European AIDS Clinical Society Guidelines Research Articles

DXA In People Living With HIV

Abstract Background As people with HIV now live a near normal life-span, prevention of fractures is increasingly important. Alongside conventional risk factors for fractures, antiretrovirals and chronic inflammation are believed to contribute to their increased fracture risk compared to the general population. Methods We audited a 1-year series of consecutive DXA scans conducted on people living with HIV vs the European AIDS Clinical Society guidelines on bone health. These guidelines specify indications for DXA, for repeat DXA and for osteoporosis treatment. We recorded DXA results, any prior DXA, fracture history, fracture risks and drug treatment history. We assessed frequency of scanning and pharmacological management of low bone mass vs. guidelines. Results N=90 referred for DXA, of whom 18% did not attend, leaving n=74; 58% female, 42% male, median age 52 years [36-64] and 56 years [49-69] respectively. Of the 18% (n=14) who were aged under 50, 43% had no clear indication (fracture risk factor) for DXA. Of those aged >50 years (n=60), all scans were indicated as the guidelines advises this in those aged >50 years. Bone density was normal in n=32 (43%), osteopenic in 36 (49%) and osteoporotic in 7 (9%). Fifteen percent overall had a fragility fracture history, none of whom were taking osteoporosis treatment though it was indicated in at least 4 based on their DXA result. N=12 (16%) had a DXA in preceding years, and just 2 of the repeat scans were indicated according to guidelines. For the 12 with serial scans, there was no significant change in T score after a median three-year period. Conclusion Through an audit of consecutive DXA referrals, rather than consecutive individuals, low bone mass and fragility fractures are prevalent in people living with HIV. With advancing age, fracture incidence may rise sizeable in this group therefore due attention to bone health guidelines in required.

Treatment patterns and preferences of people living with HIV starting or switching antiretroviral therapy: Real-world evidence from Portugal.

There is a lack of up-to-date real-life evidence on antiretroviral therapy (ART) strategies among people living with HIV (PLWH) in Portugal. This study aimed to describe the treatment strategy used in PLWH either initiating or switching ART. Non-interventional, cross-sectional, multicenter study carried out between December 2019 and October 2021 in Portugal. A total of 237 PLWH were included in this study, 171 of whom were ART-experienced and 66 were ART-naïve. The study showed that triple regimens were the most common ART strategy and integrase strand transfer inhibitors-based therapy was the most frequently used therapeutic class in both ART-naïve and ART-experienced PLWH. Nevertheless, about a third of PLWH who started a triple regimen transitioned to a dual regimen. Patient-reported outcomes revealed high HIV literacy and similar ART preferences in both groups. This real-world study showed that triple regimens were the most widely used ART strategy, even after the European AIDS Clinical Society guidelines introduced the recommendation of a dual regimen for naïve patients. The cohorts of this study presented a high level of HIV literacy at the time of inclusion. Our findings highlighted that taking pills only once a day is considered a very important feature for most patients.

Major revision version 12.0 of the European AIDS Clinical Society guidelines 2023.

The European AIDS Clinical Society (EACS) guidelines were revised in 2023 for the 19th time, and all aspects of HIV care were updated. Version 12.0 of the guidelines recommend the same six first-line treatment options for antiretroviral treatment (ART)-naïve adults as versions 11.0 and 11.1: tenofovir-based backbone plus an unboosted integrase inhibitor or doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with lamivudine or emtricitabine plus dolutegravir. The long-acting section has been expanded in the ART and drug-drug interaction (DDI) panels. Tables for preferred and alternative ART in children and adolescents have been updated, as has the section on prevention of vertical transmission, particularly with new guidance for breastfeeding. A new DDI table has been included for the ART and anti-infective drugs used for opportunistic infections, sexually transmitted infections, and other infectious conditions; lenacapavir has been included in all DDI tables. New sections on alcohol use and patient-reported outcome measures (PROMs) have been included in the comorbidity panel, in addition to updates on many relevant topics, such as new resource guidance for deprescribing in people with HIV. Other sections, including travel, cognitive impairment, cancer screening, sexual health, and diabetes have also been revised extensively. The algorithm for the management of acute hepatitis C virus infection has been removed, as current guidelines recommend immediate treatment of all people with recently acquired hepatitis C virus. Updates on vaccination for hepatitis B virus and recommendations for simplification to tenofovir-free two-drug regimens in people with isolated anti-hepatitis B core antibodies are provided. In the opportunistic infections and COVID-19 panel, guidance on the management of COVID-19 in people with HIV has been updated according to the most up-to-date evidence, and a new section on monkeypox has been added. In 2023, the EACS guidelines were updated extensively and now include several new sections. The recommendations are available as a free app, in interactive web format, and as a pdf online.

HIV treatment strategies across Central, Eastern and Southeastern Europe: New times, old problems.

In the last decade, substantial differences in the epidemiology of, antiretroviral therapy (ART) for, cascade of care in and support to people with HIV in vulnerable populations have been observed between countries in Western Europe, Central Europe (CE) and Eastern Europe (EE). The aim of this study was to use a survey to explore whether ART availability and therapies have evolved in CE and EE according to European guidelines. The Euroguidelines in Central and Eastern Europe (ECEE) Network Group conducted two identical multicentre cross-sectional online surveys in 2019 and 2021 concerning the availability and use of antiretroviral drugs (boosted protease inhibitors [bPIs], integrase inhibitors [INSTIs] and nucleoside reverse transcriptase inhibitors [NRTIs]), the introduction of a rapid ART start strategy and the use of two-drug regimens (2DRs) for starting or switching ART. We also investigated barriers to the implementation of these strategies in each region. In total, 18 centres participated in the study: four from CE, six from EE and eight from Southeastern Europe (SEE). Between those 2 years, older PIs were less frequently used and darunavir-based regimens were the main PIs (83%); bictegravir-based and tenofovir alafenamide-based regimens were introduced in CE and SEE but not in EE. The COVID-19 pandemic did not significantly interrupt delivery of ART in most centres. Two-thirds of centres adopted a rapid ART start strategy, mainly in pregnant women and to improve linkage of care in vulnerable populations. The main obstacle to rapid ART start was that national guidelines in several countries from all three regions did not support such as strategy or required laboratory tests first; an INSTI/NRTI combination was the most commonly prescribed regimen (75%) and was exclusively prescribed in SEE. 2DRs are increasingly used for starting or switching ART (58%), and an INSTI/NRTI was the preferred regimen (75%) in all regions and exclusively prescribed in SEE, whereas the use of bPIs declined. Metabolic disorders and adverse drug reactions were the main reasons for starting a 2DR; in the second survey, HIV RNA <500 000 c/ml and high cluster of differentiation (CD)-4 count emerged as additional important reasons. In just 2 years and in spite of the emergence of the COVID-19 pandemic, significant achievements concerning ART availability and strategies have occurred in CE, EE and SEE that facilitate the harmonization of those strategies with the European AIDS Clinical Society guidelines. Few exceptions exist, especially in EE. Continuous effort is needed to overcome various obstacles (administrative, financial, national guideline restrictions) in some countries.

“A fog that impacts everything”: a qualitative study of health-related quality of life in people living with HIV who have cognitive impairment

BackgroundCognitive impairment (CI) in people living with HIV (PLWH) is an important health concern in the context of an ageing HIV population. Impacting 14–28% of PLWH, CI is associated with lower health-related quality of life (HRQoL), however, evaluation of the illness-specific factors comprising HRQoL in PLWH with CI have not been assessed.ObjectiveWe sought to contribute evidence toward an understanding of HRQoL and identify domains of HRQoL in PLWH with CI.MethodsQualitative interviews with 25 PLWH with objective CI related to HIV disease were conducted with participants attending HIV clinics in the UK. Clinically significant CI was defined based on The European AIDS Clinical Society guidelines, requiring: (i) subjective reporting of cognitive symptoms; (ii) symptoms to be related to HIV (e.g. potentially confounding non-HIV related conditions have been excluded or are being optimally managed) and; (iii) formal neuropsychological assessment confirming CI. Median age was 56 years (range 35–80); 18 participants were men (72%); 11 (44%) were white British and 8 (32%) were Black African; 14 (56%) were men that have sex with men and 10 (40%) were heterosexual; median number of years living with HIV was 17 (range 1–34); and all participants were on combination antiretroviral therapy. Analyses employed techniques from grounded theory, underpinned by an inductive, collaborative team-based approach.ResultsFindings revealed seven interrelated domains comprising HRQoL experiences were identified: Physical function, Cognition, Social connectedness, Physical and mental health, Stigma, Self-concept, and Control and acceptance, and each was defined by specific descriptive components.ConclusionThis study provides valuable insights on the factors that drive HRQoL in PLWH with CI and contribute to a body of evidence which provides targets for the development of targeted interventions to maintain or improve quality of life.

Major revision version 11.0 of the European AIDS Clinical Society Guidelines 2021.

BackgroundThe European AIDS Clinical Society (EACS) Guidelines were revised in 2021 for the 17th time with updates on all aspects of HIV care.Key points of the Guidelines updateVersion 11.0 of the Guidelines recommend six first‐line treatment options for antiretroviral treatment (ART)‐naïve adults: tenofovir‐based backbone plus an unboosted integrase inhibitor or plus doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with lamivudine or emtricitabine plus dolutegravir. Recommendations on preferred and alternative first‐line combinations from birth to adolescence were included in the new paediatric section made with Penta. Long‐acting cabotegravir plus rilpivirine was included as a switch option and, along with fostemsavir, was added to all drug–drug interaction (DDI) tables. Four new DDI tables for anti‐tuberculosis drugs, anxiolytics, hormone replacement therapy and COVID‐19 therapies were introduced, as well as guidance on screening and management of anxiety disorders, transgender health, sexual health for women and menopause. The sections on frailty, obesity and cancer were expanded, and recommendations for the management of people with diabetes and cardiovascular disease risk were revised extensively. Treatment of recently acquired hepatitis C is recommended with ongoing risk behaviour to reduce transmission. Bulevirtide was included as a treatment option for the hepatitis Delta virus. Drug‐resistant tuberculosis guidance was adjusted in accordance with the 2020 World Health Organization recommendations. Finally, there is new guidance on COVID‐19 management with a focus on continuance of HIV care.ConclusionsIn 2021, the EACS Guidelines were updated extensively and broadened to include new sections. The recommendations are available as a free app, in interactive web format and as an online pdf.

Prevalence of HIV-associated neurocognitive disorder (HAND) in Turkey and assessment of Addenbrooke's Cognitive Examination Revised (ACE-R) test as a screening tool.

We aimed to assess the Addenbrooke's Cognitive Examination Revised (ACE-R) and three questions (3Qs, European Aids Clinical Society Guidelines) as potential screening tools for HIV-associated neurocognitive disorder (HAND). In addition, we tried to determine the prevalence and associated factors for HAND among people living with HIV (PLWH) in Turkey. Persons living with HIV were enrolled from two teaching hospitals between March 2018 and September 2018. Participants underwent screening tools, a neuropsychological test battery (NTB) and an assessment of activities of daily living. HAND was diagnosed according to Frascati's criteria and applying the Global Deficit Score (GDS) approach. A receiver operating characteristic (ROC) curve analysis was performed to compare the predictive accuracy of ACE-R to that of the NP test battery. Factors associated with HAND were evaluated using multivariate logistic regression analysis. The study sample included 162 participants (94% male). The HAND prevalence was 45.7% [asymptomatic neurocognitive impairment (ANI), 37.7%; mild neurocognitive disorder (MND), 7.4%; HIV-associated dementia (HAD), 0.6%] according to the Frascati criteria and 31.5% (ANI, 25.9%; MND, 4.9%; HAD, 0.6%) using the GDS. In the ROC analysis, the ACE-R showed an area under the curve of 0.68 at a cut-off score of 89. The sensitivity, specificity and correct classification rate of screening tests for HAND diagnosis were as follows: ACE-R (62.2%, 67%, 64.8%) and 3Qs (10.8%, 88.6%, 53%). In multivariate analysis, only education level (adjusted odds ratio [aOR] = 0.84, 95% CI: 0.76-0.92, P≤0.001) was an independent risk factor for HAND. HAND is a common comorbidity in PLWH in Turkey. The sensitivities and specificities of 3Qs and the ACE-R as screening tools are lower than desired.

2019 update of the European AIDS Clinical Society Guidelines for treatment of people living with HIV version 10.0

BackgroundThe European AIDS Clinical Society (EACS) Guidelines cover key aspects of HIV management with major updates every two years.Guideline highlightsThe 2019 Guidelines were extended with a new section focusing on drug–drug interactions and other prescribing issues in people living with HIV (PLWH). The recommendations for treatment‐naïve PLWH were updated with four preferred regimens favouring unboosted integrase inhibitors. A two‐drug regimen with dolutegravir and lamivudine, and a three‐drug regimen including doravirine were also added to the recommended initial regimens. Lower thresholds for hypertension were expanded to all PLWH and for cardiovascular disease prevention, the 10‐year predicted risk threshold for consideration of antiretroviral therapy (ART) modification was lowered from 20% to 10%. Frailty and obesity were added as new topics. It was specified to use urine albumin to creatinine ratio to screen for glomerular disease and urine protein to creatinine ratio for tubular diseases, and thresholds were streamlined with the Kidney Disease: Improving Global Outcomes (KDIGO) recommendations. Hepatitis C virus (HCV) treatment recommendations were split into preferred and alternative treatment options. The algorithm for management of recently acquired HCV infection was updated and includes recommendations for early chronic infection management. Treatment of resistant tuberculosis (TB) was streamlined with the World Health Organization (WHO) recommendations, and new tables on immune reconstitution inflammatory syndrome, on when to start ART in the presence of opportunistic infections and on TB drug dosing were included.ConclusionsThe EACS Guidelines underwent major revisions of all sections in 2019. They are available in four different formats including a new interactive web‐based version and are translated into Chinese, French, German, Japanese, Portuguese, Russian and Spanish.

Is It Feasible to Impact on Smoking Habits in HIV-Infected Patients? Mission Impossible From the STOPSHIV Project Cohort.

Assessment of the feasibility and effectiveness of a brief intervention for smoking cessation in people living with HIV (PLWH). Multicenter cohort prospective study involving PLWH from 10 Italian infectious disease centers. During routine HIV care, clinicians delivered the 5As brief intervention (Ask, Advise, Assess, Assist, Arrange) to each patient who enrolled in the study, following the European AIDS Clinical Society guidelines. At study end, participating clinicians evaluated their own adherence to intervention: "standard" if counseling was delivered in at least half of the follow-up visits, "soft" if less. The main outcome measure was smoking abstinence ≥6 months. Abstinence predictors were evaluated using a Cox-proportional hazard regression model. One thousand eighty-seven PLWH-patients (age 47.9 ± 10.8, male 73.5%) were followed for a median of 23 months (interquartile range 21-25). At baseline, current smokers were 561 (51.6%). Standard intervention was performed in 4 of 10 centers and included 343 smokers; soft intervention was performed in 6 centers (218 smokers). At last visit, 35 patients in standard (10.8%) and 6 in soft intervention (2.8%) achieved self-reported tobacco abstinence ≥6 months (P = 0.0009). Overall, the 5As intervention led to 7.3% 6-month interruptions. In the multivariable analysis, significant predictors for 6-month smoking cessation were: lower Fagerström score, stage of change (preparation/contemplation vs. precontemplation), and standard intervention. Adherence to the 5As brief intervention emerged as a critical factor for success. In fact, compared with soft intervention, the standard intervention significantly increased abstinence, highlighting that clinicians need more time and supporting tools to encourage PLWH to quit smoking.

Evolving chronic disease management in HIV care in an era of improved long-term survival.

Adults ageing with HIV and on antiretroviral therapy have a greater burden of chronic diseases compared with adults without HIV as reported by Althoff et al. (Curr Opin HIV AIDS 11:527-36, 2016). Therefore, it is important in this clinically stable HIV+ population to monitor and evaluate their risk of chronic kidney disease and intervene when appropriate. The European AIDS Clinical Society (EACS) advise that yearly screening for CKD with eGFR calculation and spot urine protein measurements should be performed (European AIDS Clinical SocietyGuidelines 2018). The Centre for Excellence for Health, Immunity and Infection (CHIP) have created a validated study calculator to estimate a patient's risk for CKD as reported by Mocroft et al. (PLoS Med 12(3):e1001809, 2015). (1) To determine the proportion of patients who had a urinary protein-creatinine ratio checked in 2018; (2) To calculate an eGFR for each patient in our cohort utilizing the Modification of Diet in Renal Disease (MDRD) calculation; (3) To calculate the full chronic kidney disease score in our cohort of patients. We undertook a retrospective chart review of 80 HIV-positive patients who attended our weekly clinic in Beaumont Hospital, Dublin, Ireland. In our subset of 31 patients who had all the requirements to estimate their eGFR and full chronic kidney disease risk score, 100% (31/31) of eGFRs calculated were reported as > 90mL/min/1.73m2. The median eGFR was 215mL/min/1.73m2 (range 95.69-418.08mL/min/1.73m2). The average CHIP full chronic kidney disease 5-year risk score for patients developing CKD was 0.91% (95% CI 0.60-1.21%). One patient was identified with a risk score of 5.05% as they had suffered an acute coronary syndrome event in the past. Although this audit was small and with limitations, it highlights the importance of collecting relevant and accurate patient data annually to estimate and mitigate the risk of chronic kidney disease in patients with HIV.

Prevalence of HIV indicator conditions in late presenting patients with HIV: a missed opportunity for diagnosis?

To evaluate prior prevalence of HIV indicator conditions in late-presenters with HIV infection. Retrospective cohort study between 2000 and 2014 in a healthcare network in Melbourne, Australia comparing patients presenting with late diagnosis of HIV infection (CD4 < 350 cells/ml) to those patients who had a CD greater than or equal to 350 cells/ml at presentation. The European AIDS Clinical Society guidelines on HIV indicator guided testing were used to assess for any indicator conditions in their prior medical history which may have represented a missed opportunity for earlier diagnosis. Main outcome measures: Descriptive statistics and prevalence of HIV indicator conditions. Of 436 patients with HIV infection, 82 were late presenters. Late presenters were more commonly male (83% vs. 75%, P = 0.11), older (mean age 45 vs. 39 years), born overseas (61% vs. 58%, P = 0.68) and report heterosexual transmission as their exposure risk (51% vs. 31%, P < 0.001). Of 80 patients with late presentation of HIV infection, 54 (55%) had at least one, 29 (36%) at least 2, 12 (15%) at least 3 and 5 (6%) had 4 or more previous HIV indicator conditions which would have triggered HIV testing according to guidelines. The most common indicator conditions were: unexplained loss of weight (31%), herpes zoster (10%), thrombocytopenia or leukopenia (10%), oral or oesophageal candidiasis (10%) and community acquired pneumonia (9%). Twenty patients (25%) had HIV indicator conditions diagnosed at least 12 months before the eventual diagnosis of HIV infection. Patients diagnosed with late-presenting HIV often had an HIV indicator condition prior to presentation, presenting a missed opportunity for earlier diagnosis.

Patient-reported outcomes in daily clinical practise in HIV outpatient care

IntroductionThe use of patient-reported outcomes (PROs) in outpatient care holds promise as a tool to enhance the quality of care. The management of chronic HIV infection is multidimensional, and clinical assessment includes broad screening to identify complications. With growing constraints on time and resources, the use of PROs may provide a much-needed tool to ensure optimal HIV care. The aim of this study was to evaluate the clinical implementation and use of a Web-based tool to collect PROs in a cohort of HIV-infected individuals. MethodsIn December 2015, the PRO system AmbuFlex, a Web-based tool for self-reporting of clinical symptoms, was implemented in HIV outpatient care at Aarhus University Hospital. The HIV-specific questionnaire was designed to cover items in the European AIDS Clinical Society guidelines. Patients responded through a Web-based system from home. Based on an HIV-specific algorithm, responses were automatically assigned a green, yellow, or red colour code reflecting the severity of the symptom. HIV-related data from the electronic hospital management system were used to compare respondents and non-respondents. For cognitive and red symptoms, patient records were accessed to address whether PRO provided new information. Furthermore, it was sought to determine whether implementing PROs in clinical care can help focus the consultation on current needs. This was done by checking if a flagged symptom was assessed clinically at the following consultation. ResultsFive hundred and five HIV patients were invited to participate and 277 (55%) accepted the invitation. Compared to respondents, non-respondents were significantly younger and more often female, born outside Denmark, newly diagnosed, and with a plasma viral load >50 copies/ml. Among the 262 correctly received PRO questionnaires, 104 (39%) had solely green colour-coded responses, whereas 59 (23%) had one or more red colour-coded responses. Of 69 red symptoms, 28 (41%) led to a specific clinical assessment. In many cases, PROs appeared to provide new information on cognitive (76%) and red-coded symptoms (42%). ConclusionsThe use of PROs identified several cases where physical or cognitive symptoms appeared to have been unnoticed. A substantial proportion of patients reported no symptoms requiring medical attention, suggesting a potential to individualize outpatient care and redistribute resource utilization.

European AIDS Clinical Society Second Standard of Care Meeting, Brussels 16-17 November 2016: a summary.

The European AIDS Clinical Society (EACS) organized a second meeting on Standard of Care in Europe on November 16-17 th, 2016. The aims of the meeting were to discuss and propose actions on three topics, namely: Adherence to guidelines for treatment initiation, treatment monitoring and outcomes, Retention in care and HIV and tuberculosis co-infection. Several actions need to be implemented in order to further improve quality of care and treatment of HIV in Europe. A common ground for standard of care, based on the EACS Guidelines should be established throughout Europe. EACS plans to interact with policy makers and other stakeholders to insure this common minimal level of standard of care, in particular for initiating of ART, accessibility of drugs and monitoring of ART with viral load. Progress should be made to monitor retention in care, prevent lost to follow and insure return to care. Improving integration of services and accessibility to care play a major role. Integration is also key for optimizing care of HIV-tuberculosis co-infection, as well as diagnosis and prevention of tuberculosis in population at risk. The Standard of Care meeting organized every other year by EACS provides a unique opportunity to monitor progresses and pitfalls in HIV patient care throughout Europe. It is also a forum for advocacy towards policy makers and other stakeholders to constantly improve HIV patient global management, aiming to provide the same level of quality on the whole continent.

The cardiovascular risk management for people living with HIV in Europe: how well are we doing?

HIV has become a chronic condition associated with comorbidities. We investigated cardiovascular risk and risk modification in a European HIV cohort. EuroSIDA patients (from 1 January 2000) for whom cardiovascular risk could be calculated (DAD risk equation) were included in the analysis. Moderate-to-high risk was defined as 5-year cardiovascular risk more than 5% and risk modification as two measurements meeting the European AIDS Clinical Society guidelines. Factors associated with risk development and modifications were investigated using Poisson regression. Of 8762 individuals, 32.1% were hypertensive, 45.0% had high cholesterol, 47.4% were current smokers, and 27.1% were overweight. A total of 1504 (17.2%) had a 5-year cardiovascular risk of more than 5%. Of 7258 individuals with a 5-year risk less than 5%, 1905 (26.2%) developed cardiovascular risk more than 5% (6.53/100 person-years). These patients were more likely to be older, men, living in East Europe, with traditional cardiovascular risk factors. MSM with longer exposure to antiretroviral therapy, low CD4 nadir, higher current CD4 and prior AIDs events were more likely to develop cardiovascular risk. Those on antihypertensive treatment and living in central Europe were less likely to develop cardiovascular risk. Of those clinically indicated for risk modification, 1205 of 2077 (58.0%) successfully modified BP; 1283 of 3919 (32.8%) stopped smoking; 277 of 1394 (19.9%) modified cholesterol and 543 of 2163 (25.1%) reduced their BMI. There was variation in modification of individual risk factors, by sex, age, HIV-related factors and region of follow-up. Risk modification for BP and smoking improved over time (P < 0.001). Cardiovascular risk was common. More than half modified their cardiovascular risk, and this improved over time.

UG1 Digital Ano-Rectal Examination (DARE) as anal cancer screening in HIV positive Men who have Sex with Men (HMSM) – is it acceptable to patients?

Background/introduction Anal cancer is more common in HMSM than in HIV negative MSM or the general population. Tumours in HMSM tend to be larger and more advanced at diagnosis resulting in poorer prognosis. The European AIDS Clinical Society Guidelines recommend DARE with a screening interval of 1–3 years. However, this is only based on expert opinion. The benefit of such a strategy in a UK GUM managed HIV cohort is still unknown. Aim(s)/objectives To assess acceptability of annual DARE to HMSM and establish patient experience of having DARE. Methods From pre-published clinic lists covering the 8-week recruitment period, patients fitting the inclusion criteria (HMSM aged ≥ 35) were invited to participate in the study when they attended clinic. Patients were asked to complete a questionnaire and invited to have DARE as part of their consultation. Results Of the 43 patients invited into the study, 29 [67%; 95% confidence interval (CI) 53–81] proceeded to DARE. Principal reason for refusal of DARE was ‘lack of time’ and ‘not feeling clean’. Of the 29 having DARE, 12 [41%; 95% CI 23–59] were found to have a previously unrecorded clinical abnormality. 5 [17%; 95% CI 3–31] required colorectal referral - 3 [10%] for lesions suspicious of anal intraepithelial neoplasia. Outcomes of colorectal consultation are awaited. 100% of respondents said they would have DARE again. Discussion/conclusion Annual DARE is an acceptable addition to the routine care of HMSM. Pre-warning patients to expect DARE at a routine visit when it is due may further improve acceptability.

Statins and Aspirin use in HIV-infected people: gap between European AIDS Clinical Society guidelines and clinical practice: the results from HIV-HY study.

To investigate the use of statins and acetylsalicylic acid (ASA) in HIV people in clinical practice. A multicenter, nationwide, prospective cohort study, including 1182 consecutive HIV patients was conducted. Statin and ASA prescription was evaluated in primary and secondary cardiovascular disease prevention, according to the European AIDS Clinical Society (EACS) guidelines. Followed-up patients (998) were mostly males (70.9%) with a mean age at enrolment of 46.5years (SD 9.5). The mean time of follow-up was 3.3years (SD 0.8). At the last follow-up visit, statins would have been recommended for 31.2% and ASA for 16% by EACS guidelines. Conversely, only 15.6 and 7.6% of patients were on statin and ASA treatment, respectively; only 50.3% of patients treated with statins achieved recommended low-density lipoprotein cholesterol (LDL-c) levels. At the last follow-up visit, agreement between statin therapy and EACS recommendation was 0.58 (95% CI 0.52-0.63). The corresponding figure for ASA therapy was 0.50 (95% CI 0.42-0.58), whereas the agreement for ASA therapy in secondary prevention was 0.59 (95% CI 0.50-0.68). The prescription of statins and ASA in HIV-infected patients remains largely suboptimal, as only about 50% of patients requiring statins and ASA are properly treated. Higher attention on this relevant issue and further investigation are warranted in this at risk population.

Toward a comprehensive care of HIV patients: finding a strategy to detect depression in a Spanish HIV cohort

ABSTRACTDepression is a common but frequently undiagnosed feature in individuals with HIV infection. To find a strategy to detect depression in a non-specialized clinical setting, the overall performance of the Hospital Anxiety and Depression Scale (HADS) and the depression identification questions proposed by the European AIDS Clinical Society (EACS) guidelines were assessed in a descriptive cross-sectional study of 113 patients with HIV infection. The clinician asked the two screening questions that were proposed under the EACS guidelines and requested patients to complete the HADS. A psychiatrist or psychologist administered semi-structured clinical interviews to yield psychiatric diagnoses of depression (gold standard). A receiver operating characteristic (ROC) analysis for the HADS-Depression (HADS-D) subscale indicated that the best sensitivity and specificity were obtained between the cut-off points of 5 and 8, and the ROC curve for the HADS-Total (HADS-T) indicated that the best cut-off points were between 12 and 14. There were no statistically significant differences in the correlations of the EACS (considering positive responses to one [A] or both questions [B]), the HADS-D ≥ 8 or the HADS-T ≥ 12 with the gold standard. The study concludes that both approaches (the two EACS questions and the HADS-D subscale) are appropriate depression-screening methods in HIV population. We believe that using the EACS-B and the HADS-D subscale in a two-step approach allows for rapid, assumable and accurate clinical diagnosis in non-psychiatric hospital settings.

Prevalence and concordance of high cardiovascular disease scores in HIV/AIDS patients from Croatia and Serbia with four international algorithms.

IntroductionWe evaluated cardiovascular risks in HIV-infected patients from Croatia and Serbia and the eligibility for statin therapy as recommended by the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, European AIDS Clinical Society (EACS) Guidelines and European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS) guidelines for cardiovascular disease (CVD) prevention [1–3].Materials and MethodsA cross-sectional analysis of consecutive patients between 40 and 79 years old who had received antiretroviral therapy for at least 12 months was performed.ResultsOf 254 (132 from Croatia and 122 from Serbia) persons included in the study, 76% were male; median age was 49 years. Up to 51.6% of persons had a high CVD risk. The prevalence of current smoking was 42.9%, hypertension 31.5% and hypercholesterolaemia (>6.2 mmol/L) 35.4%. Statins would be recommended to 21.3% (95% CI, 16.3% to 27.4%) of persons by the EACS, 25.6% (95% CI, 20.2% to 31.9%) by ESC/EAS and 37.9% (95% CI, 31.6 to 44.6%) by the ACC/AHA guidelines. A high 5-year data collection on adverse effects of anti-HIV drugs study risk score (>5%) had a moderate agreement with the high (≥20%) 10-year CVD Framingham risk score (kappa=0.47) and high (≥5%) 10-year European systematic coronary risk evaluation score algorithm (kappa=0.47), and substantial agreement with the elevated (≥7.5%) 10-year Pooled Cohort Atherosclerotic CVD risk equation score (kappa=0.63).ConclusionWe found a high prevalence of CVD risks in patients from Croatia and Serbia. The ACC/AHA guideline would recommend statins more often than ESC/EAS and EACS guidelines.

Regional and national guideline recommendations for digital ano-rectal examination as a means for anal cancer screening in HIV positive men who have sex with men: a systematic review.

BackgroundAlthough anal cancer is common in HIV positive men who have sex with men, few centres offer systematic screening. Regular digital ano-rectal examination (DARE) is a type of screening that has been recommended by some experts. How widely this forms part of HIV management guidelines is unclear.MethodsThe protocol was registered prospectively (CRD42013005188; http://www.crd.york.ac.uk/PROSPERO/). We systematically reviewed 121 regional and national HIV guidelines and searched for guidelines from http://hivinsite.ucsf.edu/global?page=cr-00-04#SauguidelineX, PubMed and Web of Science databases up to 5th August 2013 for recommendations of DARE as a means of anal cancer screening in HIV positive MSM. Guidelines were examined in detail if they were clinical guidelines, including both prevention and treatment protocols and were in English. Guidelines were excluded if they were restricted to limited areas (e.g. antiretroviral therapy only, children or pregnant women, strategies for prevention/testing). Information was extracted regarding recommendation of DARE as a screening method, the frequency of DARE recommended, target population for screening and the strength of evidence supporting this.Results30 regional and national guidelines were included and examined in detail. Only 2 recommended DARE. The ‘European AIDS Clinical Society Guidelines’ recommends DARE every 1–3 years for HIV positive MSM whilst the ‘US Guideline for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents’ recommends an annual DARE for the HIV + population in general. None of these guidelines specify the age of commencing screening. In each case, the highest level of evidence supporting these two recommendations was expert opinion.ConclusionsFew HIV guidelines discuss or recommend DARE as a means of anal cancer screening. Studies of the efficacy, acceptability and cost-effectiveness of DARE are needed to assess its role in anal cancer screening.

Monotherapy is a possibility of simplifying an antiretroviral therapy regimen

The European AIDS Clinical Society guidelines (November 2009, Version 5) are the first to propose to use ritonavir-boosted protease inhibitors (PI) as monotherapy. These treatment regimens may be the modality of choice for HIV-infected patients if nucleoside reverse transcriptase inhibitors (NRTI) are not tolerated or the ART regimen should be simplified. The paper gives the results of the largest studies (MONET, OK04, OREY) dealing with switching from a standard ART regimen (2 NRTIs + PI) to PI monotherapy. The results of these studies provide strong evidence that ART regimen simplification to boosted PI monotherapy did not affect in the least therapeutic efficiency. After 48-96 weeks of monotherapy, treatment failure was recorded in 15-23% of patients; however, return to the previous therapeutic regime (addition of two former drugs from a NRTI group) allowed complete suppression of virus replication to be achieved again in 80% of cases. Development of PI resistance mutations in HIV was recorded only in single patients. PI monotherapy regimens were well tolerated, there were no adverse reactions associated with the use of NRTIs.