Search

Background: Enfuvirtide was shown to be highly effective in treatment- experienced patients. Data on discontinuation of enfuvirtide and switch to new antiretroviral drugs are scarce. We aimed to evaluate the efficacy and the impact of discontinuing and/or switching enfuvirtide on virologic and clinical parameters in clinical practice. Methods: All HIV-infected individuals participating in the Swiss HIV Cohort Study who were treated with enfuvirtide for at least 4 weeks in combination with an optimized background antiretroviral regimen were included in this study. Results: A total of 151 patients were analyzed. The median baseline CD4 cell count was 108 cells/μL (interquartile range [IQR] 50–206) and HIV RNA was 4.7 log10 copies/mL (IQR 4.1–5.2). Virologic suppression, defined as a viral load below 50 copies/mL at 12 months, was achieved by 57.6% of patients. Overall, a median CD4 cell increase of 121 cells/μL (IQR 50–189) from baseline was noted. Up to 50% of patients discontinued enfuvirtide within the first year of treatment, mainly because of the patient’s choice. After discontinuation of enfuvirtide, high rates of virologic failure and clinical progression were observed, notably when CD4 cell count at stopping enfuvirtide was below 100 cells/μL and no switch to new potent antiretroviral drugs such as darunavir, maraviroc, or raltegravir was performed. Conclusions: Enfuvirtide provides high virologic and immunologic response in treatment-experienced patients in the setting of clinical practice. Enfuvirtide should not be discontinued but should be replaced by new potent antiretrovirals, particularly in case of severe immunosuppression. [ABSTRACT FROM AUTHOR]

Purpose: Antiretroviral therapy (ART) may induce metabolic changes and increase the risk of coronary heart disease (CHD). Based on a health care system approach, we investigated predictors for normalization of dyslipidemia in HIV-infected individuals receiving ART. Method: Individuals included in the study were registered in the Swiss HIV Cohort Study (SHCS), had dyslipidemia but were not on lipidlowering medication, were on potent ART for ⩾3 months, and had ⩾2 follow-up visits. Dyslipidemia was defined as two consecutive total cholesterol (TC) values above recommended levels. Predictors of achieving treatment goals for TC were assessed using Cox models. Results: Analysis included 958 individuals with median followup of 2.3 years (IQR 1.2–4.0). 454 patients (47.4%) achieved TC treatment goals. In adjusted analyses, variables significantly associated with a lower hazard of reaching TC treatment goals were as follows: older age (compared to 18–37 year olds: hazard ratio [HR] 0.62 for 45–52 year olds, 95% CI 0.47–0.82; HR 0.40 for 53–85, 95% CI 0.29–0.54), diabetes (HR 0.39, 95% CI 0.26–0.59), history of coronary heart disease (HR 0.27, 95% CI 0.10–0.71), higher baseline TC (HR 0.78, 95% CI 0.71–0.85), baseline triple nucleoside regimen (HR 0.12 compared to PI-only regimen, 95% CI 0.07–0.21), longer time on PI-only regimen (HR 0.39, 95% CI 0.33–0.46), longer time on NNRTI only regimen (HR 0.35, 95% CI 0.29–0.43), and longer time on PI/NNRTI regimen (HR 0.34, 95% CI 0.26–0.43). Switching ART regimen when viral load was undetectable was associated with a higher hazard of reaching TC treatment goals (HR 1.48, 95% CI 1.14–1.91). Conclusion: In SHCS participants on ART, several ART-related and not ART-related epidemiological factors were associated with insufficient control of dyslipidemia. Control of dyslipidemia in ART recipients must be further improved. [ABSTRACT FROM AUTHOR]

Body fat changes and metabolic abnormalities such as hyperlipidaemia and diabetes have been increasingly reported following the successful introduction of highly active antiretroviral therapy (HAART). These side effects were attributed initially to the use of protease inhibitors (PIs). As a consequence, a series of trials were conducted where patients with well-controlled HIV viraemia either continued on PIs or were switched to a simplified maintenance therapy (SMT) without PIs. Evidence from these trials is still insufficient to show that switching from PIs to either abacavir, nevirapine or efavirenz is safe. However, patients with suboptimal pre-HAART treatment are at increased risk of virological failure if switched to an SMT. Patients switched from PI regimens tend to stay longer on an SMT and those switched to abacavir show a reduction in total cholesterol, but there is no evidence of any additional benefit from non-PI-based SMT. There is a clear need for a better understanding of HAART-related lipodystrophy and metabolic toxicity, and pharmacogenetic tests to identify those patients most at risk. The advent of simpler formulations for all drug classes, and new PIs with less metabolic toxicity, is likely to reshape completely the role of SMT. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "The impact of prebiopsy antibiotics on pathogen recovery in hematogenous vertebral osteomyelitis," by J. Marschall and colleagues in the 2011 issue.

Potent antiretroviral therapy (ART) has dramatically improved the prognosis of HIV-1-infected individuals. However, 10% to 30% of patients in Western countries still present late for care, when CD4 T cells are below 200 cells/mm3 and symptomatic HIV disease has occurred. Clinical considerations for advanced HIV disease are paramount as morbidity and mortality are directly correlated with a low initial CD4 T cell count, which is commonly associated with the simultaneous occurrence of co-morbidities, particularly opportunistic infections. Upon start of ART, the clinical entity of immune reconstitution inflammatory syndrome may occur and, in this context, raise the question of early versus delayed ART in patients treated for opportunistic infections. Recent data clearly indicate that an earlier start of ART is warranted in this latter situation. Guidelines for specific antiretroviral treatment for late-presenting patients are lacking. Knowledge about drug–drug interactions and co-morbidities should guide treatment choices and influence the clinical management and monitoring of drug-related side effects and interactions. Importantly, the outlook of patients who present late is very much dependent upon the initial response to ART. Nevertheless, even if optimal response to treatment has been achieved, long-term prognosis may be impaired in patients who initially presented with advanced HIV disease. We encourage physicians to perform HIV testing more frequently in order to detect HIV-infected individuals in time. [ABSTRACT FROM AUTHOR]