Continued improvement in survival among HIV-infected individuals with newer forms of highly active antiretroviral therapy

Social-structural factors associated with supportive service use among a cohort of HIV-positive individuals on antiretroviral therapy

As mortality rates decrease in British Columbia, Canada, supportive services (e.g. housing, food, counseling, addiction treatment) are increasingly conceptualized as critical components of care for people living with HIV/AIDS. Our study investigates social and clinical correlates of supportive service use across differing levels of engagement. Among 915 participants from the Longitudinal Investigations into Supportive and Ancillary health services (LISA) cohort, 742 (81%) reported using supportive services. Participants were nearly twice as likely to engage daily in supportive services if they self-identified as straight (95% confidence interval [CI], adjusted odds ratio [AOR]: 1.69), had not completed high school (95% CI, AOR: 1.97), had an annual income of < $15,000 (95% CI, AOR: 1.81), were unstably housed (95% CI, AOR: 1.89), were currently using illicit drugs (95% CI, AOR: 1.60), or reported poor social capital in terms of perceived neighborhood problems (95% CI, AOR: 1.15) or standard of living (95% CI, AOR: 1.70). Of interest, after adjusting for sociodemographic and socioeconomic variables, no clinical markers remained an independent predictor of use of supportive services. High service use by those demonstrating social and clinical vulnerabilities reaffirms the need for continued expansion of supportive services to facilitate a more equitable distribution of health among persons living with HIV.

CIHR Canadian HIV Trials Network Coinfection and Concurrent Diseases Core: Canadian guidelines for management and treatment of HIV/hepatitis C coinfection in adults

BACKGROUND

Hepatitis C virus (HCV) coinfection occurs in 20% to 30% of Canadians living with HIV, and is responsible for a heavy burden of morbidity and mortality. HIV-HCV management is more complex due to the accelerated progression of liver disease, the timing and nature of antiretroviral and HCV therapy, mental health and addictions management, socioeconomic obstacles and drug-drug interactions between new HCV direct-acting antiviral therapies and antiretroviral regimens.

OBJECTIVE

To develop national standards for the management of HCV-HIV coinfected adults in the Canadian context.

METHODS

A panel with specific clinical expertise in HIV-HCV co-infection was convened by The CIHR HIV Trials Network to review current literature, existing guidelines and protocols. Following broad solicitation for input, consensus recommendations were approved by the working group, and were characterized using a Class (benefit verses harm) and Level (strength of certainty) quality-of-evidence scale.

RESULTS

All HIV-HCV coinfected individuals should be assessed for HCV therapy. Individuals unable to initiate HCV therapy should initiate antiretroviral therapy to slow liver disease progression. Standard of care for genotype 1 is pegylated interferon and weight-based ribavirin dosing plus an HCV protease inhibitor; traditional dual therapy for 24 weeks (for genotype 2/3 with virological clearance at week 4); or 48 weeks (for genotypes 2-6). Therapy deferral for individuals with mild liver disease may be considered. HIV should not be considered a barrier to liver transplantation in coinfected patients.

DISCUSSION

Recommendations may not supersede individual clinical judgement.

Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies

BACKGROUND

Few estimates exist of the life expectancy of HIV-positive adults receiving antiretroviral treatment (ART) in low- and middle-income countries. We aimed to estimate the life expectancy of patients starting ART in South Africa and compare it with that of HIV-negative adults.

METHODS AND FINDINGS

Data were collected from six South African ART cohorts. Analysis was restricted to 37,740 HIV-positive adults starting ART for the first time. Estimates of mortality were obtained by linking patient records to the national population register. Relative survival models were used to estimate the excess mortality attributable to HIV by age, for different baseline CD4 categories and different durations. Non-HIV mortality was estimated using a South African demographic model. The average life expectancy of men starting ART varied between 27.6 y (95% CI: 25.2-30.2) at age 20 y and 10.1 y (95% CI: 9.3-10.8) at age 60 y, while estimates for women at the same ages were substantially higher, at 36.8 y (95% CI: 34.0-39.7) and 14.4 y (95% CI: 13.3-15.3), respectively. The life expectancy of a 20-y-old woman was 43.1 y (95% CI: 40.1-46.0) if her baseline CD4 count was ≥ 200 cells/µl, compared to 29.5 y (95% CI: 26.2-33.0) if her baseline CD4 count was <50 cells/µl. Life expectancies of patients with baseline CD4 counts ≥ 200 cells/µl were between 70% and 86% of those in HIV-negative adults of the same age and sex, and life expectancies were increased by 15%-20% in patients who had survived 2 y after starting ART. However, the analysis was limited by a lack of mortality data at longer durations.

CONCLUSIONS

South African HIV-positive adults can have a near-normal life expectancy, provided that they start ART before their CD4 count drops below 200 cells/µl. These findings demonstrate that the near-normal life expectancies of HIV-positive individuals receiving ART in high-income countries can apply to low- and middle-income countries as well. Please see later in the article for the Editors' Summary.

Disparities in the burden of HIV/AIDS in Canada

Background

We aimed to characterize changes in patterns of new HIV diagnoses, HIV-related mortality, and HAART use in Canada from 1995 to 2008.

Methods

Data on new HIV diagnoses were obtained from Health Canada, HIV-related mortality statistics were obtained from Statistics Canada, and information on the number of people on HAART was obtained from the single antiretroviral distribution site in British Columbia (BC), and the Intercontinental Marketing Services Health for Ontario and Quebec. Trends of new HIV-positive tests were assessed using Spearman rank correlations and the association between the number of individuals on HAART and new HIV diagnoses were estimated using generalized estimating equations (GEE).

Results

A total of 34,502 new HIV diagnoses were observed. Rates of death in BC are higher than those in Ontario and Quebec with the rate being 2.03 versus 1.06 and 1.21 per 100,000 population, respectively. The number of HIV infected individuals on HAART increased from 5,091 in 1996 to 20,481 in 2008 in the three provinces (4 fold increase). BC was the only province with a statistically significant decrease (trend test p<0.0001) in the rate of new HIV diagnoses from 18.05 to 7.94 new diagnoses per 100,000 population. Our analysis showed that for each 10% increment in HAART coverage the rate of new HIV diagnoses decreased by 8% (95% CI: 2.4%, 13.3%)

Interpretation

Except for British Columbia, the number of new HIV diagnoses per year has remained relatively stable across Canada over the study period. The decline in the rate of new HIV diagnoses per year may be in part attributed to the greater expansion of HAART coverage in this province.

A study on epidemiological profile of anxiety disorders among people living with HIV/AIDS in a sub-Saharan Africa HIV clinic

The aim of this study is to find out the prevalence, types and correlates of anxiety disorders among people living with HIV/AIDS (PLWHA) attending a sub-Saharan Africa HIV clinic. Three hundred HIV positive adults were subjected to semi-structured clinical interview using the Schedule for Clinical Assessment in Neuropsychiatry to diagnose anxiety disorders in them. Additionally, a socio-demographic/clinical profile questionnaire designed for the study was administered to the study participants. The prevalence of anxiety disorders among PLWHA in this study was 21.7 %, and anxiety disorder unspecified (6.2 %), mixed anxiety-depressive disorder (5.3 %) and social phobia (4 %) among others were the subtypes of anxiety disorders elicited among the participants. Lack of family support [correlation coefficient (r) = 0.212, P < 0.001], unemployment (r = 0.168, P = 0.004) and being unmarried (r = 0.182, P = 0.002) were much more likely to be found among participants with anxiety disorders; while younger age group (r = -0.126, P = 0.039) and negative previous mental illness (r = -0.894, P = 0.021) seem protective against anxiety disorders in this study. Our findings suggest a high burden of anxiety disorders among PLWHA and up to five-folds when compared to the general population. Thus, integration of proactive mental health screening as well as treatment services with inclusion of targeted intervention for anxiety disorders among PLWHA is recommended.

A switch in therapy to a reverse transcriptase inhibitor sparing combination of lopinavir/ritonavir and raltegravir in virologically suppressed HIV-infected patients: a pilot randomized trial to assess efficacy and safety profile: the KITE study

A nucleoside reverse transcriptase inhibitor (NRTI) backbone is a recommended component of standard highly active antiretroviral therapy (sHAART). However, long-term NRTI exposure can be limited by toxicities. NRTI class-sparing alternatives are warranted in select patient populations. This is a 48-week single-center, open-label pilot study in which 60 HIV-infected adults with plasma HIV-1 RNA (<50 copies/ml) on sHAART were randomized (2:1) to lopinavir/ritonavir (LPV/r) 400/100 mg BID+raltegravir (RAL) 400 mg BID switch (LPV-r/RAL arm) or to continue on sHAART. The primary endpoint was the proportion of subjects with HIV-RNA<50 copies/ml at week 48. Secondary efficacy and immunologic and safety endpoints were evaluated. Demographics and baseline lipid profile were similar across arms. Mean entry CD4 T cell count was 493 cells/mm(3). At week 48, 92% [95% confidence interval (CI): 83-100%] of the LPV-r/RAL arm and 88% (95% CI: 75-100%) of the sHAART arm had HIV-RNA<50 copies/ml (p=0.70). Lipid profile (mean ± SEM, mg/dl, LPV-r/RAL vs. sHAART) at week 24 was total-cholesterol 194 ± 5 vs. 176 ± 9 (p=0.07), triglycerides 234 ± 30 vs. 133 ± 27 (p=0.003), and LDL-cholesterol 121 ± 6 vs. 110 ± 8 (p=0.27). There were no serious adverse events (AEs) in either arm. Regimen change occurred in three LPV-r/RAL subjects (n=1, due to LPV-r/RAL-related AEs) vs. 0 in sHAART. There were no differences between arms in bone mineral density, total body fat composition, creatinine clearance, or CD4 T cell counts at week 48. In virologically suppressed patients on HAART, switching therapy to the NRTI-sparing LPV-r/RAL combination produced similar sustained virologic suppression and immunologic profile as sHAART. AEs were comparable between arms, but the LPV-r/RAL arm experienced higher triglyceridemia.

Impact of paediatric human immunodeficiency virus infection on children's and caregivers' daily functioning and well-being: a qualitative study

BACKGROUND

Human immunodeficiency virus (HIV) infection impacts not only upon the physical health of affected children, but also their psychosocial functions, family relationships and economical status. Caregivers are confronted with complex challenges related to the physical, emotional and financial demands of raising these children. The purpose of this study was to enhance our understanding of the impact of HIV disease on both children's and caregivers' well-being, using a qualitative inquiry approach.

METHODS

A total of 35 primary caregivers of HIV-infected children participated in in-depth interviews. The issues discussed included the major negative impacts on children's daily functioning and well-being, and the perceived caregiver/parental burden. Participants included parents (40%), grandparents (22.8%), other relatives (e.g. uncles, aunts) (34.3%) and one foster parent (2.8%).

RESULTS

Qualitative analysis revealed that the major negative impacts of HIV/AIDS included physical symptoms, school performance and relationship changes. The major negative impacts on caregivers' well-being included acceptance of the diagnosis, dealing with the financial burden and keeping the diagnosis private.

CONCLUSIONS

Approaches are needed to address these challenges by enhancing families' coping skills and building supportive networks.

Assessing the effectiveness of antiretroviral regimens in cohort studies involving HIV-positive injection drug users

OBJECTIVE

We compared the effectiveness of different highly active antiretroviral therapy (HAART) regimens considering, separately, history of injection drug use (IDU) (yes/no). DESIGN, METHODS: A total of 1163 HIV-infected patients initiated HAART between 1 January 2000 and 28 February 2009 in British Columbia, Canada, and were followed until 28 February 2010. HAART effectiveness was measured by the ability to achieve viral suppression below 50 copies/ml at 6 months. We compared HAART regimens containing efavirenz and boosted atazanavir. We developed logistic regression models using different techniques to control for potential confounders.

RESULTS

Among the 1163 patients, 796 (68%) achieved viral suppression at 6 months (32% reporting a history of IDU). Different confounding models yielded very similar odds ratios for achieving viral suppression. Boosted atazanavir-based HAART demonstrated to be the most effective regimen, showing a surprisingly higher benefit for patients with a history of IDU (odds ratios from different models ranged from 1.74-1.95 to 1.45-1.51).

CONCLUSIONS

The literature has conflicting results regarding the effectiveness of HAART to treat HIV infection among those with a history of IDU. We have shown that most patients, with and without a history of IDU, were able to achieve viral suppression at 6 months. Boosted atazanavir-based HAART was the most resilient regimen and it was more effective than efavirenz-based HAART among IDUs. Given the limited inclusion of IDU in clinical trials of HAART's efficacy, a randomized clinical trial comparing different first-line HAART regimens among IDU is warranted based on these results.

Efeito da terapia antirretroviral e dos níveis de carga viral no complexo médio-intimal e no índice tornozelo-braço em pacientes infectados pelo HIV

OBJETIVOS: Identificar precocemente a prevalência de aterosclerose, por causa do espessamento do complexo médio-intimal das carótidas comuns e do índice tornozelo-braço. Essas medidas foram relacionadas com os fatores de risco clássicos de aterosclerose e os específicos dos infectados pelo HIV (tempo de doença, tempo de tratamento, tipo de tratamento, tipo de terapia antirretroviral utilizada, CD4 e carga viral). MÉTODOS: Setenta casos infectados com o HIV foram avaliados pela medida automática do complexo médio-intimal nas carótidas e do índice tornozelo-braço. Consideraram-se os fatores de risco clássicos de aterosclerose (idade, sexo, hipertensão arterial sistêmica, tabagismo, hipercolesterolemia, hipertrigliceridemia, obesidade e história familiar de evento cardiovascular), as medidas antropométricas e as variáveis relacionadas ao HIV. O nível de significância assumido foi de 5%. RESULTADOS: O tempo médio de diagnóstico do HIV foi de 104,9 meses e de tratamento foi de 97,9 meses. Quanto ao tipo de tratamento, 47 (67,1%) fizeram uso de inibidor de protease por mais de seis meses e 36 (51,4%) estão em uso atualmente. O índice tornozelo-braço estava aumentado em um único paciente (0,7%) e não se evidenciou espessamento do complexo médio-intimal em nenhum indivíduo. Não existiu associação significante da medida do complexo médio-intimal da carótida comum direita com nenhuma das variáveis analisadas. CONCLUSÕES: Indivíduos jovens, sob o uso de terapia antirretroviral por cinco anos ou mais, não apresentaram espessamento do complexo médio-intimal ou aumento do índice tornozelo-braço. Não houve diferença do espessamento do complexo médio-intimal associada ao tipo de esquema antirretroviral utilizado ou nível de carga viral.

HIV and hepatitis C virus coinfection in Canada: challenges and opportunities for reducing preventable morbidity and mortality

OBJECTIVES

Hepatitis C virus (HCV) has emerged as an important health problem in the era of effective HIV treatment. However, very few data exist on the health status and disease burden of HIV/HCV-coinfected Canadians.

METHODS

HIV/HCV-coinfected patients were enrolled prospectively in a multicentre cohort from 16 centres across Canada between 2003 and 2010 and followed every 6 months. We determined rates of a first liver fibrosis or endstage liver disease (ESLD) event and all-cause mortality since cohort enrolment and calculated standardized mortality ratios compared with the general Canadian population.

RESULTS

A total of 955 participants were enrolled in the study and followed for a median of 1.4 (interquartile range 0.5-2.3) years. Most were male (73%) with a median age of 44.5 years; 13% self-identified as aboriginal. There were high levels of current injecting drug and alcohol use and poverty. Observed event rates [per 100 person-years; 95% confidence interval (CI)] were: significant fibrosis (10.21; 8.49, 12.19), ESLD (3.16; 2.32, 4.20) and death (3.72; 2.86, 4.77). The overall standardized mortality ratio was 17.08 (95% CI 12.83, 21.34); 12.80 (95% CI 9.10, 16.50) for male patients and 28.74 (95% CI 14.66, 42.83) for female patients. The primary causes of death were ESLD (29%) and overdose (24%).

CONCLUSIONS

We observed excessive morbidity and mortality in this HIV/HCV-coinfected population in care. Over 50% of observed deaths may have been preventable. Interventions aimed at improving social circumstances, reducing harm from drug and alcohol use and increasing the delivery of HCV treatment in particular will be necessary to reduce adverse health outcomes among HIV/HCV-coinfected persons.

Availability of nutritional support services in HIV care and treatment sites in sub-Saharan African countries

OBJECTIVE

To examine the availability of nutritional support services in HIV care and treatment sites across sub-Saharan Africa.

DESIGN

In 2008, we conducted a cross-sectional survey of sites providing antiretroviral therapy (ART) in nine sub-Saharan African countries. Outcomes included availability of: (i) nutritional counselling; (ii) micronutrient supplementation; (iii) treatment for severe malnutrition; and (iv) food rations. Associations with health system indicators were explored using bivariate and multivariate methods.

SETTING

President's Emergency Plan for AIDS Relief-supported HIV treatment and care sites across nine sub-Saharan African countries.

SUBJECTS

A total of 336 HIV care and treatment sites, serving 467 175 enrolled patients.

RESULTS

Of the sites under study, 303 (90 %) offered some form of nutritional support service. Nutritional counselling, micronutrient supplementation, treatment for severe acute malnutrition and food rations were available at 98 %, 64 %, 36 % and 31 % of sites, respectively. In multivariate analysis, secondary or tertiary care sites were more likely to offer nutritional counselling (adjusted OR (AOR): 2.2, 95 % CI 1.1, 4.5). Rural sites (AOR: 2.3, 95 % CI 1.4, 3.8) had increased odds of micronutrient supplementation availability. Sites providing ART for >2 years had higher odds of availability of treatment for severe malnutrition (AOR: 2.4, 95 % CI 1.4, 4.1). Sites providing ART for >2 years (AOR: 1.6, 95 % CI 1.3, 1.9) and rural sites (AOR: 2.4, 95 % CI 1.4, 4.4) had greater odds of food ration availability.

CONCLUSIONS

Availability of nutritional support services was high in this large sample of HIV care and treatment sites in sub-Saharan Africa. Further efforts are needed to determine the uptake, quality and effectiveness of these services and their impact on patient and programme outcomes.

Independent effects of HIV, aging, and HAART on brain volumetric measures

BACKGROUND

Neurocognitive impairment remains prevalent in HIV-infected (HIV+) individuals despite highly active antiretroviral therapy (HAART). We assessed the impact of HIV, HAART, and aging using structural neuroimaging.

METHODS

Seventy-eight participants [HIV- (n = 26), HIV+ on stable HAART (HIV+/HAART+; n = 26), HIV+ naive to HAART (HIV+/HAART-; n = 26)] completed neuroimaging and neuropsychological testing. A subset of HIV+ subjects (n = 12) performed longitudinal assessments before and after initiating HAART. Neuropsychological tests evaluated memory, psychomotor speed, and executive function, and a composite neuropsychological score was calculated based on normalized performances (neuropsychological summary Z score, NPZ-4). Volumetrics were evaluated for the amygdala, caudate, thalamus, hippocampus, putamen, corpus callosum, and cerebral gray and white matter. A 3-group 1-way analysis of variance assessed differences in neuroimaging and neuropsychological indices. Correlations were examined between NPZ-4 and volumetrics. Exploratory testing using a broken-stick regression model evaluated self-reported duration of HIV infection on brain structure.

RESULTS

HIV+ individuals had significant reductions in brain volumetrics within select subcortical regions (amygdala, caudate, and corpus callosum) compared with HIV- participants. However, HAART did not affect brain structure as regional volumes were similar for HIV+/HAART- and HIV+/HAART+. No association existed between NPZ-4 and volumetrics. HIV and aging were independently associated with volumetric reductions. Exploratory analyses suggest caudate atrophy due to HIV slowly occurs after self-reported seroconversion.

CONCLUSIONS

HIV associated volumetric reductions within the amygdala, caudate, and corpus callosum occurs despite HAART. A gradual decline in caudate volume occurs after self-reported seroconversion. HIV and aging independently increase brain vulnerability. Additional longitudinal structural magnetic resonance imaging studies, especially within older HIV+ participants, are required.

Cohort Profile: Longitudinal Investigations into Supportive and Ancillary health services

The Longitudinal Investigations into Supportive and Ancillary health services (LISA) study is a cohort of people living with HIV/AIDS who have ever accessed anti-retroviral therapy (ART) in British Columbia, Canada. The LISA study was developed to better understand the outcomes of people living with HIV with respect to supportive services use, socio-demographic factors and quality of life. Between July 2007 and January 2010, 1000 participants completed an interviewer-administered questionnaire that included questions concerning medical history, substance use, social and medical support services, food and housing security and other social determinants of health characteristics. Of the 1000 participants, 917 were successfully linked to longitudinal clinical data through the provincial Drug Treatment Program. Within the LISA cohort, 27% of the participants are female, the median age is 39 years and 32% identify as Aboriginal. Knowledge translation activities for LISA include the creation of plain language summaries, internet resources and arts-based engagement activities such as Photovoice.

HIV Co-receptor usage in HIV-related non-hodgkin's lymphoma

In this study 15 banked samples of HIV-related Non-Hodgkin's Lymphoma (NHL) cases were tested for HIV co-receptor usage and SDF1 3'A polymorphism. Reportable tropism from 9 plasma samples had 1 (11.1%) HIV case with CXCR4 and 8 (88.9%) with CCR5 usage, even though most of the cases occurred at a late stage of HIV (2/3 had CD4 counts below 200), where expected CXCR4 usage would be 60%. Based on the expected proportion of less than 50% CCR5 in chronically infected individuals, this would suggest that in NHL may be associated with CCR5 usage (P = 0.04).

Clinical, demographic and laboratory parameters at HAART initiation associated with decreased post-HAART survival in a U.S. military prospective HIV cohort

Background

Although highly active antiretroviral therapy (HAART) has improved HIV survival, some patients receiving therapy are still dying. This analysis was conducted to identify factors associated with increased risk of post-HAART mortality.

Methods

We evaluated baseline (prior to HAART initiation) clinical, demographic and laboratory factors (including CD4+ count and HIV RNA level) for associations with subsequent mortality in 1,600 patients who began HAART in a prospective observational cohort of HIV-infected U.S. military personnel.

Results

Cumulative mortality was 5%, 10% and 18% at 4, 8 and 12 years post-HAART. Mortality was highest (6.23 deaths/100 person-years [PY]) in those with ≤ 50 CD4+ cells/mm³ before HAART initiation, and became progressively lower as CD4+ counts increased (0.70/100 PY with ≥ 500 CD4+ cells/mm³). In multivariate analysis, factors significantly (p < 0.05) associated with post-HAART mortality included: increasing age among those ≥ 40 years (Hazard ratio [HR] = 1.32 per 5 year increase), clinical AIDS events before HAART (HR = 1.93), ≤ 50 CD4+ cells/mm³ (vs. CD4+ ≥ 500, HR = 2.97), greater HIV RNA level (HR = 1.36 per one log₁₀ increase), hepatitis C antibody or chronic hepatitis B (HR = 1.96), and HIV diagnosis before 1996 (HR = 2.44). Baseline CD4+ = 51-200 cells (HR = 1.74, p = 0.06), and hemoglobin < 12 gm/dL for women or < 13.5 for men (HR = 1.36, p = 0.07) were borderline significant.

Conclusions

Although treatment has improved HIV survival, defining those at greatest risk for death after HAART initiation, including demographic, clinical and laboratory correlates of poorer prognoses, can help identify a subset of patients for whom more intensive monitoring, counseling, and care interventions may improve clinical outcomes and post-HAART survival.

Factors Associated with Antiretroviral Medication Adherence among HIV-Positive Adults Accessing Highly Active Antiretroviral Therapy (HAART) in British Columbia, Canada

Background: Among those accessing treatment, highly active antiretroviral therapy (HAART) has transformed HIV into a chronic and manageable condition. However, high levels of adherence are required to derive a sustained, long-term clinical benefit. The aim of this study was to examine the predictors of adherence based on prescription refill among persons on HAART in British Columbia, Canada. Methods: This study utilizes data collected between July 2007 and January 2010, as part of the Longitudinal Investigations into Supportive and Ancillary health services (LISA) cohort, which is a study of HIV-positive persons who have accessed antiretroviral therapy (ART) in British Columbia. Participants were considered optimally adherent if they were dispensed ≥95% of their prescribed antiretrovirals. Results: Of a total of 566 participants, only 316 (55.8%) were optimally adherent to HAART. Independent predictors of optimal adherence were increasing age (adjusted odds ratio [AOR] = 1.84, 95% confidence interval [CI]: 1.44-2.33), male gender (AOR = 1.68, 95% CI: 1.07-2.64), and being enrolled in a comprehensive adherence assistance program (AOR = 4.26, 95% CI: 2.12-8.54). Having an annual income <$15 000 (AOR = 0.47, 95% CI: 0.31-0.72) and both former and current injection drug use (AOR = 0.46, 95% CI: 0.29-0.73 and AOR = 0.35, 95% CI: 0.20-0.58, respectively) were independently associated with suboptimal (<95%) adherence. Conclusions: We found that women and people who inject drugs are at increased risk of being suboptimally adherent to HAART. Optimal adherence remains a significant public health and clinical goal in the context of rapidly expanding access to HAART.

Safety and tolerability of varenicline tartrate (Champix(®)/Chantix(®)) for smoking cessation in HIV-infected subjects: a pilot open-label study

The prevalence of smoking in HIV-infected subjects is high. As a smoking cessation aid, varenicline (Champix(®), Pfizer, Saint-Laurent, QC, Canada or Chantix(®), Pfizer, Mission, KS) has not been previously evaluated in HIV-infected smokers. In this multicenter pilot open label study, varenicline 1.0 mg was used twice daily for 12 weeks with dose titration in the first week. Adverse events (AEs) during the treatment period were recorded. Changes from baseline in laboratory tests, vital signs, daily cigarette consumption, nicotine dependence, and withdrawal were measured through week 24. Self-reported abstinence was validated by serum cotinine at week 12. We enrolled 36 subjects with a mean of 29 pack-years of smoking and a minimum of 4 cigarettes per day. All but 1 were male, 33 (92%) were white. The most frequently reported AEs were nausea (33%), abnormal dreams (31%), affect lability (19%), and insomnia (19%). Six (17%) subjects discontinued varenicline due to AEs. No grade 3/4 laboratory abnormalities or serious AEs occurred during the study. There was no significant change in HIV viral load. CD4 counts increased by 69 cells/mm3 (p = 0.001) at week 24. Serum cotinine-verified 4-week continuous abstinence rate through weeks 9-12 was 42% (95% confidence interval [CI]: 26-58%). AEs and abstinence rates were comparable to those in published randomized controlled trials conducted in generally healthy HIV-negative smokers. Varenicline was safe and appears effective among HIV-infected smokers in this exploratory study, although AEs were common. The most common AE was nausea, with no adverse effect on HIV treatment outcome. Close monitoring of liver enzymes and blood pressure is recommended for HIV-positive smokers taking varenicline.

Outcomes of assisted reproductive techniques for HIV-1-discordant couples using thawed washed sperm in Taiwan: comparison with control and testicular sperm extraction/microscopic epididymal sperm aspiration groups

BACKGROUND/PURPOSE

An increasing number of human immunodeficiency virus-1 (HIV-l)-discordant couples in Taiwan have been seeking fertility help. We conducted the first clinical trial in Taiwan of assisted reproductive technology (ART) using sperm washing and viral load measurement.

METHODS

From 2005 to 2009, we performed 22 ART cycles on 14 HIV-1-discordant couples. The sperm washing involved density gradient centrifugation followed by swim-up method. HIV-1 RNA was checked by real-time reverse transcription-polymerase chain reaction with a sensitivity of 40 copies/mL. In addition, we enrolled two other groups of ART recipients using frozen sperm to compare the clinical outcomes.

RESULTS

There were five pregnancies in the fresh cycles (23.8%) of HIV-1-discordant couples and the cumulative pregnancy per couple was 42.9% (6/14). The data were comparable with normal controls and testicular sperm extraction/microscopic epididymal sperm aspiration groups. The nine babies and the 14 women in this study showed no seroconversion.

CONCLUSION

The preliminary data showed good ART results in HIV-1-discordant couples. Fertility services should not be withheld from individuals with HIV-1, although larger series are needed to reach conclusions about safety.

HIV intervention for providers study: a randomized controlled trial of a clinician-delivered HIV risk-reduction intervention for HIV-positive people

Clinician-delivered prevention interventions offer an opportunity to integrate risk-reduction counseling as a routine part of medical care. The HIV Intervention for Providers study, a randomized controlled trial, developed and tested a medical provider HIV prevention training intervention in 4 northern California HIV care clinics. Providers were assigned to either the intervention or control condition (usual care). The intervention arm received a 4-hour training on assessing sexual risk behavior with HIV-positive patients and delivering risk-reduction-oriented prevention messages to patients who reported risk behaviors with HIV-uninfected or unknown-status partners. To compare the efficacy of the intervention versus control on transmission risk behavior, 386 patients of the randomized providers were enrolled. Over six-months of follow-up, patients whose providers were assigned the intervention reported a relative increase in provider-patient discussions of safer sex (OR = 1.49; 95% CI = 1.06 to 2.09), assessment of sexual activity (OR = 1.60; 95% CI = 1.05 to 2.45), and a significant decrease in the number of sexual partners (OR = 0.49, 95% CI = 0.26 to 0.92). These findings show that a brief intervention to train HIV providers to identify risk and provide a prevention message results in increased prevention conversations and significantly reduced the mean number of sexual partners reported by HIV-positive patients.

Case series of fertility treatment in HIV-discordant couples (male positive, female negative): the Ontario experience

The success of combination antiretroviral therapies for the treatment of human immunodeficiency virus (HIV) has resulted in prolonged life expectancy (over 40 years from diagnosis) and an improved quality of life for people living with HIV. The risk of vertical HIV transmission during pregnancy has been reduced to less than 1%. As a result of these breakthroughs and as many of these individuals are of reproductive age, fertility issues are becoming increasingly important for this population. One population in which conception planning and reduction of horizontal HIV transmission warrants further research is HIV-discordant couples where the male partner is HIV-positive and the female partner is HIV-negative. Sperm washing is a technique carried out in a fertility clinic that separates HIV from the seminal fluid. Although sperm washing followed by intrauterine insemination significantly reduces the risk of horizontal HIV transmission, there has been limited access to the procedure in North America. Furthermore, little is known about the conception decision-making experiences of HIV-discordant couples who might benefit from sperm washing. Chart reviews and semi-structured interviews were completed with 12 HIV-discordant couples in Ontario, Canada. Couples were recruited through HIV clinics and one fertility clinic that offered sperm washing. Participants identified a number of factors that affected their decision-making around pregnancy planning. Access to sperm washing and other fertility services was an issue (cost, travel and few clinics). Participants identified a lack of information on the procedure (availability, safety). Sources of support (social networks, healthcare providers) were unevenly distributed, especially among those who did not disclose their HIV status to friends and family. Finally, the stigmatisation of HIV continues to have a negative affect on HIV-discordant couples and their intentions to conceive. Access to sperm washing and fertility service is significantly limited for this population and is accompanied with a number of challenges.

Factors associated with non-adherence to antiretroviral therapy in the SUN study

BACKGROUND

Adherence of 95% or greater to highly active combination antiretroviral therapy is generally considered necessary to achieve optimal virologic suppression in HIV-infected patients. Understanding factors associated with poor adherence is essential to improve patient compliance, maximize virologic suppression, and reduce morbidity and mortality.

METHODS

We evaluated baseline data from 528 patients taking antiretrovirals, enrolled from March 2004 to June 2006, in a multicenter, longitudinal, prospective cohort study (the SUN study). Using multiple logistic regression, we examined independent risk factors for non-adherence, defined as reporting having missed one or more antiretroviral doses in the past three days on the baseline questionnaire.

RESULTS

Of 528 participants (22% female, 28% black, median age 41 years, and median CD4 cell count 486 cells/mm(3)), 85 (16%) were non-adherent. In the final parsimonious multivariate model, factors independently associated with non-adherence included black race (adjusted odds ratio (aOR): 2.08, 95% confidence interval (CI): 1.20-3.60 vs. white race), being unemployed and looking for work (aOR: 2.03, 95% CI: 1.14-3.61 vs. all other employment categories), having been diagnosed with HIV ≥5 years ago (aOR: 1.95, 95% CI: 1.18-3.24 vs. being HIV-diagnosed <5 years ago), drinking three or more drinks per day (aOR: 1.73, 95% CI: 1.02-2.91 vs. drinking <3 drinks per day), and having not engaged in any aerobic exercise in the last 30 days (aOR: 2.13, 95% CI: 1.25-3.57).

CONCLUSION

Although the above factors may not be causally related to non-adherence, they might serve as proxies for identifying HIV-infected patients at greatest risk for non-adherence who may benefit from additional adherence support.

Trends in reported AIDS defining illnesses (ADIs) among participants in a universal antiretroviral therapy program: an observational study

BACKGROUND

We examined trends in AIDS-defining illnesses (ADIs) among individuals receiving highly active antiretroviral therapy (HAART) in British Columbia (BC), Canada to determine whether declines in ADIs could be contributing to previously observed improvements in life-expectancy among HAART patients in BC since 1996.

METHODS

HAART-naïve individuals aged ≥ 18 years who initiated treatment in BC each of the following time-periods 1996 - 1998; 1999 - 2001; 2002 - 2004; 2005 - 2007 were included. The proportion of participants with reported ADIs were examined for each time period and trends were analyzed using the Cochran-Armitage Trend Test. Cox proportional hazards models were used to examine factors associated with ADIs.

RESULTS

A total of 3721 individuals (81% male) initiated HAART during the study period. A total of 251 reports of ADIs were received from 214 unique patients. These occurred in a median of 4 months (IQR = 1-19 months) from HAART initiation. The proportion of individuals with a reported ADI did not change significantly from 4.6% in the earliest time period to 5.8% in the latest period (p = 0.181 for test of trend). There were no significant declines in any specific ADI over the study period. Multivariable Cox models found that individuals initiating HAART during 2002-04 were at an increased risk of ADIs (AHR = 1.55; 95% CI 1.04-2.32) in comparison to 1996 - 98, but there were no significant differences in other time periods.

CONCLUSIONS

Trends in reported ADIs among individuals receiving HAART since 1996 in BC do not appear to parallel improvements in life-expectancy over the same period.

The effect of injecting drug use history on disease progression and death among HIV-positive individuals initiating combination antiretroviral therapy: collaborative cohort analysis

BACKGROUND

We examined whether determinants of disease progression and causes of death differ between injecting drug users (IDUs) and non-IDUs who initiate combination antiretroviral therapy (cART).

METHODS

The ART Cohort Collaboration combines data from participating cohort studies on cART-naïve adults from cART initiation. We used Cox models to estimate hazard ratios for death and AIDS among IDUs and non-IDUs. The cumulative incidence of specific causes of death was calculated and compared using methods that allow for competing risks.

RESULTS

Data on 6269 IDUs and 37 774 non-IDUs were analysed. Compared with non-IDUs, a lower proportion of IDUs initiated cART with a CD4 cell count <200 cells/μL or had a prior diagnosis of AIDS. Mortality rates were higher in IDUs than in non-IDUs (2.08 vs. 1.04 per 100 person-years, respectively; P<0.001). Lower baseline CD4 cell count, higher baseline HIV viral load, clinical AIDS at baseline, and later year of cART initiation were associated with disease progression in both groups. However, the inverse association of baseline CD4 cell count with AIDS and death appeared stronger in non-IDUs than in IDUs. The risk of death from each specific cause was higher in IDUs than non-IDUs, with particularly marked increases in risk for liver-related deaths, and those from violence and non-AIDS infection.

CONCLUSION

While liver-related deaths and deaths from direct effects of substance abuse appear to explain much of the excess mortality in IDUs, they are at increased risk for many other causes of death, which may relate to suboptimal management of HIV disease in these individuals.

Cost-effectiveness of nucleoside reverse transcriptase inhibitor pairs in efavirenz-based regimens for treatment-naïve adults with HIV infection in the United States

OBJECTIVE

To estimate the cost-effectiveness of once-daily tenofovir/emtricitabine compared with twice-daily zidovudine/lamivudine and once-daily abacavir/lamivudine in treatment-naïve adults with HIV-1 infection in the United States.

METHODS

A Markov model with four therapy lines and six health states based on CD4(+) cell-count ranges was developed to estimate lifetime costs and health outcomes. Efficacy data (virologic response and CD4(+) cell-count changes) for first-line therapy were from 144-week results of Study 934 comparing tenofovir/emtricitabine with zidovudine/lamivudine and 48-week results of Study CNA30024 comparing abacavir/lamivudine with zidovudine/lamivudine, all in combination with efavirenz. Data from Study CNA30024 for abacavir/lamivudine were adjusted to allow for an indirect comparison with tenofovir/emtricitabine. Subsequent therapy lines were based on likely baskets of antiretroviral therapy recommended by US treatment guidelines. Utility values, mortality rates, and costs (2009 US dollars) were obtained from published sources. Base-case results were tested in sensitivity and variability analyses.

RESULTS

Average discounted results showed that individuals using tenofovir/emtricitabine were predicted to remain on first-line therapy for 7.7 years, accrue lifetime costs of $747,327, and experience 15.75 quality-adjusted life-years (QALYs), compared with 6.0 years, $777,090, and 15.68 QALYs for individuals using abacavir/lamivudine and 5.8 years, $778,287, and 15.44 QALYs for individuals using zidovudine/lamivudine. Tenofovir/emtricitabine was cost-effective compared with the other two first-line regimens in more than 75% of all probabilistic sensitivity analysis simulation runs for every willingness-to-pay threshold between $0 and $250,000 per QALY gained. Results were robust in variability and one-way sensitivity analyses.

CONCLUSIONS

Tenofovir/emtricitabine was predicted to be more effective and cost-saving compared with abacavir/lamivudine and zidovudine/lamivudine in treatment-naïve adults with HIV-1 infection in the United States.

HIV antiviral drug resistance: patient comprehension

A patient's understanding and use of healthcare information can affect their decisions regarding treatment. Better patient understanding about HIV resistance may improve adherence to therapy, decrease population viral load and extend the use of first-line HIV therapies. We examined knowledge of developing HIV resistance and explored treatment outcomes in a cohort of HIV+ persons on highly active antiretroviral therapy (HAART). The longitudinal investigations into supportive and ancillary health services (LISA) cohort is a prospective study of HIV+ persons on HAART. A comprehensive interviewer-administrated survey collected socio-demographic variables. Drug resistance knowledge was determined using a three-part definition. Clinical markers were collected through linkage with the Drug Treatment Program (DTP) at the British Columbia Centre for Excellence in HIV/AIDS. Categorical variables were compared using Fisher's Exact Test and continuous variables using the Wilcoxon rank-sum test. Proportional odds logistic regression was performed for the adjusted multivariable analysis. Of 457 LISA participants, less than 4% completely defined HIV resistance and 20% reported that they had not discussed resistance with their physician. Overall, 61% of the cohort is >or=95% adherent based on prescription refills. Owing to small numbers pooling was preformed for analyses. The model showed that being younger (OR=0.97, 95% CI: 0.95-0.99), having greater than high school education (OR=1.64, 95% CI: 1.07-2.51), discussing medication with physicians (OR=3.67, 95% CI: 1.76-7.64), having high provider trust (OR=1.02, 95% CI: 1.01-1.03), and receiving one-to-one counseling by a pharmacist (OR=2.14, 95% CI: 1.41-3.24) are predictive of a complete or partial definition of HIV resistance. The probability of completely defining HIV resistance increased from 15.8 to 63.9% if respondents had discussed HIV medication with both a physician and a pharmacist. Although the understanding of HIV resistance showed no differences in treatment outcomes in this cohort, overall adherence and complete understanding of HIV resistance were low. If patient understanding could be improved through discussions with physicians and pharmacists, potential exists to enhance overall adherence and treatment outcomes.

Use of antineoplastic agents in patients with cancer who have HIV/AIDS

Highly active antiretroviral therapy (HAART) has substantially reduced morbidity and mortality of AIDS-related complications in patients with HIV; however, the prevalence of AIDS-defining cancers and non-AIDS-defining cancers has increased. In this Review we discuss the management of HAART pharmacotherapy in relation to cytotoxic chemotherapy or targeted antineoplastic agents. We will review potential pharmacological interactions between antiretroviral and antineoplastic therapies and consider how to combine antiretroviral and antineoplastic agents in patients with HIV who are receiving HAART therapy.

Economic modeling of the combined effects of HIV-disease, cholesterol and lipoatrophy based on ACTG 5142 trial data

BACKGROUND

This study examines the cost and consequences of initiating an ARV regimen including Lopinavir/ritonavir (LPV/r) or Efavirenz (EFV), using data from a recent clinical trial in a previously published model of HIV-disease.

METHODS

We populated the Markov model of HIV-disease with data from ACTG 5142 study to estimate the economic outcomes of starting ARV therapy with a PI-containing regimen as compared to an NNRTI-containing regimen, given their virologic and immunologic efficacy and effects on cholesterol and lipoatrophy. CNS toxicities and GI tolerability were not included in the model because of their transient nature or low cost remedies, and therefore lack of economic impact. CD4+ T-cell counts and the HIV-1 RNA (viral load) values from the study were used to assign a specific health state (HS) to each patient for each quarter year. The resulting frequencies used as "raw" data directly into the model obviate the reliance on statistical tests, and allow the model to reflect actual patient behavior in the clinical trial. An HS just below the last observed HS was used to replace a missing value.

RESULTS

The modeled estimates (undiscounted) for the LPV/r-based regimen resulted in 1.41 quality-adjusted life months (QALMs) gained over a lifetime compared to the EFV-based regimen. The LPV/r-based regimen incurred $7,458 (1.8%) greater cost over a lifetime due to differences in drug costs and survival. The incremental cost effectiveness ratio using the discounted cost and QALYs was $88,829/QALY. Most of the higher costs accrue before the 7th year of treatment and were offset by subsequent savings. The estimates are highly sensitive to the effect of lipoatrophy on Health-related Quality of Life (HRQOL), but not to the effect of cholesterol levels.

CONCLUSIONS

The cost effectiveness of ARV regimens may be strongly affected by enduring AEs, such as lipoatrophy. It is important to consider specific AE effects from all drugs in a regimen when ARVs are compared.

TRIAL REGISTRATION

(ClinicalTrials.gov number, NCT00050895http://[ClinicalTrials.gov]).

Antiretroviral treatment interruption leads to progression of liver fibrosis in HIV-hepatitis C virus co-infection

OBJECTIVE

Despite potential negative consequences, HIV/hepatitis C virus (HCV) co-infected patients may discontinue antiretroviral treatment (ART) for several reasons. We examined the impact of ART interruption on liver fibrosis progression in co-infected adults, using the aspartate aminotransferase-to-platelet ratio index (APRI) as a surrogate marker of liver fibrosis.

METHOD

Data were analyzed from a multisite prospective cohort of 541 HIV-HCV co-infected adults. ART interruption was included as a time-updated variable and defined as the cessation of all antiretrovirals for at least 14 days. The primary endpoint was the development of an APRI score at least 1.5. Time-dependent Cox proportional hazards regression and inverse probability-of-treatment weighting (IPTW) in a marginal structural model were used to evaluate the association of baseline and time-varying covariates with developing significant fibrosis.

RESULTS

Patients were followed for a median of 1.02 years; 10% (n = 53) interrupted ART and 10% (n = 53) developed significant fibrosis. After accounting for potential confounders, including CD4 T-cell count, HIV viral load, baseline APRI score, age and gender, the hazard ratio for ART interruption was 2.52 (95% confidence interval 1.20-5.28). Use of IPTW resulted in a similar effect estimate, suggesting that mediation by time-varying confounders was negligible.

CONCLUSION

ART interruption was associated with an increased risk of fibrosis progression in HIV-HCV co-infection that was only partially accounted for by HIV viral load and CD4 T-cell counts. Our findings suggest that liver disease progression observed in ART-treated co-infected patients is partly due to the consequences of treatment interruptions.

Learning from Interviews with HIV-Discordant Couples (Male Positive, Female Negative): The Challenges and Successes

This article examines the challenges and successes of recruiting participants and maintaining momentum in a small qualitative study on the experiences of HIV-discordant couples (where the male is HIV-positive and the female is HIV-negative) undergoing fertility assessment and/or treatment in Ontario, Canada, to reduce the risk of HIV transmission to the woman and fetus. The purpose of this article is to identify barriers and successes encountered in our study, consider how these are addressed in the literature, and highlight specific factors that need to be considered when studying a unique population similar to ours.

Acute toxicity of second generation HIV protease-inhibitors in combination with radiotherapy: a retrospective case series

BACKGROUND

There is little data on the safety of combining radiation therapy and human immunodeficiency virus (HIV) protease inhibitors to treat cancers in HIV-positive patients. We describe acute toxicities observed in a series of HIV-positive patients receiving modern radiation treatments, and compare patients receiving HIV protease inhibitors (PI) with patients not receiving HIV PIs.

METHODS

By reviewing the clinical records beginning January 1, 2009 from the radiation oncology department, we identified 29 HIV-positive patients who received radiation therapy to 34 body sites. Baseline information, treatment regimen, and toxicities were documented by review of medical records: patient age, histology and source of the primary tumor, HIV medication regimen, pre-radiation CD4 count, systemic chemotherapy, radiation therapy dose and fractionation, irradiated body region, toxicities, and duration of follow-up. Patients were grouped according to whether they received concurrent HIV PIs and compared using Pearson's chi-square test.

RESULTS

At baseline, the patients in the two groups were similar with the exception of HIV medication regimens, CD4 count and presence of AIDS-defining malignancy. Patients taking concurrent PIs were more likely to be taking other HIV medications (p = 0.001) and have CD4 count >500 (p = 0.006). Patients taking PIs were borderline less likely to have an AIDS-defining malignancy (p = 0.06). After radiation treatment, 100 acute toxicities were observed and were equally common in both groups (64 [median 3 per patient, IQR 1-7] with PIs; 36 [median 3 per patient, IQR 2-3] without PIs). The observed toxicities were also equally severe in the two groups (Grades I, II, III respectively: 30, 30, 4 with PIs; 23, 13, 0 without PIs: p = 0.38). There were two cases that were stopped early, one in each group; these were not attributable to toxicity.

CONCLUSIONS

In this study of recent radiotherapy in HIV-positive patients taking second generation PIs, no difference in toxicities was observed in patients taking PIs compared to patients not taking PIs during radiation therapy. This suggests that it is safe to use unmodified doses of PIs and radiation therapy in HIV cancer patients, and that it is feasible to use PIs as a radiosensitizer in cancer therapy, as has been suggested by pre-clinical results.

Regional and temporal changes in HIV-related mortality in British Columbia, 1987-2006

BACKGROUND

HIV-related mortality has been declining in Canada; however, little is known about regional differences in HIV-related mortality. The objective of this study was to characterize regional changes in HIV-related mortality from 1987-2006 in British Columbia (BC).

METHODS

BC Vital Statistics provided death certificate data for individuals > or =18 years who died of an HIV-related cause in BC between 1987 and 2006. Annual mortality rates were calculated for all BC, five regional health authorities, and two areas within Vancouver. Joinpoint regression analyses measured changes in mortality rates.

RESULTS

There were 3899 HIV-related deaths in BC from 1987-2006. Over time, HIV-related mortality rates were highest in the densely populated, southern regions, and lowest in the north. In BC, mortality significantly increased from 1987-1994 (annual percent change [APC] 16.3%). In 1994, the trend changed to a significant decrease in mortality from 1994-1998 (APC -20.0%), followed by a sustained reduction from 1998-2006. Four of the five health authorities showed mortality trends similar to the province; however, the north showed significantly increasing mortality from 1987-2006 (APC 6.7%). In Vancouver, the City Centre showed a mortality pattern similar to the province, but the Downtown Eastside had rising mortality rates until 1997, followed by a modest decline.

CONCLUSION

In most areas of BC, HIV-related mortality declined after the introduction of effective antiretroviral therapy; however, this decline was delayed or absent in some regions. These regional variations may reflect differential access to health care, even in a setting where antiretroviral therapy is provided at no cost to patients.

Replicative phenotyping adds value to genotypic resistance testing in heavily pre-treated HIV-infected individuals--the Swiss HIV Cohort Study

Background

Replicative phenotypic HIV resistance testing (rPRT) uses recombinant infectious virus to measure viral replication in the presence of antiretroviral drugs. Due to its high sensitivity of detection of viral minorities and its dissecting power for complex viral resistance patterns and mixed virus populations rPRT might help to improve HIV resistance diagnostics, particularly for patients with multiple drug failures. The aim was to investigate whether the addition of rPRT to genotypic resistance testing (GRT) compared to GRT alone is beneficial for obtaining a virological response in heavily pre-treated HIV-infected patients.

Methods

Patients with resistance tests between 2002 and 2006 were followed within the Swiss HIV Cohort Study (SHCS). We assessed patients' virological success after their antiretroviral therapy was switched following resistance testing. Multilevel logistic regression models with SHCS centre as a random effect were used to investigate the association between the type of resistance test and virological response (HIV-1 RNA <50 copies/mL or ≥1.5log reduction).

Results

Of 1158 individuals with resistance tests 221 with GRT+rPRT and 937 with GRT were eligible for analysis. Overall virological response rates were 85.1% for GRT+rPRT and 81.4% for GRT. In the subgroup of patients with >2 previous failures, the odds ratio (OR) for virological response of GRT+rPRT compared to GRT was 1.45 (95% CI 1.00-2.09). Multivariate analyses indicate a significant improvement with GRT+rPRT compared to GRT alone (OR 1.68, 95% CI 1.31-2.15).

Conclusions

In heavily pre-treated patients rPRT-based resistance information adds benefit, contributing to a higher rate of treatment success.

Regional and temporal trends in migration among people living with HIV/AIDS in British Columbia, 1993-2005

OBJECTIVES

To examine regional and temporal trends in migration among patients receiving HIV treatment in British Columbia (BC).

METHODS

Patients initiating antiretroviral therapy in BC between January 1993 and November 2004 were followed until November 2005. Migration was calculated as the cumulative number of times a patient's residential address changed during their course of treatment. Analyses were performed at the provincial and at the regional health authority (HA) and local health area levels. Demographic methods were used to estimate the in- and out-migration rates, indices of dissimilarity and concentration across regions over time.

RESULTS

A total of 3,588 participants were followed during the study period. Individuals who migrated most often migrated to the Vancouver Coastal HA (from the Interior: 30%, Fraser: 41%, Vancouver Island: 28%, and Northern: 19%), specifically the city of Vancouver, which has been treating the most patients with HIV since the early stages of the epidemic. We also showed that this movement intensified as more contemporary HAART regimens became available (p-value for trend < 0.01).

DISCUSSION

Our results demonstrate that migration among people with HIV in BC is not homogeneous, with areas around large urban centres having the highest influx of patients. It is thus important that health authorities in BC work in partnership to monitor and evaluate accessibility of HIV-related health care services to ensure universal access for all patients. Furthermore, enhanced HIV care and support services need to be developed, on a province-wide basis, and funding allocation needs to be adjusted to reflect patient migration in BC.

Glycemic control in HIV-infected patients with diabetes mellitus and rates of meeting American Diabetes Association management guidelines

Limited data exist on the prevalence of inadequate glycemic control and rates of meeting American Diabetic Association (ADA) management guidelines in HIV-infected adults with diabetes mellitus. We conducted a retrospective cross-sectional study of 142 HIV-infected adults with type 2 diabetes at an urban academic HIV clinic during 2008. We estimated the prevalence of and assessed associations with inadequate glycemic control, defined as hemoglobin A(1c) ≥ 7.5% for ≥ 50% of quarters over the year, and determined rates of meeting ADA clinical goals. Ninety-two percent of patients received antiretroviral therapy. The prevalence of inadequate glycemic control was 33% (95% confidence interval [CI] 25%-42%). Compared to patients with adequate control, those with inadequate control had fewer years since HIV diagnosis (12.7 versus 15.1, p = 0.01), increased use of insulin (60% versus 20%, p < 0.001) or any diabetic medication (98% versus 85%, p = 0.02), and higher triglyceride levels (238 versus 168 mg/dL, p = 0.008). Rates of achieving ADA goals were 42% for blood pressure, 66% for low-density lipoprotein cholesterol (LDL-C), 33% for high-density lipoprotein cholesterol, and 31% for triglycerides. Thirty-six percent of patients who did not meet the LDL-C goal received statin therapy. Forty-seven percent of patients were screened for retinopathy and 19% of patients without preexisting renal disease were screened for nephropathy. In conclusion, the prevalence of inadequate glycemic control in HIV-infected patients with diabetes is similar to published data from the general population. Suboptimal rates of meeting ADA blood pressure and lipid goals and adherence to screening guidelines demonstrate need for further clinician and patient education.

Prevalence of bone mineral density abnormalities and related risk factors in an ambulatory HIV clinic population

Bone mineral density (BMD) abnormalities are observed frequently among human immunodeficiency virus (HIV)-infected patients. Risk factors for reduced BMD in the setting of HIV have been previously studied, but detailed antiretroviral treatment history is often not available. A cross-sectional observational study was conducted between 2005 and 2007 among unselected HIV-infected adults attending an ambulatory urban HIV clinic. Dual-energy X-ray absorptiometry (DXA) scans of lumbar spine and femoral neck, full laboratory profile, detailed questionnaire, and antiretroviral history were obtained. Univariate and multivariate logistic regression analyses were performed to investigate factors associated with BMD below the expected range for age. Two hundred ninety patients completed the study: 80% Caucasians, 89% males, with median age of 49 yr. Low BMD as assessed by Z-score was present in 19.7% of the patients. By multivariate analysis, only lower body mass index (BMI) was an independent risk factor for low BMD. Cumulative exposure to protease inhibitors, non-nucleosides, and individual nucleoside and nucleotide analogs were not independently associated with low BMD. In conclusion, a 19.7% prevalence of abnormal BMD by DXA scan was identified in an unselected group of HIV-infected adults. Lower BMI was independently associated with low BMD. No correlation was found between abnormal BMD and cumulative exposure to any antiretroviral agents.

Virologic outcomes of first-line HAART and associated factors among Chinese patients with HIV in three sentinel antiretroviral treatment sites

OBJECTIVE

To evaluate HIV drug resistance (HIVDR) among Chinese patients with HIV receiving first-line highly active antiretroviral therapy (HAART).

METHODS

Based on the WHO HIVDR surveys, a prospective cohort study with 12-month follow-up was conducted to estimate the prevalence of HIV RNA<1000 copies/ml and HIVDR.

RESULTS

A total of 341 study subjects naïve to prior antiretroviral therapy (ART) were followed up for a median of 12.1 months. The overall mortality rate was 9.9 per 100 person-years. The median of CD4 counts increased from 182 cells/mm(3) at baseline to 268 cells/mm(3) at 12 months (P<0.0001). Of patients with plasma HIV-1 RNA concentrations ≥1000 copies/ml at 12 months, the proportions of resistance to non-nucleoside reverse transcriptase drugs, nucleoside/nucleotide reverse transcriptase inhibitors, and protease inhibitor drugs were 34.2%, 23.7% and 0%, respectively. The overall proportion of HIV RNA<1000 copies/ml was 85.7% at 12 months. Occupation of farmer (AOR=0.3, 95% CI: 0.08, 0.94; P=0.0393) and HAART counselling and instruction through telephone (AOR=2.8, 95% CI: 1.4, 5.6; P=0.0047) were significantly associated with HIV RNA<1000 copies/ml.

CONCLUSION

Our study demonstrated that the community-based ART had significant effects on viral suppression and immune recovery. HIVDR should be monitored in the long term to guide informed decisions on preventing HIVDR and choices of first- and second-line regimens.

Prospective study of bone mineral density changes in aging men with or at risk for HIV infection

OBJECTIVE

To investigate rates and predictors of change in bone mineral density (BMD) in a cohort of aging men with or at risk for HIV infection.

DESIGN

A prospective cohort study among 230 HIV-infected and 159 HIV-uninfected men aged at least 49 years.

METHODS

Longitudinal analyses of annual change in BMD at the femoral neck, total hip, and lumbar spine.

RESULTS

At baseline, 46% of men had normal BMD, 42% had osteopenia, and 12% had osteoporosis. Of those men with normal BMD, 14% progressed to osteopenia and 86% continued to have normal BMD. Of the men initially with osteopenia, 12% progressed to osteoporosis and 83% continued to have osteopenia. Osteopenia incidence per 100 person-years at risk was 2.6 for HIV-uninfected men and 7.2 for HIV-infected men; osteoporosis incidence was 2.2 per 100 person-years at risk among men with osteopenia, regardless of HIV status. In multivariable analysis of annual change in BMD at the femoral neck, we found a significant interaction between heroin use and AIDS diagnosis, such that the greatest bone loss occurred with both AIDS and heroin use (adjusted predicted mean annual bone loss 0.0196 g/cm). Hepatitis C virus seropositivity was also associated with femoral neck bone loss (P = 0.04). The interaction between AIDS and heroin use also was associated with bone loss at the total hip, as was current methadone use (P < 0.01).

CONCLUSION

We found an association of heroin use and AIDS with BMD change, suggesting that heroin users with AIDS may be at particular risk for bone loss.

Th17, gut, and HIV: therapeutic implications

PURPOSE OF REVIEW

The purpose of this review is to discuss the apparent impact of persistent-immune activation and inflammation on morbidity and mortality among treated HIV-infected individuals, to explore the potential role of Th17 T-cell depletion in this process, and to discuss potential-therapeutic implications.

RECENT FINDINGS

Although the vast majority of HIV-infected individuals can now achieve and maintain viral suppression with modern-antiretroviral therapy (ART), their life expectancy remains much shorter than the general population and they continue to be at much higher risk for non-AIDS-associated diseases commonly associated with aging (non-AIDS-associated cancer, cardiovascular disease, etc). Abnormal levels of immune activation and inflammation persist despite sustained viral suppression and may drive these clinical events. Although the causes of persistent-immune activation remain incompletely characterized, persistent low-level HIV replication and/or release from latently infected cells in gut-associated lymphoid tissue (GALT) and microbial translocation probably play a major role. Failure to restore Th17 cells in GALT during ART might impair both the recovery of the gut mucosal barrier and the clearance of microbial products.

SUMMARY

Insights from recent-pathogenesis studies might suggest novel-therapeutic approaches designed to restore Th17 cells in GALT, thereby decreasing microbial translocation, immune activation, and ultimately morbidity and mortality during treated HIV infection.

Cost-effectiveness of an intervention to reduce HIV/STI incidence and promote condom use among female sex workers in the Mexico-US border region

BACKGROUND

Previous research demonstrated efficacy of a brief behavioral intervention to reduce incidence of HIV and sexually transmitted infections (STIs) among female sex workers (FSWs) in Tijuana and Ciudad Juarez, Mexico, cities on Mexico's border with the US. We assessed this intervention's cost-effectiveness.

METHODOLOGY AND PRINCIPAL FINDINGS

A life-time Markov model was developed to estimate HIV cases prevented, changes in quality-adjusted life expectancy (QALE), and costs per additional quality-adjusted life year gained (QALY), comparing (in US$2,009) no intervention to a once-only and annual intervention. Future costs and health benefits were discounted annually at 3%. Sensitivity analyses evaluated model robustness. We found that for a hypothetical 1,000 FSWs receiving the once-only intervention, there were 33 HIV cases prevented and 5.7 months of QALE gained compared to no intervention. The additional cost per QALY gained was US$183. For FSWs receiving the intervention annually, there were 29 additional HIV cases prevented and 4.5 additional months of QALE compared to the once-only intervention. The additional cost per QALY was US$1,075. When highly active antiretroviral therapy (HAART) was included in the model, the annual intervention strategy resulted in net savings and dominated both once-only and no intervention strategies, and remained robust across extensive sensitivity analyses. Even when considering clinical benefits from HAART, ignoring added costs, the cost per QALY gained remained below three times the Mexican GDP per capita, and below established cost-effectiveness thresholds.

CONCLUSIONS/SIGNIFICANCE

This brief intervention was shown to be cost-effective among FSWs in two Mexico-US border cities and may have application for FSWs in other resource-limited settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00338845.

Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals

OBJECTIVE

To compare life expectancies between recently diagnosed HIV-infected patients and age and sex-matched uninfected individuals from the general population.

DESIGN

: National observational HIV cohort in the Netherlands.

METHODS

Four thousand, six hundred and twelve patients diagnosed with HIV between 1998 and 2007 and still antiretroviral therapy-naive as of 24 weeks after diagnosis were selected. Progression to death compared to the age and sex-matched general population was studied with a multivariate hazards model in 4174 (90.5%) patients without AIDS events at 24 weeks. Life expectancy and number of life years lost were calculated using the predicted survival distribution.

RESULTS

During 17 580 person-years of follow-up since 24 weeks after diagnosis [median follow-up 3.3 years, interquartile range (IQR) 1.6-5.8], 118 deaths occurred, yielding a mortality rate of 6.7 [95% confidence interval (CI) 5.5-8.0] per 1000 person-years. Median CD4 cell counts at 24 weeks were 480 cells/microl (IQR 360-650). According to the model, the median number of years lived from age 25 was 52.7 (IQR 44.2-59.3; general population 53.1) for men and 57.8 (49.2-63.7; 58.1) for women without CDC-B event. The number of life years lost varied between 0.4 if diagnosed with HIV at age 25 and 1.4 if diagnosed at age 55; for patients with a CDC-B event this range was 1.8-8.0 years.

CONCLUSION

The life expectancy of asymptomatic HIV-infected patients who are still treatment-naive and have not experienced a CDC-B or C event at 24 weeks after diagnosis approaches that of non-infected individuals. However, follow-up time is short compared to the expected number of years lived.

Sex with older partners is associated with primary HIV infection among men who have sex with men in North Carolina

BACKGROUND

Studies from the 1990s suggested sex with older partners was associated with HIV infection. We evaluated the hypothesized association between primary HIV infection (PHI) and having older sexual partners among men who have sex with men (MSM).

METHODS

MSM with PHI and HIV-uninfected MSM completed audio computer-assisted self-interviews exploring behaviors involving their 3 most recent sexual partners before enrollment (if uninfected) or diagnosis (if PHI).

RESULTS

Of 74 men reporting any lifetime sex with men, 20 had PHI (27%). Demographics (including age) were similar between groups; 39% were non-white and 74% identified as gay. The mean age of sex partners differed significantly: men with PHI had partners on average 6 years older than themselves, whereas uninfected men's partners were 4 months their junior (P < 0.001). After adjusting for race, sex while intoxicated, and having a serodiscordant/serostatus unknown partner, a participant had twice the odds of PHI if his sex partner was 5 years his senior (odds ratio 2.0, 95% confidence interval: 1.2 to 3.3).

CONCLUSIONS

Among a sample of young MSM, the odds of HIV infection increased significantly as the age of sexual partners increased. These findings can inform behavioral interventions in communities of at-risk MSM and secondary prevention efforts among those already living with HIV.