Dubravka Salemovic

The metabolic syndrome, an epidemic among HIV-infected patients on HAART.

BACKGROUND HAART has dramatically changed the prognosis of AIDS, but has led to long-term toxicities of antiretroviral drugs. A major chronic complication is the metabolic syndrome (MS), including hyperlipidemia, lipodystrophy (LD), and impaired glucose metabolism. METHODS A cross-sectional study of a series of 582 patients from the Serbian HIV/AIDS cohort, treated with HAART for a mean period of 3.3+/-2.1 years (range 1-10), was performed to evaluate the prevalence and risk factors for MS during HAART. RESULTS The prevalence of LD was 29.1%, with a 100% probability of development after 10 years of treatment. Risk factors for LD included female gender (OR 1.7, 95% CI 1.0-2.7, P=0.02), age>40 (OR 1.7, 95% CI 1.1-2.7, P=0.01) and AIDS at HAART initiation (OR 1.9, 95% CI 1.2-2.2, P<0.01), as well as prolonged usage of NRTIs (OR 2.7, 95% CI 1.6-4.5, P<0.01). The NNRTI-based regimens were less likely to induce LD than those PI-based (OR 1.87, 95% CI 1.2-2.9 vs. OR 3.7, 95% CI 2.3-6.1, respectively). Hyperlipidemia occurred in 47% of the patients, and was associated with male gender (OR 2.2, 95% CI 1.4-3.5, P<0.01) and prolonged usage of PI+NNRTI HAART (OR 3.0, 95% CI 1.8-4.9, P<0.01). In contrast, regimens composed of 2 NRTI+NNRTI were less likely to induce hyperlipidemia (OR 0.4, 95% CI 0.3-0.7, P=0.03). Glucose intolerance and/or diabetes mellitus was recorded in 9.6%, if with AIDS at HAART initiation (OR 3.7, 95% CI 1.2-11.4, P<0.01), male gender (OR 5.2, 95% CI 1.8-15.1, P<0.01) and age>40 (OR 2.6, 95% CI 1.1-6.3, P=0.02). CONCLUSION MS seems an inevitable consequence of long-term successful HAART.

HIV-1 subtypes in Yugoslavia.

To gain insight concerning the genetic diversity of HIV-1 viruses associated with the HIV-1 epidemic in Yugoslavia, 45 specimens from HIV-1-infected individuals were classified into subtypes by sequence-based phylogenetic analysis of the polymerase (pol) region of the viral genome. Forty-one of 45 specimens (91.2%) were identified as pol subtype B, 2 of 45 as subtype C (4.4%), 1 of 45 as CRF01_AE (2.2%), and 1 as CRF02_AG recombinant (2.2%). Nucleotide divergence among subtype B sequences was 4.8%. Results of this study show that among HIV-1-infected patients in Yugoslavia subtype B predominates (91.5%), whereas non-B subtypes are present at a low percentage, mostly related to travel abroad.

The incidence of and risk factors for HIV-associated cognitive-motor complex among patients on HAART.

BACKGROUND While highly active antiretroviral therapy (HAART) allows for the considerable decline in the incidence of HIV-related opportunistic infections and tumors, its effect on treating HIV infection of the brain, such as HIV-associated dementias (HADs), remains unclear. METHODS A cross-sectional study of consecutive series of 96 patients from the Serbian HIV/AIDS cohort, treated with HAART in our HIV unit was performed to evaluate the incidence of and risk factors for cognitive/motor complex during HAART. CD4+T cell counts and pVL values at the time of neurological evaluation were parameters of the response to HAART. The mini-mental test and neurologic examination were performed at one point of time during treatment to reveal cognitive and/or motor disorders. RESULTS After mean HAART duration of 47 months, unimpaired cognition, minor cognitive impairment, and HIV-associated dementia were recorded in 56 (58.3%), 27 (28.1%), and 13 (13.5%), respectively. Motor abnormalities had 39 (40.6%) patients. Of these, 21, 12, and 6 patients belong to the subgroups with normal cognition, minor cognitive impairment and HAD patients, respectively. Factors predictive for HAD were age over 40 (OR 3.7, 95% CI 1.07-13.28, P=0.039), and AIDS diagnosis prior to HAART initiation (OR 14.19, 95% CI 1.76-114.16, P=0.013). Conversely, factors shown to be protective against HAD were the usage of AZT and NNRTIs, as components of HAART regimens (OR 0.18, 95% CI 0.046-0.76, P=0.019, and OR 0.14, 95% CI 0.034-0.6, P=0.008). CONCLUSION Cognitive/motor complex has still remained a significant neuropathology among late presenters and elder HIV/AIDS patients. Certain HAART regimens containing AZT, and/or NNRTIs, could be protective for these patients.

Comparison of nucleoside reverse transcriptase inhibitor use as part of first-line therapy in a Serbian and a UK HIV clinic.

Abstract Background: Use of dideoxynucleoside reverse transcriptase inhibitors (dNRTIs) may lead to increased mitochondrial toxicity. We compared nucleoside reverse transcriptase inhibitor (NRTI) use as part of antiretroviral therapy (ART) in two HIV clinics: one in a low-middle income (HIV Centre Belgrade [HCB], Serbia) and one a high income (ICDC, Royal Free Hospital, London, UK) country. Methods: Antiretroviralnaïve patients starting ART from 2003 to 2005 were included. Specifi c NRTIs were compared between centers, focusing on dNRTI use. Kaplan-Meier estimates of the percentage of patients making changes to their NRTI backbone (a) for any reason or (b) for mitochondrial toxicity (peripheral neuropathy, pancreatitis, lactic acidosis) were calculated. Results: Of 287 HCB patients, 89 (31.0%) received didanosine (ddI)-containing, 39 (13.6%) stavudine (d4T)-containing, and 39 (13.6%) ddI+d4Tcontaining regimens; for 539 ICDC patients, these were 18 (3.3%), 66 (12.2%), and 0 (0.0%), respectively (p < .0001). After 12 months, 57.5% and 52.6% at HCB and ICDC had switched their NRTI backbone. This was reduced to 34.5% at HCB after excluding changes due to drug supply interruption and to 11.2% and 1.3% at HCB and ICDC after changes were made for mitochondrial-related reasons. At 6 months, 73/80 (91.3%) and 385/488 (78.9%) had viral load below 50 copies/mL at HCB and ICDC, respectively. Conclusion: Patients treated at HCB faced higher levels of mitochondrial-related toxicity, likely due to greater dNRTI use.

Molecular typing of the local HIV-1 epidemic in Serbia.

Worldwide HIV-1 pandemic is becoming increasingly complex, with growing heterogeneity of subtypes and recombinant viruses. Previous studies have documented HIV-1 subtype B as the predominant one in Serbia, with limited presence and genetic diversity of non B subtypes. In recent years, MSM transmission has become the most frequently reported risk for HIV infection among newly diagnosed patients in Serbia, but very little is known of the network structure and dynamics of viral transmission in this and other risk groups. To gain insight about the HIV-1 subtypes distribution pattern as well as characteristics of HIV-1 transmission clusters in Serbia, we analyzed the genetic diversity of the pol gene segment in 221 HIV-1-infected patients sampled during 2002-2011. Subtype B was found to still be the most prevalent one in Serbia, accounting for over 90% of samples, while greater diversity of other subtypes was found than previously reported, including subtypes G, C, A, F, CRF01 and CRF02. In total, 41.3% of analyzed subtype B sequences were found associated in transmission clusters/network, that are highly related with MSM transmission route.

The prognosis of highly active antiretroviral therapy (HAART) treated HIV infected patients in Serbia, related to the time of treatment initiation.

BACKGROUND With the introduction of highly active antiretroviral treatment (HAART) an impressive improvement in patient survival and quality of life has bee observed. However, the optimal timing of initial HAART is still under consideration. OBJECTIVE To investigate the prognosis of HAART treated patients in Serbia, related to the timing of HAART initiation. STUDY DESIGN A series of 563 patients on HAART was retrospectively analyzed to investigate treatment response and survival. RESULTS After a mean of 6 years (range 1-14) of treatment with PI-based and/or NNRTI-based regimens, a favorable response was achieved in 72.4%, treatment failure occurred in 7.9%, while 19.7% had a dissociative immunological/virological response. If treatment was initiated during primary HIV infection it took a shorter time to achieve a favorable response than in patients who began HAART in chronic HIV infection (2.7+/-2.2 years vs. 6.9+/-2.7 years, P<0.01). A higher proportion of patients with primary HIV infection then those treated in the chronic phase achieved a favorable response to HAART (88.4% vs. 71.9%, P=0.045). Patients who initiated HAART when their CD4 cell counts were below 200 cells/microL needed longer treatment for favorable response (8 years vs. 6 years, log rank P<0.01). Forty-seven (8.3%) patients died. The overall estimated survival was 13 years. Patients older then 40 and IVDU were more likely to die during HAART (OR 2.6, 95% CI 1.1-5.9, P=0.016, and OR 2.0, 95% CI 1.0-3.7, P=0.02, respectively). However, reaching and maintaining undetectable viremia was an independent predictor of longer survival (OR 11.3, 95% CI 4.6-27.7, P<0.01). CONCLUSION Reaching and maintaining undetectable viremia during HAART predicted longer survival, even if sub-clinical immunodeficiency remained.

The Prognosis of Late Presenters in the Era of Highly Active Antiretroviral Therapy in Serbia

To examine the prognosis of patients who present with very advanced HIV-induced immunodeficiency, and their response to highly active antiretroviral therapy (HAART), a series of 101 treatment naïve patients from the Serbian cohort of HIV infected patients, who presented with a CD4 count of ≤ 50/µL before commencing HAART, was retrospectively analyzed and factors influencing response to HAART and survival investigated. After a mean of three years (range 1-9) of treatment with PI-based and/or NNRTI-based regimens, a favorable response was achieved in 54.5% of the patients, treatment failure occurred in 13.9%, while 31.7% had a dissociative immunological/virological response. The overall estimated survival was eight years. Achievement of undetectable viremia during treatment appeared life saving (OR = 42.5, 95% CI 7.1 – 251.9, P = 0.000, as was a rise in CD4 cell count to over 200/μL (OR = 6.4, 95% CI 1.2-31.8, P = 0.023). However, undetectable viremia was the single predictor of longer survival (OR = 42.5, 95% CI 7.1 – 251.9, P = 0.000), regardless of the level of immune reconstitution (log rank, P = 0.31). Late presenters had a high probability of developing the metabolic syndrome while on HAART, with a median time to hyperlipidemia and lypodystrophy of 5 and 6 years, respectively. We conclude that late presenters on HAART may have a good prognosis, a prerequisite for which is sustained undetectable viremia regardless of the immune recovery.

CMV DNA in blood and CSF of HIV infected patients

Cytomegalovirus (CMV) infection frequently affects the central nervous system in HIV infected patients. Varied clinical manifestations of CMV disease make virological detection of CMV essential for proper diagnosis and treatment. Thus, in patients in different stages of HIV-induced disease, we attempted to detect cell associated and free, non cell associated CMV DNA in cerebrospinal fluid (CSF) and in peripheral blood mononuclear cells (PBMCs). Twenty-six blood samples were collected from 22 patients included in the study. Nine of these blood samples were tested in pair with the concomitant CSF sample for the presence of CMV DNA by a commercial hybridization test. CMV serostatus and avidity of IgG antibodies were detected by a commercial ELISA test. CMV DNA was present in the cells found in CSF in all but one of the AIDS patients, independently of the presence of neurological symptoms, suggesting that it represented a marker of advanced immunodeficiency, rather than of the specific CMV-related disease. Cell-associated CMV DNA in CSF tested positive even in the samples negative for cell-free CMV DNA in the CSF, and with no detectable CMV DNA in the PBMCs of concomitant blood sample. We believe that searching for CMV DNA in different compartments of CSF merits further attention.

Intravenous drug use – an independent predictor for HCV genotypes 3 and 4 infection among HIV/HCV co-infected patients

Introduction About one quarter of human immunodeficiency virus (HIV) infected persons in Serbia have also been found to be hepatitis C virus (HCV) co-infected. In the general population, HCV genotype 1 has been shown to be the most prevalent one. Here, we present the first study on the distribution of HCV genotypes among HIV/HCV co-infected patients in Serbia, in relation to epidemiological and clinical features. Material and methods The study included HIV/HCV co-infected and a group of HCV mono-infected patients in the period 1998–2012, with collection of epidemiological, clinical, and behavioral data using a standardized questionnaire. The HCV genotyping to the level of pure genotype was performed by reverse hybridization. Results Intravenous drug use (IDU) was found to be significantly more prevalent among the co-infected patients (p < 0.01). HCV genotype 1 was detected in 87% of patients with mono-infection, compared to 46.3% of patients with co-infection (p < 0.01); genotypes 3 and 4 were significantly more common among co-infected patients (6% and 5%, vs. 27% and 25%, respectively). Multivariate logistic regression confirmed IDU, infection with non-1 HCV genotype and HCV viral load over 5 log to be predictors of HIV co-infection. Conclusions The HCV genotypes 3 and 4 were found to be significantly more prevalent among HIV/HCV co-infected patients in Serbia, compared to HCV mono-infected patients, but also more prevalent compared to the European HIV/HCV co-infected cohort. History of IDU represents an independent predictor of HCV genotypes 3 and 4 infection, with important implications for treatment.

Clinical and Immunologic Outcomes of HAART-Treated HIV-Infected Women in Resource Constrain Settings: The Belgrade Study

We performed a study to identify factors related to favorable response to highly active-antiretroviral therapy (HAART) in HIV-infected women. A retrospective study was performed on 216 women who had initiated HAART from January 1, 1998 to December 31, 2012, at the HIV/AIDS Center, Belgrade, Serbia. Participants were followed-up for 8.2 ± 3.4 years. The mean age was 37 ± 9.7 years. During follow-up, it was found that 26 patients had died. Clinical AIDS at initiation of HAART was observed in 43.9% patients, while 64.8% had a CD4+ T-cell count below 200 cells/μL. Multivariate analyses revealed that the single factor independently related to a favorable response to HAART was good compliance (odds [OR] ratio for survival = 2.9, 95% confidence intervals [CI] = 1.0–8.6, p = 0.03), while a baseline CD4+ T-cell count below 100 cells/μL, hepatitis C virus coinfection, and aged 40 years and older were all associated with an unfavorable response to HAART (OR = 0.28, 95% CI = 0.15–0.52, p < 0.001; OR = 0.49, 95% CI = 0.22–0.8, p = 0.008; OR = 0.41, 95% CI = 0.21–0.79, p = 0.008, respectively). The estimated 14-year-survival was 100% in patients with sustained viral suppression, regardless of the CD4+ counts achieved (p = 0.6, log-rank). If women with advanced HIV-related immunodeficiency reach and maintain optimal viral suppression during HAART, regardless of the level of immune recovery, and if they continue to maintain this suppression for up to a mean 8 years of treatment, their prognosis may be fairly good, even in resource-limited settings.