Going, Going, Gone ... HIV Treatment Failure Is Disappearing in People Who Take Their Meds

October 19, 2011

Paul E. Sax, M.D.

Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.

World Series time, hence the baseball reference in the title.

(Doesn't take much.)

But over in Lancet Infectious Diseases -- which has turned out to be a terrific journal, by the way -- there's a study reminding us that advances in HIV treatment in the late 2000s were truly spectacular.

The goal of the paper was to track the outcome of patients with "triple-class virologic failure" (TCVF) over the course of the last decade. Using data from 24 European cohorts, the investigators had access to over 90,000 patients, out of whom 2722 failed treatment with regimens that at some point contained the original three drug classes: NRTIs, PIs, and NNRTIs.

Rates of virologic suppression after TCVF steadily increased over the decade, from 19.5% in 2000 to 57.9% in 2009, and both AIDS complications and deaths declined. Significant predictors of virologic suppression by multivariable analysis included later calendar year, transmission category (MSM did the best), low viral load, and high CD4.

Those who had previously been able to achieve virologic suppression before TCVF were also more likely to be successfully treated -- this clearly being a marker for good adherence. And although "past performance is no guarantee of future results," it sure can be useful regardless. You have to assume that most of the 40% or so who did not achieve virologic suppression simply didn't take their meds.

So what's missing from their analysis?

Notably, because our objective was mainly descriptive, we did not attempt to further adjust for time-dependent variables such as access to new drugs ...

In other words, the single most important factor for improved treatment outcomes in the 2000s -- the introduction of darunavir, raltegravir, maraviroc, and etravirine -- is left out.

(They also didn't include data on resistance or adherence, but I suspect the former was tough to find, and the latter probably didn't change all that much.)

So these results are either truly remarkable (if you follow HIV from a distance) or, if you are actively practicing HIV medicine day-to-day, are so obvious you can legitimately wonder why they did the study in the first place.

Both reactions are appropriate.

Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.

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This article was provided by NEJM Journal Watch. NEJM Journal Watch is a publication of the Massachusetts Medical Society.

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