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Oliveira RDVCD, Shimakura SE, Campos DP, Hökerberg YHM, Victoriano FP, Ribeiro S, Veloso VG, Grinsztejn B, Carvalho MS. Effects of antiretroviral treatment and nadir CD4 count in progression to cardiovascular events and related comorbidities in a HIV Brazilian cohort: a multi-stage approach. AIDS Care 2017; 30:551-559. [PMID: 29058481 DOI: 10.1080/09540121.2017.1391984] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The use of highly active antiretroviral therapy has resulted in changes of comorbidity profile in people living with HIV (PLHIV), increasing non-AIDS-related events. The occurrence of cardiovascular events is greater in PLHIV, but the mechanism responsible for it is still controversial. This article aimed to investigate factors associated with the progression to cardiovascular events in PLHIV using HAART. A 15-years cohort study with 1135 PLHIV was conducted in Rio de Janeiro-Brazil. Clinical progression was stratified in five states: No comorbidities (s1), arterial hypertension (s2), lipid abnormalities (s3), hypertension and lipid abnormalities (s4) and major cardiovascular events (stroke, coronary artery disease, thrombosis or death) (s5). Semi-Markov models evaluated the effects of cardiovascular traditional factors, treatment and clinical covariates on transitions between these states. Hazard Ratios (HR) and 95% confidence intervals (CI) were provided. In addition to traditional factors (age, sex, educational level and skin color), the development of one comorbidity (lipid abnormalities or hypertension) increased in patients with low nadir CD4 (<50 cells/mm3), (HR = 1.59, CI 1.11-2.28 and 1.36, CI 1.11-1.66, respectively). The risk to experience a second comorbidity (s3→s4) increased 75% with low nadir CD4. Age was the only factor that increased the risk of major cardiovascular events once having lipid abnormalities with or without hypertension (s3,s4→s5). The prolonged use of certain antiretroviral drugs (abacavir, didanosine, ritonavir, lopinavir, amprenavir and fosamprenavir) increased the risk of direct transition (s1→s5) to major cardiovascular events (HR = 5.29, CI 1.16-24.05). This analysis suggests that prolonged use of certain antiretroviral drugs led directly to major cardiovascular events, while low nadir CD4 only affected the occurrence of lipid abnormalities and hypertension. Management strategies, including rational use of complex exams (such as, computed-tomography angiography), statins and antihypertensives, should be developed based on the distinct roles of antiretroviral use and of HIV infection itself on the progression to cardiovascular events.
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Affiliation(s)
| | | | - Dayse Pereira Campos
- a Instituto Nacional de Infectologia Evandro Chagas , Fundação Oswaldo Cruz , Rio de Janeiro , Brazil
| | | | - Flaviana Pavan Victoriano
- a Instituto Nacional de Infectologia Evandro Chagas , Fundação Oswaldo Cruz , Rio de Janeiro , Brazil
| | - Sayonara Ribeiro
- a Instituto Nacional de Infectologia Evandro Chagas , Fundação Oswaldo Cruz , Rio de Janeiro , Brazil
| | - Valdiléa G Veloso
- a Instituto Nacional de Infectologia Evandro Chagas , Fundação Oswaldo Cruz , Rio de Janeiro , Brazil
| | - Beatriz Grinsztejn
- a Instituto Nacional de Infectologia Evandro Chagas , Fundação Oswaldo Cruz , Rio de Janeiro , Brazil
| | - Marilia Sá Carvalho
- c Programa de Computação Científica , Fundação Oswaldo Cruz , Rio de Janeiro , Brazil
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2
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Gillis J, Loutfy M, Bayoumi AM, Antoniou T, Burchell AN, Walmsley S, Cooper C, Klein MB, Machouf N, Montaner JSG, Rourke SB, Tsoukas C, Hogg R, Raboud J. A Multi-State Model Examining Patterns of Transitioning Among States of Engagement in Care in HIV-Positive Individuals Initiating Combination Antiretroviral Therapy. J Acquir Immune Defic Syndr 2016; 73:531-539. [PMID: 27851713 PMCID: PMC5119642 DOI: 10.1097/qai.0000000000001109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 05/09/2016] [Indexed: 12/03/2022]
Abstract
BACKGROUND Common measures of engagement in care fail to acknowledge that infrequent follow-up may occur either intentionally among patients with sustained virologic suppression or unintentionally among patients with poor clinical outcomes. METHODS Five states of HIV care were defined within the Canadian Observational Cohort Collaboration following combination antiretroviral therapy (cART) initiation: (1) guidelines HIV care [suppressed viral load (VL) and CD4 >200 cells per cubic millimeter, no gaps in cART >3 months, no gaps in CD4 or VL measurement >6 months], (2) successful care with decreased frequency of follow-up (as above except no gaps in CD4 or VL measurement >12 months), (3) suboptimal care (unsuppressed VL, CD4 <200 cells per cubic millimeter on 2 consecutive visits, ≥1 gap in cART >3 months, or ≥1 gap in CD4 or VL measurement >12 months), (4) loss to follow-up (no contact for 18 months), and (5) death. Multi-state models were used to determine factors associated with transitioning among states. RESULTS In total, 7810 participants were included. Younger age, female gender, Indigenous ethnicity, and people who have injected drugs were associated with increased likelihoods of transitioning from guidelines to suboptimal care and decreased likelihoods of transitioning from suboptimal to guidelines care. One-fifth of individuals in successful, decreased follow-up after cART initiation (mean sojourn time 0.72 years) were in suboptimal care in subsequent years. CONCLUSIONS Using routinely collected data, we have developed a flexible framework that characterizes patient transitions among states of HIV clinical care. We have demonstrated that multi-state models provide a useful approach to supplement "cascade of care" work.
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Affiliation(s)
- Jennifer Gillis
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mona Loutfy
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Maple Leaf Medical Clinic, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed M. Bayoumi
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Tony Antoniou
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ann N. Burchell
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sharon Walmsley
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Immunodeficiency Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Marina B. Klein
- McGill University Health Centre, McGill University, Montreal, Québec, Canada
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Nima Machouf
- Clinique Médicale l'Actuel, Montreal, Québec, Canada
| | - Julio S. G. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean B. Rourke
- Centre for Urban Health Solutions, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Ontario HIV Treatment Network, Toronto, Ontario, Canada; and
| | - Christos Tsoukas
- McGill University Health Centre, McGill University, Montreal, Québec, Canada
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Robert Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Janet Raboud
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - the CANOC Collaboration
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Maple Leaf Medical Clinic, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Immunodeficiency Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- McGill University Health Centre, McGill University, Montreal, Québec, Canada
- Department of Medicine, McGill University, Montreal, Québec, Canada
- Clinique Médicale l'Actuel, Montreal, Québec, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Ontario HIV Treatment Network, Toronto, Ontario, Canada; and
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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3
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Johnston V, Fielding KL, Charalambous S, Churchyard G, Phillips A, Grant AD. Outcomes following virological failure and predictors of switching to second-line antiretroviral therapy in a South African treatment program. J Acquir Immune Defic Syndr 2012; 61:370-80. [PMID: 22820803 PMCID: PMC3840925 DOI: 10.1097/qai.0b013e318266ee3f] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Without resistance tests, deciding which patients with virological failure should switch to second-line antiretroviral therapy (ART) is difficult. The factors influencing this decision are poorly understood. We assess predictors of switching regimens after virological failure. DESIGN Retrospective cohort study using clinical data from a South African ART program with 6-monthly viral load (VL) monitoring. METHODS We constructed a dataset of patient visits occurring following first-line virological failure, and used random effects logistic regression (accounting for individual-level and clinic-level clustering) to assess predictors of switching at each visit. RESULTS One thousand six hundred sixty-eight patients with virological failure (73% male, mean age 41 years, median CD4 184 cells/mm, mean log10 VL 4.3) contributed 1922 person-years of viremia. 12 months after failure, the cumulative incidence of switching regimen, viral resuppression, or death was 16.9%, 13.2%, and 4.6%, respectively. In adjusted analysis, switching was more likely at the third or subsequent visit after failure; in visits occurring in 2008 versus 2003 to 2007; and in patients with ART experience pre-programme, current high VL or low CD4 count. Switching was less likely in patients with no clinic contact for 4 months, or declining VL. Switching rates varied between clinics with clinic-level clustering evident in the final model (P <0.001). CONCLUSIONS Despite 6-monthly virological monitoring and recommendations to switch after adherence interventions and confirmed viremia, patients experienced delayed switching. Individual-level covariates influenced switching but did not account for variable switching rates between clinics, suggesting differences in guideline implementation. In certain circumstances delays may be warranted; however understanding barriers to guideline implementation will limit unnecessary delays.
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Affiliation(s)
- Victoria Johnston
- London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom.
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4
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Marconi VC, Grandits G, Okulicz JF, Wortmann G, Ganesan A, Crum-Cianflone N, Polis M, Landrum M, Dolan MJ, Ahuja SK, Agan B, Kulkarni H. Cumulative viral load and virologic decay patterns after antiretroviral therapy in HIV-infected subjects influence CD4 recovery and AIDS. PLoS One 2011; 6:e17956. [PMID: 21625477 PMCID: PMC3098832 DOI: 10.1371/journal.pone.0017956] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 02/19/2011] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The impact of viral load (VL) decay and cumulative VL on CD4 recovery and AIDS after highly-active antiretroviral therapy (HAART) is unknown. METHODS AND FINDINGS Three virologic kinetic parameters (first year and overall exponential VL decay constants, and first year VL slope) and cumulative VL during HAART were estimated for 2,278 patients who initiated HAART in the U.S. Military HIV Natural History Study. CD4 and VL trajectories were computed using linear and nonlinear Generalized Estimating Equations models. Multivariate Poisson and linear regression models were used to determine associations of VL parameters with CD4 recovery, adjusted for factors known to correlate with immune recovery. Cumulative VL higher than the sample median was independently associated with an increased risk of AIDS (relative risk 2.38, 95% confidence interval 1.56-3.62, p<0.001). Among patients with VL suppression, first year VL decay and slope were independent predictors of early CD4 recovery (p = 0.001) and overall gain (p<0.05). Despite VL suppression, those with slow decay during the first year of HAART as well as during the entire therapy period (overall), in general, gained less CD4 cells compared to the other subjects (133 vs. 195.4 cells/µL; p = 0.001) even after adjusting for potential confounders. CONCLUSIONS In a cohort with free access to healthcare, independent of established predictors of AIDS and CD4 recovery during HAART, cumulative VL and virologic decay patterns were associated with AIDS and distinct aspects of CD4 reconstitution.
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Affiliation(s)
- Vincent C. Marconi
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- * E-mail: (VCM); (HK)
| | - Greg Grandits
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Jason F. Okulicz
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Infectious Disease Service, San Antonio Military Medical Center, Brooke Army Medical Center, Fort Sam Houston, Texas, United States of America
| | - Glenn Wortmann
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Infectious Disease Service, Walter Reed Army Medical Center, Washington, D.C., United States of America
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Infectious Disease Clinic, National Naval Medical Center, Bethesda, Maryland, United States of America
| | - Nancy Crum-Cianflone
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Infectious Disease Clinic, Naval Medical Center San Diego, San Diego, California, United States of America
| | - Michael Polis
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Michael Landrum
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Infectious Disease Service, San Antonio Military Medical Center, Brooke Army Medical Center, Fort Sam Houston, Texas, United States of America
| | - Matthew J. Dolan
- Henry M. Jackson Foundation, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, Texas, United States of America
| | - Sunil K. Ahuja
- Veterans Administration Research Center for AIDS and HIV-1 Infection, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas, United States of America
- Department of Microbiology and Immunology, and Biochemistry, University of Texas Health Science Center, San Antonio, Texas, United States of America
| | - Brian Agan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Hemant Kulkarni
- Veterans Administration Research Center for AIDS and HIV-1 Infection, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas, United States of America
- * E-mail: (VCM); (HK)
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5
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Hsu DC, Quin JW. Clinical audit: virological and immunological response to combination antiretroviral therapy in HIV patients at a Sydney sexual health clinic. Intern Med J 2011; 40:265-74. [PMID: 19460050 DOI: 10.1111/j.1445-5994.2009.01983.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Bigge Park Centre (BPC) is a sexual health clinic located in a socially disadvantaged area in Southwest Sydney. This served as a retrospective clinical audit, documenting patient demographics, identifying factors associated with virological, immunological and discordant responses, evaluating the centre's ability in HIV control and investigating changes in practice from 1996 to 2007. METHOD Data including age, gender, ethnicity, mode of transmission, hepatitis co-infection, prior acquired immune deficiency syndrome (AIDS)-defining-illness, HIV-1 RNA and CD4+cell counts of patients on combination antiretroviral therapy (CART) for treatment of HIV with at least 1-year follow up at the BPC were analysed. Results were compared with other cohorts in medical literature. RESULTS BPC manages HIV patients from diverse backgrounds. Sequential monotherapy was associated with poor virological control, lower CD4+cell recovery and discordant response. When patients who had sequential monotherapy were excluded, Caucasian race, high viral load at 1 month and triple-NRTI (nucleoside reverse transcriptase inhibitor) regimen were associated with lack of virological control. Lower baseline viral load and triple-NRTI regimen were associated with lower CD4+cell recovery. Lower baseline CD4+cell count and prior diagnosis of AIDS were associated with discordant response. Virological control and CD4+cell recovery achieved were comparable to that documented in medical literature. There was no significant change over time in terms of timing of CART initiation, attainment of immunological response or virological control since the late 1990 s. CONCLUSION HIV control achieved at the BPC was comparable to that reported in medical literature. Enhancement of strategies to promote screening and improve adherence as well as performance of HIV resistance assessment and avoidance of triple-NRTI therapy will likely improve patient care.
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Affiliation(s)
- D C Hsu
- Sydney South West Area Health Service, Department of Immunology, Royal Prince Alfred Hospital, Camperdown, Australia.
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6
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Tenorio AR, Jiang H, Zheng Y, Bastow B, Kuritzkes DR, Bartlett JA, Deeks SG, Landay AL, Riddler SA. Delaying a treatment switch in antiretroviral-treated HIV type 1-infected patients with detectable drug-resistant viremia does not have a profound effect on immune parameters: AIDS Clinical Trials Group Study A5115. AIDS Res Hum Retroviruses 2009; 25:135-9. [PMID: 19239354 DOI: 10.1089/aid.2008.0200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Some patients are unable to achieve and maintain an undetectable plasma HIV-1 RNA level with combination antiretroviral therapy (ART) and are therefore maintained on a partially suppressive regimen. To determine the immune consequences of continuing ART despite persistent viremia, we randomized 47 ART-treated individuals with low to moderate plasma HIV-1 RNA levels (200-9999 copies/ml) to either an immediate switch in therapy or a delayed switch (when plasma HIV-1 RNA became > or =10,000 copies/ml). After 48 weeks of follow-up, naive and memory CD4+ T cell percents were comparable in the two groups. The proportion of subjects with a lymphocyte proliferative response to Candida, Mycobacterium avium-intracellulare complex, or HIV-gag was also not significantly different at week 48. Delaying a treatment switch in patients with partial virologic suppression and stable CD4+ T cells does not have profound effects on immune parameters.
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Affiliation(s)
- Allan R. Tenorio
- Department of Medicine, Rush Medical College, Chicago, Illinois 60612
| | - Hongyu Jiang
- Department of Biostatistics, Statistical and Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts 02319
| | - Yu Zheng
- Department of Biostatistics, Statistical and Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts 02319
| | - Barbara Bastow
- Social & Scientific Systems, Inc., Silver Spring, Maryland 20910
| | - Daniel R. Kuritzkes
- Section of Retroviral Therapeutics, Brigham and Women's Hospital and Division of AIDS, Harvard Medical School, Boston, Massachusetts 02319
| | - John A. Bartlett
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27706
| | - Steven G. Deeks
- Department of Medicine, University of California–San Francisco and San Francisco General Hospital, San Francisco, California 94143
| | - Alan L. Landay
- Department Immunology and Microbiology, Rush Medical College, Chicago, Illinois 60612
| | - Sharon A. Riddler
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
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Abstract
The aim was to investigate the impact of the main prognostic factors on HIV evolution. A multi-state Markov model was applied in a cohort of 2126 patients to estimate impact of these factors on patients' clinical and immunological evolutions. Clinical progression and immunological deterioration shared most of their prognostic factors: male gender, intravenous drug use, weight loss, low haemoglobin level (<110 g/l), CD8 cell count (<500/mm(3)) and HIV viral load (>5 log(10) copies/ml). Highly active retroviral therapy reduced the risks of clinical progression and immune deterioration whatever patients' CD4 cell count. Risk reductions were 41-60% for protease inhibitor-based and 27-68% for non-nucleoside reverse transcriptase inhibitor-based regimens. Three-year transition probabilities showed that only patients with a CD4 cell count >or=350 CD4/mm(3) could in most cases maintain their immunity. This model provides 'real life' transition probabilities from one immunological stage to another, allowing decision analyses that could help determine the beneficial therapeutic strategies for HIV-infected patients.
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8
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Le Moing V, Thiébaut R, Chêne G, Sobel A, Massip P, Collin F, Meyohas M, Al Kaïed F, Leport C, Raffi F. Long-term evolution of CD4 count in patients with a plasma HIV RNA persistently <500 copies/mL during treatment with antiretroviral drugs. HIV Med 2007; 8:156-63. [PMID: 17461859 DOI: 10.1111/j.1468-1293.2007.00446.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The increase in CD4 count may reach a plateau after some duration of virological response to highly active antiretroviral therapy (HAART). METHODS A total of 1281 HIV-infected patients initiating HAART were enrolled in the AntiPROtease (APROCO) cohort. We investigated determinants of increase in CD4 count using longitudinal mixed models in patients who maintained a plasma HIV RNA <500 HIV-1 RNA copies/mL. RESULTS A total of 870 patients had a virological response at month 4. The median follow-up time was 57 months. Mean estimated increases in CD4 count in patients with persistent virological response were 29.9 cells/muL/month before month 4, 6.4 cells/microL/month between months 4 and 36, and 0.7 cells/microL/month (not significantly different from 0) after month 36. Three factors were associated with a significantly positive CD4 count slope after month 36: male gender (+0.9), no history of antiretroviral therapy at baseline (+1.7) and baseline CD4 count <100 cells/microL (+2.6). In patients who maintained a virological response after 5 years of HAART, a CD4 count >500 cells/microL was achieved in 83% of those with a baseline CD4 count >or=200 cells/microL and in 45% of those with a baseline CD4 count <200 cells/microL. CONCLUSION The increase in CD4 count reaches a plateau after 3 years of virological response. Even if patients initiating HAART with low CD4 counts still show a CD4 count increase after 3 years, it remains insufficient to overcome immune deficiency in all patients.
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Affiliation(s)
- V Le Moing
- Service des Maladies Infectieuses et Tropicales, Hôpital Gui de Chauliac, Centre Hospitalier Universitaire, Montpellier, France.
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9
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Calmy A, Ford N, Hirschel B, Reynolds SJ, Lynen L, Goemaere E, Garcia de la Vega F, Perrin L, Rodriguez W. HIV viral load monitoring in resource-limited regions: optional or necessary? Clin Infect Dis 2006; 44:128-34. [PMID: 17143828 DOI: 10.1086/510073] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 08/30/2006] [Indexed: 11/04/2022] Open
Abstract
Although it is a standard practice in high-income countries, determination of the human immunodeficiency virus (HIV) load is not recommended in developing countries because of the costs and technical constraints. As more and more countries establish capacity to provide second-line therapy, and as costs and technological constraints associated with viral load testing decrease, the question of whether determination of the viral load is necessary deserves attention. Viral load testing could increase in importance as a guide for clinical decisions on when to switch to second-line treatment and on how to optimize the duration of the first-line treatment regimen. In addition, the viral load is a particularly useful tool for monitoring adherence to treatment, performing sentinel surveillance, and diagnosing HIV infection in children aged <18 months. Rather than considering viral load data to be an unaffordable luxury, efforts should be made to ensure that viral load testing becomes affordable, simple, and easy to use in resource-limited settings.
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Affiliation(s)
- Alexandra Calmy
- Medecins sans Frontieres, Access to Medicines Campaign, Geneva, 1211, Switzerland.
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10
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Mathieu E, Loup P, Dellamonica P, Daures JP. Markov Modelling of Immunological and Virological States in HIV-1 Infected Patients. Biom J 2005; 47:834-46. [PMID: 16450856 DOI: 10.1002/bimj.200410164] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The purpose of this study was to evaluate the evolution of HIV infected patients and to bring out some significant factors associated with this pathology. The main criteria revealing the State of illness is viral load measurement (VL). However the CD4 lymphocytes also represent an important marker as these reflect the State of the immune reservoir. Many studies have been carried out in this field and different models have been proposed with a view to a better understanding of this disease. Multi State Markov models defined in terms of CD4 counts, or in terms of viral load, have proved to be very useful tools for modelling HIV disease progression. The model we have developed in this study is based on both the CD4 lymphocytes counts and VL. Markov models are characterized by transition intensities. In this paper we explored several structures in succession. First, we used a homogeneous continuous time Markov process with four states defined by crossed values of CD4 and VL in a given patient at a given time. Then, the effect of certain covariates on the infection process was introduced into the model via the transition intensity functions, as with a Cox regression model. Since the hypothesis of homogeneity may be unrealistic in certain cases, we also considered piecewise homogeneous Markov models. Finally, the effects of covariates and time were combined in a piecewise homogeneous model with a covariate. We applied these methods to data from 1313 HIV-infected patients included in the NADIS cohort.
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Affiliation(s)
- E Mathieu
- Clinical Research University Institute, Biostatistics Laboratory, 641 avenue D.G. Giraud, 34093 Montpellier, France.
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11
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Alatrakchi N, Duvivier C, Costagliola D, Samri A, Marcelin AG, Kamkamidze G, Astriti M, Agher R, Calvez V, Autran B, Katlama C. Persistent low viral load on antiretroviral therapy is associated with T cell-mediated control of HIV replication. AIDS 2005; 19:25-33. [PMID: 15627030 DOI: 10.1097/00002030-200501030-00003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND It is unclear how stable low-level viral replication and CD4 cell numbers can be maintained under highly active antiretroviral therapy (HAART). This study was designed to analyse whether HIV-specific responses in stable partially controlled patients during antiretroviral therapy (ART) differ from those observed in complete HAART failure and whether they contribute to the control of viral load (VL). METHODS Three groups of patients were selected according to plasma HIV RNA levels during 18 months of ART: persistently low VL (LoVL; HIV RNA <10,000 copies/ml; n = 28), undetectable VL (UnVL; HIV RNA <200 copies/ml; n = 29) and high VL (HiVL; HIV RNA >10,000 copies/ml; n = 14). T-cell responses were studied using lymphoproliferative and interferon (IFN)-gamma-ELISpot assays against HIV-p24, -gp160, recall antigens, and 15 pools of HIV-(Gag + RT) peptides. RESULTS Frequencies of IFN-gamma-producing CD4 T cells against HIV-p24 were higher in LoVL than in UnVL or HiVL groups [median, 131, 47 and 23 spot-forming cells (SFC)/1 x 10 peripheral blood mononuclear cells (PBMC), respectively; P = 0.012 and P = 0.047]. Lymphoproliferative responses to HIV-p24 and recall antigens were similar in LoVL and UnVL groups but lower in HiVL (P = 0.004). Frequencies of HIV-specific CD8 T cells were higher in LoVL than in UnVL (1340 versus 410 SFC/1 x 10 PBMC; P = 0.001). They correlated negatively with VL in the LoVL and HiVL (r, -0.393, P = 0.039 and r, -0.643, P = 0.024, respectively) and positively correlated with anti-HIV CD4 cell frequencies in the LoVL group only (r, 0.420; P = 0.026). CONCLUSION Persistently low viral replication (<10,000 copies/ml) during ART stimulates high frequencies of HIV-specific CD4 and CD8 T cells compared to full virus suppression or complete ART failure. The association of high anti-HIV activity with large numbers of HIV-specific CD8 T cells contribute to the control of viral replication.
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Affiliation(s)
- N Alatrakchi
- Laboratoire d'immunologie cellulaire-Inserm U543, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie Paris
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Xi LF, Kiviat NB. Cervical Neoplasia and Highly Active Antiretroviral Therapy. J Natl Cancer Inst 2004; 96:1051-3. [PMID: 15265960 DOI: 10.1093/jnci/djh223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Brigido L, Rodrigues R, Casseb J, Custodio RM, Fonseca LAM, Sanchez M, Duarte AJS. CD4+ T-cell recovery and clinical outcome in HIV-1-infected patients exposed to multiple antiretroviral regimens: partial control of viremia is associated with favorable outcome. AIDS Patient Care STDS 2004; 18:189-98. [PMID: 15142349 DOI: 10.1089/108729104323038865] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The goal of antiretroviral therapy is clinical benefit through the suppression of viral replication and the immunologic reconstitution of HIV-1-infected patients. In spite of the availability of different highly active antiretroviral therapy only some patients sustain undetectable plasma viremia. We performed an observational study from October 1987 to February 2001 on immunologic and clinical outcome of 148 HIV-1-infected patients from an open clinical cohort at São Paulo University, Brazil. The median T CD4+ at starting first monitored regimen was 227 cells per microliter, with 65% of patients previously exposed to antiretroviral regimens, mostly dual therapy. Virologic response to antiretroviral therapy, after a median period of 179 weeks of monitored treatment, allowed classifying patients as aviremic (RNA plasma viremia below 500 copies per milliliter); viremic (current viral load at historic levels), and viremic-attenuated groups (detectable viremia, but > 1 log viral suppression). HIV RNA viral load, T CD4+ cells count, HIV-1 pol sequencing, inflammatory parameters, and clinical events were documented during a median follow-up of 251 weeks. This study observed better clinical and immunologic responses in the aviremic group, but the viremic-attenuated group showed a significant gain in CD4+ cells (p < 0.013) and a decreased number of cases progressing to an AIDS-defining clinical condition (p < 0.001) compared to the viremic group.
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Affiliation(s)
- L Brigido
- Adolfo Lutz Institute, Sao Paulo, Brazil; Brazilian AIDS Program, MS, Brazilia, Brazil.
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