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Simplification of combination antiretroviral therapy (cART) and the brain—a real-life experience

  • Gabriele ArendtEmail author
  • Svenja Schlonies
  • Eser Orhan
  • Olaf Stüve
Article
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Abstract

Modern antiretroviral combination therapy (cART) has transformed HIV from a life-threatening infection into a chronic disease. However, the life-long treatment has side effects that frequently have a negative impact on patients’ quality of life. Thus, there are some efforts to “simplify” therapy, i.e. apply regimens with three or fewer antiretroviral substances. However, neurologists are relatively sceptical towards this cART “simplification”, because the capacity of simplified regimens to access the cerebrospinal fluid (CSF) might be too weak to effectively suppress viral load in this compartment. Thus, data of a big Neuro-AIDS cohort of 4992 HIV-positive patients consecutively recruited over three decades were retrospectively analysed in terms of neurocognitive performance of patients switched to simplified therapy regimens. To test whether simplified drug regimens result in new neuropsychological deficits or the worsening of pre-existing ones in HIV+ patients. Three groups of HIV+ patients were switched from triple therapy to three different two drug regimens (n = 177 to lamivudine/PI, n = 37 to INI/PI, and n = 303 to dual PI); three other groups of patients put from one to an alternative triple combination (n = 290 ABC/3TC/PI, n = 244 TDF/FTC/PI, and n = 158 TDF/FTC/NNRTI) for whatever reason served as controls. All patients were followed up over 4 years maximum. Every patient group improved immunologically and virologically after the switch. However, patients who switched to INI/PI combinations remained stable in neuropsychological tests, while a considerable percentage of patients who switched to other treatments demonstrated a decline. Remarkably, a high percentage of the patients switched to “simplified drug regimens” was not well-controlled virologically before the switch. HIV-positive patients with simplified therapy regimens show some benefit in terms of systemic infection surrogate markers (CD4 ± cell count and plasma viral load); however, neurocognitive deficits do not improve, but remain stable in most cases.

Keywords

HIV infection Antiretroviral combination therapy Two drug regimens 

Abbreviations

COBI

cobicistat

CSF

cerebrospinal fluid

EVG

elvitegravir

FTC

emtricitabine

HAND

HIV-associated neurocognitive disorder

INI

integrase inhibitors

LDR

less drug regimen

PI/r

boosted protease inhibitors

NRTI

nucleoside inhibitors of the reverse transcriptase

NNRTI

non-nucleoside inhibitors of the reverse transcriptase

SDR

simplified drug regimens

START-study

strategic timing of antiretroviral therapy

TDF

tenofovir

Notes

Acknowledgments

The authors thank all patients giving their informed consent to publish their data and all doctors presenting their patients in our out-patient department.

Author contribution

Gabriele Arendt wrote the manuscript; Svenja Schlonies collected the data; Eser Orhan helped in data evaluation and statistics; Olaf Stüve helped in writing the manuscript and did the language editing; all authors: manuscript revision.

Funding

The study was kindly supported by Janssen-Cilag GmbH, Germany.

Compliance with ethical standards

Conflicts of interest

Gabriele Arendt received financial support from Janssen-Cilag GmbH, Germany and from ViiV Healthcare and honoraria for lectures and consultancies from Abbvie, Bristol-Myers Squibb, Gilead Sciences, Janssen-Cilag GmbH, Germany and MSD. All the other authors declare that they have no conflict of interest.

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Copyright information

© Journal of NeuroVirology, Inc. 2019

Authors and Affiliations

  1. 1.Department of Neurology, Medical FacultyUniversity of DuesseldorfDüsseldorfGermany
  2. 2.Southwestern Medical CenterUniversity of TexasDallasUSA

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