Efficacy and safety of dolutegravir/rilpivirine in real-world clinical practice. GeSIDA study 1119

INTRODUCTION

Dolutegravir/rilpivirine (DTG/RPV) is an effective antiretroviral (ART) regimen endorsed by clinical trials as a switch therapy. The aim of our study was to analyse the efficacy and safety of DTG/RPV in real-world clinical practice.

METHODS

Observational, multicentre study of patients who started DTG/RPV. Efficacy, adverse events and metabolic changes at 48 weeks were analysed.

RESULTS

A total of 348 patients were included; median time of HIV infection was 21.1 years, 33.7% were AIDS cases; median nadir CD4 was 160 cells/μL; 90.5% had received ≥3 lines of ART and 179 (53.8%) had prior virological failure. Convenience (43.5%), toxicity/intolerance (28.4%) and interactions (17.0%) were the main reasons for starting DTG/RPV. Previous regimens were protease inhibitors (PI) (31.6%), non-nucleoside reverse transcriptase inhibitors (NNRTI) (20.4%) and integrase strand transfer inhibitors (INSTI) (14.9%). Efficacy (HIV-RNA <50 copies/mL) at 48 weeks was 89.7% (95% CI 86.1-92.6) by intention-to-treat (ITT) and 94.2% (95% CI 91.3-96.4) by on treatment (OT); 10 patients (3.1%) were not suppressed (3 had abandoned ART). There was a mean decrease in triglycerides, total cholesterol, low-density lipoprotein-cholesterol, glutamic-pyruvic transaminase (GPT), gamma-glutamyl transferase (GGT) and alkaline phosphatase; creatinine increased with a decrease in glomerular filtration rate.

CONCLUSIONS

This study confirms the effectiveness, tolerability and safety of DTG/RPV in real-world clinical practice in a different population from clinical trials, with many years of infection, low CD4 nadir, several previous treatment lines, more than half with virological failures, and one-third diagnosed with AIDS. The switch to DTG/RPV was safe with few discontinuations due to adverse effects. Modifications of the lipid and liver profiles were favourable. There were no relevant changes in kidney function.

Discordant Humoral and T-Cell Response to mRNA SARS-CoV-2 Vaccine and the Risk of Breakthrough Infections in Women with Breast Cancer, Receiving Cyclin-Dependent Kinase 4 and 6 Inhibitors

Few data are available about the immune response to mRNA SARS-CoV-2 vaccines in patients with breast cancer receiving cyclin-dependent kinase 4/6 inhibitors (CDK4/6i). We conducted a prospective, single-center study of patients with breast cancer treated with CDK4/6i who received mRNA-1273 vaccination, as well as a comparative group of healthcare workers. The primary endpoint was to compare the rate and magnitude of humoral and T-cell response after full vaccination. A better neutralizing antibody and anti-S IgG level was observed after vaccination in the subgroup of women receiving CDK4/6i, but a trend toward a reduced CD4 and CD8 T-cell response in the CDK4/6i group was not statistically significant. There were no differences in the rate of COVID-19 after vaccination (19% vs. 12%), but breakthrough infections were observed in those with lower levels of anti-S IgG and neutralizing antibodies after the first dose. A lower rate of CD4 T-cell response was also found in those individuals with breakthrough infections, although a non-significant and similar level of CD8 T-cell response was also observed, regardless of breakthrough infections. The rate of adverse events was higher in patients treated with CDK4/6i, without serious adverse events. In conclusion, there was a robust humoral response, but a blunted T-cell response to mRNA vaccine in women receiving CDK4/6i, suggesting a reduced trend of the adaptative immune response.

Use of Generic Antiretroviral Drugs and Single-Tablet Regimen De-Simplification for the Treatment of HIV Infection in Spain

The present study sought to describe the use of generic drugs and single-tablet regimen (STR) de-simplification for the treatment of human immunodeficiency virus (HIV) infection among 41 hospitals from the cohort of the Spanish HIV/AIDS Research Network (CoRIS). In June 2018, we collected information on when generic antiretroviral drugs (ARVs) were introduced in the different hospitals, how the decisions to use them were made, and how the information was provided to the patients. Most of the nine available generic ARVs in Spain by June 2018 had been introduced in at least 85% of the participating hospitals, except for zidovudine (AZT)/lamivudine (3TC) and AZT. The time difference between the effective marketing date of each generic ARV and its first dispensing date in the hospitals was much shorter for the more recently approved generic ARV since the year 2017. However, only up to 20% of the hospitals de-simplified efavirenz (EFV)/tenofovir disoproxil (TDF)/emtricitabine (FTC), dolutegravir (DTG)/abacavir (ABC)/3TC, and rilpivirine (RPV)/TDF/FTC (to generic EFV+TDF/FTC, DTG+generic ABC/3TC, and RPV+generic TDF/FTC, respectively), whereas the generic STR EFV/TDF/FTC was introduced in 87.8% of the centers. The median times between the date of effective marketing of generic TDF/FTC and the date of de-simplification of EFV/TDF/FTC and RPV/TDF/FTC were 723 [interquartile range (IQR): 369-1,119] and 234 (IQR: 142-264) days, respectively; this time was 155 (IQR: 28-287) days for de-simplification of DTG/ABC/3TC. In conclusion, despite the widespread use of generic ARVs, STRs de-simplification was only undertaken in <20% of the hospitals. There was wide variability in the timing of the introduction of each generic ARV after they were available in the market.

IFN-γ+ cell response and IFN-γ release concordance after in vitro SARS-CoV-2 stimulation

BACKGROUND

Healthcare workers (HCWs) are at increased risk since they are directly exposed to SARS-CoV-2-infected patients, and nevertheless, some remain without the development of anti-SARS-CoV-2 antibodies or related symptoms, suggesting less susceptibility to the infection.

METHODS

This cross-sectional, case-control study aimed to compare SARS-CoV-2 T-cell response by two different technologies, the analysis of IFN-γ⁺ CD8⁺ /CD4⁺ T cells by flow cytometry and the quantification of IFN-γ release by ELISA-related assay (without cell discrimination), both after SARS-CoV-2 stimulation among uninfected and convalescent HCWs.

RESULTS

A high proportion of uninfected HCWs (53.8%) had pre-existing IFN-γ⁺ CD8 T-cell response after stimulation with at least one of the structural viral proteins S, M or N, while 35.9% had pre-existing IFN-γ⁺ CD4 T-cell response. This proportion was nearly or greater than 90% among convalescent HCWs. Interestingly, the magnitude of the response in uninfected was lower compared to that found in convalescent HCWs, using both methods. The concordance, quantifying the specific cellular response in convalescent HCWs, between both methods was 94.1% comparing CD8 T-cell response and 89.7% comparing CD4 T-cell response. This concordance was lower but still high in uninfected HCWs (76.5%) comparing CD8 T-cell response and 71.8% comparing CD4 T-cell response.

CONCLUSIONS

The good concordance between the proportion of individuals with IFN-γ release after SARS-COV-2 stimulation with the proportion of individuals with specific IFN-γ⁺ CD8/CD4 T cells found in this study drives IFN-γ release assays to be a simple and easy way to determine the protective immunity to SARS-CoV-2 in a wide population.

Recreational Drug Use in People Living with HIV in Spain: Factors Associated with Drug Use and the Impact on Clinical Outcomes

We analysed the impact of recreational drug use (RDU) on different outcomes in people living with HIV (PLHIV). A multicentre retrospective cohort study was performed with two cohorts of PLHIV included: people using recreational drugs (PURD) vs. people not using recreational drugs (PNURD). Overall, 275 PLHIV were included. RDU was associated with men having sex with men (OR 4.14, 95% CI [1.14, 5.19]), previous sexually transmitted infections (OR 4.00, 95% CI [1.97, 8.13]), and current smoking (OR 2.74, 95% CI [1.44, 5.19]). While the CD₄/CD₈ ratio increased amongst PNURD during the follow-up year, it decreased amongst PURD (p = 0.050). PURD presented lower scores of self-reported and multi-interval antiretroviral adherence (p = 0.017, and p = 0.006, respectively), emotional well-being (p < 0.0001), and regular follow-up (p = 0.059), but paid more visits to the emergency unit (p = 0.046). RDU worsens clinical, immunological, and mental health outcomes amongst PLHIV.

Pneumococcal vaccination in adult people living with HIV on suppressive antiretroviral therapy: a case-control study

There is little information on the effectiveness of the pneumococcal vaccines (PVs), especially for the pneumococcal conjugate vaccines (PCVs), in HIV-infected patients in the modern antiretroviral era. This is a case–control study where cases were people living with HIV (PLWH) with confirmed pneumococcal infection (CPI) and controls were PLWH without CPI matched with cases by gender and year of HIV diagnosis. The selection process was blinded to the study factor (vaccination). Sample size estimation yielded 61 cases and 183 controls. We analyzed the effect of PV on CPI using Cox proportional-hazards regression model with time-dependent covariates. We included 256 subjects: 64 cases, and 192 controls. PVs had been administered to 115 (45%) patients. Only the modified Charlson Comorbidity Index (HR 1.16, 95%CI 1.06–1.27, P = 0.001) and the CD4 nadir (HR 0.99, 95% CI 0.98–0.99, P = 0.001) were independently associated with CPI. Receipt of PV was not associated with CPI after adjusting in the multivariate model with time protection as a dependent covariate (HR 0.65, 95% CI 0.35–1.32 P = 0.250). We also investigated the influence of different immunization schedules. In an adjusted model, we found no evidence of protection against CPI, including double immunization schedules (HR 0.42 95%CI 0.15–1.19 P = 0.102). In this case–control study, we could not show an association between pneumococcal vaccination and confirmed pneumococcal infection, although a protective effect of particular schedules of immunization cannot be ruled out.

Impact of a structured HIV testing program in a hospital emergency department and a primary care center

Introduction

HIV testing guidelines are poorly implemented in most clinical settings. The best screening strategy and healthcare scenario are still unknown. The aim of our study is to evaluate the impact of a structured HIV testing intervention (DRIVE), compared to HIV testing as routinely performed in clinical practice, in two different clinical settings: a primary care center and an emergency department.

Methods

Prospective evaluation of an HIV testing strategy in two clinical settings from the same healthcare area. The DRIVE program included trained nurse practitioners to perform the screening, a questionnaire to assess the risk of exposure and HIV indicator conditions (RE&IC), and rapid HIV tests. The main variables between the DRIVE program and clinical practice were the absolute number of newly diagnosed HIV infections and testing coverage.

Results

The DRIVE program included 5,329 participants, of which 51.2% reported at least one positive answer in the questionnaire. The estimated HIV testing coverage was significantly higher in the DRIVE program than in the routine clinical practice (7.17% vs. 0.96%, p < 0.001), and was better in the primary care center than in the emergency department with the two strategies. Twenty-two HIV-positive people were identified, with a rate of 8.6‰ in the emergency department vs. 2.2‰ in the primary care center (p = 0.001). A higher rate of new HIV diagnoses was found in the DRIVE program compared to routine clinical practice (29.6 vs. 3.1 per 100,000 patients attended; p < 0.001).

Conclusions

An easy-to-implement, structured intervention increased the absolute number of new HIV diagnoses and HIV tests, compared to routine clinical practice.

Evaluation of kidney function in HIV-infected patients receiving an antiretroviral regimen containing one or two inhibitors of the tubular secretion of creatinine

OBJECTIVES

The aim of this study was to determine the evolution of renal function in patients receiving one or two inhibitors, according to different baseline factors. Some antiretroviral drugs such as rilpivirine (RPV), dolutegravir (DTG), or cobicistat (COBI), interact with the tubular secretion of creatinine, but there are no data about their impact in renal function evaluation in patients with renal disease or when these drugs are used concomitantly.

METHODS

A prospective cohort study was carried out in HIV-infected patients who switched to a dual regimen including DTG, RPV or darunavir/COBI, separately or in combination. The primary endpoint was the evolution of the serum creatinine-based estimated glomerular filtration rate (eGFR-scr). A control group not receiving any transporter inhibitor was included.

RESULTS

A total of 288 patients on different dual regimens were included (DTG + RPV, 92; DTG + darunavir/COBI, 23; DTG, 26; COBI, 19; control group, 128). In patients receiving two transporter inhibitors, eGFR-scr decreased by a mean of -8.4 mL/min/1.73 m² , similar to that observed with the separate use of DTG or COBI (mean of both groups, -8.6 mL/min/1.73 m² ), while eGFR-scr improved in the control group. Similar evolution of proteinuria and tubular dysfunction was observed in all the groups, and there were no significant changes in the cystatin C-based eGFR. Mean eGFR-scr change inversely correlated with baseline eGFR-scr value (r = -0.39; P < 0.01), with a lower eGFR-scr decrease in patients with chronic kidney disease.

CONCLUSIONS

Similar eGFR-scr decreases were observed in patients using different antiretroviral drugs inhibiting the tubular transport of creatinine, separately or in combination, with no alterations in proteinuria or cystatin C-based eGFR. The lack of additional changes when the drugs were used in combination, and the lower impact in cases of previous chronic kidney disease, suggest that there are compensatory mechanisms for creatinine secretion.

Switching to dual antiretroviral regimens is associated with improvement or no changes in activation and inflammation markers in virologically suppressed HIV-1-infected patients: the TRILOBITHE pilot study

OBJECTIVES

While the use of dual antiretroviral therapies could reduce the toxicity of antiretroviral treatment in treatment-experienced HIV-1-infected patients, it is crucial to know if reducing the number of drugs could lead to an adverse increase in inflammation and activation markers.

METHODS

This was a cross-sectional pilot study conducted at the HIV-1 Unit at the Tertiary University Hospital in Madrid, Spain, evaluating biomarkers of activation [interferon-γ-induced protein 10 (IP10), high-sensitivity C-reactive protein (hs-CRP), soluble CD14 (sCD14) and sCD163], inflammation [interleukin-6 (IL-6)], blood coagulation (d-dimer), and immune response [interferon (IFN)-γ, tumour necrosis factor (TNF)-α and IL-4] in three groups of suppressed HIV-1-infected patients: patients continuing on triple therapy (26 patients), and patients who switched from triple to dual therapy, at 24 or 48 weeks after switching (13 and 36 patients, respectively).

RESULTS

Demographic and immunovirological parameters were similar in the three groups of patients. IL-6 and sCD14 levels were lower in patients at 48 weeks after switching to dual therapy compared with those found in patients who continued to receive triple therapy (P = 0.012 and P = 0.001, respectively), with no differences in the levels of the remaining biomarkers. Among patients with nadir CD4 count ≤ 200 cells/μL, sCD14 levels were lower in patients who had been on dual therapy for 48 weeks (14 patients) compared with those found in patients who received ongoing triple therapy (11 patients; P = 0.029), with no differences in the levels of the other biomarkers.

CONCLUSIONS

HIV-1-infected patients receiving dual regimens showed similar or even lower levels of inflammatory and activation markers compared with those found in patients who received ongoing triple therapy. Of note, similar data were obtained in patients with low nadir CD4 count.

Switching to abacavir versus use of a nucleoside-sparing dual regimen for HIV-infected patients with tenofovir-associated renal toxicity

OBJECTIVES

We investigated the reversibility of tenofovir disoproxil fumarate (TDF)-associated renal decline and tubular dysfunction using different antiretroviral strategies.

METHODS

A successive evaluation of renal [estimated glomerular filtration rate (eGFR)] and tubular (phosphataemia, proteinuria, albuminuria, phosphaturia, uricosuria, glycosuria and tubular proteinuria) parameters was performed in 231 patients, before and after switching from TDF to abacavir (n = 60), using dual therapy (n = 49), or continuing the same regimen including TDF (n = 122).

RESULTS

In a successive evaluation after a median of 8.86 months, or less time if treatment was switched (4.8 months vs. 13.3 months to second evaluation; P < 0.01), a significant improvement in eGFR (median change +0.3 vs. -2.91 mL/min/1.73 m2 in patients who did not discontinue TDF; P = 0.04) and tubular dysfunction (median change -40% vs. +30%, respectively; P < 0.01) was observed. Lineal regression showed that age (β = -0.14; P = 0.04), previous eGFR decline (β = -0.42; P < 0.01), and time on TDF (β = -0.19; P = 0.04) were associated with impaired eGFR recovery. There were no differences in eGFR slopes between patients using abacavir instead of TDF and those using a dual therapy, who showed similar improvement in proteinuria (-22% vs. -19%, respectively), phosphaturia (+10.1% vs. +9.4%, respectively), and urinary beta-2-microglobulin (-9% vs. -15%, respectively; P > 0.1 for all), although patients receiving the dual regimen were more heavily pretreated. A eGFR decrease (-6.17 mL/min/1.73 m2 ) was observed in patients taking dolutegravir or rilpivirine, but with similar improvement to that observed in the rest of switching patients in tubular abnormalities.

CONCLUSIONS

Tenofovir disoproxil fumarate discontinuation was associated with a rapid and significant improvement in eGFR and tubular abnormalities, regardless of whether abacavir or dual therapy was chosen. Switching to a regimen that included dolutegravir and/or rilpivirine was associated with a eGFR decrease without differences in the rate of tubular dysfunction improvement in comparison with the rest of patients who discontinued tenofovir.

Increased prevalence of asymptomatic vertebral fractures in HIV-infected patients over 50 years of age

The prevalence of asymptomatic vertebral fracture in HIV-infected patients over 50 was 20%, associated with older age, male sex, longer time since HIV diagnosis, and tubular renal alterations. Vertebral fractures were independent of osteoporosis at lumbar spine, and were not predicted by the use of the FRAX equation.

PURPOSE

Vertebral fractures (VF) are the hallmark of osteoporotic fractures. Our objective was to determine the prevalence of asymptomatic VF and associated factors in HIV-infected patients over 50 years, and the role of FRAX equation.

METHODS

In a cross-sectional study, a diagnosis of VF was established by the semiquantitative method of Genant in thoracic and lumbar radiographs. Simultaneously, a dual X-ray absorptiometry (DXA), bone and kidney-related analytical, calcium intake, physical exercise, HIV-related factors, and FRAX estimation were evaluated.

RESULTS

Overall, 128 patients (35 women, 27%) were included. Mean age was 57 years. Hypophosphatemia and tubular renal dysfunction were observed in 13 and 21%. DXA scan showed osteopenia and osteoporosis at hip in 65 and 7% of patients, and in spine in 39 and 34%, respectively. VF were observed in 26 patients (20%), with a trend to be associated with lower serum phosphate, increased alkaline phosphatase, and with lower daily calcium intake. In a multivariate analysis, older age (OR 1.2 per year; 14% of VF at 50-55; 44% at 65-70), male sex (26 vs 6%), longer time since HIV diagnosis, and renal and tubular dysfunction were the associated factors. VF were not related with osteoporosis at lumbar spine, and could not be predicted by the FRAX equation.

CONCLUSIONS

The prevalence of asymptomatic vertebral fractures is high in HIV-infected patients older than 50 years, and is not identified by the presence of osteoporosis in spine neither predicted by the FRAX equation. Spine and lumbar X-rays should be routinely performed in this aging population.

Sexualized Drug Use (Chemsex) Is Associated with High-Risk Sexual Behaviors and Sexually Transmitted Infections in HIV-Positive Men Who Have Sex with Men: Data from the U-SEX GESIDA 9416 Study

The magnitude of sexualized drug use (SDU), also known as chemsex, and its association with sexually transmitted infections (STI) has not been systematically explored in HIV-positive patients. This study aimed to calculate the prevalence of SDU and associated factors in a sample of HIV-positive men who have sex with men (MSM) in Spain. We calculated the frequency of SDU in a sample of HIV-positive MSM who responded to an anonymous online survey on sexual behavior and recreational drug use. We also analyzed differences between those who responded and those who did not (data taken from the physician's registry). The association between SDU, sexual risk behaviors, and STI was evaluated using a univariate and a multivariate analysis. Data were collected and managed using Research Electronic Data Capture (REDCap). The survey was completed by 742 HIV-positive MSM, of whom 60% had had unprotected anal intercourse (UAI), 62% had been diagnosed with a STI, and 216 (29.1%) reported recent SDU (slamsex in 16% of cases). In the multivariate analysis, patients who engaged in SDU were more likely to have had high-risk sexual behaviors and a diagnosis of STI than participants who did not engage in SDU. A diagnosis of hepatitis C was independently associated with slamsex (5.2 [95% confidence interval (CI), 2.06-13.13]; p < 0.001), chemsex (2.51 [95% CI, 1.28-4.91]; p = 0.007), and UAI (1.82 [95% CI, 0.90-3.70]; p = 0.094). The magnitude of SDU or chemsex in our sample is relatively high. We found a clear association between SDU, high-risk sexual behaviors, and STI including hepatitis C.

Dutrebis (lamivudine and raltegravir) for use in combination with other antiretroviral products for the treatment of HIV-1 infection

Raltegravir and lamivudine have been part of highly active therapy regimens throughout the past years of antiretroviral therapy. A fixed-dose, single-tablet regimen comprising a non-poloxamer formulation of the integrase inhibitor raltegravir and the transcriptase inhibitor lamivudine (raltegravir/lamivudine; Dutrebis(®)) has been recently licensed for the treatment of HIV-1 infection. In several Phase I pharmacokinetic studies, one Dutrebis (150 mg lamivudine/300 mg raltegravir) fixed-dose combination tablet showed a higher bioavailability but comparable lamivudine and 400 mg raltegravir poloxamer exposures. Thus, the co-administration of raltegravir together with lamivudine created a potent, effective, well-tolerated antiretroviral combination, which could be more convenient for the patient. However, the disadvantage of twice a day administration, and the existence of other fixed-dose combinations limit its widespread clinical use. This article reviews pharmacokinetics data and appraises their potential use in current and future HIV therapy.

Development of tuberculosis in human immunodeficiency virus infected patients receiving antiretroviral therapy

BACKGROUND

It is unclear whether optimal immunological recovery reduces the risk of tuberculosis (TB) in human immunodeficiency virus (HIV) infected patients receiving antiretroviral therapy (ART), in whom it is still significantly higher than in the general population.

METHODS

Retrospective cohort study in ART-treated patients without a previous diagnosis of TB. TB was microbiologically proven. Multivariate analyses were performed to identify risk factors associated with TB.

RESULTS

This study included 1824 patients; the median follow-up was 473 days. The median CD4 count was 207 cells/μl (90-363.8); 339 (18.6%) were tuberculin skin test positive. Increased CD4 count gain after ART initiation was a protective factor against active TB (per each 100 cells/μl increase, OR 0.683, 95%CI 0.522-0.894). Maximal protection was observed in patients reaching increments ⩾150 cells/μl after 12 months of ART (OR 0.29, 95%CI 0.11-0.8) or ⩾300 cells/μl after 24 months (OR 0.73, 95%CI 0.71-0.75). There was no association between achieving HIV RNA <50 copies/ml and risk of active TB (OR 1.43, 95%CI 0.68-2.49).

CONCLUSIONS

The risk of TB in patients starting ART is reduced among those with better immunological response, and is unrelated to the virological response. Our results emphasise the need for adjunctive strategies in immunological non-responders to minimise any residual risk of TB.

Renal and Bone Toxicity with the Use of Tenofovir: Understanding at the End

The use of tenofovir disoproxil fumarate has been associated with side effects on renal function and bone mineral density, but whether this toxicity is of clinical relevance in the middle or long term is highly debated. Current knowledge supports that the use of and time on tenofovir disoproxil fumarate, modulated by other factors such as age, baseline renal function, or classical risk factors, could led to progressive wasting in the urine of low molecular weight proteins, phosphate, uric acid, or glucose. This "partial" Fanconi syndrome seems to be slowly progressive, with increases in the proportion of patients and in the severity of different tubular abnormalities with the long term use of tenofovir disoproxil fumarate. Although progression to chronic kidney disease is relatively rare in patients on tenofovir disoproxil fumarate, in part attributed to the capacity of kidneys to compensate for loss of functioning nephrons, the severity of tubular dysfunction is associated with greater kidney function decline. In large cohorts, the use of tenofovir disoproxil fumarate is one of the main risk factors associated to chronic kidney disease. In addition, hyperphosphaturia secondary to tubular dysfunction could alter the interplay between bone, kidney, and regulatory hormones, leading to progressive bone loss in a similar manner, but in a lesser extent, to hypophosphatemic osteomalacia observed in the Fanconi syndrome. This component of osteomalacia secondary to altered phosphate metabolism explains the partial improvement observed with vitamin D supplementation, the association with altered bone-specific alkaline phosphatase, and the rapid benefit in terms of bone mineral density after tenofovir disoproxil fumarate discontinuation.

Incidence and prognosis of immune reconstitution inflammatory syndrome in HIV-associated progressive multifocal leucoencephalopathy

BACKGROUND AND PURPOSE

Progressive multifocal leucoencephalopathy-associated immune reconstitution inflammatory syndrome (PML-IRIS) is the paradoxical worsening or unmasking of preexisting infection with JC virus attributable to a rapid recovery of the immune system after highly active antiretroviral therapy (HAART) initiation. We investigated the incidence and factors associated with PML-IRIS in HIV-infected patients. We also studied its influence on mortality of PML and the effect of corticosteroid therapy.

METHODS

Single-center retrospective analysis of HIV-infected patients diagnosed with PML from 1996 to 2012 who received HAART.

RESULTS

Among 59 PML patients treated with HAART, 18 (30.51%) developed PML-IRIS (five delayed PML-IRIS, 13 simultaneous PML-IRIS). Patients who developed IRIS had lower CD4 counts prior to treatment (102 vs. 68.5, P < 0.05) and experienced a greater decline in HIV-RNA levels in response to HAART (2.5log vs. 2.95log, P < 0.05). Gadolinium enhancement on MRI was observed in 31.25% of PML-IRIS cases versus 2.56% of PML non-IRIS (P < 0.01). Survival rates were higher in patients with PML-IRIS compared to those with PML non-IRIS. Eight patients received corticosteroids, five of which had a good outcome. Patients who died were severely ill when treatment was initiated whereas patients who survived were treated before major neurological deterioration occurred.

CONCLUSIONS

Nearly one-third of HIV-infected patients with PML develop IRIS after initiating HAART. Patients severely immunocompromised who experience a rapid virological response to HAART have a higher risk for PML-IRIS. There was a trend for lower mortality in patients with IRIS. Early treatment with corticosteroids might be useful.

The influence of patient beliefs and treatment satisfaction on the discontinuation of current first-line antiretroviral regimens

OBJECTIVES

Large cohort studies have shown a high rate of first-line combination antiretroviral therapy (cART) regimen discontinuation in HIV-infected patients, attributed to characteristics of the cART regimen or toxicity.

METHODS

A cohort study of 274 patients receiving a first-line regimen was carried out. Patients' perceptions and beliefs prior to initiation were assessed using an attitude towards medication scale (0-15 points), and their satisfaction during therapy was assessed using an HIV treatment satisfaction questionnaire (HIVTSQ). Treatment discontinuation was defined as any switch in the cART regimen.

RESULTS

During 474.8 person-years of follow-up, 63 (23%) patients changed their cART regimen, mainly because of toxicity/intolerance (42; 67%). The overall rate of change was 13.2 per 100 patient-years [95% confidence interval (CI) 11.1-16.4 per 100 patient-years]. An efavirenz (EFV)-based single tablet regimen showed the highest rate of adverse events (27%), but the lowest rate of change (16%; 7.44 per 100 patient-years). Cox regression revealed a decreased hazard of first regimen termination with better initial attitude towards drugs [hazard ratio (HR) 0.76; 95% CI 0.62-0.93; P < 0.01] and higher satisfaction (HR 0.94; 95% CI 0.89-0.99; P = 0.01), and an increased hazard of termination with the presence of adverse events (HR 7.7; 95% CI 2.4-11.6; P < 0.01). One-third of patients (18 of 59; 31%) with mild/moderate adverse events (which were mainly central nervous system symptoms) continued the regimen; these patients, compared with those discontinuing therapy, showed better perception of therapy (mean score 14.4 versus 12.1, respectively; P = 0.05) and greater satisfaction during therapy (mean score 50.6 versus 44.6, respectively; P = 0.04).

CONCLUSIONS

Patients' beliefs and satisfaction with therapy influence the durability of the first antiretroviral regimen. These patient-related factors modulate the impact of mild adverse events, and could explain differences in the rate of discontinuation.

Liver toxicity and risk of discontinuation in HIV/hepatitis C virus-coinfected patients receiving an etravirine-containing antiretroviral regimen: influence of liver fibrosis

OBJECTIVES

The aim of the study was to establish the risk of liver toxicity in HIV/hepatitis C virus (HCV)-coinfected patients receiving etravirine, according to the degree of liver fibrosis.

METHODS

A prospective cohort study of 211 HIV-infected patients initiating an etravirine-containing regimen was carried out. HCV coinfection was defined as a positive HCV RNA test, and baseline liver fibrosis was assessed by transient elastography. Hepatotoxicity was defined as clinical symptoms, or an aspartate aminotransferase (AST) or alanine aminotransferase (ALT) value > 5-fold higher than the upper limit of normal if baseline values were normal, or 3.5-fold higher if values were altered at baseline.

RESULTS

Overall, 145 patients (69%) were HCV coinfected, with a lower nadir (165 versus 220 cells/μL, respectively; p = 0.03) and baseline (374 versus 498 cells/μL, respectively; p = 0.04) CD4 count than monoinfected patients. Etravirine was mainly used with two nucleoside reverse transcriptase inhibitors (129; 61%) or with a boosted protease inhibitor (PI) (28%), with no significant differences according to HCV serostatus. Transient elastography in 117 patients (81%) showed a median (range) stiffness value of 8.25 (3.5-69) kPa, with fibrosis stage 1 in 43 patients (37%) and fibrosis stage 4 in 28 patients (24%). During an accumulated follow-up time of 449.3 patient-years (median 548 days), only one patient with advanced fibrosis (50.8 kPa) had grade 3-4 liver toxicity (0.7%). Transaminases changed slightly, with no significant differences compared with baseline fibrosis, and nine and six patients had grade 1 and 2 transaminase increases, respectively. Also, HCV coinfection was not associated with a higher risk of discontinuation (25% discontinued versus 21% of monoinfected patients; p = 0.39, log-rank test) or virological failure (8% versus 12%, respectively; p = 0.4).

CONCLUSIONS

Our data suggest that etravirine is a safe option for HIV/HCV-coinfected patients, including those with significant liver fibrosis.

Effect of a monthly dose of calcidiol in improving vitamin D deficiency and secondary hyperparathyroidism in HIV-infected patients

There are no data about the optimal supplementation therapy in HIV-infected patients with vitamin D (25OHD) deficiency. The aim of this study was to assess the effect of an oral monthly dose of 16,000 IU calcidiol. We performed a longitudinal cohort study of 365 HIV-infected patients (24 % females) was with sequential determinations of 25OHD, serum parathyroid hormone (PTH), calcium, and alkaline phosphatase. The efficacy and safety of supplementation in 123 patients were compared against dietary and sun exposure advice. Overall, mean baseline 25OHD levels were 19.1 ng/ml (IQR 12-23.6), 63 % of patients had 25OHD deficiency and 27 % secondary hyperparathyroidism. After a median time of 9.3 months (95.61 patients-year on-treatment), 25OHD levels increased in comparison with non-supplemented patients (+16.4 vs. +3.2 ng/ml; p < 0.01), decreasing the rate of 25OHD deficiency (from 84 to 24 %), and decreasing serum PTH (-4.9 pg/ml) and the rate of secondary hyperparathyroidism (from 43 to 31 %; p < 0.001). This improvement was observed irrespective of HIV/HCV coinfection or the use of efavirenz. In a regression analysis, adjusting by seasonality, a lower baseline 25OHD was associated with persistence of deficiency (relative risk, RR 1.07; 95 % CI 1.03-1.1; p < 0.001), whereas calcidiol supplementation was the only factor associated with significant improvement (RR 0.38; 95 % CI 0.12-0.46; p < 0.001). This monthly dose showed no clinical toxicity, and no patient had 25OHD levels above 100 ng/ml, nor hypercalcemia. The use of monthly calcidiol is safe, easy to take, and largely effective to improve vitamin D deficiency and secondary hyperparathyroidism in HIV-infected patients.

Higher Virological Effectiveness of NNRTI-Based Antiretroviral Regimens Containing Nevirapine or Efavirenz Compared to a Triple NRTI Regimen As Initial Therapy in HIV-1-Infected Adults

PURPOSE

To compare outcomes of nonnucleoside reverse transcriptase inhibitors (NNRTIs) nevirapine or efavirenz versus abacavir-based regimens with a backbone of zidovudine and lamivudine as initial therapy of treatment-naive adults with HIV-1 infection in routine clinical care.

METHOD

All patients starting their first antiretroviral therapy with any of the studied regimens from January 1999 to December 2002 were included in the analysis. Rates of viral suppression (HIV-RNA below 50 copies/mL) and discontinuation of any component of the regimen were compared at 48 weeks.

RESULTS

Fifty-one patients started with one of the two NNRTI-based regimens and 49 started with the triple nucleoside regimen (3-NRTI). After 48 weeks, more patients in the NNRTI regimens (76.5%) than in the 3-NRTI (51.1%) regimen achieved a HIV-1 RNA level below the limit of detection (<1.7 log10 copies/mL; p = .008). Time to change the antiretroviral regimen was shorter with 3-NRTI (median [range]: 234 [139-329] days) than with NNRTI (346 [0-756] days) (p = .0901). More withdrawals related to drug toxicity or intolerance occurred with the 3-NRTI-based regimen.

CONCLUSION

In a routine clinical care setting, initial antiretroviral treatment with an NNRTI (nevirapine or efavirenz) plus zidovudine and lamivudine was virologically superior and safer than a 3-NRTI therapy (abacavir with the same NRTI backbone).

Visceral leishmaniasis as an independent cause of high immune activation, T-cell senescence, and lack of immune recovery in virologically suppressed HIV-1-coinfected patients

OBJECTIVES

Different immune alterations have been described in HIV-infected patients with visceral leishmaniasis (VL). We aimed to identify the immunological factors involved in the lack of immunological recovery and VL relapses in HIV-infected patients with VL, by comparison with other HIV-infected patients.

METHODS

We carried out a cross-sectional study of 55 patients receiving suppressive combination antiretroviral therapy (cART) for at least 1 year: nine with previous relapsing VL, 20 with an immunodiscordant response (IDR) to cART (CD4 count < 200 cells/μL) and no previous VL, and 26 with a concordant response (CR) to cART (CD4 count > 350 cells/μL) without VL. Immunosenescence was investigated by analysing CD57(+) CD28(-) levels, immune activation by analysing CD38(+) HLA-DR(+) levels, inflammation by analysing interleukin (IL)-6 levels, and microbial translocation by analysing lipopolysaccharide (LPS) and soluble CD14 (sCD14) levels.

RESULTS

In VL patients, the median time since VL diagnosis was 42 months, and all patients had had at least one relapse despite suppressive cART for a median time of 43 months. Patients with previously diagnosed VL had a higher CD8 T-cell activation level (P < 0.001) than those with IDR. Also, levels of IL-6, LPS and especially sCD14, associated with bacterial translocation and additional monocyte activation, were significantly increased in patients with previous VL compared with patients with IDR (P = 0.048, P = 0.049 and P < 0.001, respectively). In addition, patients with previous VL had higher levels of CD8 T-cell senescence. Notably, the levels of immune activation and inflammation in patients with previous VL were not related to the time of VL diagnosis, the number of VL relapses, or hepatitis C virus (HCV) coinfection.

CONCLUSIONS

Our data demonstrate that VL patients had an even worse immunological status than patients with IDR, which was probably associated with increased microbial translocation and additional monocyte/macrophage activation. These data explain the observed lack of immunological recovery and the occurrence of VL relapses in HIV-infected patients with previous VL.

Limitations of a Simplification Antiretroviral Strategy for HIV-Infected Patients with Decreasing Adherence to a Protease Inhibitor Regimen

PURPOSE

To determine the long-term efficacy of a simplification strategy in the clinical setting when used to improve adherence.

METHOD

Prospective study of 70 patients included in a regimen with ddI plus 3TC plus an NNRTI, after viral suppression with a PI-containing regimen, due to decreasing adherence. Adherence to PI was calculated as the percentage of doses taken last week before inclusion, and patients were stratified as high and low adherence (95% and <95% of doses).

RESULTS

Overall, 19 patients (27%) related adherence to PI <95% at inclusion (6 patients [9%], with adherence <80%). Mean adherence improved, with only 8% of patients presenting values <95%. At 104 weeks, 88% of patients on therapy had viral load suppression, but only 43% by ITT analysis. The main cause of therapy change or withdrawal was toxicity or drug interactions (26%). Notably, 16% of patients were lost to follow-up or left therapy, especially in the group of initially low adherent (26% vs. 12%, p = .02).

CONCLUSION

The use of a simplification strategy could be associated with long-term high risk of treatment failure, when used to improve adherence in the clinical setting.

High levels of CD4⁺ CTLA-4⁺ Treg cells and CCR5 density in HIV-1-infected patients with visceral leishmaniasis

Visceral leishmaniasis (VL) in HIV-1-infected patients has been associated with poor immunological recovery and frequent disease relapses. The aim of this study was to analyse the role of T cell populations, Treg cells and CCR5 density in patients with VL compared to HIV-1-infected patients without leishmaniasis. A cross-sectional study of nine Leishmania-HIV-1-coinfected (LH) patients with VL receiving suppressive cART for at least 1 year were compared to 16 HIV-1-infected patients with non-immunological response (NIR, CD4 count below 250 cells/mm(3)) and 26 HIV-1-infected patients with immunological response (IR, CD4 count above 500 cells/mm(3)) without leishmaniasis. LH patients had a deep depletion of naïve T cells (p = 0.002), despite similar levels of effector T cells compared to NIR patients. CD4 Treg cells were similar compared to NIR patients, but higher compared to IR patients (p < 0.001). Interestingly, CD4 Treg CTLA-4(+) cells were higher in LH patients compared to either NIR or IR patients (p = 0.022 and p < 0.001, respectively), and the CD4 Treg/TEM ratio was similar to NIR patients, but higher compared to IR patients (p = 0.017). CCR5(+) T cell levels were higher compared to IR patients (p < 0.001), while CCR5 density on T cells were higher compared to both NIR and IR patients (p < 0.005 in both cases). Higher levels of CD4(+) CTLA-4(+) Treg cells and CCR5 density on CD8(+) T cells are strongly associated with VL in HIV-1-infected patients. Also, these patients have a poor immunological profile that might explain the persistence and relapse of the pathogen.

Recent advances in rilpivirine: new data and promising treatment option

The usefulness of every antiretroviral drug in the clinical setting should be continuously evaluated, since registration studies may not adequately reflect real-world patient populations. Rilpivirine was developed in an effort to generate patient-tailored drugs with high convenience and minimal side effects. By now, rilpivirine is currently licensed for use with other antiretroviral agents, and as a single agent or a single-tablet regimen with tenofovir and emtricitabine , in antiretroviral-naive, HIV-1-infected adults with < 100,000 HIV-1 RNA copies/ml because of a higher rate of virological failure above this level. However, after its introduction several questions remained to be elucidated, such as the efficacy of rilpivirine with abacavir/lamivudine, or its use in switching strategies, a useful alternative for patients with toxicity or intolerance. Cumulative data suggest the efficacy and safety of the combination of abacavir/lamivudine plus rilpivirine in the clinical setting, and an increasing number of patients received rilpivirine after protease inhibitor, efavirenz, or nevirapine-based therapy without compromising rilpivirine exposure after the change. Moreover, rilpivirine is a substrate and weak inducer of the CYP3A4, but there are no significant pharmacokinetic interactions with new anti-hepatitis C compounds such as telaprevir, simeprevir, daclatasvir, ledipasvir, and sofosbuvir, an important issue for a drug with low risk of hepatoxicity. As a new and promising strategy, rilpivirine has been evaluated with darunavir and dolutegravir in dual therapies, without need of dose adjustment and with adequate preliminary data. Therefore, to date, new data on rilpivirine confirm the good results observed in the clinical trials.

Prevalence of primary resistance mutations to integrase inhibitors in treatment-naïve and -experienced patients infected with B and non-B HIV-1 variants

BACKGROUND

Raltegravir (RAL) constitutes the first available integrase strand transfer inhibitor (INSTI) available in clinical practice. Three independent pathways have been described to confer resistance to RAL. Secondary mutations with little effect on INSTI susceptibility and additional substitutions with an uncertain role have also been described especially in HIV-1 non-B variants.

METHODS

We evaluated the prevalence of primary, secondary, and additional resistance mutations to INSTIs in patients naïve to RAL or elvitegravir (EGV) carrying different HIV-1 variants.

RESULTS

A total of 83 patients infected by B HIV-1 subtype (64%) or non-B HIV-1 variants (36%) were evaluated. No primary mutations to RAL or EGV were found in the inte-grase sequences analyzed. Secondary mutations were detected in only 5 patients. Additional mutations were found in both in B and non-B variants. According to the geno2pheno algorithm, some of the secondary mutations detected (L74V, E138K, G163RS, and V151I) have been associated with a reduced estimated susceptibility to RAL and only the E138K mutation has been associated with a decreased estimated susceptibility to EGV. No virological failure was observed after RAL was administrated in 17 patients carrying 1 or more additional substitutions in the absence of primary or secondary mutations.

CONCLUSIONS

No primary resistance mutations to INSTI were found in treatment-naïve or -experienced patients infected with B or non-B HIV-1 variants. The vast majority had some polymorphic and non-polymorphic substitutions; however response to RAL was excellent in patients who harbored one or more of these mutations. We could not identify any clinical factors associated with the presence of any of these mutations.

Prevalence of causes of secondary osteoporosis and contribution to lower bone mineral density in HIV-infected patients

SUMMARY

Eighty-one percent of human immunodeficiency virus (HIV)-infected patients had one or more of seven evaluated causes of secondary osteoporosis, and this rate increases with age. The type and number of causes were associated with a lower bone mineral density (BMD), and with an increased rate of osteopenia/osteoporosis, regardless of age and body mass index.

INTRODUCTION

The objective of this study was to determine whether factors of secondary osteoporosis were associated with lower BMD in HIV.

METHODS

This was a cross-sectional study of 285 HIV-infected patients (25 % females) evaluating the impact of seven different factors of reduced BMD: hyperthyroidism, diabetes, chronic viral hepatitis, chronic kidney disease (CKD), hypovitaminosis D, secondary hyperparathyroidism, and hypogonadism. Dual-energy X-ray absorptiometry scan of the femoral neck was obtained at the clinical visit.

RESULTS

Mean age was 45.7 years; osteopenia and osteoporosis were diagnosed in 38 and 6 %, respectively. Overall, 230 patients (81 %) had secondary factors; 107 (38 %) had only 1 cause, 94 (33 %) had 2, and 28 (10 %) had 3 or more, predominantly vitamin D deficiency in 61 %, hepatitis C virus coinfection in 45 %, and secondary hyperparathyroidism in 27 %. The number of secondary factors was closely related to a lower BMD, which is statistically significant for patients having ≥2 causes (0.77 vs 0.73 g/cm(2), p = 0.02). The rate of osteopenia ranged from 36 % without any cause to 57 % with three or more, osteoporosis from 0 to 19 %, and Z-score <-2 SD from 0 to 27 %, respectively. In a multivariate linear regression, adjusting by age, body mass index, and HIV-related factors, the number of secondary factors was independently associated with a lower BMD (ß coefficient -0.134; p = 0.02), mainly due to patients with hepatitis C virus (HCV) coinfection, secondary hyperparathyroidism, and CKD.

CONCLUSIONS

A high prevalence of secondary causes of osteoporosis is observed in HIV-infected patients, and its type and cumulative number determine a lower BMD, after adjusting by age and body mass index.

Increased risk of serious non-AIDS-related events in HIV-infected subjects on antiretroviral therapy associated with a low CD4/CD8 ratio

BACKGROUND

A low CD4/CD8 ratio has been identified in the general population as a hallmark of inmmunosenescence and a surrogate of all-cause mortality. We aimed to investigate in treated HIV-infected individuals the relationship between the CD4/CD8 ratio and serious non-AIDS events.

METHODS

Case-control study within a prospective hospital-based cohort of HIV-infected subjects during at least one year of ART-mediated viral suppression. Cases were patients with serious non-AIDS events (non-AIDS malignancies, cardiovascular disease, and end-stage kidney disease), and controls individuals who did not developed non-AIDS events during follow-up. Data were analyzed using ROC analysis and multivariate logistic regression. Conditional logistic regression was performed in 200 cases/controls matched by age, sex, nadir CD4 and proximal CD4 counts.

RESULTS

We analyzed 407 subjects (109 cases, 298 controls). The CD4/CD8 ratio was lower in cases (0.44 vs. 0.70, P<0.0001), with higher discriminatory ability for the detection of non-AIDS events than the CD4 count, CD8 count and nadir CD4. Multivariate analyses (adjusted for age, sex, nadir CD4, proximal CD4 count, year of ART initiation and ART duration) confirmed the independent association of a low CD4/CD8 ratio with the risk of non-AIDS morbidity (per CD4/CD8 ratio quartile decrease, OR, 2.9; 95% CI, 1.3-6.2) and non-AIDS mortality (OR, 2.8; 95% CI, 1.5-5.3).

CONCLUSIONS

The CD4/CD8 ratio provides additional information to the CD4 counts and nadir CD4 in treated HIV-infected individuals, since it is independently associated with the risk of non-AIDS-related morbidity and mortality. This association is robust and maintained within different subgroups of patients.

Regression of liver fibrosis is progressive after sustained virological response to HCV therapy in patients with hepatitis C and HIV coinfection

There are few data about the long-term histological outcome of HIV-/HCV-coinfected patients after therapy with interferon and ribavirin. We performed an observational study of 216 patients who received therapy against HCV and who had at least three successive transient elastographies (TE) during the follow-up. The primary endpoint was confirmed fibrosis regression, defined as a reduction of at least 1 point in Metavir fibrosis score, confirmed and without worsening in successive TE. At baseline, 23% had fibrosis stage 4 or cirrhosis. Overall, 82 (38%) achieved sustained virological response (SVR), without differences in baseline fibrosis or time of follow-up. Confirmed fibrosis regression was observed in 55% of patients, higher for SVR (71% vs 44%; P < 0.01), and the likelihood of achieving fibrosis regression at 3, 5 and 7 years was 0.17, 0.51 and 0.67, respectively, for SVR patients, in comparison with 0.02, 0.23 and 0.41 for no SVR patients (P < 0.01, log-rank test at any time point). Progressive regression, defined as continuous improvement in successive TE, was observed in 62% of patients with advanced liver fibrosis or cirrhosis who achieved SVR. In a Cox regression model, only SVR (HR, 4.01; 95% CI, 2.33-7.57; P < 0.01) and a younger age (HR, 1.14; 95% CI, 1.05-1.25; P < 0.01; per year) were associated with fibrosis regression. This study confirms that the rate of liver fibrosis regression increases during the follow-up after SVR to interferon therapy in HIV-/HCV-coinfected patients.

Liver toxicity in HIV-infected patients receiving novel second-generation nonnucleoside reverse transcriptase inhibitors etravirine and rilpivirine

There are few data on the hepatic safety profile of the novel second-generation nonnucleoside reverse transcriptase inhibitors etravirine and rilpivirine. Previous extensive studies including other drugs of the same class, nevirapine and efavirenz, have shown an incidence of liver toxicity of 3-20%, higher in the case of nevirapine. The pathogenic mechanisms involved are related to hypersensitivity, as described with nevirapine, impaired metabolism and therefore increased drug levels, and direct toxic effects with production of toxic metabolites. Hepatitis C coinfection seems to be the most important factor for toxicity, especially in the case of advanced liver fibrosis. Etravirine showed a similar rate of liver toxicity to placebo in regulatory studies, but this seems to be lower in the clinical setting, as has been observed in the Expanded Access Program and in cohort studies including HCV/HIV-coinfected patients with different degrees of fibrosis. Also, rilpivirine showed a low rate of liver toxicity, similar to the comparator efavirenz in development studies, even in coinfected patients. Both second-generation nonnucleoside reverse transcriptase inhibitors are rarely associated to hypersensitivity reactions, and drug metabolism is not severely altered in the case of HCV coinfection, at least in the absence of severe fibrosis. Also, both drugs are weak hepatic cell inducers. Therefore, clinical and pathogenic data suggest that both etravirine and rilpivirine are safe to be used in the clinical setting, including patients with liver abnormalities at baseline.

Neutropenia during therapy with peginterferon and ribavirin in HIV-infected subjects with chronic hepatitis C and the risk of infections

BACKGROUND

It is unclear whether pegylated interferon (peg-IFN) -induced neutropenia in subjects coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is associated with increased risk of serious infections.

METHODS

This was a prospective cohort study conducted between 2000 and 2012 in HIV/HCV-coinfected subjects initiating treatment with peg-IFN plus ribavirin (RBV). Infections were defined as serious when patients required hospitalization, treatment was discontinued, or the patient died. The association between neutropenia (severe, <500 cells/μL; nonsevere, 500 -1500 cells/μL) and infections (serious infections and infections of any severity) was determined by logistic regression analysis.

RESULTS

Among 418 subjects (3928 person-weeks of therapy), infections occurred in 123 (29%), accounting for 149 episodes (3.8 infections per 100 person-weeks of therapy). Most infections (47%) involved the upper respiratory tract and were minor. After a multivariate analysis adjusted by age, sex, CD4 count, AIDS, antiretroviral therapy, cirrhosis, neutrophil count, type of peg-IFN, and granulocyte colony-stimulating factor use, none of these variables remained independently associated with the risk of infection. Twenty subjects developed a serious infection (4.8% of all patients). The frequency of serious infections was higher in subjects with severe neutropenia compared to those with nonsevere neutropenia and without neutropenia, although it was not statistically significant (8.6%, 4.8%, and 3.6%, respectively; trend test P = .281). In multivariate analysis, neutropenia was not independently associated with increased risk of serious infections.

CONCLUSIONS

In this large prospective cohort of HIV/HCV-coinfected patients treated with peg-IFN plus RBV, serious infections were uncommon, nonfatal, and unrelated to peg-IFN -induced severe neutropenia.

Intensification of antiretroviral therapy with a CCR5 antagonist in patients with chronic HIV-1 infection: effect on T cells latently infected

OBJECTIVE

The primary objective was to assess the effect of MVC intensification on latently infected CD4(+) T cells in chronically HIV-1-infected patients receiving antiretroviral therapy.

METHODS

We performed an open-label pilot phase II clinical trial involving chronically HIV-1-infected patients receiving stable antiretroviral therapy whose regimen was intensified with 48 weeks of maraviroc therapy. We analyzed the latent reservoir, the residual viremia and episomal 2LTR DNA to examine the relationship between these measures and the HIV-1 latent reservoir, immune activation, lymphocyte subsets (including effector and central memory T cells), and markers associated with bacterial translocation.

RESULTS

Overall a non significant reduction in the size of the latent reservoir was found (p = 0.068). A mean reduction of 1.82 IUPM was observed in 4 patients with detectable latent reservoir at baseline after 48 weeks of intensification. No effect on plasma residual viremia was observed. Unexpectedly, all the patients had detectable 2LTR DNA circles at week 24, while none of them showed those circles at the end of the study. No changes were detected in CD4(+) or CD8(+) counts, although a significant decrease was found in the proportion of HLA-DR(+)/CD38(+) CD4(+) and CD8(+) T-cells. LPS and sCD14 levels increased.

CONCLUSIONS

Intensification with MVC was associated with a trend to a decrease in the size of the latent HIV-1 reservoir in memory T cells. No impact on residual viremia was detected. Additional studies with larger samples are needed to confirm the results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00795444.

Observational study to evaluate clinical outcomes after first-line efavirenz-or lopinavir-ritonavir-based HAART in treatment-naive patients

PURPOSE

To evaluate clinical, immunological, and virological outcomes after first-line highly active antiretroviral therapy (HAART) with a regimen including either efavirenz (EFV) or lopinavir/ritonavir (LPV/r) in treatment-naive adult patients in routine clinical care.

METHOD

An ongoing prospective, observational follow-up study included all patients starting their first antiretroviral therapy (ART) with any of the studied regimens from July 1998 to July 2004. The follow-up period was finalized in September 2006, when all patients completed an observation of at least 96 weeks. Mortality rates, CD4 counts, viral suppression (HIV RNA below 50 copies/mL), and discontinuation of any component of the regimen were compared at 48 and 96 weeks.

RESULTS

Despite the worst immunological status of the LPV/r group patients at baseline, this regimen was at least as effective as the one based on EFV not only in terms of treatment durability but also in terms of virological responses, nevertheless with an apparently quicker immune recovery. In general terms, both regimens present similar tolerability and safety outcomes except for the higher risk of increasing triglyceride (TG) levels in the LPV/r group. Low durability was observed in both regimens.

CONCLUSION

In a routine clinical care setting, initial HAART containing LPV/r seems to present an effectiveness, tolerability, and toxicity similar to the one containing EFV.

[Chronic relapsing inflammatory optic neuropathy (CRION) without detection of IgG-NMO antibodies]

Chronic relapsing inflammatory optic neuropathy is a disease that should be distinguished from demyelinating optic neuropathy (ON). Long-term immunosuppressive therapy is usually necessary and either an inflammatory granulomatous origin or a relationship with neuromyelitis optica (NMO) is hypothesized. We report a 43-year-old man who suffered from several ON episodes affecting one eye or the other. These ON attacks completely disappeared with steroid therapy but relapsed after its withdrawal. IgG-NMO antibodies were negative.

CD4 count and viral load time-courses in patients treated with highly active antiretroviral therapy and association with the CDC staging system

OBJECTIVES

The aim of the study was to analyse CD4 cell count and viral load dynamics in patients undergoing antiretroviral therapy and their association with the Centers for Disease Control and Prevention (CDC) classification system.

METHODS

CD4 cell count and viral load were determined in 2982 patients who were classified according to clinical and immunological CDC stages. Measurements were carried out at baseline and at the 3rd, 6th and 12th months.

RESULTS

Clear differences in the immunological and virological responses to therapy were observed depending on the CDC stage, with better results associated with less advanced stages. There was a marked parallelism in the CD4 cell count curves of the different CDC stages over the year of follow up, in both naïve and experienced patients, indicating that the increase in CD4 cell count at each time-point was similar for all clinical and immunological CDC stages. However, as the baseline values were closely associated with CDC stage, the CD4 cell counts finally reached were clearly dependent on CDC stage. The highest virological responses were observed during the initial 3 months, particularly in naïve patients, but whereas naïve patients showed additional increases up to the 6th month experienced patients reached a plateau at the 3rd month. The CD4 increases were also higher during the initial 3 months but persisted during the year of follow-up.

CONCLUSION

Both clinical and immunological CDC stages at baseline are highly predictive of the immunological and virological response to therapy, a finding that could have clinical implications.

Reactivation of hepatitis B in an HIV-infected patient with antibodies against hepatitis B core antigen as the only serological marker

Presented here is the first report of clinical reactivation of hepatitis B virus (HBV) in an HIV-infected patient who previously had anti-HBc as the only serological marker of past infection (anti-HBc alone). Reactivation occurred after lamivudine was removed from the patient's antiretroviral treatment regimen due to lack of virological response. HIV-infected patients frequently present anti-HBc alone, and in some cases this serological profile is associated with occult HBV infection. The current case demonstrates the importance of ruling out the possibility of occult infection in this patient group.

Therapeutic drug monitoring and the inhibitory quotient of antiretroviral drugs: can they be applied to the current situation?

Therapeutic drug monitoring is attracting growing interest as a means of increasing the effectiveness of antiretroviral therapy and of decreasing its toxicity, although data supporting this strategy are still scarce. Currently, nucleoside analog reverse-transcriptase inhibitors (NARTI) are not candidates because their effect depends on their active intracellular form and not on plasma concentration. Protease inhibitors (PI) and non-nucleoside analogue reverse-transcriptase inhibitors (NNARTI) meet the criteria for therapeutic drug monitoring. The main limitations are that the parameters to be monitored in order to measure exposure to the drug and the effective concentration of the drug have not been well defined. The few studies performed in treatment-naive patients have demonstrated that monitoring improves therapeutic efficacy. This strategy will be particularly useful when the risk of subtherapeutic or toxic concentrations is especially high (pharmacokinetic interactions, intestinal malabsorption, adverse effects, virological failure without obvious cause, pregnancy, children). Although it remains to be standardized, the inhibitory quotient integrates pharmacological and virological parameters and is useful in patients with prior virological failure. Any therapeutic drug monitoring program should be accompanied by measures to monitor and improve treatment adherence. There are good reasons to believe that therapeutic drug monitoring can be useful to improve treatment in specific circumstances. However, before its widespread use as a routine method can be recommended, the parameters to be used should be standardized and studies with appropriate methodology should be performed to define the role of therapeutic drug monitoring in distinct clinical situations.

Recomendaciones GESIDA/SEFH/PNS para mejorar la adherencia al tratamiento antirretroviral en el año 2004

Since the early days of antiretroviral therapy, adherence has emerged as the milestone of success; in fact, it is the most potent predictor of effectiveness. The main factors related to adherence include the complexity of the therapeutic regimen, adverse effects, psychological problems, alcoholism and active addiction to drugs, lack of social and family support and the patient's beliefs and attitudes about the treatment. Adherence monitoring should be part of the HIV patient's regular care, and should be done with feasible, easily applied methods adapted to the different clinical settings. The minimally acceptable measures should include use of a validated questionnaire, together with data from the Pharmacy Department's drug dispensation registry. All patients that begin HAART or undergo a change of treatment should participate in a treatment education program imparted by health professionals with knowledge and experience in the management of patients with HIV infection. The health team (doctors, pharmacists and nursing professionals) should offer maximum availability to solve the doubts and problems that may occur during treatment. When sub-optimal adherence is detected, intervention strategies based on psychological therapy, educational efforts and personal advice should be attempted, in order to adapt the treatment scheme to the patient's habits and provide solutions to the problem of non-compliance. In certain situations, co-morbid conditions will also require attention. Treatment adherence, being a multidimensional problem, needs a multidisciplinary team approach. The choice of therapy, only one aspect of the multidimensional problem of adherence, must be a careful and individualized decision; however, simpler regimens with regard to the number of pills and daily dose are desirable.

Prevention of opportunistic infections in adult and adolescent patients with HIV infection. GESIDA/National AIDS Plan guidelines, 2004 [correction]

OBJECTIVE

To provide an update of guidelines from the Spanish AIDS Study Group (GESIDA) and the National AIDS Plan (PNS) committee on the prevention of opportunistic infections in adult and adolescent HIV-infected patients.

METHODS

These consensus recommendations have been produced by a group of experts from GESIDA and/or the PNS after reviewing the earlier document and the scientific advances in this field in the last years. The system used by the Infectious Diseases Society of America and the United States Public Health Service has been used to classify the strength and quality of the data.

RESULTS

This document provides a detailed review of the measures for the prevention of infections caused by viruses, bacteria, fungi and parasites in the context of HIV infection. Recommendations are given for preventing exposure and for primary and secondary prophylaxis for each group of pathogens. In addition, criteria are established for the withdrawal of prophylaxis in patients who respond well to highly active antiretroviral therapy (HAART).

CONCLUSIONS

HAART is the best strategy for the prevention of opportunistic infections in HIV-positive patients. Nevertheless, prophylaxis is still necessary in countries with limited economic resources, in highly immunodepressed patients until HAART achieves beneficial effects, in patients who refuse to take or who cannot take HAART, in those in whom HAART is not effective, and in the small group of infected patients with inadequate recovery of CD4+ T lymphocyte counts despite good inhibition of HIV replication.

Percentage of adherence correlates with the risk of protease inhibitor (PI) treatment failure in HIV-infected patients

OBJECTIVES

To determine the effect of adherence on the rate of protease inhibitor (PI) treatment failure among human immunodeficiency virus (HIV)-infected patients.

METHODS

A prospective study of a cohort of 282 patients who initiated PI therapy from March 1996 to December 1997. Adherence was quantified as the percentage of prescribed doses reportedly taken and treatment failure was defined as HIV RNA levels above 200 copies/ml after 1 year on therapy.

RESULTS

Overall, 190 patients (67%) missed prescribed doses. However, mean percentage of doses taken was 91% (range, 21-100%). Demographic, virological and immunological characteristics could not predict adherence outcomes. The causes of non-adherence included intolerance or side effects (35%), complexity of treatment (23%), or recurrence in active drug abuse (17%), whereas abandonment owing to HIV-related disease was uncommon (6%). A degree of adherence above 90% correlated significantly with viral suppression [relative risk (RR) 1.69; 95% confidence interval (CI) 1.1-2.56; P<0.01]. In a multivariate analysis, a lower degree of adherence (RR, 0.96; P=0.006), a higher HIV viral load (RR, 2.03; P=0.0001), prior antiretroviral therapy (RR, 2.5; P=0.01), and use of saquinavir-hard gel capsules (saquinavir-HGC) (RR, 1.77; P=0.03) were strongly associated with treatment failure.

CONCLUSION

The percentage of adherence and initial HIV viral load are the most important determinants of virological response to PI therapy and non-adherence is related to treatment-related factors in the majority of cases.