Inicio de la terapia antirretroviral en el paciente VIH a partir de un caso clínico

Nowadays HIV infection has become a potentially treatable disease, although transmission and new diagnosis rates remain high. The majority of patients reach undetectable viral replication rates and have a life expectancy similar to normal population. We present the case of a patient which was admitted to the hospital with the diagnosis of pneumonia caused by Pneumocystis jirovecii and was later diagnosed with HIV infection. According to the latest evidence, early initiation of antiretroviral therapy is the most beneficial and recommended management for patients with HIV diagnosis, not only because of benefits for the patient, but to reduce transmission.En la actualidad, la infección por el virus de la inmunodeficiencia humana (VIH) se considera una enfermedad crónica tratable, en la que se ha conseguido que la mayoría de los pacientes alcancen la supresión virológica y tengan una esperanza de vida equiparable a la de la población general. No obstante, casi la mitad de los nuevos diagnósticos siguen siendo en personas con enfermedad avanzada. Presentamos el caso de un paciente que debutó con una neumonía por Pneumocystis jirovecii y fue diagnosticado de infección por VIH. Según las últimas evidencias, el inicio de la terapia antirretroviral debe ser lo más precoz posible, tanto por los beneficios sobre el paciente como para evitar la transmisión de la infección.

Screening of infection due to the human immunodeficiency virus in primary healthcare with indicators of suspicion: DIVAPIS study

[Resumen] Introducción: El diagnóstico precoz de la infección por VIH es fundamental para mejorar el pronóstico de la enfermedad y evitar nuevos contagios. Atención Primaria (AP), al ser el primer nivel asistencial al que suele consultar el paciente, brinda la oportunidad de diagnosticar precozmente a muchos de ellos. El objetivo fue potenciar este diagnóstico mediante la identificación de condiciones indicadoras (CI) de seropositividad que permitan al profesional sospechar la infección. Métodos: Estudio observacional transversal descriptivo con participación de 89 centros de AP de Galicia (Septiembre 2013-Junio 2015). Se recogieron variables clínicas, analíticas y sociodemográficas de pacientes a los que se le realizaba el test de VIH, tanto por sospecha del médico como por petición del propio individuo. Resultados: De entre 1080 pacientes incluídos en el estudio DIVAPIS se obtuvieron 19 test positivos, con una prevalencia de nuevos diagnósticos del 1.76%. Las variables que resultaron estadísticamente predictores de seropositividad fueron: ser hombre que tiene sexo con hombres (p=0,02), serología positiva para VHB (p<0,01), serología positiva para VHB y VHC (p= 0,02) y muguet (p= 0,02). Conclusiones: El desarrollo de herramientas de trabajo en colaboración con AP para mejorar el grado de sospecha de infección por VIH permitió una alta tasa de nuevos diagnósticos y la identificación de distintas CI de seropositividad que nos deben alertar de la posibilidad de infección[Abstract] Introduction: The early diagnosis of HIV infection is essential to improve the prognosis of this entity and avoid new infections. Primary healthcare is the most accesible institution for patients, and for this reason provides the opportunity to identify new cases of HIV. The objective was to enhance this diagnostic by indicator conditions that could help the physician diagnose the infection. Methods: Cross-sectional observational and descriptive study with the participation of 89 primary healthcare centers in Galician (September 2013- June 2015). Clinical, analytical and sociodemographics variables of patients included in the study, with HIV-test requested by the physician or them, were analized. Results: 19 positive test for HIV-infection between 1080 patients included in DIVAPIS study were found, with a prevalence of new diagnoses of 1.76%. Men who have sex with men, positive serology for HBV (p<0,01), positive serology for HBV and HBC (p= 0,02) and muguet (p= 0,02). Conclusions: The development of working tools in colaboration with primary healthcare to improve the suspected of HIV-infection sohwed a high rate of new diagnosis and identified indicator conditions that may us suspect the posibility of the infection

Genotypic tropism testing in proviral DNA to guide maraviroc initiation in aviremic subjects: 48-week analysis of the PROTEST study

Introduction: In a previous interim 24-week virological safety analysis of the PROTEST study (1), initiation of Maraviroc (MVC) plus 2 nucleoside reverse-transcriptase inhibitors (NRTIs) in aviremic subjects based on genotypic tropism testing of proviral HIV-1 DNA was associated with low rates of virological failure. Here we present the final 48-week analysis of the study. Methods: PROTEST was a phase 4, prospective, single-arm clinical trial (ID: NCT01378910) carried on in 24 HIV care centres in Spain. Maraviroc-naïve HIV-1-positive adults with HIV-1 RNA (VL) 10% in a singleton), initiated MVC with 2 NRTIs and were followed for 48 weeks. Virological failure was defined as two consecutive VL>50 c/mL. Recent adherence was calculated as: (# pills taken/# pills prescribed during the previous week)*100. Results: Tropism results were available from 141/175 (80.6%) subjects screened: 87/141 (60%) were R5 and 74/87 (85%) were finally included in the study. Their median age was 48 years, 16% were women, 31% were MSM, 36% had CDC category C at study entry, 62% were HCV+ and 10% were HBV+. Median CD4+ counts were 616 cells/mm(3) at screening, and median nadir CD4+ counts were 143 cells/mm(3). Previous ART included PIs in 46 (62%) subjects, NNRTIs in 27 (36%) and integrase inhibitors (INIs) in 1 (2%). The main reasons for treatment change were dyslipidemia (42%), gastrointestinal symptoms (22%), and liver toxicity (15%). MVC was given alongside TDF/FTC in 40 (54%) subjects, ABC/3TC in 30 (40%), AZT/3TC in 2 (3%) and ABC/TDF in 2 (3%). Sixty-two (84%) subjects maintained VL<50 c/mL through week 48, whereas 12 (16%) discontinued treatment: two (3%) withdrew informed consent, one (1%) had a R5→X4 shift in HIV tropism between the screening and baseline visits, one (1%) was lost to follow-up, one (1%) developed an ART-related adverse event (rash), two (3%) died due to non-study-related causes (1 myocardial infarction at week 0 and 1 lung cancer at week 36), and five (7%) developed protocol-defined virological failure, although two of them regained VL<50 c/mL with the same MVC regimen (Table 1). Conclusions: Initiation of MVC plus 2 NRTIs in aviremic subjects based on genotypic tropism testing of proviral HIV-1 DNA is associated with low rates of virological failure up to one year

Effectiveness and safety of integrase strand transfer inhibitors in Spain: a prospective real-world study

IntroductionSecond-generation integrase strand transfer inhibitors (INSTIs) are preferred treatment options worldwide, and dolutegravir (DTG) is the treatment of choice in resource-limited settings. Nevertheless, in some resource-limited settings, these drugs are not always available. An analysis of the experience with the use of INSTIs in unselected adults living with HIV may be of help to make therapeutic decisions when second-generation INSTIs are not available. This study aimed to evaluate the real-life effectiveness and safety of dolutegravir (DTG), elvitegravir/cobicistat (EVG/c), and raltegravir (RAL) in a large Spanish cohort of HIV-1-infected patients.MethodsReal-world study of adults living with HIV who initiated integrase INSTIs DTG, EVG/c, and RAL-based regimens in three settings (ART-naïve patients, ART-switching, and ART-salvage patients). The primary endpoint was the median time to treatment discontinuation after INSTI-based regimen initiation. Proportion of patients experiencing virological failure (VF) (defined as two consecutive viral loads (VL) ≥200 copies/mL at 24 weeks or as a single determination of VL ≥1,000 copies/mL while receiving DTG, EVG/c or RAL, and at least 3 months after INSTI initiation) and time to VF were also evaluated.ResultsVirological effectiveness of EVG/c- and RAL-based regimens was similar to that of DTG when given as first-line and salvage therapy. Treatment switching for reasons other than virological failure was more frequent in subjects receiving EVG/c and, in particular, RAL. Naïve patients with CD4+ nadir &lt;100 cells/μL were more likely to develop VF, particularly if they initiated RAL or EVG/c. In the ART switching population, initiation of RAL and EVG/c was associated with both VF and INSTI discontinuation. There were no differences in the time to VF and INSTI discontinuation between DTG, EVG/c and RAL. Immunological parameters improved in the three groups and for the three drugs assessed. Safety and tolerability were consistent with expected safety profiles.DiscussionWhereas second-generation INSTIs are preferred treatment options worldwide, and DTG is one of the treatment of choices in resource-limited settings, first-generation INSTIs may still provide high virological and immunological effectiveness when DTG is not available