HIV status and participation in HIV surveillance in the era of antiretroviral treatment: a study of linked population‐based and clinical data in rural South Africa

Objective To examine whether HIV status affects participation in a population‐based longitudinal HIV surveillance in the context of an expanding HIV treatment and care programme in rural South Africa. Method We regressed consent to participate in the HIV surveillance during the most recent fieldworker visit on HIV status (based on previous surveillance participation or enrolment in pre‐antiretroviral treatment (pre‐ART) care or ART in the local HIV treatment and care programme), controlling for sex, age and year of the visit (N = 25 940). We then repeated the regression using the same sample but, in one model, stratifying HIV‐infected persons into three groups (neither enrolled in pre‐ART care nor receiving ART; enrolled in pre‐ART care but not receiving ART; receiving ART) and, in another model, additionally stratifying the group enrolled in pre‐ART and the group receiving ART into those with CD4 count ≤200/μl (i.e. the ART eligibility threshold at the time) vs. those with CD4 count >200/μl. Results HIV‐infected individuals were significantly less likely to consent to participate in the surveillance than HIV‐uninfected individuals [adjusted odds ratio (aOR), 0.74; 95% confidence interval, 0.70–0.79, P < 0.001], controlling for other factors. Persons who were receiving ART were less likely to consent to participate (aOR, 0.75, 0.68–0.84, P < 0.001) than those who had never sought HIV treatment or care (aOR, 0.82, 0.75–0.89, P < 0.001), but more likely to consent than persons enrolled in pre‐ART care (aOR 0.62, 0.56–0.69, P < 0.001). Those with CD4 count ≤200/μl were significantly less likely to consent to participate than those with CD4 count >200/μl in both the group enrolled in pre‐ART and the group receiving ART. Conclusion As HIV test results are not made available to participants in the HIV surveillance, our findings agree with the hypothesis that HIV‐infected persons are less likely than HIV‐uninfected persons to participate in HIV surveillance because they fear the negative consequences of others learning about their HIV infection. Our results further suggest that the increased knowledge of HIV status that accompanies improved ART access can reduce surveillance participation of HIV‐infected persons, but that this effect decreases after ART initiation, in particular in successfully treated patients.     

Delayed diagnosis of HIV infection and late initiation of antiretroviral therapy in the Swiss HIV Cohort Study

Objectives

To investigate delayed HIV diagnosis and late initiation of antiretroviral therapy (ART) in the Swiss HIV Cohort Study.

Methods

Two sub‐populations were included: 1915 patients with HIV diagnosis from 1998 to 2007 and within 3 months of cohort registration (group A), and 1730 treatment‐naïve patients with CD4≥200 cells/μL before their second cohort visit (group B). In group A, predictors for low initial CD4 cell counts were examined with a median regression. In group B, we studied predictors for CD4<200 cells/μL without ART despite cohort follow‐up.

Results

Median initial CD4 cell count in group A was 331 cells/μL; 31% and 10% were <200 and <50 cells/μL, respectively. Risk factors for low CD4 count were age and non‐White race. Homosexual transmission, intravenous drug use and living alone were protective. In group B, 30% initiated ART with CD4≥200 cells/μL; 18% and 2% dropped to CD4 <200 and <50 cells/μL without ART, respectively. Sub‐Saharan origin was associated with lower probability of CD4 <200 cells/μL without ART during follow‐up. Median CD4 count at ART initiation was 207 and 253 cells/μL in groups A and B, respectively.

Conclusions

CD4<200 cells/μL and, particularly, CD4<50 cells/μL before starting ART are predominantly caused by late presentation. Earlier HIV diagnosis is paramount.     

Correlates of antiretroviral utilization among hospitalized HIV-infected crack cocaine users

Despite the availability of antiretroviral therapy (ART), HIV-infected drug users, particularly crack cocaine users, continue to have high HIV-related morbidity and mortality. We conducted a cross-sectional analysis of the baseline data for hospitalized HIV-infected crack cocaine users recruited for Project HOPE (Hospital Visit Is an Opportunity for Prevention and Engagement with HIV-Positive Crack Users) in Atlanta and Miami who were eligible for ART (reported any lifetime use of ART or CD4 <350 cells/μl). Among 350 eligible participants, whose mean age was 44.9 years (SD 7.0), 49% were male, 90% were black, and 81% were heterosexual. The median CD4 count was 144 cells/μl, and 78 of 350 (22%) were taking ART. We conducted a multivariable logistic regression to examine individual, interpersonal, and structural factors as potential correlates of ART use. Reporting ≥2 visits to outpatient HIV care in the past 6 months (AOR 7.55, 95% CI 3.80-14.99), drug or alcohol treatment in the past 6 months (AOR 2.29, 95% CI 1.06-4.94), and study site being Miami (AOR 2.99, 95% CI 1.56-5.73) were associated with ART use. Current homelessness (AOR 0.41, 95% CI 0.20-0.84) and CD4 <200 cells/μl (AOR 0.29, 95% CI 0.15-0.55) were negatively associated with ART use. Among those taking ART, 60% had an HIV-1 viral load <400 copies/ml; this represented 9% of the eligible population. For HIV-infected crack cocaine users, structural factors may be as important as individual and interpersonal factors in facilitating ART utilization. Few HIV(+) crack cocaine users had viral suppression, but among those on ART, viral suppression was achievable.     

Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America

Objectives To describe temporal trends in baseline clinical characteristics, initial treatment regimens and monitoring of patients starting antiretroviral therapy (ART) in resource‐limited settings. Methods We analysed data from 17 ART programmes in 12 countries in sub‐Saharan Africa, South America and Asia. Patients aged 16 years or older with documented date of start of highly active ART (HAART) were included. Data were analysed by calculating medians, interquartile ranges (IQR) and percentages by regions and time periods. Not all centres provided data for 2006 and 2005 and 2006 were therefore combined. Results A total of 36 715 patients who started ART 1996–2006 were included in the analysis. Patient numbers increased substantially in sub‐Saharan Africa and Asia, and the number of initial regimens declined, to four and five, respectively, in 2005–2006. In South America 20 regimes were used in 2005–2006. A combination of 3TC/D4T/NVP was used for 56% of African patients and 42% of Asian patients; AZT/3TC/EFV was used in 33% of patients in South America. The median baseline CD4 count increased in recent years, to 122 cells/μl (IQR 53–194) in 2005–2006 in Africa, 134 cells/μl (IQR 72–191) in Asia, and 197 cells/μl (IQR 61–277) in South America, but 77%, 78% and 51%, respectively, started with <200 cells/μl in 2005–2006. In all regions baseline CD4 cell counts were higher in women than men: differences were 22cells/μl in Africa, 65 cells/μl in Asia and 10 cells/μl in South America. In 2005–2006 a viral load at 6 months was available in 21% of patients Africa, 8% of Asian patients and 73% of patients in South America. Corresponding figures for 6‐month CD4 cell counts were 74%, 77% and 81%. Conclusions The public health approach to providing ART proposed by the World Health Organization has been implemented in sub‐Saharan Africa and Asia. Although CD4 cell counts at the start of ART have increased in recent years, most patients continue to start with counts well below the recommended threshold. Particular attention should be paid to more timely initiation of ART in HIV‐infected men.     

Trends over time of virological and immunological characteristics in the Swiss HIV Cohort Study

Background

The long‐term outcome of antiretroviral therapy (ART) is not assessed in controlled trials. We aimed to analyse trends in the population effectiveness of ART in the Swiss HIV Cohort Study over the last decade.

Methods

We analysed the odds of stably suppressed viral load (ssVL: three consecutive values <50 HIV‐1 RNA copies/mL) and of CD4 cell count exceeding 500 cells/μL for each year between 2000 and 2008 in three scenarios: an open cohort; a closed cohort ignoring the influx of new participants after 2000; and a worst‐case closed cohort retaining lost or dead patients as virological failures in subsequent years. We used generalized estimating equations with sex, age, risk, non‐White ethnicity and era of starting combination ART (cART) as fixed co‐factors. Time‐updated co‐factors included type of ART regimen, number of new drugs and adherence to therapy.

Results

The open cohort included 9802 individuals (median age 38 years; 31% female). From 2000 to 2008, the proportion of participants with ssVL increased from 37 to 64% [adjusted odds ratio (OR) per year 1.16 (95% CI 1.15–1.17)] and the proportion with CD4 count >500 cells/μL increased from 40 to >50% [OR 1.07 (95% CI 1.06–1.07)]. Similar trends were seen in the two closed cohorts. Adjustment did not substantially affect time trends.

Conclusions

There was no relevant dilution effect through new participants entering the open clinical cohort, and the increase in virological/immunological success over time was not an artefact of the study design of open cohorts. This can partly be explained by new treatment options and other improvements in medical care.     

Vertically acquired HIV diagnosed in adolescence and early adulthood in the United Kingdom and Ireland: findings from national surveillance

Objective

The aim of the study was to describe the characteristics of young people with vertically acquired HIV diagnosed aged ≥13 years.

Methods

A retrospective review of HIV diagnoses reported to well‐established national paediatric and adult HIV surveillance systems in the United Kingdom/Ireland was conducted.

Results

Forty‐two young people with vertically acquired HIV diagnosed aged ≥13 years were identified; 23 (55%) were female, 40 (95%) were black African and 36 (86%) were born in sub‐Saharan Africa. The median age at HIV diagnosis was 14 years (range, 13–20 years). Half of the patients presented with symptoms; the remainder were screened for HIV following diagnosis of a relative. The median CD4 count at diagnosis was 210 cells/μL (range, 0–689 cells/μL), 12 patients (29%) were diagnosed with AIDS at HIV diagnosis or subsequently, and 34 (81%) started combination antiretroviral therapy (ART), most (31 of 34) within a year of diagnosis.

Conclusion

A small number of young people with vertically acquired HIV survive childhood without ART and are diagnosed at age ≥13 years in the United Kingdom/Ireland. Half of the patients were asymptomatic, highlighting the importance of considering HIV testing for all offspring of HIV‐infected women, regardless of age or symptoms. Increased awareness among clinicians and parents is required to reduce delayed presentation with advanced disease and to avoid onward transmission as these young people become sexually active.     

Use of nail and oral pigmentation to determine ART eligibility among HIV‐infected Ugandan adults

Objectives To evaluate the use of grey/distal banded nails as an indicator of advanced immunosuppression, and thus eligibility for ART, in resource poor settings. Methods We tested whether grey/distal banded nails and/or oral pigmentation could be used to identify patients with low CD4 cell counts at two cut‐offs: <200 and <350 cells/μl in ART naive adults. Results Four hundred and three nail and oral cavities were photographed and assessed. Grey/distal banded nails and/or oral pigmentation were significantly associated with a CD4 cell count <200 cells/μl (P < 0.001), with a sensitivity of 66%, a specificity of 50% and a negative predictive value of 77%. However, there was no association when a CD4 cell count cut‐off of <350 cells/μl was used. Inter‐observer agreement (k 0.46) was fair/moderate. Conclusions While grey/distal banded nails and/or oral pigmentation are associated with low CD4 counts, the sensitivity and kappa score are too low for this method to be recommended as a tool to guide ART initiation; large number of individuals eligible for ART would be missed.     

Low mortality risk but high loss to follow‐up among patients in the Tanzanian national HIV care and treatment programme

Objective To analyse survival and retention rates of the Tanzanian care and treatment programme. Methods Routine patient‐level data were available from 101 of 909 clinics. Kaplan–Meier probabilities of mortality and attrition after ART initiation were calculated. Mortality risks were corrected for biases from loss to follow‐up using Egger’s nomogram. Smoothed hazard rates showed mortality and attrition peaks. Cox regression identified factors associated with death and attrition. Median CD4 counts were calculated at 6 month intervals. Results In 88,875 adults, 18% were lost to follow up 12 months after treatment initiation, and 36% after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting for loss to follow‐up) and 14% by 36 months. Mortality and attrition rates both peaked within the first six months, and were higher among males, those under 45 kg and those with CD4 counts below 50 cells/μl at ART initiation. In the first year on ART, median CD4 count increased by 126 cells/μl, with similar changes in both sexes. Conclusion Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates if combined with better patient tracing systems. Further research is needed to explore reasons for attrition.     

Immunosuppression among HIV‐1‐positive patients attending for care: experience from two large HIV centres in the United Kingdom

Objectives

The aim of the study was to describe the prevalence of and examine the factors associated with immunosuppression (CD4<200 cells/μL) among HIV‐infected patients attending two large inner London treatment centres.

Methods

Patients attending for care who had a CD4 count <200 cells/μL during a 6‐month period (1 January to 30 June 2007) were identified from the UK national CD4 surveillance database. Corresponding case notes were reviewed and factors associated with the most recent immunosuppressive episode examined. Patients either previously had a CD4 count >200 cells/μL at any time under follow‐up which had decreased (group A) or never had a CD4 count >200 cells/μL (group B; late presenters).

Results

Of 4589 patients, 10.2% (467) had at least one CD4 count <200 cells/μL. In group A (60.1% of patients), 70.4% were not receiving antiretroviral therapy (ART) at the time at which the CD4 count fell to <200 cells/μL. Reasons included: treatment interruption (TI; 32.6%), patient declined ART (20.2%), infrequent attendance (19.1%), physician delay in offer (23.1%) and transient CD4 cell count decrease (3.9%). Among those receiving ART, one in three had poor adherence. In group B, 92.3% had started ART after presentation: most had recently started and were responding virologically. AIDS‐defining diagnoses occurred in the year preceding the decrease in CD4 cell count in 12.6% of patients in group A and 33.3% of those in group B.

Conclusion

The majority of patients became immunosuppressed while under care. Our findings suggest that, in addition to strategies aimed at earlier diagnosis, there are further opportunities to reduce severe immunosuppression in patients already attending for HIV care.     

Social support,disclosure and stigma and the association with non-adherence in the six months after antiretroviral therapy initiation among a cohort of HIV-positive adults in rural KwaZulu-Natal,South Africa*

The World Health Organisation (WHO) recommends antiretroviral treatment (ART) initiation at human immunodeficiency virus (HIV) diagnosis. As ART programmes expand, addressing barriers to adherence is vital. Past mixed findings on the association between social support, stigma and non-disclosure with ART adherence highlights the need for further research. The primary aim of this study was to examine how these factors are associated with ART non-adherence in the six months after ART initiation. The secondary aim was to explore how other factors are associated with non-adherence. We conducted secondary analysis of prospective data from HIV-positive adults initiating ART. Social support, disclosure patterns, perceived stigma and other demographic factors were collected at ART initiation and six months follow-up. Logistic regression models were used to examine factors associated with self-reported ART non-adherence in the last six months and the last month before the six month follow-up (“recent”). Non-adherence in the last six months was twenty-five percent and recent non-adherence was nine percent. There was no association between non-adherence and social support, stigma or non-disclosure of HIV status. In the final model the odds of non-adherence in the last six months were significantly higher for those: with incomplete ART knowledge (aOR 2.10, 95%CI 1.21–3.66); who visited a healthcare provider for conditions other than HIV (aOR1.98, 95%CI 1.14–3.43); had higher CD4 counts at ART initiation (CD4 100–199:aOR 2.50, 95%CI 1.30–4.81; CD4?≥?200:aOR 2.85, 95%CI 1.10–7.40;referent CD4?<?100?cells/mm³); had tested HIV-positive in the last year (aOR 2.00, 95%CI 1.10–3.72; referent testing HIV-positive outside the last year); experienced a rash/itching secondary to ART (aOR 2.48, 95%CI 1.37–4.52); and significantly lower for those ≥48 years (aOR 0.65, 95%CI 0.46–0.90). Early non-adherence remains a concern. Incorporation of adherence monitoring and ART knowledge enhancement into appointments for ART collection may be beneficial.     

Total lymphocyte count is a good marker for HIV-related mortality and can be used as a tool for starting HIV treatment in a resource-limited setting

Objectives Total lymphocyte counts (TLC) may be used as an alternative for CD4 cell counts to monitor HIV infection in resource‐limited settings, where CD4 cell counts are too expensive or not available. Methods We used prospectively collected patient data from an urban HIV clinic in Indonesia. Predictors of mortality were identified via Cox regression, and the relation between TLC and CD4 cell counts was calculated by linear regression. Receiver operating characteristics (ROC) curves were used to choose the cut‐off values of TLC corresponding with CD4 cell counts <200 and ≤350 cells/μl. Based on these analyses, we designed TLC‐based treatment algorithms. Results Of 889 antiretroviral treatment (ART)‐naïve subjects included, 66% had CD4 cell counts <200 and 81% had 350 ≤ cells/μl at baseline. TLC and CD4 cell count were equally strong predictors of mortality in our population, where ART was started based on CD4 cell count criteria. The correlation coefficient (R) between TLC and √CD4 was 0.70. Optimal cut‐off values for TLC to identify patients with CD4 cell counts <200 and ≤350 cells/μl were 1500 and 1700 cells/μl, respectively. Treatment algorithms based on a combination of TLC, gender, oral thrush, anaemia and body mass index performed better in terms of predictive value than WHO staging or TLC alone. In our cohort, such an algorithm would on average have saved $14.05 per patient. Conclusion Total lymphocyte counts is a good marker for HIV‐associated mortality. Simple algorithms including TLC can prioritize patients for HIV treatment in a resource‐limited setting, until affordable CD4 cell counts will be universally available.     

Outcomes after two years of providing antiretroviral treatment in Khayelitsha, South Africa

BACKGROUND: A community-based antiretroviral therapy (ART) programme was established in 2001 in a South African township to explore the operational issues involved in providing ART in the public sector in resource-limited settings and demonstrate the feasibility of such a service. METHODS: Data was analysed on a cohort of patients with symptomatic HIV disease and a CD4 lymphocyte count < 200 x 10 cells/l. The programme used standardized protocols (using generic medicines whenever possible), a team-approach to clinical care and a patient-centred approach to promote adherence. RESULTS: Two-hundred and eighty-seven adults naive to prior ART were followed for a median duration of 13.9 months. The median CD4 lymphocyte count was 43 x 10 cells/l at initiation of treatment, and the mean log10 HIV RNA was 5.18 copies/ml. The HIV RNA level was undetectable (< 400 copies/ml) in 88.1, 89.2, 84.2, 75.0 and 69.7% of patients at 3, 6, 12, 18 and 24 months respectively. The cumulative probability of remaining alive was 86.3% at 24 months on treatment for all patients, 91.4% for those with a baseline CD4 lymphocyte count > or =50 x 10 cells/l, and 81.8% for those with a baseline CD4 lymphocyte count < 50 x 10 cells/l. The cumulative probability of changing a single antiretroviral drug by 24 months was 15.1% due to adverse events or contraindications, and 8.4% due to adverse events alone. CONCLUSIONS: ART can be provided in resource-limited settings with good patient retention and clinical outcomes. With responsible implementation, ART is a key component of a comprehensive response to the epidemic in those communities most affected by HIV.     

Evaluation of affordable screening markers to detect CD4+ T‐cell counts below 200 cells/μl among HIV‐1‐infected Ugandan adults

Objective To evaluate validity of WHO staging, low body mass index (BMI) and anaemia in detecting HIV‐infected adults with CD4+ T‐cell counts < 200 cells/μl. Methods Between October 1995 and April 2006, we screened Ugandans aged 16 or older at enrolment into an open cohort. We analysed highly active anti‐retroviral therapy (HAART)‐naïve HIV‐infected patients with WHO stages 1–3 and complete data in a secondary cross‐sectional study. Low BMI was a BMI < 18.5 kg/m². Anaemia was a haemoglobin level < 11 or 12 g/dl among women and men respectively. Results Among 2892 HAART‐naïve patients, the median age was 32 years. 71% were women, 54% had WHO stage 3 AIDS, 34% had anaemia, 16% had a low BMI and 43% had CD4+ T‐cell counts < 200 cells/μl. WHO stage 3 compared to combined WHO stages 1 and 2 had a sensitivity (95% CI) of 70% (67, 72) and a specificity of 57% (55, 60) respectively to detect CD4+ T‐cell counts < 200 cells/μl. Anaemia compared to normal haemoglobin had sensitivity (95% CI) of 47% (44, 50) and a specificity of 76% (74, 78). Low BMI compared to normal BMI had sensitivity (95% CI) of 23% (20, 25) and a specificity of 89% (87, 90) against CD4+ T‐cell counts < 200 cells/μl. Conclusion Only WHO stage 3 had reasonably high sensitivity in detecting CD4+ T‐cell counts below 200 cells/μl in this setting. Targeted low‐cost CD4 testing strategies are urgently needed to detect patients eligible for HAART in rural Africa and other resource‐limited settings.     

Characterising B cell numbers and memory B cells in HIV infected and uninfected Malawian adults

Background

Untreated human immunodeficiency virus (HIV) disease disrupts B cell populations causing reduced memory and reduced naïve resting B cells leading to increases in specific co-infections and impaired responses to vaccines. To what extent antiretroviral treatment reverses these changes in an African population is uncertain.

Methods

A cross-sectional study was performed. We recruited HIV-uninfected and HIV-infected Malawian adults both on and off antiretroviral therapy attending the Queen Elizabeth Central hospital in Malawi. Using flow cytometry, we enumerated B cells and characterized memory B cells and compared these measurements by the different recruitment groups.

Results

Overall 64 participants were recruited - 20 HIV uninfected (HIV-), 30 HIV infected ART naïve (HIV+N) and 14 HIV-infected ART treated (HIV+T). ART treatment had been taken for a median of 33 months (Range 12-60 months). Compared to HIV- the HIV+N adults had low absolute number of naïve resting B cells (111 vs. 180 cells/μl p = 0.008); reduced memory B cells (27 vs. 51 cells/μl p = 0.0008). The HIV+T adults had B-cell numbers similar to HIV- except for memory B cells that remained significantly lower (30 vs. 51 cells/μl p = 0.02). In the HIV+N group we did not find an association between CD4 count and B cell numbers.

Conclusions

HIV infected Malawian adults have abnormal B-cell numbers. Individuals treated with ART show a return to normal in B-cell numbers but a persistent deficit in the memory subset is noted. This has important implications for long term susceptibility to co-infections and should be evaluated further in a larger cohort study.

     

Immunovirological outcomes and resistance patterns at 4 years of antiretroviral therapy use in HIV-infected patients in Cambodia

Objectives To report immunovirological outcomes and resistance patterns in adults treated with triple combination antiretroviral therapy (cART) for 4 years in an HIV programme of Phnom Penh, Cambodia. Methods It is a longitudinal study and cross‐sectional evaluation of adults receiving cART for 4 years. CD4 cell counts and HIV‐1 RNA were quantified, and resistance patterns were determined. Drug‐related toxicity was assessed by clinicians and through laboratory testing. Results After 4 years of cART start, the cumulative probability of retention in care was 0.80 and survival among patients not lost to follow‐up was 0.85. A total of 349 patients (98% of eligible) participated in the cross‐sectional evaluation. Ninety per cent were receiving first‐line therapy, 29% stavudine‐ and 58% zidovudine‐containing regimens (compared with 94% and 3% at cART initiation). Ninety‐three per cent of patients were clinically asymptomatic, and severe lipodystrophy and dyslipidemia were diagnosed in 7.2% and 4.0%, respectively. Good treatment adherence was reported by 83% of patients. Median CD4 T‐cell count was 410 cells/μl [IQR 290–511], and 90% of patients had >200 cells/μl. Only 15 (4%) patients had detectable HIV viral load (eight had <200 CD4 cells/μl), five had thymidine analogue mutations, and nine were resistant to two drug classes. In an intention‐to‐treat analysis, 26.1% (95% CI 22.0–30.5) of patients had failed first‐line therapy. Conclusions In this Cambodian cohort of adults who started cART at an advanced stage of HIV disease, we observed good clinical and immunovirological outcomes and self‐reported treatment adherence at 4 years of therapy.     

Favourable evolution of virological and immunological profiles in treated and untreated patients in Italy in the period 1998–2008

Background

This study provides an estimate of the proportion of HIV‐positive patients in Italian clinics showing an ‘adverse prognosis’ (defined as a CD4 count ≤200 cells/μL or an HIV RNA >50 HIV‐1 RNA copies/mL) over time, and investigates whether this proportion varied according to patients' characteristics.

Methods

We estimated the annual proportion of patients with a CD4 count ≤200 cells/μL or HIV RNA >50 copies/mL out of the total number of patients in the Icona Foundation cohort seen in any given year, both overall and after stratifying by demographical and treatment status groups. Generalized estimating equation models for Poisson regression were applied.

Results

In 1998–2008, the prevalence of patients with a CD4 count ≤200 cells/μL decreased from 14 to 6% [adjusted relative risk (RR) 0.86/year; 95% confidence interval (CI) 0.84–0.88; P<0.0001]. The prevalence of HIV RNA >50 copies/mL decreased from 66 to 40% (adjusted RR 0.95/year; 95% CI 0.95–0.96; P<0.0001) in all patients and from 38 to 12% in the subgroup of patients who had previously received antiretroviral therapy (ART) for ≥6 months (adjusted RR 0.89/year; 95% CI 0.88–0.90; P<0.0001).

Conclusions

There was a substantial increase in the success rate of ART in Italy in 1998–2008, resulting in a lower percentage of patients with adverse prognosis in recent years. The use of ART seemed to be the most important determinant of viral load outcome, regardless of mode of transmission. Although injecting drug users showed a less marked improvement in CD4 cell count over time than other risk groups, they showed a similar improvement in detectable viral load.     

Low Nadir CD4 Cell Count Predicts Sustained Hypertension in HIV‐Infected Individuals

Hypertension is associated with cardiovascular disease in the human immunodeficiency virus (HIV)–infected population. The authors aimed to test the hypothesis whether advanced immunosuppression with low nadir CD4 lymphocyte cell count is a predictor of sustained hypertension in HIV‐infected individuals. In a longitudinal study of an HIV cohort of 434 patients (43±11 years, 72% men, 71% Caucasians), standardized blood pressure was measured in duplicate during 3 clinical visits both at baseline and after 3.4±0.8 years. The lowest CD4 cell count in the individual history was recorded as nadir CD4. Both nadir CD4 cell count <50 cells/μL and duration of antiretroviral therapy (ART) were associated with sustained hypertension, and the highest proportion of hypertensive patients was observed in those who had both nadir CD4 cell count <50 cells/μL and prolonged ART duration. Nadir CD4 cellcount <50 cells/μL was an independent predictor of hypertension (adjusted odds ratio [OR], 2.48; 95% confidence interval [CI], 1.27–4.83), as was ART duration (adjusted OR, 1.13; 95% CI, 1.03–1.24). The predictive power of ART duration was more pronounced in patients with nadir CD4 cell count <50 cells/μL. Delaying ART initiation until a state of advanced immunosuppression might add to and even fuel the cardiovascular risk associated with ART. J Clin Hypertens (Greenwich). 2012; 00:00–00 ©2012 Wiley Periodicals, Inc.     

Once Daily Dosing Improves Adherence to Antiretroviral Therapy

We studied the association of once-daily dosing with self-reported adherence among participants of the Ontario Cohort Study who were currently taking ART and who had completed a 90-min interviewer-administered questionnaire. Suboptimal adherence was defined as missing ≥1 dose of ART in the 4 days prior to the interview. Participants (n = 779) were 85% male, 69% men having sex with men, 67% white, median age 48 years (IQR 42-54), median years of ART 9 (IQR 5-13) and median CD4 count 463 cells/mm(3) (IQR 320-638). Fifteen percent of participants reported suboptimal adherence in the 4 days prior to the interview. In a multivariable logistic regression model, participants on once daily regimens were half as likely to miss a dose during the 4 days prior to the interview. Other independent correlates of suboptimal adherence were younger age, lower positive social interaction and increased frequency of consuming > 6 alcoholic drinks on one occasion.     

Standard-dose efavirenz vs. standard-dose nevirapine in antiretroviral regimens among HIV-1 and tuberculosis co-infected patients who received rifampicin

Background

There is limited comparative data between efavirenz (EFV) 600 mg/day and nevirapine (NVP) 400 mg/day‐based antiretroviral therapy (ART) among HIV‐1 patients with tuberculosis (TB) and receiving rifampicin.

Methods

A retrospective cohort study was conducted in all ART‐naïve patients who were receiving rifampicin between January 2002 and December 2005.

Results

Of 188 patients, 77 and 111 patients were initiated on EFV‐based ART (EFV group) and NVP‐based ART (NVP group), respectively. Overall, median [interquartile range (IQR)] CD4 count was 36 (15–77) cells/μL and median (IQR) viral load was 5.6 (5.2–5.9) HIV‐1 RNA log copies/mL. At 48 weeks, 77.9% (60/77) in the EFV group and 67.6% (75/111) in the NVP group achieved HIV‐1 RNA <50 copies/mL (P=0.140, odds ratio =0.590, 95% confidence interval=0.302–1.153). At 24 and 48 weeks, respective median CD4 counts were 174 and 254 cells/μL in the EFV group and 156 and 218 cells/μL in the NVP group (P>0.05). By binary logistic regression, treatment group was not associated with HIV‐1 RNA <50 copies/mL (P>0.05). No patient in the EFV group and eight (7.2%) patients in the NVP group discontinued ART because of adverse reactions (P=0.084).

Conclusions

For HIV–TB co‐infected patients who receive rifampicin, efficacy of 600 mg EFV‐based and 400 mg NVP‐based ART may be similar, although adverse events tend to be higher in NVP‐based ART.     

湖北地区新发现HIV-Ab阳性者CD4~+T淋巴细胞检测

目的了解湖北地区新发现HIV-Ab阳性者的免疫状况。方法应用流式细胞仪检测224例新发现HIV-Ab阳性者CD4+T淋巴细胞,并对不同性别、年龄HIV-Ab阳性者CD4+T淋巴细胞数进行比较。结果新发现HIV-Ab阳性者CD4+T淋巴细胞均值为239.52个/μl,其中CD4+T淋巴细胞>350个/μl者占22.8%,200～350个/μl者占32.6%,<200个/μl者占44.6%;不同性别HIV-Ab阳性者CD4+T淋巴细胞数差异无统计学意义(P>0.05);≤17岁与≥18岁的各年龄组HIV-Ab阳性者CD4+T淋巴细胞数差异均有统计学意义(P<0.05)。结论湖北地区新发现HIV-Ab阳性者存在细胞免疫损伤,需要及时给予抗病毒药物治疗,预防机会性感染发生。