high in HIV-positive Chinese and differs by geographic region. HBV and HCV co-infection and HIV monoinfection are risks for moderate-to-significant liver disease. Only HIV–HBV is associated with greater HIV-related immunosuppression. Incorporating screening and management of hepatitis virus infections into Chinese HIV programmes is needed.
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Grarup J, Rappoport C, Engen NW, Carey C, Hudson F, Denning E, Sharma S, Florence E, Vjecha MJ. Challenges, successes and patterns of enrolment in the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial. HIV Med 2015; 16 Suppl 1:14-23. [PMID: 25711319 PMCID: PMC4373412 DOI: 10.1111/hiv.12229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2014] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The aim of this report is to describe the challenges, successes and patterns of enrolment in the Strategic Timing of AntiRetroviral Treatment (START) study. METHODS START is a collaboration of many partners with central coordination provided by the protocol team, the statistical and data management centre (SDMC), the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT) network leadership, international coordinating centres and site coordinating centres. The SDMC prepared reports on study accrual, baseline characteristics and site performance that allowed monitoring of enrolment and data quality and helped to ensure the successful enrolment of this large international trial. We describe the pattern of enrolment and challenges faced during the enrolment period of the trial. RESULTS An initial pilot phase began in April 2009 and established feasibility of accrual at 101 sites. In August 2010, funding approval for an expanded definitive phase led to the successful accrual of 4688 participants from 215 sites in 35 countries by December 2013. Challenges to accrual included regulatory delays (e.g. national/local ethics approval and drug importation approval) and logistical obstacles (e.g. execution of contracts with pharmaceutical companies, setting up of a central drug repository and translation of participant materials). The personal engagement of investigators, strong central study coordination, and frequent and transparent communication with site investigators, community members and participants were key contributing factors to this success. CONCLUSIONS Accrual into START was completed in a timely fashion despite multiple challenges. This success was attributable to the efforts of site investigators committed to maintaining study equipoise, transparent and responsive study coordination, and community involvement in problem-solving.
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Affiliation(s)
- J Grarup
- Copenhagen HIV Programme, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Lundgren J, Babiker A, Gordin F, Emery S, Fätkenheuer G, Molina JM, Wood R, Neaton JD. Why START? Reflections that led to the conduct of this large long-term strategic HIV trial. HIV Med 2015; 16 Suppl 1:1-9. [PMID: 25711317 DOI: 10.1111/hiv.12227] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2014] [Indexed: 01/17/2023]
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