Long-term Use Of Antiretroviral Therapy Research Articles

Exercise to Prevent Accelerated Vascular Aging in People Living With HIV.

Given advances in antiretroviral therapy, the mortality rate for HIV infection has dropped considerably over recent decades. However, people living with HIV (PLWH) experience longer life spans coupled with persistent immune activation despite viral suppression and potential toxicity from long-term antiretroviral therapy use. Consequently, PLWH face a cardiovascular disease (CVD) risk more than twice that of the general population, making it the leading cause of death among this group. Here, we briefly review the epidemiology of CVD in PLWH highlighting disparities at the intersections of sex and gender, age, race/ethnicity, and the contributions of social determinants of health and psychosocial stress to increased CVD risk among individuals with marginalized identities. We then overview the pathophysiology of HIV and discuss the primary factors implicated as contributors to CVD risk among PLWH on antiretroviral therapy. Subsequently, we highlight the functional evidence of premature vascular dysfunction as an early pathophysiological determinant of CVD risk among PLWH, discuss several mechanisms underlying premature vascular dysfunction in PLWH, and synthesize current research on the pathophysiological mechanisms underlying accelerated vascular aging in PLWH, focusing on immune activation, chronic inflammation, and oxidative stress. We consider understudied aspects such as HIV-related changes to the gut microbiome and psychosocial stress, which may serve as mechanisms through which exercise can abrogate accelerated vascular aging. Emphasizing the significance of exercise, we review various modalities and their impacts on vascular health, proposing a holistic approach to managing CVD risks in PLWH. The discussion extends to critical future study areas related to vascular aging, CVD, and the efficacy of exercise interventions, with a call for more inclusive research that considers the diversity of the PLWH population.

Reasons for antiretroviral switching in Colombia: A retrospective cohort study.

Long-term use of antiretroviral therapy (ART) for HIV infection might lead to the necessity of switching regimens. We aimed to analyze the reasons for the ART switch, the time-to-switch of ART, and its associated factors in a Colombian cohort. We conducted a retrospective cohort in 20 HIV clinics, including participants ≥18years old with confirmed HIV infection who underwent an ART switch from January 2017 to December 2019 with at least 6 months of follow-up. A time-to-event analysis and an exploratory Cox model were performed. 796 participants switched ART during the study period. The leading cause of ART switch was drug intolerance (n = 449; 56.4%) with a median time-to-switch of 12.2months. The longest median time-to-switch was due to regimen simplification (42.4months). People ≥50years old (HR = 0.6; 95% CI (0.5-0.7) and CDC stage 3 at diagnosis (HR = 0.8; 95% CI (0.6-0.9) had less hazard for switching ART over time. In this Colombian cohort, drug intolerance was the main cause of the ART switch, and the time-to-switch is shorter than reports from other countries. In Colombia, it is crucial to apply current recommendations for ART initiation to choose regimens with a better tolerability profile.

Lipid profiles of people with human immunodeficiency virus with dyslipidemia after switching from efavirenz to dolutegravir.

Introduction: Human immunodeficiency virus (HIV) infection and the long-term use of antiretroviral therapy, especially efavirenz (EFV)-based regimens, impact lipid profiles due to insulin resistance and lead to a higher risk of metabolic diseases. Dolutegravir (DTG) is an integrase inhibitor with better lipid profiles than EFV. However, data on treatment experience in Thailand are limited. The primary outcome was lipid profile changes at 24 weeks after switching therapy. Methods: We conducted a prospective, open-label, cohort study in people with HIV aged ≥18 years who had undergone at least 6 months of EFV-based therapy, had HIV-1 ribonucleic acid levels <50 copies/mL for ≥6 months before switching, and were diagnosed with dyslipidemia or had risk factors for atherosclerosis cardiovascular disease based on modified National Cholesterol Education Program Adult Treatment Panel III guidelines. Results: Sixty-four patients were enrolled. The mean age (standard deviation [SD]) was 48.20 ± 10.46 years, and 67.19% were male. At week 24, there were decreases from baseline in mean total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. However, mean body weight and waist circumference had increased. Conclusions: DTG resulted in better lipid profiles after switching from EFV-based therapy, suggesting that this switch could benefit patients with a high risk of cardiovascular disease. However, it is essential to note that weight gain and increased waist circumference were also observed.

Antiretroviral Therapy for HIV Infection Induced-Neuropathic Pain, A Narrative Review.

Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS). AIDS is a human disease in which there is a systematic failure of the immune system, thereby leading to severe opportunistic infections. HIV is treated with antiretroviral therapy (ART), which helps in preventing the virus from replicating in the body. ART also enables the immune system to repair itself and restrict further injury. Nevertheless, the long-term use of ART leads to multiple neurological complications (e.g.neuropathic pain). Neuropathic pain (NP) arises if the nervous system is damaged or not working correctly. NP is is characterized by pain in both hands and feet and can hinder the quality of life (QOL) as it is always linked to impaired cognition, anxiety, depression, loss of function, among others. To provide an overview of the clinical issues regarding the toxicity implications arising from the long-tern use of antiretroviral therapy (ART). In this paper, we ascertained and summarized studies on manifestations of ART-induced neuropathic pain (ART-NP)-using the relevant and up-to-date facts from Google Scholar, and PubMed, among others. While ART assists in suppressing HIV and may help to lessen neurocognitive impairments, long-term use incurs toxicity to the central nervous system (CNS). Consequently, future studies must explore the effects of ART on adaptations in distinct regions of the CNS as well as the pathophysiological feature of ART-induced NP.

Long-term use of ART in African women of reproductive age

There is strong evidence that antiretroviral therapy (ART) for cisgender women of reproductive age living with HIV reduces vertical HIV transmission1 and improves women's health and survival.2 However, there is a dearth of research on the long-term (≥5 years) effects of ART in reproductive-age women who started ART during pregnancy.

Prevalence of dyslipidemias in human immunodeficiency virus-infected patients with and without antiretroviral therapy.

Background: Disturbances in the lipid profile and dyslipidemia are prevalent among human immunodeficiency virus (HIV) patients. Furthermore, long-term use of antiretroviral therapy (ART) exacerbates the condition. Data on lipid profile abnormalities among patients receiving highly active antiretroviral treatment in Pakistan are very limited. The present study aims to assess the frequency of dyslipidemia and lipid concentrations among HIV-infected patients receiving active art in comparison to those not receiving any treatment.
 Methodology: A cross-sectional study was carried out at the HIV clinic of Pakistan Institute of Medical Sciences, Islamabad, from January to July 2018. A total of 100 HIV-infected patients aged 13 to 60 years who gave consent and fulfilled the inclusion criteria were enrolled in the study via non-probability consecutive sampling. All patients who had positive HIV antibodies via the Elisa process were considered positive. Samples were examined for fasting lipids by using standard laboratory procedures.
 Results: The patients' mean age was 32.7 ± 13.4 ranging between 13-60 years. The total patient population consisted of 71% males and 29% females with a mean BMI of 21.1 ± 3.4 kg/m2. Out of 100, 38% of the study patients had dyslipidemia. The observed prevalence rate of hypertriglyceridemia, hypercholesterolemia, low HDL-C, and high LDL-C were 21%, 30%, 20%, and 16%, respectively. None of the factors were found in significant association with abnormal lipid parameters except the older patients (41-60 years) were at higher risk of hypercholesterolemia [aOR 0.15 (95% CI 0.02-0.92); p=0.04] than the counterpart.
 Conclusion: The study has demonstrated that a higher percentage of HIV-infected patients have concomitant dyslipidemia with or without art treatment.

Metabolic comorbidities and systemic arterial hypertension: the challenge faced by HIV patients on long-term use of antiretroviral therapy

ABSTRACT Objective Our objective was to estimate the frequency of comorbidities and assess its relationship with exposure factors after long-term ART use. Methods A cross-sectional study with PLHIV (≥18 years-old), who initiated ART between 2001 and 2005 and attended an HIV/AIDS public referral center (Belo Horizonte/Brazil), was performed. Demographic, clinical, therapeutic, and lifestyle data were obtained through interviews, medical charts, public database, routine laboratory examinations, and bone densitometry. The outcome was the number of comorbidities: hyperglycemia, dyslipidemia, systemic arterial hypertension (SAH), and low bone mineral density (BMD). Absolute/relative frequencies were calculated. Factors associated with the outcome were assessed by quasi-Poisson regression. RESULTS: Of the 98 participants, 53% were male and 79% and over 43 years-old. Moderate physical activity was observed in 82%, overweight/obesity in 50%, and 58% used ART based on two nucleoside reverse transcriptase inhibitors (NRTIs) plus one non-nucleoside reverse transcriptase inhibitor (NNRTI). After a mean of 15.6 years of ART exposure, 207 comorbidities were identified and 93% participants presented at least one comorbidity (mean = 2.1/participant). The most frequent overlapping constituted two co-occurrences: dyslipidemia + hyperglycemia or dyslipidemia + SAH, n = 36 for each co-occurrence. The quasi-Poisson regression showed an increase of 3% in the number of comorbidities per year of age (OR = 1.03; 95%CI = 1.02–1.04) and 84% among PLHIV on moderate physical activity (ref = heavy physical-activity) (OR = 1.84; 95%CI = 1.08–3.13). Conclusions Our study shows that the aging slightly contributed to comorbidities. However, the practice of physical-activities is crucial to prevent chronic-diseases. Treatment and preventive measures should be encouraged to diminish the burden of disease and improve quality of life among PLHIV.

HOPX Plays a Critical Role in Antiretroviral Drugs Induced Epigenetic Modification and Cardiac Hypertrophy.

People living with HIV (PLWH) have to take an antiretroviral therapy (ART) for life and show noncommunicable illnesses such as chronic inflammation, immune activation, and multiorgan dysregulation. Recent studies suggest that long-term use of ART induces comorbid conditions and is one of the leading causes of heart failure in PLWH. However, the molecular mechanism of antiretroviral drugs (ARVs) induced heart failure is unclear. To determine the mechanism of ARVs induced cardiac dysfunction, we performed global transcriptomic profiling of ARVs treated neonatal rat ventricular cardiomyocytes in culture. Differentially expressed genes were identified by RNA-sequencing. Our data show that ARVs treatment causes upregulation of several biological functions associated with cardiotoxicity, hypertrophy, and heart failure. Global gene expression data were validated in cardiac tissue isolated from HIV patients having a history of ART. Interestingly, we found that homeodomain-only protein homeobox (HOPX) expression was significantly increased in cardiomyocytes treated with ARVs and in the heart tissue of HIV patients. Furthermore, we found that HOPX plays a crucial role in ARVs mediated cellular hypertrophy. Mechanistically, we found that HOPX plays a critical role in epigenetic regulation, through deacetylation of histone, while the HDAC inhibitor, Trichostatin A, can restore the acetylation level of histone 3 in the presence of ARVs.

Prevalence and associated factors of depressive symptoms among people living with HIV on antiretroviral therapy in Jakarta, Indonesia.

We aimed to investigate the prevalence of depressive symptoms among people living with HIV (PLHIV) on antiretroviral therapy (ART) in a large HIV treatment facility in Jakarta, Indonesia, and to assess associated factors. The Indonesian version of Beck Depression Inventory-II was used to assess depressive symptoms of 346 participants visiting the HIV Integrated Clinic Cipto Mangunkusumo hospital between June and November 2018. Depressive symptoms (BDI-II score ≥14) were exhibited by 50.9% of participants, with prevalences of mild, moderate and severe depression of 30.4%, 15.6% and 4.9%, respectively. Poisson regression with robust variance analysis indicated that having lower income (aPR=1.38, 95% CI 1.12-1.63), duration of ART for 1-5years (aPR=1.25, 95% CI 1.01-1.54) and same-sex partnership (aPR=1.27, 95% CI 1.02-1.58) were positively associated with depressive symptoms. Age, sex and history of using intravenous drugs, and ART-based regimen were not associated with depressive symptoms. Depressive symptoms were common among our population despite long-term ART use and were associated with having low-income, ART for 1-5years and same-sex partnership.

Symptomatic gallstones and HIV in black South African women: Changing trends of gallstone disease?

BackgroundThe incidence of metabolic disorders in human immunodeficiency virus (HIV) endemic settings is a prevailing burden in developing countries. Cholesterol homeostasis and fat metabolism are altered by HIV and antiretroviral therapy (ART), thereby possibly contributing to complications such as gallstone formation.ObjectivesThe aim of this study was to evaluate established risk factors for the formation of cholesterol gallstones in black South African women living with HIV (WLHIV).MethodA case series study was conducted of all black South African women undergoing cholecystectomy for gallstone disease over a 1-year period at King Edward VIII Hospital, Durban, South Africa. Age, body mass index (BMI), family history of gallstones, oestrogen exposure and lipograms were compared between WLHIV and uninfected women. Categorical variables were tested using either the Fisher’s exact test or Pearson’s chi-square test. Means were compared using independent t-tests. For non-normally distributed data, the Mann–Whitney U test was used. Statistical tests were two-sided, and p-values of less than 0.05 were considered statistically significant.ResultsA total of 52 patients were assessed, 34 HIV-uninfected and 18 WLHIV. The median age of WLHIV versus the uninfected women was 35 and 50 years, respectively, (p = 0.015). A statistically significant number of uninfected women were in the overweight/obese category (BMI > 25 kg/m2) compared to the normal weight category (BMI < 25 kg/m2) (p < 0.001). The number of obese WLHIV did not reach statistical significance.ConclusionThe age of occurrence of gallstone disease amongst black South African WLHIV was significantly lower and fewer women were obese compared with the uninfected women with gallstone disease. These findings differ from known gallstone risk factors in other populations and in uninfected black South African women. This could be attributed to the metabolic alterations caused by HIV infection itself and/or to the long-term use of ART. Larger cohort studies are required to elucidate the role of HIV and ART in cholestatic disease.

Attitudes Toward Long-Term Use of Antiretroviral Therapy Among HIV-Infected Pregnant Women in Moshi, Tanzania: A Longitudinal Study.

Adherence to antiretroviral therapy (ART) during pregnancy and the postpartum period is necessary to prevent vertical HIV transmission and to secure the long-term health of an HIV-infected woman. Health behavior theory suggests that patients' attitudes towards medication can predict their medication-taking behaviour. This study sought to understand how women's attitudes towards ART changes between the pregnancy and postpartum periods, and the factors associated with these attitudes. The study enrolled 200 pregnant women living with HIV. Structured surveys were administered during pregnancy and at three and 6months postpartum. Overall, attitudes towards ART were stable over time. More positive attitudes towards ART were associated with HIV acceptance, lower levels of depression, and lower levels of shame. Counselling interventions are needed to help HIV-infected women accept their status and reduce shameful emotions. Depression screening and treatment should be integrated into PMTCT services. This study emphasizes the importance of early attention to attitudes towards ART, in order to establish a trajectory of sustained care engagement.

Procena rizika za razvoj metaboličkog sindroma kod bolesnika sa sindromom stečene imunodeficijencije posle jednogodišnje primene antiretrovirusne terapije

Introduction: Antiretroviral therapy (ART) in the treatment of HIV infection has allowed maximum control of viral replication and reconstruction of the immune system, which has contributed to the long-term survival. However, it has been observed that a long-term use of ART can lead to cumulative toxicity and metabolic abnormalities. Aim: the aim of this study was to determine whether there is a difference in lipidogram, glycemia and body mass index (BMI) before and after the initiation of ART, and to determine in which of the antiretroviral drugs the changes in the values of the measured variables were most common. Material and methods: the research was conducted at the Clinic for Infectious Diseases, Clinical Center of Kragujevac, as a prospective study involving 40 patients diagnosed with HIV infection. Biochemical parameters and BMI calculation were performed before the initiation of ART and one year after. Results: the analysis of the observed variables indicated a statistically significant difference in total cholesterol (p = 0.001), HDL (p = 0.002), LDL (p = 0.003), triglycerides (p < 0.001), glucose (p < 0.001) and BMI (p = 0.002). By analyzing the administered АRT therapy, statistical significance was achieved in the measured triglyceride values after the administration of ritonavir and lopinavir, while the highest BMI values, compared to initial ones, were observed after the administration of ritonavir, but without achieving statistical significance. Conclusion: the results of the study showed that АRТ therapy has effect on the development of hyperlipidemia, which may be associated with an increased risk of developing cardiovascular disease and protease inhibitors of the older generation are highlighted, in particular. АRT therapy in HIV-infected cells contributes to the development of a metabolic syndrome involving dyslipidemia, lipodystrophy and insulin resistance.

Anthropometric definitions for antiretroviral-associated lipodystrophy derived from a longitudinal South African cohort with serial dual-energy X-ray absorptiometry measurements.

The development of lipodystrophy is associated with the long-term use of antiretroviral therapy (ART). We assessed agreement between patient-reported lipodystrophy and body composition measures using dual-energy X-ray absorptiometry (DXA) and developed objective measures to define lipoatrophy and lipohypertrophy in black South Africans. One hundred and eighty-seven ART-naïve HIV-infected adults were enrolled in a 24-month longitudinal study. Self-reported information on regional fat loss and fat gain, anthropometry, and DXA measures were collected at baseline, three, six, 12, 18, and 24 months after starting ART. Receiver operating characteristic curves were used to describe the performance of anthropometric variables using change in limb and trunk fat measured by DXA, as the reference standard. The proportion of men and women who developed lipoatrophy and lipohypertrophy increased over the 24-month period, with lipoatrophy occurring more frequently in men (21% versus 10%). In women, lipoatrophy was best determined by thigh skinfold thickness (80.3% correctly classified) and mid-arm circumference (77.6% correctly classified). None of the anthropometric measures performed well for defining lipoatrophy in men. Anthropometric measures performed well for defining lipoatrophy in women, but not lipohypertrophy.

Understanding Antiretroviral Treatment Adherence Among HIV-Positive Women at Four Postpartum Time Intervals: Qualitative Results from the Kabeho Study in Rwanda.

As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.

The Effect of HIV and Art on the Development of Hypertension and Type 2 Diabetes Mellitus

Diabetes mellitus and hypertension [DM] are among the major causes of morbidity and mortality among people living with human immunodeficiency virus [PLHIV]. Diabetes mellitus alone is associated with morbidities that consequently reduce life expectancy and quality of life, and causes demoralising complications inclusive of ischaemic heart disease, stroke, blindness and peripheral vascular disease. Hypertension is an important and treatable cause of cardiovascular morbidity and mortality. It is an independent risk factor for myocardial infarction, chronic kidney disease ischemic and haemorrhagic stroke, heart failure and premature death. HIV infection is associated with morbidities that consequently reduce life expectancy and quality of life. There is a perceived link between HIV infection and DM and hypertension. This is a scoop review of studies on the link between HIV and DM and hypertension, that is, both epidemiologic and biological evidence to date. The literature review shows that the incidence and prevalence of type 2 diabetes [T2DM] is higher among PLHIV on ART compared to the HIV negative population. Being infected by human immunodeficiency virus (HIV) is implied to trigger an inflammatory response that, in turn, results in insulin resistance, a risk for T2DM. HIV is linked to hypertension through alterations in triglycerides, T cells and angiotensin II as well as the aggressive use of ART. The roll out of antiretroviral therapy (ART), as means to combat HIV, has benefits for PLHIV, inclusive of increased survival and living longer; yet older age is associated with hypertension and T2DM. The side effects of ART and long term use of ART are implicated in increasing the risk of T2DM among PLHIV. The co-occurrence of HIV, hypertension and T2DM in developing countries presents an overload to the burden of diseases because these countries are already experiencing high prevalence rates of HIV thereby complicating the health status of the population. Notwithstanding the contrasting research reports on the link between HIV, hypertension and DM hypertension and DM among PLHIV is a cause for concern, and there is a need for more studies, particularly in areas most hit by HIV.

Changes in Body Fat Distribution on Dual-Energy X-Ray Absorptiometry in Black South Africans Starting First-Line Antiretroviral Therapy.

Long-term use of antiretroviral therapy (ART) increases the risk of developing lipodystrophy. Few studies from Africa have used longitudinal data to assess the development of lipoatrophy and lipohypertrophy. We use clinical anthropometry and dual-energy X-ray absorptiometry (DEXA) to describe changes in body fat distribution over a 24-month period in individuals initiated on ART. A convenience sample of black South Africans (55 men and 132 women) were recruited and followed for 24 months after commencing ART. Body fat distribution was assessed using anthropometric measurements and DEXA scans at baseline and then at 3, 6, 12, 18, and 24 months after commencing ART. DEXA was also used to estimate abdominal visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). Women gained more overall weight and more regional fat in all areas analyzed on DEXA scans. Women, not men, experienced a significant increasing trend in trunk fat and a significant decreasing trend in limb fat, when expressed as a percentage of total body fat. In men, the risk of developing lipoatrophy was more than two times greater than that of women, after adjusting for age, baseline body mass index, and ART regimen. Lipohypertrophy occurred similarly in men and women. VAT and SAT increased significantly in men and women, with women gaining considerably more than men. These findings are of great concern as an increased waist circumference is associated with increased mortality in HIV-infected populations. Further investigation is required to understand the mechanisms underlying the sex differences in changes in body fat distribution and its effects on cardiovascular risk.

Assessment of dental caries experience, periodontal status, and oral mucosal lesions among human immunodeficiency virus seropositives with and without antiretroviral therapy: A cross-sectional study

Introduction: Among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), studies shows variations in the prevalence of oral manifestations which may be attributed to differences in prescribed medications, stages of disease, way of transmission, and inadequate diet. Aim: To assess the dental caries experience, periodontal status, and oral mucosal lesions among people living with HIV/AIDS. Materials and Methods: A cross-sectional study was conducted for a period of 2 months among 130 people above the age group of 15 years, having HIV/AIDS. Oral mucosal lesions were assessed according to the World Health Organization Oral Health Assessment Form 1997; dental caries was assessed using decayed, missing, and filled teeth (DMFT) index and periodontal status was assessed using community periodontal index of treatment needs index by a single calibrated examiner. Data on antiretroviral therapy (ART) were obtained from medical records. The data were analyzed using SPSS version 16. Level of significance was set at 0.05. Results: Majority of them were females (84.6%), and 86.2% were on ART. There was no significant difference in the DMFT score among subjects with and without ART (median = 3). Fisher's exact test did not show statistically significant difference in the periodontal status between people with or without ART. Hyperpigmentation was found in 12.5% of the study subjects with ART. Conclusions: Subjects with and without ART did not show any difference in the prevalence of dental caries or periodontal status. Hyperpigmentation was the common condition found among subjects with ART. However, further follow-up studies are required to gain insight to the long-term use of ART on oral tissues.

The need for standardisation of the HIV continuum of care

In July, 2014, the Joint UN Programme on HIV/AIDS (UNAIDS) proposed an ambitious new target calling for 90% of HIV-infected individuals to be diagnosed, 90% of them to be on combination antiretroviral therapy (ART), and 90% of them to achieve sustained virological suppression, worldwide.1 Achieving this 90-90-90 target by 2020 would, by 2030, decrease the burden of HIV/AIDS by 90% from that in 2010. However, to meet these targets standardised and continuous global monitoring of HIV care outputs should become a priority. The HIV continuum of care provides a framework for the quantification of attrition as HIV-infected individuals move along a series of HIV-care related steps, from being diagnosed with HIV, to linkage and retention in HIV care, to initiating ART, and finally, to achieving sustained virological suppression (the ultimate goal of ART). The HIV continuum of care has become a key approach to monitoring in numerous HIV programmes.2, 3, 4, 5, 6, 7 However, with little standardisation of the definitions of steps in the continuum comparisons between programmes are difficult, if not inappropriate. Here, we use the definitions and outputs of four continuums from the USA;2 British Columbia (BC), Canada;4 France;5 and Denmark3 to argue for a standardisation in continuum step definitions (appendix). Numerous and substantial differences exist in these four continuums for the definitions of steps from the population of interest (or denominator) to viral suppression. The population of interest is the estimated HIV-positive population in the continuums from BC, France, and the USA; whereas, the number of diagnosed HIV cases is used in the Danish continuum. Thus the Danish continuum overestimates the proportion of individuals retained throughout. Linkage and retention in care step definitions varied across the continuums from BC, Denmark, and the USA and included clinical, medical billing, and ART prescription requirements or inclusion in an established cohort. France was the only continuum not to distinguish between linkage and retention in care, instead showing a step referred to as “in care”. As a result, the linkage and retention in care steps could not be meaningfully compared. This deficit may be difficult to overcome given the heterogeneity of data used to characterise these steps in the various settings. The step known as “on ART” was defined in the USA and Denmark as any ART record within the year of interest. Alternatively, BC and France used more stringent definitions capturing long-term use of ART within the calendar year. In their current form, the steps could not be compared, but this failing could be easily overcome with harmonisation. The only continuum to report on ART adherence was BC. For virological suppression, Denmark had the most liberal definition: latest viral load of less than 500 copies per mL. By contrast, BC had the most conservative definition of two or more measurements less than 50 copies per mL over a period of 3 months or longer within a calendar year. France defined suppression as having a viral load of less than 50 copies per mL within a calendar year. Finally, the USA defined suppression as a VL of 200 copies per mL or less at the latest available test. As a result, the reported proportion of patients suppressed was 35% in BC, 70% in Denmark, 52% in France, and 25% in the USA. Clearly, cross-continuum comparisons are problematic because of the different definitions. Thus, we argue that continuum comparisons can only be made confidently with standardised guidelines for the development of continuums. Although defining a standardised universal HIV continuum will no doubt have its challenges, these are not insurmountable. A simpler continuum model that focuses on the UNAIDS 90-90-90 target could be comprised of three steps: the number of individuals diagnosed with HIV as a proportion of the estimated HIV-infected population (step 1), the number of HIV-diagnosed individuals on ART (step 2), and the number of individuals virologically suppressed among those on ART (step 3). Further consensus on the specific methods to estimate each of these stages in a given programme is needed. Establishing global monitoring of these three steps would allow for continuum comparisons. Certainly, further continuum steps (e.g., linkage to care, retention in care, ART eligibility, or adherence to ART) could be added to address the needs of any future research and surveillance efforts of individual programmes. A concerted global effort to standardise and harmonise continuum definitions should begin immediately to facilitate the global monitoring of the UN 90-90-90 target, to identify specific areas requiring novel or enhanced public health interventions that will optimise outcomes for patients, and to enable direct comparisons of continuums between programmes.

Coronary artery disease in patients with HIV infection.

HIV-infected patients are known to be at risk for premature coronary artery disease. This emerging paradigm is a rising concern for clinicians. Due to advances in the treatment of HIV, this once fatal infection has been transformed into a chronic illness. Traditional risk factors paired with the long-term use of antiretroviral therapy (ART) and chronic inflammation leads to premature atherosclerosis, particularly progression of atherosclerotic plaque. This population of patients requires early recognition of subclinical atherosclerosis, as well aggressive primary and secondary prevention strategies among the multi-disciplinary team of physicians caring for them. We sought to present a comprehensive review of the available literature related to HIV and atherosclerosis and cardiovascular risk.

Hodgkin lymphomas in HIV/AIDS patients when treated with combined antiretroviral therapy: further studies are needed for understanding the pathogenesis of developing hodgkin lymphomas in HIV

, Volume 45, November–December, pp. 687-690, 2012. I wish to share my views on this article, especially on the Hodgkin lymphomas (HL) in HIV patients treated with combined antiretroviral therapy (cART).Antiretroviral therapy (ART) for HIV-infected patients has defi nitely improved the survival of patients. However, the long-term use of ART has some adverse effects. The widespread use of cART since the mid 1990s has led to a signifi cant decrease in Kaposi sarcoma and lymphomas