Perspectives of people with HIV and HIV clinicians on characteristics of antiretroviral treatment and HIV-related symptoms.

OBJECTIVES: We aimed to assess HIV symptoms from the perspective of both patients and HIV specialists and the impact of discontinuing antiretroviral treatment (ART) on symptomology. We gathered opinions from HIV specialists and people living with HIV about ideal ART parameters and treatment satisfaction. METHODS: Ex post-facto cross-sectional surveys were administered to 502 people living with HIV and 101 HIV clinicians in Spain (18 sites). RESULTS: The median age of participants with HIV was 43.2 years, 74.5% were male, and 91.6% had an undetectable viral load. The mean time since initiation of ART was 10.2 years. Between 54% and 67% of people living with HIV reported experiencing nervousness or anxiety, sadness, fatigue, sleep problems, or muscle/joint pain during the preceding 4 weeks. However, only 22%-27% of specialists acknowledged the presence of these symptoms. The most bothersome symptoms were related to mental health or the central nervous system. There were significant differences between the burden of symptoms reported by people living with HIV and those acknowledged by specialists. The symptoms that more frequently caused ART discontinuation were depression, dizziness, and sleep problems. Both people living with HIV and specialists prioritized ART efficacy and low toxicity, but their importance ratings differed for 5 of the 11 ART characteristics assessed. People living with HIV rated their satisfaction with ART at a mean (± standard deviation) of 8.9 ± 1.5 out of 10, whereas HIV specialists rated it lower, at 8.3 ± 0.7 (p < 0.001). CONCLUSIONS: Despite advances in HIV care and treatment, a large proportion of patients still experience symptoms. HIV specialists may not be fully aware of these. People living with HIV and HIV specialists are, overall, satisfied with ART. However, the importance they place on different ART characteristics may vary.

Darunavir en situaciones especiales / Darunavir in special situations

La infección por VIH se ha convertido en una infección crónica gracias al tratamiento antirretroviral. Darunavir/ritonavir constituye uno de los inhibidores de la proteasa más utilizados, está incluido en la mayoría de guías de tratamiento dentro de las pautas de inicio de elección y, además, es el eje de los tratamientos de rescate. Con la indicación reciente de administrar tratamiento antirretroviral a todos los pacientes con VIH, es fundamental conocer el comportamiento de los antirretrovirales en distintos escenarios, teniendo en cuenta las comorbilidades y las características de los pacientes. Darunavir/ritonavir se metaboliza a nivel hepático y se excreta sobre todo a través de las heces. Pese a que se han comunicado casos de toxicidad hepática grave, en general es seguro. Se observa mayor elevación de transaminasas en pacientes coinfectados, por lo que se recomienda una mayor monitorización. Solo está contraindicado en situaciones de insuficiencia hepática grave. No precisa ajuste de dosis en pacientes con insuficiencia renal, incluso en diálisis. En mujeres se dispone de los datos de subestudios de los ensayos clínicos POWER y ARTEMIS y el estudio GRACE, el primero diseñado para detectar diferencias de eficacia y seguridad entre sexos. Además se han generado múltiples datos de farmacocinética en embarazadas que han permitido que sea el inhibidor de la proteasa de elección en las guías de transmisión perinatal DHHS. También se utiliza ampliamente en pediatría, donde es el fármaco de elección a partir de los 12 años. Solo faltarían datos en población de edad avanzada, que se están generando en estos momentos

HIV infection has become a chronic infection due to antiretroviral therapy. Darunavir/ritonavir is one of the most widely used protease inhibitors, is included in most treatment guidelines within the preferred initiation regimens and, moreover, is the cornerstone of rescue therapy. With the recent indication of antiretroviral therapy administration in all HIV-positive patients, it is essential to determine the behaviour of antiretroviral agents in distinct scenarios, bearing in mind comorbidities and patient characteristics. Darunavir/ritonavir is metabolized in the liver and is excreted mainly in faeces. Although there have been reports of severe liver toxicity, the combination is generally safe. There is higher transaminase elevation in coinfected patients, who should consequently be monitored more closely. Darunavir/ritonavir is only contraindicated in severe liver failure. Dosage adjustment is not required in patients with renal insufficiency, even in those under dialysis. In women, data are available from the substudies of the POWER and ARTEMIS clinical trials and the GRACE study, the first study designed to detect differences in efficacy and safety between men and women. In addition, multiple data on pharmacokinetics have been obtained in pregnant women, which have allowed darunavir to become the protease inhibitor of choice recommended in Department of Health and Human Services guidelines on perinatal transmission. Darunavir is widely used in paediatrics, where it is the preferred drug in patients aged 12 years and older. Data are still required in the population of advanced age, which are currently being generated

[Consensus statement on the clinical management of human immunodeficiency virus-associated neurocognitive disorders]. / Documento de consenso sobre el manejo clínico de los trastornos neurocognitivos asociados a la infección por el virus de la inmunodeficiencia humana (enero 2013).

OBJECTIVE: To develop a consensus document containing clinical recommendations for the management of human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND). METHODS: We assembled a panel of experts appointed by GeSIDA and the Secretariat of the National AIDS Plan (PNS), including internal medicine physicians with expertise in the field of HIV, neuropsychologists, neurologists and neuroradiologists. Scientific information was reviewed to October 2012 in publications and conference papers. In support of the recommendations using two levels of evidence: the strength of the recommendation in the opinion of the experts (A, B, C) and the level of empirical evidence (I, II, III), two levels based on the criteria of the Infectious Disease Society of America, already used in previous documents GeSIDA/SPNS. RESULTS: Multiple recommendations for the clinical management of these disorders are provided, including two graphics algorithms, considering both the diagnostic and possible therapeutic strategies. CONCLUSIONS: Neurocognitive disorders associated with HIV infection is currently highly prevalent, are associated with a decreased quality of life and daily activities, and given the possibility of occurrence of an increase in the coming years, there is a need to adequately manage these disorders, from a diagnostic as well as therapeutic point of view, and always from a multidisciplinary perspective.

La comorbilidad como factor limitante del TARGA / Comorbidity as a factor limiting HAART

Desde el año 1997, y coincidiendo con la generalización del tratamiento antirretroviral de gran actividad (TARGA), se ha observado un descenso marcado de las infecciones y las enfermedades oportunistas, definitorias o no de sida, y una mejoría de la calidad de vida de los pacientes infectados por el virus de la inmunodeficiencia humana (VIH). Pero esto no se ha producido sin pagar un precio. A los efectos adversos a corto plazo estudiados en los ensayos clínicos y que plantean los problemas de tolerancia y adherencia iniciales, se añaden otros a largo plazo, como la lipodistrofia o las alteraciones metabólicas. En la actualidad siguen apareciendo infecciones oportunistas como la tuberculosis, se ha observado un incremento de la incidencia de tumores y, además, las complicaciones relacionadas con la hepatopatía por el virus de la hepatitis B y/o C son cada vez más preocupantes. Por otra parte, la media de edad de las personas infectadas va aumentando y con ello, al igual que en la población general, aparecen nuevas enfermedades y aumenta la incidencia de otras, como las cardiovasculares o las degenerativas. En estos momentos, pese a conseguir un buen control de la infección, es imposible la erradicación del virus, lo que conduce a un tratamiento de por vida, salvo en escenarios específicos. Se hace necesario un mejor conocimiento de la infección por el VIH y de los fármacos y sus combinaciones, así como el diseño de estrategias adecuadas para conseguir mantener la eficacia del tratamiento con el menor coste posible para los pacientes

Since 1997, the number of opportunistic infections and AIDS-defining and other illnesses has markedly decreased while the quality of life of HIV-infected patients has improved with the widespread use of highly active antiretroviral therapy (HAART). However, these improvements have not come without a price. There are both short-term adverse effects, which have been well studied in clinical trials and which lead to problems of initial adherence and tolerance, and long-term adverse events, such as lipodystrophy and metabolic abnormalities. Currently, opportunistic infections such as tuberculosis continue to appear, the incidence of tumors has increased, and the problems related to chronic hepatitis B and/or C are causing increasing concern. In addition, the mean age of HIV-infected patients is rising and consequently, as in the general population, these patients develop new diseases and the incidence of others, such as cardiovascular and degenerative diseases, increases. At the present time, although good control of HIV infection has been achieved, there is still no cure and treatment is for life, with few exceptions. Better knowledge of HIV infection, antiretroviral drugs and their combinations is essential, as is the design of appropriate strategies to maintain treatment effectiveness at the lowest cost possible to these patients