CUIDADO EN VIH/SIDA 5-03-2012

HIV/AIDS Clinical Care

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HIV/AIDS Clinical Care for March 5, 2012 SUMMARY AND COMMENT High Rates of Virologic Failure Among Patients on Second-Line ART in Resource-Constrained Settings Free! March 5, 2012 | Salim S. Abdool Karim, MD, PhD Most of the failures are due to suboptimal adherence. Reviewing: Ajose O et al. AIDS 2012 Feb 4; SUMMARY AND COMMENT Can We Do Better at Predicting Survival in HIV Infection? March 5, 2012 | Keith Henry, MD Adding renal, liver, and hematologic markers to age, CD4-cell count, and viral load modestly improved risk prediction. Further incremental improvements were seen with the addition of inflammatory biomarkers. Reviewing: Justice AC et al. Clin Infect Dis 2012 Feb 15; SUMMARY AND COMMENT Is ART for Treatment and Prevention a Win–Win? March 5, 2012 | Rochelle P. Walensky, MD, MPH A modeling analysis suggests that it can save both lives and money. Reviewing: Granich R et al. PLoS ONE 2012 Feb 13; 7:e30216 FEATURE Post-Exposure Prophylaxis, the World's Most Outdated HIV Guidelines, and What to Do About Them Free! March 5, 2012 Dr. Paul Sax describes how his institution is handling PEP in his blog HIV and ID Observations. Free Full-Text Article Summary and Comment High Rates of Virologic Failure Among Patients on Second-Line ART in Resource-Constrained Settings Most of the failures are due to suboptimal adherence. A growing number of HIV-infected patients in resource-constrained settings are now on second-line antiretroviral therapy (ART), but little is known about outcomes in such patients. To that end, researchers conducted a systematic review of 19 studies involving 2035 patients on second-line ART in Botswana, South Africa, Malawi, Uganda, Tanzania, Cambodia, Thailand, and rural China. The cumulative pooled proportion of patients with virologic failure on second-line ART was 22% at 6 months, 27% at 24 months, and 38% at 36 months. Mortality rates after 12 months of second-line therapy ranged from 5% to 11%. Only five studies assessed the potential role of adherence in second-line treatment failure, but they were consistent in showing that patients with poor adherence had a significantly increased risk for failure. Drug resistance mutations were assessed in 78 patients with virologic failure and were found to be relatively uncommon: 20 patients (26%) had resistance to nucleoside reverse transcriptase inhibitors, 21 (27%) had resistance to nonnucleoside reverse transcriptase inhibitors, and 14 (18%) had resistance to protease inhibitors. Comment: Despite some limitations of the data, including different definitions of failure among the studies and limited sample sizes, this systemic review shows that almost a quarter of patients have virologic failure within the first 12 months of second-line ART. Suboptimal adherence seems to be the main contributing factor, leading the authors to stress the importance of better adherence support, particularly for patients with virologic failure on first-line regimens. This study is a wake-up call because it suggests the potential for a scenario similar to what we've seen with tuberculosis — an inexorable progression toward widespread resistance to second- and third-line treatment. — Salim S. Abdool Karim, MD, PhD Published in Journal Watch HIV/AIDS Clinical Care March 5, 2012 Citation(s): Ajose O et al. Treatment outcomes of patients on second-line antiretroviral therapy in resource-limited settings: A systematic review and meta-analysis. AIDS 2012 Feb 4; [e-pub ahead of print]. (http://dx.doi.org/10.1097/QAD.0b013e328351f5b2)