Question
Is Acute Retroviral Rebound Syndrome different from Immune Reconsitution Syndrome (IRIS)?
25 November 2008. Related: All topics, Complications and coinfections, Living with HIV long-term, Opportunistic infections, Side effects.
I would like to understand more about the acute retroviral rebound syndrome mentioned in the SMART study.
Is this any different from the immune reconsitution syndrome that we see at the start of therapy?
I am a pharmacist and working with about 8500 patients on ARV treatment- and I have observed that some of our patients on 2-3 years of treatment suddenly die (cause of death unknown- not filtered back to ARV clinic) on CD4s sometimes as high as 540, but adherence is always questionable as we work in very rural areas and medication is often not picked up for 2-3 months especially by those patients who consider themselves ‘stable’.
With some, rising ALT levels have been noted, but how does one screen for cardiovascular risk if this is not regarded as standard except for lipodystrophy or PI cases.
Can you send me more information on the study please.
Answer
Thanks for your questions which cover a lot of important areas.
Firstly, acute retroviral rebound syndrome, which is sometimes reported in studies of treatment interruptions including our report from the SMART and ACTG 5170 studies is usually when someone experiences ‘symptoms similar to serosonversion symptoms’ – which come from the same cause: a rapid INCREASE in HIV viral load, often to very high levels. Sometimes this can include OIs or, as in the report above, a hepatitis-B flare up caused from stopping HIV drugs that are also controlling hepatitis B virus. Treatment guidelines now include this important caution for people who are coinfected with HepB and when changing treatment due to HIV resistance, drugs with HBV activity (tenofovir, FTC and 3TC), still need to be maintained in the new combination.
Immune reconsitution syndrome is different. This is caused by a rapid DROP in viral load and subsequent increase in CD4 responses, that uncovers infections that were previously present, but not active, in people who start treatment with very low CD4 counts – usually because immune responses were so damaged.
Sudden death can occur at any CD4 count and it is clearly difficult to always know the cause. This happens in the general population and at a slightly higher rate if you are HIV-positive. It is likely that each case needs to be looked at individually. SMART found that continuous treatment was protective of serious and fatal events including heart disease, cancers and major organ failure.
More information about the SMART study – one of the most important trials from the last 5 years – is on the INSIGHT trial network website, and includes many abstracts, presentation slides and posters presented at recent medical meetings. Those from 2007 and 2008 include a lot of papers from SMART.
If you have trouble accessing the site pls let me know and I can personally send these to you.
A research project called CoDe looking at causes of death in HIV-positive patients is being co-ordinated by the Copenhagen HIV Programme (CHIP). Information including a free protocol is available on their site.
UK and other treatment guidelines recommend that patients have their risk for cardiovascular disease (heart attack and stroke) assessed when they are diagnosed and before they start treatment. Usually this involves using online risk calculators that use a Framingham equation.
As some risk factors are easy to asses – smoking status, gender, age, blood pressure, exercise, diet and probably even lipids – this is probably important to build into treatment in any country.
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