Three-year durability of dual-nucleoside versus triple-nucleoside therapy in a Thai population with HIV infection

Treatment Experience and Repeat Pregnancy Impact the Effectiveness of Non-Nucleoside Reverse Transcription Inhibitor-Highly Active Antiretroviral Therapy for the Prevention of Mother to Child Transmission of Human Immunodeficiency Virus

Non-nucleoside reverse transcription inhibitor (NNRTI)-containing antiretroviral therapy (ART) for the prevention of mother to child transmission (PMTCT) of human immunodeficiency virus (HIV) has led to dramatic reductions in perinatal HIV infection in resource-constrained settings. Nonetheless, PMTCT programs are complicated by repeat pregnancies, in which long-term or repeat exposures to PMTCT regimens over time may lead to the acquisition of HIV drug resistance mutations, and consequent treatment failure. In this study, we retrospectively assessed the effectiveness of the NNRTI-based PMTCT protocol from 2008 to 2010 in The Bahamas National HIV/AIDS Program. We show that women who had been in repeat pregnancies and those who were already prescribed ART at conception were at increased risk of virologic failure, relative to treatment-inexperienced women and primigravida, respectively (AOR 3.1, 95% CI: 1.3-7.1, p = .008 and AOR 5.0, 95% CI: 1.8-14.1, p = .002). In addition, women undergoing treatment at conception were more likely to possess HIVDR mutations relative to treatment-naive women (AOR 447.1, 95% CI: 17.9-11,173.5, p = .001). Therefore, individual treatment history is a key metric determining the effectiveness of current and future PMTCT interventions. The implications of this to PMTCT programmatic success in light of the most recent WHO guidelines are discussed.

HIV-1 drug resistance mutations among antiretroviral-naive HIV-1-infected patients in Asia: results from the TREAT Asia Studies to Evaluate Resistance-Monitoring Study

Of 682 antiretroviral-naïve patients initiating antiretroviral therapy in a prospective, multicenter human immunodeficiency virus type 1 (HIV-1) drug resistance monitoring study involving 8 sites in Hong Kong, Malaysia, and Thailand, the prevalence of patients with ≥1 drug resistance mutation was 13.8%. Primary HIV drug resistance is emerging after rapid scaling-up of antiretroviral therapy use in Asia.

The effect of AIDS defining conditions on immunological recovery among patients initiating antiretroviral therapy at Joint Clinical Research Centre, Uganda

Background

Many HIV-infected patients only access health care once they have developed advanced symptomatic disease resulting from AIDS Defining Conditions (ADCs). We carried out a study to establish the effect of ADCs on immunological recovery among patients initiated on antiretroviral therapy (ART).

Methods

A retrospective cohort of 427 HIV-1 patients who were initiated on ART between January 2002 and December 2006 was studied. Data on ADCs was retrieved from Joint Clinical Research Centre (JCRC) data base and backed up by chart reviews. We employed Kaplan-Meier survival curves to estimate median time to 50 CD4 cells/μl from the baseline value to indicate a good immunological recovery process. Cox proportional hazard models were used at multivariate analysis.

Results

The median time to gaining 50 CD4 cells/μl from the baseline value after ART initiation was longer in the ADC (9.3 months) compared to the non-ADC group (6.9 months) (log rank test, p = 0.027). At multivariate analysis after adjusting for age, sex, baseline CD4 count, baseline HIV viral load, total lymphocyte count and adherence level, factors that shortened the median time to immunological recovery after ART initiation were belonging to the non-ADC group (HR = 1.31; 95% CI: 1.03–1.28, p = 0.028), adherence to ART of ≥ 95% (HR = 2.22; 95% CI: 1.57–3.15, p = 0.001) and a total lymphocyte count ≥ 1200 cells/mm³ (HR = 1.84; 95% CI: 1.22–2.78, p = 0.003). A low baseline CD4 count of ≤ 200 cells/μl (HR = 0.52; 95% CI: 0.37–0.77, p = 0.001) was associated with a longer time to immunological recovery. There was no interaction between low CD4 counts and ADC group.

Conclusion

Patients with ADCs take longer to regain their CD4 counts due to the defect in the immune system. This may prolong their risk of morbidity and mortality.

Evaluating the impact of antiretroviral therapy on HIV transmission

As global efforts proceed to scale up the delivery of antiretroviral therapy (ART) to HIV-infected persons in most urgent need, it is essential to understand the potential impact of treatment expansion on the transmission of new HIV infections. In this study, we use a series of simple mathematical models to explore the direction and magnitude of treatment effects on the sexual transmission of HIV. By defining the circumstances under which ART can reduce the number of new infections transmitted by treated patients, we provide critical benchmarks to aid in prioritizing efforts to maximize the population health impact of treatment and in evaluating the performance of different treatment programmes. We find that, based on the best currently available evidence of possible treatment effects on patient infectiousness, survival and behavior, the potential remains for either positive or negative changes in overall transmission. In relation to the total number of expected secondary infections caused by each infected person, however, these net treatment effects are relatively modest, particularly if treatment is initiated at advanced stages of the disease. This finding implies that treatment alone should not be expected to alter the population-level incidence of new infections dramatically, in the absence of changes in other factors including possible behavioral responses among uninfected persons and among infected persons who are not yet treatment candidates.

Dual nucleoside reverse transcriptase inhibitor therapy in the combination antiretroviral therapy era and predictors of discontinuation or switch to combination antiretroviral therapy

BACKGROUND

Contrary to current HIV/AIDS management guidelines, and despite the arrival of potent combination antiretroviral therapy (cART) many years ago, some patients are still treated with dual nucleoside reverse transcriptase inhibitor (NRTI) regimens.

METHODS

We selected 5222 patients who received dual NRTI therapy for at least 6 months during 1998 to 2002, representing 9.9% of the 52,981 ARV-treated patients recorded in the French Hospital Database on HIV. Factors associated with switching to cART or with ARV discontinuation were identified by using Cox models.

RESULTS

The 3-year probabilities of switching to cART and of antiretroviral (ARV) drug discontinuation were 55.2% (95% confidence interval [CI]: 53.8 to 56.7) and 10.9% (95% CI: 10.1 to 11.8), respectively, whereas 1591 patients (30.5%) kept the dual NRTI therapy during all the study period. Place of birth and region of care did not influence the choice of treatment strategy. After adjustment, the likelihood of switching to cART was lower among women, intravenous drug users, and patients with an undetectable plasma viral load (pVL) on at least 1 occasion during follow-up; in contrast, it was higher among patients with AIDS and those with a low CD4 cell count at enrollment or at the last follow-up visit. The likelihood of ARV discontinuation was higher among women and intravenous drug users and lower among patients with a low CD4 cell count at inclusion or at the last follow-up visit and among patients with an undetectable pVL on at least 1 occasion during follow-up. The likelihood of switching to cART or discontinuing ARV drugs was higher among patients receiving zidovudine/zalcitabine or didanosine/stavudine than among those receiving zidovudine/lamivudine.

CONCLUSIONS

In France, until recent years, some patients (mainly women and intravenous drug users) were still receiving dual NRTI therapy despite free access to care and to highly effective ARV regimens. Dual NRTI therapy is gradually being replaced by cART, although some patients with satisfactory immunovirologic status are discontinuing all ARV drugs.

Predictive factors for immunological and virological endpoints in Thai patients receiving combination antiretroviral treatment

BACKGROUND

Routine CD4 count and HIV viral load monitoring is a financial barrier in developing countries.

METHODS

We assessed factors associated with CD4 counts < or =200 cells/microL and detectable viral load in Thai HIV-infected patients receiving antiretroviral therapy (ART) at the HIV Netherlands Australia Thailand Research Collaboration and the Thai Red Cross AIDS Research Centre (HIV-NAT). Univariate and multivariate Cox proportional hazards models for multiple treatment failures were used to determine factors related to CD4 counts < or =200 cells/microL and detectable viral load. Multivariate Cox proportional hazards models for CD4 counts < or =200 cells/microL were developed with and without viral load in order to build models applicable to contexts in which viral load is not available.

RESULTS

Four hundred and seventeen patients were included in the study. Fifty-four per cent were male, and the median CD4 count and log(10) viral load at baseline were 283 cells/microL and 4.3 log(10) HIV-1 RNA copies/mL, respectively. Independent factors related to CD4 count < or =200 cells/microL were CD4 count at baseline [hazards ratio (HR) 0.20/100 cells/microL; 95% confidence interval (CI) 0.17-0.23] and changes in CD4 count (HR 0.22/100 cells/microL; 95% CI 0.17-0.28). Factors in multivariate models (in which viral load was considered for inclusion) were CD4 count at baseline (HR 0.21/100 cells/microL; 95% CI 0.18-0.24), changes in CD4 count (HR 0.25/100 cells/microL; 95% CI 0.19-0.32) and detectable viral load (HR 1.94; 95% CI 1.20-3.13). Predictive factors (independent of viral load) were triple ART or highly active antiretroviral therapy (HAART) (HR 0.28; 95% CI 0.22-0.36) and detectable viral load at baseline (HR 2.96; 95% CI 2.24-3.91). Conclusions CD4 count at baseline and changes in CD4 count were important in predicting CD4 counts < or =200 cells/microL. Triple ART and detectable viral load at baseline were important in predicting detectable viral load.

Evaluation of Human Immunodeficiency Virus Type 1-Infected Chinese Patients Treated with Highly Active Antiretroviral Therapy for Two Years

The purpose of this study was to evaluate the long-term efficacy and safety of nevirapine in combination with didanosine and stavudine in the treatment of human immunodeficiency virus (HIV)1-infected Chinese patients in routine clinical practice. The study, from April 2003 to May 2005, with follow-up through 24 mo, was conducted at the Department of Infectious Diseases, Second Xiangya Hospital, Central-South University in Changsha, Hunan Province, China. Twenty-seven HIV1-infected patients received didanosine, stavudine, and nevirapine. Information from case notes regarding age, sex, side effects, viral load, naive and memory T cells, and CD4(+) and CD8(+) T cell count at baseline, 3, 6, 12, 18, and 24 mo was collected and analyzed. Virologic suppression, defined as an HIV RNA concentration of less than 50 copies/mL at months 3, 6, 12, 18, and 24, was considered the main outcome measure. Of 27 patients, 17 were men with a mean age 33.5 yr. The mean baseline viral load was 5.15 log copies/mL and the mean CD4(+) cell count was 185 cells/dL. Of 27 patients, 3 patients discontinued study medication; treatment was changed, because of side effects, from didanosine (ddI), stavudine (d4T), and nevirapine (NVP) to zidovudine, lamivudine, and NVP for 24 patients who had completed 24 mo of treatment with ddI, d4T, and NVP; and viral load suppression was attained in 17 patients (70.8%) at 12 mo, in 14 patients (58.3%) at 18 mo, and in 13 patients (56.6%) at 24 mo. The CD4 T cell count increased by 114 cells/microL (mean, 299 cells/microL) after 12 mo of treatment and by 132 cells/microL (mean, 317 cells/microL) after 24 mo of treatment. Naive T cells and memory cells also increased in number, but at a slower rate. Activated (CD38(+)) CD8(+) T cells were elevated at baseline (67.7%) and declined by month 24 (49.7%), but did not reach normal levels. We conclude that a regimen of NVP with ddI and d4T provided durable suppression of plasma viral load in HIV-infected patients, with significant improvement in the CD4 cell count, and can be well tolerated by patients with HIV-1 infection.