Top Infectious Disease News of the Week — January 6, 2019
JAN 11, 2019 | CONTAGION® EDITORIAL STAFF
#5: Risk of Heart Failure Doubled in People Living with HIV
According to the results of a new study, people living with HIV are twice as likely to develop cardiovascular disease than noninfected individuals. Furthermore, they are more likely to have incident heart failure than the general population, even after adjustment for demographics and cardiovascular risk factors.
The study investigators analyzed 4640 people living with HIV and 4650 uninfected controls receiving care at Northwestern Medicine from January 1, 2000, to July 12, 2016. Physicians reviewed patient data from available medical records to identify heart failure diagnoses. Follow up was carried out until incident heart failure, death, or, the most recent clinical encounter through July 12, 2016, for people without incident heart failure or death.
At baseline, 33.7% of people with HIV were taking antiretroviral therapy, and the first measured viral load was undetectable for 53.5%. The overwhelming majority (87.2%) used antiretroviral therapy during follow-up, and 48.3% used a protease inhibitor during follow-up.
These days, elections in Africa garner a certain amount of global attention—and rightfully so.
Recent changes in the political landscape in countries such as Zimbabwe, Kenya, Burundi, and even relatively stable South Africa have implications not just for the local citizenry but for the region and continent as well, impacting everything from trade to the flow of migrants to worldwide health. On December 30, 2018, the Democratic Republic of the Congo (DRC) held its first formal national elections since it gained independence from Belgium in 1960—and, not surprisingly, the world was watching.
As in many countries in Africa, polling was marred by threats of violence and irregularities in the voting rolls. However, the DRC also faced a rather unique challenge: The central African country is currently experiencing the second largest Ebola outbreak in history, with 577 confirmed cases as of January 8, 2019, according to World Health Organization (WHO) figures.
“The good news is that this time around—unlike in west Africa in 2014—we have an effective Ebola vaccine, which has so far been delivered to an estimated 30,000 people,” Peter Hotez, MD, PhD, dean of the National School of Tropical Medicine and Health Policy Scholar, Baylor College of Medicine, and former US science envoy during the Obama administration, told Contagion®. “Were it not for the vaccine, we could be seeing a repeat of 2014, when 11,000 perished [from the disease]. The bad news is that conflict in the eastern DRC is preventing full deployment of the vaccine so that people will still needlessly die.”
Drugs used to treat or prevent HIV, while effective, often result in substantial side effects. An example is the tenofovir disoproxil fumarate/emtricitabine combination, sold as the pre-exposure prophylaxis (PrEP) product Truvada. Although Truvada prevents the transmission of HIV through sexual contact by a rate of more than 90%, studies have found that it can affect kidney function and reduce bone density, making it a poor choice for some individuals. Another antiviral drug, maraviroc, has a superior safety profile but has not been shown to be effective against a wide variety of HIV infections. For this reason, investigators are interested in whether maraviroc might be put to better use for the prevention rather than treatment of HIV.
A study sponsored by the US National Institutes of Health’s Division of AIDS and conducted by investigators at the University of Pittsburgh Medical School, Weill Cornell Medicine in New York, and other locations aimed to learn whether maraviroc is an effective choice for use as a PrEP medication.
The team enrolled 406 at-risk men and transgender women, none of whom had HIV. The participants were randomized to receive 1 of 4 different drug regimens used in PrEP, including maraviroc by itself, maraviroc plus emtricitabine, maraviroc plus tenofovir disoproxil fumarate, and tenofovir disoproxil fumarate plus emtricitabine. The subjects were then followed for 48 weeks, with blood and rectal fluid samples drawn at intervals.
Investigators have now detected Marburg virus in West Africa for the first time, a December 21, 2018, statement from the US Centers for Disease Control and Prevention (CDC) reports. The deadly virus was isolated from fruit bats in Sierra Leone.
Transmission of Marburg virus predominantly occurs via close contact, as well as via infected blood and other body fluids. It can also occur by infected semen.
The Egyptian fruit bat or Egyptian rousette (Rousettus aegyptiacus) is the natural reservoir host of Marburg virus. The bats shed the virus in their saliva, urine, and feces while feeding on fruit. And people become exposed to the virus when they eat fruit that has been contaminated by infected bats, or if they are bitten by infected bats while capturing them to eat.
Dolutegravir monotherapy should no longer be used as HIV maintenance therapy, according to Bart J.A. Rijnders, MD, PhD, and Casper Rokx, MD, PhD, both from Erasmus Medical Center, Rotterdam, the Netherlands.
After dolutegravir-based combination antiretroviral therapy (cART) was approved for treatment of HIV-1 in the United States in 2013, and in Europe in 2014, evaluation of dolutegravir maintenance monotherapy initially made sense, say Drs. Rijnders and Rokx in a recent article published online in the journal Clinical Infectious Diseases.
But knowledge of the effectiveness of dolutegravir antiretroviral monotherapy for HIV has significantly evolved in recent years. Despite promising early results, subsequent prospective clinical trials showed that dolutegravir monotherapy is inferior to combination antiretroviral therapy for long-term HIV treatment. Additionally, its use is associated with viral rebounds and emergences of integrase resistance.
Drs. Rijnders and Rokx highlight data from the recently published French randomized MONCAY study. Investigators on this study aimed to determine whether a switch to dolutegravir monotherapy would be noninferior to continuing dolutegravir-based triple-therapy in maintaining virological suppression.
At 24 weeks, the investigators found that dolutegravir monotherapy was noninferior compared with triple-therapy, with 94% of the participants receiving monotherapy having a viral load below 50 c/ml compared with 96% of those receiving triple therapy. Virological rebound above 50 c/ml occurred in 2 patients receiving monotherapy, and in none of those receiving triple-therapy.
However, between weeks 24 and 48 of follow-up, 5 more cases of virologic rebound occurred in patients receiving dolutegravir monotherapy. And 2 of these cases involved participants developing new integrase inhibitor resistance mutations.
“Because the risk of virological failure with resistance increases overtime, we recommend avoiding dolutegravir monotherapy as a maintenance strategy among people living with chronic HIV infection,” the investigators emphasized.
Big advances in treatment can't make up for an inability to stop new infections, which number 5,000 per day worldwide.
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