Caution: should we be treating HIV infection early?

HIV Infection: Time from Diagnosis to Initiation of Antiretroviral Therapy in Portugal, a Multicentric Study

The benefits of antiretroviral therapy (ART) for persons living with HIV (PLWH) are well established. Rapid ART initiation can lead to improved clinical outcomes. Portugal has one of the highest rates of new HIV diagnoses in the European Union, and an average time until ART initiation above the recommendations established by the national guideline according to data from the first two years after its implementation in 2015, with no more recent data available after that. This study aimed to evaluate time from the first hospital appointment until ART initiation among newly diagnosed HIV patients in Portugal between 2017 and 2018, to investigate differences between hospitals, and to understand the experience of patient associations in supporting the navigation of PLWH throughout referral and linkage to the therapeutic process. To answer to these objectives, a twofold design was followed: a quantitative approach, with an analysis of records from five Portuguese hospitals, and a qualitative approach, with individual interviews with three representatives of patient associations. Overall, 847 and 840 PLWH initiated ART in 2017 and in 2018, respectively, 21 days (median of the two years) after the first appointment, with nearly half coming outside the mainstream service for hospital referral, and with observed differences between hospitals. In 2017-2018, only 38.0% of PLWH initiated ART in less than 14 days after the first hospital appointment. From the interviews, barriers of administrative and psychosocial nature were identified that may hinder access to ART. Patient associations work to offer a tailored support to patients' navigation within the health system, which can help to reduce or overcome those potential barriers. Indicators related to time until ART initiation can be used to monitor and improve access to specialized care of PLWH.

Longitudinal trends in antiretroviral use in a cohort of men and women in Ontario, Canada

Initial studies have shown impaired access to antiretrovirals and slower adoption of new therapies by women. It is unclear if similar treatment delays still occur, especially in those with a publicly funded health care system in Ontario, Canada. The objectives of this study were (1) to evaluate longitudinal patterns of antiretroviral use in patients with HIV in Ontario and (2) to determine if gender differences exist in access to and uptake of antiretroviral drugs over time. A retrospective medical chart review was undertaken. One hundred four HIV-positive patients were recruited from nine hospital-based HIV outpatient clinics throughout Ontario. From time of study enrollment in 1999-2001 to the first clinic visit (8.1 +/- 3.2 years; range, 2.3-16.8 years), CD4+ T-cell counts, date of and agents used in initial antiretroviral regimen, and first HAART regimen were evaluated by gender. Kaplan-Meier plots were used to evaluate time to drug initiation from known HIV diagnosis. Serial cross sections of numbers and types of antiretroviral drugs prescribed in March, June, September, and December 1988 to 2001 were also compared as was number of regimens used. There were few differences between men and women in antiretroviral use; both initiated therapy within 2.2 +/- 2.3 years of HIV diagnosis at an average CD4 counts of 300.3 +/- 150.1 cells per microliter. Antiretroviral treatment regimens changed over time, with limited variation by gender. In the period immediately surrounding the first highly active antiretroviral therapy (HAART) recommendations by the U.S. Department of Health and Human Services in July 1997, significantly more antiretroviral drugs were prescribed for men than women. Antiretroviral prescribing in patients attending hospital- based HIV outpatient programs in Ontario is consistent with antiretroviral treatment guidelines over time, without substantial differences in antiretroviral access and use by gender.

When to begin highly active antiretroviral therapy? Evidence supporting initiation of therapy at CD4+ lymphocyte counts <350 cells/microL

We assessed the risk of acquired immunodeficiency syndrome (AIDS)-related opportunistic illness or death among persons first prescribed highly active antiretroviral therapy (HAART) in January 1996 or later in the Centers for Disease Control and Prevention's Adult and Adolescent HIV Spectrum of Disease Project. Patients were included if they were naive to antiretroviral drugs and had no history of AIDS-related opportunistic illness. Risk was assessed as a function of CD4+ lymphocyte count and human immunodeficiency virus load at the time of initiation of HAART in a Cox proportional hazards model. Hazard ratios for AIDS or death were 6.3, 3.5, and 1.7 for persons with baseline CD4+ cell counts of 0-49, 50-199, and 200-349 cells/microL, respectively, compared with the referent (CD4+ cell count > or =500 cells/microL). HAART should not be deferred until the CD4+ cell count reaches <200 cells/microL. The increased hazard associated with CD4+ cell counts of 200-349 cells/microL was modest but supports initiation of HAART at CD4+ cell counts <350 cells/microL, particularly in patients with high virus loads.

The chemical bases of the various AIDS epidemics: recreational drugs, anti-viral chemotherapy and malnutrition

In 1981 a new epidemic of about two-dozen heterogeneous diseases began to strike non-randomly growing numbers of male homosexuals and mostly male intravenous drug users in the US and Europe. Assuming immunodeficiency as the common denominator the US Centers for Disease Control (CDC) termed the epidemic, AIDS, for acquired immunodeficiency syndrome. From 1981-1984 leading researchers including those from the CDC proposed that recreational drug use was the cause of AIDS, because of exact correlations and of drug-specific diseases. However, in 1984 US government researchers proposed that a virus, now termed human immunodeficiency virus (HIV), is the cause of the non-random epidemics of the US and Europe but also of a new, sexually random epidemic in Africa. The virus-AIDS hypothesis was instantly accepted, but it is burdened with numerous paradoxes, none of which could be resolved by 2003: Why is there no HIV in most AIDS patients, only antibodies against it? Why would HIV take 10 years from infection to AIDS? Why is AIDS not self-limiting via antiviral immunity? Why is there no vaccine against AIDS? Why is AIDS in the US and Europe not random like other viral epidemics? Why did AIDS not rise and then decline exponentially owing to antiviral immunity like all other viral epidemics? Why is AIDS not contagious? Why would only HIV carriers get AIDS who use either recreational or anti-HIV drugs or are subject to malnutrition? Why is the mortality of HIV-antibody-positives treated with anti-HIV drugs 7-9%, but that of all (mostly untreated) HIV-positives globally is only 1.4%? Here we propose that AIDS is a collection of chemical epidemics, caused by recreational drugs, anti-HIV drugs, and malnutrition. According to this hypothesis AIDS is not contagious, not immunogenic, not treatable by vaccines or antiviral drugs, and HIV is just a passenger virus. The hypothesis explains why AIDS epidemics strike non-randomly if caused by drugs and randomly if caused by malnutrition, why they manifest in drug- and malnutrition-specific diseases, and why they are not self-limiting via anti-viral immunity. The hypothesis predicts AIDS prevention by adequate nutrition and abstaining from drugs, and even cures by treating AIDS diseases with proven medications.

Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence

OBJECTIVE

To assess the repercussion of late diagnosis of HIV infection on AIDS incidence in the era of highly active antiretroviral therapy.

DESIGN

Analysis of AIDS surveillance data.

SETTING

Spain.

PATIENTS

AIDS cases reported from 1994 though 2000.

MAIN OUTCOME MEASURES

Late testers were defined as persons who had a first positive HIV test in the month of or immediately preceding AIDS diagnosis. Their incidence trend was compared against that for the remaining cases, and the influence of demographic factors evaluated.

RESULTS

Of 30 778 AIDS cases, 8499 (28%) were late testers, and of these, 1061 (12%) died within 3 months of diagnosis of HIV infection. From 1995 to 2000, AIDS diagnoses declined by 36% among late testers versus 67% for the remainder (P < 0.001). The percentage of late testers increased from 24% in 1994-1996 to 35% in 1998-2000 (P < 0.001). Among the 7825 AIDS cases diagnosed in 1998-2000, late testing was independently associated (P < 0.01) with male sex, age over 44 years, residence in provinces with a lower AIDS incidence, foreign origin, and no record of injecting drug use or prison stay.

CONCLUSIONS

A growing proportion of AIDS cases involves late diagnosis of HIV infection. Persons who are unaware of their HIV infection cannot benefit from antiretroviral therapy and, hence, early diagnosis would strengthen the impact of such therapy and so reduce AIDS incidence.

Early and late effects of highly active antiretroviral therapy: a 2 year follow-up of antiviral-treated and antiviral-naive chronically HIV-infected patients

BACKGROUND

Control of HIV replication can be observed in highly active antiretroviral therapy (HAART)-treated and, occasionally, in HAART-naive patients. The immunological correlates of these situations were examined in a longitudinal study.

DESIGN

A prospective study. Immunovirological analyses in 16 chronically HIV-infected, HAART-naive patients (time 0) who started HAART. Fifteen patients (short-term HAART) were re-evaluated after 24 months (time 1). Results were compared with those of 30 patients who received HAART for more than 12 months before the study period (long-term HAART) and were analysed at the same timepoints. Fifteen patients who were antiviral therapy naive (naive) at both timepoints were also studied.

RESULTS

Over a 24-month period CD4 and CD8 cell counts and viraemia remained unchanged in naive and long-term HAART patients; CD4 cell counts increased and viraemia diminished in short-term HAART individuals. Antigen-stimulated proliferation was unmodified in naive and short-term HAART patients, but improved in long-term HAART individuals. Gp160-stimulated IL-2 and IFN-gamma production was augmented in long-term HAART patients and marginally modified in other patients. IL-7 production was unmodified in naive individuals, augmented in short-term HAART patients, and diminished in long-term HAART patients. Chemokine production was similar in all patients. Naive patients showed the highest CD8 cell counts at both timepoints.

CONCLUSION

HAART has a major impact on the outcome of HIV infection, even if functional immune modulation in HAART-treated patients is evident only after long periods of therapy. Low but detectable HIV replication in HAART-naive patients with preserved immune functions might not be associated with CD4 cell reduction, functional immune defects, or changes in viraemia.

Antiretroviral therapy in HIV-infected individuals in clinical practice: are the criteria for initiating and choosing the type of drug regimen based only on immunologic and virologic values?

OBJECTIVES

To determine factors associated with beginning antiretroviral therapy and with the number of drugs used.

METHODS

Longitudinal study of 3169 HIV-infected individuals naïve from antiretroviral drugs at enrollment in 65 infectious disease clinics in Italy. Initiation of antiretroviral therapy and number of drugs used (i.e., < 3 vs. > or = 3 drugs) were the main outcome measures. Adjusted odds ratios were calculated by logistic models to establish cofactors of these two measures.

RESULTS

From January 1997 to December 1998, 1288 (40.6%) individuals started therapy, 58.0% of whom were given a triple combination regimen. This regimen became more frequent over time. By multivariate analysis, high levels of HIV-RNA and low CD4 counts were the most important independent predictors of starting any type of therapy. A significant association was also found with HIV exposure category, reason for being antiretroviral-naïve, presence/absence of liver disease, presence/absence of a new AIDS-defining disease, and clinical centre. High levels of HIV-RNA and low CD4 counts were also the most important predictors of starting with > or = 3 drugs, compared to < 3 drugs, and men had an independent higher probability of starting with > or = 3 drugs, compared to women. The probability of starting with > or = 3 drugs significantly increased with calendar time.

CONCLUSIONS

CD4 and HIV-RNA were the main cofactors of initiating both any type of therapy and therapy with > or = 3 drugs. The large variability among clinical centres suggests that clinicians are uncertain as to the exact timing of beginning therapy and the specific regimen, especially among women.

Five year follow up of vertically HIV infected children in a randomised double blind controlled trial of immediate versus deferred zidovudine: the PENTA 1 trial

A total of 195 children were randomised to zidovudine (immediate) or matching placebo (deferred) in a multicentre double blind trial in vertically HIV infected children with early disease (the PENTA 1 trial). Median follow up in the blinded phase was 1.9 years. Thereafter, individual children were unblinded following the results of adult trials showing a benefit of combination antiretroviral therapy (ART) over monotherapy, but follow up continued and is reported here until December 1998 (total follow up 4.6 years). Median time to starting ART in the deferred group was 2.7 years; 19% of deferred children had not started ART by 1999. Throughout follow up, the percentage of time spent on no ART, monotherapy, dual, and triple ART was 21%, 44%, 29%, and 6% respectively for immediate and 62%, 12%, 18%, and 8% for deferred groups. During the blinded phase eight (7.8%) immediate and 12 (13.3%) deferred children developed AIDS or died (log rank p = 0.24); overall 21 immediate and 20 deferred children progressed. In an analysis including all children regardless of original allocation, the risk of progression to AIDS or death, adjusting for age and time since trial entry was significantly lower during 1997-98 (2.4 per 100 child years) than during 1992-96 (6.6 per 100 child years), most likely a result of increased use of combination ART.

HIV-1 transmission and acute HIV-1 infection

An understanding of the central events in the transmission of HIV-1 infection is critical to the development of effective strategies to prevent infection. Although the main routes of transmission have been known for some time, surprisingly little is known about the factors that influence the likelihood of transmitting or acquiring HIV-1 infection. Once infection has taken place, the series of virological and immunopathological events that constitute primary HIV-1 infection are thought to be closely linked with the subsequent clinical course of the infected person. Recent studies have provided some support for the notion that intervention with aggressive anti-retroviral drug therapy at this stage has the potential to prevent some of the damage to the immune system that will otherwise develop in the vast majority of infected people.

Immunological and virological responses in HIV-1-infected adults at early stage of established infection treated with highly active antiretroviral therapy

OBJECTIVE

To evaluate the immunological and virological responses to highly active antiretroviral therapy (HAART) in blood and lymphoid compartments of HIV-1-infected patients at an early stage of infection.

DESIGN

An open-label, observational, non-randomized, prospective trial of outpatients attending the Centre of Clinical Investigation in Infectious Diseases, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Switzerland.

SUBJECTS

Forty-one antiretroviral-naive HIV-1-infected adults with 400 CD4 T cells/microl or greater and 5000 plasma HIV-1-RNA copies/ml or greater were enrolled, and 32 finished the study. Forty-nine HIV-negative individuals were included as controls. All subjects gave written informed consent.

INTERVENTIONS

All patients received abacavir 300 mg by mouth every 12 h and amprenavir 1200 mg by mouth every 12 h for 72 weeks.

MAIN OUTCOME MEASURES

The extent of immune reconstitution in blood and lymph nodes after 72 weeks of HAART was evaluated, and compared with immunological measures of 49 HIV-negative subjects.

RESULTS

Virus replication was effectively suppressed (-3.5 log10 at week 72). Substantial increments of CD4 T cell count in blood and percentage in lymph nodes were observed over time, and these measures were comparable to HIV-negative subjects by week 24 in blood and by week 48 in lymph nodes. The increase was equally distributed between naive and memory CD4 T cells. Recovery of HIV-specific CD4 responses occurred in 40% of patients.

CONCLUSION

The initiation of HAART at an early stage of established HIV infection induces systemic quantitative normalization of CD4 T cells, a partial recovery of HIV-specific CD4 cell responses, and effective and durable suppression of virus replication.

Immunological benefits of antiretroviral therapy in very early stages of asymptomatic chronic HIV-1 infection

OBJECTIVES

To assess whether an almost complete restoration of immune system can be achieved when antiretroviral therapy is initiated at very early stages of asymptomatic chronic HIV-1 infection.

DESIGN

T cell subsets and cell-mediated responses were analysed at baseline and after 12 months of either a double or a triple antiretroviral therapy in 26 asymptomatic HIV-1-infected patients with CD4 T cell counts > 500 x 10(6) cells/l and a baseline plasma viral load > 10000 copies/ml.

RESULTS

Triple therapy was significantly more effective in reducing plasma HIV RNA to undetectable levels, in returning CD4:CD8 ratio to nearly normal levels, in reducing activated cells (CD38) and in increasing naive (CD45RA+CD45RO-) and memory (CD45RA-CD45RO+) CD4 cells. Both double and triple therapies caused a clear decrease in memory (CD45RA-CD45RO+) CD8 cells as well as a significant increase in the CD28 subset of CD8 cells. At baseline, there was an important increase in cells producing interferon-gamma (IFNgamma) with no significant abnormalities in T lymphocytes producing interleukin 2 (IL-2), tumour necrosis factor alpha and interleukin 4. Both types of therapy reduced IFNgamma- and IL2-producing CD4 T lymphocytes while IFNgamma-producing CD8 cells remained increased. Even before therapy, these HIV-1-positive patients lacked significant abnormalities in the T cell responsiveness to polyclonal stimuli as well as in the secretion of CCR5 chemokines by peripheral blood mononuclear cells.

CONCLUSIONS

Initiating highly active antiretroviral therapy at very early stages of chronic HIV-1 infection allows rapid and almost complete normalization of T cell subsets and preservation of T cell functions. These early-treated patients could be excellent candidates for receiving additional HIV-specific immune-based therapies, which might be essential for the control of HIV infection.

Prevalence of drug resistant mutants and virological response to combination therapy in patients with primary HIV-1 infection

Baseline genotype resistance analysis was carried out in 48 adults with primary HIV-1 infection between 1995 and 1998 before starting early combination therapy. Seventeen percent (8/48) of the isolates displayed key mutations conferring resistance to reverse transcriptase (RT) inhibitors such as amino acid substitutions 215Y/F (5/48,10%), 70R (3/48, 6%), 184V (2%). Two percent (1/48) had a major mutation associated with resistance to protease inhibitors (D30N). Other mutations at positions 10, 15, 20, 33, 36, 46, 63, 71, 77, 82, 93 of the protease gene were frequent (73%). Among the 46 patients who were given antiretroviral combination therapy and who responded durably to treatment after 6 and 12 months, there was no significant difference between those harboring RT mutant strains (Group I) and those with wild-type isolates (Group II). No significant difference was found at months 6 and 12 between the two groups in terms of CD4+ cell counts. These findings suggest that the presence of drug-resistant strains at the time of primary HIV-1 infection does not necessarily predict drug failure. Other factors, such as adherence to treatment, tolerance and pharmacokinetics parameters are probably major determinants of virological response in patients with early therapeutic intervention.

Dual nucleoside regimens in nonadvanced HIV infection: prospective follow-up of 130 patients, Aquitaine Cohort, 1996 to 1998. Groupe d'Epidémiologie Clinique du SIDA en Aquitaine (GECSA)

OBJECTIVE

To describe the response to combinations of two nucleoside reverse transcriptase inhibitors (NRTIs) initiated early in the course of HIV infection under routine circumstances and to research prognostic factors indicating good virologic response.

SETTING

Patients of the Aquitaine Cohort, a hospital-based open cohort that had been recruiting since 1987 in five public hospitals of the Aquitaine region in southwestern France.

METHODS

Prospective cohort study of antiretroviral-naive patients with CD4+ cell counts >0.350 x 10(9)/L who started dual NRTI therapy between January 1996 and June 1997. Intent-to-treat analysis and multivariate logistic regression were used with data collected up to March 31, 1998.

RESULTS

In this study, 130 patients were enrolled with a median follow-up of 14 months. At the time of first prescription, 79% were in U. S. Centers for Disease Control and Prevention (CDC) group A, 16% in group B, and 5% in group C; median CD4+ cell count was 0.466 x 10(9)/L and median HIV RNA level was 4.52 log10 copies/ml. The two main combinations used were zidovudine (AZT) plus zalcitabine (ddC; 38%) and AZT plus didanosine (ddI; 37%). At week 52, median CD4+ and HIV RNA responses were, respectively, +80 cells and -1.6 log; the proportions of patients with HIV RNA level <5000 and <500 copies/ml were 70% and 45%, respectively, and 96% of the patients had a CD4+ cell count >0.350 x 10(9)/L at that time. At their last follow-up, 3 patients had reached been diagnosed with full-blown AIDS and the AIDS-free survival probability at 1 year was 98.2% (95% confidence interval [CI], 93.1-99.6); 1 death had occurred. The only significant variable associated with an undetectable HIV RNA level at 1 year was a lower HIV RNA level at the first prescription of dual therapy.

CONCLUSION

Our data indicate that dual nucleoside combinations could be a therapeutic option for patients diagnosed and observed during follow-up in the early course of HIV infection.

The case for more cautious, patient-focused antiretroviral therapy

Many clinicians who care for patients with HIV infection are dissatisfied with the existing recommendations on antiretroviral therapy. Current practice focuses on the early suppression of viremia, yet the outcome of that approach may not be in the best interest of individual patients or populations. The major goal of HIV therapy is to maintain the long-term health of the patient while avoiding drug-related toxicity and preserving viable future treatment options. Recent studies have challenged the principles on which recommendations for early, aggressive treatment were based. Key studies that lead to licensure of antiretroviral medications usually involve short-term results in treatment-naive patients; it is difficult to apply these results to long-term management of therapy-experienced patients. Early, aggressive therapy often prematurely exposes patients to risks for medication-related side effects and resistance. A more cautious, patient-focused, long-term approach to therapy would help foster studies of alternate strategies, such as delayed initiation of therapy, protease-sparing therapy, class-sparing therapy, planned drug interruptions, switches in therapy, and immune-based therapy. It is time for clinicians to rethink their approach to the treatment of HIV infection.

The number of HIV DNA-infected mononuclear cells is reduced under HAART plus recombinant IL-2. IRHAN Study Group

It is common opinion that, in addition to potent antiretroviral regimens which effectively reduce plasma viremia, new strategies should be developed to ensure the reduction of cell-associated HIV DNA load together with HIV RNA plasma levels. The present study explored whether the number of provirus-infected cells can be reduced by combined antiviral and immunomodulatory regimens. Thus, 14 naive patients (with CD4 > 400/microl and plasma HIV RNA copies > 5000/ml) were randomly assigned to receive highly active antiretroviral therapy (HAART) alone or HAART plus rIL-2. Plasma viremia (measured by a commercial RT-PCR assay) and the number of provirus-infected cells (measured by an endpoint cell dilution PCR assay) were monitored at the enrollment and after 12 weeks of treatment. The results indicate that while HAART and HAART plus rIL-2 are both able to significantly reduce plasma viremia after 12 weeks of treatment, a significant reduction of the number of provirus-infected cells can be achieved only by treatment with HAART plus rIL-2.

Different immunologic profiles characterize HIV infection in highly active antiretroviral therapy-treated and antiretroviral-naïve patients with undetectable viraemia. The Master Group

BACKGROUND

Suppression of human immunodeficiency virus (HIV) replication can be obtained in chronically infected individuals by highly active antiretroviral therapy (HAART) and can also be observed in antiretroviral-naïve patients. The immunological correlates of these two situations were examined.

DESIGN AND METHODS

Cross-sectional study involving 32 HIV-infected patients with undetectable HIV plasma viraemia (< 500 copies/ml) and either antiretroviral-naive (n = 14) or undergoing HAART therapy with two nucleoside reverse transcriptase inhibitors (NRTI) plus one (n = 13) or two (n = 5) protease inhibitors (PI). CD4 counts, disease duration, and CDC clinical stage were comparable between the two groups of individuals. Immune parameters (antigen- and mitogen-stimulated proliferation and cytokine production; cytokine mRNA; beta chemokine production; HIV coreceptors mRNA) were analysed in all patients.

RESULTS

Results showed immune profiles to be profoundly different in antiretroviral-naive in comparison with HAART-treated patients. Thus: (1) T-cell proliferation to HIV-specific and HIV-unrelated antigens is potent in antiretroviral-naive but suppressed in HAART-treated individuals; (2) interleukin-(IL)2, IL-12 and interferon gamma (IFNgamma) production is robust in naive patients; and (3) a high CCR5/low CXCR4 pattern of HIV coreceptors-specific mRNA is observed in naive but not in HAART-treated patients. In contrast with these observations, no clear differences were detected when beta chemokine production by either peripheral blood mononuclear cells or purified CD8+ T-cells was analysed. Results from HAART-treated patients undergoing therapy with one PI and two NRTI or two PI and two NRTI were in very close agreement.

CONCLUSIONS

These data suggest that control over HIV replication can be independently achieved by pharmacological or immunologic means. HAART is associated with weaker HIV-specific and -non-specific immune responses.

Effects of early antiretroviral treatment on HIV-1 RNA in blood and lymphoid tissue: a randomized trial of double versus triple therapy. Swiss HIV Cohort Study

To assess the effects of early initiation of antiretroviral therapy on cell-free and cell-associated viral load in blood and lymphoid tissue, we performed a randomized, open-label, multicenter trial comparing a double (zidovudine + lamivudine) and triple (zidovudine + lamivudine + ritonavir) drug combination in treatment-naive, asymptomatic patients with CD4 counts >400 cells/microl. HIV-1 RNA was measured in plasma, peripheral blood mononuclear cells, and sequential tonsil or lymph node biopsies (27 patients); the study follow-up was 2 years. Among 42 randomized patients, the proportion with plasma HIV-1 RNA <50 copies/ml was 16% and 74% at week 24 (p<.001) in those randomized to double and triple therapy, respectively, necessitating frequent treatment intensification in the double arm. After a rapid decline within 4 weeks in both arms, cell-associated HIV-1 RNA decreased further only in those patients with sustained suppression of plasma viral load, but remained almost always detectable at low levels, indicating persisting transcription of viral RNA. CD4 counts increased by 200 to 250 cells/microl at week 96 in both arms without significant differences (intent-to-treat analyses). Thus, even if treatment is initiated early in asymptomatic patients with preserved CD4 counts, three drugs are necessary to achieve sustained decreases of HIV load in blood and lymphoid tissue.

Intravenous drug use, relationship with providers, and stage of HIV disease influence the prescription rates of protease inhibitors

OBJECTIVE

To assess rates of prescriptions of protease inhibitors (PI) and determinants of not being prescribed PIs in a cohort of HIV-infected people eligible (according to published guidelines) for highly active antiretroviral therapy (HAART).

DESIGN

Cross-sectional survey.

METHODS

A total of 684 patients with CD4+ counts <500 cells/microl were enrolled from seven Italian HIV treatment centers from October 1997 to April 1998. A questionnaire on health-related quality of life (MOS-HIV) and patient ratings of the quality of care was administered. Sociodemographic variables, HIV disease-related factors, and prescribed antiretroviral therapy were also recorded.

RESULTS

61% of those enrolled were prescribed PI (median, 7.5 months). In addition, 75% of patients had previously received antiretroviral therapy. Fewer than 1% were prescribed nonnucleoside reverse transcriptase inhibitors (NNRTIs). Using multivariable logistic regression considering those with CD4+ counts <500 cells/microl, patients reporting the least information received (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.23-2.58), injecting drug users (IDUs; OR, 1.73; 95% CI, 1.18-2.54), people with CD4+ counts >200 cells/microl (OR, 1.76; 95% CI, 1.19-2.61), and patients with early stage disease (OR, 2.24; 95% CI, 1.73-2.90) were less likely to have be prescribed PIs.

CONCLUSIONS

Of patients eligible for HAART, only 61% were prescribed PIs. People who wanted more information, IDUs, and patients in earlier disease stages are significantly less likely to be prescribed PIs. Access to HAART remains a critical issue in the management of HIV disease.

HIV epidemiology and treatment - 1999

Potent antiretroviral treatment has led to a dramatic decrease in HIV-associated morbidity and mortality. This paper reviews (1) current recommendations for the initiation of antiretroviral therapy, (2) the natural history of HIV infection after initiation of treatment, and (3) toxicity and resistance issues.

Hydroxyurea and didanosine long-term treatment prevents HIV breakthrough and normalizes immune parameters

Hydroxyurea and didanosine treatment suppressed HIV replication for more than 2 years, in the absence of viral breakthrough, in chronically infected patients. The profile of viral load reduction was unusual for a two-drug combination, since a continuous gradual decrease in viremia persisted despite residual viral replication. The increase in CD4+ T cell counts was not robust. However, unlike those of patients treated by other therapies, CD4+ T lymphocytes were functionally competent against HIV, mediating a vigorous HIV-specific helper T cell response in half of these patients. In addition, the percentages of naive CD4+ and CD8+ T lymphocytes were not different from those in uninfected individuals. These results demonstrate that prolonged antiretroviral therapy with a simple, well-tolerated combination of two affordable drugs can lead to sustained control of HIV, normalization of immune parameters, and specific anti-HIV immune response.

Apoptosis and HIV infection: T-cells fiddle while the immune system burns

Enhancement of programmed cell death (apoptosis) of CD4 T-cells by human immunodeficiency virus (HIV) is thought to be an important factor in the pathogenesis of HIV disease. Recent studies have cast doubt on this concept, however, portraying apoptosis as a potent antiviral strategy to eliminate infected cells. These studies have shed new light on the role of apoptosis in HIV infection. While cellular and immunologic mechanisms of apoptosis purge the HIV-infected lymphoid cell population, HIV thwarts apoptosis in myeloid cells, particularly monocyte/macrophages. Although HIV protease inhibitor therapy partially reverses the lymphoid cell process, this therapeutic approach fails to counter the persistence of HIV infection in myeloid cells. Thus apoptosis of T-cells may be a futile host attempt to control the spread of HIV while the infection smoulders in monocyte/macrophages. In other words, the antiviral defense system fiddles while the immune system burns.

Pooling research results: benefits and limitations of meta-analysis

BACKGROUND

Meta-analysis, the systematic and quantitative synthesis of evidence, has developed considerably in the 1990s and is emerging as an important methodology in medical decision making. As a research methodology, meta-analysis has benefits and limitations that must be acknowledged in its application.

EXAMPLES OF BENEFITS

The benefits of meta-analysis include the ability to improve the power of small or inconclusive studies to answer questions and the ability to identify sources of diversity across various types of studies. Meta-analysis may reveal how heterogeneity among populations affects the effectiveness of medical interventions in different settings and in different patients. It can also help detect biases, such as publication bias and "Tower of Babel" bias, as well as deficiencies in the design, conduct, analysis, and interpretation of research. In this way, it can also stimulate improvements in the quality of the data needed to optimize medical care.

EXAMPLES OF LIMITATIONS

Meta-analysis cannot improve the quality or reporting of the original studies. Other limitations come from misapplications of the method, such as when study diversity is ignored or mishandled in the analysis or when the variability of patient populations, the quality of the data, and the potential for underlying biases are not addressed.

CONCLUSIONS

Meta-analysis has promoted the sense that obtaining evidence is a global enterprise and that complete information needs to be evaluated and synthesized to obtain the most unbiased results. Analyzing sources of bias and diversity is essential to performing, understanding, and using meta-analyses in medical care.

Clinical progression and virological failure on highly active antiretroviral therapy in HIV-1 patients: a prospective cohort study. Swiss HIV Cohort Study

BACKGROUND

The efficacy of highly active antiretroviral therapy (HAART) in suppression of HIV-1 is well documented. We investigated virological and clinical outcomes of HAART in routine practice.

METHODS

We analysed prospective data from the Swiss HIV Cohort Study on suppression of viral load and progression to AIDS or death in 2674 outpatients (median age 36 years, 27.3% women) who started HAART in 1995-98. Viral rebound was defined as two consecutive HIV-1-RNA measurements of more than 400 copies/mL. We analysed separately outcomes in patients with a history of antiretroviral treatment and in treatment-naïve patients.

FINDINGS

An estimated 90.7% of treatment-naïve patients reached undetectable viral load (<400 copies/mL) by 12 months. Among pretreated patients, estimates ranged from 70.3% treated with one new drug to 78.7% on three new drugs. 2 years after reaching undetectable concentrations, an estimated 20.1% of treatment-naïve patients and 35.7-40.1% of pretreated patients had viral rebound. At 30 months, an estimated 6.6% (95% CI 4.6-8.6) of patients who had maintained undetectable concentrations, 9.0% (5.5-12.5) who had viral rebound, and 20.1% (15.3-24.9) who had never reached undetectable concentrations developed AIDS or died. Compared with patients who maintained undetectable viral load, the adjusted relative hazard of AIDS or death was 1.00 (0.66-1.55) for patients with viral rebound, and 2.40 (1.72-3.33) for patients who failed to reach undetectable concentrations.

INTERPRETATION

The rate of virological failure of HAART was high among these patients, but the probability of clinical progression was low even in patients with viral rebound.