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Short CES, Byrne L, Hagan-Bezgin A, Quinlan RA, Anderson J, Brook G, De Alwis O, de Ruiter A, Farrugia P, Fidler S, Hamlyn E, Hartley A, Murphy S, Noble H, Oomeer S, Roedling S, Rosenvinge M, Rubinstein L, Shah R, Singh S, Thorne E, Toby M, Wait B, Sarner L, Taylor GP. Pregnancy Management in HIV Viral Controllers: Twenty Years of Experience. Pathogens 2024; 13:308. [PMID: 38668263 PMCID: PMC11054990 DOI: 10.3390/pathogens13040308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/29/2024] Open
Abstract
(1) Background: The evidence base for the management of spontaneous viral controllers in pregnancy is lacking. We describe the management outcomes of pregnancies in a series of UK women with spontaneous HIV viral control (<100 copies/mL 2 occasions before or after pregnancy off ART). (2) Methods: A multi-centre, retrospective case series (1999-2021) comparing pre- and post-2012 when guidelines departed from zidovudine-monotherapy (ZDVm) as a first-line option. Demographic, virologic, obstetric and neonatal information were anonymised, collated and analysed in SPSS. (3) Results: A total of 49 live births were recorded in 29 women, 35 pre-2012 and 14 post. HIV infection was more commonly diagnosed in first reported pregnancy pre-2012 (15/35) compared to post (2/14), p = 0.10. Pre-2012 pregnancies were predominantly managed with ZDVm (28/35) with pre-labour caesarean section (PLCS) (24/35). Post-2012 4/14 received ZDVm and 10/14 triple ART, p = 0.002. Post-2012 mode of delivery was varied (5 vaginal, 6 PLCS and 3 emergency CS). No intrapartum ZDV infusions were given post-2012 compared to 11/35 deliveries pre-2012. During pregnancy, HIV was detected (> 50 copies/mL) in 14/49 pregnancies (29%) (median 92, range 51-6084). Neonatal ZDV post-exposure prophylaxis was recorded for 45/49 infants. No transmissions were reported. (4) Conclusion: UK practice has been influenced by the change in guidelines, but this has had little impact on CS rates.
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Affiliation(s)
- Charlotte-Eve S. Short
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College NIHR BRC, Imperial College London, London W2 1NY, UK
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Laura Byrne
- School of Medicine, St Georges, University of London, London SW17 0RE, UK
- St. George’s University Hospitals NHS Trust, London SW17 0RE, UK
| | - Aishah Hagan-Bezgin
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- School of Medicine, University of Liverpool, Liverpool L69 3GE, UK
| | - Rachael A. Quinlan
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College NIHR BRC, Imperial College London, London W2 1NY, UK
| | - Jane Anderson
- Homerton Healthcare NHS Foundation Trust, London E9 6SR, UK
- London North West University Healthcare NHS Trust, Harrow HA1 3UJ, UK
| | - Gary Brook
- London North West University Healthcare NHS Trust, Harrow HA1 3UJ, UK
| | | | - Annemiek de Ruiter
- Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
- ViiV Healthcare, Brentford TW8 9GS, UK
| | - Pippa Farrugia
- Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College NIHR BRC, Imperial College London, London W2 1NY, UK
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Eleanor Hamlyn
- Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Anna Hartley
- Barts Health NHS Trust, London E1 1BB, UK
- Leeds University Teaching Hospital NHS Trust, Leeds LS1 3EX, UK
| | - Siobhan Murphy
- London North West University Healthcare NHS Trust, Harrow HA1 3UJ, UK
| | | | - Soonita Oomeer
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Sherie Roedling
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | | | | | - Rimi Shah
- Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | | | - Elizabeth Thorne
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | | | - Brenton Wait
- Homerton Healthcare NHS Foundation Trust, London E9 6SR, UK
| | | | - Graham P. Taylor
- Department of Infectious Disease, Imperial College London, London W2 1PG, UK
- Imperial College NIHR BRC, Imperial College London, London W2 1NY, UK
- Imperial College Healthcare NHS Trust, London W2 1NY, UK
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Moreno S, Rivero A, Ventayol P, Falcó V, Torralba M, Schroeder M, Neches V, Vallejo-Aparicio LA, Mackenzie I, Turner M, Harrison C. Cabotegravir and Rilpivirine Long-Acting Antiretroviral Therapy Administered Every 2 Months is Cost-Effective for the Treatment of HIV-1 in Spain. Infect Dis Ther 2023; 12:2039-2055. [PMID: 37452174 PMCID: PMC10505114 DOI: 10.1007/s40121-023-00840-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Current antiretroviral therapies (ARTs) have improved outcomes for people living with HIV. However, the requirement to adhere to lifelong daily oral dosing may be challenging for some people living with HIV, leading to suboptimal adherence and therefore reduced treatment effectiveness. Treatment with long-acting (LA) ART may improve adherence and health-related quality of life. The objective of this study was to evaluate the cost-effectiveness of cabotegravir + rilpivirine (CAB+RPV) LA administered every 2 months (Q2M) compared with current ART administered as daily oral single-tablet regimens (STRs) from a Spanish National Healthcare System perspective. METHODS A hybrid decision-tree and Markov state-transition model was used with pooled data from three phase III/IIIb trials (FLAIR, ATLAS, and ATLAS-2M) over a lifetime horizon, with health states defined by viral load and CD4+ cell count. Direct costs (in €) were taken from Spanish public sources from 2021 and several deterministic and probabilistic analyses were carried out. An annual 3% discount rate was applied to both costs and utilities. RESULTS Over the lifetime horizon, CAB+RPV LA Q2M was associated with an additional 0.27 quality-adjusted life years (QALYs) and slightly greater lifetime costs (€4003) versus daily oral ART, leading to an incremental cost-effectiveness ratio of €15,003/QALY, below the commonly accepted €30,000/QALY willingness-to-pay threshold in Spain. All scenario analyses showed consistent results, and the probabilistic sensitivity analysis showed cost-effectiveness compared with daily oral STRs in 62.4% of simulations, being dominant in 0.3%. CONCLUSION From the Spanish National Health System perspective, CAB+RPV LA Q2M is a cost-effective alternative compared with the current options of daily oral STR regimens for HIV treatment. CLINICAL TRIALS REGISTRATION ATLAS, NCT02951052; ATLAS-2M, NCT03299049; FLAIR, NCT02938520.
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Affiliation(s)
- Santiago Moreno
- Hospital Ramón y Cajal, CIBERINFEC, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | | | | | | | | | | | - Victoria Neches
- Market Access, GSK, P.T.M Severo Ochoa, 2-28760, Tres Cantos, Madrid, Spain.
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Kirwan PD, Croxford S, Aghaizu A, Murphy G, Tosswill J, Brown AE, Delpech VC. Re-assessing the late HIV diagnosis surveillance definition in the era of increased and frequent testing. HIV Med 2022; 23:1127-1142. [PMID: 36069144 PMCID: PMC7613879 DOI: 10.1111/hiv.13394] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/10/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Late HIV diagnosis (CD4 <350 cells/mm3 ) is a key public health metric. In an era of more frequent testing, the likelihood of HIV diagnosis occurring during seroconversion, when CD4 counts may dip below 350, is greater. We applied a correction, considering markers of recent infection, and re-assessed 1-year mortality following late diagnosis. METHODS We used national epidemiological and laboratory surveillance data from all people diagnosed with HIV in England, Wales, and Northern Ireland (EW&NI). Those with a baseline CD4 <350 were reclassified as 'not late' if they had evidence of recent infection (recency test and/or negative test within 24 months). A correction factor (CF) was the number reclassified divided by the number with a CD4 <350. RESULTS Of the 32 227 people diagnosed with HIV in EW&NI between 2011 and 2019 with a baseline CD4 (81% of total), 46% had a CD4 <350 (uncorrected late diagnosis rate): 34% of gay and bisexual men (GBM), 65% of heterosexual men, and 56% of heterosexual women. Accounting for recency test and/or prior negative tests gave a 'corrected' late diagnosis rate of 39% and corresponding CF of 14%. The CF increased from 10% to 18% during 2011-2015, then plateaued, and was larger among GBM (25%) than heterosexual men and women (6% and 7%, respectively). One-year mortality among people diagnosed late was 329 per 10 000 after reclassification (an increase from 288/10 000). CONCLUSIONS The case-surveillance definition of late diagnosis increasingly overestimates late presentation, the extent of which differs by key populations. Adjustment of late diagnosis is recommended, particularly for frequent testers such as GBM.
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Affiliation(s)
- Peter D Kirwan
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge,United Kingdom Health Security Agency, London,Corresponding author Contact details: Peter Kirwan, United Kingdom Health Security Agency, London, NW9 5EQ Phone: +44 (0)7837 723563,
| | | | | | - Gary Murphy
- United Kingdom Health Security Agency, London
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Zakaria HF, Raru TB, Hassen FA, Ayana GM, Merga BT, Debele GR, Kiflemariam G, Kebede SA, Ayele TA. Incidence and Predictors of Virological Failure Among Adult HIV/AIDS Patients on Second-Line Anti-Retroviral Therapy, in Selected Public Hospital of Addis Ababa, Ethiopia: Retrospective Follow-Up Study. HIV AIDS (Auckl) 2022; 14:319-329. [PMID: 35836751 PMCID: PMC9275424 DOI: 10.2147/hiv.s367677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Objective Methods Results Conclusion
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Affiliation(s)
- Hamdi Fekredin Zakaria
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Temam Beshir Raru
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Correspondence: Temam Beshir Raru, Department of Epidemiology and Biostatistics, School of Public Health, College of Health and Medical Sciences, Haramaya University, P.O. Box: 235, Harar, Ethiopia, Email
| | - Fila Ahmed Hassen
- Department of Public Health and Health Policy, School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Galana Mamo Ayana
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Bedasa Taye Merga
- Department of Public Health and Health Policy, School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Gebiso Roba Debele
- Department of Public Health, College of Health Sciences, Metu University, Metu, Ethiopia
| | - Genet Kiflemariam
- International Institute for Primary Health Care, Addis Ababa, Ethiopia
| | - Sewnet Adem Kebede
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medical and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadesse Awoke Ayele
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medical and Health Sciences, University of Gondar, Gondar, Ethiopia
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Stirrup O, Tostevin A, Ragonnet-Cronin M, Volz E, Burns F, Delpech V, Dunn D. Diagnosis delays in the UK according to pre or postmigration acquisition of HIV. AIDS 2022; 36:415-422. [PMID: 35084383 PMCID: PMC7612284 DOI: 10.1097/qad.0000000000003110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate whether infection occurred pre or postmigration and the associated diagnosis delay in migrants diagnosed with HIV in the UK. DESIGN We analyzed a cohort of individuals diagnosed with HIV in the UK in 2014-2016 born in Africa or elsewhere in Europe. Inclusion criteria were arrival within 15 years before diagnosis, availability of HIV pol sequence, and viral subtype shared by at least 10 individuals. METHODS We examined phylogenies for evidence of infection after entry into the UK and incorporated this information into a Bayesian analysis of timing of infection using biomarkers of CD4+ cell count, avidity assays, proportion of ambiguous nucleotides in viral sequences, and last negative test dates where available. RESULTS One thousand, two hundred and fifty-six individuals were included. The final model indicated that HIV was acquired postmigration for most MSM born in Europe (posterior expectation 65%, 95% credibility interval 64-67%) or Africa (65%, 62-69%), whereas a minority (20-30%) of men and women with heterosexual transmission acquired HIV postmigration. Estimated diagnosis delays were lower for MSM than for those with heterosexual transmission, and were lower for those with postmigration infection across all subgroups. For MSM acquiring HIV postmigration, the estimated mean time to diagnosis was less than one year, but for those who acquired HIV premigration, the mean time from infection to diagnosis was more than five years for all subgroups. CONCLUSION Acquisition of HIV postmigration is common, particularly among MSM, calling for prevention efforts aimed at migrant communities. Delays in diagnosis reinforce the need for targeted testing initiatives.
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Affiliation(s)
- Oliver Stirrup
- Institute for Global Health, University College London, London, UK
| | - Anna Tostevin
- Institute for Global Health, University College London, London, UK
| | - Manon Ragonnet-Cronin
- MRC Centre for Global Infectious Disease Analysis, Jameel Institute for Disease and Emergency Analytics, Imperial College London, London, UK
| | - Erik Volz
- MRC Centre for Global Infectious Disease Analysis, Jameel Institute for Disease and Emergency Analytics, Imperial College London, London, UK
| | - Fiona Burns
- Institute for Global Health, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Valerie Delpech
- HIV and STI Department, National Infection Service, Public Health England, London, United Kingdom
| | - David Dunn
- Institute for Global Health, University College London, London, UK
- MRC Clinical Trials Unit, University College London, London, UK
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The Immunogenetics of Cutaneous Drug Reactions. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1367:411-431. [DOI: 10.1007/978-3-030-92616-8_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Li CW, Chen YC, Lee NY, Chen PL, Li MC, Li CY, Ko WC, Ko NY. Efavirenz Is Not Associated with an Increased Risk of Depressive Disorders in Patients Living with HIV: An 11-Year Population-Based Study in Taiwan. Healthcare (Basel) 2021; 9:healthcare9121625. [PMID: 34946352 PMCID: PMC8701138 DOI: 10.3390/healthcare9121625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/14/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: This study aimed to determine the association between the use of efavirenz and depressive disorders among human immunodeficiency virus (HIV)-infected patients. (2) Methods: A retrospective cohort study was conducted using Taiwan's National Health Insurance Database. We identified patients receiving anti-retroviral therapy (ART) between 2000 and 2009; these patients were followed until 2010 for diagnoses of depressive disorders using the Cox proportional hazard model to estimate hazard ratios. (3) Results: After up to 11 years of follow-up, the incidence of depressive disorders for the efavirenz-treated group was estimated at 12.2/1000 person-years (PYs), and the control group was at 12.5/1000 PY (p = 0.822). The independent risk factors for depressive disorders included an insurance premium of less than NTD 17,820 (New Taiwan Dollars-NTD) (adjusted hazard ratio (aHR) 2.59, 95% confidence interval (CI), 1.79-3.76, p < 0.001), and between NTD 17,821 and NTD 26,400 (aHR 1.55, 95% CI, 1.04-2.31, p = 0.030), living in Southern Taiwan (aHR 1.49, 95% CI, 1.21-1.84, p = 0.002), and with a psychiatric history (excluding depressive disorders) (aHR 4.59, 95% CI, 3.51-6.01, p = 0.030). (4) Conclusions: This study concluded that ART-treated patients with a past history of psychiatric disorders, lower insurance premium, and living in Southern Taiwan have an increased risk of depressive disorders, which are not associated with the use of efavirenz.
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Affiliation(s)
- Chia-Wen Li
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-W.L.); (N.-Y.L.); (P.-L.C.); (M.-C.L.); (W.-C.K.)
- Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Yen-Chin Chen
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
| | - Nan-Yao Lee
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-W.L.); (N.-Y.L.); (P.-L.C.); (M.-C.L.); (W.-C.K.)
- Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Po-Lin Chen
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-W.L.); (N.-Y.L.); (P.-L.C.); (M.-C.L.); (W.-C.K.)
- Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Ming-Chi Li
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-W.L.); (N.-Y.L.); (P.-L.C.); (M.-C.L.); (W.-C.K.)
- Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Department of Public Health, College of Public Health, China Medical University, Taichung 406, Taiwan
- Correspondence: (C.-Y.L.); (N.-Y.K.); Tel.: +886-6-2353535 (ext. 5838) (N.-Y.K.); Fax: +886-6-2377550 (N.-Y.K.)
| | - Wen-Chien Ko
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-W.L.); (N.-Y.L.); (P.-L.C.); (M.-C.L.); (W.-C.K.)
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Nai-Ying Ko
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Correspondence: (C.-Y.L.); (N.-Y.K.); Tel.: +886-6-2353535 (ext. 5838) (N.-Y.K.); Fax: +886-6-2377550 (N.-Y.K.)
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Youssef M, Zani B, Olaiya O, Soliman M, Mbuagbaw L. Virological measures and factors associated with outcomes, and missing outcome data in HIV clinical trials: a methodological study. BMJ Open 2021; 11:e039462. [PMID: 34697107 PMCID: PMC8547356 DOI: 10.1136/bmjopen-2020-039462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND To evaluate the definition of HIV virological outcomes in the literature and factors associated with outcomes and missing outcome data. METHODS We conducted a methodological review of HIV RCTs using a search (2009-2019) of PubMed, Embase and the Cochrane Central Register of Controlled Trials.Only full-text, peer-reviewed, randomised controlled trials (RCTs) that measured virological outcomes in people living with HIV, and published in English were included.We extracted study details and outcomes. We used logistic regression to identify factors associated with a viral threshold ≤50 copies/mL and linear regression to identify factors associated with missing outcome data. RESULTS Our search yielded 5847 articles; 180 were included. A virological outcome was the primary outcome in 73.5% of studies. 89 studies (49.4%) used virological success. The remaining used change in viral load (VL) (33 studies, 18.3%); virological failure (59 studies, 32.8%); or virological rebound (9 studies, 5.0%). 96 studies (53.3%) set the threshold at ≤50 copies/mL; and 33.1% used multiple measures.Compared with government and privately funded studies, RCTs with industry funding (adjusted OR 6.39; 95% CI 2.15 to 19.00; p<0.01) were significantly associated with higher odds of using a VL threshold of ≤50 copies/mL. Publication year, intervention type, income level and number of patients were not associated with a threshold of ≤50 copies/mL. Trials with pharmacological interventions had less missing data (β=-11.04; 95% CI -20.02 to -1.87; p=0.02). DISCUSSION Country source of funding was associated with VL threshold choice and studies with pharmacological interventions had less missing data, which may in part explain heterogeneous virological outcomes across studies. Multiple measures of VL were not associated with missing data. The development of formal guidelines on virological outcome reporting in RCTs is needed.
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Affiliation(s)
- Mark Youssef
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town Lung Institute, Rondebosch, South Africa
| | - Oluwatobi Olaiya
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Soliman
- Faculty of Science, University of Ottawa, Ottawa, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
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Presanis AM, Harris RJ, Kirwan PD, Miltz A, Croxford S, Heinsbroek E, Jackson CH, Mohammed H, Brown AE, Delpech VC, Gill ON, Angelis DD. Trends in undiagnosed HIV prevalence in England and implications for eliminating HIV transmission by 2030: an evidence synthesis model. Lancet Public Health 2021; 6:e739-e751. [PMID: 34563281 PMCID: PMC8481938 DOI: 10.1016/s2468-2667(21)00142-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND A target to eliminate HIV transmission in England by 2030 was set in early 2019. This study aimed to estimate trends from 2013 to 2019 in HIV prevalence, particularly the number of people living with undiagnosed HIV, by exposure group, ethnicity, gender, age group, and region. These estimates are essential to monitor progress towards elimination. METHODS A Bayesian synthesis of evidence from multiple surveillance, demographic, and survey datasets relevant to HIV in England was used to estimate trends in the number of people living with HIV, the proportion of people unaware of their HIV infection, and the corresponding prevalence of undiagnosed HIV. All estimates were stratified by exposure group, ethnicity, gender, age group (15-34, 35-44, 45-59, or 60-74 years), region (London, or outside of London) and year (2013-19). FINDINGS The total number of people living with HIV aged 15-74 years in England increased from 83 500 (95% credible interval 80 200-89 600) in 2013 to 92 800 (91 000-95 600) in 2019. The proportion diagnosed steadily increased from 86% (80-90%) to 94% (91-95%) during the same time period, corresponding to a halving in the number of undiagnosed infections from 11 600 (8300-17 700) to 5900 (4400-8700) and in undiagnosed prevalence from 0·29 (0·21-0·44) to 0·14 (0·11-0·21) per 1000 population. Similar steep declines were estimated in all subgroups of gay, bisexual, and other men who have sex with men and in most subgroups of Black African heterosexuals. The pace of reduction was less pronounced for heterosexuals in other ethnic groups and people who inject drugs, particularly outside London; however, undiagnosed prevalence in these groups has remained very low. INTERPRETATION The UNAIDS target of diagnosing 90% of people living with HIV by 2020 was reached by 2016 in England, with the country on track to achieve the new target of 95% diagnosed by 2025. Reductions in transmission and undiagnosed prevalence have corresponded to large scale-up of testing in key populations and early diagnosis and treatment. Additional and intensified prevention measures are required to eliminate transmission of HIV among the communities that have experienced slower declines than other subgroups, despite having very low prevalences of HIV. FUNDING UK Medical Research Council and Public Health England.
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Affiliation(s)
- Anne M Presanis
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | | | - Peter D Kirwan
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK; Public Health England, London, UK
| | - Ada Miltz
- Public Health England, London, UK; Institute of Global Health, University College London, London, UK
| | | | | | - Christopher H Jackson
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | | | | | | | - Daniela De Angelis
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK; Public Health England, London, UK
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Martin SA, Cane PA, Pillay D, Mbisa JL. Coevolved Multidrug-Resistant HIV-1 Protease and Reverse Transcriptase Influences Integrase Drug Susceptibility and Replication Fitness. Pathogens 2021; 10:1070. [PMID: 34578103 PMCID: PMC8470981 DOI: 10.3390/pathogens10091070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 11/23/2022] Open
Abstract
Integrase strand transfer inhibitors (InSTIs) are recommended agents in first-line combination antiretroviral therapy (cART). We examined the evolution of drug resistance mutations throughout HIV-1 pol and the effects on InSTI susceptibility and viral fitness. We performed single-genome sequencing of full-length HIV-1 pol in a highly treatment-experienced patient, and determined drug susceptibility of patient-derived HIV-1 genomes using a phenotypic assay encompassing full-length pol gene. We show the genetic linkage of multiple InSTI-resistant haplotypes containing major resistance mutations at Y143, Q148 and N155 to protease inhibitor (PI) and reverse transcriptase inhibitor (RTI) resistance mutations. Phenotypic analysis of viruses expressing patient-derived IN genes with eight different InSTI-resistant haplotypes alone or in combination with coevolved protease (PR) and RT genes exhibited similar levels of InSTI susceptibility, except for three haplotypes that showed up to 3-fold increases in InSTI susceptibility (p ≤ 0.032). The replicative fitness of most viruses expressing patient-derived IN only significantly decreased, ranging from 8% to 56% (p ≤ 0.01). Interestingly, the addition of coevolved PR + RT significantly increased the replicative fitness of some haplotypes by up to 73% (p ≤ 0.024). Coevolved PR + RT contributes to the susceptibility and viral fitness of patient-derived IN viruses. Maintaining patients on failing cART promotes the selection of fitter resistant strains, and thereby limits future therapy options.
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Affiliation(s)
- Supang A. Martin
- Antiviral Unit, Virus Reference Department, Public Health England, London NW9 5EQ, UK; (S.A.M.); (P.A.C.)
| | - Patricia A. Cane
- Antiviral Unit, Virus Reference Department, Public Health England, London NW9 5EQ, UK; (S.A.M.); (P.A.C.)
| | - Deenan Pillay
- Division of Infection and Immunity, University College London, London WC1E 6BT, UK;
| | - Jean L. Mbisa
- Antiviral Unit, Virus Reference Department, Public Health England, London NW9 5EQ, UK; (S.A.M.); (P.A.C.)
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11
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Lei JJH, Pereira B, Moyle G, Boffito M, Milinkovic A. The benefits of tenofovir discontinuation with or without bisphosphonate therapy in osteoporotic people living with HIV. HIV Med 2021; 22:816-823. [PMID: 34258828 DOI: 10.1111/hiv.13137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/15/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Treatment with bisphosphonates and discontinuation of tenofovir disoproxil fumarate (TDF) are recommended strategies for managing osteoporosis in people living with HIV (PLHIV). This study aimed to compare the effects on bone mineral density (BMD) of TDF discontinuation with and without bisphosphonate therapy in osteoporotic PLHIV. METHODS The present study is a retrospective cohort analysis of dual-energy X-ray absorptiometry scan results of PLHIV attending Chelsea and Westminster Hospital HIV clinic between 2009 and 2020. Osteoporotic (T-score < -2.5) patients with ≥ 6 months' TDF exposure were included. Changes in BMD and T-scores at the lumbar spine (LS) and femoral neck (FN) were assessed. RESULTS A total of 84 participants were included, of whom 43 discontinued TDF only (TS) and 41 switched from TDF and received bisphosphonates (TS+): 86.9% were male; 77.4% were white; median (interquartile range, IQR) age was 54.8 (51.0-58.5) years; and median (IQR) TDF exposure was 6.5 (3.5-10.4) years. At a median follow-up of 2 years after TDF-discontinuation, mean spine BMD increased significantly in both groups, but bisphosphonate recipients had greater improvements (4.83% vs. 7.79%; P < 0.019); LS T-scores improved significantly but changes were comparable between groups (TS, 0.5 vs. TS+, 0.6; P = 0.270). At the FN, no significant increases in BMD were observed (TS, 3.05% vs. TS+, 2.71%; P = 0.205); T-scores significantly improved in bisphosphonate recipients only (+0.2; P = 0.003). A greater proportion recovered from osteoporosis in the TS+ group (34.9% vs. 43.9%), although differences between groups were not significant (P = 0.503). CONCLUSIONS Our real-world data indicate that although TDF discontinuation significantly improved bone health in osteoporotic PLHIV, combining bisphosphonates with TDF discontinuation resulted in greater improvements in BMD.
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Affiliation(s)
| | - Branca Pereira
- Imperial College London, London, UK.,HIV/GUM Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Graeme Moyle
- HIV/GUM Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Marta Boffito
- Imperial College London, London, UK.,HIV/GUM Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Ana Milinkovic
- HIV/GUM Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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12
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Brizzi F, Birrell PJ, Kirwan P, Ogaz D, Brown AE, Delpech VC, Gill ON, De Angelis D. Tracking elimination of HIV transmission in men who have sex with men in England: a modelling study. Lancet HIV 2021; 8:e440-e448. [PMID: 34118196 PMCID: PMC8238681 DOI: 10.1016/s2352-3018(21)00044-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 02/03/2021] [Accepted: 02/18/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND To manage the HIV epidemic among men who have sex with men (MSM) in England, treatment as prevention strategies based on test and treat were strengthened between 2011 and 2015, and supplemented from 2015 by scale-up of pre-exposure prophylaxis (PrEP). We examined the effect of these interventions on HIV incidence and investigated whether internationally agreed targets for HIV control and elimination of HIV transmission by 2030 might be within reach among MSM in England. METHODS We used a novel, age-stratified, CD4-staged Bayesian back-calculation model to estimate HIV incidence and undiagnosed infections among adult MSM (age ≥15 years) during the 10-year period between 2009 and 2018. The model used data on HIV and AIDS diagnoses routinely collected via the national HIV and AIDS Reporting System in England, and knowledge on the progression of HIV through CD4-defined disease stages. Estimated incidence trends were extrapolated, assuming a constant MSM population from 2018 onwards, to quantify the likelihood of achieving elimination of HIV transmission, defined as less than one newly aquired infection per 10 000 MSM per year, by 2030. FINDINGS The peak in HIV incidence in MSM in England was estimated with 80% certainty to have occurred in 2012 or 2013, at least 1 year before the observed peak in new diagnoses in 2014. Results indicated a steep decrease in the annual number of new infections among MSM, from 2770 (95% credible interval 2490-3040) in 2013 to 1740 (1500-2010) in 2015, followed by a steadier decrease from 2016, down to 854 (441-1540) infections in 2018. A decline in new infections was consistently estimated in all age groups, and was particularly marked in MSM aged 25-34 years, and slowest in those aged 45 years or older. Similar trends were estimated in the number of undiagnosed infections, with the greatest decrease after 2013 in the 25-34 years age group. Under extrapolation assumptions, we calculated a 40% probability of achieving the defined target elimination threshold by 2030. INTERPRETATION The sharp decrease in HIV incidence, estimated to have begun before the scale up of PrEP, indicates the success of strengthening treatment as prevention measures among MSM in England. To achieve the 2030 elimination threshold, targeted policies might be required to reach those aged 45 years or older, in whom incidence is decreasing at the slowest rate. FUNDING UK Medical Research Council, UK National Institute of Health Research Health Protection Unit in Behavioural Science and Evaluation, and Public Health England.
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Affiliation(s)
- Francesco Brizzi
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Paul J Birrell
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK; National Infection Service, Public Health England, Colindale, UK
| | - Peter Kirwan
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK; National Infection Service, Public Health England, Colindale, UK
| | - Dana Ogaz
- National Infection Service, Public Health England, Colindale, UK
| | - Alison E Brown
- National Infection Service, Public Health England, Colindale, UK
| | | | - O Noel Gill
- National Infection Service, Public Health England, Colindale, UK
| | - Daniela De Angelis
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK.
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13
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Mbisa JL, Ledesma J, Kirwan P, Bibby DF, Manso C, Skingsley A, Murphy G, Brown A, Dunn DT, Delpech V, Geretti AM. Surveillance of HIV-1 transmitted integrase strand transfer inhibitor resistance in the UK. J Antimicrob Chemother 2021; 75:3311-3318. [PMID: 32728703 PMCID: PMC7566560 DOI: 10.1093/jac/dkaa309] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/15/2020] [Indexed: 12/16/2022] Open
Abstract
Background HIV treatment guidelines have traditionally recommended that all HIV-positive individuals are tested for evidence of drug resistance prior to starting ART. Testing for resistance to reverse transcriptase inhibitors and PIs is well established in routine care. However, testing for integrase strand transfer inhibitor (InSTI) resistance is less consistent. Objectives To inform treatment guidelines by determining the prevalence of InSTI resistance in a national cohort of recently infected individuals. Patients and methods Recent (within 4 months) HIV-1 infections were identified using a Recent Infection Testing Algorithm of new HIV-1 diagnoses in the UK. Resistance-associated mutations (RAMs) in integrase, protease and reverse transcriptase were detected by ultradeep sequencing, which allows for the sensitive estimation of the frequency of each resistant variant in a sample. Results The analysis included 655 randomly selected individuals (median age = 33 years, 95% male, 83% MSM, 78% white) sampled in the period 2014 to 2016 and determined to have a recent infection. These comprised 320, 138 and 197 samples from 2014, 2015 and 2016, respectively. None of the samples had major InSTI RAMs occurring at high variant frequency (≥20%). A subset (25/640, 3.9%) had major InSTI RAMs occurring only as low-frequency variants (2%–20%). In contrast, 47/588 (8.0%) had major reverse transcriptase inhibitor and PI RAMs at high frequency. Conclusions Between 2014 and 2016, major InSTI RAMs were uncommon in adults with recent HIV-1 infection, only occurring as low-frequency variants of doubtful clinical significance. Continued surveillance of newly diagnosed patients for evidence of transmitted InSTI resistance is recommended to inform clinical practice.
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Affiliation(s)
- Jean L Mbisa
- National Infection Service, Public Health England, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, London, UK
| | - Juan Ledesma
- National Infection Service, Public Health England, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, London, UK
| | - Peter Kirwan
- National Infection Service, Public Health England, London, UK
| | - David F Bibby
- National Infection Service, Public Health England, London, UK
| | - Carmen Manso
- National Infection Service, Public Health England, London, UK
| | | | - Gary Murphy
- National Infection Service, Public Health England, London, UK
| | - Alison Brown
- National Infection Service, Public Health England, London, UK
| | - David T Dunn
- Institute for Global Health, University College London, London, UK
| | - Valerie Delpech
- National Infection Service, Public Health England, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, London, UK
| | - Anna Maria Geretti
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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14
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Cota JM, Benavides TM, Fields JD, Jansen N, Ganesan A, Colombo RE, Blaylock JM, Maves RC, Agan BK, Okulicz JF. High frequency of potential phosphodiesterase type 5 inhibitor drug interactions in males with HIV infection and erectile dysfunction. PLoS One 2021; 16:e0250607. [PMID: 33956843 PMCID: PMC8101910 DOI: 10.1371/journal.pone.0250607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/10/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES We sought to determine the prevalence of phosphodiesterase type 5 inhibitor (PDE-5) mediated drug-drug interactions (DDIs) in males with HIV infection receiving antiretroviral therapy (ART) and identify factors associated with PDE-5-mediated DDIs. METHODS Male US Military HIV Natural History Study participants diagnosed with erectile dysfunction (ED) and having a PDE-5 inhibitor and potentially-interacting ART co-dispensed within 30 days were included. DDIs were defined according to criteria found in published guidelines and drug information resources. The primary outcome of interest was overall PDE-5 inhibitor-mediated DDI prevalence and episode duration. A secondary logistic regression analysis was performed on those with and without DDIs to identify factors associated with initial DDI episode. RESULTS A total of 235 male participants with ED met inclusion criteria. The majority were White (50.6%) or African American (40.4%). Median age at medication co-dispensing (45 years), duration of HIV infection (14 years), and duration of ED (1 year) did not differ between the two groups (p>0.05 for all). PDE-5 inhibitors included sildenafil (n = 124), vardenafil (n = 99), and tadalafil (n = 14). ART regimens included RTV-boosted protease inhibitors (PIs) atazanavir (n = 83) or darunavir (n = 34), and COBI-boosted elvitegravir (n = 43). Potential DDIs occurred in 181 (77.0%) participants, of whom 122 (67.4%) had multiple DDI episodes. The median DDI duration was 8 (IQR 1-12) months. In multivariate analyses, non-statistically significant higher odds of DDIs were observed with RTV-boosted PIs or PI-based ART (OR 2.13, 95% CI 0.85-5.37) and in those with a diagnosis of major depressive disorder (OR 1.74, 95% CI 0.83-3.64). CONCLUSIONS PDE-5-mediated DDIs were observed in the majority of males with HIV infection on RTV- or COBI-boosted ART in our cohort. This study highlights the importance of assessing for DDIs among individuals on ART, especially those on boosted regimens.
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Affiliation(s)
- Jason M. Cota
- University of the Incarnate Word, San Antonio, TX, United States of America
| | | | - John D. Fields
- University of the Incarnate Word, San Antonio, TX, United States of America
| | - Nathan Jansen
- San Antonio Military Medical Center, Fort Sam Houston, TX, United States of America
| | - Anuradha Ganesan
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States of America
- Walter Reed National Military Medical Center, Bethesda, MD, United States of America
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Rhonda E. Colombo
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States of America
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
- Madigan Army Medical Center, Joint Base Lewis-McChord, WA, United States of America
| | - Jason M. Blaylock
- Walter Reed National Military Medical Center, Bethesda, MD, United States of America
| | - Ryan C. Maves
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
- Naval Medical Center, San Diego, CA, United States of America
| | - Brian K. Agan
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States of America
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Jason F. Okulicz
- San Antonio Military Medical Center, Fort Sam Houston, TX, United States of America
- * E-mail:
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15
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Screening for HIV-Associated Neurocognitive Disorder (HAND) in Adults Aged 50 and Over Attending a Government HIV Clinic in Kilimanjaro, Tanzania. Comparison of the International HIV Dementia Scale (IHDS) and IDEA Six Item Dementia Screen. AIDS Behav 2021; 25:542-553. [PMID: 32875460 PMCID: PMC7846532 DOI: 10.1007/s10461-020-02998-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Validated screening tools for HIV-associated neurocognitive disorders (HAND) are lacking for the newly emergent ageing population of people living with HIV (PLWH) in sub-Saharan Africa (SSA). We aimed to validate and compare diagnostic accuracy of two cognitive screening tools, the International HIV dementia scale (IHDS), and the Identification and Interventions for Dementia in Elderly Africans (IDEA) screen, for identification of HAND in older PLWH in Tanzania. A systematic sample of 253 PLWH aged ≥ 50 attending a Government clinic in Tanzania were screened with the IHDS and IDEA. HAND were diagnosed by consensus American Academy of Neurology (AAN) criteria based on detailed clinical neuropsychological assessment. Strict blinding was maintained between screening and clinical evaluation. Both tools had limited diagnostic accuracy for HAND (area under the receiver operating characteristic (AUROC) curve 0.639–0.667 IHDS, 0.647–0.713 IDEA), which was highly-prevalent (47.0%). Accurate HAND screening tools for older PLWH in SSA are needed.
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16
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Drożdżal S, Rosik J, Lechowicz K, Machaj F, Kotfis K, Ghavami S, Łos MJ. FDA approved drugs with pharmacotherapeutic potential for SARS-CoV-2 (COVID-19) therapy. Drug Resist Updat 2020; 53:100719. [PMID: 32717568 PMCID: PMC7362818 DOI: 10.1016/j.drup.2020.100719] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023]
Abstract
In December 2019, a novel SARS-CoV-2 coronavirus emerged, causing an outbreak of life-threatening pneumonia in the Hubei province, China, and has now spread worldwide, causing a pandemic. The urgent need to control the disease, combined with the lack of specific and effective treatment modalities, call for the use of FDA-approved agents that have shown efficacy against similar pathogens. Chloroquine, remdesivir, lopinavir/ritonavir or ribavirin have all been successful in inhibiting SARS-CoV-2 in vitro. The initial results of a number of clinical trials involving various protocols of administration of chloroquine or hydroxychloroquine mostly point towards their beneficial effect. However, they may not be effective in cases with persistently high viremia, while results on ivermectin (another antiparasitic agent) are not yet available. Interestingly, azithromycin, a macrolide antibiotic in combination with hydroxychloroquine, might yield clinical benefit as an adjunctive. The results of clinical trials point to the potential clinical efficacy of antivirals, especially remdesivir (GS-5734), lopinavir/ritonavir, and favipiravir. Other therapeutic options that are being explored involve meplazumab, tocilizumab, and interferon type 1. We discuss a number of other drugs that are currently in clinical trials, whose results are not yet available, and in various instances we enrich such efficacy analysis by invoking historic data on the treatment of SARS, MERS, influenza, or in vitro studies. Meanwhile, scientists worldwide are seeking to discover novel drugs that take advantage of the molecular structure of the virus, its intracellular life cycle that probably elucidates unfolded-protein response, as well as its mechanism of surface binding and cell invasion, like angiotensin converting enzymes-, HR1, and metalloproteinase inhibitors.
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Affiliation(s)
- Sylwester Drożdżal
- Department of Pharmacokinetics and Monitored Therapy, Pomeranian Medical University in Szczecin, Poland
| | - Jakub Rosik
- Department of Pathology, Pomeranian Medical University in Szczecin, Poland
| | - Kacper Lechowicz
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland
| | - Filip Machaj
- Department of Pathology, Pomeranian Medical University in Szczecin, Poland
| | - Katarzyna Kotfis
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland
| | - Saeid Ghavami
- Department of Human Anatomy and Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Marek J Łos
- Biotechnology Centre, Silesian University of Technology, Krzywoustego 8 Str., 44-100, Gliwice, Poland.
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17
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Abstract
Objective: To investigate the characteristics and outcomes of people who initiated different antiretroviral therapy (ART) regimens during the era of integrase strand transfer inhibitors (INSTIs). Design: UK-based observational cohort study. Methods: UK Collaborative HIV Cohort study participants were included if they had started ART between 1 January 2012 and 30 June 2017. Virological failure was defined as the first of two consecutive plasma HIV RNA more than 50 copies/ml, at least 6 months after starting ART. Follow-up was censored at ART discontinuation, class switch or death. The risk of virological failure among those on INSTI, protease inhibitor or nonnucleoside reverse transcriptase inhibitor (NNRTI) regimens was compared using Kaplan–Meier and Cox regression methods. Results: Of 12 585 participants, 45.6% started a NNRTI, 29.0% a protease inhibitor and 25.4% an INSTI regimen. Over a median follow-up of 20.3 months (interquartile range 7.9–38.9), 7.5% of participants experienced virological failure. Compared with those starting an NNRTI regimen, people receiving INSTIs or protease inhibitors were more likely to experience virological failure: INSTI group adjusted hazard ratio 1.52, 95% confidence interval 1.19–1.95, P = 0.0009; protease inhibitor group adjusted hazard ratio 2.70, 95% confidence interval 2.27–3.21, P less than 0.0001, likelihood ratio test P less than 0.0001. Conclusion: First-line INSTI regimens were associated with a lower risk of virological failure than protease inhibitor regimens but both groups were more likely to experience virological failure than those initiating treatment with a NNRTI. There is likely to be residual channelling bias resulting from selected use of INSTIs and protease inhibitors in specific clinical contexts, including in those with a perceived risk of poor adherence.
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18
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Incidence of and risk factors for tuberculosis among people with HIV on antiretroviral therapy in the United Kingdom. AIDS 2020; 34:1813-1821. [PMID: 32501837 PMCID: PMC8635262 DOI: 10.1097/qad.0000000000002599] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objective: The United Kingdom has a low tuberculosis incidence and earlier combination antiretroviral therapy (cART) is expected to have reduced incidence among people with HIV. Epidemiological patterns and risk factors for active tuberculosis were analysed over a 20-year period among people accessing HIV care at sites participating in the UK CHIC observational study. Design: Cohort analysis. Methods: Data were included for individuals over 15 years old attending for HIV care between 1996 and 2017 inclusive, with at least 3 months follow-up recorded. Incidence rates of new tuberculosis events were calculated and stratified by ethnicity (white/Black/other) as a proxy for tuberculosis exposure. Poisson regression models were used to determine the associations of calendar year, ethnicity and other potential risk factors after cART initiation. Results: Fifty-eight thousand seven hundred and seventy-six participants (26.3% women; 54.5% white, 32.0% Black, 13.5% other/unknown ethnicity; median (interquartile range) age 34 (29–42) years) were followed for 546 617 person-years. Seven hundred and four were treated for active tuberculosis [rate 1.3; 95% confidence interval (CI) 1.2–1.4/1000 person-years). Tuberculosis incidence decreased from 1.3 (1.2–1.5) to 0.6 (0.4–0.9)/1000 person-years from pre-2004 to 2011–2017. The decline among people of Black ethnicity was less steep than among those of white/other ethnicities, with incidence remaining high among Black participants in the latest period [2.1 (1.4–3.1)/1000 person-years]. Two hundred and eighty-three participants [191 (67%) Black African] had tuberculosis with viral load less than 50 copies/ml. Conclusion: Despite the known protective effect of cART against tuberculosis, a continuing disproportionately high incidence is seen among Black African people. Results support further interventions to prevent tuberculosis in this group.
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19
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Adams JL, Murray M, Patel N, Sawkin MT, Boardman RC, Pham C, Kaur H, Patel D, Yager JL, Pontiggia L, Baxter J. Comparative effectiveness of antiretroviral drug classes for the treatment of HIV infection in patients with high viral loads: a multicentre retrospective cohort study. HIV Med 2020; 22:28-36. [PMID: 32964664 DOI: 10.1111/hiv.12959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We aimed to compare the effectiveness of antiretroviral therapy (ART) classes for achieving HIV RNA suppression to < 50 HIV-1 RNA copies/mL within 6 months of initiation with high viral loads (VLs). Secondary objectives were to compare viral suppression (VS) at 12 weeks and 12 months, partial HIV RNA suppression to < 200 copies/mL, time to VS, time to rebound, and change in CD4 cell count. METHODS This was a multicentre, retrospective, observational study. Adult patients were included if they initiated ART between January 2005 and December 2016 with a VL ≥ 100 000 copies/mL. RESULTS There were 220 patients included in the study. The median VL was 252 919 [interquartile range (IQR) 149 472-500 000] copies/mL. Nonnucleoside reverse transcriptase inhibitor (NNRTI) recipients were more likely to achieve VS by 6 months compared to those initiating ART containing protease inhibitors (PIs) [75.4% vs. 44.1%, respectively; odds ratio (OR) 3.34; 95% confidence interval (CI) 1.62-6.90] or integrase strand transfer inhibitors (INSTIs) (75.4% vs. 55.8%, respectively; OR 2.40; 95% CI 1.03-5.58). VS at 12 weeks was more frequent with INSTI-containing regimens than with PIs (28.9% vs. 9.0%, respectively; OR 4.10; 95% CI 1.69-9.92). VS at 12 months did not significantly differ between treatment regimens. Median time to complete VS for INSTI, PI and NNRTI recipients was 22.3 (95% CI 13.4-33), 30.1 (95% CI 25-36) and 19.9 (95% CI 16-22.3) weeks, respectively. There were no significant differences in time to viral rebound or change in CD4 cell counts. CONCLUSIONS Patients with high VLs initiated on NNRTIs were more likely to achieve VS by 6 months on ART compared to INSTI and PI recipients.
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Affiliation(s)
- J L Adams
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA.,Division of Infectious Diseases, Cooper University Hospital, Camden, NJ, USA
| | - M Murray
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Northwestern Memorial Hospital, Chicago, IL, USA
| | - N Patel
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, San Diego, CA, USA.,Albany Stratton VA Medical Center, Albany, NY, USA
| | - M T Sawkin
- KC CARE Health Center, Kansas City, MO, USA
| | - R C Boardman
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA
| | - C Pham
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA
| | - H Kaur
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA
| | - D Patel
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA
| | - J L Yager
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - L Pontiggia
- Misher College of Arts and Sciences, University of the Sciences, Philadelphia, PA, USA
| | - J Baxter
- Division of Infectious Diseases, Cooper University Hospital, Camden, NJ, USA.,Cooper Medical School of Rowan University, Camden, NJ, USA
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20
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Mbisa JL, Kirwan P, Tostevin A, Ledesma J, Bibby DF, Brown A, Myers R, Hassan AS, Murphy G, Asboe D, Pozniak A, Kirk S, Gill ON, Sabin C, Delpech V, Dunn DT. Determining the Origins of Human Immunodeficiency Virus Type 1 Drug-resistant Minority Variants in People Who Are Recently Infected Using Phylogenetic Reconstruction. Clin Infect Dis 2020; 69:1136-1143. [PMID: 30534981 PMCID: PMC6743824 DOI: 10.1093/cid/ciy1048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/06/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Drug-resistant minority variants (DRMinVs) detected in patients who recently acquired human immunodeficiency virus type 1 (HIV-1) can be transmitted, generated de novo through virus replication, or technical errors. The first form is likely to persist and result in treatment failure, while the latter two could be stochastic and transient. METHODS Ultradeep sequencing of plasma samples from 835 individuals with recent HIV-1 infection in the United Kingdom was performed to detect DRMinVs at a mutation frequency between 2% and 20%. Sequence alignments including >110 000 HIV-1 partial pol consensus sequences from the UK HIV Drug Resistance Database (UK-HDRD), linked to epidemiological and clinical data from the HIV and AIDS Reporting System, were used for transmission cluster analysis. Transmission clusters were identified using Cluster Picker with a clade support of >90% and maximum genetic distances of 4.5% or 1.5%, the latter to limit detection to likely direct transmission events. RESULTS Drug-resistant majority variants (DRMajVs) were detected in 66 (7.9%) and DRMinVs in 84 (10.1%) of the recently infected individuals. High levels of clustering to sequences in UK-HDRD were observed for both DRMajV (n = 48; 72.7%) and DRMinV (n = 63; 75.0%) sequences. Of these, 43 (65.2%) with DRMajVs were in a transmission cluster with sequences that harbored the same DR mutation compared to only 3 (3.6%) sequences with DRMinVs (P < .00001, Fisher exact test). Evidence of likely direct transmission of DRMajVs was observed for 25/66 (37.9%), whereas none were observed for the DRMinVs (P < .00001). CONCLUSIONS Using a densely sampled HIV-infected population, we show no evidence of DRMinV transmission among recently infected individuals.
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Affiliation(s)
- Jean L Mbisa
- National Infection Service, Public Health England, London, United Kingdom.,National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, London, United Kingdom
| | - Peter Kirwan
- National Infection Service, Public Health England, London, United Kingdom
| | - Anna Tostevin
- Institute for Global Health, University College London, London, United Kingdom
| | - Juan Ledesma
- National Infection Service, Public Health England, London, United Kingdom.,National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, London, United Kingdom
| | - David F Bibby
- National Infection Service, Public Health England, London, United Kingdom
| | - Alison Brown
- National Infection Service, Public Health England, London, United Kingdom
| | - Richard Myers
- National Infection Service, Public Health England, London, United Kingdom
| | - Amin S Hassan
- HIV/STI Group, Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gary Murphy
- National Infection Service, Public Health England, London, United Kingdom
| | - David Asboe
- Chelsea and Westminster Hospital, London, United Kingdom
| | - Anton Pozniak
- Chelsea and Westminster Hospital, London, United Kingdom
| | - Stuart Kirk
- University College London Hospital, London, United Kingdom
| | - O Noel Gill
- National Infection Service, Public Health England, London, United Kingdom.,National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, London, United Kingdom
| | - Caroline Sabin
- National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, London, United Kingdom.,Institute for Global Health, University College London, London, United Kingdom
| | - Valerie Delpech
- National Infection Service, Public Health England, London, United Kingdom.,National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, London, United Kingdom
| | - David T Dunn
- Institute for Global Health, University College London, London, United Kingdom
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21
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Stradling C, Thomas GN, Hemming K, Taylor S, Taheri S. Randomized parallel-group pilot trial (Best foods for your heart) comparing the effects of a Mediterranean Portfolio diet with a low saturated fat diet on HIV dyslipidemia. Clin Nutr 2020; 40:860-869. [PMID: 33032837 DOI: 10.1016/j.clnu.2020.08.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/04/2020] [Accepted: 08/31/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND & AIMS Mediterranean diets reduce the risk of cardiovascular disease (CVD). However, the effect is unknown in people living with HIV, who have an increased risk potentially due to the additional burdens of infection, inflammation and antiretroviral treatment (ART). We examined the feasibility of a 6-month dietary intervention in adults with HIV dyslipidemia using a sample size adequate to detect differences in LDL-cholesterol. METHODS Sixty adults with stable HIV infection on ART and LDL-cholesterol >3 mmol/l were recruited. Participants were randomized (1:1) to receive dietary advice to reduce saturated fat intake to <10% of energy intake (Diet1), or supported to adopt the Mediterranean Portfolio Diet (Diet2) with additional cholesterol-lowering foods (nuts, stanols, soya, oats, beans) for 6 months. Recruitment, retention and intervention fidelity were monitored. Measurements were conducted at baseline, 6 and 12 months. A secondary analysis examined between group differences in CVD risk factors at month 6 adjusted for baseline values and potential confounders. RESULTS Rates of recruitment, participation and attrition were 35%, 91%, and 12% respectively. Reported dietary adherence was 68% to Mediterranean foods and 59% to Portfolio components. At 6 months Diet2 participants (n = 29) had a significantly lower LDL-cholesterol (mean difference adjusted for baseline -0.4 mmol/l, 95%CI -0.7 to -0.1, P = 0.01), and systolic blood pressure (-7 mmHg, 95%CI -2 to -12, P = 0.008) compared to those in Diet1 (n = 31). These effects were not sustained at 1 year (LDL-cholesterol -0.05 mmol/l, 95%CI -0.33 to 0.23, P = 0.7; systolic blood pressure -3.5 mmHg, 95%CI -9.4 to 2.5, P = 0.2). CONCLUSION We showed the feasibility of adopting a Mediterranean Portfolio diet in people living with HIV. Our findings suggest this intervention might equate to short term improvements in diet quality, blood pressure, and LDL-cholesterol. Further definitive evaluations are required to determine if this is a viable strategy to facilitate cardiovascular risk reduction. CLINICAL TRIAL REGISTRY ISRCTN32090191 Best Foods For your heart trial.
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Affiliation(s)
- Clare Stradling
- Institute of Applied Health Research, University of Birmingham, UK; Birmingham Heartlands HIV Service, Department of Infection and Immunology, University Hospitals Birmingham NHS Foundation Trust, UK.
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, UK
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, UK
| | - Stephen Taylor
- Birmingham Heartlands HIV Service, Department of Infection and Immunology, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Shahrad Taheri
- Clinical Research Core and Department of Medicine, Weill Cornell Medicine in Qatar and New York, Doha, Qatar
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22
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Maitre T, Muret P, Blot M, Waldner A, Duong M, Si-Mohammed A, Chavanet P, Aho S, Piroth L. Benefits and Limits of Antiretroviral Drug Monitoring in Routine Practice. Curr HIV Res 2020; 17:190-197. [PMID: 31490758 DOI: 10.2174/1570162x17666190903232053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/26/2019] [Accepted: 08/20/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND HIV infection is a chronic disease for which therapeutic adherence and tolerance require particular attention. OBJECTIVE This study aimed to assess whether and when therapeutic drug monitoring (TDM) could be associated with a benefit in routine practice. METHODS All HIV-infected patients who underwent at least one TDM at the University Hospital of Dijon (France) between 1st January 2009 and 31st December 2012 were retrospectively included. Compliance with the recommendations, the results (antiretroviral concentrations), any subsequent therapeutic modifications, and the virological results at 4-8 months were analysed each time TDM was performed. TDM was defined as "practically relevant" when low or high antiretroviral concentrations led to a change in therapy. RESULTS Of the 571 patients who followed-up, 43.4% underwent TDM. TDM complying with recommendations (120 patients) was associated with a higher proportion of antiretroviral concentrations outside the therapeutic range (p=0.03). Antiretroviral treatment was modified after TDM in 22.6% of patients. Protease inhibitors, non-nucleoside reverse transcriptase inhibitors and raltegravir were more significantly modified when the measured concentration was outside the therapeutic range (p=0.008, p=0.05 and p=0.02, respectively). Overall, 11.7% of TDM was considered "practically relevant", though there was no significant correlation between subsequent changes in antiretroviral treatment and undetectable final HIV viral load. CONCLUSION TDM may be a useful tool in the management of HIV infection in specific situations, but the overall benefit seems moderate in routine practice. TDM cannot be systematic and/or a decision tool per se, but should be included in a comprehensive approach in certain clinical situations.
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Affiliation(s)
- Thomas Maitre
- Department of Infectious Diseases, University Hospital, Dijon, France
| | - Patrice Muret
- Laboratory of Clinical Pharmacology, University Hospital, Besancon, France.,UMR1098, University of Franche-Comte, Besançon, France
| | - Mathieu Blot
- Department of Infectious Diseases, University Hospital, Dijon, France
| | - Anne Waldner
- Department of Infectious Diseases, University Hospital, Dijon, France
| | - Michel Duong
- Department of Infectious Diseases, University Hospital, Dijon, France
| | | | - Pascal Chavanet
- Department of Infectious Diseases, University Hospital, Dijon, France.,UMR1347, University of Burgundy, Dijon, France
| | - Serge Aho
- Department of Hospital Hygiene, University Hospital, Dijon, France
| | - Lionel Piroth
- Department of Infectious Diseases, University Hospital, Dijon, France.,UMR1347, University of Burgundy, Dijon, France
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23
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Agegnehu CD, Merid MW, Yenit MK. Incidence and predictors of virological failure among adult HIV patients on first-line antiretroviral therapy in Amhara regional referral hospitals; Ethiopia: a retrospective follow-up study. BMC Infect Dis 2020; 20:460. [PMID: 32611405 PMCID: PMC7329399 DOI: 10.1186/s12879-020-05177-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 06/18/2020] [Indexed: 11/15/2022] Open
Abstract
Background Although the United Nations program on HIV/AIDS 90–90-90-targets recommends achieving 90% of viral suppression for patients on first-line antiretroviral therapy by 2020, virological failure is still high and it remains a global public health problem. Therefore, assessing the incidence and predictors of virological failure among adult HIV patients on first-line ART in Amhara regional referral hospitals, Ethiopia is vital to design appropriate prevention strategies for treatment failure and preventing the unnecessary switching to second-line regimens. Method An institution-based retrospective follow-up study was conducted on 490 adult HIV patients. The simple random sampling technique was used, and data were entered into Epi data Version 4.2.0.0 and was exported to Stata version 14 for analysis. The proportional hazard assumption was checked, and the Weibull regression was fitted. Cox-Snell residual was used to test the goodness of fit, and the appropriate model was selected by AIC/BIC. Finally, an adjusted hazard ratio with a 95% CI was computed, and variables with P-value < 0.05 in the multivariable analysis were taken as significant predictors of virological failure. Results The overall incidence rate of virological failure was 4.9 events per 1000 person-month observations (95%CI: 3.86–6.38). Users of CPT (AHR = 0.55, 95%CI: 0.31–0.97), poor adherence (AHR = 5.46, 95%CI: 3.07–9.74), CD4 Count <=200 cells/mm3 (AHR = 3.9, 95%CI: 1.07–13.9) and 201–350 cells/mm3 (AHR 4.1, 95%CI: 1.12–15) respectively, and NVP based first line drug regimen (AHR = 3.53, 95%CI: 1.73–7.21) were significantly associated with virological failure. Conclusion The incidence rate of virological failure was high. CPT, poor adherence, low baseline CD4 count and NVP based first-line drug regimen were independent risk factors associated with virological failure. Therefore, strengthening HIV care intervention and addressing these significant predictors is highly recommended in the study setting.
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Affiliation(s)
- Chilot Desta Agegnehu
- School of Nursing, College of Medicine and Health Sciences and Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia.
| | - Mehari Woldemariam Merid
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Melaku Kindie Yenit
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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24
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Wang L, Zhang Y, Wang W, Zhang L, Yang C, Zhuang JL, Han B, Zhou DB, Chen M. [Clinical analysis in five patients with acute leukemia and HIV infection]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:517-520. [PMID: 32654469 PMCID: PMC7378282 DOI: 10.3760/cma.j.issn.0253-2727.2020.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Indexed: 11/05/2022]
Affiliation(s)
- L Wang
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Y Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - W Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - L Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - C Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - J L Zhuang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - B Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - D B Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - M Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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25
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Brady M, Rodger A, Asboe D, Cambiano V, Clutterbuck D, Desai M, Field N, Harbottle J, Jamal Z, McCormack S, Palfreeman A, Portman M, Quinn K, Tenant-Flowers M, Wilkins E, Young I. BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018. HIV Med 2020; 20 Suppl 2:s2-s80. [PMID: 30869189 DOI: 10.1111/hiv.12718] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Michael Brady
- Consultant in Sexual Health and HIV, King's College Hospital, London
| | - Alison Rodger
- Reader and Honorary Consultant Infectious Diseases and HIV, University College London
| | - David Asboe
- Consultant HIV and Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London
| | - Valentina Cambiano
- Lecturer in Infectious Disease Modelling and Biostatistics, University College London
| | | | - Monica Desai
- Consultant Epidemiologist, Public Health England
| | - Nigel Field
- Senior Lecturer, Consultant Clinical Epidemiologist, University College London
| | | | | | - Sheena McCormack
- Professor of Clinical Epidemiology, MRC Clinical Trials Unit at University College London
| | - Adrian Palfreeman
- Consultant HIV and Sexual Health, University Hospitals of Leicester NHS Trust
| | - Mags Portman
- Consultant HIV and Sexual Health, Mortimer Market Centre, London
| | - Killian Quinn
- Consultant HIV and Sexual Health, King's College Hospital, London
| | | | - Ed Wilkins
- Consultant in Infectious Diseases, North Manchester General Hospital
| | - Ingrid Young
- Chancellor's Fellow, Usher Institute, University of Edinburgh
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26
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Abstract
Human immunodeficiency virus (HIV) is a pandemic affecting more than 35 million people worldwide. The aim of this review is to describe the association between HIV and total hip arthroplasty (THA) and assess patient risk factors to optimize functional outcomes and decrease rates of revision. Since the advent of highly active antiretroviral treatment (HAART), HIV-infected patients are living longer, which allows them to develop degenerative joint conditions. HIV and HAART act independently to increase the demand for THA. HIV-positive patients are also more predisposed to developing avascular necrosis (AVN) of the hip and femoral neck fractures due to decreased bone mineral density (BMD). Prior to the widespread implementation of access to HAART in homogenous cohorts of HIV-infected patients undergoing THA, reports indicated increased rates of complications. However, current literature describes equivocal functional outcomes and survival rates after THA in HIV-positive patients controlled on HAART when compared to HIV-negative controls. HIV-infected patients eligible for THA should be assessed for medical co-morbidities and serum markers of disease control should be optimized. Periprosthetic joint infection (PJI) is a leading cause of revision THA, and HIV is a modifiable risk factor. Importantly, the significance is negated once patients are placed on HAART and achieve viral suppression. THA should not be withheld in HIV-infected patients injudiciously. However, HIV is a burgeoning epidemic and all patients should be identified and started on HAART to avoid preventable peri-operative complications.
Cite this article: EFORT Open Rev 2020;5:164-171. DOI: 10.1302/2058-5241.5.190030
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Affiliation(s)
| | - Zia Maharaj
- Arthroplasty Unit, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Johannesburg, South Africa
| | - Lipalo Mokete
- Arthroplasty Unit, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Johannesburg, South Africa
| | - Nkhodiseni Sikhauli
- Arthroplasty Unit, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Johannesburg, South Africa
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27
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Djeha A, Girard S, Trottier H, Kakkar F, Soudeyns H, Boucher M, Lapointe N, Boucoiran I. No association between early antiretroviral therapy during pregnancy and plasma levels of angiogenic factors: a cohort study. BMC Pregnancy Childbirth 2019; 19:482. [PMID: 31815612 PMCID: PMC6902555 DOI: 10.1186/s12884-019-2600-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/14/2019] [Indexed: 01/18/2023] Open
Abstract
Background Early antiretroviral therapy (ART) during pregnancy has dramatically reduced the risk of perinatal HIV transmission. However, studies have shown an association between premature delivery and the use of ART during pregnancy (particularly protease inhibitor (PI)-based therapies), which could be explained by placental dysfunction. The objective of this study was to evaluate the association of ART (class, duration of exposure and time of initiation) with placental function by using angiogenic factors placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) as biomarkers. Methods Clinical and biological data from 159 pregnant women living with HIV were analyzed. Levels of each biomarker were measured in the first and second trimester of pregnancy. After logarithmic transformation, we compared these using generalized estimating equations according to (a) the type of ART; (b) the duration of exposure to ART; and (c) the time of initiation of ART. Results After adjusting for variables such as ethnicity, maternal age, gestational age, body mass index, parity, smoking status, and sex of the fetus, we found no significant association between the class of ART (PI-based or not) and serum concentrations of PlGF or sFlt-1. Furthermore, no significant association was found between biomarker levels and the duration of ART exposure or the timing of ART initiation (pre- or post-conception). Conclusions This study suggests that first and second trimester angiogenic factor levels are not significantly associated with ART, regardless of the duration or type (with or without PI). These observations seem reassuring when considering the use of ART during early pregnancy.
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Affiliation(s)
- Ameyo Djeha
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université de Montréal, Montreal, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Sylvie Girard
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université de Montréal, Montreal, Canada.,Centre de recherche du CHU Sainte-Justine, Montreal, Canada
| | - Helen Trottier
- Department of Social and Preventive Medicine, Faculty of Medicine, Université de Montréal, Montreal, Canada.,Centre de recherche du CHU Sainte-Justine, Montreal, Canada
| | - Fatima Kakkar
- Centre d'infectiologie Mère-Enfant, CHU Sainte-Justine, Montreal, Canada.,Division of Infectious Diseases, CHU Sainte-Justine, Montreal, Canada.,Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Hugo Soudeyns
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada.,Unité d'immunopathologie virale, Centre de recherche du CHU Sainte-Justine, Montreal, Canada.,Department of Microbiology, Infectiology & Immunology, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Marc Boucher
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université de Montréal, Montreal, Canada.,Centre d'infectiologie Mère-Enfant, CHU Sainte-Justine, Montreal, Canada.,Department of Obstetrics and Gynecology, Centre hospitalier universitaire (CHU) Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Normand Lapointe
- Centre d'infectiologie Mère-Enfant, CHU Sainte-Justine, Montreal, Canada.,Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Isabelle Boucoiran
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université de Montréal, Montreal, Canada. .,Department of Social and Preventive Medicine, Faculty of Medicine, Université de Montréal, Montreal, Canada. .,Centre de recherche du CHU Sainte-Justine, Montreal, Canada. .,Centre d'infectiologie Mère-Enfant, CHU Sainte-Justine, Montreal, Canada. .,Department of Obstetrics and Gynecology, Centre hospitalier universitaire (CHU) Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
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28
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da Costa Vieira V, Almeida Sarmento V, Leite Ribeiro PM, Martins Netto E, Brites C, Lins-Kusterer L. Unusual oral findings of the toxic epidermal necrolysis in an HIV-infected patient: a case report. Braz J Infect Dis 2019; 23:363-367. [PMID: 31562853 PMCID: PMC9428039 DOI: 10.1016/j.bjid.2019.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/22/2019] [Accepted: 08/16/2019] [Indexed: 11/28/2022] Open
Abstract
Erythema multiforme (EM), Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (TEN) have been reported as possible adverse effects of some classes of first-line antiretroviral drugs (ART) for HIV treatment. Herein we report an unusual presentation of TEN lesions associated with ART in an HIV-infected patient. The patient presented disseminated cutaneous eruption and oral lesions from the lips to the oropharynx region, causing odynophagia and dysphagia. In the tongue, circular, atypical erythematous lesions appeared, increasing in diameter over seven days and coalescing since then to complete remission. TEN treatment included efavirenz interruption, use of methylprednisolone, prophylactic antibiotic, and daily laser therapy with low-intensity red light. The circular oral lesions have not been described yet. Reporting our findings and clinical management may help diagnosing other similar cases and guide the clinical conduct. Analgesia and acceleration of oral ulcer repair with red laser therapy are recommended.
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Affiliation(s)
- Vinicius da Costa Vieira
- Complexo Hospitalar Universitário Professor Edgard Santos, Serviço de Estomatologia, Salvador, BA, Brazil.
| | | | | | - Eduardo Martins Netto
- Complexo Hospitalar Universitário Professor Edgard Santos, Laboratório de Investigação de Doenças Infecciosas, Salvador, BA, Brazil.
| | - Carlos Brites
- Complexo Hospitalar Universitário Professor Edgard Santos, Laboratório de Investigação de Doenças Infecciosas, Salvador, BA, Brazil.
| | - Liliane Lins-Kusterer
- Complexo Hospitalar Universitário Professor Edgard Santos, Laboratório de Investigação de Doenças Infecciosas, Salvador, BA, Brazil.
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29
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Glendinning E, Spiers J, Smith JA, Anderson J, Campbell LJ, Cooper V, Horne R. A Qualitative Study to Identify Perceptual Barriers to Antiretroviral Therapy (ART) Uptake and Adherence in HIV Positive People from UK Black African and Caribbean Communities. AIDS Behav 2019; 23:2514-2521. [PMID: 31520239 PMCID: PMC6766469 DOI: 10.1007/s10461-019-02670-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To inform the development of interventions to increase uptake and adherence to antiretroviral therapy (ART), we explored perceptions of ART in semi-structured interviews with 52 men and women from UK black African and black Caribbean communities. Verbatim transcripts were analyzed using framework analysis. Perceptions of ART could be grouped into two categories: doubts about the personal necessity for ART and concerns about potential adverse effects. Doubts about necessity stemmed from feeling well, doubts about the efficacy of ART, religious beliefs and the belief that treatment was futile because it could not cure HIV. Concerns about adverse effects included the fear that attending HIV services and taking treatment would lead to disclosure of HIV, feeling overwhelmed at the prospect of starting treatment soon after diagnosis, fears about side effects and potential long-term effects, and physical repulsion. The findings will facilitate the development of interventions to increase uptake and adherence to ART.
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Affiliation(s)
- Elizabeth Glendinning
- Centre for Behavioural Medicine, UCL School of Pharmacy, BMA House, Tavistock Square, London, WC1H 9JP UK
| | - Johanna Spiers
- Centre for Behavioural Medicine, UCL School of Pharmacy, BMA House, Tavistock Square, London, WC1H 9JP UK
| | - Jonathan A. Smith
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Jane Anderson
- Centre for the Study of Sexual Health and HIV, Homerton University Hospital, London, UK
| | | | - Vanessa Cooper
- Centre for Behavioural Medicine, UCL School of Pharmacy, BMA House, Tavistock Square, London, WC1H 9JP UK
| | - Rob Horne
- Centre for Behavioural Medicine, UCL School of Pharmacy, BMA House, Tavistock Square, London, WC1H 9JP UK
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30
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Sereti I, Gulick RM, Krishnan S, Migueles SA, Palfreeman A, Touzeau-Römer V, Belloso WH, Emery S, Law MG. ART in HIV-Positive Persons With Low Pretreatment Viremia: Results From the START Trial. J Acquir Immune Defic Syndr 2019; 81:456-462. [PMID: 31241541 PMCID: PMC6607914 DOI: 10.1097/qai.0000000000002052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The benefit of immediate antiretroviral therapy (ART) at CD4 >500 cells/μL was established in the Strategic Timing of Antiretroviral Treatment (START) study. The benefits and risks of immediate ART in participants with low pretreatment viremia, including virologic suppressors, were further assessed. SETTING Randomized prospective international study. METHODS START participants with enrollment viremia <3000 c/mL were included. We compared clinical outcomes (grade 4 adverse events, hospitalizations, or death), plasma viremia, CD4 counts, and changes in biomarkers in immediate versus deferred ART groups. RESULTS Participants (N = 1134 including 93 with viremia ≤50 c/mL) had a median age of 37 years, 40% were women, and median CD4 was 713 cells/µL. Ninety-seven percent in the immediate and 29% in the deferred arm initiated ART at a median of 6 and 699 days, respectively. Clinical outcomes were experienced in 64 versus 61 patients in immediate and deferred arms (hazard ratio 1.10, 95% confidence interval: 0.77 to 1.56). The CD4 count difference was 125 cells/µL at 12 and 235 cells/µL at 36 months higher in the immediate versus deferred groups. D-dimer and VCAM levels decreased, and C-reactive protein increased, in the immediate arm at month 8. No significant changes in CD4 counts or biomarkers were observed in persons who maintained spontaneous virologic suppression. CONCLUSIONS START participants with low enrollment viremia experienced higher CD4 counts, greater proportion with suppressed viremia, and decreases in D-dimer levels on immediate ART despite the lack of difference in serious clinical outcomes. These data support immediate ART in people with low viremia, although equipoise remains for suppressors.
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Affiliation(s)
- Irini Sereti
- HIV Pathogenesis Section, NIAID/NIH, Bethesda, MD
| | - Roy M Gulick
- Infectious Diseases, Weill Cornell Medicine, Weill Cornell Medical College, Cornell University, New York, NY
| | | | | | - Adrian Palfreeman
- Department of Genitourinary Medicine, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Veronique Touzeau-Römer
- Department of Immunodermatology and Infectious Skin Diseases, University Vienna General Hospital, Vienna, Austria
| | - Waldo H Belloso
- CICAL and Infectious Diseases Section, Internal Medicine Service, Hospital Italiano de Buenos Aires Argentina, Buenos Aires, Argentina
| | - Sean Emery
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Matthew G Law
- Faculty of Medicine, Kirby Institute, University of New South Wales, Sydney, Australia
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Horne R, Glendinning E, King K, Chalder T, Sabin C, Walker AS, Campbell LJ, Mosweu I, Anderson J, Collins S, Jopling R, McCrone P, Leake Date H, Michie S, Nelson M, Perry N, Smith JA, Sseruma W, Cooper V. Protocol of a two arm randomised, multi-centre, 12-month controlled trial: evaluating the impact of a Cognitive Behavioural Therapy (CBT)-based intervention Supporting UPtake and Adherence to antiretrovirals (SUPA) in adults with HIV. BMC Public Health 2019; 19:905. [PMID: 31286908 PMCID: PMC6615195 DOI: 10.1186/s12889-019-6893-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/25/2019] [Indexed: 12/02/2022] Open
Abstract
Background Delay to start antiretroviral therapy (ART) and nonadherence compromise the health and wellbeing of people living with HIV (PLWH), raise the cost of care and increase risk of transmission to sexual partners. To date, interventions to improve adherence to ART have had limited success, perhaps because they have failed to systematically elicit and address both perceptual and practical barriers to adherence. The primary aim of this study is to determine the efficacy of the Supporting UPtake and Adherence (SUPA) intervention. Methods This study comprises 2 phases. Phase 1 is an observational cohort study, in which PLWH who are ART naïve and recommended to take ART by their clinician complete a questionnaire assessing their beliefs about ART over 12 months. Phase 2 is a randomised controlled trial (RCT) nested within the observational cohort study to investigate the effectiveness of the SUPA intervention on adherence to ART. PLWH at risk of nonadherence (based on their beliefs about ART) will be recruited and randomised 1:1 to the intervention (SUPA intervention + usual care) and control (usual care) arms. The SUPA intervention involves 4 tailored treatment support sessions delivered by a Research Nurse utilising a collaborative Cognitive Behavioural Therapy (CBT) and Motivational Interviewing (MI) approach. Sessions are tailored to individual needs and preferences based on the individual patient’s perceptions and practical barriers to ART. An animation series and intervention manual have been developed to communicate a rationale for the personal necessity for ART and illustrate concerns and potential solutions. The primary outcome is adherence to ART measured using Medication Event Monitoring System (MEMS). Three hundred seventy-two patients will be sufficient to detect a 15% difference in adherence with 80% power and an alpha of 0.05. Costs will be compared between intervention and control groups. Costs will be combined with the primary outcome in cost-effectiveness analyses. Quality adjusted life-years (QALYs) will also be estimated over the follow-up period and used in the analyses. Discussion The findings will enable patients, healthcare providers and policy makers to make informed decisions about the value of the SUPA intervention. Trial registration The trial was retrospectively registered 21/02/2014, ISRCTN35514212. Electronic supplementary material The online version of this article (10.1186/s12889-019-6893-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- R Horne
- Department of Practice and Policy, Centre for Behavioural Medicine, UCL School of Pharmacy, Mezzanine Floor, Entrance A, BMA House, Tavistock Square, London, WC1H 9JP, UK.
| | - E Glendinning
- Department of Practice and Policy, Centre for Behavioural Medicine, UCL School of Pharmacy, Mezzanine Floor, Entrance A, BMA House, Tavistock Square, London, WC1H 9JP, UK
| | - K King
- Department of Practice and Policy, Centre for Behavioural Medicine, UCL School of Pharmacy, Mezzanine Floor, Entrance A, BMA House, Tavistock Square, London, WC1H 9JP, UK
| | - T Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16, De Crespigny Park, London, SE5 8AF, UK
| | - C Sabin
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, UCL, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - A S Walker
- MRC Clinical Trials Unit at UCL, 90 High Holborn, 2nd Floor, London, WC1V 6LJ, UK
| | - L J Campbell
- HIV Research Centre, King's College London, London, SE5 9RJ, UK
| | - I Mosweu
- Institute of Psychiatry at King's College London, Denmark Hill, London, SE5 8AF, UK
| | - J Anderson
- Centre for the Study of Sexual Health and HIV, Homerton University Hospital, E9 6RS, London, UK
| | - S Collins
- HIV i-Base, 107 The Maltings, 169 Tower Bridge Road, London, SE1 3LJ, UK
| | - R Jopling
- Department of Practice and Policy, Centre for Behavioural Medicine, UCL School of Pharmacy, Mezzanine Floor, Entrance A, BMA House, Tavistock Square, London, WC1H 9JP, UK
| | - P McCrone
- Institute of Psychiatry at King's College London, Denmark Hill, London, SE5 8AF, UK
| | - H Leake Date
- Departments of of Pharmacy and HIV Medicine, Brighton & Sussex University Hospitals NHS Trust, Brighton, BN2 5B, UK
| | - S Michie
- Department of Clinical, Educational and Health Psychology, UCL, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - M Nelson
- Kobler Clinic, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - N Perry
- Brighton and Sussex University Hospitals NHS Trust, Brighton, BN2 5BE, UK
| | - J A Smith
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - W Sseruma
- UK-CAB, 107 The Maltings, 169 Tower Bridge Road, London, SE1 3LJ, UK
| | - V Cooper
- Department of Practice and Policy, Centre for Behavioural Medicine, UCL School of Pharmacy, Mezzanine Floor, Entrance A, BMA House, Tavistock Square, London, WC1H 9JP, UK
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Lau JS, Smith MZ, Lewin SR, McMahon JH. Clinical trials of antiretroviral treatment interruption in HIV-infected individuals. AIDS 2019; 33:773-791. [PMID: 30883388 DOI: 10.1097/qad.0000000000002113] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
: Despite the benefits of antiretroviral therapy (ART) for people living with HIV, there has been a long-standing research interest in interrupting ART as a strategy to minimize adverse effects of ART as well as to test interventions aiming to achieve a degree of virological control without ART. We performed a systematic review of HIV clinical studies involving treatment interruption from 2000 to 2017 to describe the differences between treatment interruption in studies that contained and didn't contain an intervention. We assessed differences in monitoring strategies, threshold to restart ART, duration and adverse outcomes of treatment interruption, and factors aimed at minimizing transmission. We found that treatment interruption has been incorporated into 159 clinical studies since 2000 and is increasingly being included in trials to assess the efficacy of interventions to achieve sustained virological remission off ART. Great heterogeneity was noted in immunological, virological and clinical monitoring strategies, as well as in thresholds to recommence ART. Treatment interruption in recent intervention studies were more closely monitored, had more conservative thresholds to restart ART and had a shorter treatment interruption duration, compared with older treatment interruption studies that didn't include an intervention.
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33
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Wu D, Chen C, Zhang M, Li Z, Wang S, Shi J, Zhang Y, Yao D, Hu S. The clinical features and prognosis of 100 AIDS-related lymphoma cases. Sci Rep 2019; 9:5381. [PMID: 30926889 PMCID: PMC6441082 DOI: 10.1038/s41598-019-41869-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022] Open
Abstract
To improve outcomes and risk assessment, we systematically analyzed the clinical features of patients with acquired immunodeficiency syndrome (AIDS)-related lymphoma (ARL) and identified survival-associated factors. Data were collected from 100 patients diagnosed with ARL at the Henan Provincial Infectious Disease Hospital in China. The progression-free survival (PFS) duration and 2-year overall survival (OS) rate were determined. A multivariate analysis was used to evaluate the associations between survival and the following variables: sex, age, histological subtype, Ann Arbor stage, lactate dehydrogenase (LDH) level, primary site, baseline CD4+ count, use of chemotherapy, and age-adjusted international prognostic index IPI (aaIPI). The timing of combined antiretroviral therapy (cART) relative to chemotherapy was also assessed. The PFS duration and 2-year OS rate were significantly higher in the chemotherapy vs. the non-chemotherapy group (P < 0.001), but did not differ significantly between patients who received chemotherapy before vs. simultaneously as cART (P > 0.05). Age, aaIPI, chemotherapy, LDH level, and the Burkitt/Burkitt-like lymphoma subtype were significant prognostic factors for 2-year OS; the other factors were not associated with prognosis. Our results show that cART plus chemotherapy significantly improves the survival of patients with ARL and identifies several prognostic factors.
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Affiliation(s)
- Dedong Wu
- Department of Medical Oncology, The First People's Hospital of Zhengzhou, Zhengzhou, Henan, 450004, China.
| | - Chen Chen
- Department of Medical Oncology, The First People's Hospital of Zhengzhou, Zhengzhou, Henan, 450004, China
| | - Mingzhi Zhang
- Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, China
| | - Zhaoming Li
- Department of Medical Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, China
| | - Suqian Wang
- Personnel Section, The First People's Hospital of Zhengzhou, Zhengzhou, Henan, 450004, China
| | - Jijing Shi
- Central Lab at Zhengzhou First People's Hospital, The First People's Hospital of Zhengzhou, Zhengzhou, Henan, 450004, China
| | - Yu Zhang
- Medical Records Room, Henan Provincial Infectious Disease Hospital, Zhengzhou, Henan, 450015, China
| | - Dingzhu Yao
- Comprehensive Ward, The First People's Hospital of Zhengzhou, Zhengzhou, Henan, 450004, China
| | - Shuang Hu
- Department of Medical Oncology, Henan Provincial Infectious Disease Hospital, Zhengzhou, Henan, 450015, China
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34
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Bolukcu S, Mete B, Gunduz A, Karaosmanoglu HK, Sargin F, Durdu B, Aydin OA, Yildiz D, Dokmetas I, Aslan T, Tabak F. Assessment of the 24th Week Success of Anti-Retroviral Therapy in the Action against HIV in Istanbul Database: Results from a Region with Increasing Incidence. Jpn J Infect Dis 2019; 72:173-178. [PMID: 30700656 DOI: 10.7883/yoken.jjid.2018.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We aimed to assess the 24-week virological and immunological success of the treatment of treatment-naive and treatment-experienced patients included in the Action against HIV in Istanbul (ACTHIV-IST) database. The ACTHIV-IST database was screened retrospectively from January 2012 to January 2014. The data for these patients such as age, sex, treatment-naive or treatment-experienced status, date of diagnosis, date of commencing antiretroviral therapy, antiretroviral therapy regimen, CD4+ cell count, and viral load before and after therapy were analyzed. In the 24th week of antiretroviral therapy, there were 40 (17.9%) and 29 (14.1%) virological and immunological failures, respectively. Virological failure (VF) was associated with a baseline viral load > 100,000 copies (p = 0.004). A CD4+ cell count lower than 200 cells/μl was not found to be associated with VF (p = 0.843). Immunological failure was substantially rare in patients with a baseline CD4+ cell count > 200 cells/μl (p = 0.005). Although an HIV-RNA ≤ 100,000 copies/ml was protective against VF in the 24th week, in individuals with an HIV-RNA > 100,000 copies/ml, VF was 3.2 times more likely to occur. Baseline VF was the most predictive parameter to estimate 24th week virological success and VF. VF is an important prognostic parameter resulting in CD4+ cell depletion, AIDS-related events, and increased mortality.
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Affiliation(s)
- Sibel Bolukcu
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Faculty of Medicine
| | - Bilgul Mete
- Department of Infectious Diseases and Clinical Microbiology, Istanbul University, Cerrahpasa Medical School
| | - Alper Gunduz
- Department of Infectious Diseases and Clinical Microbiology, Sisli Etfal Education and Research Hospital
| | - Hayat Kumbasar Karaosmanoglu
- Department of Infectious Diseases and Clinical Microbiology, Bakirkoy Dr. Sadi Konuk Education and Research Hospital
| | - Fatma Sargin
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Education and Research Hospital
| | - Bulent Durdu
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Faculty of Medicine
| | - Ozlem Altuntas Aydin
- Department of Infectious Diseases and Clinical Microbiology, Bakirkoy Dr. Sadi Konuk Education and Research Hospital
| | - Dilek Yildiz
- Department of Infectious Diseases and Clinical Microbiology, Sisli Etfal Education and Research Hospital
| | - Ilyas Dokmetas
- Department of Infectious Diseases and Clinical Microbiology, Sisli Etfal Education and Research Hospital
| | - Turan Aslan
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Faculty of Medicine
| | - Fehmi Tabak
- Department of Infectious Diseases and Clinical Microbiology, Istanbul University, Cerrahpasa Medical School
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35
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Young I, Davis M, Flowers P, McDaid LM. Navigating HIV citizenship: identities, risks and biological citizenship in the treatment as prevention era. HEALTH, RISK & SOCIETY 2019; 21:1-16. [PMID: 31105468 PMCID: PMC6494283 DOI: 10.1080/13698575.2019.1572869] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
The use of HIV Treatment as Prevention (TasP) has radically changed our understandings of HIV risk and revolutionised global HIV prevention policy to focus on the use of pharmaceuticals. Yet, there has been little engagement with the very people expected to comply with a daily pharmaceutical regime. We employ the concept of HIV citizenship to explore responses by people living with HIV in the UK to TasP. We consider how a treatment-based public health strategy has the potential to reshape identities, self-governance and forms of citizenship, domains which play a critical role not only in compliance with new TasP policies, but in how HIV prevention, serodiscordant relationships and (sexual) health are negotiated and enacted. Our findings disrupt the biomedical narrative which claims an end to HIV through scaling up access to treatment. Responses to TasP were framed through shifting negotiations of identity, linked to biomarkers, cure and managing treatment. Toxicity of drugs - and bodies - were seen as something to manage and linked to the shifting possibilities in serodiscordant environments. Finally, a sense of being healthy and responsible, including appropriate use of resources, meant conflicting relationships with if and when to start treatment. Our research highlights how HIV citizenship in the TasP era is negotiated and influenced by intersectional experiences of community, health systems, illness and treatment. Our findings show that the complexities of HIV citizenship and ongoing inequalities, and their biopolitical implications, will intimately shape the implementation and sustainability of TasP.
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Affiliation(s)
- Ingrid Young
- Centre for Biomedicine, Self and Society, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Mark Davis
- School of Social Sciences, Monash University, Melbourne
| | - Paul Flowers
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Lisa M. McDaid
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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36
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Lee MJ, Venturelli S, McKenna W, Teh J, Negedu O, Florman KE, Musbahi E, Bailey AC, Mackie NE, Fox J, Fidler S. Reasons for delayed antiretroviral therapy (ART) initiation in the era of early ART initiation guidelines: a retrospective service evaluation. Int J STD AIDS 2019; 30:415-418. [PMID: 30621548 DOI: 10.1177/0956462418814985] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Following changes in national antiretroviral therapy (ART) guidelines removing the CD4 threshold for initiation of ART, we evaluated the time to ART initiation and reasons for delayed or non-initiation. A retrospective notes review of 292 newly diagnosed HIV-positive individuals attending two London clinics between August 2015 and December 2016 was performed. Two hundred and fifty-four of 292 (87%) individuals started ART. Median time to ART initiation was 29 days (range: 0-514). Thirty of 292 (13%) did not start ART. Rates of virological suppression at six months were similar regardless of time to ART initiation. People who inject drugs (16.7% vs. 3.6%) (p = 0.009), having a higher median baseline CD4 cell count (500 vs. 388 cells/mm3, p = 0.001), and having gastrointestinal/liver co-morbidities (23% vs. 9%, p = 0.001) were associated with delayed ART initiation. The cohort not on ART had a higher median baseline CD4 cell count (500 vs. 388 cells/mm3, p < 0.001). Documented reasons for delayed or ART non-initiation included patient's choice, prolonged adjustment periods, and difficulty leaving work. We conclude that delayed or non-initiation of ART was associated with injecting drug use and prolonged adjustment to a new HIV diagnosis. Clinician factors may include lack of urgency with higher baseline CD4 cell counts. Improved linkage to care and drug services pathways may encourage timely ART initiation.
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Affiliation(s)
- Ming J Lee
- 1 Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | | | | | - Jhia Teh
- 2 Imperial College Healthcare NHS Trust, London, UK
| | - Ojali Negedu
- 2 Imperial College Healthcare NHS Trust, London, UK
| | | | - Esra Musbahi
- 1 Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | | | | | - Julie Fox
- 1 Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Sarah Fidler
- 3 St Mary's Hospital and Imperial College, London, UK
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Teh J, Pasvol T, Ayres S, Foster C, Fidler S. Case series of infertility amongst young women with perinatally acquired HIV: data from a London cohort. J Virus Erad 2019. [DOI: 10.1016/s2055-6640(20)30278-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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38
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Tan NK, Carrington D, Pope CF. Verification of the Roche cobas® 6800 PCR 200 µl and 500 µl protocols for the quantification of HIV-1 RNA, HBV DNA and HCV RNA and evaluation with COBAS® Ampliprep/COBAS® TaqMan® assays. J Med Microbiol 2018; 67:1711-1717. [DOI: 10.1099/jmm.0.000838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ngee Keong Tan
- 1Department of Medical Microbiology, South West London Pathology, St George’s University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - David Carrington
- 2Infection Care Group, St George’s University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Cassie F. Pope
- 2Infection Care Group, St George’s University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
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Kityo C, Szubert AJ, Siika A, Heyderman R, Bwakura-Dangarembizi M, Lugemwa A, Mwaringa S, Griffiths A, Nkanya I, Kabahenda S, Wachira S, Musoro G, Rajapakse C, Etyang T, Abach J, Spyer MJ, Wavamunno P, Nyondo-Mipando L, Chidziva E, Nathoo K, Klein N, Hakim J, Gibb DM, Walker AS, Pett SL. Raltegravir-intensified initial antiretroviral therapy in advanced HIV disease in Africa: A randomised controlled trial. PLoS Med 2018; 15:e1002706. [PMID: 30513108 PMCID: PMC6279020 DOI: 10.1371/journal.pmed.1002706] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, individuals infected with HIV who are severely immunocompromised have high mortality (about 10%) shortly after starting antiretroviral therapy (ART). This group also has the greatest risk of morbidity and mortality associated with immune reconstitution inflammatory syndrome (IRIS), a paradoxical response to successful ART. Integrase inhibitors lead to significantly more rapid declines in HIV viral load (VL) than all other ART classes. We hypothesised that intensifying standard triple-drug ART with the integrase inhibitor, raltegravir, would reduce HIV VL faster and hence reduce early mortality, although this strategy could also risk more IRIS events. METHODS AND FINDINGS In a 2×2×2 factorial open-label parallel-group trial, treatment-naive adults, adolescents, and children >5 years old infected with HIV, with cluster of differentiation 4 (CD4) <100 cells/mm3, from eight urban/peri-urban HIV clinics at regional hospitals in Kenya, Malawi, Uganda, and Zimbabwe were randomised 1:1 to initiate standard triple-drug ART, with or without 12-week raltegravir intensification, and followed for 48 weeks. The primary outcome was 24-week mortality, analysed by intention to treat. Of 2,356 individuals screened for eligibility, 1,805 were randomised between 18 June 2013 and 10 April 2015. Of the 1,805 participants, 961 (53.2%) were male, 72 (4.0%) were children/adolescents, median age was 36 years, CD4 count was 37 cells/mm3, and plasma viraemia was 249,770 copies/mL. Fifty-six participants (3.1%) were lost to follow-up at 48 weeks. By 24 weeks, 97/902 (10.9%) raltegravir-intensified ART versus 91/903 (10.2%) standard ART participants had died (adjusted hazard ratio [aHR] = 1.10 [95% CI 0.82-1.46], p = 0.53), with no evidence of interaction with other randomisations (pheterogeneity > 0.7) and despite significantly greater VL suppression with raltegravir-intensified ART at 4 weeks (343/836 [41.0%] versus 113/841 [13.4%] with standard ART, p < 0.001) and 12 weeks (567/789 [71.9%] versus 415/803 [51.7%] with standard ART, p < 0.001). Through 48 weeks, there was no evidence of differences in mortality (aHR = 0.98 [95% CI 0.76-1.28], p = 0.91); in serious (aHR = 0.99 [0.81-1.21], p = 0.88), grade-4 (aHR = 0.88 [0.71-1.09], p = 0.29), or ART-modifying (aHR = 0.90 [0.63-1.27], p = 0.54) adverse events (the latter occurring in 59 [6.5%] participants with raltegravir-intensified ART versus 66 [7.3%] with standard ART); in events judged compatible with IRIS (occurring in 89 [9.9%] participants with raltegravir-intensified ART versus 86 [9.5%] with standard ART, p = 0.79) or in hospitalisations (aHR = 0.94 [95% CI 0.76-1.17], p = 0.59). At 12 weeks, one and two raltegravir-intensified participants had predicted intermediate-level and high-level raltegravir resistance, respectively. At 48 weeks, the nucleoside reverse transcriptase inhibitor (NRTI) mutation K219E/Q (p = 0.004) and the non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations K101E/P (p = 0.03) and P225H (p = 0.007) were less common in virus from participants with raltegravir-intensified ART, with weak evidence of less intermediate- or high-level resistance to tenofovir (p = 0.06), abacavir (p = 0.08), and rilpivirine (p = 0.07). Limitations of the study include limited clinical, radiological, and/or microbiological information for some participants, reflecting available services at the centres, and lack of baseline genotypes. CONCLUSIONS Although 12 weeks of raltegravir intensification was well tolerated and reduced HIV viraemia significantly faster than standard triple-drug ART during the time of greatest risk for early death, this strategy did not reduce mortality or clinical events in this group and is not warranted. There was no excess of IRIS-compatible events, suggesting that integrase inhibitors can be used safely as part of standard triple-drug first-line therapy in severely immunocompromised individuals. TRIAL REGISTRATION ClinicalTrials.gov NCT01825031. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number ISRCTN 43622374.
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Affiliation(s)
- Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Alexander J. Szubert
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | | | - Robert Heyderman
- Department/College of Medicine, University of Malawi, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Division of Infection and Immunity, University College London, London, United Kingdom
| | | | | | | | - Anna Griffiths
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | | | | | | | - Godfrey Musoro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Chatu Rajapakse
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | | | - James Abach
- Joint Clinical Research Centre, Gulu, Uganda
| | - Moira J. Spyer
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | | | - Linda Nyondo-Mipando
- Department/College of Medicine, University of Malawi, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Ennie Chidziva
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Kusum Nathoo
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Nigel Klein
- University College London Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
| | - Sarah L. Pett
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
- Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, Australia
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HIV Cerebrospinal Fluid Escape and Neurocognitive Pathology in the Era of Combined Antiretroviral Therapy: What Lies Beneath the Tip of the Iceberg in Sub-Saharan Africa? Brain Sci 2018; 8:brainsci8100190. [PMID: 30347806 PMCID: PMC6211092 DOI: 10.3390/brainsci8100190] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 11/17/2022] Open
Abstract
Neurocognitive impairment remains an important HIV-associated comorbidity despite combination antiretroviral therapy (ART). Since the advent of ART, the spectrum of HIV-associated neurocognitive disorder (HAND) has shifted from the most severe form to milder forms. Independent replication of HIV in the central nervous system despite ART, so-called cerebrospinal fluid (CSF) escape is now recognised in the context of individuals with a reconstituted immune system. This review describes the global prevalence and clinical spectrum of CSF escape, it role in the pathogenesis of HAND and current advances in the diagnosis and management. It highlights gaps in knowledge in sub-Saharan Africa where the HIV burden is greatest and discusses the implications for this region in the context of the global HIV treatment scale up.
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Gray ER, Bain R, Varsaneux O, Peeling RW, Stevens MM, McKendry RA. p24 revisited: a landscape review of antigen detection for early HIV diagnosis. AIDS 2018; 32:2089-2102. [PMID: 30102659 PMCID: PMC6139023 DOI: 10.1097/qad.0000000000001982] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
: Despite major advances in HIV testing, early detection of infection at the point of care (PoC) remains a key challenge. Although rapid antibody PoC and laboratory-based nucleic acid amplification tests dominate the diagnostics market, the viral capsid protein p24 is recognized as an alternative early virological biomarker of infection. However, the detection of ultra-low levels of p24 at the PoC has proven challenging. Here we review the landscape of p24 diagnostics to identify knowledge gaps and barriers and help shape future research agendas. Five hundred and seventy-four research articles to May 2018 that propose or evaluate diagnostic assays for p24 were identified and reviewed. We give a brief history of diagnostic development, and the utility of p24 as a biomarker in different populations such as infants, the newly infected, those on preexposure prophylaxis and self-testers. We review the performance of commercial p24 assays and consider elements such as immune complex disruption, resource-poor settings, prevalence, and assay antibodies. Emerging and ultrasensitive assays are reviewed and show a number of promising approaches but further translation has been limited. We summarize studies on the health economic benefits of using antigen testing. Finally, we speculate on the future uses of high-performance p24 assays, particularly, if available in self-test format.
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Affiliation(s)
- Eleanor R Gray
- London Centre for Nanotechnology, Faculty of Maths and Physical Sciences, University College London
| | - Robert Bain
- Department of Materials, Department of Bioengineering and Institute of Biomedical Engineering, Imperial College London
| | | | | | - Molly M Stevens
- Department of Materials, Department of Bioengineering and Institute of Biomedical Engineering, Imperial College London
| | - Rachel A McKendry
- London Centre for Nanotechnology, Faculty of Maths and Physical Sciences, University College London
- Division of Medicine, University College London, London, UK
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Karnes JH, Miller MA, White KD, Konvinse KC, Pavlos RK, Redwood AJ, Peter JG, Lehloenya R, Mallal SA, Phillips EJ. Applications of Immunopharmacogenomics: Predicting, Preventing, and Understanding Immune-Mediated Adverse Drug Reactions. Annu Rev Pharmacol Toxicol 2018; 59:463-486. [PMID: 30134124 DOI: 10.1146/annurev-pharmtox-010818-021818] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Adverse drug reactions (ADRs) are a significant health care burden. Immune-mediated adverse drug reactions (IM-ADRs) are responsible for one-fifth of ADRs but contribute a disproportionately high amount of that burden due to their severity. Variation in human leukocyte antigen ( HLA) genes has emerged as a potential preprescription screening strategy for the prevention of previously unpredictable IM-ADRs. Immunopharmacogenomics combines the disciplines of immunogenomics and pharmacogenomics and focuses on the effects of immune-specific variation on drug disposition and IM-ADRs. In this review, we present the latest evidence for HLA associations with IM-ADRs, ongoing research into biological mechanisms of IM-ADRs, and the translation of clinical actionable biomarkers for IM-ADRs, with a focus on T cell-mediated ADRs.
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Affiliation(s)
- Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona 85721, USA.,Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona 85724, USA.,Division of Pharmacogenomics, Center for Applied Genetics and Genomic Medicine (TCAG2M), Tucson, Arizona 85721, USA
| | - Matthew A Miller
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona 85721, USA
| | - Katie D White
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA;
| | - Katherine C Konvinse
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.,Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA
| | - Rebecca K Pavlos
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Subiaco, Western Australia 6008, Australia.,Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia 6150, Australia
| | - Alec J Redwood
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia 6150, Australia
| | - Jonathan G Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town 7925, South Africa.,Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Rannakoe Lehloenya
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Simon A Mallal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA; .,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.,Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia 6150, Australia
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA; .,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.,Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia 6150, Australia
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Tan CRC, Barta SK, Lee J, Rudek MA, Sparano JA, Noy A. Combination antiretroviral therapy accelerates immune recovery in patients with HIV-related lymphoma treated with EPOCH: a comparison within one prospective trial AMC034. Leuk Lymphoma 2018; 59:1851-1860. [PMID: 29160731 PMCID: PMC5962410 DOI: 10.1080/10428194.2017.1403597] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Drug-drug interactions between cART and chemotherapy may impact HIV and lymphoma control or lead to increased toxicities. No prospective comparative data informs potential harms and benefits. In AMC034, HIV-associated high-grade B-cell NHL patients received DA-EPOCH with rituximab. cART was given with EPOCH or delayed until chemotherapy completion per investigator choice. Pharmacokinetic, immunological, and treatment effects of concurrent cART were evaluated. CD4 counts dropped during EPOCH in both groups but recovered to higher than baseline 6 months post-EPOCH only in the cART group. HIV viral load decreased during chemotherapy in the cART group but increased in the non-cART group. Incidence of grade ≥3 infectious, hematologic, or neurological toxicities was similar. Concurrent cART was not associated with 1-year EFS or OS. cART with EPOCH was well-tolerated and allowed for faster immune recovery. While we did not observe differences in outcome, the preponderance of evidence is in favor of combining cART with chemotherapy.
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Affiliation(s)
- Carlyn Rose C. Tan
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Stefan K. Barta
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michelle A. Rudek
- Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Joseph A. Sparano
- Department of Oncology, Montefiore-Einstein Cancer Center, Montefiore Medical Center, Bronx, NY, USA
| | - Ariela Noy
- Department of Medicine, Memorial Sloan-Kettering Cancer Center/Weill-Cornell Medical College, New York, NY, USA
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44
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Rethinking recycling nucleoside reverse transcriptase inhibitors in HIV treatment: learning from dual therapy studies. AIDS 2018; 32:835-840. [PMID: 29424781 DOI: 10.1097/qad.0000000000001776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Lampejo T, Agarwal K, Carey I. Interferon-free direct-acting antiviral therapy for acute hepatitis C virus infection in HIV-infected individuals: A literature review. Dig Liver Dis 2018; 50:113-123. [PMID: 29233687 DOI: 10.1016/j.dld.2017.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 10/29/2017] [Accepted: 11/15/2017] [Indexed: 02/07/2023]
Abstract
Dramatic rises in hepatitis C virus (HCV) coinfection rates in human immunodeficiency virus (HIV)-infected individuals have been observed recently, largely attributable to increasing recreational drug use combined with increased testing for HCV. In the era of direct-acting antiviral (DAA) therapy, treatment of acute HCV infection in HIV-infected individuals with short durations of these drugs may potentially reduce the disease and economic burden associated with HCV infection as well as reducing the likelihood of onward HCV transmission. We performed an extensive literature search of PubMed, Embase and Google Scholar up to 05 September 2017 for clinical trials of acute HCV infection in HIV-infected individuals. In the studies identified, rates of sustained virologic response at 12 weeks post-treatment (SVR12) ranged from 21% with 6 weeks of therapy up to 92% with 12 weeks of therapy with sofosbuvir and ribavirin. Ledipasvir/sofosbuvir for 6 weeks achieved an SVR of 77%. No HIV-related events occurred regardless of whether patients were receiving antiretroviral therapy (ART) and DAAs were well tolerated. Data is currently limited with regards to optimal regimens and durations of therapy, which need to be tailored based on potential interactions with concurrent ART and consideration for the fact that patients with higher baseline HCV RNA levels may require an extended duration of treatment.
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Affiliation(s)
- Temi Lampejo
- Institute of Liver Studies, King's College Hospital, London, United Kingdom.
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Ivana Carey
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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46
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Di Carlofelice M, Everitt A, Muir D, Winston A. Cerebrospinal fluid HIV RNA in persons living with HIV. HIV Med 2018; 19:365-368. [PMID: 29368400 DOI: 10.1111/hiv.12594] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Despite adequate suppression of plasma HIV RNA, viral escape in cerebrospinal fluid (CSF) is widely reported. Rates of CSF HIV RNA escape vary in the literature. In persons living with HIV (PLWH) undergoing lumbar puncture examination for clinical reasons, we assessed rates of CSF HIV RNA escape. METHODS Persons living with HIV attending a designated HIV neurology service undergoing CSF assessment for clinical reasons between January 2015 and April 2017 were included in the study. CSF HIV RNA escape was defined as HIV RNA ≥ 0.5 log10 HIV-1 RNA copies/mL higher than plasma HIV RNA or detectable CSF HIV RNA when plasma HIV RNA was < 20 copies/mL. Clinical factors associated with CSF HIV RNA were assessed using logistic regression modelling. RESULTS Of 38 individuals, 35 were receiving antiretroviral therapy, 30 were male and their mean age was 51 years. Clinical reasons for CSF assessment included investigation for cognitive decline (n = 25), early syphilis (n = 4) and other central nervous system (CNS) conditions (n = 9). HIV RNA was detectable in plasma and CSF in seven and six individuals, respectively, with two individuals (5.3%) meeting the definition of CSF escape. Detectable CSF HIV RNA was associated with a detectable plasma HIV RNA (P < 0.001) and a history of known antiretroviral drug resistance mutations (P = 0.021). CONCLUSIONS The prevalence of CSF viral escape in PLWH undergoing lumbar puncture examination for clinical reasons is lower than previously reported.
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Affiliation(s)
- M Di Carlofelice
- Section of Infectious Diseases, Imperial College London, London, UK
| | - A Everitt
- Department of Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - D Muir
- Department of Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - A Winston
- Section of Infectious Diseases, Imperial College London, London, UK.,Department of Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
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Hakim JG, Thompson J, Kityo C, Hoppe A, Kambugu A, van Oosterhout JJ, Lugemwa A, Siika A, Mwebaze R, Mweemba A, Abongomera G, Thomason MJ, Easterbrook P, Mugyenyi P, Walker AS, Paton NI. Lopinavir plus nucleoside reverse-transcriptase inhibitors, lopinavir plus raltegravir, or lopinavir monotherapy for second-line treatment of HIV (EARNEST): 144-week follow-up results from a randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2018; 18:47-57. [PMID: 29108797 PMCID: PMC5739875 DOI: 10.1016/s1473-3099(17)30630-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Millions of HIV-infected people worldwide receive antiretroviral therapy (ART) in programmes using WHO-recommended standardised regimens. Recent WHO guidelines recommend a boosted protease inhibitor plus raltegravir as an alternative second-line combination. We assessed whether this treatment option offers any advantage over the standard protease inhibitor plus two nucleoside reverse-transcriptase inhibitors (NRTIs) second-line combination after 144 weeks of follow-up in typical programme settings. METHODS We analysed the 144-week outcomes at the completion of the EARNEST trial, a randomised controlled trial done in HIV-infected adults or adolescents in 14 sites in five sub-Saharan African countries (Uganda, Zimbabwe, Malawi, Kenya, Zambia). Participants were those who were no longer responding to non-NRTI-based first-line ART, as assessed with WHO criteria, confirmed by viral-load testing. Participants were randomly assigned to receive a ritonavir-boosted protease inhibitor (lopinavir 400 mg with ritonavir 100 mg, twice per day) plus two or three clinician-selected NRTIs (protease inhibitor plus NRTI group), protease inhibitor plus raltegravir (400 mg twice per day; protease inhibitor plus raltegravir group), or protease inhibitor monotherapy (plus raltegravir induction for first 12 weeks, re-intensified to combination therapy after week 96; protease inhibitor monotherapy group). Randomisation was by computer-generated randomisation sequence, with variable block size. The primary outcome was viral load of less than 400 copies per mL at week 144, for which we assessed non-inferiority with a one-sided α of 0·025, and superiority with a two-sided α of 0·025. The EARNEST trial is registered with ISRCTN, number 37737787. FINDINGS Between April 12, 2010, and April 29, 2011, 1837 patients were screened for eligibility, of whom 1277 patients were randomly assigned to an intervention group. In the primary (complete-case) analysis at 144 weeks, 317 (86%) of 367 in the protease inhibitor plus NRTI group had viral loads of less than 400 copies per mL compared with 312 (81%) of 383 in the protease inhibitor plus raltegravir group (p=0·07; lower 95% confidence limit for difference 10·2% vs specified non-inferiority margin 10%). In the protease inhibitor monotherapy group, 292 (78%) of 375 had viral loads of less than 400 copies per mL; p=0·003 versus the protease inhibitor plus NRTI group at 144 weeks. There was no difference between groups in serious adverse events, grade 3 or 4 adverse events (total or ART-related), or events that resulted in treatment modification. INTERPRETATION Protease inhibitor plus raltegravir offered no advantage over protease inhibitor plus NRTI in virological efficacy or safety. In the primary analysis, protease inhibitor plus raltegravir did not meet non-inferiority criteria. A regimen of protease inhibitor with NRTIs remains the best standardised second-line regimen for use in programmes in resource-limited settings. FUNDING European and Developing Countries Clinical Trials Partnership (EDCTP), UK Medical Research Council, Instituto de Salud Carlos III, Irish Aid, Swedish International Development Cooperation Agency, Instituto Superiore di Sanita, Merck, ViiV Healthcare, WHO.
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Affiliation(s)
- James G Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - Cissy Kityo
- Joint Clinical Research Centre (JCRC) Kampala, Kampala, Uganda
| | - Anne Hoppe
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Joep J van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Malawi
| | | | | | | | | | | | | | | | - Peter Mugyenyi
- Joint Clinical Research Centre (JCRC) Kampala, Kampala, Uganda
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Nicholas I Paton
- MRC Clinical Trials Unit at University College London, London, UK; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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48
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Roen A, Laut K, Pelchen-Matthews A, Borodulina E, Caldeira L, Clarke A, Clotet B, d'Arminio Monforte A, Fätkenheuer G, Gatell Artigas JM, Karpov I, Kuznetsova A, Kyselyova G, Mozer-Lisewska I, Mulcahy F, Ragone L, Scherrer A, Uzdaviniene V, Vandekerckhove L, Vannappagari V, Ostergaard L, Mocroft A. Abacavir usage patterns and hypersensitivity reactions in the EuroSIDA cohort. HIV Med 2017; 19:252-260. [PMID: 29271606 DOI: 10.1111/hiv.12573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Five to eight per cent of HIV-positive individuals initiating abacavir (ABC) experience potentially fatal hypersensitivity reactions (HSRs). We sought to describe the proportion of individuals initiating ABC and to describe the incidence and factors associated with HSR among those prescribed ABC. METHODS We calculated the proportion of EuroSIDA individuals receiving ABC-based combination antiretroviral therapy (cART) among those receiving cART after 1 January 2009. Poisson regression was used to identify demographic, and current clinical and laboratory factors associated with ABC utilization and discontinuation. RESULTS Between 2009 and 2016, of 10 076 individuals receiving cART, 3472 (34%) had ever received ABC-based cART. Temporal trends of ABC utilization were also heterogeneous, with 28% using ABC in 2009, dropping to 26% in 2010 and increasing to 31% in 2016, and varied across regions and over time. Poisson models showed lower ABC utilization in older individuals, and in those with higher CD4 cell counts, higher cART lines, and prior AIDS. Higher ABC utilization was associated with higher HIV RNA and poor renal function, and was more common in Central-East and Eastern Europe and lowest during 2014. During 779 person-years of follow-up (PYFU) in 2139 individuals starting ABC after 1 January 2009, 113 discontinued ABC within 6 weeks of initiation for any reason [incidence rate (IR) 14.5 (95% confidence interval (CI) 12.1, 17.5) per 100 PYFU], 13 because of reported HSR [IR 0.3 (95% CI 0.1, 1.0) per 100 PYFU] and 35 because of reported HSR/any toxicity [IR 4.5 (95% CI 3.2, 6.3) per 100 PYFU]. There were no factors significantly associated with ABC discontinuation because of reported HSR/any toxicity. CONCLUSIONS ABC remains commonly used across Europe and the incidence of discontinuation because of reported HSR was low in our study population.
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Affiliation(s)
- A Roen
- University College London, London, UK
| | - K Laut
- University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - A Clarke
- Royal Sussex County Hospital, Brighton, UK
| | - B Clotet
- Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | | | | | | | - I Karpov
- Belarus State Medical University, Minsk, Belarus
| | - A Kuznetsova
- Kharkov State Medical University, Khrakov, Ukraine
| | - G Kyselyova
- Crimean Republican AIDS Centre, Simferopol, Ukraine
| | | | | | - L Ragone
- ViiV Healthcare, Research Triangle Park, NC, USA
| | - A Scherrer
- University Hospital Zürich, Zürich, Switzerland
| | - V Uzdaviniene
- Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | | | | | | | - A Mocroft
- University College London, London, UK
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Commonly Prescribed Antiretroviral Therapy Regimens and Incidence of AIDS-Defining Neurological Conditions. J Acquir Immune Defic Syndr 2017; 77:102-109. [PMID: 28991888 DOI: 10.1097/qai.0000000000001562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The differential effects of commonly prescribed combined antiretroviral therapy (cART) regimens on AIDS-defining neurological conditions (neuroAIDS) remain unknown. SETTING Prospective cohort studies of HIV-positive individuals from Europe and the Americas included in the HIV-CAUSAL Collaboration. METHODS Individuals who initiated a first-line cART regimen in 2004 or later containing a nucleoside reverse transcriptase inhibitor backbone and either atazanavir, lopinavir, darunavir, or efavirenz were followed from cART initiation until death, lost to follow-up, pregnancy, the cohort-specific administrative end of follow-up, or the event of interest, whichever occurred earliest. We evaluated 4 neuroAIDS conditions: HIV dementia and the opportunistic infections toxoplasmosis, cryptococcal meningitis, and progressive multifocal leukoencephalopathy. For each outcome, we estimated hazard ratios for atazanavir, lopinavir, and darunavir compared with efavirenz via a pooled logistic model. Our models were adjusted for baseline demographic and clinical characteristics. RESULTS Twenty six thousand one hundred seventy-two individuals initiated efavirenz, 5858 initiated atazanavir, 8479 initiated lopinavir, and 4799 initiated darunavir. Compared with efavirenz, the adjusted HIV dementia hazard ratios (95% confidence intervals) were 1.72 (1.00 to 2.96) for atazanavir, 2.21 (1.38 to 3.54) for lopinavir, and 1.41 (0.61 to 3.24) for darunavir. The respective hazard ratios (95% confidence intervals) for the combined end point were 1.18 (0.74 to 1.88) for atazanavir, 1.61 (1.14 to 2.27) for lopinavir, and 1.36 (0.74 to 2.48) for darunavir. The results varied in subsets defined by calendar year, nucleoside reverse transcriptase inhibitor backbone, and age. CONCLUSION Our results are consistent with an increased risk of neuroAIDS after initiating lopinavir compared with efavirenz, but temporal changes in prescribing trends and confounding by indication could explain our findings.
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50
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Tariq S, Elford J, Chau C, French C, Cortina-Borja M, Brown A, Delpech V, Tookey PA. Loss to Follow-Up After Pregnancy Among Sub-Saharan Africa-Born Women Living With Human Immunodeficiency Virus in England, Wales and Northern Ireland: Results From a Large National Cohort. Sex Transm Dis 2017; 43:283-9. [PMID: 27100763 PMCID: PMC4841179 DOI: 10.1097/olq.0000000000000442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Combining 2 national United Kingdom data sets, we found that 1 in 8 human immunodeficiency virus–positive women were lost to follow-up in the year after pregnancy. This was associated with being Sub-Saharan Africa-born and recent migration. Background Little is known about retention in human immunodeficiency virus (HIV) care in HIV-positive women after pregnancy in the United Kingdom. We explored the association between loss to follow-up (LTFU) in the year after pregnancy, maternal place of birth and duration of UK residence, in HIV-positive women in England, Wales, and Northern Ireland. Methods We analyzed combined data from 2 national data sets: the National Study of HIV in Pregnancy and Childhood; and the Survey of Prevalent HIV Infections Diagnosed, including pregnancies in 2000 to 2009 in women with diagnosed HIV. Logistic regression models were fitted with robust standard errors to estimate adjusted odds ratios (AOR). Results Overall, 902 of 7211 (12.5%) women did not access HIV care in the year after pregnancy. Factors associated with LTFU included younger age, last CD4 in pregnancy of 350 cells/μL or greater and detectable HIV viral load at the end of pregnancy (all P < 0.001). On multivariable analysis, LTFU was more likely in sub-Saharan Africa-born (SSA-born) women than white UK-born women (AOR, 2.17; 95% confidence interval, 1.50–3.14; P < 0.001). The SSA-born women who had migrated to the UK during pregnancy were 3 times more likely than white UK-born women to be lost to follow-up (AOR, 3.19; 95% confidence interval, 1.94–3.23; P < 0.001). Conclusions One in 8 HIV-positive women in England, Wales, and Northern Ireland did not return for HIV care in the year after pregnancy, with SSA-born women, especially those who migrated to the United Kingdom during pregnancy, at increased risk. Although emigration is a possible explanatory factor, disengagement from care may also play a role.
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Affiliation(s)
- Shema Tariq
- From the *School of Health Sciences, City University London; †Population and Practice Programme, UCL Institute of Child Health; and ‡Public Health England, London, United Kingdom
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