Major clinical outcomes in antiretroviral therapy (ART)-naive participants and in those not receiving ART at baseline in the SMART study

Rapid initiation of bictegravir/emtricitabine/tenofovir alafenamide as first-line therapy in HIV infection. A prospective study

INTRODUCTION

Rapid initiation of ART after HIV diagnosis is recommended for individual and public health benefits. However, certain clinical and ART-related considerations hinder immediate initiation of therapy.

METHODS

An open-label, single-arm, single-centre 48-week prospective clinical trial involving ART-naïve HIV-diagnosed adults who started bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) within a week from the first hospital visit, before the availability of baseline laboratory and genotype results. The primary aim was to determine the proportion of people with at least one condition that would hinder immediate initiation of any recommended ART regimen other than BIC/FTC/TAF. Clinicaltrials.gov: NCT04416906.

RESULTS

We included 100 participants: 79% men, 64% from Latin America, median age 32 years. According to European AIDS Clinical Society (EACS) and US Department of Health and Human Services 2023 guidelines, 11% (95%CI 6; 19) of participants had at least one condition that made any ART different from BIC/FTC/TAF less appropriate for a rapid ART strategy. Seventy-nine percent of the people started BIC/FTC/TAF within the first 48 hours of their first hospital visit. There were 16 early discontinuations (11 lost to follow-up). By week 48, 92% (95%CI 86; 98) of the participants of the ITT population with observed data achieved viral suppression. Eight grade 3-4 adverse events (AEs), five serious AEs and six ART-related AEs were identified. Adherence remained high.

CONCLUSIONS

BIC/FTC/TAF is an optimal treatment for rapid initiation of ART. However, additional strategies to improve retention in care must be implemented.

Evaluation of New Hypertension Guidelines on the Prevalence and Control of Hypertension in a Clinical HIV Cohort: A Community-Based Study

The prevalence and control of hypertension (HTN) among people with HIV (PWH) have not been widely studied since the release of newer 2017 ACC/AHA guidelines ("new guidelines"). To address this research gap, we evaluated and compared the prevalence and control of HTN using both 2003 JNC 7 ("old guidelines") and new guidelines. We identified 3,206 PWH with HTN from the DC Cohort study in Washington, DC, between January 2018 and June 2019. We defined HTN using International Classification of Diseases (ICD)-9/-10 diagnosis codes for HTN or ≥2 blood pressure (BP) measurements obtained at least 1 month apart (>139/89 mm Hg per old or >129/79 mm Hg per new guidelines). We defined HTN control based on recent BP (≤129/≤79 mm Hg per new guidelines). We identified socio-demographics, cardiovascular risk factors, and co-morbidities associated with HTN control using multivariable logistic regression [adjusted odds ratio (aOR); 95% confidence interval (CI)]. The prevalence of HTN was 50.9% per old versus 62.2% per new guidelines. Of the 3,206 PWH with HTN, 887 (27.7%) had a recent BP ≤129/≤79 mm Hg, 1,196 (37.3%) had a BP 130-139/80-89 mm Hg, and 1,123 (35.0%) had a BP ≥140/≥90 mm Hg. After adjusting for socio-demographics, cardiovascular risk factors, and co-morbidities, factors associated with HTN control included age 60-69 (vs. <40) years (aOR: 1.42; 95% CI: 1.03-1.98), Hispanic (vs. non-Hispanic Black) race/ethnicity (aOR 1.49; 95% CI: 1.04-2.15), receipt of HIV care at a hospital-based (vs. community-based) clinic (aOR 1.21; 95% CI: 1.00-1.47), being unemployed (aOR 1.42; 95% CI: 1.11-1.83), and diabetes (aOR 1.35; 95% CI: 1.13-1.63). In a large urban cohort of PWH, nearly two-thirds had HTN and less than one-third of those met new guideline criteria. Our data suggest that more aggressive HTN control is warranted among PWH, with additional attention to younger patients and non-Hispanic Black patients.

Evolving mechanisms and presentations of cardiovascular disease in people with HIV: implications for management

People with HIV (PWH) are at elevated risk for cardiovascular diseases (CVDs), including myocardial infarction, heart failure, and sudden cardiac death, among other CVD manifestations. Chronic immune dysregulation resulting in persistent inflammation is common among PWH, particularly those with sustained viremia and impaired CD4+ T cell recovery. This inflammatory milieu is a major contributor to CVDs among PWH, in concert with common comorbidities (such as dyslipidemia and smoking) and, to a lesser extent, off-target effects of antiretroviral therapy. In this review, we discuss the clinical and mechanistic evidence surrounding heightened CVD risks among PWH, implications for specific CVD manifestations, and practical guidance for management in the setting of evolving data.

Characterization and outcomes of difficult-to-treat patients starting modern first-line ART regimens: Data from the ICONA cohort

OBJECTIVES

Treatment failures to modern antiretroviral therapy (ART) raise concerns, as they could reduce future options. Evaluations of occurrence of multiple failures to modern ART are missing and their significance in the long run is unclear.

METHODS

People with HIV (PWH) in the ICONA cohort who started a modern first-line ART were defined as 'difficult to treat' (DTT) if they experienced ≥1 among: i) ≥2 VF (2 viral loads, VL>200 copies/mL or 1 VL>1000 copies/mL) with or without ART change; ii) ≥2 treatment discontinuations (TD) due to toxicity/intolerance/failure; iii) ≥1 VF followed by ART change plus ≥1 TD due to toxicity/intolerance/failure. A subgroup of the DTT participants were matched to PWH that, after the same time, were non-DTT. Treatment response, analysing VF, TD, treatment failure, AIDS/death, and SNAE (Serious non-AIDS event)/death, were compared. Survival analysis by KM curves and Cox regression models were employed.

RESULTS

Among 8061 PWH, 320 (4%) became DTT. Estimates of becoming DTT was 6.5% (95% CI: 5.8-7.4%) by 6 years. DTT PWH were significantly older, with a higher prevalence of AIDS and lower CD4+ at nadir than the non-DTT. In the prospective analysis, DTT demonstrated a higher unadjusted risk for all the outcomes. Once controlled for confounders, significant associations were confirmed for VF (aHR 2.23, 1.33-3.73), treatment failure (aHR 1.70, 1.03-2.78), and SNAE/death (aHR 2.79, 1.18-6.61).

CONCLUSION

A total of 6.5% of PWH satisfied our definition of DTT by 6 years from ART starting. This appears to be a more fragile group who may have higher risk of failure.

Impact of Latent M. tuberculosis Infection Treatment on Time to CD4/CD8 Recovery in Acute, Recent, and Chronic HIV Infection

INTRODUCTION

In people living with HIV, active and latent tuberculosis (TB) coinfections are associated with immune activation that correlate with HIV progression and mortality. We investigated the effect of initiating antiretroviral therapy (ART) during acute (AHI), recent (RHI), or chronic HIV infection (CHI) on CD4/CD8 ratio normalization and associated factors, the impact of latent TB infection treatment, and prior/concomitant TB diagnosis at the time of ART initiation.

METHODS

We included sex with men and transgender women individuals initiating ART with AHI, RHI and CHI between 2013 and 2019, from a prospective cohort in Brazil. We compared time from ART initiation to the first normal CD4/CD8 ratio (CD4/CD8 ≥1) using Kaplan-Meier curves and multivariable Cox proportional hazards models. Sociodemographic and clinical variables were explored. Variables with P -values <0.20 in univariable analyses were included in multivariable analyses.

RESULTS

Five hundred fifty participants were included, 11.8% classified as AHI and 6.4% as RHI, 46.7% with CHI-CD4 cell counts ≥350 cells/mm 3 and 35.1% with CHI-CD4 cell counts <350 cells/mm 3 . Time to normalization was shortest among AHI patients, followed by RHI and CHI individuals with higher baseline CD4. In the multivariable model, AHI was associated with a six-fold increased likelihood of achieving a CD4/CD8 ratio ≥1 (hazard ratio [HR]: 6.03; 95% confidence interval [CI]: 3.70 to 9.82; P < 0.001), RHI with HR: 4.47 (95% CI: 2.57 to 7.76; P < 0.001), and CHI CD4 ≥350 cells/mm 3 with HR: 1.87 (95% CI: 1.24 to 2.84; P = 0.003). Latent TB infection treatment was significantly associated with a higher likelihood of the outcome (HR: 1.79; 95% CI: 1.22 to 2.62; P = 0.003). Previous history or concomitant active TB at ART initiation was associated with a lower likelihood of the outcome (HR: 0.41; 95% CI: 0.16 to 1.02; P = 0.054).

CONCLUSIONS

Initiating ART early during AHI may offer an opportunity to mitigate immune damage. Efforts to implement HIV diagnosis and ART initiation during AHI are critical to amplify ART benefits.

Autonomic Neuropathy as a Predictor of Morbidity and Mortality in People Living With HIV: A Retrospective, Longitudinal Cohort Study

Background and Objectives

HIV-associated autonomic neuropathy (HIV-AN) is common; however, its clinical effect is unclear. Previously, it was shown that the composite autonomic severity score is associated with markers of morbidity such as the Veterans Affair Cohort Study index. In addition, it is known that cardiovascular autonomic neuropathy due to diabetes is associated with poor cardiovascular outcomes. This study aimed to evaluate whether HIV-AN is predictive of important adverse clinical outcomes.

Method

The electronic medical records of HIV-infected participants who underwent autonomic function tests at the Mount Sinai Hospital between April 2011 and August 2012 were reviewed. The cohort was stratified into those who had no or mild autonomic neuropathy (HIV-AN [-], CASS ≤3) and those with moderate or severe autonomic neuropathy (HIV-AN [+], CASS >3). The primary outcome was a composite of the incidence of death from any cause, new major cardiovascular or cerebrovascular event, or development of severe renal or hepatic disease. Time-to-event analysis was performed using Kaplan-Meier analysis and multivariate Cox proportional hazards regression models.

Results

One hundred eleven of 114 participants had follow-up data (median follow-up for HIV-AN (-) was 94.00 months, and HIV-AN (+) was 81.29 months) and were included in the analysis. Participants were followed until March 1, 2020. The HIV-AN (+) group (N = 42) was significantly associated with the presence of hypertension, higher HIV-1 viral load, and more abnormal liver function. Seventeen (40.48%) events occurred in the HIV-AN (+) group, and 11 (15.94%) occurred in the HIV-AN (-) group. Six (14.29%) cardiac events occurred in the HIV-AN (+) group, whereas 1 (1.45%) occurred in the HIV-AN (-) group. The other subgroups of the composite outcome had a similar trend. The adjusted Cox proportional hazards model showed that the presence of HIV-AN predicted our composite outcome (HR 3.85, CI 1.61-9.20).

Discussion

These findings suggest that HIV-AN is associated with the development of severe morbidity and mortality in people living with HIV. People living with HIV with autonomic neuropathy may benefit from closer cardiac, renal, and hepatic surveillance.

Evaluating lncRNA Expression Patterns during HIV-1 Treatment Interruption

Lately, the interest in long non-coding RNAs (lncRNAs) as potential drug targets and predictive markers in the context of HIV-1 has peaked, but their in vivo expression and regulation remains largely unexplored. Therefore, the present study examined lncRNA expression patterns during a clinical antiretroviral treatment interruption (ATI) trial. Peripheral blood mononuclear cells were isolated from ten patients at four timepoints: prior to ATI, 7-15 days after stop, at viral rebound and 3 months post antiretroviral therapy re-initiation. RNA was extracted and RT-qPCR on five known HIV-1-related lncRNAs (HEAL, MALAT1, NEAT1, GAS5 and NRON) was performed and correlated with HIV-1 and host marker expression. All lncRNAs correlated stronger with interferon stimulated genes (ISGs) than with HIV-1 reservoir and replication markers. However, one lncRNA, HEAL, showed significant upregulation at viral rebound during ATI compared to baseline and re-initiation of therapy (p = 0.0010 and p = 0.0094, respectively), following a similar viral-load-driven expression pattern to ISGs. In vitro knockdown of HEAL caused a significant reduction in HIV-1 infection levels, validating HEAL's importance for HIV-1 replication. We conclude that the HIV-1-promoting lncRNA HEAL is upregulated at viral rebound during ATI, most likely induced by viral cues.

Ideal Cardiovascular Health: Distribution, Determinants and Relationship with Health Status among People Living with HIV in Urban Tanzania

Background

Ageing adults living with HIV (ALHIV) have increased risk of cardiovascular diseases as a result of HIV-infection-related chronic immune activation and inflammatory responses. Cardiovascular health index (CVHI) is a valid and relatively simple index for assessing the cardiovascular health (CVH) of the general population. Use of this index among ALHIV in Sub Saharan Africa, a resource-restricted setting where it could be mostly beneficial, remains limited. Understanding of the distribution and associated factors may inform the design of optimal interventions to improve CVH of ALHIV.

Objective

We aimed to assess the distribution and factors associated with CVHI scores among ALHIV in an urban setting in Tanzania.

Methods

A cross-sectional study was conducted among ALHIV on antiretroviral therapy at six HIV clinics in Dar-es-Salaam, Tanzania. We summed the score of each of the seven CVHI metric to obtain the overall CVHI score and assessed the distribution of the score by sex. We then categorized the overall score into ideal (5-7), intermediate (3-4) and poor (<3) CVH categories and performed ordinal regression to identify CVHI score associated factors.

Results

In all, 629 ALHIV [mean age of 43.5(SD ± 11.2) years] were enrolled. Most had ideal levels of blood glucose (96.2%) and smoking status (83.4%) while less than half had ideal BMI (48.1%), blood pressure (BP) (43.9%) and dietary intake (7.8%). Less than half (47.6%) showed ideal CVH, while less than 1% had all seven metrics at ideal level. Older age (0.96(95%CI:0.95-0.97), p-value < 0.001), being retired/unemployed (0.59(95%CI:0.43-0.81), p-value < 0.01), being employed (0.76(95%CI:0.62-0.94), p-value = 0.01) alcohol use (0.41(95%CI:0.21-0.80), p-value = 0.01) and presence of non-communicable disease comorbidities (0.68(95%CI:0.48-0.97), p-value = 0.04) had significant lower odds of ideal CVH.

Conclusion

Based on our findings, interventions to improve CVH of ALHIV should target BP management, health education on diet for BMI control and reduction in alcohol consumption, particularly among ageing ALHIV with comorbidities.

Impact of HAART Therapy and HIV Infection over Fetal Growth-An Anthropometric Point of View

Human immunodeficiency virus (HIV) infection cannot be completely eliminated from the body because the virus integrates its genetic code into that of the host cell. The prevalence of pregnancy in women with HIV infection has increased due to the efficacy of antiretroviral therapy (ART). Placental insufficiency is associated with a reduction in blood flow and circulatory redistribution, resulting in fetal hypoxia and nutrient deprivation as a consequence of an altered placental function, and it can result in a lower birthweight. The aim of the study was to determine the combined effect of HIV infection and ART on the anthropometric parameters of infants born to HIV-positive pregnant women under ART compared to the values of these parameters in a control group of infants born to healthy mothers. There are no significant differences between the two groups in terms of gestational age at birth. We found a statistically significant lower birth weight in infants born from HIV-positive mothers under ART, with 3041 g in the control group compared to 2758 g in the group of HIV positive pregnant women (p < 0.01). There were statistically significant differences in all anthropometric parameters, these showing higher values in the control group (seronegative pregnant women).

Low CD4/CD8 ratio is associated with increased morbidity and mortality in late and non-late presenters: results from a multicentre cohort study, 2004–2018

Background

To study whether the association between the CD4/CD8 ratio variation over time and the development of clinical outcomes vary in late presenters (CD4 count < 350/µL or AIDS event at enrolment) or advanced presenters (CD4 count < 200/µL or AIDS event at enrolment).

Methods

We included ART-naïve adults from the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) enrolled between January 2004 up to November 2018 and with at least 6 months of follow-up. We used extended Cox proportional hazard models to estimate the hazard ratios (HRs) for the association between CD4/CD8 ratio over time and a composite endpoint of the occurrence of the first AIDS event, first serious non-AIDS event or overall mortality occurring from 6 months after enrolment. HRs in non-late, late and advanced presenters were obtained by including an interaction term between late presentation status and CD4/CD8 ratio over time.

Results

Of 10,018 participants, 55.6% were late presenters and 26.5% were advanced presenters. Compared with CD4/CD8 ratio > 0.4, CD4/CD8 ratio ≤ 0.4 over time was associated with an increased risk of experiencing the composite endpoint in non-late (HR 1.90; 95%CI 1.48, 2.43), late (HR 1.94; 1.46, 2.57) and advanced presenters (HR 1.72; 1.26, 2.34). Similarly, CD4/CD8 ratio ≤ 0.4 over time was associated with a higher risk of developing an AIDS event (HR 3.31; 2.23, 4.93 in non-late; HR 2.75; 1.78, 4.27 in late and HR 2.25; 1.34, 3.76 in advanced presenters) or serious non-AIDS event (HR 1.39; 0.96, 2.02 in non-late, HR 1.62; 1.10, 2.40 in late and HR 1.49; 0.97, 2.29 in advanced presenters) as well as with a higher risk of overall mortality (HR 1.49; 0.92, 2.41 in non-late, HR 1.80; 1.04, 3.11 in late and HR 1.61; 0.92, 2.83 in advanced presenters) compared to CD4/CD8 > 0.4, regardless of the late presentation status.

Conclusions

A low CD4/CD8 measured over time is associated with increased risk of morbidity and mortality in people living with HIV independently of their late presentation status. These data support the prognostic role of CD4/CD8 over time and can help defining a subgroup of patients who need closer monitoring to avoid comorbidities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07352-z.

Baseline and Process Factors of Anti-Retroviral Therapy That Predict Loss to Follow-up Among People Living with HIV/AIDS in China: A Retrospective Cohort Study

We explored the predictors and predictive models of loss to follow-up (LTFU) during the first year of anti-retroviral therapy (ART). LTFU was defined as the failure to visit the clinic for antiretroviral drugs for ≥ 90 days after the last missed scheduled visit. Based on the electronic medical records of 5953 patients who were HIV positive and began ART between 2016 and 2019 in China, the LTFU rate was 7.24 (95% confidence interval 6.49-7.97) per 100 person-years during the first year of ART. ART baseline factors were associated with LTFU, but were non-optimal predictors. A model including ART process-related factors such as follow-up behaviors and physical health status had an area under the receiver operating characteristic curve of 73.4% for predicting LTFU. Therefore, the medical records of follow-up visits can be used to identify patients with a high risk of LTFU and allow interventions to be implemented proactively.

Grayscale Ultrasound Texture Features of Carotid and Brachial Arteries in People With HIV Infection Before and After Antiretroviral Therapy

Background We aimed to investigate novel grayscale ultrasound characteristics of the carotid and brachial arteries in people with HIV infection before and after starting initial antiretroviral therapy (ART). Methods and Results We performed grayscale ultrasound image analyses of the common carotid artery (CCA) and brachial artery before and after receipt of 1 of 3 randomly allocated ART regimens. We measured arterial wall echogenicity (grayscale median), contrast (gray-level difference statistic method), and entropy. These measures and their changes were compared with atherosclerotic cardiovascular disease risk factors, measures of HIV disease severity, and inflammatory biomarkers before and after ART. Changes in the grayscale measures were evaluated within and between ART arms. Among 201 ART-naïve people with HIV, higher systolic blood pressure, higher body mass index, lower CD4+ T cells, and non-Hispanic White race and ethnicity were associated independently with lower CCA grayscale median. Changes in each CCA grayscale measure from baseline to 144 weeks correlated with changes in soluble CD163: grayscale median (ρ=-0.17; P=0.044), gray-level difference statistic-contrast (ρ=-0.19; P=0.024), and entropy (ρ=-0.21; P=0.016). Within the atazanavir/ritonavir arm, CCA entropy increased (adjusted β=0.023 [95% CI, 0.001-0.045]; P=0.04), but no other within-arm changes in grayscale measures were seen. Correlations of brachial artery grayscale measures were weaker. Conclusions In ART-naïve people with HIV, CCA grayscale ultrasound measures were associated with atherosclerotic cardiovascular disease risk factors and lower grayscale median was associated with lower CD4+ T cells. Reductions in soluble CD163 with initial ART were associated with improvements in all 3 CCA grayscale measures, suggesting that reductions in macrophage activation with ART initiation may lead to less arterial injury. Registration URL: https://clinicaltrials.gov/; Unique identifiers: NCT00811954; NCT00851799.

Differentiated service delivery models among PLHIV in Akwa Ibom and Cross River States, Nigeria during the COVID-19 pandemic: descriptive analysis of programmatic data

Introduction

The rapid increase in the number of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Akwa Ibom and Cross River states in Nigeria led to overcrowding at clinics. Patients were devolved to receive ART refills through five differentiated service delivery (DSD) models: fast‐track (FT), adolescent refill clubs (ARCs), community pharmacy ART refill programs (CPARPs), community ART refill clubs (CARCs) and community ART refill groups (CARGs) designed to meet the needs of different groups of PLHIV. In the context of COVID‐19‐related travel restrictions, out‐of‐facility models offered critical mechanisms for continuity of treatment. We compared retention and viral suppression among those devolved to DSD with those who continued standard care at facilities.

Methods

A retrospective cohort study was conducted among patients devolved to DSD from January 2018 to December 2020. Bivariate analyses were conducted to assess differences in retention and viral suppression by socio‐demographic characteristics. Kaplan–Meier assessed retention at 3, 6, 9 and 12 months. Differences in proportions were compared using the chi‐square test; a p‐value of <0.05 was considered significant.

Results

A total of 40,800 PLHIV from 84 facilities received ART through the five models: CARC (53%), FT (19.1%), ARC (12.1%), CPARP (10.4%) and CARG (5.4%). Retention rates at 6 months exceeded 96% for all models compared to 94% among those continuing standard care. Among those using DSD, retention rate at 12 months was higher among adults than children (97.8% vs. 96.7%, p = 0.04). No significant sex differences in retention rates were found among those enrolled in DSD. Viral suppression rates among PLHIV served through DSD were significantly higher among adults than children (95.4% vs. 89.2%; p <0.01). Among adults, 95.4% enrolled in DSD were virally suppressed compared to 91.8% of those in standard care (p <0.01). For children, 89.2% enrolled in DSD were virally suppressed compared to 83.2% in standard care (p <0.01).

Conclusions

PLHIV receiving ART through DSD models had retention but higher viral suppression rates compared to those receiving standard care. Expanding DSD during COVID‐19 has helped ensure uninterrupted access to ART in Nigeria. Further scale‐up is warranted to decongest facilities and improve clinical outcomes.

Prevalence of severe cardiovascular abnormalities amongst West African HIV-infected patients on antiretroviral therapy followed at a referral HIV centre

Background

With success and effective long-term antiretroviral treatment (ART), HIV-infected patients live longer and frequently developed non-communicable diseases (NCDs). Few studies have been conducted in low-income countries, particularly in West Africa.

Methods

We carried out a cross-sectional study in the referral HIV centre of the Service des Maladies Infectieuses et Tropicales (SMIT) in Abidjan. From April to September 2015, we consecutively included HIV-1 infected patients aged 18 years and older, and on ART for a minimum of 12 months. Data were collected using a structured questionnaire, and entered into the centre’s computerised HIV database. Clinical assessment, laboratory tests, electrocardiogram, transthoracic echocardiography and vascular Doppler ultrasound were performed. The main outcome was the prevalence of patients with severe cardiovascular abnormalities (SCA). Univariate and multivariate logistic regressions were used to identify factors associated with SCA.

Results

Out of 278 patients (median age 46 years, interquartile range [IQR: 41–52]), 74.5% were female. Overall, the median duration of ART was 84 months (IQR: 54–126). One hundred and ninety-nine (71.6%) patients were on first-line ART regimen and 229 (82.4%) were virologically suppressed with a median CD4 count of 511 cells/mm³ (IQR: 347–529). Basically, cardiovascular abnormalities were mainly non-obstructive carotid plaques (19.1%) followed with left ventricular diastolic dysfunction (16.5%). The overall prevalence of SCA in the study population was 7.6% (95% Confidence Interval [95% CI]: 4.7–11.3). The prevalence of SCA 7.6% (95% Confidence Interval [95% CI]: 4.7–11.3). In multivariate analysis, age > 50 years and nadir CD4 count > 200 cells/mm³ were significant predictors of SCA.

Conclusion

The prevalence of SCA is high in West African HIV-treated patients. Given the high mortality associated with cardiovascular diseases in the general population, refining disease preventive strategies in HIV-positive subjects is essential to continue prolonging their life.

Summary of 2021 Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS in HIV-infected Koreans

Since the establishment of the Committee for Clinical Guidelines for the Diagnosis and Treatment of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) by the Korean Society for AIDS in 2010, clinical guidelines have been prepared in 2011, 2013, 2015, and 2018. As new research findings on the epidemiology, diagnosis, and treatment of AIDS have been published in and outside of Korea along with the development and introduction of new antiretroviral medications, a need has arisen to revise the clinical guidelines by analyzing such new data. The clinical guidelines address the initial evaluation of patients diagnosed with HIV/AIDS, follow-up tests, appropriate timing of medication, appropriate antiretroviral medications, treatment strategies for patients who have concurrent infections with hepatitis B or C virus, recommendations for resistance testing, treatment for patients with HIV and tuberculosis coinfections, and treatment in pregnant women. Through these clinical guidelines, the Korean Society for AIDS and the Committee for Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS contributes to overcoming AIDS by delivering latest data and treatment strategies to healthcare professionals who treat AIDS in the clinic.

Lipidome association with vascular disease and inflammation in HIV+ Ugandan children

OBJECTIVE

HIV infection and antiretroviral therapy (ART) have both been linked to dyslipidemia and increased cardiovascular disease (CVD). The relationships among the lipidome, immune activation, and subclinical vascular disease in children with perinatally acquired HIV (PHIV) have not been investigated.

METHODS

Serum lipid composition, including 13 lipid classes constituting 850 different lipid species were measured by direct infusion-tandem mass spectrometry in samples from 20 ART-treated PHIV and 20 age-matched and sex-matched HIV- Ugandan children. All participants were between 10 and 18 years of age with no other known active infections. PHIVs had HIV-1 RNA level 50 copies/ml or less. In addition, common carotid artery intima--media thickness (IMT), as well as plasma marker of systemic inflammation (hsCRP, IL6, sTNFRa I), monocyte activation (soluble CD14 and CD163), and T-cell activation (expression of CD38 and HLA-DR on CD4+ and CD8+) were evaluated.

RESULTS

Median age (Q1, Q3) of study participants was 13 years (11, 15), 37% were boys, 75% were on an NNRTI-based ART regimen. The concentrations of cholesterol ester, LCER, phosphatidylcholines, and sphingomyelin lipid classes were significantly increased in serum of PHIV compared with HIV (P≤0.04). Biomarkers associated with CVD risk including hsCRP, sCD163, and T-cell activation were directly correlated with lipid species in PHIV (P ≤ 0.04). Contents of free fatty acids including palmitic (16 : 0), stearic (18 : 0), and arachidic acid (20 : 0) were positively correlated with IMT in PHIV.

CONCLUSION

Serum lipidome is altered in young virally suppressed PHIV on ART. A direct association between inflammation and lipid species known to be associated with CVD was observed.

Cardiovascular Risk Assessment in People Living With HIV: A Systematic Review and Meta-Analysis of Real-Life Data

BACKGROUND

People living with HIV (PLWHIV) have a 2-fold higher risk of having a cardiovascular event than HIV-negative individuals.

OBJECTIVE

The objective of this article is to estimate the pooled proportion of moderate-high cardiovascular risk in PLWHIV obtained through different scores. In addition, this study also aims to establish the prevalence of dyslipidemia, smoking habits, diabetes and high blood pressure in the included studies.

METHODS

A bibliographic search was conducted in MEDLINE for studies on cardiovascular risk assessment in PLWHVI that took place during the period of inception to July 2018. The eligibility criteria for inclusion were: cross-sectional or longitudinal studies on HIV-positive adults in which the prevalence of moderate-high cardiovascular risk (or data to calculate it) was reported, and included at least one of the following cardiovascular risk scores: Framingham, ASCVD, D:A:D, Progetto Cuore, PROCAM, SCORE, Regicor, and World Health Organization scores.

RESULTS

Bibliographic search identified 278 studies. Finally, thirty-nine peer-reviewed publications were identified for a collective total of 13698 subjects. The pooled prevalence of moderate-high cardiovascular risk in PLWHIV obtained with nine different scores through random-effect modeling was 20.41% (95% CI: 16.77-24.31). The most prevalent concomitant cardiovascular risk factor was dyslipidemia (39.5%), smoking (33.0 %), high blood pressure (19.8%) and diabetes (7.24%).

CONCLUSION

Data obtained in this systematic review indicate that more than 1 in every five subjects with HIV have a moderate-high cardiovascular risk. In consequence, the burden of cardiovascular disease in PLWHIV represents a public health problem. There is an urgent need to develop strategies to prevent and detect cardiovascular risk effectively in PLWHIV.

Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study

Despite expanded antiretroviral therapy (ART) eligibility in South Africa, many people diagnosed with HIV do not initiate ART promptly, yet understanding of the reasons is limited. Using data from an 8-month prospective cohort interview study of women and men newly-diagnosed with HIV in three public-sector primary care clinics in the eThekwini (Durban) region, South Africa, 2010-2014, we examined if theoretically-relevant social-structural, social-cognitive, psychosocial, and health status indicators were associated with time to ART initiation. Of 459 diagnosed, 350 returned to the clinic for their CD4+ test results (linkage); 153 (33.3%) were ART-eligible according to treatment criteria at the time; 115 (75.2% of those eligible) initiated ART (median = 12.86 weeks [95% CI: 9.75, 15.97] after linkage). In adjusted Cox proportional hazard models, internalized stigma was associated with a 65% decrease in the rate of ART initiation (Adjusted hazard ratio [AHR] 0.35, 95% CI: 0.19-0.80) during the period less than four weeks after linkage to care, but not four or more weeks after linkage to care, suggesting that stigma-reduction interventions implemented shortly after diagnosis may accelerate ART uptake. As reported by others, older age was associated with more rapid ART initiation (AHR for 1-year age increase: 1.04, 95% CI: 1.01-1.07) and higher CD4+ cell count (≥300μL vs. <150μL) was associated with a lower rate of initiation (AHR 0.38, 95% CI: 0.19-0.80). Several other factors that were assessed prior to diagnosis, including stronger belief in traditional medicine, higher endorsement of stigma toward people living with HIV, food insecurity, and higher psychological distress, were found to be in the expected direction of association with ART initiation, but confidence intervals were wide and could not exclude a null finding.

Same-day antiretroviral treatment (ART) initiation and associated factors among HIV positive people in Northwest Ethiopia: baseline characteristics of prospective cohort

Background

Despite a well-established fact that same-day or rapid ART initiation after a positive HIV test result is vital for faster viral suppression and for prevention of further sexual transmissions of HIV, there is a paucity of evidence on the uptake of same-day ART initiation among newly HIV diagnosed people in Northwest, Ethiopia.

Methods

A cross-sectional study was conducted between December 1st, 2018 and July 30, 2019. About 759 newly HIV diagnosed adults were recruited from 24 health facilities. Data were collected using interviewer-administered questionnaire. Data were entered using EPI-Data and exported to SPSS and STATA software for further analysis. Bivariate logistic regression was used to select candidate variables at p-value less than 0.25 for multivariate logistic regression. Then adjusted odds ratio with 95% Confidence Interval (CI) at p-value of less than 0.05 was used to declare the statistical associations between the dependent and independent variables.

Result

Magnitude of same-day ART initiation was 318 (41.90%) [(95% CI, 38.2–45.20%)]. Factors associated with same-day ART initiation were: Patients resided in West Gojjam Zone were 2.04 times more likely to initiate same-day ART compared to those in Bahir Dar city administration [AOR = 2.04 (1.04–3.97)], patients in the health centers were 3.06 times more likely to initiate same-day ART initiation compared to those in the hospitals [AOR = 3.06 (1.90–4.92)] and Patients who were diagnosed their HIV status at the same health facility where they linked for ART were 2.16 times more likely to initiate ART at the same-day of diagnosis [AOR = 2.16 (91.24–3.74)]. Moreover, patients with no opportunistic infection [AOR = 2.08 (1.04–4.19)] and pregnant women [AOR = 3.97 (1.78–8.87)] were more likely to initiate ART same-day of diagnosis.

Conclusions

Same-day ART initiation was low among HIV patients in Ethiopia. Patients attending their treatment at hospitals and those from big city (Bahir Dar) were less likely to initiate same-day ART. Clinical factors such as having opportunistic infections and non-pregnancy status affected the immediate initiation of treatment. HIV positive people who seek care in hospitals and those tested HIV positive from another health facilities in which they did not intend to continue their ART follow-up care need special attention.

Increased incidence of glaucoma medication usage in middle-aged Australian males taking antiretroviral medication - a population-based study

BACKGROUND

To investigate a possible association between glaucoma and the use of anti-retroviral therapy (ART) for HIV in the Australian population.

METHODS

A retrospective review of Australian Pharmaceutical Benefits Scheme data was undertaken from July 2012 to December 2016, inclusive. Three patient groups were compared: those on both topical intraocular pressure (IOP) -lowering medication and ART, those on ART only, and those on IOP-lowering medication only, using the 2016 Australian resident population to estimate prevalence. Odds ratios (95% confidence intervals, [CI]) with Fishers exact test for p values were calculated stratified by age and gender.

RESULTS

The number of prescriptions for topical glaucoma medications in the general Australian population increased progressively by age with a peak prevalence in those aged 80 years and above. Prevalence of ART was highest in males aged 40-49 and 50-59 years (0.41% [CI 0.40, 0.42] and 0.44% [CI 0.43, 0.45], respectively). Our analysis identified an increase in the prescription of IOP-lowering medication in males on ART aged 30-39 (OR 2.23 [CI 1.32, 3.75], p = 0.007) and 40-49 (OR 1.86 [CI 1.42, 2.43], p < 0.001), compared to those not on ART. There were no statistically significant increased odds for females or males aged 50 years or more.

CONCLUSION

Compared with the known increase in glaucoma prevalence with age in the general Australian population, a statistically significant increased prevalence in use of IOP-lowering medications was found in males on ART aged 30-49 years. The mechanism for this is yet to be determined, but possible causes include sequelae of HIV infection, a drug-induced side effect, or increased medical surveillance.

MANAGEMENT OF RETINOBLASTOMA WITH HIV SEROPOSITIVITY

PURPOSE

To report a case of retinoblastoma with concomitant association with HIV seropositivity and its management.

METHODS

A retrospective case report of a 3-year-old male child presenting with right eye Group B and left eye Group E retinoblastoma with simultaneous positivity for HIV1 antibody. The parents were also tested positive for HIV and were referred for initiating antiretroviral therapy.

RESULTS

The child was managed with focal laser therapy for the right eye and six cycles of systemic chemotherapy, and the left eye was planned for enucleation with ball implant.

CONCLUSION

This case poses an outlook into a dilemma as to whether or not systemic chemotherapy should be started along with antiretroviral therapy for treating retinoblastoma, as there are no cited case reports in the literature of retinoblastoma coexisting with HIV and its related management regime and future considerations to be taken for management.

Carnitine Is Associated With Atherosclerotic Risk and Myocardial Infarction in HIV -Infected Adults

Background

People living with HIV (PLWH) have an increased risk of myocardial infarction (MI). Changes in the gut microbiota that occur with chronic HIV infection could play a role in HIV‐associated atherosclerosis. Choline, carnitine, betaine, and trimethylamine N‐oxide are small molecules that are, in part, metabolized or produced by the gut microbiome. We hypothesized that these metabolites would be associated with carotid artery intima‐media thickness and MI in PLWH.

Methods and Results

Carotid artery intima‐media thickness was measured at baseline and at a median interval of 4 years in 162 PLWH from the SCOPE (Study of the Consequences of the Protease Inhibitor Era) cohort in San Francisco, CA. Separately, 105 PLWH (36 cases with type I adjudicated MI and 69 controls without MI) were selected from the Center for AIDS Research Network of Integrated Clinical Systems, a multicenter clinic‐based cohort. Controls were matched by demographics, CD4 cell count, and duration of viral suppression. In the SCOPE cohort, higher carnitine levels had a significant association with presence of carotid plaque and greater baseline and progression of mean carotid artery intima‐media thickness after adjusting for traditional cardiovascular disease risk factors. In the treated and suppressed subgroup, these associations with carnitine remained significant after adjustment for cardiovascular disease risk factors. In the Center for AIDS Research Network of Integrated Clinical Systems cohort, the risk of MI was significantly increased in subjects with carnitine levels in the highest quartile after adjustment for cardiovascular disease risk factors.

Conclusions

In PLWH, including the treated and suppressed subgroup, carnitine is independently associated with carotid artery intima‐media thickness, carotid plaque, and MI in 2 separate cohorts. These results emphasize the potential role of gut microbiota in HIV‐associated atherosclerosis and MI, especially in relation to carnitine metabolism.

[Cardiovascular risk calculators for people living with human immunodeficiency virus]

The increasing access and efficacy of antiretroviral therapy has allowed people living with human immunodeficiency virus to achieve a life expectancy similar to that of the general population. However, this goal may be affected by the increased risk of cardiovascular disease in this group. This risk is multifactorial, involving the high prevalence of traditional risk factors, the development of a pro-inflammatory state related to chronic infection, and the use of antiretroviral drugs with an adverse metabolic profile. In daily practice, in order to estimate this risk and guide medical decision-making, different calculators are available. These are based on data from population cohorts, many of them from human immunodeficiency virusnegative subjects. The main aim of this review is to describe the epidemiology of cardiovascular disease in people living with human immunodeficiency virus, the available risk calculators and their use.

Assessment of two POC technologies for CD4 count in Morocco

Background

In the era of “test and treat strategy”, CD4 testing remains an important tool for monitoring HIV-infected individuals. Since conventional methods of CD4 count measurement are costly and cumbersome, POC CD4 counting technique are more affordable and practical for countries with limited resources. Before introducing such methods in Morocco, we decided to assess their reliability.

Methods

In this study 92 blood samples from HIV-infected patients, were tested by PIMA and FACSPresto to derive CD4 count. Flow cytometry using FacsCalibur, was used as reference method for CD4 count comparison. Linear regression, Bland–Altman analysis were performed to assess correlation and agreement between these POC methods and the reference method. In addition, sensitivity and specificity, positive predictive value (PPV), negative predictive value (NPV) and misclassification percentage at 350 and 200 CD4 count thresholds; were also determined. Finally, because FACSPresto can also measure hemoglobin (Hb) concentration, 52 samples were used to compare FACSPresto against an automated hematology analyzer.

Results

The coefficient of determination R² was 0.93 for both methods. Bland–Altman analysis displayed a mean bias of − 32.3 and − 8.1 cells/µl for PIMA and FACSPresto, respectively. Moreover, with a threshold of 350 CD4 count, PIMA displayed a sensitivity, specificity, PPV, NPV, were 88.57%, 94.12%, 91.18%, 92.31%; respectively. FACSPresto showed 88.23%, 96.23%, 93.75% and 92.73%; respectively. Furthermore, the upward misclassification percentage was 8.57 and 5.88%, for PIMA and FACSPresto, respectively; whereas the downward misclassification percentage was 7.84% and 7.54%; respectively. With 200 cells/µl threshold, PIMA had a sensitivity, specificity, PPV and NPV of 83.33%, 98.53%, 93.75% and 95.71%, respectively. Regarding FACSPresto, sensitivity, specificity, PPV and NPV was 82.35%, 98.57%, 88.57% and 95.83%; respectively. Upward misclassification percentage was 5.56% and 5.88%, for PIMA and FACSPresto, respectively; whereas downward misclassification percentage was 4.41% and 4.29%; respectively. Finally, the hemoglobin measurement evaluation displayed an R² of 0.80 and a mean bias of − 0.12 with a LOA between − 1.75 and 1.51.

Conclusion

When compared to the reference method, PIMA and FACSPresto have shown good performance, for CD4 counting. The introduction of such POC technology will speed up the uptake of patients in the continuum of HIV care, in our country.

Effects of Early and Delayed Antiretroviral Therapy on Plasma Anti-CD4 Autoreactive IgG and Its Association With CD4+ T-Cell Recovery in Acute HIV-Infected Individuals

Background

Plasma levels of anti-CD4 autoantibodies are increased in chronically HIV-infected patients and inversely correlated with CD4⁺ T-cell recovery under viral-suppressive antiretroviral therapy (ART). However, it remains unknown the effect of early ART on plasma anti-CD4 autoantibody levels in acute HIV infection (AHI).

Methods

In this cohort study, we evaluated the effect of early and delayed initiation of ART on plasma anti-CD4 autoantibody levels in AHI individuals (n = 90). Blood samples were collected from men who had sex with men (MSM) with acute infection, pre-ART, and 4, 24, 48, and 96 weeks after ART. Plasma levels of anti-CD4 immunoglobulin G (IgG) were measured by ELISA.

Results

We found that plasma anti-CD4 IgG levels were significantly increased in AHI individuals compared with healthy controls (HCs) prior to ART. Notably, early ART decreased plasma anti-CD4 IgG to the levels similar to HCs starting at 24 weeks (W). However, delayed initiation of ART did not significantly reduce plasma anti-CD4 IgG levels in AHI individuals. Moreover, the peripheral CD4⁺ T-cell counts were inversely correlated with plasma anti-CD4 IgG levels in AHI individuals at 48 and 96 W after early ART but not after delayed ART.

Conclusions

Taken together, our findings demonstrate for the first time that early ART, but not delayed initiation of ART, is effective in influencing anti-CD4 autoantibody production and recovering CD4⁺ T-cell counts in AHI individuals.

HIV Treatment Outcomes Among Patients Initiated on Antiretroviral Therapy Pre and Post-Universal Test and Treat Guidelines in South Africa

Introduction

Officially rolled out on 01 September 2016, South Africa’s Universal Test and Treat (UTT) policy calls for first-line antiretroviral treatment (ART) initiation among all known HIV-positive patients, irrespective of CD4 cell count. We evaluate treatment outcomes of patients initiated on first-line ART directly before and after the implementation of UTT.

Methods

We analysed prospectively collected clinical cohort data among ART-naïve adult patients within two HIV clinics in Johannesburg, South Africa. We compare two groups: 1) an unexposed pre-UTT group initiating treatment from 01 December 2014 to 31 May 2015; and 2) an exposed UTT group initiating treatment from 01 December 2016 to 31 May 2017. Primary treatment outcomes included lost to follow-up (LTFU) (>90 days late for the last scheduled visit with no subsequent clinical visit). Cox proportional hazards models were used to estimate the association between pre-UTT vs UTT initiation on LTFU by 12 months.

Results

We included 2410 patients. A total of 1267 (52.6%) patients initiated ART before UTT implementation and 1143 (47.4%) after the change in policy. LTFU (adjusted Hazard Ratio (aHR): 1.51; 95% Confidence Interval (CI): 1.16–1.98) between groups and specifically among those initiating with a CD4 cell count ≤500 cells/mm³ (aHR: 1.59; 95% CI: 1.21–2.10) was higher among patients initiating ART under UTT.

Conclusion

LTFU under UTT proved higher than that of previous periods. Patients initiating first-line therapy under the treat-all policy may often start treatment in better health, subsequently not perceiving a direct benefit to treatment which may deter patients from consistent engagement in HIV treatment programmes.

Association between changes in body fat distribution, biochemical profile, time of HIV diagnosis, and antiretroviral treatment in adults living with and without virus infection

OBJECTIVES

Individuals living with HIV seem to be more prone to changes in the redistribution of body fat, characterized as lipodystrophy, which may occur in conjunction with metabolic diseases. In the present study, such impacts were assessed in adults with and without HIV and associated with the time of virus diagnosis and treatment with antiretroviral.

METHODS

A cross-sectional study with 123 adults, in which 87 had HIV and 36 without HIV, of both sexes, in outpatient follow-up at the Specialized Care Service (SAE) in Macaé-RJ. The following were made: 1) Alteration in body fat distribution, measured by anthropometric parameters and self-reported lipodystrophy; 2) Biochemical profile; 3) Association between HIV diagnosis time and antiretroviral treatment.

RESULTS

54.47% (n = 67) males, 45.52% (n = 56) females, mean age 37 years. Of these 87 were people living with HIV, 29% (n = 25) had self-reported lipodystrophy, mean time of virus infection, and antiretroviral treatment (5.80 ± 4.56 and 5.14 ± 3.82 years), respectively. Patients with self-reported lipodystrophy had a greater change in body fat distribution between 3-6 years of HIV diagnosis and a negative cholesterol profile. The antiretroviral treatment time influenced total cholesterol and triglycerides, even for patients without self-reported lipodystrophy, with a further nine years under treatment.

CONCLUSION

In this study, the negative cholesterol profile was mainly related to antiretroviral treatment time, even for patients without self-reported lipodystrophy, and changes in body fat distribution, measured by anthropometry, was especially associated with time for HIV infection in those with lipodystrophy self-reported.

Rapid Initiation of Antiretroviral Therapy Following Diagnosis of Human Immunodeficiency Virus Among Patients with Commercial Insurance Coverage

BACKGROUND

New guidelines for the treatment of human immunodeficiency virus (HIV) advocate for rapid initiation of antiretroviral therapy (ART) ≤ 7 days after HIV diagnosis with agents that have a high genetic barrier to resistance, good tolerability, and convenient dosing.

OBJECTIVE

To describe characteristics, time to ART initiation, and health care costs in commercially insured patients living with HIV in the United States who are treated ≤ 60 days after HIV diagnosis.

METHODS

IBM MarketScan Research Databases (January 1, 2012-December 31, 2017) were used to identify ART-naive adults with HIV-1, ≥ 6 months of continuous eligibility before first HIV diagnosis, and ART initiation ≤ 60 days of first diagnosis. ART regimen had to include a protease inhibitor (PI), an integrase strand transfer inhibitor (INSTI), or a non-nucleoside reverse transcriptase inhibitor (NNRTI) with ≥ 2 nucleoside reverse transcriptase inhibitors. Cohorts were formed based on time to ART initiation after diagnosis: ≤ 7 days or 8-60 days. Health care costs were evaluated at 6, 12, 24, and 36 months after diagnosis among patients with ≥ 36 months of continuous eligibility.

RESULTS

Among 9,351 patients, median time to treatment was 31.0 days. Patients initiating ART > 60 days after HIV diagnosis were excluded (N = 2,608 [27.9%]), while 6,743 (72.1%) initiated ART ≤ 60 days after diagnosis and were analyzed; 18.3% and 81.7% were classified in the ≤ 7 days and 8-60 days cohorts, respectively. For all analyzed patients, mean age was 38.0 (SD = 12.0) years and 13.2% were female; 12.7%, 56.2%, and 31.1% initiated a PI, INSTI, or NNRTI-based regimen, respectively. Elvitegravir (32.9%), efavirenz (20.9%), dolutegravir (18.5%), and darunavir (8.5%) were the most commonly used antiretrovirals; most patients (74.3%) were initiated on single-tablet regimens. PI-based regimens were more common in the ≤ 7 days cohort (PI = 18.1%; darunavir = 11.4%) than in the 8-60 days cohort (PI = 11.5%; darunavir = 7.8%). INSTI-based regimens were more common in the 8-60 days cohort (INSTI = 57.7%; elvitegravir = 33.8%) than in the ≤ 7 days cohort (INSTI = 49.2%; elvitegravir = 29.1%). NNRTI-based regimens were as common in the ≤ 7 days (32.7%) and 8-60 days (30.7%) cohorts. Mean total accumulated costs were lower among patients in the ≤ 7 days cohort than in the 8-60 days cohort at all time points analyzed after diagnosis (e.g., 36 months: ≤ 7 days = $109,456; 8-60 days = $116,870). Total per-patient per-month costs decreased over time in the ≤ 7 days (i.e., 6 months = $4,359; 36 months = $3,040) and 8-60 days cohort (6 months = $4,727; 36 months = $3,246).

CONCLUSIONS

Although 72.1% of patients initiated ART ≤ 60 days after HIV diagnosis, only 18.3% initiated ART ≤ 7 days. Many patients initiating ART ≤ 7 days used suboptimal agents with low rather than high genetic barriers to resistance (i.e., efavirenz and elvitegravir) or agents (dolutegravir) coformulated with other antiretrovirals that require testing to prevent hypersensitivity reactions. Patients in the ≤ 7 days cohort showed lower total health care costs relative to those in the 8-60 days cohort, highlighting the potential long-term benefits of rapid ART initiation.

DISCLOSURES

This study was supported by Janssen Scientific Affairs, which was involved in the study design, interpretation of results, manuscript preparation, and publication decisions. Emond, Lefebvre, Lafeuille, and Côté-Sergent are employees of Analysis Group, a consulting company that was contracted by Janssen Scientific Affairs to conduct this study and develop the manuscript. Benson, Tandon, Chow, and Dunn are employees of Janssen Scientific Affairs and stockholders of Johnson & Johnson. Part of the material in this study has been presented at the AMCP 2019 Annual Meeting; March 25-28, 2019; San Diego, CA.

The short-term effects of the implementation of the "Treat All" guidelines on ART service delivery costs in Namibia

The introduction of "Treat All" (TA) has been promoted to increase the effectiveness of HIV/AIDS treatment by having patients initiate antiretroviral therapy at an earlier stage of their illness. The impact of introducing TA on the unit cost of treatment has been less clear. The following study evaluated how costs changed after Namibia's introduction of TA in April 2017. A two-year analysis assessed the costs of antiretroviral therapy (ART) during the 12 months before TA (Phase I-April 1, 2016 to March 31, 2017) and the 12 months following (Phase II-April 1, 2017 to March 31, 2018). The analysis involved interviewing staff at ten facilities throughout Namibia, collecting data on resources utilized in the treatment of ART patients and analyzing how costs changed before and after the introduction of TA. An analysis of treatment costs indicated that the unit cost of treatment declined from USD360 per patient per year in Phase I to USD301 per patient per year in Phase II, a reduction of 16%. This decline in unit costs was driven by 3 factors: 1) shifts in antiretroviral (ARV) regimens that resulted in lower costs for drugs and consumables, 2) negotiated reductions in the cost of viral load tests and 3) declines in personnel costs. It is unlikely that the first two of these factors were significantly influenced by the introduction of TA. It is unclear if TA might have had an influence on personnel costs. The reduction in personnel costs may have either represented a positive development (fewer personnel costs associated with increased numbers of healthier patients and fewer visits required) or alternatively may reflect constraints in Namibia's staffing. Prior to this study, it was expected that the introduction of TA would lead to a significant increase in the number of ART patients. However, there was less than a 4% increase in the number of adult patients at the 10 studied facilities. From a financial point of view, TA did not significantly increase the resources required in the ten sampled facilities, either by raising unit costs or significantly increasing the number of ART patients.

Antiretroviral treatment for HIV infection: Swedish recommendations 2019

The Swedish Reference Group for Antiviral Therapy (RAV) published recommendations for the treatment of HIV infection in this journal most recently in 2017. An expert group under the guidance of RAV here provides updated recommendations. The most important updates in the present guidelines are the following: (a) The risk of HIV transmission through condomless sex from individuals with fully suppressed HIV viral load is effectively zero. (b) Pre-exposure prophylaxis (PrEP) is recommended for groups with a high risk of HIV infection. (c) Since the last update, two new substances have been registered: bictegravir and doravirine. (d) Dual treatment may be an alternative in selected patients, using lamivudine + dolutegravir or lamivudine + boosted darunavir/atazanavir. As with previous publications, recommendations are evidence-graded in accordance with the Oxford Centre for Evidence Based Medicine. This document does not cover treatment of opportunistic infections and tumours.

Temporal changes in ART initiation in adults with high CD4 counts in Latin America: a cohort study

INTRODUCTION

In 2013, the World Health Organization (WHO) recommended initiating combination ART (cART) in all adults with HIV and CD4+ lymphocyte counts (CD4) <500 cells/mm3 . In 2015, this was updated to recommend cART initiation in all patients with HIV, regardless of CD4 count. Implementation of these guidelines in real-world settings has not been evaluated in Latin America. To assess changes in time to cART initiation during routine care, we estimated trends in time from enrolment in care to cART initiation in HIV-positive adults with high CD4 counts in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) during 2003 to 2017.

METHODS

All cART-naive individuals ≥18 years of age from 2003 to 2017 with CD4 ≥350 cells/mm3 and without AIDS at enrolment at five CCASAnet sites (Brazil, Chile, Honduras, Mexico and Peru) were included. Patients without information regarding AIDS-defining events were excluded. We estimated unadjusted median time from enrolment to cART initiation by calendar year using Kaplan-Meier methods and calculated adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for trends in cART initiation using Cox models and restricted cubic splines for continuous variables, accounting for age, sex, CD4 at enrolment, route of HIV transmission and clinic site.

RESULTS

Of the 3171 patients included, 1,650 (52%) had CD4 ≥500 cells/mm3 at enrolment. Median time to cART initiation after 2013 was 6.21 weeks (interquartile range (IQR): 1.89, 23.21), and 4.71 weeks (IQR: 1.43, 9.57) after 2015. Among 763 (24%) patients who never initiated cART, 33 (4.3%) were reported as deceased, 481 (63%) were lost to follow-up, and 249 (33%) were administratively censored before initiation. Adjusted probability of cART initiation greatly increased in recent years, in particular after 2013 and 2015 (2013 vs. 2003: HR = 7.14; 95% CI: 5.84 to 8.73, and 2015 vs. 2003: HR = 12.60; 95% CI: 10.37 to 15.32).

CONCLUSIONS

Time to cART initiation decreased substantially, roughly following changes in WHO guidelines in this real-world setting in Latin America. However, a very high proportion of patients never started cART, compromising retention in care and survival, as shown by their higher proportion of LTFU and death, which reinforce the notion that earlier treatment implementation strategies are needed.

Self-reported lipodystrophy, nutritional, lipemic profile and its impact on the body image of HIV-1-infected persons, with and without antiretroviral therapy

A cross-sectional study was conducted with 227 adults, 162 using antiretroviral therapy (ART), both sexes, in Secondary Immunodeficiency Outpatient Clinic of the Department of Dermatology of the Hospital das Clínicas of the Faculty of Medicine of University of São Paulo. The patients were grouped into 92 under ART and self-reported lipodystrophy (G1); 70 under ART and without self-reported lipodystrophy (G2); 65 without ART (G3). We evaluated: (1) self-reported lipodystrophy, self-perception and feeling about body image; (2) Anthropometric and lipemic profile. We included 67% (n = 152) male; 33% (n = 77) female. There was a negative impact of self-reported lipodystrophy on body image, where female was more critical, although it was significant for male (p = 0.014). BMI revealed excess weight in female (p = 0.058). Hip waist ratio was shown to be a better parameter than abdominal perimeter when measuring fat in central region of male and lipohypertrophy was characterized in both sexes. There was lipoatrophy in upper and lower limbs for individuals of the (G1) and the male of this group presented hypertriglyceridemia, (p = 0.012). There was a difference in sex, pattern of self - perceived morphologic alterations and feeling in relation to body image when associated with self - reported lipodystrophy, ART use, anthropometric and lipemic profile.

Long-term evolution of CD4+ cell count in patients under combined antiretroviral therapy

OBJECTIVE

Combined antiretroviral treatment (cART) results in profound immunologic improvement, but it is unclear whether CD4 cell counts return to levels similar to those of HIV-negative individuals. We explore long-term CD4 cell count evolution post-cART and its association with baseline levels, virologic suppression, pre-cART cumulative viremia and other factors.

DESIGN

Data were derived from the AMACS. Included individuals were adults who started cART, at least 2003, while previously ART-naive.

METHODS

Changes in CD4 cell counts were modeled through piecewise linear mixed models.

RESULTS

A total of 3405 individuals were included. The majority was male (86.0%), homosexual (58.8%) with median (IQR) age at cART initiation 36 (31-44) years and a median (IQR) follow-up of 3.9 (2.0-6.9) years. Most persons (57%) starting cART with less than 200 cells/μl did not reach 600 cells/μl after 7 years of treatment. Those starting cART with 200-349 CD4 cells/μl could reach 600 cells/μl within less than 2 years of fully suppressive treatment. Probability of CD4 normalization (i.e. >800 cells/μl) after 7 years of suppressive treatment was 24 and 46% for those starting treatment with less than 200 or 200-349 CD4 cells/μl, respectively. Lower pre-cART cumulative viremia was associated with faster CD4 recovery. CD4 cell count increases after 4 years were either insignificant or very slow, irrespectively of baseline levels.

CONCLUSION

cART initiation before CD4 cell count drops below 350 cells/μl is crucial for achieving normal CD4 levels. These findings underline the importance of timely diagnosis and cART initiation as the risk of both AIDS and non-AIDS-related morbidity/mortality remains increased in patients with incomplete CD4 recovery.

Brachial Artery Echogenicity and Grayscale Texture Changes in HIV-Infected Individuals Receiving Low-Dose Methotrexate

Objective- We evaluated the biological effects of low-dose methotrexate on 3 novel brachial artery grayscale ultrasound measures that may indicate subclinical arterial injury. Approach and Results- Exploratory analysis from a clinical trial of people with HIV infection at increased cardiovascular disease risk who were randomly assigned to low-dose methotrexate (target dose 15 mg/wk) or placebo. Brachial artery ultrasound grayscale median, gray level difference statistic texture-contrast (GLDS-CON), and gray level texture entropy were measured at baseline and after 24 weeks of intervention. Findings from the intention-to-treat (N=148) and adequately-dosed (N=118) populations were consistent, so the adequately-dosed population results are presented. Participants were a median (Q1, Q3) age of 54 (50, 60) years. After 24 weeks, the low-dose methotrexate intervention was associated with a 25.4% (-18.1, 58.6; P=0.007) increase in GLDS-CON compared with 1.3% (-29.1, 44.7; P=0.97) with placebo ( P=0.05) and a 0.10 u (-0.06, 0.23; P=0.026) increase in entropy compared with 0.02 u (-0.11, 0.14; P=0.54) with placebo ( P=0.14). At week 24, changes in CD4+ T cells correlated inversely with changes in GLDS-CON (ρ=-0.20; P=0.031), and entropy (ρ=-0.21; P=0.023). Changes in D-dimer levels, but no other inflammatory biomarkers, also correlated inversely with changes in GLDS-CON (ρ=-0.23; P=0.014) and entropy (ρ=-0.26; P=0.005). Conclusions- Brachial artery GLDS-CON and entropy increased after 24 weeks of low-dose methotrexate, though the latter was not significantly different from placebo. Grayscale changes were associated with decreases in CD4+ T-cell and D-dimer concentrations and may indicate favorable arterial structure changes.

[Ocular lesions in HIV-infected patients of the ophthalmic hospitals]

PURPOSE

To analyze ophthalmic pathologies in HIV-infected patients of the ophthalmic hospitals of Perm city.

MATERIAL AND METHODS

Medical records of 75 HIV patients registered in Perm Regional Centre for Prevention and Control of AIDS and Infectious Diseases who had received treatment in ophthalmic in-patient clinics of Perm in 2005-2015 years were analyzed retrospectively. Patient examination included traditional ophthalmological methods, as well as immunological (determination of CD4 cells and viral load), serological (detection of antibodies to herpes simplex virus, cytomegalovirus, chlamydia, toxoplasma), general clinical methods, and consultations by allied specialists.

RESULTS

Ophthalmopathology requiring in-patient care was detected in 75 people (84 eyes). Men comprised 76%, women - 24%; average age was 32.82±8.68 years. The stage of HIV infection was known in 78.66% of patients: stage II - in 5% of cases, stage III - in 32%, stage IV - in 63%. Co-infection (hepatitis B and C, syphilis, tuberculosis) was detected in 81% of patients. HIV-related diseases (cytomegalovirus and herpes infection, candidiasis, toxoplasmosis) were observed in 48% of individuals. The time of emergence of ocular pathology from the time of HIV detection ranged from 1 day to 14 years. Inflammatory ocular diseases occurred in 55% of cases, dystrophic disorders - in 18%, eye traumas - in 24%, and strabismus - in 3% of patients. Reduced level of CD4 (less than 500 cells/mm³) was more prevalent (72.13%) among the study patients. As of the time of the study, only 36.4% of patients were receiving antiretroviral therapy.

CONCLUSION

Among the studied individuals, eye lesion was mostly severe, inflammatory in nature; it occurred more frequently in stage IV HIV patients with reduced number of CD4 lymphocytes who was not receiving antiretroviral therapy.

Impact of initiation of combination antiretroviral therapy according to the WHO recommendations on the survival of HIV-positive patients in Taiwan

BACKGROUND/PURPOSE

Early initiation of antiretroviral therapy (ART) reduces the risks for serious infections and mortality. We aimed to assess the outcomes of initiating ART among HIV-positive Taiwanese according to the CD4 cut-off values by the WHO recommendations.

METHODS

We reviewed medical records of patients with newly diagnosed HIV infection between 2004 and 2015 and 3 groups of patients were defined according to the timing of ART initiation based on CD4 count recommended by WHO: Group 1 between 2004 and 2009; Group 2 between 2010 and 2012; and Group 3 between 2013 and 2015. The primary outcome was all-cause mortality. All patients were followed until 2 years after the last patient was included in each group.

RESULTS

Of 2022 patients included, the mortality rate was 18.28, 14.01, and 9.10 deaths per 1000 person-years of follow-up (PYFU) in Groups 1, 2, and 3, respectively. In multivariable Cox regression analysis, factors associated with mortality were age (per 1-year increase, adjusted hazard ratio [AHR], 1.06; 95% CI, 1.05-1.08), presence of AIDS-defining disease at HIV diagnosis (AHR, 4.81; 95% CI, 2.99-7.74), solid-organ malignancy (AHR, 3.10; 95% CI, 1.86-5.18), and initiation of ART (AHR, 0.09; 95% CI, 0.05-0.16). By competing risk regression model for non-AIDS-related death, the AHR for Group 3 versus Group 1 was 0.27 (95% CI, 0.09-0.80).

CONCLUSIONS

While continued efforts are needed to improve early diagnosis and linkage to care, initiation of cART improved survival among HIV-positive patients in Taiwan according to the increasing CD4 cut-off values that were recommended by the WHO.

Immunological and virologic outcomes of people living with HIV in Guangxi, China: 2012-2017

BACKGROUND

Limited data are available on clinical outcomes of people living with HIV (PLWH) in China, especially after the implementation of the 2016 national treatment guideline. The objective of the current study is to examine the treatment patterns, clinical outcomes and their associated factors among PLWH in Guangxi, China before and after this new guideline.

METHODS

Data from three community-based projects conducted at different time points over a period of six years (2012-2017) in Guangxi were analyzed in our study. The interviewer-administered questionnaire was used for data collection. Measures of clinical outcomes were retrieved from the patients' medical records. Descriptive analysis was employed to display treatment patterns and the time trends of clinical outcomes. Chi-square test or ANOVA was used to compare the differences in background characteristics and treatment history between different levels of clinical outcomes.

RESULTS

Among the pooled sample of 4224 participants, 77.3% were receiving antiretroviral therapy (ART), the median CD4 count was 328 cells/mm3, and 82.5% were virally suppressed. An increasing trend in both ART coverage (from 72.1% to 91.2%) and CD4 count (from 318 cells/mm3 to 357 cells/mm3) was observed over time in the three samples, while rates of viral suppression did not show a similar trend. A number of socio-demographic characteristics (e.g., female gender, younger age, Han ethnicity, and employment) and treatment-related variables (e.g., longer durations of HIV diagnosis and ART uptake, lower prevalence of comorbidity, fewer treatment interruptions, and more knowledge on ART) were associated with improved clinical outcomes.

CONCLUSIONS

We observed a high rate of viral suppression and increasing trends in ART coverage and CD4 count over six years in Guangxi, China. However, suboptimal clinical outcomes continue to be a problem, particularly among some subgroups of PLWH. Future clinical management strategies should be tailored for PLWH with different sociodemographic characteristics and treatment trajectories.

Determinants of survival of people living with HIV/AIDS on antiretroviral therapy in Brazil 2006-2015

Background

We compared AIDS-related mortality rates in people living with HIV (PLHIV) starting antiretroviral therapy (ART) in Brazil during 2006–2015 and examined associated risk factors .

Methods

Data on ART use in PLHIV and AIDS mortality in Brazil was analysed with piecewise constant exponential models. Mortality rates and hazard ratios were estimated for 0–6, 6–12, 13–24, 25–36 and > 36 months of ART use and adjusted for region, age, sex, baseline CD4 cell count and calendar year of ART initiation. An additional analysis restricted to those with data on risk group was also performed.

Results

269,076 individuals were included in the analysis, 165,643 (62%) males and 103,433 (38%) females, with 1,783,305 person-years of follow-up time. 21,749 AIDS deaths were reported and 8898 deaths occurred in the first year of ART. The risk of death in the first six months decreased with early ART initiation; those starting treatment early with CD4 > 500 cells per μL had a hazard ratio of 0.06 (95% CI 0.05–0.07) compared with CD4 < 200 cells per μL. Older age, male sex, intravenous drug use and starting treatment in earlier calendar years were associated with higher mortality rates. People living in the North, Northeast and South of Brazil experienced significantly higher AIDS mortality rates than those in the Southeast (HR 1.44, [95% CI 1.35–1.54], 1.10 [1.05–1.16] and 1.22 [1.17–1.28] respectively).

Conclusions

Early treatment is likely to have contributed to the improved survival in PLHIV on ART, with the greatest benefits observed in women, younger age-groups and those living in the North.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3844-3) contains supplementary material, which is available to authorized users.

Prevalence of hepatitis E infection in HIV/HCV-coinfected patients in Spain (2012-2014)

Hepatitis E virus (HEV) has emerged as a relevant pathogen for HIV-infected patients. However, there is scarce data on HEV infection in HIV/HCV-coinfected individuals with advanced fibrosis, which seems to increase the risk of HEV infection and worsen the prognosis of liver disease. We aimed to determine the prevalence of anti-HEV antibodies, acute hepatitis E, resolved hepatitis E, and exposure to HEV in HIV/HCV-coinfected patients and to evaluate associations with clinical and epidemiological characteristics. We performed a cross-sectional study on 198 HIV/HCV-coinfected patients, 30 healthy controls and 36 HIV-monoinfected patients. We found a low concordance between techniques used for detection of anti-HEV antibodies (ELISA versus Immunoblot), particularly in HIV/HCV-coinfected patients. HIV/HCV-coinfected patients showed the highest prevalence of IgG against HEV, resolved hepatitis E, and exposure to HEV (19.2%, 17.2%, and 22.2% respectively). However, we did not find any samples positive for HEV-RNA nor significant differences between groups. Moreover, HIV/HCV-coinfected patients with CD4 T-cells <350 cells/mm³ had higher prevalence for anti-HEV IgG antibodies, resolved hepatitis E, and exposure to HEV than healthy controls or those with CD4 T-cells ≥ 350 cells/mm³ (p = 0.034, p = 0.035, and p = 0.053; respectively). In conclusion, HIV/HCV-coinfected patients in Spain have a high prevalence for IgG anti-HEV antibodies, resolved hepatitis E, and exposure to HEV; particularly patients with CD4+T-cells <350 cells/mm³.

The 2018 Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS in HIV-Infected Koreans

Since the establishment of the Committee for Clinical Guidelines for the Diagnosis and Treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) by the Korean Society for AIDS in 2010, clinical guidelines have been prepared in 2011, 2013, and 2015. As new research findings on the epidemiology, diagnosis, and treatment of AIDS have been published in and outside of Korea along with the development and introduction of new antiretroviral medications, a need has arisen to revise the clinical guidelines by analyzing such new data. The clinical guidelines address the initial evaluation of patients diagnosed with HIV/AIDS, follow-up tests, appropriate timing of medication, appropriate antiretroviral medications, treatment strategies for patients who have concurrent infections with hepatitis B or C virus, and treatment in pregnant women. Through these clinical guidelines, the Korean Society for AIDS and the Committee for Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS would like to contribute to overcoming AIDS by delivering the latest data and treatment strategies to healthcare professionals who treat AIDS in the clinic.

Diagnosis of Human Immunodeficiency Virus Infection

HIV diagnostics have played a central role in the remarkable progress in identifying, staging, initiating, and monitoring infected individuals on life-saving antiretroviral therapy. They are also useful in surveillance and outbreak responses, allowing for assessment of disease burden and identification of vulnerable populations and transmission "hot spots," thus enabling planning, appropriate interventions, and allocation of appropriate funding. HIV diagnostics are critical in achieving epidemic control and require a hybrid of conventional laboratory-based diagnostic tests and new technologies, including point-of-care (POC) testing, to expand coverage, increase access, and positively impact patient management. In this review, we provide (i) a historical perspective on the evolution of HIV diagnostics (serologic and molecular) and their interplay with WHO normative guidelines, (ii) a description of the role of conventional and POC testing within the tiered laboratory diagnostic network, (iii) information on the evaluations and selection of appropriate diagnostics, (iv) a description of the quality management systems needed to ensure reliability of testing, and (v) strategies to increase access while reducing the time to return results to patients. Maintaining the central role of HIV diagnostics in programs requires periodic monitoring and optimization with quality assurance in order to inform adjustments or alignment to achieve epidemic control.

Non-AIDS-related comorbidities in people living with HIV-1 aged 50 years and older: The AGING POSITIVE study

OBJECTIVE

To characterize the profile of non-AIDS-related comorbidities (NARC) in the older HIV-1-infected population and to explore the factors associated with multiple NARC.

METHODS

This was a multicentre, cross-sectional study including HIV-1-infected patients aged ≥50 years, who were virologically suppressed and had been on a stable antiretroviral therapy (ART) regimen for at least 6 months. A multiple regression model explored the association between demographic and clinical variables and the number of NARC.

RESULTS

Overall, 401 patients were enrolled. The mean age of the patients was 59.3 years and 72.6% were male. The mean duration of HIV-1 infection was 12.0 years and the median exposure to ART was 10.0 years. The mean number of NARC was 2.1, and 34.7% of patients had three or more NARC. Hypercholesterolemia was the most frequent NARC (60.8%), followed by arterial hypertension (39.7%) and chronic depression/anxiety (23.9%). Arterial hypertension and diabetes mellitus were the most frequently treated NARC (95.6% and 92.6% of cases, respectively). The linear regression analysis showed a positive relationship between age and NARC (B=0.032, 95% confidence interval 0.015-0.049; p=0.0003) and between the duration of HIV-1 infection and NARC (B=0.039, 95% confidence interval 0.017-0.059; p=0.0005).

CONCLUSIONS

A high prevalence of NARC was found, the most common being metabolic, cardiovascular, and psychological conditions. NARC rates were similar to those reported for the general population, suggesting a larger societal problem beyond HIV infection. A multidisciplinary approach is essential to reduce the burden of complex multi-morbid conditions in the HIV-1-infected population.

Low HIV testing rates among US women who report anal sex and other HIV sexual risk behaviors, 2011-2015

OBJECTIVE

In 2016, 19% of HIV diagnoses were in women. About 40% of HIV infections in women aged 18-34 years have been attributed to anal sex, suggesting that women who report high risk behaviors such as anal sex might benefit from HIV testing and prevention with preexposure prophylaxis (PrEP). In this analysis, we estimated HIV testing rates among women who reported anal sex.

STUDY DESIGN

We analyzed data from the 2011-2015 National Survey of Family Growth to estimate the proportion of sexually active, nonpregnant US women aged 15-44 years who had an HIV test within the past year, stratified by those who reported anal sex and other risk factors, including ≥2 sexual partners, condomless sex with a new partner or multiple partners, gonorrhea in the past year, or any history of syphilis.

RESULTS

Overall, 7.9 million of 42.4 million sexually active, nonpregnant US women (18.7%) reported an HIV test within the past year. Among 42.4 million sexually active women, 9.0 million (20.1%) reported they had anal sex in the past year. Among these 9.0 million women, 19.2% reported that their providers asked about their type of intercourse, and 20.1% reported an HIV test within the past year. Overall, HIV testing was higher among women who reported anal sex and reported that their providers asked about type of sex than those whose provider did not ask (37.8% vs 15.9%; P < .001). HIV testing in the past year was higher for women with other risk behaviors compared with anal sex, ranging from 35.8% to 47.2%.

CONCLUSION

Overall, HIV testing rates within the past year were low among women with sexual behaviors that increase their risk of acquiring HIV and especially low among those who reported anal sex. Early detection and treatment of HIV, and HIV prevention with PrEP, are effective health services that protect women's health and well-being but that can be offered only based on HIV testing results. Women's health care providers are uniquely poised to assess risk for acquiring HIV, including taking a sexual history that asks about anal sex, and performing HIV testing to identify women who need HIV treatment or might benefit from PrEP.

In silico thrombin generation: Plasma composition imbalance and mortality in human immunodeficiency virus

Background

Effective HIV treatment with antiretroviral therapy has prolonged survival and shifted causes of death to non-AIDS illnesses such as cardiovascular disease. We have shown that inflammation and HIV viral load associate with pro- and anticoagulant factor imbalances resulting in increased thrombin generation when mathematically modeled. We explore the hypothesis that factor compositional imbalance, corresponding to increased in silico thrombin generation, predicts mortality among HIV+ persons.

Methods

In a nested case-control study of HIV+ individuals on continuous antiretroviral therapy in two large trials, we evaluated cases (any non-violent mortality, n = 114) and matched controls (n = 318). Thrombin generation in response to a tissue-factor initiator for each individual was calculated by a mathematical model incorporating levels of factors (F)II, V, VII, VIII, IX, X, antithrombin, tissue factor pathway inhibitor, and protein C (PC) measured at study entry to the trials. In silico thrombin generation metrics included clot time, maximum rate (MaxR), maximum level (MaxL), and area under the curve (AUC).

Results

Levels of antithrombin and PC decreased, while FV and FVIII were higher in cases vs controls. This resulted in a more procoagulant phenotype with increased MaxR, MaxL, and AUC in cases compared to controls (P < 0.05 for all).

Conclusions

Antithrombin, FV, FVIII, and PC were the major contributors to the increased thrombin generation associated with mortality risk. Our results suggest that mortality in HIV is associated with an increase in in silico thrombin generation via altered balance of pro- and anticoagulant factors, likely due to an inflammatory response signal, and resulting coagulopathy.

[Survival in HIV-1 patients receiving antiretroviral therapy in Morocco]

BACKGROUND

The purpose was to study factors associated with the survival of HIV-1 patients receiving antiretroviral therapy in Morocco.

MATERIAL AND METHOD

This was a retrospective study of a cohort of 182 HIV-1 patients receiving antiretroviral therapy in the department of dermatology venereology at the Military Instruction Hospital Mohamed V in Rabat during the period from 1 January 2006 to 1 January 2017. Death of any cause during the study period was considered to be the result of HIV infection. The log-rank test was used to compare the survival curves based on determinants. The Cox regression model analyzed the determinants of survival since induction of antiretroviral therapy.

RESULTS

The median follow-up time was 4.7 years (IQR: 1.97-8.18). The mortality rate was 75 deaths per 1000 person-years. Advanced clinical stage CDC C (RR: 2.72; CI 95%: 1.33-5.56) and treatment with indinavir (RR: 1.41; CI 95%: 0.77-2.59) were significantly associated with death.

CONCLUSION

Initiation of antiretroviral therapy in the early stage of the disease and use of less toxic molecules are recommended to reduce mortality.

Thai national guidelines for antiretroviral therapy in HIV-1 infected adults and adolescents 2010

In Thailand, more than 150,000 patients are currently treated with antiretroviral drugs under the support of the National AIDS Program (NAP). The appointed Adults and Adolescents Committee consisted of 28 members who are experts in HIV research, patient care or health care policy. Relevant published literature, guidelines, and the most recent relevant clinical trials presented internationally were reviewed. Several peer review and clinical studies conducted in Thailand were included in the review process. Special considerations for patients with co-infection of tuberculosis or hepatitis B were incorporated. Appropriate cut-off of CD4+ T-cell counts when to commence ART among Thai patients have been considered. It is now recommended to start ART at CD4+ T-cell count <350 cells/mm3. For treatment-naive patients, the preferred initial therapy is a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen containing lamivudine plus zidovudine or tenofovir. Stavudine will be phased out in a two-year plan at the national program level. Viral load and CD4+ T-cell counts should be monitored at least once and twice a year. To achieve long-term treatment success, enhancing adherence together with the proper management of antiretroviral-related toxicity is critical. In summary, the major changes from the Thai 2008 guidelines include commencing ART earlier. ART is recommended regardless of CD4+ T cell count if patients have an indication to treat their HBV co-infection. Preferred first regimen uses AZT or TDF, not d4T as the NRTI-backbone. Furthermore, efavirenz is now considered a preferred NNRTI, along with nevirapine.

Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics

BACKGROUND

Pharyngitis is a common disease in the emergency department (ED). Despite a relatively low incidence of complications, there are many dangerous conditions that can mimic this disease and are essential for the emergency physician to consider.

OBJECTIVE

This article provides a review of the evaluation and management of group A β-hemolytic Streptococcal (GABHS) pharyngitis, as well as important medical conditions that can mimic this disease.

DISCUSSION

GABHS pharyngitis often presents with fever, sore throat, tonsillar exudates, and anterior cervical lymphadenopathy. History and physical examination are insufficient for the diagnosis. The Centor criteria or McIsaac score can help risk stratify patients for subsequent testing or treatment. Antibiotics may reduce symptom duration and suppurative complications, but the effect is small. Rheumatic fever is uncommon in developed countries, and shared decision making is recommended if antibiotics are used for this indication. Oral analgesics and topical anesthetics are important for symptom management. Physicians should consider alternate diagnoses that may mimic GABHS pharyngitis, which can include epiglottitis, infectious mononucleosis, Kawasaki disease, acute retroviral syndrome, Lemierre's syndrome, Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, and viral pharyngitis. A focused history and physical examination can help differentiate these conditions.

CONCLUSIONS

GABHS may present similarly to other benign and potentially deadly diseases. Diagnosis and treatment of pharyngitis should be based on clinical evaluation. Consideration of pharyngitis mimics is important in the evaluation and management of ED patients.

Insulin Resistance in HIV-Patients: Causes and Consequences

Here we review how immune activation and insulin resistance contribute to the metabolic alterations observed in HIV-infected patients, and how these alterations increase the risk of developing CVD. The introduction and evolution of antiretroviral drugs over the past 25 years has completely changed the clinical prognosis of HIV-infected patients. The deaths of these individuals are now related to atherosclerotic CVDs, rather than from the viral infection itself. However, HIV infection, cART, and intestinal microbiota are associated with immune activation and insulin resistance, which can lead to the development of a variety of diseases and disorders, especially with regards to CVDs. The increase in LPS and proinflammatory cytokines circulating levels and intracellular mechanisms activate serine kinases, resulting in insulin receptor substrate-1 (IRS-1) serine phosphorylation and consequently a down regulation in insulin signaling. While lifestyle modifications and pharmaceutical interventions can be employed to treat these altered metabolic functions, the mechanisms involved in the development of these chronic complications remain largely unresolved. The elucidation and understanding of these mechanisms will give rise to new classes of drugs that will further improve the quality of life of HIV-infected patients, over the age of 50.