JAC Advance Access published online on November 13, 2007
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkm438
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Long-distance interactive expert advice in highlytreatment-experienced HIV-infected patients
1 Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain 2 Hospital Sant Pau, Barcelona, Spain 3 Hospital General, Valladolid, Spain 4 Hospital Xeral, Vigo, Spain 5 Hospital Clínico, Valencia, Spain 6 Hospital Virgen de la Victoria, Málaga, Spain 7 Hospital Ramón y Cajal, Madrid, Spain 8 National Hemophilia Center, Sheba Medical Center, Tel Aviv, Israel
Received 12 September 2007; returned 3 October 2007; revised 9 October 2007; accepted 12 October 2007
* Corresponding author. Tel: +34-93-4657897; Fax: +34-93-4657602; E-mail: jmllibre{at}flsida.org
Objectives: To determine the feasibility and outcomes of long-distance interactive expert advice for treatment-experienced patients.
Methods: HIV-1-infected patients on failing highly active antiretroviral therapy (HAART) were prospectively submitted for consultation by treating physicians to an expert panel using a standard e-mail form including: resistance tests, antiretroviral history, adherence, CD4 counts, HIV-1-RNA levels and HCV/HBV co-infection. Conference calls (CCs) were scheduled monthly to discuss 10 new patients.
Results: One hundred and fifteen patients were discussed (86% male; 45% intravenous drug users). The median length of HIV infection was 10 years and subjects were treated for a median of 8 years with a median of 5.25 previous HAART regimens. Ninety per cent were triple-class experienced [nucleoside reverse transcriptase inhibitors (NRTIs)/non-NRTIs (NNRTIs)/protease inhibitors (PIs)]. Median CD4 cell count was 298 cells/mm3 and median viral load was 19 700 copies/mL. Overall, 60% had 
5 reverse transcriptase mutations and 67% had 5 protease mutations, and most patients were NNRTI-resistant. Drugs more frequently recommended by experts were: lamivudine/emtricitabine > tenofovir > abacavir > zidovudine > didanosine > stavudine (NRTIs) and tipranavir > lopinavir > atazanavir > saquinavir (PIs). Enfuvirtide was recommended in 65% of cases. Concordance between recommended and prescribed regimens was 74.7%. Virtually all discordances were due to patient refusal of complex regimens. Outcomes at 24 weeks: HIV-1-RNA <50 copies/mL in 42% of patients, HIV-1-RNA <400 copies/mL in 59.4% of patients and median CD4 increase was 77 (14–140) cells/mm3.
Conclusions: Long-distance interactive expert advice is feasible for complex treatment-experienced HIV patients using e-mail and CCs. Adherence to treatment recommendations is high, with encouraging viro-immunological outcomes at 24 weeks. This strategy merits further investigation, especially in clinical settings where availability of local experts is limited.
Key Words: teleconference , genotypic resistance testing , expert opinion , antiretroviral treatment , salvage therapy