Long-term follow-up of 11 protease inhibitor (PI)-naïve and PI-treated HIV-infected patients harbouring virus with insertions in the HIV-1 protease gene

OBJECTIVES

Amino acid insertions in the protease gene have been reported rarely, and mainly in patients receiving protease inhibitors (PIs). The aim of the study was to assess the long-term viro-immunological follow-up of HIV-infected patients harbouring virus with protease insertions.

METHODS

Cases of virus exhibiting protease insertions were identified in routine resistance genotyping tests. Therapeutic, immunological and virological data were retrospectively collected.

RESULTS

Eleven patients harbouring virus with a protease gene insertion were detected (prevalence 0.24%), including three PI-naïve patients. The insertions were mainly located between codons 33 and 39 and associated with surrounding mutations (M36I/L and R41K). The three PI-naïve patients were infected with an HIV-1 non-B subtype. Follow-up of these PI-naïve patients showed that the insert-containing virus persisted for several years, was archived in HIV DNA, and displayed a reduced viral replicative capacity with no impact on resistance level. Of the eight PI-experienced patients, 63% were infected with HIV-1 subtype B; one had been antiretroviral-free for 5 years and seven were heavily PI-experienced (median duration of follow-up 24 months; range 10-62 months). The protease insertion was selected under lopinavir in four patients and under darunavir in one, in the context of major PI-resistance mutations, and following long-term exposure to PIs. The insert-containing virus persisted for a median of 32 months (range 12-62 months) and displayed no specific impact on phenotypic resistance level or viral replicative capacity.

CONCLUSION

Our data, obtained during long-term follow-up, show that insertions in the protease gene do not seem to have an impact on resistance level. This finding supports the recommendation of PI-based regimens, although further work is required to confirm it.

Gag mutations can impact virological response to dual-boosted protease inhibitor combinations in antiretroviral-naïve HIV-infected patients

ANRS 127 was a randomized pilot trial involving naïve patients receiving two dual-boosted protease inhibitor (PI) combinations. Virological response, defined as a plasma HIV RNA level of <50 copies/ml at week 16, occurred in only 41% patients. Low baseline plasma HIV RNA level was the only significant predictor of virological response. The purpose of this study was to investigate the impact on virological response of pretherapy mutations in cleavage sites of gag, gag-pol, and the gag-pol frameshift region. The whole gag gene and protease-coding region were amplified and sequenced at baseline and at week 16 for 48 patients still on the allocated regimen at week 16. No major PI resistance-associated mutations were detected either at baseline or in the 26 patients who did not achieve virological response at week 16. Baseline cleavage site substitutions in the product of the gag open reading frame at positions 128 (p17/p24) (P = 0.04) and 449 (p1/p6(gag)) (P = 0.01) were significantly more frequent in those patients not achieving virological response. Conversely, baseline cleavage site mutation at position 437 (TFP/p6(pol)) was associated with virological response (P = 0.04). In multivariate analysis adjusted for baseline viral load, these 3 substitutions remained independently associated with virological response. We demonstrated here, in vivo, an impact of baseline polymorphic gag mutations on virological response in naïve patients receiving a combination of two protease inhibitors. However, it was not possible to link the substitutions selected under PI selective pressure with virological failure.

[Emergence of Chagas' disease in Europe: description of the first cases observed in Latin American immigrants in mainland France]

This article describes the first cases of imported Chagas' disease detected in Paris, France. A total of 18 cases were recorded in two teaching hospitals between 2004 and 2007. There were 12 women and six men with a mean age of 38 years. All patients were Latin American immigrants who had recently arrived in France from Bolivia (Cochabamba and Santa-Cruz departments) 17 cases and from Salvador in 1. Eleven patients presented an asymptomatic indeterminate form of the chronic disease. Seven presented chronic Chagas cardiomyopathy including two with severe symptoms requiring placement of a pacemaker. Obtaining serological tests to confirm the diagnosis was difficult. All except one patient who was older than 50 years were treated with benznidazole. Based on these findings, the main priorities for management imported Chagas' disease in France are improvement of serological diagnosis and prevention of vertical transmission.

[Experience of targeted screening of Chagas disease in Ile-de-France]

2009 is marked by the centenary of the discovery by Carlos Chagas of Human American Trypanosomiasis. As a result of international cooperation its incidence has been falling in endemic areas, whereas North America and Europe are witnessing an increase in the number of imported cases. In metropolitan France, 18 such cases were reported between 2004 and 2007. Recently, estimates based on immigration figures have been made and suggest that about 1,500 imported cases can be expected in France. The object of this article is to assess the value of targeted screening of an at-risk population, originally from Latin America and now living in the Ile-de-France (area centred on Paris). The serological techniques employed were indirect immunofluorescence (IIF) and, depending on the case, 2 or 3 Elisa tests (Biomérieux, Biokit and Wiener). Trypanosoma cruzi serology was considered positive when the IIF was superior or equal to 200, or when two Elisa's were > 1, or when the IIF was superior or equal to 100 with at least one Elisa > 1. PCR was performed in 48 cases, which were considered to be positive. The tests were carried out on a voluntary basis after a publicity campaign within the Latin American community in the Ile-de-France. In this article, we present the findings of the first year of screening. Two hundred and fifty-four individuals were screened for Chagas' disease between June 2008 and June 2009. The median age was 33 years [11-63], the male/female ratio 102/152. Overall prevalence of positive serology was 23.6% (60/254). For six patients, the results were classified as "uncertain" (discordant serological tests). Of the seropositive group, 87.4% were Bolivian and 100% presented as a chronic form. Of these, 23.6% presented with functional cardiac manifestations and 22% with gastro-intestinal problems. The PCR was positive in 61% of the seropositive individuals. Clinical evaluation together with other investigations and therapeutic intervention is being carried out at present. These results confirm that metropolitan France is subject to the emergence of Chagas' disease in a non-endemic zone. This confirms the value of screening in at-risk populations, in particular because of the recent broadening of indications for antiparasitic treatment. In addition it is relevant to the prevention of vertical transmission or infection via organ donation, which could arise in France. These results also demonstrate continuing difficulties in the interpretation of serological results and the usefulness of PCR, which might increase sensitivity substantially.

A case of ciguatera fish poisoning in a French traveler

Ciguatera is a toxic poisoning due to ingestion of fish and is rarely reported in France. Little is known about this imported tropical disease. We present a case observed in Paris in a traveller returning from the Dominican Republic.

A case of ciguatera fish poisoning in a French traveler

Ciguatera is a toxic poisoning due to ingestion of fish and is rarely reported in France. Little is known about this imported tropical disease. We present a case observed in Paris in a traveller returning from the Dominican Republic.

[Alcohol, steatohepatitis, insulin resistance and hepatitis C]

Patients with chronic hepatitis C have frequently other morbidities, either because they are frequent in the general population (metabolic syndrome) and/or because the route of contamination (chronic alcohol consumption succeeding to drug abuse). These co-morbidities have a harmfull impact on fibrosis progression during the natural history of HCV infection and reduce the efficacy of antiviral treatments. Thus, it is crucial to diagnose early and treat these different diseases which may be combined. They are the metabolic syndrome and/or chronic alcohol consumption resulting in insuline resistance, infection by the human immune deficiency virus or by the hepatitis B virus as well as chronic tobacco use or excessive consumption of cannabis. An optimal is based on a multidisciplinary approach to reduce fibrosis progression and improve the efficiency of antiviral therapies. However, the hepatologist has to come back to a global care, which is mandatory at the individual level as well as for the public health.

Viral efficacy maintained and safety parameters improved with a reduced dose of stavudine: a pilot study

OBJECTIVES

Stavudine (d4T) is a potent but potentially toxic nucleoside reverse transcriptase inhibitor that is still widely used in developing countries. This study's aim was to determine the efficacy and safety profile of lower-dose d4T.

METHODS

Multi-centre, open-label, single-arm, pilot, 48-week study in French patients weighing >60 kg with viral load <400 HIV-1 RNA copies/mL who were receiving d4T 40 mg twice daily and then switched to 30 mg twice daily. The primary endpoint was the proportion with plasma viral load <400 copies/mL at week 24. Secondary endpoints included the proportion with <50 copies/mL at weeks 24 and 48, changes in mitochondrial DNA, CD4 cell count and pharmacokinetics, and clinical and laboratory safety.

RESULTS

Fifty-seven patients enrolled. Baseline CD4 count was 584 cells/microL; viral loads were <400 copies/mL and <50 copies/mL in 100% and 89%, respectively. Prior antiretroviral drug exposure was 6.9 years, d4T exposure was 6.3 years. Fifty-six out of 57 (98%) patients had viral load <400 copies/mL and 51 (89%) had viral load <50 copies/mL at week 24. Median CD4 count increased by 63 cells/microL at week 48 (P=0.006). At 48 weeks, total cholesterol decreased by 0.24 mmol (P=0.02), high-density lipoprotein cholesterol by 0.15 mmol (P=0.0001) and alanine aminotransferase by 5.74 mg/dL (P=0.01). Paired baseline DNA and week 24 RNA mutations were unchanged. Mitochondrial DNA (copies/cell) content increased from 672+/-254 to 682+/-269. d4T area under the plasma concentration time curve (AUC) decreased by 31% (P=0.003) and C(max) by 44% (P=0.004). Clinical and laboratory parameters improved or were unchanged.

CONCLUSIONS

Reduced-dose d4T is effective with improved safety parameters.