Response of severe HIV-associated thrombocytopenia to highly active antiretroviral therapy including protease inhibitors

Challenges in Platelet Functions in HIV/AIDS Management

The interest in platelet functions in HIV/AIDS is due to the high incidence of microvascular thrombosis in these individuals. A lot of laboratory data have been generated regarding platelet functions in this population. The tests demonstrate platelet hyperactivity but decreased aggregation, though results are inconsistent depending on the study design. Antiretroviral treatments currently in use display complex interactions. Many studies on platelet functions in these patients have been for research purposes, but none have found utility in guiding drug treatment of thrombosis.

The global prevalence of thrombocytopenia among HIV-infected adults: A systematic review and meta-analysis

BACKGROUND

Thrombocytopenia is the second most frequent complication of human immunodeficiency virus (HIV) infection, occurring in about 4-40% of HIV-infected patients. This study aimed to determine the global prevalence of thrombocytopenia among HIV/AIDS adults and its association with highly active antiretroviral therapy (HAART).

METHOD

This systematic review and meta-analysis was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Joana Brigg's Institute (JBI) critical appraisal checklist was used for quality appraisal of the included articles. A random-effect model was fitted to calculate the pooled estimates using STATA version-11. A sub-group analysis and sensitivity analysis were carried out to determine the potential source of heterogeneity.

RESULT

Of the 1823 articles that were retrieved, 20 full-text articles were eligible for meta-analysis. The overall pooled prevalence of thrombocytopenia among HIV-infected adults was 17.9% (95% CI: 14.69, 21.12) I² = 96.4%. The pooled prevalence of thrombocytopenia was 21.00% (95% CI: 17.35, 24.65) and 11.64% (95% CI: 6.66, 16.62), before and after initiation of HAART, respectively.

CONCLUSION

Thrombocytopenia is a common comorbidity in HIV patients and HAART was significantly associated with reduced thrombocytopenia. Therefore, prompt start of HAART might help to decrease the prevalence of thrombocytopenia and its subsequent complications.

Successful Use of Eltrombopag in a Pediatric Patient With Human Immunodeficiency Virus (HIV)–Associated Thrombocytopenia

Thrombocytopenia and other hematologic manifestations related to HIV are not uncommon. Treatment of HIV-related thrombocytopenia is challenging: treatment options are not effective in all patients, or less well studied, particularly in the pediatric population. We aim to present and discuss the case of a 13-year-old with HIV and persistent thrombocytopenia who, after failing monthly IVIG infusions, showed normalization of platelet count on the novel thrombopoietin receptor agonist, eltrombopag. A retrospective chart review of the case patient's medical record was conducted. Additionally, a thorough literature review was performed on this topic, including the pathophysiology of underlying HIV-related thrombocytopenia and its treatment modalities. The patient was treated initially with monthly IVIG infusions for about 1 year but did not show a sustained response, particularly in between infusions. After initiation with eltrombopag 50 mg daily, the patient showed a sustained increase in his platelet count. During a brief lapse in eltrombopag treatment, his platelet count dropped, which then increased upon his reinitiation of therapy. He has continued to show a sustained platelet response and has not been symptomatic or required IVIG for more than 1 year. To our knowledge, this is the first report of a pediatric patient with HIV-related thrombocytopenia who has benefited from the use of eltrombopag.

Prevalence of thrombocytopenia before and after initiation of HAART among HIV infected patients at black lion specialized hospital, Addis Ababa, Ethiopia: a cross sectional study

Background

Hematological abnormalities are common in HIV positive patients. Of these, thrombocytopenia is a known complication which has been associated with a variety of bleeding disorders. However, its magnitude and related factors have not been well-characterized in the era of highly active antiretroviral therapy (HAART) in Ethiopia. Therefore, this study aimed to assess the prevalence of thrombocytopenia before and after initiation of HAART among HIV positive patients attending Black Lion Specialized Hospital, Addis Ababa, Ethiopia.

Methods

A cross sectional study was conducted from February to April 2017 in Black Lion Specialized Hospital, Addis Ababa, Ethiopia. A total of 176 patients on HAART were selected using simple random sampling techniques. Socio-demographic and clinical characteristics of the study patients were collected using structured questionnaire. Measurements of platelet counts and CD4 + T cell counts were made using Sysmex XT 2000i hematology analyzer and BD FACS Count CD4 analyzer, respectively. Statistical analysis of the data (Paired T- test and binary logistic regression) was done using SPSS version 20. P-value < 0.05 was considered as statistically significant.

Results

A total of 176 patients (Age > 18 years old) were enrolled in this study and had a mean age of 40.08 ± 9.38 years. There was significant increase in the mean values of platelet counts (218.44 ± 106.6 × 10³/μl vs 273.65 ± 83.8 × 10³/μl, p < 0.001) after six months of HAART initiation compared to the baseline. Prevalence of thrombocytopenia before and after HAART initiation was 25 and 5.7% respectively. HIV patients whose CD4 counts < 200 Cells/μl were more likely to have thrombocytopenia than HIV patients whose CD4 count ≥350 Cells/μl. However, it was not statistically associated with prevalence of thrombocytopenia.

Conclusions

This study has shown that the prevalence of thrombocytopenia after HAART initiation was decreased significantly. Based on our results, a number of study participants still had thrombocytopenia after initiation of HAART. Therefore, continuous screening for thrombocytopenia among HIV infected patients should be performed to decrease the risk of morbidity and mortality.

Electronic supplementary material

The online version of this article (10.1186/s12878-018-0103-6) contains supplementary material, which is available to authorized users.

Impact of the highly active antiretroviral therapy era on the epidemiology of primary HIV-associated thrombocytopenia

BACKGROUND

Primary HIV-associated thrombocytopenia (PHAT) typically improves with highly active antiretroviral therapy (HAART); however, cases continue to occur. Data comparing the epidemiology of PHAT between the pre-HAART and HAART eras are limited. We retrospectively examined the incidence of PHAT over 28 years in the US Military HIV Natural History Study (NHS) from 1986 to 2013.

RESULTS

Subjects had a nadir platelet count <100 × 10(9)/l with no other identifiable cause. Time periods were categorized as pre-HAART (1986-1995), early HAART (1996-2001), and later HAART (2002-2013). Incidence, demographic data, and CD4 count were compared across the three eras. A generalized estimating equations model was used to assess any association of platelet count and HIV viral load in cases diagnosed during the HAART eras. 218 participants met the case definition. 86.2 % of cases occurred prior to 2002. The incidence of PHAT per 1000 person-years of follow-up was 16.3, 4.6, and 1.9 during pre-HAART, early HAART and later HAART eras respectively. CD4 cell counts were significantly higher in the HAART eras at the time of thrombocytopenia (p < 0.001). Of patients diagnosed after 1996, 96.4 % were viremic within six months preceding the platelet nadir and over half were antiretroviral naïve. Viral load (per log10 copies/ml) inversely correlated with platelet count throughout the HAART eras (p < 0.0001).

CONCLUSIONS

The incidence of PHAT has markedly decreased in the HAART era. However, viremic individuals, including those with healthy CD4 cell counts, may be at risk. Achieving viral suppression as early as possible may decrease the incidence further.

Changes in the incidence of severe thrombocytopenia and its predisposing conditions in HIV-infected patients since the introduction of highly active antiretroviral therapy

BACKGROUND

Severe thrombocytopenia (TCP, platelets <50 × 10⁹/L) is relatively frequent during HIV infection and is associated with bleeding risk and disease progression. We investigated the changes in the incidence of severe TCP and its predisposing conditions in a cohort of HIV-positive subjects.

METHODS

The incidence and predictors of platelet counts <50 × 10⁹/L were investigated in all patients enrolled at our institution between 1985 and 2012. Three different periods were considered on the basis of the available antiretroviral regimens: P1 (1985-1989), P2 (1990-1996), and P3 (1997-2012). Incidence rates were assessed using Poisson regression models and the predictors by means of Cox regression.

RESULTS

The study involved 5137 patients with platelet counts >50 × 10⁹/L at enrollment. Severe TCP occurred in 597 subjects, and its incidence decreased over time. The incidence decreased in patients with opportunistic diseases and malignancies but increased in patients with chronic liver disease; TCP unrelated to any cause other than HIV infection remained stable. Multivariate analysis showed that injected drug use, a diagnosis of AIDS, low CD4⁺ cell counts, increased serum alanine aminotransferase levels, and an earlier year of enrollment were predictors of an increased risk of severe TCP, whereas the use of highly active antiretroviral therapy (HAART) was associated with a reduced risk.

CONCLUSIONS

A considerable reduction in the incidence of severe TCP after the introduction of HAART was found, probably because of its ability to limit bone marrow damage induced by uncontrolled HIV replication and opportunistic infections. On the contrary, HAART may have a reduced impact on TCP related to chronic liver disease.

Immune thrombocytopaenic purpura: an autoimmune cross-link between infections and vaccines

Immune thrombocytopaenic purpura (ITP) is an autoimmune systemic disease detectable by the presence of low blood platelets count (<10(5)/µl) and the production of autoantibodies against glycoproteins expressed on the platelet surface. The clinical course is often acute, and life-threatening events may occur especially in children, with 52% of paediatric patients recovering either spontaneously or after treatment. A chronic ITP evolution is observed in 64% of adults, of whom 12% will develop an overlapping autoimmune disease. Several microbial agents such as CagA-positive Helicobacter pylori or Candida albicans and a number of viruses including CMV, EBV or HIV can potentially trigger ITP through molecular mimicry. Moreover, ITP improves after treatment of the underlying infection. Similarly, vaccines such as MMR may prompt ITP (IRR 5.48, 1.61-18.64, p < 0.006). Early recognition of the underlying microbial trigger and the removal of modifiable aetiopathogenetic factors should be integrated as a complementary treatment strategy in all patients who do not readily improve with standard ITP care.

Autoimmune diseases in HIV-infected patients: 52 cases and literature review

OBJECTIVES

1) To describe autoimmune diseases (AD) in HIV-infected people; and 2) to perform a literature review concerning this issue.

DESIGN

52 HIV-infected patients that presented an AD in 14 medical departments in Paris and Ile-de-France area were retrospectively included in this study.

RESULTS

The ADs were vasculitis (11), immune cytopenias (8), rheumatic diseases (8), lupus (7), sarcoidosis (7), thyroid diseases (6), hepatic diseases (5), and antiphospholipid syndrome (4). Four patients presented 2 ADs. In 5 patients the AD preceded HIV infection, in 14 HIV infection was diagnosed at the same time as the AD and 34 were HIV-infected when they developed an AD. 40 ADs (80%) occurred in patients with a CD4 T lymphocyte count of more than 200/mm(3). Cases of autoimmune hemolytic anemia occurred only in patients severely immunodepressed. In five patients (a vasculitis case, a sarcoidosis case, three thyroid disease cases) the AD presented as a form of immune restoration inflammatory syndrome (IRIS). Some ADs allowed HIV-infection diagnosis at a stage of moderate immune deficiency (vasculitis, antiphospholipid syndrome, immune thrombocytopenia). 37 patients received immunosuppressant treatments with good tolerance. These results confirm in a large series of patients previous data concerning autoimmune diseases occurrence in HIV-infected people.

CONCLUSION

In the HAART era, when HIV-infected people are treated more and more early, autoimmune diseases can occur, mainly at the phase of immunological recovery. HIV infection should not limit immunosuppressant treatment use.

Immature platelet fraction levels in a variety of bone marrow pathologies in South African HIV-positive patients with thrombocytopenia

OBJECTIVES

Thrombocytopenia is common in HIV-infected individuals and often requires a diagnostic bone marrow examination. Interpretation may, however, be limited due to the multifactorial nature of HIV-associated thrombocytopenia and the difficulty in assessing megakaryocyte function morphologically. The immature platelet fraction (IPF) is a parameter which reportedly reflects megakaryocyte activity, with an IPF >7.7% suggesting increased platelet production. The aim of this study was to correlate the IPF with the bone marrow findings as well as other clinical variables of interest in South African patients with HIV-associated thrombocytopenia.

METHODS

Seventy-eight HIV-positive patients with thrombocytopenia were enrolled from the Charlotte Maxeke Johannesburg Academic Hospital. The IPF levels were measured using a Sysmex XE-5000 haematology analyzer and were correlated with bone marrow and other findings.

RESULTS

The median IPF was 7.6%, ranging from 1.3 to 44%. It was raised in 78% of patients with immune thrombocytopenia (ITP) (median = 16.3%) and low in 79% of patients with hypocellular marrow (median = 6.5%). Surprisingly, it was highly variable among patients with malignant marrow infiltration and mycobacterial infection of the bone marrow (BMTB) (median = 8.4 and 7.1%, respectively). Multivariate linear regression analysis confirmed a significant independent inverse relationship between the IPF and hypocellular marrow (P < 0.0001), a marginally significant positive association with ITP (P = 0.059), and the absence of any relationship with malignant infiltration or BMTB. The IPF had a significant inverse association with the platelet count (P = 0.0006), but was unrelated to the CD4 count and exposure to anti-retroviral therapy. Unexpectedly, it showed a significant positive association with the HIV viral load (P = 0.005). We speculate this to reflect increased megakaryocyte activity in compensation for accelerated platelet clearance due to HIV-driven platelet activation.

CONCLUSION

This study investigates the role of the IPF in HIV-associated thrombocytopenia, and emphasizes the limitations of morphological analysis in determining megakaryocyte function.

Resolution of autoimmune thrombocytopenia associated with raltegravir use in an HIV-positive patient

About 10% of the human immunodeficiency virus (HIV) patients show thrombocytopenia. We describe the case of an HIV/HCV-positive patient whose autoimmune thrombocytopenia resolved with the addition of raltegravir to previous highly active antiretroviral therapy (HAART). It is noteworthy that the effect on platelet count appeared to be independent of viral load suppression, which was achieved with previous antiretroviral regimens. In fact, it has been suggested that the positive effect exerted by raltegravir on autoimmune diseases is due to its inhibition on herpes viruses, and hence on activation of endogenous human retroviruses. This consideration, if confirmed, could open new avenues in the treatment of autoimmune thrombocytopenia in the HIV setting.

Hematological manifestations of human immunodeficiency virus infection and the effect of highly active anti-retroviral therapy on cytopenia

BACKGROUND

The aim of this study is to investigate the hematological manifestations of human immunodeficiency virus (HIV) infection, the risk factors for cytopenia, and the effect of highly active anti-retroviral therapy (HAART) on cytopenia.

METHODS

Medical records of patients treated for HIV at the Seoul National University Hospital from January 2005 to March 2010 were retrospectively reviewed. To determine the impact of HIV itself, we excluded HIV patients who had other conditions that could have resulted in hematological manifestations. Multiple logistic regression analyses were performed to identify risk factors for cytopenia.

RESULTS

A total of 621 cases were investigated, and after exclusion, data of 472 patients were analyzed. The frequency of cytopenia was anemia, 3.0% (14/472); neutropenia, 10.0% (47/472); thrombocytopenia, 2.4% (12/472); lymphopenia, 25.7% (121/470); isolated cytopenia, 11.2% (53/472); and bicytopenia, 2.1% (10/472). The leading risk factor for cytopenia identified by multivariate logistic regression methods was AIDS status at initial presentation. After HAART, cytopenia was reversed in the majority of patients (thrombocytopenia, 100%; neutropenia, 91.1%; and anemia, 84.6%).

CONCLUSION

This study isolated the impact of HIV infection alone on hematologic manifestations and confirmed that these changes were reversible by HAART. Control of the HIV infection will have the main role in the management of hematological manifestations of the virus.

Thrombocytopenia in HIV-Infected Patients

Thrombocytopenia is a common feature among HIV-positive patients. However, there are few reports about this subject after highly active antiretroviral therapy (HAART) introduction. The authors show a retrospective description of epidemiology, clinical aspects, and treatment observed in 55 HIV-positive outpatients with thrombocytopenia treated in two reference centers for HIV treatment in São Paulo, Brazil. Thirty-four (62%) patients were male, 50 (91%) were Caucasian, with median of lymphocytes TCD4 of 394 cells/mm(3). In 63.6% patients, the cause of thrombocytopenia was classified as immune thrombocytopenic purpura and non immune in 25.5%. Regular use of HAART was present in 43.6% of the population studied. In 20% HAART was initiated for thrombocytopenia treatment with improvement in platelets count observed after 3 months. Platelet transfusion was needed in 23.7% of the patients and one patient died due to bleeding. Thrombocytopenia is still common among patients infected with HIV, considered a multifactor disorder, commonly due to immune mechanisms in our cases. In the clinical setting, a diagnostic approach related to the hematological consequences of HIV infection is needed for a better therapy option for this population.

Prevalence, severity, and duration of thrombocytopenia among HIV patients in the era of highly active antiretroviral therapy

Thrombocytopenia is a clinically relevant outcome in HIV. However, the epidemiology of this condition, including frequency, severity, and duration, has not been well-characterized in the era of highly active antiretroviral therapy (HAART). In this study, we describe the epidemiology of thrombocytopenia using two methods. We conducted a systematic review of the literature published between 1997 and 2009 to characterize the frequency of thrombocytopenia in different populations in the HAART era. Secondly, we examined the frequency, severity, and duration of thrombocytopenia among HIV patients in the Collaborations in HIV Outcomes Research/US (CHORUS) Cohort from 1997 to 2006 and among HIV patients participating in GlaxoSmithKline HIV Clinical Trials between 1996 and 2004. Prevalence estimates of thrombocytopenia (<150 000 platelets/µl) in the literature varied greatly but were generally above 10%. The thrombocytopenia prevalence estimates in the CHORUS Cohort and the HIV Clinical Trials were both 14%. In the CHORUS Cohort, the platelet count was ≤50 000/µl among 3.1% and ≤30 000/µl among 1.7%; in the HIV clinical trials database, the platelet count was ≤50 000/µl among 1.3% and ≤30 000/µl among 0.67%. Duration of severe thrombocytopenia varied greatly, with the medium duration to ≥75 000 platelets/µl taking 147 days in the CHORUS Cohort and 33 days in the HIV clinical trials database. Among 111 patients with severe thrombocytopenia in the CHORUS Cohort, 23% never achieved a higher platelet count over follow-up. In conclusion, while the prevalence of severe thrombocytopenia was low, it occurred at levels associated with bleeding and was persistent among a small proportion of patients despite receipt of HAART.

The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia

Immune thrombocytopenia (ITP) is commonly encountered in clinical practice. In 1996 the American Society of Hematology published a landmark guidance paper designed to assist clinicians in the management of this disorder. Since 1996 there have been numerous advances in the management of both adult and pediatric ITP. These changes mandated an update in the guidelines. This guideline uses a rigorous, evidence-based approach to the location, interpretation, and presentation of the available evidence. We have endeavored to identify, abstract, and present all available methodologically rigorous data informing the treatment of ITP. We provide evidence-based treatment recommendations using the GRADE system in those areas in which such evidence exists. We do not provide evidence in those areas in which evidence is lacking, or is of lower quality--interested readers are referred to a number of recent, consensus-based recommendations for expert opinion in these clinical areas. Our review identified the need for additional studies in many key areas of the therapy of ITP such as comparative studies of "front-line" therapy for ITP, the management of serious bleeding in patients with ITP, and studies that will provide guidance about which therapy should be used as salvage therapy for patients after failure of a first-line intervention.

Subdural haematoma: an uncommon presentation of thrombocytopaenia in HIV infection

Isolated thrombocytopaenia can occur in 30-60% of HIV-infected patients. The majority of patients with HIV-related immune thrombocytopaenia have only minor submucosal bleeding problems. Cases of subarachnoid haemorrhage and subdural haematoma are very rare and management of such cases is a challenging problem for physicians. We report a rare case of subdural haematoma due to thrombocytopaenia in a 40-year-old HIV-positive man.

Infectious causes of chronic immune thrombocytopenia

Persistent thrombocytopenia may be the consequence of chronic infections with hepatitis C virus (HCV), human immunodeficiency virus (HIV), and Helicobacter pylori, and should be considered in the differential diagnosis of primary immune thrombocytopenia (ITP). Studies have shown that on diagnosis of infections, treatment of the primary disease often results in substantial improvement or complete recovery of the thrombocytopenia. In patients with thrombocytopenia due to HCV-related chronic liver disease, the use of eltrombopag, a thrombopoietin receptor agonist, normalizes platelet levels, thereby permitting the initiation of antiviral therapy. Antiviral therapy with highly active antiretroviral therapy for HIV has aided in platelet recovery, with a corresponding decrease in circulating viral load. Thrombocytopenia in the absence of other disease symptoms requires screening for H. pylori, especially in countries such as Japan, where there is a high prevalence of the disease and the chances of a platelet response to eradication therapy are high.

Risk factors for thrombocytopenia in HIV-infected persons in the era of potent antiretroviral therapy

OBJECTIVE

Before potent antiretroviral therapy, thrombocytopenia was observed frequently. Little is known about risk factors for or severity and consequences of thrombocytopenia since establishment of highly effective therapy for HIV.

METHODS

We conducted a retrospective-matched case-control study of HIV-infected adult outpatients with and without thrombocytopenia to elucidate the contribution of HIV viremia, hepatitis C infection, and other potential risk factors for thrombocytopenia. Seventy-three cases with thrombocytopenia (platelet count <100 x 10(9)/L persistent for >3 months) were matched by age, sex, and first clinic visit with 73 nonthrombocytopenic controls. Risk factors and outcomes were assessed using conditional logistic regression.

RESULTS

Nadir platelet counts in cases were <or=50 x 10(9)/L in 58% and <or=30 x 10(9)/L in 38%. In multivariate modeling, HIV RNA >400 copies/ml, hepatitis C virus infection, and cirrhosis were significantly associated with thrombocytopenia with adjusted odds ratios of 5.3 [confidence interval (CI) 1.6-17.1, P = 0.006], 6.1 (CI 1.6-22.6, P = 0.007), and 24.0 (CI 1.7-338, P = 0.019), respectively. Thrombocytopenia was significantly associated with major bleeding events and nonbleeding-related death.

CONCLUSIONS

Thrombocytopenia in the era of potent antiretroviral therapy is associated with hepatitis C virus infection, cirrhosis, and uncontrolled HIV replication, and serious complications including major bleeding and death.

Therapeutic strategies for hepatitis- and other infection-related immune thrombocytopenias

Secondary thrombocytopenia may result from autoimmune diseases, lymphoproliferative disorders, infections, myelodysplastic syndromes, common variable immunodeficiency, agammaglobulinemia, hypogammaglobulinemia, immunoglobulin A deficiency, and drugs. The presence of thrombocytopenia may result from chronic infections with hepatitis C virus (HCV), human immunodeficiency virus (HIV), and Helicobacter pylori and should be considered in the differential diagnosis of immune thrombocytopenic purpura (ITP). Studies have shown that upon diagnosis of infections, treatment of the primary disease allows for stabilization of platelet counts. Antiviral therapy with highly active antiretroviral therapy (HAART) for HIV has aided in platelet recovery with a corresponding decrease in circulating viral load. In some cases, the use of a thrombopoietin (TPO) agonist, eltrombopag, normalizes platelet levels in patients with these infections. Thrombocytopenia in the absence of other disease symptoms requires screening for H pylori, especially in regions where there is a high prevalence of the disease, such as in Japan, and in cases where platelets have normalized following eradication therapy. In other regions where these infections are not prevalent, such testing is controversial.

The ITP syndrome: pathogenic and clinical diversity

Immune thrombocytopenia (ITP) is mediated by platelet autoantibodies that accelerate platelet destruction and inhibit their production. Most cases are considered idiopathic, whereas others are secondary to coexisting conditions. Insights from secondary forms suggest that the proclivity to develop platelet-reactive antibodies arises through diverse mechanisms. Variability in natural history and response to therapy suggests that primary ITP is also heterogeneous. Certain cases may be secondary to persistent, sometimes inapparent, infections, accompanied by coexisting antibodies that influence outcome. Alternatively, underlying immune deficiencies may emerge. In addition, environmental and genetic factors may impact platelet turnover, propensity to bleed, and response to ITP-directed therapy. We review the pathophysiology of several common secondary forms of ITP. We suggest that primary ITP is also best thought of as an autoimmune syndrome. Better understanding of pathogenesis and tolerance checkpoint defects leading to autoantibody formation may facilitate patient-specific approaches to diagnosis and management.

Superior effect of intravenous anti-D compared with IV gammaglobulin in the treatment of HIV-thrombocytopenia: results of a small, randomized prospective comparison

This small, prospective, randomized study compared increases in platelet counts and duration of response after intravenous gammaglobulin (IVIG) and IV anti-D in patients with HIV-related thrombocytopenia (HIV-TP). Nine Rh+, nonsplenectomized HIV-positive patients with thrombocytopenia were treated sequentially, in random order, with IVIG and IV anti-D in a cross over design, receiving each therapy for 3 months. Peak platelet counts and duration of effect after each treatment were compared. In addition, viral load measurements and CD4 counts were followed serially, as well as thrombopoietin levels. IV anti-D resulted in a mean peak platelet count of 77 x 10(9)/L compared to only 29 x 10(9)/L after IVIG (P = 0.07). The mean duration of response was significantly longer in patients treated with anti-D (41 days) compared to IVIG (19 days, P = 0.01). No consistent changes were seen in the CD4 counts or viral load measurements as a result of either therapy. Thrombopoietin levels were normal in all patients despite often severe thrombocytopenia. Anti-D was more efficacious than IVIG for the treatment of HIV-TP, confirming and extending previous results. Anti-D should be the first line therapy in HIV-positive, Rh+ patients, when antiretroviral agents are not indicated, not effective, or there is an urgent need to increase the platelet count.

Recurring thrombocytopenia associated with structured treatment interruption in patients with human immunodeficiency virus infection

In a structured treatment interruption (STI) trial, 3 of 23 patients in a CD4 cell count-guided treatment arm developed recurring thrombocytopenia associated with the interruption of antiretroviral therapy. All 3 patients had slightly low or normal platelet counts before initiating antiretroviral therapy. STI may play a role in inducing thrombocytopenia in patients with human immunodeficiency virus infection.