Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKbH4TTImqenVAHxkFJp/XpPk1L/H3vMGwqMxG9jwOd8eJPG+b4DlKuAX44qu/vwzmc= on 07/30/2018 EPIDEMIOLOGY AND SOCIAL SCIENCE Virologic and Immunologic Response to Highly Active Antiretroviral Therapy in Indigenous and Nonindigenous HIV-1–Infected Patients in The Netherlands Jeannine F. Nellen, MD,* Ferdinand W. Wit, MD, PhD,*† Frank de Wolf, MD, PhD,‡§ Suzanne Jurriaans, PhD,  Joep M. Lange, MD, PhD,*† and Jan M. Prins, MD, PhD* Objective: To compare the results of antiretroviral treatment (highly active antiretroviral therapy [HAART]) in indigenous Dutch (ID) and nonindigenous HIV-1–infected patients in Amsterdam, the Netherlands. We focused on the largest groups of nonindigenous people visiting our outpatient clinic: patients from other industrial- ized countries (western), from Surinam/Netherlands Antilles (SNA), and from sub-Saharan Africa (SSA). Design: Retrospective cohort analysis of 692 therapy-naive HIV-1– positive individuals who visited our outpatient clinic for the first time between July 1, 1996 and December 31, 2001. Methods: We compared the groups at the time of their first visit to our clinic; at the start of HAART; and according to the virological, immunologic, and clinical treatment response during the 96 weeks after the start of HAART. Results: Of the patients starting antiretroviral therapy, 362 were ID, 84 were western, 72 were from SNA, and 110 were from SSA. SNA and SSA patients had a lower CD4 cell count at first visit (ID = 330 cells/mm 3 , western = 330 cells/mm 3 , SNA = 250 cells/mm 3 , and SSA = 170 cells/mm 3 ; P = 0.0002). Treatment in SNA and SSA patients was also started at a lower CD4 cell count, but the plasma HIV-1 RNA level was comparable. After the start of HAART, a similar rise in CD4 cell count was seen in the 4 groups (P = 0.33), but the baseline dif- ference in CD4 cell count remained present during the follow-up pe- riod of 96 weeks. After adjusting for variables potentially influencing treatment outcome, the proportion of patients not reaching a plasma HIV-1 RNA level <400 copies/mL was not different for the 4 groups in contrast to the percentage not reaching a plasma HIV-1 RNA level <50 copies/mL (at 48 weeks: ID = 4.8%, western = 27.5%, SNA = 23.1%, and SSA = 24.2%; P = 0.017 over the 96-week time period). After the start of HAART, nonindigenous patients also more often had progression to Centers for Disease Control and Prevention (CDC) stage C or died (P = 0.006). Conclusions: In nonindigenous patients, treatment with HAART was equally successful in terms of the increase in CD4 cell count but was substantially less effective in achieving a plasma HIV-1 RNA level below 50 copies/mL. Further investigations should explore dif- ferences in adherence and pharmacokinetics in these patient groups. Key Words: HIV-1 infection, ethnic groups, highly active antiretro- viral therapy, cohort studies, viral load (J Acquir Immune Defic Syndr 2004;36:943–950) S ince the 1990s, highly active antiretroviral therapy (HAART) has been prescribed in the developed world for the treatment of HIV infection, resulting in a significant de- cline in HIV related morbidity and mortality. 1,2 In the Nether- lands, the effect of HAART was monitored in a multicenter clinical cohort of HIV-1–infected patients, the ATHENA co- hort, comprising more than 3000 patients. It showed a decrease in incidence of Centers for Disease Control and Prevention (CDC) stage C events in the time period between 1996 and 2000 from 2.63 to 0.04 per person-year, and mortality rates declined from 0.09 to 0.02 per person-year in the same period. 3 During the past years, the absolute and relative number of nonindigenous HIV-infected patients in the Netherlands is increasing. Of the new patients visiting the outpatient clinic of the Academic Medical Center, the percentage of nonindig- enous patients increased from 36% in 1995 to 60% in 2001. Most of these new nonindigenous patients are immigrants from sub-Saharan Africa (SSA) and the former Dutch colonies in the Americas (Surinam and the Netherlands Antilles [SNA]). Whether or not the results obtained in the ATHENA cohort also apply to these nonindigenous patients is not known because they are underrepresented in this cohort for reasons of Received for publication September 8, 2003; accepted November 24, 2003. From the *Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, and  Department of Human Retrovirology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; †International Antiviral Therapy Evaluation Center, Amster- dam, the Netherlands; ‡HIV Monitoring Foundation, Amsterdam, the Netherlands; and §Department of Infectious Disease Epidemiology, Im- perial College, Medical Faculty, London, United Kingdom. Supported by the AIDS Fonds, the Netherlands (grant 7004). Reprints: Jan M. Prins, Academic Medical Center, Room F4-217, PO Box 22660, 1100 DD, Amsterdam, the Netherlands (e-mail: j.m.prins@amc. uva.nl). Copyright © 2004 by Lippincott Williams & Wilkins J Acquir Immune Defic Syndr • Volume 36, Number 4, August 1 2004 943