Cardiovascular risk factors and lifetime risk estimation in HIV-infected patients under antiretroviral treatment in Spain.

BACKGROUND AND OBJECTIVES: Cardiovascular disease is a major concern in HIV-infected patients. Lifetime risk estimations use the risk of developing it over the course of remaining lifetime, and are useful in communicating this risk to young patients. We aim to describe the prevalence of cardiovascular risk factors among a representative sample of HIV-infected subjects under antiretroviral therapy in Spain, and to estimate their lifetime risk of cardiovascular disease. METHODS: Cross-sectional survey about cardiovascular risk factors in 10 HIV units across Spain. Lifetime risk assessed according to Barry was classified in two major categories: low and high lifetime risk. RESULTS: We included 895 subjects, 72% men, median age 45.7 years; median CD4 lymphocyte count 598 cells/µl, median time since HIV diagnosis 11 years, median time on antiretroviral treatment 6.3 years, 87% had undetectable HIV viral load. Tobacco smoking was the most frequent risk factor (54%), followed by dyslipidemia (48.6%) and hypertension (38.6%). Estimated 10-year coronary risk (Framingham/Regicor Risk Score) risk was low ( < 5%) in 78% of the patients, and intermediate (5-10%) in 20%. Lifetime risk estimation showed a high risk profile for 71.4% of the population studied, which was associated with increasing age, prolonged antiretroviral therapy and patient's place of origin. CONCLUSIONS: Modifiable cardiovascular risk factors in this population are very common. There are significant disparities between the low 10-year risk estimated with the Framingham/Regicor score and the higher lifetime risk in HIV patients on antiretroviral therapy. A more aggressive management of modifiable cardiovascular risk factors in these patients seems advisable.

Incremental cost per newly diagnosed HIV infection (NDHI): routine (RTS), targeted (TTS), and current clinical practice testing strategies (CPTS).

INTRODUCTION: Although RTS as HIV Diagnosis was considered cost effectiveness [1], overall budget may be unaffordable for some countries. We explore Incremental cost per NDHI associated with different TS. MATERIALS AND METHODS: From a health care perspective, using direct costs and Euros currency, we calculated budget and cost per NDHI of RTS (all patients were tested), TTS (Universal risk practices and clinical conditions-RP&CC - only positive were tested), and CPTS (Only patients physicians considered were tested). We considered DRIVE (Spanish acronym of HIV infection Rapid Diagnosis) study and clinical Practice outcomes. Population between 18-60 years, attending to a Hospital Emergency Room or to a Primary Care Center performed an HIV RP&CC questionnaire (Q) and an HIV rapid test (HIV RT). Unitary costs considered were: HIV RT, nurse, registry, transport and HIV confirmation when necessary, imputed to all population in RTS and CPTS and only in HIV RP&CC-Q positive in TTS analysis, while HIV RP&CC-Q costs were added to all population in TTS. Sensitivity analyses were performed with varying rates of NDHI and of positive HIV RP&CC-Q population, and different RP&CC Q sensitivity (SE) to predict HIV infection. RESULTS: 5,329 HIV RP&CC-Q and HIV RT were performed to 49.64% women, median age 37 years old, 74.9% Spaniards. In DRIVE and CP, NDHI were 4.1‰, and 1.6‰, while HIV RP&CC-Q was positive in 51.2%. HIV RP&CC-Q SE was 100%. Overall budget employed in HIV testing was in RTS 43,503€, in TTS 24,472€ and in CPTS 5,032€. Cost per 1 NDHI was 1,977€, 1,112€ and 5,032€, respectively. A reduction in cost of 865€, favouring TTS vs. RTS, while an increased cost of 824€ in CPTS vs. RTS was obtained. Considering NDHI rate of 2.6‰ saving costs increased to 1379€ in TTS, while were reduced to 576€ if NDHI rate increases 6.2‰. Effect of RP&CC-Q positivity rate was similar, if 25% saving costs were 1368€, while if 75% were reduced to 399€. Varying SE of RP&CC-Q to 95%, 91% and 50% cost saving was 810€, 754€, and 208€, and number of MHI one, two and 11. CONCLUSIONS: In DRIVE study Targeted TS with universal screening of RP&CC before an HIV rapid test is cost saving, without missing NDHI, with respect to Routine TS. Lower rates of HIV infection and RP&CC in the population, increase costs savings.

Comparison of routine versus targeted HIV testing strategies: coverage and estimated missed infections in emergency room and primary care centre.

INTRODUCTION: Different HIV Testing Strategies (TS) and clinical care settings had not been face to face evaluated (1). We compared coverage, Newly Diagnosed HIV Infection (NDHI) and Estimated Missing HIV Infections (MHI) in Hospital Emergency Room (HER) and Primary Care Center (PCC), in DRIVE study (Spanish acronym of HIV infection Rapid Diagnosis) and in clinical practice the year before DRIVE. MATERIALS AND METHODS: In DRIVE study, 18-60 years old, non-HIV-infected population visiting an HER or a PCC were proposed both a structured risk practices and clinical conditions questionnaire (RP&CC-Q) and a rapid HIV test. This arm is the HIV Routine TS. We analyze a hypothetical arm, where risk practices were universally assessed with an RP&CC-Q, subsequently risk-positive patients where HIV tested, Targeted-TS. Coverage was assessed as the ratio of tested population (TP)/attended population (AP) in HER and PCC. TP/AP ratios were also calculated in the year before, the Clinical Practice-TS. NDHI was expressed per ‰ tests performed. MHI was estimated assuming in the non-tested population, overall DRIVE rate of NDHI ‰ and NDHI ‰ in negative RP&CC-Q. RESULTS: A total of 5329 RP&CC-Q and rapid HIV tests were performed to 49.64% women, median age 37 (28-47) years old, mainly 74.9% Spaniards. Confirmed NDHI was 4.1‰, and in 48, 8% of RP&CC-Q negative NDH was 0‰. HIV screening coverage was always better in PCC than in HER, and higher in DRIVE study than in clinical practice. Estimated MHI was higher in HER and in the clinical practice-TS. Targeted-TS coverage was lower, but resulted in similar NDHI and MHI than routine-TS, testing half the population, see Table 1. CONCLUSIONS: Best HIV Testing Strategy is routine-TS in Primary Care Center. Targeted-TS resulted in same newly HIV diagnoses and missed HIV infections than routine-TS with half the resources employed.

Use of maraviroc in patients with undetectable viral load: efficacy, tolerance and predictors of viral response in MARAVIROC-cohort study.

INTRODUCTION: No controlled clinical trials had studied the role of maraviroc (MRV) in fully suppressed patients (1). MATERIALS AND METHODS: MRV-cohort is an observational, retrospective, multicentric (27 sites) large cohort study of patients starting MRV in clinical practice under different circumstances, with at least 48 weeks of follow-up. For the present analysis we selected all those patients starting with an HIV-RNA<50 copies/mL. Demographics, baseline CD4 cell count, past history of antiretroviral treatment (ART), tropism, reasons for MRV use, MRV based therapy and change/end of MRV use were assessed. Paired analysis of lipid, hepatic and kidney profile changes and univariate and multivariate analyses of HIV-RNA<50 copies/mL at 48 weeks were explored. RESULTS: We included 247 out of 667 subjects from the entire cohort. At study entry, their median age was 47 years, 23% were women, 31% MSM, 49% had CDC category C, median CD4+ counts were 468 cells/mm(3), 46% were HCV+ and 4.5% AgHBs+. Tropism information was available in 197 (94% R5). Median length of prior ARTV was 10.7 years, with exposure to a median of three drug families. Main reasons for prescribing MRV were: toxicity 38%, inmunodiscordance 23%, simplification 19% and admission in a clinical trial 10.4%. MRV based therapies used were MRV+2NRTIs 9%, MRV+PI 46%, MRV+PI+other 40% and MRV+other 5%. At 48 weeks, 23% of patients had changed or finished MRV therapy due to toxicity 2.4%, virological failure 2%, immunological failure 1.2%, simplification 3,2%, trial requirement 9.7%, medical decision 2.8%, treatment suspension 1.2% and unknown 0.4%. At 48 weeks, no significant changes were observed in lipid, hepatic or kidney profiles, and 85% of patients remained with HIV-RNA<50 copies/mL. Focusing on viral response univariate and multivariate models did not show any significant baseline variable explaining viral failure. CONCLUSIONS: In clinical practice MRV was used, mostly in R5 positive patients, with adequate efficacy and tolerance, but important number of patients changed due to non-clinical reasons. In this scenario neither reason for use of MRV nor MRV-based therapy explained viral failure.