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JAMA. 2002;288:137.

HIV/AIDS
A JAMA THEME ISSUE
Edited by Jeanette M. Smith, MD

Challenges in Antiretroviral Therapy
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.

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Antiretroviral Regimens and Perinatal HIV Transmission
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.

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Hepatitis C Infection and Progression of HIV Disease
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 and HCV.

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Abacavir Substitution for Patients With HIV Lipoatrophy
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.

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Real-Time Universal Screening for Acute HIV Infection
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.

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Medical News & Perspectives
A concerted effort is under way to develop and deliver inexpensive, simple, and effective technologies to monitor effects of anti-HIV drugs in resource-poor settings.

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CLINICIAN'S CORNER
Antiretroviral Treatment for Adult HIV Infection
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.

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HIV/AIDS Epidemic in Global Perspective
De Cock and Janssen discuss differences in the epidemiology of the HIV/AIDS epidemic in regions around the world and suggest potential interventions.

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Mother-to-Child HIV Transmission in Thailand
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.

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JAMA Patient Page
For your patients: A primer on HIV infection.

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