Viral Rebound Syndrome in Two HIV-1–Positive Patients after Structured Treatment Interruption

Interruptions of antiretroviral therapy in human immunodeficiency virus infection: are they detrimental to neurocognitive functioning?

Because interruptions of antiretroviral treatment may entail clinical risks for human immunodeficiency virus (HIV)-infected individuals, we investigated their impact on neurocognitive functioning. Cross-sectional study was carried out, comparing HIV-infected persons who had interrupted antiretroviral therapy in the past (interruption group, IG) with persons who had never discontinued therapy (noninterruption group, NIG). Interruption was defined as the discontinuation of highly active antiretroviral therapy (HAART) for more than 15 days after previous treatment of at least 15 days. All the participants were on therapy. Demographic, clinical, and neurocognitive variables were assessed. The primary end point was the percentage of people with neurocognitive impairment. The score in different neurocognitive domains was a secondary end point. A total of 83 subjects participated in the study (IG: n = 27; NIG: n = 56). Demographic and clinical characteristics were balanced between the groups, except for years since HIV diagnosis (IG, 13.8; NIG, 10.2 [P = .003]). The percentage of people with neurocognitive impairment was significantly higher in the IG group (IG, 59.25%; NIG, 33.92% [P = 0.02]). As for scores in neurocognitive domains, individuals in the IG showed worse neurocognitive functioning, and significant differences in attention/working memory and information processing speed were found. The adjusted analysis supported the unadjusted analysis. In this study, a higher prevalence of neurocognitive impairment was detected in HIV-infected persons who had interrupted antiretroviral therapy in the past. Additionally, neurocognitive functioning was observed to be more impaired in the same individuals. Further studies should examine the potential negative effects of antiretroviral therapy interruptions on neurocognitive functioning.

Short-term antiretroviral therapy to prevent mother-to-child transmission is safe and results in a sustained increase in CD4 T-cell counts in HIV-1-infected mothers

BACKGROUND

Short-term antiretroviral therapy (START) to prevent mother-to-child transmission (MTCT) is currently recommended for all HIV-1-infected pregnant women. The objective of this study was to assess the effect on CD4 cell counts and viral load dynamics the withdrawal of START after birth could generate.

METHODS

This was a 5-year cohort study involving HIV-1-infected pregnant women who presented with CD4 counts >300 cells/microL and had received START to prevent MTCT.

RESULTS

Seventy-five pregnancies were assessed. In 24 cases, there was a history of antiretroviral therapy prior to prophylaxis. The median baseline CD4 count was 573 cells/microL. In 75% of cases, prophylaxis was started after 26.6 weeks of gestation. The median CD4 cell count increase over baseline during prophylaxis was 24.5%. In only five cases did HIV-1 viral load remain detectable during prophylaxis. After START, CD4 cell counts did not drop significantly, and the HIV-1 viral load plateau was near the baseline level. The estimated mean time for CD4 count to fall below 300 cells/microL was 3.5 years and was directly associated with high baseline CD4 cell count, as well as with CD4 increase after prophylaxis, whereas it was negatively correlated with previous use of antiretroviral (ARV) drugs and persistence of detectable HIV-1 viral load during prophylaxis.

CONCLUSIONS

A potent, well-tolerated prophylactic ARV regimen can improve CD4 cell counts during and after START. In women receiving such prophylaxis, there is a remarkable time interval for CD4 cell counts to drop to levels that indicate treatment.

Virological rebound and its consequences during treatment interruption

PURPOSE OF REVIEW

This paper provides an overview of the current knowledge on virological rebound during treatment interruption and its consequences in patients with chronic HIV-1 infection.

RECENT FINDINGS

After interruption of antiretroviral therapy, plasma viremia inevitably returns to individual pretherapy set point levels in almost all patients with chronic HIV infection. This virological rebound leads to a state of massive immune activation and consequently an increased turnover of CD4+ and CD8+ T cells resulting in a biphasic decay of T-helper cell numbers. Rebound has been shown to be associated with an increased risk of clinical events by some (albeit not all) randomized trials published during the last few months. Secondary consequences of immunologic deterioration include worsening of comorbidity (e.g. hepatitis and renal impairment) and an increased risk of cardiovascular disease as well as an elevated HIV transmission risk during treatment interruption. The individual course after treatment interruption cannot be predicted by any of the known surrogate markers.

SUMMARY

Treatment interruptions cannot be recommended in HIV-infected patients outside clinical trials, especially when profound immune deficiency is found to be preexisting.