History of viral suppression on combination antiretroviral therapy as a predictor of virological failure after a treatment change*

Objectives

HIV‐infected persons experience different patterns of viral suppression after initiating combination antiretroviral therapy (cART). The relationship between such differences and risk of virological failure after starting a new antiretroviral could help with patient monitoring strategies.

Methods

A total of 1827 patients on cART starting at least one new antiretroviral from 1 January 2000 while maintaining a suppressed viral load were included in the analysis. Poisson regression analysis identified factors predictive of virological failure after baseline in addition to traditional demographic variables. Baseline was defined as the date of starting new antiretrovirals.

Results

Four hundred and fifty‐one patients (24.7%) experienced virological failure, with an incidence rate (IR) of 7.3 per 100 person‐years of follow‐up (PYFU) [95% confidence interval (CI) 6.7–8.0]. After adjustment, patients who had rebounded in the year prior to baseline had a 2.4‐times higher rate of virological failure after baseline (95% CI 1.77–3.26; P<.0001), while there was no increased incidence in patients whose last viral rebound was >3 years prior to baseline [Incidence rate ratio (IRR) 1.06; 95% CI 0.75–1.50; P=0.73] compared with patients who had never virally rebounded. Patients had an 86% (95% CI 1.36–2.55; P<.0001), 53% (95% CI 1.06–2.04; P=0.02) and 5% (95% CI 0.80–1.38; P=0.72) higher virological failure rate after baseline if they were virally suppressed <50%, 50–70% and 70–90% of the time they were on cART prior to baseline, respectively, compared with those virally suppressed >90% of the time.

Discussion

Intensive monitoring after a treatment switch is required in patients who have rebounded recently or have a low percentage of time suppressed while on cART. Consideration should be given to increasing the provision of adherence counselling.     

A comparison of the long‐term durability of nevirapine,efavirenz and lopinavir in routine clinical practice in Europe: a EuroSIDA study

Objectives

The durability of combination antiretroviral therapy (cART) regimens can be measured as time to discontinuation because of toxicity or treatment failure, development of clinical disease or serious long‐term adverse events. The aim of this analysis was to compare the durability of nevirapine, efavirenz and lopinavir regimens based on these measures.

Methods

Patients starting a nevirapine, efavirenz or lopinavir‐based cART regimen for the first time after 1 January 2000 were included in the analysis. Follow‐up started ≥3 months after initiation of treatment if viral load was <500 HIV‐1 RNA copies/mL. Durability was measured as discontinuation rate or development/worsening of clinical markers.

Results

A total of 603 patients (21%) started nevirapine‐based cART, 1465 (51%) efavirenz, and 818 (28%) lopinavir. After adjustment there was no significant difference in the risk of discontinuation for any reason between the groups on nevirapine and efavirenz (P=0.43) or lopinavir (P=0.13). Compared with the nevirapine group, those on efavirenz had a 48% (P=0.0002) and those on lopinavir a 63% (P<0.0001) lower risk of discontinuation because of treatment failure and a 31% (P=0.01) and 66% (P<.0001) higher risk, respectively, of discontinuation because of toxicities or patient/physician choice. There were no significant differences in the incidence of non‐AIDS‐related events, worsening anaemia, severe weight loss, increased aspartate aminotransferase (AST)/alanine aminotransferase (ALT) levels or increased total cholesterol. Compared with patients on nevirapine, those on lopinavir had an 80% higher incidence of high‐density lipoprotein (HDL) cholesterol decreasing below 0.9 mmol/L (P=0.003), but there was no significant difference in this variable between those on nevirapine and those on efavirenz (P=0.39).

Conclusions

The long‐term durability of nevirapine‐based cART, based on risk of all‐cause discontinuation and development of long‐term adverse events, was comparable to that of efavirenz or lopinavir, in patients in routine clinical practice across Europe who initially tolerated and virologically responded to their regimen.     

Highlights of the 2017 European AIDS Clinical Society (EACS) Guidelines for the treatment of adult HIV‐positive persons version 9.0

Background

The European AIDS Clinical Society (EACS) Guidelines have since 2005 provided multidisciplinary recommendations for the care of HIV‐positive persons in geographically diverse areas.

Guideline highlights

Major revisions have been made in all sections of the 2017 Guidelines: antiretroviral treatment (ART), comorbidities, coinfections and opportunistic diseases. Newly added are also a summary of the main changes made, and direct video links to the EACS online course on HIV Management. Recommendations on the clinical situations in which tenofovir alafenamide may be considered over tenofovir disoproxil fumarate are provided, and recommendations on which antiretrovirals can be used safely during pregnancy have been revised. Renal and bone toxicity and hepatitis C virus (HCV) treatment have been added as potential reasons for ART switches in fully virologically suppressed individuals, and dolutegravir/rilpivirine has been included as a treatment option. In contrast, dolutegravir monotherapy is not recommended. New recommendations on non‐alcoholic fatty liver disease, chronic lung disease, solid organ transplantation, and prescribing in elderly are included, and human papilloma virus (HPV) vaccination recommendations have been expanded. All drug–drug interaction tables have been updated and new tables are included. Treatment options for direct‐acting antivirals (DAAs) have been updated and include the latest combinations of sofosbuvir/velpatasvir/voxilaprevir and glecaprevir/pibrentasvir. Recommendations on management of DAA failure and acute HCV infection have been expanded. For treatment of tuberculosis (TB), it is underlined that intermittent treatment is contraindicated, and for resistant TB new data suggest that using a three‐drug combination may be as effective as a five‐drug regimen, and may reduce treatment duration from 18‐24 to 6‐10 months.

Conclusions

Version 9.0 of the EACS Guidelines provides a holistic approach to HIV care and is translated into the six most commonly spoken languages.