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Ananworanich J, Nuesch R, Le Braz M, Chetchotisakd P, Vibhagool A, Wicharuk S, Ruxrungtham K, Furrer H, Cooper D, Hirschel B, Bernasconi E, Cavassini M, Ebnöther C, Fagard C, Genné D, Khanna N, Perrin L, Phanupak P, Ubolyam S, Vernazza P, Yerly S. Failures of 1 week on, 1 week off antiretroviral therapies in a randomized trial. AIDS 2003; 17:F33-7. [PMID: 14523294 DOI: 10.1097/00002030-200310170-00001] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Scheduled treatment interruptions are being evaluated in an effort to decrease costs and side effects of highly active antiretroviral therapy (HAART). A schedule of 1 week on and 1 week off therapy offers the promise of 50% less drug exposure with continuously undetectable HIV RNA concentration. METHODS In the Staccato study 600 patients on successful HAART were to be randomized to either continued therapy, CD4-guided therapy, or one week on, one week off therapy. A scheduled preliminary analysis evaluated effectiveness in the 1-week-on-1-week-off arm. RESULTS Of 36 evaluable patients, 19 (53%) had two successive HIV RNA concentrations > 500 copies/ml at the end of the week off therapy, and were classified as virological failure. Most of those who failed took didanosine, stavudine, saquinavir, and ritonavir (11 patients). In these patients, there was no evidence of mutations suggestive of drug resistance, and plasma saquinavir levels were within the expected range. Two of three patients failing on triple nucleotides had drug resistance mutations, but nonetheless responded to reintroduction of triple nucleotide therapy. One of two patients taking nevirapine, and one of eight taking efavirenz, also failed. Both had resistance mutations at the time of failure, but not at baseline. CONCLUSIONS The 1-week-on-1-week-off schedule, as tested in the Staccato study, showed an unacceptably high failure rate and was therefore terminated.
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Staehelin C, Rickenbach M, Low N, Egger M, Ledergerber B, Hirschel B, D'Acremont V, Battegay M, Wagels T, Bernasconi E, Kopp C, Furrer H. Migrants from Sub-Saharan Africa in the Swiss HIV Cohort Study: access to antiretroviral therapy, disease progression and survival. AIDS 2003; 17:2237-44. [PMID: 14523281 DOI: 10.1097/00002030-200310170-00012] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the proportion of migrants from Sub-Saharan Africa entering the Swiss HIV Cohort Study (SHCS) and to compare these participants with participants from Northwestern Europe for access to antiretroviral therapy, progression to AIDS and survival. DESIGN Prospective national cohort study of HIV-1-infected adults from seven HIV centres in Switzerland. METHODS Trends in the proportion of participants from Sub-Saharan Africa were followed in 11 872 HIV-infected adults entering the SHCS from 1984 to 2001. Survival methods were used to compare uptake of antiretroviral therapy, survival and progression to AIDS in the 2684 participants from Sub-Saharan Africa and Northwest Europe enrolled from 1997-2001. RESULTS There was a steady increase in the proportion of Sub-Saharan African participants over time, reaching 11.9% in 1997-2001. These participants were more likely to be younger, female, to have been infected by heterosexual intercourse and had lower CD4 cell counts at presentation. There were no differences between Sub-Saharan Africans and Northwest Europeans in uptake of triple antiretroviral therapy, progression to AIDS or survival up to 48 months after starting treatment. Tuberculosis was the most frequent AIDS-defining event in Sub-Saharan African patients. CONCLUSIONS There is no evidence that access to potent antiretroviral therapy is influenced by geographic origin of participants. The prognosis of Sub-Saharan African patients on triple therapy is equivalent to that of Northwest European patients. Future research should address wider issues about access to specialist health services for HIV-infected people from Sub-Saharan Africa.
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Furrer H, Erb P. Editorial. THERAPEUTISCHE UMSCHAU 2003; 60:587. [PMID: 14626208 DOI: 10.1024/0040-5930.60.10.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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304
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Wolf K, Young J, Rickenbach M, Vernazza P, Flepp M, Furrer H, Bernasconi E, Hirschel B, Telenti A, Weber R, Bucher HC. Prevalence of unsafe sexual behavior among HIV-infected individuals: the Swiss HIV Cohort Study. J Acquir Immune Defic Syndr 2003; 33:494-9. [PMID: 12869838 DOI: 10.1097/00126334-200308010-00010] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Sexual contact is the major mode of HIV transmission. Increased sexual risk taking has been described in HIV-infected individuals receiving potent antiretroviral therapy. A new questionnaire on sexual behavior was introduced into the Swiss HIV Cohort Study on April 1, 2000. We evaluated sexual behavior in all individuals who completed the questionnaire for the first time within 1 year after its introduction. Our primary hypothesis was that self-reported unsafe sexual behavior would be more prevalent among individuals with optimal viral suppression. On April 1, 2000, 4948 individuals were registered in the study, and 4723 (95%) completed the questionnaire. Of these individuals, 12% reported unsafe sex, 78% received antiretroviral therapy, and 25% had optimal viral suppression (HIV RNA level always <50 copies/mL during the preceding 12 months). During the preceding 6 months, 55% of individuals had stable and 19% had occasional partners, and 6% had both types of partners. Sexual intercourse was reported by 82% of individuals with stable and 87% of individuals with occasional partners, and of those reporting sexual intercourse in each group, 76% and 86%, respectively, said that they always used condoms. After adjustment for covariates, reported unsafe sex was not associated with optimal viral suppression (odds ratio, 1.04; 95% confidence interval, 0.81-1.33) or antiretroviral therapy (odds ratio, 0.83; 95% confidence interval, 0.65-1.07), but it was associated with gender, age, ethnicity, HIV transmission group, HIV status of partner, having occasional partners, and living alone. There is no evidence that self-reported unsafe sexual behavior is more prevalent among HIV-infected individuals with optimal viral suppression. However, unsafe sex is associated with other factors.
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Fagard C, Oxenius A, Günthard H, Garcia F, Le Braz M, Mestre G, Battegay M, Furrer H, Vernazza P, Bernasconi E, Telenti A, Weber R, Leduc D, Yerly S, Price D, Dawson SJ, Klimkait T, Perneger TV, McLean A, Clotet B, Gatell JM, Perrin L, Plana M, Phillips R, Hirschel B. A prospective trial of structured treatment interruptions in human immunodeficiency virus infection. ARCHIVES OF INTERNAL MEDICINE 2003; 163:1220-6. [PMID: 12767960 DOI: 10.1001/archinte.163.10.1220] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND According to the "autovaccination hypothesis," reexposure to human immunodeficiency virus (HIV) during treatment interruptions may stimulate the HIV-specific immune response and lead to low viremia after withdrawal of highly active antiretroviral treatment (HAART). Many patients who started HAART earlier in their disease course than is currently recommended would like to discontinue, but it is unknown whether it is safe to do so. OBJECTIVES To determine whether repeated treatment interruptions of HAART (1) stimulated the cytotoxic HIV-specific immune response and whether such stimulation correlated with low viremia off treatment, and (2) were safe with respect to clinical complications, development of viral resistance, and decline in CD4 cell counts. DESIGN Interventional study with before-after comparison. SETTING Outpatient clinics of university hospitals in Switzerland and Spain. PATIENTS A total of 133 patients receiving HAART, with a median CD4 cell count of 740/ microL, and whose viral load had been undetectable for a median of 21 months. INTERVENTIONS HAART was interrupted for 2 weeks, restarted, and continued for 8 weeks. After 4 such cycles, treatment was indefinitely suspended 40 weeks after study entry. MAIN OUTCOME MEASURES HIV-specific cytotoxic T-cell responses were evaluated by interferon gamma enzyme-linked immunospot analysis. The proportion of "responders" (viral load <5000 copies/mL) was measured at weeks 52 and 96. HIV-related diseases and CD4 cell counts were recorded. RESULTS Seventeen percent of patients (95% confidence interval, 11%-25%) were responders at week 52, and 8% at week 96. Low pre-HAART viral load and lack of rebound during weeks 0 to 40 predicted response. HIV-specific CD8+ T cells increased between week 0 (median, 343 spot-forming cells per million peripheral blood lymphocytes [SFC/106 PBL]) and week 52 (median, 1930 SFC/106 PBL), but there was an inverse correlation between response and the number of spot-forming cells. Eighty-five (64%) of 133 patients stopped therapy for at least 12 weeks, and 55 (41%) for at least 56 weeks. The median CD4 cell count decreased from 792/ microL to 615/ microL during the first 12 weeks without treatment, but stabilized thereafter. One patient (0.75%) developed drug resistance necessitating salvage treatment. There were no AIDS-related clinical complications. CONCLUSIONS Results of this study do not favor the autovaccination hypothesis. Treatment interruptions did not provoke clinical complications, and there was little drug resistance. Comparative trials will have to show what benefit, if any, is associated with intermittent, as opposed to continuous treatment.
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306
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Furrer H, Battegay M, Spirig R, Flepp M. [Challenges in HIV long-term care]. Dtsch Med Wochenschr 2003; 128:1064-9. [PMID: 12736858 DOI: 10.1055/s-2003-39106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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307
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Eigenmann C, Flepp M, Bernasconi E, Schiffer V, Telenti A, Bucher H, Wagels T, Egger M, Furrer H. Low incidence of community-acquired pneumonia among human immunodeficiency virus-infected patients after interruption of Pneumocystis carinii pneumonia prophylaxis. Clin Infect Dis 2003; 36:917-21. [PMID: 12652393 DOI: 10.1086/368190] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2002] [Accepted: 11/03/2002] [Indexed: 11/03/2022] Open
Abstract
We compared the incidence of bacterial pneumonia among 336 patients who discontinued trimethoprim-sulfamethoxazole (TMP-SMX) as prophylaxis against Pneumocystis carinii pneumonia (PCP) with that among 75 patients who fulfilled the criteria for discontinuation but continued receiving prophylaxis. The difference in the overall incidence rates for the 2 groups (1.2 events per 100 person-years) was not statistically significant. Discontinuation of TMP-SMX prophylaxis against PCP is not associated with a significant increase in the incidence of bacterial pneumonia among patients with a sustained CD4 cell count increase to >200 cells/microL.
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Furrer H, Barloggio A, Egger M, Garweg JG. Retinal microangiopathy in human immunodeficiency virus infection is related to higher human immunodeficiency virus-1 load in plasma. Ophthalmology 2003; 110:432-6. [PMID: 12578793 DOI: 10.1016/s0161-6420(02)01750-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To evaluate the prevalence of retinal microangiopathy in human immunodeficiency virus (HIV)-1-infected patients and its association with virologic, immunologic, and sociodemographic parameters. DESIGN Single-center cross-sectional study. PARTICIPANTS One hundred eighty-eight HIV-1-positive individuals from a single outpatient clinic. METHODS Human immunodeficiency virus-positive patients were screened for signs of HIV-associated retinal angiopathy. Plasma HIV-1 RNA and CD4-positive cell counts were monitored within 3 months of the ophthalmologic assessment. The absence or presence of angiopathy or of opportunistic viral retinitis was then correlated to data respecting CD4-positive cell count, plasma viral load of HIV-1, and sociodemographic parameters. MAIN OUTCOME MEASURES Association between CD4-positive cell count, HIV-1 plasma viral load, sociodemographic parameters, and the manifestation of retinal microangiopathy. RESULTS At the baseline consultation, 130 (69%) patients exhibited no retinal pathologic features, 45 (24%) manifested retinal angiopathy, and 13 (7%) had opportunistic viral retinitis. In univariate analysis, retinal angiopathy was associated with lower CD4-positive cell count and higher HIV-1 plasma viral load. In a multivariate logistic model, the presence of retinal microangiopathy was associated with higher age (P = 0.02) and higher viral load of HIV-1 (P < 0.005), but not with lower CD4 cell counts (P > 0.05). CONCLUSIONS Human immunodeficiency virus-associated retinal microangiopathy is likely a multifactorial condition. Its presence is associated with higher age and higher replication of HIV-1 as measured by plasma HIV-1 RNA levels. In contrast to opportunistic infectious retinitis, the degree of immunodeficiency does not seem to be independently correlated with retinal angiopathy.
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309
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Bucher HC, Bichsel M, Taffé P, Furrer H, Telenti A, Hirschel B, Weber R, Bernasconi E, Vernazza P, Minder C, Battegay M. Ritonavir plus saquinavir versus single protease inhibitor therapy in protease inhibitor-naive HIV-infected patients: the Swiss HIV Cohort Study. HIV Med 2002; 3:247-53. [PMID: 12444942 DOI: 10.1046/j.1468-1293.2002.00113.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To compare the response to ritonavir (RTV) plus saquinavir (SQV) with single protease inhibitor (PI) therapies among PI-naive HIV-1 infected individuals. METHODS Response to treatment was analysed according to the intent-to-treat principle in a prospective observational cohort study of 177 patients who between May 1995 and March 2000 started a double PI therapy with RTV and SQV (nonboosting dosages) plus at least one nucleoside reverse transcriptase inhibitor (NRTI) and 2,214 patients with a single PI therapy plus two NRTIs. We used survival analysis and Cox's proportional hazard regression methods. The primary endpoint was the time to a plasma viral load of < 400 copies/mL. Secondary endpoints were taken as a gain in the CD4 count of >100 cells/microL, and change of initial PI for any reason. RESULTS Baseline characteristics in both treatment groups were balanced. Median follow-up in both groups was 10.4 months. Time to an HIV-1 viral load of < 400 copies/mL and an increase in the CD4 count of >100 x 10(6) cells/L was shorter for RTV plus SQV compared with single PI regimens (log rank test for each endpoint P < 0.05). The adjusted hazard ratios of RTV plus SQV compared with single PI regimens were 1.21 (95% confidence interval 0.99-1.47) for achieving an HIV-1 viral load of < 400 copies/mL, 1.12 (0.88-1.42) for an increase in the CD4 count of > 100 cells/microL, and 0.90 (0.73-1.11) for change of first PI regimen. CONCLUSIONS Treatment with RTV plus SQV compared with single PI regimens appeared to give similar results for virological or immunological response.
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310
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Greub G, Cozzi-Lepri A, Ledergerber B, Staszewski S, Perrin L, Miller V, Francioli P, Furrer H, Battegay M, Vernazza P, Bernasconi E, Günthard HF, Hirschel B, Phillips AN, Telenti A. Intermittent and sustained low-level HIV viral rebound in patients receiving potent antiretroviral therapy. AIDS 2002; 16:1967-9. [PMID: 12351960 DOI: 10.1097/00002030-200209270-00017] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lotti B, Wendland T, Furrer H, Yawalkar N, von Greyerz S, Schnyder K, Brandes M, Vernazza P, Wagner R, Nguyen T, Rosenberg E, Pichler WJ, Brander C. Cytotoxic HIV-1 p55gag-specific CD4+ T cells produce HIV-inhibitory cytokines and chemokines. J Clin Immunol 2002; 22:253-62. [PMID: 12405158 DOI: 10.1023/a:1020066404226] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
CD4+ T-helper cells appear to be essential in sustaining immune responses in chronic viral infections, as the maintenance of CD8+ cytotoxic T-lymphocyte responses and the control of viremia were demonstrated to depend on CD4+ T cell help. In order to investigate the function of HIV-specific CD4+ T cells in chronic HIV-1-infection, 49 chronically HIV-infected patients were analyzed before and 3 and 6 months after initiation of antiviral treatment. Ten patients showed a substantial, although weak, proliferative response to HIV-1-p55gag protein for which no improvement was observed upon initiation of HAART. From one individual, HIV-1-p55gag-specific CD4-positive T-cell clones were generated that were heterogeneous in their TCR Vbeta gene usage and HLA-DRB1*13 and DRB1*03 restricted, respectively. In addition, some CD4+ TCC produced substantial amounts of IFN-gamma and MIP-1alpha/beta were perforin-positive, and showed cytotoxic activity. These diverse functional features of HIV-specific CD4+ T cells suggest that they may exert direct antiviral activity.
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312
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Kirk O, Reiss P, Uberti-Foppa C, Bickel M, Gerstoft J, Pradier C, Wit FW, Ledergerber B, Lundgren JD, Furrer H. Safe interruption of maintenance therapy against previous infection with four common HIV-associated opportunistic pathogens during potent antiretroviral therapy. Ann Intern Med 2002; 137:239-50. [PMID: 12186514 DOI: 10.7326/0003-4819-137-4-200208200-00008] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The safety of interrupting maintenance therapy for previous opportunistic infections other than Pneumocystis carinii pneumonia among patients with HIV infection who respond to potent antiretroviral therapy has not been well documented. OBJECTIVE To assess the safety of interrupting maintenance therapy for cytomegalovirus (CMV) end-organ disease, disseminated Mycobacterium avium complex (MAC) infection, cerebral toxoplasmosis, and extrapulmonary cryptococcosis in patients receiving antiretroviral therapy. DESIGN Observational study. SETTING Seven European HIV cohorts. PATIENTS 358 patients taking potent antiretroviral therapy (> or =3 drugs) who interrupted maintenance therapy at a CD4 lymphocyte count greater than 50 x 10(6) cells/L. MEASUREMENTS Recurrence of opportunistic infection after interruption of maintenance therapy. RESULTS 379 interruptions of maintenance therapy were identified: 162 for CMV disease, 103 for MAC infection, 75 for toxoplasmosis, and 39 for cryptococcosis. During 781 person-years of follow-up, five patients had relapse. Two relapses (one of CMV disease and one of MAC infection) were diagnosed after maintenance therapy was interrupted when the CD4 lymphocyte count was less than 100 x 10(6) cells/L or when only one recent measurement exceeded this value. Two relapses (one of CMV disease and one of MAC infection) were diagnosed after maintenance therapy was interrupted once CD4 counts were greater than 100 x 10(6) cells/L for 10 and 8 months, respectively. One relapse (toxoplasmosis) was diagnosed after maintenance therapy interruption at a CD4 lymphocyte count greater than 200 x 10(6) cells/L for 15 months. The overall incidences of recurrent CMV disease, MAC infection, toxoplasmosis, and cryptococcosis were 0.54 per 100 person-years (95% CI, 0.07 to 1.95 per 100 person-years), 0.90 per 100 person-years (CI, 0.11 to 3.25 per 100 person-years), 0.84 per 100 person-years (CI, 0.02 to 4.68 per 100 person-years), and 0.00 per 100 person-years (CI, 0.00 to 5.27 per 100 person-years), respectively. CONCLUSION Maintenance therapy against previous infection with CMV, MAC, Toxoplasma gondii, or Cryptococcus neoformans in patients with HIV infection can be interrupted after sustained CD4 count increases to greater than 200 (or possibly 100 to 200) x 10(6) cells/L for at least 6 months after the start of potent antiretroviral therapy.
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313
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Opravil M, Ledergerber B, Furrer H, Hirschel B, Imhof A, Gallant S, Wagels T, Bernasconi E, Meienberg F, Rickenbach M, Weber R. Clinical efficacy of early initiation of HAART in patients with asymptomatic HIV infection and CD4 cell count > 350 x 10(6) /l. AIDS 2002; 16:1371-81. [PMID: 12131214 DOI: 10.1097/00002030-200207050-00009] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy of early initiation of highly active antiretroviral therapy (HAART), we compared the clinical course of two nested, matched cohorts within the Swiss HIV Cohort Study. METHODS We selected all asymptomatic patients who started HAART between 1 January 1996 and 31 December 1999 with a CD4 cell count > 350 x 10(6)/l. We then matched them with asymptomatic participants who were seen at around the same time and who remained untreated during the following 12 months. This control group was further matched for age, sex, CD4 cell count, viral load, and HIV risk category, generating 283 pairs of treated versus untreated patients. RESULTS During observation of median 3.19 versus 2.66 years, CDC stage B/C occurred in 6.4% versus 21.2%, AIDS in 1.8% versus 5.3%, death in 2.1% versus 6.4%, and AIDS or death of 'natural' causes in 2.8% versus 6.7% of the treated versus untreated patients. In multivariable Cox regression analysis, treatment reduced the risk of clinical progression by a factor of four- to five fold. During follow-up, the treated group had significantly higher CD4 counts and lower HIV-1 RNA levels. Intolerance/adverse events led to change or stop of at least one drug in 35% of treated patients. The entire regimen was interrupted at least once by 41% of patients, and 24% had no treatment anymore at the end of follow-up. CONCLUSIONS The initiation of HAART in asymptomatic patients with CD4 cell count > 350 x 10(6)/l significantly delayed clinical progression. However, the risk of severe clinical events with deferred therapy was low and must be counter balanced against the burden and toxicity of HAART.
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Opravil M, Hirschel B, Lazzarin A, Furrer H, Chave JP, Yerly S, Bisset LR, Fischer M, Vernazza P, Bernasconi E, Battegay M, Ledergerber B, Günthard H, Howe C, Weber R, Perrin L. A randomized trial of simplified maintenance therapy with abacavir, lamivudine, and zidovudine in human immunodeficiency virus infection. J Infect Dis 2002; 185:1251-60. [PMID: 12001042 DOI: 10.1086/340312] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2001] [Revised: 12/11/2001] [Indexed: 11/03/2022] Open
Abstract
This randomized study evaluated the efficacy and tolerability of continued treatment with protease inhibitor plus nucleoside-analogue combination regimens (n=79) or a change to the simplified regimen of abacavir-lamivudine-zidovudine (n=84) in patients with suppressed human immunodeficiency virus type 1 (HIV-1) RNA for > or = 6 months who did not have the reverse transcriptase 215 mutation. After a median follow-up of 84 weeks, virologic failure was 6% in the continuation and 15% in the simplified group (P=.081). Previous zidovudine monotherapy or dual therapy and archived reverse transcriptase resistance mutations in HIV-1 DNA at baseline were significant predictors of failure. Study treatment was discontinued because of adverse events in 20% of the continuation and 7% of the simplified group (P=.021). Simplification to abacavir-lamivudine-zidovudine significantly decreased nonfasting cholesterol and triglyceride levels; however, this switch strategy carries a risk of virologic failure when treatment history or resistance testing suggest the presence of archived resistance mutations to the simplified regimen.
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315
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Furrer H, Cohort Study tS TSHIV. Management of Opportunistic Infection Prophylaxis in the Highly Active Antiretroviral Therapy Era. Curr Infect Dis Rep 2002; 4:161-174. [PMID: 11927049 DOI: 10.1007/s11908-002-0058-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Prophylaxis and maintenance therapy against opportunistic infections are a mainstay of management of HIV-infected patients and have led to a significant improvement in quality of life and survival. Antiretroviral combination therapy (ART) has markedly changed the natural course of HIV infection. Incidence of opportunistic infections (OIs) has declined and survival after an OI has improved. Achieving a CD4 count of 200 cells/L after 6 months of ART is a valuable marker for low risk of OI afterwards. Therefore, recommendations on prophylaxis and maintenance therapy need to be redefined. Criteria for discontinuation, such as a CD4 count rise above threshold values and time above threshold values as response to ART, should be evaluated for the most frequent OIs. Reliable data in favor of discontinuation of primary prophylaxis against Pneumocystis carinii pneumonia, toxoplasmic encephalitis, and Mycobacterium avium infection have been published. Discontinuation of maintenance therapy against P. carinii pneumonia is possible, and may be safe against cytomegalovirus retinitis, M. avium, and cryptococcosis and toxoplasmosis in selected patients. Pharmacologic interactions between drugs used for OI prophylaxis and antiretroviral drugs need to be taken into account.
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316
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Taffé P, Rickenbach M, Hirschel B, Opravil M, Furrer H, Janin P, Bugnon F, Ledergerber B, Wagels T, Sudre P. Impact of occasional short interruptions of HAART on the progression of HIV infection: results from a cohort study. AIDS 2002; 16:747-55. [PMID: 11964531 DOI: 10.1097/00002030-200203290-00010] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES AND DESIGN To investigate the clinical consequences of occasional and short (<or= 3 months) treatment interruptions in patients having initiated highly active antiretroviral therapy (HAART). Data from the prospective Swiss HIV Cohort Study were used. METHODS Four different endpoints [death, Centers for Disease Control and Prevention (CDC) stages B and C, and CD4 cell count increase >or= 50 x 106/l] were studied in relation to the number of interruptions that occurred. In order to focus on short interruptions exclusively, observations of patients with a treatment interruption of > 3 months were censored. The CD4 cell count and viraemia were treated as time-dependent variables because of the importance of these factors when an interruption occurs. RESULTS Between 1 January 1996 and 31 October 2000, 4720 Swiss HIV Cohort Study participants initiated HAART, which was interrupted at least once by 1299 participants. The main reasons for the interruptions were social factors. Interruptions did not increase significantly the risk of HIV-associated morbidity and mortality, except for a marginally increased risk for a CDC stage C event after the first interruption. The first interruption decreased significantly the likelihood of increasing the CD4 cell count. Subsequent interruptions had no further significant effect. High CD4 cell count and low viraemia, assessed as baseline and as longitudinal variables, were associated with a decreased risk of clinical progression. CONCLUSIONS Occasional treatment interruptions of < 3 months neither worsen nor improve disease outcome on an average term (3-4 years). Our results suggest that interruptions might be non-risky, particularly when viraemia is low and CD4 cell count is high. These results require confirmation.
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317
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Furrer H, Fux C. Opportunistic infections: an update. JOURNAL OF HIV THERAPY 2002; 7:2-7. [PMID: 11956497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
With highly active antiretroviral therapy (HAART), the overall incidence of opportunistic infections (OIs) has declined and survival after an AIDS-defining event has improved. However, rates of mycobacterial diseases and cytomegalovirus (CMV) disease remain high for the first 3 months before declining. Achieving a CD4 count of 200 cells/ micro l after 6 months of HAART is a valuable marker for a subsequent low risk of OIs. Different clinical manifestations of OIs may be attributable to immunopathogenic mechanisms linked to immune reconstitution on HAART. The recommendations on prophylaxis and maintenance therapy need to be redefined to allow for the decreased risk of OIs in HAART-treated patients. There are strong data in favour of discontinuing primary prophylaxis against Pneumocystis carinii pneumonia, toxoplasma encephalitis and Mycobacterium avium infection.
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318
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Fellay J, Marzolini C, Meaden ER, Back DJ, Buclin T, Chave JP, Decosterd LA, Furrer H, Opravil M, Pantaleo G, Retelska D, Ruiz L, Schinkel AH, Vernazza P, Eap CB, Telenti A. Response to antiretroviral treatment in HIV-1-infected individuals with allelic variants of the multidrug resistance transporter 1: a pharmacogenetics study. Lancet 2002; 359:30-6. [PMID: 11809184 DOI: 10.1016/s0140-6736(02)07276-8] [Citation(s) in RCA: 497] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND HIV-1-infected patients vary considerably by their response to antiretroviral treatment, drug concentrations in plasma, toxic events, and rate of immune recovery. This variability could have a genetic basis. We did a pharmacogenetics study to analyse the association between response to antiretroviral treatment and allelic variants of several genes. METHODS In 123 patients, we did PCR analyses of the gene for the multidrug-resistance transporter (MDR1), which codes for P-glycoprotein, of genes coding for isoenzymes of cytochrome P450, CYP3A4, CYP3A5, CYP2D6, and CYP2C19, and of the gene for the chemokine receptor CCR5. We measured concentrations in plasma of the antiretroviral agents efavirenz and nelfinavir by high-performance liquid-chromatography, and measured levels of P-glycoprotein expression, CD4-cell count, and HIV-1 viraemia. FINDINGS Median drug concentrations in patients with the MDR1 3435 TT, CT, and CC genotypes were at the 30th, 50th, and 75th percentiles, respectively (p=0.0001). In patients with CYP2D6 extensive-metaboliser or poor-metaboliser alleles, median drug concentrations were at percentiles 45 and 62.5, respectively (p=0.04). Patients with the MDR1 TT genotype 6 months after starting treatment had a greater rise in CD4-cell count (257 cells/microL) than patients with the CT (165 cells/microL) and CC (121 cells/microL) genotype (p=0.0048), and the best recovery of naïve CD4-cells. INTERPRETATION The polymorphism MDR1 3435 C/T predicts immune recovery after initiation of antiretroviral treatment. This finding suggests that P-glycoprotein has an important role in admittance of antiretroviral drugs to restricted compartments in vivo.
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Boubaker K, Flepp M, Sudre P, Furrer H, Haensel A, Hirschel B, Boggian K, Chave JP, Bernasconi E, Egger M, Opravil M, Rickenbach M, Francioli P, Telenti A. Hyperlactatemia and antiretroviral therapy: the Swiss HIV Cohort Study. Clin Infect Dis 2001; 33:1931-7. [PMID: 11692306 DOI: 10.1086/324353] [Citation(s) in RCA: 159] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2001] [Revised: 06/28/2001] [Indexed: 11/03/2022] Open
Abstract
The prevalence, clinical presentation, and risk factors for hyperlactatemia among patients receiving antiretroviral therapy was determined during a 1-month period for patients in the Swiss HIV Cohort Study. Overall, 73 (8.3%) of 880 patients presented an increase in serum lactate of >1.1 times the upper normal limit (UNL). For 9 patients (1%), lactate elevation was moderate or severe (>2.2 times the UNL). Patients who presented with hyperlactatemia were more likely to be receiving stavudine with or without didanosine (odds ratio, 2.7; 95% confidence interval, 1.5-4.8), as compared with patients who received zidovudine-based regimens. The risk increased with increasing time receiving stavudine with or without didanosine. The association between hyperlactatemia and stavudine with or without didanosine was not biased by these medications being more recently available and, therefore, being given preferentially to patients who had prolonged use of nucleoside analog reverse-transcriptase inhibitors. Hyperlactatemia was associated with lipoatrophy, hyperlipidemia, and hyperglycemia. Age, sex, or stage of infection with human immunodeficiency virus were not predictive of hyperlactatemia. Determination of lactate levels may prove useful in the screening for mitochondrial toxicity.
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Fellay J, Boubaker K, Ledergerber B, Bernasconi E, Furrer H, Battegay M, Hirschel B, Vernazza P, Francioli P, Greub G, Flepp M, Telenti A. Prevalence of adverse events associated with potent antiretroviral treatment: Swiss HIV Cohort Study. Lancet 2001; 358:1322-7. [PMID: 11684213 DOI: 10.1016/s0140-6736(01)06413-3] [Citation(s) in RCA: 234] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Data on adverse events to antiretroviral treatment have been recorded in clinical trials, post-marketing analyses, and anecdotal reports. Such data might not be an up-to-date or comprehensive assessment of all possible treatment combinations defined as potent antiretroviral treatment. METHODS Using a standard clinical and laboratory method, we assessed prevalence of adverse events in 1160 patients who were receiving antiretroviral treatment. We measured the toxic effects associated with the drug regimen (protease inhibitor [PI], non-nucleoside and nucleoside analogue reverse transcriptase inhibitor) and specific compounds using multivariate analyses. FINDINGS 47% (545 of 1160) of patients presented with clinical and 27% (194 of 712) with laboratory adverse events probably or definitely attributed to antiretroviral treatment. Among these, 9% (47 of 545) and 16% (30 of 194), respectively, were graded as serious or severe. Single-PI and PI-sparing-antiretroviral treatment were associated with a comparable prevalence of adverse events. Compared with single-PI treatment, use of dual-PI-antiretroviral treatment and three-class-antiretroviral treatment was associated with higher prevalence of adverse events (odds ratio [OR] 2.0 [95% CI 1.0-4.0], and 3.9 [1.2-12.9], respectively). Compound specific associations were identified for zidovudine, lamivudine, stavudine, didanosine, abacavir, ritonavir, saquinavir, indinavir, nelfinavir, efavirenz, and nevirapine. INTERPRETATION We recorded a high prevalence of toxic effects attributed to antiretroviral treatment for HIV-1. Such data provides a reference for regimen-specific and compound-specific adverse events and could be useful in postmarketing analyses of toxic effects.
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321
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Friedl AC, Ledergerber B, Flepp M, Hirschel B, Telenti A, Furrer H, Bucher HC, Bernasconi E, Weber R. Response to first protease inhibitor- and efavirenz-containing antiretroviral combination therapy. The Swiss HIV Cohort Study. AIDS 2001; 15:1793-800. [PMID: 11579241 DOI: 10.1097/00002030-200109280-00008] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the response to protease inhibitor (PI) and efavirenz-containing combination therapy among treatment-naive HIV-infected persons. DESIGN Prospective observational cohort study. METHODS Response to treatment was analysed according to the intent-to-treat principle among antiretroviral-naive patients who started either efavirenz (n = 89) or PI (n = 183) plus two nucleoside reverse transcriptase inhibitors between February 1999 and March 2000 using Kaplan-Meier and multivariable Cox proportional hazard regression methods. Primary endpoint was time to undetectable plasma viral load. Secondary endpoints included the number of CD4 cells gained, virological rebound, treatment change, and clinical progression. RESULTS Patients on PI regimens had lower median CD4 counts (165 versus 216 x 5 106/l; P = 0.15) and were more likely to have AIDS at initiation of treatment (25% versus 15% P = 0.048) than patients starting efavirenz regimens. The probability of reaching plasma HIV-1 RNA < 400 copies/ml was higher with efavirenz- than with PI-containing regimens [adjusted hazard ratio, 1.75; 95% confidence interval (CI), 1.34-2.29]. Median times to undetectable viral load were 58 days (95% CI, 44-70 days) for efavirenz-treated and 88 days (95% CI, 79-98 days) for PI-treated patients. The median number of CD4 cells gained in the first 6 months (90 x 10(6) cells/l with efavirenz, 10(7) x 10(6) cells/l with PI; P = 0.63), time to and reasons for treatment change, time to viral rebound, drug intolerance and clinical progression rates were similar in the two treatment groups. CONCLUSIONS Treatment with efavirenz-, compared with PI-based regimens, appeared to result in a superior virological response but no difference in immunological or clinical efficacy. The relevance of these observations remains to be determined in studies with longer follow-up.
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Furrer H, Chan P, Weber R, Egger M. Increased risk of wasting syndrome in HIV-infected travellers: prospective multicentre study. Trans R Soc Trop Med Hyg 2001; 95:484-6. [PMID: 11706654 DOI: 10.1016/s0035-9203(01)90011-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
HIV-infected patients from moderate regions who travel in tropical countries may experience clinical disease progression due to exposure to bacteria (including mycobacteria), fungi and parasites. In the Swiss HIV Cohort Study we examined the hypothesis that travelling increases the risk of tuberculosis, wasting syndrome, cryptosporidiosis, isosporiasis, cryptococcosis, coccidiomycosis, histoplasmosis and Salmonella septicaemia. A total of 4549 participants were included (in 1988-98) of whom 596 (13.1%) travelled at least once. During 16,800 person-years of follow-up 231 patients developed at least 1 of the diseases of interest. Wasting syndrome was the only diagnosis significantly associated with travelling (hazard ratio 2.16, 95% confidence interval 1.09 to 4.30). The risk of wasting syndrome ('slim disease') should be taken into account when counselling HIV-infected patients intending to travel in tropical regions.
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Rossi M, Flepp M, Telenti A, Schiffer V, Egloff N, Bucher H, Vernazza P, Bernasconi E, Weber R, Rickenbach M, Furrer H. Disseminated M. avium complex infection in the Swiss HIV Cohort Study: declining incidence, improved prognosis and discontinuation of maintenance therapy. Swiss Med Wkly 2001; 131:471-7. [PMID: 11641970 DOI: 10.4414/smw.2001.09728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Introduction of potent antiretroviral combination therapy (ART) has reduced overall morbidity and mortality amongst HIV-infected adults. Some prophylactic regimes against opportunistic infections can be discontinued in patients under successful ART. QUESTIONS UNDER STUDY (1) The influence of the availability of ART on incidence and mortality of disseminated M. avium Complex infection (MAC). (2) The safety of discontinuation of maintenance therapy against MAC in patients on ART. SETTING The Swiss HIV-Cohort Study, a prospective multicentre study of HIV-infected adults. METHODS Patients with a nadir CD4 count below 50 cells/mm3 were considered at risk for MAC and contributed to total follow-up time for calculating the incidence. Survival analysis was performed by using Kaplan Meier and Cox proportional hazards methods. Safety of discontinuation of maintenance therapy was evaluated by review of the medical notes. RESULTS 398 patients were diagnosed with MAC from 1990 to 1999. 350 had a previous CD4 count below 50 cells/mm3. A total of 3208 patients had a nadir CD4 count of less than 50 cells/mm3 during the study period and contributed to a total follow-up of 6004 person-years. The incidence over the whole study period was 5.8 events per 100 person-years. In the time period of available ART the incidence of MAC was significantly reduced (1.4 versus 8.8 events per 100 person-years, p < 0.001). Being diagnosed after 1995 was the most powerful predictor of better survival (adjusted hazard ratio for death: 0.27; p < 0.001). None of 24 patients discontinuing maintenance therapy while on ART experienced recurrence of MAC during a total follow-up of 56.6 person-years (upper 95% confidence limit 5.3 per 100 person-years). CONCLUSION Introducing ART has markedly reduced the risk of MAC for HIV-infected individuals with a history of very low CD4 counts. Survival after diagnosis of MAC has improved after ART became available. In patients responding to ART, discontinuation of maintenance therapy against M. avium may be safe.
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Rossi M, Flepp M, Telenti A, Schiffer V, Egloff N, Bucher H, Vernazza P, Bernasconi E, Weber R, Rickenbach M, Furrer H. Disseminated M. avium complex infection in the Swiss HIV Cohort Study: declining incidence, improved prognosis and discontinuation of maintenance therapy. Swiss Med Wkly 2001; 131:471-7. [PMID: 11641970 DOI: 2001/31/smw-09728] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Introduction of potent antiretroviral combination therapy (ART) has reduced overall morbidity and mortality amongst HIV-infected adults. Some prophylactic regimes against opportunistic infections can be discontinued in patients under successful ART. QUESTIONS UNDER STUDY (1) The influence of the availability of ART on incidence and mortality of disseminated M. avium Complex infection (MAC). (2) The safety of discontinuation of maintenance therapy against MAC in patients on ART. SETTING The Swiss HIV-Cohort Study, a prospective multicentre study of HIV-infected adults. METHODS Patients with a nadir CD4 count below 50 cells/mm3 were considered at risk for MAC and contributed to total follow-up time for calculating the incidence. Survival analysis was performed by using Kaplan Meier and Cox proportional hazards methods. Safety of discontinuation of maintenance therapy was evaluated by review of the medical notes. RESULTS 398 patients were diagnosed with MAC from 1990 to 1999. 350 had a previous CD4 count below 50 cells/mm3. A total of 3208 patients had a nadir CD4 count of less than 50 cells/mm3 during the study period and contributed to a total follow-up of 6004 person-years. The incidence over the whole study period was 5.8 events per 100 person-years. In the time period of available ART the incidence of MAC was significantly reduced (1.4 versus 8.8 events per 100 person-years, p < 0.001). Being diagnosed after 1995 was the most powerful predictor of better survival (adjusted hazard ratio for death: 0.27; p < 0.001). None of 24 patients discontinuing maintenance therapy while on ART experienced recurrence of MAC during a total follow-up of 56.6 person-years (upper 95% confidence limit 5.3 per 100 person-years). CONCLUSION Introducing ART has markedly reduced the risk of MAC for HIV-infected individuals with a history of very low CD4 counts. Survival after diagnosis of MAC has improved after ART became available. In patients responding to ART, discontinuation of maintenance therapy against M. avium may be safe.
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Roos F, Flepp M, Figueras G, Bodmer T, Furrer H. Clinical Manifestations and Predictors of Survival in AIDS Patients with Disseminated Mycobacterium avium Infection. Eur J Clin Microbiol Infect Dis 2001. [DOI: 10.1007/s100960100496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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326
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Hatz FR, Beck B, Blum J, Funk M, Furrer H, Genton B, Holzer B, Loutan L, Markwalder K, Raeber PA, Schlagenhauf P, Siegl G, Steffen R, Stürchler D, Wyss R. [Malaria--chemoprophylaxis 2001]. THERAPEUTISCHE UMSCHAU 2001; 58:347-51. [PMID: 11441694 DOI: 10.1024/0040-5930.58.6.347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
An estimated 20,000 to 30,000 cases of imported malaria are annually diagnosed in industrialised countries. Some 700 of them concern Swiss travellers and foreign guests. Exposure prophylaxis and chemoprophylaxis for high risk destinations lower the risk of malarial disease. The latter is defined as regular intake of antimalarial drugs in subtherapeutic dosage in order to suppress the development of clinical disease. Drugs are usually taken from one week before travel until four weeks after return from an endemic area. Mefloquine, doxycycline, chloroquine plus proguanil, and presumably soon also atovaquone plus proguanil are available in Switzerland for chemoprophylaxis.
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Rossi M, Furrer H. [Travel medicine for HIV-infected patients]. THERAPEUTISCHE UMSCHAU 2001; 58:381-6. [PMID: 11441700 DOI: 10.1024/0040-5930.58.6.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Many HIV-infected persons travel from temperate zones to (sub)tropical destinations. HIV-specific immigration issues, medical resources abroad and problems regarding travelling with multiple medications have to be anticipated. When prescribing immunizations and specific chemoprophylaxis, the stage of immunodeficiency as well as drug interactions with antiretrovirals and medicaments against opportunistic infections have to be taken into account. Live vaccines may be contraindicated. Immunocompromised HIV-infected travellers have a higher risk for serious courses of diseases by enteropathogens. Therefore a good information about food hygiene is important and a prescription of an antibiotic to take in case of severe diarrhea may be indicated. A new antiretroviral combination therapy should not be started immediately before travelling to the tropics. The possibility to continue an established HIV treatment during travel has to be evaluated cautiously. With good pre-travel advice the risk of severe health problems is low for most HIV-infected travellers.
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Roos F, Flepp M, Figueras G, Bodmer T, Furrer H. Clinical manifestations and predictors of survival in AIDS patients with disseminated Mycobacterium avium infection. Eur J Clin Microbiol Infect Dis 2001; 20:428-30. [PMID: 11476447 DOI: 10.1007/pl00023923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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329
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Egloff N, Oehler T, Rossi M, Nguyen XM, Furrer H. Chronic watery diarrhea due to co-infection with Cryptosporidium spp and Cyclospora cayetanensis in a Swiss AIDS patient traveling in Thailand. J Travel Med 2001; 8:143-5. [PMID: 11468117 DOI: 10.2310/7060.2001.24456] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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330
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Furrer H, Opravil M, Rossi M, Bernasconi E, Telenti A, Bucher H, Schiffer V, Boggian K, Rickenbach M, Flepp M, Egger M. Discontinuation of primary prophylaxis in HIV-infected patients at high risk of Pneumocystis carinii pneumonia: prospective multicentre study. AIDS 2001; 15:501-7. [PMID: 11242147 DOI: 10.1097/00002030-200103090-00009] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the safety of discontinuation of primary prophylaxis in HIV-infected patients on antiretroviral combination therapy at high risk of developing Pneumocystis carinii pneumonia. DESIGN Prospective multicentre study. PATIENTS AND METHODS The incidence of P. carinii pneumonia after discontinuation of primary prophylaxis was studied in 396 HIV-infected patients on antiretroviral combination therapy who experienced an increase in their CD4 cell count to at least 200 x 10(6)/l and 14% of total lymphocytes; the study population included 191 patients with a history of CD4 cell counts below 100 x 10(6)/l (245 person-years) and 144 patients with plasma HIV RNA above 200 copies/ml (215 person-years). RESULTS There was one case of Pneumocystis pneumonia, an incidence of 0.18 per 100 person-years [95% confidence interval (CI), 0.005--1.0 per 100 person-years]. No case was diagnosed in groups with low nadir CD4 cell counts (95% CI, 0--1.2 per 100 person-years) or detectable plasma HIV RNA (95% CI, 0--1.4 per 100 person-years). CONCLUSIONS Discontinuation of primary prophylaxis against Pneumocystis pneumonia is safe in patients who have responded with a sustained increase in their CD4 cell count to antiretroviral combination therapy, irrespective of the CD4 cell count nadir and the viral load at the time of stopping prophylaxis.
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331
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Ledergerber B, Mocroft A, Reiss P, Furrer H, Kirk O, Bickel M, Uberti-Foppa C, Pradier C, D'Arminio Monforte A, Schneider MM, Lundgren JD. Discontinuation of secondary prophylaxis against Pneumocystis carinii pneumonia in patients with HIV infection who have a response to antiretroviral therapy. Eight European Study Groups. N Engl J Med 2001; 344:168-74. [PMID: 11188837 DOI: 10.1056/nejm200101183440302] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with human immunodeficiency virus (HIV) infection and a history of Pneumocystis carinii pneumonia are at high risk for relapse if they are not given secondary prophylaxis. Whether secondary prophylaxis against P. carinii pneumonia can be safely discontinued in patients who have a response to highly active antiretroviral therapy is not known. METHODS We analyzed episodes of recurrent P. carinii pneumonia in 325 HIV-infected patients (275 men and 50 women) in eight prospective European cohorts. Between October 1996 and January 2000, these patients discontinued secondary prophylaxis during treatment with at least three anti-HIV drugs after they had at least one peripheral-blood CD4 cell count of more than 200 cells per cubic millimeter. RESULTS Secondary prophylaxis was discontinued at a median CD4 cell count of 350 per cubic millimeter; the median nadir CD4 cell count had been 50 per cubic millimeter. The median duration of the increase in the CD4 cell count to more than 200 per cubic millimeter after discontinuation of secondary prophylaxis was 11 months. The median follow-up period after discontinuation of secondary prophylaxis was 13 months, yielding a total of 374 person-years of follow-up; for 355 of these person-years, CD4 cell counts remained at or above 200 per cubic millimeter. No cases of recurrent P. carinii pneumonia were diagnosed during this period; the incidence was thus 0 per 100 patient-years (99 percent confidence interval, 0 to 1.2 per 100 patient-years, on the basis of the entire follow-up period, and 0 to 1.3 per 100 patient-years, on the basis of the follow-up period during which CD4 cell counts remained at or above 200 per cubic millimeter). CONCLUSIONS It is safe to discontinue secondary prophylaxis against P. carinii pneumonia in patients with HIV infection who have an immunologic response to highly active antiretroviral therapy.
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Greub G, Ledergerber B, Battegay M, Grob P, Perrin L, Furrer H, Burgisser P, Erb P, Boggian K, Piffaretti JC, Hirschel B, Janin P, Francioli P, Flepp M, Telenti A. Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfection: the Swiss HIV Cohort Study. Lancet 2000; 356:1800-5. [PMID: 11117912 DOI: 10.1016/s0140-6736(00)03232-3] [Citation(s) in RCA: 619] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is highly prevalent among HIV-1-infected individuals, but its contribution to the morbidity and mortality of coinfected patients who receive potent antiretroviral therapy is controversial. We used data from the ongoing Swiss HIV Cohort Study to analyse clinical progression of HIV-1, and the virological and immunological response to potent antiretroviral therapy in HIV-1-infected patients with or without concurrent HCV infection. METHODS We analysed prospective data on survival, clinical disease progression, suppression of HIV-1 replication, CD4-cell recovery, and frequency of changes in antiretroviral therapy according to HCV status in 3111 patients starting potent antiretroviral therapy. RESULTS 1157 patients (37.2%) were coinfected with HCV, 1015 of whom (87.7%) had a history of intravenous drug use. In multivariate Cox's regression, the probability of progression to a new AIDS-defining clinical event or to death was independently associated with HCV seropositivity (hazard ratio 1.7 [95% CI 1.26-2.30]), and with active intravenous drug use (1.38 [1.02-1.88]). Virological response to antiretroviral therapy and the probability of treatment change were not associated with HCV serostatus. In contrast, HCV seropositivity was associated with a smaller CD4-cell recovery (hazard ratio for a CD4-cell count increase of at least 50 cells/microL=0.79 [0.72-0.87]). INTERPRETATION HCV and active intravenous drug use could be important factors in the morbidity and mortality among HIV-1-infected patients, possibly through impaired CD4-cell recovery in HCV seropositive patients receiving potent antiretroviral therapy. These findings are relevant for decisions about optimum timing for HCV treatment in the setting of HIV infection.
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333
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Oehler T, Büchel B, Hatz C, Furrer H. [Advice to HIV infected persons travelling to tropical or subtropical destinations]. SCHWEIZERISCHE MEDIZINISCHE WOCHENSCHRIFT 2000; 130:1041-50. [PMID: 10953854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Many HIV-infected persons travel from temperate zones to (sub)tropical destinations. HIV-specific immigration issues, medical resources abroad and problems regarding travel with multiple medication need to be anticipated. When prescribing immunisations and specific chemoprophylaxis, the stage of immunodeficiency as well as drug interactions with antiretrovirals must be taken into account. Live vaccines may be contraindicated. With good pretravel advice the risk of severe health problems is low for most HIV-infected travellers.
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334
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Furrer H, Telenti A, Rossi M, Ledergerber B. Discontinuing or withholding primary prophylaxis against Mycobacterium avium in patients on successful antiretroviral combination therapy. The Swiss HIV Cohort Study. AIDS 2000; 14:1409-12. [PMID: 10930156 DOI: 10.1097/00002030-200007070-00014] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the safety of discontinuing or withholding primary prophylaxis against disseminated Mycobacterium avium infection (MAC) in HIV infected patients on successful antiretroviral combination therapy. SETTING National prospective multicentre cohort study. DESIGN HIV-infected patients were eligible for the analysis if: (i) they had a history of at least two CD4 cell counts < 50 x 10(6)/l; (ii) they had never had MAC; (iii) they had discontinued or never begun primary prophylaxis against MAC; (iv) they received antiretroviral therapy and demonstrated an increase in CD4 cell counts to > or = 100 x 10(6)/l that was sustained for at least 12 weeks. From this time point until last follow-up, incidence of disseminated MAC disease was measured, and 99% confidence intervals were calculated assuming a Poisson distribution of events. RESULTS Two-hundred and fifty-three patients (22.5% female; median age, 37 years, 30% injecting drug users) were eligible for analysis. Sixty-six per cent were in Centers for Disease Control and Prevention (CDC) stage C, and 28% were in CDC stage B. Their median nadir CD4 cell count was 10 x 10(6)/l, the median duration of CD4 cell count < 50 x 10(6)/l was 12 months. During a total follow-up of 364.3 patient-years there was no case of disseminated MAC. The one-sided 99% confidence limit for incidence density of MAC was 1.3 per 100 person-years. CONCLUSION Discontinuing or withholding primary prophylaxis against MAC is safe in patients who have a sustained increase in their CD4 cell count to > or = 100 x 10(6)/l.
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Furrer H, Opravil M, Bernasconi E, Telenti A, Egger M. Stopping primary prophylaxis in HIV-1-infected patients at high risk of toxoplasma encephalitis. Swiss HIV Cohort Study. Lancet 2000; 355:2217-8. [PMID: 10881897 DOI: 10.1016/s0140-6736(00)02407-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Discontinuation of primary prophylaxis against toxoplasma encephalitis was studied in 199 HIV-1-infected patients on antiretroviral combination treatment who had experienced a sustained increase in their CD4 count. During a follow-up of 272 person-years, no cases of toxoplasma encephalitis arose.
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336
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Egloff N, Rossi M, Furrer H. [Anemia in HIV infection]. PRAXIS 2000; 89:1007-1013. [PMID: 10909323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Anemia is a common finding in HIV-infected patients, especially in late stages of the disease. The grade of anemia is an independent marker for mortality. Beside the classical causes of anemia we find in HIV-infected patients typically cytokine mediated suppression of the bone marrow, infiltration of the latter by opportunistic agents and side effects of drugs. These causes have to be taken into account in the diagnostic approach. The therapeutic intervention should be focused on the aetiology and pathogenesis of anemia in the individual patient. Successful antiretroviral combination therapy is associated with a substantial decrease of morbidity and mortality and lowers the incidence of severe anemia. However, several antiretroviral agents, especially zidovudine, and drugs against opportunistic infections can cause anemia.
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Furrer H. Prevalence and clinical significance of splenomegaly in asymptomatic human immunodeficiency virus type 1-infected adults. Swiss HIV cohort study. Clin Infect Dis 2000; 30:943-5. [PMID: 10880308 DOI: 10.1086/313816] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In a prospective cohort study of 70 consecutive, asymptomatic human immunodeficiency virus type 1 (HIV-1)-infected adults, splenomegaly was found by physical examination in 23% of patients and by ultrasound in 66%. Patients with concomitant liver disease had a higher prevalence of splenomegaly (RR 1.84; P<.001). During a 1-year follow-up of 66 patients, splenomegaly at enrollment was not predictive of any clinical event, and splenomegaly was not associated with a higher risk of developing AIDS during a median follow-up of 6.1 years.
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Yerly S, Kaiser L, Perneger TV, Cone RW, Opravil M, Chave JP, Furrer H, Hirschel B, Perrin L. Time of initiation of antiretroviral therapy: impact on HIV-1 viraemia. The Swiss HIV Cohort Study. AIDS 2000; 14:243-9. [PMID: 10716500 DOI: 10.1097/00002030-200002180-00006] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The current recommendation that patients infected with HIV-1 be treated early is based on little evidence. We examined whether the early initiation of antiretroviral treatment affects residual HIV-1 viraemia. METHODS Viraemia was measured using an assay with a detection limit of 3 HIV-1 RNA copies/ml in drug-naive patients who started antiretroviral therapy at the time of primary HIV-1 infection (PHI) (n = 10), during chronic infection without immune suppression (CD4 cell counts > or = 500/mm3; median 577) (n = 10), or after immune suppression developed (CD4 cell counts < 500/mm3; median 113) (n = 21). RESULTS In 249 samples collected 24 to 120 weeks after treatment initiation, the mean proportion of samples with HIV-1 RNA levels of less than 3 copies/ml was 75% for PHI patients compared with 32 and 8% for immunocompetent and immunosuppressed chronically infected patients, respectively. Fifty per cent of PHI patients, but none of the chronically infected patients, had persistently fewer than 3 HIV-1 RNA copies/mL. PHI patients had lower residual HIV-1 RNA levels than chronically infected patients, and immunocompetent patients had lower residual HIV-1 RNA levels than immunosuppressed patients (all pairwise, P< 0.001). The mean residual HIV-1 RNA level was independently associated with the initiation of therapy during PHI and baseline CD4 cell counts (P < 0.001 for both associations). CONCLUSION Viraemia levels are associated with clinical progression and predict virological treatment failure. The initiation of antiretroviral therapy at the time of PHI and while CD4 cell counts are high results in lower residual viraemia. These results support early antiretroviral therapy in HIV-1-infected patients.
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Ledergerber B, Egger M, Erard V, Weber R, Hirschel B, Furrer H, Battegay M, Vernazza P, Bernasconi E, Opravil M, Kaufmann D, Sudre P, Francioli P, Telenti A. AIDS-related opportunistic illnesses occurring after initiation of potent antiretroviral therapy: the Swiss HIV Cohort Study. JAMA 1999; 282:2220-6. [PMID: 10605973 DOI: 10.1001/jama.282.23.2220] [Citation(s) in RCA: 328] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Acquired immunodeficiency syndrome-related opportunistic illnesses (Ols) continue to occur after initiation of potent antiretroviral therapy in patients with human immunodeficiency virus (HIV) infection. Risk factors for clinical progression to Ols during potent therapy are not well defined. OBJECTIVE To examine the incidence of and risk factors for Ols among patients treated with potent antiretroviral therapy in a population-based study. DESIGN The Swiss HIV Cohort Study, a prospective cohort study of adult HIV-infected persons. SETTING Seven study centers throughout Switzerland. PATIENTS A total of 2410 cohort study participants with a potential follow-up of at least 15 months after starting potent therapy between September 1995 and December 1997. MAIN OUTCOME MEASURES Disease-specific incidence of Ols during the 6 months preceding potent antiretroviral therapy and at 3 intervals after initiating therapy; risk factors for development of Ols during therapy. RESULTS Of the 2410 participants, 143 developed 186 Ols after initiation of potent antiretroviral therapy. Incidence of any OI decreased from 15.1 per 100 person-years in the 6 months before therapy to 7.7 in the first 3 months after starting treatment, 2.6 in the following 6 months, and 2.2 per 100 person-years between 9 and 15 months. Reductions in incidence ranged from 38% per month for Kaposi sarcoma (P<.001) to 5% per month for non-Hodgkin lymphoma (P = .31). Baseline CD4 cell count continued to predict the risk of disease progression after initiating potent therapy. Compared with CD4 cell counts above 200 x 10(6)/L, the hazard ratio for developing Ols was 2.5 (95% confidence interval [CI], 1.4-4.5) for counts between 51 and 200 x 10(6)/L and 5.8 (95% CI, 3.2-10.5) for counts below 51 x 10(6)/L at baseline. Independent of baseline CD4 cell count, a rise in CD4 cell count by 50 x 10(6)/L or more and undetectable HIV-1 RNA in plasma (<400 copies/mL) by 6 months reduced risk of subsequent events, with hazard ratios of 0.32 (95% CI, 0.20-0.52) and 0.39 (0.24-0.65), respectively. CONCLUSIONS Our data indicate that the risk of developing an OI for a person receiving potent antiretroviral therapy is highest during the initial months of therapy. Baseline CD4 cell count and immunologic and virologic response to treatment were strong predictors of disease progression in patients receiving potent therapy. Individuals with CD4 cell counts of 50 x 10(6)/L or below may need close clinical surveillance after initiation of potent therapy.
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Sudre P, Pfyffer GE, Bodmer T, Prod'hom G, Furrer H, Bassetti S, Bernasconi E, Matter L, Telenti A, Strässle A, Jacques JP, Weber R. Molecular epidemiology of tuberculosis among HIV-infected persons in Switzerland: a countrywide 9-year cohort study. Swiss HIV Cohort Study. Infection 1999; 27:323-30. [PMID: 10624591 DOI: 10.1007/s150100050037] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We investigated tuberculosis transmission during a nine-year period (1988-1996) in a countrywide community-based cohort of HIV-infected persons in Switzerland (the Swiss HIV Cohort Study [SHCS]). We estimated the proportion of tuberculosis cases due to reinfection and relapse, and assessed factors which may increase the risk of tuberculosis transmission. HIV-infected persons were followed prospectively and molecular fingerprinting with insertion sequence (IS) 6110, 36-bp direct repeat, and IS6110-PCR was used to determine M. tuberculosis case clustering. Out of 7999 SHCS participants, 267 persons developed tuberculosis. 158 M. tuberculosis isolates from 138 patients were available for study. Molecular analysis identified 33 (24%) episodes of tuberculosis associated with 12 clusters including 2 to 8 patients. Two patients experienced reinfection, and nine had a relapse. Detailed contact investigation identified definite or possible epidemiological links between 21 of 33 cluster patients (64%). Multivariate logistic regression analysis did not identify any risk marker significantly associated with clustering. During a nine-year period, one fourth of tuberculosis cases were grouped in clusters within a selection of 138 HIV-infected patients. This may represent the lowest estimation of recently acquired tuberculosis infection. There were no large institutional or community outbreaks among HIV-infected participants of the Swiss HIV Cohort Study.
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Abstract
Neurological manifestations are frequent in patients with AIDS. Many neurological disorders have disappeared with the advent of highly active antiretroviral combination therapies. We can speculate that some of these disorders may reappear in patients under antiretroviral therapy, possibly with different clinical manifestations and at a different stage during HIV-infection. We discuss the appearance of the most common neurological complications in relation to the CD4-cell count during HIV-infection. The most frequent causes of seizures and headache in HIV-infected patients are shown. We recommend a systematic diagnostic work-up in patients with headache, starting from 3 typical clinical situations: focal signs, convulsions or altered mental status; no focal signs, CD4-cells > 200 microliters, meningism; fever and/or meningism, no focal signs. The analysis of the cerebrospinal fluid by polymerase chain reaction is now a well established diagnostic method for investigating the most common CNS-infections in AIDS-patients. Neuroimaging (by MRI or CT-scan) is an additional, useful investigation. Cerebral toxoplasmosis, cryptococcosis, PML, encephalitis due to herpes-viruses and neurosyphilis are discussed.
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Wendland T, Furrer H, Vernazza PL, Frutig K, Christen A, Matter L, Malinverni R, Pichler WJ. HAART in HIV-infected patients: restoration of antigen-specific CD4 T-cell responses in vitro is correlated with CD4 memory T-cell reconstitution, whereas improvement in delayed type hypersensitivity is related to a decrease in viraemia. AIDS 1999; 13:1857-62. [PMID: 10513643 DOI: 10.1097/00002030-199910010-00007] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyse prospectively the effect of highly active antiretroviral treatment (HAART) on CD4 T-cell responses in vitro and in vivo in HIV-infected patients. DESIGN Prospective study with 49 protease inhibitor-naive adult patients. Data were collected at baseline and after 3 and 6 months of HAART. METHODS In vitro CD4 T-cell reactivity was analysed by stimulation of peripheral blood mononuclear cells with several antigens. In vivo CD4 T-cell reactivity (delayed type hypersensitivity) was assessed by Multitest Merieux. Both measurements were correlated to CD4 (memory) T-cell count and HIV-1 viraemia. RESULTS Restoration of specific CD4 T-cell proliferation was observed in most patients. The in vitro T-cell response was restored more frequently against antigens to which the immune system is constantly exposed (Candida albicans, Mycobacterium tuberculosis, M. avium) as compared with a low-exposure antigen (tetanus toxoid). Overall, delayed type hypersensitivity detection rate increased under HAART. Multivariate analysis showed improvement of antigen-specific T-cell proliferation to be significantly associated with an increase in memory CD4 T-cells, whereas improvement of the delayed type hypersensitivity response was associated with a decrease in plasma HIV-1 RNA. CONCLUSIONS HAART for 6 months restored antigen-specific CD4 T-cell response to several antigens. In vitro immune reconstitution was closely correlated with an increase in memory CD4 cells. Restoration of delayed type hypersensitivity was associated with suppression of viraemia. It appears that in addition to expansion of memory CD4 cells, suppression of viraemia following HAART may allow an improved inflammatory reaction, thus providing even stronger immune reconstitution.
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Mosimann M, Nguyen XM, Furrer H. [Excessive watery diarrhea and pronounced fatigue due to Cyclospora cayetanensis infection in an HIV infected traveler returning from the tropics]. SCHWEIZERISCHE MEDIZINISCHE WOCHENSCHRIFT 1999; 129:1158-61. [PMID: 10515777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
We report the case of a 46-year-old HIV-1 infected patient who acquired a Cyclopsora cayetanensis infection during travel to southeast Asia. He developed excessive watery diarrhoea and pronounced fatigue, which resolved after treatment with cotrimoxazole. The term Cyclospora cayetanensis was first suggested in 1993 for the infectious agent of diarrhoea in tropical and subtropical regions. The infection is usually self-limiting. However, in HIV-1 infected persons the symptoms are often more severe and protracted. Microbiological diagnosis is performed by light microscopy and at X400 magnification of faeces fixed in SAF medium or 10% formalin preservatives.
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Bassetti S, Battegay M, Furrer H, Rickenbach M, Flepp M, Kaiser L, Telenti A, Vernazza PL, Bernasconi E, Sudre P. Why is highly active antiretroviral therapy (HAART) not prescribed or discontinued? Swiss HIV Cohort Study. J Acquir Immune Defic Syndr 1999; 21:114-9. [PMID: 10360802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
In this cross-sectional survey conducted at the end of 1997 among the physicians of participants of the Swiss HIV Cohort Study (SHCS), 1487 of 2154 patients (69.0%) were treated with highly active antiretroviral treatment (HAART) defined as triple therapy with a combination of one or two reverse transcriptase inhibitors, and one or two protease inhibitors; 541 patients (25.1%) had never received such treatment. The physician's perception that the patient would not comply with treatment was one reason for not prescribing HAART to 20% of these patients (110). Physicians indicated that the most common reasons for the patient to refuse HAART were the fear of side effects (18%) and the patient's perception that treatment was too complicated (18%). Among 126 patients (5.8%) no longer receiving HAART, the most common reasons for discontinuing treatment were actual side effects (61%) or the fear of side effects (25%). Overall, 16% of patients did not receive therapy in accord with official Swiss guidelines. Multivariate logistic regression analysis indicated that patients with lower education, active intravenous drug users outside of a drug substitution program, and those who acquired HIV infection through intravenous drug use had a significantly higher risk of inadequate treatment. The physician's judgment of patient adherence and the physician's perception of the patient's fear of side effects are critical for the prescription of HAART. Physicians should address these issues to prevent unilateral withholding of treatment and increase the proportion of patients who may benefit from current antiretroviral therapy.
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Furrer H, Egger M, Opravil M, Bernasconi E, Hirschel B, Battegay M, Telenti A, Vernazza PL, Rickenbach M, Flepp M, Malinverni R. Discontinuation of primary prophylaxis against Pneumocystis carinii pneumonia in HIV-1-infected adults treated with combination antiretroviral therapy. Swiss HIV Cohort Study. N Engl J Med 1999; 340:1301-6. [PMID: 10219064 DOI: 10.1056/nejm199904293401701] [Citation(s) in RCA: 198] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unclear whether primary prophylaxis against Pneumocystis carinii pneumonia can be discontinued in patients infected with the human immunodeficiency virus (HIV) who are successfully treated with combination antiretroviral therapy. We prospectively studied the safety of stopping prophylaxis among patients in the Swiss HIV Cohort Study. METHODS Patients were eligible for our study if their CD4 counts had increased to at least 200 cells per cubic millimeter and 14 percent of total lymphocytes while they were receiving combination antiretroviral therapy, with these levels sustained for at least 12 weeks. Prophylaxis was stopped at study entry, and patients were examined every three months thereafter. The development of P. carinii pneumonia was the primary end point, and the development of toxoplasmic encephalitis the secondary end point. RESULTS Of the 262 patients included in our analysis, 121 (46.2 percent) were positive for IgG antibodies to Toxoplasma gondii at base line. The median CD4 count at study entry was 325 per cubic millimeter (range, 210 to 806); the median nadir CD4 count was 110 per cubic millimeter (range, 0 to 240). During a median follow-up of 11.3 months (range, 3.0 to 18.8), prophylaxis was resumed in nine patients, and two patients died. There were no cases of P. carinii pneumonia or toxoplasmic encephalitis. The one-sided upper 99 percent confidence limit for the incidence of P. carinii pneumonia was 1.9 cases per 100 patient-years (based on 238 patient-years of follow-up). The corresponding figure for toxoplasmic encephalitis was 4.2 per 100 patient-years (based on 110 patient-years of follow-up). CONCLUSIONS Stopping primary prophylaxis against P. carinii pneumonia appears to be safe in HIV-infected patients who are receiving combination antiretroviral treatment and who have had a sustained increase in their CD4 counts to at least 200 cells per cubic millimeter and to at least 14 percent of total lymphocytes.
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Ledergerber B, Egger M, Opravil M, Telenti A, Hirschel B, Battegay M, Vernazza P, Sudre P, Flepp M, Furrer H, Francioli P, Weber R. Clinical progression and virological failure on highly active antiretroviral therapy in HIV-1 patients: a prospective cohort study. Swiss HIV Cohort Study. Lancet 1999; 353:863-8. [PMID: 10093977 DOI: 10.1016/s0140-6736(99)01122-8] [Citation(s) in RCA: 698] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The efficacy of highly active antiretroviral therapy (HAART) in suppression of HIV-1 is well documented. We investigated virological and clinical outcomes of HAART in routine practice. METHODS We analysed prospective data from the Swiss HIV Cohort Study on suppression of viral load and progression to AIDS or death in 2674 outpatients (median age 36 years, 27.3% women) who started HAART in 1995-98. Viral rebound was defined as two consecutive HIV-1-RNA measurements of more than 400 copies/mL. We analysed separately outcomes in patients with a history of antiretroviral treatment and in treatment-naïve patients. FINDINGS An estimated 90.7% of treatment-naïve patients reached undetectable viral load (<400 copies/mL) by 12 months. Among pretreated patients, estimates ranged from 70.3% treated with one new drug to 78.7% on three new drugs. 2 years after reaching undetectable concentrations, an estimated 20.1% of treatment-naïve patients and 35.7-40.1% of pretreated patients had viral rebound. At 30 months, an estimated 6.6% (95% CI 4.6-8.6) of patients who had maintained undetectable concentrations, 9.0% (5.5-12.5) who had viral rebound, and 20.1% (15.3-24.9) who had never reached undetectable concentrations developed AIDS or died. Compared with patients who maintained undetectable viral load, the adjusted relative hazard of AIDS or death was 1.00 (0.66-1.55) for patients with viral rebound, and 2.40 (1.72-3.33) for patients who failed to reach undetectable concentrations. INTERPRETATION The rate of virological failure of HAART was high among these patients, but the probability of clinical progression was low even in patients with viral rebound.
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Furrer H, Malinverni R. Systemic inflammatory reaction after starting highly active antiretroviral therapy in AIDS patients treated for extrapulmonary tuberculosis. Am J Med 1999; 106:371-2. [PMID: 10190387 DOI: 10.1016/s0002-9343(99)00015-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Furrer H, Low N, Egger M. [Can one predict the prognosis of HIV infection?]. PRAXIS 1998; 87:1361-1367. [PMID: 9828667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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349
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Furrer H, Wendland T, Minder C, Christen A, von Overbeck J, Grunow R, Pichler W, Malinverni RP. Association of syncytium-inducing phenotype of HIV-1 with CD4 cell count, viral load and sociodemographic characteristics. AIDS 1998; 12:1341-6. [PMID: 9708414 DOI: 10.1097/00002030-199811000-00016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To study whether syncytium-inducing (SI)/non-SI (NSI) phenotype of HIV-1 is associated with CD4+ lymphocyte count, plasma HIV RNA level, clinical stage and sociodemographic characteristics in antiretroviral-naive HIV-1-infected patients. DESIGN Cross-sectional analysis of single centre cohort study data. METHODS SI/NSI phenotype was determined using a cocultivation assay using patients' peripheral blood mononuclear cells and MT2 cells. Standard procedures were used for CD4+ cell counts and viral load measurements in plasma. Univariate and multivariate analyses of association of CD4+ cell counts, viral load, clinical stage, age, sex and mode of HIV transmission were performed. RESULTS In univariate analysis, SI phenotype was significantly associated with lower CD4+ cell counts, higher HIV RNA plasma levels, symptomatic HIV disease, male sex and age 32-36 years (middle tercile). In multivariate analysis, only lower CD4+ cell counts were associated with SI phenotype (odds ratio per increase of 100 x 10(6)/l, 0.54; 95% confidence interval, 0.38-0.78). CONCLUSIONS HIV-1 SI phenotype was associated with lower CD4+ cell counts but not with higher plasma viral load, clinical stage or sociodemographic variables.
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Furrer H. [Surrogate endpoints in clinical studies exemplified by HIV infection]. SCHWEIZERISCHE MEDIZINISCHE WOCHENSCHRIFT 1998; 128:1079-1088. [PMID: 9691341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Surrogate endpoints are used extensively in clinical studies to evaluate the efficacy of therapy. The effect of a treatment on surrogate endpoints should predict efficacy with regard to clinical endpoints such as morbidity and death. Benefits and risks in the use of surrogate endpoints in clinical trials and daily practice are discussed using the example of HIV infection. CD4-lymphocyte counts and plasma HIV-RNA are powerful markers of disease progression in HIV infection. They are also increasingly used as surrogate endpoints to evaluate the efficacy of antiretroviral treatments. Surrogate endpoints should be biologically plausible and must be validated statistically. However, clinical endpoints are still of paramount importance in assessing the value of treatments for chronic diseases.
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