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Incidence of symptomatic CSF viral escape in HIV infected adults receiving atazanavir/ritonavir (ATV/r)-containing ART: A tertiary care cohort in western India
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Reported by Jules Levin
IDWeek2017/IDSA, October 4-8, 2017, San Diego
-- The incidence of CSF escape was 9.5 (95% CI 5.7 to 15.7) in patients with a baseline CD4 ≤200
compared to 0.49 (95% CI 6.98e-02 to 3.5) in patients with a CD4 >200 per 10,000 person-months
resulting in IRR of 0.05 (95% CI 0.001 to 0.34) which was statistically significant (p<0.0001)
-- None of the patients receiving AZT/3TC or ABC/3TC backbone developed CSF escape, while 16
out of 686 receiving TDF/FTC developed CSF escape (Fisher's exact test two sided mid-P = 0.0086
is significant for TDF/FTC compared to AZT/3TC)
-- Treatment: ART was optimized in all patients with a median CPE score of 10.5(7-13) -- New regimens were TDF/FTC/AZT/LPV/r (n=6), TDF/3TC/AZT/LPV/r (n=2), AZT/3TC/LPV/r (n=2),
TDF/FTC/LPV/r (n=2) & TDF/FTC/LPV/r/RAL (n=1), AZT/3TC/LPV/r/RAL (n=1), AZT/3TC/LPV/r/IDV (n=1), TDF/FTC/IDV/r (n=1)
-- All patients had rapid neurological improvement after change in ART & reported complete recovery
at first follow up after 1 month


Program Abstract
 CSF viral escape (CSF-VE) in patients receiving effective antiretroviral treatment (ART) has been increasingly described in the last decade. This single-center study attempts to quantify the incidence of symptomatic CSF escape in patients receiving ATV/r containing regimen.
Objectives: Primary objective was to assess the incidence of symptomatic CSF-VE in patients receiving ATV/r-containing ART in clinical practice. Secondary objectives were to describe clinical presentation, risk factors and clinical response after ART was changed. Methods: We performed a retrospective analysis of adults receiving ATV/r-containing ART who were diagnosed with symptomatic CSF-VE from August 2013 to January 2017 at a tertiary care center. Patients with active CNS infections were excluded. Incidence rates were calculated by dividing the number of patients who experienced CSF-VE by the number of person-months at risk and summarized as per 10000 (ten thousand) person-months at risk. Difference in incidence of CSF-VE as per the ART regimen was assessed using Fisher exact test.
           Results:  933 HIV-1 adults with a total of 36,068 person-months of follow up were included.  Of 26 patients diagnosed with CSF-VE, 16 (61.5%) received ATV/r-containing regimens. Impaired memory (56.3%), dizziness (50%) and tremors (43.8%) were the three most common presenting symptoms. Incidence rate of symptomatic CSF-VE was 4.4 per 10,000 person-months (95% CI 2.7 to 7.2). Incidence of CSF-VE was not associated with age, sex, weight, or ART status (naïve vs first line failure) of the patient. The incidence of CSF-VE was 9.5 per 10,000 person-months (95% CI 5.7 to 15.7) when the nadir CD4 count was ²200 compared to 0.49 (95% CI 0.07 to 3.5) with a nadir CD4 count >200 (IRR 19.1 (95% CI 2.93 to 802.8), p<0.0001) (figure 1). None receiving AZT/3TC developed CSF-VE, while 16 out of 686 receiving TDF/FTC developed CSF-VE (p=0.001). ART was optimized in all patients with a median CPE score of 10.5(7-13). All patients had rapid neurological improvement after change in ART.
Conclusion: Symptomatic CSF-VE with ATV/r containing regimen was a rare but clinically significant condition in this single-center study. Nadir CD4 count ² 200 was associated with substantially increased risk of symptomatic CSF-VE, further strengthening efforts to diagnose and treat patients early in disease.


Atul Patel MD, FIDSA1,2, Ketan Patel MD2, Swati Gohel MD2, A.Kumar MD, MPH 1,Scott Letendre MD3 1Departement of Internal Medicine, University of South Florida, Tampa, FL, USA; 2Vedanta Institute of medical sciences, Infectious disease clinic, Ahmedabad- 380009, INDIA, 3Department of medicine, University of California, San Diego, LaJolla, CA, USA.





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