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From August 11th to August 13th, 2022, the 17th National Academic Conference on Infectious Diseases of the Chinese Medical Association and the 3rd International Forum on Infectious Diseases (CSID 2022) will be held in Hefei City, Anhui Province in the form of a combination of online and offlin.
Professor Sun Yongtao of Tangdu Hospital of Air Force Military Medical University, Professor Chen Yahong of Mengchao Hepatobiliary Hospital of Fujian Medical University, and Professor Wang Hui of Shenzhen Third People's Hospital delivered keynote speeches respectivel.
Definition of HIV cure
Can the cure for the "Berlin patient" be widely promoted?
Cardiovascular disease risk management strategies in HIV-infected patients
Expert consensus on the management of acute HIV infection
Professor Sun Yongtao of Tangdu Hospital of Air Force Military Medical University, Professor Chen Yahong of Mengchao Hepatobiliary Hospital of Fujian Medical University, and Professor Wang Hui of Shenzhen Third People's Hospital delivered keynote speeches respectivel.
Definition of HIV cure
The reason why HIV-infected people currently take lifelong medication is that HIV is undetectable during antiretroviral therapy (ART), but rebounds when the drug is stopped (Figure 1.
➤ HIV RNA remains undetectable without ART;
➤CD4 cell count and immune function remained normal;
➤ No disease progression and related complications;
➤ No HIV transmissibility;
➤ It can be maintained for XX years (the specific number of years is not yet determined.
Figure 1 HIV-1 viral load before and after ART withdrawal
Can the cure for the "Berlin patient" be widely promoted?
The world's first HIV cure "Berlin patient" was cured by bone marrow transplantation, but this method is currently not suitable for widespread clinical promotio.
➤Bone marrow transplantation is expensive, complicated and full of risks;
➤Donors must carry the missing CCR5 receptor delta32 gene, and the proportion of Chinese people carrying this gene is 00119;
➤Also consider HLA matchin.
➤The HIV virus reservoir is located in a variety of cells and tissues, and it is difficult to study;
➤Related to insufficient tissue diffusion of some ART drugs;
➤Inherent characteristics of the disease favor persistent HIV infectio.
Based on the above difficulties in curing HIV, it is required that the strategy to clear the virus should target all HIV-infected cells, and achieve tissue specificit.
Based on this, the following (Table 1) is the research progress in different direction.
Table 1 Summary of HIV functional cure strategies and research progress
Cardiovascular disease risk management strategies in HIV-infected patients
Professor Chen Yahong said that with the prolongation of the survival period of HIV-infected patients, various non-HIV-defining diseases, such as cardiovascular and cerebrovascular diseases, are on the rise, becoming the post-high-efficiency combined antiretroviral therapy (HAART) era and affecting the quality of life of HIV-infected patient.
and prognostic factor.
The pathogenesis of cardiovascular disease in HIV-infected patients is not yet clear, and it is currently believed to be the result of the interaction of multiple factors:
➤ HIV infection-related factors (Figure 2);
Figure 2 HIV-related inflammation may be an important cause of cardiovascular disease in HIV-infected patients
➤Related to HAART, a retrospective study from Peru showed that the dyslipidemia rate was as high as 50% in patients treated with ART for ≥5 years (Figure 3);
Figure 3 Incidence of abnormal lipid metabolism in different years of ART treatment
➤ Traditional risk factors for cardiovascular disease, such as aging, smoking and other unhealthy lifestyle.
In 2021, the European AIDS Clinical Association has made clear recommendations for the prevention and management of cardiovascular disease in HIV-infected patient.
The low-density lipoprotein (LDL-C) of HIV-infected patients should be controlled to at least 0mmol/L or less, which is higher than that of normal peopl.
More stringent, relevant management recommendations are as follows:
①Adjust living and eating habits
➤Reducing dietary saturated fat intake improves LDL-L levels;
➤ Fewer calories, more exercise, weight loss and smoking cessation tend to improve (increase); high-density lipoprotein (HDL) levels;
➤ Eating fish, reducing calorie intake, saturated fat, and alcohol lowers triglyceride (TG) level.
②The above measures are ineffective, consider replacing antiviral drugs, and adjust the choice of ART program for the purpose of reducing the risk of cardiovascular disease
➤ Use of other non-nucleoside reverse transcriptase inhibitors, integrase inhibitors, or other ritonavir-enhanced protease inhibitors known to cause less metabolic disturbance and/or reduced risk of cardiovascular disease;
➤Consider replacing zidovudine or abacavir with tenofovir disoproxil, or using a nucleoside reverse transcriptase inhibitor protection regime.
③ Finally, consider using lipid-lowering drugs
➤Indications for application: All patients with confirmed vascular disease and patients who do not meet the LDL-c target corresponding to their cerebrovascular disease risk level should use statins regardless of their blood lipid levels;
➤Drug interactions between high-intensity statins and ART should be considered in statin-intolerant HIV-infected patients; patients who fail to achieve LDL-c targets on statin and/or ezetimibe therapy, PCSK9 inhibitors should be considered;
➤The good lipid-lowering efficacy and clear cardiovascular benefits of statins have been affirme.
However, due to their wide application, many adverse reactions related to the drugs have also been reporte.
Attention should be paid to the safety of statins (Figure 4.
Figure 4 At present, the mechanism of some side effects of statins is still unclea.
In order to reduce the incidence of adverse reactions of statins as much as possible, low doses should be used to start treatment
Expert consensus on the management of acute HIV infection
The symptoms of HIV infection in the acute phase lack specificity, and multi-specialty visits are easy to be ignore.
Patients in this period are highly contagious, and it is necessary to pay attention to the epidemiological history and carry out HIV screening to identify patients as soon as possibl.
➤ Infection with HIV within 6 months;
➤Some infected people have clinical manifestations related to HIV viremia and acute damage to the immune system;
➤Fever is the most common clinical manifestation, which can be accompanied by sore throat, night sweats, nausea, vomiting, diarrhea, rash, joint pain, lymphadenopathy and neurological symptoms; most of the clinical symptoms are mild and resolve spontaneously after 1-3 weeks;
➤ HIV RNA and P24 antigen can be detected in blood;
➤ Transient decrease in CD4+ T lymphocyte count and inverted CD4+/CD8+ T lymphocyte ratio;
➤ Some patients may have mild leukopenia and thrombocytopenia or abnormal liver biochemical indicator.
Figure 5 Flow chart of screening and diagnosis of HIV-infected patients in the acute phase
Treatment and Management RecommendationsRapid/immediate initiation of treatment is recommended for acute HIV infection to achieve clinical benefit:
➤Rapidly inhibit virus replication and accelerate immune reconstruction;
➤Relieve symptoms in the acute phase and reduce the risk of transmission;
➤Reduce inflammatory activity, thereby reducing the risk of potential co-morbidity;
➤ Inhibit virus pool expansion, alter infection process, protect T cell function,et.
Antiviral treatment regimens containing rapid viral and high resistance barriers are recommended:
HIV integrase strand transfer inhibitor (INSTI) or HIV protease inhibitor (PI.