Acquired Immunodeficiency Syndrome: López-Aldeguer J

Iribarren JA, Labarga P, Rubio R, Berenguer J, Miró JM, Antela A, González J, Moreno S, Arrizabalaga J, Chamorro L, Clotet B, Gatell JM, López-Aldeguer J, Martínez E, Polo R, Tuset M, Viciana P, Santamaría JM, Kindelán JM, Ribera E, Segura F, Anonymous00086, Anonymous00087. · Hospital Donostia, San Sebastián, Spain. · Enferm Infecc Microbiol Clin. · Pubmed #15596051 links to  free full text

Abstract: OBJECTIVE: This consensus document is an update of antiretroviral therapy (ART) recommendations for adult patients infected with the human immunodeficiency virus (HIV). METHODS: To formulate these recommendations, a panel composed of members of the Grupo de Estudio de Sida (GESIDA; AIDS Study Group) and the Plan Nacional sobre el Sida (PNS; Spanish AIDS Plan) reviewed the advances in current understanding of the pathophysiology of HIV, the safety and efficacy findings from clinical trials, and the results from cohort and pharmacokinetic studies published in biomedical journals or presented at scientific meetings over the last years. Three levels of evidence were defined according to the source of the data: randomized studies (level A), cohort or case-control studies (level B), and expert opinion (level C). The decision to recommend, consider or not recommend ART was established in each of these situations. RESULTS: ART consisting of at least three drugs is currently the initial treatment of choice for chronic HIV infection. These regimens should include 2 NRTI + 1 NNRTI or 2 NRTI + 1 PI. Initiation of ART is recommended in patients with symptomatic HIV infection. In asymptomatic patients, initiation of ART is recommended on the basis of CD4+ lymphocyte counts per L and plasma viral load, as follows: 1) Therapy should be started in patients with CD4+ counts of < 200 cells/microL; 2) Therapy should be started in most patients with CD4+ counts of 200-350 cells/microL, although it can be delayed when CD4+ count persists at around 350 cells/microL and viral load is low; and 3) Initiation of therapy can be delayed in patients with CD4+ counts of > 350 cells/microL. The initial objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining the antiviral response. Because of the development of cross resistance, therapeutic options are limited when ART fails. Genotype studies are useful in these cases. Toxicity is a limiting factor in the use of ART, although the benefits outweigh the risks. In addition, the criteria for the use of ART are discussed in situations of acute infection, pregnancy, and post-exposure prophylaxis, and in the management of co-infection of HIV with HCV or HBV. CONCLUSIONS: CD4+ lymphocyte count is the most important reference factor for initiating ART in asymptomatic patients. The large number of available drugs, the increased sensitivity of tests to monitor viral load, and the possibility to determine viral resistance is leading to a more individualized approach to therapy.

Reus S, Portilla J, Gimeno A, Sánchez-Payá J, García-Henarejos JA, Martínez-Madrid O, Usó J, Roca B, Galindo MJ, López-Aldeguer J. · Servicio de Enfermedades Infecciosas. Hospital General Universitario de Alicante. Spain. · Enferm Infecc Microbiol Clin. · Pubmed #14987534 links to  free full text

Abstract: INTRODUCTION: To assess the factors associated with progression of infection and death in HIV-positive patients with severe immunodepression in the era of highly active antiretroviral therapy (HAART). METHODS: We studied 146 HIV-infected patients with < 100 x 10(6)/L CD4+ lymphocytes and positive cytomegalovirus (CMV) serology enrolled between December 1997 and October 1998 and prospectively followed a median of 12.1 months. The main outcome measures were progression of HIV infection, defined as the appearance of a new AIDS-defining disease (CDC category C) or death. HIV viral load, lymphocyte count (CD4+ and CD8+), HAART administration and other clinical variables were evaluated at baseline. CMV viremia (determined by PCR) and HAART efficacy were recorded during follow-up. RESULTS: Progression was observed in 40% of patients and 17% died. Factors associated with progression or death were CD4+ lymphocyte count less than 50 x 10(6)/L, CD8+ lymphocyte count less than 500 x 10(6)/L, HIV viral load more than 300,000 copies RNA/mL, CMV viremia, and absence or inefficacy of HAART. In the multivariate model, absence of HAART and low CD4+ and CD8+ counts remained statistically associated with progression, but the only variable associated with death was CMV viremia. CONCLUSIONS: In patients with advanced HIV infection, CD4+ and CD8+ cell count and HAART were the most important factors related to progression, and CMV viremia was the strongest predictor of death.

Lorenzo JI, Moscardó F, López-Aldeguer J, Aznar JA. · Unidad de Coagulopatías Congénitas, Hospital La Fe, Valencia, Spain. · Haematologica. · Pubmed #11357820 links to  free full text

Abstract: BACKGROUND AND OBJECTIVES: Human immunodeficiency virus (HIV) infection was transmitted to many hemophilics treated with non-inactivated factor concentrates before 1986. The aim of this study was to know the long-term incidence of AIDS and risk factors for its development in HIV-infected hemophiliacs. DESIGN AND METHODS: This study was a retrospective analysis of 94 HIV-infected hemophilics. The cumulative incidence of AIDS during a follow-up of 16 years from seroconversion was determined by Kaplan-Meier analysis,and potential risk factors were also studied by multivariate analysis. RESULTS: The 16-year estimated incidence of AIDS was 38% (95%CI 27%-52%). The AIDS incidence was significantly higher in patients with hemophilia B (p <0.0001), older age at seroconversion (p=0.0004), lower CD4 counts at seroconversion (p=0.004), and lower concentrate consumption during follow-up (p=0.02), than it was in those patients without these characteristics. However, only hemophilia type and age at seroconversion remained significant in the multivariate analysis, with a relative risk of 0.06 (95%CI 0.02-0.20) for hemophilia A and 1.04(95%CI 1.01-1.06) for every year of increase in age at seroconversion. The severity of hemophilia, history of inhibitors and concentrate consumption before seroconversion were not significantly associated with AIDS development. INTERPRETATION AND CONCLUSIONS: A considerable proportion of HIV-infected hemophiliacs remained AIDS-free 16 years after seroconversion. The risk of AIDS was particularly high in patients with hemophilia B and for patients who were older at seroconversion.