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A JAMA THEME ISSUEEdited by Jeanette M. Smith, MD
Antiretroviral treatment failure and multidrug-resistant HIV are major
challenges in the management of HIV infection. Hammer and colleagues conducted
a randomized clinical trial among patients with HIV infection who experienced
virologic failure while receiving a protease inhibitor (PI)–containing
drug regimen to assess whether adding a second new PI (saquinavir, indinavir,
or nelfinavir) would improve antiretroviral efficacy. The proportion of patients
who achieved a viral load below 200 copies/mL after 24 weeks of treatment
was significantly greater in the dual-PI groups compared with the single-PI
(amprenavir)-placebo group. In addition to use of 2 PIs, being naive to nonnucleoside
reverse transcriptase inhibitors (NNRTIs) and baseline hypersensitivity to
efavirenz were associated with favorable outcomes. Grant and colleagues analyzed
time trends of primary drug resistance of HIV isolates from recently infected
patients in a geographic area with high penetration of antiretroviral therapy.
Primary resistance to NNRTIs increased significantly from June 1996 through
June 2001, but resistance to all 3 available antiretroviral drug classes remained
rare. In an editorial, Trachtenberg and Sande discuss the importance of the
NNRTI class of drugs for the management of HIV infection, especially in resource-limited
areas, and of safeguards to minimize the emergence of NNRTI resistance.
In this clinical trial, the International PACTG 316 Team randomly assigned
HIV-infected pregnant women receiving standard antiretroviral therapy to placebo
or to a 2-dose intrapartum/newborn nevirapine regimen, which has previously
been shown to reduce perinatal HIV transmission among pregnant women not receiving
prenatal antiretroviral therapy. Perinatal HIV transmission rates were low
and not significantly different in the 2 treatment groups.
Results of studies on the effect of HCV infection on progression of
HIV disease are inconsistent. In this prospective study of patients infected
with HIV, Sulkowski and colleagues found no significant difference in risk
of AIDS-defining illness, death, CD4 cell count decline to below 200/µL,
or CD4 cell count response to effective highly active antiretroviral therapy
in patients with and without HCV coinfection. In an editorial, Rossi and coauthors
discuss the complexities of drug treatment for patients coinfected with HIV
Peripheral lipoatrophy and central fat accumulation have been associated
with nucleoside reverse transcriptase inhibitor therapy, perhaps as a result
of mitochondrial toxicity. The MITOX Study Group conducted a randomized trial
to determine whether substituting abacavir, which may be less toxic to mitochondria,
for stavudine or zidovudine in HIV-infected adults with moderate or severe
lipoatrophy would improve lipoatrophy without affecting disease control. Limb
fat mass measured by dual-energy x-ray absorptiometry increased significantly
in the abacavir group compared with the stavudine/zidovudine group during
24 weeks of therapy, and HIV RNA levels did not differ significantly, but
subjectively determined lipoatrophy was not judged to have improved.
Acute HIV infection cannot be diagnosed by routine antibody tests, and
HIV nucleic-acid–based testing, which is used to screen for antibody-negative
acute infection among low-risk blood donors, is not used to diagnose acute
HIV infection in clinical practice. Pilcher and colleagues report that in
a routine HIV-testing population, in which HIV prevalence is low, specimen
pooling and HIV RNA reverse transcriptase-polymerase chain reaction testing
identified persons with acute HIV infection in real time who would otherwise
have been missed by routine antibody testing.
A concerted effort is under way to develop and deliver inexpensive,
simple, and effective technologies to monitor effects of anti-HIV drugs in
Updated treatment recommendations from the International AIDS Society-USA
Panel focus on when to start antiretroviral therapy, choice of initial therapy,
and management of treatment failure.
De Cock and Janssen discuss differences in the epidemiology of the HIV/AIDS
epidemic in regions around the world and suggest potential interventions.
Results of the first year of monitoring a national program in Thailand
to prevent mother-to-child HIV transmission indicate that major components
of the program have been implemented.
For your patients: A primer on HIV infection.
This Week in JAMA. JAMA. 2002;288(2):137. doi:10.1001/jama.288.2.137