HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

Nevirapine Use Is Associated with Higher Bone Mineral Density in HIV-1 Positive Subjects on Long-Term Antiretroviral Therapy

We assessed bone mineral density (BMD) in a cohort of human immunodeficiency virus (HIV)-positive patients after a median of 11 years of combination antiretroviral therapy (cART) and evaluated the respective role of HIV infection and antiretroviral drugs (ARVs). A cross-sectional study of 162 participants (131 male) from the ANRS-C08 cohort was performed with bone dual-energy X-ray absorptiometry (DXA) scans and renal assessment. The window of exposure to ARVs was defined as an exposure of more than six cumulative months during the last 3 years before the DXA evaluation to account for a cumulative exposure that could affect bone remodeling. The association with low BMD (Z-score < -2) was assessed by a multiple logistic regression model. The study population was 50 years (median), hepatitis C virus (HCV) (18%), and hepatitis B virus (HBV) (8%) coinfection with HIV-RNA <50 c/mL in 89%, median CD4 of 619/mm³. Prevalence of low BMD was 18% in males and 6% in females. The factors associated with a Z-score < -2 in males were uric acid renal loss [adjusted odds ratio (aOR): 6.1; 95% confidence interval (CI): 1.2-31.5; p = .03], HCV coinfection (aOR: 4.0; 95% CI: 1.3-12.2; p = .02), and less frequent window of exposure to nevirapine (NVP) (aOR: 0.1; 95% CI: 0.02-0.6; p = .01). For the full study sample, there was a strong positive association between duration of exposure to NVP and lumbar spine Z-score (p = .004). HIV-positive patients exposed to long-term cART have a high incidence of low BMD. Tenofovir disoproxil fumarate and ritonavir-boosted protease inhibitors did not seem to be associated with increased risk of low BMD, whereas NVP exposure appeared to have an independent positive association.

One-stage versus two-stage prosthesis replacement for prosthetic knee infections

INTRODUCTION

Periprosthetic knee infection is a severe complication. Confirmed criteria are lacking to choose between one-stage or two-stage prosthesis replacement to treat the infection. The one-stage replacement could lead to a satisfactory control of the infection and to better functional results.

METHOD

Retrospective study conducted between January 1, 2009 and December 31, 2014. The objectives of this study were to compare the infection outcome and functional results between the one-stage and two-stage replacement procedures. Functional results were evaluated using the IKS score, KOOS score, and SF-12 quality of life score.

RESULTS

Forty-one patients underwent a two-stage replacement procedure and 21 patients a one-stage replacement. The average follow-up was 22 months after surgery. The infection was cured in 78% of patients who underwent a two-stage replacement and 90% of patients who underwent a one-stage replacement (P=0.3). The flexion range of motion was significantly better in the one-stage group than in the two-stage group (P=0.04). Results of the IKS score and of the KOOS score were better in the one-stage group. No difference was observed for the SF-12 score.

CONCLUSION

The one-stage replacement procedure for periprosthetic knee infection was associated with a similar healing frequency as the two-stage replacement procedure, and with better knee function.

Efficacy, safety and patient-reported outcomes of ledipasvir/sofosbuvir in NS3/4A protease inhibitor-experienced individuals with hepatitis C virus genotype 1 and HIV coinfection with and without cirrhosis (ANRS HC31 SOFTRIH study)

OBJECTIVES

Studies evaluating the efficacy and safety of the fixed-dose combination ledipasvir (LDV)/sofosbuvir (SOF) in patients coinfected with HIV-1 and hepatitis C virus (HCV) have mainly included treatment-naïve patients without cirrhosis. We aimed to evaluate the efficacy and safety of this combination in treatment-experienced patients with and without cirrhosis.

METHODS

We conducted a multicentre, open-label, double-arm, nonrandomized study in patients coinfected with HIV-1 and HCV genotype 1 with and without cirrhosis, who had good viral suppression on their antiretroviral regimens. All patients were pretreated with a first-generation NS3/4A protease inhibitor (PI) plus pegylated interferon/ribavirin. Patients received a fixed-dose combination of LDV/SOF for 12 weeks, or for 24 weeks if cirrhosis was present. The primary endpoint was a sustained virological response (SVR) 12 weeks after the end of therapy. Secondary endpoints included safety, pharmacokinetics and patient-reported outcomes.

RESULTS

Of the 68 patients enrolled, 39.7% had cirrhosis. Sixty-five patients [95.6%; 95% confidence interval (CI): 87.6-99.1%; P < 0.0001] achieved an SVR, with similar rates of SVR in those with and without cirrhosis. Tolerance was satisfactory, with mainly grade 1 or 2 adverse events. Among patient-reported outcomes, only fatigue significantly decreased at the end of treatment compared with baseline [odds ratio (OR): 0.36; 95% CI: 0.14-0.96; P = 0.04]. Mean tenofovir area under the plasma concentration-time curve (AUC) at week 4 was high, with mean ± SD AUC variation between baseline and week 4 higher in cirrhotic than in noncirrhotic patients (3261.57 ± 1920.47 ng/mL vs. 1576.15 ± 911.97 ng/mL, respectively; P = 0.03). Mild proteinuria (54.4%), hypophosphataemia (50.0%), blood bicarbonate decrease (29.4%) and hypokalaemia (13.2%) were reported. The serum creatinine level was not modified.

CONCLUSIONS

LDV/SOF provided a high SVR rate in PI-experienced subjects coinfected with HCV genotype 1 and HIV-1, including patients with cirrhosis.

Interest of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of relapse in patients with spinal infection: a prospective study

Relapse after treatment of a spinal infection is infrequent and difficult to diagnose. The aim of this study was to assess the diagnostic performance of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in this setting. Thirty patients (21 men, nine women; median age 61.2 years) with a suspected spinal infection relapse were prospectively included between March 2010 and June 2013. The initial diagnosis of spinal infection was confirmed by positive bacterial cultures. The patients underwent [(18)F]FDG PET/CT and magnetic resonance imaging (MRI) 1 month after antibiotic treatment interruption. PET/CT data were interpreted both visually and semi-quantitatively (SUVmax). The patients were followed for ≥12 months and the final diagnosis of relapse was based on new microbiological cultures. Seven patients relapsed during follow up. Sensitivity, specificity, positive predictive value and negative predictive value were 66.6%, 61.9%, 33.3% and 86.6%, respectively for MRI and 85.7, 82.6, 60.0 and 95.0 for PET/CT. Although these values were higher for PET/CT than for MRI, the difference was not statistically significant (p=0.3). [(18)F]FDG PET/CT may be useful for diagnosing a relapse of spinal infections, in particular if metallic implants limit the performance of MRI.

Primary liver abscess due to CC23-K1 virulent clone of Klebsiella pneumoniae in France

Since the mid-1980s, Klebsiella pneumoniae hypermucoviscous isolates have emerged in Taiwan and other Asian countries. We reported the first autochthonous European liver abscess due to an ST57 isolate, which belongs to virulent clonal complex CC23-K1. This case highlights the emergence in France and Europe of hypermucoviscous virulent K. pneumoniae isolates.

Prolonged shedding of influenza A(H1N1)v virus: two case reports from France 2009

We observed a prolonged shedding of virus 14 and 28 days after symptom onset in two patients with pandemic H1N1 influenza, who did not have immunodepression and were treated with neuraminidase inhibitor. This prolonged shedding was not associated with the emergence of resistance mutation H275Y in the viral neuraminidase gene.

Prolonged shedding of influenza A(H1N1)v virus: two case reports from France 2009

We observed a prolonged shedding of virus 14 and 28 days after symptom onset in two patients with pandemic H1N1 influenza, who did not have immunodepression and were treated with neuraminidase inhibitor. This prolonged shedding was not associated with the emergence of resistance mutation H275Y in the viral neuraminidase gene.

Prevalence and factors associated with renal impairment in HIV-infected patients, ANRS C03 Aquitaine Cohort, France

OBJECTIVES

The aims of the present study were to estimate the prevalence of renal impairment (RI) among HIV-infected adult patients and to investigate the associated factors.

METHODS

A cross-sectional survey was conducted in a French hospital-based cohort. Clearance of creatinine (CC) was calculated using the Cockcroft-Gault formula. Four stages of RI were defined: mild (60-90 mL/min), moderate (30-60), severe (15-30) and end stage (<15). Logistic regression models were used to investigate factors associated with RI.

RESULTS

The male/female ratio of the 2588 patients enrolled was 3:1 and the median age was 42 years. At the time of assessment of CC, the median CD4 count was 430 cells/microL and HIV plasma viral load (VL) was<50 copies/mL in 60%. The overall prevalence of RI was 39.0%: 34.2% mild, 4.4% moderate, 0.3% severe and 0.2% end-stage. Mild RI was associated with female gender [odds ratio (OR)=3.3: 95% CI 2.6-4.3)], age >50 years (OR=9.8: 7.4-13.0) and 40-50 years (OR=1.9: 1.5-2.4), body mass index (BMI) <22 kg/m(2) (OR=3.3: 2.7-4.3) and tenofovir exposure (OR=1.4: 1.0-1.9 for <1 year and OR=1.5: 1.2-2.0 for >1 year). Advanced RI (CC <60 mL/min) was associated with age >50 years (OR=5.6: 2.9-10.9) and 40-50 years (OR=2.2: 1.1-1.4), BMI <22 kg/m(2) (OR=1.5: 1.0-2.4), hypertension (OR=2.5: 1.4-2.5) and indinavir (IDV) exposure >1 year (OR=2.3: 1.5-3.6).

CONCLUSION

This survey confirms the high prevalence of RI in HIV-infected patients and indicates the importance of the investigation of renal function especially in women, older patients, those with a low BMI or treated with tenofovir or IDV.

[Compensation for vaccination accidents]

The compensation of the inoculation accidents evolved after the law of August 9th, 2004 which stated the conditions of a complete repair of the attributable damages in a compulsory inoculation in conformance with the National Solidarity. The Office National d'Indemnisation des Accidents Médicaux, des Affections Iatrogènes et des Infections Nosocomiales (ONIAM) ensures this repair. For the not compulsory inoculations, the medical responsibility can be called only in conformance with a fault committed by the doctor. In spite of the absence of link scientifically established as in the inoculation of the hepatitis B and the induction of a multiple sclerosis at the end of 2008, the jurisprudence in vaccinal accidents varies according to the civil, social, administrative jurisdictions. The appreciation of the link of causality between the inoculation and its consequences is more rigorous in front of the civil jurisdictions than in front of the administrative or social jurisdictions.

Cold Bone Defect on Granulocytes Labelled with Technetium-99m-HMPAO Scintigraphy: Significance and Usefulness for Diagnosis and Follow-up of Osteoarticular Infections

We wished to determine the frequency and significance of cold bone defect on granulocytes labelled with technetium-99-m-hexamethylpropyleneamine oxime (99mTc-HMPAO-PMN) in non-spinal bone infection. Cold bone defect was investigated as part of a retrospective review during a 2-y period. Patients who had possible osteoarticular infection underwent bone scintigraphy combined with 99mTc-HMPAO-PMN for diagnosis and follow-up. Osteomyelitis was confirmed by isolation of the responsible pathogen. Among 210 patients who had possible infection, 17 (8%) demonstrated a cold bone defect. The site of cold bone defect was for all patients the hip. All 17 patients had proven bacterial orthopaedic hardware-related infection. The single causative micro-organism was staphylococcus. Whatever the outcome, cold bone defect was constant regardless of follow-up equal to or longer than 18 months. These data suggest that this uncommon scintigraphic pattern is an indication of an infectious process similar to increased uptake.

Cost-effectiveness of linezolid versus vancomycin for hospitalized patients with complicated skin and soft-tissue infections in France

Studies have shown similar clinical cure rates and shorter length of hospitalization when using linezolid compared to vancomycin in patients with complicated skin and soft-tissue infections due to suspected or proven methicillin-resistant Staphylococcus aureus (MRSA).

OBJECTIVE

This study had for aim to compare the cost-effectiveness of linezolid versus vancomycin in French healthcare settings.

METHOD

A decision-analytic model followed an average patient from the initiation of an empiric treatment until cure, death or second-line treatment failure. A clinical data probability was obtained from clinical trials, resource utilization data (including treatment duration and length of hospitalization) and prevalence of MRSA was obtained from a Delphi panel, and costs from published sources.

RESULTS

First-line cure rate for linezolid-treated patients was 90.7% versus 85.5% for vancomycin; the total cure rates after two lines of treatment were 98.5% and 98.0%, respectively. The average total cost was 7,778euro for linezolid versus 8,777euro for vancomycin. The mean estimated length of hospitalization after two lines of treatment was 10.7 days for linezolid versus 13.3 days for vancomycin. The increased effectiveness and reduced cost lead to more frequent prescription. This did not change after one-way sensitivity analyses.

CONCLUSION

Linezolid may be considered as a cost-effective treatment for patients with complicated skin and soft-tissue infections suspected to be MRSA related in France.

[Management of 315neutropenic febrile episodes in a cancer center]

Management of febrile neutropenic patients is described in guidelines. Each cancer center can adapt these according to its local bacterial ecology. We present a retrospective study made in a cancer center from 2001 to 2003.

METHOD

Three hundred and fifteen febrile neutropenic episodes after chemotherapy (66% for solid tumor) were analysed.

RESULTS

For 279 episodes, no antibiotic therapy was given before admission. Clinical or radiological manifestations occurred in 46%; microbiologically documented infections by hemocultures in 28% (Gram positive: 42%; Gram negative: 51%) and by puncture in 14% (Gram negative: 58%). The length of pyrexia was inferior to 7 days in 88% and neutropenia inferior 7 days in 80.8%. 79.7% of episodes were treated with one of the three antibiotic therapy recommended by the center (ceftriaxone+tobramycin; ceftriaxone+ciprofloxacin; ceftriaxone+ofloxacin); 13.3% were treated with an other therapy; 7% received no antibiotic therapy. 68.5% of patients treated with one of the three antibiotic therapies, became afebrile without changing the antibiotic protocol.

CONCLUSION

In our study, there were a majority of Gram negative bacteria except for Pseudomonas aeruginosa. The three antibiotic therapy recommended by the center (third generation cephalosporin+aminoglycosides or fluoroquinolones) were effective and glycopeptide was not necessary in first intention treatment.

99mTc-HMPAO labelled white blood cell scintigraphy in patients with osteoarticular infection: the value of late images for diagnostic accuracy and interobserver reproducibility

The objectives of this study were to evaluate the diagnostic value of 99mTc-HMPAO labelled white blood cell scintigraphy (WBCS) in patients with suspected osteomyelitis using late images and to study interobserver reproducibility. This study prospectively included 120 patients, and after a follow-up of one year, only 70 patients (n = 49 with implants, n = 21 without implants) were selected. The final diagnosis of infection was based either on microbiological data (n = 54) or follow-up (n = 16). We performed WBCS with 4 h and 24 h scans. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 77%, 72%, 83%, 64%, and 75% at 4 h, and 74%, 87%, 91%, 59%, and 79% at 24 h, respectively. The interobserver reproducibility shows a 63% prevalence of agreement between results (kappa = 0.5) at 4 h and 80% (kappa = 0.74) at 24 h, respectively. WBCS with 24-h images improves specificity and interobserver reproducibility in patients with suspected osteoarticular sepsis.

Trends and determinants of severe morbidity in HIV-infected patients: the ANRS CO3 Aquitaine Cohort, 2000-2004

OBJECTIVE

The aim of the study was to characterize the causes, trends and determinants of severe morbidity in a large cohort of HIV-infected patients between 2000 and 2004.

METHOD

Severe morbid events were defined as medical events associated with hospitalization or death. Epidemiological and biological data were recorded at the time of the morbid event. Trends were estimated using Poisson regression.

RESULTS

Among 3863 individuals followed between 2000 and 2004, 1186 experienced one or more severe events, resulting in 1854 hospitalizations or deaths. The severe events recorded included bacterial infections (21%), AIDS events (20%), psychiatric events (10%), cardiovascular events (9%), digestive events including cirrhosis (7%), viral infections (6%) and non-AIDS cancers (5%). Between 2000 and 2004, the incidence rate of AIDS events decreased from 60 to 20 per 1000 person-years, that of bacterial infections decreased from 45 to 24 per 1000 person-years, and that of psychiatric events decreased from 26 to 14 per 1000 person-years (all P<0.01), whereas the incidences of cardiovascular events and of non-AIDS cancers remained stable at 14 and 10 per 1000 person-years, on average, respectively.

CONCLUSION

Severe morbidity has shifted from AIDS-related to non-AIDS-related events during the course of HIV infection in developed countries. Limiting endpoints to AIDS events and death is insufficient to describe HIV disease progression in the era of combination antiretroviral therapy.

Prognostic factors in adult community-acquired bacterial meningitis: a 4-year retrospective study

The aim of this 4-year, observational, single-center study was to identify prognostic factors and evaluate the need for intensive care in cases of bacterial meningitis. During the study period, 60 cases of adult bacterial meningitis were identified. Fifty-one patients were transferred to the intensive care unit at various times during their hospital stay. In the multivariate analysis, factors significantly associated with the need for mechanical ventilation and/or vasopressive drugs included comorbidity and a Glasgow coma score of less than 12 at hour 6 following presentation. The results indicate patients with a decreased level of consciousness, neurological deficit or comorbidity should be admitted to the intensive care unit at an early stage of illness. When patients lack these criteria 6 h following presentation, admission to the medical ward is reasonable.

HIV-1 reverse transcriptase (RT) genotypic patterns and treatment characteristics associated with the K65R RT mutation

BACKGROUND

The K65R HIV-1 reverse transcriptase (RT) mutation is a multidrug resistance mutation which may be correlated with specific antiretroviral combinations and with the presence or absence of other RT resistance mutations.

OBJECTIVES

The aims of this study were: (i) to determine the prevalence of the K65R mutation in a cohort of antiretroviral-treated patients; (ii) to study genotypic patterns and treatment characteristics in patients in whom the K65R mutation was present.

STUDY DESIGN

We included in the study all antiretroviral-experienced patients followed up at the Bordeaux University Hospital in 2003 and 2004 for whom an HIV-1 genotypic resistance analysis was available. Information on RT resistance mutations was reported from a hospital database including therapeutic and biological parameters. The prevalence of K65R was investigated for all patients. Genotypic patterns and treatment characteristics were examined at the time of detection of the K65R mutation.

RESULTS

The prevalence of K65R was 1.9% (26 of 1404 patients). K65R was associated with nucleoside RT inhibitor-based regimens in 22 patients, and with tenofovir disoproxil fumarate, lamivudine, didanosine and abacavir in 23, 17, 17 and eight patients, respectively. The M184V and Q151M mutations were the most commonly co-selected substitutions. Thymidine analogue mutations (TAMs) were rarely co-selected with K65R and inversely associated with K65R.

CONCLUSION

The K65R mutation may emerge preferentially in the absence of zidovudine and TAMs, suggesting the possibility of an antagonistic interaction between K65 and TAMs.

[Evaluation of antibiotic prophylaxis for hip and knee replacement: a multicentered study in Aquitaine public and private hospitals (SouthWestern France)]

OBJECTIVE

The aim of the study was to estimate the prescription and administration of antibioprophylaxis for hip and knee replacement in Aquitaine (SouthWestern France).

METHODS

In 2003, "Social Security" medical experts performed a descriptive and retrospective study on a sample of scheduled surgical operations in all the Aquitaine public and private hospitals. Antibioprophylaxis, protocols, and practice were assessed by studying the patients' medical files. The analysis was made on adjusted numbers to take into account the size of every institution.

RESULTS

In 51 hospitals, 58.8% of antibioprophylaxis protocols followed French guidelines. The sample corresponded to an adjusted number of 9,651 patients. Antibiopropylaxis was prescribed for 99.3% of patients, the course of antibioprophylaxis followed guidelines for 77.4% of the patients, the choice of the molecule and the dosage in 85.4% of the cases. Interval between antibiotic injection and surgical section was the main criterion of nonconformity (56.3%); it was under30 minutes for 43.7% of cephalosporin injections. In the post-operative period, administration complied with the medical prescription for 76.4% of the patients and dosage was adapted for 60.0% of the patients. According to the studied variables, 3 to 23.5% of data was missing in the medical files.

CONCLUSION

If the quality of care and practice must be improved, it is mandatory to implement written and confirmed antibioprophylaxis protocols, to better document medical files, to insure an improved coordination among professionals before, during, and after surgery.

Carotid intima-media thickness is slightly increased over time in HIV-1-infected patients

OBJECTIVES

HIV-infected patients are at risk of atherosclerosis and cardiovascular diseases. In a 12-month follow-up study, we aimed to investigate changes in carotid intima-media thickness (IMT), a surrogate marker of atherosclerosis, and its determinants in HIV-1-infected patients.

METHODS

Our multicentre prospective longitudinal cohort study included 346 HIV-infected patients, for each of whom two IMT measurements were taken by B-mode ultrasonography at baseline (M0) and 1 year later (M12).

RESULTS

We observed a significant but moderate increase in the common carotid artery (CCA) median IMT, from 0.54 to 0.56 mm (P<10(-4)), i.e. an increase of 0.020 mm (95% confidence interval 0.012-0.029). There was a significant association between cross-sectional CCA IMT measures at M12 and conventional cardiovascular risk factors (higher CCA IMT with older age, P<10(-4); male gender, P=0.02; tobacco consumption, P=0.05), as well as higher CD4 cell count at M12 (>median 455 cells/microL, P=0.01). Only CD4 cell count at M0 was strongly and positively associated with the variation in IMT between M0 and M12 (P=4 x 10(-3)). IMT progression was +0.0020 mm for the lowest quartile of CD4 cell count distribution at M0, i.e. 3-253 cells/microL, +0.010 mm for 253-402 cells/microL, +0.043 mm for 402-590 cells/microL, and +0.028 mm for 590-2270 cells/microL. No association was found with type or duration of antiretroviral exposure.

CONCLUSIONS

Conventional cardiovascular risk factors are major determinants of IMT evolution. The link between immunological status and carotid IMT requires further study.

[Linezolid, the first oxazolidinone antibiotic]

The spread of multiresistant Staphylococcus and Enterococcus strains required the development of new drugs. Linezolid is the first molecule of a new antibiotic family, oxazolidinones, with an original mechanism of action. In this general review, the authors first present its antibacterial activity, its pharmacokinetic properties, its therapeutic uses in serious Gram-positive infections, pneumonia, skin and soft tissue infections, and also in other indications. They then explain the rules for administration and tolerability.

Symptomatic bone disorders in HIV-infected patients: incidence in the Aquitaine cohort (1999-2002)

BACKGROUND

Since the inception of highly active antiretroviral therapy (HAART), mortality among HIV-infected patients has decreased, but this has been accompanied by the appearance of several complications.

OBJECTIVES

To estimate the incidence of symptomatic bone disorders in HIV-infected patients of the Aquitaine cohort (from south-west France) for the period 1999-2002, and to describe cases.

METHODS

We retrospectively studied the records of 2700 patients of the Aquitaine cohort, which was derived from a hospital-based surveillance system of HIV infection in France. All cases of symptomatic bone disorders diagnosed from 1 January 1999 to 30 June 2002 were reviewed.

RESULTS

Fourteen cases of bone disorders were diagnosed, eight cases of aseptic osteonecrosis and six cases of severe osteoporosis, representing incidences of 0.3/1000 patient-years [95% confidence interval (CI): 0.14-0.62] and 0.22/1000 patient-years (95% CI: 0.09-0.52), respectively. All patients with aseptic osteonecrosis were male, while all but one with osteoporosis were female. The ages of patients ranged from 36 to 54 years for osteonecrosis and from 39 to 50 for severe osteoporosis. At the time of clinical diagnosis, all patients were treated with nucleoside reverse transcriptase inhibitors (duration of treatment ranging from 19 to 123 months for osteonecrosis and from 46 to 132 months for severe osteoporosis). Ten patients were treated with nonnucleoside reverse transcriptase inhibitors [duration of treatment ranging from 6 to 31 months for osteonecrosis (n=6) and from 4 to 29 months for severe osteoporosis (n=4)]. Thirteen patients were treated with protease inhibitors [duration of treatment ranging from 12 to 62 months for osteonecrosis (n=8) and from 3 to 44 months for severe osteoporosis (n=5)]. All osteonecrosis and five osteoporosis patients had at least one known risk factor or comorbidity associated with the bone disorder occurrence.

CONCLUSIONS

In our study, the aetiology of clinical bone disorders seemed to be multifactorial, as almost all the patients had at least one possible risk factor in addition to HAART exposure.

Unexpected effects of inhaled fluticasone in an HIV patient with asthma

International guidelines recommend prescription of inhaled corticosteroids to improve asthma control. Chronic secondary adrenal suppression due to inhaled corticosteroids has been described. We report a case of acute adrenal suppression due to drug interaction between Fluticasone and antiretroviral therapy in a HIV patient. Seeing an increased prevalence of hyperresponsiveness among HIV-infected men, we conclude that coprescription of Fluticasone and highly active antiretroviral therapy must be carefully controlled.

Fibrates or statins and lipid plasma levels in 245 patients treated with highly active antiretroviral therapy. Aquitaine Cohort, France, 1999-2001

OBJECTIVES

To describe the effect and tolerance of lipid-lowering drugs (LLD; fibrates and statins) in patients treated with highly active antiretroviral therapy (HAART).

METHODS

A prospective study was performed in a large cohort of HAART-treated HIV-infected patients using guidelines for case management of dyslipidaemia. Inclusion criteria were: age over 18 years; HIV infection treated with HAART including at least one protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor (NNRTI); total cholesterol (TC)>5.5 mmol/L and/or triglycerides (TG)>2.2 mmol/L; and initiation of fibrates or statins. Viral load, CD4 cell count, plasma lipid levels and liver enzymes were measured at baseline (M0) and 3(M3) and 12(M12) months thereafter. Muscular enzymes were not assessed.

RESULTS

Fibrates were prescribed to 179 patients and statins to 66 patients. There was a significant mean decrease of TG in the fibrates group between M0 and M3 [-2.29 mmol/L; 95% confidence interval (CI)=-3.53, -1.05; P<10(-4)] and between M0 and M12 (-2.25 mmol/L; 95% CI:-4.23, -0.29; P<10(-4)); a significant decrease of TC was also noticed between M0 and M3 (-0.55 mmol/L; 95% CI:-0.95, -0.15; P=0.008) but not at M12 (-0.33 mmol/L; 95% CI:-0.94, 0.26; P=0.27). In the statins group, TC significantly decreased between M0 and M3 (-0.78 mmol/L; 95% CI:-1.3, -0.27; P=0.004) and between M0 and M12 (-0.70 mmol/L; 95% CI:-1.31, -0.09; P=0.03). There was no significant difference between the decreases of TG or TC observed in patients treated with PI or NNRTI. There were no significant modifications of viral load, CD4 cell count or liver enzymes during the 12 months of followup.

CONCLUSIONS

In this HAART-treated cohort, fibrates and statins were safe and associated with a favourable but moderate effect on lipid plasma levels.

Isolated antibodies against the core antigen of hepatitis B virus in HIV-infected patients

The aim of this study was to describe the frequency and significance of isolated antibodies against the hepatitis B virus (HBV) core antigen (HBc) in 2185 HIV-infected patients of the Aquitaine Cohort. Antibodies against HBc were found in 372 subjects (17%). Patients with isolated anti-HBc antibodies were more frequently coinfected with hepatitis C virus (HCV) (58.2%) than those who were anti-HB surface (HBs) antibody positive (22.9%, P<0.001) and those who were dually reactive anti-HBs/anti-HBc antibody positive (27.3%, P<0.001). These results suggest interactions between HBV and HCV. As observed in patients not infected with HIV, the "anti-HBc-alone" serological profile could reflect essentially late immunity with undetectable anti-HBs antibodies. However, an occult HBV infection cannot be ruled out.