Search

This article discusses a case study of a 60-year-old woman living with HIV who had developed resistance to multiple classes of antiretroviral drugs. Despite various treatment adjustments, sustained virologic suppression remained elusive due to poor adherence and the accumulation of resistance mutations. The patient's viral sequence showed extensive resistance to multiple classes of drugs. However, through a combination of antivirals the patient was naïve to and the recycling of partially active drugs, virological control was regained. The article emphasizes the importance of a personalized therapy that meets the patient's desired quality of life and highlights the need for patient engagement and adherence for treatment efficacy. [Extracted from the article]

Objective: To describe the trajectories of the homeostatic model assessment for insulin resistance (HOMA‐IR) index in a cohort of HIV‐1 infected patients during their first‐line antiretroviral (ART) regimen. Methods: Retrospective analysis of naïve patients who started ART from 2007 at the Infectious Diseases Unit of the San Raffaele Hospital, Milan. We included patients treated with two nucleoside reverse transcriptase inhibitors (NRTIs, tenofovir, abacavir, lamivudine or emtricitabine), and one anchor drug (ritonavir‐boosted protease inhibitor [PI/r], non‐NRTI [NNRTI], or integrase strand transfer inhibitor [InSTI]), and with HOMA‐IR assessed both before and after the start of ART. Univariate and multivariate mixed linear models estimated HOMA‐IR changes during ART. Results: Among 618 patients included in the study, 218 received InSTI‐, 210 PI/r‐, and 190 NNRTI‐based regimens. Median follow‐up was 27.4 (16.3‐41.2) months. Adjusted mean change in HOMA‐IR index was significantly higher (P = .041) in patients treated with InSTI‐based regimens [0.160 (95% CI: 0.003‐0.321) units per year] compared with NNRTI‐based regimens [−0.005 (95% CI: −0.184‐0.074) units per year]; no difference was observed between patients treated with NNRTI‐ and PI/r‐based regimens or between INSTI‐based and PI/r‐based regimens. Conclusion: InSTI‐based first‐line ARTs were independently associated with greater increases in HOMA‐IR index. [ABSTRACT FROM AUTHOR]

Introduction: Switching to a rilpivirine, tenofovir and emtricitabine (RTE) single-tablet regimen (STR) has been evaluated in a limited number of virologically suppressed patients. The aim of this study was to describe clinical outcomes in HIV-positive patients switched from a suppressive antiretroviral regimen to RTE STR in routine clinical practice. Methods: In this retrospective study of antiretroviral-treated patients with <50 copies of HIV RNA/mL switched to RTE STR, virological failure (VF) was defined as two consecutive measurements of ≥50 copies/mL or a single measurement of ≥50 copies/mL followed by any change in treatment. Treatment failure (TF) was defined as VF or discontinuation of the STR for any reason. Univariate mixed-linear models were used to identify differences in laboratory parameters over time. Results and discussion: The analysis involved 307 patients (83% males) with a median age of 45.8 years (interquartile range (IQR 39.3–50.9), who were followed up for a median of 7.4 months (IQR 4.6–10.9). VF occurred in three patients (1%) switched from a protease inhibitor (PI)-based regimen, after a median of 2.6 months (IQR 1.6–3.0), and TF in 34 patients (11%) after a median of three months (IQR 1.4–5.8), 24 of whom (71%) were receiving a PI-based regimen at baseline. Overall, there was a slight but statistically significant improvement in the mean monthly change from baseline in CD4+ cell counts (p=0.027), the CD4+/CD8+ ratio (p=0.0001), and Hb (p=0.024), alanine amino transferase (ALT) (p=0.009), total bilirubin (p<0.0001), indirect bilirubin (p<0.0001), total cholesterol (p<0.0001) and triglyceride (p<0.0001) levels. There was also a slight but statistically significant increase in serum creatinine (p=0.0004), aspartate amino transferase (AST) (p=0.001) and liver fibrosis index (FIB-4) (p=0.002), and a decrease in eGFRcreat (p<0.0001) and high-density lipoprotein (HDL) cholesterol (p<0.0001) values. The study limitations include its retrospective design, the relatively short follow-up, and the absence of data concerning the severity of clinical adverse events; however, it does provide new information concerning the laboratory changes that occur in patients switching from PI-based or PI-sparing regimens to RTE STR. Conclusions: The study findings confirm the efficacy and safety in clinical practice of switching to RTE STR in virologically suppressed patients receiving other antiretrovirals [ABSTRACT FROM AUTHOR]

BACKGROUND The objective of this study was to compare immunologic, virologic, and clinical outcomes between living human immunodeficiency virus (HIV)-infected individuals who had a diagnosis of lymphoma versus outcomes in a control group of cancer-free, HIV-infected patients. METHODS In this matched cohort study, patients in the case group were survivors of incident lymphomas that occurred between 1997 and June 2010. Controls were living, cancer-free, HIV-infected patients who were matched to cases at a 4:1 ratio by age, sex, nadir CD4 cell count, and year of HIV diagnosis. The date of lymphoma diagnosis served as the baseline in cases and in the corresponding controls. RESULTS In total, 62 patients (cases) who had lymphoma (20 with Hodgkin disease [HD] and 42 with non-Hodgkin lymphoma [NHL]) were compared with 211 controls. The overall median follow-up was 4.8 years (interquartile range, 2.0-7.9 years). The CD4 cell count at baseline was 278 cells/mm3 (interquartile range, 122-419 cells/mm3) in cases versus 421 cells/mm3 (interquartile range, 222-574 cells/mm3) in controls ( P = .003). At the last available visit, the CD4 cell count was 412 cells/mm3 (range, 269-694 cells/mm3) in cases versus 518 cells/mm3 (interquartile range, 350-661 cells/mm3) in controls ( P = .087). The proportion of patients who achieved virologic success increased from 30% at baseline to 74% at the last available visit in cases ( P = .008) and from 51% to 81% in controls ( P = .0286). Patients with HD reached higher CD4 cell counts at their last visit than patients with NHL (589 cells/mm3 [range, 400-841 cells/mm3] vs 332 cells/mm3 [interquartile range, 220-530 cells/mm3], respectively; P = .003). Virologic success was similar between patients with HD and patients with NHL at the last visit. Forty cases (65%) and 76 controls (36%) experienced at least 1 clinical event after baseline ( P < .0001); cases were associated with a shorter time to occurrence of the first clinical event compared with controls ( P < .0001). CONCLUSIONS HIV-infected lymphoma survivors experienced more clinical events than controls, especially during the first year of follow-up, but they reached similar long-term immunologic and virologic outcomes. Cancer 2013;119:2710-2719. © 2013 American Cancer Society. [ABSTRACT FROM AUTHOR]

Few data are available regarding the 10-year survival among subjects with HIV and cancer. The aim of this study was to evaluate the 10-year survival of HIV-infected subjects with AIDS-defining malignancies (ADM) or non-AIDS-defining malignancies (NADM). This was a single center, retrospective, observational study of subjects with HIV infection and a subsequent cancer diagnosis; the data were collected from January 1991 to April 2010. Malignancies were divided into ADM or NADM on the basis of the Centre of Diseases Control-1993 classification. Survival curves were estimated using Kaplan-Meyer method and compared by the log-rank test. Six hundred and fifteen (9.5%) of the 6,495 subjects recorded in the San Raffaele Infectious Diseases Database developed a malignancy: 431 (70%) an ADM and 184 (30%) a NADM. In the case of ADM, survival was more favorable when cancer was diagnosed during post-highly active antiretroviral therapy (HAART) era (10-year survival: 43.2% ± 4.4%) than when diagnosed during the pre-HAART era (10-year survival: 16.4% ± 2.7%; log-rank test: p < 0.001). The same was true in the case of NADM (10-year survival: 44.7% ± 5.5% vs. 33.3 ± 9.6%; log-rank test: p = 0.03). An evaluation of survival probability by cancer type showed higher survival rates during the post-HAART era in the case of non-Hodgkin lymphoma (10-year survival: 42.1% ± 5.3% vs. 11.4% ± 3.3%; log-rank test: p = <0.001), Kaposi's sarcoma (10-year survival: 44.0% ± 8.4% vs. 23.5% ± 3.9%; log-rank test: p < 0.001) and Hodgkin's disease (10-year survival: 49.5% ± 14.5% vs. 40.0% ± 12.7%; log-rank test: p = 0.005). Despite the better cancer prognosis during the post-HAART era, the 10-year survival of HIV-infected subjects with an ADM or NADM is poor. [ABSTRACT FROM AUTHOR]

Introduction The 48-week interim analysis of the MODAT study showed that confirmed virologic failure (CVF) was more frequent in patients simplifying to ATV/r monotherapy compared to maintaining ATV/r-based triple therapy. The DSMB recommended stopping study enrollment but continuing follow-up of enrolled patients. We present the 96-week efficacy analysis. Material and Methods Multicentre, randomized, open-label, non-inferiority trial (non-inferiority margin −10%). Treatment failure (TF) was defined as CVF (two consecutive HIV-RNA >50 cp/mL) or discontinuation for any cause. In the monotherapy arm, patients with CVF re-introduced their previous NRTIs and remained in the study if HIV-RNA <50 copies/mL within 12 weeks of re-intensification. Results 101 patients evaluated (Figure 1): 85% males, 21% HCV-positive, median (IQR) age of 42 (36-48) years, baseline CD4+ 576 (447-743) cells/µL. In the 96-week analysis (ITT; TF=failure), efficacy was 64% (32/50) in the monotherapy arm and 63% (32/51) in the triple-therapy arm (difference +1.3%, 95% CI −17.5-20.1). Fourteen patients in monotherapy and two in triple-therapy arm had CVF; median HIV-RNA was 136 (72-376) copies/mL. In monotherapy arm, no PI or NRTI associated resistance mutations were observed at CVF. All patients who re-intensified re-suppressed. In monotherapy arm, TF was more frequent in HCV-co-infected patients (64% vs 28%; p=0.041). In the secondary analysis (ITT; re-intensification=success), 82% (41/50) in monotherapy arm and 63% (32/51) in triple-therapy arm were on study at week 96 (difference +19.3%, 95% CI 2.2-36.3). SAEs occurred in four (8%) patients in the monotherapy arm (one left basal pneumonia, one acute coronary stenosis, one traumatic lesion, one nephrolithiasis) and two (4%) in the triple therapy arm (one sepsis, one renal failure). Drug-related adverse events (AEs) leading to discontinuation were three (6%) in the monotherapy arm (two AEs occurred in patients after successful re-intensification) and 12 (23.5%) in the triple-therapy (p=0.023). Conclusions Despite the small sample size, the primary 96-week analysis showed that simplification to ATV/r monotherapy showed inferior efficacy to maintaining ATV/r triple-therapy but appeared to be superior when re-intensification was considered success. [ABSTRACT FROM AUTHOR]

Introduction Unboosted atazanavir (ATV) including regimens have been investigated as a ritonavir-sparing simplification strategy. No data are available on removal of one NRTI in subjects effectively treated with unboosted atazanavir+2NRTIs. We present the 48-week virological efficacy and safety of unboosted atazanavir plus lamivudine (3TC) or emtricitabine (FTC) (lamivudine/emtricitabine/Reyataz©, LAREY Study). Materials and Methods Single arm, prospective, pilot study on HIV-treated patients, HBsAg negative, with HIV-RNA<50 cps/mL since at least 2 years, who switched from ATV+2NRTIs to ATV 400 mg QD +3TC or FTC. Virological failure was defined as 2 consecutive values of HIV-RNA>50 cps/ml; viral blip was defined as a single HIV-RNA value>50 cps/ml not subsequently confirmed. Results as median (IQR). Changes between baseline (BL) and week 48 assessed by the Wilcoxon signed rank test. Results Forty patients enrolled: 75% males, 51 (47-54) years, 14% HCV co-infected, infected with HIV since 16 (9-21) years, on antiretroviral therapy since 13 (5-16) years, with a nadir CD4+ of 254 (157-307) cells/mm3, virologically suppressed since 4.2 (2.2-5.4) years; 53 patients switched from a tenofovir (TDF)-based regimens; ATV was associated with 3TC in 83% patients. No virological failures or discontinuations were observed; three patients had a single viral blip in the range 50-250 copies/mL; CD4+ increased from 610 (518-829) cells/mm3 at BL to 697 (579-858) cells/mm3 at week 48 [48-week change: 39 (−63/+160) cells/mm3 p=0.081]. Three clinical events were observed (one herpes zoster, one pneumonia, one syphilis) in absence of renal lithiasis, AIDS-defining or drug-related events or death. Overall, significant 48-week amelioration of ALP [BL: 83 (71-107) mg/dL; 48-week change: −15 (−27/−8) mg/dL p<0.0001] and CKD-EPI [BL: 100 (86-108) ml/min/1.73 m2; 48-week change: 1.5 (−3/+8) ml/min/1.73 m2, p=0.042] were observed. Patients switching from TDF (Table 1) significantly improved CD4+, lymphocytes, hepatic profile, renal profile and ALP; these patients had also a modest but significant decrease in haemoglobin. Conclusions Switch from an unboosted atazanavir-based regimen to ATV+3TC or FTC regimen was effective and safe in this small sample, supporting the hypothesis of a potential two-steps de-intensification (removal of ritonavir and removal of one NRTI) in patients on long-lasting virological suppression. [ABSTRACT FROM AUTHOR]

Introduction The aim of this study was to determine factors associated with lack of serological response (LSR) to treatment of syphilis among HIV-infected subjects. Materials and Methods Retrospective, longitudinal study on HIV-infected subjects diagnosed and treated for syphilis and with an assessable serological response between 1 January 2004 and 15 September 2013. LSR was defined as a <4-fold decline of rapid plasma reagin (RPR) titer or a failed reversion to nonreactive (if RPR ≤1:4 at diagnosis) after one year since treatment. Diagnoses of syphilis were staged in early syphilis (primary, secondary and early latent) or late syphilis (tertiary and late latent) according to clinical examination and patient's history. Syphilis was classified in new infections [NI: positive RPR and TPHA ( Treponema pallidum Haemagglutination assay) titers in subjects without previous history of syphilis] or re-infections [ReI: a ≥4-fold increase of RPR titer in subjects previously successfully treated for syphilis]. Syphilis treatment was prescribed according to CDC guidelines. The crude incidence rates (IRs) of LSR were calculated per 1000-person months of follow-up (PMFU) as the total number of LSR episodes divided by the cumulative time contributed by all subjects (interval time since each syphilis diagnosis and the date of ascertainment of response). Results are described as median (IQR) or frequency (%). Results 565 diagnoses of syphilis with an assessable serological response in 421 patients; 458 (81%) were early syphilis, 189 (33%) were NI, 376 (67%) were ReI. At first, diagnosis of syphilis median age was 41 (36-47) years, 419 (99.5%) males, 391 (93%) MSM, HIV-infected since 7.7 (3.5-12.9) years, 75 (18%) HCV or HBV co-infected, 56 (13%) with a previous AIDS diagnosis, 82 (19%) antiretroviral treatment naïve, 102 (24%) with HIV-RNA ≥50 cp/mL, CD4+=576 (437-749) cells/mm3, nadir CD4+=308 (194-406) cells/mm3. LSRs were observed in 70/565 (12.4%) treated syphilis. Incidence of LSR decreased over time [2004-2008 IR=25.1 (17.2-33.1)/1000 PMFU; 2009-2010 IR=21.1 (12.3-29.9)/1000 PMFU; 2011-2013 IR=10.6 (5.1-18.2)/1000 PMFU; Poisson regression: p=0.001]. Results of univariate and multivariate analysis on the risk of LSR are reported in Table 1. Conclusions In HIV-infected subjects we observed 12% of LSR to treatment of syphilis. LSR was associated with an older age, late syphilis, lower nadir CD4+ and detectable HIV viral load. [ABSTRACT FROM AUTHOR]