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Kokorelias KM, Grosse A, Zhabokritsky A, Walmsley SL, Sirisegaram L. Exploring implementation considerations for geriatric-HIV clinics: A secondary analysis from a scoping review on HIV models of geriatric care. HIV Med 2024; 25:38-59. [PMID: 37794607 DOI: 10.1111/hiv.13549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES This review aimed to map the current state of knowledge regarding the implementation considerations of existing geriatric-HIV models of care, to identify areas of further research and to inform the implementation of future geriatric-HIV interventions that support older adults living with HIV. METHODS We conducted a scoping review that was methodologically informed by the Arskey and O'Malley's 5 step framework and theoretically informed by the Consolidated Framework for Implementation Research (CFIR). A systematic search of six databases was conducted for peer-reviewed literature. The grey literature was also searched. Article screening was performed in duplicate. Data was extracted for the purpose of this secondary analysis using a data extraction template informed by the CFIR. Data was inductively and deductively analyzed. RESULTS In total, 11 articles met the inclusion criteria. The models of care described varied in terms of their location and setting, the number and type of care providers involved, the mechanism of patient referral, the type of assessments and interventions performed and the methods of longitudinal patient follow-up. Four key categories emerged to describe factors that influenced their implementation: care provider buy-in, patient engagement, mechanisms of communication and collaboration, and available resources. CONCLUSIONS The findings from this scoping review provide an initial understanding of the key factors to consider when implementing geriatric-HIV models of care. We recommend health system planners consider mechanisms of communication and collaboration, opportunities for care provider buy-in, patient engagement and available resources. Future research should explore implementation in more diverse settings to understand the nuances that influence implementation and care delivery.
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Affiliation(s)
- Kristina Marie Kokorelias
- Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anna Grosse
- Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alice Zhabokritsky
- Department of Medicine, The University of Toronto, Toronto, Ontario, Canada
- Infectious Diseases, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- CIHR Canadian HIV Trails Network, Vancouver, British Columbia, Canada
| | - Sharon L Walmsley
- Department of Medicine, The University of Toronto, Toronto, Ontario, Canada
- Infectious Diseases, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- CIHR Canadian HIV Trails Network, Vancouver, British Columbia, Canada
| | - Luxey Sirisegaram
- Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Hazra A, Zucker J, Bell E, Flores J, Gordon L, Mitjà O, Suñer C, Lemaignen A, Jamard S, Nozza S, Nori AV, Pérez-Barragán E, Rodríguez-Aldama JC, Blanco JL, Delaugerre C, Turner D, Fuertes I, Leiro V, Walmsley SL, Orkin CM. Mpox in people with past infection or a complete vaccination course: a global case series. Lancet Infect Dis 2024; 24:57-64. [PMID: 37678309 DOI: 10.1016/s1473-3099(23)00492-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Since May, 2022, a large global outbreak of human mpox (formerly known as monkeypox) has predominantly affected men who have sex with men. The strain responsible, Clade IIb, has mutated substantially from precursors originating from the 2017-18 outbreak in Nigeria. Immunity to smallpox, another orthopoxvirus, via previous infection or vaccination provides lifelong immunity. However, since the 2022 mpox outbreak, recent clusters were described in individuals with presumed immunity through recent infection or vaccination. We aim to describe the epidemiological and clinical characteristics of mpox in individuals with past infection or vaccination to improve the understanding of this disease in the setting of previous immunity. METHODS In this global case series, international collaborators from nine countries provided data on individuals with PCR-confirmed mpox after documented previous infection or vaccination between May 11, 2022, and June 30, 2023. We excluded cases that could not confirm vaccination status or cases with partial immunisation or any doses received before the current multi-national mpox outbreak (cutoff date May 1, 2022). Data were collected via a case report spreadsheet that reported on dates of infection and vaccination, route of immunisation, demographic characteristics, clinical findings, HIV status, concomitant sexually transmitted infections, and markers of disease severity (mpox severity score system). We describe case epidemiology, clinical course, and mpox severity scores; all analyses were descriptive. FINDINGS We report mpox infections in 37 gay and bisexual men who have sex with men: seven individuals had mpox reinfections, 29 individuals had mpox infections that occurred after two appropriately spaced Modified Vaccinia Ankara-Bavarian Nordic vaccine courses, and one individual had an infection that met the criteria for both reinfection and infection after vaccination. The median age of individuals was 36 years (IQR 30-45; range 21-58). Those with natural immunity after initial infection had a shorter disease course with less mucosal disease upon reinfection than with their initial infection. Infections post-vaccination were characterised by few lesions, little mucosal disease, and minimal analgesia requirements; two people received oral tecovirimat. Overall, there were no deaths, no bacterial superinfections, and all individuals were managed in the ambulatory clinic with one hospital admission for a necrotising neck lesion. INTERPRETATION The epidemiology of people with mpox reinfection or infection post-vaccination was similar to other published cohorts during the 2022 outbreak-predominantly young, sexually active gay and bisexual men who have sex with men. Clinical features and outcomes of repeat infection and infection after vaccination appear to be less clinically severe than those described in 2022 case literature. Specifically, compared with the 2022 case series, these individuals in the present study had fewer confluent lesions, less mucosal involvement, reduced analgesia requirement, and fewer admissions. Natural immunity and vaccine-induced immunity are not fully protective against mpox infection. However, in this small series both disease duration and severity appear to be reduced. FUNDING None.
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Affiliation(s)
- Aniruddha Hazra
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, USA; Howard Brown Health, Chicago, IL, USA
| | - Jason Zucker
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Elizabeth Bell
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, USA
| | - John Flores
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, USA
| | | | - Oriol Mitjà
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections section, Fight Infectious Diseases Foundation, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Clara Suñer
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections section, Fight Infectious Diseases Foundation, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Adrien Lemaignen
- Department of Infectious Diseases, University Hospital of Tours, Tours, France
| | - Simon Jamard
- Department of Infectious Diseases, University Hospital of Tours, Tours, France
| | - Silvia Nozza
- Vita-Salute San Raffaele University, Infectious Diseases Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | | | | | - Jose Louis Blanco
- Infectious Diseases Department, Hospital Clínic de Barcelona, Barcelona University, Barcelona, Spain
| | - Constance Delaugerre
- Service de Virologie, Hôpital Saint-Louis, AP-HP, Université Paris Cité, Paris, France
| | - Dan Turner
- Crusaid Kobler AIDS Center, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Irene Fuertes
- Dermatology Department, Hospital Clinic, Barcelona, Spain
| | - Viviana Leiro
- Dermatology Department, Hospital Muñiz, Buenos Aires, Argentina
| | - Sharon L Walmsley
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Chloe M Orkin
- Blizard Institute and SHARE Collaborative, Queen Mary University of London, London, UK; Department of Infection and Immunity, Barts Health NHS Trust, London, UK.
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3
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Cinque F, Saeed S, Kablawi D, Ramos Ballesteros L, Elgretli W, Moodie EEM, Price C, Monteith K, Cooper C, Walmsley SL, Pick N, Murray MCM, Cox J, Kronfli N, Costiniuk CT, de Pokomandy A, Routy JP, Lebouché B, Klein MB, Sebastiani G. Role of fatty liver in the epidemic of advanced chronic liver disease among people with HIV: protocol for the Canadian LIVEHIV multicentre prospective cohort. BMJ Open 2023; 13:e076547. [PMID: 37607785 PMCID: PMC10445396 DOI: 10.1136/bmjopen-2023-076547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION Advanced chronic liver disease (ACLD) is a major cause of death for people with HIV (PWH). While viral hepatitis coinfections are largely responsible for this trend, metabolic dysfunction-associated steatotic liver disease (MASLD) is an emerging concern for PWH. We aimed to assess the contribution of MASLD to incident ACLD in PWH. METHODS AND ANALYSIS This multicentre prospective observational cohort study will enrol 968 consecutive HIV monoinfected patients from four Canadian sites, excluding subjects with alcohol abuse, liver disease other than MASLD, or ACLD at baseline. Participants will be followed annually for 4 years by clinical evaluation, questionnaires, laboratory testing and Fibroscan to measure liver stiffness measurement (LSM) and controlled attenuation parameter (CAP). The primary outcome will be incidence of ACLD, defined as LSM>10 kPa, by MASLD status, defined as CAP≥285 dB/m with at least one metabolic abnormality, and to develop a score to classify PWH according to their risk of ACLD. Secondary outcomes will include health-related quality of life (HRQoL) and healthcare resource usage. Kaplan-Meier survival method and Cox proportional hazards regression will calculate the incidence and predictors of ACLD, respectively. Propensity score methods and marginal structural models will account for time-varying exposures. We will split the cohort into a training set (to develop the risk score) and a validation set (for validation of the score). HRQoL scores and healthcare resource usage will be compared by MASLD status using generalised linear mixed effects model. ETHICS AND DISSEMINATION This protocol has been approved by the ethics committees of all participating institutions. Written informed consent will be obtained from all study participants. The results of this study will be shared through scientific publications and public presentations to advocate for the inclusion of PWH in clinical trials of MASLD-targeted therapies and case-finding of ACLD in PWH.
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Affiliation(s)
- Felice Cinque
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sahar Saeed
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Dana Kablawi
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Luz Ramos Ballesteros
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wesal Elgretli
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Erica E M Moodie
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Colleen Price
- Canadian HIV/AIDS and Chronic Pain Society, Ottawa, Ontario, Canada
| | | | - Curtis Cooper
- Department of Medicine, Division of Infectious Diseases, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sharon L Walmsley
- Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Neora Pick
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Melanie C M Murray
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph Cox
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Nadine Kronfli
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Alexandra de Pokomandy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Pierre Routy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bertrand Lebouché
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
| | - Marina B Klein
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Giada Sebastiani
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Papp KA, Beecker J, Cooper C, Kirchhof MG, Pozniak AL, Rockstroh JK, Dutz JP, Gooderham MJ, Gniadecki R, Hong CH, Lynde CW, Maari C, Poulin Y, Vender RB, Walmsley SL. Correction to: Use of Systemic Therapies for Treatment of Psoriasis in People Living with Controlled HIV: Inference-Based Guidance from a Multidisciplinary Expert Panel. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00950-y. [PMID: 37410208 PMCID: PMC10366035 DOI: 10.1007/s13555-023-00950-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Affiliation(s)
- Kim A Papp
- Probity Medical Research Inc., Waterloo, ON, Canada.
- K Papp Clinical Research, Waterloo, ON, Canada.
| | - Jennifer Beecker
- Probity Medical Research Inc., Waterloo, ON, Canada
- University of Ottawa, Ottawa, ON, Canada
- Division of Dermatology, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Curtis Cooper
- University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital and Regional Hepatitis Program, Ottawa, ON, Canada
| | - Mark G Kirchhof
- University of Ottawa, Ottawa, ON, Canada
- Division of Dermatology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Anton L Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Jan P Dutz
- Skin Care Center, Vancouver, BC, Canada
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Melinda J Gooderham
- Probity Medical Research Inc., Waterloo, ON, Canada
- SKiN Centre for Dermatology, Peterborough, ON, Canada
| | - Robert Gniadecki
- Division of Dermatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Chih-Ho Hong
- Probity Medical Research Inc., Waterloo, ON, Canada
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
- Dr. Chih-Ho Hong Medical Inc., Surrey, BC, Canada
| | - Charles W Lynde
- Probity Medical Research Inc., Waterloo, ON, Canada
- Lynde Institute for Dermatology, Markham, ON, Canada
| | | | - Yves Poulin
- Centre de Recherche Dermatologique du Québec Métropolitain, Quebec, QC, Canada
| | - Ronald B Vender
- Dermatrials Research Inc., Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sharon L Walmsley
- Toronto General Hospital Research Institute, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
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5
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Eaton AD, Chan Carusone S, Murzin K, Hui J, McCullagh JW, Walmsley SL. Cognitive screening considerations for psychosocial clinical trials in HIV, aging, and cognition. Clin Trials 2023; 20:176-180. [PMID: 36924070 DOI: 10.1177/17407745221136970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Cognitive impairment is a common comorbidity among individuals aging with HIV, which can be an extreme source of stress and anxiety for many. Psychosocial interventions have the potential to alleviate symptoms associated with cognitive impairment and help improve the quality of life of people with HIV as they continue to age; these interventions are in the infancy of development and require further testing via clinical trials. The slow development of interventions may be partially attributed to a common trend of requiring a formal HIV-associated neurocognitive disorder diagnosis to qualify for psychosocial clinical trials. HIV-associated neurocognitive disorder is diagnosed through intensive, time-consuming tests, and still many cases of HIV-associated neurocognitive disorder remain undiagnosed, misdiagnosed, or misclassified due to the limitations of the assessment process. This commentary suggests an alternate method of screening for cognitive impairments through the use of a brief, low-barrier assessment, alongside validity considerations. Such alternate screening may improve enrollment and completion rates in psychosocial clinical trials for people aging with HIV and cognitive impairment, by removing the burden of extensive testing that is commonly associated with an HIV-associated neurocognitive disorder diagnosis from clinical trial eligibility, while still providing valuable insight into individuals' cognitive functioning.
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Affiliation(s)
- Andrew D Eaton
- Faculty of Social Work-Saskatoon Campus, University of Regina, Saskatoon, SK, Canada.,Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Soo Chan Carusone
- Casey House, Toronto, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Jenny Hui
- Faculty of Social Work-Saskatoon Campus, University of Regina, Saskatoon, SK, Canada.,Ontario Institute for Studies in Education, University of Toronto, Toronto, ON, Canada
| | | | - Sharon L Walmsley
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
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Walmsley SL, Szadkowski L, Wouters B, Clarke R, Colwill K, Rochon P, Brudno M, Ravindran R, Raboud J, McGeer A, Oza A, Graham C, Silva A, Manase D, Maksymowsky P, Parente L, Dayam RM, Simpson J, Pasculescu A, Gingras AC. COVID-19 Vaccine Antibody Responses in Community Dwelling Adults to 48 weeks Post Primary Vaccine Series. iScience 2023; 26:106506. [PMID: 37073374 PMCID: PMC10043971 DOI: 10.1016/j.isci.2023.106506] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/16/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
We report a decentralized prospective cohort study of self-reported adverse events and antibody responses to COVID vaccines derived from dried blood spots. Data is presented for 911 older (aged >70 years) and 375 younger (30-50 years) recruits to 48 weeks after the primary vaccine series. After a single vaccine, 83% younger and 45% older participants had overall seropositivity (p<0.0001) increasing to 100/98% with the second dose respectively (p=0.084). A cancer diagnosis (p=.009), no mRNA1273 vaccine doses (p<.0001) and older age (p <.0001) predicted lower responses. Antibody levels declined in both cohorts at 12 and 24 weeks increasing with booster doses. At 48 weeks, for participants with 3 vaccine doses, the median antibody levels were higher in the older cohort (p=.04) with any dose of mRNA-1273 (p<.0001) and with COVID infection (p<.001). The vaccines were well tolerated. Breakthrough COVID infections were uncommon (16% older cohort, 29% younger cohort; p<0.0001) and mild.
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Affiliation(s)
- Sharon L. Walmsley
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Corresponding author
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Bradly Wouters
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Rosemarie Clarke
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Karen Colwill
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Paula Rochon
- Women’s College Hospital Research Institute, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Michael Brudno
- Department of Computer Science, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Rizanni Ravindran
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Janet Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Allison McGeer
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Amit Oza
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Christopher Graham
- Trillium Health Partners, Department of Medicine, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Amanda Silva
- Department of BioInformatics, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Dorin Manase
- Department of BioInformatics, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Peter Maksymowsky
- Department of BioInformatics, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Laura Parente
- Health Care Human Factors, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Roaya Monica Dayam
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Jacqueline Simpson
- Health Care Human Factors, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Adrian Pasculescu
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Anne-Claude Gingras
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Murzin K, Racz E, Behrens DM, Conway T, Da Silva G, Fitzpatrick E, Lindsay JD, Walmsley SL. "We can hardly even do it nowadays. So, what's going to happen in 5 years from now, 10 years from now?" The health and community care and support needs and preferences of older people living with HIV in Ontario, Canada: a qualitative study. J Int AIDS Soc 2022; 25 Suppl 4:e25978. [PMID: 36176028 PMCID: PMC9522634 DOI: 10.1002/jia2.25978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The population of people living with HIV (PLWH) is ageing consequent to effective treatment and a steady stream of new diagnoses among older adults. PLWH experience a greater burden of age‐related comorbidities and poorer social determinants of health compared to their HIV‐negative peers, yet comprehensive requisites for care and support as PLWH age remain poorly understood. Preferences And Needs for Ageing Care among HIV‐positive Elderly people in Ontario, Canada (PANACHE ON), explored the health and community care and social support needs and preferences of a diverse group of older PLWH (age 60+) and described life course experiences among older PLWH that shape these needs and preferences and whether they are met. Methods PANACHE ON was a qualitative community‐based participatory research study. In‐person focus groups using a semi‐structured interview guide were co‐facilitated by pairs of trained older PLWH from July to October 2019. Purposive sampling bolstered the inclusion of communities disproportionately affected by HIV in Ontario. Descriptive analysis was used to summarize demographic data; participatory data analysis was conducted by a subset of the research team, with transcripts double‐coded and analysed using NVIVO 12 Plus. Results A total of 73 PLWH participated, 66% identified as men. The mean age was 64 years (range 55–77) and median time living with HIV was 23 years (range 2–37). The current and anticipated needs of older PLWH, many of which were only partially met, included necessities such as food and housing, mobility and sensory aids, in‐home support, social and emotional support, transportation and information. Three experiences—trauma, stigma and uncertainty—intersected in the lives of many of our participants, shaping their needs for care and support, and impacting the ease with which these needs were met. Conclusions Unmet health and social needs and limited control over the availability and accessibility of ageing‐related care and support due to resource constraints or reduced capacity for self‐advocacy results in anxiety about the future among older PLWH, despite their well‐developed coping strategies and experience navigating systems of care. These study findings will inform the development of the first national needs assessment of older PLWH in Canada.
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Affiliation(s)
| | | | | | | | | | - Eimear Fitzpatrick
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Joanne D Lindsay
- Realize, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Sharon L Walmsley
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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8
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Wobeser WL, McBane JE, Balfour L, Conway B, Gill MJ, Huff H, Kilby DLP, Fergusson DA, Mallick R, Mills EJ, Muldoon KA, Rachlis A, Ralph ED, Rosenes R, Singer J, Singhal N, Tan D, Tremblay N, Vo D, Walmsley SL, Cameron DW. A randomized control trial of high-dose micronutrient-antioxidant supplementation in healthy persons with untreated HIV infection. PLoS One 2022; 17:e0270590. [PMID: 35834528 PMCID: PMC9282469 DOI: 10.1371/journal.pone.0270590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 06/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background Although micronutrient and antioxidant supplementation are widely used by persons with human immunodeficiency virus (HIV), a therapeutic role beyond recommended daily allowances (RDA) remains unproven. An oral high-dose micronutrient and antioxidant supplement (Treatment) was compared to an RDA supplement (Control) for time to progressive immunodeficiency or initiation of antiretroviral therapy (ART) in people living with HIV (PLWH). Methods This study was a randomized, double-blind, placebo-controlled multicenter clinical trial. PLWH were recruited from Canadian HIV Trials Network sites, and followed quarterly for two years. Eligible participants were asymptomatic, antiretroviral treatment (ART)-naïve, HIV-seropositive adults with a CD4 T lymphocyte count (CD4 count) between 375–750 cells/μL. Participants were randomly allocated 1:1 to receive Treatment or Control supplements. The primary outcome was a composite of time-to-first of confirmed CD4 count below 350 cells/μL, initiation of ART, AIDS-defining illness or death. Primary analysis was by intention-to-treat. Secondary outcomes included CD4 count trajectory from baseline to ART initiation or two years. A Data and Safety Monitoring Board reviewed the study for safety, recruitment and protocol adherence every six months. Results Of 171 enrolled participants: 66 (38.6%) experienced a primary outcome: 27 reached a CD4 count below 350 cells/μL, and 57 started ART. There was no significant difference in time-to-first outcome between groups (Hazard Ratio = 1.05; 95%CI: 0.65, 1.70), or in time to any component outcome. Using intent-to-treat censoring, mean annualized rates of CD4 count decline were -42.703 cells/μL and -79.763 cells/μL for Treatment and Control groups, with no statistical difference in the mean change between groups (-37.06 cells/μL/52 weeks, 95%CI: (-93.59, 19.47); p = 0.1993). Accrual was stopped at 171 of the 212 intended participants after an interim analysis for futility, although participant follow-up was completed. Conclusions In ART-naïve PLWH, high-dose antioxidant, micronutrient supplementation compared to RDA supplementation had no significant effect on disease progression or ART initiation. Clinical trial registration ClinicalTrials.gov Identifier: NCT00798772.
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Affiliation(s)
- Wendy L. Wobeser
- Department of Biomedical and Molecular Sciences and Public Health, Queen’s University, Kingston, Ontario, Canada
| | - Joanne E. McBane
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Louise Balfour
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian Conway
- Vancouver Infectious Disease Clinic, Vancouver, British Columbia, Canada
| | - M. John Gill
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Harold Huff
- Canadian College of Naturopathic Medicine, Toronto, Ontario, Canada
| | - Donald L. P. Kilby
- Faculty of Health Services, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean A. Fergusson
- Clinical Epidemiology Program (CEP), University of Ottawa at The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Ranjeeta Mallick
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Edward J. Mills
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- Global Evaluative Sciences, Vancouver, British Columbia, Canada
| | - Katherine A. Muldoon
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Obstetrics and Maternal Investigations Research Group, The Ottawa Hospital, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anita Rachlis
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Edward D. Ralph
- Division of Infectious Diseases, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Ron Rosenes
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
| | - Joel Singer
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neera Singhal
- Global Evaluative Sciences, Vancouver, British Columbia, Canada
| | - Darrell Tan
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- La Ka Shing Knowledge Institute, St. Michael’s, Toronto, Ontario, Canada
| | - Nancy Tremblay
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dong Vo
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sharon L. Walmsley
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - D. William Cameron
- CIHR Canadian HIV Trials Network (CIHR-CTN), Vancouver, British Columbia, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program (CEP), University of Ottawa at The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
- * E-mail:
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9
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Papp KA, Beecker J, Cooper C, Kirchhof MG, Pozniak AL, Rockstroh JK, Dutz JP, Gooderham MJ, Gniadecki R, Hong CH, Lynde CW, Maari C, Poulin Y, Vender RB, Walmsley SL. Use of Systemic Therapies for Treatment of Psoriasis in People Living with Controlled HIV: Inference-Based Guidance from a Multidisciplinary Expert Panel. Dermatol Ther (Heidelb) 2022; 12:1073-1089. [PMID: 35445963 PMCID: PMC9110627 DOI: 10.1007/s13555-022-00722-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/30/2022] [Indexed: 11/28/2022] Open
Abstract
Background People living with human immunodeficiency virus (PLHIV) have a similar prevalence of psoriasis as the general population, though incidence and severity correlate with HIV viral load. Adequately treating HIV early renders the infection a chronic medical condition and allows PLHIV with a suppressed viral load (PLHIV-s) to live normal lives. Despite this, safety concerns and a lack of high-level data have hindered the use of systemic psoriasis therapies in PLHIV-s. Objectives We aim to provide a structured framework that supports healthcare professionals and patients discussing the risks and benefits of systemic psoriasis therapy in PLHIV-s. Our goal was to address the primary question, are responses to systemic therapies for the treatment of psoriasis in PLHIV-s similar to those in the non-HIV population? Methods We implemented an inference-based approach relying on indirect evidence when direct clinical trial data were absent. In this instance, we reviewed indirect evidence supporting inferences on the status of immune function in PLHIV. Recommendations on systemic treatment for psoriasis in PLHIV were derived using an inferential heuristic. Results We identified seven indirect indicators of immune function informed by largely independent bodies of evidence: (1) functional assays, (2) vaccine response, (3) life expectancy, (4) psoriasis manifestations, (5) rate of infections, (6) rate of malignancies, and (7) organ transplant outcomes. Conclusions Drug-related benefits and risks when treating a patient with systemic psoriasis therapies are similar for non-HIV patients and PLHIV with a suppressed viral load and normalized CD4 counts. Prior to initiating psoriasis treatment in PLHIV, HIV replication should be addressed by an HIV specialist. Exercise additional caution for patients with a suppressed viral load and discordant CD4 responses on antiretroviral therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s13555-022-00722-0. People living with human immunodeficiency virus (PLHIV) develop psoriasis as often as everyone else. We asked: what are effective and safe treatments when PLHIV need systemic therapy (pills or injections) for their psoriasis? HIV infection attacks the immune system. When HIV is not treated, the immune system declines. A less effective immune system makes it harder for the body to fight infections and certain cancers. Psoriasis is a skin condition caused by overactive immune cells. Effective psoriasis treatments reduce immune-cell activity. There are some concerns that treatments for psoriasis may not work and could worsen infections or cancers. To answer the question, we gathered 11 dermatologists and 4 HIV specialists. We reviewed the international scientific literature on PLHIV and psoriasis. The absence of direct evidence and volume of information to review made the process challenging. The end results were worthwhile. We concluded that people who are diagnosed early and take antiretroviral therapy to control their HIV infection (PLHIV-c) can live long, healthy lives. Accordingly, we determined that PLHIV-c can likely expect the same safety and efficacy for systemic psoriasis treatments as the general population. Treatment decisions should be made on a case-by-case basis through consultation with the patient and treating physician(s). Pillars of modern medicine are evidence-based care and collaborative decision-making. Too often, neither care provider nor patient are adequately informed. We have tried to fill one information gap for PLHIV and psoriasis. This process may help answer questions in other disease populations where direct evidence is scarce or absent.
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Affiliation(s)
- Kim A Papp
- Probity Medical Research Inc., Waterloo, ON, Canada. .,K Papp Clinical Research, Waterloo, ON, Canada.
| | - Jennifer Beecker
- Probity Medical Research Inc., Waterloo, ON, Canada.,University of Ottawa, Ottawa, ON, Canada.,Division of Dermatology, The Ottawa Hospital, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Curtis Cooper
- University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital and Regional Hepatitis Program, Ottawa, ON, Canada
| | - Mark G Kirchhof
- University of Ottawa, Ottawa, ON, Canada.,Division of Dermatology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Anton L Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Jan P Dutz
- Skin Care Center, Vancouver, BC, Canada.,Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Melinda J Gooderham
- Probity Medical Research Inc., Waterloo, ON, Canada.,SKiN Centre for Dermatology, Peterborough, ON, Canada
| | - Robert Gniadecki
- Division of Dermatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Chih-Ho Hong
- Probity Medical Research Inc., Waterloo, ON, Canada.,Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada.,Dr. Chih-Ho Hong Medical Inc., Surrey, BC, Canada
| | - Charles W Lynde
- Probity Medical Research Inc., Waterloo, ON, Canada.,Lynde Institute for Dermatology, Markham, ON, Canada
| | | | - Yves Poulin
- Centre de Recherche Dermatologique du Québec Métropolitain, Quebec, QC, Canada
| | - Ronald B Vender
- Dermatrials Research Inc., Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sharon L Walmsley
- Toronto General Hospital Research Institute, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Department of Medicine, University Health Network, Toronto, ON, Canada
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10
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McClean AR, Trigg J, Ye M, McLinden T, Kooij KW, Bacani N, Hui C, Sereda P, Burchell AN, Walmsley SL, Kelly D, Machouf N, Montaner JSG, Loutfy M, Hogg RS. Neighbourhood-level material deprivation and response to combination antiretroviral therapy in the Canadian Observational Cohort (CANOC): a longitudinal cohort study. CMAJ Open 2022; 10:E183-E189. [PMID: 35292476 PMCID: PMC8929426 DOI: 10.9778/cmajo.20200249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Socioeconomic status has been associated with higher viral loads and lower CD4 cell counts among people living with HIV. The objective of this study was to evaluate the relation between neighbourhood-level material deprivation and immunologic and virologic response to combination antiretroviral therapy (ART) among people living with HIV in Canada. METHODS The Canadian Observational Cohort (CANOC) is a longitudinal cohort of people living with HIV, containing data from 2000-2016 from 5 Canadian provinces. We defined response to combination ART as positive if the CD4 cell count increased by 50 cells/mm3 (0.05 cells × 109/L) or more (CD4+) and viral load decreased to 50 copies/mL or less (VL+) within 6 months of treatment initiation. We further categorized response to therapy as concordant positive (CD4+/VL+), concordant negative (CD4-/VL-) or discordant (CD4+/VL- or CD4-/VL+). We used adjusted multinomial logistic regression to quantify the relation between neighbourhood-level material deprivation and immunologic and virologic response. RESULTS This study included 8274 people living with HIV, of which 1754 (21.2%) lived in the most materially deprived neighbourhoods. Most individuals (62.2%) showed a concordant positive response to combination ART. After adjustment, living in the most materially deprived neighbourhoods was associated with a CD4-/VL+ discordant response (adjusted odds ratio [OR] 1.31, 95% confidence interval [CI] 1.06-1.62) and a concordant negative response (adjusted OR 1.45, 95% CI 1.13-1.86), using a concordant positive response as the reference. No other deprivation quartile was independently associated with a particular response. INTERPRETATION People living with HIV from the most materially deprived neighbourhoods had increased odds of poor immunologic or virologic response to combination ART. These results motivate further study of the specific socioeconomic factors that potentially affect response to combination ART among people living with HIV in Canada.
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Affiliation(s)
- Alison R McClean
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont.
| | - Jason Trigg
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Monica Ye
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Taylor McLinden
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Katherine W Kooij
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Nicanor Bacani
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Christian Hui
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Paul Sereda
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Ann N Burchell
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Sharon L Walmsley
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Deborah Kelly
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Nimâ Machouf
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Mona Loutfy
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS (McClean, Trigg, Ye, McLinden, Kooij, Bacani, Sereda, Montaner, Hogg); Faculty of Medicine (McClean, Montaner), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Kooij, Hogg), Simon Fraser University, Burnaby, BC; Faculty of Arts (Hui), Ryerson University, Toronto Ont.; Canadian Institutes of Health Research Canadian HIV Trials Network (Hui, Walmsley), Vancouver, BC; Department of Family and Community Medicine (Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Burchell), Faculty of Health Sciences, University of Toronto; University Health Network (Walmsley), Toronto, Ont.; Faculty of Medicine and School of Pharmacy (Kelly), Memorial University of Newfoundland, St. John's, NL; Clinique de Médecine Urbaine du Quartier Latin (Machouf), Montréal, Que.; Division of Infectious Disease (Loutfy), Department of Medicine, University of Toronto; Women's College Hospital (Loutfy), Toronto, Ont
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11
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Malazogu F, Rousseau RK, Shivappa N, Huibner S, Walmsley SL, Kovacs CM, Benko E, Reinhard RJ, Rosenes R, Hebert JR, Kaul R. The Dietary Inflammatory Index Is Not Associated With Gut Permeability or Biomarkers of Systemic Inflammation in HIV Immunologic Non-responders. Front Nutr 2021; 8:736816. [PMID: 34881278 PMCID: PMC8646029 DOI: 10.3389/fnut.2021.736816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Abstract
Immunologic non-responders (INRs) are a subset of individuals living with HIV who have suboptimal blood CD4+ T cell recovery despite effective antiretroviral therapy (ART). They are at an increased risk of serious non-AIDS co-morbidities and death, and demonstrate enhanced systemic immune activation. In other populations diet has been correlated with markers of systemic inflammation through the Diet Inflammatory Index (DII), but this association has not been studied in persons living with HIV (PLWH). Blood was collected from 28 INR PLWH with a blood CD4+ T cell count <350/μL despite ≥2 years of effective ART. Participants completed a Canadian Diet History Questionnaire, and their responses were used to calculate the DII. Plasma inflammatory markers (IFNγ, TNF, IL-6, sVCAM, D-dimer, sCD14 and CRP) were assayed by ELISA, cellular immune activation (HLA-DR and CD38 on CD4+ and CD8+ T cells) was quantified using flow cytometry, and small bowel permeability assessed by calculation of the urine LacMan ratio after drinking a mix of lactulose and mannitol. Participants were a median age of 57 years, had been on effective ART for 15 years, and the median DII was -1.91 (range of -3.78 to +2.23). No correlation was observed between DII and plasma markers of inflammation, levels of T cell activation, gut permeability, or the biomarker of bacterial translocation sCD14. Self-reported alcohol intake, a potential confounder of the relationship between diet and inflammatory biomarkers, was also not associated with systemic inflammation or gut permeability. Our findings suggest that other mechanisms, rather than diet, are likely to be the major driver of systemic inflammation in INR individuals.
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Affiliation(s)
- Fat Malazogu
- Departments of Medicine and Immunology, University of Toronto, Toronto, ON, Canada
| | - Rodney K Rousseau
- Departments of Medicine and Immunology, University of Toronto, Toronto, ON, Canada
| | - Nitin Shivappa
- Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, United States.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States.,Department of Nutrition, Connecting Health Innovations Limited Liability Corporation (LLC), Columbia, SC, United States
| | - Sanja Huibner
- Departments of Medicine and Immunology, University of Toronto, Toronto, ON, Canada
| | - Sharon L Walmsley
- Departments of Medicine and Immunology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Colin M Kovacs
- Departments of Medicine and Immunology, University of Toronto, Toronto, ON, Canada.,Maple Leaf Medical Clinic, Toronto, ON, Canada
| | - Erika Benko
- Maple Leaf Medical Clinic, Toronto, ON, Canada
| | | | | | - James R Hebert
- Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, United States.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States.,Department of Nutrition, Connecting Health Innovations Limited Liability Corporation (LLC), Columbia, SC, United States
| | - Rupert Kaul
- Departments of Medicine and Immunology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University Health Network, Toronto, ON, Canada
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12
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Rousseau RK, Walmsley SL, Lee T, Rosenes R, Reinhard RJ, Malazogu F, Benko E, Huibner S, Kovacs CM, Singer J, Kim CJ, Kaul R. A randomized, blinded, placebo-controlled trial of De Simone formulation probiotic during HIV-associated suboptimal CD4+ T cell recovery. J Acquir Immune Defic Syndr 2021; 89:199-207. [PMID: 34693932 DOI: 10.1097/qai.0000000000002840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether probiotic supplementation may reduce disease-linked systemic immune activation in people living with HIV with the immunologic non-responder (INR) phenotype. DESIGN Phase 2b, randomized, double-blind, placebo-controlled pilot trial. METHODS HIV-positive individuals with blood CD4+ T cell counts <350/mm3 despite viral suppression were randomized 2:1 to receive De Simone Formulation Probiotic (DSFP; "Visbiome" commercially) or placebo for 48 weeks; target enrolment was 36 patients. The primary endpoint was change in blood CD8+ T cell co-expression of HLA-DR and CD38 ("CD8 activation"). Secondary endpoints included biomarkers of inflammation, immune reconstitution, bacterial translocation, and gut permeability. Adjusted linear regression and linear mixed methods regression evaluated the differences between study arms from baseline to week 48. Study monitoring was done by the CIHR Canadian HIV Trials Network Data Safety Monitoring Committee. RESULTS Nineteen patients received DSFP, while 10 received placebo. One probiotic-arm patient withdrew early. Blood CD8 activation increased 0.82 percentage points (pp) in the probiotic arm (95% confidence interval [CI];-1.23,2.87;) and decreased by 2.06pp in the placebo arm (-4.81,0.70; between arms p=0.097). CD4+ T cell activation (%HLA-DR+) decreased in the placebo arm (-3.79pp [-7.32,-0.26]) but increased in the probiotic arm (1.64 [-0.98,4.26]; between arms p=0.018). No differences were observed in plasma or urine biomarkers of inflammation or microbial translocation. CONCLUSIONS Blood immune activation markers in INR individuals on effective ART were not reduced by supplementation with DSFP; CD4+ T cell activation may have been increased.
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Affiliation(s)
- Rodney K Rousseau
- University of Toronto, Departments of Immunology, Medicine, and Internal Medicine, Toronto, Canada University Health Network, Toronto General Hospital Immunodeficiency Clinic, Toronto, Canada Toronto General Hospital Research Institute, Toronto, Canada CIHR Canadian HIV Trials Network, Vancouver, Canada Centre for Health Evaluation & Outcomes Sciences, Vancouver, Canada Community Health Advocate and Consultant (Independent), Toronto, Canada Public/Global Health Consultant (Independent), San Francisco, USA Maple Leaf Medical Clinic, Toronto, Canada
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13
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Zhabokritsky A, Szadkowski L, Burchell AN, Cooper C, Hogg RS, Hull M, Kelly DV, Klein M, Loutfy M, McClean A, Montaner J, Walmsley SL. Immunological and virological response to initial antiretroviral therapy among older people living with HIV in the Canadian Observational Cohort (CANOC). HIV Med 2021; 22:759-769. [PMID: 34075683 DOI: 10.1111/hiv.13125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The aim of this study was to assess the adequacy of immunological recovery and virological suppression in response to antiretroviral therapy (ART) in the growing population of older people living with HIV (PLWH), as treatment regimens become more effective and tolerable. METHODS An interprovincial Canadian cohort of treatment-naïve PLWH who initiated ART after 1 January 2000 was used and age assessed in decades. Longitudinal absolute CD4 count response to treatment was modelled using generalized estimating equations. Cumulative incidence functions and proportional hazards models with a competing risk of death were used to estimate time to: (1) CD4 ≥ 200 cells/µL, (2) CD4 ≥ 500 cells/µL, (3) virological suppression (≤ 50 copies/mL), and (4) virological failure (> 200 copies/mL). RESULTS In all, 12 489 individuals starting ART between 2000 and 2016 with one or more post-treatment CD4 count or viral load were included in the analysis. Age > 60 years was associated with lower absolute CD4 recovery (adjusted β = -31 cells/µL) compared with age ≤ 30 years when pre-treatment CD4 count and other covariates were accounted for. Older age groups were less likely to achieve a CD4 ≥ 500 cells/µL, with the greatest effect in the > 60 group [adjusted hazard ratio (aHR) = 0.69, 95% confidence interval (CI): 0.57-0.84 vs. age ≤ 30). Older age groups were more likely to achieve viral suppression (age > 60, aHR = 1.20, 95% CI: 1.05-1.37) and less likely to have virological failure (age > 60, aHR = 0.46, 95% CI: 0.3-0.71) compared with those aged ≤ 30 years. CONCLUSIONS Older adults have robust virological responses to ART; however, individuals over the age 60 are more likely to experience blunted CD4 recovery.
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Affiliation(s)
- A Zhabokritsky
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - L Szadkowski
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - A N Burchell
- Department of Family and Community Medicine and Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - C Cooper
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - R S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - M Hull
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - D V Kelly
- School of Pharmacy, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - M Klein
- McGill University Health Center, Montreal, QC, Canada
| | - M Loutfy
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - A McClean
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - J Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - S L Walmsley
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
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14
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Zhabokritsky A, Szadkowski L, Cooper C, Loutfy M, Wong A, McClean A, Hogg RS, Walmsley SL. Increased CD4 : CD8 ratio normalization with implementation of current ART management guidelines. J Antimicrob Chemother 2021; 76:729-737. [PMID: 33249444 PMCID: PMC7879150 DOI: 10.1093/jac/dkaa484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To determine the time to CD4 : CD8 ratio normalization among Canadian adults living with HIV in the modern ART era. To identify characteristics associated with ratio normalization. PATIENTS AND METHODS Retrospective analysis of the Canadian Observational Cohort (CANOC), an interprovincial cohort of ART-naive adults living with HIV, recruited from 11 treatment centres across Canada. We studied participants initiating ART between 1 January 2011 and 31 December 2016 with baseline CD4 : CD8 ratio <1.0 and ≥2 follow-up measurements. Normalization was defined as two consecutive CD4 : CD8 ratios ≥1.0. Kaplan-Meier estimates and log-rank tests described time to normalization. Univariable and multivariable proportional hazards (PH) models identified factors associated with ratio normalization. RESULTS Among 3218 participants, 909 (28%) normalized during a median 2.6 years of follow-up. Participants with higher baseline CD4+ T-cell count were more likely to achieve normalization; the probability of normalization by 5 years was 0.68 (95% CI 0.62-0.74) for those with baseline CD4+ T-cell count >500 cells/mm3 compared with 0.16 (95% CI 0.11-0.21) for those with ≤200 cells/mm3 (P < 0.0001). In a multivariable PH model, baseline CD4+ T-cell count was associated with a higher likelihood of achieving ratio normalization (adjusted HR = 1.5, 95% CI 1.5-1.6 per 100 cells/mm3, P < 0.0001). After adjusting for baseline characteristics, time-dependent ART class was not associated with ratio normalization. CONCLUSIONS Early ART initiation, at higher baseline CD4+ T-cell counts, has the greatest impact on CD4 : CD8 ratio normalization. Our study supports current treatment guidelines recommending immediate ART start, with no difference in ratio normalization observed based on ART class used.
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Affiliation(s)
- Alice Zhabokritsky
- Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Leah Szadkowski
- Department of Medicine, University Health Network, Toronto, Canada
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Curtis Cooper
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mona Loutfy
- Department of Medicine, University of Toronto, Toronto, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Canada
| | - Alexander Wong
- Department of Medicine, University of Saskatchewan, Regina, Canada
| | - Alison McClean
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Sharon L Walmsley
- Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
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15
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Yampolsky M, Shlakhter O, Deng D, Kala S, Walmsley SL, Murphy KE, Yudin MH, MacGillivray J, Loutfy M, Dunk C, Serghides L. Exploring the impact of HIV infection and antiretroviral therapy on placenta morphology. Placenta 2020; 104:102-109. [PMID: 33310298 DOI: 10.1016/j.placenta.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/05/2020] [Accepted: 12/03/2020] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Women living with HIV experience more adverse birth outcomes; the mechanisms are not fully understood. We examined placenta morphology and associations with birth outcomes in a Canadian cohort of women living with HIV (HIV+) on antiretroviral therapy (ART) from conception and HIV-uninfected (HIV-) women. METHODS Term placentas from 94 women (40 HIV-, 54 HIV+) were studied. Trimmed placenta weight was collected. Placenta digital photos were used to compute morphometric parameters. Regression models investigated associations between log-transformed placenta parameters and birth outcomes. RESULTS We observed a trend towards lower placenta weight and smaller placenta area in the HIV+ group, both of which were significantly associated with small for gestational age births. HIV+ serostatus was associated with 6-fold (95%CI 2-20) greater odds of having placenta area in the lowest quartile (<236 cm2). Cord marginality (distance from the edge) was significantly lower in the HIV+ group (p = 0.004), with 35% of placenta having an abnormal (marginal or velamentous) cord insertion vs. 12.5% in the HIV- group (p = 0.01). Velamentous cord insertion was seen in 13% of placentas in the HIV+ vs. 0% in HIV- group (p = 0.02). A significant correlation between cord marginality and placenta thickness was observed in the HIV- group, with a more marginal cord being associated with a thicker placenta. This correlation was not observed in the HIV+ group. HIV+ placentas exposed to protease inhibitors were significantly less circular compared to the HIV- group (p = 0.03). CONCLUSION Our data suggest that HIV/ART exposure affects placenta morphology and is associated with higher rates of abnormal cord insertion.
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Affiliation(s)
| | | | - Dianna Deng
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Smriti Kala
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Sharon L Walmsley
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Kellie E Murphy
- Department of Obstetrics and Gynaecology, Sinai Health System, University of Toronto, Toronto, Canada
| | - Mark H Yudin
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Jay MacGillivray
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Canada; Ryerson University, Toronto, Canada
| | - Mona Loutfy
- Department of Medicine, University of Toronto, Toronto, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Caroline Dunk
- Research Centre for Women's and Infants' Health, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Sinai Health System, Toronto, Canada
| | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Canada; Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Canada.
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16
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Wright JK, Tan DHS, Walmsley SL, Hulme J, O’Connor E, Snider C, Cheng I, Chan AK, Borgundvaag B, McLeod S, Gollob MH, Clarke RJ, Dresser L, Haji F, Mazzulli T, Mubareka S, Jüni P, Lee D, Tomlinson G, Kain KC, Landes M. Protecting Frontline Health Care Workers from COVID-19 with Hydroxychloroquine Pre-exposure Prophylaxis: A structured summary of a study protocol for a randomised placebo-controlled multisite trial in Toronto, Canada. Trials 2020; 21:647. [PMID: 32665039 PMCID: PMC7359423 DOI: 10.1186/s13063-020-04577-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Primary Objective: To determine if pre-exposure prophylaxis (PrEP) with 400mg hydroxychloroquine (HCQ), taken orally once daily reduces microbiologically confirmed COVID-19 among front line health care workers at high risk for SARS-CoV-2 exposure. Secondary Objectives: To compare the following between study arms: adverse events; symptomatic COVID-19; duration of symptomatic COVID-19; days hospitalized attributed to COVID-19; respiratory failure attributable to COVID-19 requiring i) non-invasive ventilation or ii) intubation/mechanical ventilation; mortality attributed to COVID-19, number of days unable to work attributed to COVID-19, seroconversion (COVID-19 negative to COVID-19 positive over the study period); ability of participant plasma to neutralize SARS-CoV-2 virus in vitro; To describe short-term psychological distress associated with risk of COVID-19 exposure at 1, 60, 120 days of the study. To explore laboratory markers within participants with confirmed COVID-19: including circulating markers of host immune and endothelial activation in participant plasma and their correlation with disease severity and outcome TRIAL DESIGN: The HEROS study is a two-arm, parallel-group, individually randomized (1:1 allocation ratio), placebo controlled, participant and investigator-blinded, multi-site superiority trial of oral HCQ 400 mg taken once daily for 90 days as PrEP to prevent COVID-19 in health care workers at high risk of SARS-CoV-2 exposure. At 90 days, there is an open label extension wherein all participants are offered a one-month course of HCQ 400mg once daily for PrEP of COVID-19. PARTICIPANTS Frontline HCWs aged 18 years of age or older, at high risk of SARS-CoV-2 exposure (including staff of emergency departments, intensive care units, intubation teams, COVID-wards, and staff deployed to Long Term Care facilities) of five academic hospitals in downtown Toronto, Canada. Exclusion criteria include: currently pregnant, planning to become pregnant during the study period, and/or breast feeding; known hypersensitivity/allergy to hydroxychloroquine or to 4-aminoquinoline compounds; current use of hydroxychloroquine; known prolonged QT syndrome and/or baseline resting ECG with QTc>450 ms and/or concomitant medications which simultaneously may prolong the QTc that cannot be temporarily suspended/replaced; known pre-existing retinopathy, G6PD deficiency, porphyria, liver disease including cirrhosis, encephalopathy, hepatitis or alcoholism, diabetes on oral hypoglycemics or insulin, or renal insufficiency/failure; disclosure of self-administered use of hydroxychloroquine or chloroquine within 12 weeks prior to study; confirmed symptomatic COVID-19 at time of enrollment. INTERVENTION AND COMPARATOR Intervention: hydroxychloroquine, 400mg (2 tablets) orally per day. Comparator: placebo, two tablets visually identical to the intervention, orally per day MAIN OUTCOMES: The primary outcome is microbiologically confirmed COVID-19 (i.e. SARS-CoV-2 infection). This is a composite endpoint which includes positive results from any validated SARS-CoV-2 diagnostic assay including detection of viral RNA, and/or seroconversion. Participants will be assessed at baseline, and then undergo monthly follow-up at day 30, 60, and 90, 120. At each visit, participants will provide an oropharyngeal sample, blood sample, and will undergo electrocardiogram monitoring of the QTc interval. Secondary outcome measures include: adverse events; symptom duration of COVID-19; days of hospitalization attributed to COVID-19; respiratory failure requiring ventilator support attributed to COVID-19; mortality attributed to COVID-19; total days off work attributed to COVID-19; seropositivity (reactive serology by day 120); and short term psychological impact of exposure to SARS-CoV-2 at day 1, 60, 120 days using the K10, a validated measure of non-specific psychological distress. RANDOMISATION Within each site, participants will be individually randomized to either the intervention arm with HCQ or the placebo arm using a fixed 1:1 allocation ratio using an interactive web-based response system to ensure concealment of allocation. Randomization schedules will be computer-generated and blocked using variable block sizes. BLINDING (MASKING) All participants, research coordinators, technicians, clinicians and investigators will be blinded to the participant allocation group. Numbers to be randomised (sample size) N=988, randomised into two groups of 494 patients. TRIAL STATUS This summary describes protocol version No. 1.6, May 15, 2020. Recruitment is ongoing - started April 20, 2020 and anticipated end date is July 30, 2021 TRIAL REGISTRATION: ISRCTN.com Identifier: ISRCTN14326006, registered April 14, 2020. FULL PROTOCOL The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).
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Affiliation(s)
- Julie K. Wright
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Eliot Phillipson Clinician Scientist Training Program, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario Canada
- Division of Infectious Diseases, Department of Medicine, University Health Network/Sinai Health System, Toronto, Ontario Canada
- Sandra Rotman Laboratories, Sandra Rotman Centre for Global Health, UHN-Toronto General Hospital, Toronto, Ontario Canada
| | - Darrell H. S. Tan
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- Division of Infectious Diseases, Department of Medicine, St. Michael’s Hospital, Toronto, Ontario Canada
- MAP Centre for Urban Health Solutions, St Michaels Hospital, Toronto, Ontario Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario Canada
| | - Sharon L. Walmsley
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- Immunodeficiency Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario Canada
| | - Jennifer Hulme
- Divisions of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario Canada
- Emergency Department, University Health Network, Toronto, Ontario Canada
| | - Erin O’Connor
- Emergency Department, University Health Network, Toronto, Ontario Canada
- Divisions of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Carolyn Snider
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario Canada
- Divisions of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Emergency Department, St. Michael’s Hospital, Toronto, Ontario Canada
| | - Ivy Cheng
- Divisions of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Emergency Department, Sunnybrook Health Sciences Centre, Toronto, Ontario Canada
| | - Adrienne K. Chan
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario Canada
| | - Bjug Borgundvaag
- Divisions of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario Canada
| | - Shelley McLeod
- Divisions of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario Canada
| | - Michael H. Gollob
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario Canada
| | - Rosemarie J. Clarke
- Immunodeficiency Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario Canada
| | - Linda Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario Canada
- Antimicrobial Stewardship Program, Sinai Health System/University Health Network, Toronto, Ontario Canada
| | - Fatima Haji
- Investigational Pharmacy Services, University Health Network, Toronto, Ontario Canada
| | - Tony Mazzulli
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario Canada
- Division of Infectious Diseases, Department of Medicine, University Health Network/Sinai Health System, Toronto, Ontario Canada
- Department of Microbiology, University Health Network / Sinai Health System, Toronto, Ontario Canada
| | - Samira Mubareka
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario Canada
| | - Peter Jüni
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Applied Health Research Centre (AHRC), St. Michael’s Hospital, Toronto, Ontario Canada
| | - Dominic Lee
- Applied Health Research Centre (AHRC), St. Michael’s Hospital, Toronto, Ontario Canada
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- Department of Medicine, University Health Network, Toronto, Ontario Canada
| | - Kevin C. Kain
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario Canada
- Division of Infectious Diseases, Department of Medicine, University Health Network/Sinai Health System, Toronto, Ontario Canada
- Sandra Rotman Laboratories, Sandra Rotman Centre for Global Health, UHN-Toronto General Hospital, Toronto, Ontario Canada
| | - Megan Landes
- Divisions of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario Canada
- Emergency Department, University Health Network, Toronto, Ontario Canada
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17
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Tan DHS, Raboud JM, Szadkowski L, Grinsztejn B, Madruga JV, Figueroa MI, Cahn P, Barton SE, Clarke A, Fox J, Zubyk W, Walmsley SL. Effect of valaciclovir on CD4 count decline in untreated HIV: an international randomized controlled trial. J Antimicrob Chemother 2020; 74:480-488. [PMID: 30376108 PMCID: PMC6337901 DOI: 10.1093/jac/dky433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/26/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives To determine the impact of valaciclovir on HIV disease progression in treatment-naive HIV-positive adults. Methods In this fully blind, multicentre, 1:1 randomized placebo-controlled trial, treatment-naive HIV-1-positive adults with CD4 counts 400–900 cells/mm3 and not meeting contemporaneous recommendations for combination ART (cART) were randomized to valaciclovir 500 mg or placebo twice daily, and followed quarterly until having two consecutive CD4 counts ≤350 cells/mm3 or initiating cART for any reason. The primary analysis compared the rate of CD4 count decline by study arm after adjusting for baseline CD4 count and viral load (VL). Secondary analyses compared the rate of CD4 percentage decline, HIV VL, herpes simplex virus (HSV) recurrences and drug-related adverse events. The trial closed after release of the START trial results in August 2015. Results We enrolled 198 participants in Canada, Brazil, Argentina and the UK. Median (IQR) age was 35 (30–43) years. Baseline CD4 count was 592 (491–694) cells/mm3 and VL was 4.04 (3.5–4.5) log10 copies/mL. Over 276 person-years of follow-up, CD4 counts declined by 49 cells/mm3/year in the valaciclovir arm versus 58 cells/mm3/year in the placebo arm (P = 0.65). No differences were seen in the rate of change in CD4 percentage (−1.2%/year versus −1.7%/year, P = 0.34). VL was 0.27 log10 copies/mL lower in valaciclovir participants overall (P<0.001). Placebo participants had more HSV recurrences (62 versus 21/100 person-years, P < 0.0001) but similar rates of grade ≥2 drug-related adverse events. Conclusions Unlike prior trials using aciclovir, we found that valaciclovir did not slow CD4 count decline in cART-untreated adults, although power was limited due to premature study discontinuation. Valaciclovir modestly lowered HIV VL.
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Affiliation(s)
- Darrell H S Tan
- Division of Infectious Diseases, St. Michael's Hospital, Toronto, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Division of Infectious Diseases, University Health Network, Toronto, Canada
| | - Janet M Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Toronto General Research Institute, Toronto, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Beatriz Grinsztejn
- Instituto de Pesquisa Clínica Evandro Chagas (IPEC), Fundaçao Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | - Pedro Cahn
- Fundación Huesped, Buenos Aires, Argentina
| | | | - Amanda Clarke
- Brighton & Sussex University Hospital NHS Trust, Brighton, UK
| | - Julie Fox
- Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Wendy Zubyk
- CIHR Canadian HIV Trials Network, Vancouver, Canada
| | - Sharon L Walmsley
- Department of Medicine, University of Toronto, Toronto, Canada.,Division of Infectious Diseases, University Health Network, Toronto, Canada.,Toronto General Research Institute, Toronto, Canada.,CIHR Canadian HIV Trials Network, Vancouver, Canada
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18
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Eaton AD, Walmsley SL, Craig SL, Rourke SB, Sota T, McCullagh JW, Fallon BA. Protocol for a pilot randomised controlled trial evaluating feasibility and acceptability of cognitive remediation group therapy compared with mutual aid group therapy for people ageing with HIV-associated neurocognitive disorder (HAND) in Toronto, Canada. BMJ Open 2019; 9:e033183. [PMID: 31676660 PMCID: PMC6830703 DOI: 10.1136/bmjopen-2019-033183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION HIV-associated neurocognitive disorder (HAND) may affect 30%-50% of people ageing with HIV. HAND may increase stress and anxiety, and impede coping. Psychosocial group therapy may ameliorate HAND's symptoms, yet the ideal intervention is unclear. This protocol outlines a pilot randomised controlled trial (RCT)-designed using community-based participatory research-to pilot cognitive remediation group therapy (CRGT) against an active comparator. METHODS AND ANALYSIS This is a pilot, parallel design, two-arm RCT that will recruit participants diagnosed with the mild neurocognitive disorder form of HAND from a neurobehavioural research unit at a tertiary care hospital in Toronto, Canada. Eligibility criteria include age ≥40 years, known HIV status for 5+ years, English fluency, able to consent and able to attend 8 weeks of group therapy. Eligible participants will be randomised to one of two treatment arms, each consisting of eight-session group interventions delivered once weekly at 3 hours per session. Arm 1 (novel) is CRGT, combining mindfulness-based stress reduction with brain training activities. Arm 2 (active control) is mutual aid group therapy. The primary outcomes are feasibility, measured by proportions of recruitment and completion, and acceptability, determined by a satisfaction questionnaire. The secondary outcome is intervention fidelity, where content analysis will be used to assess facilitator session reports. A between-group analysis will be conducted on exploratory outcomes of stress, anxiety, coping and use of intervention activities that will be collected at three time points. ETHICS AND DISSEMINATION Ethical approval was obtained from the Research Ethics Boards of St. Michael's Hospital and the University of Toronto. Findings will be disseminated through peer-reviewed publications, conference presentations and community reporting. This study could provide insight into design (eg, recruitment, measures) and intervention considerations (eg, structure, content) for a larger trial to lessen the burden of cognitive decline among people ageing with HIV. TRIAL REGISTRATION NUMBER NCT03483740; Pre-results.
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Affiliation(s)
- Andrew David Eaton
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Sharon L Walmsley
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Shelley L Craig
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Sean B Rourke
- Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Teresa Sota
- Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Barbara A Fallon
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
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19
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Balogun KA, Guzman Lenis MS, Papp E, Loutfy M, Yudin MH, MacGillivray J, Walmsley SL, Silverman M, Serghides L. Elevated Levels of Estradiol in Human Immunodeficiency Virus-Infected Pregnant Women on Protease Inhibitor-Based Regimens. Clin Infect Dis 2019; 66:420-427. [PMID: 29020282 DOI: 10.1093/cid/cix761] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/21/2017] [Indexed: 01/30/2023] Open
Abstract
Background Human immunodeficiency virus (HIV)-infected pregnant women on protease inhibitor (PI)-based combination antiretroviral therapy (cART) have a greater risk for adverse birth outcomes, and an association with steroid hormone levels has been implicated. The objective of this study was to investigate the association between PI-cART and estradiol levels in pregnancy. Methods Fifty-five HIV-infected and 49 HIV-uninfected Canadian pregnant women were followed prospectively throughout gestation. All HIV-infected women were on a PI-based cART regimen. Maternal plasma samples were collected at 12-18 weeks, 24-28 weeks, 34-38 weeks, at delivery, and from the cord. Birth outcomes were recorded. Levels of estradiol, dehydroepiandrosterone sulfate (DHEAS), sex hormone-binding globulin (SHBG), cortisol, and adrenocorticotropic hormone (ACTH) were quantified by enzyme-linked immunosorbent assay. Results (median [interquartile range] for cord estradiol: 23.9 ng/mL [16.4-36.4] for HIV-infected exposed to PI-cART and 15.7 ng/mL [12.2-21.2] for HIV-negative; P = .0025). HIV-infected women had higher DHEAS levels in cord plasma that correlated with cord and maternal delivery estradiol levels. Cortisol and ACTH levels did not differ between groups. In the HIV-infected women, cord estradiol levels correlated negatively with birth weight centile (r = -0.47, P = .0016). Conclusions Our data suggest that PI-cART exposure in pregnancy is associated with elevated levels of estradiol, likely driven by higher fetal DHEAS production. Cord estradiol levels were inversely correlated with birth weight centile in infants born to PI-cART-exposed women, suggesting that fetal exposure to high estradiol levels may be contributing to cART-associated fetal growth restriction.
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Affiliation(s)
- Kayode A Balogun
- Toronto General Research Institute, University Health Network, Canada
| | | | - Eszter Papp
- Toronto General Research Institute, University Health Network, Canada
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, Canada.,Department of Medicine, University of Toronto, Canada.,St Michael's Hospital, Canada
| | - Mark H Yudin
- Department of Medicine, University of Toronto, Canada.,St Michael's Hospital, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Canada
| | | | - Sharon L Walmsley
- Toronto General Research Institute, University Health Network, Canada.,Department of Medicine, University of Toronto, Canada
| | | | - Lena Serghides
- Toronto General Research Institute, University Health Network, Canada.,Women's College Research Institute, Women's College Hospital, Canada.,Department of Immunology and Institute of Medical Sciences, University of Toronto, Canada
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20
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Tan DHS, Rolon MJ, Figueroa MI, Sued O, Gun A, Kaul R, Raboud JM, Szadkowski L, Hull MW, Walmsley SL, Cahn P. Inflammatory biomarker levels over 48 weeks with dual vs triple lopinavir/ritonavir-based therapy: Substudy of a randomized trial. PLoS One 2019; 14:e0221653. [PMID: 31490959 PMCID: PMC6730918 DOI: 10.1371/journal.pone.0221653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background Inflammation has been associated with increased morbidity and mortality in HIV-positive patients. We compared inflammatory biomarkers with dual therapy using lopinavir/ritonavir plus lamivudine (LPV/r+3TC) versus triple therapy using LPV/r plus two nucleoside reverse transcriptase inhibitors (LPV/r+2NRTIs) in treatment-naïve HIV-positive adults. Methods This was a substudy among Argentinian participants in the randomized trial GARDEL. We measured hsCRP, IL-6, MCP-1, TNF, D-dimer and sCD14 from plasma collected at baseline, week 24 and week 48. Generalized estimating equations with an identity/logit link were used to model the average impact of dual versus triple therapy on each biomarker over time, controlling for baseline levels. Additional models estimated the average effect of virologic suppression on biomarker levels over time, adjusting for age, sex, and baseline CD4 count. Results Of 191 trial participants enrolled in Argentina, 172 had baseline and follow-up measurements and were included. Median (IQR) age was 35.5 (28.5, 45) years and CD4 cell count was 310 (219, 414) cells/mm3. Dual therapy was not associated with significantly different biomarker levels over 48 weeks relative to triple therapy. Virologic suppression was associated with statistically significant decreases in MCP-1, TNF and D-dimer levels and an unexpected increase in sCD14 levels. No change was observed in hsCRP or the proportion of participants with undetectable IL-6 levels. Conclusions In addition to having virologic non-inferiority, LPV/r+3TC dual therapy is generally associated with similar inflammatory biomarker levels over 48 weeks compared to LPV/r+2NRTIs triple therapy in treatment-naïve adults. Further study of dual treatment regimens is warranted.
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Affiliation(s)
- Darrell H. S. Tan
- St. Michael’s Hospital Division of Infectious Diseases, Toronto, ON, Canada
- University Health Network Division of Infectious Diseases, Toronto, ON, Canada
- University of Toronto Department of Medicine, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- * E-mail:
| | - Maria Jose Rolon
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Maria Ines Figueroa
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Omar Sued
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Ana Gun
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Rupert Kaul
- University Health Network Division of Infectious Diseases, Toronto, ON, Canada
- University of Toronto Department of Medicine, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Department of Immunology, Toronto, ON, Canada
| | - Janet M. Raboud
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Leah Szadkowski
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | | | - Sharon L. Walmsley
- University Health Network Division of Infectious Diseases, Toronto, ON, Canada
- University of Toronto Department of Medicine, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Pedro Cahn
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
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21
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Tseng AL, Wong AY, McLelland CJ, Walmsley SL. Drug interactions are not always predictable: the curious case of valproic acid and dolutegravir and a possible explanation. AIDS 2019; 33:1677-1679. [PMID: 31305336 DOI: 10.1097/qad.0000000000002256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Moayedi Y, Walmsley SL. Heart Failure With Preserved Ejection Fraction in Women Living With HIV: Another Inflammatory Comorbidity? J Infect Dis 2019; 221:1219-1222. [DOI: 10.1093/infdis/jiz185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 01/14/2023] Open
Affiliation(s)
- Yasbanoo Moayedi
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, University of Toronto
- Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support Group, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, California
| | - Sharon L Walmsley
- Division of Infectious Diseases, Department of Medicine, Toronto, Canada, University Health Network, University of Toronto, Canada
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23
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McLinden T, Moodie EEM, Hamelin AM, Harper S, Walmsley SL, Paradis G, Aibibula W, Klein MB, Cox J. Injection Drug Use, Unemployment, and Severe Food Insecurity Among HIV-HCV Co-Infected Individuals: A Mediation Analysis. AIDS Behav 2017; 21:3496-3505. [PMID: 28726043 DOI: 10.1007/s10461-017-1850-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Severe food insecurity (FI), which indicates reduced food intake, is common among HIV-hepatitis C virus (HCV) co-infected individuals. Given the importance of unemployment as a proximal risk factor for FI, this mediation analysis examines a potential mechanism through which injection drug use (IDU) is associated with severe FI. We used biannual data from the Canadian Co-infection Cohort (N = 429 with 3 study visits, 2012-2015). IDU in the past 6 months (exposure) and current unemployment (mediator) were self-reported. Severe FI in the following 6 months (outcome) was measured using the Household Food Security Survey Module. An overall association and a controlled direct effect were estimated using marginal structural models. Among participants, 32% engaged in IDU, 78% were unemployed, and 29% experienced severe FI. After adjustment for confounding and addressing censoring through weighting, the overall association (through all potential pathways) between IDU and severe FI was: risk ratio (RR) = 1.69 (95% confidence interval [CI] = 1.15-2.48). The controlled direct effect (the association through all potential pathways except that of unemployment) was: RR = 1.65 (95% CI = 1.08-2.53). We found evidence of an overall association between IDU and severe FI and estimated a controlled direct effect that is suggestive of pathways from IDU to severe FI that are not mediated by unemployment. Specifically, an overall association and a controlled direct effect that are similar in magnitude suggests that the potential impact of IDU on unemployment is not the primary mechanism through which IDU is associated with severe FI. Therefore, while further research is required to understand the mechanisms linking IDU and severe FI, the strong overall association suggests that reductions in IDU may mitigate severe FI in this vulnerable subset of the HIV-positive population.
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24
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Cahn P, Kaplan R, Sax PE, Squires K, Molina JM, Avihingsanon A, Ratanasuwan W, Rojas E, Rassool M, Bloch M, Vandekerckhove L, Ruane P, Yazdanpanah Y, Katlama C, Xu X, Rodgers A, East L, Wenning L, Rawlins S, Homony B, Sklar P, Nguyen BY, Leavitt R, Teppler H, Cahn PE, Cassetti I, Losso M, Bloch MT, Roth N, McMahon J, Moore RJ, Smith D, Clumeck N, Vanderkerckhove L, Vandercam B, Moutschen M, Baril J, Conway B, Smaill F, Smith GHR, Rachlis A, Walmsley SL, Perez C, Wolff M, Lasso MF, Chahin CE, Velez JD, Sussmann O, Reynes J, Katlama C, Yazdanpanah Y, Ferret S, Durant J, Duvivier C, Poizot-Martin I, Ajana F, Rockstroh JK, Faetkanheuer G, Esser S, Jaeger H, Degen O, Bickel M, Bogner J, Arasteh K, Hartl H, Stoehr A, Rojas EM, Arathoon E, Gonzalez LD, Mejia CR, Shahar E, Turner D, Levy I, Sthoeger Z, Elinav H, Gori A, Monforte AD, Di Perri G, Lazzarin A, Rizzardini G, Antinori A, Celesia BM, Maggiolo F, Chow TS, Lee CKC, Azwa RISR, Mustafa M, Oyanguren M, Castillo RA, Hercilla L, Echiverri C, Maltez F, da Cunha JGS, Neves I, Teofilo E, Serrao R, Nagimova F, Khaertynova I, Orlova-Morozova E, Voronin E, Sotnikov V, Yakovlev AA, Zakharova NG, Tsybakova OA, Botes ME, Mohapi L, Kaplan R, Rassool MS, Arribas JR, Gatell JM, Negredo E, Ortega E, Troya J, Berenguer J, Aguirrebengoa K, Antela A, Calmy A, Cavassini M, Rauch A, Stoeckle M, Sheng WH, Lin HH, Tsai HC, Changpradub D, Avihingsanon A, Kiertiburanakul S, Ratanasuwan W, Nelson MR, Clarke A, Ustianowski A, Winston A, Johnson MA, Asmuth DM, Cade J, Gallant JE, Ruane PJ, Kumar PN, Luque AE, Panther L, Tashima KT, Ward D, Berger DS, Dietz CA, Fichtenbaum C, Gupta S, Mullane KM, Novak RM, Sweet DE, Crofoot GE, Hagins DP, Lewis ST, McDonald CK, DeJesus E, Sloan L, Prelutsky DJ, Rondon JC, Henn S, Scarsella AJ, Morales JO, Ramirez, Santiago L, Zorrilla CD, Saag MS, Hsiao CB. Raltegravir 1200 mg once daily versus raltegravir 400 mg twice daily, with tenofovir disoproxil fumarate and emtricitabine, for previously untreated HIV-1 infection: a randomised, double-blind, parallel-group, phase 3, non-inferiority trial. The Lancet HIV 2017; 4:e486-e494. [DOI: 10.1016/s2352-3018(17)30128-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/22/2017] [Accepted: 06/23/2017] [Indexed: 12/20/2022]
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25
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Siou K, Walmsley SL, Murphy KE, Raboud J, Loutfy M, Yudin MH, Silverman M, Ladhani NN, Papp E, Serghides L. Erratum to: Progesterone supplementation for HIV-positive pregnant women on protease inhibitor-based antiretroviral regimens (the ProSPAR study): a study protocol for a pilot randomized controlled trial. Pilot Feasibility Stud 2017; 3:21. [PMID: 28461906 PMCID: PMC5410045 DOI: 10.1186/s40814-017-0135-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
[This corrects the article DOI: 10.1186/s40814-016-0087-6.].
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Affiliation(s)
- Kaitlin Siou
- Toronto General Research Institute, Toronto, Canada
| | - Sharon L Walmsley
- Toronto General Hospital, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Kellie E Murphy
- Mount Sinai Hospital, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Janet Raboud
- Toronto General Research Institute, Toronto, Canada
| | - Mona Loutfy
- Maple Leaf Medical Clinic, Toronto, Canada.,Women's College Research Institute, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Mark H Yudin
- St. Michael's Hospital, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Michael Silverman
- St. Joseph's Health Care London, London, Canada.,University of Western Ontario, London, Canada
| | - Noor N Ladhani
- Sunnybrook Health Sciences Centre, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Eszter Papp
- Toronto General Research Institute, Toronto, Canada
| | - Lena Serghides
- Toronto General Research Institute, Toronto, Canada.,University of Toronto, Toronto, Canada.,Women's College Research Institute, Toronto, Canada
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26
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Squires KE, Young B, Santiago L, Dretler RH, Walmsley SL, Zhao HH, Pakes GE, Ross LL, Shaefer MS. Response by gender of HIV-1-infected subjects treated with abacavir/lamivudine plus atazanavir, with or without ritonavir, for 144 weeks. HIV AIDS (Auckl) 2017; 9:51-61. [PMID: 28424561 PMCID: PMC5344433 DOI: 10.2147/hiv.s108756] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Purpose The 144-week results of the open-label, multicenter Atazanavir/Ritonavir Induction with Epzicom Study (ARIES) were stratified by gender to compare treatment responses. Methods A total of 369 HIV-infected, antiretroviral-naïve subjects receiving once-daily abacavir/lamivudine + atazanavir/ritonavir (ATV/r) whose HIV-1 RNA was <50 copies/mL by week 30 were randomized 1:1 at week 36 to maintain or discontinue ritonavir for 108 subsequent weeks. Between- and within-treatment gender-related efficacy and safety differences were analyzed. Results Subjects were 85% male; 64% white; and had a mean age of 39 years, baseline median HIV-1 RNA of 114,815 copies/mL, and median CD4+ cell count of 198 cells/mm3. Gender (ATV [n=189]: 29 females/160 males; ATV/r [n=180]: 25 females/155 males) and most other demographics were similar between groups; more females than males were black (65% vs 25%) and fewer females had baseline HIV-1 RNA ≥100,000 copies/mL (41% vs 58%). At week 144, no significant differences between genders were observed in proportion maintaining HIV-1 RNA <50 copies/mL (ATV, 79% vs 77%; ATV/r, 60% vs 75%) or <400 copies/mL (ATV, 83% vs 84%; ATV/r, 68% vs 82%) (intent-to-treat-exposed: time to loss of virologic response analysis); median CD4+ change from baseline (ATV, +365 vs +300 cells/mm3; ATV/r, +344 vs +301 cells/mm3); proportion with treatment-related grade 2–4 adverse events (baseline to week 144: ATV, 41% vs 31%; ATV/r, 36% vs 43%; weeks 36 to 144: ATV, 14% vs 13%; ATV/r, 24% vs 23%); or proportion developing fasting lipid changes. Female and male virologic failure rates (ATV, 0 vs 5; ATV/r, 2 vs 4) and proportions completing the study were similar during the extension phase. Primary withdrawal reasons were loss to follow-up and pregnancy for females and loss to follow-up and other for males. Conclusion Over 144 weeks, no significant gender differences were observed in efficacy, safety, or fasting lipid changes with abacavir/lamivudine +ATV or abacavir/lamivudine +ATV/r.
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Affiliation(s)
| | - Benjamin Young
- Apex Family Medicine and Research, Denver, CO.,International Association of Physicians in AIDS Care, Washington DC, USA
| | | | | | | | | | - Gary E Pakes
- ViiV Healthcare, Research Triangle Park, NC, USA
| | - Lisa L Ross
- ViiV Healthcare, Research Triangle Park, NC, USA
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27
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Cox J, Hamelin AM, McLinden T, Moodie EEM, Anema A, Rollet-Kurhajec KC, Paradis G, Rourke SB, Walmsley SL, Klein MB. Food Insecurity in HIV-Hepatitis C Virus Co-infected Individuals in Canada: The Importance of Co-morbidities. AIDS Behav 2017; 21:792-802. [PMID: 26912217 PMCID: PMC5306219 DOI: 10.1007/s10461-016-1326-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While research has begun addressing food insecurity (FI) in HIV-positive populations, knowledge regarding FI among individuals living with HIV-hepatitis C virus (HCV) co-infection is limited. This exploratory study examines sociodemographic, socioeconomic, behavioral, and clinical factors associated with FI in a cohort of HIV-HCV co-infected individuals in Canada. We analyzed longitudinal data from the Food Security and HIV-HCV Co-infection Study of the Canadian Co-infection Cohort collected between November 2012-June 2014 at 15 health centres. FI was measured using the Household Food Security Survey Module and classified using Health Canada criteria. Generalized estimating equations were used to assess factors associated with FI. Among 525 participants, 59 % experienced FI at their first study visit (baseline). Protective factors associated with FI (p < 0.05) included: enrolment at a Quebec study site (aOR: 0.42, 95 % CI: 0.27, 0.67), employment (aOR: 0.55, 95 % CI: 0.35, 0.87), and average personal monthly income (aOR per $100 CAD increase: 0.98, 95 % CI: 0.97, 0.99). Risk factors for FI included: recent injection drug use (aOR: 1.98, 95 % CI: 1.33, 2.96), trading away food (aOR: 5.23, 95 % CI: 2.53, 10.81), and recent experiences of depressive symptoms (aOR: 2.11, 95 % CI: 1.48, 3.01). FI is common in this co-infected population. Engagement of co-infected individuals in substance use treatments, harm reduction programs, and mental health services may mitigate FI in this vulnerable subset of the HIV-positive population.
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Affiliation(s)
- Joseph Cox
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada.
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.
- CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.
| | - Anne-Marie Hamelin
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada
| | - Taylor McLinden
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada
| | - Erica E M Moodie
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada
| | - Aranka Anema
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | | | - Gilles Paradis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada
| | - Sean B Rourke
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- The Ontario HIV Treatment Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Sharon L Walmsley
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Marina B Klein
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada
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Tan DHS, Raboud J, Szadkowski L, Szabo E, Hu H, Wong Q, Cheung AM, Walmsley SL. Novel imaging modalities for the comparison of bone microarchitecture among HIV+ patients with and without fractures: a pilot study. HIV Clin Trials 2016; 18:28-38. [PMID: 27951753 DOI: 10.1080/15284336.2016.1266074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND HIV-infected adults have increased fracture risk. OBJECTIVES To generate pilot data comparing bone density, structure, and strength between HIV-infected adults with and without a prior fracture. METHODS Adults with and without a prior fracture after their HIV diagnosis were matched 1:1 based on age, sex, race, and smoking history. Participants underwent dual-energy X-ray absorptiometry (DXA), trabecular bone score (TBS), hip structural analyses (HSA), vertebral fracture assessment (VFA), high-resolution peripheral quantitative tomography (HR-pQCT) and measurement of bone turnover markers. Results were compared between cases and controls, with differences expressed as percentages of control group values. RESULTS 23 pairs were included. On DXA, cases had lower areal bone mineral density (aBMD) at the total hip (median difference in T-score -0.25, p = 0.04), but not the lumbar spine (median difference in T-score 0.10, p = 0.68). Cases had greater abnormalities in HSA and most HR-pQCT and HSA measures, by up to 15%. VFA revealed two subclinical fractures among cases but none among controls. TBS, CTX, and P1NP levels were similar between groups, with differences of 1.9% (p = 0.90), 9.7% (p = 0.55), and 10.0% (p = 0.24), respectively. For each parameter, we report the median and interquartile range for the absolute and relative difference between cases and controls, the correlation between cases and controls, and our recruitment rates, to inform the design of future studies. CONCLUSIONS These pilot data suggest potential differences in bone structure, estimated bone strength, and asymptomatic vertebral fractures among HIV-infected adults with and without fracture, warranting further study as markers of fracture risk in HIV.
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Affiliation(s)
- Darrell H S Tan
- a Division of Infectious Diseases , St. Michael's Hospital , Toronto , Canada.,b Division of Infectious Diseases , University Health Network , Toronto , Canada.,c Toronto General Research Institute , University Health Network , Toronto , Canada.,d Department of Medicine , University of Toronto , Toronto , Canada.,e CIHR - Canadian HIV Trials Network , Vancouver , Canada
| | - Janet Raboud
- c Toronto General Research Institute , University Health Network , Toronto , Canada.,f Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Leah Szadkowski
- c Toronto General Research Institute , University Health Network , Toronto , Canada
| | - Eva Szabo
- g Centre for Excellence in Skeletal Health Assessment , University Health Network , Toronto , Canada
| | - Hanxian Hu
- g Centre for Excellence in Skeletal Health Assessment , University Health Network , Toronto , Canada
| | - Queenie Wong
- g Centre for Excellence in Skeletal Health Assessment , University Health Network , Toronto , Canada
| | - Angela M Cheung
- c Toronto General Research Institute , University Health Network , Toronto , Canada.,d Department of Medicine , University of Toronto , Toronto , Canada.,f Dalla Lana School of Public Health , University of Toronto , Toronto , Canada.,g Centre for Excellence in Skeletal Health Assessment , University Health Network , Toronto , Canada.,h Divisions of General Internal Medicine and Endocrinology , University Health Network , Toronto , Canada
| | - Sharon L Walmsley
- b Division of Infectious Diseases , University Health Network , Toronto , Canada.,c Toronto General Research Institute , University Health Network , Toronto , Canada.,d Department of Medicine , University of Toronto , Toronto , Canada.,e CIHR - Canadian HIV Trials Network , Vancouver , Canada
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29
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Siou K, Walmsley SL, Murphy KE, Raboud J, Loutfy M, Yudin MH, Silverman M, Ladhani NN, Serghides L. Progesterone supplementation for HIV-positive pregnant women on protease inhibitor-based antiretroviral regimens (the ProSPAR study): a study protocol for a pilot randomized controlled trial. Pilot Feasibility Stud 2016; 2:49. [PMID: 27965866 PMCID: PMC5153916 DOI: 10.1186/s40814-016-0087-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 07/26/2016] [Indexed: 12/04/2022] Open
Abstract
Background In Canada, the majority of HIV-positive pregnant women receive combination antiretroviral therapy that includes a ritonavir-boosted protease inhibitor to prevent mother-to-child HIV transmission. However, protease inhibitor-based combination antiretroviral therapy has been associated with increased rates of preterm, low birth weight, and small for gestational age births. Our previous experimental findings demonstrate that protease inhibitor use during pregnancy is associated with decreased progesterone levels that correlate with fetal growth, and that progesterone supplementation can improve protease inhibitor-induced fetal growth restriction. We hypothesize that HIV-positive pregnant women who receive protease inhibitor-based combination therapy may also benefit from progesterone supplementation during pregnancy. Methods/design In order to test this hypothesis, we have designed an open-label, multi-centre, randomized controlled (parallel group) pilot trial. The initial goal of this trial is to test feasibility and acceptability of our intervention. Forty HIV-positive pregnant women who are either on, or intending to start or switch to a boosted protease inhibitor-based combination antiretroviral regimen will be enrolled from six sites across Ontario, Canada. Twenty-five women will be randomized to self-administer natural progesterone (Prometrium, 200 mg) vaginally every night starting between gestational week 16 and 24 until week 36, and 15 women will be randomized to no intervention. While the participants and treating physicians will not be blinded, the laboratory personnel performing the biochemical and morphological evaluations will be blinded to ensure unbiased evaluation. The primary outcome of the pilot study is the feasibility of enrolment as measured by the recruitment rate and patient-reported reasons to decline participation. Secondary outcomes in participants include safety, acceptability, and adherence to progesterone supplementation. Discussion Given the safety of intravaginal progesterone and its current use in the general obstetrical population to prevent recurrent preterm delivery, this pilot study will provide data to determine the feasibility of a larger randomized controlled trial to assess the impact of this intervention on improving neonatal health in the context of HIV-positive pregnancies. Trial registration ClinicalTrials.gov, NCT02400021
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Affiliation(s)
- Kaitlin Siou
- Toronto General Research Institute, Toronto, Canada
| | - Sharon L Walmsley
- Toronto General Hospital, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Kellie E Murphy
- Mount Sinai Hospital, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Janet Raboud
- Toronto General Research Institute, Toronto, Canada
| | - Mona Loutfy
- Maple Leaf Medical Clinic, Toronto, Canada ; Women's College Research Institute, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Mark H Yudin
- St. Michael's Hospital, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Michael Silverman
- St. Joseph's Health Care London, London, Canada ; University of Western Ontario, London, Canada
| | - Noor N Ladhani
- Sunnybrook Health Sciences Centre, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Lena Serghides
- Toronto General Research Institute, Toronto, Canada ; University of Toronto, Toronto, Canada ; Women's College Research Institute, Toronto, Canada
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30
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Kim CJ, Walmsley SL, Raboud JM, Kovacs C, Coburn B, Rousseau R, Reinhard R, Rosenes R, Kaul R. Can Probiotics Reduce Inflammation and Enhance Gut Immune Health in People Living with HIV: Study Designs for the Probiotic Visbiome for Inflammation and Translocation (PROOV IT) Pilot Trials. HIV Clin Trials 2016; 17:147-57. [PMID: 27267710 DOI: 10.1080/15284336.2016.1184827] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Despite substantial improvements in HIV outcomes with combination antiretroviral therapy (cART), morbidity and mortality remain above population norms. The gut mucosal immune system is not completely restored by cART, and the resultant microbial translocation may contribute to chronic inflammation, inadequate CD4 T-cell recovery, and increased rates of serious non-AIDS events. Since the microbial environment surrounding a CD4 T cell may influence its development and function, we hypothesize that probiotics provided during cART might reduce inflammation and improve gut immune health in HIV-positive treatment-naïve individuals (PROOV IT I) and individuals with suboptimal CD4 recovery on cART (PROOV IT II). METHODS These prospective, double-blinded, randomized, placebo-controlled, multicenter pilot studies will assess the impact of the probiotic Visbiome at 900 billion bacteria daily. Forty HIV positive cART-naïve men will be randomized in the PROOV IT I study, coincident with antiretroviral initiation, and be followed for 24 weeks. In PROOV IT II, 36 men on cART, but with a CD4 T-cell count below 350 cells/mm(3) will be followed for 48 weeks. The primary outcome for both studies is the comparison of blood CD8 T-cell immune activation. Secondary analyses will include comparison of blood inflammatory biomarkers, microbial translocation, blood and gut immunology and HIV levels, the bacterial community composition, diet, intestinal permeability, and the safety, adherence and tolerability of the study product. DISCUSSION These studies will evaluate the ability of probiotics as a safe and tolerable therapeutic intervention to reduce systemic immune activation and to accelerate gut immune restoration in people living with HIV.
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Affiliation(s)
- Connie J Kim
- a Toronto General Research Institute , University Health Network , Toronto , Canada
| | - Sharon L Walmsley
- a Toronto General Research Institute , University Health Network , Toronto , Canada.,c Department of Immunology, Dalla Lana School of Public Health, and Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada
| | - Janet M Raboud
- a Toronto General Research Institute , University Health Network , Toronto , Canada.,c Department of Immunology, Dalla Lana School of Public Health, and Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada
| | | | - Bryan Coburn
- a Toronto General Research Institute , University Health Network , Toronto , Canada.,c Department of Immunology, Dalla Lana School of Public Health, and Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada
| | - Rodney Rousseau
- c Department of Immunology, Dalla Lana School of Public Health, and Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada
| | | | - Ron Rosenes
- e Community Health Advocate and Consultant , Toronto , ON , Canada
| | - Rupert Kaul
- a Toronto General Research Institute , University Health Network , Toronto , Canada.,c Department of Immunology, Dalla Lana School of Public Health, and Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada
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32
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Andany N, Walmsley SL. What's new for antiretroviral treatment in women with HIV. J Virus Erad 2016; 2:67-77. [PMID: 27482438 PMCID: PMC4965248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Currently, women represent 52% of persons infected with HIV worldwide and 23% of those in the United States. Combination antiretroviral therapy (cART) has resulted in remarkable reductions in HIV-associated morbidity and mortality, and has dramatically improved life expectancy. Treatment guidelines do not differ for HIV-infected men and non-pregnant women. However, clinical trials of antiretroviral agents have limited female enrolment, and results from these predominantly male studies are extrapolated to the female population. Furthermore, many of these studies do not report gender subgroup analyses, and those that do are underpowered to detect differences between men and women, limiting the ability to assess if results are equally applicable to both sexes. Women may have differential responses to and adverse events from cART. A limited number of female-only clinical trials have demonstrated that female recruitment and retention in these studies is feasible. Therefore, urgent attention is required to improve the body of knowledge regarding clinical efficacy, safety and tolerability of cART in women. In particular, women living with HIV are faced with various sexual and reproductive health concerns that may influence choice of cART. These include potential interactions with hormonal contraception, safety in pregnancy, and the impact of the transition through menopause and development of age-related comorbidities. Finally, the ongoing advances in biomedical HIV prevention, particularly pre-exposure prophylaxis (PrEP), provide an enormous opportunity to enhance HIV prevention in high-risk women, in efforts to further reduce global burden of the pandemic.
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Affiliation(s)
- Nisha Andany
- Department of Medicine,
University of Toronto,
Ontario,
Canada
| | - Sharon L Walmsley
- Department of Medicine,
University of Toronto,
Ontario,
Canada
- Division of Infectious Diseases,
University Health Network,
Toronto,
Ontario,
Canada
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33
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Shuper PA, Joharchi N, Irving H, Fletcher D, Kovacs C, Loutfy M, Walmsley SL, Wong DKH, Rehm J. Differential predictors of ART adherence among HIV-monoinfected versus HIV/HCV-coinfected individuals. AIDS Care 2016; 28:954-62. [PMID: 26971360 DOI: 10.1080/09540121.2016.1158396] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although adherence is an important key to the efficacy of antiretroviral therapy (ART), many people living with HIV (PLWH) fail to maintain optimal levels of ART adherence over time. PLWH with the added burden of Hepatitis C virus (HCV) coinfection possess unique challenges that potentially impact their motivation and ability to adhere to ART. The present investigation sought to (1) compare ART adherence levels among a sample of HIV/HCV-coinfected versus HIV-monoinfected patients, and (2) identify whether ART-related clinical and psychosocial correlates differ by HCV status. PLWH receiving ART (N = 215: 105 HIV/HCV-coinfected, 110 HIV-monoinfected) completed a comprehensive survey assessing ART adherence and its potential correlates. Medical chart extraction identified clinical factors, including liver enzymes. Results demonstrated that ART adherence did not differ by HCV status, with 83.7% of coinfected patients and 82.4% of monoinfected patients reporting optimal (i.e., ≥95%) adherence during a four-day recall period (p = .809). Multivariable logistic regression demonstrated that regardless of HCV status, optimal ART adherence was associated with experiencing fewer adherence-related behavioral skills barriers (AOR = 0.56; 95%CI = 0.43-0.73), lower likelihood of problematic drinking (AOR = 0.15; 95%CI = 0.04-0.67), and lower likelihood of methamphetamine use (AOR = 0.14; 95%CI = 0.03-0.69). However, among HIV/HCV-coinfected patients, optimal adherence was additionally associated with experiencing fewer ART adherence-related motivational barriers (AOR = 0.23; 95%CI = 0.08-0.62) and lower likelihood of depression (AOR = 0.06; 95%CI = 0.00-0.84). Findings suggest that although HIV/HCV-coinfected patients may face additional, distinct barriers to ART adherence, levels of adherence commensurate with those demonstrated by HIV-monoinfected patients might be achievable if these barriers are addressed.
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Affiliation(s)
- Paul A Shuper
- a Centre for Addiction and Mental Health , Toronto , Canada.,b Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | | | - Hyacinth Irving
- c Centre for Management of Technology & Entrepreneurship , University of Toronto , Toronto , Canada
| | | | | | - Mona Loutfy
- b Dalla Lana School of Public Health , University of Toronto , Toronto , Canada.,d Maple Leaf Medical Clinic , Toronto , Canada.,e Women's College Hospital , Toronto , Canada.,f Department of Medicine , University of Toronto , Toronto , Canada
| | - Sharon L Walmsley
- f Department of Medicine , University of Toronto , Toronto , Canada.,g Toronto General Hospital, University Health Network , Toronto , Canada
| | - David K H Wong
- g Toronto General Hospital, University Health Network , Toronto , Canada
| | - Jürgen Rehm
- a Centre for Addiction and Mental Health , Toronto , Canada.,b Dalla Lana School of Public Health , University of Toronto , Toronto , Canada.,g Toronto General Hospital, University Health Network , Toronto , Canada.,h Department of Psychiatry , University of Toronto , Toronto , Canada.,i TU Dresden, Institute for Clinical Psychology and Psychotherapy , Dresden , Germany.,j Department of Community Health and Institute of Medical Science , University of Toronto , Toronto , Canada
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34
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Costiniuk CT, Brunet L, Rollet-Kurhajec KC, Cooper CL, Walmsley SL, Gill MJ, Martel-Laferriere V, Klein MB. Tobacco Smoking Is Not Associated With Accelerated Liver Disease in Human Immunodeficiency Virus-Hepatitis C Coinfection: A Longitudinal Cohort Analysis. Open Forum Infect Dis 2016; 3:ofw050. [PMID: 27047987 PMCID: PMC4817089 DOI: 10.1093/ofid/ofw050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/01/2016] [Indexed: 11/30/2022] Open
Abstract
Background. Tobacco smoking has been shown to be an independent risk factor for liver fibrosis in hepatitis C virus (HCV) infection in some cross-sectional studies. No longitudinal study has confirmed this relationship, and the effect of tobacco exposure on liver fibrosis in human immunodeficiency virus (HIV)-HCV coinfected individuals is unknown. Methods. The study population consisted of participants from the Canadian Co-infection Cohort study (CTN 222), a multicenter longitudinal study of HIV-HCV coinfected individuals from 2003 to 2014. Data were analyzed for all participants who did not have significant fibrosis or end-stage liver disease (ESLD) at baseline. The association between time-updated tobacco exposure (ever vs nonsmokers and pack-years) and progression to significant liver fibrosis (defined as an aspartate-to-platelet ratio index [APRI] ≥1.5) or ESLD was assessed by pooled logistic regression. Results. Of 1072 participants included in the study, 978 (91%) had ever smoked, 817 (76%) were current smokers, and 161 (15%) were previous smokers. Tobacco exposure was not associated with accelerated progression to significant liver fibrosis nor with ESLD when comparing ever vs never smokers (odds ratio [OR] = 1.06, 95% confidence interval [CI], 0.43–1.69 and OR = 1.20, 95% CI, 0.21–2.18, respectively) or increases in pack-years smoked (OR = 1.05, 95% CI, 0.97–1.14 and OR = 0.94, 95% CI, 0.83–1.05, respectively). Both time-updated alcohol use in the previous 6 months and presence of detectable HCV ribonucleic acid were associated with APRI score ≥1.5. Conclusions. Tobacco exposure does not appear to be associated with accelerated progression of liver disease in this prospective study of HIV-HCV coinfected individuals.
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Affiliation(s)
- Cecilia T Costiniuk
- Chronic Viral Illnesses Service , Division of Infectious Diseases and Research Institute of the McGill University Health Centre , Montreal
| | - Laurence Brunet
- Department of Epidemiology , Biostatistics and Occupational Health, McGill University , Montreal, Quebec
| | - Kathleen C Rollet-Kurhajec
- Chronic Viral Illnesses Service , Division of Infectious Diseases and Research Institute of the McGill University Health Centre , Montreal
| | - Curtis L Cooper
- Division of Infectious Diseases, The Ottawa Hospital, Ontario, Canada; Canadian HIV Trials Network, Vancouver, British Columbia
| | - Sharon L Walmsley
- Canadian HIV Trials Network, Vancouver, British Columbia; Division of Infectious Diseases, University Health Network, University of Toronto, Ontario
| | - M John Gill
- Canadian HIV Trials Network, Vancouver, British Columbia; Southern Alberta HIV Clinic, Calgary
| | | | - Marina B Klein
- Chronic Viral Illnesses Service, Division of Infectious Diseases and Research Institute of the McGill University Health Centre, Montreal; Canadian HIV Trials Network, Vancouver, British Columbia
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35
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Saeed S, Strumpf EC, Walmsley SL, Rollet-Kurhajec K, Pick N, Martel-Laferrière V, Hull M, Gill MJ, Cox J, Cooper C, Klein MB, Cohen J, Conway B, Cooper C, Côté P, Cox J, Gill J, Haider S, Harris M, Haase D, Hull M, Montaner J, Moodie E, Pick N, Rachlis A, Rouleau D, Sandre R, Tyndall JM, Vachon ML, Walmsley S, Wong D. How Generalizable Are the Results From Trials of Direct Antiviral Agents to People Coinfected With HIV/HCV in the Real World? Clin Infect Dis 2016; 62:919-926. [PMID: 26743093 PMCID: PMC4787608 DOI: 10.1093/cid/civ1222] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/18/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Direct-acting antivirals (DAAs) against hepatitis C virus (HCV) have been described as revolutionary. However, it remains uncertain how effective these drugs will be for individuals coinfected with human immunodeficiency virus (HIV)-HCV. Bridging this gap between efficacy and effectiveness requires a focus on the generalizability of clinical trials. METHODS Generalizability of DAA trials was assessed by applying the eligibility criteria from 5 efficacy trials: NCT01479868, PHOTON-1 (NCT01667731), TURQUOISE-I (NCT01939197), ION-4 (NCT02073656), and ALLY-2 (NCT02032888) that evaluated simeprevir; sofosbuvir; ombitasvir, paritaprevir/ritonavir/dasabuvir; sofosbuvir/ledipasvir; and daclatasvir/sofosbuvir, respectively, to the Canadian Coinfection Cohort, representing approximately 23% of the total coinfected population in care in Canada. RESULTS Of 874 active participants, 70% had chronic HCV, of whom 410, 26, 94, and 11 had genotypes 1, 2, 3, and 4, respectively. After applying trial eligibility criteria, only 5.9% (24/410) would have been eligible for enrollment in the simeprevir trial, 9.8% (52/530) in PHOTON-1, 6.3% (26/410) in TURQUOISE-I, and 8.1% (34/421) in ION-4. The ALLY-2 study was more inclusive; 43% (233/541) of the cohort would have been eligible. The most exclusive eligibility criteria across all trials with the exception of ALLY-2 were restriction to specific antiretroviral therapies (63%-79%) and active illicit drug use (53%-55%). CONCLUSIONS DAA trial results may have limited generalizability, since the majority of coinfected individuals were not eligible to participate. Exclusions appeared to be related to improving treatment outcomes by not including those at higher risk of poor adherence and reinfection--individuals for whom real-world data are urgently needed.
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Affiliation(s)
- Sahar Saeed
- Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, McGill University Health Centre.,Department of Epidemiology & Biostatistics
| | - Erin C Strumpf
- Department of Epidemiology & Biostatistics.,Department of Economics, McGill University, Montreal, Quebec
| | - Sharon L Walmsley
- Division of Infectious Diseases, Toronto Hospital, University Health Network, Ontario.,Canadian Institutes of Health Research, Canadian HIV Trials Network
| | - Kathleen Rollet-Kurhajec
- Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, McGill University Health Centre
| | - Neora Pick
- Division of Infectious Diseases, Oak Tree Clinic, BC Women's Hospital, Vancouver, British Columbia
| | | | - Mark Hull
- Department of Infectious Disease, Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia
| | | | - Joseph Cox
- Department of Epidemiology & Biostatistics.,Public Health Department, Montreal Health and Social Services Agency, Quebec
| | - Curtis Cooper
- Department of Medicine, University of Ottawa, Ontario, Canada
| | - Marina B Klein
- Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, McGill University Health Centre.,Canadian Institutes of Health Research, Canadian HIV Trials Network
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Papp E, Balogun K, Banko N, Mohammadi H, Loutfy M, Yudin MH, Shah R, MacGillivray J, Murphy KE, Walmsley SL, Silverman M, Serghides L. Low Prolactin and High 20-α-Hydroxysteroid Dehydrogenase Levels Contribute to Lower Progesterone Levels in HIV-Infected Pregnant Women Exposed to Protease Inhibitor-Based Combination Antiretroviral Therapy. J Infect Dis 2016; 213:1532-40. [PMID: 26740274 DOI: 10.1093/infdis/jiw004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/29/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND It has been reported that pregnant women receiving protease inhibitor (PI)-based combination antiretroviral therapy (cART) have lower levels of progesterone, which put them at risk of adverse birth outcomes, such as low birth weight. We sought to understand the mechanisms involved in this decline in progesterone level. METHODS We assessed plasma levels of progesterone, prolactin, and lipids and placental expression of genes involved in progesterone metabolism in 42 human immunodeficiency virus (HIV)-infected and 31 HIV-uninfected pregnant women. In vitro studies and a mouse pregnancy model were used to delineate the effect of HIV from that of PI-based cART on progesterone metabolism. RESULTS HIV-infected pregnant women receiving PI-based cART showed a reduction in plasma progesterone levels (P= .026) and an elevation in placental expression of the progesterone inactivating enzyme 20-α-hydroxysteroid dehydrogenase (20α-HSD; median, 2.5 arbitrary units [AU]; interquartile range [IQR], 1.00-4.10 AU), compared with controls (median, 0.89 AU; IQR, 0.66-1.26 AU;P= .002). Prolactin, a key regulator of 20α-HSD, was lower (P= .012) in HIV-infected pregnant women. We observed similar data in pregnant mice exposed to PI-based cART. In vitro inhibition of 20α-HSD activity in trophoblast cells reversed PI-based cART-induced decreases in progesterone levels. CONCLUSIONS Our data suggest that the decrease in progesterone levels observed in HIV-infected pregnant women exposed to PI-based cART is caused, at least in part, by an increase in placental expression of 20α-HSD, which may be due to lower prolactin levels observed in these women.
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Affiliation(s)
- Eszter Papp
- Toronto General Research Institute, University Health Network
| | - Kayode Balogun
- Toronto General Research Institute, University Health Network
| | - Nicole Banko
- Toronto General Research Institute, University Health Network
| | | | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital Department of Medicine
| | | | | | | | | | - Sharon L Walmsley
- Toronto General Research Institute, University Health Network Department of Medicine
| | | | - Lena Serghides
- Toronto General Research Institute, University Health Network Women's College Research Institute, Women's College Hospital Department of Immunology, University of Toronto
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Abstract
Dolutegravir is the newest integrase strand transfer inhibitor to be approved for the treatment of human immunodeficiency virus (HIV) infection. Dolutegravir is equivalent or superior to existing treatment regimens in both treatment-naïve and treatment-experienced patients including those with previous raltegravir or elvitegravir failure. The consistent efficacy coupled with excellent tolerability and infrequent drug–drug interactions makes the co-formulation of dolutegravir with two nucleotide reverse-transcriptase inhibitors an attractive treatment option. This review summarizes the pharmacokinetics, adverse event profile, and efficacy of dolutegravir in the treatment of HIV.
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Affiliation(s)
| | - Sharon L Walmsley
- Department of Medicine, University of Toronto, Toronto, ON, Canada ; Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
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Lake JE, McComsey GA, Hulgan T, Wanke CA, Mangili A, Walmsley SL, Currier JS. Switch to Raltegravir From Protease Inhibitor or Nonnucleoside Reverse-Transcriptase Inhibitor Does not Reduce Visceral Fat In Human Immunodeficiency Virus-Infected Women With Central Adiposity. Open Forum Infect Dis 2015; 2:ofv059. [PMID: 26380350 PMCID: PMC4567084 DOI: 10.1093/ofid/ofv059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/22/2015] [Indexed: 11/14/2022] Open
Abstract
Human immunodeficiency virus-infected women with central adiposity switched to raltegravir-based antiretroviral therapy immediately or after 24 weeks. No statistically significant changes in computed tomography-quantified visceral adipose tissue (VAT) or subcutaneous fat were observed, although 48 weeks of raltegravir was associated with a 6.4% VAT decline. Raltegravir for 24 weeks was associated with improvements in lipids.
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Affiliation(s)
- Jordan E Lake
- Department of Medicine , University of California, Los Angeles, California
| | - Grace A McComsey
- Department of Pediatrics and Medicine , Case Western Reserve University , Cleveland, Ohio
| | - Todd Hulgan
- Department of Medicine , Vanderbilt University , Nashville, Tennessee
| | | | | | | | - Judith S Currier
- Department of Medicine , University of California, Los Angeles, California
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Tan DH, Raboud JM, Szadkowski L, Yi TJ, Shannon B, Kaul R, Liles WC, Walmsley SL. Herpes simplex virus type 2 serostatus is not associated with inflammatory or metabolic markers in antiretroviral therapy-treated HIV. AIDS Res Hum Retroviruses 2015; 31:276-81. [PMID: 25399537 DOI: 10.1089/aid.2014.0183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Systemic inflammation and immune activation may persist in HIV-infected persons on suppressive combination antiretroviral therapy (cART) and contribute to adverse health outcomes. We compared markers of immune activation, inflammation, and abnormal glucose and lipid metabolism in HIV-infected adults according to herpes simplex virus type 2 (HSV-2) serostatus in a 6-month observational cohort study in Toronto, Canada. HIV-infected adults on suppressive (viral load <50 copies/ml) cART were categorized as HSV-2 seropositive or seronegative using the HerpeSelect ELISA, and underwent study visits at baseline, 3 months, and 6 months. The primary outcome was the median percentage of activated (CD38(+)HLADR(+)) CD8 T cells. Secondary outcome measures included additional immune (activated CD4, regulatory T cells) and inflammatory (hsCRP, D-dimer, IL-1b, IL-6, MCP-1, TNF, sICAM-1, sVCAM-1, Ang1/Ang2 ratio) markers. Metabolic outcomes included the proportion with impaired fasting glucose/impaired glucose tolerance/diabetes, insulin sensitivity (calculated using the Matsuda index), insulin resistance (homeostasis model assessment of insulin resistance), and fasting lipids. The impact of HSV-2 on each outcome was estimated using generalized estimating equation regression models. Of 84 participants, 38 (45%) were HSV-2 seropositive. HSV signs and symptoms were uncommon. Aside from D-dimer, which was more often detectable in HSV-2 seropositives (adjusted odds ratio=3.58, 95% CI=1.27, 10.07), HSV-2 serostatus was not associated with differences in any other immune, inflammatory cytokine, acute phase reactant, endothelial activation, or metabolic markers examined in univariable or multivariable models. During the study, CD8 and CD4 T cell activation declined by 0.16% and 0.08% per month, respectively, while regulatory T cells increased by 0.05% per month. HSV-2 serostatus was not consistently associated with immune activation, inflammatory, or lipid and glucose metabolic markers in this cohort of HIV-infected adults on suppressive cART.
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Affiliation(s)
- Darrell H.S. Tan
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, St. Michael's Hospital, Toronto, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Canada
- Toronto General Research Institute, Toronto, Canada
| | - Janet M. Raboud
- Toronto General Research Institute, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Tae Joon Yi
- Department of Immunology, University of Toronto, Toronto, Canada
| | - Brett Shannon
- Department of Immunology, University of Toronto, Toronto, Canada
| | - Rupert Kaul
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Canada
- Toronto General Research Institute, Toronto, Canada
- Department of Immunology, University of Toronto, Toronto, Canada
| | - W. Conrad Liles
- Department of Medicine, University of Washington, Seattle, Washington
| | - Sharon L. Walmsley
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Canada
- Toronto General Research Institute, Toronto, Canada
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Sharma M, Walmsley SL. Contraceptive options for HIV-positive women: making evidence-based, patient-centred decisions. HIV Med 2015; 16:329-36. [PMID: 25689044 DOI: 10.1111/hiv.12221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Women of reproductive age represent a large proportion of the global population living with HIV/AIDS. With improvements in morbidity and mortality since the advent of combination antiretroviral therapy, contraception and pregnancy planning are an increasingly important issue for women living with HIV. This review aims to outline the key considerations when choosing contraceptive methods in HIV-positive women and provides a review of the literature to inform decision-making. METHODS Pubmed was searched using the terms 'HIV', 'contraception', 'HIV progression', 'HIV acquisition', 'HIV transmission' and the combination of 'antiretroviral' and 'contraception'. Abstracts were reviewed and relevant articles were retrieved. Reference lists were also reviewed for pertinent citations. RESULTS HIV and contraceptive methods can interact in several clinically meaningful ways. Concomitant use may result in altered contraceptive efficacy, drug-drug interactions, or increased toxicity. Hormonal contraceptives have not been shown to affect HIV progression. Notably, the impact of hormonal contraceptives on HIV transmission and acquisition remains unclear, particularly for injectable forms. Data are lacking on several newer methods of contraception including contraceptive rings, patches and intrauterine systems. CONCLUSIONS Effective, reliable contraception is important for HIV-positive women. Efficacy, toxicity, drug interactions, and potential impacts on HIV disease progression, transmission, and acquisition must be assessed when making clinical decisions.
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Affiliation(s)
- M Sharma
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - S L Walmsley
- Division of Experimental Therapeutics - Infection and Immunity, Toronto General Research Institute, Toronto, Canada
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Walmsley SL, Raboud J, Angel JB, Mazzulli T, Shen S, Casciaro L, Young CD, Moussa G, Gough K, Rachlis A, Hopkins J. Long-Term Follow-up of a Cohort of HIV-Infected Patients Who Discontinued Maintenance Therapy for Cytomegalovirus Retinitis. HIV Clinical Trials 2015; 7:1-9. [PMID: 16632459 DOI: 10.1310/9m23-qn0x-w6n8-80jd] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the long-term safety of discontinuation of maintenance therapy for cytomegalovirus retinitis (CMVR) and to identify predictors for relapse. METHOD This was a prospective cohort study. Patients with treated CMVR who responded to HAART were followed by ophthalmologic assessment, markers for CMV replication (blood and urine cultures, CMV antigenemia, CMV DNA by PCR), and in vitro lymphoproliferative responses to CMV and other antigens after discontinuation of CMVR maintenance therapy. RESULTS 23 patients were followed a median of 34 (range, 5-61) months. Median CD4 count was 321/mm3 at enrollment and 395/mm3 at last follow-up. HIV RNA was <50 copies/mL in 78% of patients at enrollment and 65% at last follow-up. One CMVR reactivation occurred at 12 months at a CD4 count of 395/mm3 (21%) and HIV RNA <50 copies/mL. Urine cultures were a poor predictive marker for reactivation. Other CMV replication markers had good negative predictive value. 96% of patients had a good lymphoproliferative response to CMV antigen in vitro. CONCLUSION Maintenance therapy for CMVR can safely be discontinued in patients who have responded to HAART. Combining our results with the published literature, the risk of reactivation is estimated at 0.016 per person year of follow-up. Markers to predict relapse and the need for re-initiation of maintenance therapy are not yet identified.
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Affiliation(s)
- Sharon L Walmsley
- Department of Medicine, Toronto Hospital, University Health Network, University of Toronto, Canada.
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Loutfy MR, Ackad N, Antoniou T, Baril JG, Conway B, de Wet J, Trottier B, Kovacs CM, Thompson W, Martel AY, Trottier S, Rouleau D, Shafran SD, Rachlis A, Fraser C, Smaill F, Walmsley SL, Tseng AL, Sampalis JS. Randomized Controlled Trial of Once-Daily Tenofovir, Lamivudine, and Lopinavir/Ritonavir Versus Remaining on the Same Regimen in Virologically Suppressed HIV-Infected Patients on Their First PI-Containing HAART Regimen. HIV Clinical Trials 2015; 8:259-68. [DOI: 10.1310/hct0805-259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Papp E, Mohammadi H, Loutfy MR, Yudin MH, Murphy KE, Walmsley SL, Shah R, MacGillivray J, Silverman M, Serghides L. HIV protease inhibitor use during pregnancy is associated with decreased progesterone levels, suggesting a potential mechanism contributing to fetal growth restriction. J Infect Dis 2015; 211:10-8. [PMID: 25030058 PMCID: PMC4264589 DOI: 10.1093/infdis/jiu393] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/09/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Protease inhibitor (PI)-based combination antiretroviral therapy (cART) is administered during pregnancy to prevent perinatal human immunodeficiency virus (HIV) transmission. However, PI use has been associated with adverse birth outcomes, including preterm delivery and small-for-gestational-age (SGA) births. The mechanisms underlying these outcomes are unknown. We hypothesized that PIs contribute to these adverse events by altering progesterone levels. METHODS PI effects on trophoblast progesterone production were assessed in vitro. A mouse pregnancy model was used to assess the impact of PI-based cART on pregnancy outcomes and progesterone levels in vivo. Progesterone levels were assessed in plasma specimens from 27 HIV-infected and 17 HIV-uninfected pregnant women. RESULTS PIs (ritonavir, lopinavir, and atazanavir) but not nucleoside reverse transcriptase inhibitors (NRTIs) or nonnucleoside reverse transcriptase inhibitors reduced trophoblast progesterone production in vitro. In pregnant mice, PI-based cART but not dual-NRTI therapy was associated with significantly lower progesterone levels that directly correlated with fetal weight. Progesterone supplementation resulted in a significant improvement in fetal weight. We observed lower progesterone levels and smaller infants in HIV-infected women receiving PI-based cART, compared with the control group. In HIV-infected women, progesterone levels correlated significantly with birth weight percentile. CONCLUSIONS Our data suggest that PI use in pregnancy may lead to lower progesterone levels that could contribute to adverse birth outcomes.
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Affiliation(s)
- Eszter Papp
- Toronto General Research Institute, University Health Network
| | | | - Mona R. Loutfy
- Women's College Research Institute, Women's College Hospital
- University of Toronto
| | | | | | - Sharon L. Walmsley
- Toronto General Research Institute, University Health Network
- University of Toronto
| | | | | | - Michael Silverman
- University of Toronto
- Lakeridge Health, Rouge Valley Hospital, Ajax, Canada
| | - Lena Serghides
- Toronto General Research Institute, University Health Network
- Women's College Research Institute, Women's College Hospital
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Kuster SP, Rudnick W, Shigayeva A, Green K, Baqi M, Gold WL, Lovinsky R, Muller MP, Powis JE, Rau N, Simor AE, Walmsley SL, Low DE, McGeer A. Previous antibiotic exposure and antimicrobial resistance in invasive pneumococcal disease: results from prospective surveillance. Clin Infect Dis 2014; 59:944-52. [PMID: 24973312 DOI: 10.1093/cid/ciu497] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Estimating the risk of antibiotic resistance is important in selecting empiric antibiotics. We asked how the timing, number of courses, and duration of antibiotic therapy in the previous 3 months affected antibiotic resistance in isolates causing invasive pneumococcal disease (IPD). METHODS We conducted prospective surveillance for IPD in Toronto, Canada, from 2002 to 2011. Antimicrobial susceptibility was measured by broth microdilution. Clinical information, including prior antibiotic use, was collected by chart review and interview with patients and prescribers. RESULTS Clinical information and antimicrobial susceptibility were available for 4062 (90%) episodes; 1193 (29%) of episodes were associated with receipt of 1782 antibiotic courses in the prior 3 months. Selection for antibiotic resistance was class specific. Time elapsed since most recent antibiotic was inversely associated with resistance (cephalosporins: adjusted odds ratio [OR] per day, 0.98; 95% confidence interval [CI], .96-1.00; P = .02; macrolides: OR, 0.98; 95% CI, .96-.99; P = .005; penicillins: OR [log(days)], 0.62; 95% CI, .44-.89; P = .009; fluoroquinolones: profile penalized-likelihood OR [log(days)], 0.62; 95% CI, .39-1.04; P = .07). Risk of resistance after exposure declined most rapidly for fluoroquinolones and penicillins and reached baseline in 2-3 months. The decline in resistance was slowest for macrolides, and in particular for azithromycin. There was no significant association between duration of therapy and resistance for any antibiotic class. Too few patients received multiple courses of the same antibiotic class to assess the significance of repeat courses. CONCLUSIONS Time elapsed since last exposure to a class of antibiotics is the most important factor predicting antimicrobial resistance in pneumococci. The duration of effect is longer for macrolides than other classes.
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Affiliation(s)
- Stefan P Kuster
- Mount Sinai Hospital, Toronto, Canada University Hospital Zurich and University of Zurich, Switzerland
| | - Wallis Rudnick
- Mount Sinai Hospital, Toronto, Canada University of Toronto
| | | | | | - Mahin Baqi
- University of Toronto William Osler Health System, Etobicoke General Site
| | | | | | | | - Jeff E Powis
- University of Toronto Toronto East General Hospital, Toronto
| | - Neil Rau
- University of Toronto Halton Healthcare, Oakville
| | - Andrew E Simor
- University of Toronto Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Donald E Low
- Mount Sinai Hospital, Toronto, Canada University of Toronto University Health Network
| | - Allison McGeer
- Mount Sinai Hospital, Toronto, Canada University of Toronto
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Kis O, Walmsley SL, Bendayan R. In Vitro and In Situ Evaluation of pH-Dependence of Atazanavir Intestinal Permeability and Interactions with Acid-Reducing Agents. Pharm Res 2014; 31:2404-19. [DOI: 10.1007/s11095-014-1336-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/08/2014] [Indexed: 12/12/2022]
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Lake JE, McComsey GA, Hulgan T, Wanke CA, Mangili A, Walmsley SL, Stramotas SA, Tracy R, Currier JS. Switch to raltegravir decreases soluble CD14 in virologically suppressed overweight women: the Women, Integrase and Fat Accumulation Trial. HIV Med 2014; 15:431-41. [PMID: 24506429 DOI: 10.1111/hiv.12128] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Soluble CD14 (sCD14) is a monocyte activation marker associated with increased mortality in HIV infection. We assessed 48-week changes in sCD14 and other inflammatory biomarkers in virologically suppressed, HIV-infected women switching to raltegravir (RAL) from a protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor (NNRTI). METHODS HIV-infected women with central adiposity and HIV-1 RNA < 50 HIV-1 RNA copies/mL continued their thymidine-sparing nucleoside reverse transcriptase inhibitor (NRTI) backbone and were randomized to switch to open-label RAL at week 0 (immediate) or 24 (delayed). In an exploratory analysis, inflammatory biomarkers were measured on stored fasting plasma. RESULTS Of the 37 evaluable subjects, 78% were non-White; the median age was 43 years, the median body mass index (BMI) was 32 kg/m(2) and the median CD4 count was 558 cells/μL. At baseline, biomarker values were similar between groups. After 24 weeks, median sCD14 significantly declined in subjects switching to RAL [-21% (P < 0.001) vs. PI/NNRTI -5% (P = 0.49); between-group P < 0.01]. After 48 weeks, immediate-switch subjects maintained this decline and delayed-switch subjects experienced a similar decline following the switch to RAL (-10%; within-group P < 0.01). Immediate-switch subjects also experienced an initial increase in tumour necrosis factor (TNF)-α that was neither maintained after 48 weeks nor seen in delayed-switch subjects. After adjustment for multiple testing, only declines in sCD14 remained significant. CONCLUSIONS In this randomized trial of women with central adiposity, a switch to RAL from a PI or NNRTI was associated with a statistically significant decline in sCD14. Further studies are needed to determine whether integrase inhibitors have improved monocyte activation profiles compared with PIs and/or NNRTIs, and whether measured differences between antiretroviral agents translate to demonstrable clinical benefit.
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Affiliation(s)
- J E Lake
- Department of Medicine, University of California, Los Angeles, CA, USA
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Abstract
OBJECTIVES Herpes simplex virus types 1 and 2 (HSV-1/2) may have adverse consequences on HIV type 1 infection. We quantified the frequency of HSV reactivations in highly active antiretroviral therapy (HAART)-treated adults with HIV, and compared it with that in HAART-naïve patients. SETTING 2 academic hospital sites in Toronto, Canada. PARTICIPANTS Asymptomatic HAART-naive (n=44) or treated (with HIV RNA <50 copies/mL, n=41) adults with HSV-1 and/or 2, HIV coinfection. OUTCOME MEASURES HSV-1 and HSV-2 shedding as measured by PCR on oral, genital and anal swabs self-collected daily for 28 days. RESULTS Of the 85 participants, 88%, 67% and 53% were coinfected with HSV-1, HSV-2 and both HSV types, respectively. Median (IQR) CD4 count was 516 (382, 655) cells/mm(3). HSV (type 1 and/or 2) shedding occurred on a median (IQR) of 7.1% (0, 17.9%) of days in HAART users and 3.6% (0, 10.7%) of days in non-HAART users. No significant relationship was observed between HAART and HSV-1/2 shedding in univariable (OR=1.55, 95% CI 0.83 to 2.87) or multivariable negative binomial models adjusted for sex, baseline CD4 count, recent immigrant status and time since HIV diagnosis (adjusted OR, aOR=1.05, 95% CI 0.43 to 2.58). Similar null results were observed for HSV-2 shedding in HSV-2 seropositive participants (aOR=1.16, 95% CI 0.40 to 3.36) and HSV-1 shedding in HSV-1 seropositive participants (aOR=0.70, 95% CI 0.14 to 3.47). CONCLUSIONS HSV reactivations persist despite suppressive HAART among adults coinfected with HSV and HIV. Clinical trials of suppressive anti-HSV therapy are warranted in this population.
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Affiliation(s)
- Darrell H S Tan
- Division of Infectious Diseases, St Michael's Hospital, Toronto, Ontario, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Janet M Raboud
- Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Rupert Kaul
- Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sharon L Walmsley
- Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Kennedy VL, Serghides L, Raboud JM, Su D, Blitz S, Hart TA, Walmsley SL, Angel JB, Smaill FM, Ralph ED, Tharao WE, Loutfy MR. The importance of motherhood in HIV-positive women of reproductive age in Ontario, Canada. AIDS Care 2013; 26:777-84. [DOI: 10.1080/09540121.2013.855295] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- V. Logan Kennedy
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Lena Serghides
- Sandra Rotman Centre for Global Health, Toronto General Research Institute, University Health Network, Toronto, Canada
| | - Janet M. Raboud
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - DeSheng Su
- University Health Network, Toronto, Ontario, Canada
| | - Sandra Blitz
- University Health Network, Toronto, Ontario, Canada
| | - Trevor A. Hart
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | - Sharon L. Walmsley
- University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan B. Angel
- Ottawa Health Research Institute and The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Fiona M. Smaill
- McMaster University Medical Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Edward D. Ralph
- Infectious Diseases Care Program, St. Joseph's Health Care, London, Ontario, Canada
| | | | - Mona R. Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Walmsley SL, Antela A, Clumeck N, Duiculescu D, Eberhard A, Gutiérrez F, Hocqueloux L, Maggiolo F, Sandkovsky U, Granier C, Pappa K, Wynne B, Min S, Nichols G. Dolutegravir plus abacavir-lamivudine for the treatment of HIV-1 infection. N Engl J Med 2013; 369:1807-18. [PMID: 24195548 DOI: 10.1056/nejmoa1215541] [Citation(s) in RCA: 611] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Dolutegravir (S/GSK1349572), a once-daily, unboosted integrase inhibitor, was recently approved in the United States for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in combination with other antiretroviral agents. Dolutegravir, in combination with abacavir-lamivudine, may provide a simplified regimen. METHODS We conducted a randomized, double-blind, phase 3 study involving adult participants who had not received previous therapy for HIV-1 infection and who had an HIV-1 RNA level of 1000 copies per milliliter or more. Participants were randomly assigned to dolutegravir at a dose of 50 mg plus abacavir-lamivudine once daily (DTG-ABC-3TC group) or combination therapy with efavirenz-tenofovir disoproxil fumarate (DF)-emtricitabine once daily (EFV-TDF-FTC group). The primary end point was the proportion of participants with an HIV-1 RNA level of less than 50 copies per milliliter at week 48. Secondary end points included the time to viral suppression, the change from baseline in CD4+ T-cell count, safety, and viral resistance. RESULTS A total of 833 participants received at least one dose of study drug. At week 48, the proportion of participants with an HIV-1 RNA level of less than 50 copies per milliliter was significantly higher in the DTG-ABC-3TC group than in the EFV-TDF-FTC group (88% vs. 81%, P=0.003), thus meeting the criterion for superiority. The DTG-ABC-3TC group had a shorter median time to viral suppression than did the EFV-TDF-FTC group (28 vs. 84 days, P<0.001), as well as greater increases in CD4+ T-cell count (267 vs. 208 per cubic millimeter, P<0.001). The proportion of participants who discontinued therapy owing to adverse events was lower in the DTG-ABC-3TC group than in the EFV-TDF-FTC group (2% vs. 10%); rash and neuropsychiatric events (including abnormal dreams, anxiety, dizziness, and somnolence) were significantly more common in the EFV-TDF-FTC group, whereas insomnia was reported more frequently in the DTG-ABC-3TC group. No participants in the DTG-ABC-3TC group had detectable antiviral resistance; one tenofovir DF-associated mutation and four efavirenz-associated mutations were detected in participants with virologic failure in the EFV-TDF-FTC group. CONCLUSIONS Dolutegravir plus abacavir-lamivudine had a better safety profile and was more effective through 48 weeks than the regimen with efavirenz-tenofovir DF-emtricitabine. (Funded by ViiV Healthcare; SINGLE ClinicalTrials.gov number, NCT01263015 .).
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Affiliation(s)
- Sharon L Walmsley
- From the University Health Network, Toronto (S.L.W.); Hospital Clinico Universitario, Santiago de Compostela (A.A.), and Hospital General de Elche and Universidad Miguel Hernández, Alicante (F.G.) - both in Spain; Centre Hospitalier Universitaire Saint-Pierre, Brussels (N.C.); Dr. Victor Babes Infectious and Tropical Diseases Hospital, Bucharest, Romania (D.D.); Medizinisches Versorgungszentrum Karlsplatz HIV Research and Clinical Care Center, Munich, Germany (A.E.); Centre Hospitalier Régional d'Orléans, Orléans, France (L.H.); Antiviral Therapy Unit, Ospedali Riuniti, Bergamo, Italy (F.M.); University of Nebraska Medical Center, Omaha (U.S.); GlaxoSmithKline, Stockley Park, United Kingdom (C.G.); and GlaxoSmithKline, Research Triangle Park, NC (K.P., B.W., S.M., G.N.)
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