Suchergebnisse

ObjectiveTo analyze self‐reported adherence to antiretroviral regimens containing ritonavir‐boosted protease inhibitors, non‐nucleoside reverse transcriptase inhibitors (NNRTI), raltegravir, and maraviroc.MethodsOverall, 372 consecutive subjects attending a reference center for HIV treatment in Florence, Italy, were enrolled in the study, from December 2010 to January 2012 (mean age 48 years). A self‐report questionnaire was filled in. Patients were defined as "non‐adherent" if reporting one of the following criteria:<90% of pills taken in the last month, ≥1 missed dose in the last week, spontaneous treatment interruptions reported, or refill problems in the last 3 months. Gender, age, CD4, HIV‐RNA, years of therapy, and type of antiretroviral regimen were analyzed with respect to adherence.ResultsAt the time of the questionnaire, 89.8% of patients had <50 copies/mL HIV‐RNA and 14.2% were on their first combined antiretroviral therapy. 57% of patients were prescribed a regimen containing ritonavir boosted protease inhibitors (boosted PI), 41.7% NNRTI, 17.2% raltegravir, and 4.8% maraviroc; 49.5% of the subjects were on bis‐in‐die regimens, while 50.5% were on once‐daily regimens, with 23.1% of these on the single tablet regimen (STR): tenofovir/emtricitabine/efavirenz. The non‐adherence proportion was lower in NNRTI than in boosted‐PI treatments (19.4% vs 30.2%), and even lower in STR patients (17.4%). In multivariable logistic regression, patients with the NNRTI regimen (OR: 0.56, 95% CI: 0.34–0.94) and the STR (OR: 0.45, 95% CI: 0.22–0.92) reported lower non‐adherence. Efavirenz regimens were also associated with lower non‐adherence (OR: 0.42, 95% CI: 0.21–0.83), while atazanavir/ritonavir regimens were associated with higher non‐adherence. No other relation to specific antiretroviral drugs was found. A higher CD4 count, lower HIV‐RNA, and older age were also found to be associated with lower non‐adherence, while a longer time on combined antiretroviral therapy was related to higher non‐adherence.ConclusionIn conclusion, older age, higher CD4 cell counts, lower HIV‐RNA viral loads, and the use of STR are all related to lower non‐adherence. In particular, the use of STR maintains an advantage in improving adherence with respect to other cARTs, even with the availability of new, well‐tolerated antiretroviral drugs and drug classes in recent years.

Nonadherence to antiretroviral therapy (ART) may cause virologic failure and disease progression has been associated with switch of viral coreceptor usage from CCR5 to CXCR4. We aimed to assess the association between patient‐reported non‐adherence and HIV tropism. This is a cross‐sectional analysis. HIV‐tropism was performed within routine clinical practice either at start of ART or at virological failure. Adherence questionnaire includes: how many times ART has been taken during the last month, missed doses in the last week, timing deviation, refill interruption, drug holidays. Demographics, epidemiological data, HIV and ART history, CD4 and HIVRNA were collected. To assess co‐receptor tropism, env V3 genotyping from viremic plasma HIVRNA was performed. For the analysis, dual/mixed viruses were considered as X4. We included 102 individuals: 76% males; median age 42 y (IQR, 37–46); transmission was heterosexual 37%, homosexual 31%, intravenous drug use 29%. Median nadir of CD4 154/mmc (IQR, 53–274), median zenith of HIVRNA 5.26 (4.72–5.70), 46% had AIDS. 124 tropism tests were: 78% R5, 17% X4, 5% dual/mixed. In cases with previous ART, mono/dual ART was found in 26%, median number of regimens was 5 (IQR, 2–10), median time on triple‐ART was 54 months (IQR, 0–123) with median time of HIVRNA <50 c/ml of 16 months (IQR, 6.5–34.9). At HIV‐tropism, median CD4 and HIV RNA were 321/mmc (IQR, 210–436) and 2.65 (IQR, 2.65–4.91), respectively. Median time between adherence questionnaire and HIV‐tropism was 68 days (IQR, 23–116). At adherence questionnaire, median percentage of ART taken during the last month was 100% (IQR, 90–100), 39% reported missed doses in the last week, 40% timing deviation, 7% refill interruption, 17% drug holidays. At univariate analysis, no statistically significant association between non‐adherence and dual/mixed‐X4 viruses was found (p>0.1). Also gender, age, HIV transmission, AIDS, CD4 nadir, HIVRNA zenith, mono/dual ART, and number of ART regimens were not associated with type of tropism. Only longer time with undetectable HIVRNA before tropism test showed a lower probability of dual/mixed‐X4 viruses (OR for each month 0.95; 95% CI 0.90–1.00; p=0.06). No significant association between adherence and HIV‐tropism was found in this preliminary analysis. It is possible that patient self‐reported adherence is not able to capture nonadherence behaviors that underlie more pronounced viral replication which may be necessary for tropism switch.

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

Purpose of the studyEfavirenz (EFV) is still discussed for its high rate of interruption due to adverse event, in particular central nervous system side effects (CNS‐SE). Aim of the study was to define if better drug formulations up to single tablet regimen (STR), including (EFV) plus NRTI backbone (tenofovir‐emtricitabine), reduced the risk of interruption.MethodsFrom the database of two reference centers, patients starting any cART regimen including EFV+2 NRTI or switching to EFV+2 NRTI for simplification after virological suppression were selected. Probability of interruption by virological failure, side effects, CNS‐SE and any cause were assessed with survival analysis and Cox proportional hazard model.Summary of resultsOverall, 533 patients, starting EFV‐containing regimen from May 1998 to March 2012, were included (51.2% naïve, 48.8% switched). Patients characteristics: males 70.7%, median age 39 years, injecting drug use (IDU) 11.2%, median nadir CD4 194/mmc, median CD4 at EFV start 305/mmc: 38.7% started BID regimen, 43.9% OD regimen and 17.4% STR. At survival analysis, the overall proportion of EFV interruption was 19.1% at 1 year and 33.0% at 3 years; interruption for virological failure were 2.8% and 7.4% and for toxicity 10.2% and 15.9%, respectively. CNS‐SE accounted for about half of interruptions for toxicity (5.7% and 8.0% at 1 and 3 years, respectively). Naïve patients had a higher risk of interruption as compared to switched patients: 37.7% vs. 28.0% at 3 years (p=0.06). While no significant difference was observed comparing OD vs. B ID regimens, starting with STR was associated with significant lower proportion of overall interruption at 3 years (17.1% vs. 36.6%, p<0.01). No virological failure was observed with STR up to 3 years (0.0% vs. 8.9%, p=0.05); no difference of interruption by overall toxicity and higher, though non‐significant, frequency of interruption by CNS‐SE (12.8% vs. 6.8%) were also observed. STR also accounted for lower proportion of interruption by patient wish, including low adherence (1.5% vs. 12.3%, p=0.01). At adjusted Cox model, STR (HR: 0.44; 95% CI: 0.26–0.77) and male gender (HR: 0.71; 95% CI: 0.53–0.97) were associated with lower risk of EFV interruption and IDU with higher risk (HR: 1.64; 95% CI: 1.11–2.42).ConclusionsIn our experience, EFV co‐formulated in STR was associated with lower virological failure and higher adherence, despite keeping CNS toxicity, thus reducing the risk of treatment interruption.

Purpose of the studySince X4/DM HIV‐1 tropism is associated with poorer prognosis and worse response to treatment, the aim of this study was to assess whether X4/DM HIV‐1 tropism is also related with a higher accumulation of resistance in patients experiencing treatment failure.MethodsHIV protease (PR) and reverse transcriptase (RT) resistance mutations and tropism test results were extracted from a national database. Viral tropism data included enhanced sensitivity Trofile assay (ESTA) and geno2pheno results at 10% false positive rate. Historical resistance mutations (HRM) for PI, NRTI and NNRTI, detected in all genotypic tests performed during patient treatment history, were selected according to IAS‐USA indications.Summary of resultsOverall, 1280 patients were included: males 65%, median age 45 years (IQR: 40–50), median CD4 nadir 116 (IQR: 34–272), median past regimens 7 (IQR: 3–12), median previous NRTI used 5 (IQR: 4–7), median previous NNRTI used 1 (IQR 1–2) and median previous PI used 3 (IQR 1–5). HIV tropism was assessed by ESTA in 271 patients (21.2%) and by geno2pheno in 1009 patients (78.8%). Four hundred and fifteen patients (32.4%) carried X4/DM virus and 321 (25.1%) had ≥1 HRM for each antiretroviral class. The mean number of HRM was higher in patients harboring X4/DM virus than in patients harboring R5 virus (5.1±6.4 vs. 4.3±5.9, p = 0.02 at ANOVA test). X4/DM strains also harbored a higher mean number of PI‐related HRM (1.8±2.8 vs. 1.5±2.6, p = 0.003) and NNRTI‐related HRM (1.2±1.6 vs. 0.9±1.4, p = 0.001), but not of NRTI‐related HRM (2.2±2.6 vs. 2.0±2.6). At logistic regression, patients with HRM for all the 3 classes had a significant higher risk of also harboring X4/DM virus (OR: 1.6, 95% CI: 1.0–2.4, p = 0.04). Moreover, X4/DM virus was found to be associated with previous use of NNRTI‐containing regimens (OR: 1.4, 95% CI: 1.1–1–9, p = 0.03) and lower CD4 nadir (OR: 0.9, 95% CI: 0.9–1.0, p = 0.001, per 50‐CD4 increase). The analysis was adjusted by number of genotypic tests, number of treatment lines, age and HV subtype. Single mutations significantly associated with X4/DM tropism were: for PI, V32I and L76V; for NRTI: M41L, K70R, L74V and T215Y and for NNRTI: E138G and V179T.ConclusionsOur data suggest that X4/DM tropism is associated with accumulation of resistance mutations during treatment history. X4/DM tropism is also confirmed to be a marker of a more compromised clinical and immune‐virological condition.