A randomized crossover study to compare efavirenz and etravirine treatment

Factors Associated With Symptoms of Anxiety and Depression in People Living With HIV in Northeast Brazil

BACKGROUND

The diagnosis of HIV infection can cause mental disorders or exacerbate existing symptoms because of the stigma, psychological stress, and need for the self-management of the illness. The aim of this study was to determine the prevalence of anxiety and depression symptoms in people with HIV and to identify the associated factors.

METHODS

This is a cross-sectional study. A sample of 385 people living with HIV (PLWH) was interviewed using the Sociodemographic, Epidemiological, and Clinical Form; the Beck Anxiety Inventory; the Beck Depression Inventory; and Pittsburgh Sleep Quality Index. Univariate and multivariate logistic regression analysis were performed. The odds ratio and 95% confidence interval were calculated.

RESULTS

The prevalence of anxiety was 27.1% and depression was 39.8%. Being female (P = 0.0227), antiretroviral therapy (ART) for 8 years or less (P = 0.0042), and having depression (P < 0.0001) were associated with the occurrence of anxiety. Having a detectable viral load (P = 0.0476), not exercising regularly (P = 0.0070), and having sleep disorders (P = 0.0001) and anxiety (P < 0.0001) were associated with depression. Retired and on leave or sick pay were, respectively, 2.67 and 3.90 times more likely to have depression than those who were employed.

CONCLUSIONS

A considerable percentage of PLWH have anxiety and depression symptoms. Being female, less than 8 years of ART, and depression are associated with anxiety, while detectable viral load, not practicing physical exercise, having sleep disorders, anxiety, and being retired or on leave or sick pay are associated with depression. The study showed important data for health interventions by members of the multidisciplinary team for PLWH.

Quality of life and adherence to antiretroviral therapy in people living with HIV in the Ceará, Brazil

The aim of this study was to investigate the quality of life (QOL) and adherence to antiretroviral therapy (ART) in people living with HIV (PLWH) in Fortaleza, Ceará, Brazil. A cross-sectional study with a sample of 385 patients followed-up on an outpatient basis. Interviews were conducted using the Sociodemographic, Epidemiological and Clinical Form, the World Health Organization's Quality of Life in PLWH Instrument, the Assessment of Adherence to Antiretroviral Treatment Questionnaire and Pittsburgh Sleep Quality Index. Descriptive statistics and univariate and multivariate logistic regression analysis were performed. The odds ratio and confidence interval were calculated, considering P < 0.05 as statistically significant. Of the 385 PLWH, 134 (34.8%) had unsatisfactory QOL which was associated with unemployment (P = 0.0037), monthly income less than the minimum wage (P < 0.0001), sleep disorders (P = 0.0039) and not doing regular exercise (P = 0.0032). Inadequate adherence to ART occurred in 24 patients (6.23%) and was associated with detectable viral load (P = 0.0001) and unsatisfactory QOL (P = 0.0033). QOL was more unsatisfactory for those unemployed and with low income, sleep disorders and sedentary lifestyle. People with detectable viral load and unsatisfactory QOL had more inadequate adherence to ART.

Sleep deficiency among people living with human immunodeficiency virus: A growing challenge

PURPOSE OF REVIEW

The purpose of this narrative review is to consolidate and summarize the existing literature on sleep deficiency among people living with human immunodeficiency virus (HIV; PLWH), to discuss the potential impact of antiretroviral therapy on sleep deficiency and to identify priorities for future research in this area.

RECENT FINDINGS

Three important domains of sleep deficiency include alterations in sleep quality (including sleep disorders), duration and timing. The existing HIV and sleep deficiency literature, which is robust for sleep quality but sparser for sleep duration or sleep timing, has identified epidemiological correlates and outcomes associated with sleep deficiency including sociodemographic factors, HIV-specific factors, aspects of physical and mental health and cognition.

SUMMARY

Sleep deficiency is a common problem among PLWH and is likely underdiagnosed, although more high-quality research is needed in this area. Sleep quality has received the most attention in the literature via methodologies that assess subjective/self-reported sleep quality, objective sleep quality or both. There is significantly less research on sleep duration and minimal research on sleep timing. Use of certain antiretroviral therapy drugs may be associated with sleep deficiency for some individuals. Future research should utilize larger, longitudinal studies with consistent, comprehensive and validated methods to assess both subjective and objective measures of sleep deficiency to better understand the prevalence, correlates and clinical implications of sleep deficiency in PLWH.

Prevalence of Sleep Disorders and Associated Factors in People Living With HIV in the Ceará, Brazil: A Cross-sectional Study

ABSTRACT

The aim of this study was to determine the prevalence of sleep disorders and associated factors in people living with HIV (PLWH). This was a cross-sectional study with a sample of 385 participants followed-up on an outpatient basis in Fortaleza, Ceará, Brazil. Interviews were conducted using the Sociodemographic, Epidemiological and Clinical Form for PLWH and the Pittsburgh Sleep Quality Index. Descriptive statistics and univariate and multivariate logistic regression analysis were performed, and the odds ratio (OR) and 95% confidence interval (95% CI) were calculated, considering p < .05 as statistically significant. The prevalence of sleep disorders was 43.38%. Having children (p = .0054; OR = 1.91; 95% CI = 1.21-3.01), less than 8 years of education (p = .0013; OR = 2.11; 95% CI = 1.34-3.34), and not engaging in regular physical exercise (p = .0001; OR = 2.61; 95% CI = 1.61-4.23) were factors associated with the occurrence of sleep disorders. It was concluded that almost half of the sample had sleep disorders, especially those with children, low level education, and sedentary habits. These data point to the need for increased guidance on sleep hygiene, in addition to the practice of regular physical exercise for this population.

Relationships Among Trajectories of Sleep Disturbance, Depression, and Antiretroviral Therapy in Persons Newly Diagnosed with HIV: A One-and-a-Half-Year Observational Longitudinal Study

PURPOSE

Sleep disturbance is one of the most prevalent symptoms among persons living with HIV (PLWH). However, the trajectory of sleep patterns in persons newly diagnosed with HIV remains underrecognized. The current study aimed to estimate the trajectory of sleep quality and its associated factors among newly diagnosed PLWH.

PATIENTS AND METHODS

A prospective study was conducted in the outpatient clinic of a medical center in southern Taiwan from January 2015 to December 2017. Our primary outcome was sleep quality using the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI). Participants completed the questionnaire at baseline and at four follow-up interval visits: at 3-6, 6-9, 9-12 and 12-15 months. A generalized equation estimation (GEE) model was applied to analyze the relationships among poor sleep quality, depression and antiretroviral therapy among persons newly diagnosed with HIV.

RESULTS

A total of 217 PLWH were included. The mean age of the sample was 29.3 years, and males (98.6%) were predominant. A total of 56.2% of HIV-infected persons were considered to have poor sleep quality at baseline. After controlling for the confounding effects of demographic characteristics, the following factors increased the risk of poor sleep quality: older age (ß= 0.07, CI: 0.03-0.11, p=0.001), level of depression (ß= 0.32, CI: 0.27-0.37, p<0.001) and detectable viral load (ß= 0.61, CI: 0.04 - 1.18, p= 0.037). However, there was no significant difference in BMI, CD4 counts, HIV viral load, disclosure status, or highly active antiretroviral therapy (HAART) regimen.

CONCLUSION

Our results demonstrate that one in two persons with newly diagnosed HIV had poor sleep quality. Being older, having higher levels of depression, and having detectable HIV viral loads were identified as risk factors for developing poor sleep quality in persons living with HIV.

Diagnostic ability of OCT parameters and retinal ganglion cells count in identification of glaucoma in myopic preperimetric eyes

BACKGROUND

The aim of the study is to evaluate the diagnostic ability of OCT parameters and retinal ganglion cells (RGCs) count in identify glaucomatous disease in myopic preperimetric eyes.

METHODS

This was a cross-sectional observational study. The study group consisted of 154 eyes: 36 controls, 64 preperimetric (PPG), and 54 primary openangle glaucoma (POAG) eyes. Each group was divided into three subgroups based on axial length: emmetropic, myopic with axial length (AL) < 25 mm, and myopic with AL > 25 mm, to analyze the effect of myopia. The RGCs count was obtained using a model described later. As regard the influence of myopia on OCT parameters and RGC count, we performed Pearson's correlation. The Area Under Receiver Operator Characteristics Curves (AUROC curves) evaluated which parameter had the best sensitivity and specificity in identifying glaucoma in myopic eyes.

RESULTS

In Pearson's test, all Ganglion Cell Complex (GCC) thicknesses showed the weakest and less significant correlation with AL in all groups. All the AUROCs were statistically significant, and above 0.5. Inferior GCC and Global Loss Volume (GLV) showed the highest AUCs in all myopic group and the best diagnostic ability in distinguishing control from glaucomatous eyes. RGCcount showed good AUROC in all groups, with sensitivities of about 83% in myopic eyes, and specificity over 91% in all groups.

CONCLUSIONS

GCC is the parameter less influenced by the AL, and the inferior GCC and the GLV have the best diagnostic performance. The RGCcount has good sensitivity and specificity, so it can be used as a complementary test in the diagnosis of glaucoma in myopic preperimetric eyes.

Depression is associated with efavirenz-containing treatments in newly antiretroviral therapy initiated HIV patients in Ecuador

Background

It is well known that people living with HIV (PLWH) is in higher risk for the development of depression and it has also been suggested that the use of efavirenz into the antiretroviral regimens increases even that risk.

Objective

To evaluate the effect of efavirenz-containing antiretroviral regimens on the development of depression in newly ART initiated HIV patients in Ecuador.

Methods

In a prospective cohort study from June 2016 to May 2017, all newly HIV diagnosed patients at the HIV/AIDS Unit of the Hospital Eugenio Espejo in Quito, Ecuador were evaluated using the Hamilton Rating Scale for Depression followed by a second assessment 8–12 weeks after antiretroviral therapy containing efavirenz was initiated.

Results

A total of 79 patients, mainly males younger than 35 years were studied. Majority of them were on TDF/FTC/EFV. Initial score in Hamilton Rating Scale revealed that less than 30% had no depression symptoms while almost 40% had mild depression. However, in the second assessment, 22.6% of the subjects had a score in the Hamilton Rating Scale compatible with severe or very severe depression (RR 1.58, 95% CI 1.09 to 2.28; p = 0.05).

Conclusion

In our cohort study, depression was much higher in patients on Efavirenz-containing treatments. Therefore, assessment for depression must be essential as part of follow-up in these patients.

Neuropsychological changes in efavirenz switch regimens

BACKGROUND

Efavirenz is associated with side effects involving the central nervous system. However, it remains largely unknown whether switching off EFV improves neuropsychological performance.

METHODS

We utilized data from the Multicenter AIDS Cohort Study (MACS). Participants were categorized by their use of EFV: never on EFV (No EFV), continuously on EFV (No Switch-OFF) and on EFV and then switched off (Switch-OFF). Baseline time points were defined as visits when first neuropsychological data were available. In Analysis 1, we compared neuropsychological and Center for Epidemiological Studies-Depression Scale (CES-D) scores before and after EFV switch in Switch-OFF group, aligning participants at the time of switch. Analysis 2 evaluated trajectory of neuropsychological/CES-D score among the three groups.

RESULTS

This analysis included 1989 HIV-seropositive participants with neuropsychological data (1675 in No EFV, 44 in No Switch-OFF, and 270 in Switch-OFF group). At baseline, participants had a median age of 37 years, median CD4 cell count 442 cells/μl, and 22.9% viral suppression rate. In Analysis 1, neuropsychological and CES-D scores did not show clinically significant changes over 2 years prior to and 4 years after switch in Switch-OFF group. In Analysis 2, trends in neuropsychological and CES-D scores in the three different groups did not show significant differences during a median of 3.2 years of follow-up.

CONCLUSION

Discontinuation of EFV is not associated with changes in neuropsychological performance or severity of depression in men. Furthermore, we did not observe differences among participants who were never on EFV, continuously on EFV, and on EFV and then switched off.

Etravirine combined with antiretrovirals other than darunavir/ritonavir for HIV-1-infected, treatment-experienced adults: Week 48 results of a phase IV trial

Objective:

VIOLIN (TMC125IFD3002; NCT01422330) evaluated the safety, tolerability, and pharmacokinetics of etravirine with antiretrovirals other than darunavir/ritonavir in HIV-1-infected patients.

Methods:

In a 48-week, phase IV, single-arm, multicenter study, patients on prior antiretroviral therapy (⩾8 weeks) who needed to change regimen for virologic failure (viral load ⩾ 500 copies/mL) or simplification/adverse events (viral load < 50 copies/mL) received etravirine 200 mg bid with ⩾1 other active antiretroviral, excluding darunavir/ritonavir or only nucleoside/tide reverse transcriptase inhibitors.

Results:

Of 211 treated patients, 73% (n = 155) had baseline viral load ⩾ 50 copies/mL and 27% (n = 56) had baseline viral load < 50 copies/mL. Protease inhibitors were the most common background antiretrovirals (83%). Diarrhea was the most frequent adverse event (17%). Serious adverse events (no rash) occurred in 5% of patients; none were etravirine related. Overall, median etravirine AUC_12h was 5390 ng h/mL and C_0h was 353 ng/mL (N = 199). Week 48 virologic response rates (viral load < 50 copies/mL; Food and Drug Administration Snapshot algorithm) were 48% (74/155) (baseline viral load ⩾ 50 copies/mL) and 75% (42/56) (baseline viral load < 50 copies/mL). Virologic failure rates were 42% and 13%, respectively. The most frequently emerging etravirine resistance-associated mutations in virologic failures were Y181C, E138A, and M230L. Virologic response rates for patients with baseline viral load ⩾ 50 copies/mL were 38% (30/79) (non-adherent) versus 64% (44/69) (adherent subset).

Conclusion:

Etravirine 200 mg bid in combination with antiretrovirals other than darunavir/ritonavir was well tolerated in the studied treatment-experienced HIV-1-infected population. The overall etravirine safety and tolerability profile and pharmacokinetics (specifically in those patients who were adherent) were similar to those previously observed for etravirine in HIV-1-infected adults. The relatively high level of non-adherence, also observed in the pharmacokinetic assessments, negatively impacted virologic response, especially in patients with ⩾50 copies/mL at baseline.

Antitumor effect of combination of the inhibitors of two new oncotargets: proton pumps and reverse transcriptase

Tumor therapy needs new approaches in order to improve efficacy and reduce toxicity of the current treatments. The acidic microenvironment and the expression of high levels of endogenous non-telomerase reverse transcriptase (RT) are common features of malignant tumor cells. The anti-acidic proton pump inhibitor Lansoprazole (LAN) and the non-nucleoside RT inhibitor Efavirenz (EFV) have shown independent antitumor efficacy. LAN has shown to counteract drug tumor resistance. We tested the hypothesis that combination of LAN and EFV may improve the overall antitumor effects. We thus pretreated human metastatic melanoma cells with LAN and then with EFV, both in 2D and 3D spheroid models. We evaluated the treatment effect by proliferation and cell death/apoptosis assays in classical and in pulse administration experiments. The action of EFV was negatively affected by the tumor microenvironmental acidity, and LAN pretreatment overcame the problem. LAN potentiated the cytotoxicity of EFV to melanoma cells and, when administered during the drug interruption period, prevented the replacement of tumor cell growth.This study supports the implementation of the current therapies with combination of Proton Pumps and Reverse Transcriptase inhibitors.

Modifying Antiretroviral Therapy in Virologically Suppressed HIV-1-Infected Patients

HIV-1-infected patients with suppressed plasma viral loads often require changes to their antiretroviral (ARV) therapy to manage drug toxicity and intolerance, to improve adherence, and to avoid drug interactions. In patients who have never experienced virologic failure while receiving ARV therapy and who have no evidence of drug resistance, switching to any of the acceptable US Department of Health and Human Services first-line therapies is expected to maintain virologic suppression. However, in virologically suppressed patients with a history of virologic failure or drug resistance, it can be more challenging to change therapy while still maintaining virologic suppression. In these patients, it may be difficult to know whether the discontinuation of one of the ARVs in a suppressive regimen constitutes the removal of a key regimen component that will not be adequately supplanted by one or more substituted ARVs. In this article, we review many of the clinical scenarios requiring ARV therapy modification in patients with stable virologic suppression and outline the strategies for modifying therapy while maintaining long-term virologic suppression.

Switching antiretroviral regimes for the treatment of HIV: safety implications

INTRODUCTION

There are multiple reasons to switch from a virologically successful antiretroviral regimen. Some of them are related to toxicity. Lately, combination antiretroviral treatment (cART) switches have often been related to drug-drug interactions which may also eventually entail safety issues as well.

AREAS COVERED

The purpose of this review is to analyze causes of switching between virologically successful cART regimes related to safety issues. The most relevant papers were selected and summarized.

EXPERT OPINION

Switching cART has been a popular strategy to address safety issues throughout the antiretroviral era. The myriad of switching studies have paralleled the study and release into clinical practice of new antiretroviral drugs with different and often improved safety profiles. Most of them have been successful in improving antiretroviral toxicity while keeping HIV replication under control. However, it should be taken into account that, whenever a new drug is given, there is a possibility of new drug-related toxicity. Notwithstanding that, an increase in cART switching is foreseen, given the fact that we have a wide antiretroviral drug armamentarium and that people living with HIV are ageing and thus more prone to developing age-related co-morbidities whose therapies may entail new interactions and eventually new toxicities.

Long-term efficacy and safety of etravirine-containing regimens in a real-life cohort of treatment-experienced HIV-1-infected patients

OBJECTIVES

Etravirine (ETR) was approved in France in September 2008 and is used in combination with a boosted protease inhibitor (bPI) and other anti-retrovirals (ART) in HIV-infected pre-treated patients. This study aimed to report in a real-life setting the efficacy and tolerability of ETR-based regimens and factors associated with virological response.

METHODS

The study population included all treatment-experienced patients who initiated an ETR-based regimen between September 2008 and July 2013 from the French Dat'AIDS cohort. Analyses were performed in ART-experienced patients starting ETR after virological failure (VF) or as a maintenance therapy (MT), with or without bPI.

RESULTS

A total of 2006 patients (VF, n = 1014 (51%); MT, n = 992 (49%)) were included. At M12, the proportion of patients with HIV RNA < 50 copies/ml was 71.7% (72.0% and 71.1% with or without bPI) in the VF group and 90.5% (85.0% and 92.3% with or without bPI) in the MT group, without significant differences regarding the use of bPI. ETR was discontinued in 8.8% of patients for adverse events in 23.9% of cases (21.5% in VF, 29.5% in MT), treatment failure in 15.2% (16.2% in VF, 7.4% in MT) or simplification in 5.4% (4.6% in VF, 7.4% in MT). In the VF group, factors associated with virological response were a longer duration of HIV infection (OR = 2.7; p < 0.001) and baseline HIV RNA < 5 log10 copies/mL (OR = 2.1; p = 0.002).

CONCLUSION

This study shows that in ART-experienced patients ETR is well tolerated with a high efficacy when combined with other active drugs, even when the regimen does not include a bPI.

Switch to etravirine for HIV-positive patients receiving statin treatment: a prospective study

BACKGROUND

Lifestyle changes and statins are the cornerstones in management of dyslipidaemia in patients with HIV infection. Replacement of an antiretroviral therapy (ART) component is a proposed therapeutic strategy to reduce cardiovascular risk. In dyslipidaemic patients with HIV infection, we assessed the efficacy of replacing boosted protease inhibitor (bPI) or efavirenz (EFV) by etravirine (ETR) as an alternative to statin therapy.

MATERIALS AND METHODS

A prospective, open-label, multicentre, 12-week study of patients with HIV infection on ART including bPI or EFV, and statin treatment. Four weeks after statin interruption, bPI or EFV was switched to ETR (400 mg, 8 weeks) if serum low-density lipoprotein cholesterol (LDL-C) was ≥ 3 mM. The primary endpoint was the proportion of patients on ETR with no indication for statin treatment at study completion. Serum levels of HIV RNA, lipids and biomarkers of cardiovascular disease were also measured. (ClinicalTrials.gov: NCT01543035).

RESULTS

The 31 included patients had a HIV-1 RNA < 50 copies/mL (median age, 52 years; median CD4, 709 cell/mL; median LDL-C, 2·89 mM), 68% were on EFV, and 32% were on bPI. At week 4, 27 patients switched to ETR. At study completion, 15 patients (56%) on ETR did not qualify for statin treatment. After the ETR switch, serum levels of the cardiovascular biomarkers sICAM and MCP1/CCL2 decreased by 11·2% and 18·9%, respectively, and those of CCL5/RANTES and tissue inhibitor of metalloproteinase-1 increased by 14·3% and 13·4%, respectively, indicating reduced cardiovascular risk. There were no notable treatment-related adverse events.

CONCLUSIONS

Replacing bPI or EFV by ETR is a viable strategy to obviate primary prevention statin treatment.

Dysregulation of Endoplasmic Reticulum Stress and Autophagic Responses by the Antiretroviral Drug Efavirenz

Increasing evidence demonstrates that the antiretroviral drugs (ARVds) used for human immunodeficiency virus (HIV) treatment have toxic effects that result in various cellular and tissue pathologies; however, their impact on the cells composing the blood-brain barrier is poorly understood. The current study focused on ARVds, used either in combination or alone, on the induction of endoplasmic reticulum (ER) stress responses in human brain endothelial cells. Among studied drugs (efavirenz, tenofovir, emtricitabine, lamivudine, and indinavir), only efavirenz increased ER stress via upregulation and activation of protein kinase-like ER kinase PERK and inositol requiring kinase 1α (IRE1α). At the same time, efavirenz diminished autophagic activity, a surprising result because typically the induction of ER stress is linked to enhanced autophagy. These results were confirmed in microvessels of HIV transgenic mice chronically administered with efavirenz. In a series of further experiments, we identified that efavirenz dysregulated ER stress and autophagy by blocking the activity of the Beclin-1/Atg14/PI3KIII complex in regard to synthesis of phosphatidylinositol 3-phosphate, a process that is linked to the formation of autophagosomes. Because autophagy is a protective mechanism involved in the removal of dysfunctional proteins and organelles, its inhibition can contribute to the toxicity of efavirenz or the development of neurodegenerative disease in HIV patients treated with this drug.

[GESIDA/National AIDS Plan: Consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (Updated January 2015)]

OBJECTIVE

This consensus document is an update of combined antiretroviral therapy (cART) guidelines and recommendations for HIV-1 infected adult patients.

METHODS

To formulate these recommendations, a panel composed of members of the AIDS Study Group and the AIDS National Plan (GeSIDA/Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, and cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations, and the evidence that supports them, are based on modified criteria of the Infectious Diseases Society of America.

RESULTS

In this update, cART is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and level of the recommendation depends on the CD4+T-lymphocyte count, the presence of opportunistic diseases or comorbid conditions, age, and prevention of transmission of HIV. The objective of cART is to achieve an undetectable plasma viral load. Initial cART should always comprise a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors, and a third drug from a different family. Three out of the ten recommended regimes are regarded as preferential (all of them with an integrase inhibitor as the third drug), and the other seven (based on a non-nucleoside reverse transcriptase inhibitor, a ritonavir-boosted protease inhibitor, or an integrase inhibitor) as alternatives. This update presents the causes and criteria for switching cART in patients with undetectable plasma viral load, and in cases of virological failure where rescue cART should comprise 3 (or at least 2) drugs that are fully active against the virus. An update is also provided for the specific criteria for cART in special situations (acute infection, HIV-2 infection, and pregnancy) and with comorbid conditions (tuberculosis or other opportunistic infections, kidney disease, liver disease, and cancer).

CONCLUSIONS

These new guidelines update previous recommendations related to cART (when to begin and what drugs should be used), how to monitor and what to do in case of viral failure or drug adverse reactions. cART specific criteria in comorbid patients and special situations are equally updated.

Efavirenz modulation of sleep spindles and sleep spectral profile

Non-nucleoside reverse transcriptase inhibitors are important antiretroviral agents for the treatment of human immunodeficiency virus. Some non-nucleoside reverse transcriptase inhibitors, in particular efavirenz, have prominent effects on sleep, cognition and psychiatric variables that limit their tolerability. To avoid confounds due to drug-drug and drug-disease interactions, we assessed the effects of efavirenz in healthy volunteers on sleep, cognition and psychological endpoints during the first week of treatment. Forty healthy male subjects were randomized to receive placebo or efavirenz 600 mg nightly for 7 days after completion of a 3-day placebo run-in period. Treatment with efavirenz was associated with reduced time to sleep onset in the Maintenance of Wakefulness Test, an increase in non-rapid eye movement sleep, a large exposure-related decrease in sigma band spectral density and sleep spindle density during non-rapid eye movement sleep, and reduced performance on an attention switching task. Because efavirenz has been shown to have serotonin 2A receptor partial-agonist properties, we reasoned that antagonism of serotonin 2A receptor signalling in the thalamic reticular nucleus, which generates sleep spindles and promotes attention, may be responsible. Consistent with predictions, treatment of healthy volunteers with a single dose of a serotonin 2A receptor antagonist was found to significantly suppress sigma band spectral density in an exposure-related manner and modulated the overall spectral profile in a manner highly similar to that observed with efavirenz, consistent with the notion that efavirenz exhibits serotonin 2A receptor partial-agonist pharmacology in humans.

Switch strategies in antiretroviral therapy regimens

Despite great advances in antiretroviral therapy in the last decade, several limitations still remain such as adverse effects, lack of adherence and drug-drug interactions. Switching antiretroviral therapy in stable, virologically suppressed patients with the aim of improving tolerability and convenience is an expanding strategy in clinical practice. Several factors need to be taken into consideration when switching a suppressive regimen, such as previous virologic failure, genetic barrier of the new regimen, prior duration of virologic suppression and expected level of adherence. The most frequently used strategies include reductions in the number of pills, drugs or doses. Although switching strategies may be useful, not all the regimens used in clinical practice are based on data from randomized clinical trials and some may not be the best option for certain patients; therefore, therapy should be individualized taking into consideration available information as well as patient and drug characteristics.

[GeSIDA/National AIDS Plan: Consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (Updated January 2014)]

OBJECTIVE

This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients.

METHODS

To formulate these recommendations a panel composed of members of the Grupo de Estudio de Sida and the Plan Nacional sobre el Sida reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. Recommendations strength and the evidence in which they are supported are based on modified criteria of the Infectious Diseases Society of America.

RESULTS

In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and grade of the recommendation varies with the clinical circumstances: CDC stage B or C disease (A-I), asymptomatic patients (depending on the CD4+ T-lymphocyte count: <350cells/μL, A-I; 350-500 cells/μL, A-II, and >500 cells/μL, B-III), comorbid conditions (HIV nephropathy, chronic hepatitis caused by HBV or HCV, age >55years, high cardiovascular risk, neurocognitive disorders, and cancer, A-II), and prevention of transmission of HIV (mother-to-child or heterosexual, A-I; men who have sex with men, A-III). The objective of ART is to achieve an undetectable plasma viral load. Initial ART should always comprise a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors and a third drug from a different family (non-nucleoside reverse transcriptase inhibitor, protease inhibitor, or integrase inhibitor). Some of the possible initial regimens have been considered alternatives. This update presents the causes and criteria for switching ART in patients with undetectable plasma viral load and in cases of virological failure where rescue ART should comprise 2 or 3 drugs that are fully active against the virus. An update is also provided for the specific criteria for ART in special situations (acute infection, HIV-2 infection, and pregnancy) and with comorbid conditions (tuberculosis or other opportunistic infections, kidney disease, liver disease, and cancer).

CONCLUSIONS

These new guidelines updates previous recommendations related to cART (when to begin and what drugs should be used), how to monitor and what to do in case of viral failure or drug adverse reactions. cART specific criteria in comorbid patients and special situations are equally updated.

Etravirine as a Switching Option for Patients with HIV RNA Suppression: A Review of Recent Trials

Unlike other nonnucleoside reverse transcriptase inhibitors, etravirine is only approved for use in treatment-experienced patients. In the DUET 1 and 2 trials, 1203 highly treatment-experienced patients were randomized to etravirine or placebo, in combination with darunavir/ritonavir and optimized background treatment. In these trials, etravirine showed significantly higher rates of HIV RNA suppression when compared with placebo (61% versus 40% at Week 48). There was no significant rise of lipids or neuropsychiatric adverse events, but there was an increase in the risk of rash with etravirine treatment. In the SENSE trial, which evaluated etravirine and efavirenz in 157 treatment-naïve patients in combination with 2 nucleoside analogues, there was a lower risk of lipid elevations and neuropsychiatric adverse events with etravirine when compared to efavirenz. Etravirine has been evaluated in three randomized switching studies. In the SSAT029 switch trial, 38 patients who had neuropsychiatric adverse events possibly related to efavirenz showed an improvement in these after switching to etravirine. The Swiss Switch-EE recruited 58 individuals without neuropsychiatric adverse events who were receiving efavirenz, and no benefit was shown when switching to etravirine. In the Spanish ETRA-SWITCH trial (n = 46), there were improvements in lipids when individuals switched from a protease inhibitor to etravirine. These switching trials were conducted in patients with full HIV RNA suppression: <50 copies/mL and with no history of virological failure or resistance to therapy. The results from these three randomized switching studies suggest a possible new role for etravirine, in combination with two nucleoside analogues, as a switching option for those with HIV RNA suppression but who are reporting adverse events possibly related to antiretroviral therapy. However a large well-powered trial would need to be conducted to strengthen the evidence from the pilot studies conducted so far.

Randomised study to assess the efficacy and safety of once-daily etravirine-based regimen as a switching strategy in HIV-infected patients receiving a protease inhibitor-containing regimen. Etraswitch study

Background

Etravirine (ETR) was approved for patients with virological failure and antiretroviral resistance mutations. It has also shown antiviral efficacy in antiretroviral-naïve patients. However, data on the switching from protease inhibitors (PI) to ETR are lacking.

Methods

HIV-1-infected patients with suppressed viral load (VL) during a PI-containing regimen (>12 months) and no previous virological failure were randomized to switch from the PI to ETR (400 mg/day, dissolved in water) (ETR group, n = 22) or to continue with the same regimen (control group, n = 21). Percentage of patients with VL≤50 copies/mL were assessed at week 48, as well as changes in CD4 T-cell counts and metabolic profile.

Results

We included 43 patients [72.9% male, 46.3 (42.2; 50.6) years]. Two patients receiving ETR (grade-1 diarrhea and voluntary discontinuation) and another in the control group (simplification) discontinued therapy early. No patients presented virological failure (two consecutive VL>50 copies/mL); treatment was successful in 95.2% of the control group and 90.9% of the ETR group (intention-to-treat analysis, missing = failure) (p = 0.58). CD4+ T-cell counts did not significantly vary [+49 cells/µL in the ETR group (p = 0.25) and −4 cells/µL in the control group (p = 0.71)]. The ETR group showed significant reductions in cholesterol (p<0.001), triglycerides (p = <0.001), and glycemia (p = 0.03) and higher satisfaction (0–10 scale) (p = 0.04). Trough plasma concentrations of ETR were similar to observed in studies using ETR twice daily.

Conclusion

Switch from a PI-based regimen to a once-daily combination based on ETR maintained undetectable VL during 48 weeks in virologically suppressed HIV-infected patients while lipid profile and patient satisfaction improved significantly.

Trial Registration

ClinicalTrials.gov NCT01034917

Evaluating sleep and cognition in HIV

OBJECTIVE

To examine the relationship between measures of sleep quality and cognitive performance in HIV-positive individuals stable on combination antiretroviral therapy.

DESIGN

Multimethod assessments of sleep quality, patterns, and cognitive performance were assessed in a predominantly black HIV-positive cohort.

METHODS

Sleep quality and patterns were characterized in 36 subjects by polysomnogram, 2-week actigraphy monitoring, and validated sleep questionnaires. Cognitive performance was assessed with a battery of neuropsychological tests.

RESULTS

The majority of participants were cognitively impaired [based on Frascati (75%) criteria]. Self-reported mean scores on the Pittsburgh sleep quality index and the insomnia severity scale suggested poor sleep quality. Better cognitive performance, particularly on tasks of attention, frontal/executive function, and psychomotor/motor speed, was associated with polysomnogram sleep indices (ie, reduced wake after sleep onset, greater sleep efficiency, greater sleep latency, and greater total sleep time). Thirty-seven percent of participants had sleep patterns suggestive of chronic partial sleep deprivation, which was associated with significantly worse performance on the digit symbol test (P = 0.006), nondominant pegboard (P = 0.043), and verbal fluency tests (P = 0.044).

CONCLUSIONS

Our results suggest that compromised sleep quality and duration may have a significant impact on cognitive performance in HIV-positive individuals. Future studies are warranted to determine the utility of sleep quality and quantity indices as potential predictive biomarkers for development and progression of future HIV-associated neurocognitive disorder.

Risk of clinically significant depression in HIV-infected patients: effect of antiretroviral drugs

OBJECTIVES

We aimed to characterize depression in newly diagnosed HIV-infected patients, to determine the effect of antiretroviral therapy (ART) on its incidence, and to investigate whether efavirenz use was associated with a higher risk, compared with non-efavirenz-containing regimens, in the Spanish CoRIS cohort.

METHODS

CoRIS is a contemporary, multicentre cohort of HIV-infected patients, antiretroviral-naïve at entry, launched in 2004. Poisson regression models were used to investigate demographic, clinical and treatment-related factors associated with a higher incidence of clinically significant depression to October 2010.

RESULTS

In total, 5185 patients (13 089 person-years) participated in the study, of whom 3379 (65.2%) started ART during follow-up. The incidence rates of depression before and after starting ART were 11.68 [95% confidence interval (CI) 9.01-15.15] and 7.06 (95% CI 5.45-9.13) cases per 1000 person-years, respectively. After adjustment, there was an inverse association between the occurrence of depression and the initiation of ART [incidence rate ratio (IRR) 0.53; 95% CI 0.28-0.99], while the likelihood of depression increased in patients of age > 50 years (IRR 1.94; 95% CI 1.21-3.12). Longer exposure to ART was associated with a decreased IRR of depression in unadjusted and adjusted analyses. The IRR for patients receiving < 2, 2-4 and > 4 years of ART was 0.72 (95% CI 0.36-1.44), 0.10 (95% CI 0.04-0.25) and 0.05 (95% CI 0.01-0.17), respectively, compared with ART-naïve patients. This protective effect was also observed when durations of exposure to nonnucleoside reverse transcriptase inhibitor-based regimens and efavirenz-containing regimens were analysed separately.

CONCLUSIONS

The incidence of clinically significant depression was lower among HIV-infected patients on ART. The protective effect of ART was also observed with efavirenz-containing regimens.

Review of the impact of NNRTI-based HIV treatment regimens on patient-reported disease burden

While the burden of HIV disease is well documented, the value of non-nucleoside reverse transcriptase inhibitor (NNRTI)-based therapy regimens in reducing patient burden is not well understood. The purpose of this study was to examine patient-reported health among those receiving NNRTI-based regimens to understand their incremental value in reducing the burden of HIV. We conducted a structured literature review using PubMed to identify NNRTI trials utilizing validated patient-reported outcome (PRO) instruments during 2005-2011. The search strategy included a PubMed search to identify relevant studies based on disease, instrument, PRO, and NNRTI medication terms; and a manual search of bibliographies of identified papers. Data abstracted from each study included study type, treatment regimen(s), and PRO results. Of 11 trials identified, 8 (73%) reported significance of changes in a PRO over time and 10 (91%) reported significance of PRO changes between groups. Several domains were assessed, with significant findings (between or within groups) observed in: physical health/well-being (n = 5), emotional status/well-being (n = 2), symptoms (n = 2), anxiety (n = 2), gastrointestinal upset (n = 2), psychological health (n = 1), functional and global well-being (n = 1), fatigue/energy (n = 1), depression (n = 1), change in body appearance (n = 1), pain (n = 1), headache (n = 1), bad dreams/nightmares (n = 1), problems having sex (n = 1), and general health perception (n = 1). In conclusion, NNRTIs have been observed most frequently to improve patient-reported physical health and well-being. Treatments are needed that can also reduce patient burden in areas of emotional well-being, cognitive functioning, and overall symptom profile.

Patient reported outcome instruments used in clinical trials of HIV-infected adults on NNRTI-based therapy: a 10-year review

BACKGROUND

Patient-reported outcomes (PROs) may provide valuable information to clinicians and patients when choosing initial antiretroviral therapy.

OBJECTIVE

To identify and classify PRO instruments used to measure treatment effects in clinical trials evaluating NNRTIs.

METHODS

We conducted a structured literature review using PubMed to identify NNRTI trials published from March 2003 to February 2013. Studies identified--based on disease, instrument, PRO, and NNRTI medication terms were reviewed--to identify PRO instruments. Domains measured within each instrument were recorded to understand key areas of interest in NNRTIs.

RESULTS

Of 189 articles reviewed, 27 validated instruments were administered in 26 unique trials, with a mean of 1.9 instruments (median: 1; range: 1-7) per trial. The Medical Outcomes Study HIV Health Survey (MOS-HIV) was the most commonly used instrument (n = 8 trials). Seventeen trials (65%) included at least one multidimensional health-related quality of life (HRQL) instrument (HIV-targeted, n = 11; general, n = 8). Other validated instruments measured sleep (n = 5), depression (n = 5), anxiety (n = 4), psychiatric symptoms (n = 2), beliefs about HIV medications (n = 2), HIV symptoms (n = 1), and stress (n = 1).

CONCLUSIONS

Although review of recent NNRTI trials suggests a lack of consensus on the optimal PRO instruments, a typical battery is comprised of a multidimensional HRQL measure coupled with one or more symptom measures. Further work is needed to clarify advantages and disadvantages of using specific PRO instruments to measure relevant constructs and to identify the most useful batteries of instruments for NNRTI trials.

Representation of women and pregnant women in HIV research: a limited systematic review

BACKGROUND

HIV-related outcomes may be affected by biological sex and by pregnancy. Including women in general and pregnant women in particular in HIV-related research is important for generalizability of findings.

OBJECTIVE

To characterize representation of pregnant and non-pregnant women in HIV-related research conducted in general populations.

DATA SOURCES

All HIV-related articles published in fifteen journals from January to March of 2011. We selected the top five journals by 2010 impact factor, in internal medicine, infectious diseases, and HIV/AIDS.

STUDY ELIGIBILITY CRITERIA

HIV-related studies reporting original research on questions applicable to both men and women of reproductive age were considered; studies were excluded if they did not include individual-level patient data.

STUDY APPRAISAL AND SYNTHESIS METHODS

Articles were doubly reviewed and abstracted; discrepancies were resolved through consensus. We recorded proportion of female study participants, whether pregnant women were included or excluded, and other key factors.

RESULTS

In total, 2014 articles were published during this period. After screening, 259 articles were included as original HIV-related research reporting individual-level data; of these, 226 were determined to be articles relevant to both men and women of reproductive age. In these articles, women were adequately represented within geographic region. The vast majority of published articles, 183/226 (81%), did not mention pregnancy (or related issues); still fewer included pregnant women (n=33), reported numbers of pregnant women (n=19), or analyzed using pregnancy status (n=9).

LIMITATIONS

Data were missing for some key variables, including pregnancy. The time period over which published works were evaluated was relatively short.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The under-reporting and inattention to pregnancy in the HIV literature may reduce policy-makers' ability to set evidence-based policy around HIV/AIDS care for pregnant women and women of child-bearing age.

Discontinuation of efavirenz therapy in HIV patients due to neuropsychiatric adverse effects

BACKGROUND

Efavirenz (EFV) is associated with neuropsychiatric manifestations that may compromise the course of HIV treatment.

METHODS

Adverse effects leading to drug discontinuation among naïve HIV-1 patients starting on a first-line antiretroviral therapy (ART) regimen were investigated by a review of patient medical files.

RESULTS

Among 276 patients, 168 (61%) were given EFV as part of the initial ART regimen. Female gender and past mental disorders were identified as predictors for selecting a non-EFV based regimen. EFV was later discontinued during the course of treatment for 90 (54%) patients. The EFV discontinuation rate due to neuropsychiatric disturbances, such as dizziness, abnormal dreams, mood changes, and anxiety, was 60%, versus 3% among patients on a third non-EFV agent based regimen (p < 0.0001). Half of the patients discontinued EFV later than 12 months after initiation of treatment, and in most cases at the discretion of the physician. Improvement in neuropsychiatric symptoms was reported by more than 90% of the patients for whom EFV discontinuation and follow-up outcome had been reported in the medical charts.

CONCLUSIONS

Discontinuation of EFV occurs in more than half the treated patients. Neuropsychiatric adverse effects are by far the most common reasons for discontinuation. Discontinuation occurs late in the course of treatment suggesting persistence of central nervous system toxicity, which may impact quality of life negatively on a long-term basis. The role of EFV as a first-line ART agent should be reconsidered in the current guidelines, in particular due to the availability of other equally effective, but less toxic, ART agents.

Discontinuation of Atripla as first-line therapy in HIV-1 infected individuals

BACKGROUND

Central nervous system (CNS) adverse events are common with initiation of efavirenz, but these are often described as transient. We aimed to describe the outcomes of individuals commencing Atripla (Gilead Sciences Inc, Foster City, California; Bristol-Myers Squibb Co, Princeton, New Jersey, USA) as a first-line regimen.

METHODS

We performed a retrospective case-based analysis of all individuals within our HIV cohort who had received Atripla as their first antiretroviral combination. In individuals who discontinued Atripla data was collected on evolution of adverse events.

RESULTS

Four hundred and seventy-two individuals commenced Atripla as first-line therapy at 12 months, 383 individuals (81%) remained on Atripla with 98% achieving HIV-1 RNA less than 50 copies/ml (on treatment analysis). CNS toxicity was the commonest reason for switching therapy in 63 (71%) cases. The median duration of first reported CNS toxicity was 27 days (IQR 7-104 days) and the commonest reported symptoms were nightmares or vivid dreams in 28 (44%), insomnia in 27 (43%) and depression in 22 (35%). In those with CNS toxicity, six (10%) switched at 0-4 weeks, four (6%) at 4-12 weeks, 30 (48%) at 12-52 weeks and 23 (36%) changed regimen 52-96 weeks after commencing Atripla. Among those with available documentation 25 of 63 (40%) had reported improvement or resolution of their CNS side effects.

DISCUSSION

One-fifth of all individuals commencing Atripla will need to switch therapy, often for adverse events. The commonest reason for switch in our cohort was CNS toxicity, which although it may develop shortly after initiation may persist, ultimately leading to discontinuation of Atripla months or years later.

Prevalence and factors associated with sleep disturbances among early-treated HIV-infected persons

BACKGROUND

Sleep disturbances are reportedly common among persons infected with human immunodeficiency virus (HIV), but recent data, including comparisons with HIV-uninfected persons, are limited.

METHODS

We performed a cross-sectional study among early-treated HIV-infected military beneficiaries (n = 193) to determine the prevalence and factors associated with insomnia (Pittsburgh Sleep Quality Index [PSQI]) and daytime sleepiness (Epworth Sleepiness Scale [ESS]). Data were compared with HIV-uninfected persons (n = 50) matched by age, sex, race or ethnicity, and military rank.

RESULTS

Forty-six percent of HIV-infected persons had insomnia (PSQI >5), and 30% reported daytime drowsiness (ESS ≥10). The prevalence of insomnia and daytime sleepiness was not significantly higher compared with the HIV-uninfected group (38% [P = .30] and 20% [P = .18], respectively). In the multivariate model, factors associated with insomnia among HIV infected patients included depression (odds ratio [OR], 16.8; 95% confidence interval [CI], 2.0-142.1; P = .01), increased waist size (OR, 2.7; 95% CI, 1.4-5.1; P = .002), and fewer years of education (OR, 0.8; 95% CI, .7-.95; P = .006). Neurocognitive impairment (diagnosed in 19% of HIV-infected participants) was not associated with insomnia; however, HIV-infected persons with insomnia were 3.1-fold more likely to have a decline in activities of daily living than those without insomnia (23% vs 9%; P = .01). Only 18% of HIV-infected persons reported using a sleep medication at least weekly.

CONCLUSIONS

HIV-infected persons have a high prevalence of insomnia, but among an early-treated cohort this rate was not significantly higher compared with HIV-uninfected persons. Factors associated with insomnia among HIV-infected patients include depression and increased waist size. Prompt diagnosis and treatment of sleep disturbances are advocated and may improve quality of life.

Phase 2 double-blind, randomized trial of etravirine versus efavirenz in treatment-naive patients: 48-week results

BACKGROUND

The Study of Etravirine Neuropsychiatric Symptoms versus Efavirenz (SENSE) trial compared etravirine with efavirenz in treatment-naive patients. The primary endpoint was neuropsychiatric adverse events up to week 12; HIV RNA suppression at week 48 was a secondary endpoint.

METHODS

Patients with HIV RNA more than 5000  copies/ml were randomized to etravirine 400  mg once daily (n = 79) or efavirenz (n = 78), plus two nucleoside analogues. HIV RNA less than 50  copies/ml at week 48 was analysed using the time to loss of virological response (TLOVR) algorithm. Drug resistance at treatment failure and safety endpoints were also evaluated.

RESULTS

At baseline, the median CD4 cell count was 302  cells/μl and HIV RNA was 4.8 log10  copies/ml. In the intent to treat TLOVR analysis at week 48, 60 of 79 (76%) patients on etravirine versus 58 of 78 (74%) on efavirenz had HIV RNA less than 50  copies/ml. In the on-treatment analysis, 60 of 65 (92%) taking etravirine had HIV RNA les than 50 copies/ml versus 58 of 65 (89%) for efavirenz: etravirine showed noninferior efficacy versus efavirenz in both analyses (P < 0.05). Four patients had virological failure in the etravirine arm: none developed resistance to nucleoside analogues or nonnucleosides. Seven patients had virological failure in the efavirenz arm: three developed treatment-emergent resistance to nucleoside analogues and/or nonnucleosides. At the week 48 visit, the percentage with ongoing neuropsychiatric adverse events was 6.3% for etravirine and 21.5% for efavirenz (P = 0.011).

CONCLUSION

First-line treatment with etravirine 400 mg once daily and two nucleoside reverse transcriptase inhibitors (NRTIs) led to similar rates of HIV RNA suppression, compared with efavirenz and two NRTIs. None of the patients with virological failure in the etravirine arm developed resistance to nonnucleosides.

A randomized cross-over study to compare raltegravir and efavirenz (SWITCH-ER study)

BACKGROUND

Efavirenz (EFV) causes neuropsychiatric side-effects and an unfavorable blood lipid profile. We investigated the effect of replacing EFV with raltegravir (RAL) on patient preference, daytime sleepiness, sleep quality, anxiety, and lipid levels.

METHOD

Switch-ER was a randomized, double-blind, cross-over study. Patients who tolerated EFV, with less than 50 copies/ml HIV-RNA, were randomized into two groups: the RAL-first group started with RAL (400 mg twice daily) and EFV placebo, and the EFV-first group with EFV (600 mg once daily) and RAL placebo. After 2 weeks, both groups switched to the alternate regimen. The primary endpoint was patient preference for the first or the second regimen, assessed after 4 weeks.

RESULTS

Fifty seven participants were enrolled with a median CD4 cell count 600/μl, and duration of previous EFV therapy 3.4 years. Fifty three participants completed the study. When asked about treatment preference after 4 weeks, 22 preferred RAL and 12 preferred EFV, whereas 19 did not express a preference. A significant difference in anxiety and stress scores favoring RAL (P = 0.04 and 0.03, respectively) was observed. Median plasma cholesterol levels decreased by 0.4 mmol/l (16 mg/dl, P < 0.001), triglycerides by 0.2 mmol/l (18 mg/dl, P = 0.036), and low-density lipoprotein by 0.2 mmol/l (8 mg/dl, P = 0.004) after replacing EFV with RAL. After study completion, 51% of patients switched to RAL.

CONCLUSION

Half of patients previously on a stable EFV preferred to switch to RAL, after double-blind exposure to RAL for 2 weeks. Substitution of EFV by RAL significantly impacted on lipid levels, stress, and anxiety scores.