101
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Floridia M, Fragola V, Galluzzo CM, Giannini G, Pirillo MF, Andreotti M, Tomino C, Vella S. HIV-related morbidity and mortality in patients starting protease inhibitors in very advanced HIV disease (CD4 count of < 50 cells/microL): an analysis of 338 clinical events from a randomized clinical trial. HIV Med 2002; 3:75-84. [PMID: 12010353 DOI: 10.1046/j.1468-1293.2002.00104.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AIDS defining events occur infrequently in the presence of CD4 counts above 200 cells/microL. It is, however, uncertain for most of the AIDS defining conditions whether this threshold can be considered equally safe in patients with a previously very low CD4 nadir. METHODS We evaluated in detail all the AIDS defining events observed during a 48-week clinical trial in 1251 nucleoside reverse transcriptase inhibitor-experienced patients who started protease inhibitors (PIs) at CD4 counts below 50 cells/microL. The type of event, immunological status at the moment of event and time between start of PI treatment and event occurrence were analysed cumulatively and by event type; event rates were calculated. RESULTS Concomitant data on CD4 counts were available for 338 AIDS defining events (81% of total events). Median time between start of treatment with PI and event was 94.5 days and median absolute CD4 value at the occurrence of event was 20 per microL. Only 14 events (in 12 patients) were observed above the threshold of 200 CD4 cells/microL. An analysis of the 67 deaths with concomitantly available CD4 counts (57%) showed a median CD4 count of 10 cells/microL, with only four deaths occurring in the presence of a CD4 count above 100 cells/microL. CONCLUSIONS Very few clinical AIDS defining conditions were observed in patients who start PIs at very low CD4 counts and with treatment restore absolute values in CD4 counts above 200 cells/microL. This threshold can therefore be considered a clinically effective goal of treatment with respect to occurrence of all AIDS defining conditions in patients starting PIs in very advanced HIV disease.
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Affiliation(s)
- M Floridia
- ISS-IP 1 Study Group, Laboratory of Virology, Istituto Superiore di Sanità, Rome, Italy
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102
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Emery S, Abrams DI, Cooper DA, Darbyshire JH, Lane HC, Lundgren JD, Neaton JD. The evaluation of subcutaneous proleukin (interleukin-2) in a randomized international trial: rationale, design, and methods of ESPRIT. CONTROLLED CLINICAL TRIALS 2002; 23:198-220. [PMID: 11943448 DOI: 10.1016/s0197-2456(01)00179-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Evaluation of Subcutaneous Proleukin in a Randomized International Trial (ESPRIT) is a large ongoing randomized trial of subcutaneous interleukin-2 (IL-2) plus antiretroviral therapy versus antiretroviral therapy alone in patients with HIV (human immunodeficiency virus) disease and CD4 cell counts of at least 300 cells/mm(3). The primary objective is to determine whether the addition of IL-2 to combination antiretroviral therapy improves morbidity and mortality. The aim is to recruit 4000 participants and follow them for an average of 5 years. Eligible subjects will be recruited at 275 investigational sites in 23 countries around the world. Coupled with broad eligibility criteria this will ensure widely applicable results. A range of secondary objectives will also be addressed in this setting that will include the conduct of observational studies and nested substudies with a public health focus. This article describes the rationale supporting the trial in addition to reviewing the study design, coordination, and governance.
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Affiliation(s)
- Sean Emery
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Level 2, 376 Victoria Street, Sydney, NSW 2010, Australia.
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103
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Zeller V, Truffot C, Agher R, Bossi P, Tubiana R, Caumes E, Jouan M, Bricaire F, Katlama C. Discontinuation of secondary prophylaxis against disseminated Mycobacterium avium complex infection and toxoplasmic encephalitis. Clin Infect Dis 2002; 34:662-7. [PMID: 11810599 DOI: 10.1086/338816] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2001] [Revised: 10/01/2001] [Indexed: 11/03/2022] Open
Abstract
We retrospectively studied outcomes for patients infected with human immunodeficiency virus who received highly active antiretroviral therapy (HAART) and had stopped receiving secondary prophylaxis against toxoplasmic encephalitis (TE) or disseminated Mycobacterium avium complex (MAC) infection. Nineteen patients had a history of TE, and 26 had a history of disseminated MAC infection. The median duration of secondary prophylaxis was 27 months, and the median duration of HAART before discontinuation of secondary prophylaxis was 22 months. Median CD4(+) cell counts at the time of cessation of secondary prophylaxis against TE or disseminated MAC infection were 404 and 105 cells/mm(3), respectively. Plasma virus load was undetectable in 68% of the patients who had a history of TE and in 31% of patients who had a history of disseminated MAC infection. Patients were followed up for a median of 29 months after discontinuation of secondary prophylaxis; no relapses occurred in patients with a history of TE, and 3 relapses occurred in patients with a history of disseminated MAC infection (incidence, 4 relapses per 100 person-years).
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Affiliation(s)
- Valérie Zeller
- Service des Maladies Infectieuses et Tropicales, CHU Pitié-Salpêtrière, 75651 Paris Cedex 013, France.
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104
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105
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Berenguer J, González J, Pulido F, Padilla B, Casado JL, Rubio R, Arribas JR. Discontinuation of secondary prophylaxis in patients with cytomegalovirus retinitis who have responded to highly active antiretroviral therapy. Clin Infect Dis 2002; 34:394-7. [PMID: 11753827 DOI: 10.1086/338401] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2001] [Revised: 09/05/2001] [Indexed: 11/03/2022] Open
Abstract
We performed a prospective study of discontinuation of secondary prophylaxis against cytomegalovirus (CMV) in 36 patients with acquired immunodeficiency syndrome and quiescent CMV retinitis after successful treatment with highly active antiretroviral therapy (HAART). No reactivation or progression of retinitis was observed in 35 patients with persistent response to HAART, findings that support the discontinuation of secondary prophylaxis against CMV retinitis in such patients.
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Affiliation(s)
- Juan Berenguer
- Services of Infectious Diseases , Hospital Gregorio Marañón, 28007, Madrid, Spain.
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106
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Cooney EL. Clinical indicators of immune restoration following highly active antiretroviral therapy. Clin Infect Dis 2002; 34:224-33. [PMID: 11740712 DOI: 10.1086/323898] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2001] [Revised: 08/03/2001] [Indexed: 11/03/2022] Open
Abstract
The course of human immunodeficiency virus (HIV) disease is characterized by a progressive decline in immune function. The advent of highly active antiretroviral therapy (HAART) has allowed patients to experience a significant degree of immune restoration when compared with the era before the availability of HAART. Multiple studies, which have employed sophisticated in vitro measures of immune function, have demonstrated improvement in CD4(+) lymphocyte (T4) responses to various opportunistic pathogens. In addition, for patients treated during acute HIV infection, HIV-specific T4 responses have been restored. By contrast, there are a limited number of in vivo measures of T4 function available to assess immune recovery following initiation of HAART. The primary measurement is an increase in CD4 lymphocyte count, the significance of which may be underappreciated. Delayed-type hypersensitivity testing to recall antigens and serological response to prophylactic vaccines may also have a role. This review discusses available markers of immune function and offers suggestions regarding their use in HAART recipients.
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107
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Chariyalertsak S, Supparatpinyo K, Sirisanthana T, Nelson KE. A controlled trial of itraconazole as primary prophylaxis for systemic fungal infections in patients with advanced human immunodeficiency virus infection in Thailand. Clin Infect Dis 2002; 34:277-84. [PMID: 11740718 DOI: 10.1086/338154] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2001] [Revised: 08/16/2001] [Indexed: 11/03/2022] Open
Abstract
Cryptococcal meningitis and Penicillium marneffei infection are common serious fungal infections in patients infected with human immunodeficiency virus (HIV) in Southeast Asia. In a prospective, double-blind trial, 63 patients with HIV infection and CD4+ lymphocyte counts of <200 cells/microL were randomized to receive oral itraconazole (200 mg per day), and 66 similar patients received a matched placebo. Both groups were monitored for evidence of invasive fungal infections. Baseline characteristics and the CD4+ cell counts of the 2 groups were similar. In the intent-to-treat analysis, a systemic fungal infection developed in 1 patient (1.6%) assigned to receive itraconazole (P. marneffei) and in 11 patients (16.7%) given placebo (7 patients had cryptococcal meningitis, and 4 patients had P. marneffei infection; P=.003, by the log-rank test). The incidence of recurrent or refractory mucosal candidiasis was significantly reduced in the itraconazole group. The 2 groups did not differ with regard to adverse effects. Primary prophylaxis with oral itraconazole is well tolerated and prevents cryptococcosis and penicilliosis marneffei in patients with advanced HIV infection, especially those with CD4+ lymphocyte counts of <100 cells/microL. However, prophylaxis with itraconazole was not found to be associated with a survival advantage when it was given to patients with advanced HIV disease.
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109
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Estudio de las variables asociadas a la aparición de éxito y fracaso en términos de carga viral en individuos con infección por el virus de la inmunodeficiencia humana. Med Clin (Barc) 2002. [DOI: 10.1016/s0025-7753(02)72498-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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110
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2001 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. Infect Dis Obstet Gynecol 2002; 10:3-64. [PMID: 12090361 PMCID: PMC1784605 DOI: 10.1155/s1064744902000029] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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111
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Felipe García F. Interrupciones estructuradas del tratamiento antirretroviral: ¿una nueva estrategia terapéutica? Enferm Infecc Microbiol Clin 2002. [DOI: 10.1016/s0213-005x(02)72821-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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112
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Wolff AJ, O'Donnell AE. Pulmonary manifestations of HIV infection in the era of highly active antiretroviral therapy. Chest 2001; 120:1888-93. [PMID: 11742918 DOI: 10.1378/chest.120.6.1888] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To determine whether the spectrum of HIV-related pulmonary disease seen by a university medical center Pulmonary and Critical Care Medicine Service has changed since the introduction of highly active antiretroviral therapy (HAART). DESIGN Retrospective chart review. SETTING A tertiary care university hospital. PATIENTS All HIV-infected patients referred to the Pulmonary and Critical Care Medicine Service from January 1, 1993, through December 31, 1995 (era 1) and from July 1, 1997, through June 30, 2000 (era 2). INTERVENTIONS Inpatient and outpatient charts were reviewed for data regarding patient demographics, CD4 cell counts, viral load levels, duration of HIV seropositivity, history of opportunistic infections, and final diagnosis. RESULTS Pneumocystis carinii pneumonia (PCP) was less common in the HAART era than in the pre-HAART era, whereas bacterial pneumonia and non-Hodgkin's lymphoma (NHL) were more common in the HAART era than in the pre-HAART era. HAART was protective against PCP (odds ratio [OR], 0.37; confidence interval [CI], 0.16 to 0.89) in a manner dependent on the CD4 cell count. Patients receiving HAART were at increased risk for the development of bacterial pneumonia (OR, 2.41; CI, 1.12 to 5.17) and NHL (OR, 15.11; CI, 3.14 to 28.32). A history of PCP indicated a risk factor for bacterial pneumonia (OR, 2.14; CI, 1.13 to 4.04). A history of cytomegalovirus infection indicated a risk factor for NHL (OR, 6.0; CI, 1.27 to 28.32). CONCLUSIONS There have been significant changes in the spectrum of HIV-related pulmonary complications seen by our Pulmonary and Critical Care Medicine Service in the HAART era.
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Affiliation(s)
- A J Wolff
- Division of Pulmonary and Critical Care Medicine, Georgetown University Medical Center, Washington, DC 20007-2197, USA
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113
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Beck JM, Rosen MJ, Peavy HH. Pulmonary complications of HIV infection. Report of the Fourth NHLBI Workshop. Am J Respir Crit Care Med 2001; 164:2120-6. [PMID: 11739145 DOI: 10.1164/ajrccm.164.11.2102047] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
MESH Headings
- AIDS-Related Opportunistic Infections/epidemiology
- AIDS-Related Opportunistic Infections/virology
- Adult
- Antiretroviral Therapy, Highly Active
- Child
- HIV Infections/complications
- HIV Infections/drug therapy
- HIV Infections/epidemiology
- HIV Infections/immunology
- Humans
- Incidence
- Lung Diseases/epidemiology
- Lung Diseases/virology
- Lung Diseases, Fungal/epidemiology
- Lung Diseases, Fungal/virology
- Lung Neoplasms/epidemiology
- Lung Neoplasms/virology
- Pneumonia, Bacterial/epidemiology
- Pneumonia, Bacterial/virology
- Pneumonia, Pneumocystis/epidemiology
- Pneumonia, Pneumocystis/virology
- Pneumonia, Viral/epidemiology
- Pneumonia, Viral/virology
- Pulmonary Disease, Chronic Obstructive/epidemiology
- Pulmonary Disease, Chronic Obstructive/virology
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/virology
- United States/epidemiology
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Affiliation(s)
- J M Beck
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, and Veterans Affairs Medical Center, Ann Arbor, Michigan 48105-2300, USA. jamebeck@umich
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114
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Trikalinos TA, Ioannidis JP. Discontinuation of Pneumocystis carinii prophylaxis in patients infected with human immunodeficiency virus: a meta-analysis and decision analysis. Clin Infect Dis 2001; 33:1901-9. [PMID: 11692302 DOI: 10.1086/323198] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2001] [Revised: 04/30/2001] [Indexed: 11/03/2022] Open
Abstract
We performed a meta-analysis and a decision analysis on the discontinuation of prophylaxis for Pneumocystis carinii pneumonia (PCP) in patients infected with human immunodeficiency virus who had adequate immune recovery while receiving highly active antiretroviral therapy. In the meta-analysis (14 studies with 3584 subjects who had discontinued prophylaxis), 8 cases of PCP occurred during 3449 person-years (0.23 cases per 100 person-years [95% confidence interval, 0.10-0.46]). In the decision analysis, mortality and time spent alive without immunodeficiency in the modeled discontinuation strategy were similar to those in the continuation strategy. For patients who received primary prophylaxis, the discontinuation strategy led to slightly fewer episodes of PCP and fewer toxicity-related prophylaxis withdrawals (e.g., 8.6 vs. 34.5 cases per 100 patients during a 10-year period). Patients on the discontinuation strategy were more likely to be receiving trimethoprim-sulfamethoxazole when they became immunodeficient. Comparative results were similar for patients with prior PCP. Discontinuation of PCP prophylaxis in patients with adequate immune recovery is a useful strategy that should be widely considered.
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Affiliation(s)
- T A Trikalinos
- Clinical Trials and Evidence-Based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, 45110, Greece
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115
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2001 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. HIV CLINICAL TRIALS 2001; 2:493-554. [PMID: 11742438 DOI: 10.1310/aqml-uabk-5llb-e615] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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116
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Fishman JA. Prevention of infection caused by Pneumocystis carinii in transplant recipients. Clin Infect Dis 2001; 33:1397-405. [PMID: 11565082 DOI: 10.1086/323129] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2001] [Revised: 06/05/2001] [Indexed: 11/04/2022] Open
Abstract
Pneumocystis carinii remains an important pathogen in patients who undergo solid-organ and hematopoietic transplantation. Infection results from reactivation of latent infection and via de novo acquisition of infection from environmental sources. The risk of infection depends on the intensity and duration of immunosuppression and underlying immune deficits. The risk is greatest after lung transplants, in individuals with invasive cytomegalovirus disease, during intensive immunosuppression for allograft rejection, and during periods of neutropenia. Prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMZ) prevents many opportunistic infections, including infection with P. carinii, Toxoplasma gondii, and community-acquired respiratory, gastrointestinal, and urinary tract pathogens. Intolerance of TMP-SMZ is common; desensitization is useful less often in transplant patients than in patients with AIDS. Alternative agents provide a narrower spectrum of protection than does TMP-SMZ and less adequate protection against Pneumocystis species. Clinically, the diagnosis of breakthrough Pneumocystis pneumonia often requires invasive procedures. Strategies for the prevention of Pneumocystis infection must be individualized on the basis of a stratification of risk for each patient.
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Affiliation(s)
- J A Fishman
- Infectious Disease Division and Transplantation Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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117
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Street AC, Lewin SR. Pneumocystis carinii pneumonia after cessation of secondary prophylaxis in a patient on highly active antiretroviral therapy with a CD4 cell count greater than 200/mm3. AIDS 2001; 15:1912-3. [PMID: 11579267 DOI: 10.1097/00002030-200109280-00034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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118
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Urschel S, Schuster T, Dunsch D, Wintergerst U, Hofstetter R, Belohradsky BH. Discontinuation of primary Pneumocystis carinii prophylaxis after reconstitution of CD4 cell counts in HIV-infected children. AIDS 2001; 15:1589-91. [PMID: 11504999 DOI: 10.1097/00002030-200108170-00024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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119
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Koletar SL, Heald AE, Finkelstein D, Hafner R, Currier JS, McCutchan JA, Vallee M, Torriani FJ, Powderly WG, Fass RJ, Murphy RL. A prospective study of discontinuing primary and secondary Pneumocystis carinii pneumonia prophylaxis after CD4 cell count increase to > 200 x 106 /l. AIDS 2001; 15:1509-15. [PMID: 11504983 DOI: 10.1097/00002030-200108170-00008] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the incidence of Pneumocystis carinii pneumonia (PCP) after discontinuation of either primary or secondary prophylaxis. DESIGN This was a prospective, non-randomized, non-blinded study. SETTING Twenty-five University-based AIDS Clinical Trials Group units. PARTICIPANTS Participants either had a CD4 cell count < or = 100 x 106/l at any time in the past and no history of confirmed PCP (group I; n = 144), or had a confirmed episode of PCP > or = 6 months prior to study entry (group II; n = 129). All subjects had sustained CD4 cell counts > 200 x 106/l in response to antiretroviral therapy. INTERVENTIONS Subjects discontinued PCP prophylaxis within 3 months or at the time of study entry. Evaluations for symptoms of PCP and CD4 cell counts were performed every 8 weeks. Prophylaxis was resumed if two consecutive CD4 cell counts were < 200 x 106/l. MAIN OUTCOME MEASURE(S) The main outcome was development of PCP. RESULTS No cases of PCP occurred in 144 subjects (median follow-up, 82 weeks) in group I or in the 129 subjects (median follow-up, 63 weeks) in group II (95% upper confidence limits on the rates of 1.3 per 100 person-years and 1.96 per 100 person-years for groups I and II, respectively). Eight subjects (five in group I and three in group II) resumed PCP prophylaxis after two consecutive CD4 cell counts < 200 x 106/l. CONCLUSIONS The risk of developing initial or recurrent PCP after discontinuing prophylaxis is low in HIV-infected individuals who have sustained CD4 cell count increases in response to antiretroviral therapy. Neither lifelong primary nor secondary PCP prophylaxis is necessary.
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Affiliation(s)
- S L Koletar
- The Ohio State University Hospitals, Columbus, Ohio, USA
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120
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121
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Rollot F, Bossi P, Tubiana R, Caumes E, Zeller V, Katlama C, Bricaire F. Discontinuation of secondary prophylaxis against cryptococcosis in patients with AIDS receiving highly active antiretroviral therapy. AIDS 2001; 15:1448-9. [PMID: 11504971 DOI: 10.1097/00002030-200107270-00019] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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122
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123
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