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Akagi Y, Tanaka K, Mawatari M, Toda Y, Kumasaka T, Ueda A. Clinical Characteristics of Retroviral Rebound Syndrome: A Case Report and Literature Review. Intern Med 2023; 62:1089-1093. [PMID: 37005296 PMCID: PMC10125823 DOI: 10.2169/internalmedicine.9661-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
We herein report a case of retroviral rebound syndrome (RRS) complicated with hemophagocytic lymphohistiocytosis. Owing to the paucity of comprehensive data on RRS, we also conducted a literature review. All 19 cases included in the review presented within 2 months after the discontinuation of antiretroviral therapy. They were usually accompanied by both a significant decrease in CD4 count (median 292/μL) and a rapid increase in plasma human immunodeficiency virus loads (median 3.5×105/mL). Although life-threatening complications were reported, the overall prognosis was favorable. The outcomes of this review aided in the diagnosis of the present case.
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Affiliation(s)
- Yu Akagi
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Japan
| | - Kosuke Tanaka
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Japan
| | - Momoko Mawatari
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Japan
| | - Yuta Toda
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Japan
| | - Toshio Kumasaka
- Department of Pathology, Japanese Red Cross Medical Center, Japan
| | - Akihiro Ueda
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Japan
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2
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Gilbertson A, Tucker JD, Dubé K, Dijkstra M, Rennie S. Ethical considerations for HIV remission clinical research involving participants diagnosed during acute HIV infection. BMC Med Ethics 2021; 22:169. [PMID: 34961509 PMCID: PMC8714439 DOI: 10.1186/s12910-021-00716-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/20/2021] [Indexed: 11/16/2022] Open
Abstract
HIV remission clinical researchers are increasingly seeking study participants who are diagnosed and treated during acute HIV infection—the brief period between infection and the point when the body creates detectable HIV antibodies. This earliest stage of infection is often marked by flu-like illness and may be an especially tumultuous period of confusion, guilt, anger, and uncertainty. Such experiences may present added ethical challenges for HIV research recruitment, participation, and retention. The purpose of this paper is to identify potential ethical challenges associated with involving acutely diagnosed people living with HIV in remission research and considerations for how to mitigate them. We identify three domains of potential ethical concern for clinicians, researchers, and ethics committee members to consider: 1) Recruitment and informed consent; (2) Transmission risks and partner protection; and (3) Ancillary and continuing care. We discuss each of these domains with the aim of inspiring further work to advance the ethical conduct of HIV remission research. For example, experiences of confusion and uncertainty regarding illness and diagnosis during acute HIV infection may complicate informed consent procedures in studies that seek to recruit directly after diagnosis. To address this, it may be appropriate to use staged re-consent procedures or comprehension assessment. Responsible conduct of research requires a broad understanding of acute HIV infection that encompasses its biomedical, psychological, social, and behavioral dimensions. We argue that the lived experience of acute HIV infection may introduce ethical concerns that researchers and reviewers should address during study design and ethical approval.
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Affiliation(s)
- Adam Gilbertson
- Pacific Institute for Research and Evaluation, Chapel Hill Center, 101 Conner Drive, Suite 200, Chapel Hill, NC, 27514-7038, USA. .,UNC Center for Bioethics, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Joseph D Tucker
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WCE1, UK.,UNC Project-China, 2 Lujing Road, Guangzhou, China
| | - Karine Dubé
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maartje Dijkstra
- Department of Infectious Diseases, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, The Netherlands
| | - Stuart Rennie
- UNC Center for Bioethics, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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Hellmuth J, Muccini C, Colby DJ, Kroon E, de Souza M, Crowell TA, Chan P, Sacdalan C, Intasan J, Benjapornpong K, Tipsuk S, Puttamaswin S, Chomchey N, Valcour V, Sarnecki M, Tomaka F, Krebs SJ, Slike BM, Jagodzinski LL, Dumrongpisutikul N, Sailasuta N, Samboju V, Michael NL, Robb ML, Vasan S, Ananworanich J, Phanuphak P, Phanuphak N, Paul R, Spudich S. Central nervous system safety during brief analytic treatment interruption of antiretroviral therapy within four HIV remission trials: an observational study in acutely treated people living with HIV. Clin Infect Dis 2020; 73:e1885-e1892. [PMID: 32916708 DOI: 10.1093/cid/ciaa1344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/09/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The central nervous system (CNS) is a likely reservoir of HIV, vulnerable to viral rebound, inflammation, and clinical changes upon stopping antiretroviral therapy (ART). It is critical to evaluate the CNS safety of studies using analytic treatment interruption (ATI) to assess HIV remission. METHODS Thirty participants who started ART during acute HIV infection underwent CNS assessments across four ATI remission trials. ART resumption occurred with plasma viral load >1000 copies/mL. CNS measures included paired pre- vs. post-ATI measures of mood, cognitive performance, and neurologic examination, with elective cerebrospinal fluid (CSF) sampling, brain diffusion tensor imaging (DTI) and magnetic resonance spectroscopy (MRS). RESULTS Median participant age was 30 years old and 29/30 were male. Participants' median time on ART prior to ATI was 3 years, and ATI lasted a median of 35 days. Post-ATI, there were no differences in median mood scores or neurologic findings and cognitive performance improved modestly. During ATI, a low level of CSF HIV-1 RNA was detectable in six of 20 participants with plasma viremia, with no group changes in CSF immune activation markers or brain DTI measures. Mild worsening was identified in post-ATI basal ganglia total choline MRS, suggesting an alteration in neuronal membranes. CONCLUSION No adverse CNS effects were observed with brief, closely-monitored ATI in participants with acutely treated HIV, except a MRS alteration in basal ganglia choline. Further studies are needed to assess CNS ATI safety in HIV remission trials, particularly for studies using higher thresholds to restart ART and longer ATI durations.
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Affiliation(s)
- Joanna Hellmuth
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, California, USA
| | - Camilla Muccini
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Donn J Colby
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Eugène Kroon
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Mark de Souza
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Trevor A Crowell
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Phillip Chan
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Carlo Sacdalan
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Jintana Intasan
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Somporn Tipsuk
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Nitiya Chomchey
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Victor Valcour
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, California, USA
| | | | - Frank Tomaka
- Janssen Research & Development LLC, Titusville, NJ, USA
| | - Shelly J Krebs
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Bonnie M Slike
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Linda L Jagodzinski
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | | | - Napapon Sailasuta
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, University of Hawaii, Honolulu, Hawaii, USA
| | - Vishal Samboju
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, California, USA
| | - Nelson L Michael
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Merlin L Robb
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Sandhya Vasan
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Jintanat Ananworanich
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Department of Global Health, The University of Amsterdam, Amsterdam, The Netherlands
| | - Praphan Phanuphak
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Robert Paul
- Missouri Institute of Mental Health, University of Missouri-St. Louis, MO, USA
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Julg B, Dee L, Ananworanich J, Barouch DH, Bar K, Caskey M, Colby DJ, Dawson L, Dong KL, Dubé K, Eron J, Frater J, Gandhi RT, Geleziunas R, Goulder P, Hanna GJ, Jefferys R, Johnston R, Kuritzkes D, Li JZ, Likhitwonnawut U, van Lunzen J, Martinez-Picado J, Miller V, Montaner LJ, Nixon DF, Palm D, Pantaleo G, Peay H, Persaud D, Salzwedel J, Salzwedel K, Schacker T, Sheikh V, Søgaard OS, Spudich S, Stephenson K, Sugarman J, Taylor J, Tebas P, Tiemessen CT, Tressler R, Weiss CD, Zheng L, Robb ML, Michael NL, Mellors JW, Deeks SG, Walker BD. Recommendations for analytical antiretroviral treatment interruptions in HIV research trials-report of a consensus meeting. Lancet HIV 2019; 6:e259-e268. [PMID: 30885693 PMCID: PMC6688772 DOI: 10.1016/s2352-3018(19)30052-9] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/11/2019] [Accepted: 02/12/2019] [Indexed: 04/16/2023]
Abstract
Analytical antiretroviral treatment interruption (ATI) is an important feature of HIV research, seeking to achieve sustained viral suppression in the absence of antiretroviral therapy (ART) when the goal is to measure effects of novel therapeutic interventions on time to viral load rebound or altered viral setpoint. Trials with ATIs also intend to determine host, virological, and immunological markers that are predictive of sustained viral control off ART. Although ATI is increasingly incorporated into proof-of-concept trials, no consensus has been reached on strategies to maximise its utility and minimise its risks. In addition, differences in ATI trial designs hinder the ability to compare efficacy and safety of interventions across trials. Therefore, we held a meeting of stakeholders from many interest groups, including scientists, clinicians, ethicists, social scientists, regulators, people living with HIV, and advocacy groups, to discuss the main challenges concerning ATI studies and to formulate recommendations with an emphasis on strategies for risk mitigation and monitoring, ART resumption criteria, and ethical considerations. In this Review, we present the major points of discussion and consensus views achieved with the goal of informing the conduct of ATIs to maximise the knowledge gained and minimise the risk to participants in clinical HIV research.
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Affiliation(s)
- Boris Julg
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA; Infectious Disease Division, Massachusetts General Hospital, Boston, MA, USA.
| | - Lynda Dee
- AIDS Action Baltimore, Baltimore, MD, USA
| | | | - Dan H Barouch
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Katharine Bar
- Department of Medicine, University of Pennsylvania, Pennsylvania, PA, USA
| | - Marina Caskey
- Laboratory of Molecular Immunology, Rockefeller University, New York, NY, USA
| | - Donn J Colby
- Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - Liza Dawson
- National Institute of Allergy and Infectious Diseases, Fishers ln Rockville, MD, USA
| | - Krista L Dong
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA; University of KwaZulu Natal, Durban, South Africa
| | - Karine Dubé
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Joseph Eron
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - John Frater
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford National Institute of Health Research Biomedical Research Centre, Oxford, UK
| | - Rajesh T Gandhi
- Infectious Disease Division, Massachusetts General Hospital, Boston, MA, USA
| | | | - Philip Goulder
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | | | - Daniel Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Cambridge, MA, USA
| | - Jonathan Z Li
- Division of Infectious Diseases, Brigham and Women's Hospital, Cambridge, MA, USA
| | | | | | - Javier Martinez-Picado
- AIDS Research Institute IrsiCaixa, Barcelona, Spain; Catalan Institution for Research and Advanced Studies, Barcelona, Spain; University of Vic-Central University of Catalonia, Barcelona, Spain
| | | | - Luis J Montaner
- The Montaner Laboratory, The Wistar Institute, Philadelphia, PA, USA
| | - Douglas F Nixon
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical College, New York City, NY, USA
| | - David Palm
- Global HIV Prevention, and Treatment Clinical Trials Unit, University of North Carolina, Chapel Hill, NC, USA
| | - Giuseppe Pantaleo
- Service Immunology and Allergy, and Swiss Vaccine Research Institute, Centre Hospitalier Universitaire, Lausanne, Switzerland
| | - Holly Peay
- Research Triangle Institute, Research Triangle Park, NC, USA
| | - Deborah Persaud
- Pediatrics Infectious Disease, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | - Karl Salzwedel
- National Institute of Allergy and Infectious Diseases, Fishers ln Rockville, MD, USA
| | - Timothy Schacker
- Division of Infectious Disease and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Virginia Sheikh
- Division of Antiviral Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ole S Søgaard
- Department of Infectious Diseases, Aarhus University, Aarhus, Denmark
| | - Serena Spudich
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Kathryn Stephenson
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, University of North Carolina, Chapel Hill, NC, USA
| | - Jeff Taylor
- Collaboratory for AIDS Researchers for Eradication, University of North Carolina, Chapel Hill, NC, USA
| | - Pablo Tebas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline T Tiemessen
- Cell Biology Research Laboratory, Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Randall Tressler
- National Institute of Allergy and Infectious Diseases, Fishers ln Rockville, MD, USA
| | - Carol D Weiss
- Division of Antiviral Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Lu Zheng
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Merlin L Robb
- US Military HIV Research Program, Henry Jackson Foundation, Bethesda, MD, USA
| | - Nelson L Michael
- US Military HIV Research Program, Henry Jackson Foundation, Bethesda, MD, USA
| | - John W Mellors
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven G Deeks
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Bruce D Walker
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA; Howard Hughes Medical Institute, Chevy Chase, MD, USA
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5
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Affiliation(s)
- David R Boulware
- From the Department of Medicine, University of Minnesota Medical Center and University of Minnesota Medical School, Minneapolis (D.R.B.); and the Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (A.T.M.)
| | - A Tariro Makadzange
- From the Department of Medicine, University of Minnesota Medical Center and University of Minnesota Medical School, Minneapolis (D.R.B.); and the Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (A.T.M.)
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Abstract
Combination antiretroviral therapy (cART) is highly effective at preventing morbidity and mortality due to infection with human immunodeficiency virus (HIV), but does not eradicate the virus. Consequently, cART must be administered life-long. Recent progress has stimulated research towards a cure of HIV infection. Approaches under investigation include hematopoietic stem cell transplantation, latency reactivating agents, immune based therapies, and cell-based therapies. Each of these approaches carries potential risks that must be weighed against the availability of safe and effective cART. Balancing the risks and benefits of this research poses unique challenges to potential study participants, clinicians and investigators.
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Affiliation(s)
- Daniel R Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Abstract
CNS infection is a nearly constant facet of systemic CNS infection and is generally well controlled by suppressive systemic antiretroviral therapy (ART). However, there are instances when HIV can be detected in the cerebrospinal fluid (CSF) despite suppression of plasma viruses below the clinical limits of measurement. We review three types of CSF viral escape: asymptomatic, neuro-symptomatic, and secondary. The first, asymptomatic CSF escape, is seemingly benign and characterized by lack of discernable neurological deterioration or subsequent CNS disease progression. Neuro-symptomatic CSF escape is an uncommon, but important, entity characterized by new or progressive CNS disease that is critical to recognize clinically because of its management implications. Finally, secondary CSF escape, which may be even more uncommon, is defined by an increase of CSF HIV replication in association with a concomitant non-HIV infection, as a consequence of the local inflammatory response. Understanding these CSF escape settings not only is important for clinical diagnosis and management but also may provide insight into the CNS HIV reservoir.
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8
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Affiliation(s)
- Nir Eyal
- Division of Medical Ethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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9
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Intracranial hypertension following highly active antiretroviral therapy interruption in an HIV-infected woman: case report and review of the literature. AIDS 2013; 27:668-70. [PMID: 23364446 DOI: 10.1097/qad.0b013e32835db0af] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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del Saz SV, Sued O, Falcó V, Agüero F, Crespo M, Pumarola T, Curran A, Gatell JM, Pahissa A, Miró JM, Ribera E. Acute meningoencephalitis due to human immunodeficiency virus type 1 infection in 13 patients: clinical description and follow-up. J Neurovirol 2010; 14:474-9. [PMID: 19037815 DOI: 10.1080/13550280802195367] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The objective of this study is to describe a series of cases of severe meningitis caused by human immunodeficiency virus type 1 (HIV-1) occurring during primary infection or after antiretroviral treatment interruption. In an observational cohort study, 13 patients with clinical diagnosis of meningitis or meningoencephalitis were reviewed. Ten cases occurred during primary HIV-1 infection and 3 after antiretroviral therapy (ART) withdrawal. Demographic parameters, clinical presentation and outcome, and laboratory and cerebrospinal fluid (CSF) parameters were recorded. The risk factor for HIV-1 infection acquisition was sexual transmission in all cases. The most frequent systemic symptoms were fever (12/13) and headeache (9/13). Among neurologic symptoms, focal signs appeared in seven patients (53.8%), confusion in six (46.2%), and agitation in five (38.5%). The median CD4 cell count was 434 cells/mm3. In all cases, CSF was a clear lymphocytaire fluid with normal glucose levels. Cranial computerized tomography was performed in seven patients, with a normal result in all of them; brain magnetic resonance in eight patients was normal in five cases and showing cortical atrophy, limbic encephalitis, and leptomeningeal enhancement in one patient each. The electroencephalographs (EEG) just showed diffuse dysfunction in three cases. ART was started in 11 patients. HIV RNA load at 12 months was <50 copies/ml in all treated patients. The 13 patients recovered without neurologic sequela. Meningitis or meningoencephalitis during primary HIV-1 infection or after ART cessation are unusual but sometimes a life-threatening manifestation. Although all patients tend to recover and the necessity of ART is not well established, some data suggest its potential benefit in these patients.
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Affiliation(s)
- S Villar del Saz
- Hospital Universitari Vall d'Hebron, Infectious Diseases Department, Autonomous University of Barcelona, Barcelona, Spain.
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Palacios R, Senise J, Vaz M, Diaz R, Castelo A. 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. HIV Med 2010; 10:157-62. [PMID: 19245537 DOI: 10.1111/j.1468-1293.2008.00665.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- R Palacios
- Multidisciplinary Group for Infectious Diseases on Pregnancy - NUPAIG - Hospital São Paulo, UNIFESP (Federal University of Sao Paulo), Sao Paulo, Brazil.
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Abstract
The human immunodeficiency virus (HIV), the cause of AIDS, has infected an estimated 33 million individuals worldwide. HIV is associated with immunodeficiency, neoplasia, and neurologic disease. The continuing evolution of the HIV epidemic has spurred an intense interest in a hitherto neglected area of medicine, neuroinfectious diseases and their consequences. This work has broad applications for the study of central nervous system (CNS) tumors, dementias, neuropathies, and CNS disease in other immunosuppressed individuals. HIV is neuroinvasive (can enter the CNS), neurotrophic (can live in neural tissues), and neurovirulent (causes disease of the nervous system). This article reviews the HIV-associated neurologic syndromes, which can be classified as primary HIV neurologic disease (in which HIV is both necessary and sufficient to cause the illness), secondary or opportunistic neurologic disease (in which HIV interacts with other pathogens, resulting in opportunistic infections and tumors), and treatment-related neurologic disease (such as immune reconstitution inflammatory syndrome).
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Affiliation(s)
- Elyse J Singer
- Department of Neurology, David Geffen School of Medicine at UCLA, 11645 Wilshire Boulevard, Suite 770, Los Angeles, CA 90025, USA.
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13
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Pogány K, van Valkengoed IGM, Vanvalkengoed IG, Prins JM, Nieuwkerk PT, van der Ende I, Kauffmann RH, Kroon FP, Verbon A, Nievaard MF, Lange JMA, Brinkman K. Effects of Active Treatment Discontinuation in Patients With a CD4+ T-Cell Nadir Greater Than 350 Cells/mm3. J Acquir Immune Defic Syndr 2007; 44:395-400. [PMID: 17195761 DOI: 10.1097/qai.0b013e31802f83bc] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of discontinuing highly active antiretroviral therapy (HAART) in HIV-1-positive patients who initiated HAART at a CD4+ T-cell count >350 cells/mm. METHODS Eligible patients were identified from the Dutch AIDS Therapy Evaluation, The Netherlands (ATHENA) national observational cohort. Interruption or continuation of HAART was offered to all. RESULTS Of 71 patients enrolled, 46 (64%) interrupted HAART (STOP group) and 25 (36%) continued HAART (control group). The median CD4+ T-cell nadirs at the start of HAART were 469 (interquartile range [IQR]: 430-720) cells/mm3 and 510 (IQR: 440-637) cells/mm3, respectively. At week 48, the median plasma HIV RNA level in the STOP group had stabilized at approximately pre-HAART values (4.55 log10, IQR: 4.2-4.9 copies/mL), but the CD4+ T-cell count still exceeded the pre-HAART count (563 cells/mm3, IQR: 450-710 cells/mm3). Only 5 patients (11%) had reinitiated HAART after 48 weeks, all for personal reasons. No Centers for Disease Control and Prevention category events or death occurred after interruption. In 6 (13%) of 46 patients, mild symptoms of acute retroviral rebound syndrome (ARVS) were identified. No improvement was observed in mental or physical health scores. In 37% of patients, nonnucleoside reverse transcriptase inhibitor drug concentrations were still detectable 1 week after stopping. CONCLUSIONS Although HAART can safely be interrupted in patients with a high CD4 T-cell nadir, no improvement in quality of life was established. Patients can experience ARVS, the risk for development of resistance after treatment interruption is realistic, and there is a potential hazard of HIV transmission to sexual partners. We would not actively advise stopping treatment in patients who started treatment too early according to current guidelines.
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Affiliation(s)
- Katalin Pogány
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
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15
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Sorli L, Tellez E, Taverner D, Knobel H. Meningitis aséptica con ADA elevado tras interrupción del tratamiento antirretroviral. Enferm Infecc Microbiol Clin 2006; 24:138-9. [PMID: 16545326 DOI: 10.1157/13085025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Boschi A, Tinelli C, Ortolani P, Arlotti M. Safety and factors predicting the duration of first and second treatment interruptions guided by CD4+ cell counts in patients with chronic HIV infection. J Antimicrob Chemother 2005; 57:520-6. [PMID: 16387747 DOI: 10.1093/jac/dki472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the safety of treatment interruption (TI) guided by CD4+ count in HIV-infected patients followed-up prospectively. METHODS Patients on HAART with a CD4+ cell count >500 cells/mm3 discontinued therapy with instructions to start therapy again before their CD4+ count dropped below 200 cells/mm3. RESULTS We report data on 112 HIV-infected patients. The median follow-up after starting the first TI was 34.7 months (IQR: 23.1-43.8). The median duration of the first TI was 12 months (IQR: 5.2-25). In the multivariate analysis the factor which most strongly correlated with the duration of the first TI was the CD4+ cell count at the end of the TI. Among the 34 patients who had completed a second TI, the duration of the two periods of interruption was similar if the treatment was recommenced at the end of the first TI at a CD4+ count higher than the nadir count. CONCLUSIONS The strategy of TI is safe if the criteria for restarting therapy are applied correctly. The factor with the greatest influence on the duration of the first TI is the number of CD4+ cells at the end of the TI.
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Affiliation(s)
- Andrea Boschi
- Division of Infectious Diseases, AUSL Rimini, Via Settembrini 2, 47900 Rimini, Italy.
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Mussini C, Pinti M, Bugarini R, Borghi V, Nasi M, Nemes E, Troiano L, Guaraldi G, Bedini A, Sabin C, Esposito R, Cossarizza A. Effect of treatment interruption monitored by CD4 cell count on mitochondrial DNA content in HIV-infected patients: a prospective study. AIDS 2005; 19:1627-33. [PMID: 16184032 DOI: 10.1097/01.aids.0000186019.47297.0d] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV infection per se and HAART can alter mitochondrial functionality, leading to a decrease in mitochondrial DNA content. OBJECTIVE To evaluate whether treatment interruption monitored by CD4 cell count can restore mitochondrial DNA content in peripheral blood lymphocytes. METHODS Mitochondrial DNA content was measured in platelet-free CD4 and CD8 T cells by real-time polymerase chain reaction; flow cytometry was used to identify and quantify activated CD4 and CD8 T lymphocytes. RESULTS The 30 patients had been treated for a mean of 107 months (range, 27-197). Median CD4 cell count at discontinuation was 702 cells/microl (range, 547-798). Median observational time from HAART discontinuation was 11.3 months (range, 4-26). Discontinuation of treatment provoked significant increases in mitochondrial DNA in CD8 T cells, which started only 6 months after therapy discontinuation [5.12 copies/cell per month from 0 to 6 months (P = 0.37) and 26.96 copies/cell per month from 6 to 12 months (P < 0.0001)]. CONCLUSIONS This study is the first showing that mitochondrial DNA content can increase in peripheral blood lymphocytes during treatment interruption, but only after at least 6 months of interruption. Consequently, interruptions of shorter periods, whether by clinician or patient decision, are unlikely to allow restoration of mitochondrial DNA and so decrease HAART-related toxicity.
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Affiliation(s)
- Cristina Mussini
- Clinic of Infectious and Tropical Diseases, University of Modena and Reggio Emilia, Modena, Italy.
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Knysz B, Gasiorowski J, Czarnecki M, Gladysz A. Viral Rebound Syndrome in Two HIV-1–Positive Patients after Structured Treatment Interruption. Viral Immunol 2005; 18:579-81. [PMID: 16212537 DOI: 10.1089/vim.2005.18.579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Brygida Knysz
- Department of Infectious Diseases, Wrocaw Medical University, Wrocaw, Poland
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Jacobs B, Neil N, Aboulafia DM. Retrospective analysis of suspending HAART in selected patients with controlled HIV replication. AIDS Patient Care STDS 2005; 19:429-38. [PMID: 16053400 DOI: 10.1089/apc.2005.19.429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We sought to determine the consequences of stopping highly active antiretroviral therapy (HAART) in a group of 41 HIV-infected individuals with undetectable HIV viral loads and CD4+ counts greater than 500 cells per microliter for 6 months or more. Clinical and laboratory parameters were monitored, as was the time to HAART reinitiation. Three months after HAART interruption, the median CD4+ count declined by 162 cells per microliter and HIV viral load increased by 24,000 copies per milliliter. Over the next year, CD4+ counts continued to decrease by an average of 11 cells per microliter per 3-month intervals. In contrast, HIV viral loads remained stable over the same period. Five of 7 patients (71%) with elevated cholesterol levels and 6 of 13 patients (46%) with elevated triglyceride levels had these values normalize after stopping HAART. After a median of 21 months follow-up, 26 of 41 patients (63%) have restarted HAART. Patients with Centers for Disease Control (CDC) HIV/AIDS C classification were more likely to restart HAART than those with A or B classification (p = 0.008). Reasons for HAART restart included clinical events in 8 patients. Fifteen patients restarted HAART for immunologic reasons: CD4+ count less than 300 cells per microliter (n = 7); HIV viral load greater than 55,000 copies per milliliter (n = 3); or both (n = 5). Three patients restarted HAART because of personal preference. Within 4 months, all 26 patients who restarted HAART achieved HIV viral loads less than 50 copies per milliliter. Although patients were able to rapidly achieve nondetectable HIV viral loads after restarting HAART, the inability to foresee clinical events among 8 patients (20%) is disconcerting. We advise caution before HAART interruption, particularly for those patients with a preceding history of significant HIV-related complications.
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Affiliation(s)
- Benjamin Jacobs
- University of Washington College of Arts and Sciences, Seattle, Washington, USA
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Ananworanich J, Hirschel B. Interrupting highly active antiretroviral therapy in patients with HIV. Expert Rev Anti Infect Ther 2005; 3:51-60. [PMID: 15757457 DOI: 10.1586/14787210.3.1.51] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Scheduled treatment interruptions are preplanned interruptions of antiretroviral treatment, which may be directed by time (e.g., cycles of 8 weeks on treatment and 8 weeks off treatment); the concentration of CD4+ lymphocytes (the CD4 count); HIV-1 RNA concentration (viral load); or other factors. This review covers the rationale of scheduled treatment interruptions and the different strategies that have been explored. It examines the issue of autovaccination, resistance and other risks and benefits. Scheduled-treatment-interruption studies in three populations are discussed: patients who initiated highly active antiretroviral therapy during acute HIV infection; patients with successfully treated chronic HIV infection; and patients with highly active antiretroviral therapy failure.
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Affiliation(s)
- Jintanat Ananworanich
- The HIV Netherlands, Australia, Thailand Research Collaboration (HIV-NAT) and The Thai Red Cross AIDS Research Center, Bangkok, Thailand.
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