Low-level HIV viremia during antiretroviral therapy

In most cases, antiretroviral therapy (ART) results in undetectable plasma HIV viral load (VL). Still, up to 25% of ART recipients may have detectable low-level viremia (LLV) of different amplitude and persistence. This thesis explores the impact of LLV during ART on virologic and clinical outcomes. Paper I–III are retrospective analyses based on InfCare HIV, a national quality register for people with HIV in Sweden. Time-updated viremia categories were used. Paper I included all participants in Malmö and Gothenburg between 1996 and 2016. Compared with viral suppression, individuals with LLV of 200–999 c/mL, but not 50–199 c/mL, had increased risk of future virologic failure (adjusted hazard ratio [aHR], 3.1; 95% confidence interval [CI], 1.4–7.0). LLV was associated with increased all-cause mortality, although this was not statistically significant in multivariable analysis. For paper II and III, we linked the nationwide InfCare HIV cohort (1996–2017) to national health registers. After 49 986 person-years of follow-up (median 5.7 years), 4177/6956 (60%) were classified as viral suppression, 339 (5%) as LLV of 50–199 c/mL, 258 (4%) as LLV of 200–999 c/mL, and 2182 (31%) as non-suppression. LLV of 50–999 c/mL was associated with increased all-cause mortality when compared with viral suppression (aHR, 2.2; 95% CI, 1.3–3.6). In subanalysis, LLV of 50–199 c/mL had an aHR of 2.2 (95% CI, 1.3–3.8) and LLV of 200–999 c/mL of 2.1 (95% CI, 0.96–4.7). LLV was not associated with AIDS, but individuals with LLV of 200–999 c/mL had increased risk of serious non-AIDS events (SNAE; cardiovascular disease being the most common diagnosis). Neither time-updated viremia category nor cumulative viremia during ART had statistically significant associations with cancer incidence. Higher pre-ART VL was associated with cancer (adjusted subhazard ratio, 1.4; 95% CI, 1.0–1.8). In subanalysis, the association between pre-ART VL and cancer was restricted to AIDS-defining malignancies and infection-related non–AIDS-defining cancer. In paper IV, we measured the levels of nine biomarkers in people with LLV (≥3 VLs in the range 50–999 c/mL) and matched controls with viral suppression. We found no difference in markers of inflammation and immune activation, but patients with LLV had higher levels of growth differentiation factor 15 (GDF-15) and D-dimer. Lastly, we analyzed 21 blood biomarkers and measures of cardiovascular function and structure in participants of a South African research cohort (paper V). We observed similar cardiovascular profiles among individuals with detectable viremia (50–999 c/mL in one measurement) and those with viral suppression (<50 c/mL). In conclusion, this thesis adds to mounting evidence that LLV is associated with inferior clinical outcomes in ART recipients. Specifically, we observed associations between LLV and virologic failure, all-cause mortality, and SNAE, respectively. Our findings suggest that this is likely not mediated through inflammation or immune activation, but elevated GDF-15 and D-dimer for people with LLV in repeated VL measurements could suggest higher cardiovascular risk. We found no evidence of increased risk of cancer or AIDS for people with LLV

Virological_failure_and_all-cause_mortality_in_ patients_with_low-level_HIV_viremia .xlsx

Raw data for "Virological failure and all-cause mortality in HIV-positive adults with low-level viremia during antiretroviral treatment

ROTEM monitoring of activated and non-activated prothrombin complex concentrate correction of dilutional coagulopathy.

Objectives Prothrombin complex concentrates have been used to correct dilutional coagulopathy, but many preparations contain anticoagulants, such as heparin, to counteract their prothrombotic effects. These anticoagulants can interfere with haemostatic assays. The aim of this study was to monitor two different prothrombin complex concentrates for the treatment of albumin dilution in vitro, using rotational thromboelastometry with or without the heparin-antagonising agent protamine. Methods Citrated blood from 10 healthy volunteers was, in vitro, diluted 1:1 with 5% albumin and then corrected with a four-factor prothrombin complex concentrate with heparin anticoagulant (Confidex®) corresponding to a clinical dose of 43 IU/kg. Blood samples were tested with or without protamine. An activated prothrombin complex concentrate (APCC) (FEIBA®) without heparin in doses of 50 IU/kg and 100 IU/kg was also tested. Thromboelastometry was performed after recalcification. Results Albumin dilution significantly affected all thromboelastometry parameters. The four-factor PCC had an additional anticoagulant effect when added to the albumin-diluted blood; it was partially corrected by protamine for all parameters except maximum clot firmness. The APCC significantly improved all parameters, with over-correction of clotting time but only partial correction of maximum clot firmness. Conclusions The anticoagulant content of many prothrombin complex concentrates needs to be considered when performing in vitro testing. A heparin-free APCC better corrected an in vitro albumin-induced dilutional coagulopathy than a four-factor PCC, despite of blocking heparin with protamine

Rosuvastatin treatment affects both basal and glucose-induced insulin secretion in INS-1 832/13 cells

Rosuvastatin is a member of the statin family. Like the other statins it is prescribed to lower cholesterol levels and thereby reduce the risk of cardiovascular events. Rosuvastatin lowers the cholesterol levels by inhibiting the key enzyme 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMG-CoA reductase) in the cholesterol producing mevalonate pathway. It has been recognized that apart from their beneficial lipid lowering effects, statins also exhibit diabetogenic properties. The molecular mechanisms behind these remain unresolved. To investigate the effects of rosuvastatin on insulin secretion, we treated INS-1 832/13 cells with varying doses (20 nM to 20 μM) of rosuvastatin for 48 h. At concentrations of 2 μM and above basal insulin secretion was significantly increased. Using diazoxide we could determine that rosuvastatin did not increase basal insulin secretion by corrupting the KATP channels. Glucose-induced insulin secretion on the other hand seemed to be affected differently at different rosuvastatin concentrations. Rosuvastatin treatment (20 μM) for 24-48 h inhibited voltage-gated Ca2+ channels, which lead to reduced depolarization-induced exocytosis of insulin-containing granules. At lower concentrations of rosuvastatin (≤ 2 μM) the stimulus-secretion coupling pathway was intact downstream of the KATP channels as assessed by the patch clamp technique. However, a reduction in glucose-induced insulin secretion could be observed with rosuvastatin concentrations as low as 200 nM. The inhibitory effects of rosuvastatin on glucose-induced insulin secretion could be reversed with mevalonate, but not squalene, indicating that rosuvastatin affects insulin secretion through its effects on the mevalonate pathway, but not through the reduction of cholesterol biosynthesis. Taken together, these data suggest that rosuvastatin has the potential to increase basal insulin secretion and reduce glucose-induced insulin secretion. The latter is possibly an unavoidable side effect of rosuvastatin treatment as it occurs through the same mechanisms as the lipid-lowering effects of the drug

Difficult-to-treat HIV in Sweden: a cross-sectional study

Abstract Background Our aim was to examine the prevalence and characteristics of difficult-to-treat HIV in the current Swedish HIV cohort and to compare treatment outcomes between people with difficult and non-difficult-to-treat HIV. Methods In this cross-sectional analysis of the Swedish HIV cohort, we identified all people with HIV currently in active care in 2023 from the national register InfCareHIV. We defined five categories of difficult-to-treat HIV: 1) advanced resistance, 2) four-drug regimen, 3) salvage therapy, 4) virologic failure within the past 12 months, and 5) ≥ 2 regimen switches following virologic failure since 2008. People classified as having difficult-to-treat HIV were compared with non-difficult for background characteristics as well as treatment outcomes (viral suppression and self-reported physical and psychological health). Results Nine percent of the Swedish HIV cohort in 2023 (n = 8531) met at least one criterion for difficult-to-treat HIV. Most of them had ≥ 2 regimen switches (6%), and the other categories of difficult-to-treat HIV were rare (1–2% of the entire cohort). Compared with non-difficult, people with difficult-to-treat HIV were older, had an earlier first year of positive HIV test and lower CD4 counts, and were more often female. The viral suppression rate among people with difficult-to-treat HIV was 84% compared with 95% for non-difficult (p = 0.001). People with difficult-to-treat HIV reported worse physical (but not psychological) health, and this remained statistically significant after adjustment for age, sex, and transmission group. Conclusions Although 9% of the HIV cohort in Sweden in 2023 were classified as having difficult-to-treat HIV, a large proportion of these were virally suppressed, and challenges such as advanced resistance and need for salvage therapy are rare in the current Swedish cohort

Effects of 24–48 h of rosuvastatin treatment on exocytosis in INS-1 832/13 cells.

<p>(A) Example traces of depolarization-induced exocytosis measured as changes in cell membrane capacitance, from rosuvastatin-treated cells (20 μM; black trace) and control cells (grey trace). Exocytosis was evoked by a train of ten 500 ms depolarizing pulses from -70 mV to 0 mV. (B) Summary of the total capacitance change during the train in control cells (white bars) and rosuvastatin-treated cells (Ros; black bars). The concentration of rosuvastatin in these experiments ranged from 20 nM-20 μM as marked in the figure. (C) A graph describing the exocytotic response to all 10 pulses (∑_all) to the first 2 pulses (∑_1–2) or to the latter 8 pulses (∑_3–10) in cells incubated with 20 μM rosuvastatin (black bars) and their controls (white bars). (D) Calcium sensitivity of cells incubated with 20 μM rosuvastatin (Ros; black bars) or their controls (white bars). Calcium sensitivity is calculated by dividing the exocytotic response to the first pulse with the calcium charge measured during the same pulse. Data are given as mean ± SEM of 21–31 cells. * p≤ 0.05; ** p≤ 0.01.</p

Electrophysiological characterization of voltage-gated ion channels in rosuvastatin treated INS-1 832/13.

<p>Cells were treated with 20 μM rosuvastatin for 24-48h. (A) Example traces of currents evoked by a depolarization to 0 mV in a single rosuvastatin-treated (Ros; black trace) and control (grey trace) cell. I_sus and I_p measured in (B) and (D) are marked. (B) Sustained current (I_sus)-voltage (V) relationship (C) charge (Q)-voltage (V) relationship. Charge is measured as the area enclosed by the curve in (A). (D) peak current (I_p)-voltage (V) relationship in INS-1 832/13 cells treated with 20 μM rosuvastatin (Ros; black dots) or control cells (Control; white squares). Data are given as mean ± SEM of 28–38 cells.</p

Factors associated with low-level viraemia in people with HIV starting antiretroviral therapy : A Swedish observational study

OBJECTIVE: Low-level viraemia (LLV) occurs in some people with HIV (PWH) receiving antiretroviral therapy (ART) and has been linked to inferior treatment outcomes. We investigated factors associated with LLV in a nationwide cohort of Swedish PWH starting ART.METHODS: Participants were identified from the InfCareHIV register, with the following inclusion criteria: ART initiation 2006-2017, age >15 years, ≥4 viral load (VL) results available and no documented treatment interruptions or virologic failure (≥2 consecutive VL ≥200 copies/ml) during follow-up. Starting from 6 months after ART initiation, participants were followed for 24 months and categorised as viral suppression (VS; VL <50 copies/ml) or LLV (≥2 consecutive VL 50-199 copies/ml). We analysed the association between the following factors and LLV using multivariable logistic regression: sex, age, pre-ART VL and CD4 count, ART regimen, country of birth, HIV-1 subtype and transmission category.RESULTS: Among 3383 participants, 3132 (92.6%) had VS and 251 (7.4%) had LLV. In univariable analyses, factors associated with LLV were male sex, higher age, lower pre-ART CD4 count, higher pre-ART VL and ART regimen. After adjustment, the following factors were associated with LLV (adjusted odds ratio; 95% confidence interval): male sex (1.6; 1.1-2.3), higher pre-ART VL (2.7; 2.2-3.3), pre-ART CD4 count <200 cells/μl (1.6; 1.2-2.2), protease inhibitor (PI)-based regimen (1.5; 1.1-2.1), non-standard ART (2.4; 1.0-5.5) and injecting drug use (2.0; 1.1-3.7).CONCLUSION: Among Swedish PWH, LLV during ART was associated with markers of HIV disease severity before starting ART, male sex, injecting drug use and use of PI-based or non-standard ART regimens

Associations between Plasma HIV RNA Levels and Incidence of Invasive Cancer in People with HIV after Initiation of Combination Antiretroviral Therapy

BACKGROUND: Human immunodeficiency virus (HIV) viremia could be involved in the increased risk of cancer in people with HIV (PWH) receiving combination antiretroviral therapy (cART). We analyzed the association between plasma HIV ribonucleic acid levels in PWH starting cART and incident invasive cancer using the Swedish cohort InfCare HIV linked with national registers. METHODS: Adults starting cART in 1996–2017 were included if they had ≥1 viral load (VL) measurement before receiving any antiretroviral agent (pre-ART VL) and ≥2 VLs ≥6 months after start of cART. Viremia during cART was analyzed both as viremia-copy-years and categorized as suppression (<50 copies/mL), low-level viremia ([LLV] 50–999 copies/mL), and nonsuppression (≥1000 copies/mL). The main outcome was a composite of invasive malignancies with increased incidence among PWH. We fitted proportional subhazard models (including sex, age, pre-ART CD4 count, and injection drug use) for both pre-ART VL and viremia during cART. RESULTS: After 32 105 person-years, 3254 of 4931 participants (66%) were classified as suppressed, 438 (9%) were classified as LLV, and 1221 (25%) were classified as nonsuppressed. Neither viremia category nor cumulative viremia during cART had a statistically significant association with cancer. Higher pre-ART VL was associated with cancer (adjusted subhazard ratio, 1.4; 95% confidence interval, 1.0–1.8); this remained statistically significant with viremia during cART in the model. In subanalysis, the association with pre-ART VL was statistically significant for acquired immune deficiency syndrome (AIDS)-defining and infection-related non-AIDS-defining cancer, but not for other malignancies. CONCLUSIONS: In this nationwide cohort, pre-ART VL was an independent predictor of invasive cancer, whereas viremia profile during cART was not associated with cancer incidence