Respuesta inmunológica discordante en pacientes con infección por el virus de la inmunodeficiencia humana no tratados previamente que inician terapia antirretroviral de gran actividad (TARGA): prevalencia, factores predictores y evolución clínica

摘要

Since the introduction of highly active antiretroviral therapy the prognostic of patientsudwith HIV infection has been improved significantly. We know that most patients who startudHAART achieve a complete immunovirological response but about 10-30% of patients,udaccording published studies, presents a poor CD4 T cell increment despite indetectable HIVudviral load (discordant immunological response, DIR).The definition of DIR and theudcharacteristics of patients included in published studies, are heterogeneous and it is difficult toudreach a conclusion respect the prevalence, independent associated factors and clinical outcomesudin patients with DIR. We included 272 naïve-antiretroviral HIV infected patients in audretrospective cohorts study, who started antiretroviral therapy with a HAART regimen in theudHIV Unit of Hospital Universitario 12 de Octubre in Madrid between January 1997 and Januaryud2003. The patients included presented a complete HIV viral load suppression at least in twoudconsecutive determinations during the first year of follow-up and one of them at month 12. Theudselected patients had no any concomitant immunossupresor therapy. Epidemiolgy, clinical,udbiological and therapeutic variables were collected at baseline visit and the patients wereudfollowed-up every 4 months and the determinations of CD4 cell counts, HIV viral load andudopportunistics diseases (CDC guidelines, Atlanta 1993) were specifically collected too. Theudpatients were followed-up until 24 months on HAART were completed or until two consecutiveudHIV viral load were detectable, the suspension of HAART were necessary or the patient wereudlost during the follow-up or dead. DIR was defined as the increment in CD4 cell counts less orudsimilar to 100cell/mm3 respect baseline count despite indetectable HIV viral load at month 12udon HAART. The study aims were to analyze the DIR prevalence at months 12 and 24, theudindependent associated factors to DIR and describe the clinical outcomes observed in patientsudwith DIR. We analyzed the same goals in patients with less than 200 CD4 cell/mm3 counts atudbaseline. The prevalence of DIR was 33% at month12 and 18% at month 24. The independentudassociated factors to DIR were a minor baseline HIV viral load (RR=0.52, IC95%=0.33-0.81,udp=0.004), HCV co-infection (RR=2.28, IC95%=1.24-4.19, p=0.008) and d4T versus AZTudtreatment (RR=0.48, IC95%=0.25-0.89, p=0.02) at month12 and a minor baseline HIV viraludload (RR=0.48, IC95%=0.26-0.90, p=0.02), HCV co-infection (RR=2.81, IC95%=1.19-6.61,udp=0.01) and a mayor baseline CD4 cell counts (RR=1.36, IC95%=1.09-1.69, p=0.005) at monthud24. The opportunistic diseases incidence was 8.4% and there were no significant statisticaluddifferences between patients with and without DIR. The patients with severe baselineudimmunodepression had a prevalence of DIR of 33% and 11% at months 12 and 24 respectively;udthe independent associated factor to DIR was d4T versus AZT treatment (RR=0.41,udIC95%=0.19-0.87, p=0.02) at month 12 and no independent associated factor were observed atudmonth 24; the opportunistic diseases incidence was 8.7% and no significant statisticaluddifferences were observed between patients with and without DIR.