Long-distance interactive expert advice in highly treatment-experienced HIV-infected patients.
OBJECTIVE
To determine the feasibility and outcomes of long-distance interactive expert advice for treatment-experienced patients.


METHODS
HIV-1-infected patients on failing highly active antiretroviral therapy (HAART) were prospectively submitted for consultation by treating physicians to an expert panel using a standard e-mail form including: resistance tests, antiretroviral history, adherence, CD4 counts, HIV-1-RNA levels and HCV/HBV co-infection. Conference calls (CCs) were scheduled monthly to discuss 10 new patients.


RESULTS
One hundred and fifteen patients were discussed (86% male; 45% intravenous drug users). The median length of HIV infection was 10 years and subjects were treated for a median of 8 years with a median of 5.25 previous HAART regimens. Ninety per cent were triple-class experienced [nucleoside reverse transcriptase inhibitors (NRTIs)/non-NRTIs (NNRTIs)/protease inhibitors (PIs)]. Median CD4 cell count was 298 cells/mm(3) and median viral load was 19 700 copies/mL. Overall, 60% had >or=5 reverse transcriptase mutations and 67% had >or=5 protease mutations, and most patients were NNRTI-resistant. Drugs more frequently recommended by experts were: lamivudine/emtricitabine > tenofovir > abacavir > zidovudine > didanosine > stavudine (NRTIs) and tipranavir > lopinavir > atazanavir > saquinavir (PIs). Enfuvirtide was recommended in 65% of cases. Concordance between recommended and prescribed regimens was 74.7%. Virtually all discordances were due to patient refusal of complex regimens. Outcomes at 24 weeks: HIV-1-RNA <50 copies/mL in 42% of patients, HIV-1-RNA <400 copies/mL in 59.4% of patients and median CD4 increase was 77 (14-140) cells/mm(3).


CONCLUSIONS
Long-distance interactive expert advice is feasible for complex treatment-experienced HIV patients using e-mail and CCs. Adherence to treatment recommendations is high, with encouraging viro-immunological outcomes at 24 weeks. This strategy merits further investigation, especially in clinical settings where availability of local experts is limited.
Llibre
Josep M
JM
Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. jmllibre@flsida.org
Domingo
Pere
P
del Pozo
Miguel A
MA
Miralles
Celia
C
Galindo
Maria J
MJ
Viciana
Isabel
I
Moreno
Santiago
S
Schapiro
Jonathan M
JM
Clotet
Bonaventura
B
D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D024921:Drug Resistance, Multiple, Viral / Q000187:drug effects / Q000235:genetics; D005260:Female; D005838:Genotype; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology; D015497:HIV-1 / Q000235:genetics / Q000302:isolation & purification; D006801:Humans; D008297:Male; D010349:Patient Compliance; D011446:Prospective Studies; D012367:RNA, Viral / Q000097:blood; D019114:Remote Consultation / Q000379:methods*; D017211:Treatment Failure; D019562:Viral Load
D019380:Anti-HIV Agents; D012367:RNA, Viral