Adverse effects of medications and trade-offs between length of life and quality of life in human immunodeficiency virus infection

Factors Correlated with Body Image Dissatisfaction in Children and Adolescents Diagnosed with HIV: A Cross-Sectional Study

(1) Background: The adverse effects of continuous use of antiretroviral therapy can generate dissatisfaction with body image in children and adolescents diagnosed with Human Immunodeficiency Virus infection (HIV) infection. The aim of this study was to verify the prevalence and factors associated with body image dissatisfaction (BI) in children and adolescents diagnosed with HIV infection; (2) This is a cross-sectional study with 60 children and adolescents (32 females; 28 males) aged 8-15 years diagnosed with HIV, carried out in Florianópolis, Brazil. Information on BI was collected through a silhouette scale, as well as sociodemographic information, biological maturation, lifestyle, self-esteem, adherence to antiretroviral treatment and aspects of HIV infection; (3) Results: The results indicated that 53.13% of female patients and 53.57% of male patients were dissatisfied with their BI. Lower subscapular skinfold and higher calf skinfold values were associated with BI dissatisfaction in females. Pre-pubertal maturation stage, higher economic level, lower concentrations of CD4+ lymphocytes, lower viral load, lower level of physical activity and longer time in front of the computer and/or video game were associated with BI dissatisfaction in males; (4) Conclusions: BI dissatisfaction was observed in more than half of patients and morphological, economic, behavioral and HIV infection aspects were associated with BI dissatisfaction.

3D Spheroids of Human Primary Urine-Derived Stem Cells in the Assessment of Drug-Induced Mitochondrial Toxicity

Mitochondrial toxicity (Mito-Tox) risk has increased due to the administration of several classes of drugs, particularly some life-long antiretroviral drugs for HIV+ individuals. However, no suitable in vitro assays are available to test long-term Mito-Tox (≥4 weeks). The goal of this study is to develop a 3D spheroid system of human primary urine-derived stem cells (USC) for the prediction of drug-induced delayed Mito-Tox. The cytotoxicity and Mito-Tox were assessed in 3D USC spheroids 4 weeks after treatment with antiretroviral drugs: zalcitabine (ddC; 0.1, 1 and 10 µM), tenofovir (TFV; 3, 30 and 300 µM) or Raltegravir (RAL; 2, 20 and 200 µM). Rotenone (RTNN, 10 µM) and 0.1% DMSO served as positive and negative controls. Despite only mild cytotoxicity, ddC significantly inhibited the expression of oxidative phosphorylation enzyme Complexes I, III, and IV; and RAL transiently reduced the level of Complex IV. A significant increase in caspase 3 and ROS/RNS level but a decrease in total ATP were observed in USC treated with ddC, TFV, RAL, and RTNN. Levels of mtDNA content and mitochondrial mass were decreased in ddC but minimally or not in TFV- and RAL-treated spheroids. Thus, 3D USC spheroid using antiretroviral drugs as a model offers an alternative platform to assess drug-induced late Mito-Tox.

Association Between Body Fat Distribution Assessed by Different Techniques and Body Image Perception in HIV-Infected Children and Adolescents

PURPOSE

verify whether there is difference in body fat values assessed by different methods according to the body image perception of HIV-infected children and adolescents.

DESIGN AND METHODS

This is a cross-sectional study with 65 HIV-infected children and adolescents (aged 8-15 years). Total fat mass, trunk fat mass, arm fat mass and leg fat mass were obtained through dual-energy X-ray absorptiometry (DXA). Anthropometric variables were measured according to international standardization. Body image was assessed using a scale of body silhouettes. Bone age covariates were assessed using carpal wrist X-rays and physical activity by accelerometers. Information regarding viral load and use of combined antiretroviral therapy was obtained from medical records. In males, no significant difference in body fat values and body image categories was observed.

RESULTS

In the model with covariates, girls who desired to reduce body weight had higher BMI (18.96 kg / m2 ± 2.47, R² adj: 0.613), total fat mass (14.25 kg ± 1.37, R² adj: 0.589), trunk fat mass (6.50 kg ± 0.66, R² adj: 0.611) and leg fat mass values (6.01Kg ± 0.57, R² adj: 0.503) in comparison to girls who were satisfied and to those who desired to increase body weight.

CONCLUSIONS

HIV + girls who desired to reduce body weight had greater amount of BMI, total fat mass, trunk fat mass and leg fat mass compared to those who were satisfied and those who desired to increase body weight.

PRACTICE IMPLICATIONS

These data can be used to assist in the process of coping and accepting body image.

Upregulation of Apoptosis Pathway Genes in Peripheral Blood Mononuclear Cells of HIV-Infected Individuals with Antiretroviral Therapy-Associated Mitochondrial Toxicity

A case-control study of the effect of antiretroviral therapy (ART) on apoptosis pathway genes comprising 16 cases (HIV infected with mitochondrial toxicity) and 16 controls (HIV uninfected) was conducted. A total of 26 of 84 genes of the apoptosis pathway were differentially expressed. Two of the upregulated genes, DFFA and TNFRSF1A, classified 75% of study participants correctly as either a case or control. Thus, apoptosis may be in the causal pathway of ART-associated mitochondrial toxicity. These two genes could be markers for detecting and monitoring ART-induced mitochondrial toxicity.

Fat Matters: Understanding the Role of Adipose Tissue in Health in HIV Infection

More than one-third of adults in the USA are obese and obesity-related disease accounts for some of the leading causes of preventable death. Mid-life obesity may be a strong predictor of physical function impairment later in life regardless of body mass index (BMI) in older age, highlighting the benefits of obesity prevention on health throughout the lifespan. Adipose tissue disturbances including lipodystrophy and obesity are prevalent in the setting of treated and untreated HIV infection. This article will review current knowledge on fat disturbances in HIV-infected persons, including therapeutic options and future directions.

Utilities Derived from Visual Analog Scale Scores in Patients with HIV/AIDS

Background. Visual analog scale (VAS) scores are used as global quality-of-life indicators and, unlike true utilities (which assess the desirability of health states v. an external metric), are often collected in HIV-related clinical trials. The purpose of this study was to derive and evaluate transformations relating aggregate VAS scores to utilities for current health in patients with HIV/AIDS. Methods. HIV-specific transformations were developed using linear and nonlinear regression to attain models that best fit mean VAS and standard gamble (SG) utility values directly derived from 299 patients with HIV/AIDS participating in a multicenter study of health values. The authors evaluated the transformations using VAS and SG utility values derived directly from patients in other HIV/AIDS studies. Derived transformations were also compared with published transformations. Results. A simple linear transformation was derived (u = 0.44v + 0.49), as was the exponent for a curvilinear model (u = 1-[1- v ]1.6 ), where u = the sample mean utility and v the sample mean VAS score. The curvilinear transformation predicted values within 0.10 of the actual SG utility in 5 of 8 estimates and within 0.05 in 3 of 8 estimates (absolute error ranged from -0.01 to +0.21). The linear transformation performed some-what better, predicting within 0.10 of the actual SG value in 6 of 8 cases and within 0.05 in 5 of 8 estimates (absolute error ranged from -0.05 to +0.13). An alternative linear model (u =v + 0.018) derived from the literature performed similarly to our linear model (7 of 8 predictions within 0.10, 1 of 8 estimates within 0.05, and absolute error ranging from -0.15 to +0.10), whereas an alternative published curvilinear model (u = 1 - [1 - v ]2.3 ) performed the least well (2 of 8 estimates within 0.10 of the actual values and no estimates within 0.05). Conclusions. Predicted utilities are a reasonable alter-native for use in HIV/AIDS decision analyses and costeffectiveness analyses. Linear transformations performed better than curvilinear transformations in this context and can be used to convert aggregate VAS scores to aggregate SG values in large HIV/AIDS studies that collect VAS data but not utilities.

Adverse Effects Associated With Antiretroviral Therapy and Potential Management Strategies

A variety of adverse drug reactions (ADRs) affecting many organ systems may be observed with antiretroviral therapy (ARV), and they can be differentiated into short- and long- term effects, class effects, or individual drug effects. Commonly seen ADRs include dermatological reactions, associated with nonnucleoside reverse transcriptase inhibitors (NNRTIs) and some protease inhibitors (PIs), and gastrointestinal problems, a major side effect of PIs and of some nucleoside reverse transcriptase inhibitors (NRTIs). Metabolic complications are frequently reported in HIV-infected patients on ARV and often coexist. Lipodystrophy, hyperinsulinemia/hyperglycemia, and bone disorders (osteoporosis, osteonecrosis) are mainly associated with PIs, while lactic acidemia/acidosis are primarily a problem of NRTIs. Hyperlipidemia may be caused by almost all PIs, few NRTIs, and NNRTIs. All antiretroviral drug classes may cause both asymptomatic and symptomatic hepatotoxicity, although nevirapine is the agent most implicated in hepatic events. More drug-specific ADRs include nephrotoxicity (indinavir and tenofovir), central nervous system problems (efavirenz), hematological disturbances (zidovudine), and hypersensitivity reactions (abacavir). Anticipation of ADRs may influence a patient’s decision to delay ARV or to choose specific and potentially less active agents. Occurrence of ADRs may significantly impact a patient’s quality of life and drug adherence. Pharmacists counseling HIV-infected patients should be aware of common ADRs with ARV and potential management strategies.

The Unknown/The Unanticipated: A Surgical Journey of Correcting HIV-Related Abdominal Lipodystrophy

The aim of this study was to explore the pre- and postsurgical journey to correct severe abdominal lipodystrophy of a woman living as AIDS defined for over 23 years. It utilized interpretative phenomenological analysis (IPA) and a single-case-study approach to capture the subjective understanding and sense-making of this surgical process. Verbatim transcripts of seven semi-structured interviews, three participant-created word boards of words or phrases clipped from magazines, field notes, and a reflexive journal were collected as data. Analysis revealed two superordinate themes: the unknown and the unanticipated. These themes simultaneously manifest with shared and nuanced meanings, including the unknown and unanticipated of surviving AIDS and discovering lipodystrophy, the unknown and the unanticipated of the surgical intervention itself, and finally the unknown and the unanticipated of postsurgical complications and experiences within outpatient and inpatient medical settings.

Longitudinal and cross sectional assessments of health utility in adults with HIV/AIDS: a systematic review and meta-analysis

Background

Utility estimates are important health outcomes for economic evaluation of care and treatment interventions for patients with HIV/AIDS. We conducted a systematic review and meta-analysis of utility measurements to examine the performance of preference-based instruments, estimate health utility of patients with HIV/AIDS by disease stages, and investigate changes in their health utility over the course of antiretroviral treatment.

Methods

We searched PubMed/Medline, Cochrane Database of Systematic Review, NHS Economic Evaluation Database and Web of Science for English-language peer-reviewed papers published during 2000–2013. We selected 49 studies that used 3 direct and 6 indirect preference based instruments to make a total of 218 utility measurements. Random effect models with robust estimation of standard errors and multivariate fractional polynomial regression were used to obtain the pooled estimates of utility and model their trends.

Results

Reliability of direct-preference measures tended to be lower than other types of measures. Utility elicited by two of the indirect preference measures - SF-6D (0.171) and EQ-5D (0.114), and that of Time-Trade off (TTO) (0.151) was significantly different than utility elicited by Standard Gamble (SG). Compared to asymptomatic HIV patients, symptomatic and AIDS patients reported a decrement of 0.025 (p&#×2009;=&#×2009;0.40) and 0.176 (p&#×2009;=&#×2009;0.001) in utility scores, adjusting for method of assessment. In longitudinal studies, the pooled health utility of HIV/AIDS patients significantly decreased in the first 3 months of treatment, and rapidly increased afterwards. Magnitude of change varied depending on the method of assessment and length of antiretroviral treatment.

Conclusion

The study provides an accumulation of evidence on measurement properties of health utility estimates that can help inform the selection of instruments for future studies. The pooled estimates of health utilities and their trends are useful in economic evaluation and policy modelling of HIV/AIDS treatment strategies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0640-z) contains supplementary material, which is available to authorized users.

Self-reported body fat change in HIV-infected men is a marker of decline in physical health-related quality of life with aging, independent of co-morbidity

OBJECTIVE

Self-perception of changes in body fat among HIV+ persons is associated with decreased health related quality of life in cross-sectional studies. The longitudinal impact of body fat changes on health related quality of life, while accounting for comorbidity and anatomic location or severity of body fat changes, is unknown.

DESIGN

This was a longitudinal analysis of HIV+ and HIV- Multicenter AIDS Cohort Study (MACS) participants who completed questionnaires assessing self-perceived body fat changes (baseline visit) and a health related quality of life (Short Form-36) at baseline and then ≥5 years later.

METHODS

Relationships between body fat changes and change in Short Form-36 Physical and Mental Component Summary scores were investigated using mixed-model regression.

RESULTS

We studied 270 HIV+ and 247 HIV- men. At baseline, ≥50% of HIV+ men reported body fat changes; physical component but not mental component summary scores were lower among HIV+ men who reported moderate/severe leg or abdominal fat changes (p<0.05). At follow-up, physical component summary scores were significantly lower among men with face, leg, or abdominal fat changes compared to men without perceived fat changes (p<0.05). No significant changes were seen in mental component scores by fat change location or severity. In the final model, body fat changes at any site or severity were significant predictors of a decline in physical component summary score (p<0.05), independent of demographics or comorbidities. Mental component summary score was not associated with body fat changes, but higher mental component summary score was associated with increasing age and time.

CONCLUSIONS

Negative self-perceived body fat changes were associated with decline in physical health related quality of life, independent of comorbidities, and may be a marker of an increased risk for physical function decline with aging.

What determines health-related quality of life among people living with HIV: an updated review of the literature

BACKGROUND

As infection with the Human Immunodeficiency Virus (HIV) has evolved to a chronic disease, perceived health-related quality of life (HRQoL) is becoming a prominent and important patient-reported outcome measure in HIV care. Literature discusses different factors influencing HRQoL in this population, however, currently no consensus exists about the main determinants. In this review a clear, up-to-date overview of the determinants influencing HRQOL among people living with HIV is provided.

METHODS

All studies published before July 2013 that identified determinants of HRQoL among people living with HIV in high-income countries, were considered in this narrative review. PubMed, Web of Science and The Cochrane Library were consulted using the keywords 'determinants', 'quality of life', 'HIV' and 'AIDS'. To be included, studies should have reported overall health and/or physical/mental health scores on a validated instrument and performed multivariable regression analyses to identify determinants that independently influence perceived HRQoL.

RESULTS

In total, 49 studies were included for further analysis and they used a variety of HRQoL instruments: Medical Outcomes Study Short Form-36 or variants, Medical Outcomes Study-HIV, HIV Cost and Services Utilization Study measure, Multidimensional Quality of Life Questionnaire, HIV targeted quality of life instrument, Functional Assessment of Human Immunodeficiency Virus Infection, HIV Overview of Problems Evaluation System, EuroQol, Fanning Quality of Life scale, Health Index and PROQOL-HIV. In this review, the discussed determinants were thematically divided into socio-demographic, clinical, psychological and behavioural factors. Employment, immunological status, presence of symptoms, depression, social support and adherence to antiretroviral therapy were most frequently and consistently reported to be associated with HRQoL among people living with HIV.

CONCLUSIONS

HRQoL among people living with HIV is influenced by several determinants. These determinants independently, but simultaneously impact perceived HRQoL. Most HRQoL instruments do not capture all key determinants. We recommend that the choice for an instrument should depend on the purpose of the HRQoL assessment.

Antiretroviral therapy-induced mitochondrial toxicity: potential mechanisms beyond polymerase-γ inhibition

We hypothesized that competition between nucleotide reverse-transcriptase inhibitor triphosphate and endogenous deoxyribonucleotide triphosphate (dNTP) may lead to depletion of dNTP pools and mitochondrial dysfunction independent of polymerase-γ (pol-γ) inhibition. We collected peripheral blood mononuclear cells from 75 adults (25 cases: HIV-infected patients with mitochondrial toxicity, 25 HIV-infected positive controls, and 25 HIV-negative controls). We observed statistically significant individual and group differences in ribonucleotide (RN) and deoxyribonucleotide (dRN) pools. The median values for the RN pools were 10,062 (interquartile range (IQR): 7,090-12,590), 4,360 (IQR: 3,058-6,838), and 2,968 (IQR: 2,538-4,436) pmol/10(6) cells for negative controls, positive controls, and cases, respectively. Cases had significantly higher absolute mitochondrial DNA copy number as compared with negative controls (P < 0.05). Moreover, cases had significantly higher expression levels of pol-γ, nucleotide transporters, cellular kinases, and adenosine triphosphate (ATP)-binding cassette (ABC) proteins as compared with controls. Antiretroviral therapy (ART) perturbs RN and dRN pools. Depletion of RN and dRN pools may be associated with ART-induced mitochondrial toxicity independent of pol-γ inhibition.

Social isolation in HIV-infected patients according to subjective patient assessment and DEXA-confirmed severity of lipodystrophy

This study was designed to investigate the persistence of lipodystrophy (LD)-related social distress and isolation in HIV-infected patients in the current era, according to confirmatory dual energy X-ray absorptiometry (DEXA) measurements. Cross-sectional interview data were collected from 168 HIV-positive adult patients taking more than 2 years of antiretroviral therapy (133 cases with LD diagnosed a mean of 7.2 years before; 35 without LD, controls). Mean time of HIV infection was 16.2 years (2.1-27.3), and the mean time of exposure to highly active antiretroviral therapy of 11.7 years (2.1-21.1). The presence and severity of LD, confirmed by DEXA measurements, correlated with social isolation through a validated scale, including avoidance of social relationships, sex, work, or sport activities. In comparison with control patients, social distress was observed for patients having moderate body changes. The significant correlation between LD and social isolation was irrespective of age, CD4+ count, HIV RNA level, AIDS diagnosis, time of HIV infection, anxiety, or depressive symptoms. These results confirm that patient assessment of LD is correlated with whole-body DEXA scan, and they highlight the role of LD as an independent cause of social isolation even after years of the diagnosis.

[Lipodystrophies]

Human lipodystrophies represent a group of diseases characterized by altered body fat amount and/or repartition. Most forms of lipodystrophies are associated with metabolic alterations such as insulin resistance, diabetes and dyslipemia, leading to diabetic complications, increased cardiovascular risk or liver steatosis. Lipodystrophies can be classified as genetic or acquired, generalized or partial. Genetic forms such as Berardinelli-Seip syndrome or partial familial lipodystrophies are uncommon and acquired forms are much more frequent. Beside the rare Lawrence or Barraquer-Simons syndromes, the main forms of acquired lipodystrophies are those observed in HIV-infected people treated with antiretroviral therapies or in people exposed to an endogenous or an exogenous hypercortisolism. The treatment of lipodystrophies is difficult. Lifestyle modifications (e.g., specific diet, physical training) may be helpful but are usually insufficient. Associated metabolic disorders should be treated as soon as possible with insulin sensitizers, insulin and lipid lowering drugs. New therapies such as leptin have been proven to be helpful in some genetic or acquired forms of lipodystrophy.

Insomnia symptoms and HIV infection among participants in the Women's Interagency HIV Study

OBJECTIVES

This study assessed the prevalence of insomnia symptoms among women with and without HIV-infection and examined factors associated with insomnia.

DESIGN

Participants (n = 1682) were enrolled in the Women's Interagency HIV Study (WIHS); 69% were infected with HIV. This was a cross-sectional analysis of data from standardized interviewer-administered instruments and physical/gynecological exams. Analysis focused on sociodemographics, sleep measures, depressive symptoms, drug use, alcohol consumption, medications, and HIV-related clinical variables. Women were classified as having symptoms of insomnia if they reported either difficulty initiating sleep, difficulty maintaining sleep, or early morning awakening ≥ 3 times a week in the past 2 weeks.

RESULTS

Overall, HIV-infected women were 17% more likely to endorse insomnia symptoms than uninfected women (OR = 1.17, 95% CI: 1.04-1.34, P < 0.05). The adjusted prevalence of insomnia symptoms varied by HIV status and age groups. Among women ages 31-40 years, those with HIV infection were 26% more likely to endorse insomnia symptoms than their counterparts (OR = 1.26, 95% CI: 1.01-1.59, P < 0.05). No significant differences were observed in the likelihood of reporting insomnia symptoms based on HIV treatment type. Multivariate-adjusted regression analyses showed that depression was the most consistent and significant independent predictor of the likelihood of reporting insomnia symptoms across all age strata.

CONCLUSIONS

Insomnia symptoms are common among both HIV-infected and uninfected women. Prevalence of insomnia did not vary significantly by HIV status, except among younger women. Younger women with HIV infection are at greater risk for experiencing insomnia symptoms.

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.

Women living with HIV/AIDS and the bodily transformation process known as the lipodystrophy syndrome: a grounded theory study

Over the past decade, the lipodystrophy syndrome has become one of the biggest challenges in the field of HIV/AIDS. Yet, few qualitative studies have examined how lipodystrophy affects the lives of people living with HIV/AIDS by reconfiguring their bodies in unexpected ways. The main objective of this qualitative study was to explore and describe the transformation process that women experience following the onset of lipodystrophy. The data were collected using semi-structured interviews and were then analysed following the principles of grounded theory. Overall, the research participants explained how lipodystrophy had transformed their bodies, disrupted their identities and confined them to a fragile social trajectory. In this sense, the experience of lipodystrophy was described as a profoundly disruptive transformation that includes three distinct stages: normalisation, problematisation and pathologisation. This process was characterised by the progression of lipodystrophy, as well as an intensification of the efforts to regain control over the body. At last, this study provides health care providers with a better understanding of the psychosocial impact of lipodystrophy and the needs of women who suffer from this condition.

Monitoring Antiretroviral Therapy in HIV-Infected Children in Resource-Limited Countries: A Tale of Two Epidemics

Twenty-nine years into the HIV epidemic, several advances have been made; however, there remain several challenges particularly with pediatric HIV in resource-limited countries. The obstacles facing pediatric antiretroviral therapy (ART) delivery in resource-limited countries are multifaceted: lack of health care infrastructure, limited availability of pediatric drug formulations, lack of early HIV diagnostic and monitoring techniques, limited manpower with expertise in pediatric HIV care, limited donor funding, and competing public health priorities with limited health care budget. In this paper, the challenges with various ART monitoring tools in resource-limited countries are discussed. Noninvasive (e.g., patient, clinical events outcome, and adherence) and invasive (e.g., immunologic and virologic) monitoring tools are discussed. Several cheap and technically less complex laboratory tests for monitoring are becoming available. Funding agencies and country programs should invest in validating the use of current technologies to optimize pediatric HIV care in resource-limited countries.

Obstacles and opportunities to improve antiretroviral regimen access in low-income countries

Increasing evidence suggests that dramatically increasing access to effective and well-tolerated antiretroviral medications is key to reversing the HIV pandemic. Currently used first-line therapies in developing countries have multiple toxicities that cause significant morbidity and mortality. New World Health Organization HIV treatment guidelines support earlier treatment initiation and the use of less toxic first-line therapies. Adoption of these guidelines requires political and financial commitment from multiple stakeholders including country governments and donors. This review summarizes the major adverse effects associated with commonly used ARV regimens in low-income countries and also analyzes some of the barriers and potential solutions that affect the ability of low-income countries to implement the new World Health Organization guidelines.

Cost-effectiveness of tenofovir as first-line antiretroviral therapy in India

BACKGROUND

World Health Organization guidelines for antiretroviral treatment (ART) in resource-limited settings recommend either stavudine or tenofovir as part of initial therapy. We evaluated the clinical outcomes and cost-effectiveness of first-line ART using tenofovir in India, compared with current practice using stavudine or zidovudine.

METHODS

We used a state-transition model of human immunodeficiency virus (HIV) disease to examine strategies using different nucleoside reverse-transcriptase inhibitors, combined with lamivudine and nevirapine, compared with no ART: (1) stavudine, (2) stavudine with substitution by zidovudine after 6 months, (3) zidovudine, and (4) tenofovir. Data were from the Y. R. Gaitonde Centre for AIDS Research and Education in Chennai, India, and published studies. Results. Discounted mean per person survival was 36.9 months (40.2 months undiscounted) with no ART, 115.5 months (145.3) with stavudine-containing ART, 115.7 months (145.6) with stavudine and 6-month zidovudine substitution, 115.8 months (145.6) with zidovudine-containing ART, and 125.8 months (162.0) with initial tenofovir. Discounted lifetime medical costs were $610 with no ART and ranged from $5580 with stavudine-containing ART to $5720 with zidovudine-containing ART. Initial tenofovir had an incremental cost-effectiveness ratio of $670 per year of life saved, compared with no ART, and was more economically efficient than the other regimens.

RESULTS

were most sensitive to variations in the costs of first-line tenofovir, access to additional ART after treatment failure, and quality of life adjustment.

CONCLUSIONS

Using tenofovir as part of first-line ART in India will improve survival, is cost-effective by international standards, and should be considered for initial therapy for HIV-infected patients in India.

Prevalence and impact of body physical changes in HIV patients treated with highly active antiretroviral therapy: results from a study on patient and physician perceptions

Patients infected with HIV treated with highly active antiretroviral therapy (HAART) frequently develop body physical changes (BPC) that have an important psychosocial burden. The purpose of this study was to determine the prevalence of BPC observed by HIV-infected patients and their attending physicians and to assess the impact BPC had on daily life. In this epidemiologic multicenter study, patients with HIV infection and their treating physicians filled out parallel questionnaires about their perceptions of specific BPC and their impact on daily activities. A total of 965 patient-physician questionnaires were collected across 98 health centers. Patient's mean age was 43.7 +/- 8.5 years and 72.6% were men. Adjusted prevalence of perceived BPC by patients and physicians was 55.1% (95% confidence interval [CI]: 52.0-58.1) and 55.2% (95% CI: 52.1-58.2), respectively (p = 1.000). Overall patient-physician agreement concerning perception of BPC was 83% (p < 0.0005). The most common BPC was lipoatrophy, described by 46.8% (95% CI: 43.7-49.8) of patients and 49.4% (95% CI: 46.3-52.5) of physicians (p = 0.033) followed by lipohypertrophy. No gender differences were observed in the global prevalence of BPC (p = 0.649). However, significantly more women reported lipoatrophy of the lower limbs (p = 0.009) and buttocks (p = 0.007), as well as lipohypertrophy (p = 0.007), than men; 58.2% (95% CI: 54.0-62.4) patients noted that BPC negatively affected their daily activities. This study reflects the high prevalence of patient and physician-perceived BPC in the HIV population, and the adverse impact on daily life. Physicians should be aware of the psychosocial consequences of BPC in HIV patients in order to improve patient well-being.

Impact of metabolic complications on antiretroviral treatment adherence: clinical and public health implications

Antiretroviral therapy (ART) is an effective strategy for preventing disease progression of HIV infection, particularly when patients adhere closely to the treatment regimen. However, ART medications can cause side effects, including metabolic complications that can impact patients' adherence levels. Selected chronic complications associated with ART include lipodystrophy, hyperlipidemia, insulin resistance and diabetes, peripheral neuropathy, and bone disorders such as osteopenia/osteoporosis. In this article, we review the effects of these metabolic complications on ART adherence and approaches to prevent or reverse them.

Health-related quality of life in a randomized trial of antiretroviral therapy for advanced HIV disease

OBJECTIVE

To assess and compare alternative approaches of measuring preference-based health-related quality of life (HRQoL) in treatment-experienced HIV patients and evaluate their association with health status and clinical variables.

DESIGN

Cross-sectional study.

SETTING

Twenty-eight Veterans Affairs hospitals in the United States, 13 hospitals in Canada, and 8 hospitals in the United Kingdom.

PATIENTS

Three hundred sixty-eight treatment-experienced HIV-infected patients enrolled in the Options in Management with Antiretrovirals randomized trial.

MEASUREMENTS

Baseline sociodemographic and clinical indicators and baseline HRQoL using the Medical Outcome Study HIV Health Survey (MOS-HIV), the EQ-5D, the EQ-5D visual analog scale (EQ-5D VAS), the Health Utilities Index Mark 3 (HUI3), and standard gamble (SG) and time trade-off (TTO) techniques.

RESULTS

The mean (SD) baseline HRQoL scores were as follows: MOS-HIV physical health summary score 41.70 (11.16), MOS-HIV mental health summary score 44.76 (11.38), EQ-5D 0.77 (0.19), HUI3 0.59 (0.32), EQ-5D VAS 65.94 (21.71), SG 0.75 (0.29), and TTO 0.80 (0.31). Correlations between MOS-HIV summary scores and EQ-5D, EQ-5D VAS, and HUI3 ranged from 0.60 to 0.70; the correlation between EQ-5D and HUI3 was 0.73; and the correlation between SG and TTO was 0.43. Preference-based HRQoL scores were related to physical, mental, social, and overall health as measured by MOS-HIV. Concomitant medication use, CD4 cell count, and HIV viral load were related to some instruments' scores.

CONCLUSIONS

On average, preference-based HRQoL for treatment-experienced HIV patients was decreased relative to national norms but also highly variable. Health status and clinical variables were related to HRQoL.

Improved measures of quality of life, lipid profile, and lipoatrophy after treatment interruption in HIV-infected patients with immune preservation: results of ACTG 5170

BACKGROUND

Antiretroviral treatment interruption (TI) occurs frequently in routine clinical practice. The consequences of TI on quality of life (QOL), body habitus, and lipid parameters have not been studied.

METHODS

We assessed QOL, symptoms, lipid measurements, and body circumference changes in patients who underwent prolonged TI (up to 96 weeks) in AIDS Clinical Trials Group 5170, a multicenter, prospective study. Major entry criteria were pre-antiretroviral therapy (ART) and entry CD4 count > 350 cells/mm3, entry HIV RNA < 55,000 copies/mL, and on ART for > 6 months. QOL was assessed at baseline and subsequent time points (to week 96) by patient self-report (0-100 scale), by patient-reported Symptoms Distress Module, and by the Multidimensional Health Status tool. Fasting total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, and triglycerides were measured at baseline and subsequent time points to week 24. Neck, arm, mid-thigh, waist, and hip circumferences were measured through week 96. Paired t tests, Wilcoxon signed rank tests, and the generalized estimating equation approach were used in the data analysis.

RESULTS

A total of 167 subjects enrolled with median baseline and nadir CD4 count of 833 and 436 cells/mm3, respectively, and median time on ART 4.5 years. One hundred forty-nine subjects were receiving a thymidine analog-containing regimen (zidovudine or stavudine before TI). Self-reported QOL score on ART started high (mean 83.4 at baseline) and remained so after TI (83.0 at week 96, P = 0.49). Mean number of symptoms decreased from 8.2 at baseline to 7.0 at week 96, P = 0.016. The overall symptom summary score decreased from baseline to week 96, P = 0.01. The symptoms most frequently reported during TI were fatigue, feeling sad, nervousness, insomnia, myalgias, and changes in body appearance. There were no significant changes from baseline in the Multidimensional Health Status mental or physical domain scores. After TI, lipids (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) decreased at weeks 12 and 24. Lipid changes were similar in patients stopping a nonnucleoside reverse transcriptase inhibitor vs a protease inhibitor regimen, except for HDL, which showed greater decreases in those interrupting an nonnucleoside reverse transcriptase inhibitor. Body circumference measurements of arm, waist, hip, and mid-thigh increased after TI.

CONCLUSIONS

In a cohort of individuals with high QOL and preserved immune function, QOL did not change during a prolonged TI. Modest decreases in total cholesterol, LDL and HDL cholesterol, and triglycerides and a modest increase in limb fat were observed.

Impact of lipoatrophy on quality of life in HIV patients receiving anti-retroviral therapy

Metabolic and morphological side-effects occur in HIV-infected individuals receiving anti-retroviral treatment (ART). Peripheral fat loss that occurs particularly in the face, limbs and/or buttocks is referred to as lipoatrophy and has been found to be highly stigmatizing and to adversely impact the health-related quality of life (HRQL). Consumer Health Sciences Survey data collected between November 2003 and January 2006 were utilized to evaluate the impact of lipoatrophy on the HRQL in HIV-infected individuals receiving ART. This was evaluated using analysis of variance with item scores and mental component summary (MCS) and physical component summary (PCS) scores from the Medical Outcomes Trust questionnaire, SF-8 as dependent variables and lipoatrophy as the independent variable controlling for baseline age, sex and ethnicity. Clinical meaningfulness (mean difference divided by population standard deviation, delta/sigma) of differences between the groups with and without lipoatrophy was also evaluated. A cohort of 1124 subjects with at least six months of ART was selected based on the availability of data on whether or not lipoatrophy was present. Subjects were primarily male (80%), between the ages of 30 and 60 years (90%), Hispanic (37%) and about 25% each of African American and White. Overall, prevalence of lipoatrophy in this cohort of HIV patients was 18.9%. Statistically significant (p<0.001) differences in quality of life (as measured by SF-8 individual item scores and MCS and PCS scores) were observed between the two groups. The differences between the groups in item and summary scores were clinically meaningful in the small to near medium range (0.28-0.43). HIV-infected patients already experience a considerable deficiency in HRQL compared to general population; this study demonstrates that lipoatrophy further enhances that negative impact on HRQL.

A comparison of lipoatrophy and aging: volume deficits in the face

BACKGROUND

Insight into the physical processes of aging can be gained by comparing the loss of facial volume that occurs during aging with the dramatic fat loss resulting from acquired lipoatrophy, including human immunodeficiency virus (HIV) treatment-associated lipoatrophy. The superficial effects of aging, such as rhytid formation, often are the focus of investigations into this phenomenon. However, age-related volume loss often is ignored.

METHODS

A review of the relevant literature was conducted to provide an overview of age-related lipoatrophy and its etiology and to compare it by facial region with HIV-associated facial lipoatrophy.

RESULTS

As a side effect of highly active antiretroviral therapy, HIV-associated lipoatrophy results in fat lipodystrophy (including both lipoatrophy and lipohypertrophy) and progresses toward nearly complete subdermal facial fat loss. Aging is accompanied by changes in the soft tissues of the face, leaving atrophic regions of generalized tissue ptosis. Some facial regions are affected differently by fat loss, depending on its cause. In the aging patient, certain parts of the face display only minimal fat loss.

CONCLUSIONS

The role of fat loss in facial aging is slight compared with its considerable role in HIV-associated lipoatrophy. The losses of various facial tissues and the ptosis of some soft tissues are strong contributors to the appearance of the aged face. This regional anatomic assessment of the face engenders a more thorough understanding of the progression that characterizes volume changes associated with aging.

Antiretroviral therapy and the human immunodeficiency virus--improved survival but at what cost?

Patients infected with human immunodeficiency virus are living longer since the introduction of combination antiretroviral therapy more than a decade ago - but at what cost? Highly active antiretroviral therapy has been associated with lipodystrophy and associated metabolic derangements such as dyslipidaemia, insulin resistance and diabetes. These complications are likely to contribute to an increased risk of premature and accelerated atherosclerosis with growing concern about potential cardiovascular consequences.

Assessment of quality of life in HAART-treated HIV-positive subjects with body fat redistribution in Rwanda

Background

The introduction of HAART has initially improved the quality of life (QoL) of HIV-positive (HIV+) patients, however body fat redistribution (BFR) and metabolic disorders associated with long-term HAART use may attenuate this improvement. As access to treatment improves in sub-Saharan Africa, the disfiguring nature of BFR (peripheral atrophy and/or central adiposity) may deter treatment adherence and initiatives and decrease QoL. We examined the relationship between BFR and domains of QoL in HAART-treated HIV+ African men and women with (HIV+BFR, n = 50) and without (HIV+noBFR, n = 50) BFR in Rwanda.

Results

HIV+ subjects with BFR were less satisfied with their body image (4.3 ± 0.1 versus 1.5 ± 0.2; p < .001), self-esteem and social life (4.1 ± 1.4 versus 2.1 ± 0.3; p = 0.003). HIV+BFR were more ashamed in public (4.5 ± 1.2 versus 1.1 ± 1.1), reported less confident about their health (4.6 ± 1.4 versus 1.5 ± 1.2) and were frequently embarrassed due to body changes (4.1 ± 1.1 versus 1.1 ± 0.9) (p < .001) than HIV+noBFR. HIV+ Rwandan women with BFR reported more dissatisfaction with psychological (8.3 ± 2.9 versus 13.7 ± 1.9), social relationships (6.9 ± 2.3 versus 11.1 ± 4.1) and HIV HAART-specific domain of wellbeing (3.1 ± 4.8 versus 6.3 ± 3.6) (p < .001). Age was associated with independence (r² = 0.691; p = 0.009) and marital status was associated with psychological (r² = 0.593; p = 0.019) and social relationships (r² = 0.493; p = 0.007). CD4 count (r² = 0.648; p = 0.003) and treatment duration (r² = 0.453; p = 0.003) were associated with HIV HAART-specific domain of wellbeing. HIV+ Rwandan women with BFR were significantly more affected by abdominal adiposity (p < .001), facial and buttocks atrophy (p < .05) than HIV+ men with BFR.

Conclusion

Body fat alterations negatively affect psychological and social domains of quality of life. These symptoms may result in stigmatization and marginalization mainly in HAART-treated African women, adversely affecting HAART adherence and treatment initiatives. Efforts to evaluate self-perceived body fat changes may improve patients' wellbeing, HAART adherence and treatment outcomes and contribute towards stability in quality of life continuum.

Potential risks and benefits of HIV treatment simplification: a simulation model of a proposed clinical trial

BACKGROUND

In recent studies, subjects who had achieved suppression of the human immunodeficiency virus (HIV) RNA level while receiving an initial 3-drug antiretroviral regimen successfully maintained suppression while receiving treatment with a "boosted" protease inhibitor (PI) alone. We projected the long-term outcomes of this treatment simplification strategy to inform the design of a proposed multicenter, randomized clinical trial.

METHODS

We used published studies to estimate the efficacy, adverse effects, and cost of a sequence of HIV drug regimens for the simplification strategy, compared with those outcomes for the current standard-of-care (SOC) strategy. Using a published simulation model of HIV disease, we projected life expectancy, discounted quality-adjusted life expectancy (QALE), and discounted lifetime medical costs for each strategy.

RESULTS

Subjects who have not developed PI-resistant HIV infection at the time of failure of the simplification regimen have a greater life expectancy (27.9 vs. 27.1 years) and QALE (14.9 vs. 14.7 years), compared with SOC subjects, because they receive an additional line of therapy without negative consequences for future treatment options. The QALE for the simplification strategy remains higher than that for the SOC, unless a large proportion of patients experiencing virologic failure while receiving the simplification regimen develop PI resistance. Depending on the probability of simplification regimen failure, the advantage is maintained even if HIV develops PI resistance in 42%-70% of subjects. Projected lifetime costs are $26,500-$72,400 per person lower for the simplification strategy than for the SOC strategy.

CONCLUSIONS

An HIV treatment simplification strategy involving use of a boosted PI alone may lead to longer survival overall at lower cost, compared with the SOC combination therapy, because the simplification strategy potentially adds an additional line of therapy. The risk of emergence of PI resistance during treatment with a simplified regimen is a critical determinant of the viability of this strategy.

Intracellular metabolism and persistence of the anti-human immunodeficiency virus activity of 2',3'-didehydro-3'-deoxy-4'-ethynylthymidine, a novel thymidine analog

The therapeutic benefits of current antiretroviral therapy are limited by the evolution of drug-resistant virus and long-term toxicity. Novel antiretroviral compounds with activity against drug-resistant viruses are needed. 2',3'-didehydro-3'-deoxy-4'-ethynylthymidine (4'-Ed4T), a novel thymidine analog, has potent anti-human immunodeficiency virus (HIV) activity, maintains considerable activity against multidrug-resistant HIV strains, and is less inhibitory to mitochondrial DNA synthesis in cell culture than its progenitor stavudine (D4T). We investigated the intracellular metabolism and anti-HIV activity of 4'-Ed4T. The profile of 4'-Ed4T metabolites was qualitatively similar to that for zidovudine (AZT), with the monophosphate metabolite as the major metabolite, in contrast to that for D4T, with relatively poor formation of total metabolites. The first phosphorylation step for 4'-Ed4T in cells was more efficient than that for D4T but less than that for AZT. The amount of 4'-Ed4T triphosphate (4'-Ed4TTP) was higher than that of AZTTP at 24 h in culture. There was a dose-dependent accumulation of 4'-Ed4T diphosphate and 4'-Ed4TTP on up-regulation of thymidylate kinase and 3-phosphoglycerate kinase expression in Tet-On RKO cells, respectively. The anti-HIV activity of 4'-Ed4T in cells persisted even after 48 h of drug removal from culture in comparison with AZT, D4T, and nevirapine (NVP). The order of increasing persistence of anti-HIV activity of these compounds after drug removal was 4'-Ed4T > D4T > AZT > NVP. In conclusion, with the persistence of 4'-Ed4TTP and persistent anti-HIV activity in cells, we anticipate less frequent dosing and fewer patient compliance issues than for D4T. 4'-Ed4T is a promising antiviral candidate for HIV type 1 chemotherapy.

Balancing disfigurement and fear of disease progression: Patient perceptions of HIV body fat redistribution

This study was conducted to identify and describe the perceived morphologic changes of body fat redistribution and related distress among persons taking combination antiretroviral therapy. Six focus group interviews were conducted in four different US cities with men and women (n = 58) who reported antiretroviral-related symptoms of body fat loss and/or gain. Interview data were audiotaped, transcribed verbatim and systematically analysed using inductive techniques. Physical discomfort and impairment and psychological and social distress were reported across sex, sexual orientation and geographic subgroups. While participants acknowledged that antiretroviral drugs were keeping them alive, there was tension between the desire for life-sustaining treatment and optimal quality of life. Some participants engaged in harmful heath behaviours in an attempt to control bodily changes (e.g. non-adherence to antiretroviral regimen). Participants feared that fat loss represented disease progression and worried that visible changes would lead to unintentional disclosure of their HIV status. Although a potential source of support, healthcare providers were commonly perceived as ignoring and, in so doing, discrediting patient distress. Participants recognised the limitations of current lipodystrophy treatment options, yet a cure for the syndrome seemed less important to them in the short term than simply being listened to and the powerful, but oblique sources of distress addressed.

Body image in older men with or at-risk for HIV infection

We performed a cross-sectional analysis of factors associated with negative body image among 550 older men with or at-risk for HIV infection, including demographics, depression, illicit drug use, and antiretroviral therapy adherence. Overall, 31 per cent of participants reported negative body image, which was independently associated with increased BMI, self-rated fair/poor health, depression, and erectile dysfunction, but not HIV status. Screening for and treating depression, sexual dysfunction, and obesity in older men should be considered.

Adverse quality of life consequences of antiretroviral medications

To identify the effects of antiretroviral therapy on quality of life, we performed a qualitative content analysis of the Medical Outcomes Study-Human Immunodeficiency Virus (MOS-HIV) Health Survey. We used focus groups to elicit views about antiretroviral effects on quality of life from a purposive sample of treatment-experienced participants. Data were analysed using a grounded theory approach. We appraised the content of the MOS-HIV against the themes identified from our analysis. Participants also completed the MOS-HIV survey and were asked whether the survey captured all important medication-related aspects of quality of life. Participants (n=38) viewed the use of antiretrovirals as a trade-off between poorer quality of life and being alive. The net effect was increased longevity but without hope and future. Features of quality of life included the downstream consequences of side effects and toxicities, tensions with health care providers and loss of independent decision-making, dilemmas regarding drugs and career, burdens of medication-taking responsibilities, and the stress of living life under a pretense and hiding an HIV diagnosis. The MOS-HIV missed or under-emphasised these features. Quality of life concerns of people living with HIV, particularly those related to medication use, are not well captured by the MOS-HIV. A broad concept of quality of life is needed to encompass all dimensions important to people living with HIV.

Health-related quality of life in veterans and nonveterans with HIV/AIDS

PURPOSE

To compare health-related quality of life (HRQoL) between patients receiving care in Veterans Administration (VA) settings (veterans) and non-VA settings (nonveterans), and to explore determinants of HRQoL and change in HRQoL over time in subjects living with HIV/AIDS.

SUBJECTS

One hundred veterans and 350 nonveterans with HIV/AIDS from 2 VA and 2 university-based sites in 3 cities interviewed in 2002 to 2003 and again 12 to 18 months later.

METHODS

We assessed health status (functional status and symptom bother), health ratings, and health values (time tradeoff [TTO] and standard gamble [SG] utilities). We also explored bivariate and multivariable associations of HRQoL measures with a number of demographic, clinical, spiritual/religious, and psychosocial characteristics.

RESULTS

Compared with nonveterans, the veteran population was older (47.7 vs 42.0 years) and consisted of a higher proportion of males (97% vs 83%), of participants with a history of injection drug use (23% vs 15%), and of subjects with unstable housing situations (14% vs 6%; P<.05 for all comparisons). On scales ranging from 0 (worst) to 100 (best), veterans reported significantly poorer overall function (mean [SD]; 65.9 [17.2] vs 71.9 [16.8]); lower rating scale scores (67.6 [21.7] vs 73.5 [21.0]), lower TTO values (75.7 [37.4] vs 89.0 [23.2]), and lower SG values (75.0 [35.8] vs 83.2 [28.3]) than nonveterans (P<.05 for all comparisons); however, in multivariable models, veteran status was only a significant determinant of SG and TTO values at baseline. Among other determinants that were associated with multiple HRQoL outcomes in baseline and follow-up multivariable analyses were: symptom bother, overall function, religiosity/spirituality, depressive symptoms, and financial worries.

CONCLUSIONS

Veterans reported significantly poorer HRQoL than nonveterans, but when controlling for other factors, veteran status was only a significant determinant of TTO and SG health values at baseline. Correlates of HRQoL such as symptom bother, spirituality/religiosity, and depressive symptoms could be fruitful potential targets for interventions to improve HRQoL in patients with HIV/AIDS.

Effects of lipodystrophy on quality of life and depression in HIV-infected men on HAART

The aim of the study was a prospective assessment of the possible consequences of a diagnosis of lipodystrophy on health-related quality of life (HRQL) and depressive symptomatology in HIV-seropositive men who have sex with men. A standardized physical assessment for lipodystrophy was introduced within a prospective study in April 1999. Over a 2-year follow- up, 37 HIV-seropositive men who met the criteria for lipodystrophy were longitudinally compared to 92 HIV-seropositive men without lipodystrophy and 88 HIV-seronegative men on measures of HRQL and depression. A series of questionnaires, which included the Medical Outcomes Study Short-Form 36 (SF-36) and the Center for Epidemiological Studies-Depression (CES-D), were administered to assess HRQL and depression, respectively. SF-36 scores were summarized using the mental and physical components; CES-D results were reported as both dichotomous (with or with clinical depression) and continuous scores. Neither the mental nor physical components of the SF-36 showed any significant differences between patients with lipodystrophy versus HIV-seropositive patients without lipodystrophy. Similarly, lipodystrophy status was not significantly associated with either continuous depression scores or presence of clinical depression. However, consistent with previous results, HIV-seropositive men without lipodystrophy (compared to HIV-seronegative men) reported higher scores on both components of the SF-36 scales and both categorizations of the CES-D. The results of this study suggest that lipodystrophy does not negatively affect HRQL or depression, above and beyond, the diagnosis of HIV infection, although the impact of the severity of lipodystrophy on these conditions will require further study.

Health values of patients coinfected with HIV/hepatitis C: are two viruses worse than one?

OBJECTIVES

We sought to assess health values of patients coinfected with HIV/hepatitis C (HCV) and compare them with those of patients singly infected with HIV or HCV and to characterize and assess the relationship of clinical and nonhealth-related factors with health values.

SUBJECTS

We studied a total of 203 subjects infected with HIV, HCV, or both.

MEASURES

We assessed rating scale (RS), time tradeoff (TTO), and standard gamble (SG) values, and we explored associations of health values with the Mental Component Summary (MCS) and Physical Component Summary (PCS) of the SF-12; number of bothersome symptoms from the HIV Symptoms Index; spirituality, as assessed by the Functional Assessment of Chronic Illness Therapy, Spiritual Well-being scale; as well as with a number of demographic, clinical, and psychosocial characteristics.

RESULTS

Of the 203 subjects, 59 (29%) had HIV monoinfection, 69 (34%) had HCV monoinfection, and 75 (37%) were coinfected. The mean (SD) health values for the cohort were: RS = 0.69 (0.23), TTO= 0.88 (0.24), and SG = 0.78 (0.30). Infection type was related, albeit differently, to TTO values (mean values for patients with coinfection = 0.82; HIV = 0.91; and HCV = 0.91 [P < 0.05]) and SG values (coinfection = 0.77; HIV = 0.70; and HCV = 0.87; P < 0.05). In multivariable models, RS scores were significantly associated with sexual orientation, PCS scores, MCS scores, symptoms, and spirituality (adjusted R = 0.61); TTO with symptoms and spirituality (adjusted R = 0.23); and SG with infection type, PCS scores, and symptoms (adjusted R = 0.24).

CONCLUSIONS

Health values and their correlates varied by method of assessment. Health values appear to be driven more by symptoms, health status, and spirituality than by number of viral infections.

Correction options for lipoatrophy in HIV-infected patients

Lipoatrophy (LA) is a form of lipodystrophy, characterized by volume depletion caused by fat loss in the limbs, buttocks, and face. Facial volume loss is the most obvious outward sign of LA because it alters the facial contours in the cheeks, temples, and orbits. Lipodystrophy and LA are most commonly seen in patients with HIV on highly active antiretroviral therapy (HAART), which was introduced in the mid-1990s for the management of HIV, and is currently considered the mainstay therapy for HIV-infected patients. However, the etiology of LA is likely multifactorial as underlying patient conditions, including duration and severity of HIV and increasing age, have also been found to contribute to its occurrence. The volume loss of LA can be very dramatic with some patients exhibiting no signs of facial fat. As a result, many HIV-infected patients with associated LA suffer from psychological and lifestyle effects, which can lead to noncompliance with HAART. Thus, increases in facial volume and improvement in morphology is anticipated to reduce anxiety caused by LA in HIV-infected patients, and improve quality of life. This review discusses the benefits and limitations of several treatment options available to correct the volume depletion associated with LA, including antiretroviral switching, permanent surgical implants and injectables, poly-L-lactic acid, collagen, and hyaluronic acid derivatives.

Caring for HIV-positive and aging patients with associated facial lipoatrophy

Facial lipoatrophy is characterized by fat loss and redistribution. It is a natural, biological phenomenon that occurs over time, presenting as mild-to-moderate volume depletion that gives the skin the appearance of sagging. More recently, highly active antiretroviral therapy, introduced for the management of human immunodeficiency virus, has been associated with moderate-to-severe facial lipoatrophy, and is characterized by sunken cheeks, accentuated nasolabial folds, and protruding musculature and bones. Furthermore, the consequences of facial lipoatrophy have been found to substantially impact patient quality of life. Nurses play an integral role in the treatment of facial lipoatrophy by educating the patients on available therapies and assisting them in making informed treatment decisions. It is important that treating nurses conduct a well-organized interview to understand patient treatment goals. This article will discuss several treatment options available to correct facial lipoatrophy-associated volume deficits, including collagen, hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, and permanent implants and injectables.

Appearance-related side effects of HIV-1 treatment

In the early years of the AIDS epidemic, HIV infection was associated with visible signs and symptoms, adding to the stigma associated with the disease. Physical manifestations associated with HIV infection included muscle wasting, lymphadenopathy, Kaposi's sarcoma, candidiasis, molluscum contagiosum, and hairy leukoplakia. With the advent of antiretroviral therapy, particularly the introduction of highly active antiretroviral therapy in 1996, many of these outward manifestations of the disease became rare. Ironically, however, the treatments used to control HIV infection (and its visible markers) have themselves been associated with appearance-related side effects. Patients may develop changes in fat distribution, rashes, skin hyperpigmentation, or paronychia. These effects not only have cosmetic and psychological consequences but also may decrease adherence to therapy, potentially causing regimen failure and drug resistance. Newer antiretroviral agents offer improved potency, more convenient dosing, and more treatment options with the potential for fewer side effects and drug interactions, which should foster optimal adherence by the patient. However, these newer drugs are also associated with appearance-related side effects, which must be considered in the selection of treatment regimens. This paper reviews the appearance-related side effects associated with classes of antiretroviral drugs as well as individual agents, including the newer antiretrovirals.

The relationship between lipodystrophy-associated body changes and measures of quality of life and mental health for HIV-positive adults

OBJECTIVES

To investigate the relationship between lipodystrophy-specific symptom severity and wellbeing.

METHODS

HIV-positive adult patients with body fat redistribution (lipodystrophy syndrome) associated with antiretroviral therapy reported their total non-lipodystrophy symptoms and side effects and completed measures assessing body fat changes (yielding Atrophy, Hypertrophy and Total Lipodystrophy scores), mental health and quality of life. Effects of total symptom complex and lipodystrophy severity on quality of life and mental health were analyzed using Spearman's rho correlations. Logistic regression analyses were utilized to determine the relative-odds of depression produced by overall symptom count and lipodystrophy score increments.

RESULTS

Mean ratings for Hypertrophy and Atrophy corresponded to 'very mild' and 'mild' degrees of severity, respectively. The total symptom complex was associated with ratings for most of the mental health and quality of life measures. Patient-perceived body image scores were the sole study variable responsive to lipodystrophy severity ratings. In comparison to reference norms, a pronounced degree of body image impairment was evident.

CONCLUSION

Although responsive to the total symptom profile, psychosocial measures typically utilized for evaluating quality of life and mental health status in HIV disease lacked sensitivity and specificity for measuring the consequences of lipodystrophy-associated fat distribution changes alone. Lipodystrophy severity did impact negatively on body image.

Body image in patients with HIV/AIDS: assessment of a new psychometric measure and its medical correlates

HIV infection and its treatment can have significant effects on physical appearance and functioning, which can affect self-perceived body image. We assessed the psychometric properties of a newly developed Body Image Scale (BIS), a subjective measure of body image perception in persons with HIV infection, as well as the scale's relationship to disease progression, symptoms, and demographic factors. HIV-positive men (n = 129) and women (n = 21) attending two outpatient HIV clinics were administered the BIS survey along with a one-page questionnaire. A subset (n = 38) were administered the survey on two occasions to assess test-retest reliability. Nearly half of the sample (46%) had AIDS and 25% had a CD4 count below 200 cells/mm(3) within the prior 3 months. The BIS had unidimensional factor structure, good internal consistency reliability (Chronbach alpha = 0.91), and good test-retest reliability (r = 0.71, p < 0.001) after controlling for the length of interval between assessments. Patients' current perception of their body image was worse then what they perceived it to be prior to HIV infection (p < 0.001), but better than their perception of how others view people with HIV (p < 0.001). The presence of symptomatic disease (p < 0.001) and a diagnosis of AIDS (p = 0.02) were associated with a less favorable body image, although laboratory markers of disease progression (CD4 count and plasma HIV viral load) were not. We conclude that the BIS has good construct validity and is a highly reproducible measure of self-perceptive of body image in HIV-infected patients. Further exploration of its relationship to psychological well being, medication adherence and other aspects of medical care is indicated.

The effects of low-dose growth hormone in HIV-infected men with fat accumulation: a pilot study

Pharmacologic doses of growth hormone (GH) reduce HIV-associated fat accumulation but may worsen glucose metabolism. We investigated the effects of a low dose of GH (1 mg per day) in HIV-infected men with fat accumulation and found that such treatment reduced total fat and increased lean body mass without significant changes in glucose tolerance or insulin sensitivity. Visceral adipose tissue (VAT) levels did not change significantly for the group as a whole, although a reduction in the VAT level was seen in patients with a greater VAT level at baseline.

Impact of indinavir on the quality of life in patients with advanced HIV infection treated with zidovudine and lamivudine

OBJECTIVE

In AIDS Clinical Trial Group (ACTG) study 320, triple-combination antiretroviral therapy including indinavir significantly slowed progression to acquired immunodeficiency syndrome or death, compared with treatment with dual nucleoside reverse-transcriptase inhibitors (NRTIs) alone, in zidovudine-experienced patients with advanced human immunodeficiency virus (HIV) infection. We examined the impact of indinavir on quality of life in participants from this study.

METHODS

A total of 1156 protease inhibitor- and lamivudine-naive patients stratified by CD4 cell count (<or=50 and 51-200 cells/mm(3)) were randomized to receive zidovudine (or stavudine) and lamivudine, with or without indinavir. Health-related quality of life was measured using the ACTG QoL601-602 questionnaire, which assesses general health status measured on a visual analogue scale and 8 specific health-related domains. Quality-adjusted survival time was estimated using the visual analogue scale for general health.

RESULTS

Mean changes in general health scores after 24 weeks were +2.9 in the triple-therapy group versus -0.2 in the dual-therapy group (P=.018). By week 24, scores in all specific domains were higher with triple-drug therapy than dual-drug therapy, with statistically significant differences in role function, energy, and pain scores. Benefits of triple-drug therapy were largely confined to patients with CD4 cell counts of <or=50 cells/mm(3). Quality-adjusted survival time did not differ significantly between the 2 treatment groups.

CONCLUSIONS

Triple-drug therapy with indinavir and 2 NRTIs resulted in a significant improvement in general health status after 24 weeks, especially in patients with low CD4 cell counts. Patients receiving triple-drug therapy also had significantly better role function, energy, and pain scores than did patients treated with dual-drug therapy.

The cellular pharmacology of nucleoside- and nucleotide-analogue reverse-transcriptase inhibitors and its relationship to clinical toxicities

Nucleoside- and nucleotide-analogue reverse-transcriptase inhibitors (NRTIs) require intracellular phosphorylation for anti-human immunodeficiency virus (HIV) activity and toxicity. Long-term toxicities associated with NRTIs may be related to overactivation of this process. In vitro experiments have shown increased rates of NRTI and endogenous nucleoside phosphorylation to be associated with cellular activation. Patients with advanced HIV disease often have overexpression of cytokines, which corresponds to an elevated cellular activation state. These patients also have higher rates of NRTI phosphorylation and NRTI toxicity, suggesting an interaction between a proinflammatory biological state, NRTI phosphorylation, and toxicity. Studies suggest that women may have higher rates of NRTI phosphorylation than do men, as well as increased risk for NRTI-induced toxicity. Future research is needed to understand the NRTI activation process and improve the long-term toxicity profile of NRTIs. Such research should include comparisons of NRTI phosphorylation according to sex and cellular activation state (i.e., elevated vs. low).

Pharmacodynamics and clinical use of anti-HIV drugs

Antiretroviral drug exposure has been linked to both antiviral efficacy and the development of toxicity and further research in this area is ongoing and necessary. Use of these data may have important implications for TDM of HAART regimens in clinical practice. TDM, in conjunction with an assessment of the patient's viral resistance in the form of an IQ, needs to be examined and validated in large clinical trials.

An objective lipodystrophy severity grading scale derived from the lipodystrophy case definition score

HIV lipodystrophy can be objectively diagnosed using a score derived from the 10 parameters in the HIV lipodystrophy case definition (LDCD). Lipodystrophy severity remains subjectively determined by physical examination and patient assessment. Regional dual-energy x-ray absorptiometry (DEXA) and single-slice abdominal computed tomography (CT) scanning are objective but are gender-dependent body composition measures. The LDCD score may provide a means of generating an objective and lipodystrophy grading/severity scale applicable to both men and women. Total and regional clinical lipodystrophy severity scores (generated using the HIV Outpatient Study [HOPS] scale: nil (0), mild (1), moderate (2), and severe (3) lipoatrophy or fat accumulation in 8 body regions) were correlated with objective measures of LD (LDCD score, DEXA, abdominal CT) and metabolic (lipid, glycemic, acid-base) parameters known to correlate significantly with lipodystrophy severity. Analysis was based on 417 lipodystrophic adults and 371 controls recruited to the HIV LDCD study. Correlation coefficients were used to compare physician and patient assessments (rPhysician, rPatient) with objective LD measures and metabolic parameters. The strongest objective correlate of total clinical lipodystrophy severity was the LDCD score (rPhysician = 0.641 [95% CI, 0.584-0.698]; rPatient = 0.620 [95% CI, 0.561-0.678]), whereas the strongest imaging correlate (trunk:limb fat ratio on DEXA) was significantly lower (rPhysician = 0.483 [95% CI, 0.420-0.546]; rPatient = 0.475 [95% CI, 0.412-0.538]; P < 0.001). The LDCD score also yielded significantly greater correlations with 7 of the 8 metabolic parameters than did clinical lipodystrophy severity scores. Based on quartiles of physician-rated severity, the LDCD scores were categorized to allow for rating of lipodystrophy as absent (LDCD score < 0), grade 1 (0-9.9), grade 2 (10-14.9), grade 3 (15-22.9), and grade 4 (>or=23). In conclusion, the LDCD score is the best objective measure of lipodystrophy severity and, in contrast to DEXA and CT, it is also gender independent. Subjective assessment of lipodystrophy severity could possibly be abandoned in cross-sectional studies. The LDCD score and its derived lipodystrophy grading scale merit prospective evaluation.

Cardiovascular and cerebrovascular events in patients treated for human immunodeficiency virus infection

BACKGROUND

Metabolic abnormalities associated with human immunodeficiency virus (HIV) infection, including dysglycemia and hyperlipidemia, are increasingly prevalent, and there is concern about the possibility of an association with accelerated cardiovascular and cerebrovascular disease.

METHODS

We conducted a retrospective study of the risk of cardiovascular and cerebrovascular disease among the 36,766 patients who received care for HIV infection at Veterans Affairs facilities between January 1993 and June 2001.

RESULTS

For antiretroviral therapy, 70.2 percent of the patients received nucleoside analogues, 41.6 percent received protease inhibitors, and 25.6 percent received nonnucleoside reverse-transcriptase inhibitors for a median of 17 months, 16 months, and 9 months, respectively. Approximately 1000 patients received combination therapy with a protease inhibitor for at least 48 months, and approximately 1000 patients received combination therapy with a nonnucleoside reverse-transcriptase inhibitor for at least 24 months. Between 1995 and 2001, the rate of admissions for cardiovascular or cerebrovascular disease decreased from 1.7 to 0.9 per 100 patient-years, and the rate of death from any cause decreased from 21.3 to 5.0 deaths per 100 patient-years. Patient-level regression analyses indicated that there was no relation between the use of nucleoside analogues, protease inhibitors, or nonnucleoside reverse-transcriptase inhibitors and the hazard of cardiovascular or cerebrovascular events, but the use of antiretroviral drugs was associated with a decreased hazard of death from any cause.

CONCLUSIONS

Use of newer therapies for HIV was associated with a large benefit in terms of mortality that was not diminished by any increase in the rate of cardiovascular or cerebrovascular events or related mortality. Fear of accelerated vascular disease need not compromise antiretroviral therapy over the short term. However, prolonged survival among HIV infected patients means that longer-term observation and analysis are required.