Elzi Luigia, Erb Stefan, Furrer Hansjakob, Ledergerber Bruno, Cavassini Matthias, Hirschel Bernard, Vernazza Pietro, Bernasconi Enos, Weber Rainer, Battegay Manuel
Arch Intern Med. 2012 Sep 24;172(17):1313-21. doi: 10.1001/archinternmed.2012.3216.
BACKGROUND Current guidelines give recommendations for preferred combination antiretroviral therapy (cART). We investigated factors influencing the choice of initial cART in clinical practice and its outcome. METHODS We analyzed treatment-naive adults with human immunodeficiency virus (HIV) infection participating in the Swiss HIV Cohort Study and starting cART from January 1, 2005, through December 31, 2009. The primary end point was the choice of the initial antiretroviral regimen. Secondary end points were virologic suppression, the increase in CD4 cell counts from baseline, and treatment modification within 12 months after starting treatment. RESULTS A total of 1957 patients were analyzed. Tenofovir-emtricitabine (TDF-FTC)-efavirenz was the most frequently prescribed cART (29.9%), followed by TDF-FTC-lopinavir/r (16.9%), TDF-FTC-atazanavir/r (12.9%), zidovudine-lamivudine (ZDV-3TC)-lopinavir/r (12.8%), and abacavir/lamivudine (ABC-3TC)-efavirenz (5.7%). Differences in prescription were noted among different Swiss HIV Cohort Study sites (P < .001). In multivariate analysis, compared with TDF-FTC-efavirenz, starting TDF-FTC-lopinavir/r was associated with prior AIDS (relative risk ratio, 2.78; 95% CI, 1.78-4.35), HIV-RNA greater than 100 000 copies/mL (1.53; 1.07-2.18), and CD4 greater than 350 cells/μL (1.67; 1.04-2.70); TDF-FTC-atazanavir/r with a depressive disorder (1.77; 1.04-3.01), HIV-RNA greater than 100 000 copies/mL (1.54; 1.05-2.25), and an opiate substitution program (2.76; 1.09-7.00); and ZDV-3TC-lopinavir/r with female sex (3.89; 2.39-6.31) and CD4 cell counts greater than 350 cells/μL (4.50; 2.58-7.86). At 12 months, 1715 patients (87.6%) achieved viral load less than 50 copies/mL and CD4 cell counts increased by a median (interquartile range) of 173 (89-269) cells/μL. Virologic suppression was more likely with TDF-FTC-efavirenz, and CD4 increase was higher with ZDV-3TC-lopinavir/r. No differences in outcome were observed among Swiss HIV Cohort Study sites. CONCLUSIONS Large differences in prescription but not in outcome were observed among study sites. A trend toward individualized cART was noted suggesting that initial cART is significantly influenced by physician's preference and patient characteristics. Our study highlights the need for evidence-based data for determining the best initial regimen for different HIV-infected persons.
背景 现行指南给出了首选联合抗逆转录病毒疗法（cART）的建议。我们调查了临床实践中影响初始cART选择及其结果的因素。方法 我们分析了参与瑞士HIV队列研究且在2005年1月1日至2009年12月31日期间开始cART治疗的初治成人HIV感染者。主要终点是初始抗逆转录病毒治疗方案的选择。次要终点是病毒学抑制、CD4细胞计数相对于基线的增加以及开始治疗后12个月内的治疗调整。结果 共分析了1957例患者。替诺福韦-恩曲他滨（TDF-FTC）-依非韦伦是最常开具的cART方案（29.9%），其次是TDF-FTC-洛匹那韦/利托那韦（16.9%）、TDF-FTC-阿扎那韦/利托那韦（12.9%）、齐多夫定-拉米夫定（ZDV-3TC）-洛匹那韦/利托那韦（12.8%）以及阿巴卡韦/拉米夫定（ABC-3TC）-依非韦伦（5.7%）。瑞士HIV队列研究的不同站点之间在处方上存在差异（P <.001）。在多变量分析中，与TDF-FTC-依非韦伦相比，开始使用TDF-FTC-洛匹那韦/利托那韦与既往有艾滋病（相对风险比，2.78；95%可信区间，1.78 - 4.35）、HIV-RNA大于100 000拷贝/mL（1.53；1.07 - 2.18）以及CD4大于350个细胞/μL（1.67；1.04 - 2.70）相关；TDF-FTC-阿扎那韦/利托那韦与患有抑郁症（1.77；1.04 - 3.01）、HIV-RNA大于100 000拷贝/mL（1.54；1.05 - 2.25）以及阿片类药物替代治疗计划（2.76；1.09 - 7.00）相关；而ZDV-3TC-洛匹那韦/利托那韦与女性（3.89；2.39 - 6.31）以及CD4细胞计数大于350个细胞/μL（4.50；2.58 - 7.86）相关。在12个月时，1715例患者（87.6%）实现病毒载量低于50拷贝/mL，CD4细胞计数中位数（四分位间距）增加了173（89 - 269）个细胞/μL。TDF-FTC-依非韦伦更易实现病毒学抑制，而ZDV-3TC-洛匹那韦/利托那韦使CD4增加更高。瑞士HIV队列研究的不同站点之间在结果方面未观察到差异。结论 研究站点之间在处方上存在很大差异，但在结果方面无差异。注意到了个体化cART的趋势，这表明初始cART受到医生偏好和患者特征的显著影响。我们的研究强调了需要基于证据的数据来确定针对不同HIV感染者的最佳初始治疗方案。
