HIV RNA measurement in dried blood spots of HIV-infected patients in Thailand using Abbott m2000 system.

World Health Organization recommends using dried blood spots (DBS) for HIV RNA viral load (VL) measurement whenever plasma processing is not convenient or feasible. DBS collected from 80 treatment-naïve HIV-infected patients presenting in three hospitals of two different regions of Thailand were shipped to a central laboratory along with corresponding plasma specimens. Viral load was measured in both DBS and plasma using the Abbott m2000 system. HIV RNA levels were strongly correlated (r = 0.94) with a mean of differences of 0.23 log10 copies/mL. Using the 1,000 copies/mL cut-off, the sensitivity of DBS was 97% (95%CI, 91-100%) and specificity was 75% (95%CI, 19-99%). DBS are useful to scale-up HIV RNA VL testing in settings with limited access to VL testing

New-Onset Diabetes and Antiretroviral Treatments in HIV-Infected Adults in Thailand

BACKGROUND: Use of several antiretrovirals (ARVs) has been shown to be associated with a higher risk of diabetes in HIV-infected adults. We estimated the incidence of new-onset diabetes and assessed the association between individual ARVs and ARV combinations, and diabetes in a large cohort in Thailand. METHODS: We selected all HIV-1-infected, nondiabetic, antiretroviral-naive adults enrolled in the Program for HIV Prevention and Treatment cohort (NCT00433030) between January 2000 and December 2011. Diabetes was defined as confirmed fasting plasma glucose >/= 126 mg/dL or random plasma glucose >/= 2 00 mg/dL. Incidence was the number of cases divided by the total number of person-years of follow-up. Association between ARVs and ARV combinations, and new-onset diabetes was assessed using Cox proportional hazards models. RESULTS: Overall, 1594 HIV-infected patients (76% female) were included. Median age at antiretroviral therapy initiation was 32.5 years. The incidence rate of diabetes was 5.0 per 1000 person-years of follow-up (95% confidence interval: 3.8 to 6.6) (53 cases). In analyses adjusted for potential confounders, exposure to stavudine + didanosine [adjusted hazard ratio (aHR) = 3.9; P = 0.001] and cumulative exposure >/= 1 year to zidovudine (aHR = 2.3 vs. no exposure; P = 0.009) were associated with a higher risk of diabetes. Conversely, cumulative exposure >/= 1 year to tenofovir (aHR = 0.4 vs. no exposure; P = 0.02) and emtricitabine (aHR = 0.4 vs. no exposure; P = 0.03) were associated with a lower risk. CONCLUSIONS: The incidence of diabetes in this predominantly female, young, lean population was relatively low. Although stavudine and didanosine have now been phased out in most antiretroviral therapy programs, our analysis suggests a higher risk of diabetes with zidovudine, frequently prescribed today in resource-limited settings

Switching HIV treatment in adults based on CD4 count versus viral load monitoring: a randomized, non-inferiority trial in Thailand.

BACKGROUND: Viral load (VL) is recommended for monitoring the response to highly active antiretroviral therapy (HAART) but is not routinely available in most low- and middle-income countries. The purpose of the study was to determine whether a CD4-based monitoring and switching strategy would provide a similar clinical outcome compared to the standard VL-based strategy in Thailand. METHODS AND FINDINGS: The Programs for HIV Prevention and Treatment (PHPT-3) non-inferiority randomized clinical trial compared a treatment switching strategy based on CD4-only (CD4) monitoring versus viral-load (VL). Consenting participants were antiretroviral-naïve HIV-infected adults (CD4 count 50-250/mm(3)) initiating non-nucleotide reverse transcriptase inhibitor (NNRTI)-based therapy. Randomization, stratified by site (21 public hospitals), was performed centrally after enrollment. Clinicians were unaware of the VL values of patients randomized to the CD4 arm. Participants switched to second-line combination with confirmed CD4 decline >30% from peak (within 200 cells from baseline) in the CD4 arm, or confirmed VL >400 copies/ml in the VL arm. Primary endpoint was clinical failure at 3 years, defined as death, new AIDS-defining event, or CD4 400 copies/ml at switch was 7.2 months (5.8-8.0) in VL versus 15.8 months (8.5-20.4) in CD4 (p=0.002). FDO scores were not significantly different at time of switch. No adverse events related to the monitoring strategy were reported. CONCLUSIONS: The 3-year rates of clinical failure and loss of treatment options did not differ between strategies although the longer-term consequences of CD4 monitoring would need to be investigated. These results provide reassurance to treatment programs currently based on CD4 monitoring as VL measurement becomes more affordable and feasible in resource-limited settings. TRIAL REGISTRATION: ClinicalTrials.govNCT00162682 Please see later in the article for the Editors' Summary

Number of primary outcomes by arm.

a<p>Including nine cases followed by death.</p>b<p>Tuberculosis (8), cryptococcal meningitis (3), <i>P. jirovecii</i> pneumonia (2), systemic <i>P. marneffei</i> (2), disseminated <i>Mycobacterium avium intracellulare</i> (1), sepsis (2).</p>c<p>Tuberculosis (4), cryptococcal meningitis (4), <i>P. jirovecii</i> pneumonia (2), systemic <i>P. marneffei</i> (2), sepsis (3).</p>d<p>Sepsis (3), cerebrovascular accidents (2), heart failure (1), asthma attack (1), <i>P. jirovecii</i> pneumonia (1), hepatic failure (1), unknown cause (2).</p>e<p>Heart failure (3), cancer (2, 1 breast cancer, 1 liver cancer), suicide (2), renal failure (1), hepatic failure (1), pneumonia (1), sepsis (1).</p

Primary outcomes (clinical failure) at 3 y: death, new AIDS-defining events, or confirmed CD4 <50/mm³.

a<p>The 95% CI of the difference, −0.6% was −4.5% to 3.4%. The upper limit of this CI was below the pre-determined criterion for non-inferiority, 7.4%.</p

Serious adverse events by trial arm.

<p>Serious adverse events by trial arm.</p

Characteristics of the patients at baseline, according to randomization arm.

a<p>There were eight protocol deviations reported related to inclusion criteria: One patient was not ARV naive, one woman was pregnant, one was chronically infected with hepatitis C, two had hemoglobin level <8.0 g/dl, two had absolute neutrophil count <1,000 cells/mm³, one had serum creatinine above 1.0× ULN.</p

Risk factors for clinical failure.

a<p>HR, hazard ratio.</p>b<p>Adjusted HR (AHR, Cox proportional analysis) adjusted for hemoglobin, CDC stage, CD4 count, VL, BMI, sex, and randomization arm.</p

Resistance mutations found at first ARV switch (VL arm).

<p>This table shows 18 patients randomized to the VL arm who reached switching criteria of >400 copies/ml. The last samples collected before switch were genotyped. One participant with extensive PI resistance in the pretreatment specimen is omitted from this table.</p>a<p>“Duration of replication before genotype” is defined as time from first detection of VL >400 copies/ml to genotyping. This may be shorter than the duration before ARV drug switching.</p>b<p>These two participants were not included in calculations related to ARV drug switches since, although they met VL criteria for switching during the study, they both switched after the end of the study (April 1, 2010).</p

Treatment switch to second-line, PI-based treatment.

a<p>Calculated starting in the middle of the time period between the last VL <400 copies/ml and first VL above.</p>b<p>Calculated starting in the middle of the time period between the last VL <50 copies/ml and first VL above.</p