A case report of clinical implications of a delayed antiretroviral therapy switch in a patient with multiple treatment interruptions

The Namibia national antiretroviral therapy guidelines recommend that patients living with HIV who interrupt antiretrovirals and in the process disengage from care be restarted on their usual antiretroviral therapy regimen upon return. We introduce a 39-year-old male patient on first-line antiretroviral therapy, namely, tenofovir disoproxil fumarate, lamivudine and efavirenz, from 2015 to 2019 (4 years), who returned to care after the fourth episode of interrupting his treatment, though his adherence to antiretroviral therapy was deemed poor. Thus, he presented with severe immunosuppression and an AIDS-defining condition. Hence, he was switched to second-line antiretroviral therapy, treated with fluconazole for oesophageal candidiasis and reinitiated on cotrimoxazole prophylaxis. The client is currently clinically stable with a suppressed viral load. Medical and drug history taking with an emphasis on the previous history of treatment failure in patients returning to care are paramount in guiding the choice of future prescriptions of antiretrovirals. The multiple antiretroviral therapy interruptions from the patient and the delay in decision-making on the side of the clinician to switch treatments contributed to the emergence of an AIDS-defining condition.

Clinical Characteristics and Immune Status of Patients with Severe Fever with Thrombocytopenia Syndrome

Severe fever with thrombocytopenia syndrome (SFTS) is a novel infectious disease caused by bunya virus. The purpose of this study was to investigate the clinical characteristics of SFTS patients and their virus-related immune disorders in vivo. Patients with SFTS admitted to Nanjing Drum Tower Hospital from 2017 to 2020 were retrospectively analyzed, and divided into survival group and death group according to the 28-day survival. Clinical characteristics and laboratory examination results of SFTS patients were recorded, and dynamic changes of immune function and inflammatory factors were statistically analyzed. Prolonged activated prothrombin time (APTT) (p = 0.001), high viral load (p = 0.001), and elevated human leukocyte antigen DR (HLA-DR) level (p = 0.002) were independent prognostic risk factors for SFTS patients. Compared to the survival group, the nonsurvival group was more prone to hemorrhagic and neurological symptoms (p < 0.05). Natural kill (NK) cell count, interleukin-10, interferon-α, and tumor necrosis factor-α scores in the nonsurvival group continued to increase after admission, while CD3+ T, CD4+ T, and CD8+ T cell counts continued to decrease. CD3+ T lymphocyte count was negatively correlated with viral load (R = 0.3883, p < 0.001), CD4+ T lymphocyte count was negatively correlated with viral load (R = 0.28933, p < 0.001), CD8+ T lymphocyte count was negatively correlated with viral load (R = 0.781, p < 0.001), and HLA-DR was positively correlated with viral load (R = 0.489, p < 0.001). High viral load, prolonged APTT time, and elevated HLA-DR level are independent prognostic risk factors for SFTS patients. The T lymphocyte subsets of SFTS patients continue to decrease after infection, and the number of T lymphocyte subsets can reflect the severity of the disease.

High SARS-CoV-2 viral load in travellers arriving in Spain with a negative COVID-19 test prior to departure

Hundred and ninety-six travellers with negative-COVID-19-tests prior to departure tested positive, on arrival at Madrid (April/June 2021), from a total of 45 211 travellers tested (0.43%). Viral loads (Ct: 20.3) were higher compared to the general population (Ct: 27.09). Our data reveal weaknesses in pre-departure testing and alert about high-viral-load-SARS-CoV-2 carriers in intercontinental flights.

Virologic Outcomes Among People Living With Human Immunodeficiency Virus With High Pretherapy Viral Load Burden Initiating on Common Core Agents

Background

People living with human immunodeficiency virus (PLWH) initiating antiretroviral therapy (ART) with viral loads (VLs) ≥100 000 copies/mL are less likely to achieve virologic success, but few studies have characterized real-world treatment outcomes.

Methods

ART-naive PLWH with VLs ≥100 000 copies/mL initiating dolutegravir (DTG), elvitegravir (EVG), raltegravir (RAL), or darunavir (DRV) between 12 August 2013 and 31 July 2017 were identified from the OPERA database. Virologic failure was defined as (i) 2 consecutive VLs ≥200 copies/mL after 36 weeks of ART; (ii) 1 VL ≥200 copies/mL with core agent discontinuation after 36 weeks; (iii) 2 consecutive VLs ≥200 copies/mL after suppression (≤50 copies/mL) before 36 weeks; or (iv) 1 VL ≥200 copies/mL with discontinuation after suppression before 36 weeks. Cox modeling estimated the association between regimen and virologic failure.

Results

There were 2038 ART-naive patients with high VL who initiated DTG (36%), EVG (46%), DRV (16%), or RAL (2%). Median follow-up was 18.1 (interquartile range, 12.4–28.9) months. EVG and DTG initiators were similar at baseline, but RAL initiators were older and more likely to be female with low CD4 cell counts while DRV initiators differed notably on factors associated with treatment failure. Virologic failure was experienced by 9.2% DTG, 13.2% EVG, 18.4% RAL, and 18.8% DRV initiators. Compared to DTG, the adjusted hazard ratio (95% confidence interval) was 1.46 (1.05–2.03) for EVG, 2.24 (1.50–3.34) for DRV, and 4.13 (1.85–9.24) for RAL.

Conclusions

ART-naive PLWH with high VLs initiating on DTG were significantly less likely to experience virologic failure compared to EVG, RAL, and DRV initiators.

Antiretroviral therapy-naïve people living with HIV (PLWH) initiating therapy with viral loads ≥100,000 copies/mL varied markedly at baseline. In adjusted models, PLWH initiating dolutegravir-based regimens were less likely to experience virologic failure as compared to elvitegravir, raltegravir and darunavir initiators.

Serum Hepatitis B Virus RNA Levels Predict HBeAg Seroconversion and Virological Response in Chronic Hepatitis B Patients with High Viral Load Treated with Nucleos(t)ide Analog

Background and Aim

Hepatitis B virus (HBV) RNA has attracted increasing attention as a novel serum marker for intrahepatic HBV replication. However, the predictive value of the serum level of HBV RNA for hepatitis B e-antigen (HBeAg) seroconversion and viral response among patients with a high viral load (HVL) is unclear. We evaluated the role of the serum level of HBV RNA as a predictor of treatment response in chronic HBV (CHB) patients with an HVL.

Patients and Methods

The study cohort was 66 HBeAg-positive CHB patients with an HVL (serum HBV DNA >1.9×10⁶ IU/mL) at baseline from our previous prospective cohort study treated with lamivudine (LAM) and adefovir dipivoxil(ADV) (N=31) or entecavir alone (N=35) for ≤96 weeks. The serum HBV RNA level was quantified by TaqMan^® probe-based reverse transcription real-time quantitative polymerase chain reaction at four time points.

Results

The baseline serum HBV RNA level (in log₁₀ copies/mL) in patients treated with LAM+ADV and ETV monotherapy was 8.97±1.22 and 9.15±0.92, respectively. After nucleos(t)ide analog (NA) therapy, the serum HBV RNA level decreased steadily in all patients (week 0 vs week 12, p<0.001; week 12 vs week 24, p=0.010; week 24 vs week 48, p<0.001). Fifty-three (80.3%) patients achieved a virologic response (VR), and 12 (18.2%) achieved HBeAg seroconversion after 96 weeks. Multivariate analyses revealed that the serum HBV RNA level at week 12 could predict HBeAg seroconversion (OR 3.560, 95% CI: 1.39–9.110, p=0.008) and VR (1.908, 1.115–3.265, 0.018) at 96 weeks. Analyses of receiver operating characteristic curves indicated that the serum HBV RNA level 12 weeks after NA treatment had predictive value for HBeAg seroconversion (AUC=0.847, p<0.001) and VR (AUC=0.736, p=0.011).

Conclusion

The serum level of HBV RNA at 12 weeks could predict HBeAg seroconversion and a VR during NA treatment in CHB patients with an HVL.

People with high HIV viral load within risk networks: who are these people and who refers them best?

Introduction:

Viral load is one of the most important determinants for HIV transmission. Identification of people with high viral load (PHVL) can be effective in limiting onward HIV transmission. In order to improve the identification of these individuals within risk networks, we determined a) the number of PHVL recruited through risk networks b) their socio-demographic, behavioural and clinical characteristics and c) the characteristics of individuals who referred these PHVL to the study.

Methodology:

From November 2013 to March 2016, in Odessa, Ukraine, Transmission Reduction Intervention Project (TRIP) was implemented to identify people recently infected with HIV within the risk networks of “seeds” and “venues” where they engaged in risk behaviour.

Results:

TRIP identified 53 PHVL, of whom 32 (60%) injected drugs; 42 (79%) were unaware of their HIV status; 25 (47%) had more than one sex partner, and only 14 (26%) were using condoms. There were 164 people who referred individuals into the study; 33 of them (20%) referred PHVL. In terms of referrers, those with lower than secondary level of education, not living with a sex partner, and reporting regular condom use were significantly more likely (p < 0.05) to refer PHVL. Most PHVL (38, 72%) and their referrers (27, 82%) were found through venues.

Conclusions:

In Odessa city, PHVL are at high risk of transmitting HIV as the majority inject drugs, do not know their HIV status, and have unprotected sex and/or multiple partners. Targeting these individuals for HIV prevention, harm reduction and initiation of antiretroviral treatment (ART) is urgent.

Genotypic Resistance Remains A Concern In Chronic Hepatitis B Patients With High Viral Load After Lamivudine And Adefovir Combination Therapy

Aims

Previous studies have shown that baseline high viral load is closely related to treatment response in chronic hepatitis B (CHB). This study was designed to evaluate the differences of treatment responses between de novo lamivudine (LAM) plus adefovir (ADV) combination therapy compared with entecavir monotherapy (ETV).

Methods

A total of 185 HBeAg-positive CHB patients with high viral load were enrolled and assigned to the LAM+ADV group (n=90) or ETV group (n=95). Clinical variables are extracted from medical records.

Results

No significant differences in baseline variables were found between the two groups before antiviral treatment. After 104 weeks of antiviral therapy, the mean HBV DNA viral load in the LAM+ADV group decreased from 8.01±0.65 log₁₀ copies/mL to 0.41±1.04 log₁₀ copies/mL, compared with 8.04±0.57 log₁₀ copies/mL to 0.57±1.28 log₁₀ copies/mL in the ETV group (P=0.35). The virological response rate of LAM+ADV group was 82.2% (74/90) at 104 weeks of treatment, and 80.0% (76/95) in the ETV group (P=0.70). For HBeAg serological responses, HBeAg loss occurred in 23.3% (21/90) and 17.9% (17/95) in the LAM+ADV group and the ETV group, respectively (P=0.36). HBeAg seroconversion was observed in 15.6% (14/90) and 15.8% (15/95) in the LAM+ADV group and ETV group, respectively (P=0.96). However, after 104 weeks of treatment, genotypic resistance was confirmed in 8 cases in the LAM+ADV group, a proportion of 8.8% (8/90), compared with an absence of genotypic resistance in the ETV group (P=0.003).

Conclusion

Both de novo combination therapy of LAM+ADV and ETV monotherapy could effectively inhibit HBV replication in patients with high viral load. However, the rate of genotypic resistance in LAM+ADV treatment remains a concern. For CHB patients with high viral load, ETV treatment may be superior.

Circulating miR-122 Is a Predictor for Virological Response in CHB Patients With High Viral Load Treated With Nucleos(t)ide Analogs

Chronic hepatitis B (CHB) infection remains worldwide health problem. Antiviral treatment options for CHB patients include nucleos(t)ide analogs (NAs) and interferon. Most of the current biomarkers for predicting treatment response are virus-dependent. MicroRNA-122 is the most abundant liver-specific miRNA and has been identified involved in multiple liver physiology and pathology including hepatotropic virus infection. To identify the role of miR-122 in NA therapy, 80 CHB patients with high viral load (HVL) were enrolled and serum miR-122 levels at baseline, week 12 and week 24 were measured. Serum miR-122 levels were significantly lower in patients who developed virological response (VR), compared with non-VR group. Levels of miR-122 at week 12 and week 24 were determined to be independent prognostic indicators for a VR with satisfactory AUROC values at 0.812 and 0.800, respectively. During NA therapy, serum miR-122 level deceased steadily and an earlier reduction was observed in VR group, indicating early reduction of miR-122 level might increase the possibility of developing virological response. In conclusion, we identified the dynamic change of serum miR-122 level and miR-122 levels at week 12 and week 24 as independent predictors for VR in CHB patients with HVL treated with NAs.

Serum hepatitis B core antibody levels predict HBeAg seroconversion in chronic hepatitis B patients with high viral load treated with nucleos(t)ide analogs

Background

Patients with chronic hepatitis B virus (HBV) infection who are hepatitis B virus e antigen (HBeAg) positive are increasingly being treated with nucleos(t)ide analogs (NUCs). However, the predictive value of serum hepatitis B virus core antibody (HBcAb) levels for HBeAg seroconversion among patients with high viral load remains unclear.

Methods

This study consisted of 74 patients with high viral load (HBV DNA >1 × 10⁷ copies/mL) enrolled in a multicenter, randomized, controlled trial, treated with lamivudine and adefovir (N = 32) or entecavir (N = 42) for up to 96 weeks. Serum HBV DNA, quantitative hepatitis B virus surface antigen (HBsAg), HBeAg, and HBeAb was tested at each visit. Quantitative HBcAb evaluation was conducted for all the available samples in the trial, by using a newly developed double-sandwich anti-HBc immunoassay.

Results

Serum HBcAb levels were significantly higher in patients with a serum alanine aminotransferase (ALT) level more than five times the upper limit of normal (ULN) compared with patients with ALT levels within 5 × ULN (4.25 ± 0.61 vs. 3.94 ± 0.47 log₁₀ IU/mL, P = 0.0345). Patients with HBeAg seroconversion were associated with a higher level of HBcAb at baseline, compared with those without HBeAg seroconversion (4.38 ± 0.54 vs. 4.02 ± 0.58 log₁₀ IU/mL, P = 0.029). The area under receiver operating characteristic curve of baseline HBcAb for HBeAg seroconversion was 0.71 (95% CI: 0.55-0.86, P = 0.013). When the baseline HBcAb level was >4.375 log₁₀ IU/mL, the sensitivity and specificity to predict HBeAg seroconversion at week 96 were 62.5% and 74.2%, and the positive likelihood ratio (LR) and negative LR were 2.42 and 0.51, respectively. The multivariate analysis result indicated that baseline serum HBcAb level was the only independent predictor for HBeAg seroconversion at week 96, with an odds ratio of 4.78.

Conclusion

Baseline serum HBcAb level >4.375 log₁₀ IU/mL could satisfactorily predict HBeAg seroconversion among patients with high viral load treated with NUC.

Long-term outcome of telbivudine versus entecavir in treating higher viral load chronic hepatitis B patients without cirrhosis

Chronic hepatitis B (CHB) patients with higher hepatitis B virus (HBV) load (higher viral load [HVL], HBV DNA ≥1 × 10⁷ copies/mL) require antiviral therapy, but data for evaluating the long-term outcome of this therapy with antiviral agents remain limited. We comparatively evaluated the efficacy and the safety of nucleoside analogues in 179 noncirrhotic CHB patients with HVL over 5 years. The HBeAg-positive (n = 104) or HBeAg-negative (n = 75) patients were treated consecutively with telbivudine (LdT, n = 88) or entecavir (ETV, n = 91) and evaluated for viral response, drug resistance and safety. HBV DNA, viral serology, biochemistries, HBV mutation and off-therapy relapse were determined. The cumulative rates of HBV DNA negativity were 86.4% and 94.5% for LdT and ETV at year 5, respectively. The rates of early viral response (EVR, HBV DNA <10³ copies/mL at month 6) under LdT and ETV treatments were 58.0% and 34.1%, respectively (P < .05). Hepatitis B e antigen (HBeAg) and Hepatitis B surface antigen (HBsAg) loss-seroconversions were 47.7% and 18.2% on LdT and 16.5% and 2.2% on ETV (P < .01). Eighteen patients (age 28.2 ± 3.1) experienced HBsAg loss-seroconversion, followed by 33 ± 4.6 month off-therapy without a relapse. Viral mutations and serum creatine kinase elevation were 9.1% and 8.0% on LdT, but only 1.1% and 0% on ETV. Both LdT and ETV suppressed HBV replication in HVL CHB patients within 5 years. LdT therapy achieved a higher EVR, HBeAg and HBsAg seroconversion, especially in the younger patients, whereas ETV caused lower drug resistance and fewer adverse events. This finding might help to identify the optimal treatment for CHB patients with HVL.

Sequential therapy with entecavir and pegylated interferon in a cohort of young patients affected by chronic hepatitis B

The treatment of patients affected by active chronic hepatitis B (CHB) could be performed using a finite-time therapy with pegylated-interferon alpha (PEG-IFN) or indefinite time treatment with nucleos(t)ide analogues (NAs). Current practice guidelines do not provide the combined use of PEG-IFN and NAs, but some studies analyzed various combined approach with NAs and PEG-IFN with encouraging result. In this perspective study, we have treated 39 patients with different hepatitis B virus (HBV) genotypes, hepatitis B "e" antigen (HBeAg)-positive/negative using a sequential therapy with entecavir (ETV) 0.5 mg/day monotherapy for 12 weeks followed by combination of ETV and PEG-IFN α-2a 180 µg/week for 12 weeks, then PEG-IFN monotherapy for 36 weeks. HBeAg seroconversion rate was 68.2%; HBsAg loss was 33.3%; sustained virological response (SVR) was 64.1%; primary non-response was observed in eight patients (20.5%) after 12 weeks of PEG-IFN therapy; virological relapse was reported in six (15.3%) patients. Viral genotype and hepatitis B surface antigen (HBsAg) decline were the most important predictive factor for PEG-IFN response. The stopping rule after 12 weeks of PEG-IFN therapy is useful for identify the non-responders. Our study offers interesting and promising results using a sequential combined therapy with ETV and PEG-IFN in a cohort of young patient with active CHB. These results, however, should not be generalized and further investigations are required for the confirmation of advantage of this combination approach. J. Med. Virol. 88:1953-1959, 2016. © 2016 Wiley Periodicals, Inc.

Pharmacokinetics of ribavirin in combined interferon-alpha 2b and ribavirin therapy for chronic hepatitis C virus infection

AIMS

The aim of this study was to clarify the pharmacokinetics of ribavirin and interferon-alpha (IFN-alpha) 2b when administered in combination for 24 weeks and effects of pharmacokinetics of both on treatment outcome in chronic hepatitis C with genotype 1b and high viral load.

METHODS

In this multicentre open study, 27 patients received 2-week daily induction therapy followed by 22-week, three-times-a-week maintenance therapy of intramuscular IFN-alpha 2b at a dose of 6 million units and oral ribavirin at 400 mg twice daily for 24 weeks, and followed up for 24 weeks post-treatment. Single- and multiple-dose pharmacokinetic studies were assessed by serial measurements of serum concentrations of both compounds at weeks 1 and 24.

RESULTS

Five patients attained sustained virological response. Serum ribavirin concentrations asymptoted after 4-8 weeks of treatment in all patients. The steady-state concentration correlated significantly with serum ribavirin clearance after multiple dosing (r = -0.875; 95% CI -0.932, -0.721; P < 0.001). Serum concentrations at weeks 4 and 8, Cmax and AUC(0,12 h) after multiple dosing and AUC(0,28 weeks) of ribavirin were significantly higher in sustained virological responders than in virological responders or nonresponders (P < 0.05, each). Increased Cmax and accumulation index of AUC(0,12 h) (median 10.5; 95% CI 6.4, 12.4), and prolonged washout half-life after multiple dosing reflected accumulation and slow clearance of ribavirin from the tissue compartments.

CONCLUSIONS

Continuous exposure and accumulation of ribavirin may be necessary for sustained virological response to combination therapy in chronic hepatitis C with genotype 1b and high viral load.