The challenge of HIV treatment in an era of polypharmacy

Highlights on the Development, Related Patents, and Prospects of Lenacapavir: The First-in-Class HIV-1 Capsid Inhibitor for the Treatment of Multi-Drug-Resistant HIV-1 Infection

The multidrug-resistant (MDR) human immunodeficiency virus 1 (HIV-1) infection is an unmet medical need. HIV-1 capsid plays an important role at different stages of the HIV-1 replication cycle and is an attractive drug target for developing therapies against MDR HIV-1 infection. Lenacapavir (LEN) is the first-in-class HIV-1 capsid inhibitor approved by the USFDA, EMA, and Health Canada for treating MDR HIV-1 infection. This article highlights the development, pharmaceutical aspects, clinical studies, patent literature, and future directions on LEN-based therapies. The literature for this review was collected from PubMed, authentic websites (USFDA, EMA, Health Canada, Gilead, and NIH), and the free patent database (Espacenet, USPTO, and Patent scope). LEN has been developed by Gilead and is marketed as Sunlenca (tablet and subcutaneous injection). The long-acting and patient-compliant LEN demonstrated a low level of drug-related mutations, is active against MDR HIV-1 infection, and does not reveal cross-resistance to other anti-HIV drugs. LEN is also an excellent drug for patients having difficult or limited access to healthcare facilities. The literature has established additive/synergistic effects of combining LEN with rilpivirine, cabotegravir, islatravir, bictegravir, and tenofovir. HIV-1 infection may be accompanied by opportunistic infections such as tuberculosis (TB). The associated diseases make HIV treatment complex and warrant drug interaction studies (drug-drug, drug-food, and drug-disease interaction). Many inventions on different aspects of LEN have been claimed in patent literature. However, there is a great scope for developing more inventions related to the drug combination of LEN with anti-HIV/anti-TB drugs in a single dosage form, new formulations, and methods of treating HIV and TB co-infection. Additional research may provide more LEN-based treatments with favorable pharmacokinetic parameters for MDR HIV-1 infections and associated opportunistic infections such as TB.

Dual trajectories of antiretroviral therapy adherence and polypharmacy in women with HIV in the United States

BACKGROUND

Polypharmacy, using five or more medications, may increase the risk of nonadherence to prescribed treatment. We aimed to identify the interrelationship between trajectories of adherence to antiretroviral therapy (ART) and polypharmacy.

METHODS

We included women with HIV (aged ≥ 18) enrolled in the Women's Interagency HIV Study in the United States from 2014 to 2019. We used group-based trajectory modeling (GBTM) to identify trajectories of adherence to ART and polypharmacy and the dual GBTM to identify the interrelationship between adherence and polypharmacy.

RESULTS

Overall, 1,538 were eligible (median age of 49 years). GBTM analysis revealed five latent trajectories of adherence with 42% of women grouped in the consistently moderate trajectory. GBTM identified four polypharmacy trajectories with 45% categorized in the consistently low group.

CONCLUSIONS

The joint model did not reveal any interrelationship between ART adherence and polypharmacy trajectories. Future research should consider examining the interrelationship between both variables using objective measures of adherence.

Beyond Undetectable: Modeling the Clinical Benefit of Improved Antiretroviral Adherence in Persons With Human Immunodeficiency Virus With Virologic Suppression

Background

Incomplete antiretroviral therapy (ART) adherence has been linked to deleterious immunologic, inflammatory, and clinical consequences, even among virally suppressed (<50 copies/mL) persons with human immunodeficiency virus (PWH). The impact of improving adherence in the risk of severe non-AIDS events (SNAEs) and death in this population is unknown.

Methods

We estimated the reduction in the risk of SNAEs or death resulting from an increase in ART adherence by (1) applying existing data on the association between adherence with high residual inflammation/coagulopathy in virally suppressed PWH, and (2) using a Cox proportional hazards model derived from changes in plasma interleukin 6 (IL-6) and D-dimer from 3 randomized clinical trials. Comparatively, assuming 100% ART adherence in a PWH who achieves viral suppression, we estimated the number of persons in whom a decrease in adherence to <100% would need to be observed for an additional SNAE or death event to occur during 3- and 5-year follow-up.

Results

Increasing ART adherence to 100% in PWH who are suppressed on ART despite imperfect adherence translated into a 6%-37% reduction in the risk of SNAEs or death. Comparatively, based on an anticipated 12% increase in IL-6, 254 and 165 PWH would need to decrease their adherence from 100% to <100% for an additional event to occur over 3- and 5-year follow-up, respectively.

Conclusions

Modest gains in ART adherence could have clinical benefits beyond virologic suppression. Increasing ART adherence (eg, via an intervention or switch to long-acting ART) in PWH who remain virally suppressed despite incomplete adherence should be evaluated.

Potential drug-drug interactions due to concomitant medicine use among people living with HIV on antiretroviral therapy in Australia

AIMS

We quantified concomitant medicine use and occurrence of potential drug-drug interactions in people living with HIV in Australia who are treated with antiretroviral therapy (ART).

METHODS

In this cohort study using dispensing claims of a 10% random sample of Australians, we identified 2230 people dispensed ART between January 2018 and December 2019 (mean age 49.0 years, standard deviation 12.0 years, 88% male). We examined concomitant medicine use by identifying nontopical medicines dispensed within 90-days of any antiretroviral medicine dispensing during a 12-month follow-up period. For every antiretroviral and nonantiretroviral pair, we identified and classified possible drug-drug interactions using the University of Liverpool HIV drug interactions database.

RESULTS

A total of 1728 (78%) people were dispensed at least 1 and 633 (28%) 5 or more unique medicines in addition to ART in a 12-month period; systemic anti-infectives and medicines acting on the nervous system were the most common (68% and 56%, respectively). Among comedicated people, 1637 (95%) had at least 1 medicine combination classified as weak interactions, 558 (32%) interactions requiring close monitoring/dose adjustment and 94 (5%) that should not be coadministered. Contraindication or interactions requiring close monitoring/dose adjustment were more common among people receiving protease inhibitors (50-73% across different antiretrovirals), non-nucleoside reverse transcriptase inhibitors (35-64%), people using single-tablet combinations containing elvitegravir (30-46%) and those using tenofovir disoproxil (26-30%).

CONCLUSION

Concomitant medicine use is widespread among people living with HIV in Australia. Despite a relatively low prevalence of contraindicated medicines, almost a third received medicines that require close monitoring or dose adjustment.

Barriers and facilitators to maintaining a high level of polypharmacy adherence in people living with HIV: A scoping review

Objectives: With the prolongation of life span and increasing incidence of comorbidities, polypharmacy has become a challenge for people living with HIV/AIDS (PLWH). This review aimed to identify barriers and facilitators to maintaining a high level of polypharmacy adherence in people living with HIV/AIDS. Methods: Nine electronic databases were searched for studies from 1996 to October 2021. Studies were included if they were conducted with adults living with HIV/AIDS and reported barriers and facilitators to maintaining a high level of polypharmacy adherence. This review presents a conceptual framework model to help understand the barriers and facilitators. Results: Twenty-nine studies were included. The majority of publications were observational studies. Eighty specific factors were identified and further divided into five categories, including individual factors, treatment-related factors, condition-related factors, healthcare provider-related factors, and socioeconomic factors, based on the multidimensional adherence model (MAM). Conclusion: Eighty factors associated with polypharmacy adherence among people living with HIV/AIDS were identified and grouped into five major categories. Healthcare providers can make decisions based on the five categories of relevant factors described in this paper when developing interventions to enhance polypharmacy adherence. It is recommended that medications be evaluated separately and that an overall medication evaluation be conducted at the same time to prevent inappropriate polypharmacy use.

Ageing with HIV: Medicine Optimisation Challenges and Support Needs for Older People Living with HIV: A Systematic Review

BACKGROUND

Older people living with HIV (PLWH) are at increased risks of co-morbidities and polypharmacy. However, little is known about factors affecting their needs and concerns about medicines. This systematic review aims to describe these and to identify interventions to improve medicine optimisation outcomes in older PLWH.

METHODS AND DATA SOURCES

Multiple databases and grey literature were searched from inception to February 2022 including MEDLINE, CINAHL, PsycInfo, PsychArticles, the Cochrane Database of Systematic Reviews and the Cochrane Controlled Register of Trials, Abstracts in Social Gerontology, and Academic Search Complete.

ELIGIBILITY CRITERIA

Studies reporting interventions/issues affecting older PLWH (sample populations with mean/median age ≥ 50 years; any aspect of medicine optimisation, or concerns). Quality assessments were completed by means of critical appraisal checklists for each study design. Title and abstract screening was led by one reviewer and a sample reviewed independently by two reviewers. Full-paper reviews were completed by one author and a 20% sample was reviewed independently by two reviewers.

SYNTHESIS

Data were extracted by three independent reviewers using standardised data extraction forms and synthesised according to outcomes or interventions reported. Data were summarised to include key themes, outcomes or concerns, and summary of intervention.

RESULTS

Seventy-nine (n = 79) studies met the eligibility criteria, most of which originated from the USA (n = 36). A few studies originated from Australia (n = 5), Canada (n = 5), Spain (n = 9), and the UK (n = 5). Ten studies originated from Sub-Saharan Africa (Kenya n = 1, South Africa n = 6, Tanzania n = 1, Uganda n = 1, Zimbabwe n = 1). The rest of the studies were from China (n = 1), France (n = 1), Germany (n = 1), Italy (n = 1), the Netherlands (n = 1), Pakistan (n = 1), Switzerland (n = 1), Saudi Arabia (n = 1) and Ukraine (n = 1). Publication dates ranged from 2002 to 2022. Sample sizes ranged from 10 to 15,602 across studies. The factors affecting older PLWH's experience of and issues with medicines were co-morbidities, health-related quality of life, polypharmacy, drug interactions, adverse drug reactions, adherence, medicine burden, treatment burden, stigma, social support, and patient-healthcare provider relationships. Nine interventions were identified to target older persons, five aimed at improving medication adherence, two to reduce drug interactions, and two for medicine self-management initiatives.

CONCLUSION

Further in-depth research is needed to understand older PLWH's experiences of medicines and their priority issues. Adherence-focused interventions are predominant, but there is a scarcity of interventions aimed at improving medicine experiences for this population. Multi-faceted interventions are needed to achieve medicine optimisation outcomes for PLWH.

TRIAL REGISTRATION

This study is registered with PROSPERO registration number: CRD42020188448.

Prevalence of Potentially Clinically Significant Drug-Drug Interactions With Antiretrovirals Against HIV Over Three Decades: A Systematic Review of the Literature

BACKGROUND

Contemporary first-line antiretrovirals have considerably reduced liability for clinically significant drug-drug interactions (DDI). This systematic review evaluates the prevalence of DDI among people receiving antiretrovirals across 3 decades.

METHODS

We searched 3 databases for studies reporting the prevalence of clinically significant DDIs in patients receiving antiretrovirals published between January 1987 and July 2022. Clinically significant DDIs were graded by severity. All data extractions were undertaken by 2 independent reviewers, adjudicated by a third.

RESULTS

Of 21,665 records returned, 13,474 were duplicates. After screening the remaining 13,596 abstracts against inclusion criteria, 122 articles were included for full-text analysis, from which a final list of 34 articles were included for data synthesis. The proportion of patients experiencing a clinically significant DDI did not change over time (P = 0.072). The most frequently reported classes of antiretrovirals involved in DDIs were protease inhibitors and non-nucleoside reverse transcriptase inhibitors; of note, integrase use in the most recent studies was highly variable and ranged between 0% and 89%.

CONCLUSIONS

The absolute risk of DDIs has not decreased over the period covered. This is likely related to continued use of older regimens and an ageing cohort of patients. A greater reduction in DDI prevalence can be anticipated with broader uptake of regimens containing unboosted integrase inhibitors or non-nucleoside reverse transcriptase inhibitors.

A new era of HIV care for age-associated multimorbidity

PURPOSE OF REVIEW

The management of people with HIV has shifted focus from acute AIDS-defining illness towards improving detection of chronic disease and reducing impact of multimorbidity. In this review, we explore this shifting paradigm of HIV care and the evidence for alternative models proposed to provide integrated holistic services for people with HIV (PWH) with multimorbidity.

RECENT FINDINGS

Despite 25 years of the antiretroviral treatment (ART) era an increased incidence of noncommunicable disease (NCD) and multimorbidity in PWH persists. As the world moves closer to universal ART coverage this phenomenon is now reported in low- and middle-income settings. Multimorbidity affects PWH disproportionately compared to the general population and results in reduced health related quality of life (HRQoL), greater hospitalization and higher mortality. There is evidence that NCD care provision and outcomes may be inferior for PWH than their HIV negative counterparts. Various models of integrated multimorbidity care have developed and are grouped into four categories; HIV specialist clinics incorporating NCD care, primary care services incorporating HIV care, community NCD clinics offering integrated HIV care, and multidisciplinary care integrated with HIV in secondary care. Evidence is limited as to the best way to provide multimorbidity care for PWH.

SUMMARY

A new era of HIV care for an ageing population with multimorbidity brings challenges for health providers who need to develop holistic patient focused services which span a range of coexisting conditions.

Dual Trajectories of Antiretroviral Therapy Adherence and Polypharmacy in Women with HIV in the United States

Background Polypharmacy, using five or more medications, may increase the risk of nonadherence to prescribed treatment. We aimed to identify the interrelationship between trajectories of adherence to antiretroviral therapy (ART) and polypharmacy. Methods We included women with HIV (aged ≥ 18) enrolled in the Women's Interagency HIV Study in the United States from 2014 to 2019. We used group-based trajectory modeling (GBTM) to identify trajectories of adherence to ART and polypharmacy and the dual GBTM to identify the interrelationship between adherence and polypharmacy. Results Overall, 1,538 were eligible (median age of 49 years). GBTM analysis revealed five latent trajectories of adherence with 42% of women grouped in the consistently moderate trajectory. GBTM identified four polypharmacy trajectories with 45% categorized in the consistently low group. Conclusions The joint model did not reveal any interrelationship between ART adherence and polypharmacy trajectories. Future research should consider examining the interrelationship between both variables using objective measures of adherence.

Factors Associated with Periodontitis in Patients with and without HIV

Purpose

The aim of this study was to compare clinical periodontal conditions in HIV-positive people on HAART with an HIV-negative group, in addition to investigating factors associated with periodontitis in the entire sample.

Methods

This was a cross-sectional study. Data were collected by oral clinical examination for the diagnosis of periodontitis, review of medical records, and application of a questionnaire containing personal data, deleterious habits, and oral hygiene habits for the other variables. The results were analyzed by Pearson's χ ² test and Student's t-test. A logistic regression model was constructed for the multivariate analysis and periodontitis was defined as a dependent variable. The analysis was performed on the entire sample (HIV+ and HIV-) and also on the group consisting of only people living with HIV.

Results

Individuals older than 43 years old and with HIV were more likely to develop moderate and severe periodontitis (47.80 and 4.84 times, respectively). When analyzing only HIV+, in addition to age (OR = 2.795; CI = 1.080-7.233), the use of nonnucleoside reverse transcriptase inhibitors (NNRTIs) (OR = 2.841; CI = 1.135-7.112) was also associated with moderate and severe periodontitis.

Conclusion

It was possible to observe a higher prevalence of periodontitis among individuals with HIV, showing an association between the virus, advanced age, and moderate or severe periodontitis.

Potential drug-drug interactions between antiretroviral drugs and comedications, including dietary supplements, among people living with HIV: A clinical survey

OBJECTIVE

Age-related comorbidities, polypharmacy and thereby the risk of potential drug-drug interactions (PDDIs) among people living with HIV (PLWH) have increased over the years. We estimated the prevalence of comedications, including dietary supplements, and evaluated PDDIs among PLWH receiving antiretroviral therapy (ART) in Denmark in an outpatient setting.

METHODS

Information on prescription medication, over-the-counter medication and dietary supplements was obtained from adult PLWH receiving ART attending two outpatient clinics in Denmark. The PDDIs were identified using the University of Liverpool's drug interaction database. Associations between PDDIs and relevant variables were compared using logistic regression models.

RESULTS

A total of 337 PLWH receiving ART with a median age of 53 years (interquartile range: 45-61) were included; 77% were male and 96% had a HIV-RNA viral load < 50 copies/mL. Twenty-six per cent of participants received five or more comedications and 56% consumed dietary supplements. Co-administration of drugs requiring dose adjustment or monitoring was identified in the medication lists of 52% of participants, and 4.5% were on drugs that should not be co-administered. Male sex [odds ratio (OR) = 1.9, 95% confidence interval (CI): 1.0-3.4], being on a protease inhibitor (OR = 4.3, 95% CI: 1.9-9.7), receiving five or more comedications (OR = 3.3, 95% CI: 1.5-7.2), taking over-the-counter medications (OR = 1.9, 95% CI: 1.1-3.3) and dietary supplements (OR = 2.0, 95% CI: 1.2-3.3) were independent predictors of PDDIs.

CONCLUSION

Potential drug-drug interactions were common among our study population Our study confirms that polypharmacy and being on a protease inhibitor-based regimen increase the risk of PDDIs considerably and highlights the importance of questioning PLWH about dietary supplement intake.

Treatment Regimens and Care Models for Older Patients Living with HIV: Are We Doing Enough?

With improved access to antiretroviral therapy throughout the world, people are aging with HIV, and a large portion of the global population of people with HIV (PWH) is now age 50 or older. Older PWH experience more comorbidities, aging-related syndromes, mental health challenges, and difficulties accessing fundamental needs than the population of older adults without HIV. As a result, ensuring that older PWH are receiving comprehensive healthcare can often be overwhelming for both PWH and the providers. Although there is a growing literature addressing the needs of this population, gaps remain in care delivery and research. In this paper, we suggest seven key components to any healthcare program designed to address the needs of older people with HIV: management of HIV, comorbidity screening and treatment, primary care coordination and planning, attention to aging related-syndromes, optimization of functional status, support of behavioral health, and improved access to basic needs and services. We review many of the difficulties and controversies related to the implementation of these components, which include the absence of screening guidelines for this population and the challenges of care integration, and we suggest key next steps.

Pharmacometrics: The Already-Present Future of Precision Pharmacology

The use of mathematical modeling to represent, analyze, make predictions or providing information on data obtained in drug research and development has made pharmacometrics an area of great prominence and importance. The main purpose of pharmacometrics is to provide information relevant to the search for efficacy and safety improvements in pharmacotherapy. Regulatory agencies have adopted pharmacometrics analysis to justify their regulatory decisions, making those decisions more efficient. Demand for specialists trained in the field is therefore growing. In this review, we describe the meaning, history, and development of pharmacometrics, analyzing the challenges faced in the training of professionals. Examples of applications in current use, perspectives for the future, and the importance of pharmacometrics for the development and growth of precision pharmacology are also presented.

Pharmacist-Involved Antiretroviral Stewardship Programs in People Living with HIV/AIDS: A Systematic Review

People living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS; PLWHA) frequently encounter antiretroviral (ARV) therapy-related problems. Clinical pharmacists with specialized training in ARV stewardship play an important role in managing these problems. However, there is a paucity of evidence to clarify the impact of clinical pharmacists' interventions on managing ARV therapy-related problems in PLWHA. Therefore, we aim to systematically review the literature to determine the nature and impact of pharmacists' interventions on managing medication-related problems in PLWHA. The review protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO; CRD42020173078). Relevant records were identified from six electronic bibliographic databases (PubMed, Embase, EBSCOhost, ProQuest, Scopus, and the Cochrane Central Register) from their inception until September 2022. We included all randomized and nonrandomized interventional studies that were published in English. After the abstract and full-text screening, data were extracted from the selected studies, and the quality of the studies was assessed. The electronic database search and citation tracking identified two thousand and three citations. The review included 21 of these studies, involving 2998 PLWHA, published between 2014 and 2022. Pharmacists' interventions, working alone or in a multi-disciplinary team, comprised ARV medication review, management of adverse drug reactions (ADRs), therapeutic drug monitoring, prevention of drug interactions, and provision of drug information to PLWHA or the health care team. The pharmacist-involved interventions significantly reduced incorrect/incomplete ARV regimens, drug interactions, incorrect dosages, duplicate therapy, polypharmacy, administration errors, missing medication, wrong formulation, ADRs, and prescribing errors. Most studies reported that physicians usually accept more than 90% of the pharmacists' recommendations. ARV medication-related problems remain highly prevalent in PLWHA. Pharmacist-led interventions and stewardship significantly reduce ARV therapy-related problems in PLWHA and are widely accepted by physicians. Dedicated pharmacists with specialized training and credentialing in infectious diseases or HIV/AIDS have a great potential to improve health outcomes in PLWHA.

HIV-Specific Reported Outcome Measures: Systematic Review of Psychometric Properties

BACKGROUND

The management of people living with HIV and AIDS is multidimensional and complex. Using patient-reported outcome measures (PROMs) has been increasingly recognized to be the key factor for providing patient-centered health care to meet the lifelong needs of people living with HIV and AIDS from diagnosis to death. However, there is currently no consensus on a PROM recommended for health care providers and researchers to assess health outcomes in people living with HIV and AIDS.

OBJECTIVE

The purpose of this systematic review was to summarize and categorize the available validated HIV-specific PROMs in adults living with HIV and AIDS and to assess these PROMs using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology.

METHODS

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of 3 recommended databases (PubMed, Embase, and PsychINFO) was conducted on January 15, 2021. Studies were included if they assessed any psychometric property of HIV-specific PROMs in adults living with HIV and AIDS and met the eligibility criteria. The PROMs were assessed for 9 psychometric properties, evaluated in each included study following the COSMIN methodology by assessing the following: the methodological quality assessed using the COSMIN risk of bias checklist; overall rating of results; level of evidence assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation approach; and level of recommendation.

RESULTS

A total of 88 PROMs classified into 8 categories, assessing the psychometric properties of PROMs for adults living with HIV and AIDS, were identified in 152 studies including 79,213 people living with HIV and AIDS. The psychometric properties of most included PROMs were rated with insufficient evidence. The PROMs that received class A recommendation were the Poz Quality of Life, HIV Symptom Index or Symptoms Distress Module of the Adult AIDS Clinical Trial Group, and People Living with HIV Resilience Scale. In addition, because of a lack of evidence, recommendations regarding use could not be made for most of the remaining assessed PROMs (received class B recommendation).

CONCLUSIONS

This systematic review recommends 3 PROMs to assess health outcomes in adults living with HIV and AIDS. However, all these PROMs have some shortcomings. In addition, most of the included PROMs do not have sufficient evidence for assessing their psychometric properties and require a more comprehensive validation of the psychometric properties in the future to provide more scientific evidence. Thus, our findings may provide a reference for the selection of high-quality HIV-specific PROMs by health care providers and researchers for clinical practice and research.

Antiretroviral drug-drug interactions: A comparison of online drug interaction databases

WHAT IS KNOWN AND OBJECTIVE

Antiretrovirals have a high drug interaction potential, which can lead to increased toxicity and/or decreased efficacy. Multiple databases are available to assess drug-drug interactions. The aim of our study was to compare interaction identification for commonly used ARVs and concomitant medications between six different online drug-drug interaction databases.

COMMENT

This was a cross-sectional review using each of the following six databases: LexiComp®, Clinical Pharmacology®, Micromedex®, Epocrates®, University of Liverpool, and University of Toronto. Sixteen antiretroviral drugs and 100 of the DrugStats Database "Top 200 of 2019" list of medications were included. Each of the six databases identified a different number of actual or potential interactions. The number of interactions ranged from 211 to 283.

WHAT IS NEW AND CONCLUSIONS

A variety of databases exist with inconsistent identification of actual or potential drug-drug interactions amongst them. It may be beneficial to cross-reference multiple databases prior to making decisions regarding patient care.

Prevalence and global trends of polypharmacy among people living with HIV: a systematic review and meta-analysis

Background:

There has been a rising prevalence of polypharmacy among people living with HIV (PLWH). Uncertainty however remains regarding the exact estimates of polypharmacy among these cohorts of patients.

Methods:

We conducted a systematic search of PubMed; EMBASE, CROI, Cochrane Database of Systematic Reviews; Science Citation Index and Database of Abstracts of Reviews of Effects for studies between 1 January 2000 and 30 June 2021 that reported on the prevalence of polypharmacy (ingestion of > 5 non-ART medications) among PLWH on antiretroviral therapy regimen (ART). Prevalence of polypharmacy among HIV-positive patients on ART with Clopper–Pearson 95% confidence intervals were presented. The heterogeneity between studies was evaluated using I2 and τ2 statistics.

Results:

One hundred ninety-seven studies were initially identified, 23 met the inclusion criteria enrolling 55,988 PLWH, of which 76.7% [95% confidence interval (CI): 76.4–77.1] were male. The overall pooled prevalence of polypharmacy among PLWH was 33% (95% CI: 25–42%) (I² = 100%, τ² = 0.9170, p < 0.0001). Prevalence of polypharmacy is higher in the Americas (44%, 95% CI: 27–63%) (I² = 100%, τ² = 1.0886, p < 0.01) than Europe (29%, 95% CI: 20–40%) (I² = 100%, τ² = 0.7944, p < 0.01).

Conclusion:

The pooled prevalence estimates from this synthesis established that polypharmacy is a significant and rising problem among PLWH. The exact interventions that are likely to significantly mitigate its effect remain uncertain and will need exploration by future prospective and systematic studies.

Registration:

PROSPERO: CRD42020170071

Plain Language Summary

Background: In people living with HIV (PLWH), what is the prevalence of polypharmacy and is this influenced by sociodemographic factors?

Methods and Results: In this systematic review and meta-analysis of 23 studies comprising 55,988 participants, we have for the first time found an estimated polypharmacy pooled prevalence of 33% among PLWH. There was a relatively higher pooled prevalence of polypharmacy among the America’s compared with European cohorts of PLWH.

Conclusion: Polypharmacy among PLWH is a rising morbidity that needs urgent intervention both at policy and patient levels of care.

Sarcopenia in people living with HIV in Hong Kong: which definition correlates with health outcomes?

Introduction

Sarcopenia is an important clinical syndrome in older people living with HIV (PLWH). With a change to the Asia sarcopenia definition in 2019, we aimed to determine whether health outcomes were associated with different definitions of sarcopenia among Asian PLWH.

Methods

We performed a prospective cross‐sectional study enrolling PLWH aged ≥35 years from January 2018 to November 2021. We defined sarcopenia by the Asia Working Group of Sarcopenia (AWGS) criteria in 2014 and 2019. AWGS‐2014 included low muscle mass plus weak handgrip strength and/or slow gait speed. AWGS‐2019 included low muscle mass plus low muscle strength or physical performance, while the presence of all defines severe sarcopenia. We measured appendicular skeletal muscle mass using dual‐energy X‐ray absorptiometry, handgrip strength, usual gait speed, five‐time chair stand test and Short Physical Performance Battery. Correlations between each sarcopenia definition and health‐related quality of life (using EQ‐5D‐5L and SF‐36) and functional disability were determined.

Results

One hundred and fifty Asian PLWH were enrolled, 132 (88%) were male, mean age was 60±10 years, duration of HIV diagnosis was 13 (IQR 8–18) years and current CD4 count was 574 (IQR 362–762) cells/mm³, 67 (45%) had multimorbidity, 64 (43%) had polypharmacy. Prevalence of sarcopenia by AWGS‐2014, AWGS‐2019 and severe sarcopenia was 17.3%, 27.3% and 18.0%, respectively. Age, education and polypharmacy were associated with sarcopenia. Sarcopenia (AWGS‐2014) and severe sarcopenia were associated with mobility, physical functioning and physical component score (SF‐36). All three criteria were associated with impaired instrumental activities of daily living (IADL). After age and sex adjustment, sarcopenia (AWGS‐2014) (adjusted odds ratio/aOR 5.4, 95% confidence interval/CI 2.0–15.1) and severe sarcopenia (aOR 5.1, 95% CI 1.9–14.0) were associated with mobility and physical component score (SF‐36) (β coefficients –5.3342, p = 0.022 and –5.412, p = 0.019). Sarcopenia (AWGS 2014) (aOR 5.2, 95% CI 1.7–16.2), sarcopenia (AWGS‐2019) (aOR 4.5, 95% CI 1.5–13.1) and severe sarcopenia (aOR 3.5, 95% CI 1.1–10.9) were associated with impaired IADL in fully adjusted models.

Conclusions

In a sample of Asian PLWH, 17.3%, 27.3% and 18.0% had sarcopenia as defined by AWGS‐2014, AWGS‐2019 and severe sarcopenia, respectively. Sarcopenia by AWGS‐2014 and severe sarcopenia correlated with parameters of poor health outcomes, while sarcopenia by AWGS‐2019 correlated with functional disability.

Providing differentiated service delivery to the ageing population of people living with HIV

Introduction

Differentiated service delivery (DSD) models for HIV are a person‐centred approach to providing services across the HIV care cascade; DSD has an increasing policy and implementation support in high‐burden HIV countries. The life‐course approach to DSD for HIV treatment has focused on earlier life phases, childhood and adolescence, families, and supporting sexual and reproductive health during childbearing years. Older adults, defined as those over the age of 50, represent a growing proportion of HIV treatment cohorts with approximately 20% of those supported by PEPFAR in this age band and have specific health needs that differ from younger populations. Despite this, DSD models have not been designed or implemented to address the health needs of older adults.

Discussion

Older adults living with HIV are more likely to have significant co‐morbid medical conditions. In addition to the commonly discussed co‐morbidities of hypertension and diabetes, they are at increased risk of cognitive impairment, frailty and mental health conditions. Age and HIV‐related cognitive impairment may necessitate the development of adapted educational materials. Identifying the optimal package of differentiated services to this population, including the frequency of clinical visits, types and location of services is important as is capacitating the healthcare cadres to adapt to these challenges. Technological advances, which have made remote monitoring of adherence and other aspects of disease management easier for younger populations, may not be as readily available or as familiar to older adults. To date, adaptations to service delivery have not been scaled and are limited to nascent programmes working to integrate treatment of common co‐morbidities.

Conclusions

Older individuals living with HIV may benefit from a DSD approach that adapts care to the specific challenges of ageing with HIV. Models could be developed and validated using outcome measures, such as viral suppression and treatment continuity. DSD models for older adults should consider their specific health needs, such as high rates of co‐morbidities. This may require educational materials, health worker capacity building and outreach designed specifically to treat this age group.

What is polypharmacy in people living with HIV/AIDS? A systematic review

Polypharmacy in people living with HIV/AIDS (PLWHA) is a rising morbidity that exacts hefty economic burden on health budgets in addition to other adverse clinical outcomes. Despite recent advances, uncertainty remains around its exact definition in PLWHA. In this systematic review and Meta-analysis, we explored relevant databases (PUBMED, EMBASE, CROI) for studies evaluating polypharmacy in PLWHA from January 2000 to August 2021 to ascertain the exact numerical threshold that defines this morbidity. Two independent reviewers extracted and reviewed relevant variables for analyses. The review included a total of 31 studies involving n = 53,347 participants with a mean age of 49.5 (SD ± 17.0) years. There was a total of 36 definitions, with 93.5% defining polypharmacy as the concomitant use of 5 or more medications. We found significant variation in the numerical definition of polypharmacy, with studies reporting it as "minor" (N = 3); "major" (N = 29); "severe" (N = 2); "excessive" (N = 1); and "higher" (N = 1). Most studies did not incorporate a duration (84%) in their definition and excluded ART medications (67.7%). A plurality of studies in PLWHA have established that polypharmacy in this cohort of patients is the intake of ≥ 5 medications (including both ART and non-ART). To standardize the approach to addressing this rising morbidity, we recommend incorporation of this definition into national and international PLWHA treatment guidelines.

How do geriatricians feel about managing older people living with HIV? A scoping review

PURPOSE

The proportion of people living with HIV being older adults is increasing and due to high rates of multimorbidity and frailty within this group geriatricians are well placed to contribute to their care. However, little is known about how geriatricians feel about this new opportunity.

METHODS

A scoping review was performed following the Arksey & O'Malley's methodological framework with nine databases searched in December 2021 for studies reporting the experiences or views of geriatricians on caring for people living with HIV. Study inclusion was not limited by language or year of publication. Narrative reviews were excluded. Two reviewers independently performed the extraction using predetermined criteria. A descriptive analysis of extracted information was performed.

RESULTS

Six publications reporting four studies, all conducted in the USA, were identified. The current barriers to geriatricians being involved in the care of older people living with HIV are: their current experience in managing people living with HIV, their knowledge of HIV, specific issues related to older people living with HIV and screening for HIV in older people as well as their attitudes to people living with HIV and experience of managing older LGBTQ + people.

CONCLUSION

Prior to geriatricians being routinely involved in the care of older people living with HIV further research outside of the USA is required. Geriatricians will also require specific training which should be incorporated into geriatric medicine training curricula as well as the creation of learning tools and quality clinical practice guidelines ideally created in collaboration with HIV organisations.

Issues Related to the Treatment of H. pylori Infection in People Living with HIV and Receiving Antiretrovirals

Treatment of Helicobacter pylori infection in people living with HIV is associated with several challenges, including those related to drug metabolism which plays a major role in treatment efficacy. In this review, we will discuss the enzymes involved in the metabolism of anti-Helicobacter pylori and anti-HIV drugs to provide a basis for understanding the potential for interactions between these drug classes. We will also provide a clinical perspective on other issues related to the treatment of Helicobacter pylori and HIV infections such as comorbidities, adherence, and peer communication. Finally, based on our understanding of the interplay between the above issues, we propose a new concept “Antimicrobial susceptibility testing-drug interaction-supports-referent physician” (AISR), to provide a framework for improving rates of H. pylori eradication in people living with HIV.

Viro-Immunological, Clinical Outcomes and Costs of Switching to BIC/TAF/FTC in a Cohort of People Living with HIV: A 48-Week Prospective Analysis

To date, therapeutic switches are performed to reduce and prevent toxicity, improve adherence, promote virological control, and save costs. Drug switches are a daily challenge in the management of people living with HIV (PLWH), especially in those with multiple comorbidities and on polypharmacy. The objectives of this prospective analysis were: (I) to evaluate the viro-immunological efficacy of BIC/FTC/TAF in a cohort of PLWH who switched to this regimen from any other previous, at the Infectious and Tropical Diseases Unit of the Padua University Hospital; (II) to assess the impact on body weight, lipids, and renal function parameters at week 48; and (III) to evaluate daily costs changes, adherence, and the rate and causes of discontinuation of the regimen. We included all adult PLWH who switched to BIC/FTC/TAF from 1 February 2020 to 31 October 2021. We collected demographic, clinical, and laboratory data at baseline and week 48 after the switch. In addition, the estimated cART-related cost changes over the follow-up period were calculated. Over the study period, 290 individuals who switched to BIC/FTC/TAF, 76.9% were males, with a median age of 52 years, and 94.8% had an undetectable baseline HIV viremia. After a median time of 35 days (IQR: 1–55), 41 (14.1%) individuals discontinued the regimen. Factors significantly associated with discontinuation were switching from dual regimens, and neurological disorders. At week 48, we detected a significant increase in body weight, BMI, CD4 T-cell count, and CD4/CD8 ratio, and a significant reduction in triglycerides and costs; all patients had undetectable HIV RNA. Our results showed that switching to BIC/FTC/TAF may favor slightly immunological recovery and cost saving (−4.2 EUR/day from baseline to week 48, equivalent to a mean saving of 1533 EUR/year/person). The reduction in triglycerides does not appear to be clinically relevant, even if statistically significant, nor do both the increase in body weight and BMI (+1 kg and +0.29 BMI, respectively) and the increase in CD4 T-cell count (+45 cells/mmc). Further studies are needed to confirm our results.

Detecting drug-drug interactions between therapies for COVID-19 and concomitant medications through the FDA adverse event reporting system

Background: COVID-19 patients with underlying medical conditions are vulnerable to drug-drug interactions (DDI) due to the use of multiple medications. We conducted a discovery-driven data analysis to identify potential DDIs and associated adverse events (AEs) in COVID-19 patients from the FDA Adverse Event Reporting System (FAERS), a source of post-market drug safety.

Materials and Methods: We investigated 18,589 COVID-19 AEs reported in the FAERS database between 2020 and 2021. We applied multivariate logistic regression to account for potential confounding factors, including age, gender, and the number of unique drug exposures. The significance of the DDIs was determined using both additive and multiplicative measures of interaction. We compared our findings with the Liverpool database and conducted a Monte Carlo simulation to validate the identified DDIs.

Results: Out of 11,337 COVID-19 drug-Co-medication-AE combinations investigated, our methods identified 424 signals statistically significant, covering 176 drug-drug pairs, composed of 13 COVID-19 drugs and 60 co-medications. Out of the 176 drug-drug pairs, 20 were found to exist in the Liverpool database. The empirical p-value obtained based on 1,000 Monte Carlo simulations was less than 0.001. Remdesivir was discovered to interact with the largest number of concomitant drugs (41). Hydroxychloroquine was detected to be associated with most AEs (39). Furthermore, we identified 323 gender- and 254 age-specific DDI signals.

Conclusion: The results, particularly those not found in the Liverpool database, suggest a subsequent need for further pharmacoepidemiology and/or pharmacology studies.

Detecting Drug-Drug Interactions in COVID-19 Patients

COVID-19 patients with multiple comorbid illnesses are more likely to be using polypharmacy to treat their COVID-19 disease and comorbid conditions. Previous literature identified several DDIs in COVID-19 patients; however, various DDIs are unrecognized. This study aims to discover novel DDIs by conducting comprehensive research on the FDA Adverse Event Reporting System (FAERS) data from January 2020 to March 2021. We applied seven algorithms to discover DDIs. In addition, the Liverpool database containing DDI confirmed by clinical trials was used as a gold standard to determine novel DDIs in COVID-19 patients. The seven models detected 2,516 drug-drug pairs having adverse events (AEs), 49 out of which were confirmed by the Liverpool database. The remaining 2,467 drug pairs tested to be significant by the seven models can be candidate DDIs for clinical trial hypotheses. Thus, the FAERS database, along with informatics approaches, provides a novel way to select candidate drug-drug pairs to be examined in COVID-19 patients.

Drug-drug interactions of Integrase Strand Transfer Inhibitors among older people living with HIV: Interazioni farmacologiche degli inibitori delle integrase tra le persone anziane che vivono con HIV

The advancement of Human Immunodeficiency Virus (HIV) treatment improves the life expectancy of HIV-positive individuals. People living with HIV have more polypharmacy and drug-drug interactions than those without HIV. Integrase strand transfer inhibitors (INSTIs) are the newest class commonly used for HIV treatment. There are five INSTIs currently approved by the Food and Drug Administration, including raltegravir, elvitegravir, dolutegravir, bictegravir, and cabotegravir. INSTIs class contributes to better safety and efficacy profile, making them the preferred or recommended antiretroviral regimens in HIV treatment guidelines worldwide. Despite the shared mechanism of action, INSTIs differ in pharmacokinetics, contributing to different drug-drug interactions. This review summarized the potential drug interactions of INSTIs and the management of the drug interactions in clinical practice.

Prevalence of PIMDINAC criteria and associated factors in elderly HIV patients

INTRODUCTION

Aging of people living with HIV could be related to potentially inappropiate medication prescriptions, drugs interactions and lack of drugs adherence. PIMDINAC criteria seek to jointly analyze these problems. The objective of this study is to determine the prevalence of PIMDINAC criteria in an elderly HIV population.

METHODS

Observational, cross-sectional, multicenter study that included patients older than 65 years in pharmacotherapeutic follow-up between February-April 2020. The main endpoint was the percentage of PIMDINAC criteria identified in the study population.

RESULTS

Forty-seven patientes were included, identifying total PIMDINAC in 12.5%. Non-adherence to concomitant treatment was detected in 65.6% of patients, potentially inappropiate medication in 48.9% and drugs interactions in 25.2%. The number of concomitant drugs and polypharmacy were associated with a higher appearance of PIMDINAC criteria.

CONCLUSION

The prevalence of PIMDINAC criteria in elderly HIV patients is high.

Baseline and time-updated factors in preclinical development of anionic dendrimers as successful anti-HIV-1 vaginal microbicides

Although a wide variety of topical microbicides provide promising in vitro and in vivo efficacy, most of them failed to prevent sexual transmission of human immunodeficiency virus type 1 (HIV-1) in human clinical trials. In vitro, ex vivo, and in vivo models must be optimized, considering the knowledge acquired from unsuccessful and successful clinical trials to improve the current gaps and the preclinical development protocols. To date, dendrimers are the only nanotool that has advanced to human clinical trials as topical microbicides to prevent HIV-1 transmission. This fact demonstrates the importance and the potential of these molecules as microbicides. Polyanionic dendrimers are highly branched nanocompounds with potent activity against HIV-1 that disturb HIV-1 entry. Herein, the most significant advancements in topical microbicide development, trying to mimic the real-life conditions as closely as possible, are discussed. This review also provides the preclinical assays that anionic dendrimers have passed as microbicides because they can improve current antiviral treatments' efficacy. This article is categorized under: Nanotechnology Approaches to Biology > Nanoscale Systems in Biology Therapeutic Approaches and Drug Discovery > Nanomedicine for Infectious Disease Toxicology and Regulatory Issues in Nanomedicine > Regulatory and Policy Issues in Nanomedicine.

How health systems can adapt to a population ageing with HIV and comorbid disease

As people age with HIV, their needs increase beyond solely managing HIV care. Ageing people with HIV, defined as people with HIV who are 50 years or older, face increased risk of both age-regulated comorbidities and ageing-related issues. Globally, health-care systems have struggled to meet these changing needs of ageing people with HIV. We argue that health systems need to rethink care strategies to meet the growing needs of this population and propose models of care that meet these needs using the WHO health system building blocks. We focus on care provision for ageing people with HIV in the three different funding mechanisms: President's Emergency Plan for AIDS Relief and Global Fund funded nations, the USA, and single-payer government health-care systems. Although our categorisation is necessarily incomplete, our efforts provide a valuable contribution to the debate on health systems strengthening as the need for integrated, people-centred, health services increase.

Evolving patterns of antiretroviral drug interactions in people living with HIV in British Columbia, Canada

OBJECTIVES

To characterize the annual prevalence of antiretroviral/non-antiretroviral drug interactions (DIs) in relation to antiretroviral therapy (ART) prescribing patterns, and to describe DI-related ART changes.

DESIGN/METHODS

This cohort study included ART-treated adults in British Columbia, Canada between 01-Jan-2010 and 31-Dec-2016. Medication dispensing records were abstracted from a population-based, linked administrative-health dataset and used to identify antiretroviral-comedication DIs ("caution"/"avoid" DIs in HIV-focused DI-checkers). We identified temporal trends in annual DI prevalence and quantified the association between taking higher DI-risk ART and receiving non-recommended antiretroviral-comedication combinations using Poisson regression models, modified for binary outcomes and correlated data. Clinician-reported, DI-related ART changes and associated adverse events were abstracted from an HIV drug treatment registry and summarized descriptively.

RESULTS

Among 8571 ART-treated adults who received non-antiretroviral comedications, prevalence of having any DI or receiving non-recommended drug combination(s) significantly declined from 85% to 71% and 5.6% to 3.2%, respectively, between 2010 and 2016 (p < 0.001). This paralleled a shift from higher DI-risk ART (e.g. ritonavir/cobicistat-boosted protease inhibitors) to lower DI-risk ART (e.g. unboosted integrase inhibitors). Risk of receiving a non-recommended antiretroviral-comedication combination was greater for persons taking higher versus lower DI-risk ART (aRR 3.12, 95%CI 2.24-4.35). Boosted antiretroviral-inhaled corticosteroid DIs accounted for the most commonly dispensed, non-recommended drug combinations, and the most commonly reported DI-related adverse events (adrenal insufficiency).

CONCLUSION

The prevalence of antiretroviral-comedication DIs is declining as ART shifts towards antiretrovirals with lower DI potential, but non-recommended drug combinations remain a concern. Healthcare providers should screen for DIs whenever drugs are prescribed or dispensed.

A conceptual model of alcohol use and adherence to antiretroviral therapy: systematic review and theoretical implications for mechanisms of action

Alcohol consumption is one of the most prevalent correlates of antiretroviral therapy (ART) adherence, yet causal processes underlying this association remain largely unexplored. The goal of this systematic review was to develop a conceptual model that describes the causal effect of alcohol consumption on ART nonadherence. We reviewed 230 studies that examined the association between alcohol consumption and ART adherence with three primary aims: (1) to replicate and extend previous reviews of the literature, (2) to summarize and critique study designs capable of answering questions about temporal overlap and (3) to summarize potential mechanisms of action. A model of alcohol-associated ART nonadherence was proposed to guide future work, integrating general theories of ART adherence and theory on the psychological and behavioral effects of alcohol intoxication. The conceptual model describes two mechanistic processes-prospective memory impairment and interactive toxicity beliefs/avoidance behaviors-involved in alcohol-associated intentional and unintentional nonadherence, respectively. This model can be used to guide future research on the causal processes involved in the frequently observed correlation between alcohol consumption and adherence.

Drug-Drug Interactions in People Living with HIV at Risk of Hepatic and Renal Impairment: Current Status and Future Perspectives

Despite the advancement of antiretroviral therapy (ART) for the treatment of human immunodeficiency virus (HIV), drug–drug interactions (DDIs) remain a relevant clinical issue for people living with HIV receiving ART. Antiretroviral (ARV) drugs can be victims and perpetrators of DDIs, and a detailed investigation during drug discovery and development is required to determine whether dose adjustments are necessary or coadministrations are contraindicated. Maintaining therapeutic ARV plasma concentrations is essential for successful ART, and changes resulting from potential DDIs could lead to toxicity, treatment failure, or the emergence of ARV‐resistant HIV. The challenges surrounding DDI management are complex in special populations of people living with HIV, and often lack evidence‐based guidance as a result of their underrepresentation in clinical investigations. Specifically, the prevalence of hepatic and renal impairment in people living with HIV are between five and 10 times greater than in people who are HIV‐negative, with each condition constituting approximately 15% of non‐AIDS‐related mortality. Therapeutic strategies tend to revolve around the treatment of risk factors that lead to hepatic and renal impairment, such as hepatitis C, hepatitis B, hypertension, hyperlipidemia, and diabetes. These strategies result in a diverse range of potential DDIs with ART. The purpose of this review was 2‐fold. First, to summarize current pharmacokinetic DDIs and their mechanisms between ARVs and co‐medications used for the prevention and treatment of hepatic and renal impairment in people living with HIV. Second, to identify existing knowledge gaps surrounding DDIs related to these special populations and suggest areas and techniques to focus upon in future research efforts.

Dolutegravir plus lamivudine versus efavirenz plus tenofovir disoproxil fumarate and lamivudine in antiretroviral-naive adults with HIV-1 infection

Background

Concerns regarding potential toxicity and drug-drug interactions during long-term treatment with three-drug active antiretroviral therapy (ART) regimens have been attracting increasing attention. We aimed to evaluate the efficacy and safety of dolutegravir (DTG) plus lamivudine (3TC) in ART-naive adults in China.

Methods

This prospective observational cohort study enrolled HIV-naive inpatients treated with DTG + 3TC (2DR arm) or efavirenz (EFV) plus tenofovir disoproxil fumarate (TDF) and 3TC (3DR arm). There were no limits on baseline viral load. Inflammatory biomarkers were also investigated in the 2DR arm.

Results

Between September 2019 and January 2020, 27 patients treated with DTG + 3TC and 28 patients treated with EFV + TDF + 3TC were enrolled in the study. At week 12, the proportion of patients with viral loads < 50 copies/mL in the 2DR arm was 81.5% (22/27) compared with 53.6% (15/28) in the 3DR arm (p < 0.01). At week 24, the proportion of patients with viral loads < 50 copies/mL in the 2DR arm was 100% (26/26) compared with 83.3% (20/24) in the 3DR arm (p < 0.05). Mean changes in CD4 cell counts from baseline at week 12 were 125.46 cells/µL in the 2DR arm and 41.20 cells/µL in the 3DR arm (p < 0.05). Mean changes in CD4 cell counts from baseline at week 24 were 209.68 cells/µL in the 2DR arm and 73.28 cells/µL in the 3DR arm (p < 0.05).

Conclusions

DTG + 3TC achieved virologic suppression more rapidly than EFV + TDF + 3TC after 12 and 24 weeks. DTG + 3TC could represent an optimal regimen for advanced patients.

Clinical Trial Registration ChiCTR1900027640 (22/November/2019).

Pharmacokinetic drug interactions of integrase strand transfer inhibitors

The integrase strand transfer inhibitor (INSTI)-containing regimens are currently considered as the first-line treatment of human immunodeficiency virus (HIV) infection. Although possessing a common mechanism of action to inhibit HIV integrase irreversibly to stop HIV replication cycle, the INSTIs, including raltegravir, elvitegravir, dolutegravir, and bictegravir, differ in pharmacokinetic characteristics. While raltegravir undergoes biotransformation by the UDP-glucuronosyltransferases (UGTs), elvitegravir is primarily metabolized by cytochrome P450 (CYP) 3A4 and co-formulated with cobicistat to increase its plasma exposure. The metabolism pathways of dolutegravir and bictegravir are similar, both including CYP3A and UGT1A1, and both agents are substrates to different drug transporters. Because of their differences in metabolism, INSTIs interact with other medications differently through CYP enzymes and transporters as inducers or inhibitors. These drug interactions may become an important consideration in the long-term clinical use because the life expectancy of people with HIV (PWH) approaches to that of the general population. Also, common geriatric challenges such as multimorbidity and polypharmacy have been increasingly recognized in PWH. This review provides a summary of pharmacokinetic interactions with INSTIs and future perspectives in implications of INSTI drug interactions.

Retrospective evaluation of an observational cohort by the Central and Eastern Europe Network Group shows a high frequency of potential drug-drug interactions among HIV-positive patients receiving treatment for coronavirus disease 2019 (COVID-19)

OBJECTIVES

The aim of this international multicentre study was to review potential drug-drug interactions (DDIs) for real-life coadministration of combination antiretroviral therapy (cART) and coronavirus disease 2019 (COVID-19)-specific medications.

METHODS

The Euroguidelines in Central and Eastern Europe Network Group initiated a retrospective, observational cohort study of HIV-positive patients diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Data were collected through a standardized questionnaire and DDIs were identified using the University of Liverpool's interaction checker.

RESULTS

In total, 524 (94.1% of 557) patients received cART at COVID-19 onset: 117 (22.3%) were female, and the median age was 42 (interquartile range 36-50) years. Only 115 (21.9%) patients were hospitalized, of whom 34 required oxygen therapy. The most frequent nucleoside reverse transcriptase inhibitor (NRTI) backbone was tenofovir disoproxil fumarate (TDF)/tenofovir alafenamide (TAF) with lamivudine or emtricitabine (XTC) (79.3%) along with an integrase strand transfer inhibitor (INSTI) (68.5%), nonnucleoside reverse transcriptase inhibitor (NNRTI) (17.7%), protease inhibitor (PI) (13.7%) or other (2.5%). In total, 148 (28.2%) patients received COVID-19-specific treatments: corticosteroids (15.7%), favipiravir (7.1%), remdesivir (3.1%), hydroxychloroquine (2.7%), tocilizumab (0.6%) and anakinra (0.2%). In total, 62 DDI episodes were identified in 58 patients (11.8% of the total cohort and 41.9% of the COVID-19-specific treatment group). The use of boosted PIs and elvitegravir accounted for 43 DDIs (29%), whereas NNRTIs were responsible for 14 DDIs (9.5%).

CONCLUSIONS

In this analysis from the Central and Eastern European region on HIV-positive persons receiving COVID-19-specific treatment, it was found that potential DDIs were common. Although low-dose steroids are mainly used for COVID-19 treatment, comedication with boosted antiretrovirals seems to have the most frequent potential for DDIs. In addition, attention should be paid to NNRTI coadministration.

Antiretroviral therapies and corticosteroids: Drug-drug interactions

ABSTRACT

Antiretroviral therapies for HIV may cause systemic toxicities when coadministered with corticosteroids. Potential drug-drug interactions may occur, leading to iatrogenic Cushing syndrome or adrenal insufficiency. This article highlights the drug-drug interactions of antiretroviral therapies with corticosteroids. Practice implications are discussed.

Potential drug-drug interactions in the era of integrase strand transfer inhibitors: a cross-sectional single-center study in Japan

BACKGROUND

Potential drug-drug interactions (PDDIs) commonly occur because of aging and comorbidities in people living with human immunodeficiency virus (HIV; PLWH). Protease inhibitors and non-nucleoside reverse transcriptase inhibitors have been reported to cause PDDIs in these patients. However, there are few reports of PDDIs in the era of treatment using integrase strand transfer inhibitors. Therefore, we investigated PDDIs in Japanese PLWH receiving antiretroviral drugs (ARVs).

METHODS

This was a cross-sectional observational study conducted in Japanese outpatients. All eligible patients who had received ARV therapy for at least 48 weeks were enrolled. The primary endpoint was the incidence of PDDIs detected using the Lexicomp® interface.

RESULTS

Of the 71 eligible patients, 51 (71.8%) were prescribed concomitant non-ARV medications. In 21 patients (29.6%), PDDIs with the potential to reduce the effects of ARVs occurred, although the HIV load was suppressed in all cases. Polypharmacy (the use of ≥5 non-ARVs) was observed in 25 patients (35.2%). There was a significantly higher median number of non-ARV medications in the PDDI group than in the non-PDDI group (6 vs. 3, P <  0.001). Furthermore, the proportion of patients on polypharmacy was significantly higher in those with PDDIs than in those without PDDIs (81.0% vs. 26.7%, P <  0.001).

CONCLUSIONS

The incidence of PDDIs is relatively high in Japanese PLWH, even in the era of treatment using integrase strand transfer inhibitors. Therefore, it is important for patients and health care providers to be constantly aware of PDDIs associated with ARV treatment.

Comorbidities and co-medications among 28 089 people living with HIV: A nationwide cohort study from 2009 to 2019 in Japan

OBJECTIVES

Comorbidities are associated with a high burden of disease in people living with HIV (PLWH). The objective was to investigate the prevalence of chronic comorbidities and use of co-medications in PLWH in Japan.

METHODS

This study retrospectively analysed clinical information from PLWH receiving antiretroviral therapy (ART) between April 2009 and March 2019. Demographic characteristics, numbers and types of chronic comorbidities, and numbers and types of non-ART co-medications, were described by age groups. The source of data was the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB).

RESULTS

Overall, 28 089 PLWH (male 91.9%) who used ART were identified. Out of 28 089 PLWH, 81.5% had at least one chronic comorbidity. The numbers of AIDS-defining cancers and non-AIDS-defining cancers in this Japanese cohort were 2432 (8.7%) and 2485 (8.8%), respectively. The cumulative burden of comorbidities including non-AIDS-defining cancer increased with age. Changes in trend between 2009 and 2019 were observed, including a higher proportion of PLWH diagnosed at ≥ 70 years old [2019 (4.7%) vs. 2009 (2.4%)] and a decreasing percentage of patients with AIDS-defining cancers (down from 6.3% to 4.8% between 2009 and 2019). The most common co-medications during the most recent 3-month period were lipid-regulating/anti-atheroma preparations (11.3%), antacids, antiflatulents and anti-ulcerants (9.6%), and agents acting on the renin-angiotensin system (8.1%). The three most common therapeutic categories of co-medications during the study period were antacids, antiflatulents and anti-ulcerants (35.0%), systemic antihistamines (33.7%) and psycholeptics (27.1%). More than 30% of PLWH aged > 40 years used at least one co-medication in a 3-month period, while more than half of PLWH aged > 30 years had at least one co-medication prescribed concomitantly for a total of ≥ 90 days during the study period, and the numbers of co-medications used were greater in the older age groups.

CONCLUSIONS

The burden of chronic comorbidities and co-medication were found to be greater in older, as compared to younger patients, among 28 089 PLWH in a nationwide study in Japan. This finding suggests the need to identify elderly PLWH and to appropriately manage their HIV and comorbidities.

Prevalence, beliefs and impact of drug-drug interactions between antiretroviral therapy and illicit drugs among people living with HIV in Spain

Drug use implies important challenges related to HIV management, particularly due to an increased risk of potential interactions between antiretroviral therapy (ART) and illicit drugs (pDDIs). This study analyses the prevalence and severity of pDDIs among people living with HIV (PLHIV). It also explores their awareness of pDDIs and their beliefs about the toxicity that they may cause, as well as the impact of pDDIs on selected health variables. We conducted an on-line cross-sectional survey across 33 Spanish hospitals and NGOs to collect demographics and clinical data. pDDIs were checked against the Interaction Checker developed by Liverpool University. The sample of the present study was composed of 694 PLHIV who used illicit drugs. They represented 49.5% of the 1,401 PLHIV that participated in the survey. After excluding 38 participants due to lack of information on their ART or illicit drug use, 335 (51.1%) participants consuming drugs presented with some potentially significant pDDIs between their ART and illicit drugs, with a mean of 2.1±1.7 (1-10) pDDIs per patient. The drugs most frequently involved in pDDIs were cocaine, cannabis, MDMA and nitrates ("poppers"). The prevalence of pDDIs across ART regimens was: protease inhibitors (41.7%); integrase inhibitor-boosted regimens (32.1%), and non-nucleoside reverse transcriptase inhibitors (26.3%). An awareness of pDDIs and beliefs about their potential toxicity correlated positively with intentional non-adherence (p<0.0001). Participants with pDDIs exhibited a higher prevalence of intentional non-adherence (2.19±1.04 vs. 1.93±0.94; p = 0.001). The presence of pDDIs was not associated with poorer results in the clinical variables analysed. A significant proportion of PLHIV who use drugs experience pDDIs, thereby requiring close monitoring. pDDIs should be considered in the clinical management of HIV patients. Adequate information about pDDIs and indicators about how to manage ART when PLHIV use drugs could improve ART non-adherence.

Current Considerations for Clinical Management and Care of People with HIV: Findings from the 11th Annual International HIV and Aging Workshop

The number of people with HIV (PWH) aged 50 years or older continues to steadily increase. The convergence of age- and HIV-related complications in these individuals presents a challenge for both patients and clinicians alike. New findings continue to emerge, as numerous researchers evaluate the combined impact of these two factors on quality of life, physiological systems, and mental health in PWH. Since its first occurrence in 2009, the International Workshop on HIV and Aging has served as a multidisciplinary meeting to share basic biomedical data, clinical trial results, treatment strategies, and epidemiological recommendations, toward better understanding and outcomes among like-minded scientific professionals. In this article, we share a selection of key findings presented in plenary talks at the 11th Annual International Workshop on HIV and Aging, held virtually from September 30, 2020 to October 2, 2020. We will also address the future directions of HIV and aging research, to further assess how the aging process intersects with chronic HIV.

The intersection of drug interactions and adverse reactions in contemporary antiretroviral therapy

PURPOSE OF REVIEW

Advances in antiretroviral therapy (ART) have transformed HIV infection into a chronic and manageable condition. The introduction of potent and more tolerable antiretrovirals (ARVs) with favorable pharmacokinetic profiles has changed the prevalence and nature of drug-drug interactions (DDIs). Here, we review the relevance of DDIs in the era of contemporary ART.

RECENT FINDINGS

Management of DDIs remains an important challenge with modern ART, primarily due to increased polypharmacy in older persons living with HIV. Significant DDIs exist between boosted ARVs or older nonnucleoside reverse transcriptase inhibitors and comedications for chronic comorbidities (e.g., anticoagulants, antiplatelets, statins) or complex conditions (e.g., anticancer agents, immunosuppressants). Newer ARVs such as unboosted integrase inhibitors, doravirine, and fostemsavir have reduced DDI potential, but there are clinically relevant DDIs that warrant consideration. Potential consequences of DDIs include increased toxicity and/or reduced efficacy of ARVs and/or comedications. Management approaches include switching to an ARV with less DDI potential, changing comedications, or altering medication dosage or dosing frequency. Deprescribing strategies can reduce DDIs and polypharmacy, improve adherence, minimize unnecessary adverse effects, and prevent medication-related errors.

SUMMARY

Management of DDIs requires close interdisciplinary collaboration from multiple healthcare disciplines (medicine, nursing, pharmacy) across a spectrum of care (community, outpatient, inpatient).

Durability of Integrase STrand Inhibitor (InSTI)-based regimen in geriatric people living with HIV in the GEPPO cohort

OBJECTIVE

To investigate the durability of the first integrase inhibitor-based regimen in a HIV geriatric multicentric prospective cohort and to explore the reasons of regimen discontinuation.

DESIGN

This is an analysis conducted on the Geriatric Patients Living with HIV/AIDS (GEPPO) cohort, an Italian prospective observational multicentre cohort of people living with HIV with 65 years of age or more.

METHODS

The analysis was performed using R (version 4.0.2). The tests performed were two sided assuming a 5% significance level (Kruskal-Wallis test, Chi-squared test, log-rank test and a Cox Proportional Hazard model). The proportion of participants discontinuing the three regimens was displayed using cumulative curves.

RESULTS

Among 1531 patients enrolled between 2017 and 2019 in the GEPPO cohort, we included 822 participants in this analysis. At baseline, median age was 69.8, the immunovirological profile good, multimorbidity was present in 42.3% of participants, while 27.4% were on polypharmacy. Overall, 483, 243 and 96 participants received DTG, RAL and EVG/c respectively as first InSTI. At the end of the follow up 6.4%, 21.1% and 22.9% participants discontinued DTG, RAL and EVG/c respectively. Using a log-rank test, EVG showed a significantly lower durability than DTG (p<0.001) or RAL (p 0.05) or both, DTG and RAL (p<0.001). Among participants who discontinued their regimen we found 0 virological failure and 56.7% simplification/deprescription.

CONCLUSIONS

The three integrase inhibitors considered showed a good durability and no virological failures in geriatric patients such as those enrolled in the GEPPO cohort when used in a two or three drug regimen.

Predicting Drug-Drug Interactions between Rifampicin and Ritonavir-Boosted Atazanavir Using PBPK Modelling

Objectives

The aim of this study was to simulate the drug–drug interaction (DDI) between ritonavir-boosted atazanavir (ATV/r) and rifampicin (RIF) using physiologically based pharmacokinetic (PBPK) modelling, and to predict suitable dose adjustments for ATV/r for the treatment of people living with HIV (PLWH) co-infected with tuberculosis.

Methods

A whole-body DDI PBPK model was designed using Simbiology 9.6.0 (MATLAB R2019a) and verified against reported clinical data for all drugs administered alone and concomitantly. The model contained the induction mechanisms of RIF and ritonavir (RTV), the inhibition effect of RTV for the enzymes involved in the DDI, and the induction and inhibition mechanisms of RIF and RTV on the uptake and efflux hepatic transporters. The model was considered verified if the observed versus predicted pharmacokinetic values were within twofold. Alternative ATV/r dosing regimens were simulated to achieve the trough concentration (C_trough) clinical cut-off of 150 ng/mL.

Results

The PBPK model was successfully verified according to the criteria. Simulation of different dose adjustments predicted that a change in regimen to twice-daily ATV/r (300/100 or 300/200 mg) may alleviate the induction effect of RIF on ATV C_trough, with > 95% of individuals predicted to achieve C_trough above the clinical cut-off.

Conclusions

The developed PBPK model characterized the induction-mediated DDI between RIF and ATV/r, accurately predicting the reduction of ATV plasma concentrations in line with observed clinical data. A change in the ATV/r dosing regimen from once-daily to twice-daily was predicted to mitigate the effect of the DDI on the C_trough of ATV, maintaining plasma concentration levels above the therapeutic threshold for most patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-021-01067-1.

Use of dietary supplements containing polyvalent cations and antacids among people with HIV and its impact on viral suppression

Dietary supplements and medications containing polyvalent cations can interact with integrase strand transfer inhibitors (INSTIs) and decrease exposure to INSTIs. In this cross-sectional study of 513 people with HIV (PWH) who were on stable antiretroviral therapy, 57.5% and 6.6% reported concurrent use of dietary supplements and antacids, respectively. In the multivariable analysis, the use of antacids, but not dietary supplements containing polyvalent cations, was associated with HIV viremia in PWH who received INSTI-based ART.

Quality of life in people living with HIV in Romania and Spain

Background

Health-related quality of life (HRQoL) is a crucial component in assessing and addressing the unmet needs of people, especially those with chronic illnesses such as HIV. The aim of the study was to examine and compare the health-related quality of life of people living with HIV in Romania and Spain, compared to the general populations of each country.

Methods

A cross-sectional survey was conducted among adults (≥ 18 years) attending for HIV care in Romania and Spain from October 2019 to March 2020. The survey included two validated HRQoL instruments: a generic instrument, EQ-5D-5L, and an HIV-specific instrument, PozQoL, and questions on socio-demographics, HIV-related characteristics, physical and mental health conditions, and substance use. Multivariable linear regression was used to determine factors associated with HRQoL.

Results

570 people living with HIV responded (170 in Romania and 400 in Spain). The median age was 31 (18–67) in Romania and 52 (19–83) in Spain. Anxiety/depression symptoms were frequently reported by people with HIV (Romania: 50% vs 30% in the Romanian population; Spain: 38% vs 15% in Spanish population). Spain reported higher mean EQ-5D_utility scores than Romania (0.88 and 0.85, respectively) but identical PozQoL scores (3.5, on a scale of 0–5). In both countries, health concerns were highlighted as a key issue for people with HIV. In multivariable analysis, two factors were consistently associated with worse HRQoL in people with HIV: bad or very bad self-rated health status and presence of a mental health condition. In Romania, being gay/bisexual and being disabled/unemployed were associated with worse HRQoL. Whereas in Spain, older age and financial insecurity were significant predictors.

Conclusions

Our results indicated a good HRQoL for people living with HIV in Romania and Spain; however, worse HRQoL profiles were characterized by health concerns, poor self-rated health status, and the presence of mental health conditions. This study highlights the importance of monitoring HRQoL in people living with HIV due to the chronic nature of the disease. In this highly-treatment experienced group, disparities were found, particularly highlighting mental health as an area which needs more attention to improve the well-being of people living with HIV.

Clinical Safety Considerations of Integrase Strand Transfer Inhibitors in the Older Population Living with HIV

There are approximately 40 million people living with HIV globally, and 21% (7.9 million) are older adults (aged > 50 years) as of 2019. The average age of HIV-positive patients is predicted to increase to 58 by 2035. The favorable clinical efficacy of integrase strand transfer inhibitors has led to high rates of viral suppression and have now become the preferred agents by the AIDS guideline when initiating antiretroviral therapy. There are concerns of increasing adverse effects from HIV medications, such as integrase strand transfer inhibitors, as a result of changes in pharmacodynamic and pharmacokinetic parameters within the older population. The authors aim to describe the safety concerns of the current integrase strand transfer inhibitors based upon a narrative literature review, including recommendations for drug-drug interactions, and relevant comorbidities to consider for selection of the most appropriate integrase strand transfer inhibitor for older people living with HIV. Raltegravir is a well-tolerated option with minor adverse events; however, adherence to a twice-daily regimen may be difficult in older patients who are also taking many other medications for various comorbidities. Elvitegravir is also well tolerated with limited adverse effects, but has many drug-drug interactions that may pose problems for older patients with polypharmacy. Dolutegravir has been associated with more frequent adverse events, such as neuropsychiatric disorders.

Structured medicines reviews in HIV outpatients: a feasibility study (The MOR Study)

OBJECTIVES

Polypharmacy in people living with HIV (PLWH) increases the risks of medicine-related problems (events or circumstances involving drug therapy that actually or potentially interfere with desired health outcomes). We aimed to examine the feasibility and acceptability of a Medicines Management Optimisation Review (MOR) toolkit in HIV outpatients.

METHODS

This was a multi-centre randomized controlled study across four HIV centres. In all, 200 PLWH on combination antiretroviral therapy, either > 50 years old or < 50 years with other comorbidities, were enrolled to have a MOR or received standard pharmaceutical care. The primary outcome was the difference in the number of medicine-related problems (MRPs) between intervention and standard care groups at baseline and 6 months. Acceptability, cost of the intervention and health-related quality of life were also examined.

RESULTS

In all, 164 patients were analysed: 70 in the intervention group and 94 in the standard care group. A significant number of MRPs were detected in those patients receiving MOR compared with the standard care group at baseline (93 vs. 2; p = 0.001, z = -8.6, r = 0.6) and 6 months (33 vs. 3; p = 0.001, z = -5.7, r = 0.4). A significant reduction in the number of new MRPs at 6 months in the intervention group versus baseline was also observed (p = 0.001, Z = -3.7, r = 0.2); 44% of MRPs were fully resolved at baseline and 51% at 6 months. No changes in health-related quality of life following MOR or between MOR and standard care groups were observed. The MORs were highly acceptable among patients and healthcare professionals.

CONCLUSIONS

The MOR toolkit was feasible and acceptable, suggesting that HIV outpatient services might consider implementing MOR for targeted populations under their care.

Comorbidities and psychosocial factors as correlates of self-reported falls in a nationwide sample of community-dwelling people aging with HIV in Germany

BACKGROUND

Falls are a frequent health problem with potentially severe consequences among the elderly. Due to the aging HIV population, there is a growing interest in falls as a geriatric syndrome in HIV research and clinical practice. Previous studies found rather high prevalences of falls in this population and focused on biomedical and demographic risk factors for falls. Psychosocial risk factors like stigma, social support or loneliness were not previously assessed as correlates of fall events in this population.

METHODS

We assessed self-reported fall frequency in the past 12 months in a nationwide sample of 897 community-dwelling people aged 50 years or older living with HIV in Germany using a cross-sectional study design. We calculated odds of any fall for sociodemographic and HIV-related variables in bivariate analyses and for comorbidities, and psychosocial variables in bivariate and adjusted analyses.

RESULTS

Eighteen percent of our participants reported at least one fall in the preceding 12 months, 12 % reported recurring falls. A lower socioeconomic status, being single and living alone were significantly associated with a higher risk for falling. An AIDS diagnosis was related to fall risk, but time since diagnosis and a detectable viral load were not. Reporting at least one comorbidity increased fall risk in our sample 2.5 times (95% CI: 1.59; 3.97). The strongest association with fall risk was found for diseases of the central nervous system, heart disease, rheumatism, osteoporosis, and chronic pain. Experienced HIV stigma (AOR: 2.11; 95% CI: 1.58; 2.83) and internalized HIV stigma (AOR: 1.43; 95% CI: 1.12; 1.85), as well as social support (AOR: .92; 95% CI: .86; .99) and loneliness (AOR: 1.51; 95% CI: 1.22; 1.87) were significantly related to fall risk in bivariate and adjusted analyses.

CONCLUSIONS

We found a low prevalence of falls in our sample of community-dwelling people aging with HIV. Our results show evidence for a strong association between comorbidity and falling, and between psychosocial factors and falling. Especially the strong association between experienced HIV stigma and fall risk is noteworthy and adds falls to the list of health outcomes affected by HIV stigma.