Riesgo de enfermedad cardiovascular en pacientes con infección VIH en tratamiento antirretroviral / Risk of cardiovascular disease in patients with HIV infection undergoing antiretroviral therapy

ANTECEDENTES: La mayor supervivencia de los pacientes con infección por VIH gracias al tratamiento antirretroviral (TAR) se acompaña de una mayor frecuencia de enfermedad cardiovascular (ECV). Analizamos la prevalencia de los factores de riesgo cardiovascular (FRCV) y la estimación del riesgo de ECV en una cohorte de personas con infección por VIH en España. MÉTODOS: Estudio transversal, observacional de los FRCV en la cohorte española VACH de pacientes con infección por VIH que recibían TAR. RESULTADOS: Se evaluaron 15.559 pacientes con infección por VIH (76% varones; edad media: 46 años). Un 3,7% había experimentado al menos un evento de ECV. La prevalencia de FRCV era elevada: hiperlipidemia, 64%; tabaquismo, 47%; HTA, 22%; y diabetes, 16%. Según la escala Framingham, un 10,9% presentaba alto riesgo de ECV y un 28,8% riesgo moderado. De los pacientes con elevado riesgo de ECV, el 49% recibía inhibidores de proteasa y el 43% abacavir. Se usaron fármacos hipotensores en el 53% de los pacientes con diagnóstico de HTA, y fármacos antidiabéticos en el 2,6% de los pacientes con diabetes. CONCLUSIONES: Los FRCV tradicionales son frecuentes en los pacientes con infección por VIH con TAR en España, y una elevada proporción de ellos tiene riesgo moderado-alto de ECV. Por tanto, el control de los FRCV modificables en los pacientes con infección por VIH debería mejorarse y valorar el uso de fármacos con mejor perfil de riesgo cardiovascular

BACKGROUND: The increased survival of patients with HIV infection thanks to antiretroviral therapy (ART) is accompanied by a higher rate of cardiovascular disease (CVD). We analysed the prevalence of the cardiovascular risk factors (CRFs) and estimated the risk of CVD in a cohort of patients with HIV in Spain. METHODS: We conducted a cross-sectional, observational study of CRFs in the Spanish VACH cohort of patients with HIV who undergo ART. RESULTS: The study assessed 15,559 patients with HIV (76% men; mean age, 46 years). Some 3.7% had experienced at least 1 CVD event. The prevalence of CRFs was high (hyperlipidaemia, 64%; tobacco use, 47%; arterial hypertension, 22%; and diabetes, 16%). According to the Framingham scale, 10.9% of the patients presented a high CVD risk, and 28.8% presented a moderate risk. Of the patients with a high CVD risk, 49% took protease inhibitors and 43% took abacavir. Fifty-three percent of the patients diagnosed with arterial hypertension took antihypertensive drugs, and 2.6% of the patients with diabetes took antidiabetic agents. CONCLUSIONS: Classical CRFs are common in patients with HIV undergoing ART in Spain, and a large proportion of them have a moderate-high risk of CVD. Therefore, controlling the modifiable CRFs in patients with HIV should be improved, and the use of drugs with a better cardiovascular risk profile should be assessed

Risk of cardiovascular disease in patients with HIV infection undergoing antiretroviral therapy. / Riesgo de enfermedad cardiovascular en pacientes con infección VIH en tratamiento antirretroviral.

BACKGROUND: The increased survival of patients with HIV infection thanks to antiretroviral therapy (ART) is accompanied by a higher rate of cardiovascular disease (CVD). We analysed the prevalence of the cardiovascular risk factors (CRFs) and estimated the risk of CVD in a cohort of patients with HIV in Spain. METHODS: We conducted a cross-sectional, observational study of CRFs in the Spanish VACH cohort of patients with HIV who undergo ART. RESULTS: The study assessed 15,559 patients with HIV (76% men; mean age, 46 years). Some 3.7% had experienced at least 1 CVD event. The prevalence of CRFs was high (hyperlipidaemia, 64%; tobacco use, 47%; arterial hypertension, 22%; and diabetes, 16%). According to the Framingham scale, 10.9% of the patients presented a high CVD risk, and 28.8% presented a moderate risk. Of the patients with a high CVD risk, 49% took protease inhibitors and 43% took abacavir. Fifty-three percent of the patients diagnosed with arterial hypertension took antihypertensive drugs, and 2.6% of the patients with diabetes took antidiabetic agents. CONCLUSIONS: Classical CRFs are common in patients with HIV undergoing ART in Spain, and a large proportion of them have a moderate-high risk of CVD. Therefore, controlling the modifiable CRFs in patients with HIV should be improved, and the use of drugs with a better cardiovascular risk profile should be assessed.

Simplification to dual therapy (atazanavir/ritonavir + lamivudine) versus standard triple therapy [atazanavir/ritonavir + two nucleos(t)ides] in virologically stable patients on antiretroviral therapy: 96 week results from an open-label, non-inferiority, randomized clinical trial (SALT study).

OBJECTIVES: We evaluated whether maintenance therapy with atazanavir/ritonavir plus lamivudine (ATV/r + 3TC) was non-inferior to ATV/r plus two nucleosides (ATV/r + 2NUCs) at 96 weeks of follow-up. METHODS: SALT is a multicentre, open-label, non-inferiority clinical trial in HIV-1-infected virologically suppressed patients. Hepatitis B virus surface antigen-negative subjects with no previous treatment failure/resistance mutations and HIV-1-RNA <50 copies/mL for ≥6 months were randomized (1 : 1) to ATV/r + 3TC or ATV/r + 2NUCs. The primary endpoint was HIV-1-RNA <50 copies/mL in the PP population. Non-inferiority was demonstrated if the lower bound of the 95% CI for the difference was not below -12%. RESULTS: Some 286 patients were analysed. At week 96, 74.4% had HIV-1-RNA <50 copies/mL in the ATV/r + 3TC arm versus 73.9% in the ATV/r + 2NUCs arm (95% CI for the difference, -9.9%-11.0%). In both groups, similar values were observed for patients with confirmed virological failure in ATV/r + 3TC versus ATV/r + 2NUCs (9 versus 5), death (1 versus 0), discontinuation due to ART-related toxicity (7 versus 11), withdrawal from the study (7 versus 9) and loss to follow-up (6 versus 6). One patient taking ATV/r + 2NUCs developed resistance mutations (M184V and L63P). Similar values were obtained for change in mean CD4 count [19 versus 18 cells/mm3 (95% CI for the difference, -49.3-50.7), grade 3-4 adverse events (70.7% versus 70.2%) and changes in the global deficit score, -0.3 (95% CI, -0.5 to -0.1) for ATV/r + 3TC, versus -0.2 (95% CI, -0.4 to -0.1) for ATV/r + 2NUCs]. CONCLUSIONS: The long-term results of switching to ATV/r + 3TC show that this strategy is effective, safe and non-inferior to ATV + 2NUCs in virologically suppressed HIV-infected patients.

Very low level viraemia and risk of virological failure in treated HIV-1-infected patients.

OBJECTIVES: The aim of the study was to investigate whether very low level viraemia (VLLV) (20-50 HIV-1 RNA copies/mL) was associated with increased risk of virological failure (VF) as compared with persistent full suppression (< 20 copies/mL). METHODS: From the VACH Cohort database, we selected those patients who started antiretroviral therapy (ART) after January 1997 and who achieved effective viral suppression [two consecutive viral loads (VLs) < 50 copies/mL] followed by full suppression (at least one VL <20 copies/mL). We carried out survival analyses to investigate whether the occurrence of VLLV rather than maintaining full suppression at < 20 copies/mL was associated with virological failure (two consecutive VLs > 200 copies/mL or one VL > 200 copies/mL followed by a change of ART regimen, administrative censoring or loss to follow-up), adjusted for nadir CD4 cell count, sex, age, ethnicity, transmission group, type of ART and time on effective suppression at < 50 copies/mL. RESULTS: Of 21 480 patients who started ART, 13 674 (63.7%) achieved effective suppression at < 50 copies/mL, of whom 4289 (31.4%) further achieved full suppression at < 20 copies/mL after May 2009. A total of 2623 patients (61.1%) remained fully suppressed thereafter, while 1666 had one or more episodes of VL detection > 20 copies/mL (excluding virological failure). A total of 824 patients had VLLV after suppression at < 20 copies/mL. VLLV was not associated with virological failure as compared with persistent full suppression [hazard ratio (HR) 0.67; 95% confidence interval (CI) 0.44-1.00], independently of the number of blips recorded (from one to 18). CONCLUSIONS: In our population of HIV-infected patients on ART who achieved viral suppression at < 20 copies/mL, the risk of virological failure was no different for patients who remained fully suppressed compared with those who experienced subsequent episodes of VLLV.

Late initiation of HAART among HIV-infected patients in Spain is frequent and related to a higher rate of virological failure but not to immigrant status.

PURPOSE: To determine whether immigrant status is associated with late initiation of highly active antiretroviral treatment (HAART) and/or poor response to antiretrovirals. METHODS: GESIDA 5808 is a multicenter, retrospective cohort study (inclusion period January 2005 through December 2006) of treatment-naïve patients initiating HAART that compares HIV-infected patients who are immigrants with Spanish-born patients. A late starter (LS) was defined as any patient starting HAART with a CD4+ lymphocyte count <200 cells/µL and/or diagnosis of an AIDS-defining illness before or at the start of therapy. The primary endpoint was time to treatment failure (TTF), defined as virological failure (VF), death, opportunistic infection, treatment discontinuation/switch (D/S), or missing patient. Secondary endpoints were time to treatment failure as observed data (TTO; censoring missing patients) and time to virological failure (TVF; censoring missing patients and D/S not due to VF). RESULTS: LS accounted for 56% of the patients. Lower educational and socioeconomic level and intravenous drug use (IVDU) were associated with categorization as LS, but immigrant status was not. Cox regression analysis (hazard ratio [HR]; 95% CI) between LS and non-LS patients showed no differences in TTF (0.97; 0.78-1.20) or TTO (1.18; 0.88-1.58), although it did reveal a difference in TVF (1.97; 1.18-3.29). CD4+ lymphocyte recovery was equivalent for both LS and non-LS patients (159 vs 173). CONCLUSIONS: In our cohort, immigrant status was not shown to be related to late initiation of HAART. Although LS patients did not have a longer TTF for any reason, TVF was significantly shorter. Despite universal free access to HAART in Spain, measures to ensure early diagnosis and treatment of HIV infection are necessary.

The relationship between antiretroviral prescription patterns and treatment guidelines in treatment-naïve HIV-1-infected patients.

BACKGROUND: Reports have shown that the publication of practice guidelines does not guarantee their use in clinical practice. The objective of this study was to evaluate the agreement between antiretroviral treatments (ARTs) prescribed in clinical practice and the recommendations in published guidelines. METHODS: A retrospective cohort study was carried out in ART-naïve adults of the Spanish Asociacion Medica Vach de Estudios Multicentricos (VACH) Cohort for the period from 2003 to 2006. RESULTS: A total of 945 patients initiated ART. Of these patients, 12.3% had a CD4 cell count above 350 cells/microL. A 'nonrecommended' antiretroviral regimen was prescribed to 5.3, 5.1 and 7.8% of patients with CD4 counts <200, 200-350 and >350 cells/microL, respectively. Multivariate analyses demonstrated that only a higher viral load was associated with the selection of a combination treatment that was recommended by the guidelines. CONCLUSIONS: Most patients were prescribed initial treatments in agreement with the recommendations. Appropriate routine data collection in databases can be used to evaluate the level of antiretroviral guideline compliance. We propose that routine evaluations of the guidelines must be part of quality assessment to improve medical care.

[Malignant syphilis in patient with human immunodeficiency virus (HIV): case report and literature review]. / Sífilis maligna en el paciente infectado por el virus de la inmunodeficiencia humana (VIH): descripción de un caso y revision de la literatura.

Malignant syphilis is an infrequent manifestation of syphilis in HIV infected patients. Only 21 cases have been published in medical literature. Most frequent in men, 62%, the mean age of presentation is 34 years. The most frequent symptoms are: 100% ulcerative cutaneous lesions, 47% fever and 33% ocular affectation. About 80% of the patients have a CD4 count >200. Lues serological test was 100% positive and 81% responded to penicillin. We report a 18 year old woman diagnosed of HIV infection, admitted to our service because of fever, painful oral sores, over-elevated eritematous lesions and cratered ulcers all over the body, with the initial suspicion of chickenpox. Lues serology turned out to be positive, as well as the Warthin Starry stain. After penicillin treatment was initiated, skin lesions improved, although residual lesions currently persist. Malignant syphilis should be considered in infected HIV patients with fever and ulcerated skin injuries as a possible diagnosis. Eventhough serological tests allow diagnosis confirmation, Warthin Starry stain can be useful when serology is negative. The first choice of treatment is penicillin and in case of penicillin allergy, a third generation cefalosporine should be used.

Sífilis maligna en el paciente infectado por el virus de la inmunodeficiencia humana (VIH):descripción de un caso y revisión de la literatura / Malignant syphilis in patient with human immunodeficiency virus (HIV): case report and literature review

La sífilis maligna es una manifestación infrecuente de la sífilis en personas infectadas por el VIH. Sólo existen 21 casos publicados en la literatura. Con un 62 por ciento de predominio en hombres, la edad media de presentación es de 34 años. Los síntomas predominantes son lesiones cutáneas ulceradas en el 100 por ciento de los casos, fiebre en el 47 por ciento y afectación ocular en el 33 por ciento. El 80 por ciento tienen CD4 >200. La serología luética resultó positiva en todos los casos y el 81 por ciento respondieron a penicilina.Presentamos el caso de una mujer de 18 años, diagnosticada de infección VIH, que ingresa por fiebre, úlceras orales dolorosas, lesiones eritematosas sobreelevadas y úlceras con crater por todo el cuerpo, con la sospecha inicial de varicela. La serología luética resultó positiva, así como la tinción de Warthin Starry. Tras la instauración de tratamiento con penicilina mejoraron las lesiones, aunque persisten lesiones residuales cutáneas en la actualidad. En pacientes infectados por el VIH con fiebre y lesiones cutáneas ulceradas hay que considerar la sífilis maligna entre las posibilidades diagnósticas. Aunque los test serologicos permiten confirmar el diagnóstico, la tinción de Warthin Starry puede ser de utilidad cuando la serología es negativa. El tratamiento de primera elección es la penicilina y en caso de alergia una cefalosporina de tercera generación (AU)

Malignant syphilis is an infrequent manifestation of syphilis in HIV infected patients. Only 21 cases have been published in medical literatu re. Most frequent in men, 62%, the mean age of presentation is 34 years. The most frequent symptoms are: 100% ulcerative cutaneous lesions, 47% fever and 33% ocular affectation. About 80% of the patients have a CD4 count >200. Lues serological test was 100% positive and 81% responded to penicillin. We report a 18 year old woman diagnosed of HIV infection, admitted to our service because of fever, painful oral sores, over-elevated eritematous lesions and cratered ulcers all over the body, with the initial suspicion of chikenpox. Lues serology turned out to be positive, as well as the Warthin Starry stain. After penicillin treatment was initiated, skin lesions improved, although residual lesions currently persist. Malignant syphilis should be considered in infected HIV patients with fever and ulcerated skin injuries as a possible diagnosis. Even though serological tests allow diagnosis confirmation, Warthin Starry stain can be useful when serology is negative. The first choice of treatment is penicillin and in case of penicillin allergy, a third generation cefalosporine should be used (AU)