Use of protease inhibitors among persons with AIDS in Los Angeles County

Effectiveness of potent antiretroviral therapies on the incidence of opportunistic infections before and after AIDS diagnosis

OBJECTIVES

To determine the effectiveness of potent antiretroviral therapy in reducing opportunistic infections (OI) as both a presenting event and subsequent to an AIDS-defining event.

DESIGN AND METHODS

A total of 543 seroconverters and 1470 men with AIDS were compared for the time to development of OI as the presenting AIDS event and as a subsequent event in the 1984-1989, 1990-1992, 1993-1995, and 1996-1998 periods, when the major treatments were no therapy, monotherapy, combination therapy, and potent antiretroviral therapy, respectively.

RESULTS

The seroconverters suffered 132 OI and the participants with AIDS had 717 OI. The relative hazard (RH) of OI as the presenting AIDS event declined by 81% in the calendar period when potent antiretroviral therapy was available compared with the monotherapy period. Declines were observed for Mycobacterium avium complex, cytomegalovirus disease, and esophageal candidiasis, but were statistically significant only for Pneumocystis carinii pneumonia. The RH of OI as a secondary infection dropped by 77% in the last calendar period compared with the monotherapy period. A significant decline was observed for all four OI. Prophylactic drug use did not increase in the era of potent antiretroviral therapy.

CONCLUSION

The hazard of OI in the era of potent antiretroviral therapy has declined dramatically compared with the era of monotherapy, despite the concurrent decrease in the use of prophylactic drugs. Physicians should consider whether it is necessary to include prophylactic drugs as part of the complex drug regimen for patients on potent antiretroviral therapy.

Association of antiretroviral therapy with detection of HIV-1 RNA and DNA in the anorectal mucosa of homosexual men

OBJECTIVE

To determine whether combination antiretroviral therapy is associated with reduced detection of HIV-1 RNA and DNA in the anorectal mucosa of men who have sex with men (MSM).

DESIGN

Cross-sectional study of 233 MSM recruited from community and clinic sites in Seattle, Washington between July 1996 and December 1997.

METHODS

HIV-1 RNA and HIV-1 DNA were detected in anorectal swab specimens by polymerase chain reaction amplification assays.

RESULTS

HIV-1 RNA was detected significantly less often in anorectal specimens from users of combination antiretroviral therapies, whether a protease inhibitor was received (15/89; 17%) or not (16/53; 30%), than in men not receiving therapy (43/88; 49%) (P < 0.001, P = 0.03, respectively). In contrast, HIV-1 DNA was detected only slightly less frequently in anorectal specimens obtained from men receiving protease inhibitors (35/81; 43%) or reverse transcriptase inhibitors alone (22/48; 46%) than in specimens from men not receiving therapy (45/78; 58%) (P = 0.07, P = 0.20, respectively). Among men with < 50 copies HIV-1 RNA/ml plasma, detection of HIV-1 RNA in anorectal specimens was rare (1/54; 2%) but detection of HIV-1 DNA was common (14/50; 28%).

CONCLUSIONS

Combination antiretroviral therapy is associated with reductions in HIV-1 RNA, but HIV-1 DNA remains detectable in the anorectal canal of almost half of MSM receiving such therapy. Condom use during anal intercourse should be encouraged, regardless of plasma viral load response to potent antiretroviral therapy.

Evaluating the cost of medications for ambulatory HIV-infected persons in association with landmark changes in antiretroviral therapy

Costs of medications for ambulatory HIV-infected people increase as knowledge of antiretroviral therapy and therapy for opportunistic infection grows. We evaluated the evolution of drug costs for HIV-infected persons who attend a university clinic in Baltimore, Maryland. Cross-sectional abstracts of a cohort of patients for four periods, corresponding to landmark changes in therapy, who attended the clinic between June 1995 and September 1996 were obtained. Monthly medication costs for all patients were calculated. Mean costs increased significantly (p < .01) from period 1 ($447 U.S.) to period 4 ($1048 U.S.). Multivariate analysis only revealed higher costs for patients with a CD4+ count <200 cells/mm3 (p < .001). The proportion of costs attributable to antiretroviral therapy increased from 34% in period 1 to 53% in period 4. Combination therapy increased >10-fold, from 8% in period 1 to 94% in period 4. Protease inhibitor use also increased significantly, from 4% in period 2 to 53% in period 4. We quantified the increase in costs of medications from mid-1995 to late 1996. Increases in costs appear to be the result of increasing complexity of drug regimens, particularly antiretroviral therapy in combinations.