Laboratory adverse events and discontinuation of therapy according to CD4(+) cell count at the start of antiretroviral therapy

Effect of antiretroviral therapy initiation time and baseline CD4+ cell counts on AIDS-related mortality among former plasma donors in China: a 21-year retrospective cohort study

Background

The conventional survival analysis model on HIV/AIDS prognosis is the Cox proportional hazard model, which deals with only one event type, death, regardless of the cause. Few studies have used a competing risk model to evaluate the predictors of AIDS-related mortality.

Objective

To estimate the influence of antiretroviral therapy (ART) initiation time and baseline CD4⁺ cell counts on acquired immunodeficiency syndrome (AIDS)-related death among former plasma donors.

Methods

A retrospective cohort study was conducted involving 11,905 human immunodeficiency virus (HIV) or AIDS patients in a high-risk area of Henan province in China between 1995 and 2016. Demographic and clinical data were collected. Sub-distribution hazard ratios (sHRs) for AIDS-related mortality with baseline CD4⁺ cell counts and ART initiation time were determined using a competing risk model.

Results

Patients who initiated ART within 90 days of HIV/AIDS diagnosis (sHR: 0.24, 95% CI: 0.22–0.27) or had baseline CD4⁺ counts of >500 cells/μL (sHR: 0.23, 95% CI: 0.19–0.28) were associated with lower AIDS-related mortality risk. Patients with ART initiation time >1 year but CD4⁺ counts >350 cells/μL (sHR: 4.42, 95% CI: 3.30–5.91) had a higher AIDS-related mortality risk than those with ART initiation time >90 days but CD4⁺ counts ≤350 cells/μL (sHR: 4.33, 95% CI: 3.58–5.23).

Conclusions

Our results demonstrate that patients with high CD4⁺ cell counts and late ART had a 9% higher risk of AIDS-related death than those with low CD4⁺ cell counts and early ART. This study confirms the great significance of immediate ART initiation among former plasma donor HIV patients in China.

Immediate Antiretroviral Therapy Decreases Mortality Among Patients With High CD4 Counts in China: A Nationwide, Retrospective Cohort Study

Background

Clinical trials have demonstrated that immediate initiation of antiretroviral therapy (ART) reduces AIDS-related morbidity and mortality. We tested the hypothesis that initiating ART ≤30 days after human immunodeficiency virus (HIV) diagnosis would be associated with reduced mortality among people living with HIV (PLWH) with CD4 counts >500 cells/μL.

Methods

PLWH enrolled in the Chinese National HIV Information System between January 2012 and June 2014 with CD4 counts >500 cells/μL were followed for 12 months. Cox proportional hazards model was used to determine hazard ratios (HRs) for PLWH who initiated ART after HIV diagnosis. ART initiation was treated as a time-dependent variable.

Results

We enrolled 34581 PLWH with CD4 >500 cells/μL; 1838 (5.3%) initiated ART ≤30 days after diagnosis (immediate ART group), and 19 deaths were observed with a mortality rate of 1.04 per 100 person-years (PY). Fifty-eight deaths were documented among the 5640 PLWH in the delayed ART group with a mortality rate of 2.25 per 100 PY. There were 713 deaths among the 27103 PLWH in the no ART group with a mortality rate of 2.39 per 100 PY. After controlling for potential confounding factors, ART initiation at ≤30 days (adjusted HR, 0.37 [95% confidence interval, .23–.58]) was a statistically significant protective factor.

Conclusions

We found that immediate ART is associated with a 63% reduction in overall mortality among PLWH with CD4 counts >500 cells/μL in China, supporting the recommendation to initiate ART immediately following HIV diagnosis.

Health outcomes of asymptomatic HIV-infected pregnant women initiating antiretroviral therapy at different baseline CD4 counts in Ethiopia

OBJECTIVE

To compare health outcomes following initiation of antiretroviral therapy (ART) for asymptomatic HIV-infected pregnant women at different CD4 levels.

METHODS

We analyzed data from 706 asymptomatic HIV-infected Ethiopian women initiating ART during pregnancy between February 2012 and October 2016. The outcomes evaluated were CD4 gain, CD4 normalization (CD4 count ≥750cells/mm3) and occurrence of HIV-related clinical events after twelve months of treatment.

RESULT

On average, CD4 count (cells/mm3) increased from 391 (95% CI: 372-409) at baseline to 523 (95% CI: 495-551) after twelve months of treatment. Rate of CD4 gain was higher among women with baseline CD4 between 350 and 499 compared to CD4 ≥500 (207 versus 6, p<0.001). But women with baseline CD4 between 350 and 499 could not catch up with women with CD4 ≥500. Women with baseline CD4 ≥500 had significantly higher likelihood of achieving CD4 normalization as compared to those with CD4 between 350 and 499 (AOR=0.32, 95% CI: 0.13-0.76). No strong evidence of differential risk in the occurrence of HIV-related clinical events.

CONCLUSION

Starting ART for asymptomatic HIV-infected women with CD4 count ≥500cells/mm3 was beneficial to preserve or recover immunity after 12 months of treatment in a resource limited setting.

Real-world persistence with antiretroviral therapy for HIV in the United Kingdom: A multicentre retrospective cohort study

Objectives

Persistence with an antiretroviral therapy (ART) regimen for HIV can be defined as the length of time a patient remains on therapy before stopping or switching. We aimed to describe ART persistence in treatment naïve patients starting therapy in the United Kingdom, and to describe differential persistence by treatment regimen.

Methods

We performed a retrospective cohort study at eight UK centres of ART-naïve adults commencing ART between 2012 and 2015. Aggregate data were extracted from local treatment databases. Time to discontinuation was compared for different third agents and NRTI backbones using incidence rates.

Results

1949 patients contributed data to the analysis. Rate of third agent change was 28 per 100 person-years of follow up [95% CI 26–31] and NRTI backbone change of 15 per 100 person-years of follow up [95% CI 14–17]). Rilpivirine, as co-formulated rilpivirine/tenofovir/emtricitabine had a significantly lower discontinuation rate than all other third agents and, excluding single tablet regimens, co-formulated tenofovir/emtricitabine had a significantly lower discontinuation rate than co-formulated abacavir/lamivudine. The reasons for discontinuation were not well recorded.

Conclusions

Treatment discontinuation is not an uncommon event. Rilpivirine had a significantly lower discontinuation rate than other third agents and tenofovir/emtricitabine a lower rate than co-formulated abacavir/lamivudine.

Factors associated with the first antiretroviral therapy modification in older HIV-1 positive patients

Background

Rates of first antiretroviral therapy (cART) modifications are high in most observational studies. The age-related differences in treatment duration and characteristics of first cART modifications remain underinvestigated. With increasing proportion of older patients in HIV population it is important to better understand age-related treatment effects.

Methods

Patients were included into this analysis, if being cART naïve at the first visit at the clinic. Follow-up time was measured from the first visit date until first cART modification or 28 February 2013. First cART modification was defined as any change in the third drug component i.e. protease inhibitor (PI), non-nucleoside reverse transcriptase inhibitor (NNRTI), integrase inhibitor or fusion inhibitor. Cox proportional hazard models were used to identify factors related to first cART modification in three age groups: <30, 30–50 and >50.

Results

In total 2027 patients with 14,965 person-years of follow-up (PYFU) were included. The oldest group included 136 patients with 1901, middle group 1202 with 8416 PYFU and youngest group consisted of 689 patients with 4648 PYFU. Median follow-up time was 5.8 (IQR 3.4–9.4) years, median time on first cART was 4.4 (IQR 2.1–8.5) years. 72.4 % of patients started PI-based and 26.1 % NNRTI-based regimen. In total 1268 (62.5 %) patients had cART modification (non-adherence 30.8 %, toxicity 29.6 %). Durability of first cART was the best in patients over 50 y.o. (log-rank test, p = 0.001). Factors associated with discontinuation in this group were late presentation (HR 0.45, [95 % CI 0.23–0.90], p = 0.02) and PI use (HR 2.17, [95 % CI 1.18–4.0], p = 0.01).

Conclusions

Rates of first cART modifications or discontinuation were comparable in all groups; however older patients were significantly longer on first cART regimen.

Virological failure and development of new resistance mutations according to CD4 count at combination antiretroviral therapy initiation

Objectives

No randomized controlled trials have yet reported an individual patient benefit of initiating combination antiretroviral therapy (cART) at CD4 counts > 350 cells/μL. It is hypothesized that earlier initiation of cART in asymptomatic and otherwise healthy individuals may lead to poorer adherence and subsequently higher rates of resistance development.

Methods

In a large cohort of HIV‐positive individuals, we investigated the emergence of new resistance mutations upon virological treatment failure according to the CD4 count at the initiation of cART.

Results

Of 7918 included individuals, 6514 (82.3%), 996 (12.6%) and 408 (5.2%) started cART with a CD4 count ≤ 350, 351–499 and ≥ 500 cells/μL, respectively. Virological rebound occurred while on cART in 488 (7.5%), 46 (4.6%) and 30 (7.4%) with a baseline CD4 count ≤ 350, 351–499 and ≥ 500 cells/μL, respectively. Only four (13.0%) individuals with a baseline CD4 count > 350 cells/μL in receipt of a resistance test at viral load rebound were found to have developed new resistance mutations. This compared to 107 (41.2%) of those with virological failure who had initiated cART with a CD4 count < 350 cells/μL.

Conclusions

We found no evidence of increased rates of resistance development when cART was initiated at CD4 counts above 350 cells/μL.

Dispelling myths and focusing on notable concepts in HIV pathogenesis

Since the discovery of HIV over three decades ago, major efforts have been made to control and perhaps eliminate HIV infection worldwide. During these studies, certain myths or misconceptions about this infectious disease have been emphasized and other potentially beneficial concepts have received less attention. A true long-term solution to HIV infection merits an appreciation of alternative ideas and findings that could be beneficial in the ultimate control of HIV/AIDS. Here, I discuss six issues and call for more attention to the science of HIV and well-designed clinical trials.