Protease inhibitors are known to alter the lipid profiles in subjects treated for HIV/AIDS. However, the magnitude of this effect on plasma lipoproteins and lipids has not been adequately quantified.To estimate the changes in plasma lipoproteins and triglycerides occurring within 12 months of initiating PI-based antiretroviral therapy among HIV/AIDS afflicted subjects.We included all antiretroviral naïve HIV-infected persons treated at St-Paul's Hospital, British Columbia, Canada, who initiated therapy with protease inhibitor antiretroviral (ARV) drugs between August 1996 and January 2002 and who had at least one plasma lipid measurement. Longitudinal associations between medication use and plasma lipids were estimated using mixed effects models that accounted for repeated measures on the same subjects and were adjusted for age, sex, time dependent CD4+ T-cell count, and time dependent cumulative use of non-nucleoside reverse transcriptase inhibitors and adherence. The cumulative number of prescriptions filled for PIs was considered time dependent. We estimated the changes in the 12 months following any initiation of a PI based regimen.A total of 679 eligible subjects were dispensed nucleoside analogues and PI at the initiation of therapy. Over a median 47 months of follow-up (interquartile range (IQR): 29–62), subjects had a median of 3 (IQR: 1–6) blood lipid measurements. Twelve months after treatment initiation of PI use, there was an estimated 20%  increase in total cholesterol and 22% (12% – 33%) increase in triglycerides.Twelve months after treatment initiation with PIs, statistically significant increases in total cholesterol and triglycerides levels were observed in HIV-infected patients under conditions of standard treatment. Our results contribute to the growing body of evidence implicating PIs in the development of blood lipid abnormalities. In conjunction with the predominance or men, high rates of smoking, and aging of the treated HIV-positive population, elevated lipoproteins and triglycerides may mean that patients such as these are at elevated risk for cardiovascular events in the future. Abnormalities in the lipid metabolism of persons infected with human immunodeficiency virus (HIV), potentially induced by the disease itself and the medications used for treatment, were first reported in the early 1990s-5, elevaUp to one-half of subjects treated with PIs have shown elevated levels of triglycerides, total cholesterol (TChol), LDL, insulin, and fasting glucose -10. The We included all antiretroviral naïve HIV-infected persons treated at St-Paul's Hospital, British Columbia (BC), Canada, who initiated use of PIs between August 1996 and January 2002. Plasma lipoprotein and triglyceride levels were obtained from measurements taken over the course of regular monitoring. Longitudinal effects of the impact of PIs on lipoproteins and triglycerides were estimated using statistical models that accounted for correlation due to repeated measurements on the same individuals.In BC, antiretroviral drugs have been centrally distributed at no cost to eligible HIV-infected individuals since 1986,13. In OAt the BC Centre for Excellence in HIV/AIDS, records of CD4+ T-cell counts and a profile of dispensed antiretroviral therapy are routinely maintained, including the: prescription fill dates, medications prescribed, and amount dispensed. Records of dispensed antiretroviral medications,  were used to determine the drugs dispensed and available to each subject during each month of follow-up. Subjects were considered unexposed until the first month that a PI was dispensed. The exposure at the time of the lipid measurement was calculated as the cumulative number of consecutive months of drug exposure up until and including the month in which a measurement was taken. As we were interested in estimating changes that occur in plasma lipoproteins and triglycerides within the first year after treatment initiation, we included measurements with a cumulative PI exposure up to a maximum of twelve months. Subjects were considered unexposed thirty days after the last PI was dispensed and, at that time, the cumulative exposure was set to zero.Approximately one-half of HIV-infected patients in BC are followed at one treatment centre located at St. Paul's Hospital, a large teaching hospital in Vancouver. For these subjects, in addition to virological testing, the hospital laboratory records the results of plasma lipoproteins and triglycerides. Subjects were routinely instructed to fast for 12 hours prior to the sample being drawn. Blood samples were collected in 10-1 EDTA-coated vacutainer tubes. Plasma was separated by centrifugation for 10 minutes at 2,000 revolutions per minute. TChol in the plasma was determined using an enzymatic method and plasFor some subjects, the first lipid measurement was taken prior to the dispensation of any antiretroviral drug ("treatment naïve" baseline lipid measurements). Other subjects had their first recorded plasma lipoproteins and triglycerides after HAART was initiated (initiation lipid levels).© function lme(.). An analysis of variance indicated that simple parallel-line models, where the exposure effect was assumed to be constant over subjects, could adequately explain variation in the data compared to more complex models with random slopes. To account for correlated responses due to repeated measurements on the same individual, the correlation structure of the model was specified to include only a random intercept for each subject.We used linear mixed effects models to estimThe following explanatory variables were included in the models: age, sex, and CD4+ T- cell count at PI initiation, concomitant use of NNRTI, and a measure of adherence to antiretroviral therapy. Exposure to NNRTI was considered time-dependent and quantified using the same algorithm that was used to calculate time dependent PI exposure. Adherence was calculated by dividing the number of months of antiretroviral medications dispensed by the number of months of follow-up in the first twelve months after treatment initiation. Incomplete adherence represents the gap between the time that the previous medication supply ran out until the next refill date, and/or until the last contact date with the program. This method is reliably associated with both clinical outcomes and un-timed drug level monitoring,21.For each outcome and associated regression coefficient β, the quantity exp(β)-1 represented the adjusted monthly percent change in that plasma lipid fraction. These values were annualized using the formula exp(12 × β)-1. Ninety five percent confidence intervals (95% CI) for the effect estimates were obtained using the standard error for each regression coefficient.Two sensitivity analyses were conducted. The first analysis involved restricting the analysis to lipid measurements which were taken on subjects prior to any change from baseline antiretroviral therapy. The second sensitivity analysis included only subjects who had lipid measurements taken prior to initiation of therapy.3. All subjects initiated therapy that included a nucleoside analog and a PI.There were 679 subjects who were eligible for analysis, 91% of whom were male  measurements per subject. The median time between lipid measurements was 3 (IQR 2–5) months for all subjects.Table The sensitivity analyses indicated that the models were robust to changes in the sub-population studied and the exposures that were included. In the analysis that included subjects who had a baseline measurement prior to start of HAART, a plasma profile prior to antiretroviral therapy initiation showed a similar pattern but with wider confidence intervals. In the analysis which was restricted to lipid measurements taken on subjects prior to switching from baseline therapy, the effect estimates were similar to those in Table In patients treated for HIV infection with HAART in a naturalistic setting, we observed that treatment with PIs was estimated to result in 20% increases in the levels of total cholesterol, HDL- and LDL-cholesterol and triglycerides twelve months after treatment initiation. Our results contribute to the growing body of evidence implicating PIs in the development of blood lipid abnormalities and are Low HDL levels and other forms of dyslipidemia, and disturbances in glucose metabolism, as well as central obesity, have been shown to be strong independent risk factors for cardiovascular morbidity and mortality in the general population,26. FurtTwo large observational cohort studies, published in 2003, showed discrepant results regarding the risks of cardiovascular disease among persons treated with HAART,30. A reThis study has a number of features that add credence to the results. First, while only based at one hospital, the study population comprised about one-half of the treated population in BC. The study sample had similar demographic composition (age and sex) and CD4+ T-cell count at initiation of therapy as other treated subjects in the province. We believe that these results are therefore generalizable to PI-regimen treated HIV-infected patients in BC, as well as to other target populations with similar demographic characteristics. Second, as all dispensed PIs and other antiretroviral medications are paid for and recorded centrally, there was complete information on all HAART medications available to all study subjects. We adjusted for adherence using each subjects' refill compliance in the first year of treatment. Third, data on the plasma lipid profile, including both lipoproteins and triglycerides, were of high quality. The measurements, while lacking the feature of being taken at uniformly spaced intervals as in closely monitored system such as randomized trial, represent the actual experience in an observational setting. Fourth, the enrollment period lasted over five years, allowing a large sample size. We employed repeated measures analyses to account for the correlated structure of the data.This study was also subject to several limitations. First, lipid measurements were not collected in a predetermined manner as is typical in a prospective research study. Consequently, the timing of measurements was irregular and not all lipid fractions were measured when blood was drawn. Second, despite instructions some subjects may not have fasted for the full 12 hour period prior to blood draws. Non-fasting triglyceride measurements are still useful for predicting cardiovascular disease and death. Third, Due to changes in the HAART regimen that occurred because of resistance, non-compliance, or other reasons, it was not possible to isolate the effect of individual PIs. Over the period under study, most subjects initiating PI-based HAART were prescribed either indinavir or nelfinavir.As PI-based HAART is very effective in increasing survival in HIV-infected patients, discontStatins have been shown to be effective drugs to prevent cardiovascular disease in non-HIV patients. While tFibrates are effective in lowering triglycerides and increasing HDL and have been shown to be effective in HIV patients. DespiteWe conclude that there was an estimated 20% increase in lipoproteins and triglycerides in the first year after initiating PI-based antiretroviral therapy in HIV-infected patients under conditions of standard treatment. Whether these increases continue beyond one year is of considerable interest because lipoproteins and triglycerides are known risk factors for cardiovascular disease. In conjunction with the predominance or men, high rates of smoking, and aging of the treated HIV-positive population, elevated lipoproteins and triglycerides may mean that patients such as these are at elevated risk for cardiovascular events in the future.


Another study casts doubt on the value of early treatment and treatment interruptions. What are the implications of this study for our understanding of HIV pathogenesis, treatment, and vaccine development? The devastating effects of HIV infection worldwide are reason enough for AIDS researchers to grasp at thin rays of hope. But seldom has a single anecdotal case stimulated as much hope as the 1999 report of an acutely infected patient who appeared to control HIV replication after two short treatment interruptions [Consistent with this hypothesis was the prior finding that early antiretroviral therapy led to induction of HIV-specific proliferative responses similar to those that had been observed in patients with long-term, non-progressing HIV . This leA series of discoveries from clinical trials began to chip away at the enthusiasm for both early treatment of HIV infection and supervised treatment interruptions (STIs) as a way to boost the immune response.Several small trials of STIs in chronically infected patients were carried out , buoyed Larger trials clearly showed that STIs were of little if any benefit in chronic infection and that when therapy was stopped, viral loads invariably returned to pre-treatment levels . Other sPLoS Medicine that found that in 14 patients who were treated early and who had controlled viral loads for at least 90 days, the virologic control was only transient [Now comes a study in this month's ransient . While oThere was a disconnect between the low viral loads and an unexpectedly high rate of CD4+ T cell decline in several patients. While the small number of patients and the single-arm nature of the study preclude definitive comparisons, it is possible that the early treatment and STIs did not result in a delay in CD4+ T cell decline  beyond what would have occurred had the patients received no early treatment.This study raises important questions in our understanding of HIV pathogenesis, treatment, and vaccine development.First, why is it that early antiretroviral treatment, even if it does lead to better control of viral replication, does not protect against CD4+ T cell depletion? It is possible that by the time patients present with acute retroviral syndrome their CD4+ T cell reserves (in gut and lymphoid tissues) have been severely depleted, despite the fairly normal CD4+ profile of their peripheral blood. Thus, even low-level viral replication is then sufficient to deplete the remaining central and peripheral reserves .Second, how do these findings affect treatment guidelines during acute infection? None of the current treatment guidelines in either resource-rich or resource-poor settings recommend early antiretroviral therapy. In the light of these new data , there dbefore any HIV replication (a prophylactic vaccine) might be better able to control virus replication. Far be it for us to stop grasping at rays of hope.Finally, is this good or bad news for HIV vaccine development? Since most current vaccine strategies are based upon the hypothesis that induction of T cell immunity will lead to control of viral replication, it is difficult to be optimistic when a strong and broad immune response is unable to prevent disease progression. However, one must recall that phenotypic and functional assessments of HIV-specific T cell responses, even in antiretroviral-treated patients, show that these responses clearly differ from responses against viruses that are normally cleared or controlled by the immune system . Therefo


Adverse side effects, viral resistance, and the high cost of antiretroviral therapies remain obstacles in the way of turning HIV/AIDS into a manageable chronic disease. Structured treatment interruptions (STIs) in individuals who have good viral control on therapy have been proposed as a strategy for overcoming these obstacles. The initial hope that STIs would help patients achieve greater viral control has so far not been supported by data from clinical trials, but interrupting treatment has also been proposed as a strategy to reduce the cost of long-term therapy and drug-associated toxicity.Luis Montaner and colleagues now report results from a randomized trial of 42 participants  who received either continuous therapy for 40 weeks or three successive treatment interruptions of two, four, and six weeks, followed by a final open-ended interruption for both groups.The study was designed to be able to detect a difference of four weeks or greater between the two groups for the time to viral rebound during the open-ended interruption—the primary outcome. No difference between the two groups was seen .Secondary outcomes included serious adverse events , changes in CD4 count on therapy, immune reconstitution changes , and detection of viral mutations There were no study-related serious adverse events in either group and no increase of therapy failure in the STI arm. CD4 counts fluctuated between the start and end of each monitored treatment interruption, but levels recovered after resuppression of virus, with retention of recall responses throughout. Viral resistance was detected in both groups (in seven of 21 patients in the continuous treatment group and ten of 21 patients in the STI group), but it was more commonly detected (50% versus 18%) in the STI group during the open-ended final interruption, even though all subjects suppressed virus upon reinitiating the same therapy.Possible risks and benefits of STIs remain controversial, but data from this and other published trials do not support short-term clinical benefits of treatment interruptions. However, because they do not see increased therapy failure and find preservation of immune function in the STI group, the authors conclude that, in light of the possibility of reducing costs and drug-related toxicity, additional trials of STIs are warranted.Particularly important in the debate over the safety of STIs is whether the detection of resistant mutants should be of concern. The authors point out that all participants were able to resuppress the mutant virus when they resumed their previous drug regimens but state that it remains undetermined to what extent resistant mutations are a signal for future therapy failure. Moreover, viral replication and rebound—which eventually occurred in all participants—is seen by some researchers as inherently detrimental, and these experts argue that treatment interruptions are unsafe and their use should be discontinued.What seems clear is that STIs have no place outside controlled clinical trials and that questions regarding long-term safety remain unanswered. At least a dozen additional trials that examine STIs are currently recruiting patients and will help answer these questions.


We investigated patient perspectives on switching from injection to oral B12 therapy.Although oral replacement with high doses of vitamin B12 therapy. One hundred and thirty-three patients who receive regular B12 injections were included from three family practice units  in Toronto.This study involved a quantitative arm using questionnaires and a qualitative arm using semi-structured interviews, both to assess patient views on injection and oral therapy. Patients were also offered a six-month trial of oral B12. In a multivariate analysis, patient factors associated with a "willingness to switch" to oral B12 included being able to get to the clinic in less than 30 minutes , and believing that frequent visits to the health care provider  or the increased costs to the health care system  were disadvantages of injection B12. Fifty-five patients attempted oral therapy and 52 patients returned the final questionnaire. Of those who tried oral therapy, 76% (39/51) were satisfied and 71% (39/55) wished to permanently switch. Factors associated with permanently switching to oral therapy included believing that the frequent visits to the health care provider  and travel/parking costs  were disadvantages of injection B12. Interview participants consistently cited convenience as an advantage of oral therapy.Seventy-three percent (63/86) of respondents were willing to try oral B12 is both feasible and acceptable to patients. Oral B12 supplementation is well received largely due to increased convenience. Clinicians should offer oral B12 therapy to their patients who are currently receiving injections, and newly diagnosed B12-deficient patients who can tolerate and are compliant with oral medications should be offered oral supplementation.Switching patients from injection to oral B However, because approximately 1% of orally ingested B12 is absorbed via simple diffusion throughout the gastrointestinal tract [12 deficiency [Intramuscular injections of vitamin Bficiency -12.12 therapy would decrease physician burden, increase patient control over therapy, and avoid patient discomfort and inconvenience. Switching patients from B12 injections to oral therapy would also result in savings to the health care system [12 therapy [12.Oral Be system . While s therapy -15, litt12 are willing to switch to oral therapy and to explore the reasons for their choice.Efforts to switch patients who are well established on parenteral therapy (and who have previously been told they require lifelong injections) may fail without an understanding of what factors influence patient acceptability of oral therapy. Therefore, we combined qualitative and quantitative methods to test the hypothesis that patients offered oral B12 deficiency, offered the option of a six-month trial of oral replacement, and administered a follow-up questionnaire. Throughout the study, semi-structured interviews were conducted for the qualitative arm. We received ethics approval from the Sunnybrook and Women's College Health Sciences Centre Research Ethics Board. All patients provided informed consent.We administered a questionnaire to patients with B12 deficiency. We excluded patients if their last injection occurred more than three months before the start of patient recruitment, if they had left the practice, if their B12 therapy had been discontinued or if they had already switched to oral therapy, if they did not speak English and did not have access to a translator, or if they had been recently diagnosed with a serious illness. After applying these criteria, 133 patients were included in the study , regardless of age and etiology of B12 therapy to injections: "Studies have shown that vitamin B12 pills are just as effective and safe as B12 injections." Educational sessions on the effectiveness of oral therapy were held with the nursing staff (since they administer the injections) at all sites, and they were encouraged to pass this information on to their patients. As well, contact information for the study investigators was provided to the patients in case they had any questions.The recruitment cover letter included one sentence describing the equivalency of oral B12 injection. The initial questionnaire elicited demographic data, medication history, logistical aspects of B12 related visits, history of past B12 therapy, and attitudes about injection and oral therapy. Non-responders received up to two telephone reminders.We placed the initial questionnaire see   in pati12 tablets (one 1000 μg tablet daily), and were offered testing of serum B12 levels at baseline (one month after their last injection) and after the six-month trial. Patients had the option to withdraw from the trial and return to injections at any time for any reason. A follow-up questionnaire was placed in the charts of patients who tried the pills. This questionnaire re-assessed patients' attitudes about the different forms of B12 therapy and asked whether they would continue on oral supplementation or return to injection therapy  as the cut-off for inclusion of individual patient factors into multivariate logistic regression models. We then performed backwards stepwise regression to determine statistically significant relationships after adjustment. We generated both crude and adjusted odds ratios with 95% confidence intervals.Where variables were not already dichotomous , we dichotomized the variable of interest . To ascertain the relationship between questionnaire responses and preference for oral therapy (as "willingness to switch" and "permanently switching") we performed bivariate and multivariate analyses. We used a p-value of 0.20 . Amongst the 17 participants, four were selected from those not willing to switch, while of the 13 who were willing to try oral therapy, six were interviewed prior to, two during, and five after the trial of oral therapy.One investigator (D.C.) conducted 17 semi-structured interviews in a private meeting room at the family practice unit. A purposive sample was selected amongst those willing to be interviewed to reflect diversity in terms of sex, age, willingness to switch, and final choice of therapy after the trial of B12 therapy, his or her relationship with health care providers, perceived advantages and disadvantages of both pills and injections, and attitudes about past and current B12 therapy. Analyses of the transcripts were performed independently by two investigators (J.K. and D.T-K.), using a three-step content analysis approach to identify and collate relevant themes [The interviews were audiotaped and transcribed. They lasted 20–30 minutes, with questions about the patient's knowledge and history of their Bt themes . ThroughFor our initial questionnaire, we received responses from 86 out of the sample of 133 patients, for a response rate of 64.7%. Selected characteristics of the study population are presented in Table 12 therapy, number of non-B12 related visits per month, improvement in perceived well-being since initiating B12 injections, several perceived disadvantages of injections , and several perceived disadvantages of pills .Sixty-three of our 86 respondents reported a willingness to switch to oral therapy. A large number of patient factors had no clear statistical relationship to a "willingness to switch" to oral therapy  and were excluded from the multivariate model: age, education, income, drug insurance coverage, study site, number of prescription medications, mode of travel to the clinic, years of past B12 injections, several perceived disadvantages of injections , and one perceived disadvantage of pills (won't see MD/nurse as often). Factors associated with willingness to switch after multivariate adjustment were: being able to get to the clinic more quickly  , and believing that injection therapy is disadvantageous due to the need for frequent visits to health care provider  and the increased costs to the health care system   chose pills.Fifty-two patients returned the follow-up questionnaire. Over three-quarters (39 of 51 respondents) reported being satisfied or very satisfied with oral therapy. Only 8% of patients (4/51) perceived that they felt worse with pills, while 23.5% (12/51) felt better and the rest felt the same. Self-reported compliance was good; 48 patients or 92% reported forgetting to take the pills two times or less per month. Thirty-nine patients  stated that they wished to permanently switch to B12. Patient factors that on bivariate analyses had a p-value of less than 0.20 and were consequently included in the multivariate model were: patient beliefs that frequent visits to see the doctor or nurse and the associated travel/parking costs are disadvantages of injections, and the belief oral B12 would add unnecessarily to an already large number of prescribed oral medications. Table Again, many patient factors had no association with a desire to permanently switch to oral B12 levels were obtained for 39 of the 55 patients who switched to pills . Only one patient's serum level decreased but even she remained within the normal range.Baseline and post-intervention serum BThe mean age of interview participants was 71 (range 54–92) years, with 7 men and 10 women.12 injections they had been receiving in the past were effective: "I find it gives me more energy." Patients who expressed this view were often not willing to switch to oral therapy, or if they did try the pills, they eventually went back to injections. Others felt that the injections hadn't helped much: "There is a little feeling that, 'Oh, I'm taking this. I should feel better,' but I'm not sure if I do." These patients tended to switch permanently to oral therapy.Some patients felt that the BWhen asked about the anticipated efficacy of oral therapy, some patients, particularly those who were not willing to switch, were sceptical: "Well, I don't think it will work. If the doctors suggested that I needed to go on the injections, I'm certainly pretty sure that the pills are not going to work. Otherwise he'd have put me on pills, would he not?" Many others were unsure about the efficacy of oral therapy.12 pill. Other advantages of oral therapy included savings to the health care system and ease of travel. Cited disadvantages of injections included decreased compliance due to the need for frequent visits and potential complications associated with injections. A number of patients decided to switch because they were interested in participating in a research study. Some patients acknowledged that oral therapy would benefit those who are averse to needles, however, needles did not bother most of the patients interviewed: "...needles don't bother me, because – well, I don't know. They just don't seem to bother me. I know some people are very concerned about it."Nearly every patient cited convenience as an advantage of switching to B12 and for three of the five patients interviewed afterward, all of whom permanently switched to oral therapy, there was a high level of satisfaction with oral B12. One patient even reported feeling better on oral B12: "Well, I'm more level. I don't feel at the end of the month that I'm running out of energy. I'm quite well aware of that."  and the other cited decreased energy . . see .12 is both feasible and acceptable to patients. Of those who responded to our initial questionnaire, nearly three-quarters were willing to try oral B12, and of those who did switch, most were satisfied and the majority wished to remain permanently on oral therapy. These patients believed that injections are disadvantageous because they are associated with too many visits to their health care provider and with higher patient costs (in terms of travel and parking expenses). In the qualitative arm of our study, most patients cited convenience as the reason for wanting to switch from injections to pills. We were also able to confirm findings from other studies indicating that oral B12 is biochemically equivalent to, if not better than, parenteral therapy.We found that switching patients from injection to oral BOne non-intuitive finding from the initial questionnaire assessing the factors associated with trying oral therapy Table  was that12 levels  and again 6 months after oral therapy, we observed that one patient was a non-responder , and 4 patients had serum levels that increased but remained below 295 pmol/L (a level considered by some to be borderline B12 deficient)[12 levels and, if available, functional tests such as serum homocysteine and methlymalonic acid. The sub-optimal response in these patients may be due to patient non-compliance or sub-optimal dosing  [By monitoring trough serum Beficient). This re et al.) . FurtherThe primary strength of our study was that we achieved triangulation through the use of both quantitative and qualitative methods. By using questionnaires, we were able to provide estimates such as switch rates and levels of patient satisfaction; with the qualitative arm, we were able to more thoroughly explore patient perspectives.12. However, the sample was large enough to identify a number of patient factors associated with switching from injection to oral therapy and to determine that patient attitudes toward oral B12 therapy are greatly influenced by its convenience. A second limitation was that we did not assess the knowledge and attitudes of our patients' physicians and nurses, as they may have influenced patient's expectations and perceptions regarding the effective of oral B12 therapy. Finally, another limitation was the potential participant bias, evidenced by the differences between responders and non-responders in terms of age and sex. However, among the responders, neither age nor sex was significantly associated with switching to oral therapy, suggesting that any differences between participants and non-participants were likely irrelevant.The main limitation of our study was the relatively small sample size for the quantitative arm, which led to large confidence intervals for the estimates of the relationship between patient factors and switching to oral B12 deficiency and providing educational sessions to encourage discontinuing injections, 38% stated they would leave the practice if denied their injections [While there have been several studies examining physicians' perspectives on switching from intramuscular to oral therapy -21, we kjections . Explana12 therapy may be acceptable for most patients, it may not be appropriate for those who will not be compliant with oral medications, such as patients with significant memory impairment or cognitive dysfunction, unless they have caregivers who could ensure compliance. Oral therapy also may not be appropriate for those with swallowing difficulties; for such patients, sublingual B12 therapy, which has been shown to be equally effective, may more appropriate [While oral Bropriate .12 therapy to their patients who are currently receiving injections if they can tolerate and are compliant with oral medications. Most patients who switch from parenteral to oral therapy are satisfied and wish to stay permanently on oral therapy. They often cite the inconvenience and the travel-related expenses associated with frequent visits to the doctor as disadvantages of parenteral therapy. Therefore, oral B12 therapy is generally well-received by patients, and should be considered by clinicians as a superior alternative to the traditional injections for most patients.In summary, the results of our study suggest that clinicians should offer oral BThe author(s) declare that they have no competing interests.JK designed and coordinated the study, analyzed the qualitative and quantitative data, and drafted the manuscript. DC conducted the in-depth interviews and assisted in data collection. ID helped to develop the questionnaire and performed statistical analyses of the quantitative data. DTK analyzed the qualitative data. RU conceived the study and provided guidance on all aspects of the project. All authors participated in the development of the manuscript and gave approval to its final submission for publication.The pre-publication history for this paper can be accessed here:Initial questionnaireClick here for fileFollow-up questionnaireClick here for fileReasons for switching to oral therapyClick here for fileReasons for not switching to oral therapyClick here for file


Highly active antiretroviral therapy (HAART) for the treatment of individuals infected by HIV-1 is limited by high costs, drug resistance, and drug-related toxicities. This has led researchers to investigate new treatment options, including ways to boost immune responses to better control HIV. One such approach has been termed supervised treatment interruption (STI)—in which HAART is intermittently stopped once viral load has been reduced to a low level, in order to boost natural immunity by brief exposure to virus. The goal is to allow for the eventual discontinuation of drug treatment.Nature in 2000, suggested that this approach worked in persons treated in the earliest stages of acute HIV infection. HIV-1 viral loads in newly infected patients remained suppressed for a median of six months after therapy had been stopped. However, a follow up paper, published this month in PLoS Medicine by the same research group, shows that the viral load rebounded in eight of the 14 patients by one year.Preliminary evidence, published by Bruce Walker and his colleagues from Harvard Medical School in “The findings are very straightforward and very important,” comments Danny Douek from the Vaccine Research Center, National Institutes of Health, United States, who was not involved in the study. “In almost every case, virus rebounded and no clinical benefit from the interruption could be determined.”Walker's team first considered the possibility of STI in 1997 after they demonstrated that HAART given to patients recently infected with HIV could protect T helper cells, which are normally destroyed in the earliest stages of infection. They hypothesized that early treatment of acute HIV-1 infection with HAART might boost the immune response, allowing it to control the HIV-1 infection without the need for continuous therapy. “We did not know at that time whether the T helper cells would be functional,” explains Walker. “The only way to tell this was to stop medications and see if the immune response could control the virus.”Nature paper. “The key finding was that we were able to get at least transient control of virus in all eight persons studied, and in five of eight the viral load was less than 500 copies (very low!) at the time of publication,” explains Walker. However, at that point they did not know how long the protective effects would last.To test this hypothesis the researchers did an open-label trial of STIs; they published data from six months follow-up in the The first evidence that protection was not complete came two years later when Walker's team reported a case of superinfection; one of the patients in the original experiment was infected with a second strain of HIV, even though the first virus was still well controlled. “This paper was important because it indicated that the amount of immunity might be enough for the person's own virus, but might not protect against closely related viruses circulating in the population,” says Walker.PLoS Medicine study adds more concern since it shows that although most persons can indeed transiently control their own virus, they do so for only a limited amount of time. “We expanded the study to 14 persons, and now have about five years of follow-up on some of the patients,” says Walker. “Although we were able to use early treatment and structured treatment interruption to boost immunity and have 11 of 14 patients control their virus, most of the persons ultimately ‘broke through,’ meaning that they had a recurrence of viremia.” At the present time the researchers do not know what causes the loss of viral control.The Walker and colleagues conclude that treatment interruptions should probably be avoided outside the setting of controlled clinical trials, whereas Douek goes a step further: “The study shows that even early short-term treatment and structured treatment interruptions, using current strategies, impart only transient benefit and are unlikely to serve as a reasonable therapeutic option in the future.”


Approaches to limiting exposure to antiretroviral therapy (ART) drugs are an active area of HIV therapy research. Here we present longitudinal follow-up of a randomized, open-label, single-center study of the immune, viral, and safety outcomes of structured therapy interruptions (TIs) in patients with chronically suppressed HIV-1 infection as compared to equal follow-up of patients on continuous therapy and including a final therapy interruption in both arms.Forty-two chronically HIV-infected patients on suppressive ART with CD4 counts higher than 400 were randomized 1:1 to either (1) three successive fixed TIs of 2, 4, and 6 wk, with intervening resumption of therapy with resuppression for 4 wk before subsequent interruption, or (2) 40 wk of continuous therapy, with a final open-ended TI in both treatment groups. Main outcome was analysis of the time to viral rebound  during the open-ended TI. Secondary outcomes included study-defined safety criteria, viral resistance, therapy failure, and retention of immune reconstitution.n = 21; repeated TI, median [interquartile range] = 5  = 4 –8 wk, n Cycles of 2- to 6-wk time-fixed TIs in patients with suppressed HIV infection failed to confer a clinically significant benefit with regard to viral suppression off ART. Also, secondary analysis showed no difference between the two strategies in terms of safety, retention of immune reconstitution, and clinical therapy failure. Based on these findings, we suggest that further clinical research on the long-term consequences of TI strategies to decrease drug exposure is warranted. Structured treatment interruptions, or "drug holidays", in HIV patients yield no clinical benefits but don't lead to short- term treatment failure either Antiretroviral therapy (ART) has been a milestone in the treatment of HIV infection. Current treatment guidelines for HIV-1 infection in the United States recommend the initiation of ART in patients with CD4 T cell counts of less than 350 cells/μl , and theWe completed a randomized, controlled trial on the outcome of repeated 2- to 6-wk TIs in patients with chronic infection in which the comparator group maintained continuous therapy and then an open-ended interruption period was applied in both treatment groups. The study addressed the potential for repeated interruptions of therapy to delay time to viral rebound as a primary outcome and analyzed secondary outcomes regarding study-defined safety criteria, viral suppression and resistance, and retention of immune reconstitution.Between August 2000 and December 2003, we enrolled 42 patients infected with HIV who were older than 18 y and on ART; eligibility criteria included CD4 counts of greater than 400 cells/μl on ART with a nadir of no less than 100 cells/μl, ART-mediated suppression (< 500 copies/ml) for more than 6 mo and less than 50 copies/ml at recruitment on any antiretroviral regimen. Approval of the study protocol was obtained from the institutional review board (IRB) of the Philadelphia Field Initiating Group for HIV Trials . Written informed consent was obtained from all patients. Human experimentation guidelines of the United States Department of Health and Human Services and of the authors' institutions were followed. The study protocol, including the patient consent form, the CONSORT form, and the IRB approval, can be found in Forty-two eligible patients from the Jonathan Lax Immune Disorder Clinic in Philadelphia, Pennsylvania, were randomized via sealed envelopes in a 1:1 fashion to a first phase (phase I) of either (1) three successive TIs of 2, 4, and 6 wk, respectively, or (2) maintenance of ART for 40 wk before a final interruption of therapy in both arms (phase II) subject to therapy reinitiation criteria as described below. Phase II consisted of an open-ended interruption to allow for virological and immunological comparisons between the groups off therapy. Study visits were every 2 wk for the repeated interruptions group and every 4 wk for the continuous ART group during phase I. Both groups were followed every 2 wk during phase II. We followed a study design with step-wise increases in the length of TI cycles to address potential safety concerns (resuppression was confirmed after shorter TIs before longer interruptions were initiated) and the hypothesis that sequential viral replication intervals would stimulate viral control and a delay in time to viral rebound.Phase I procedures for the repeated interruptions group included the following. (1) Interruption of therapy was individually timed to occur after two HIV RNA measurements of less than 50 copies/ml without any viral load measurements greater than 400 copies/ml in between; these interruptions increased from 2 to 4 to 6 wk sequentially. (2) If a 0.5-log or greater reduction in viral load did not occur by 6 wk of reinitiated therapy or less than 50 copies/ml was not achieved within 20 wk of reinitiated therapy, patients were withdrawn as therapy failures and a resistance test was performed. (3) Patients were also withdrawn as therapy failures if (a) the CD4 cell number declined by more than 45% of the baseline CD4 count, (b) participants developed an opportunistic infection, even if retaining required CD4 count levels, or (c) a viral load of greater than 500,000 copies/ml occurred once, with or without development of acute retroviral syndrome as defined by fever, skin lesions, and pharyngitis.Phase I procedures for the continuous therapy arm included the following: (1) patient monitoring if detected viremia was between 50 and 999 copies/ml, with the patient withdrawn if their viral load did not return to less than 50 copies/ml immediately prior to phase II, and (2) patient study withdrawal as therapy failure if during the 40-wk ART period viral load rebounded to more than 1,000 copies/ml at two consecutive time points.Phase II procedures for both arms included the following: (1) monitoring for patient study withdrawal criteria as described in phase I, (2) determining time to primary end point of a viral load greater than 5,000 copies/ml, (3) monitoring until the time of therapy reinitiation at a viral load greater than 30,000 copies/ml for three consecutive time points, and (4) after reinitiation of therapy, follow-up on therapy to confirm resuppression to less than 50 copies/ml at 6, 10, and 14 wk on therapy. Clinical and laboratory parameters  were monitored at each visit, and venous blood was collected for additional secondary outcomes during selected study visits.In both phase I and II, participants taking non-nucleoside reverse-transcriptase inhibitors (NNRTIs) were instructed to stop them a day earlier than the remaining drugs in the regimen.HIV RNA) was measured as a secondary outcome at weeks 12 and 20 of phase II based on reinitiation-of-therapy criteria outlined above.The primary outcome was time to confirmed virological rebound during phase II. Rebound was defined as first time point with greater than 5,000 copies/ml. Viral replication magnitude as defined by mean HIV-1 plasma RNA area under the curve  safety outcomes , (2) retention of ART-mediated immune reconstitution, and (3) detection of viral resistance. Retention of immune reconstitution was analyzed by (1) same-day whole blood flow-cytometry-based analysis of CD4 and CD8 T cells, including total and naïve (CD62 l/CD45RA) and memory (CD45RO) subsets as described , and (2)escribed . Viral rescribed ,19.The sample size required was calculated using PS  softwareHIV RNA up to 12 and 20 wk. In all cases, a two-sided alpha level of 0.05 was used to define statistical significance. Unless otherwise stated, results are presented as median (interquartile range) in text and tables.The primary analysis was an intent-to-treat analysis in which dropouts were assigned a week 0 rebound time . In secondary analyses, these dropouts were excluded. The log-rank test was used to test the null hypothesis of no difference between arms in the number of weeks from initiation of the open-ended TI to reaching viral rebound as defined. Patients not reaching end point at 26 wk after the beginning of the open-ended TI were censored. Wilcoxon rank sum tests were used to compare baseline and week 0 of the open-ended interruption between groups. Wilcoxon signed rank tests were used to test for no change from baseline to week 0 of phase II. Finally, Wilcoxon rank sum tests were employed to test between groups for equality of the mean AUCn = 1; patient moved away) and virological failure during continuous therapy . In the repeated interruptions arm, 18 of 21 patients reached the open-ended interruption following three TIs of 2, 4, and 6 wk duration, with median peak rises in viral loads of 136 , 13,651 , and 18,887  copies/ml, respectively. Median time to less than 50 copies/ml after resumption of therapy was 2 (0–4), 3 (1.8–12), and 9.5 (2–12) wk, respectively, with 9, 18, and 20 wk as the maximum time needed to achieve suppression in 100% of patients before reaching the open-ended interruption. Study discontinuation in the repeated interruptions arm was due to protocol violation , loss to follow-up , and virological failure during on-therapy period .Trial patient flow is summarized in . No significant difference was found in baseline parameters between arms, with 33%–47% of patients on protease-inhibitor-containing and 61%–71% on NNRTI-containing regimens. Owing to the high participation of patients on NNRTI-based regimens and concerns about TI and safety in general, patient outcomes and treatment failure were reviewed monthly by the IRB of this study during the first 8 mo of study, quarterly for the following 4 mo, and semi-annually thereafter. The demographic and clinical characteristics of the two groups at baseline are summarized in n = 21; repeated TI, median = 5 [n = 21; p = 0.36). n = 21 per group). Exclusion of drop-outs in an as-treated analysis did not alter conclusions . Additional secondary analysis of the magnitude of viral load as shown in HIV RNA analysis at week 12  or week 20 .An intent-to-treat analysis of the time to viral rebound  in the open-ended interruption showed no difference between groups  or due to study-associated SAEs . However, four non-study-related SAEs occurred: two patients from the continuous therapy/single interruption arm were hospitalized, one for a cholecystectomy and one for acute rectal bleeding, during the 40-wk ART period; a patient from the repeated interruptions arm died of liver cancer during week 26 of the open-ended interruption after previously reaching a viral load greater than 5,000 copies/ml yet electing to stay off ART; and a patient from the repeated interruptions arm developed a transient ileitis.C. albicans was observed, confirming the absence of significant differences in the retention of baseline immune reconstitution correlates between arms. However, a significant decrease in the abundance of CD4 cells relative to other T cell types as summarized in CD4% (but not in absolute CD4 count ) was present in the repeated TI arm, corresponding to a significant increase in CD8 T cell count. In spite of fluctuations in CD4 T cell count levels between the start and end of each monitored TI, a recovery of CD4 count levels was achieved upon resuppression following each TI in conjunction with a retention of lymphoproliferative responses against C. albicans before, during, and after each TI, as illustrated in No significant difference was observed between groups in CD4 T cell counts at the start of phase II, as illustrated in p > 0.05).An intent-to-treat analysis of the combined number of patients per arm with detected resistance mutations irrespective of therapy failure in phase I and during the final TI in phase II showed no significant difference between arms  in association with self-reported nonadherence to therapy and detection of resistance mutations in phase I, as listed in p = 0.06). A greater number of resistance mutations was detected in the repeated interruption arm, as summarized in In patients who reached phase II in the absence of therapy failure, a total of 12 patients were identified to have resistance mutations at the first viremic time point  or clinical disease progression (as indicated by CD4 count on therapy or opportunistic infections) was not observed to be different between arms. Prospective safety outcomes in our study are in accordance with reports from a retrospective analysis of 1,290 patients who interrupted treatment at least once (< 3 mo) without an increased risk of HIV-associated morbidity or mortality (with the exception of patients in Center for Disease Control and Prevention stage C during first interruption only) . In regad TI see , nor fold TI see . The latd TI see . InteresImportantly, no evidence for an increase of viral resistance in association with therapy failure was present in the repeated interruptions arm See . We did In spite of the lack of difference in the total number of patients with resistant mutations detected on therapy during phase I and off therapy in phase II  in both arms, we do report in similarity to others a greater detection of resistance mutations in the TI arm when restricting analysis to the last off-drug period only ,30 as thDrug resistance that occurs during virological drug failure predicts virological responses to salvage treatment ,32,33. ITaken together, while our data show no clinically significant benefit for repeated TIs of less than 1.5 mo in patients with CD4 counts greater than 400 on therapy with regard to viral control as defined by time to rebound, secondary outcomes document no significant difference in levels of retention of immune reconstitution between arms and no increased incidence of virological failure as a consequence of TIs. While our data indicate that this TI strategy should not be pursued outside of a clinical trial setting, we argue that it will be important to collect additional data on the potential benefits of drug-sparing regimens (such as reduced long-term toxicity and reduced cost) and to define long-term outcomes in comparison with continuous therapy.clinicaltrials.gov under identifier NCT00051818.Registration of randomized trial at Protocol S1(614 KB DOC).Click here for additional data file.Protocol S2Current IRB approval for study at clinical site.(179 KB PDF).Click here for additional data file.Protocol S3IRB approval to receive study biological material at the Wistar Institute for research.(201 KB PDF).Click here for additional data file.Protocol S4(50 KB DOC).Click here for additional data file.Table S1(36 KB DOC).Click here for additional data file.Highly active antiretroviral therapy has revolutionized HIV treatment for patients who have access to the medications. But the drugs are expensive, have side effects, and can become ineffective when the virus develops resistance. Structured treatment interruptions (STIs), also known as “drug holidays” (because patients take a holiday from their drugs), have been suggested as possible alternatives to continuous therapy. Initially, there was fear that patients who went back on therapy after an interruption would not be able to control the virus again, but there was also hope that STIs might actually strengthen the immune system. In addition, STIs might alleviate some side effects, and they would certainly reduce costs. This study uses a particular design to examine the risks and benefits of STIs.The researchers studied 42 patients who received either continuous therapy for 40 weeks or three successive treatment interruptions of two, four, and six weeks, followed by a final open-ended interruption for both groups. The researchers then recorded how long patients were able to control the virus before their viral load reached a certain threshold and they had to restart therapy. They also examined CD4 counts and therapy failure, and looked for resistant viruses on and off therapy.In terms of being able to control the virus, it made no difference whether patients were on continuous therapy or had three STIs. In other words, when both groups stopped treatment at 40 weeks, the length of time that the patients could control the virus was the same in both groups. Eventually, all patients  re-initiated therapy because of a rising viral load, and the patients once on therapy all regained control over the virus. Resistant viruses were found in patients from both groups, but during the final interruption they were more common in the group that had received the three STIs.The study confirms that STIs do not help with viral control, consistent with other studies that found that STIs had no clinical benefit. On the other hand, no short-term adverse events were present, as all patients were able to regain control over the virus after they went back on treatment (without a drop in CD4 count), even after several rounds of interruptions and tests to detect of resistant viruses. There remains concern about whether recurrent cycles of viral replication and suppression might in themselves be harmful, and whether the presence of resistant virus is a signal for future treatment failure. Given these unanswered questions, STIs should only be undertaken within clinical trials.Possible risks and benefits of STIs in the management of therapy remain an active area of research. Evidence so far has not shown clinical benefits. Ongoing studies need to clarify whether there are long-term risks (and what they are), so that we can weigh these against the benefits of reducing costs and side effects.http://www.thebody.com/treat/sti.htmlThe Body information Web page on STIs: http://www.avert.org/conttrt.htmInformation on “continuing antriretroviral treatment” from AVERT, an international HIV and AIDS charity based in the United Kingdom: http://www.aidsmap.com/en/docs/7980314C-97B5–412F-93B1-AD8B64F51F73.aspInformation on STIs from NAM, a United Kingdom registered charity: http://www.niaid.nih.gov/factsheets/treat-hiv.htmFactsheet on HIV treatments from the United States National Institute for Allergy and Infectious Diseases: http://www.clinicaltrials.gov/search/term=%22Treatment+Interruption%22%5BCONDITION%5D+AND+HIV+%5BCONDITION%5DSearch results from Clinicaltrials.gov when searching for “HIV” and “treatment interruption” combined terms:


Lamivudine inhibits replication of both human immunodeficiency virus (HIV) and hepatitis B virus (HBV) and is commonly used as part of antiretroviral therapy. The main limitation in the use of lamivudine is resistant mutation selection. Most of these mutations affect the YMDD motif of the HBV DNA polymerase. The resistance occurs through M550V or M550I aminoacid replacements. The M550V variation may be accompanied by L526M mutation, notably in HIV-HBV co-infected patients. The aim of this study was to investigate mutations associated with lamivudine resistance in a hemodialysis patient chronically co-infected with HIV-1 and HBV, who was submitted to several antiretroviral treatments.HBV isolates derived from three blood samples collected at different times of antiretroviral therapies with and without lamivudine, were titred and submitted to nucleotide sequencing.in vitro reduction of virus antigenicity (escape mutant). HBV DNA was detected at high levels (108–109 copies/ml) in the three blood samples.HBV isolate derived from a sample collected in 1999 during an antiretroviral treatment with lamivudine showed the lamivudine resistant double mutation . However, no mutation associated with lamivudine resistance was observed in the HBV genome derived from the sample collected during a period of treatment without lamivudine (2001). After reinstitution of lamivudine (2002), the predominant HBV population exhibited a rare triple mutation , which has previously been associated with an Reintroduction of lamivudine as part of antiretroviral treatment in a patient who had developed lamivudine resistant HBV strains favored the predominance of an HBV isolate with reduced antigenicity. The absence of hepatitis acute exacerbation in this patient may be correlated to the absence of significant variations of the viral load, which was independent of the presence of mutations in the HBV DNA polymerase. Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) share common routes of transmission, mainly sexual, parenteral and vertical. Therefore, the prevalence of HBV serological markers is higher among HIV infected patients than in non-HIV infected individuals ,2. ConsiLamivudine is a nucleoside analogue that inhibits the reverse transcriptase activity of both HIV and HBV  and is cThe consequences of drug resistance mutations for the evolution of HBV induced liver disease are currently under study. Hepatitis B acute exacerbation has been described after withdrawal of lamivudine therapy . Such anThe present study was performed to characterize HBV variants and genetic patterns of lamivudine resistant HBV strains in a patient co-infected with HIV-1 at different periods of an antiretroviral treatment with and without lamivudine.5 copies/ml) was observed, indicating HIV resistance. At that time the patient started an anti-tuberculosis treatment with rifampicin. However, due to interaction of antiretroviral drugs with rifampicin, the administration of antiretroviral drugs was discontinued. This resulted in a decrease of CD4 counts to 156 cells/ml, while elevated levels of HIV persisted at the end of 1999. Antiretroviral treatment resumed in January 2000, composed of four drugs, namely ddI, stavudine, nevirapine (NVP) and nelfinavir (NFV). As a consequence, CD4 cell counts increased noticeably, and HIV RNA became undetectable. Unfortunately, resistance to therapy was observed during the second semester of 2001, when HIV load reached 1.2 × 105 copies/ml and CD4 counts decreased to 120 cells/ml. The treatment was then replaced by another including lamivudine associated to AZT, NVP and NFV. No HIV resistance was observed until the end of the follow-up (November 2002). The patient died of renal failure at the end of 2003.A 30-year-old male patient initiated a hemodialysis treatment in August 1995. At that time, he was negative for hepatitis B surface antigen (HBsAg) as well as for anti-HBc and anti-HIV antibodies. The patient received three blood transfusions during the first trimester of 1996 and developed a posttransfusional hepatitis. He became HBsAg and anti-HIV positive and remained positive for both markers in all routine tests performed between 1996 and 2002. Data of other tests, such as serum transaminases, CD4 levels, and HIV load, performed in external laboratories between 1995 and 2002, were available. Resistance to different HIV therapies was evaluated by the medical staff based on HIV load and CD4 levels. HIV treatment started in April 1996, with a combination of zidovudine (AZT) and didanosine (ddI). In November 1996, this treatment was modified to a combination of AZT and lamivudine which was maintained until March 1997, when treatment was once again changed to triple therapy with AZT, lamivudine and invirase. In May 1999, high HIV load , as described previously [4 HBV genome copies per milliliter of serum. Quantitative results were estimated by dividing 104 copies/ml by the last positive dilution.Quantification of HBV DNA was performed by endpoint dilution. DNA samples were diluted to a tenfold series up to 10eviously . Serial eviously , equivalPre-S/S PCR products were cloned into pCRII plasmid vector using TA cloning kit . For nucleotide sequencing, recombinant plasmid DNAs were purified by a commercially available kit . Nucleotide sequences were determined using the Cy5 auto read sequencing kit  with M13 universal and reverse primers, as well as internal, HBV specific primers. For direct sequencing (S region), PCR products were extracted from low melting agarose gels . Sequencing reactions with HBV specific primers were done using the thermo sequenase Cy5 dye terminator sequencing kit and analyzed on an ALFexpress automated sequencer (Amersham Biosciences). Independent plus and minus strand sequencing was completed.Nucleotide sequences were aligned using PILEUP . A phylogenetic tree was generated by neighbour-joining analysis of genetic distances, using the TREECON software package for Windows . HBV seqThe patient under study developed an acute hepatitis and became anti-HIV positive in 1996, soon after receiving blood transfusions during the initial period of hemodialysis treatment. He became an HBV chronic carrier, with all blood samples collected between 1996 and 2002 being positive for HBsAg and HBeAg. During this period, the patient remained asymptomatic without clinical signs for HBV infection. Aspartate aminotransferase and alkaline phosphatase levels remained normal all during the follow-up. However, an increase of alanine aminotransferase (ALT) levels to 180 IU/L was observed in March 1999  in the blood sample collected in March 1999, during this first period of lamivudine treatment  HBV DNA titre mesured in this study. HBV DNA was again detected at high levels (108copies/ml) after reintroduction of lamivudine  derived from HBsAg/HBeAg positive samples collected in March 1999, August 2001 and November 2002 were determined (three clones each). Phylogenetic analysis showed that all nine clones belonged to genotype A. This genotype has been subdivided into two subgenomic groups, designated A-A' (genotype A excluding A') and A'  or Ae anTable Due to overlapping of polymerase and S genes on the HBV genome, mutations at positions 473, 519 and 550 of the polymerase were accompanied by mutations at positions 119, 164 and 195 of the small S protein  or isoleucine (M550I). More rarely, HBV variant presenting M550S replacement may be selected during lamivudine treatment  The M550mivudine , since emivudine . It is bmivudine . Even somivudine . Here, bmivudine ,31, namemivudine . The trint G145R ,31. The 8 copies/ml) in the blood sample collected in 1999, in which the double mutant represents the major viral population. Similar high HBV loads were observed in the sample containing the triple mutant (2002). This result is in agreement with a recent study, showing that V519L mutation also enhances viral replication [There is a general consensus that the lamivudine resistant single mutants in the YMDD motif (M550V/I) replicate substantially more slowly than the wild type. The addition of the mutation at position 526 may act as a compensatory change that partially restores the replication fitness of the virus . Here, ilication .9 copies/ml) was moderately higher during the lamivudine interruption period than that found during lamivudine periods.The HBV population that emerged during the interruption of lamivudine treatment did not show mutations at polymerase positions 519, 526 and 550. However, another substitution, namely G473E, was observed that was associated to G119R substitution in the small S protein. Such a virus might be present as a minor population but not detected during the first lamivudine treatment. Although two out three clones of this population possessed stop codon mutations in S gene, HBV load (108–109 copies/ml) at different periods of antiretroviral treatment with and without lamivudine.HBV chronically infected patients submitted to lamivudine treatment may have acute exacerbation after withdrawal of drug therapy or when lamivudine resistance emerges ,26,35-37A rare HBV triple mutant, belonging to genotype A, subgroup A', appeared predominantly in a patient submitted to lamivudine as part of HIV treatment. This type of mutant, previously found in isolates belonging to genotypes A, D and G ,36, may None declared.EAS and MVS carried out cloning and sequencing of HBV DNA. JA was involved in clinical evaluation of the patient and supervised the antiretroviral treatment. SAG conceived the study, participated in its design and coordination, and wrote the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Early treatment of acute HIV infection with highly active antiretroviral therapy, followed by supervised treatment interruption (STI), has been associated with at least transient control of viremia. However, the durability of such control remains unclear. Here we present longitudinal follow-up of a single-arm, open-label study assessing the impact of STI in the setting of acute HIV-1 infection.Fourteen patients were treated during acute HIV-1 infection and subsequently subjected to an STI protocol that required retreatment if viral load exceeded 50,000 RNA copies/ml plasma or remained above 5,000 copies/ml for more than three consecutive weeks. Eleven of 14 (79%) patients were able to achieve viral loads of less than 5,000 RNA copies/ml for at least 90 d following one, two, or three interruptions of treatment. However, a gradual increase in viremia and decline in CD4+ T cell counts was observed in most individuals. By an intention-to-treat analysis, eight (57%), six (43%), and three (21%) of 14 patients achieved a maximal period of control of 180, 360, and 720 d, respectively, despite augmentation of HIV-specific CD4+ and CD8+ T cell responses. The magnitude of HIV-1-specific cellular immune responses before treatment interruption did not predict duration of viremia control. The small sample size and lack of concurrent untreated controls preclude assessment of possible clinical benefit despite failure to control viremia by study criteria.These data indicate that despite initial control of viremia, durable viral control to less than 5,000 RNA copies/ml plasma in patients following treated acute HIV-1 infection occurs infrequently. Determination of whether early treatment leads to overall clinical benefit will require a larger and randomized clinical trial. These data may be relevant to current efforts to develop an HIV-1 vaccine designed to retard disease progression rather than prevent infection since they indicate that durable maintenance of low-level viremia may be difficult to achieve. Long-term follow-up of 14 patients on HAART during acute infection followed by supervised treatment interruptions shows that most failed to achieve lasting control of viremia. The use of highly active antiretroviral therapy (HAART) can dramatically prolong the life of individuals infected by human immunodeficiency virus 1 (HIV-1) . The sucIn the present study, we performed a detailed longitudinal assessment of the impact of early treatment followed by STIs in patients treated during acute or early HIV-1 infection. The main hypothesis of the study was that early treatment of acute HIV-1 infection followed by STI would lead to immune boosting and subsequent control of viremia without the need for drugs. The primary endpoint was the time to viral rebound above 50,000 copies/ml once or above 5,000 copies for three determinations separated by a week each. The early results of this trial were previously reported, showing that five of eight patients were able to achieve a plasma viral load of 500 copies/ml or less at a median of 6 mo off therapy [The hypothesis of the study was that early treatment of acute HIV-1 infection would confer immunologic maturation and subsequent control of HIV-1 without the need for ongoing drug therapy. Alternatively, if a breakthrough of virus replication was observed, this would provide a boost in HIV-1-specific immunity after reinstitution of antiviral therapy. The primary endpoint was the time to viral rebound to more than 50,000 copies/ml or viral loads above 5,000 copies/ml for three determinations separated by a week each. The secondary objective was to correlate immunologic and virologic parameters with any observed effects including evolution of HIV-1-specific T helper and cytotoxic T lymphocyte responses. The original study protocol, including the patient consent form and the institutional review board approval, can be found in Fourteen patients presenting with acute or early HIV-1 infection were enrolled in this study between July 1997 and January 2000 . Acute HSix of the 14 individuals were investigated in an interim study . These pEntry criteria included treatment with HAART before or shortly after HIV-1 seroconversion, viral suppression on HAART to less than 400 RNA copies/ml for 2 mo, HIV-1 viral load at the time of entry into the study of less than 50 RNA copies/ml, and lack of significant mutations conferring drug resistance ,12. LympHigh- and intermediate-resolution human leukocyte antigen class I typing was performed at a commercial laboratory  by sequence-specific PCR as described .GB virus C (GBV-C) RNA was detected using a two-step nested PCR amplification reaction from whole plasma RNA. Briefly, GBV-C RNA was extracted from plasma using the Qiagen Viral RNA Mini Kit  according to the manufacturer's instructions. Extracted RNA was reverse transcribed using the Qiagen OneStep RT-PCR Kit and amplified by nested PCR; in both steps primers specific for the 5′ UTR of GBV-C were used, as described previously .In order to analyze the chemokine receptor (CCR) 5Δ32 deletion polymorphism, the region spanning the 32-nt deletion was amplified by PCR, and the two alleles were separated by gel electrophoresis . The CCRWe synthesized 410 synthetic peptides 15–20 amino acids long at the Massachusetts General Hospital Peptide Core Facility on an automated peptide synthesizer using Fmoc technology, as described . Peptide6 PBMCs and if the well had at least three times the mean number of SFCs in the three control wells. The dependence of responses on CD8+ T cells was determined by measuring the depletion of CD4+ T cells using the Minimacs cell depletion system . When HIV-1-specific CD8+ T cell responses were detected against adjacent peptides, and therefore might represent targeting of the overlap region, responses to the weaker peptide were excluded for calculations of magnitude and breadth, as previously described [ELISPOT assays were carried out as described previously . Peripheescribed .5 cells) were incubated with baculovirus-derived recombinant p24 protein  at 5 μg/ml for 6 d and then pulsed with 3H thymidine at 1.0 μCi for 6 h before harvesting as previously described [Freshly isolated PBMCs  were able to achieve virologic control to less than 5,000 RNA copies/ml plasma for at least 90 d after one, two, or three treatment interruptions . The perOnce control was achieved, the majority of the patients experienced a subsequent rise in viremia. The median time between cessation of therapy and rebound of viremia  was 17 d .Six of 14 patients (43%) achieved a period of control after stopping therapy for 1 y, but only three of 14 (21%) were able to control viremia off therapy at less than 5,000 RNA copies/ml plasma for more than 2 y. Duration of viremia control during successive treatment interruptions was highly variable, and there was no increase in the sustainability of viral containment during successive STI cycles. The three patients achieving control of viremia for more than 2 y did so during the first (AC-10), the second (AC-02), and the third (AC-14) treatment interruption, respectively A. A pairThese data show that at least transient control of viremia to less than 5,000 RNA copies/ml plasma was achieved in the majority of study participants during at least one of the treatment interruptions, but that durable viral control in participants following treated acute infection occurred infrequently. Moreover, the data do not show a consistent pattern of augmentation of viral control with sequential treatment interruptions.3; range, 492–986), but the effect of treatment interruption was variable, even in those doing well, as defined by sustained low viral loads. Overall, 11 of 14 patients interrupted therapy for at least 12 mo, and these individuals were evaluated regarding the effect of treatment interruption on CD4+ T cell loss . Of the three patients who did not meet viral load criteria for restarting therapy for more than 2 y, one (AC-02) had an increasing CD4+ T cell count of 157 cells/mm3/y, one (AC-10) had a stable CD4+ T cell count (−9 cells/mm3/y) , and one (AC-14) experienced a decline of 344 cells/mm3/y. Comparison with data from the Multicenter AIDS Cohort Study (MACS) showed that the kinetics of CD4+ T cell loss was faster  than in untreated patients with early chronic HIV-1 infection (average loss of −67 cells/mm3/y in patients with a CD4+ T cell count of more than 350 cells/mm3 at baseline). However, CD4+ T cell loss rate was in the same range as what has been described after treatment interruption in chronic HIV-1 infection [3/y; AC-10, +44 cells/mm3/y; and AC-14, −110 cells/mm3/y. When the first 3 mo off therapy were excluded in order to minimize the potential effects of recent treatment on CD4+ T cell number, the rate of change in CD4+ T cell counts during the first year off therapy no longer differed statistically from the MACS data . A possible reason for steep CD4+ T cell slopes may be high CD4+ T cell counts at time of treatment interruption. Comparison with MACS data . The individuals who controlled viremia for a longer time either during the first STI or during any of the treatment interruptions were not different from those who experienced earlier breakthrough as measured by ELISA and Western blot status at initiation of HAART, coreceptor polymorphisms , or the presence or absence of GBV-C coinfection . The only parameter that was predictive of prolonged viral control during the first treatment interruption was a low viremia at time of institution of therapy (p = 0.01): there was a 2.8-fold increase in hazard per order of magnitude increase in viral load. This factor was no longer predictive when the period of longest control of viremia was considered. The time to rebound of viremia (>50 copies/ml or >400 copies/ml) did not correlate with the duration of viral control. Although 11 out of 14 individuals achieved at least transient control of viremia, and three experienced prolonged control, none of these patients possessed the HLA alleles B27 or B57 associated with better disease outcome [Although the study was small, we evaluated clinical and laboratory parameters to see if any was predictive of duration of viral control. Analyses included clinical and laboratory parameters at time of presentation with acute HIV-1 infection, genetic markers associated with different rates of disease progression, and the presence or absence of GBV-C coinfection. All patients presented with symptomatic acute infection. Time between onset of symptoms and institution of therapy did not affect duration of control following STI  (p < 0.05) during the first off-treatment period, reaching a median total magnitude of 2,725 SFCs/106 PBMCs and targeting a median of eight epitopes, and then were sustained when therapy was reintroduced. A further increase in the magnitude and breadth of HIV-1-specific CD8+ T cells was observed in the subsequent off-treatment periods, although these augmentations failed to reach statistical significance. The CD8+ T cell–mediated immune responses emerging during these consecutive cycles of treatment interruption were broadly directed, targeting all structural and most accessory and regulatory HIV-1 gene products (data not shown). However, the magnitude of HIV-1-specific CD8+ T cell responses at the beginning of the first , second , or third  treatment interruptions was not predictive of the time the study participants were subsequently able to stay off therapy according to study criteria.To assess the relationship between the clinical outcome and evolution of HIV-1-specific CD8+ T cells, we longitudinally analyzed the breadth and magnitude of CD8+ T cell responses using an interferon-γ ELISPOT and a panel of 410 overlapping peptides spanning the entire HIV-1 clade B consensus sequence. At the beginning of the first STI, HIV-1-specific CD8+ T cells were weak (median of 590 SFCs/106 PBMCs) A and nar6 PBMCs) B. CD8+ Tr = 0.92, p < 0.001) . The increase in CD8+ T cell epitopes targeted during the first treatment interruption was also linearly correlated to the duration until virological failure   C. Simila< 0.001) D. Howevep = 0.72; second, p = 0.12; and third, p = 0.60, respectively). These HIV-1-specific CD4+ T cell responses also tended to rise with reinitiation of therapy, and some of them were very robust, with stimulation indices over 50 detected in several individuals  , or third  treatment interruption was not statistically predictive of the time the study participants were subsequently able to stay off therapy according to study criteria.We next analyzed evolution of lymphoproliferative responses to recombinant HIV-1 p24 Gag protein in order to assess HIV-1-specific CD4+ T cell function. Most individuals had no detectable response at baseline prior to treatment, consistent with prior reports of patients with acute HIV-1 infection . After iividuals E. Simila = 0.43) F, secondAlthough early treatment of acute HIV-1 infection followed by treatment interruptions may enhance control of viremia ,8, the dThe standard immunologic assays and virologic assessments in this cohort revealed considerable heterogeneity among the study participants, and did not show a consistent pattern in duration of viremia control during successive treatment interruptions. Eleven of 14 patients (79%) were able to maintain a viral load of less than 5,000 copies/ml for at least 90 d, but progressive loss of control ensued in the majority of patients and only three patients (21%) were able to maintain control for more than 2 y. These three patients did so during the first (AC-10), the second (AC-02), and the third (AC-14) STI. Clinical, genetic, and immunological parameters did not distinguish these three individuals from the other 11 patients, nor did they predict the duration of control following treatment interruption. Indeed, the longer a patient was off therapy, the stronger and more broadly directed the CD8+ T cell responses became, but these were still not sufficient to maintain prolonged control in most patients. Although three patients did not complete the study as initially intended , the results are not substantially different if these three are censored rather than considered to have failed to control.Loss of viral control in this cohort occurred not only in the presence of strong CD8+ T cell responses, but in most cases also in the presence of virus-specific CD4+ T cell responses, although the CD4+ T cell responses often declined during periods of viremia. In addition, total CD4+ T cell numbers were also monitored and declined in most patients over time, including one of the three patients who were able to maintain low viral loads for at least 2 y. Mechanisms leading to rapid CD4+ T cell loss need to be further studied in future STI trials. Other parameters including chemokine receptor polymorphisms  and GBV-The reasons for progressive loss of control despite augmentation of virus-specific CD4+ and CD8+ T cell responses remain to be defined. In one individual (AC-06), HIV-1 superinfection in the setting of strong and broadly directed HIV-specific cellular immune responses was associated with the loss of viral control, as previously reported . No otheThese data are important in light of other recent data on treatment interruption in both acute and chronic infection. In chronic HIV-1 infection, STI studies showed only marginal, if any, improvements of HIV-1 viremia control following a number of treatment interruptions cycles, despite at least transient increases in HIV-1-specific CD8+ and CD4+ T cell responses ,53,54,55Although durable control of viremia was not achieved, it is noteworthy that the majority of patients were able to achieve transient relative containment of viremia, providing rationale for future studies aimed at further enhancing immune control. Early treatment alone should still be considered an important therapeutic option. Therapeutic vaccinations administered after treated acute HIV-1 infection and before cessation of therapy have given disappointing results thus far , but theAlthough the present study shows progressive viral breakthrough, it was not designed to address whether there might be a change in set point viremia achieved or overall clinical benefit through transient early treatment of acute HIV infection. The definition of failure chosen for this study was a viral load of greater than 5,000 RNA copies/ml plasma, which at the time the study was initiated corresponded to the level of viremia at which treatment was recommended. Larger randomized trials will be needed to determine the potential clinical and virologic benefit of approaches based on STIs. In studies of untreated infection, there is only a 5-fold difference in viremia separating the quartile with the slowest disease progression from the quartile with the most rapid progression , suggestProtocol S1(68 KB DOC).Click here for additional data file.Protocol S2(47 KB PDF).Click here for additional data file.Protocol S3(187 KB PDF).Click here for additional data file.Protocol S4(36 KB PDF).Click here for additional data file.Highly active antiretroviral therapy (HAART), which is used to treat patients with HIV, can have nasty side effects and is expensive. As a result, for the last five years scientists have been trying to determine if it is possible to give patients breaks from taking antiretroviral drugs, without patients' health suffering. It is likely that such a treatment strategy  will not work in patients who have been infected with HIV for a long time. However, until now, the jury was out about whether STI could be of benefit to patients who had only recently been infected with HIV. Some research suggested that if newly infected patients had short “holidays” from taking HAART, it might help to boost their immune system—which in turn might help to keep HIV at bay.The researchers studied 14 patients who had recently been infected with HIV. Patients were treated until their viral load was below the limit of detection by using a very sensitive method. As they were then watched after treatment interruption, most of them were able to maintain a low, though detectable, viral load for some time. The researchers then stopped the treatment and carefully watched the patients over a period of up to five years. If the number of viruses in the patients' blood rose too high, the researchers gave the patients HAART again until the number of viruses fell again. In about half the patients, treatment needed to be restarted within a year because the viruses had started becoming more numerous in the blood. The doctors had hoped that it would take much longer for the number of viruses to reach this level. In other words, giving patients “drug holidays” did not help to keep the virus at bay for long periods of time.It is relatively rare for doctors to be able to diagnose HIV shortly after an individual becomes infected with the virus. Many people have HIV for a long time before they see a doctor. Therefore, even if the STI strategy had worked, it would only have been relevant to a few patients. In addition, the study was small and preliminary, so we have to be careful about reading too much into the results. A limitation in the study is that it did not address whether there might be a long-term clinical benefit despite a gradual increase in viral load.It is important to remember that this was an experimental trial—patients with HIV should not stop taking antiretroviral drugs unless their doctor specifically tells them to do so. Although it looks as though STI may not work in the way everyone had hoped, these results may help scientists develop an HIV vaccine that is designed to keep the disease at bay. Whether early treatment of acute infection has an overall benefit in terms of time-to-development of AIDS or need for long-term treatment after drug discontinuation will need to be answered in larger clinical trials designed to answer these important questions.http://www.aidsinfo.nih.gov/AIDSinfo: http://www.aidsmap.com/AIDSmap: http://www.nlm.nih.gov/medlineplus/aids.htmlMedline Plus AIDS Information:


In a retrospective study of HIV-infected patients, we investigated the influence of the MDR1 genotype (G2677T/A and C3435T) on the virological and immunological response of treatment naïve patients.The MDR1 genotype was analysed from 72 patients in whom antiretroviral therapy was initiated between 1998 and 2004. Data were obtained at week 4, 12, 24 and 48 and were analysed by the Kruskal-Wallis test.During the first 48 weeks of antiretroviral therapy, there were no significant differences in the virological and immunological response with respect to the MDR1 2677 and 3435 genotypes and the 2677/3435 haplotype.In view of different results from several studies concerning the influence of MDR1 polymorphisms on the immunological and virological response to antiretroviral therapy, further studies with larger patient groups and longer follow-up are necessary in order to resolve conflicting issues. P-gp isgenotype . Howevergenotype -12. Howegenotype .The genetic variant C3435T in exon 26 is a synonymous polymorphism that does not alter the amino acid sequence. How this variant could affect P-gp expression is still unknown [Because of the unresolved issues surrounding the potential effects of MDR1 polymorphisms and P-gp function in HIV infection, we investigated whether there was an association between the MDR1 polymorphisms 3435 and 2677 and the immunological response in HIV infected individuals after initiation of antiretroviral therapy.Of the HIV 1 infected patients seen at the Department of Infectious Diseases of the University of Würzburg, Germany, 72 patients , started antiretroviral therapy between 1998 and 2004. The therapy consisted of three nucleoside reverse transcriptase inhibitors (NRTI) (n = 12), two NRTIs plus at least one PI  or two NRTIs plus one NNRTI (n = 20). HIV load and CD4 cell count were determined four weeks after initiation of therapy and approximately every three months thereafter. In patients who received NNRTI or PI drugs as part of their therapy, plasma levels were monitored and adjusted to therapeutic drug levels when necessary as previously described ,15. The The study was in accordance with the Helsinki Declaration and was approved by the local ethics committee. Patients gave informed consent for the study.DNA was extracted from 200 μl blood and the MDR1 3435 genotype was determined with genotype specific hybridisation probes and melting curve analysis on the LightCycler  as previously described . The 267P-value of 0.05 was considered to be significant. Analogous to [Data were analysed by the Kruskal-Wallis test, which as a nonparametric test compairs three or more unpaired groups. Because of the small number of samples a nonparametric test was needed. SPSS version 12.0  was used for statistical analysis. A ogous to , the SNPAt initiation of antiretroviral therapy 8 patients had viral loads of <10.000 copies/ml, 24 patients between >10.000 and <100.000 copies/ml, and 40 patients >100.000 copies/ml. 39 patients had a CD4 cell count of <200 cells/μl, 16 patients between >200 and <350 cells/μl, and 17 patients >350 cells/μl. Determination of NNRTI- and PI drug levels indicated compliance of the patients with a NNRTI or PI containing regimen, because the measured drug levels were in the therapeutic range. Genotype analysis of the MDR1 gene at position 3435 in exon 26 revealed 20 patients with the CC genotype, 33 with the CT genotype and 19 with the TT genotype . Analysis of the 2677 polymorphism in exon 21 demonstrated that 24 patients had the GG-, 23 the GT-, 18 the TT-, 4 the AG-, and 3 the AT genotype; the AA genotype was not found in this group . Detailed genotype and haplotype results with respect to the initial viral load and CD4 cell count are presented in table Table In an analysis of the virological and immunological response of treatment naïve patients with respect to the MDR1 G2677T/A and C3435T polymorphisms, virus load and CD4 cell count were assessed longitunally after initiation of antiretroviral therapy. We did not find an association between the CD4-cell increase or the HIV load decline and the MDR1 2677 or 3435 genotype during the first year of therapy.et al. that showed a significantly greater mean CD4-cell rise in patients with the MDR1 3435TT genotype during an observation period of 24 weeks [et al. selected part of the patients on the basis of long-term viral suppression. In both studies, a variety of antiretroviral regimens was used. While all of the patients in the study of Fellay et al. received either nelfinavir or efavirenz, the treatment regimens in our study were more heterogenous and did not allow a meaningful separate analysis.Our data are in contrast to a report of Fellay 24 weeks . The num24 weeks , 20CC/19et al. [The results of our study are supported by Nasi et al.  who analet al. .et al. [The MDR1 3435 polymorphism is a synonymous polymorphism. The TT genotype may have a reduced translation efficiency or lead to post-translational differences -23. It het al. , who shop = 0.07) with no effect of the C3435T polymorphism in the MDR-1 gene on immunological failure. However, the difference in the virological response was not observed during the first 10 months. Further follow-up of our patient group is ongoing in order to detect long-term effects that may not have been apparent during the observation period analysed in this report.In a retrospective study of 455 treatment naïve patients initiating antiretroviral therapy with 40 months of follow-up , there wDuring a follow-up of 48 weeks, we found no evidence for an association between the MDR1 G2677T/A and C3435T polymorphisms and the virological and immunological response to therapy in HIV-positive drug-naïve patients. The individual response to antiretroviral therapy is a complex phenomenon, which is influenced by a large number of biological variables. Further studies on the role of polymorphisms of the MDR1 and other transporters and enzymes involved in drug metabolism are necessary in order to elucidate the role of pharmacogenetic effects in HIV therapy.None declared.RW participated in the design of the study and the molecular genetic studies, performed the statistical analysis and drafted the manuscript. PL participated in the design of the study, obtained and reviewed clinical data and helped in the data analysis. MZ participated in the clinical management of the study patients. FT and JS participated in the molecular genetic studies and the virological and immunological analysis. HK participated in the study design and coordinated clinical management of the study patients. BW participated in the study design and coordination and made contributions to the manuscript. All authors read and approved the final manuscript.