ABSTRACT
BACKGROUND: HIV treatment recommendations are updated as clinical trials are published. Whether recommendations drive clinicians to change antiretroviral therapy in well-controlled patients is unexplored. METHODS: We selected patients with undetectable viral loads (VLs) on nonrecommended regimens containing double-boosted protease inhibitors (DBPIs), triple-nucleoside reverse transcriptase inhibitors (NRTIs), or didanosine (ddI) plus stavudine (d4T) at publication of the 2006 International AIDS Society recommendations. We compared demographic and clinical characteristics with those of control patients with undetectable VL not on these regimens and examined clinical outcome and reasons for treatment modification. RESULTS: At inclusion, 104 patients were in the DBPI group, 436 in the triple-NRTI group, and 19 in the ddI/d4T group. By 2010, 28 (29%), 204 (52%), and 1 (5%) patient were still on DBPIs, triple-NRTIs, and ddI plus d4T, respectively. 'Physician decision,' excluding toxicity/virological failure, drove 30% of treatment changes. Predictors of recommendation nonobservance included female sex [adjusted odds ratio (aOR) 2.69, 95% confidence interval (CI) 1 to 7.26; P = 0.01] for DPBIs, and undetectable VL (aOR 3.53, 95% CI 1.6 to 7.8; P = 0.002) and lack of cardiovascular events (aOR 2.93, 95% CI 1.23 to 6.97; P = 0.02) for triple-NRTIs. All patients on DBPIs with documented diabetes or a cardiovascular event changed treatment. Recommendation observance resulted in lower cholesterol values in the DBPI group (P = 0.06), and more patients having undetectable VL (P = 0.02) in the triple-NRTI group. CONCLUSION: The physician's decision is the main factor driving change from nonrecommended to recommended regimens, whereas virological suppression is associated with not switching. Positive clinical outcomes observed postswitch underline the importance of observing recommendations, even in well-controlled patients.
Subject(s)
Guideline Adherence , HIV Infections/drug therapy , HIV Protease Inhibitors/therapeutic use , Practice Guidelines as Topic , Practice Patterns, Physicians' , Reverse Transcriptase Inhibitors/therapeutic use , Adult , Cardiovascular Diseases/chemically induced , Cardiovascular Diseases/prevention & control , Chi-Square Distribution , Cholesterol/blood , Diabetes Complications/complications , Didanosine/therapeutic use , Drug Therapy, Combination/standards , Female , HIV Infections/complications , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Retrospective Studies , Sex Factors , Statistics, Nonparametric , Stavudine/therapeutic use , Switzerland , Viral LoadABSTRACT
A 79-y-old man presented with systemic inflammatory response syndrome (SIRS) and jaundice, 6 h after the first intravesical instillation of bacillus Calmette-Guérin (BCG) for bladder cancer; he had a subsequent reaction 4 weeks later. Liver biopsy findings were compatible with BCG hepatitis. Anti-mycobacterial treatment induced complete recovery. The first episode probably represents a hypersensitivity reaction, whereas the latter course suggests BCG dissemination.