Cuales son las implicaciones de una pobre respuesta inmunologica al Tratamiento Antiretroviral / What Are the Implications of Poor Immunologic Response to ART?

HIV/AIDS Clinical Care

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HIV/AIDS Clinical Care for December 12, 2011 SUMMARY AND COMMENT What Are the Implications of Poor Immunologic Response to ART? December 12, 2011 | Keith Henry, MD Among patients with virologic suppression, those with initially poor immunologic response continued to have persistently low CD4-cell counts and had an increased risk for morbidity and mortality. Reviewing: Van Lelyveld SFL et al. AIDS 2011 Nov 22; ANTIRETROVIRAL ROUNDS If At First You Don't Succeed . . . Free! December 12, 2011 An HIV-infected patient who has discontinued antiretroviral therapy (ART) needs to restart treatment, but the choice of regimen is complicated by a history of hyperlipidemia on ART, severe adverse drug reactions, and antiviral resistance. What would you do? SUMMARY AND COMMENT Monitoring Decisions Depend on Risk for Virologic Failure — and on Cost Free! December 12, 2011 | Mauro Schechter, MD, PhD When risk for failure is high, and resources are available, virologic monitoring is preferred over CD4-cell monitoring. When risk is low or funding is unavailable, both may be skipped altogether. Reviewing: Rawizza HE et al. Clin Infect Dis 2011 Dec 15; 53:1283 Mermin J et al. BMJ 2011 Nov 9; 343:d6792 Kahn JG et al. BMJ 2011 Nov 9; 343:d6884 SUMMARY AND COMMENT Raltegravir for Bone Health? Or Just Lose the PI? December 12, 2011 | Abigail Zuger, MD One year after switching from boosted protease inhibitors to raltegravir, patients had significant improvement in some bone-mineral density measurements. Reviewing: Curran A et al. AIDS 2011 Nov 22; SUMMARY AND COMMENT Optimizing the Approach to HIV Testing December 12, 2011 | Charles B. Hicks, MD What adds value in the STI clinic? Reviewing: Truong HM et al. PLoS ONE 2011 Oct 6; 6:e25281 FEATURE Big TB Prevention Study Important, Highly Relevant — Even Here Free! December 12, 2011 Dr. Paul Sax offers both a personal and professional take on the study, in his blog HIV and ID Observations. Free Full-Text Article Summary and Comment What Are the Implications of Poor Immunologic Response to ART? Among patients with virologic suppression, those with initially poor immunologic response continued to have persistently low CD4-cell counts and had an increased risk for morbidity and mortality. Most HIV-infected patients who achieve virologic success on potent antiretroviral therapy (ART) also experience adequate CD4-cell recovery. However, a small proportion do not, and the clinical implications of this discordant response to treatment have been unclear. In this retrospective observational study, participants in the Dutch ATHENA cohort who achieved viral loads <500 copies/mL during the first 2 years on ART were divided into four groups based on their CD4 counts at 1 to 2 years (<200, 200–350, 351–500, and >500 cells/mm3). Those with CD4 counts <200 cells/mm3 were considered to have poor immunologic recovery. Outcomes of interest included a composite endpoint (cardiovascular events, AIDS, cancer, cirrhosis, or death), non–AIDS-defining diseases overall, cardiovascular events, and non–AIDS-defining malignancies specifically. The 3068 patients included in the analysis (83% male) had a median age of 41, a median nadir CD4 count of 170 cells/mm3, and a median baseline CD4 count of 360 cells/mm3; 6.5% had poor CD4-cell recovery. Independent predictors of poor CD4-cell recovery included older age, lower nadir CD4-cell count, and lower viral load at ART initiation. During more than 10,000 person-years of follow-up, patients with poor CD4-cell recovery had the highest frequency of the composite endpoint, non–AIDS-defining diseases overall, and cardiovascular events. A key observation was that the patients with poor immunologic recovery had a median CD4 count of only 320 cells/mm3 after 7 years of potent ART. Comment: The low median nadir CD4 count for the entire cohort (170 cells/mm3), together with the failure of many patients to achieve CD4 counts >500 cells/mm3 after years of suppressive ART, underscores the need for expansion of HIV testing and outreach efforts. The aim of those efforts would be to identify recently infected individuals, engage them in care, and initiate potent ART at higher CD4-cell counts, thus optimizing immune recovery and clinical benefit, with decreased transmission of HIV as a likely public health bonus. Although the potential benefits of early treatment seem clear, actual experience and the current economic outlook indicate that expanding provision of care to include most individuals with new HIV diagnoses will be difficult. — Keith Henry, MD Published in Journal Watch HIV/AIDS Clinical Care December 12, 2011 Citation(s): Van Lelyveld SFL et al. Long term complications in patients with poor immunological recovery despite virological successful HAART in Dutch ATHENA cohort. AIDS 2011 Nov 22; [e-pub ahead of print]. (http://dx.doi.org/10.1097/QAD.0b013e32834f32f8)