Disclosure and religion among people living with HIV/AIDS in France

The aim of this study was to examine associations between the importance of religion and disclosure of HIV seropositivity within sero-nonconcordant couples. In 2003, a face-to-face survey was conducted among patients selected in a random stratified sample of 102 French hospital departments delivering HIV care. Respondents who reported being in a couple with a non-HIV-positive partner were asked whether they had disclosed their HIV positive status to their partner and if religion represented an important aspect of their life. Among the 2932 respondents, 1285 were in a sero-non-concordant regular partnership. Among these, 37.5% reported that religion played an important role in their life; 7.2% had not disclosed their HIV-positive status to their partner, and 11.6% were unaware of their partner's HIV status. Lack of HIV disclosure to the partner was encountered more often among those who considered religion as an important aspect of their life. After multiple adjustment for socio-demographic factors, and for partnership characteristics, the importance of religion in the respondent's life remained independently associated with a lack of HIV disclosure to the regular partner. In conclusion, individuals who place importance on religion appear to have difficulties in disclosing their HIV-positive status due to the associated stigma and fear of discrimination.

Self-reported fatigue and depressive symptoms as main indicators of the quality of life (QOL) of patients living with HIV and Hepatitis C: implications for clinical management and future research

PURPOSE

To analyze the impact of self-reported fatigue and depressive symptoms on the quality of life (QOL) of patients co-infected with HIV and hepatitis C virus (HCV) not receiving anti-HCV therapy.

METHOD

We used data from a cross-sectional survey conducted among 115 co-infected adults including an assessment of QOL (WHOQOL-HIV bref questionnaire), depressive symptomatology (Center for Epidemiological Studies Depression Scale [CES-D]), and fatigue (Fatigue Impact Scale [FIS]).

RESULTS

Eighty-four percent of patients had been infected through injecting drug use (IDU). Half reported a history of depression or other psychiatric co-morbidities, 57% presented depressive symptoms, and 69% reported fatigue. FIS and CES-D scores accounted for 54% and 66% of total variance in psychological QOL and level of independence-related QOL, respectively, in a multivariate analysis adjusted for sociodemographic and clinical characteristics and alcohol or drug use. High FIS scores were independently associated with impaired physical QOL and social relationships, whereas high CES-D scores were independently associated with lower environmental QOL.

CONCLUSION

Self-reported fatigue and depressive symptoms are the best indicators of co-infected patients' QOL. These two indicators could be more easily used for a better clinical management of co-infected patients and also introduced as patient outcome measures in clinical research.

[Anhedonia and depressive symptomatology among HIV-infected patients with highly active antiretroviral therapies (ANRS-EN12-VESPA)]

INTRODUCTION

Anhedonia is defined as the loss of the capacity to feel pleasure and there is no consensus with its relationship with depressive symptomatology. Furthermore, no study has investigated the problematic of anhedonia in the context of HIV-infection, which concern a lot of patients with depressive symptoms. Depressive symptomatology presents a major challenge in the management of HIV-infection due to its central role in clinical progression.

OBJECTIVE

This study aims to disentangle relationship between determinants of anhedonia, depression and anxiety in order to optimise mental management of HIV infection.

METHOD

In 2003, a face-to-face survey (ANRS-EN12-VESPA) was conducted among patients selected in a random stratified sample of 102 French hospital departments delivering HIV care. Eligible respondents were HIV-infected outpatients, aged 18 or older living in France and diagnosed for at least six months. Among solicited patients, 2932 agreed to participate (response rate: 59%) and data about anhedonia, anxiety and depression are available for 1427 patients. The face-to-face gathered information on sociodemographic characteristics, such as education level, gender, partner, children, financial situation or housing and also psychosocial and sociobehavioural characteristics, such as drug use. Self-reported side effects of treatment were also available.

ASSESSMENT TOOLS

Anxiety and depression were assessed using the hospital anxiety and depression (HAD) scale. Physical anhedonia was assessed using the French version of the Chapman scale. Three regression models were used to identify factors associated with anhedonia, anxiety and depression among demographic, psychosocial and clinical characteristics.

RESULTS

Factors independently associated with anhedonia were older age (>50), lower education level, unemployment and men HIV contaminated by heterosexual relation or injecting drug use. Women, with lower education level, unemployment, without steady partner, with a detectable viral load and who reported side effect of HAART presented more frequently anxiety. Unemployment, uncomfortable housing, no social support from friends, self-reported side effect and lipodystrophy were independently associated with depression.

CONCLUSION

Our results underline the multiplicity of factors associated with mental disorders related to depression. These results can be explained by the fact that the anxiety and anhedonia are two cardinal symptoms of depression. Determinants of anhedonia and anxiety reported in this study may provide the key to a more exact delineation of depressive disorders in the context of HIV infection in order to optimize long-term psychological follow up of concerned patients.

Adding HCV treatment to HIV treatment in HIV-HCV coinfected patients: the impact on the different dimensions of fatigue and self-reported side effects

Hepatitis C virus (HCV) infection is frequent among human immunodeficiency virus (HIV)-infected patients, and is often associated with disabling symptoms such as fatigue. The purpose of this study was to assess the effect of HCV treatments on the perceived physical, cognitive, and psychosocial impact of fatigue (Fatigue Impact Scale) among HIV-HCV coinfected patients. A cross-sectional survey was conducted among 223 adult coinfected patients being followed-up in two clinical centers located in the south of France. Analysis was focused on patients who answered a self-administered questionnaire and who were being treated for their HIV infection (n=139). The cognitive, physical, and psychosocial impact of fatigue was significantly worse in patients also receiving HCV treatment (n=24) than in those receiving HIV treatment only (n=115). Along with depression, the number of self-reported treatment-related side effects was independently associated with fatigue scores after adjustment for all other characteristics. This number was significantly higher among patients on HCV treatment than among those who were not (relative risk [95% confidence interval]=1.4 [1.1; 1.7], P=0.002). In particular, skin or hair problems and general symptoms such as loss of appetite, loss of weight, fever, and headache were more prevalent among these patients. In conclusion, the combination of HIV and HCV treatments results in more self-reported side effects that exacerbate the perceived impact of fatigue among HIV-HCV coinfected patients. Effective follow-up of HCV-treated HIV-coinfected patients should, therefore, include close consideration and management of patients' subjective experience with treatments to reduce the burden of HCV-associated fatigue.

Time perspective and quality of life among HIV-infected patients in the context of HAART

We explored associations between time perspective (TP) and quality of life (QOL) among HIV-infected patients. With the French validated version of the Zimbardo Time Perspective Inventory, we evaluated the TP of patients. A self-administered questionnaire gathered information about QOL (WHOQOL-HIV), TP, relationship with medical staff and self-reported side effects of HAART. Six scores of QOL - physical, psychological, social relationship, environment, patient independence and spirituality were used as dependent variables in the linear regressions to identify factors associated with QOL. The sample (n=72) for this study was recruited from a hospital department specialising in HIV care and consisted of 48 (67%) HIV-infected women and 24 (33%) HIV-infected men with a mean age of 42 years. Using hierarchical regression analysis adjusted on socio-demographic characteristics, clinical characteristics and co-factors, significant relationships were observed between the several TP orientations and an impaired physical, environmental QOL as well as level-of-independence QOL. Specific dimensions of QOL are influenced by specific orientations of TP, which provides information on self-perception and subjective evaluation of QOL. The TP construct provides keys to managing HIV infection in order to improve QOL.

Health-related quality of life in HIV-1-infected patients on HAART: a five-years longitudinal analysis accounting for dropout in the APROCO-COPILOTE cohort (ANRS CO-8)

BACKGROUND

The long-term efficacy of Highly Active Antiretroviral Therapies (HAART) has enlightened the crucial role of health-related quality of life (HRQL) among HIV-infected patients. However, any analysis of such extensive longitudinal data necessitates a suitable handling of dropout which may correlate with patients' health status.

METHODS

We analysed the HRQL evolution over 5 years for 1,000 patients initiating a protease inhibitor (PI)-containing therapy, using MOS SF-36 physical (PCS) and mental (MCS) scores. In parallel with a classical separate random effects model, we used a joint parameter-dependent selection model to account for non-ignorable dropout.

RESULTS

HRQL evolved according to a two-phase pattern, characterized by an initial improvement during the year following HAART initiation and a relative stabilization thereafter. Immunodepression and self-reported side effects were found to be negative predictors of both PCS and MCS scores. Hepatitis C virus coinfection and AIDS clinical stage were found to affect physical HRQL. Results were not significantly altered when accounting for dropout.

CONCLUSION

Such results, obtained on a large sample of HIV-infected patients with extensive follow-up, underline the need for a regular monitoring of patients' immunological status and for a better management of their experience with hepatitis C and HAART.

Health related quality of life among both current and former injection drug users who are HIV-infected

BACKGROUND

This study aimed to determine factors associated with higher levels of health related quality of life (HRQL) among individuals HIV-infected through drug injection and to evaluate the impact of injecting drug status and opiate substitution treatment (OST) on HRQL.

METHODS

Two hundred and forty-three patients, enrolled in the MANIF cohort of patients HIV-infected through IDUs, participated. They completed a self-administered questionnaire, which included an HRQL evaluation (SF-12) and socio-demographic/clinical characteristics at the 42-month visit. Injecting drug status, OST and experience of negative life events (NLE) were collected at any follow-up visit in order to reconstitute individual trajectories.

RESULTS

Among the 243 patients, 35% reported a normal mental HRQL and 37% a normal physical HRQL. Independent predictors of "normal" mental HRQL were social support from partner, being a former IDU, no experience of violence-related NLE and few self-reported HAART-related side effects. "Normal" physical HRQL was predicted by younger age, stable partner, being a former IDU (> or = 6 months), CD4 cell count > 500, no experience of financial-related NLE and few HAART self-reported side effects.

CONCLUSIONS

As HRQL has been found to have a prognostic value on the survival of HIV patients infected through drug injection, then providing more comprehensive care (for example by paying more attention to patients' experience of stressful events, meeting their needs in psychosocial support and better management of perceived toxicity) could globally improve treatment outcomes in this vulnerable population.

Unprotected sex in regular partnerships among homosexual men living with HIV: a comparison between sero-nonconcordant and seroconcordant couples (ANRS-EN12-VESPA Study)

OBJECTIVE

We investigated factors associated with unprotected sex in regular partnerships among homosexual men living with HIV.

METHOD

We used data from a French national representative sample of people living with HIV (ANRS-EN12-VESPA survey). This analysis included men in a regular partnership with another man for at least twelve months. Unprotected sex was defined as reporting at least one episode of sexual intercourse without a condom with this regular partner in the previous 12 months. Separate analyses were conducted in sero-nonconcordant couples and in HIV-positive seroconcordant couples.

RESULTS

285 and 193 homosexual men respectively reported a regular sero-nonconcordant and seroconcordant partner. Unprotected sex was reported by a higher number of respondents within seroconcordant (46.7%) than within sero-nonconcordant couples (15.6%). In both seroconcordant and sero-nonconcordant partnerships, unprotected sex was significantly more frequent when episodes of unprotected sex with casual partners were reported. In seroconcordant couples, those who had more than four casual partners were also more likely to practise unprotected sex with their regular partner. Among sero-nonconcordant couples, binge drinking and absence of disclosure of one's HIV-positive status to the partner were also independently associated with unprotected sex.

CONCLUSIONS

A limited number of sero-nonconcordant homosexual couples persist in reporting risky sexual behaviour. Prevention messages should encourage communication and HIV disclosure. The relationship between unprotected sex with both casual and regular partners also calls attention about the underlying psycho-social and interactional factors that may influence sexual behaviours of people living with HIV in regular relationships, independently of the status of the partner.

Unsafe sex in regular partnerships among heterosexual persons living with HIV: evidence from a large representative sample of individuals attending outpatients services in France (ANRS-EN12-VESPA Study)

OBJECTIVE

Risky sexual behaviour remains frequent among people living with HIV. We analysed factors associated with unsafe sex within serodiscordant couples among heterosexual individuals living with HIV in France.

METHODS

In 2003, a face-to-face survey was conducted among individuals selected in a random stratified sample of 102 French hospital departments delivering HIV care. This analysis included adults heterosexual participants in a regular partnership for at least 12 months with a seronegative/unknown serostatus partner, HIV-diagnosed for at least 12 months. Unsafe sex was defined as reporting inconsistent condom use in the prior 12 months. Among men and women, participants who reported unsafe sex were compared with those who did not.

RESULTS

663 heterosexual adults reported being in a serodiscordant regular partnership. Women accounted for 41% of participants and 26% of the sample were immigrants. Unsafe sex with the steady partner was reported by 26% of men and 34% of women (p=0.024). For men, factors independently associated with unsafe sex were being in a relationship for more than 10 years, being in a difficult financial situation and reporting regular consumption of alcohol to excess. Among women, having a history of drug use, not being aware of partner's serostatus, and reporting a difficult financial situation were independently associated with unsafe sex. In addition, immigrant women were associated with safer sex.

CONCLUSIONS

A high number of serodiscordant couples continue to report risky sexual behaviour, and related factors are gender-specific. Couple-level interventions are essential in order to prevent HIV-transmission and to encourage negotiation within couples.

Health-related quality of life in French people living with HIV in 2003: results from the national ANRS-EN12-VESPA Study

OBJECTIVE

Since the advent of HAART, the assessment of health-related quality of life (HRQL) has become a major concern in the therapeutic follow-up of people living with HIV.

DESIGN

HRQL was evaluated for 2235 participants in the ANRS-EN12-VESPA Study. These participants completed the Medical Outcome Study 36-Item Short Form Health Survey (MOS SF-36) questionnaire. Anxiety and depression were assessed using the Hospital Anxiety and Depression (HAD) scale. Individuals were considered to have an 'acceptable' physical (and mental) HRQL if their MOS SF-36 scores were greater than the 25 percentile of the corresponding age-sex-specific distribution of scores in the French general population.

METHODS

Logistic regression models were used to identify factors associated with an 'acceptable' physical and mental HRQL among demographic, psychosocial and clinical characteristics. Potential selection bias caused by non-random missing responses to the MOS SF-36 questionnaire was statistically tested.

RESULTS

Physical and mental HRQL were 'acceptable' in 1176 (53%) and 1152 (51%) individuals, respectively. After adjusting for sociodemographic factors, HIV clinical status and hepatitis C co-infection, high HAD scores and the consumption of anxiolytic, antidepressant and hypnotic drugs were found to be negatively associated with normal physical and mental HRQL.

CONCLUSION

The role of disclosure and discrimination is determinant in HRQL, and the various cultural and psychological dimensions require further research. The presence of other infections or co-morbidities requires a comprehensive care system including medical staff and social worker teams. HIV should increasingly be regarded as a chronic disease characterized by different pathological conditions requiring a comprehensive and multidisciplinary approach.

Qualité de vie et syndrome lipodystrophique chez les patients infectés par le VIH

AIM OF THE STUDY

The aim of this work is to show to what extent a psychosocial evaluation can lead bring to comprehension of the subjectivity of Quality of Life (QoL) among HIV-infected patients. Evaluation of QoL makes it possible to understand the link between the therapeutic effectiveness and the subjective evaluation of the treatment, but also to estimate more precisely how people live and take their treatment in the context of HIV infection.

METHOD

This work confronts the variation of QoL with the variation of several social and psychosocial parameters identified as of the components of the system, which is the subjective evaluation, and more precisely to a specific side effect of Highly Active AntiRetroviral Therapies (HAART): lipodystrophy syndrome that consists in body fat redistribution. This side effect could consist in an accumulation of body fat, or a loss of body fat or a combination of both symptoms. The analysis was made on the data from APROCO-COPILOTE cohort composed of HIV-infected patients initiating HAART.

RESULTS

Among a sample of 706 patients follow-up for three years and with available QoL data, we identified the variations of QoL according to the variation of this specific side effect and according to gender. Results show that lipodystrophy syndrome has a determinant impact on QoL different among male and female patients. Adjusted on clinical and socio-demographic characteristics, impaired women's QoL is associated with accumulation of body fat and impaired men's QoL is associated with loss of body fat.

CONCLUSION

These results underline the role of body image on subjective evaluation of QoL. The analysis of empirical data made it possible to highlight the social implication of the evaluation of QoL from the role of the social support, patient-provider relationship and the social context.

Unsafe sex with casual partners and quality of life among HIV-infected gay men: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA)

INTRODUCTION

The introduction of highly active antiretroviral therapy has relaunched the debate on risky sexual behavior among HIV-infected gay men. It was proposed to study the influences of lifestyle characteristics and health-related quality of life (HRQL) on unsafe sex with casual partners in a representative sample of HIV-infected gay men.

METHODS

In 2003, a national survey based on face-to-face interviews was conducted among a representative sample of patients selected in a random stratified sample of 102 French hospital departments delivering HIV care. The patients selected for this analysis were gay men who reported having had sex with casual partners during the previous 12 months. Unsafe sex was defined as at least 1 episode of anal sexual intercourse without a condom with a casual partner during the previous 12 months. Health-related quality of life was assessed using the SF-36 Scale. Patients who declared that they had engaged in unsafe sex were compared with those who declared that they had not done so, using the chi test and logistic regressions.

RESULTS

Among the 1,117 gay men who participated in the study, 607 declared having had casual partners during the previous 12 months, and 140 (20%) of this latter group had engaged in unsafe sex. Poor mental HRQL was encountered in 68% of the patients and found to be independently associated with unsafe sex, even after multiple adjustment for number of partners, occurrences of binge drinking, use of anxiolytics, use of the Internet, and use of outdoor and commercial venues for sexual encounters.

CONCLUSIONS

Risky sexual behavior with casual partners is frequent among HIV-infected gay men. In addition to other well-known factors, behavior of this kind was found in this study to be related to poor mental HRQL. A more comprehensive approach to care designed to improve mental quality of life might therefore make for more effective secondary prevention.

[Health related quality of life among HIV-HCV co-infected patients]

BACKGROUND

To assess factors associated with higher levels of health-related quality-of-life among HIV-HCV co-infected injecting drug users and more specifically, to explore the role of injecting drug status and drug maintenance treatment on health-related quality-of-life.

METHODS

The two hundred and forty participants were patients enrolled in the MANIF cohort of HIV-HCV patients infected through injecting drug use who completed a self-administered questionnaire that included a health-related quality-of-life evaluation at the 42 month follow-up. A self-administered questionnaire collected information about socio-demographic characteristics, health-related quality-of-life (as measured by SF-12), injecting drug status and drug maintenance treatment, depressive symptoms, self-reported symptoms related to HIV treatment; clinical characteristics were obtained from medical records.

RESULTS

Higher levels of both mental and physical health-related quality-of-life were found in patients with no depressive symptoms, abstinent from drugs and experiencing few drug related problems. Patients on drug maintenance treatment who stopped injecting drugs had better mental health-related quality-of-life than injectors but lower levels of mental health-related quality-of-life than abstinent patients. Mental health-related quality-of-life was also independently higher in patients receiving high social support. Physical health-related quality-of-life was independently higher for patients who stopped injection, whether on drug maintenance treatment or not, for patients on anti-retroviral treatment and for patients who remained in clinical stage A.

CONCLUSIONS

Drug maintenance treatment seems to be associated with higher health-related quality-of-life among patients HIV-HCV co-infected by drug use, but it is still necessary to help patients cope with the mental impact of drug cessation. These results underline the need to provide regular psychological support and counselling for HIV-HCV co-infected injecting drug users during the medical follow-up for HIV-disease.

Health-related quality of life and health locus of control beliefs among HIV-infected treated patients

OBJECTIVE

This study examined the relations between health locus of control (HLOC) beliefs and health-related quality of life (HRQL) in 302 HIV-infected patients enrolled in a French cohort, 44 months (M44) after they began highly active antiretroviral therapy (HAART).

METHODS

HLOC beliefs were measured with the Multidimensional Health Locus of Control (MHLOC) scale and HRQL, with the Medical Outcome Study Short-Form Health Survey (MOS-SF-36).

RESULTS

Internal HLOC beliefs at the initiation of treatment were associated with both physical HRQL in multivariate analysis, while chance HLOC beliefs on beginning HAART were associated with mental HRQL at M44.

CONCLUSION

These findings suggest the importance of considering the psychological characteristics and psychosocial beliefs of patients at the initiation of ARV treatment to optimise the long-term HRQL of HIV-infected patient and to develop adaptive intervention on coping strategies.

Depression and clinical progression in HIV-infected drug users treated with highly active antiretroviral therapy

OBJECTIVE

To disentangle the impact of adherence from that of injecting drug status and depressive syndrome on HIV clinical progression in a cohort of highly active antiretroviral therapy (HAART)-treated HIV patients infected through drug use.

DESIGN

MANIF 2000 is a French cohort of HIV-infected drug users with scheduled medical visits every 6 months. Only patients enrolled in the MANIF 2000 cohort who had a CD4 cell count >200 cells/microl at HAART initiation were selected. The follow-up period included all post-HAART initiation visits.

METHODS

HIV clinical progression was defined as either AIDS-related death or reaching a CD4 level <200 cells/microl. Adherence was assessed using a self-administered questionnaire and a structured face-to-face interview. Depressive symptoms were evaluated by a Center for Epidemiologic Studies Depression Scale (CES-D) score at each visit. Cox proportional hazards model was used to calculate crude and adjusted relative hazards and 95% confidence intervals and thus identify independent predictors of clinical progression.

RESULTS

Of the 305 HAART-treated patients in the cohort, 243 had CD4 cell count >200 cells/microl at HAART initiation. At the first visit after HAART initiation, median CD4 cell count was 466 cells/microl and 45% had undetectable viral load. Injecting drug users accounted for 17% of the study group. Over the follow-up period, 32 patients experienced HIV clinical progression. Probable depression was encountered in 46% of patients and non-adherence in 31% of the sample. After adjustment on baseline CD4 cell count, predictors of clinical progression were: having a higher level of cumulative non-adherence over the follow-up period [HR (95% CI)=1.2 (1.1-1.3) per 10% increase] and having a high score of depressive symptoms following HAART initiation [HR (95% CI)=5.3 (2.21-3.0)].

CONCLUSIONS

Although depressive syndrome is known to influence non-adherence behaviours that are amongst the major reasons for clinical progression, it is also a predictor of clinical progression in HIV-infected intravenous drug users on HAART, independently of non-adherence behaviours. HIV care providers should be more sensitive to depressive symptoms in order to detect them early and supply HIV patients with specific care. Further research is needed to determine whether treating depressive symptoms may improve adherence and thus delay disease progression and mortality.

Depression and Clinical Progression in HIV-Infected Drug Users Treated with Highly Active Antiretroviral Therapy

Objective

To disentangle the impact of adherence from that of injecting drug status and depressive syndrome on HIV clinical progression in a cohort of highly active anti-retroviral therapy (HAART)-treated HIV patients infected through drug use.

Design

MANIF 2000 is a French cohort of HIV-infected drug users with scheduled medical visits every 6 months. Only patients enrolled in the MANIF 2000 cohort who had a CD4 cell count >200 cells/μl at HAART initiation were selected. The follow-up period included all post-HAART initiation visits.

Methods

HIV clinical progression was defined as either AIDS-related death or reaching a CD4 level <200 cells/μl. Adherence was assessed using a self-administered questionnaire and a structured face-to-face interview. Depressive symptoms were evaluated by a Center for Epidemiologic Studies Depression Scale (CES-D) score at each visit. Cox proportional hazards model was used to calculate crude and adjusted relative hazards and 95% confidence intervals and thus identify independent predictors of clinical progression.

Results

Of the 305 HAART-treated patients in the cohort, 243 had CD4 cell count >200 cells/μl at HAART initiation. At the first visit after HAART initiation, median CD4 cell count was 466 cells/μl and 45% had undetectable viral load. Injecting drug users accounted for 17% of the study group. Over the follow-up period, 32 patients experienced HIV clinical progression. Probable depression was encountered in 46% of patients and non-adherence in 31% of the sample. After adjustment on baseline CD4 cell count, predictors of clinical progression were: having a higher level of cumulative non-adherence over the follow-up period [HR (95% CI)=1.2 (1.1–1.3) per 10% increase] and having a high score of depressive symptoms following HAART initiation [HR (95% CI)=5.3 (2.21–3.0)]. Conclusions: Although depressive syndrome is known to influence non-adherence behaviours that are amongst the major reasons for clinical progression, it is also a predictor of clinical progression in HIV-infected intravenous drug users on HAART, independently of non-adherence behaviours. HIV care providers should be more sensitive to depressive symptoms in order to detect them early and supply HIV patients with specific care. Further research is needed to determine whether treating depressive symptoms may improve adherence and thus delay disease progression and mortality.

Plasma Levels of Indinavir and Nelfinavir at Time of Virologic Response May Have a Different Impact on the Risk of Further Virologic Failure in HIV-Infected Patients

Indinavir and nelfinavir plasma levels were studied in 407 patients having plasma HIV RNA <500 copies/mL after 4 months of treatment with these drugs. For each drug, an observed/predicted (O/P) ratio was calculated between individual and mean time-adjusted population plasma drug levels. The relationship between the O/P ratio and the risk of rebound of plasma HIV RNA >500 copies/mL beyond month 4 was studied using Cox proportional hazard models. Median follow-up was 20 months. There was no association between indinavir plasma levels and risk of virologic rebound, whereas low nelfinavir + M8 (active nelfinavir metabolite) plasma levels were associated with a higher risk of virologic rebound. In multivariate analysis, the adjusted relative hazard of virologic rebound for patients with an O/P ratio of nelfinavir + M8 metabolite <0.8 compared with others was 2.2 (P = 0.01). In some patients, plasma levels of nelfinavir sufficient to achieve early viral response may not be sufficient to maintain it in the long term. This may be related to insufficient compliance with dietary recommendations. Monitoring of nelfinavir plasma levels thus seems useful, even in patients having early virologic response.