51
|
Lo Re V, Teal V, Localio AR, Amorosa VK, Kaplan DE, Gross R. Adherence to hepatitis C virus therapy in HIV/hepatitis C-coinfected patients. AIDS Behav 2013; 17:94-103. [PMID: 22907288 DOI: 10.1007/s10461-012-0288-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Adherence to hepatitis C virus (HCV) therapy has been incompletely examined among HIV-infected patients. We assessed changes in interferon and ribavirin adherence and evaluated the relationship between adherence and early (EVR) and sustained virologic response (SVR). We performed a cohort study among 333 HIV/HCV-coinfected patients who received pegylated interferon and ribavirin between 2001 and 2006 and had HCV RNA before and after treatment. Adherence was calculated over 12-week intervals using pharmacy refills. Mean interferon and ribavirin adherence declined 2.5 and 4.1 percentage points per 12-week interval, respectively. Among genotype 1/4 patients, EVR increased with higher ribavirin adherence, but this association was less strong for interferon. SVR among these patients was higher with increasing interferon and ribavirin adherence over the first, second, and third, but not fourth, 12-week intervals. Among HIV/HCV patients, EVR and SVR increased with higher interferon and ribavirin adherence. Adherence to both antivirals declined over time, but more so for ribavirin.
Collapse
Affiliation(s)
- Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | | | | | | |
Collapse
|
52
|
Antiretroviral adherence among rural compared to urban veterans with HIV infection in the United States. AIDS Behav 2013; 17:174-80. [PMID: 23080359 DOI: 10.1007/s10461-012-0325-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Rural-dwelling persons with HIV infection face barriers to maintaining high levels of antiretroviral adherence. We compared adherence among 1,782 rural and 18,519 urban veterans initiating antiretroviral therapy in the Veterans Affairs (VA) healthcare system in the United States between 1998 and 2007. Residence was determined using rural urban commuting area codes and adherence using pharmacy-based refill measures. The median proportion of days covered (PDC) by combination antiretroviral therapy in the first year of treatment ranged from 0.72 among urban residents to 0.79 among rural-small town/remote residents (p < 0.0001). In multivariable logistic regression, predictors of high adherence (PDC greater than 0.90) were residence in a rural-small town/remote setting (odds ratio 1.24, 95 % CI 1.09-1.56, relative to urban), increasing age, white race, absence of an alcohol or substance use disorder, and absence of hepatitis C infection. Results may differ outside VA healthcare, where there may be fewer resources to support adherence among rural-dwelling persons with HIV.
Collapse
|
53
|
Comparing adherence to two different HIV antiretroviral regimens: an instrumental variable analysis. AIDS Behav 2013; 17:160-7. [PMID: 22869102 DOI: 10.1007/s10461-012-0266-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The objective of this observational cohort study was to compare adherence to protease inhibitor (PI)-based regimens or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. HIV-seropositive, antiretroviral-naïve patients initiating therapy between 1998 and 2006 were identified using Veterans Health Administration databases. First-year adherence ratios were calculated as proportion of days covered (PDC). Multivariable regressions were run with an indicator for PDC >95, 90, 85, and 80 % as the dependent variable and an indicator for a PI-based regimen as the key independent variable. We controlled for residual unmeasured confounding by indication using an instrumental variable technique, using the physician's prescribing preference as the instrument. Out of 929 veterans on PI-based and 747 on NNRTI-based regimens, only 19.7 % of PI patients had PDC >80 %, compared to 35.1 % of NNRTI patients. In multivariable analysis, starting a PI regimen was significantly associated with poor adherence for all 4 adherence thresholds using conventional regressions and instrumental variable methods.
Collapse
|
54
|
Cottin Y, Lorgis L, Gudjoncik A, Buffet P, Brulliard C, Hachet O, Grégoire E, Germin F, Zeller M. Observance aux traitements : concepts et déterminants. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2012. [DOI: 10.1016/s1878-6480(12)70845-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
55
|
Yeh RF, Gupta SA, Sangani DN, Sansgiry SS. The association of pharmacy drug-delivery services with adherence in an urban HIV population†. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2012. [DOI: 10.1111/j.1759-8893.2012.00099.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Objective
The aim of this study was to examine the effect of drug-distribution methods on antiretroviral medication adherence in HIV-positive patients.
Methods
This was a longitudinal, retrospective study of an independent retail pharmacy providing complementary delivery services. Patients of 18 years of age or older receiving antiretroviral therapy were evaluated from 1 January to 30 June 2004. Patients were included if they had a minimum of one prescription claim for any antiretroviral medication during the study period and received state medication assistance. Using data obtained from computerized pharmacy records a medication possession ratio was calculated to assess adherence measured by pharmacy refill history over 6 months. To assess the consistency of adherence over time a modified medication possession ratio, termed the compliance/non-compliance index (CNI) at each refill, was developed and compared between each group.
Key findings
Of the 181 patients included in the study, those who had medications delivered had significantly better adherence (90.3% compared with 82.6%, P = 0.001) and CNI value (73.5% compared with 57.9%, P = 0.001) in comparison with those who picked up their medications. After controlling for age, gender, drug class, insurance type and time and distance from the pharmacy, use of medication-delivery services was significantly associated with adherence (P < 0.0001) and CNI score (P = 0.012).
Conclusion
Complementary medication-delivery services by pharmacies significantly increased adherence at each refill for antiretroviral therapy in HIV-positive patients. Further research is needed on how medication-distribution strategies can be implemented universally and the economic impact on cost of care to increase medication adherence in this high-risk population.
Collapse
Affiliation(s)
- Rosa F Yeh
- Department of Clinical Sciences and Administration, University of Houston, College of Pharmacy, Houston, TX, USA
| | | | | | - Sujit S Sansgiry
- Department of Clinical Sciences and Administration, University of Houston, College of Pharmacy, Houston, TX, USA
| |
Collapse
|
56
|
Prosperi MCF, Fabbiani M, Fanti I, Zaccarelli M, Colafigli M, Mondi A, D'Avino A, Borghetti A, Cauda R, Di Giambenedetto S. Predictors of first-line antiretroviral therapy discontinuation due to drug-related adverse events in HIV-infected patients: a retrospective cohort study. BMC Infect Dis 2012; 12:296. [PMID: 23145925 PMCID: PMC3519703 DOI: 10.1186/1471-2334-12-296] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 11/01/2012] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Drug-related toxicity has been one of the main causes of antiretroviral treatment discontinuation. However, its determinants are not fully understood. Aim of this study was to investigate predictors of first-line antiretroviral therapy discontinuation due to adverse events and their evolution in recent years. METHODS Patients starting first-line antiretroviral therapy were retrospectively selected. Primary end-point was the time to discontinuation of therapy due to adverse events, estimating incidence, fitting Kaplan-Meier and multivariable Cox regression models upon clinical/demographic/chemical baseline patients' markers. RESULTS 1,096 patients were included: 302 discontinuations for adverse events were observed over 1,861 person years of follow-up between 1988 and 2010, corresponding to an incidence (95% CI) of 0.16 (0.14-0.18). By Kaplan-Meier estimation, the probabilities (95% CI) of being free from an adverse event at 90 days, 180 days, one year, two years, and five years were 0.88 (0.86-0.90), 0.85 (0.83-0.87), 0.79 (0.76-0.81), 0.70 (0.67-0.74), 0.55 (0.50-0.61), respectively. The most represented adverse events were gastrointestinal symptoms (28.5%), hematological (13.2%) or metabolic (lipid and glucose metabolism, lipodystrophy) (11.3%) toxicities and hypersensitivity reactions (9.3%). Factors associated with an increased hazard of adverse events were: older age, CDC stage C, female gender, homo/bisexual risk group (vs. heterosexual), HBsAg-positivity. Among drugs, zidovudine, stavudine, zalcitabine, didanosine, full-dose ritonavir, indinavir but also efavirenz (actually recommended for first-line regimens) were associated to an increased hazard of toxicity. Moreover, patients infected by HIV genotype F1 showed a trend for a higher risk of adverse events. CONCLUSIONS After starting antiretroviral therapy, the probability of remaining free from adverse events seems to decrease over time. Among drugs associated with increased toxicity, only one is currently recommended for first-line regimens but with improved drug formulation. Older age, CDC stage, MSM risk factor and gender are also associated with an increased hazard of toxicity and should be considered when designing a first-line regimen.
Collapse
Affiliation(s)
- Mattia C F Prosperi
- Viral Immunodeficiency Unit, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
57
|
Helleberg M, Kronborg G, Larsen CS, Pedersen G, Pedersen C, Nielsen L, Laursen AL, Obel N, Gerstoft J. Decreasing rate of multiple treatment modifications among individuals who initiated antiretroviral therapy in 1997-2009 in the Danish HIV Cohort Study. Antivir Ther 2012; 18:345-354. [PMID: 23072939 DOI: 10.3851/imp2436] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND We hypothesized that rates and reasons for treatment modifications have changed since the implementation of combination antiretroviral therapy (cART) due to improvements in therapy. METHODS From a nationwide population-based cohort study we identified all HIV-1-infected adults who initiated cART in Denmark 1997-2009 and were followed ≥1 year. Incidence rate ratios (IRRs) and reasons for treatment modifications were estimated and compared between patients, who initiated treatment in 1997-1999, 2000-2004 and 2005-2009. Rates of discontinuation of individual antiretroviral drugs (ARVs) were evaluated. RESULTS A total of 3,107 patients were followed for a median of 7.3 years (IQR 3.8-10.8). Rates of first treatment modification ≤1 year after cART initiation did not change (IRR 0.88 [95% CI 0.78, 1.01] and 1.03 [95% CI 0.90, 1.18] in 2000-2004 and 2005-2009, respectively, compared with 1997-1999). Rates of multiple modifications decreased markedly (2000-2004 IRR 0.60 [95% CI 0.53, 0.67] and 2005-2009 IRR 0.38 [95% CI 0.32, 0.46]). Rates of treatment modifications due to virological failure, toxicity and other/unknown reasons decreased (IRR 0.25 [95% CI 0.14, 0.45], 0.69 [95% CI 0.56, 0.83] and 0.45 [95% CI 0.36, 0.57], respectively, in 2005-2009 compared with 1997-1999), whereas the rate of modifications with the aim of simplification increased (IRR 1.85 [95% CI 1.52, 2.25]). CONCLUSIONS Rates of first treatment modification ≤1 year after cART initiation have not changed since the early cART era, whereas the risk of multiple modifications has decreased markedly. Modifications due to virological failure and toxicity have decreased substantially, whereas rates of switch to simpler and less toxic regimens have increased.
Collapse
Affiliation(s)
- Marie Helleberg
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Gitte Kronborg
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - Carsten S Larsen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Gitte Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Lars Nielsen
- Department of Infectious Diseases, Hillerød Hospital, Hillerød, Denmark
| | - Alex L Laursen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jan Gerstoft
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| |
Collapse
|
58
|
Moore RD, Keruly JC, Bartlett JG. Improvement in the health of HIV-infected persons in care: reducing disparities. Clin Infect Dis 2012; 55:1242-51. [PMID: 23019271 DOI: 10.1093/cid/cis654] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Despite advances in human immunodeficiency virus (HIV) treatment, major challenges remain in achieving access, retention, and adherence. Our inner-city HIV clinical practice in Baltimore has a diverse patient population with high rates of poverty, black race, and injection drug use (IDU), providing us the opportunity to compare health process and outcomes. METHODS Using data collected in a clinical HIV cohort in Baltimore, we compared receipt of combination antiretroviral therapy (ART), HIV type 1 (HIV-1) RNA, CD4, incidence of opportunistic illness, and mortality from 1995 to 2010. Comparisons were made of these outcomes by HIV risk group, sex, and race (black, white). RESULTS From 1995 to 2010, we followed 6366 patients comprising 27 941 person-years (PY) of follow-up. By 2010, 87% of patients were receiving ART; median HIV-1 RNA was <200 copies/mL, median CD4 was 475 cells/mm(3), opportunistic illness rates were 2.4 per 100 PY, and mortality rates were 2.1 per 100 PY, with no differences by demographic or HIV risk group. The only differences were that the IDU risk group had a median CD4 that was 79 cells/mm(3) lower and HIV-1 RNA 0.16 log(10 )copies/mL higher compared with other risk groups (P < .01). In 2009 a 28-year-old HIV-infected person was estimated to have 45.4 years of life remaining, which did not differ by demographic or behavioral risk group. DISCUSSION Our results emphasize that advances in HIV treatment have had a positive impact on all affected demographic and behavioral risk groups in an HIV clinical setting, with an expected longevity for HIV-infected patients that is now 73 years.
Collapse
Affiliation(s)
- Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 E Monument St, Baltimore, MD 21287, USA.
| | | | | |
Collapse
|
59
|
Comorbid diabetes and the risk of progressive chronic kidney disease in HIV-infected adults: data from the Veterans Aging Cohort Study. J Acquir Immune Defic Syndr 2012; 60:393-9. [PMID: 22592587 DOI: 10.1097/qai.0b013e31825b70d9] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Approximately, 15% of HIV-infected individuals have comorbid diabetes. Studies suggest that HIV and diabetes have an additive effect on chronic kidney disease (CKD) progression; however, this observation may be confounded by differences in traditional CKD risk factors. METHODS We studied a national cohort of HIV-infected and matched HIV-uninfected individuals who received care through the Veterans Healthcare Administration. Subjects were divided into 4 groups based on baseline HIV and diabetes status, and the rate of progression to an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73m was compared using Cox-proportional hazards modeling to adjust for CKD risk factors. RESULTS About 31,072 veterans with baseline eGFR ≥45 mL/min/1.73m (10,626 with HIV only, 5088 with diabetes only, and 1796 with both) were followed for a median of 5 years. Mean baseline eGFR was 94 mL/min/1.73m, and 7% progressed to an eGFR < 45 mL/min/1.73m. Compared with those without HIV or diabetes, the relative rate of progression was increased in individuals with diabetes only [adjusted hazard ratio (HR) 2.48; 95% confidence interval (CI): 2.19 to 2.80], HIV only [HR: 2.80, 95% CI: 2.50 to 3.15], and both HIV and diabetes [HR: 4.47, 95% CI: 3.87 to 5.17]. DISCUSSION Compared with patients with only HIV or diabetes, patients with both diagnoses are at significantly increased risk of progressive CKD even after adjusting for traditional CKD risk factors. Future studies should evaluate the relative contribution of complex comorbidities and accompanying polypharmacy to the risk of CKD in HIV-infected individuals and prospectively investigate the use of cART, glycemic control, and adjunctive therapy to delay CKD progression.
Collapse
|
60
|
Gutierrez EB, Sartori AMC, Schmidt AL, Piloto BM, França BB, de Oliveira AS, Pouza AR, Moreno RV, de Melo Picone C, de Almeida Ribeiro MCS. Measuring adherence to antiretroviral treatment: the role of pharmacy records of drug withdrawals. AIDS Behav 2012; 16:1482-90. [PMID: 22392157 DOI: 10.1007/s10461-012-0168-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
This study aimed to evaluate adherence to antiretroviral treatment (ART) among HIV + adults, assess its association with HIV viral load (VL) and identify factors associated to adherence. A survey involving a random sample of adults followed at a HIV/AIDS reference center in São Paulo city, Brazil, from 2007 to 2009 was done. A questionnaire was applied and data were retrieved from the pharmacy and medical records. The study involved 292 subjects: 70.2% men; median age: 43 years; median duration of ART: 8 years. 89.3% self-reported taken all prescribed pills in the last 3 days but only 39.3% picked up ≥95% of the prescribed ART from the pharmacy in the last 12 months. At the multivariate analysis having symptoms prior to ART, taking fewer ART pills, and not missing medical appointments were independently associated to higher adherence. Adherence was strongly associated with undetectable HIV VL. Rates of undetectable HIV VL did not differ from 80 to ≥95% of adherence.
Collapse
|
61
|
Edelman EJ, Gordon K, Rodriguez-Barradas MC, Justice, for the VACS Project Team AC. Patient-reported symptoms on the antiretroviral regimen efavirenz/emtricitabine/tenofovir. AIDS Patient Care STDS 2012; 26:312-9. [PMID: 22612469 DOI: 10.1089/apc.2012.0044] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Most patients (80-90%) newly diagnosed with HIV are started on the antiretroviral regimen efavirenz, emtricitabine, and tenofovir (EFV/FTC/TDF). Existing studies of patient tolerability, however, are limited. We compared symptom experiences of patients on EFV/FTC/TDF, and the subsequent impact on health-related quality of life, with those of patients on other combination antiretroviral therapy (cART). We conducted a cross-sectional analysis of the Veterans Aging Cohort Study from February 2008 to August 2009 to compare the symptom experiences of patients on EFV/FTC/TDF vs. other cART, unadjusted and then adjusted for treatment characteristics, and comorbid disease severity. We then assessed the association between EFV/FTC/TDF use and health-related quality of life. Among the 1,759 patients in our analytic sample, EFV/FTC/TDF use was associated with fewer symptoms than was other cART. The use of EFV/FTC/TDF was independently associated with health-related quality of life, and this association was at least partially explained by symptom burden.
Collapse
Affiliation(s)
- E. Jennifer Edelman
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kirsha Gordon
- Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Maria C. Rodriguez-Barradas
- Section of Infectious Diseases, Department of Medicine, Michael E. De Bakey VAMC and Baylor College of Medicine, Houston, Texas
| | - Amy C. Justice, for the VACS Project Team
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
| | | |
Collapse
|
62
|
Zerah L, Arena C, Morin AS, Blanchon T, Cabane J, Fardet L. [Patients' beliefs about long-term glucocorticoid therapy and their association to treatment adherence]. Rev Med Interne 2012; 33:300-4. [PMID: 22444116 DOI: 10.1016/j.revmed.2012.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Revised: 01/26/2012] [Accepted: 02/12/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND In patients treated with systemic glucocorticoids (GCs), it is unknown if beliefs about the treatment are associated with level of reported adherence. PATIENTS AND METHODS Cross-sectional study conducted in two departments of internal medicine during a six-month period. All patients receiving long-term GCs therapy were asked to fill in a questionnaire regarding their beliefs about (specific scale of the Beliefs about Medicines Questionnaire) and their adherence to (four-item Morisky-Green scale) GCs. Logistic regression analysis was used to assess association between beliefs about GCs and adherence to treatment. RESULTS One hundred and eighty one questionnaires were analysed (women: 79%, median age [IQR]: 47 [33-61] years, median duration of treatment: 18 [7-72] months, median daily dosage of prednisone equivalent: 10 [6-20] mg). Among these 181 patients, 83 (46%) reported a "concern" score equal to or higher than the "necessity" score. Nineteen percent of patients reported a low adherence level. In multivariate analysis, these patients were significantly younger (OR: 0.96 [0.93-0.98] per increasing year of age, P=0.002) and reported more frequently a "concern" score higher than a "necessity" score (OR: 3.08 [1.27-7.46], P=0.01) as compared to patients reporting a high adherence level. CONCLUSION Informing patients about the "necessity" of GCs and taking into account their "concerns" about adverse events or their fear of becoming dependent on the medication may improve their adherence to treatment.
Collapse
Affiliation(s)
- L Zerah
- Service de médecine interne, hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
| | | | | | | | | | | |
Collapse
|
63
|
Ammassari A, Trotta MP, Shalev N, Marconi P, Antinori A. Beyond virological suppression: the role of adherence in the late HAART era. Antivir Ther 2012; 17:785-92. [PMID: 22414552 DOI: 10.3851/imp2084] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2011] [Indexed: 10/28/2022]
Abstract
HAART has increased the life expectancy of HIV-infected individuals significantly. Optimal adherence to HAART results in viral suppression and immune recovery in the majority of HIV-infected persons. Data from the early HAART era suggest that adherence levels of greater than 95% are necessary to achieve and maintain virological suppression. However, the optimal threshold of adherence required to maximize the pharmacological benefits of contemporary antiretroviral regimens, particularly in the virologically suppressed patient, is unknown. This review examines new data on the role of adherence in the late HAART era, focusing on virological, immunological and epidemiological aspects. We begin with a discussion of the impact of adherence on viral dynamics and immunological parameters in the virologically suppressed patient. We then review the importance of adherence in emerging antiretroviral treatment strategies. Finally, we summarize accumulating data on the role of antiretroviral adherence in the prevention of HIV transmission. Taken together, the data reviewed reinforce the critical importance of adherence in the management of HIV infection in the late HAART era.
Collapse
Affiliation(s)
- Adriana Ammassari
- National Institute for Infectious Diseases L Spallanzani IRCCS, Rome, Italy.
| | | | | | | | | |
Collapse
|
64
|
Using different calculations of pharmacy refill adherence to predict virological failure among HIV-infected patients. J Acquir Immune Defic Syndr 2011; 55:635-40. [PMID: 21934556 DOI: 10.1097/qai.0b013e3181fba6ab] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Refill data are increasingly used to assess adherence in HIV-infected patients on combination antiretroviral therapy. However, it is not clear how feasible this method is when multiple pharmacies are involved. Also, the effects of inclusion of leftover medication from previous refills and prescribed treatment time on adherence calculations are unknown. We addressed these questions in the present study. METHODS Adult HIV-1-infected patients were recruited at the outpatient clinic of the Academic Medical Centre in Amsterdam and asked for their pharmacies' names. Refill data were obtained from pharmacies. Percentages of patients misclassified as nonadherent when disregarding leftover medication and prescribed treatment interruptions were calculated. Finally, we investigated whether an average adherence calculation of all drugs or a calculation based on one drug in the regimen best predicted virological failure (plasma HIV-1 RNA >40 copies/mL). RESULTS Two hundred one patients were included. Collecting data from multiple pharmacies (132) was found to be feasible. Forty-three percent of patients were misclassified as nonadherent when disregarding leftover medication and 2 percent when disregarding prescribed treatment time. There was no difference in predicting virological failure by different calculations of adherence. CONCLUSIONS These findings suggest that studies using pharmacy refill data should include leftover medication.
Collapse
|
65
|
Nolan S, Milloy MJ, Zhang R, Kerr T, Hogg RS, Montaner JSG, Wood E. Adherence and plasma HIV RNA response to antiretroviral therapy among HIV-seropositive injection drug users in a Canadian setting. AIDS Care 2011; 23:980-7. [PMID: 21480010 DOI: 10.1080/09540121.2010.543882] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
HIV-positive individuals who use injection drugs (IDU) may have lower rates of adherence to highly active antiretroviral therapy (ART). However, previous studies of factors associated with adherence to ART among IDU have been limited primarily to samples drawn from clinical settings and in areas with financial barriers to healthcare.We evaluated patterns of ART adherence and rates of plasma HIV RNA response among a Canadian cohort of community-recruited IDU. Using data from a community-recruited cohort of antiretroviral-naive HIV-infected IDU, we investigated ART adherence patterns based on prescription refill compliance and factors associated with time to plasma HIV-1 RNA suppression (<500 copies/mL) using Cox proportional hazards regression in a setting with universal health care, including free ART. Between 1996 and 2008, 267 antiretroviral-naive HIV-infected IDU initiated ART and had a median of 51 months (inter-quartile range: 17-95 months) of follow-up. Overall, 81 (30.3%) were ≥95% adherent during the first year of HAART and 187 (70.0%) achieved HIV RNA suppression at least once over the study period, for an incidence-density of 34.5 (95% confidence interval [CI]: 29.8-39.9) per 100 person-years. The Kaplan-Meier cumulative plasma HIV RNA suppression rates at 12 months after the initiation of ART were 80.8% (95% CI: 71.2-88.7) for adherent and 28.9% (95% CI: 22.8-36.1) for non-adherent participants. While several socio-demographic characteristics and drug-using behaviours were identified as barriers to successful treatment in unadjusted analyses, the factor most strongly associated with time to HIV RNA suppression in multivariate analysis was adherence to ART of at least 95% (adjusted hazard ratio [AHR] = 6.0, 95% CI: 4.2-8.6, p<0.001). These results demonstrate low rates of adherence to ART among a community-recruited cohort of IDU and reinforce the importance of adherence as the key determinant of successful virological response to antiretroviral therapy.
Collapse
Affiliation(s)
- Seonaid Nolan
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | |
Collapse
|
66
|
Maskew M, Brennan AT, MacPhail AP, Sanne IM, Fox MP. Poorer ART outcomes with increasing age at a large public sector HIV clinic in Johannesburg, South Africa. ACTA ACUST UNITED AC 2011; 11:57-65. [PMID: 21951728 DOI: 10.1177/1545109711421641] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND As the current HIV-positive population ages, the absolute number of patients >50 years on treatment is increasing. METHODS We analyze the differences in treatment outcomes by age category (18-29, 30-39, 40-49, 50-59, and ≥ 60) among 9139 HIV-positive adults initiating ART in South Africa. RESULTS The adjusted hazard ratios (HRs) for all-cause mortality increased with increasing age, with the strongest association in the first 12 months of follow-up among patients 50 to 59 years (HR 1.67; 95% confidence interval [CI]: 1.24-2.23) versus those <30 years. However, patients 50 to 59 years were less likely to be lost during 24 months on antiretroviral therapy ([ART] HR 0.75; 95% CI: 0.59-0.94) versus patients <30 years. By 6 and 12 months on treatment, older patients were less likely to increase their CD4 count by ≥ 50 cells/mm(3). CONCLUSION Although older patients are at higher risk of mortality and have poorer immunological responses than their younger counterparts, they are more likely to adhere to care and treatment in the first 24 months on ART.
Collapse
Affiliation(s)
- Mhairi Maskew
- 1Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | |
Collapse
|
67
|
Lo Re V, Teal V, Localio AR, Amorosa VK, Kaplan DE, Gross R. Relationship between adherence to hepatitis C virus therapy and virologic outcomes: a cohort study. Ann Intern Med 2011; 155:353-60. [PMID: 21930852 PMCID: PMC3366635 DOI: 10.7326/0003-4819-155-6-201109200-00003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Adherence to therapy with pegylated interferon and ribavirin for hepatitis C virus (HCV) infection has been incompletely examined. OBJECTIVE To evaluate the relationship between adherence to HCV therapy and early and sustained virologic response, assess changes in adherence over time, and examine risk factors for nonadherence. DESIGN Retrospective cohort study. SETTING National Veterans Affairs Hepatitis C Clinical Case Registry. PATIENTS 5706 HCV-infected patients (genotypes 1, 2, 3, or 4) with at least 1 prescription for both pegylated interferon and ribavirin between 2003 and 2006 and HCV RNA results before and after treatment initiation. MEASUREMENTS Adherence was calculated over 12-week intervals by using pharmacy refill data. End points included early virologic response (decrease of ≥2 log(10) HCV RNA at 12 weeks) and sustained virologic response (undetectable HCV RNA 24 weeks after the end of treatment). RESULTS Early virologic response increased with higher levels of adherence to ribavirin therapy over the initial 12 weeks (patients with HCV genotype 1 or 4, 25 of 68 [37%] with ≤40% adherence vs. 1367 of 2187 [63%] with 91% to 100% adherence [P < 0.001]; patients with HCV genotype 2 or 3, 12 of 18 [67%] with ≤40% adherence vs. 651 of 713 [91%] with 91% to 100% adherence [P < 0.001]). Among patients with HCV genotype 1 or 4, sustained response increased with higher adherence to ribavirin therapy over the second, third, and fourth 12-week intervals. Results were similar for adherence to interferon therapy. Mean adherence to therapy with interferon and ribavirin decreased by 3.4 and 6.6 percentage points per 12-week interval, respectively (P for trend < 0.001 for each drug). Patients who received growth factors or thyroid medications during treatment had higher mean adherence to antiviral therapy. LIMITATION This was an observational study without standardized timing for outcome measurements. CONCLUSION Early and sustained virologic responses increased with higher levels of adherence to interferon and ribavirin therapy. Adherence to therapy with both antivirals decreased over time, but more so for ribavirin.
Collapse
Affiliation(s)
- Vincent Lo Re
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | | | | | | | | | | |
Collapse
|
68
|
Wang EA, McGinnis KA, Fiellin DA, Goulet JL, Bryant K, Gibert CL, Leaf DA, Mattocks K, Sullivan LE, Vogenthaler N, Justice AC. Food insecurity is associated with poor virologic response among HIV-infected patients receiving antiretroviral medications. J Gen Intern Med 2011; 26:1012-8. [PMID: 21573882 PMCID: PMC3157515 DOI: 10.1007/s11606-011-1723-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 03/30/2011] [Accepted: 04/05/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND OBJECTIVE Food insecurity negatively impacts HIV disease outcomes in international settings. No large scale U.S. studies have investigated the association between food insecurity and severity of HIV disease or the mechanism of this possible association. The objective of this study was to examine the impact of food insecurity on HIV disease outcomes in a large cohort of HIV-infected patients receiving antiretroviral medications. DESIGN This is a cross-sectional study. PARTICIPANTS AND SETTING Participants were HIV-infected patients enrolled in the Veterans Aging Cohort Study between 2002-2008 who were receiving antiretroviral medications. MAIN MEASUREMENTS Participants reporting "concern about having enough food for you or your family in the past 30 days" were defined as food insecure. Using multivariable logistic regression, we explored the association between food insecurity and both low CD4 counts (<200 cells/μL) and unsuppressed HIV-1 RNA (>500 copies/mL). We then performed mediation analysis to examine whether antiretroviral adherence or body mass index mediates the observed associations. KEY RESULTS Among 2353 HIV-infected participants receiving antiretroviral medications, 24% reported food insecurity. In adjusted analyses, food insecure participants were more likely to have an unsuppressed HIV-1 RNA (AOR 1.37, 95% CI 1.09, 1.73) compared to food secure participants. Mediation analysis revealed that neither antiretroviral medication adherence nor body mass index contributes to the association between food insecurity and unsuppressed HIV-1 RNA. Food insecurity was not independently associated with low CD4 counts. CONCLUSIONS Among HIV-infected participants receiving antiretroviral medications, food insecurity is associated with unsuppressed viral load and may render treatment less effective. Longitudinal studies are needed to test the potential causal association between food insecurity, lack of virologic suppression, and additional HIV outcomes.
Collapse
Affiliation(s)
- Emily A Wang
- Department of Internal Medicine, Yale University School of Medicine, Harkness Hall Building A 367 Cedar Street, Suite 410A, New Haven, CT 06510, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
69
|
Sullivan LE, Goulet JL, Justice AC, Fiellin DA. Alcohol consumption and depressive symptoms over time: a longitudinal study of patients with and without HIV infection. Drug Alcohol Depend 2011; 117:158-63. [PMID: 21345624 PMCID: PMC3113463 DOI: 10.1016/j.drugalcdep.2011.01.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Revised: 01/14/2011] [Accepted: 01/15/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND The impact of alcohol consumption on depressive symptoms over time among patients who do not meet criteria for alcohol abuse or dependence is not known. OBJECTIVE To evaluate the impact of varying levels of alcohol consumption on depressive symptoms over time in patients with and without HIV infection. DESIGN We used data from the Veterans Aging Cohort Study (VACS). We used generalized estimating equation models to assess the association of alcohol-related categories, as a fixed effect, on the time-varying outcome of depressive symptoms. PARTICIPANTS VACS is a prospectively enrolled cohort study of HIV-infected patients and age-, race- and site-matched HIV uninfected patients. MAIN MEASURES Hazardous, binge drinking, alcohol abuse and alcohol dependence were defined using standard criteria. Depressive symptoms were measured by the Patient Health Questionnaire (PHQ-9). KEY RESULTS Among the 2446 patients, 19% reported past but not current alcohol use, 50% non-hazardous drinking, 8% hazardous drinking, 14% binge drinking, and 10% met criteria for alcohol or dependence. At baseline, depressive symptoms were higher in hazardous and binge drinkers than in past and non-hazardous drinkers (OR=2.65; CI=1.50/4.69; p<.001) and similar to those with abuse or dependence. There was no difference in the association between alcohol-related category and depressive symptoms by HIV status (OR=0.99; CI=.83/1.18; p=.88). Hazardous drinkers were 2.53 (95% CI=1.34/4.81) times and binge drinkers were 2.14 (95% CI=1.49/3.07) times more likely to meet criteria for depression when compared to non-hazardous drinkers. The associations between alcohol consumption and depressive symptoms persisted over three years and were responsive to changes in alcohol-related categories. CONCLUSIONS HIV-infected and HIV-uninfected hazardous and binge drinkers have depressive symptoms that are more severe than non-hazardous and non-drinkers and similar to those with alcohol abuse or dependence. Patients who switch to a higher or lower level of drinking experience a similar alteration in their depressive symptoms. Interventions to decrease unhealthy alcohol consumption may improve depressive symptoms.
Collapse
Affiliation(s)
| | - Joseph L. Goulet
- Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Amy C. Justice
- Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | | |
Collapse
|
70
|
Nelson RE, Hicken B, West A, Rupper R. The effect of increased travel reimbursement rates on health care utilization in the VA. J Rural Health 2011; 28:192-201. [PMID: 22458320 DOI: 10.1111/j.1748-0361.2011.00387.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE The reimbursement rate that eligible veterans receive for travel to Department of Veterans Affairs (VA) facilities increased from 11 to 28.5 cents per mile on February 1, 2008. We examined the effect of this policy change on utilization of outpatient, inpatient, and pharmacy services, stratifying veterans based on distance from a VA facility. METHODS We compared health care utilization and costs on a sample of VA patients in the 10.5 months before the reimbursement rate increase and the 10.5 months after the reimbursement rate increase. Using a difference-in-difference technique, we ran multivariable logistic and count regressions for utilization and generalized linear models (GLM) for cost outcomes. Regressions were stratified based on urban and rural residence, as well as by distance thresholds. FINDINGS Our cohort contained 250,958 veterans, 76.7% (n = 192,559) of whom were eligible to receive a travel reimbursement. After the reimbursement rate increase, eligible veterans at all distances were 6.8% more likely to have an outpatient encounter and had 2.6% more outpatient encounters in the VA compared to those not eligible for the reimbursement (P< .001). Similar results were found for prescription fills at all distances, but inpatient encounters remained generally unaffected. CONCLUSIONS Our results suggest that this policy change was successful in increasing access to VA care for patients regardless of location of residence.
Collapse
Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah 84148, USA.
| | | | | | | |
Collapse
|
71
|
Braithwaite RS, Nucifora KA, Yiannoutsos CT, Musick B, Kimaiyo S, Diero L, Bacon MC, Wools-Kaloustian K. Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives? J Int AIDS Soc 2011; 14:38. [PMID: 21801434 PMCID: PMC3163507 DOI: 10.1186/1758-2652-14-38] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 07/30/2011] [Indexed: 12/11/2022] Open
Abstract
Background Updated World Health Organization guidelines have amplified debate about how resource constraints should impact monitoring strategies for HIV-infected persons on combination antiretroviral therapy (cART). We estimated the incremental benefit and cost effectiveness of alternative monitoring strategies for east Africans with known HIV infection. Methods Using a validated HIV computer simulation based on resource-limited data (USAID and AMPATH) and circumstances (east Africa), we compared alternative monitoring strategies for HIV-infected persons newly started on cART. We evaluated clinical, immunologic and virologic monitoring strategies, including combinations and conditional logic (e.g., only perform virologic testing if immunologic testing is positive). We calculated incremental cost-effectiveness ratios (ICER) in units of cost per quality-adjusted life year (QALY), using a societal perspective and a lifetime horizon. Costs were measured in 2008 US dollars, and costs and benefits were discounted at 3%. We compared the ICER of monitoring strategies with those of other resource-constrained decisions, in particular earlier cART initiation (at CD4 counts of 350 cells/mm3 rather than 200 cells/mm3). Results Monitoring strategies employing routine CD4 testing without virologic testing never maximized health benefits, regardless of budget or societal willingness to pay for additional health benefits. Monitoring strategies employing virologic testing conditional upon particular CD4 results delivered the most benefit at willingness-to-pay levels similar to the cost of earlier cART initiation (approximately $2600/QALY). Monitoring strategies employing routine virologic testing alone only maximized health benefits at willingness-to-pay levels (> $4400/QALY) that greatly exceeded the ICER of earlier cART initiation. Conclusions CD4 testing alone never maximized health benefits regardless of resource limitations. Programmes routinely performing virologic testing but deferring cART initiation may increase health benefits by reallocating monitoring resources towards earlier cART initiation.
Collapse
Affiliation(s)
- R Scott Braithwaite
- Section on Value and Comparative Effectiveness, Department of Medicine, New York University School of Medicine, USA.
| | | | | | | | | | | | | | | |
Collapse
|
72
|
Juday T, Grimm K, Zoe-Powers A, Willig J, Kim E. A retrospective study of HIV antiretroviral treatment persistence in a commercially insured population in the United States. AIDS Care 2011; 23:1154-62. [PMID: 21500025 PMCID: PMC3320099 DOI: 10.1080/09540121.2010.543884] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study examined factors associated with persistence (time from initiation to discontinuation of treatment) on initial antiretroviral (ARV) therapy in commercially insured HIV patients in the United States, a population not well researched. This retrospective analysis of US health insurance claims data from 1 January 2003 to 30 June 2008 included treatment-naive patients aged 18–65 years with an HIV diagnosis receiving ARV therapy consisting of at least two individual nucleoside reverse transcriptase inhibitors (NRTIs) or one fixed-dose combination NRTI, plus at least one nonnucleoside reverse transcriptase inhibitor (NNRTI) or one protease inhibitor (PI), with or without ritonavir. Descriptive statistics, Kaplan-Meier survival estimation, and Cox proportional hazards regression models were completed. Patients were considered persistent until any component of the regimen was modified or there was a gap in treatment > 90 days. A total of 2460 patients met full inclusion criteria (1388 NNRTI and 1072 PI). Mean (SD) time to discontinuation for NNRTI- vs PI-based regimens was 370 (346) vs 295 (338) days (p < 0.001). Female sex, substance use, low comorbidity score, index year before 2007, geographical region, and taking a lopinavir/ritonavir regimen predicted discontinuation. Relative to NNRTI-based regimens, PI-based regimens demonstrated a greater risk of discontinuation (hazard ratio [HR], 1.32; p <0.001). The fixed-dose efavirenz/emtricitabine/tenofovir combination yielded the lowest risk of discontinuation (HR, 0.39; p < 0.001). HIV treatment persistence was longer with NNRTI-based regimens than PI-based regimens. The fixed-dose regimen of once-daily efavirenz/emtricitabine/tenofovir had the lowest risk of discontinuation.
Collapse
Affiliation(s)
- Timothy Juday
- Bristol-Myers Squibb Research and Development, Plainsboro, NJ, USA.
| | | | | | | | | |
Collapse
|
73
|
Purohit V, Rapaka RS, Schnur P, Shurtleff D. Potential impact of drugs of abuse on mother-to-child transmission (MTCT) of HIV in the era of highly active antiretroviral therapy (HAART). Life Sci 2011; 88:909-16. [DOI: 10.1016/j.lfs.2011.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 03/19/2011] [Indexed: 11/16/2022]
|
74
|
Arena C, Morin AS, Blanchon T, Hanslik T, Cabane J, Dupuy A, Fardet L. Impact of glucocorticoid-induced adverse events on adherence in patients receiving long-term systemic glucocorticoid therapy. Br J Dermatol 2011; 163:832-7. [PMID: 20518780 DOI: 10.1111/j.1365-2133.2010.09877.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Factors influencing adherence to long-term (i.e. ≥ 3 months) systemic glucocorticoid therapy are poorly understood. OBJECTIVE To evaluate the relationship between glucocorticoid-induced adverse events and therapeutic adherence in patients on long-term glucocorticoid treatment. METHODS A cross-sectional survey was conducted in three departments of dermatology/internal medicine between April and September 2008. Patients were asked to provide data regarding symptoms they attributed to glucocorticoids, and adherence to treatment was measured using the four-item Morisky-Green adherence scale. Logistic regression analyses were used to assess the association between reported adverse events and adherence to glucocorticoids. RESULTS A total of 255 questionnaires were completed and analysed [women 78%; median age 48 years (interquartile range (IQR) 34-65); connective tissue diseases 59%; median duration of treatment 24 months (IQR 8-72); median daily dose 10 mg (IQR 6-20)]. Among these 255 patients, 199 (78%) reported themselves as 'good adherents' and 56 (22%) as 'poor adherents' to treatment. Poor adherence was associated with younger age [odds ratio (OR) 0·97, 95% confidence interval (CI) 0·95-0·99, per increasing year; P < 0·01], presence of glucocorticoid-induced epigastralgia (OR 4·02, 95% CI 2·00-8·09; P < 0·01) and presence of glucocorticoid-induced morphological changes (OR 2·49, 95% CI 1·19-5·21; P = 0·02). Moreover, patients with poor adherence were likely to report concomitantly poor adherence to dietary advice associated with glucocorticoid therapy (OR 2·44, 95% CI 1·12-5·26; P = 0·02). CONCLUSIONS As with other chronic therapies, the presence of glucocorticoid-induced adverse events is associated with an altered self-reported adherence to glucocorticoids. Patients who report epigastric pain or morphological changes that they associate with glucocorticoid therapy are particularly at risk of poor adherence. Adherence to dietary advice associated with glucocorticoid therapy may be an indirect measure of treatment adherence.
Collapse
|
75
|
Medication persistence in the treatment of HIV infection: a review of the literature and implications for future clinical care and research. AIDS 2011; 25:279-90. [PMID: 21239892 DOI: 10.1097/qad.0b013e328340feb0] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Persistence, continuous treatment with a prescribed medication or intervention, is an important, but underrecognized aspect of medication treatment, especially for HIV. In contrast to adherence, which measures the percentage of patient behavior to a prescribed therapy, persistence measures the duration during which a patient remains on a prescribed therapy. Decreased persistence for HIV treatment, or shorter duration on therapy, is associated with increased rates of virological failure, development of antiretroviral resistance, and increased morbidity and mortality. Additionally, frequency and duration of nonpersistent episodes rather than adherence may be a better predictor of clinical outcomes in HIV-infected patients on certain regimens. In this review, we codify the constructs of persistence and adherence, and further define persistence as either patient or regimen persistence. Furthermore, current literature on the clinical consequences of and factors associated with suboptimal persistence is summarized. Finally, methods to measure persistence as well as interventions that may improve persistence and clinical outcomes are suggested.
Collapse
|
76
|
McMahon JH, Jordan MR, Kelley K, Bertagnolio S, Hong SY, Wanke CA, Lewin SR, Elliott JH. Pharmacy adherence measures to assess adherence to antiretroviral therapy: review of the literature and implications for treatment monitoring. Clin Infect Dis 2011; 52:493-506. [PMID: 21245156 DOI: 10.1093/cid/ciq167] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Prescription or pill-based methods for estimating adherence to antiretroviral therapy (ART), pharmacy adherence measures (PAMs), are objective estimates calculated from routinely collected pharmacy data. We conducted a literature review to evaluate PAMs, including their association with virological and other clinical outcomes, their efficacy compared with other adherence measures, and factors to consider when selecting a PAM to monitor adherence. PAMs were classified into 3 categories: medication possession ratio (MPR), pill count (PC), and pill pick-up (PPU). Data exist to recommend PAMs over self-reported adherence. PAMs consistently predicted patient outcomes, but additional studies are needed to determine the most predictive PAM parameters. Current evidence suggests that shorter duration of adherence assessment (≤ 6 months) and use of PAMs to predict future outcomes may be less accurate. PAMs which incorporate the number of days for which ART was prescribed without the counting of remnant pills, are reasonable minimum-resource methods to assess adherence to ART.
Collapse
Affiliation(s)
- James H McMahon
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston MA, USA.
| | | | | | | | | | | | | | | |
Collapse
|
77
|
Cost-effectiveness of antiretroviral regimens in the World Health Organization's treatment guidelines: a South African analysis. AIDS 2011; 25:211-20. [PMID: 21124202 DOI: 10.1097/qad.0b013e328340fdf8] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE the World Health Organization (WHO) recently changed its first-line antiretroviral treatment guidelines in resource-limited settings. The cost-effectiveness of the new guidelines is unknown. DESIGN comparative effectiveness and cost-effectiveness analysis using a model of HIV disease progression and treatment. METHODS using a simulation of HIV disease and treatment in South Africa, we compared the life expectancy, quality-adjusted life expectancy, lifetime costs, and cost-effectiveness of five initial regimens. Four are currently recommended by the WHO: tenofovir/lamivudine/efavirenz; tenofovir/lamivudine/nevirapine; zidovudine/lamivudine/efavirenz; and zidovudine/lamivudine/nevirapine. The fifth is the most common regimen in current use: stavudine/lamivudine/nevirapine. Virologic suppression and toxicities determine regimen effectiveness and cost-effectiveness. RESULTS choice of first-line regimen is associated with a difference of nearly 12 months of quality-adjusted life expectancy, from 135.2 months (tenofovir/lamivudine/efavirenz) to 123.7 months (stavudine/lamivudine/nevirapine). Stavudine/lamivudine/nevirapine is more costly and less effective than zidovudine/lamivudine/nevirapine. Initiating treatment with a regimen containing tenofovir/lamivudine/nevirapine is associated with an incremental cost-effectiveness ratio of $1045 per quality-adjusted life year compared with zidovudine/lamivudine/nevirapine. Using tenofovir/lamivudine/efavirenz was associated with the highest survival, fewest opportunistic diseases, lowest rate of regimen substitution, and an incremental cost-effectiveness ratio of $5949 per quality-adjusted life year gained compared with tenofovir/lamivudine/nevirapine. Zidovudine/lamivudine/efavirenz was more costly and less effective than tenofovir/lamivudine/nevirapine. Results were sensitive to the rates of toxicities and the disutility associated with each toxicity. CONCLUSION among the options recommended by WHO, we estimate only three should be considered under normal circumstances. Choice among those depends on available resources and willingness to pay. Stavudine/lamivudine/nevirapine is associated with the poorest quality-adjusted survival and higher costs than zidovudine/lamivudine/nevirapine.
Collapse
|
78
|
Mbuagbaw LC, Irlam JH, Spaulding A, Rutherford GW, Siegfried N. Efavirenz or nevirapine in three-drug combination therapy with two nucleoside-reverse transcriptase inhibitors for initial treatment of HIV infection in antiretroviral-naïve individuals. Cochrane Database Syst Rev 2010:CD004246. [PMID: 21154355 DOI: 10.1002/14651858.cd004246.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The advent of highly active antiretroviral therapy (HAART) has reduced the morbidity and mortality due to HIV. The World Health Organisation (WHO) antiretroviral treatment (ART) guidelines focus on three classes of antiretroviral drugs, namely: nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI) and protease inhibitors (PI). Two of the most common medications given in first-line treatment are the NNRTIs, efavirenz (EFV) and nevirapine (NVP). It is unclear which NNRTI is more efficacious for initial therapy. OBJECTIVES To determine which NNRTI, EFV or NVP, is more efficacious when given in combination with two NRTIs as part of initial ART for HIV infection in adults and children. SEARCH STRATEGY We used a comprehensive and exhaustive strategy in an attempt to identify all relevant studies, regardless of language or publication status, in electronic databases and conference proceedings from 1996 to 2009. SELECTION CRITERIA All randomised controlled trials comparing EFV to NVP in HIV-infected individuals without prior exposure to ART, irrespective of the dosage or NRTI backbone.The primary outcome of interest was virologic response to ART. Other primary outcomes included mortality, clinical progression, severe adverse events, and discontinuation of therapy for any reason. Secondary outcomes were immunologic response to ART, treatment failure, development of ART drug resistance, and prevention of sexual transmission of HIV. DATA COLLECTION AND ANALYSIS Two authors assessed each reference for inclusion and exclusion criteria established a priori. Data were abstracted independently using a standardised abstraction form. Data were analysed on an intention-to-treat basis and reported as per dosage of NVP. MAIN RESULTS We identified seven randomised controlled trials that met our inclusion criteria.The trials were pooled as per dosage of NVP. None of these trials included children.The seven trials enrolled 1,688 participants and found no critical differences between EFV and NVP, except for different toxicity profiles. EFV is more likely to cause central nervous system side-effects, while NVP is more likely to result in raised transaminases and neutropoenia. There was a higher mortality rate in the NVP 400mg once daily arm.The quality of literature to support these conclusions is moderate to high. Drug resistance was slightly less common with EFV than NVP, but the quality of this literature is low since only one of the seven studies reported on this outcome. No studies reported on sexual transmission of HIV. The length of follow-up time, study settings, and NRTI backbone varied greatly. AUTHORS' CONCLUSIONS Both drugs have equivalent efficacies in initial treatment of HIV infection when combined with two NRTIs, but different side effects.
Collapse
|
79
|
Lake JE, Currier JS. Switching antiretroviral therapy to minimize metabolic complications. ACTA ACUST UNITED AC 2010; 4:693-711. [PMID: 22171239 DOI: 10.2217/hiv.10.47] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Advances in HIV therapy have made living with HIV for decades a reality for many patients. However, antiretroviral therapy has been associated with multiple long-term complications, including dyslipidemia, fat redistribution, insulin resistance and increased cardiovascular risk. As newer agents with improved metabolic profiles have become available, there is growing interest in the safety and efficacy of switching ART as a strategy to reduce long-term complications. This article reviews recently published data on switching ART to minimize the contributions of specific agents to these complications.
Collapse
Affiliation(s)
- Jordan E Lake
- University of California Los Angeles, Division of Infectious Diseases, Center for Clinical AIDS Research, & Education, 9911 West Pico, Boulevard, Suite 980, Los Angeles, CA 90035, USA
| | | |
Collapse
|
80
|
Mother-to-child transmission (MTCT) of HIV and drugs of abuse in post-highly active antiretroviral therapy (HAART) era. J Neuroimmune Pharmacol 2010; 5:507-15. [PMID: 20838913 DOI: 10.1007/s11481-010-9242-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Accepted: 08/19/2010] [Indexed: 10/19/2022]
Abstract
In the pre-highly active antiretroviral therapy (HAART) era, prenatal "vertical" mother-to-child transmission (MTCT) of HIV was about 25% and exposure of pregnant mothers to drugs of abuse (illicit drugs and tobacco smoking) was a significant contributory factor of MTCT. However, with the introduction of HAART, the rate of MTCT of HIV has decreased to less that 2%. But, it is estimated that currently about 5.1% of pregnant women use illicit drugs and 16.4% smoke tobacco. The residual prevalence of MTCT is of concern and may be related to this continued prevalence of substance use among pregnant mothers. In this report, we review and present evidence that supports the hypothesis that drugs of abuse do have the potential to increase MTCT of HIV in the presence of HAART. Exposure to drugs of abuse during pregnancy may increase MTCT of HIV through a variety of mechanisms that are addressed in detail including possible damage to the placenta, induction of preterm birth, and increasing maternal plasma viral load though a variety of putative mechanisms such as: (a) promoting HIV replication in monocyte/macrophages; (b) increasing the expression of CCR5 receptors; (c) decreasing the expression of CCR5 receptor ligands; (d) increasing the expression of CXCR4 receptors; (e) increasing the expression of DC-SIGN; (f) impairing the efficacy of HAART through drug-drug interaction; and (g) promoting HIV mutation and replication through non-adherence to HAART.
Collapse
|
81
|
Braithwaite RS, Fiellin DA, Nucifora K, Bryant K, Roberts M, Kim N, Justice AC. Evaluating interventions to improve antiretroviral adherence: how much of an effect is required for favorable value? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:535-542. [PMID: 20345544 PMCID: PMC3032536 DOI: 10.1111/j.1524-4733.2010.00714.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Uncertainty about the value of antiretroviral therapy (ARV) adherence interventions may be a barrier to implementation and evaluation. Our objective is to estimate the minimum effectiveness required for ARV adherence interventions to deliver acceptable value. METHODS We used a validated HIV computer simulation to estimate the impact of ARV adherence interventions on incremental costs and life expectancy. Across a wide range of intervention costs ($1000-10,000, one time or per year), we estimated the smallest effect size compatible with acceptable value (incremental cost-effective ratio < or =$100,000 per life-year). Effect sizes were measured using relative risk (RR) and absolute risk reduction (ARR), and these metrics were applied to nonadherence and nonadherence risk factors. Costs were estimated from a societal perspective ($2003) discounted at 3%. RESULTS To give acceptable value, a one-time $1000 intervention must reduce ARV nonadherence by RR < or = 0.82 (ARR > or = 0.04) for moderately nonadherent patients (20% of ARV doses missed) and RR < or = 0.90 (ARR > or = 0.05) for severely nonadherent patients (50% of ARV doses missed). A one-time $5000 intervention has an unacceptable value regardless of effect size for moderately nonadherent patients, and must reduce ARV nonadherence by RR <or = 0.31 (ARR > or = 0.69) for severely nonadherent patients. Interventions aimed at behavioral risk factors (e.g., unhealthy alcohol use) may confer acceptable value (e.g., if < or = $2000 and effect RR < or = 0.71 [ARR > or = 0.29]). CONCLUSIONS ARV adherence interventions with plausible effect sizes may offer favorable value if they cost <$5000 one time or per year. ARV adherence interventions with a favorable value should become more integral components of HIV care.
Collapse
|
82
|
Breaux K, Gadde S, Graviss EA, Rodriguez-Barradas MC. One year survival of HIV-infected veterans with CD4 < 100 cells/mm3: data from a veteran cohort. AIDS Care 2010; 22:886-94. [DOI: 10.1080/09540120903499162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Katharine Breaux
- Department of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
| | | | | | | |
Collapse
|
83
|
Using mechanistic models to simulate comparative effectiveness trials of therapy and to estimate long-term outcomes in HIV care. Med Care 2010; 48:S90-5. [PMID: 20473184 DOI: 10.1097/mlr.0b013e3181e2b744] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND In HIV care, it is difficult to decide when to initiate therapy, which drugs to use for initial treatment, and which drugs to use if drug resistance develops. With hundreds of possible drug regimens available and variable patterns of drug resistance, randomized controlled trials cannot answer all HIV treatment decisions. Mechanistic models of HIV infection can be used to conduct virtual therapeutic trials with the goal of predicting outcomes, some of which are long-term and may not fall within the time frame of a typical therapeutic trial. METHODS We used a previously developed and validated model of HIV infection to replicate 2 arms of an HIV initial treatment trial (ACTG A5142) and predict long-term outcomes. The model incorporated data about biologic processes involved in the development of drug resistance. RESULTS The model reproduced the proportion that developed AIDS (0.04 and 0.05 for the efavirenz arm and lopinavir arms, respectively, vs. 0.04 and 0.06 for the trial), the development of virologic failure (0.27 and 0.33 for the Efavirenz arm and lopinavir arms, respectively, vs. 0.24 and 0.37 for the trial), and drug resistance. The hazard ratio for the time to treatment failure, a combination of resistance and other causes (0.96 for the model vs. 0.75 for the trial; 95% confidence interval, 0.57-0.98), and changes in CD4 cell count, were less accurate. The model estimated longer-term life expectancy, quality-adjusted life expectancy, and HIV-related deaths. CONCLUSIONS Mechanistic models of HIV infections have the potential to be useful in comparative effectiveness research.
Collapse
|
84
|
Wouters E, Van Loon F, Van Rensburg D, Meulemans H. State of the ART: clinical efficacy and improved quality of life in the public antiretroviral therapy program, Free State province, South Africa. AIDS Care 2010; 21:1401-11. [PMID: 20024717 DOI: 10.1080/09540120902884034] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The South African public-sector antiretroviral treatment (ART) program has yielded promising early results. To extend and reinforce these preliminary findings, we undertook a detailed assessment of the clinical efficacy and outcomes over two years of ART. The primary objective was to assess the clinical outcomes and adverse effects of two years of ART, while identifying the possible effects of baseline health and patient characteristics. A secondary objective was to address the interplay between positive and negative outcomes (clinical benefits versus adverse effects) in terms of the patients' physical and emotional quality of life (QoL). Clinical outcome, baseline characteristics, health status, and physical and emotional QoL scores were determined from clinical files and interviews with 268 patients enrolled in the Free State ART program at three time points (6, 12, and 24 months of ART). Age, sex, education, and baseline health (CD4 cell count and viral load) were all independently associated with the ART outcome in the early stages of treatment, but their impact diminished as the treatment progressed. The number of patients classified as treatment successes increased over the first two years of ART, whereas the proportion of patients experiencing adverse effects diminished. Importantly, our findings show that ART had strong and stable positive effects on physical and emotional QoL. These favorable results demonstrate that a well-managed public-sector ART program can be very successful within a high-HIV-prevalence resource-limited setting. This finding emphasizes the need to adopt treatment scale-up as a key policy priority, while at the same time ensuring that the highest standards of healthcare provision are maintained. Healthcare services should also target vulnerable groups (males, less-educated patients, those with low baseline CD4 cell counts, and high baseline viral loads) who are most likely to experience treatment failure.
Collapse
Affiliation(s)
- E Wouters
- Department of Sociology and Research Centre for Longitudinal and Life Course Studies, University of Antwerp, Antwerp, Belgium.
| | | | | | | |
Collapse
|
85
|
Ding H, Wilson CM, Modjarrad K, McGwin G, Tang J, Vermund SH. Predictors of suboptimal virologic response to highly active antiretroviral therapy among human immunodeficiency virus-infected adolescents: analyses of the reaching for excellence in adolescent care and health (REACH) project. ACTA ACUST UNITED AC 2010; 163:1100-5. [PMID: 19996046 DOI: 10.1001/archpediatrics.2009.204] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the prevalence and biopsychosocial predictors of suboptimal virologic response to highly active antiretroviral therapy (HAART) among human immunodeficiency virus-infected adolescents. DESIGN Population-based cohort study. SETTING Sixteen academic medical centers across 13 cities in the United States. PARTICIPANTS One hundred fifty-four human immunodeficiency virus-infected adolescents who presented for at least 2 consecutive visits after initiation of HAART. MAIN OUTCOME MEASURES Viral load (plasma concentration of human immunodeficiency virus RNA) and CD4(+) lymphocyte count. RESULTS Of the 154 adolescents enrolled in the study, 50 (32.5%) demonstrated early and sustained virologic suppression while receiving HAART. The remaining 104 adolescents (67.5%) had a poor virologic response. Adequate adherence (>50%)-reported by 70.8% of respondents-was associated with 60% reduced odds of suboptimal virologic suppression in a multivariable logistic regression model (adjusted odds ratio = 0.4; 95% confidence interval, 0.2-1.0). Exposure to suboptimal antiretroviral therapy prior to HAART, on the other hand, was associated with more than 2-fold increased odds of suboptimal virologic response (adjusted odds ratio = 2.6; 95% confidence interval, 1.1-5.7). CONCLUSIONS Fully two-thirds of human immunodeficiency virus-infected adolescents in the current study demonstrated a suboptimal virologic response to HAART. Nonadherence and prior single or dual antiretroviral therapy were associated with subsequent poor virologic responses to HAART. These predictors of HAART failure echo findings in pediatric and adult populations. Given the unique developmental stage of adolescence, age-specific interventions are indicated to address high rates of nonadherence and therapeutic failure.
Collapse
Affiliation(s)
- Helen Ding
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | | |
Collapse
|
86
|
Ballif M, Ledergerber B, Battegay M, Cavassini M, Bernasconi E, Schmid P, Hirschel B, Furrer H, Rickenbach M, Opravil M, Weber R. Impact of previous virological treatment failures and adherence on the outcome of antiretroviral therapy in 2007. PLoS One 2009; 4:e8275. [PMID: 20011544 PMCID: PMC2789943 DOI: 10.1371/journal.pone.0008275] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 11/20/2009] [Indexed: 11/19/2022] Open
Abstract
Background Combination antiretroviral treatment (cART) has been very successful, especially among selected patients in clinical trials. The aim of this study was to describe outcomes of cART on the population level in a large national cohort. Methods Characteristics of participants of the Swiss HIV Cohort Study on stable cART at two semiannual visits in 2007 were analyzed with respect to era of treatment initiation, number of previous virologically failed regimens and self reported adherence. Starting ART in the mono/dual era before HIV-1 RNA assays became available was counted as one failed regimen. Logistic regression was used to identify risk factors for virological failure between the two consecutive visits. Results Of 4541 patients 31.2% and 68.8% had initiated therapy in the mono/dual and cART era, respectively, and been on treatment for a median of 11.7 vs. 5.7 years. At visit 1 in 2007, the mean number of previous failed regimens was 3.2 vs. 0.5 and the viral load was undetectable (<50 copies/ml) in 84.6% vs. 89.1% of the participants, respectively. Adjusted odds ratios of a detectable viral load at visit 2 for participants from the mono/dual era with a history of 2 and 3, 4, >4 previous failures compared to 1 were 0.9 (95% CI 0.4–1.7), 0.8 (0.4–1.6), 1.6 (0.8–3.2), 3.3 (1.7–6.6) respectively, and 2.3 (1.1–4.8) for >2 missed cART doses during the last month, compared to perfect adherence. From the cART era, odds ratios with a history of 1, 2 and >2 previous failures compared to none were 1.8 (95% CI 1.3–2.5), 2.8 (1.7–4.5) and 7.8 (4.5–13.5), respectively, and 2.8 (1.6–4.8) for >2 missed cART doses during the last month, compared to perfect adherence. Conclusions A higher number of previous virologically failed regimens, and imperfect adherence to therapy were independent predictors of imminent virological failure.
Collapse
Affiliation(s)
- Marie Ballif
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bruno Ledergerber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, Basel, Switzerland
| | - Matthias Cavassini
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, Lausanne, Switzerland
| | - Enos Bernasconi
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital, Lugano, Switzerland
| | - Patrick Schmid
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital, St. Gallen, Switzerland
| | - Bernard Hirschel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, Geneva, Switzerland
| | - Hansjakob Furrer
- Division of Infectious Diseases, University Hospital Bern, and University of Bern, Bern, Switzerland
| | - Martin Rickenbach
- Swiss HIV Cohort Study, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Milos Opravil
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Rainer Weber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | |
Collapse
|
87
|
Cicconi P, Cozzi-Lepri A, Castagna A, Trecarichi EM, Antinori A, Gatti F, Cassola G, Sighinolfi L, Castelli P, d'Arminio Monforte A. Insights into reasons for discontinuation according to year of starting first regimen of highly active antiretroviral therapy in a cohort of antiretroviral-naïve patients. HIV Med 2009; 11:104-13. [PMID: 19732176 DOI: 10.1111/j.1468-1293.2009.00750.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of the study was to determine whether the incidence of first-line treatment discontinuations and their causes changed according to the time of starting highly active antiretroviral therapy (HAART) in an Italian cohort. METHODS We included in the study patients from the Italian COhort Naïve Antiretrovirals (ICoNA) who initiated HAART when naïve to antiretroviral therapy (ART). The endpoints were discontinuation within the first year of >or= 1 drug in the first HAART regimen for any reason, intolerance/toxicity, poor adherence, immunovirological/clinical failure and simplification. We investigated whether the time of starting HAART (stratified as 'early', 1997-1999; 'intermediate', 2000-2002; 'recent', 2003-2007) was associated with the probability of reaching the endpoints by a survival analysis. RESULTS Overall, the 1-year probability of discontinuation of >or= 1 drug in the first regimen was 36.1%. The main causes of discontinuation were intolerance/toxicity (696 of 1189 patients; 58.5%) and poor adherence (285 of 1189 patients; 24%). The hazards for all-reason change were comparable according to calendar period [2000-2002, adjusted relative hazard (ARH) 0.82, 95% confidence interval (CI) 0.69-0.98; 2003-2007, ARH 0.94, 95% CI 0.76-1.16, vs. 1997-1999; global P-value = 0.08]. Patients who started HAART during the 'recent' period were less likely to change their initial regimen because of intolerance/toxicity (ARH 0.67, 95% CI 0.51-0.89 vs. 'early' period). Patients who started in the 'intermediate' and 'recent' periods had a higher risk of discontinuation because of simplification (ARH 15.26, 95% CI 3.21-72.45, and ARH 37.97, 95% CI 7.56-190.64, vs. 'early' period, respectively). CONCLUSIONS It seems important to evaluate reason-specific trends in the incidence of discontinuation in order to better understand the determinants of changes over time. The incidence of discontinuation because of intolerance/toxicity has declined over time while simplification strategies have become more frequent in recent years. Intolerance/toxicity remains the major cause of drug discontinuation.
Collapse
Affiliation(s)
- Paola Cicconi
- Department of Infectious Diseases and Tropical Medicine, Università degli Strudi di Milano H. S. Paolo, Milan, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
88
|
Abstract
PURPOSE OF REVIEW To review the data that contribute to the debate on the optimal time to initiate highly active antiretroviral therapy in HIV-infected individuals, with a focus on the information that is available from cohort studies. RECENT FINDINGS The findings from cohort studies generally support initiation of highly active antiretroviral therapy at CD4 cell counts more than 350 cells/microl. In particular, the findings that death rates among treated HIV-infected individuals are higher than those in the general population, and that the risks of AIDS and serious non-AIDS events are higher in those with lower CD4 cell counts (even when the count remains >350 cells/microl), suggest that earlier initiation of highly active antiretroviral therapy may prevent some excess morbidity and mortality. However, given the lack of adjustment for lead-time bias in many analyses, the potential for residual confounding and the possible incomplete ascertainment of relevant outcomes in cohorts, it cannot be concluded that the benefits of highly active antiretroviral therapy when started at higher CD4 cell counts will outweigh the possible detrimental effects. SUMMARY Whereas the data from cohort studies currently support initiation of highly active antiretroviral therapy at CD4 cell counts more than 350 cells/microl, there is an urgent need for data from randomized trials to inform this decision.
Collapse
|
89
|
van den Berg-Wolf M, Hullsiek KH, Peng G, Kozal MJ, Novak RM, Chen L, Crane LR, Macarthur RD. Virologic, immunologic, clinical, safety, and resistance outcomes from a long-term comparison of efavirenz-based versus nevirapine-based antiretroviral regimens as initial therapy in HIV-1-infected persons. HIV CLINICAL TRIALS 2009; 9:324-36. [PMID: 18977721 DOI: 10.1310/hct0905-324] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To compare long-term virologic, immunologic, and clinical outcomes in antiretroviral-naïve persons starting efavirenz (EFV)- versus nevirapine (NVP)-based regimens. METHOD The FIRST study randomized patients into three strategy arms: PI+NRTI, NNRTI+NRTI, and PI+NNRTI+NRTI. NNRTI was determined by optional randomization (NVP or EFV) or by choice. For this randomized substudy, the primary endpoint was HIV RNA >50 copies/mL after 8 months or death. Genotypic resistance testing was done at virologic failure (VF; HIV RNA >1,000 copies/mL at or after 4 months). RESULTS 228 persons (111 randomized to EFV, 117 to NVP) were followed for median 5 years. Rates per 100 person years for the primary endpoint were 41.2 (EFV) and 42.8 (NVP; p = .59). The percent of persons with HIV RNA <50 copies/mL was similar throughout follow-up (p = .24), as were average increases in CD4+ cells (p = .30). 423 persons declining the substudy chose EFV; 264 chose NVP. There were 915 persons in the combined cohort (randomized and choice). In the combined cohort, the risk of VF and VF with any NNRTI or NRTI resistance or resistance of any class was significantly less for EFV compared to NVP. CONCLUSIONS EFV-based regimens as initial therapy resulted in a lower risk of VF and VF with resistance than did NVP-based regimens, although immunologic and clinical outcomes were similar.
Collapse
|
90
|
Braithwaite RS, Roberts MS, Goetz MB, Gibert CL, Rodriguez-Barradas MC, Nucifora K, Justice AC. Do benefits of earlier antiretroviral treatment initiation outweigh harms for individuals at risk for poor adherence? Clin Infect Dis 2009; 48:822-6. [PMID: 19210173 PMCID: PMC3032571 DOI: 10.1086/596768] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Clinicians may defer antiretroviral treatment for patients with suboptimal adherence. We used a validated computer simulation of HIV disease progression to compare alternative treatment thresholds for patients with suboptimal adherence. Earlier treatment increased life expectancy across a wide adherence range (50%-100% of doses taken). Delaying treatment for patients with suboptimal adherence may not always be appropriate.
Collapse
Affiliation(s)
- R Scott Braithwaite
- Department of Medicine, Section of General Internal Medicine, Yale University, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA.
| | | | | | | | | | | | | |
Collapse
|
91
|
Maartens G, Decloedt E, Cohen K. Effectiveness and safety of antiretrovirals with rifampicin: crucial issues for high-burden countries. Antivir Ther 2009; 14:1039-43. [DOI: 10.3851/imp1455] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
92
|
Does short-term virologic failure translate to clinical events in antiretroviral-naïve patients initiating antiretroviral therapy in clinical practice? AIDS 2008; 22:2481-92. [PMID: 19005271 DOI: 10.1097/qad.0b013e328318f130] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether differences in short-term virologic failure among commonly used antiretroviral therapy (ART) regimens translate to differences in clinical events in antiretroviral-naïve patients initiating ART. DESIGN Observational cohort study of patients initiating ART between January 2000 and December 2005. SETTING The Antiretroviral Therapy Cohort Collaboration (ART-CC) is a collaboration of 15 HIV cohort studies from Canada, Europe, and the United States. STUDY PARTICIPANTS A total of 13 546 antiretroviral-naïve HIV-positive patients initiating ART with efavirenz, nevirapine, lopinavir/ritonavir, nelfinavir, or abacavir as third drugs in combination with a zidovudine and lamivudine nucleoside reverse transcriptase inhibitor backbone. MAIN OUTCOME MEASURES Short-term (24-week) virologic failure (>500 copies/ml) and clinical events within 2 years of ART initiation (incident AIDS-defining event, death, and a composite measure of these two outcomes). RESULTS Compared with efavirenz as initial third drug, short-term virologic failure was more common with all other third drugs evaluated; nevirapine (adjusted odds ratio = 1.87, 95% confidence interval (CI) = 1.58-2.22), lopinavir/ritonavir (1.32, 95% CI = 1.12-1.57), nelfinavir (3.20, 95% CI = 2.74-3.74), and abacavir (2.13, 95% CI = 1.82-2.50). However, the rate of clinical events within 2 years of ART initiation appeared higher only with nevirapine (adjusted hazard ratio for composite outcome measure 1.27, 95% CI = 1.04-1.56) and abacavir (1.22, 95% CI = 1.00-1.48). CONCLUSION Among antiretroviral-naïve patients initiating therapy, between-ART regimen, differences in short-term virologic failure do not necessarily translate to differences in clinical outcomes. Our results should be interpreted with caution because of the possibility of residual confounding by indication.
Collapse
|
93
|
Impact of baseline health and community support on antiretroviral treatment outcomes in HIV patients in South Africa. AIDS 2008; 22:2545-8. [PMID: 19005281 DOI: 10.1097/qad.0b013e32831c5562] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The importance of community support when scaling-up antiretroviral treatment (ART) in resource-limited settings is poorly understood. We assessed the impact of baseline health, patient characteristics and community support on ART outcomes at 6 and 12 months in a representative sample of 268 patients enrolled in the Free State public sector ART program (South Africa). Delayed ART initiation reduced ART response, whereas support from treatment buddies, community health workers and support groups significantly improved treatment outcomes.
Collapse
|
94
|
Efavirenz versus nevirapine-based initial treatment of HIV infection: clinical and virological outcomes in Southern African adults. AIDS 2008; 22:2117-25. [PMID: 18832875 DOI: 10.1097/qad.0b013e328310407e] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the effectiveness of efavirenz versus nevirapine in initial antiretroviral therapy regimens for adults in sub-Saharan Africa. DESIGN Observational cohort study. METHODS Study participants were 2817 HIV-infected, highly active antiretroviral therapy-naive adults who began nevirapine-based or efavirenz-based highly active antiretroviral therapy between January 1998 and September 2004 via a private-sector HIV/AIDS program in nine countries of southern Africa. The primary outcome was time to virologic failure (two measurements of viral loads >or=400 copies/ml). Secondary outcomes included all-cause mortality, time to viral load less than 400 copies/ml, pharmacy-claim adherence, and discontinuation of nevirapine or efavirenz without virologic failure. RESULTS The median follow-up period was 2.0 years (interquartile range 1.2-2.6). Patients started on nevirapine were significantly less likely than those started on efavirenz to achieve high adherence, whether defined as 100% (30.2 versus 38.1%, P < 0.002) or more than 90% (44.8 versus 49.4%, P < 0.02) pharmacy-claim adherence. In a multivariate analysis, patients on nevirapine had greater risk of virologic failure [hazard ratio (HR 1.52; 95% confidence interval (CI) 1.24-1.86)], death (2.17; 1.31-3.60), and regimen discontinuation (1.67; 1.32-2.11). Switching from nevirapine to efavirenz had no significant virologic effect, whereas switching from efavirenz to nevirapine resulted in significantly slower time to suppression (hazard ratio 0.58, 95% confidence interval 0.35-0.93) and faster time to failure (hazard ratio 3.92; 95% confidence interval 1.61-9.55) than remaining on efavirenz. CONCLUSION In initial highly active antiretroviral therapy regimens, efavirenz was associated with superior virologic and clinical outcomes than nevirapine, suggesting that efavirenz might be the preferred nonnucleoside reverse transcriptase inhibitor in resource-limited settings. However, its higher cost and potential teratogenicity are important barriers to implementation.
Collapse
|
95
|
Geretti AM, Smith C, Haberl A, Garcia-Diaz A, Nebbia G, Johnson M, Phillips A, Staszewski S. Determinants of Virological Failure after Successful Viral Load Suppression in First-Line Highly Active Antiretroviral Therapy. Antivir Ther 2008. [DOI: 10.1177/135965350801300707] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We aimed to investigate the long-term virological outcomes of a cohort initially showing good responses to first-line highly active antiretroviral therapy (HAART) with no evidence of virological failure during the first year after achieving viral load (VL) undetectability (<50 copies/ml). Methods Virological failure was defined as a confirmed VL>400 copies/ml or a single VL>400 copies/ml followed by a treatment change or end of follow-up. Risk factors for low-level VL rebound (50–400 copies/ml) in the first year after achieving undetectability and for virological failure during subsequent follow-up were investigated by logistic and Poisson regression. Results In the first year after achieving VL undetectability, 354/1,386 (25.5%) patients experienced low-level VL rebound, the remaining patients maintained consistent undetectability. Low-level rebound occurred less commonly with non-nucleoside reverse transcriptase inhibitor (NNRTI)-based HAART than with other regimens ( P=0.01). Over median 2.2 (range 0.0–7.4) years of subsequent follow-up, 86 (6.2%) patients experienced virological failure, corresponding to 2.30 failures per 100 person-years (95% confidence interval [CI] 1.82–2.79). Independent predictors of virological failure included low-level rebound during the first year after achieving undetectability relative to consistent undetectability (rate ratio [RR] 2.18, 95% CI 1.15–4.10), female gender (RR 1.79, 95% CI 1.12–2.85) and receiving a ritonavir-boosted protease inhibitor (PI/r) relative to NNRTI-based HAART (RR 1.88, 95% CI 1.02–3.46). Conclusions Patients on first-line HAART who maintain consistent VL undetectability for 1 year have a low risk of subsequent virological failure. A subset might benefit from targeted interventions, including women and patients on PI/r-based HAART.
Collapse
Affiliation(s)
- Anna M Geretti
- Royal Free and University College Medical School, London, UK
| | - Colette Smith
- Royal Free and University College Medical School, London, UK
| | - Annette Haberl
- Johann Wolfgang Goethe University Hospital, Frankfurt, Germany
| | - Ana Garcia-Diaz
- Royal Free and University College Medical School, London, UK
| | - Gaia Nebbia
- Royal Free and University College Medical School, London, UK
| | | | - Andrew Phillips
- Royal Free and University College Medical School, London, UK
| | | |
Collapse
|
96
|
Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet 2008; 372:293-9. [PMID: 18657708 PMCID: PMC3130543 DOI: 10.1016/s0140-6736(08)61113-7] [Citation(s) in RCA: 1255] [Impact Index Per Article: 78.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Combination antiretroviral therapy has led to significant increases in survival and quality of life, but at a population-level the effect on life expectancy is not well understood. Our objective was to compare changes in mortality and life expectancy among HIV-positive individuals on combination antiretroviral therapy. METHODS The Antiretroviral Therapy Cohort Collaboration is a multinational collaboration of HIV cohort studies in Europe and North America. Patients were included in this analysis if they were aged 16 years or over and antiretroviral-naive when initiating combination therapy. We constructed abridged life tables to estimate life expectancies for individuals on combination antiretroviral therapy in 1996-99, 2000-02, and 2003-05, and stratified by sex, baseline CD4 cell count, and history of injecting drug use. The average number of years remaining to be lived by those treated with combination antiretroviral therapy at 20 and 35 years of age was estimated. Potential years of life lost from 20 to 64 years of age and crude mortality rates were also calculated. FINDINGS 18 587, 13 914, and 10 854 eligible patients initiated combination antiretroviral therapy in 1996-99, 2000-02, and 2003-05, respectively. 2056 (4.7%) deaths were observed during the study period, with crude mortality rates decreasing from 16.3 deaths per 1000 person-years in 1996-99 to 10.0 deaths per 1000 person-years in 2003-05. Potential years of life lost per 1000 person-years also decreased over the same time, from 366 to 189 years. Life expectancy at age 20 years increased from 36.1 (SE 0.6) years to 49.4 (0.5) years. Women had higher life expectancies than did men. Patients with presumed transmission via injecting drug use had lower life expectancies than did those from other transmission groups (32.6 [1.1] years vs 44.7 [0.3] years in 2003-05). Life expectancy was lower in patients with lower baseline CD4 cell counts than in those with higher baseline counts (32.4 [1.1] years for CD4 cell counts below 100 cells per muL vs 50.4 [0.4] years for counts of 200 cells per muL or more). INTERPRETATION Life expectancy in HIV-infected patients treated with combination antiretroviral therapy increased between 1996 and 2005, although there is considerable variability between subgroups of patients. The average number of years remaining to be lived at age 20 years was about two-thirds of that in the general population in these countries.
Collapse
|
97
|
Vo TTN, Ledergerber B, Keiser O, Hirschel B, Furrer H, Battegay M, Cavassini M, Bernasconi E, Vernazza P, Weber R. Durability and outcome of initial antiretroviral treatments received during 2000--2005 by patients in the Swiss HIV Cohort Study. J Infect Dis 2008; 197:1685-94. [PMID: 18513155 DOI: 10.1086/588141] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Little is known about time trends, predictors, and consequences of changes made to antiretroviral therapy (ART) regimens early after patients initially start treatment. METHODS We compared the incidence of, reasons for, and predictors of treatment change within 1 year after starting combination ART (cART), as well as virological and immunological outcomes at 1 year, among 1866 patients from the Swiss HIV Cohort Study who initiated cART during 2000--2001, 2002--2003, or 2004--2005. RESULTS The durability of initial regimens did not improve over time (P = .15): 48.8% of 625 patients during 2000--2001, 43.8% of 607 during 2002--2003, and 44.3% of 634 during 2004--2005 changed cART within 1 year; reasons for change included intolerance (51.1% of all patients), patient wish (15.4%), physician decision (14.8%), and virological failure (7.1%). An increased probability of treatment change was associated with larger CD4+ cell counts, larger human immunodeficiency virus type 1 (HIV-1) RNA loads, and receipt of regimens that contained stavudine or indinavir/ritonavir, but a decreased probability was associated with receipt of regimens that contained tenofovir. Treatment discontinuation was associated with larger CD4+ cell counts, current use of injection drugs, and receipt of regimens that contained nevirapine. One-year outcomes improved between 2000--2001 and 2004--2005: 84.5% and 92.7% of patients, respectively, reached HIV-1 RNA loads of <50 copies/mL and achieved median increases in CD4+ cell counts of 157.5 and 197.5 cells/microL, respectively (P < .001 for all comparisons). CONCLUSIONS Virological and immunological outcomes of initial treatments improved between 2000--2001 and 2004--2005, irrespective of uniformly high rates of early changes in treatment across the 3 study intervals.
Collapse
|
98
|
Braithwaite RS, Conigliaro J, McGinnis KA, Maisto SA, Bryant K, Justice AC. Adjusting alcohol quantity for mean consumption and intoxication threshold improves prediction of nonadherence in HIV patients and HIV-negative controls. Alcohol Clin Exp Res 2008; 32:1645-51. [PMID: 18616666 DOI: 10.1111/j.1530-0277.2008.00732.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Screening for hazardous drinking may fail to detect a substantial proportion of individuals harmed by alcohol. We investigated whether considering an individual's usual drinking quantity or threshold for alcohol-induced cognitive impairment improves the prediction of nonadherence with prescribed medications. METHOD Cross-sectional analysis of participants in a large, multi-site cohort study. We used the timeline followback to reconstruct 30-day retrospective drinking histories and the timeline followback modified for adherence to reconstruct 30-day medication adherence histories among 3,152 individuals in the Veterans Aging Cohort Study, 1,529 HIV infected and 1,623 uninfected controls. We categorized daily alcohol consumption by using quantity alone, quantity after adjustment for the individual's mean daily alcohol consumption, and self-reported level of impairment corresponding to each quantity. A standard drink was defined as 14 g of ethanol. Nonadherence was defined as the proportion of days with > or =1 medication doses missed or taken > or =2 hours late, and clinically significant nonadherence was defined as > or =5% absolute increase in the proportion of days with nonadherence. RESULTS The mean adjusted- and impairment-based methods showed greater discrimination of nonadherence risk compared to the measure based on quantity alone (quantity-based categorization, 3.2-fold increase; quantity adjusted for mean daily consumption, 4.6-fold increase, impairment-based categorization, 3.6-fold increase). The individualized methods also detected greater numbers of days with clinically significant nonadherence associated with alcohol. Alcohol was associated with clinically significant nonadherence at a lower threshold for HIV infected versus uninfected patients (2 standard drinks vs. 4 standard drinks) using quantity-based categorization, but this difference was no longer apparent when individualized methods were used. CONCLUSIONS Tailoring screening questions to an individual's usual level of alcohol consumption or threshold for impairment improves the ability to predict alcohol-associated medication nonadherence.
Collapse
Affiliation(s)
- R Scott Braithwaite
- Department of Medicine, Section of General Internal Medicine, Yale University School of Medicine and Connecticut Veterans Administration Medical Center, West Haven, Connecticut 06516, USA.
| | | | | | | | | | | |
Collapse
|
99
|
Abstract
This article provides an overview and reviews the HIV pandemic, the basic biology and immunology of the virus (e.g., genetic diversity of HIV and the viral life cycle), the phases of disease progression, modes of HIV transmission, HIV testing, immune response to the infection, and current therapeutic strategies. HIV is occurring in epidemic proportions, especially in Sub-Saharan Africa. In the US, men who have sex with men account for over half of AIDS diagnoses; racial and ethnic minorities are disproportionally affected. Factors influencing the progression and severity of HIV infection include type of immune response, coinfection (e.g., another sexually transmitted infection, including hepatitis B or C), age and behavioral and psychosocial factors. Antiretroviral therapies can achieve reduction in blood levels of the HIV virus below the limits of detection by current technology. However, effective treatment requires adherence to therapy. Patient failure to adhere to treatment regimens results in detectible circulating virus and in HIV disease progression, and is the primary cause of drug resistance. In addition to research on the immunology and virology of the disease, other studies focus on behavioral and psychosocial factors that may affect medication adherence and risk behaviors.
Collapse
|
100
|
Comparison of genotypic resistance profiles and virological response between patients starting nevirapine and efavirenz in EuroSIDA. AIDS 2008; 22:367-76. [PMID: 18195563 DOI: 10.1097/qad.0b013e3282f3cc35] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare virological outcome and genotypic resistance profiles in HIV-1-infected patients starting non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing regimens. METHODS NNRTI-naive patients were included who started treatment with nevirapine (NVP) or efavirenz (EFV) with genotypic resistance test results available at time of initiation (baseline). Virological failure was defined as two consecutive values > 500 copies/ml after starting the regimen. Cox models were used to investigate time to virological failure (the first of two values). RESULTS A total of 759 patients were included (13% antiretroviral-naive): 389 initiated NVP and 370 initiated EFV. Baseline IAS-USA NNRTI resistance mutations were detected in 3%. Using the Rega algorithm (version 7.1) to interpret resistance, 460 (64%) patients had resistance (full or intermediate) to at least one drug they were starting (69% NVP, 60% EFV, P = 0.011); 287 (74%) NVP and 168 (45%) EFV patients experienced virological failure after treatment initiation, P < 0.001. After adjustment for previous antiretroviral use, previous AIDS, year started NNRTI, CD4 cell count (baseline, nadir), viral load (baseline, maximum), and baseline drug resistance (measured by Rega), the relative hazards (EFV versus NVP) of virological failure was 0.50, 95% confidence interval: 0.39-0.65, P < 0.001. At time of virological failure, comparable levels of NNRTI resistance were detected. The K103N mutation emerged more in patients failing EFV and Y181C in patients failing NVP. CONCLUSIONS NVP may be associated with an inferior virological outcome compared to EFV in NNRTI-naive patients with extensive resistance to other drug classes. The profile of NNRTI resistance mutations when virologically failing an NNRTI-containing regimen appears to depend on the NNRTI the patients fail.
Collapse
|