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Hatleberg CI, Ryom L, Kamara D, De Wit S, Law M, Phillips A, Reiss P, D'Arminio Monforte A, Mocroft A, Pradier C, Kirk O, Kovari H, Bonnet F, El-Sadr W, Lundgren JD, Sabin C. Predictors of Ischemic and Hemorrhagic Strokes Among People Living With HIV: The D:A:D International Prospective Multicohort Study. EClinicalMedicine 2019; 13:91-100. [PMID: 31517266 PMCID: PMC6737207 DOI: 10.1016/j.eclinm.2019.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 06/25/2019] [Accepted: 07/18/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Hypertension is a stronger predictor of hemorrhagic than ischemic strokes in the general population. We aimed to identify whether hypertension or other risk factors, including HIV-related factors, differ in their associations with stroke subtypes in people living with HIV (PLWHIV). METHODS HIV-1-positive individuals from the Data collection on Adverse events of anti-HIV Drugs (D:A:D) study were followed from the time of first blood pressure (BP) measurement after 1/1/1999 or study entry until the first of a validated stroke, 6 months after last follow-up or 1/2/2014. Stroke events were centrally validated using standardized criteria. Hypertension was defined as one systolic BP ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg. Poisson and Cox proportional hazards regression models determined associations of established cerebro/cardiovascular disease and HIV-related risk factors with stroke and tested whether these differed by stroke subtype. FINDINGS 590 strokes (83 hemorrhagic, 296 ischemic, 211 unknown) occurred over 339,979 person-years (PYRS) (incidence rate/1000 PYRS 1.74 [95% confidence interval (CI) 1.60-1.88]). Common predictors of both hemorrhagic and ischemic strokes were hypertension (relative hazard 3.55 [95% CI 2.29-5.50] and 2.24 [1.77-2.84] respectively) and older age (1.28 [1.17-1.39] and 1.19 [1.12-1.25]). Male gender (1.62 [1.14-2.31] and 0.60 [0.35-0.91]), previous cardiovascular events (4.03 [2.91-5.57] and 1.44 [0.66-3.16]) and smoking (1.90 [1.41-2.56] and 1.08 [0.68-1.71]) were stronger predictors of ischemic then hemorrhagic strokes, whereas hypertension, hepatitis C (1.32 [0.72-2.40] and 0.46 [0.30-0.70]) and estimated glomerular filtration rate < 60 mL/min/1.72 m3 (4.80 [2.47-9.36] and 1.04 [0.67-1.60]) were stronger predictors of hemorrhagic than ischemic strokes. A CD4 count < 200 cells/μL was associated with an increased risk of hemorrhagic stroke only. INTERPRETATION Risk factors for stroke may differ by subtype in PLWHIV, emphasizing the importance of further research to increase the precision of stroke risk estimation.
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Affiliation(s)
- Camilla Ingrid Hatleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark
- Corresponding author at: Dept. of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
| | - Lene Ryom
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark
| | - David Kamara
- Institute for Global Health, UCL, London, United Kingdom
| | - Stephane De Wit
- Division of Infectious Diseases, Saint Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Matthew Law
- The Kirby Institute, UNSW Australia, Sydney, Australia
| | | | - Peter Reiss
- Amsterdam University Medical Center (location AMC), Dept. of Global Health and Div. of Infectious Diseases, University of Amsterdam, Amsterdam, the Netherlands
- HIV Monitoring Foundation, Amsterdam, the Netherlands
| | - Antonella D'Arminio Monforte
- Dipartimento di Scienze della Salute, Clinica di Malattie Infettive e Tropicali, Azienda Ospedaliera-Polo Universitario San Paolo, Milan, Italy
| | - Amanda Mocroft
- Institute for Global Health, UCL, London, United Kingdom
| | | | - Ole Kirk
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark
| | - Helen Kovari
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Switzerland
| | - Fabrice Bonnet
- Université de Bordeaux, ISPED, INSERM U1219, CHU de Bordeaux, Bordeaux, France
| | - Wafaa El-Sadr
- ICAP-Columbia University, Harlem Hospital, New York, USA
| | - Jens D. Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark
| | - Caroline Sabin
- Institute for Global Health, UCL, London, United Kingdom
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Haddow LJ, Sudre CH, Sokolska M, Gilson RC, Williams IG, Golay X, Ourselin S, Winston A, Sabin CA, Cardoso MJ, Jäger HR, Boffito M, Mallon P, Post F, Sabin C, Sachikonye M, Winston A, Anderson J, Asboe D, Boffito M, Garvey L, Mallon P, Post F, Pozniak A, Sabin C, Sachikonye M, Vera J, Williams I, Winston A, Post F, Campbell L, Yurdakul S, Okumu S, Pollard L, Williams I, Otiko D, Phillips L, Laverick R, Beynon M, Salz AL, Fisher M, Clarke A, Vera J, Bexley A, Richardson C, Mallon P, Macken A, Ghavani-Kia B, Maher J, Byrne M, Flaherty A, Babu S, Anderson J, Mguni S, Clark R, Nevin-Dolan R, Pelluri S, Johnson M, Ngwu N, Hemat N, Jones M, Carroll A, Whitehouse A, Burgess L, Babalis D, Winston A, Garvey L, Underwood J, Stott M, McDonald L, Boffito M, Asboe D, Pozniak A, Higgs C, Seah E, Fletcher S, Anthonipillai M, Moyes A, Deats K, Syed I, Matthews C, Fernando P, Sabin C, De Francesco D, Bagkeris E. Magnetic Resonance Imaging of Cerebral Small Vessel Disease in Men Living with HIV and HIV-Negative Men Aged 50 and Above. AIDS Res Hum Retroviruses 2019; 35:453-460. [PMID: 30667282 DOI: 10.1089/aid.2018.0249] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
We assessed whether HIV status was associated with white matter hyperintensities (WMH), a neuroimaging correlate of cerebral small vessel disease (CSVD), in men aged ≥50 years. A cross-sectional substudy was nested within a larger cohort study. Virologically suppressed men living with HIV (MLWH) and demographically matched HIV-negative men aged ≥50 underwent magnetic resonance imaging (MRI) at 3 Tesla. Sequences included volumetric three-dimensional (3D) T1-weighted, fluid-attenuated inversion recovery and pseudocontinuous arterial spin labeling. Regional segmentation by automated image processing algorithms was used to extract WMH volume (WMHV) and resting cerebral blood flow (CBF). The association between HIV status and WMHV as a proportion of intracranial volume (ICV; log-transformed) was estimated using a multivariable linear regression model. Thirty-eight MLWH [median age 59 years (interquartile range, IQR 55-64)] and 37 HIV-negative [median 58 years (54-63)] men were analyzed. MLWH had median CD4+ count 570 (470-700) cells/μL and a median time since diagnosis of 20 (14-24) years. Framingham 10-year risk of cardiovascular disease was 6.5% in MLWH and 7.4% in controls. Two (5%) MLWH reported a history of stroke or transient ischemic attack and five (13%) reported coronary heart disease compared with none of the controls. The total WMHV in MLWH was 1,696 μL (IQR 1,229-3,268 μL) or 0.10% of ICV compared with 1,627 μL (IQR 1,032-3,077 μL), also 0.10% of ICV in the HIV-negative group (p = .43). In the multivariable model, WMHV/ICV was not associated with HIV status (p = .86). There was an age-dependent decline in cortical CBF [-3.9 mL/100 mL/min per decade of life (95% confidence interval 1.1-6.7 mL)] but no association between CBF and HIV status (p > .2 in all brain regions analyzed). In conclusion, we found no quantitative MRI evidence of an increased burden of CSVD in MLWH aged 50 years and older.
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Affiliation(s)
- Lewis J. Haddow
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
- Central and North West London NHS Foundation Trust, London, United Kingdom
| | - Carole H. Sudre
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Magdalena Sokolska
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Richard C. Gilson
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
- Central and North West London NHS Foundation Trust, London, United Kingdom
| | - Ian G. Williams
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
- Central and North West London NHS Foundation Trust, London, United Kingdom
| | - Xavier Golay
- Research Department of Brain Repair and Rehabilitation, University College London, London, United Kingdom
| | - Sebastien Ourselin
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Alan Winston
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Caroline A. Sabin
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
| | - M. Jorge Cardoso
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - H. Rolf Jäger
- Research Department of Brain Repair and Rehabilitation, University College London, London, United Kingdom
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Measurement of Retinal Vessels as a Biomarker of Cerebrovascular Aging in Older HIV-Positive Men Compared With Controls. J Acquir Immune Defic Syndr 2018; 77:199-205. [PMID: 29040166 DOI: 10.1097/qai.0000000000001570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND To compare retinal vascular measurements, biomarkers of cerebral small vessel disease, in HIV-positive men aged 50 years and older with similarly aged HIV-negative men and younger HIV-positive men. METHODS We recruited white, nondiabetic men into a cross-sectional substudy of a larger cohort including 3 demographically matched groups. Optic disc-centered 45-degree color fundus photographs were used to calculate central retinal arterial and venous caliber and the arterial-venous ratio (AVR). We used univariate and multivariable linear regression to compare retinal vessel measurements in the 3 groups and to identify factors associated with AVR. RESULTS All HIV-positive men were virologically suppressed. In a multivariable model, study group was not associated with AVR [adjusted β 0.010 for HIV-positive men <50 (n = 39) compared with HIV-positive men aged ≥50 years (n = 120), 95% confidence interval [CI] -0.018 to 0.038, P = 0.47; adjusted β 0.00002 for HIV-negative men ≥50 years (n = 52), 95% CI -0.022 to 0.022, P = 0.99]. Factors associated with lower AVR were systolic blood pressure (adjusted β -0.009 per +10 mm Hg, 95% CI -0.015 to -0.003, P = 0.002), history of stroke or transient ischemic attack (adjusted β -0.070, 95% CI -0.12 to -0.015, P = 0.01), and recent recreational drug use (adjusted β -0.037, 95% CI -0.057 to -0.018, P = 0.0002). CONCLUSIONS There were no differences in retinal vascular indices between HIV-positive men aged ≥50 years and HIV-negative men aged ≥50 years or HIV-positive men aged <50 years, suggesting that HIV is not associated with an increased burden of cerebral small vessel disease.
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Abstract
PURPOSE OF REVIEW The increasing prevalence of cardiovascular disease comorbidity in persons infected with the HIV has become a global concern. The electrocardiogram (ECG) is increasingly being utilized to provide clinically relevant information regarding cardiac arrhythmias and cardio-autonomic dysfunction. The purpose of this review is to summarize the latest research comparing QT and R-to-R interval length as a function of HIV+ status or antiretroviral therapy (ART) regimen. RECENT FINDINGS Prolongation of the corrected QTc interval may be acquired in HIV+ ART-naive individuals, exacerbated by various classes of ART drugs, and is generally predictive of lethal cardiac arrhythmias, with effects observed from childhood to adulthood. Recent literature also suggests the trend of lower heart rate variability in HIV is indicative of cardiorespiratory and inflammatory-immune dysfunction. SUMMARY These emergent studies support the clinical relevance of the ECG across the age and HIV disease spectrum. Furthermore, the reported findings have implications for the management of cardiovascular and chronic inflammatory disease comorbidity in persons living with HIV.
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Hatleberg CI, Ryom L, El‐Sadr W, Mocroft A, Reiss P, De Wit S, Dabis F, Pradier C, d'Arminio Monforte A, Kovari H, Law M, Lundgren JD, Sabin CA. Gender differences in the use of cardiovascular interventions in HIV-positive persons; the D:A:D Study. J Int AIDS Soc 2018; 21:e25083. [PMID: 29509305 PMCID: PMC5839235 DOI: 10.1002/jia2.25083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 01/29/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION There is paucity of data related to potential gender differences in the use of interventions to prevent and treat cardiovascular disease (CVD) among HIV-positive individuals. We investigated whether such differences exist in the observational D:A:D cohort study. METHODS Participants were followed from study enrolment until the earliest of death, six months after last visit or February 1, 2015. Initiation of CVD interventions [lipid-lowering drugs (LLDs), angiotensin-converting enzyme inhibitors (ACEIs), anti-hypertensives, invasive cardiovascular procedures (ICPs) were investigated and Poisson regression models calculated whether rates were lower among women than men, adjusting for potential confounders. RESULTS Women (n = 12,955) were generally at lower CVD risk than men (n = 36,094). Overall, initiation rates of CVD interventions were lower in women than men; LLDs: incidence rate 1.28 [1.21, 1.35] vs. 2.40 [2.34, 2.46]; ACEIs: 0.88 [0.82, 0.93] vs. 1.43 [1.39, 1.48]; anti-hypertensives: 1.40 [1.33, 1.47] vs. 1.72 [1.68, 1.77] and ICPs: 0.08 [0.06, 0.10] vs. 0.30 [0.28, 0.32], and this was also true for most CVD interventions when exclusively considering periods of follow-up for which individuals were at high CVD risk. In fully adjusted models, women were less likely to receive CVD interventions than men (LLDs: relative rate 0.83 [0.78, 0.88]; ACEIs: 0.93 [0.86, 1.01]; ICPs: 0.54 [0.43, 0.68]), except for the receipt of anti-hypertensives (1.17 [1.10, 1.25]). CONCLUSION The use of most CVD interventions was lower among women than men. Interventions are needed to ensure that all HIV-positive persons, particularly women, are appropriately monitored for CVD and, if required, receive appropriate CVD interventions.
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Affiliation(s)
- Camilla I Hatleberg
- Department of Infectious Diseases Section 2100CHIPUniversity of CopenhagenFinsencentretRigshospitaletCopenhagenDenmark
| | - Lene Ryom
- Department of Infectious Diseases Section 2100CHIPUniversity of CopenhagenFinsencentretRigshospitaletCopenhagenDenmark
| | - Wafaa El‐Sadr
- ICAP‐Columbia University and Harlem HospitalNew YorkNYUSA
| | | | - Peter Reiss
- Academic Medical CenterDepartment of Global Health and Division of Infectious DiseasesUniversity of AmsterdamHIV Monitoring FoundationAmsterdamThe Netherlands
| | - Stephane De Wit
- Division of Infectious DiseasesSaint Pierre University HospitalUniversité Libre de BruxellesBrusselsBelgium
| | - Francois Dabis
- CHU de Bordeaux and INSERM U897Université de BordeauxTalenceFrance
| | | | - Antonella d'Arminio Monforte
- Dipartimento di Scienze della SaluteClinica di Malattie Infettive e TropicaliAzienda Ospedaliera‐Polo Universitario San PaoloMilanItaly
| | - Helen Kovari
- Division of infectious diseases and hospital epidemiologyUniversity hospital ZurichUniversity of ZurichZurichSwitzerland
| | | | - Jens D Lundgren
- Department of Infectious Diseases Section 2100CHIPUniversity of CopenhagenFinsencentretRigshospitaletCopenhagenDenmark
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Wright EJ, Thakur KT, Bearden D, Birbeck GL. Global developments in HIV neurology. HANDBOOK OF CLINICAL NEUROLOGY 2018; 152:265-287. [PMID: 29604981 DOI: 10.1016/b978-0-444-63849-6.00019-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neurologic conditions associated with HIV remain major contributors to morbidity and mortality, and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence suggests that the central nervous system (CNS) serves as a reservoir for viral replication with major implications for human immunodeficiency virus (HIV) eradication strategies. Though there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of HIV-associated neurologic conditions, significant scientific gaps remain. In many low-income settings, second- and third-line cART regimens that carry substantial neurotoxicity remain treatment mainstays. Further, patients continue to present severely immunosuppressed with CNS opportunistic infections. Public health efforts should emphasize improvements in access and optimizing treatment of HIV-positive patients, specifically in resource-limited settings, to reduce the risk of neurologic sequelae.
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Affiliation(s)
- Edwina J Wright
- Department of Infectious Diseases, Alfred Health, Monash University, Melbourne, Australia; The Burnet Institute, Melbourne, Australia; Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.
| | - Kiran T Thakur
- Division of Critical Care and Hospitalist Neurology, Columbia University Medical Center, New York, NY, United States
| | - David Bearden
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Gretchen L Birbeck
- Strong Epilepsy Center, Department of Neurology, University of Rochester, Rochester, NY, United States; Chikankata Epilepsy Care Team, Chikankata Hospital, Mazabuka, Zambia
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Abstract
Effective combination antiretroviral therapy has transformed HIV infection into a chronic disease, with HIV-infected individuals living longer and reaching older age. Neurological disease remains common in treated HIV, however, due in part to ongoing inflammation and immune activation that persist in chronic infection. In this review, we highlight recent developments in our understanding of several clinically relevant neurologic complications that can occur in HIV infection despite treatment, including HIV-associated neurocognitive disorders, symptomatic CSF escape, cerebrovascular disease, and peripheral neuropathy.
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Affiliation(s)
- Nisha S Bhatia
- Department of Neurology, University of California, San Francisco, CA, USA.
| | - Felicia C Chow
- Departments of Neurology and Medicine (Infectious Diseases), University of California, San Francisco, CA, USA
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Relationship Between HIV Infection, Antiretroviral Therapy, Inflammatory Markers, and Cerebrovascular Endothelial Function Among Adults in Urban China. J Acquir Immune Defic Syndr 2017; 74:339-346. [PMID: 27875362 DOI: 10.1097/qai.0000000000001254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cerebrovascular risk is increased in people living with HIV infection compared with age-matched uninfected individuals. Cerebrovascular endothelial dysfunction related to antiretroviral therapy (ART) and inflammation may contribute to higher stroke risk in HIV infection. METHODS We compared cerebral vasoreactivity-a measure of cerebrovascular endothelial function assessed by the breath-holding index (BHI) using transcranial Doppler ultrasound-between virologically suppressed Chinese HIV-infected individuals followed in an HIV clinic in Beijing, China, and uninfected controls. We constructed mixed-effects models to evaluate the association of HIV, ART, and inflammatory markers with cerebral vasoreactivity. RESULTS In an unadjusted model, HIV infection was associated with a trend toward lower cerebral vasoreactivity (BHI 1.08 versus 1.26, P = 0.079). In multivariable analyses, cholesterol modified the association between HIV infection and cerebral vasoreactivity (P = 0.015 for interaction). At a lower total cholesterol of 4.15 mmol/L, HIV was associated with lower cerebral vasoreactivity (BHI -0.28, P = 0.019), whereas at a cholesterol of 5.15 mmol/L, the reduction in cerebral vasoreactivity associated with HIV was no longer statistically significant (BHI -0.05, P = 0.64). Among HIV-infected individuals, use of lopinavir/ritonavir compared with efavirenz was associated with lower cerebral vasoreactivity (BHI -0.24, P = 0.040). We did not find a significant association between inflammatory markers and cerebral vasoreactivity. CONCLUSIONS Cerebrovascular endothelial dysfunction associated with HIV infection may be most relevant for individuals with less traditional vascular risk, such as those with lower cholesterol. Further study of the impact of ART on cerebrovascular endothelial function is warranted to aid with ART selection in individuals at high cerebrovascular risk.
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D'Ascenzo F, Quadri G, Cerrato E, Calcagno A, Omedè P, Grosso Marra W, Abbate A, Bonora S, Biondi Zoccai G, Moretti C, Gaita F. A meta-analysis investigating incidence and features of stroke in HIV-infected patients in the highly active antiretroviral therapy era. J Cardiovasc Med (Hagerstown) 2016; 16:839-43. [PMID: 24979113 DOI: 10.2459/jcm.0b013e328365ca31] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Recent studies have suggested a close biological and clinical association between HIV infection and risk of myocardial infarction, whereas contrasting data have been reported about incidence of stroke and its clinical predictors. DESIGN AND SETTING Studies including HIV-infected patients developing a cerebral ischemic event were systematically searched for in MEDLINE/PubMed. PATIENTS AND MAIN OUTCOME MEASURES Baseline, treatment and outcome data were appraised and pooled with random-effects methods computing summary estimates (95% confidence intervals). RESULTS Five studies comprising 89,713 participants were included: they were young [46 (46-50) years, mainly male (70% (68-79)] with a moderate prevalence of diabetes [19% (14-21)]. Atrial fibrillation and history of previous coronary artery disease were observed in 3% (2-5) and 18% (15-22), respectively. All patients were on highly active antiretroviral therapy (HAART) and had been treated for a mean of 5 (2-6) years. After a median of 4 (3-5) years of follow-up, 1245 ischemic strokes occurred [1.78% (0.75-2.81)]. Traditional risk factors such as age (five studies), hypertension (three studies), smoking (two studies), hyperlipidemia (one study), atrial fibrillation (one study) and diabetes (one study) were identified as independent predictors of stroke. In one study, RNA viral load [log of odds ratio = 1.10 (1.04-1.17)] and CD4+ cell count less than 200/μl were clinically related to stroke, whereas HAART therapy showed a neutral effect. CONCLUSION Stroke represents a relatively common complication in young, HAART-treated HIV patients. Apart from traditional cardiovascular risk factors, HIV-RNA viral load may help to target and manage patients at risk.
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Affiliation(s)
- Fabrizio D'Ascenzo
- aDivision of Cardiology, University of Turin, Turin bDepartment of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy cVCU Pauley Heart Center, Richmond, Virginia, USA dUnit of Infectious Diseases, Department of Medical Sciences, University of Turin, Turin eMeta-analysis and Evidence Based Medicine Training in Cardiology (METCARDIO), Ospedaletti, Italy
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Burrowes S, Cahill P, Kottilil S, Bagchi S. Contribution of antiretroviral therapy to cardiovascular disease risk in HIV-infected patients. Future Virol 2016. [DOI: 10.2217/fvl-2016-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Rates of cardiovascular disease (CVD) are over twice as high in HIV-infected compared with uninfected patients, and this excess risk could be due to the effect of antiretroviral medications (ARVs) but the data regarding this are mixed. We described the literature on associations reported between classes and individual ARVs and rates of CVD and to changes in surrogate markers of subclinical CVD. Many PIs and certain NRTIs contribute to the development of CVD though recent generations of PIs appear to have less effect on development of CVD as assessed by surrogate measures of subclinical CVD. Future antiretroviral drug development efforts should include surrogate measures of subclinical cardiovascular to minimize the potential contributions of new ARVs to subclinical or clinical CVD.
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Affiliation(s)
- Shana Burrowes
- Department of Epidemiology & Human Genetics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Patrick Cahill
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shyamasundaran Kottilil
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shashwatee Bagchi
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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Lang S, Boccara F, Mary-Krause M, Cohen A. Epidemiology of coronary heart disease in HIV-infected versus uninfected individuals in developed countries. Arch Cardiovasc Dis 2015; 108:206-15. [DOI: 10.1016/j.acvd.2015.01.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 01/26/2015] [Accepted: 01/26/2015] [Indexed: 10/23/2022]
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Gillis J, Smieja M, Cescon A, Rourke SB, Burchell AN, Cooper C, Raboud JM. Risk of cardiovascular disease associated with HCV and HBV coinfection among antiretroviral-treated HIV-infected individuals. Antivir Ther 2015; 19:309-17. [PMID: 24429380 DOI: 10.3851/imp2724] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The increased risk for cardiovascular disease (CVD) in HIV is well established. Despite high prevalence of viral hepatitis coinfection with HIV, there are few studies on the risk of CVD amongst antiretroviral therapy (ART)-treated coinfected patients. METHODS Ontario HIV Treatment Network Cohort Study participants who initiated ART without prior CVD events were analysed. HBV and HCV coinfection were identified by serology and RNA test results. CVD was defined as any of: coronary artery disease including atherosclerosis, chronic ischaemic heart disease and arteriosclerotic vascular disease; myocardial infarction; congestive heart failure; cerebrovascular accident or stroke; coronary bypass; angioplasty; and sudden cardiac death. The impact of HBV and HCV coinfection on time to CVD was assessed using multivariable competing risk models accounting for left truncation between ART initiation and study enrolment. RESULTS A total of 3,416 HIV-monoinfected, 432 HIV-HBV- and 736 HIV-HCV-coinfected individuals were followed for a median (IQR) of 2.32 years (1.36-8.02). Over the study period, 167 CVD events and 613 deaths were documented. After adjustment for age, gender, race, year initiating ART, weight and smoking status, HBV was not associated with time to CVD onset (aHR=1.05, 95% CI [0.63, 1.74]; P=0.86). There was an elevated risk of CVD for HCV-coinfected individuals, which approached statistical significance (aHR=1.44, 95% CI [0.97, 2.13]; P=0.07). CONCLUSIONS Our results are consistent with a moderate increase of CVD among individuals with HIV-HCV coinfection relative to those with HIV infection alone, lending support to consideration of initiation of HCV antiviral treatment.
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Affiliation(s)
- Jennifer Gillis
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
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Lennox JL, Landovitz RJ, Ribaudo HJ, Ofotokun I, Na LH, Godfrey C, Kuritzkes DR, Sagar M, Brown TT, Cohn SE, McComsey GA, Aweeka F, Fichtenbaum CJ, Presti RM, Koletar SL, Haas DW, Patterson KB, Benson CA, Baugh BP, Leavitt RY, Rooney JF, Seekins D, Currier JS. Efficacy and tolerability of 3 nonnucleoside reverse transcriptase inhibitor-sparing antiretroviral regimens for treatment-naive volunteers infected with HIV-1: a randomized, controlled equivalence trial. Ann Intern Med 2014; 161:461-71. [PMID: 25285539 PMCID: PMC4412467 DOI: 10.7326/m14-1084] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Nonnucleoside reverse transcriptase inhibitor-based antiretroviral therapy is not suitable for all treatment-naive HIV-infected persons. OBJECTIVE To evaluate 3 nonnucleoside reverse transcriptase inhibitor-sparing initial antiretroviral regimens to show equivalence for virologic efficacy and tolerability. DESIGN A phase 3, open-label study randomized in a 1:1:1 ratio with follow-up for at least 96 weeks. (ClinicalTrials.gov: NCT00811954). SETTING 57 sites in the United States and Puerto Rico. PATIENTS Treatment-naive persons aged 18 years or older with HIV-1 RNA levels greater than 1000 copies/mL without resistance to nucleoside reverse transcriptase inhibitors or protease inhibitors. INTERVENTION Atazanavir, 300 mg/d, with ritonavir, 100 mg/d; raltegravir, 400 mg twice daily; or darunavir, 800 mg/d, with ritonavir, 100 mg/d, plus combination emtricitabine, 200 mg/d, and tenofovir disoproxil fumarate, 300 mg/d. MEASUREMENTS Virologic failure, defined as a confirmed HIV-1 RNA level greater than 1000 copies/mL at or after 16 weeks and before 24 weeks or greater than 200 copies/mL at or after 24 weeks, and tolerability failure, defined as discontinuation of atazanavir, raltegravir, or darunavir for toxicity. A secondary end point was a combination of virologic efficacy and tolerability. RESULTS Among 1809 participants, all pairwise comparisons of incidence of virologic failure over 96 weeks showed equivalence within a margin of equivalence defined as -10% to 10%. Raltegravir and ritonavir-boosted darunavir were equivalent for tolerability, whereas ritonavir-boosted atazanavir resulted in a 12.7% and 9.2% higher incidence of tolerability discontinuation than raltegravir and ritonavir-boosted darunavir, respectively, primarily because of hyperbilirubinemia. For combined virologic efficacy and tolerability, ritonavir-boosted darunavir was superior to ritonavir-boosted atazanavir, and raltegravir was superior to both protease inhibitors. Antiretroviral resistance at the time of virologic failure was rare but more frequent with raltegravir. LIMITATION The trial was open-label, and ritonavir was not provided. CONCLUSION Over 2 years, all 3 regimens attained high and equivalent rates of virologic control. Tolerability of regimens containing raltegravir or ritonavir-boosted darunavir was superior to that of the ritonavir-boosted atazanavir regimen. PRIMARY FUNDING SOURCE National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Jeffrey L. Lennox
- Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Raphael J. Landovitz
- Division of Infectious Diseases, Center for Clinical AIDS Research and Education, University of California, Los Angeles, CA
| | | | - Ighovwerha Ofotokun
- Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | | | - Catherine Godfrey
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD
| | | | - Manish Sagar
- Boston University, School of Medicine, Boston, MA
| | | | - Susan E. Cohn
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Francesca Aweeka
- University of California, San Francisco School of Pharmacy, San Francisco, CA
| | | | | | | | - David W. Haas
- Vanderbilt University School of Medicine, Nashville, TN
| | | | | | | | | | | | | | - Judith S. Currier
- Division of Infectious Diseases, Center for Clinical AIDS Research and Education, University of California, Los Angeles, CA
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Ramos-Sanchez EM, Goto H, Rivero DHRF, Mauad T, de Souza FN, Monteiro AM, Gidlund M. In vivo assessment of antiretroviral therapy-associated side effects. Mem Inst Oswaldo Cruz 2014; 109:484-7. [PMID: 25075786 PMCID: PMC4155852 DOI: 10.1590/0074-0276130559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 04/08/2014] [Indexed: 12/11/2022] Open
Abstract
Antiretroviral therapy has been associated with side effects, either from the drug itself or in conjunction with the effects of human immunodeficiency virus infection. Here, we evaluated the side effects of the protease inhibitor (PI) indinavir in hamsters consuming a normal or high-fat diet. Indinavir treatment increased the hamster death rate and resulted in an increase in triglyceride, cholesterol and glucose serum levels and a reduction in anti-oxLDL auto-antibodies. The treatment led to histopathological alterations of the kidney and the heart. These results suggest that hamsters are an interesting model for the study of the side effects of antiretroviral drugs, such as PIs.
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Affiliation(s)
- Eduardo Milton Ramos-Sanchez
- Departamento de Imunologia, Instituto de Ciências Biomédicas, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Hiro Goto
- Instituto de Medicina Tropical, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Thais Mauad
- Departamento de Patologia, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Fernando Nogueira de Souza
- Departamento de Clínica Médica, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Andrea Moreira Monteiro
- Departamento de Imunologia, Instituto de Ciências Biomédicas, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Magnus Gidlund
- Departamento de Imunologia, Instituto de Ciências Biomédicas, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, SP, Brasil
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Abstract
OBJECTIVE HIV-associated neurocognitive disorders (HANDs) remain prevalent in patients who receive HAART and may be associated with cumulative exposure to antiretroviral medications and other factors. We proposed that chronic toxic effects of antiretroviral drugs could contribute to cerebral small vessel disease (CSVD), which might be one of the key underpinnings of HAND. DESIGN Clinicopathological cross-sectional study of HIV-infected adults in the California NeuroAIDS Tissue Network. METHODS We employed multivariable logistic regression methods to determine associations between HAART exposure (protease inhibitor-based, nonprotease inhibitor-based, or no HAART) and CSVD occurrence (standard histopathology: moderate/severe, mild, or absent). We also associated HAND (relative to normal cognition) with CSVD, HIV-related neuropathologic changes, older age at death (≥50 years), sex, or hepatitis C virus infection. RESULTS We found that both mild and moderate/severe CSVD were associated with protease inhibitor-based HAART exposure after adjusting for diabetes mellitus [odds ratio (OR) 2.8 (95% confidence interval, CI 1.03-7.9) and 2.6 (95% CI 1.03-6.7), respectively, n = 134]. Moderate/severe CSVD was associated with diabetes after adjusting for HAART exposure [OR 7.4 (95% CI 1.6-70.7), n = 134]. Notably, HAND was associated with mild CSVD [OR 4.8 (95% CI 1.1-21.2), n = 63], which remained statistically significant after adjusting for vessel mineralization, HIV encephalitis, microglial nodular lesions, white matter lesions, or older age. CONCLUSION Protease inhibitor-based HAART exposure may increase the risk of CSVD and thereby neurocognitive impairment in HIV-infected adults. Apart from the possible direct toxicity to cerebral small vessels, protease inhibitor-based HAART may contribute indirectly to CSVD by inducing metabolic abnormalities.
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Abstract
Most infectious pathogens have anecdotal evidence to support a link with stroke, but certain pathogens have more robust associations, in which causation is probable. Few dedicated prospective studies of stroke in the setting of infection have been done. The use of head imaging, a clinical standard of diagnostic care, to confirm stroke and stroke type is not universal. Data for stroke are scarce in locations where infections are probably most common, making it difficult to reach conclusions on how populations differ in terms of risk of infectious stroke. The treatment of infections and stroke, when concomitant, is based on almost no evidence and requires dedicated efforts to understand variations that might exist. We highlight the present knowledge and emphasise the need for stronger evidence to assist in the diagnosis, treatment, and secondary prevention of stroke in patients in whom an infectious cause for stroke is probable.
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Longenecker CT, Triant VA. Initiation of antiretroviral therapy at high CD4 cell counts: does it reduce the risk of cardiovascular disease? Curr Opin HIV AIDS 2014; 9:54-62. [PMID: 24275676 PMCID: PMC4030754 DOI: 10.1097/coh.0000000000000015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Inflammation and immune activation associated with untreated HIV infection may increase the risk for cardiovascular disease (CVD) and are not entirely reversed by antiretroviral therapy (ART). Although older ART regimens were associated with drug-specific risks for CVD, this may not be true for modern ART. Thus, with regard to CVD risk, the net benefit of initiating ART at higher CD4 T-cell counts remains unclear. RECENT FINDINGS In addition to the well established risk of coronary heart disease, emerging evidence now suggests that chronic HIV infection is associated with higher risk of ischemic stroke, heart failure, and arrhythmias. These epidemiologic studies have associated immunodeficiency and active viral replication with higher CVD risk. Novel methods of imaging subclinical vascular disease continue to implicate inflammation and immune activation as likely mediators of CVD among patients with HIV. Newer generation protease inhibitors, chemokine receptor 5 antagonists, and integrase inhibitors do not appear to be associated with the adverse cardiometabolic risks of older drugs. SUMMARY Recent evidence suggests that treating HIV infection with ART may reduce the risk of CVD, even at higher CD4 T-cell counts; however, the definitive answer to this question will come from clinical trials and long-term observational studies.
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Affiliation(s)
- Chris T. Longenecker
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Virginia A. Triant
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Division of General Medicine, Massachusetts General Hospital, Boston, MA
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Abstract
The field of HIV medicine has changed rapidly in the last two decades since effective and tolerable antiretroviral treatment became available. As a result, although classical opportunistic infections of the brain have become less common, clinicians need to be aware of a wider range of acute and chronic complications of HIV and its treatment. In this article, we summarise major opportunistic infections, immune reconstitution inflammatory syndrome, HIV-associated neurocognitive disorders, and cerebrovascular disease in HIV positive patients. We also emphasise the preventability and reversibility of most of the central nervous system complications of HIV, and hence the importance of early diagnosis of HIV and involvement of clinicians with special expertise in HIV medicine.
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Affiliation(s)
- Lewis J Haddow
- Research Department of Infection and Population Health, University College London, UK
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Wongcharoen W, Khienprasit K, Phrommintikul A, Sukonthasarn A, Chattipakorn N. Heart rate variability and heart rate turbulence in HIV-infected patients receiving combination antiretroviral therapy. Ann Noninvasive Electrocardiol 2013; 18:450-6. [PMID: 24047489 DOI: 10.1111/anec.12064] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Previous studies have demonstrated the presence of autonomic dysfunction in human immunodeficiency virus (HIV)-infected patients. However, the data in those receiving combination antiretroviral therapy (cART) are conflicting. The aim of this study was to assess the autonomic function using heart rate variability (HRV) and heart rate turbulence (HRT) analysis in HIV-infected patients receiving cART. METHODS Eighty-one HIV-infected patients receiving cART and 42 control subjects were enrolled in the study. The HRV and HRT parameters were assessed on 24-hour digital Holter electrocardiogram recordings. RESULTS Baseline characteristics were comparable between HIV-infected and control subjects, except the higher fasting glucose and triglyceride and lower high-density lipoprotein cholesterol observed in HIV-infected patients. All components of HRV were significantly reduced in HIV-infected patients. After adjustment with biochemical parameters, most of the HRV parameters were still significantly reduced in HIV-infected patients. However, HRV parameters reflecting vagal activity were no longer different between 2 groups. In addition, HRT parameters did not differ between HIV-infected and control subjects. The standard deviation of normal-to-normal intervals significantly correlated with CD4 lymphocyte counts in HIV-infected patients but did not with protease inhibitors therapy. CONCLUSIONS We demonstrated the overall decrease in HRV in HIV-infected patients receiving cART. The metabolic disturbance observed in HIV-infected patients possibly accounted for decreased vagal activity.
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Affiliation(s)
- Wanwarang Wongcharoen
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Cardiac Electrophysiology Research and Training Center, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Singer EJ, Valdes-Sueiras M, Commins DL, Yong W, Carlson M. HIV stroke risk: evidence and implications. Ther Adv Chronic Dis 2013; 4:61-70. [PMID: 23556125 DOI: 10.1177/2040622312471840] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
An estimated 34 million men, women, and children are infected with human immunodeficiency virus type 1 (HIV-1), the virus that causes acquired immunodeficiency syndrome (AIDS). Current technology cannot eradicate HIV-1, and most patients with HIV-1-infection (HIV+) will require lifelong treatment with combined antiretroviral therapy (cART). Stroke was recognized as a complication of HIV-1 infection since the early days of the epidemic. Potential causes of stroke in HIV-1 include opportunistic infections, tumors, atherosclerosis, diabetes, hypertension, autoimmunity, coagulopathies, cardiovascular disease, and direct HIV-1 infection of the arterial wall. Ischemic stroke has emerged as a particularly significant neurological complication of HIV-1 and its treatment due to the aging of the HIV+ population, chronic HIV-1 infection, inflammation, and prolonged exposure to cART. New prevention and treatment strategies tailored to the needs of the HIV+ population are needed to address this issue.
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Affiliation(s)
- Elyse J Singer
- National Neurological AIDS Bank, Department of Neurology, David Geffen School of Medicine at UCLA, 11645 Wilshire Blvd, Suite 770, Los Angeles, CA 90025, USA
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De Clercq E. The nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors in the treatment of HIV infections (AIDS). ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2013; 67:317-58. [PMID: 23886005 DOI: 10.1016/b978-0-12-405880-4.00009-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The majority of the drugs currently used for the treatment of HIV infections (AIDS) belong to either of the following three classes: nucleoside reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs). At present, there are 7 NRTIs, 5 NNRTIs, and 10 PIs approved for clinical use. They are discussed from the following viewpoints: (i) chemical formulae; (ii) mechanism of action; (iii) drug combinations; (iv) clinical aspects; (v) preexposure prophylaxis; (vi) prevention of mother-to-child transmission; (vii) their use in children; (viii) toxicity; (ix) adherence (compliance); (x) resistance; (xi) new NRTIs, NNRTIs, or PIs in (pre)clinical development; and (xii) the prospects for a "cure" of the disease.
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Affiliation(s)
- Erik De Clercq
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium.
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Tseng ZH, Moyers B, Secemsky EA, Havlir DV, Hsue PY. PR Interval and sudden cardiac death in patients with HIV infection. J Infect Dis 2012. [PMID: 23186784 DOI: 10.1093/infdis/jis655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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