Bernardino Roca

Hepatitis C virus and human immunodeficiency virus coinfection in Spain

OBJECTIVE AND METHODS In a cross-sectional study, based on a cohort composed of HIV-infected patients of fifteen tertiary level institutions of Spain, the main data of the entire cohort are described, characteristics of patients with or without hepatitis C coinfection are compared, and the possible association of hepatitis C virus coinfection with socioeconomic, HIV-related, and hepatitis B-related variables is assessed. RESULTS A total of 4,709 patients are studied. Median of age is 37 years, 78.3% are male. HIV risk behaviours are: parenteral drug use in 63.8% of patients, heterosexual in 22.3%, and homosexual in 10.8%. Serology of hepatitis C is positive in 69.2% of participants. The following variables are associated with increased prevalence of hepatitis C coinfection, both in univariate and in multivariate analysis: HIV risk behaviour, positive anti-HBs, longer time elapsed since HIV infection diagnosis, younger age, lower social status, lower CD4 cell count increase between nadir and last available result, and lower educational level (all P<0.001). Patients with heterosexual behaviour are more frequently coinfected than patients with homosexual behaviour (P<0.001). CONCLUSION This study highlights that, in Spain, more than two thirds of patients with HIV infection are coinfected with hepatitis C virus.

Stavudine, lamivudine and indinavir in drug abusing and non-drug abusing HIV-infected patients: Adherence, side effects and efficacy

OBJECTIVES To compare adherence and clinical outcome with highly active antiretroviral therapy (HAART) in intravenous drug users (IDUs) and subjects with other HIV risk behaviours (non-IDUs). METHODS A total of 133 non-naive HIV-infected patients, 95 (71%) IDUs and 38 (29%) non-IDUs received triple drug therapy with stavudine, lamivudine, and indinavir. Adherence, side effects, and immunological and virological efficacy of treatment were assessed every 3 months. RESULTS During a median follow-up of 12 months, 43 patients (32% of the total) showed adequate adherence in all clinical appointments. Adherence was superior in non-IDUs than in IDUs in every visit, but a significant difference was found only at 6 months, when 22 (58%) non-IDUs versus 37 (39%) IDUs were adherent (P = 0.047). Mildly increased bilirubin was observed in 69 (52%) patients, and renal colic in 34 (26%). No difference in side effects was found between IDUs and non-IDUs. After 6 months of treatment, 35 (43%) participants presented a CD4 cell count increase >100x10(6)/l, and 47 (58%) achieved undetectable HIV RNA (lower limit of detection: 200 copies/ml). CD4 cell count and HIV RNA responses were similar in both groups. CONCLUSIONS Adherence to the employed HAART regimen was poor. Non-IDUs were more adherent than IDUs, but the difference between both groups was small. Side effects and efficacy were similar in IDUs and non-IDUs.

A randomized, comparative study of lamivudine plus stavudine, with indinavir or nelfinavir, in treatment-experienced HIV-infected patients.

ObjectiveTo compare adherence and clinical outcome with two modalities of highly active antiretroviral therapy (HAART), in HIV-infected patients. DesignRandomized, open-label, prospective study. SettingTertiary care centre in Spain. PatientsA total of 112 non-naive HIV-infected patients, recruited from March 1998 through August 1998, were studied. InterventionsTriple drug therapy with stavudine and lamivudine, plus indinavir or nelfinavir. Main outcome measuresAdherence, side-effects, and immunological, virological, and clinical efficacy of treatment were assessed at 3-month intervals. ResultsAfter a median follow-up of 9 months, 32% of patients in the indinavir group versus 50% of those in the nelfinavir group showed adequate adherence in all clinical appointments (P  = 0.0559). Adherence was superior in the nelfinavir group in every visit. After 6 months of treatment 48% of subjects in the indinavir group and 70% of those in the nelfinavir group exhibited adequate adherence (P =  0.0311). After 9 months 35% of patients in the indinavir group and 59% of those in the nelfinavir group showed adequate adherence (P =  0.0291). Side-effects provoked discontinuation of treatment in 34% of patients in the indinavir group and 12% of patients in the nelfinavir group (P =  0.0073). Immunological and virological efficacy were similar in both groups. ConclusionsAdherence to a HAART regimen with stavudine plus lamivudine plus nelfinavir was superior to a regimen with stavudine plus lamivudine plus indinavir. Side-effects provoked more discontinuation of treatment in the indinavir group than in the nelfinavir group.

Interobserver discrepancy in liver fibrosis using transient elastography.

Summary.  Transient elastography is a useful method to assess liver fibrosis, but uncertainties still exist regarding reliability and reproducibility of the technique. We aimed to improve knowledge on interobserver variability with the procedure and tried to find factors associated with such variability. This was a cross‐sectional study to compare the results of transient elastography performed by two different operators, one test made just after the other. We assessed both results with correlation tests and with repeated parametric or nonparametric tests, as needed. We also carried out a multivariate analysis to find factors associated with discrepancy in the results obtained by the two operators. We included a total of 333 pairs of transient elastography tests, belonging to 274 different patients. A total of 325 pairs of tests (97.6%) were valid. Results of the first and the second tests were, respectively, median (and interquartile range) of direct measurement 6.2 (4.6–10.6) and 6.0 (4.4–10.1) kPa (P = 0.012), and mean ± standard deviation of log10 of direct measurement 0.892 ± 0.316 and 0.871 ± 0.324 (P = 0.001). In 87 pairs of tests (26.7%), a discrepancy of at least 2 kPa between both results was found, and in 15 pairs of tests (4.6%), a discrepancy of at least 10 kPa was found. Discordance of at least one stage between both measurements was noted in 74 pairs of tests (22.8%). An association was found between higher stiffness and discrepancy between both operators (P < 0.001). Although transient elastography is a very convenient test to assess liver fibrosis in clinical practice, interobserver discrepancy in results is common and represents a significant problem with the technique. Discrepant results are more common in patients with higher values of stiffness.

Borreliosis de Lyme

La borreliosis de Lyme es una zoonosis transmitida por garrapatas y producida por la espiroqueta Borrelia burgdorferi. Existen casos de esta infeccion al menos desde principios del siglo xx, sin embargo su descripcion completa no se realizo hasta 1982. Clinicamente se caracteriza por una afeccion cutanea caracteristica, el eritema migratorio, y por una variada sintomatologia sistemica, que evoluciona en fases, durante meses o anos. El diagnostico suele realizarse mediante serologia, y responde bien a diversos antibioticos, especialmente si se administran en las primeras fases de la enfermedad.

Patrón epidemiológico de la infección por el VIH en 15 hospitales españoles: casos de nuevo diagnóstico incluidos en la cohorte VACH en 2001 y 2002*

Antecedentes El estudio de los cambios en las tendencies de la epidemia del virus de la inmunodeficiencia humana (VIH) constituye un metodo util para evaluar los resultados de los planes preventivos actuales, asi como para definir futuras necesidades y objetivos de los proximos. Metodos Estudio descriptivo transversal de los casos nuevos incluidos en la cohorte VACH. Definimos “caso nuevo” a los sujetos cuyo diagnostico de infeccion por el VIH se realizo entre enero de 2001 y diciembre de 2002. Comparamos sus caracteristicas epidemiologicas con las de los sujetos incluidos en la misma cohorte diagnosticados de infeccion por el VIH entre enero de 1998 y diciembre de 2000. Resultados Estudiamos 603 nuevos casos (27% mujeres). En 146 (24,4%) el riesgo de transmision habia sido el uso de drogas (usuarios de drogas por via parenteral, UDVP), 171 (28,6%) eran hombres que tuvieron relaciones sexuales con otros hombres (HSH) y 247 (41,3%) reconocian alguna exposicion heterosexual de riesgo. La mediana de edad fue 36 anos (limites: 16-80). Solamente 1,5% tenian menos de 20 anos y 32,1% superaban 40 anos. Este porcentaje fue significativamente superior al correspondiente al trienio 98-00 (27,5%; p Conclusiones Confirmamos las tendencias observadas en estudios previos: crecimiento de la proporcion de mujeres con diagnostico reciente de VIH, progresiva disminucion de la proporcion de UDVP y aumento de HSH y tendencia al diagnostico en edades mas avanzadas.

Impact of body weight on virological and immunological responses to efavirenz-containing regimens in HIV-infected, treatment-naive adults

Objective:The prevalence of overweight and obesity is increasing among HIV-infected patients. Whether standard antiretroviral drug dosage is adequate in heavy individuals remains unresolved. We assessed the virological and immunological responses to initial efavirenz (EFV)-containing regimens in heavy compared to normal-weight HIV-infected patients. Design:Observational European cohort collaboration study. Methods:Eligible patients were antiretroviral-naïve with documented weight prior to EFV start and follow-up viral loads after treatment initiation. Cox regression analyses evaluated the association between weight and time to first undetectable viral load (<50 copies/ml) after treatment initiation, and time to viral load rebound (two consecutive viral load >50 copies/ml) after initial suppression over 5 years of follow-up. Recovery of CD4+ cell count was evaluated 6 and 12 months after EFV initiation. Analyses were stratified by weight (kg) group (I – <55; II – >55, <80 (reference); III – >80, <85; IV – >85, <90; V – >90, <95; VI – >95). Results:The study included 19 968 patients, of whom 9.1, 68.3, 9.1, 5.8, 3.5, and 4.3% were in weight groups I–VI, respectively. Overall, 81.1% patients attained virological suppression, of whom 34.1% subsequently experienced viral load rebound. After multiple adjustments, no statistical difference was observed in time to undetectable viral load and virological rebound for heavier individuals compared to their normal-weight counterparts. Although heaviest individuals had significantly higher CD4+ cell count at baseline, CD4+ cell recovery at 6 and 12 months after EFV initiation was comparable to normal-weight individuals. Conclusion:Virological and immunological responses to initial EFV-containing regimens were not impaired in heavy individuals, suggesting that the standard 600 mg EFV dosage is appropriate across a wide weight range. Video Abstract:http://links.lww.com/QAD/A635

HIV infection presenting with Fournier's gangrene.

Fourniers gangrene represents an acute severe necrotizing inflammatory process affecting the scrotum and penis. We report the case of a patient with Fourniers gangrene as the presenting sign of HIV infection. The process began with balanitis and rapidly destroyed the penis. Aggressive medical and surgical management proved successful.

Dyslipidaemia in HIV-infected women on antiretroviral therapy. Analysis of 922 patients from the Spanish VACH cohort

BackgroundInformation concerning lipid disturbances in HIV-infected women on antiretroviral therapy (ART) is scarce. The objective of the study is to describe the lipid profile in a large cohort of HIV-infected women on contemporary ART and analyse differences between regimes and patients characteristics.MethodsObservational, multicentre, cross-sectional study from the Spanish VACH Cohort. 922 women on stable ART without lipid-lowering treatment were included.ResultsMedian age was 42 years, median CD4 lymphocyte count was 544 cells/mm3, and 85.6% presented undetectable HIV-1 viral load. Median total cholesterol (TC) was 189 mg/dL (interquartile range, IQR, 165-221), HDL cholesterol 53 mg/dL (IQR, 44-64), LDL cholesterol 108 mg/dL (IQR, 86-134), and triglycerides 116 mg/dL (IQR, 85-163). Mean accumulated time on ART was 116 months; 47.4% were on NNRTI-based regimes, 44.7% on PI, and 6.7% on only-NRTI therapy. 43.8% were also hepatitis C (HCV) coinfected. Patients on PI treatment presented higher TC/HDL ratio than those on NNRTI (p < 0.001). Significantly higher HDL values were observed in NNRTI-treated patients. HCV-coinfected patients presented lower TC/HDL ratio than the non HCV-coinfected. In multivariate analysis, factors independently associated with TC/HDL ratio were age, triglyceride levels and HCV co-infection. PI treatment presented a non-significant association with higher TC/HDL ratio.ConclusionsIn HIV-infected women, the NNRTI-based ART is associated with a better lipid profile than the PI-based. Factors unrelated to ART selection may also exert an independent, significant influence on lipids; in particular, age, and triglyceride levels are associated with an increased TC/HDL ratio while HCV co-infection is associated with a reduced TC/HDL ratio.

Adherencia al tratamiento antirretroviral

1. El principal objetivo que se pretende con el TARGA es mantener indefinidamente indetectable la carga viral del VIH, lo cual se correlaciona con una recuperacion parcial del recuento de linfocitos CD4 y con un buen pronostico a largo plazo 2 . La eficacia del TARGA se halla limitada por dos circunstancias interrelacionadas entre si: las resistencias del VIH y la falta de adherencia al tratamiento. Con los farmacos existentes en la actualidad la erradicacion del VIH no es posible, y con el paso del tiempo el virus desarrolla mutaciones que le confieren resistencia, lo cual comporta el rebrote de la carga viral y la deplecion de linfocitos CD4. La falta de adherencia al TARGA disminuye la presion contra el virus y favorece claramente el desarrollo de resistencias y la progresion de la infeccion 3,4 . La adherencia al tratamiento es dificil en todas las enfermedades cronicas 5 , pero este problema es especialmente trascendente en la infeccion por el VIH. Diversos estudios, algunos de ellos realizados en nuestro medio, recogen tasas alarmantemente bajas de adherencia al TARGA 6-9 . Existe bastante desconocimiento sobre las motivaciones de la falta de adherencia