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Brief Report: Integrase Strand Transfer Inhibitors Are Associated With Lower Risk of Incident Cardiovascular Disease in People Living With HIV. J Acquir Immune Defic Syndr 2021; 84:396-399. [PMID: 32243280 DOI: 10.1097/qai.0000000000002357] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several antiretroviral therapy (ART) classes have been associated with increased myocardial infarction (MI) risk. Cardiovascular disease in people living with HIV (PLWH) on integrase strand transfer inhibitors (INSTI) has not been examined. Here we aim to examine this. SETTING Retrospective cohort design study. METHODS We used the IBMMarketScan databases for U.S. commercially insured and Medicaid covered adults to identify PLWH newly initiated on ART between January 1, 2008 and December 30, 2015. Major adverse cardiac event (MACE), a composite of acute MI, ischemic stroke, coronary artery bypass grafting, and percutaneous coronary intervention was the primary outcome. We used calendar time-specific probability-weighted Cox proportional hazards models to estimate hazard ratios and 95% confidence intervals for the association between INSTI use and MACE. We used propensity score weighting methods to account for potential confounding. RESULTS Twenty thousand two hundred forty-two new ART initiators were identified. 5069 (25%) PLWH initiated INSTI-based regimens. 203 MACE events occurred; acute MI 16 (0.32%) vs 66 (0.43%), stroke 24 (0.47%) vs 54 (0.36), coronary artery bypass grafting 2 (0.04%) vs 9 (0.06%), percutaneous coronary intervention 7 (0.14%) vs 25 (0.16%) of INSTI users vs non-users. INSTI-based ART was associated with significantly lower risk of MACE events (hazard ratios 0.79; 95% confidence intervals: 0.64 to 0.96) compared with non-INSTI-based regimens. CONCLUSION In this cohort, INSTI-based regimens were associated with a 21% decreased risk of incident cardiovascular disease. These finding require validation in other cohorts and with longer follow-up.
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Randomized study evaluating the efficacy and safety of switching from an an abacavir/lamivudine-based regimen to an elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide single-tablet regimen. AIDS 2019; 33:1583-1593. [PMID: 31305329 DOI: 10.1097/qad.0000000000002244] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of switching from an abacavir/lamivudine (ABC/3TC)-based regimen to an elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) single-tablet regimen in virologically suppressed, HIV-1-infected adults. DESIGN Randomized, open-label, noninferiority study. METHODS Participants with HIV-1 RNA levels less than 50 copies/ml receiving ABC/3TC plus a third agent for at least 6 months were randomized 2 : 1 to switch immediately to E/C/F/TAF (immediate-switch group) for 48 weeks or to continue receiving ABC/3TC plus a third agent for 24 weeks followed by E/C/F/TAF for 24 weeks (delayed-switch group). The primary endpoint was HIV-1 RNA less than 50 copies/ml at Week 24 by Food and Drug Administration Snapshot algorithm (-12% noninferiority margin). RESULTS Baseline characteristics of 274 participants (183 in immediate-switch group and 91 in delayed-switch group) were similar. Virologic response was maintained at Week 24 by 93.4 and 97.8% of participants in the immediate-switch and delayed-switch groups, respectively, with a treatment difference of -4.4% (95% confidence interval: -9.4 to 1.9%), confirming noninferiority. Adverse events of any grade were similar between groups through Week 24 (66% E/C/F/TAF, 64% ABC/3TC); adverse event-related drug discontinuations occurred in 4% of participants switching to E/C/F/TAF (no discontinuations because of renal events) and no participants continuing ABC/3TC. Renal biomarkers of urine albumin:creatinine and beta-2-microglobulin:creatinine ratios significantly improved on E/C/F/TAF. Self-reported treatment satisfaction was significantly higher with E/C/F/TAF. CONCLUSION Switching to E/C/F/TAF was noninferior to continuing ABC/3TC plus a third agent for maintenance of HIV RNA suppression at Week 24. This study supports E/C/F/TAF as an efficacious and well tolerated option for participants switching from ABC/3TC-based regimens.
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Todd JV, Cole SR, Wohl DA, Simpson RJ, Jonsson Funk M, Brookhart MA, Cocohoba J, Merenstein D, Sharma A, Lazar J, Milam J, Cohen M, Gange S, Lewis TT, Burkholder G, Adimora AA. Underutilization of Statins When Indicated in HIV-Seropositive and Seronegative Women. AIDS Patient Care STDS 2017; 31:447-454. [PMID: 29087746 DOI: 10.1089/apc.2017.0145] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Increased life expectancy of persons living with HIV infection receiving antiretroviral therapy heightens the importance of preventing and treating chronic comorbidities such as cardiovascular disease. While guidelines have increasingly advocated more aggressive use of statins for low-density lipoprotein (LDL) cholesterol reduction, it is unclear whether people with HIV, especially women, are receiving statins when indicated, and whether their HIV disease is a factor in access. We assessed the cumulative incidence of statin use after an indication in the Women's Interagency HIV Study (WIHS), from 2000 to 2014. Additionally, we used weighted proportional hazards regression to estimate the effect of HIV serostatus on the time to initiation of a statin after an indication. Cumulative incidence of statin use 5 years after an indication was low: 38% in HIV-seropositive women and 30% in HIV-seronegative women. Compared to HIV-seronegative women, the weighted hazard ratio for initiation of a statin for HIV-seropositive women over 5 years was 0.94 [95% confidence interval (CI) 0.62, 1.43]. Applying the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines increased the proportion of HIV-seropositive women with a statin indication from 16% to 45%. Clinicians treating HIV-seropositive women should consider more aggressive management of the dyslipidemia often found in this population.
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Affiliation(s)
- Jonathan V Todd
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina , Chapel Hill, North Carolina
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Stephen R Cole
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina , Chapel Hill, North Carolina
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - David A Wohl
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina , Chapel Hill, North Carolina
| | - Ross J Simpson
- 3 Division of Cardiology, Department of Medicine, University of North Carolina , Chapel Hill, North Carolina
| | - Michele Jonsson Funk
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - M Alan Brookhart
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Jennifer Cocohoba
- 4 Department of Clinical Pharmacy, University of California San Francisco School of Pharmacy , San Francisco, California
| | - Daniel Merenstein
- 5 Department of Family Medicine, Georgetown University Medical Center , Washington, District of Columbia
| | - Anjali Sharma
- 6 Department of Medicine, Albert Einstein College of Medicine , Bronx, New York
| | - Jason Lazar
- 7 Department of Cardiovascular Disease, SUNY Downstate Medical Center , Brooklyn, New York
| | - Joel Milam
- 8 Department of Preventive Medicine, Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Mardge Cohen
- 9 Department of Medicine, Cook County Health and Hospital System and Rush University , Chicago, Illinois
| | - Stephen Gange
- 10 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Tené T Lewis
- 11 Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta, Georgia
| | - Greer Burkholder
- 12 Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Adaora A Adimora
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina , Chapel Hill, North Carolina
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
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Raffi F, Esser S, Nunnari G, Pérez-Valero I, Waters L. Switching regimens in virologically suppressed HIV-1-infected patients: evidence base and rationale for integrase strand transfer inhibitor (INSTI)-containing regimens. HIV Med 2017; 17 Suppl 5:3-16. [PMID: 27714978 DOI: 10.1111/hiv.12440] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2016] [Indexed: 11/30/2022]
Abstract
In an era when most individuals with treated HIV infection can expect to live into old age, clinicians should proactively review their patients' current and future treatment needs and challenges. Clinical guidelines acknowledge that, in the setting of virological suppression, treatment switch may yield benefits in terms of tolerability, regimen simplification, adherence, convenience and long-term health considerations, particularly in the context of ageing. In this paper, we review evidence from six key clinical studies on switching virologically suppressed patients to regimens based on integrase strand transfer inhibitors (INSTIs), the antiretroviral class increasingly preferred as initial therapy in clinical guidelines. We review these studies and focus on the virological efficacy, safety, and tolerability of switching to INSTI-based regimens in suppressed HIV-positive individuals. We review the early switch studies SWITCHMRK and SPIRAL [assessing a switch from a ritonavir-boosted protease inhibitor (PI/r) to raltegravir (RAL)-containing regimens], together with data from STRATEGY-PI [assessing a switch to elvitegravir (EVG)-containing regimens; EVG/cobicistat (COBI)/emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF) vs. remaining on a PI/r-containing regimen], STRATEGY-NNRTI [assessing a switch to EVG/COBI/FTC/TDF vs. continuation of a nonnucleoside reverse transcriptase inhibitor (NNRTI) and two nucleoside reverse transcriptase inhibitors (NRTIs)], STRIIVING [assessing a switch to a dolutegravir (DTG)-containing regimen (abacavir (ABC)/lamivudine (3TC)/DTG) vs. staying on the background regimen], and GS study 109 [assessing a switch to EVG/COBI/FTC/tenofovir alafenamide fumarate (TAF) vs. continuation of FTC/TDF-based regimens]. Switching to INSTI-containing regimens has been shown to support good virological efficacy, with evidence from two studies demonstrating superior virological efficacy for a switch to EVG-containing regimens. In addition, switching to INSTI regimens was associated with improved tolerability and greater reported patient satisfaction and outcomes in some studies. INSTI-based regimens offer an important contemporary switch option that may be tailored to meet and optimize the needs of many patients.
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Affiliation(s)
- F Raffi
- Infectious Diseases Department, University Hospital Hotel Dieu, Nantes, France.
| | - S Esser
- Department of Dermatology and Venerology, University HIV/STD Center Essen, University Hospital Essen, Essen, Germany
| | - G Nunnari
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, Policlinico 'G. Martino', University of Messina, Messina, Italy
| | | | - L Waters
- Mortimer Market Centre, Central & North West London NHS Trust, London, UK
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Njoroge A, Guthrie BL, Bosire R, Wener M, Kiarie J, Farquhar C. Low HDL-cholesterol among HIV-1 infected and HIV-1 uninfected individuals in Nairobi, Kenya. Lipids Health Dis 2017; 16:110. [PMID: 28599673 PMCID: PMC5466788 DOI: 10.1186/s12944-017-0503-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/29/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Antiretroviral treatment (ART) is associated with dyslipidemia yet little is known about the burden of dyslipidemia in the absence of ART in sub-Saharan Africa. We compared the prevalence and risk factors for dyslipidemia among HIV-infected ART-naïve adults and their uninfected partners in Nairobi, Kenya. METHODS Non-fasting total cholesterol (TC) and high density lipoprotein cholesterol (HDL) levels were measured by standard lipid spectrophotometry on thawed plasma samples obtained from HIV-infected participants and their uninfected partners. Dyslipidemia, defined by high TC (>200 mg/dl) or low HDL (<40 mg/dl) was compared between HIV-infected and uninfected men and women. RESULTS Among 196 participants, median age was 32 years [IQR: 23-41]. Median CD4 count among the HIV-infected was 393 cells/ μl (IQR: 57-729) and 90% had a viral load >1000 copies/ml. Mean TC and HDL were comparable for HIV-infected and uninfected participants. Prevalence of dyslipidemia was 83.8% vs 78.4% (p = 0.27). Among the HIV-infected, those with a viral load >1000 copies/ml were 1.5-fold more likely to have dyslipidemia compared to those with ≤1000 copies/ml (adjusted prevalence ratio [aPR] 1.5, 95% CI: 1.22-30.99, p = 0.02). BMI, age, gender, blood pressure and smoking were not significantly associated with dyslipidemia. CONCLUSIONS Among ART-naïve HIV-infected adults, high viral load and low CD4 cell count were independent predictors of dyslipidemia, underscoring the importance of early initiation of ART for viral suppression.
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Affiliation(s)
- Anne Njoroge
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- University of Washington, Seattle, WA USA
| | - B. L. Guthrie
- University of Washington, Seattle, WA USA
- Department of Epidemiology, University of Washington, Seattle, WA USA
| | - Rose Bosire
- Centre for Public Health Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mark Wener
- Department of Medicine, University of Washington, Seattle, WA USA
| | - James Kiarie
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Carey Farquhar
- University of Washington, Seattle, WA USA
- Department of Epidemiology, University of Washington, Seattle, WA USA
- Department of Medicine, University of Washington, Seattle, WA USA
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Antela A, Aguiar C, Compston J, Hendry BM, Boffito M, Mallon P, Pourcher-Martinez V, Di Perri G. The role of tenofovir alafenamide in future HIV management. HIV Med 2016; 17 Suppl 2:4-16. [PMID: 26952360 DOI: 10.1111/hiv.12401] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2016] [Indexed: 01/14/2023]
Abstract
HIV infection has become a chronic condition rather than an acute life-threatening disease in developed countries, thanks to consistent innovation and evolution of effective interventions. This has altered HIV management and created new challenges. People living with HIV (PLWHIV) are living longer and so encounter comorbidities linked not only with their disease, but also with ageing, lifestyle and chronic exposure to antiretroviral therapy (ART). Although longevity, viral suppression and the prevention of viral transmission remain key goals, more needs to be achieved to encompass the vision of attaining an optimum level of overall health. Treatment choices and management practices should ensure patients' long-term health with minimal comorbidity. Treatments that balance optimal efficacy with the potential for improved long-term safety are needed for all patients. In this review, we consider the evolution and development of tenofovir alafenamide (TAF), a novel prodrug of tenofovir which offers high antiviral efficacy at doses over ten times lower than that of tenofovir disoproxil fumarate (TDF). Emerging clinical data suggest that elvitegravir, cobicistat, emtricitabine and TAF (E/C/F/TAF) as a single-tablet regimen offers highly effective viral suppression in treatment-naïve and treatment-experienced patients with an improved renal and bone safety profile compared with TDF, this having been demonstrated in diverse groups including patients with existing renal impairment and adolescents. The profile of TAF identifies it as an agent with a promising role within future ART regimens that aim to deliver the vision of undetectable viral load, while requiring less monitoring and having a safety profile designed to minimize comorbid risks while supporting good long-term health.
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Affiliation(s)
- A Antela
- Infectious Diseases Department, University Hospital of Santiago de Compostela, La Coruña, Spain
| | - C Aguiar
- Hospital Santa Cruz, CHLO, Av. Prof. Reynaldo dos Santos, 2970-134, Carnaxide, Portugal
| | - J Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - B M Hendry
- Renal Medicine, King's College London, London, UK
| | - M Boffito
- St Stephens Centre, Chelsea and Westminster Hospital and Imperial College London, London, UK
| | - P Mallon
- School of Medicine, University College Dublin, Dublin, Ireland
| | - V Pourcher-Martinez
- Infectious Diseases Department, Pitie-Salpetriere University Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - G Di Perri
- Infectious Diseases Clinic, Amedeo di Savoia Hospital, University of Torino, Torino, Italy
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O'Halloran JA, Dunne E, Gurwith M, Lambert JS, Sheehan GJ, Feeney ER, Pozniak A, Reiss P, Kenny D, Mallon P. The effect of initiation of antiretroviral therapy on monocyte, endothelial and platelet function in HIV-1 infection. HIV Med 2015; 16:608-19. [PMID: 26111187 DOI: 10.1111/hiv.12270] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Monocyte activation, endothelial dysfunction and platelet activation all potentially contribute to the increased risk of cardiovascular disease (CVD) reported in those with HIV-1 infection. To date, no study has examined how initiation of antiretroviral therapy (ART) affects markers of all three processes. We aimed to compare markers of monocyte, endothelial and platelet function between untreated HIV-positive subjects and HIV-negative controls and to examine the early effects of ART initiation on these markers. METHODS We measured monocyte [soluble CD14 (sCD14) and sCD163], endothelial [von Willebrand factor (vWF), intercellular adhesion molecule-1 (ICAM-1) and vascular adhesion molecule-1 (VCAM-1)] and platelet [soluble P-selectin (sP-selectin), soluble CD40 ligand (sCD40L) and soluble glycoprotein VI (sGPVI)] biomarkers before and at weeks 4 and 12 post ART initiation in HIV-positive and well-matched HIV-negative controls. RESULTS We examined 40 subjects, 25 HIV-positive subjects and 15 controls, with a median age of 34 years [interquartile range (IQR) 31, 40 years], of whom 60% were male and 47.5% Caucasian. Pre-ART, all biomarkers (monocyte, endothelial and platelet) were significantly higher in HIV-positive patients versus controls (all P < 0.05) and decreased with ART initiation, except for sCD14, which remained unchanged [median 1680 (IQR 1489, 1946) ng/mL at week 12 versus 1570 (IQR 1287, 2102) ng/mL at week 0; P = 0.7]. Although platelet activation markers reduced to levels comparable to those in controls, endothelial dysfunction markers remained elevated, as did sCD163 [at week 12, median 1005 (IQR 791, 1577) ng/mL in HIV-positive patients versus 621 (IQR 406, 700) ng/mL in controls; P < 0.0001]. CONCLUSIONS ART initiation resulted in reductions in levels of CVD-associated biomarkers; however, although they improved, markers of endothelial dysfunction and monocyte activation remained elevated. How these persistent abnormalities affect CVD risk in HIV infection remains to be determined.
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Affiliation(s)
- J A O'Halloran
- HIV Molecular Research Group, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - E Dunne
- Cardiovascular Biology Group, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mmp Gurwith
- HIV Molecular Research Group, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - J S Lambert
- HIV Molecular Research Group, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - G J Sheehan
- HIV Molecular Research Group, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - E R Feeney
- HIV Molecular Research Group, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - A Pozniak
- HIV Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - P Reiss
- Department of Global Health and Stichting HIV Monitoring, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - D Kenny
- Cardiovascular Biology Group, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pwg Mallon
- HIV Molecular Research Group, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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