Long-distance interactive expert advice in highly treatment-experienced HIV-infected patients

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/mm(3) 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/mm(3). 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.