Background: 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 (nave 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.
S. Gohel, None
A. Kumar, None
S. Letendre, None