Longitudinal Analysis of Adherence to First-Line Antiretroviral Therapy: Evidence of Treatment Sustainability from an Indian HIV Cohort

INTRODUCTION

Given the chronic nature of HIV infection and the need for life-long antiretroviral therapy (ART), maintaining long-term optimal adherence is an important strategy for maximizing treatment success. In order to understand better the dynamic nature of adherence behaviors in India where complex cultural and logistic features prevail, we assessed the patterns, trajectories and time-dependent predictors of adherence levels in relation to virological failure among individuals initiating first-line ART in India.

METHODS

Between July 2010 and August 2013, eligible ART-naïve HIV-infected individuals newly initiating first-line ART within the national program at three sites in southern India were enrolled and monitored for two years. ART included zidovudine/stavudine/tenofovir plus lamivudine plus nevirapine/efavirenz. Patients were assessed using clinical, laboratory and adherence parameters. Every three months, medication adherence was measured using pill count, and a structured questionnaire on adherence barriers was administered. Optimal adherence was defined as mean adherence ≥95%. Statistical analysis was performed using a bivariate and a multivariate model of all identified covariates. Adherence trends and determinants were modeled as rate ratios using generalized estimating equation analysis in a Poisson distribution.

RESULTS

A total of 599 eligible ART-naïve patients participated in the study, and contributed a total of 921 person-years of observation time. Women constituted 43% and mean CD4 count prior to initiating ART was 192 cells/mm3. Overall mean adherence among all patients was 95.4%. The proportion of patients optimally adherent was 75.6%. Predictors of optimal adherence included older age (≥40 years), high school-level education and beyond, lower drug toxicity-related ART interruption, full disclosure, sense of satisfaction with one's own health and patient's perception of having good access to health-care services. Adherence was inversely proportional to virological failure (IRR 0.55, 95%CI 0.44-0.69 p<0.001). Drug toxicity and stigma-related barriers were significantly associated with virological failure, while forgetfulness was not associated with virological failure.

CONCLUSION

Our study highlights the overall high level of medication adherence among individuals initiating ART within the Indian national program. Primary factors contributing towards poor adherence and subsequent virological failure in the proportion of individuals with poor adherence included drug toxicity, perceived stigma and poor access to health care services. Strategies that may contribute towards improved adherence include minimizing drug interruptions for medical reasons, use of newer ART regimens with better safety profiles and increasing access with more link ART centers that decentralize ART dispensing systems to individuals.

Ceftaroline fosamil versus ceftriaxone for the treatment of Asian patients with community-acquired pneumonia: a randomised, controlled, double-blind, phase 3, non-inferiority with nested superiority trial

BACKGROUND

Ceftriaxone with or without a macrolide antibiotic is a recommended treatment for patients with community-acquired pneumonia requiring hospital admission and intravenous antibiotic treatment. We aimed to assess the efficacy and safety of ceftaroline fosamil compared with ceftriaxone in the treatment of Asian patients admitted to hospital with community-acquired pneumonia.

METHODS

In this international, randomised, controlled, double-blind, phase 3, non-inferiority with nested superiority trial, adult Asian patients with Pneumonia Outcomes Research Team (PORT) risk class III-IV acute community-acquired pneumonia were randomly assigned (1:1) to receive intravenous ceftaroline fosamil (600 mg every 12 h) or ceftriaxone (2 g every 24 h) for 5-7 days. Patients were randomly assigned via centralised telephone and web-based system; patients and treating clinicians were masked to treatment allocation. Investigators who did study assessments remained masked to treatment allocation until completion of the study. The primary endpoint was clinical cure at the test-of-cure visit (8-15 days after last dose of study drug) in the clinically evaluable population. Non-inferiority of ceftaroline fosamil was defined as a lower limit of the two-sided 95% CI for the difference in the proportion of patients clinically cured of -10% or higher; if non-inferiority was achieved, superiority was to be concluded if the lower limit of the 95% CI was greater than 0%. This trial is registered with ClinicalTrials.gov, number NCT01371838.

FINDINGS

Between Dec 13, 2011, and April 26, 2013, 847 patients were enrolled at 64 centres in China, India, South Korea, Taiwan, and Vietnam, of whom 771 were randomly assigned and 764 received study treatment. In the clinically evaluable population (n=498) 217 (84%) of 258 patients in the ceftaroline fosamil group and 178 (74%) of 240 patients in the ceftriaxone group were clinically cured at the test-of-cure visit (difference 9·9%, 95% CI 2·8-17·1). The superiority of ceftaroline fosamil was consistent across all preplanned patient subgroup analyses (split by age 65 years, age 75 years, sex, PORT risk class, and previous antibiotic use) apart from patients younger than 65 years. The frequency of adverse events was similar between treatment groups and the safety results for ceftaroline fosamil were consistent with the cephalosporin class and previous clinical trial data.

INTERPRETATION

Ceftaroline fosamil 600 mg given every 12 h was superior to ceftriaxone 2 g given every 24 h for the treatment of Asian patients with PORT III-IV community-acquired pneumonia. These data suggest that ceftaroline fosamil should be regarded as an alternative to ceftriaxone in empirical treatment regimens for this patient population.

FUNDING

AstraZeneca.

Guidelines for Diagnosis and Management of Bronchial Asthma: Joint Recommendations of National College of Chest Physicians (India) and Indian Chest Society

Bronchial asthma is an important public health problem in India with significant morbidity. Several international guidelines for diagnosis and management of asthma are available, however there is a need for country-specific guidelines due to vast differences in availability and affordability of health-care facilities across the globe. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have collaborated to develop evidence-based guidelines with an aim to assist physicians at all levels of health-care in diagnosis and management of asthma in a scientific manner. Besides a systematic review of the literature, Indian studies were specifically analysed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (1) definitions, epidemiology and impact, (2) diagnosis, (3) pharmacologic management of stable disease, (4) management of acute exacerbations, and (5) non-pharmacologic management and special situations. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

Increased risk of respiratory illness associated with kerosene fuel use among women and children in urban Bangalore, India

BACKGROUND

Kerosene is a widely used cooking and lighting fuel in developing countries. The potential respiratory health effects of cooking with kerosene relative to cooking with cleaner fuels such as liquefied petroleum gas (LPG) have not been well characterised.

METHODS

We sampled 600 households from six urban neighbourhoods in Bangalore, India. Each household's primary cook, usually the woman of the house, was interviewed to collect information on current domestic fuel use and whether there was any presence of respiratory symptoms or illness in her or in the children in the household. Our analysis was limited to 547 adult females (ages 18-85) and 845 children (ages 0-17) in households exclusively cooking with either kerosene or LPG. We investigated the associations between kerosene use and the likelihood of having respiratory symptoms or illness using multivariate logistic regression models.

RESULTS

Among adult women, cooking with kerosene was associated with cough (OR=1.88; 95% CI 1.19 to 2.99), bronchitis (OR=1.54; 95% CI 1.00 to 2.37), phlegm (OR=1.51; 95% CI 0.98 to 2.33) and chest illness (OR=1.61; 95% CI 1.02 to 2.53), relative to cooking with LPG in the multivariate models. Among children, living in a household cooking with kerosene was associated with bronchitis (OR=1.91; 95% CI 1.17 to 3.13), phlegm (OR=2.020; 95% CI 1.29 to 3.74) and chest illness (OR=1.70; 95% CI 0.99 to 2.90) after adjusting for other covariates. We also found associations between kerosene use and wheezing, difficulty breathing and asthma in adults and cough and wheezing in children, though these associations were not statistically significant.

CONCLUSIONS

Women and children in households cooking with kerosene were more likely to have respiratory symptoms and illnesses compared with those in households cooking with LPG. Transitioning from kerosene to LPG for cooking may improve respiratory health among adult women and children in this population.

Crosstalk between PKCα and Notch-4 in endocrine-resistant breast cancer cells

The Notch pathway is functionally important in breast cancer. Notch-1 has been reported to maintain an estrogen-independent phenotype in estrogen receptor α (ERα)+ breast cancer cells. Notch-4 expression correlates with Ki67. Notch-4 also plays a key role in breast cancer stem-like cells. Estrogen-independent breast cancer cell lines have higher Notch activity than estrogen-dependent lines. Protein kinase Cα (PKCα) overexpression is common in endocrine-resistant breast cancers and promotes tamoxifen (TAM)-resistant growth in breast cancer cell lines. We tested whether PKCα overexpression affects Notch activity and whether Notch signaling contributes to endocrine resistance in PKCα-overexpressing breast cancer cells.Analysis of published microarray data from ERα+ breast carcinomas shows that PKCα expression correlates strongly with Notch-4. Real-time reverse transcription PCR and immunohistochemistry on archival specimens confirmed this finding. In a PKCα-overexpressing, TAM-resistant T47D model, PKCα selectively increases Notch-4, but not Notch-1, expression in vitro and in vivo. This effect is mediated by activator protein-1 (AP-1) occupancy of the Notch-4 promoter. Notch-4 knockdown inhibits estrogen-independent growth of PKCα-overexpressing T47D cells, whereas Notch-4IC expression stimulates it. Gene expression profiling shows that multiple genes and pathways associated with endocrine resistance are induced in Notch-4IC- and PKCα-expressing T47D cells. In PKCα-overexpressing T47D xenografts, an orally active γ-secretase inhibitor at clinically relevant doses significantly decreased estrogen-independent tumor growth, alone and in combination with TAM. In conclusion, PKCα overexpression induces Notch-4 through AP-1. Notch-4 promotes estrogen-independent, TAM-resistant growth and activates multiple pathways connected with endocrine resistance and chemoresistance. Notch inhibitors should be clinically evaluated in PKCα- and Notch-4-overexpressing, endocrine-resistant breast cancers.

Clinico-epidemiological profile of tobacco users attending a tobacco cessation clinic in a teaching hospital in Bangalore city

Background:

Tobacco-attributable mortality in India is estimated to be at least 10%. Tobacco cessation is more likely to avert millions of deaths before 2050 than prevention of tobacco use initiation.

Objective:

To describe the clinico-epidemiological profile of attendees of a tobacco cessation clinic in a teaching hospital in Bangalore city.

Materials and Methods:

A descriptive study of 189 attendees seen over 2 years in the Tobacco Cessation Clinic of a tertiary-care teaching hospital in Bangalore, with information on socio demographic characteristics, tobacco-use details, nicotine dependence, family/medical history, past quit attempts, baseline stage-of-change, and treatment initiated.

Results:

Only 5% were ‘walk-in’ patients; 98% of attendees were smokers; 97% were males. The mean (±SD) age of attendees was 48.0 (±14.0) years. Most participants were married (88%), and predominantly urban (69%). About 62% had completed at least 8 years of schooling. Two-thirds of smokers reported high levels of nicotine dependence (Fagerström score >5/10). About 43% of patients had attempted quitting earlier. Four-fifths (79%) of tobacco-users reported a family member using tobacco. Commonly documented comorbidities included: Chronic respiratory disease (44%), hypertension (23%), diabetes (12%), tuberculosis (9%), myocardial infarction (2%), stroke (1%), sexual dysfunction (1%) and cancer (0.5%). About 52% reported concomitant alcohol use. At baseline, patients’ motivational stage was: Precontemplation (14%), contemplation (48%), preparation/action (37%) and maintenance (1%). Treatment modalities started were: Counseling alone (41%), nicotine replacement therapy alone (NRT) (34%), medication alone (13%), and NRT+medication (12%).

Conclusions:

This is the first study of the baseline profile of patients attending a tobacco cessation clinic located within a chest medicine department in India. Important determinants of outcome have been captured for follow-up and prospective documentation of outcomes.

Supporting adherence to antiretroviral therapy with mobile phone reminders: results from a cohort in South India

Background

Adherence is central to the success of antiretroviral therapy. Supporting adherence has gained importance in HIV care in many national treatment programs. The ubiquity of mobile phones, even in resource-constrained settings, has provided an opportunity to utilize an inexpensive, contextually feasible technology for adherence support in HIV in these settings. We aimed to assess the influence of mobile phone reminders on adherence to antiretroviral therapy in South India. Participant experiences with the intervention were also studied. This is the first report of such an intervention for antiretroviral adherence from India, a country with over 800 million mobile connections.

Methods

Study design: Quasi-experimental cohort study involving 150 HIV-infected individuals from Bangalore, India, who were on antiretroviral therapy between April and July 2010. The intervention: All participants received two types of adherence reminders on their mobile phones, (i) an automated interactive voice response (IVR) call and (ii) A non-interactive neutral picture short messaging service (SMS), once a week for 6 months. Adherence measured by pill count, was assessed at study recruitment and at months one, three, six, nine and twelve. Participant experiences were assessed at the end of the intervention period.

Results

The mean age of the participants was 38 years, 27% were female and 90% urban. Overall, 3,895 IVRs and 3,073 SMSs were sent to the participants over 6 months. Complete case analysis revealed that the proportion of participants with optimal adherence increased from 85% to 91% patients during the intervention period, an effect that was maintained 6 months after the intervention was discontinued (p = 0.016). Both, IVR calls and SMS reminders were considered non-intrusive and not a threat to privacy. A significantly higher proportion agreed that the IVR was helpful compared to the SMS (p<0.001).

Conclusion

Mobile phone reminders may improve medication adherence in HIV infected individuals in this setting, the effect of which was found to persist for at least 6 months after cessation of the intervention.

Serum antibodies to the HPV16 proteome as biomarkers for head and neck cancer

BACKGROUND

Human papillomavirus (HPV) type 16 is associated with oropharyngeal carcinomas (OPC). Antibodies (Abs) to HPV16 E6 and E7 oncoproteins have been detected in patient sera; however, Abs to other early HPV-derived proteins have not been well explored.

METHODS

Antibodies to the HPV16 proteome were quantified using a novel multiplexed bead assay, using C-terminal GST-fusion proteins captured onto Luminex beads. Sera were obtained from untreated patients with OPC (N=40), partners of patients with HPV16+ OPC (N=11), and healthy controls (N=50).

RESULTS

Oropharyngeal carcinomas patients with known virus-like capsid particle+ Abs had elevated serum Abs to HPV16 E1, E2, E4, E6, and E7, and L1 antibody levels, but not E5. The ratios of specific median fluorescence intensity to p21-GST compared with controls were E1: 50.7 vs 2.1; E4: 14.6 vs 1.3; E6: 11.3 vs 2.4; E7: 43.1 vs 2.6; and L1: 10.3 vs 2.6 (each P≤0.01). In a validation cohort, HPV16 E1, E2, and E7 antibody levels were significantly elevated compared with healthy control samples (P≤0.02) and partners of OPC patients (P≤0.01).

CONCLUSION

Patients with HPV16+ OPC have detectable Abs to E1, E2, and E7 proteins, which are potential biomarkers for HPV-associated OPC.

Associations between medical service use and HIV risk among HIV-positive drug users in Baltimore, MD

The objectives of this study were first, to identify psychosocial and medical service utilization factors associated with unprotected sex with HIV-negative or unknown serostatus partners among persons living with HIV/AIDS, and second, to identify risk behaviours associated with HIV medical service use. We assessed 244 HIV-positive participants in an HIV intervention targeting drug users (1997-99). Fifty-seven per cent of HIV-positive participants reported unprotected sex within the past 90 days, 16.4% with serodiscordant partners. Odds of risky sex were lower among those currently receiving HIV medical care (odds ratio (OR)=0.36), and were greater among females (OR=2.6), those having friends with lower norms of condom use (OR=3.3), and those having a main sexual partner (OR=6.2). Lower odds of receiving HIV medical care were associated with current drug use (OR=0.33), sharing drugs with a sex partner (OR=0.27), and exchanging sex for drugs or money (OR=0.24). Findings suggest the importance of community-based HIV prevention intervention targeting HIV-positive drug users not recovery HIV medical care.

Co-receptor tropism prediction among 1045 Indian HIV-1 subtype C sequences: Therapeutic implications for India

Background

Understanding co-receptor tropism of HIV-1 strains circulating in India will provide key analytical leverage for assessing the potential usefulness of newer antiretroviral drugs such as chemokine co-receptor antagonists among Indian HIV-infected populations. The objective of this study was to determine using in silico methods, HIV-1 tropism among a large number of Indian isolates both from primary clinical isolates as well as from database-derived sequences.

Results

R5-tropism was seen in 96.8% of a total of 1045 HIV-1 subtype C Indian sequences. Co-receptor prediction of 15 primary clinical isolates detected two X4-tropic strains using the C-PSSM matrix. R5-tropic HIV-1 subtype C V3 sequences were conserved to a greater extent than X4-tropic strains. X4-tropic strains were obtained from subjects who had a significantly longer time since HIV diagnosis (96.5 months) compared to R5-tropic strains (20.5 months).

Conclusions

High prevalence of R5 tropism and greater homogeneity of the V3 sequence among HIV-1 subtype C strains in India suggests the potential benefit of CCR5 antagonists as a therapeutic option in India.

Three Cases of Abulia in the Elderly: A Call to Care

The symptom of abulia is a state of diminished motivation where an individual may appear apathetic, disinterested, asocial and emotionally remote. It can exist independently but more commonly occurs as part of a constellation of symptoms accompanying a specific disorder, normally neurological or psychiatric. Although it is not a normal part of ageing, it has been observed in a number of conditions seen in later life. These include Alzheimer's disease, vascular dementia, Parkinson's disease, dementia with Lewy bodies, and frontotemporal dementia. Abulia and depression are separate entities but abulic patients are often thought to be depressed and experience long periods of anti-depressant treatment without benefit. the key difference is that abulic patients fail to disclose any sign of sadness or negative thoughts and show an obvious lack of concern for their condition.

Abulia has significant clinical implications as it is associated with decreased function, poor prognosis and worse carer stress. It is also potentially treatable. the pharmacological agents that have received the most attention are dopaminergic drugs including Carbidopa/Levodopa, Amantadine, Bupropion and Bromocriptine. the research predominantly consists of case reports but no studies have focussed on the elderly. in this paper, the authors review the current literature and describe three cases of abulia in older people that have been successfully treated with Bromocriptine. the cases highlight the importance of recognising abulia and differentiating it from depression. They also show the need to consider treatment.

Measurement of 24 h energy expenditure in male tuberculosis patients

BACKGROUND & OBJECTIVES

The total daily energy expenditure in patients with infectious disease is presumed to be high because of an increase in the basal metabolic rate (BMR), a reason for the weight loss observed in these patients. A reduction in daily physical activity, which may reduce the total daily energy expenditure. The aim of this study was to measure the free living total daily energy expenditure and physical activity of newly diagnosed hospitalized patients with tuberculosis using the labelled bicarbonate method.

METHODS

In 6 healthy volunteers and 6 patients with newly diagnosed tuberculosis, 13C labelled bicarbonate method was used to measure free living total daily energy expenditure and physical activity. The 13C sodium bicarbonate (NaH13CO3) tracer was infused intravenously over a 48 h period and breath samples collected at regular intervals to estimate expired 13CO2.

RESULTS

The patients had a 14 per cent increase in their BMR although they were not febrile at the time of measurement. However, their total daily energy expenditure was lower than that of the controls (mean value of 8.3 and 10.3 mJ/day respectively) and their physical activity level was also lower (mean 1.4 and 1.6 units respectively).

INTERPRETATION & CONCLUSION

The total daily energy expenditure of afebrile patients with newly diagnosed tuberculosis is not higher than that of sedentary controls, despite an increased basal metabolic rate. It is possible that the observed weight loss in patients with tuberculosis is due to a reduced energy intake linked to anorexia associated with the disease. These findings may have relevance in nutritional treatment of chronic infections.