Table of Contents

• Racial and Gender Disparities in Receipt of Highly Active Antiretroviral Therapy Persist in a Multistate Sample of HIV Patients in 2001
• Emergence of Antiretroviral Resistance in HIV-Positive Women Receiving Combination Antiretroviral Therapy in Pregnancy
• Understanding the Role of HIV Load in Determining Weight Change in the Era of Highly Active Antiretroviral Therapy
• Metabolic Syndrome Among HIV-Infected Patients: Prevalence, Characteristics, and Related Factors

Racial and Gender Disparities in Receipt of Highly Active Antiretroviral Therapy Persist in a Multistate Sample of HIV Patients in 2001

Gebo KA, Fleishman JA, Conviser R, et al. for the HIV Research Network

Background: National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization.

Methods: Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART.

Results: In our cohort in 2001, 84 percent of patients received HAART and 66 percent had four or more outpatient visits during calendar year (CY) 2001. Of those with two or more CD4 counts below 350 cells/mm in 2001, 91 percent received HAART; 82 percent of those with one CD4 test result below 350 cells/mm received HAART; and 77 percent of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having one or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having four or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART.

Conclusions: Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs). [J Acquir Immune Defic Syndr 2005;38(1):96-103.]

Emergence of Antiretroviral Resistance in HIV-Positive Women Receiving Combination Antiretroviral Therapy in Pregnancy

Lyons FE, Coughlan S, Byrne CM, et al.

Background: Antenatal antiretroviral therapy is integral to preventing vertical transmission of HIV-1. The impact of temporary triple antiretroviral therapy in pregnancy on the emergence of antiretroviral resistance has not been studied.

Objective: To determine the impact of temporary triple antiretroviral therapy in pregnancy on emergence of antiretroviral resistance.

Methods: Pregnant HIV-1 infected women with a pre-treatment CD4 cell count >300 x 10l initiated triple antiretroviral therapy in the third trimester and discontinued postpartum. Genotypic resistance testing was performed after antiretroviral cessation and on pretreatment samples when postpartum samples showed primary mutations.

Results: In a cohort of 50 women who initiated antiretroviral therapy in pregnancy, 39 (78 percent) had postpartum HIV-1 nucleotide sequences available for analysis: 35 of these (90 percent) were previously antiretroviral naive. Seven primary mutations, V106A (one), Y181C (two), G190A (one), K101E (one), M184V (one), T215S (one) were detected in five (13 percent) women. All five were on regimens that included nevirapine and all were antiretroviral therapy naive prior to the index pregnancy. Four had no mutations detected pretreatment (one did not have a pretreatment analysis available; viral load 83 copies/ml). The median duration of antiretroviral exposure was 70 days.

Conclusion: Emergence of genotypic resistance is significant in this cohort of pregnant women. All mutations detected were in those that took nevirapine-containing regimens. The clinical implications of these mutations are unknown. [AIDS 2005;19(1):63-67.]

Understanding the Role of HIV Load in Determining Weight Change in the Era of Highly Active Antiretroviral Therapy

Mwamburi DM, Wilson IB, Jacobson DL, et al.

Background: In this prospective cohort study, we determined the relationship between human immunodeficiency virus (HIV) RNA load and body weight in patients with HIV infection.

Methods: Repeated-measures analysis was restricted to patients with two or more study visits, four- to nine-month intervals between study visits, and complete data on virus load, resting energy expenditure (REE), and highly active antiretroviral therapy (HAART). The outcome was change in body weight across study intervals. The main predictor was virus load. Separate analyses were performed for weight change in patients receiving and patients not receiving HAART.

Results: The eligible sample consisted of 318 participants associated with 1,886 study intervals. Sixty-one patients (19 percent) were women, and 173 (54 percent) were undergoing HAART at the time of enrollment. There was a significant interaction (p = 0.01) between virus load and HAART use. In the absence of HAART, each log₁₀ increase in virus load was associated with a 0.92-kg decrease in body weight (p = 0.003), but during HAART, virus load was not significantly associated with weight change. During HAART, a CD4 count decrease of 100 cells/mm³, rather than a change in the virus load, was associated with a 0.35-kg decrease in body weight (p<0.001). REE was independently associated with weight change in both models (p<0.001).

Conclusions: Patients with HIV infection who are losing weight and are not taking HAART should be considered for HAART. Patients who are already receiving HAART and have unsuppressed virus loads may benefit virologically from an intensified regimen, because such a regimen may lead to complete suppression if there is an accompanying increase in CD4 counts. Further research is needed to understand the strong independent effect of changes in REE among patients receiving and patients not receiving HAART. [Clin Infect Dis 2005;40(1):167-173.]

Metabolic Syndrome Among HIV-Infected Patients: Prevalence, Characteristics, and Related Factors

Jerico C, Knobel H, Montero M, et al.

Objective: To assess the prevalence in HIV-infected patients of the metabolic syndrome as defined by the National Cholesterol Education Program (ie, three or more of the following components: abdominal obesity, hypertriglyceridemia, low HDL cholesterol, high blood pressure, and high fasting glucose).

Research Design and Methods: In this cross-sectional study, 710 HIV-infected patients managed at the outpatient clinic of a tertiary hospital during 2003 completed the study protocol consisting of a medical examination and laboratory analysis after a 12-hour overnight fast.

Results: Metabolic syndrome prevalence was 17 percent and increased from 5.1 percent among HIV-infected patients under age 30 years to 27.0 percent for those aged 50-59 years. Age (per 10-year increment) (odds ratio [OR] 1.41 [95 percent CI 1.12-1.77]), BMI (1.27 [1.19-1.36]), past and present protease inhibitor exposure (2.96 [1.03-3.55] and 4.18 [1.4-12.5], respectively) were independently associated with the metabolic syndrome on logistic regression analysis. Furthermore, only stavudine (d4T) (1.74 [1.01-2.98]) and lopinavir/ritonavir (2.46 [1.28-4.71]) were associated with the metabolic syndrome after adjustment for age and BMI.

Conclusions: The prevalence of metabolic syndrome among these HIV-infected patients is similar to that previously reported in uninfected individuals. Of specific concern is the association of protease inhibitor exposure with the metabolic syndrome and, more specifically, with exposure to stavudine and lopinavir/ritonavir when individual antiretroviral drugs were analyzed. [Diabetes Care 2005;28(1):132-137.]