Antiretroviral therapy in Indian setting: when & what to start with, when & what to switch to?

Efficacy and safety of pan-genotypic sofosbuvir and velpatasvir in patients with hepatitis C and HIV coinfection on dolutegravir-based antiretroviral therapy

Hepatitis C virus (HCV) infection is more prevalent in people living with HIV-AIDS (PLHA) and portends a poorer prognosis. Pharmacokinetic studies suggest the absence of significant interaction between velpatasvir and dolutegravir which has been recently recommended as part of preferred first-line antiretroviral therapy (ART) regimens by WHO. However, clinical data on the use of velpatasvir-based regimen in PLHA taking dolutegavir is lacking. Hence, we aimed to assess the efficacy and safety of sofosbuvir and velpatasvir (SOF + VEL) in HCV and HIV coinfected patients on dolutegravir-based ART. Forty-five consecutive PLHA with HCV coinfection on dolutegravir-based ART were prospectively enrolled. All patients were treated SOF + VEL for 12 weeks. Complete haemogram, liver and renal function tests were assessed at baseline, 4 weeks and at end of treatment. Sustained virological response (SVR) was assessed at 12 weeks after end of treatment. The majority were males (95.5%) with a mean age of 32.8 ± 12.3 years. Cirrhosis was present in 6 (13.3%) patients. All patients completed 12 weeks of therapy with SOF + VEL, but SVR could not be assessed in two patients. Forty-two (97.7%) of the remaining 43 patients attained SVR-12. SVR-12 rate was 97.7% and 93.3% by per protocol and intention to treat analysis, respectively. No grade III/IV adverse events were reported, and there was no worsening of blood counts, liver or renal function test parameters. The pan-genotypic regimen of SOF + VEL is safe and effective in PLHA with HCV coinfection who are on dolutegravir-based ART.

A prospective study to estimate the incidence and pattern of adverse drug reactions to first-line antiretroviral therapy (tenofovir, efavirenz, and lamivudine)

Background

Antiretroviral drugs are efficacious but are associated with long-term toxicities, drug interactions, and emergence of drug resistance.

Objective

To study the incidence and pattern of adverse drug reactions in human immunodeficiency virus (HIV) patients receiving first-line antiretroviral therapy (ART) (tenofovir, efavirenz, and lamivudine (TEL) which was introduced by NACO in 2013.

Materials and Methods

A prospective, single-center observational study that included 135 treatment-naive HIV patients who were started on fixed drug once-daily regimen (TEL). At baseline, detailed clinical history, body weight, waist-hip ratio, complete blood count, liver and renal function test, CD4 cell count were performed. Clinical monitoring for cutaneous, neuropsychiatric, and gastrointestinal side effects was done every month along with laboratory monitoring and anthropometric measurement for every 6 months. CD4 counts were measured at baseline and end of the study at 12 months.

Results

Out of 135 participants, 89 (65.9%) were males and 46 (34%) were females. The mean age and the mean duration of illness at inclusion were 35.10 ± 8.97 years and 1.2 ± 0.6 years, respectively. The mean increase in weight at baseline and at 12 months (57.55 ± 6.56 to 64.04 ± 8.2) was statistically significant (95% confidence interval [CI]: 4.35-8.62, P < 0.001). The mean CD4 counts at baseline were 309.73 ± 118.44 and increased after 12 months of treatment to 421 ± 129.4 which was statistically significant (95% CI: 81.54-140.99, P < 0.001). The mean difference in platelet count was statistically significant between baseline and 12 months (95% CI: 10.32-46.13, P = 0.002). The mean difference in serum urea levels at baseline and at 6 months (95% CI: 0.60-1.61, P < 0.001) as well as 12 months were statistically significant (95% CI: 0.08-1.03, P = 0.02). The mean increase in serum creatinine at baseline (0.75 ± 0.12) and at 12 months (0.97 ± 0.16) was also significant (95% CI: 0.21-0.28, P < 0.001). There was a significant difference between mean creatinine clearance at baseline and at 12 months (109.9 ± 13.75 to 99.33 ± 12.52, P < 0.0001). One patient discontinued treatment due to adverse effects while two patients were shifted to second-line antiretroviral treatment.

Limitations

Small sample size, single-center study and short follow-up period, long-term toxicities were not appreciated.

Conclusion

Fixed drug combination with TEL as a first-line ART for HIV is a safe regime as we observed minimal side effects with current regimen.

Comparison of salivary total protein and electrolyte profile in HIV patients with and without antiretroviral therapy

BACKGROUND

Saliva provides a primary defense mechanism against several infectious diseases through its numerous immunological and non-immunological factors. Alteration in the composition of saliva often compromises its defense mechanisms, predisposing the oral cavity to disease entities. HIV patients under antiretroviral therapy (ART) have shown to exhibit altered salivary composition. These changes are postulated to be a result of the effect of ART on the salivary protein and electrolytes levels.

OBJECTIVES

The present study aims to assess the potential difference in the salivary total protein and electrolyte levels in HIV patients with and without ART.

METHODS

Patients were divided into 3 groups- Group A (HIV-1 positive patient under ART for at least 6 months)-66, Group B (HIV-1 positive patient not started on ART)-66, Group C (HIV negative patients)-66. Saliva samples were collected and evaluated for total salivary protein and electrolyte levels in all the 3 groups.

RESULTS

There was a statistically significant difference in the salivary protein (p = 0.000) and electrolyte (Sodium, p = 0.000; Potassium, p = 0.039; chlorine, p = 0.027; ionized calcium, p = 0.002) levels among the three groups.

CONCLUSION

HIV positive individuals with and without ART have alteration in the salivary composition. Some of these alterations (total protein and iCa levels) are due to the HIV infection, while others (Na, K, Cl) could be due to ART or a combined effect of both. Salivary changes in HIV positive individuals could predispose them to oral diseases. Thus, regular oral examination and prophylactic regimen must be formulated to maintain their oral hygiene and quality of life.

Dental caries status of children receiving Highly active antiretroviral therapy (HAART) - A multicentric cross-sectional study in Tamil Nadu, India

Background:

Highly active antiretroviral therapy (HAART) has progressively improved the life expectancies in HIV positive children. These antiretroviral drugs could possibly have an influence on the oral health status. Different age groups of children under HAART with caries had implications in approach to dental treatment, which were attempted to be identified in the study.

Aims/Objectives:

The aim of the study was to assess the caries status among HIV positive children receiving HAART. To characterize the age group with high caries indices and treatment needs.

Methods:

A cross-sectional study was conducted among 313 HIV infected children aged 3–14 years receiving HAART from various ART centers Tamil Nadu, India. Dental examinations were performed and caries status of primary and permanent dentition was assessed using Decayed, Missing, and Filled teeth (DMFT)/Decayed, Missing, and Filled surface (DMFS) indices.

Statistical Analysis:

The one way ANOVA with post-hoc Tukey HSD test.

Results:

The mean deft/DMFT scores were 3.15 ± 2.72/2.07 ± 1.31 and defs/DMFS scores were 7.42 ± 5.90/4.30 ± 2.58. The caries incidence was significantly different across the three age groups compared. DMFT scores of 13 − 14 years age group were significantly higher than in the 3−6 years (P < 0.0000) and 7−12 years (P < 0.0001).

Conclusion:

A higher caries experience was present among children on HAART as compared to the general population in Tamil Nadu. A significant association with increasing age and DMFT scores was noted. Age groups of 13−14 had high caries prevalence than age groups of 3−6 and 7−12 years in given study population. The individualized treatment approaches based on the age groups is suggested.

Timely care linkage of people living with HIV in a reference health service, Belo Horizonte, Minas Gerais

INTRODUCTION

Linkage is a critical step in the ongoing care of human immunodeficiency virus (HIV/aids) infection and is essential for providing access to antiretroviral therapy, as well as comprehensive care.

METHODOLOGY

Cross-sectional study on people living with HIV (PLHIV), aged ≥ 18 years old, linked between January and December 2015, in a referral service for outpatient and hospital care specialized in HIV/AIDS in Belo Horizonte, Minas Gerais. Linkage time was defined as the time from diagnosis to service linkage. Timely care linkage was considered when this time was ≤ 90 days. Data were collected through clinical records. A logistic regression analysis with a confidence interval of 95% (95%CI) was performed.

RESULTS

Among 208 patients, most of them were males (77.8%) with a mean age of 39 years. About 45% presented AIDS-defining conditions at the moment of linkage. Linkage time presented a mean of 138 ± 397 days. And timely linkage occurred for 76.9% of the patients. The variables associated with timely care linkage were: age ≥ 48 years (odds ratio - OR = 8.50; 95%CI 1.53 - 47.28), currently working (OR = 3.69; 95%CI 1.33 - 10.25) at the time of linkage, and present CD4+ T lymphocyte count (CD4+ T) ≤ 200 cells/mm3 at the time of HIV diagnosis (OR = 4.84; 95%CI 1.54 - 15.18). There was an important proportion of timely care linkage among PLHIV, but with late diagnosis.

CONCLUSION

Interventions should be targeted at younger people with higher CD4+ T lymphocyte counts, in order to better provide continuous HIV care.

T cell functionality in HIV-1, HIV-2 and dually infected individuals: correlates of disease progression and immune restoration

The role of suppressive anti-retroviral therapy (ART) in eliciting restoration of dysregulated immune function remains unclear in HIV-1 infection. Also, due to tailoring of therapeutic regimens towards HIV-1, this possible impairment of therapy may be even more pronounced in HIV-2 and dual (HIV-D) infection. Thus, we evaluated the impact of ART on immune restoration by assessing T cell functions, including HIV specific responses in HIV-1-, HIV-2- and HIV-D-infected individuals. Both ART-treated and naive infected subjects showed persistently altered frequency of CD4+ T cell subsets [regulatory T cells (Treg ), naive/central memory, effector memory], increased immune activation, cytoxicity and decreased frequency of natural killer T (NKT)- like cells and T helper type 17 (Th17)/Treg ratio with elevated microbial translocation. Further, HIV-specific responses were dominated by gag-specific CD4+ T cells in virologically suppressed HIV-D individuals, suggesting retention of T cell memory for both viruses. Increased antigen-specific responses, including dual-functional interleukin (IL)-2/interferon (IFN)-γ CD4+ T cells, were detected in therapy receiving HIV-2-infected individuals indicative of a greater and more functionally diverse T cell memory repertoire. We delineated immune signatures specific to therapy-naive single HIV infection, as well as a unique signature associated with HIV-2 disease progression and immune restoration. Circulating Treg frequency, T cell activation and microbial translocation levels correlated with disease progression and immune restoration among all types of HIV infection. Also, memory responses negatively correlated, irrespective of type of infection, in ART receiving infected individuals, with CD4 rebound and decreased pan T cell activation. Our data highlight the need for adjunct immunomodulatory therapeutic strategies to achieve optimal immune restoration in HIV infection.

Determination of medication adherence and related factors among people living with HIV/AIDS in a Turkish university hospital

Background/aim

Widespread use of antiretroviral treatment (ART) has led to decrease in the incidence of HIV/AIDS-related mortality. Besides the availability of ART, medication adherence is essential for treatment success. There is a scarcity of data reported from Turkey regarding ART adherence among people living with HIV/AIDS (PLWHA). Therefore, this study was undertaken to determine medication adherence and related factors among PLWHA in Turkey.

Materials and methods

The sample consisted of 158 PLWHA, who were being followed up at Infectious Diseases Outpatient Clinic of Hacettepe University Hospital. Data were collected using an individual questionnaire and the Turkish version of the Morisky Medication Adherence Scale.

Results

The median patient age was 38 years, 80.4% were male, and 51.3% were married. The median duration of both HIV infection and ART was 3 years. Sixty-one percent used two drug regimens. Sixty-one percent were highly adherent to ART while 37.9% were moderately adherent. The absence/presence of social support resources, disease duration, ART duration, and being informed about the ART regimen were statistically associated with medication adherence.

Conclusion

Our results suggest that medication adherence is excellent among Turkish PLWHA. Interventions, including effective social support, and continuous counseling about ART, might further boost the adherence of PLWHA.

Evaluation of Adverse Drug Reaction Profile of Drugs Used as First-Line Antiretroviral Therapy

Background and Objectives

The objective was to study the adverse drug reaction (ADR) profile in HIV patients receiving first-line antiretroviral therapy.

Methods

This was a prospective, observational study that included 171 HIV patients with a follow-up at six months. Demographic details, medical history, details of HIV infection including most recent CD4 count, details of antiretroviral therapy, and other concomitant medication were recorded. Adverse drug reactions were elicited by reviewing patient records and also by interviewing the patient/attendants directly.

Results

171 patients completed the study out of which 88 (51.5%) were males and 83 (48.5%) were females. The study subjects included HIV-positive, treatment naïve patients who were started on treatment regimens recommended by the NACO guidelines. The ADRs observed were a fall in haemoglobin or absolute anaemia in response to zidovudine, nonspecific symptoms like headache, and a nonspecific feeling of being unwell in response to tenofovir, stavudine, and efavirenz; dyslipidaemia, pancreatitis, peripheral neuropathy, and lactic acidosis in response to stavudine; generalised rash in response to nevirapine and one case of nephrotoxicity to efavirenz. Majority of the ADRs satisfied the ‘probable' category (60.1%), and the rest were “possible”. ADRs to zidovudine and nevirapine superseded all others.

Interpretation and Conclusion

Gastrointestinal effects were the most commonly observed group of ADRs, with nausea being the most common ADR, the others being gastritis and diarrhoea. The other ADRs included rash, hepatotoxicity, blood dyscrasias like anaemia, neutropenia, and thrombocytopenia, and fatigue. Few cases of lactic acidosis, peripheral neuropathy, headache, lipoatrophy, and pancreatitis were reported.

Nano-ART and NeuroAIDS

Human immunodeficiency virus (HIV) is a neurotropic virus that enters the central nervous system (CNS) early in the course of infection. Although highly active antiretroviral therapy (HAART) has resulted in remarkable decline in the morbidity and mortality in AIDS patients, controlling HIV infections still remains a global health priority. HIV access to the CNS serves as the natural viral preserve because most antiretroviral (ARV) drugs possess inadequate or zero delivery across the brain barriers. The structure of the blood-brain barrier (BBB), the presence of efflux pumps, and the expression of metabolic enzymes pose hurdles for ARV drug-brain entry. Thus, development of target-specific, effective, safe, and controllable drug delivery approach is an important health priority for global elimination of AIDS progression. Nanoformulations can circumvent the BBB to improve CNS-directed drug delivery by affecting such pumps and enzymes. Alternatively, they can be optimized to affect their size, shape, and protein and lipid coatings to facilitate drug uptake, release, and ingress across the barrier. Improved drug delivery to the CNS would affect pharmacokinetic and drug biodistribution properties. This review focuses on how nanotechnology can serve to improve the delivery of antiretroviral medicines, termed NanoART, across the BBB and affect the biodistribution and clinical benefit for NeuroAIDS.

Switching Lopinavir/Ritonavir to Atazanavir/Ritonavir vs Adding Atorvastatin in HIV-Infected Patients Receiving Second-Line Antiretroviral Therapy With Hypercholesterolemia: A Randomized Controlled Trial

A randomized controlled trial was conducted among human immunodeficiency virus-infected patients receiving lopinavir/ritonavir-based regimens with hypercholesterolemia. Reduction of total cholesterol and low-density lipoprotein was significantly greater in patients who were randomized to the addition of atorvastatin compared with those who were switched from lopinavir/ritonavir to atazanavir/ritonavir.

Spinal CPEB-mtROS-CBP signaling pathway contributes to perineural HIV gp120 with ddC-related neuropathic pain in rats

Human immunodeficiency virus (HIV) patients treated with nucleoside reverse transcriptase inhibitors (NRTIs), have been known to develop neuropathic pain. While there has been a major shift away from some neurotoxic NRTIs in current antiretroviral therapy, a large number of HIV patients alive today have previously received them, and many have developed painful peripheral neuropathy. The exact mechanisms by which HIV with NRTIs contribute to the development of neuropathic pain are not known. Previous studies suggest that cytoplasmic polyadenylation element-binding protein (CPEB), reactive oxygen species (ROS), and cAMP-response element-binding protein (CREB)-binding protein (CBP), are involved in the neuroimmunological diseases including inflammatory/neuropathic pain. In this study, we investigated the role of CPEB, mitochondrial ROS (mtROS), or CBP in neuropathic pain induced by HIV envelope protein gp120 combined with antiretroviral drug. The application of recombinant gp120 into the sciatic nerve plus systemic ddC (one of NRTIs) induced mechanical allodynia. Knockdown of CPEB or CBP using intrathecal antisense oligodeoxynucleotide (AS-ODN) reduced mechanical allodynia. Intrathecal mitochondrial superoxide scavenger mito-tempol (Mito-T) increased mechanical withdrawal threshold. Knockdown of CPEB using intrathecal AS-ODN, reduced the up-regulated mitochondrial superoxide in the spinal dorsal horn in rats with gp120 combined with ddC. Intrathecal Mito-T lowered the increased expression of CBP in the spinal dorsal horn. Immunostaining studies showed that neuronal CPEB positive cells were co-localized with MitoSox positive profiles, and that MitoSox positive profiles were co-localized with neuronal CBP. Our studies suggest that neuronal CPEB-mtROS-CBP pathway in the spinal dorsal horn, plays an important role in the gp120/ddC-induced neuropathic pain in rats.

Ocular Manifestations in Patients with Human Immunodeficiency Virus Infection in the Pre-HAART Versus the HAART Era in the North Indian Population

PURPOSE

To compare changes in the demographic profile and ocular manifestations in patients with HIV in the pre-HAART and HAART era in North India.

METHODS

In this single-center cross-sectional study, 100 HIV patients receiving HAART and 96 HIV patients in the pre-HAART era were enrolled. Prevalence of ocular manifestations of HIV was calculated for both cohorts.

RESULTS

The prevalence of ocular manifestations was not statistically different in the two eras (38%, SE: 4.85% in HAART era; 41.67%, SE: 5% in pre-HAART era) (p = 0.60). Mean CD4 counts were lower in the pre-HAART era compared with the HAART era (p < 0.001). In the HAART era, cytomegalovirus (CMV) retinitis and HIV retinopathy continued to remain the most common infectious and non-infectious cause of visual morbidity.

CONCLUSIONS

While the introduction of HAART has resulted in a major impact on the overall health of patients with HIV, the spectrum of ocular disease remains largely unchanged in developing countries such as India.

HIV patients' decision of switching to second-line antiretroviral therapy in India

The objective is to examine when patients should switch to second-line antiretroviral therapy (ART) under health uncertainty and in the absence of viral load monitoring. We formalize and solve the therapeutic dilemma about whether or not, and when, to switch a therapy. The model's main value-added consists in the concrete application to patients with HIV in India. In our dynamic stochastic model, health level volatility can be understood as the variation in CD4 count and the trend of health level as increases in CD4 count and, thus, decreases in the incidence of opportunistic infections and mortality. The results of the empirical application suggest that the theoretical model can explain ART treatment switch. Treatment switch depends negatively on the volatility of patients' health, and on trend of health, i.e., the greater the variation in CD4 count and the more CD4 count increase, the fewer treatment switches one expects to occur. Treatment switch also depends negatively on the degree of irreversibility. Under irreversibility, low-risk patients must begin the second-line treatment as soon as possible, which is precisely when the second-line treatment is least valuable. The existence of an option value means that ART first-line regimen may be the better choice when considering lifetime welfare. Conversely, treatment switch depends positively on the discount rate and on the correlation between the patient's health under first- and second-line treatments. This means that treatment switch is likelier to succeed in second-line treatments that are similar to the first-line treatments, implying that a decision-maker should not rely on treatment switch as a risk diversification tool.

Development, validation and clinical evaluation of a low cost in-house HIV-1 drug resistance genotyping assay for Indian patients

Human Immunodeficiency Virus-1 (HIV-1) drug resistance genotyping assay is a part of clinical management of HIV-1 positive individuals under treatment with highly active antiretroviral therapy (HAART). Routine monitoring of drug resistance mutations in resource limited settings like India is not possible due to high cost of commercial drug resistance assays. In this study we developed an in-house, cost effective HIV-1 drug resistance genotyping assay for Indian patients and validated it against the US-FDA-approved ViroSeq HIV-1 drug resistance testing system. A reference panel of 20 clinical samples was used to develop and validate the assay against ViroSeq HIV-1 drug resistance testing system which was subsequently used to genotype a clinical panel of 225 samples. The Stanford HIV database was used to identify drug resistant mutations. The analytical sensitivity of the assay was 1000 HIV-1 RNA copies/ml of plasma sample while precision and reproducibility was 99.68±0.16% and 99.76±0.18% respectively. One hundred and one drug resistant mutations were detected by the in-house assay compared to 104 by ViroSeq system in the reference panel. The assay had 91.55% success rate in genotyping the clinical panel samples and was able to detect drug resistant mutations related to nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse-transcriptase inhibitor (NNRTI) as well as protease inhibitor (PI) classes of antiretroviral drugs. It was found to be around 71.9% more cost effective compared to ViroSeq genotyping system. This evaluation of the assay on the clinical panel demonstrates its potential for monitoring clinical HIV-1 drug resistance mutations and population-based surveillance in resource limited settings like India.

Enhancing HIV medication adherence in India

BACKGROUND

This pilot study evaluated an intervention designed to enhance adherence among those new to antiretroviral therapy.

METHODS

Participants (n = 80) were recruited from a hospital clinic in Chandigarh, India, and randomized to a 3-month group intervention or individual enhanced standard of care followed by crossover of condition and assessed over 6 months. Adherence was measured by prescription refill, pill count, and self-report.

RESULTS

At baseline, 56% of group condition (immediate intervention) and 54% of individual condition (delayed intervention) participants were nonadherent by pill count and 23% of group and 26% of individual condition participants self-reported skipping medication at least once over the last 3 months. From the postintervention to long-term follow-up, adherence in the group condition (immediate intervention) improved in comparison with adherence in the individual condition (delayed intervention; χ(2) = 5.67, P = .02).

CONCLUSIONS

Results support the use of interventions early in treatment to provide information and social support to establish long-term healthy adherence behaviors.