[Care and information for an HIV-positive patient]. / Parcours de soins et information d'un patient séropositif.

Since the year 2000, AIDS has become a chronic disease that can be treated and monitored. The two specific and necessary parameters for monitoring patients are the CD4 lymphocyte rate, which indicates the state of the immune system, and the viral load, which makes it possible to monitor the effectiveness of the antiretroviral treatments prescribed; in addition, blood antiretroviral drugs can be measured in certain cases. Today, it is clear that a patient who is effectively treated with an undetectable viral load is no longer a contaminant and that he or she will live with the disease, while facing the health issues common to everyone: emotional life, aging, other pathologies. Each caregiver, whether in the city or in a health care facility, will have a role to play in the care process.

[The place of therapeutic education in the care of an HIV-positive patient]. / Place de l'éducation thérapeutique dans le parcours de soins d'un patient séropositif.

Since the advent of triple therapy, HIV has become a chronic disease. Therapeutic patient education (TPE) seems to have a place in this accompaniment, which has sometimes lasted several decades. The role of a nurse in TPE is still essential for the accompaniment of an HIV positive patient.

Impact of atazanavir-based HAART regimen on the carotid intima-media thickness of HIV-infected persons: a comparative prospective cohort.

OBJECTIVE: With the advent of highly active antiretroviral therapy regimens, it is crucial to consider their long-term benefits to risk ratios among HIV-infected persons. The impact of protease inhibitors on the cardiovascular risk is controversial. DESIGN: This observational cohort was designed to investigate the cardiovascular impact of boosted atazanavir (ATV/r), a protease inhibitor that does not provide major dyslipidemia or insulin resistance. SETTING: This study was carried out at the University Hospital of Brest (France). PATIENTS: Among the 229 HIV-infected persons of the cohort, 33 cases treated by ATV/r-containing regimen since less than 6 months were compared to 99 age-matched and sex-matched ATV/r naive controls. INTERVENTION: None. MAIN OUTCOME MEASURE: The main outcome measure was carotid intima-media thickness (cIMT) at the baseline, 6, 12, and 18 months. RESULTS: Although the cIMT was not different at inclusion (0.633 ± 0.05 vs. 0.666 ± 0.09, P = 0.07), the cIMT course significantly decreased (P = 0.018) in cases at 18 months. The differences remained significant even after adjustment on the variables that differed between cases and controls (P < 0.1) at inclusion (high-density lipoprotein cholesterol, cardiovascular family history) and the cumulated and current exposure to the nucleosidic reverse transcriptase inhibitor, nonnucleosidic reverse transcriptase inhibitor, and protease inhibitor class. CONCLUSION: Despite similar HIV and cardiovascular characteristics at baseline, cIMT decreased after 6 months of follow-up among the patients exposed to ATV/r, even after adjustment for the exposure to the three antiretroviral classes. Considering the shortcomings of this study, especially the absence of randomization and the heterogeneity of the control group, the benefit of ATV/r treatment in patients with high cardiovascular should be confirmed by randomized trials.

Metabolic syndrome: a major risk factor for atherosclerosis in HIV-infected patients (SHIVA study).

OBJECTIVE: Metabolic syndrome (MetS) is directly related to a high incidence of cardiovascular disease in the general population. The association is more doubtful among HIV-infected patients, although MetS has an elevated prevalence in this population. We explored the impact of MetS on early atherosclerosis markers. RESEARCH DESIGN AND METHODS: All HIV-infected outpatients followed at the Brest University Hospital were included in this cross-sectional hospital-based study (SHIVA study, France) (n=154). The MetS status (NCEP ATPIII definition, at least three of these five criteria: fasting glucose, triglycerides, HDL-C, waist circumference and hypertension.) of each patient was analyzed (Mann-Whitney test) according to carotid intima-media thickness, number of plaques, and a combined cardiovascular score. RESULTS: After exclusion of 6 patients treated with statins or insulin or both, MetS status was available for 140 (90.9%) patients and positive for 10 (7.1%). MetS status was due predominantly to blood glucose and triglyceride levels and was strongly correlated with all atherosclerosis markers (p < or = 0.01). CONCLUSION: The MetS prevalence in this population is low for a group with HIV infection, even after inclusion of the statin-treated patients (11.4%), but remains higher than among the general population. MetS in this population is probably a heterogeneous cluster of side effects of antiretroviral therapy (high triglycerides, lower HDL-C, and hypertension) and direct effects of HIV (glucose disturbances). Because it is strongly linked to the presence of plaque and intimal thickness, it is a pertinent criterion for deciding about cardiovascular prevention.

Correlations between carotid IMT, factor VIII activity level and metabolic disturbances: a cardio-vascular risk factor in the HIV positive persons.

In the HIV infection, the short time-scale between the HIV-induced cardiovascular events and the onset of antiretroviral therapy elicits a thrombophilic co-factor that worsens the induced atherosclerosis. We compared the factor VIII plasma activity, previously implicated in arterial and venous thrombosis, with a surrogate marker of atherosclerosis, the carotid intima-media thickness, and with the usual atherosclerosis risk factors in 154 HIV infected outpatients. The FVIII plasma activity is significantly associated with the carotid intima-media thickness and, strongly, with blood glucose and triglycerides levels. A raised FVIII plasma activity is an important feature of the metabolic syndrome and a putative co-factor of HAART induced cardiovascular events. Thus the prevention of the HAART-induced cardio-vascular events should probably not be exclusively focused on atherosclerosis but likewise on the thrombus formation process.

Premature atherosclerosis in HIV positive patients and cumulated time of exposure to antiretroviral therapy (SHIVA study).

BACKGROUND: With the advent of antiretroviral therapy regimens in HIV positive patients, it is crucial to consider their long-term benefits to risk ratios. The responsibility of treatment in premature atherosclerosis is not clear. Thus, the aim of this study is to evaluate the impact of exposure to reverse transcriptase inhibitors (nucleosidic and non-nucleosidic) and to protease inhibitors on the cardiovascular status of an entire hospital based cohort of patients. METHODS: 154 patients were included. Using a linear analysis, we sought an association between the cumulative time of exposure to these three classes of antiretroviral drugs and the carotid intima-media thickness measured by ultrasonography and a cardiovascular composite score. RESULTS: The study confirms premature atherosclerosis, which not only correlates with the usual risk factors, such as triglyceride level, but also with protease inhibitor exposure, especially that of lopinavir. Nevertheless as regards current drug exposure, the clinical impact was low: five clinical complications of atherosclerosis and only one out of 35 scintigraphic and ECG exercise tests warranted a coronary angiography which was negative. CONCLUSION: These data should not lead to the rejection of protease inhibitors but should strengthen the prevention of cardiovascular diseases as an integral part of the management of HIV patients.

HIV-1 genetic diversity in Western Brittany, France.

We describe human immunodeficiency virus type 1 (HIV-1) diversity in Western Brittany, France, and trace the dissemination of HIV-1 non-B subtype infection. The strategy for HIV-1 subtyping used involved subtype specific enzyme immunoassays, heteroduplex mobility assays and phylogenetic analysis of the sequences of env encoding the V3 loop region. Samples were obtained from 567 patients: 465 (82%) were of subtype B and 66 (11.6%) were not (20 were subtype A, 11 subtype C, four subtype D, seven subtype F, five subtype G and 19 others with circulating recombinant forms: 4CRF01_AE, 11CRF02_AG, 1H, 3CRF11_cpx). These findings are consistent with other studies of French populations. There is an epidemiological correlation between subtype B and homosexual or heterosexual contamination in France and between non-B subtype and heterosexual contamination in Africa.