A Comparative Systematic Review of the Optimal CD4 Cell Count Threshold for HIV Treatment Initiation

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

Background

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

Methods

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

Results

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

Conclusions

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

A systematic review and cost-effectiveness analyses of the new World Health Organization guidelines for the treatment of HIV-positive adults in India

Background

The World Health Organization (WHO) in 2013 has revised its guidelines on antiretroviral therapy (ART) treatment for human immunodeficiency virus (HIV)-positive adults and further updated it in 2016. Based on the WHO recommendations, in May 2017, National AIDS Control Organisation, India recommended initiation of ART treatment for all people living with HIV, regardless of CD4 count, clinical stage, age, or population. This systematic review aims to assess the clinical effectiveness and cost implication of the new guidelines for India.

Methods

A systematic and comprehensive literature search on PubMed, OvidSP, Cochrane Library, and Google Scholar was carried out. Studies reporting either acquired immunodeficiency syndrome (AIDS) or mortality or both as outcome variables were selected. A meta-analysis of the available studies was carried out. The risk ratio was calculated to assess the reduction in AIDS or mortality or both. Cost-effectiveness analysis using health technology principles evaluating the lives saved in terms of incremental cost-effectiveness ratio and cost per quality-adjusted life years gained was carried out.

Results

Nine eligible studies were included for the meta-analysis. For India, the pooled relative risk of AIDS or mortality or both being 0.84 (95% confidence interval [CI], 0.76-0.92) and 0.78 (95% CI, 0.68-0.89) for ART initiation at CD4 count of ≤350 vs CD4 count of ≤500 and at CD4 count of ≤500 vs CD4 count > 500 cells/mm³, respectively. The incremental cost for per additional life saved is US$ 2592 and US$ 2357 for ART initiation at ≤500 and > 500 CD4 count, respectively.

Conclusion

The adoption of the new WHO guidelines is beneficial with substantial reduction in AIDS or mortality or both. This study suggests that adopting new WHO guidelines is cost-effective for India.

CD4+ cells recovery in HIV positive patients with severe immunosuppression at HAART initiation at Centre Medico-Social Cor-Unum, Kigali

INTRODUCTION

Up to 30% of HIV infected patients who are receiving HAART do not exhibit a marked increase in the CD4+ T cell count. There is still a concern that immune recovery may not be complete once CD4+ T cells have decreased below 200 cells/μl. The objective is to assess CD4+ cell recovery in HIV+ patients with CD4 count below 200 cells/μl) at HAART initiation.

METHODS

This was a retrospective cohort study among 110 HIV+ patients with initial CD4 count < 200 cells/μl. Baseline Age, sex, CD4 count and viral load were extracted from the patient's database. After12 months of HAART; CD4 count was done using flow cytometry and viremia by COBAS AmpliPrep/COBAS TaqMan HIV-1 test v 2.0 technology.

RESULTS

The mean age of the respondents was 35 years; males being 57% and females were 43%. The mean CD4 count before HAART was 110.18 cells/μl whereas at 12 months of HAART; this was 305.01 cells/μl. Though some patients did not achieve a CD4 count of more than 200 cells/μl or a drop in viral load; there was a significant recovery of CD4+ cells (P value=0.000) and viremia following HAART (P value=0.001). Participants aged 18-30 years were likely to have less than 200 cells/μl CD4 count (46.4%) [OR=4.33; 95%CI: 1.29-14.59; P=0.018] than participants aged above 40 years (16.7%).

CONCLUSION

HAART was associated with viremia suppression but many patients failed to achieve a CD4 count >200 cells/μl. HAART before severe immunosuppression is a key factor for immune restoration among HIV+ patients.

Epidemiological Distribution and Genotype Characterization of the Hepatitis C Virus Among HIV Patients in Kashan, Iran

BACKGROUND

Parenteral transmission is a common route of transmission for both human immunodeficiency virus (HIV) and hepatitis C virus (HCV); therefore, hepatitis C viral infection is highly prevalent among people infected with HIV.

OBJECTIVES

This study was designed to examine the epidemiology and describe the clinical manifestation as well as the HCV genotypes in patients from the city of Kashan, Iran, who are coinfected with HIV and HCV.

PATIENTS AND METHODS

This descriptive study was conducted in 2014 in the city of Kashan. The population consisted of all the HIV-infected patients who were referred to the behavioral counseling center and jail in Kashan. Demographic information and HCV- and HIV-related risk behaviors were obtained through the use of an interviewer-assisted questionnaire. After the participants gave written informed consent to participate, 10 cc venous blood samples were collected. The serum samples were screened for HCV infection using an enzyme-linked immunosorbent assay (ELISA). In the event of a positive test for HCV, the RNA was then amplified by polymerase chain reaction (PCR) amplification. The HCV subtypes were determined via the direct sequencing of the amplicons. All data analysis was performed using SPSS version 16.0 for the descriptive statistics, and then the chi-square test and Pearson coefficient were performed for additional analysis.

RESULTS

The results of the analysis indicated that 54 (85%) of the 63 HIV-infected patients were males who were also HCV positive and who had less than a high school level education. There was a significant association between HCV infection and both occupation (P < 0.0001) and level of education (P < 0.05). All the HIV/HCV coinfected cases had a history of illicit drug use, while 92.6% had a history of imprisonment and 40.7% had high risk sexual contacts. Overall, genotype 1 was found in 75.9% of HCV patients, while genotype 3 was found in 24.1%. Some 94.4% of HCV patients had subtype A. There were no clinical symptoms of chronic hepatitis C.

CONCLUSIONS

The majority of HIV-infected persons in the city of Kashan were also HCV positive. Genotype 1 was the predominant type, alongside subtype A. Considering the high prevalence of HCV among the HIV-infected persons, as well as the impact of occupation, education, illicit drug use, and imprisonment on the incidence of both infections, health policy makers must introduce health programs and plans to reduce the prevalence of these infections.

The gut microbiome in human immunodeficiency virus infection

HIV/AIDS causes severe dysfunction of the immune system through CD4+ T cell depletion, leading to dysregulation of both the adaptive and innate immune arms. A primary target for viral infection is the gastrointestinal tract, which is a reservoir of CD4+ T cells. In addition to being a major immune hub, the human gastrointestinal tract harbors trillions of commensal microorganisms, the microbiota, which have recently been shown to play critical roles in health. Alterations in the composition and function of microbiota have been implicated in a variety of 'multi-factorial' disorders, including infectious, autoimmune, metabolic, and neoplastic disorders. It is widely accepted that, in addition to its direct role in altering the gastrointestinal CD4+ T cell compartment, HIV infection is characterized by gut microbiota compositional and functional changes. Herein, we review such alterations and discuss their potential local and systemic effects on the HIV-positive host, as well as potential roles of novel microbiota-targeting treatments in modulating HIV progression and associated adverse systemic manifestations.

Effectiveness of first-line antiretroviral therapy in HIV/AIDS patients: A 5-year longitudinal evaluation in Fujian Province, Southeast China

The aim of this study was to evaluate the long-term effectiveness of first-line antiretroviral therapy in HIV/AIDS patients in Southeast China. A total of 450 eligible patients were selected to initiate first-line antiretroviral therapy from February 2005 through August 2009. During the study period from 2009 through 2013, each subject received clinical and laboratory monitoring for effectiveness, safety and toxicity once every 3 months in the first year, and once every 6 months in the following years. The response to first-line antiretroviral therapy was evaluated through body weight gain and immunological and virological outcomes. During the mean follow-up period of 70.86 ± 28.9 months, the overall mortality was 14.2%. The mean body weight and CD4(+) counts increased significantly following antiretroviral therapy as compared to baselines across the follow-up period, and the rate of immunological effectiveness was over 85% in all subjects at 2 to 5 years of treatment. The rate of inhibition of HIV virus was 87.67%, 89.32%, 91.73%, 92.8% and 91.63% across the study period. In addition, significant differences were detected after treatment as compared to baselines, and Pearson correlation analysis revealed a positive correlation between immunological effectiveness and viral inhibition. Forty-eight percent of the subjects changed antiretroviral drugs once, and 16.22% twice, and 31 patients switched from first-line to second-line antiretroviral therapy. Long-term antiretroviral therapy remains effective for treatment of HIV/AIDS, resulting in higher mean body weight, effective viral inhibition and a higher CD4 count. Immunological effectiveness of antiretroviral therapy positively correlates with HIV viral inhibition.

Knowledge, Beliefs and Practices Regarding Antiretroviral Medications for HIV Prevention: Results from a Survey of Healthcare Providers in New England

Background

Antiretroviral treatment for HIV-infection before immunologic decline (early ART) and pre-exposure chemoprophylaxis (PrEP) can prevent HIV transmission, but routine adoption of these practices by clinicians has been limited.

Methods

Between September and December 2013, healthcare practitioners affiliated with a regional AIDS Education and Training Center in New England were invited to complete online surveys assessing knowledge, beliefs and practices regarding early ART and PrEP. Multivariable models were utilized to determine characteristics associated with prescribing intentions and practices.

Results

Surveys were completed by 184 practitioners. Respondent median age was 44 years, 58% were female, and 82% were white. Among ART-prescribing clinicians (61% of the entire sample), 64% were aware that HIV treatment guidelines from the Department of Health and Human Services recommended early ART, and 69% indicated they would prescribe ART to all HIV-infected patients irrespective of immunologic status. However, 77% of ART-prescribing clinicians would defer ART for patients not ready to initiate treatment. Three-fourths of all respondents were aware of guidance from the U.S. Centers for Disease Control and Prevention recommending PrEP provision, 19% had prescribed PrEP, and 58% of clinicians who had not prescribed PrEP anticipated future prescribing. Practitioners expressed theoretical concerns and perceived practical barriers to prescribing early ART and PrEP. Clinicians with higher percentages of HIV-infected patients (aOR 1.16 per 10% increase in proportion of patients with HIV-infection, 95% CI 1.01–1.34) and infectious diseases specialists (versus primary care physicians; aOR 3.32, 95% CI 0.98–11.2) were more likely to report intentions to prescribe early ART. Higher percentage of HIV-infected patients was also associated with having prescribed PrEP (aOR 1.19, 95% CI 1.06–1.34), whereas female gender (aOR 0.26, 95% CI 0.10–0.71) was associated with having not prescribed PrEP.

Conclusions

These findings suggest many clinicians have shifted towards routinely recommending early ART, but not PrEP, so interventions to facilitate PrEP provision are needed.