Predictors of bone mineral density in human immunodeficiency virus-1 infected children

OBJECTIVES

To compare bone mineral density (BMD) among human immunodeficiency virus (HIV)-infected children with population norms and to determine predictors of BMD in HIV-infected children.

METHODS

Total body BMD was measured by dual energy x-ray absorptiometry in 37 HIV-infected children and nine sibling controls at baseline. Clinical, dietary and anthropometric data were obtained at the time of the dual energy x-ray absorptiometry examination. Age- and gender-adjusted z scores were calculated for BMD, body mass index, weight and height from population standards. Age-adjusted percentiles were determined for dietary intake of calcium and vitamin D. Differences in BMD z scores between HIV-infected children and sibling controls were determined and adjusted for height and weight, as were independent risk factors for lower BMD among infected children. Eighteen HIV-infected children and 5 controls had serial BMD measures.

RESULTS

Compared with population norms, HIV-infected children had significantly lower BMD z scores (-0.51 SD, P = 0.004), in contrast with controls who had normal z scores (0.38 SD, P = 1.0). However, there was no difference in BMD z scores between HIV-infected children and the small number of sibling controls, adjusted for height and weight. Among HIV-infected children, lower BMD z scores were independently associated with lower weight z scores (P < 0.0001), lower height z scores (P = 0.01), advanced (stage B or C) HIV stage (P = 0.01) and age greater than 8 years (P < 0.0001). In the same model, multivitamin use (P = 0.009) and African American race (P = 0.001) were associated with better BMD z scores, with nevirapine use showing borderline positive effect (P = 0.06). All results were adjusted for Tanner stage. Change in BMD z score over time showed that there was no change or an increase in BMD in 100% of controls but in only 44% of the HIV-infected children (P = 0.09).

CONCLUSION

When compared with population norms, HIV-infected children had lower than expected bone mass for their age and gender that may be attributable to delays in growth, sexual maturity, time (length of HIV infection), ethnicity and disease severity. Dietary intake of calcium and vitamin D were not associated with bone loss, but most children had suboptimal intake. However, multivitamin use was strongly associated with better bone mineral density.

Ritonavir-based highly active antiretroviral therapy in human immunodeficiency virus type 1-infected infants younger than 24 months of age

BACKGROUND

Few data are available regarding clinical outcomes or dosing requirements for the protease inhibitor ritonavir in human immunodeficiency virus (HIV)-infected children younger than under 24 months of age.

METHODS

This prospective, multicenter phase I/II open label treatment trial used ritonavir, zidovudine and lamivudine to treat protease inhibitor-naive, HIV-infected infants between the ages of 4 weeks and 24 months. Two sequential dosing cohorts were treated with 350 or 450 mg/m(2) ritonavir every 12 hours; this report includes results of pharmacokinetics, safety, tolerability and efficacy through 104 weeks of follow-up of all subjects.

RESULTS

Fifty HIV-infected children were treated. By week 16, 36 had achieved HIV-1 RNA <400 copies/mL (72% intent-to-treat, 84% as-treated analysis); by week 104, 18 maintained durable viral suppression (36% intent-to-treat, 46% as-treated). Poor medication adherence by caregiver report contributed to virologic failure. Few subjects experienced treatment-limiting toxicity: emesis or ritonavir refusal in 6 (12%); and severe but reversible anemia or elevated serum hepatic transaminases in 1 (4%) each. Apparent oral clearance was higher and the median predose concentrations were substantially lower than those found in adults. Median z scores for weight and height for age/gender were below normal at baseline but improved by week 104.

CONCLUSIONS

A combination regimen of ritonavir, zidovudine and lamivudine was generally safe and produced sustained viral suppression in more than one-third of infants who initiated therapy before 2 years of age. Improved palatability of liquid preparations of protease inhibitors, supporting infrastructure and behavioral approaches to improve medication adherence with antiretrovirals will likely be necessary to further improve efficacy.

Laser scanning as a tool for assessment of HIV-related facial lipoatrophy: evaluation of accuracy and reproducibility

BACKGROUND

Facial lipoatrophy (LA) is a common complication of highly active antiretroviral therapy (HAART). Research into causes and treatment of facial LA is hindered by the lack of an objective measurement tool.

OBJECTIVE

To evaluate the accuracy and reproducibility of three-dimensional laser scanning (LS) for estimating cheek volume changes.

METHODS

Paired laser scans were performed and the images superimposed using commercial software. The volume difference between images was computed within a circle of radius 25 mm placed in a standardized position over the cheek area. Accuracy was tested by scanning before and after known volumes of plasticine (0.5--5 mL) were applied to the cheek area of a mannequin to simulate volume change. Reproducibility was tested by repeated scanning of the mannequin with and without 2 mL of plasticine, and repeated scanning of 10 healthy subjects over the course of 1 week.

RESULTS

The mean difference between actual and estimated volume change was small across the range of volumes tested [mean difference 0.08 mL; 95% confidence interval (CI)-0.36 to 0.20 mL). The coefficient of variation for repeated measurements of 2-mL volume change was 5.8%. The intraclass correlation coefficient for scan-to-scan variability was 0.812 (95% CI 0.515--0.947) and for day-to-day variability it was 0.764 (95% CI 0.332--0.935). Conclusions LS is an accurate and reproducible method for estimating cheek volume changes. It may be useful as an objective tool for assessment of facial LA in clinical research studies.

Circulating resistin levels are not associated with fat redistribution, insulin resistance, or metabolic profile in patients with the highly active antiretroviral therapy-induced metabolic syndrome

CONTEXT

The mechanisms underlying the development of the highly active antiretroviral therapy (HAART)-induced metabolic syndrome remain to be fully elucidated.

OBJECTIVE

The objective of this study was to investigate whether the adipocyte-secreted hormone, resistin, is associated with anthropometric and metabolic abnormalities of the HAART-induced metabolic syndrome.

DESIGN, SETTING, AND PATIENTS

We conducted a cross-sectional study of 227 HIV-positive patients (37 women and 190 men) recruited from the infectious diseases clinics. On the basis of history, physical examination, dual-energy x-ray absorptiometry, and single-slice computed tomography, patients were classified into four groups: non-fat redistribution (n = 85), fat accumulation (n = 42), fat wasting (n = 35), and mixed fat redistribution (n = 56).

MAIN OUTCOME MEASURES

The main outcome measures were serum resistin levels and anthropometric and metabolic variables.

RESULTS

Mean serum resistin levels were not significantly different among subjects with fat accumulation, fat wasting, or mixed fat redistribution or between these groups and the non-fat redistribution group. We found a weak, but significant, positive correlation between resistin and percent total body fat (r = 0.20; P < 0.01), total extremity fat (r = 0.18; P < 0.01), and abdominal sc fat (r = 0.19; P < 0.01), but not abdominal visceral fat (r = -0.10; P = 0.16) or waist to hip ratio (r = -0.05; P = 0.43). When adjustments were made for gender (women, 3.92 +/- 2.71 ng/ml; men, 2.96 +/- 2.61 ng/ml; P = 0.05), correlations between resistin and the above parameters were no longer significant. Importantly, resistin levels were not correlated with fasting glucose, insulin, homeostasis model assessment of insulin resistance index, triglycerides, or cholesterol levels in the whole group.

CONCLUSIONS

Resistin is related to gender, but is unlikely to play a major role in the insulin resistance and metabolic abnormalities of the HAART-induced metabolic syndrome.

Antiretroviral Therapy in HIV-Infected Children: The Metabolic Cost of Improved Survival

Although highly active antiretroviral therapy (HAART) has positively altered the morality rates in HIV-infected children, these drugs have the potential to cause significant morbidity. These drugs cause changes in fat distribution, lipid profiles, glucose, homeostasis, and bone turnover. The direct relationship between duration of drug exposure and increased risk of cardiovascular disease is particularly concerning for HIV-infected infants and children, who likely will have longer cumulative exposure to HAART. It is unclear whether the metabolic effects of decades of exposure would be reversible with cessation of therapy. The benefits of HAART in HIV infection are indisputable, but the impetus to find a cure or design more tolerable therapy is clear. Infarction may replace infection as the major cause of morbidity and mortality from HIV.

Alopecia in association with severe seborrhoeic dermatitis following combination antiretroviral therapy for acute retroviral syndrome

We present a case where alopecia occurred with severe seborrhoeic dermatitis associated with the commencement of combination antiretroviral therapy for acute retroviral syndrome. We postulate that the eruption could represent a novel manifestation in association with immunological response to antiretroviral therapy.

Three-year durability of dual-nucleoside versus triple-nucleoside therapy in a Thai population with HIV infection

We compared the long-term immunologic and virologic efficacy of the dual- and triple-nucleoside therapy for HIV infection. This was a retrospective analysis of 2 randomized clinical trials in antiretroviral-naive patients. In the dual-nucleoside group, 15 started with didanosine (ddI) monotherapy and then added stavudine (d4T) after 24 weeks, 63 started with various doses of d4T and ddI, and 53 started with zidovudine (ZDV) and lamivudine (3TC). In the triple-nucleoside group, 53 started with ZDV, 3TC, and ddI. After 48 weeks, patients who were not failing were randomized to immediate (before treatment failure) versus delayed (at the time of virologic failure) switching from ddI and d4T to ZDV and 3TC or vice versa and from ZDV, 3TC, and ddI to d4T, 3TC, and abacavir (ABC). Failure was defined as a plasma HIV-1 RNA level>or=1 log10 above nadir or >or=10,000 copies/mL when nadir was <500 copies/mL. Patients failing therapy before week 48 received the new treatment as in the immediate switching group. Hydroxyurea was added to the last treatment regimen if patients failed after week 96. CD4 count and plasma HIV-1 RNA level (branched DNA assay with a cutoff point of 50 copies/mL) at week 144 were analyzed by intention to treat. Compared with the dual-nucleoside group, the triple-nucleoside group had a higher proportion of patients with <50 copies/mL at 144 weeks (60% vs. 18%; P<0.001), higher median CD4 count (388 cells/microL vs. 346 cells/microL; P=0.018), and longer duration of response, defined as the time from onset of viral suppression (<500 copies/mL) to the time of treatment failure (the first of 2 consecutive HIV-1 RNA measurements >500 copies/mL never followed by 2 consecutive visits showing suppressible viremia to <500 copies/mL) or discontinuation from the study (144 weeks vs. 104 weeks; P=0.002). Multivariate regression analyses showed that significant predictors for treatment success, defined as a plasma viral load <50 copies/mL at week 144, were asymptomatic clinical status at enrollment, a baseline plasma viral load <or=30,000 copies/mL, treatment with triple nucleosides, and a viral load response of <500 copies/mL by week 12. Triple-nucleoside therapy with ZDV, 3TC, and ddI or d4T, 3TC, and ABC in patients with HIV infection is more effective in inducing a sustained virologic response than the dual combinations of ZDV and 3TC or ddI and d4T.

Premature atherosclerosis in HIV positive patients and cumulated time of exposure to antiretroviral therapy (SHIVA study)

BACKGROUND

With the advent of antiretroviral therapy regimens in HIV positive patients, it is crucial to consider their long-term benefits to risk ratios. The responsibility of treatment in premature atherosclerosis is not clear. Thus, the aim of this study is to evaluate the impact of exposure to reverse transcriptase inhibitors (nucleosidic and non-nucleosidic) and to protease inhibitors on the cardiovascular status of an entire hospital based cohort of patients.

METHODS

154 patients were included. Using a linear analysis, we sought an association between the cumulative time of exposure to these three classes of antiretroviral drugs and the carotid intima-media thickness measured by ultrasonography and a cardiovascular composite score.

RESULTS

The study confirms premature atherosclerosis, which not only correlates with the usual risk factors, such as triglyceride level, but also with protease inhibitor exposure, especially that of lopinavir. Nevertheless as regards current drug exposure, the clinical impact was low: five clinical complications of atherosclerosis and only one out of 35 scintigraphic and ECG exercise tests warranted a coronary angiography which was negative.

CONCLUSION

These data should not lead to the rejection of protease inhibitors but should strengthen the prevention of cardiovascular diseases as an integral part of the management of HIV patients.

Safety and tolerability of nevirapine-based antiretroviral therapy in HIV-infected patients receiving fluconazole for cryptococcal prophylaxis: a retrospective cohort study

BACKGROUND

To compare the adverse events after initiation of NVP-based ART among HIV-infected patients who did not receive fluconazole (group A), received fluconazole 400 mg/week (group B), and received fluconazole 200 mg/day (group C).

METHODS

A retrospective cohort study was conducted among HIV-infected patients who began NVP-based ART between December 2003 and September 2004. Patients were followed up for 6 months. Clinical hepatitis, elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (> 3 times from baseline), and skin rashes were studied.

RESULTS

There were 686 patients; 225, 392, and 69 patients in group A, B, and C, respectively. Baseline characteristics including age, previous opportunistic infections, use of antituberculous drugs, and baseline aminotransferase levels among the three groups were similar. Group C had a higher proportion of men (p = 0.016). Baseline median (IQR) CD4 cell counts were 85 (21-159), 18 (7-48), and 16 (5-35) cell/mm3 in group A, B, and C, respectively (p < 0.001). Of 2/225 (0.9%), 4/392 (1.0%), and 0/69 (0%) patients in group A, B, and C developed clinical hepatitis (p = 0.705). There were no significant difference of elevated AST or ALT among the three groups (p > 0.05). By logistic regression, receiving fluconazole was not predictive of clinical hepatitis, elevated aminotransferase, or skin rashes. At 6 months after initiating NVP, 174 (77.3%) patients in group A, 309 (78.8%) patients in group B, and 58 (84.1%) patients in group C remained on NVP.

CONCLUSION

Initiation of NVP-based ART among Thais with advance HIV disease receiving fluconazole is safe and well-tolerated. NVP should not be contraindicated for patients receiving fluconazole for treatment or prophylaxis of cryptococcosis.

HIV-associated tuberculosis and cryptococcosis in resource-limited settings

Tuberculosis (TB) and cryptococcosis are common infectious complications in HIV in resource-limited settings and contribute substantial morbidity and mortality. The increasing access to highly active antiretroviral treatment (HAART) has invited numerous challenges such as timing of HAART, cotreatment (drug dosages and interaction), immune reconstitution syndromes, and withdrawal of chemoprophylaxis. Numerous small studies propose the feasibility of concomitant TB/HIV treatment that needs to be confirmed in large, randomized trials. Treatment of acute cryptococcocal meningo-encephalitis with amphoterecin B is fraught with logistic problems in resource-limited settings. An effective safe dose of fluconazole as monotherapy needs to be determined in phase II studies. Current management guidelines extrapolated from developed countries may not necessarily apply and need validation in resource-limited settings.

Treatment of dyslipidaemia in HIV-infected persons

Accumulating evidence suggests that HIV-infected individuals have an increased risk of cardiovascular events. This risk seems to be at least partially mediated by dyslipidaemia, which is related to the use of highly active antiretroviral therapy (HAART). As HIV-infected individuals live longer due to HAART, their cardiovascular risk will invariably increase. Because HAART is likely to be used indefinitely, HAART-related dyslipidaemia has emerged as a major cardiovascular concern. This article summarises the evaluation of dyslipidaemia and cardiovascular risk in HIV-infected individuals, the potential pathophysiological and genetic mechanisms involved in HAART-related dyslipidaemia and the current treatment approaches. In general, dyslipidaemia is evaluated and treated as in HIV-negative persons. The first step is cardiovascular risk assessment and the determination of target lipid levels. A healthier lifestyle and, in particular, smoking cessation should be promoted. Lowering levels of low-density lipoprotein cholesterol (or, in the setting of significant hypertriglyceridaemia, non-high-density lipoprotein cholesterol) is the primary target of intervention. Switching HAART to a more lipid-favourable regimen should be considered if this does not jeopardise virological control. Many patients will need lipid-lowering drug therapy. Appropriate low-density lipoprotein cholesterol target levels may be more difficult to reach than in the HIV-negative population, and the potential for drug interactions when using lipid-lowering agents together with HAART needs to be considered. The identification of HAART strategies with no or minimal metabolic toxicity, and the identification of the safest and most efficacious lipid-lowering therapies for HIV-infected individuals with dyslipidaemia are important research goals.

Progressive neuropsychiatric problems following institution of highly active antiretroviral therapy

A 31 year old HIV infected woman developed neuropsychiatric problems soon after starting highly active antiretroviral therapy (HAART). Despite modifying and subsequently stopping HAART her condition progressively worsened. Cranial magnetic resonance imaging revealed multiple areas of abnormal signal suggestive of either a vasculitis or demyelination.

Acanthosis nigricans as an adverse effect of highly active antiretroviral therapy in an adolescent girl with human immunodeficiency virus infection

We report an 11-year-old girl with acanthosis nigricans that appeared after 4 years of treatment with didanosine, stavudine and amprenavir. Laboratory studies showed hyperglycemia, hyperinsulinemia and hypertriglyceridemia. Withdrawal of amprenavir resulted in disappearance of acanthosis nigricans and improvement of metabolic abnormalities.

Severe dyshidrosis in two patients with HIV infection shortly after starting highly active antiretroviral treatment

The use of highly active antiretroviral therapy (HAART) is the gold-standard treatment for HIV infected patients. We here describe two HIV positive patients whose histories are suggestive for dyshidrosis as an immune reconstitution inflammatory syndrome (IRIS). Several factors have been associated with the exacerbation of dyshidrosis lesions but no direct relationship with HAART has been reported until now.

Raised intracranial pressure complicating cryptococcal meningitis: immune reconstitution inflammatory syndrome or recurrent cryptococcal disease?

We report the case of a patient with advanced HIV disease and cryptococcal meningitis, who after an initially good clinical and mycological response to systemic anti-fungal treatment developed symptomatic raised intracranial pressure 10 days after initiation of highly active anti-retroviral therapy. We describe the subsequent clinical management and the features that suggest that this persistently raised ICP was more likely due to an immune reconstitution syndrome (IRIS) following HAART rather than relapse of cryptococcal disease or failure of anti-fungal therapy.

Transgenic expression of the deoxynucleotide carrier causes mitochondrial damage that is enhanced by NRTIs for AIDS

Nucleoside reverse transcriptase inhibitors (NRTIs) are antiretrovirals for AIDS with limiting mitochondrial side effects. The mitochondrial deoxynucleotide carrier (DNC) transports phosphorylated nucleosides for mitochondrial DNA replication and can transport phosphorylated NRTIs into mitochondria. Transgenic mice (TG) that exclusively overexpress DNC in the heart tested DNC's role in mitochondrial dysfunction from NRTIs. Two TG lines were created that overexpressed the human DNC gene in murine myocardium. Cardiac and mitochondrial structure and function were examined by magnetic resonance imaging, echocardiography, electrocardiography, transmission electron microscopy, and plasma lactate. Antiretroviral combinations (HAART) that contained NRTIs (stavudine (2', 3'-didehydro-2', 3'-deoxythymidine or d4T)/lamivudine/indinavir; or zidovudine (3' azido-3'-deoxythymidine or AZT)/lamivudine/indinavir; 35 days) were administered to simulate AIDS therapy. In parallel, a HAART combination without NRTIs (nevirapine/efavirenz/indinavir; 35 days) served as an NRTI-sparing, control regimen. Untreated DNC TGs exhibited normal cardiac function but abnormal mitochondrial ultrastructure. HAART that contained NRTIs caused cardiomyopathy in TGs with increased left ventricle mass and volume, heart rate variability, and worse mitochondrial ultrastructural defects. In contrast, treatment with an NRTI-sparing HAART regimen caused no cardiac changes. Data suggest the DNC is integral to mitochondrial homeostasis in vivo and may relate mechanistically to mitochondrial dysfunction in patients treated with HAART regimens that contain NRTIs.

Short communication: HIV infection, antiretrovirals, and apoptosis: studies on skeletal muscle

Increased apoptosis in CD4+ T lymphocytes plays an important role in the pathogenesis of HIV infection and it has also invoked some HIV-related as well as antiretroviral-related adverse events. We assessed whether increased apoptosis is also present in the skeletal muscle of HIV-infected patients. We included 36 consecutive individuals, 18 without (group A) and 18 with HIV infection. The latter group consisted of five asymptomatic antiretroviral-naive HIV-infected individuals (group B), six asymptomatic HIV-infected individuals on highly active antiretroviral therapy (HAART, group C), and seven HIV-infected individuals on HAART with lipodystrophy (group D). Immunohistochemical reaction using deoxyribonucleotidyltransferase-mediated- dUTP-biotin nick-end labeling (TUNEL) was performed on skeletal muscle samples. None of the uninfected patients (group A) showed data of increased apoptosis, while 16 out of 18 infected patients did (p < 0.001). All subgroups of infected subjects (groups B-D) showed a significant increase of apoptosis in TUNEL with respect to uninfected individuals, but the comparison between the different subgroups of infected patients did not reveal significant differences. We conclude that skeletal muscle of HIV-infected patients exhibits increased apoptosis compared with that of uninfected patients, but the role of HAART in inducing apoptosis remains to be established.

When to initiate antiretroviral therapy in HIV-1-infected adults: a review for clinicians and patients

One of the most controversial topics in the medical management of HIV disease is the optimal time to initiate highly active antiretroviral therapy (HAART) in HIV-1-infected adults. Premature exposure to antiretrovirals may precipitate early evolution of resistance and unnecessary side-effects, whereas remaining off HAART until late in the course of HIV disease may lead to reduced therapeutic benefits and elevated mortality. The lack of a randomised clinical trial to consider this issue has resulted in ongoing revision of expert recommendations and substantial variability between international consensus guidelines regarding the optimal time to initiate therapy. Since this uncertainty is a source of unease for both patients and clinicians, we summarise the latest evidence regarding the optimal time to initiate HAART with consideration of the potential benefits and drawbacks of starting HIV treatment at the different levels presently recommended in leading consensus guidelines.

Treatment of HIV-1-associated Kaposi's sarcoma with pegylated liposomal doxorubicin and HAART simultaneously induces effective tumor remission and CD4+ T cell recovery

BACKGROUND

The combination of highly active antiretroviral therapy (HAART) and liposomal doxorubicin is a promising approach for the treatment of progressive HIV-related Kaposi's sarcoma (KS). Here, we determined the safety, tolerability, and efficacy of liposomal doxorubicin and HAART as a combined treatment approach for advanced KS, and assessed the impact of liposomal doxorubicin on HAART-mediated immune reconstitution and viral suppression.

PATIENTS AND METHODS

In an uncontrolled observational trial, KS treatment responses were assessed in 54 HIV-1-infected patients with advanced KS according to ACTG criteria. Immunological and virological treatment responses were compared to 54 non-KS-affected HIV-1 patients who were individually matched to the study participants according to sex, age (+/- 5 years), CD4+ T cell count (+/- 25%), HIV RNA load (+/- 25%) and previous antiretroviral therapy exposure.

RESULTS

In 81.5% of the study patients, complete or partial responses were observed within a median of 8 weeks. Treatment-related side effects were predominantly confined to leukopenia (44.4% of patients) and mild-to-moderate liver enzyme elevation (22.3% of patients). Relative CD4+ T cell counts increased to a similar degree both in study patients and matched pairs (7% vs 6%, respectively), yet, absolute CD4+ T cell counts augmented considerably stronger in chemotherapy-naive matched pairs than in the study patients.

CONCLUSION

The simultaneous administration of HAART and liposomal doxorubicin is a safe and effective treatment approach for advanced KS and HAART-mediated recovery of relative CD4+ T cell counts does not seem to be impaired by concomitant treatment with liposomal doxorubicin.

Incidence and risk factors for liver enzyme elevation during highly active antiretroviral therapy in HIV-HCV co-infected patients: results from the Italian EPOKA-MASTER Cohort

BACKGROUND

The risk of hepatotoxicity associated with different highly active antiretroviral therapy (HAART) regimens (containing multiple-protease inhibitors, single-protease inhibitors or non nucleoside reverse transcriptase inhibitors) in HIV-HCV co-infected patients has not been fully assessed.

METHODS

Retrospective analysis of a prospective cohort of 1,038 HIV-HCV co-infected patients who commenced a new HAART in the Italian MASTER database. Patients were stratified into naïve and experienced to antiretroviral therapy before starting the study regimens. Time to grade > or =III hepatotoxicity (as by ACTG classification) was the primary outcome. Secondary outcome was time to grade IV hepatotoxicity.

RESULTS

Incidence of grade > or =III hepatotoxicity was 17.71 per 100 patient-years (p-yr) of follow up in naïve patient group and 8.22 per 100 p-yrs in experienced group (grade IV: 4.13 per 100 p-yrs and 1.08 per 100 p-yrs, respectively). In the latter group, the only independent factors associated with shorter time to the event at proportional hazards regression model were: previous liver transaminase elevations to grade > or =III, higher baseline alanine amino-transferase values, and use of a non nucleoside reverse transcriptase inhibitor based regimen. In the naive group, baseline aspartate transaminase level was associated with the primary outcome.

CONCLUSION

Use of a single or multiple protease inhibitor based regimen was not associated with risk of hepatotoxicity in either naïve or experienced patient groups to a statistically significant extent. A cautious approach with strict monitoring should be applied in HIV-HCV co-infected experienced patients with previous liver transaminase elevations, higher baseline alanine amino-transferase values and who receive regimens containing non nucleoside reverse transcriptase inhibitors.

High-risk dysmetabolism disorders associated with HAART-treated HIV disease, and reimbursement of lipid-lowering drugs, in a clinical and a socio-economic perspective

The significant advances achieved in the management of HIV disease, thanks to highly active antiretroviral therapy, are at risk of being frustrated by the recent changes in the cost reimbursement rules for all lipid-lowering drugs available in Italy. Unfortunately, the remarkably increased life expectancy achieved since mid-1996 by HIV-infected persons after the introduction of protease inhibitors and combined anti-HIV treatment, is accompanied by significant risks of developing diet-uncontrolled hypercholesterolemia and/or hypertriglyceridemia, often concurrent with insulin resistance, visceral adiposity, and hypertension, all known factors which can strongly predispose to severe cardiovascular events. International and national health care system recommendations regarding the reimbursability of lipid-lowering drugs have to take into careful consideration of this "special" category of patients (HIV-infected ones). These patients are exposed to a very frequent and severe, drug-induced dyslipidemia, and a subsequently elevated and progressively increasing cardiovascular risk, despite their proportionally lower mean age compared with that of the general at-risk population, and the lack of many concurrent risk factors which are employed to calculate the strict need for a lipid-lowering therapy, and its consequent cost reimbursement by the different health care systems.

Low frequency of renal function impairment during one-year of therapy with tenofovir-containing regimens in the real-world: a case-control study

Concern exists about the risk of nephrotoxicity using tenofovir (TDF) in HIV-infected patients. We performed a retrospective case-control study including 122 consecutive TDF-naive patients who started treatment with TDF-containing regimens and 194 patients receiving antiretroviral therapy with other antiretroviral drugs. During a 12-month observation period 5 (4.1%) patients in the TDF group versus 1 (0.5%) in the control group developed grade 1 or higher serum creatinine elevations (p = 0.018). Only 2 (1.6%) patients discontinued TDF treatment as a result of serum creatinine level elevations. In 4 of the 5 patients developing creatinine elevations TDF was combined with lopinavir-ritonavir. The use of TDF in clinical practice during a 12-month period is associated with low risk of mild renal failure. Further studies to assess long-term renal safety of this drug are needed.

Risk factors for CD4 lymphopenia in patients treated with a tenofovir/didanosine high dose-containing highly active antiretroviral therapy regimen

In this study, the dynamics of CD4 cell depletion during tenofovir/didanosine co-administration were analysed. Ninety-five HIV-positive patients were followed for 562 days, and 37 lost at least 50 CD4 cells, with a median delay of 274 days. Cox analysis showed that the CD4 cell decrease was associated with a duration of treatment by didanosine of more than 853 days and a didanosine dose of more than 5.50 mg/kg.