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Santos MA, Guimarães MDC, Helena ETS, Basso CR, Vale FC, Carvalho WMDES, Alves AM, Rocha GM, Acurcio FDA, Ceccato MDGB, do Prado RR, Menezes PR, Nemes MIB. Monitoring self-reported adherence to antiretroviral therapy in public HIV care facilities in Brazil: A national cross-sectional study. Medicine (Baltimore) 2018; 97:S38-S45. [PMID: 29912815 PMCID: PMC5991539 DOI: 10.1097/md.0000000000009015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Patient adherence to antiretroviral therapy (ART) is critical for HIV treatment success. Monitoring rates of adherence in public HIV outpatient care facilities can improve outcomes in Brazil where ART is universally available. METHODS We conducted a national cross-sectional survey of ART adherence in 2010. Participants were selected using a multistage probability sample. First, HIV outpatient care facilities were stratified according to 7 Organizational Quality Classification (OQC) groups and regions. Second, 1 or 2 facilities were selected per region for each OQC group. Finally, patients were randomly selected at each facility. In a first component, patients were invited to answer to a web-based questionnaire (WebAd-Q), a validated self-reported tool that includes 3 questions on adherence to ART in the past 7 days (time scheduling-timing, drug regimen-medication, and pill counts-dose), herein named indicators of potential nonadherence (IPN). In addition, a subsample of participants were interviewed in order to obtain further data on sociodemographic and clinical characteristics (second component). The proportion of each IPN was estimated using weighted data to account for the sampling design with 95% confidence interval (CI) and descriptive analysis was carried out. RESULTS Fifty-five facilities were chosen and 2424 patients completed the WebAd-Q in the first component of the study, while 598 patients were interviewed for the second component. The weighted proportions of the IPN were 50.9%, 31.8%, and 19.5%, for timing, medication, and dose, respectively, while11.7% had all 3 indicators, varying from 5.9% in the Southeast and 21.9% in the Northeast regions. Overall, 61.1% of the patients had at least 1 IPN (95% CI: 58.5-63.7%). Patients reporting depression symptoms, illicit drug use and those who missed medical appointments had worse nonadherence outcomes. CONCLUSIONS Overall, there was a high proportion of all indicators IPN and timing was the main component associated with low adherence. Although these indicators may not necessarily indicate individual nonadherence, they represent a worrisome scenario in the public Brazilian HIV care facilities. On a routine basis, these facilities can identify gaps in providing counseling and ART orientation to their clientele and develop innovative strategies to prevent nonadherence.
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Affiliation(s)
- Maria Altenfelder Santos
- Faculty of Medicine of University of Sao Paulo, Department of Preventive Medicine, São Paulo, São Paulo
| | | | | | - Cáritas Relva Basso
- Faculty of Medicine of University of Sao Paulo, Department of Preventive Medicine, São Paulo, São Paulo
| | - Felipe Campos Vale
- Faculty of Medicine of University of Sao Paulo, Department of Preventive Medicine, São Paulo, São Paulo
| | | | - Ana Maroso Alves
- Faculty of Medicine of University of Sao Paulo, Department of Preventive Medicine, São Paulo, São Paulo
| | | | | | | | | | - Paulo Rossi Menezes
- Faculty of Medicine of University of Sao Paulo, Department of Preventive Medicine, São Paulo, São Paulo
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Abstract
Antiretroviral therapy (ART) is a combination treatment involving three or more antiretroviral agents for patients with HIV. ART has reduced HIV-related morbidity and mortality via single-tablet or multiple-tablet regimens. Single-tablet regimens, with their lower pill burdens, have demonstrated higher adherence rates, improved viral suppression, and reduced resource use compared with multiple-tablet regimens. In addition, select newer ARTs do not require the high levels of adherence for viral load suppression required by older ART formulations.
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Harris RA, Haberer JE, Musinguzi N, Chang KM, Schechter CB, Doubeni CA, Gross R. Predicting short-term interruptions of antiretroviral therapy from summary adherence data: Development and test of a probability model. PLoS One 2018; 13:e0194713. [PMID: 29566096 PMCID: PMC5864044 DOI: 10.1371/journal.pone.0194713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/08/2018] [Indexed: 11/18/2022] Open
Abstract
Antiretroviral therapy (ART) for HIV is vulnerable to unplanned treatment interruptions-consecutively missed doses over a series of days-which can result in virologic rebound. Yet clinicians lack a simple, valid method for estimating the risk of interruptions. If the likelihood of ART interruption could be derived from a convenient-to-gather summary measure of medication adherence, it might be a valuable tool for both clinical decision-making and research. We constructed an a priori probability model of ART interruption based on average adherence and tested its predictions using data collected on 185 HIV-infected, treatment-naïve individuals over the first 90 days of ART in a prospective cohort study in Mbarara, Uganda. The outcome of interest was the presence or absence of a treatment gap, defined as >72 hours without a dose. Using the pre-determined value of 0.50 probability as the cut point for predicting an interruption, the classification accuracy of the model was 73% (95% CI = 66%- 79%), the specificity was 87% (95% CI = 79%- 93%), and the sensitivity was 59% (95% CI = 48%- 69%). Overall model performance was satisfactory, with an area under the receiver operator characteristic curve (AUROC) of 0.85 (95% CI = 0.80-0.91) and Brier score of 0.20. The study serves as proof-of-concept that the probability model can accurately differentiate patients on the continuum of risk for short-term ART interruptions using a summary measure of adherence. The model may also aid in the design of targeted interventions.
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Affiliation(s)
- Rebecca Arden Harris
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Jessica E. Haberer
- Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | | | - Kyong-Mi Chang
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
- Philadelphia VA Medical Center, Philadelphia, Pennsylvania, United States of America
| | - Clyde B. Schechter
- Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Chyke A. Doubeni
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Robert Gross
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
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54
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McCoy C, Badowski M, Sherman E, Crutchley R, Smith E, Chastain DB. Strength in Amalgamation: Newer Combination Agents for HIV and Implications for Practice. Pharmacotherapy 2017; 38:86-107. [PMID: 29105160 DOI: 10.1002/phar.2055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antiretroviral (ART) therapy for the treatment of human immunodeficiency virus (HIV) infection has undergone significant changes over the past 30 years. Many single-tablet regimens (STRs), including newer fixed-dose combination (FDC) tablets, are available, offering patients several options for choosing a treatment regimen that works best for them. Given these changes, patients are more likely to adhere to treatment, achieve better clinical outcomes, and experience both fewer side effects and drug-drug interactions. Newer STRs include dolutegravir (DTG)/lamivudine (3TC)/abacavir (ABC) (Triumeq; Viiv Healthcare, Research Triangle Park, NC), rilpivirine (RPV)/emtricitabine (FTC)/tenofovir alafenamide (TAF) (Odefsey; Gilead, Foster City, CA), RPV/FTC/tenofovir disoproxil fumarate (TDF) (Complera; Gilead), elvitegravir (EVG)/cobicistat (COBI)/FTC/TDF (Stribild; Gilead), and EVG/COBI/FTC/TAF (Genvoya; Gilead). Recently approved FDCs, such as atazanavir (ATV)/COBI (Evotaz; Bristol-Myers Squibb, Princeton, NJ), darunavir (DRV)/COBI (Prezcobix; Janssen Products, Titusville NJ), and FTC/TAF (Descovy; Gilead), are also now available. The Department of Health and Human Services treatment guidelines for HIV recommend many of these integrase strand transfer inhibitor (INSTI) STRs as a preferred choice for initiation of treatment in both ART-naive and -experienced patients because they offer comparably faster rates of virologic suppression, reduced rates of resistance development (especially with DTG), and overall better adherence than protease inhibitors or NNRTIs. Numerous phase 3 clinical trials support these recommendations including several switch or simplification clinical trials. Notably, the novel pharmacokinetic booster COBI, with its water soluble properties, has enabled the development and coformulation of a few of these STRs and FDCs. Also, a newer tenofovir salt formulation, TAF, has an advantageous pharmacokinetic profile, contributing to better overall renal and bone tolerability compared with TDF. Further simplification regimens comprising dual ART therapies are currently being explored. This review provides an overview of the clinical efficacy and safety data for these coformulated agents, highlighting the relative impact on comparative adverse events, assessing the potential for experiencing fewer drug-drug interactions, and discussing the clinical implications regarding adherence to treatment.
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Affiliation(s)
- Christopher McCoy
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Melissa Badowski
- Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois
| | - Elizabeth Sherman
- Department of Pharmacy Practice, Nova Southeastern University, Fort Lauderdale, Florida
| | - Rustin Crutchley
- Department of Pharmacotherapy, Washington State University, College of Pharmacy, Yakima, Washington
| | - Ethan Smith
- Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia
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55
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Li L, Luo S, Lan CW, Lin C, Tuan LA, Feng N, Tuan NA. Alcohol Use, HIV Treatment Adherence, and Sexual Risk Among People with a History of Injecting Drug Use in Vietnam. AIDS Behav 2017; 21:167-173. [PMID: 28726041 DOI: 10.1007/s10461-017-1860-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Alcohol use can limit the effectiveness of antiretroviral therapy (ART) for people living with HIV (PLH) who have a history of injecting drug use. This study described the patterns of alcohol use among PLH with a history of injecting drug use in Vietnam and examined the relationships between alcohol use, adherence to ART, and sexual risks. We utilized cross-sectional data of 109 PLH on ART collected from a randomized controlled intervention trial in Vietnam. Approximately 30 and 46% of the participants were frequent and occasional drinkers, respectively. Frequent drinkers reported the highest number of missed medication days. About 61% of frequent drinkers reported having sex after using alcohol. Additionally, 23, 34, and 24% of nondrinkers, occasional drinkers, and frequent drinkers, respectively, reported inconsistent condom use during sex. Future intervention programs should address the issues of alcohol use and sexual risks to maximize the effectiveness of HIV treatment programs in Vietnam.
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Abstract
PURPOSE OF REVIEW Current HIV treatment options require daily use of combination antiretroviral drugs. Many persons living with HIV experience treatment fatigue and suboptimal adherence as a result. Long-acting antiretroviral drugs are being developed to expand options for HIV treatment. Here, we review the agents in development, and evaluate data from recent clinical trials. In addition, we anticipate challenges to successful widespread use of long-acting antiretrovirals. RECENT FINDINGS Parenteral nanosuspensions of cabotegravir and rilpivirine, and dapivirine vaginal ring are the farthest in clinical development. Long-acting modalities in earlier development stages employ drug-loaded implants, microparticles, or targeted mutagenesis, among other innovations. Long-acting antiretroviral drugs promise new options for HIV prevention and treatment, and ways to address poor adherence and treatment fatigue. Further studies will identify the long-acting agents or combinations that are suitable for routine use. Creative solutions will be needed for anticipated implementation challenges.
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Affiliation(s)
- Amesika N Nyaku
- Division of Infectious Diseases, Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Sean G Kelly
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Babafemi O Taiwo
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine & Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA.
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57
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Gellad WF, Thorpe CT, Steiner JF, Voils CI. The myths of medication adherence. Pharmacoepidemiol Drug Saf 2017; 26:1437-1441. [PMID: 28994158 DOI: 10.1002/pds.4334] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/24/2017] [Accepted: 09/11/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Walid F Gellad
- Division of General Medicine and Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - John F Steiner
- Institute for Health Research, Kaiser Permanente, Denver, CO, USA
| | - Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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58
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Gutierrez-Valencia A, Benmarzouk-Hidalgo OJ, Llaves S, Fernandez-Magdaleno T, Espinosa N, Viciana P, Lopez-Cortes LF. Pharmacokinetic interactions between cobicistat-boosted elvitegravir and darunavir in HIV-infected patients. J Antimicrob Chemother 2017; 72:816-819. [PMID: 27999051 DOI: 10.1093/jac/dkw487] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/10/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives To evaluate if there are significant drug-drug interactions between cobicistat-boosted elvitegravir and 800 mg darunavir once daily taken simultaneously, as has been suggested previously. Methods The study population consisted of three groups of unselected volunteers taking a regimen of elvitegravir, cobicistat, emtricitabine and tenofovir disoproxil fumarate (150, 150, 200 and 300 mg, respectively) co-formulated in a single tablet plus 800 mg darunavir (group A); only co-formulated elvitegravir, cobicistat, emtricitabine and tenofovir disoproxil fumarate (group B); and cobicistat-boosted darunavir (800 mg darunavir + 150 mg cobicistat) plus two nucleos(t)ide analogues (group C). Elvitegravir, cobicistat and darunavir concentrations at the end of the dosing interval ( C 24 ) were quantified using a validated LC with tandem MS method. Results A total of 170 samples were obtained from 24, 32 and 32 patients in groups A, B and C, respectively. In group A, the elvitegravir C 24 were similar to those in group B (233.67 versus 250.39 ng/mL) ( P = 0.406) and the darunavir C 24 were similar to those in group C (1293.54 versus 1319.34 ng/mL) ( P = 0.908). The cobicistat C 24 were comparable in groups A and B (20.2 versus 20.9 ng/mL) and slightly higher in group C (27.7 ng/mL) ( P = 0.059). Conclusions The results provide evidence of similar elvitegravir and darunavir C 24 concentrations when these drugs are co-administered as co-formulated elvitegravir, cobicistat, emtricitabine and tenofovir disoproxil fumarate plus 800 mg darunavir or dosed separately.
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59
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Cook RL, Zhou Z, Kelso-Chichetto NE, Janelle J, Morano JP, Somboonwit C, Carter W, Ibanez GE, Ennis N, Cook CL, Cohen RA, Brumback B, Bryant K. Alcohol consumption patterns and HIV viral suppression among persons receiving HIV care in Florida: an observational study. Addict Sci Clin Pract 2017; 12:22. [PMID: 28950912 PMCID: PMC5615807 DOI: 10.1186/s13722-017-0090-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/18/2017] [Indexed: 01/25/2023] Open
Abstract
Background Alcohol consumption has been associated with poor antiretroviral therapy (ART) adherence but less is known about its relationship to HIV viral suppression, or whether certain drinking patterns have a stronger association than others. The objectives of this study were to determine the association of different patterns of alcohol consumption to HIV viral suppression and ART adherence, and to determine whether any associations of alcohol with HIV viral suppression were mediated by poor ART adherence. Methods This observational study used baseline data from 619 HIV+ participants, recruited across 8 clinical and community settings across Florida as part of the Florida Cohort from 2014 to 2016. Alcohol consumption was measured by self-report, and grouped into four categories: heavy drinking (>7/week for women or >14 drinks/week for men); binge, but not heavy drinking (≥4 or >5 drinks/occasion for women and men, respectively), low level drinking (neither heavy nor binge), and abstinence. Serum HIV RNA measurements were obtained from statewide HIV surveillance data, and durable viral suppression was defined as achieving HIV viral suppression (<200 copies/ml) at every assessment in the past 12 months. Results The majority of the 619 participants were male (63%) and aged 45 or greater (65%). The proportion of participants with heavy, binge, low-level drinking and abstinence was 9, 25, 37 and 30%, respectively. Optimal ART adherence (≥95%) was reported by 68%, and 60% achieved durable viral suppression. In multivariable analysis controlling for demographic factors, drug use, and homelessness, heavy drinking (compared to abstinence) was associated with increased odds of failing to achieve durable viral suppression (OR 2.16, 95% CI 1.08–4.32) whereas binge drinking alone was not significantly associated with this outcome (OR 1.04, 95% CI 0.64–1.70). Both heavy drinking and binge drinking were significantly associated with suboptimal ART adherence. Mediation analyses suggested that only a small proportion of the relationship between heavy drinking and suboptimal viral suppression was due to poor ART adherence. Conclusions Exceeding weekly recommended levels of alcohol consumption (heavy drinking) was significantly associated with poor HIV viral suppression and ART non-adherence, while binge drinking was associated with suboptimal ART adherence in this sample. Clinicians should attempt to address heavy drinking in their patients with HIV.
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Affiliation(s)
- R L Cook
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, PO Box 100231, Gainesville, FL, 32610, USA.
| | - Z Zhou
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, PO Box 100231, Gainesville, FL, 32610, USA
| | - N E Kelso-Chichetto
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, PO Box 100231, Gainesville, FL, 32610, USA
| | - J Janelle
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, PO Box 100231, Gainesville, FL, 32610, USA.,Department of Medicine, University of Florida, Gainesville, FL, USA
| | - J P Morano
- Division of Infectious Diseases and International Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - C Somboonwit
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - W Carter
- Florida Department of Health, Orange County Office of Clinical Services, Disease Investigation and Research, Orlando, FL, USA
| | - G E Ibanez
- Department of Epidemiology, Florida International University, Miami, FL, USA
| | - N Ennis
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - C L Cook
- Department of Family, Community, and Health System Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - R A Cohen
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - B Brumback
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - K Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
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Spratt ES, Papa CE, Mueller M, Patel S, Killeen T, Maher E, Drayton C, Dixon TC, Fowler SL, Treiber F. Using Technology to Improve Adherence to HIV Medications in Transitional Age Youth: Research Reviewed, Methods Tried, Lessons Learned. JOURNAL OF GENERAL MEDICINE (DOVER, DEL.) 2017; 1:1002. [PMID: 30345429 PMCID: PMC6195351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In transitional age youth living with HIV or AIDS, non-adherence (<80%) to anti-retroviral medication is associated with viral resistance, disease progression, and an increased risk of death. This feasibility study investigated the Maya MedMinder electronic pillbox and cell phone texting with personalized motivational interviewing strategies to improve medication adherence in non-adherent youth. Twenty patients out of 30 identified as non-adherent by the Pediatric HIV team at the Medical University of South Carolina were approached, and 15 were recruited (Ages 12 to 20; 13.3% male, 86.7% female; 100% African-American). Following baseline MedMinder monitoring, subjects were randomized to intervention groups with reminder signals on or off. The time medications were taken was collected by the MedMinder, resulting in adherence scores. All were interviewed for readiness to change utilizing the Motivational Interviewing (MI) Stages of Change scores. Viral load and CD4 labs were scheduled every 6 weeks. Despite monetary incentives and personalized support, recruitment and adherence to the protocol was a challenge. Only 6/15 subjects completed the entire study scheduled for 6-months .Stages of change scores revealed that those that transitioned to making changes had higher CD4 percentages midway through the study. Challenges included missed appointments and labs despite efforts by text and phone to schedule convenient appointment times with participants. Device challenges included the large size of the MedMinder and faulty electronic signaling, especially from rural areas. The methodology was feasible with these patients. This small feasibility study highlights that technological tools to promote adherence and motivational enhancement strategies in teens and young adults who are non-adherent to HIV medication regimens can enhance biomarker outcomes associated with medication adherence.
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Affiliation(s)
- E S Spratt
- Department of Pediatrics, Medical University of South Carolina, USA
| | - C E Papa
- Department of Pediatrics, Medical University of South Carolina, USA
| | - M Mueller
- College of Nursing, Medical University of South Carolina, USA
| | - S Patel
- Technology Applications Center for Healthful Lifestyles, Medical University of South Carolina, USA
| | - T Killeen
- Department of Psychiatry, Medical University of South Carolina, USA
| | - E Maher
- Department of Medicine, University of North Carolina, USA
| | - C Drayton
- Department of Pediatrics, Medical University of South Carolina, USA
| | - T C Dixon
- Department of Pediatrics, Medical University of South Carolina, USA
| | - S L Fowler
- Department of Pediatrics, Medical University of South Carolina, USA
| | - F Treiber
- College of Nursing, Medical University of South Carolina, USA
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Byrd KK, Bush T, Gardner LI. Do Persons Living with HIV Continue to Fill Prescriptions for Antiretroviral Drugs during a Gap in Care? Analysis of a Large Commercial Claims Database. J Int Assoc Provid AIDS Care 2017; 16:632-638. [PMID: 28899258 DOI: 10.1177/2325957417729750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The significance of a gap in HIV care depends, at least partially, on whether patients continue to fill prescriptions for antiretroviral (ARV) drugs during the gap in care. We used a billing claims database to determine the proportion of persons who filled ≥1 prescription for ARV drugs during a gap in care (no clinic visit in >6 months). Persons were stratified into 3 groups: "never" (prescriptions never filled), "sometimes" (prescriptions filled >0%-<100% of months), and "always" (prescriptions filled monthly). Logistic regression analyses were conducted to determine factors associated with "never" filling ARV drugs. Of 14 308 persons, 69% (n = 9817), 13% (n = 1928), and 18% (n = 2563) "never," "sometimes," and "always" filled ARV drugs during the gap in care. Persons aged 18 to 29 years (odds ratio [OR] = 1.56, 95% confidence interval [CI] 1.39-1.74), women (OR = 1.67, CI 1.52-1.83), and persons from the Northeast region of the United States (OR = 1.86, CI 1.69-2.03) were more likely to never fill ARV drugs than persons aged ≥30 years, men, and persons outside the Northeast, respectively. Efforts should be made to minimize gaps in care, emphasize importance of therapy, and provide adherence support.
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Affiliation(s)
- Kathy K Byrd
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tim Bush
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lytt I Gardner
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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62
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Yager J, Faragon J, McGuey L, Hoye-Simek A, Hecox Z, Sullivan S, Neubert S, Patel N. Relationship Between Single Tablet Antiretroviral Regimen and Adherence to Antiretroviral and Non-Antiretroviral Medications Among Veterans' Affairs Patients with Human Immunodeficiency Virus. AIDS Patient Care STDS 2017; 31:370-376. [PMID: 28771023 DOI: 10.1089/apc.2017.0081] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Several antiretrovirals (ART) have been coformulated as single tablet regimens (STR). Study objectives were to compare ART and non-ART adherence between STR and multiple tablet regimens (MTR) recipients, determine whether STR independently predicts ART adherence, and determine whether ART adherence influences non-ART adherence. A retrospective cohort study was performed among Upstate New York Veterans' Healthcare Administration (VISN-2) patients from 2000 to 2013. Inclusion criteria were age ≥18 years, human immunodeficiency virus (HIV) infection, receipt of ≥3 ART medications for ≥3 months, and available pharmacy refill records. The two study outcomes were adherence to ART medications and non-ART medications. Adherence was determined with pharmacy refill records that were used to calculate medication possession ratios. Among the 1202 subjects, there were 165 (13.7%) STR and 1037 (86.3%) MTR recipients. Mean ± standard deviation (SD) ART adherence was significantly higher for STR recipients (81.5% ± 15.3%) than MTR recipients (66.1% ± 21.1%), p < 0.001. Use of STR [adjusted odds ratio (aOR): 5.76, 95% confidence interval (CI): 3.84-8.65, p < 0.001] was independently associated with optimal (≥90%) adherence to ART. Mean ± SD non-ART adherence did not differ between STR (78.8% ± 15.6%) and MTR recipients (80.8% ± 16.0%), p = 0.17. Optimal adherence to ART medications (aOR: 2.30, 95% CI: 1.57-3.38, p < 0.001) was independently associated with optimal adherence to non-ART medications. The use of STRs are associated with optimal adherence to ART medications, but not directly associated with adherence to non-ART medications.
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Affiliation(s)
- Jenna Yager
- Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, Albany, New York
| | - John Faragon
- Departments of Pharmacy and Medicine, Albany Medical Center Hospital, Albany, New York
| | - Liam McGuey
- Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, Albany, New York
| | - Adam Hoye-Simek
- Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, Albany, New York
| | - Zachary Hecox
- Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, Albany, New York
| | - Steven Sullivan
- Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, Albany, New York
| | - Stefanie Neubert
- Division of Infectious Diseases, Samuel S. Stratton Veterans' Affairs Medical Center, Albany, New York
| | - Nimish Patel
- Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, Albany, New York
- Division of Infectious Diseases, Samuel S. Stratton Veterans' Affairs Medical Center, Albany, New York
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Blashill AJ, Safren SA, Wilhelm S, Jampel J, Taylor SW, O'Cleirigh C, Mayer KH. Cognitive behavioral therapy for body image and self-care (CBT-BISC) in sexual minority men living with HIV: A randomized controlled trial. Health Psychol 2017; 36:937-946. [PMID: 28541068 DOI: 10.1037/hea0000505] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Body image disturbance is a distressing and interfering problem among many sexual minority men living with HIV, and is associated with elevated depressive symptoms and poor HIV self-care (e.g., antiretroviral therapy [ART] nonadherence). The current study tested the preliminary efficacy of a newly created intervention: cognitive-behavioral therapy for body image and self-care (CBT-BISC) for this population. METHOD The current study entailed a 2-arm randomized controlled trial (N = 44) comparing CBT-BISC to an enhanced treatment as usual (ETAU) condition. Analyses were conducted at 3 and 6 months after baseline. The primary outcome was body image disturbance (BDD-YBOCS), and secondary outcomes were ART adherence (electronically monitored via Wisepill), depressive symptoms (MADRS), and global functioning (GAF). RESULTS At 3 months, the CBT-BISC condition showed substantial improvement in BDD-YBOCS (b = -13.6, SE = 2.7, 95% CI [-19.0, -8.3], p < .001; dppc2 = 2.39); MADRS (b = -4.9, SE = 2.8, 95% CI [-10.6, .70], p = .086; dppc2 = .87); ART adherence (b = 8.8, SE = 3.3, 95% CI [2.0, 15.6], p = .01; dppc2 = .94); and GAF (b = 12.3, SE = 3.2, 95% CI [6.1, 18.6], p < .001; dppc2 = 2.91) compared with the ETAU condition. Results were generally maintained, or improved, at 6 months; although, adherence findings were mixed depending on the calculation method. CONCLUSIONS CBT-BISC shows preliminary efficacy in the integrated treatment of body image disturbance and HIV self-care behaviors among sexual minority men living with HIV. (PsycINFO Database Record
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Sutton SS, Magagnoli J, Hardin JW. Odds of Viral Suppression by Single-Tablet Regimens, Multiple-Tablet Regimens, and Adherence Level in HIV/AIDS Patients Receiving Antiretroviral Therapy. Pharmacotherapy 2017; 37:204-213. [PMID: 28028855 DOI: 10.1002/phar.1889] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE To evaluate the odds of achieving viral suppression in human immunodeficiency virus (HIV) patients using antiretroviral therapy as a single-tablet regimen (STR) or multiple-tablet regimen (MTR). DESIGN Retrospective cohort study. DATA SOURCES South Carolina Medicaid medical and pharmacy paid claims data were obtained from the South Carolina Revenue and Fiscal Affairs Office; laboratory data were obtained from the South Carolina Department of Health and Environmental Control. PATIENTS A total of 1536 patients who were dispensed a complete STR (477 patients) or MTR (1059 patients) regimen lasting at least 60 days between January 1, 2006, and December 31, 2013. MEASUREMENTS AND MAIN RESULTS The analysis examined adherence levels and regimen type on odds of viral load suppression. Regimen adherence levels (90-94%, 85-89%, 80-84%, and less than 80%) were compared with the gold standard adherence for HIV of 95% or greater. Patients were followed from index date until the earliest date of regimen discontinuation, treatment switch, end of study period, last date of eligibility, or death. Differences in outcomes were evaluated by χ2 , Wilcoxon rank sum statistical tests, and multivariate regression models controlling for covariates. For STR regimens we find that, when compared with 95% or greater adherence, there is no statistical difference in the odds of viral suppression with adherence levels greater than or equal to 80%. However, adherence levels greater than or equal to 95% were associated with a greater odds of viral suppression when compared with less than 80% STR adherence (odds ratio [OR] 2.57, Dunnett 95% confidence interval [CI] 1.04-6.32). For MTR regimens, there was no statistical difference in the odds of viral suppression for the adherence level 90-94% compared with the 95% or greater adherence (OR 3.59, Dunnett 95% CI 0.805-16.043). However, the 95% or greater adherence has greater odds of viral suppression compared with all other MTR adherence levels. In addition, no difference was found in the odds of viral suppression between STR and MTR for all adherence levels. CONCLUSIONS Compared with 95% or greater adherence, STR regimens achieve viral suppression with adherence levels of 80% or greater, whereas MTR regimens require adherence levels of 90% or greater to achieve viral suppression in South Carolina Medicaid patients with HIV/AIDS.
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Affiliation(s)
- S Scott Sutton
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Joseph Magagnoli
- Health and Demographics, South Carolina Revenue and Fiscal Affairs Office, Columbia, South Carolina
| | - James W Hardin
- Department of Epidemiology & Biostatistics, University of South Carolina, Columbia, South Carolina
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Boretzki J, Wolf E, Wiese C, Noe S, Balogh A, Meurer A, Krznaric I, Zink A, Lersch C, Spinner CD. Highly specific reasons for nonadherence to antiretroviral therapy: results from the German adherence study. Patient Prefer Adherence 2017; 11:1897-1906. [PMID: 29184394 PMCID: PMC5687417 DOI: 10.2147/ppa.s141762] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Reasons for and frequency of nonadherence to antiretroviral therapy (ART) may have changed due to pharmacological improvements. In addition, the importance of known non-pharmacologic reasons for nonadherence is unclear. METHODS We performed a cross-sectional, noninterventional, multicenter study to identify current reasons for nonadherence. Patients were categorized by physicians into the following adherence groups: good, unstable, or poor adherence. Co-variables of interest included age, sex, time since HIV diagnosis, ART duration, current ART regimen, HIV transmission route, comorbidity, HIV-1 RNA viral load (VL), and CD4 cell count. Patients self-reported the number of missed doses and provided their specific reasons for nonadherent behavior. Statistical analyses were performed using Fisher's extended exact test, Kruskal-Wallis test, and logistic regression models. RESULTS Our study assessed 215 participants with good (n=162), unstable (n=36), and poor adherence (n=17). Compared to patients with good adherence, patients with unstable and poor adherence reported more often to have missed at least one dose during the last week (good 11% vs unstable 47% vs poor 63%, p<0.001). Physicians' adherence assessment was concordant with patients' self-reports of missed doses during the last week (no vs one or more) in 81% cases. Similarly, we found a strong association of physicians' assessment with viral suppression. Logistic regression analysis showed that "reduced adherence" - defined as unstable or poor - was significantly associated with patients <30 years old, intravenous drug use, history of acquired immune deficiency syndrome (AIDS), and psychiatric disorders (p<0.05). Univariate analyses showed that specific reasons, such as questioning the efficacy/dosing of ART, HIV stigma, interactive toxicity beliefs regarding alcohol and/or party drugs, and dissatisfaction with regimen complexity, correlated with unstable or poor adherence (p<0.05). CONCLUSION Identification of factors associated with poor adherence helps in identifying patients with a higher risk for nonadherence. Reasons for nonadherence should be directly addressed in every patient, because they are common and constitute possible adherence intervention points.
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Affiliation(s)
- Johanna Boretzki
- Department of Medicine II, University Hospital Klinikum rechts der Isar, Munich
- German Center for Infection Research, Partner Site Munich
- Correspondence: Johanna Boretzki, Department of Medicine II, University Hospital Klinikum rechts der Isar, Ismaninger Street 22, 81675 Munich, Germany, Tel +49 89 4140 5236, Fax +49 89 4140 7555, Email
| | | | - Carmen Wiese
- MVZ Karlsplatz, HIV Clinical Care Center, Munich
| | | | | | - Anja Meurer
- Center for Infectiology and Internal Medicine, Munich
| | | | - Alexander Zink
- Department of Dermatology and Allergology, University Hospital Klinikum rechts der Isar, Munich, Germany
| | - Christian Lersch
- Department of Medicine II, University Hospital Klinikum rechts der Isar, Munich
| | - Christoph D Spinner
- Department of Medicine II, University Hospital Klinikum rechts der Isar, Munich
- German Center for Infection Research, Partner Site Munich
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Beer L, Bradley H, Mattson CL, Johnson CH, Hoots B, Shouse RL. Trends in Racial and Ethnic Disparities in Antiretroviral Therapy Prescription and Viral Suppression in the United States, 2009-2013. J Acquir Immune Defic Syndr 2016; 73:446-453. [PMID: 27391389 PMCID: PMC5085853 DOI: 10.1097/qai.0000000000001125] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To examine trends in racial/ethnic disparities in antiretroviral therapy (ART) prescription and viral suppression among HIV-infected persons in care, overall and among men who have sex with men (MSM), from 2009 to 2013. DESIGN The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States. METHODS We used weighted interview and medical record data collected June 2009-May 2014 to estimate the prevalence of ART prescription and viral suppression among racial/ethnic groups overall and among MSM. RESULTS We found significant increases in ART prescription and viral suppression among all racial/ethnic groups from 2009 to 2013, both overall and among MSM. By 2013, overall and among MSM, the Hispanic-white disparity in ART prescription was nonexistent, and the black-white disparity was not significant after accounting for differences between blacks and whites in age and length of HIV diagnosis. Despite reductions in racial/ethnic disparities in viral suppression over the time period, significant disparities remained among the total population, even after adjusting for differences in racial/ethnic group characteristics. Encouragingly, however, there was no significant Hispanic-white disparity in viral suppression among MSM by 2013. CONCLUSIONS Despite significant improvements in ART prescription and viral suppression in recent years, racial and ethnic disparities persist, particularly for black persons. If the United States is to achieve the National HIV/AIDS Strategy goal of reducing HIV-related health disparities, continued efforts to accelerate the rate of improvement in ART prescription and viral suppression among Hispanic and black persons may need to be prioritized.
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Affiliation(s)
- Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Heather Bradley
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christine L. Mattson
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christopher H. Johnson
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brooke Hoots
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - R. Luke Shouse
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Castillo-Mancilla JR, Brown TT, Erlandson KM, Palella FJ, Gardner EM, Macatangay BJC, Breen EC, Jacobson LP, Anderson PL, Wada NI. Suboptimal Adherence to Combination Antiretroviral Therapy Is Associated With Higher Levels of Inflammation Despite HIV Suppression. Clin Infect Dis 2016; 63:1661-1667. [PMID: 27660234 DOI: 10.1093/cid/ciw650] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/12/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected individuals exhibit residual inflammation regardless of virologic suppression. We evaluated whether suboptimal adherence to combination antiretroviral therapy (cART) is associated with greater residual inflammation than optimal adherence, despite virologic suppression. METHODS Longitudinal self-reported cART adherence data and serum concentrations of 24 biomarkers of inflammation and immune activation were measured at the same study visit in HIV RNA-suppressed (<50 copies/mL) HIV-infected men in the Multicenter AIDS Cohort Study from 1998 to 2009. Associations between dichotomized 6-month (<100% vs 100%) and categorized 4-day (<85%, 85%-99%, and 100%) cART adherence with biomarker concentrations were evaluated. RESULTS A total of 912 men provided 2816 person-visits with documented plasma HIV RNA suppression. In adjusted models, person-visits at which <100% cART 6-month adherence was reported had higher concentrations of interleukin 2, 6, and 10, interferon γ, tumor necrosis factor α, and C-reactive protein than person-visits at which 100% cART adherence (P < .05) was reported. These same differences were observed in person-visits reporting <85% versus 100% 4-day cART adherence, but not in visits reporting 85%-99% versus 100% cART adherence. After adjustment for multiple comparisons, tumor necrosis factor α remained significantly higher (11% increase; P < .001) in person-visits at which <100% adherence was reported. CONCLUSIONS Higher concentrations of inflammatory biomarkers were observed among HIV RNA-suppressed men who reported <100% cART adherence than among more adherent men. Residual HIV replication (ie, below the limit of detection), more likely among men with suboptimal adherence, is a plausible mechanism. Whether improving cART adherence could affect residual inflammation and associated morbidity and mortality rates should be investigated.
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Affiliation(s)
| | - Todd T Brown
- Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine
| | | | - Frank J Palella
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Bernard J C Macatangay
- Division of Infectious Diseases/HIV/AIDS Unit, University of Pittsburgh School of Medicine, Pennsylvania
| | - Elizabeth C Breen
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA, University of California, Los Angeles
| | - Lisa P Jacobson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Nikolas I Wada
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Park LS, Tate JP, Sigel K, Rimland D, Crothers K, Gibert C, Rodriguez-Barradas MC, Goetz MB, Bedimo RJ, Brown ST, Justice AC, Dubrow R. Time trends in cancer incidence in persons living with HIV/AIDS in the antiretroviral therapy era: 1997-2012. AIDS 2016; 30:1795-806. [PMID: 27064994 PMCID: PMC4925286 DOI: 10.1097/qad.0000000000001112] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Utilizing the Veterans Aging Cohort Study, the largest HIV cohort in North America, we conducted one of the few comprehensive comparisons of cancer incidence time trends in HIV-infected (HIV+) versus uninfected persons during the antiretroviral therapy (ART) era. DESIGN Prospective cohort study. METHODS We followed 44 787 HIV+ and 96 852 demographically matched uninfected persons during 1997-2012. We calculated age-, sex-, and race/ethnicity-standardized incidence rates and incidence rate ratios (IRR, HIV+ versus uninfected) over four calendar periods with incidence rate and IRR period trend P values for cancer groupings and specific cancer types. RESULTS We observed 3714 incident cancer diagnoses in HIV+ and 5760 in uninfected persons. The HIV+ all-cancer crude incidence rate increased between 1997-2000 and 2009-2012 (P trend = 0.0019). However, after standardization, we observed highly significant HIV+ incidence rate declines for all cancer (25% decline; P trend <0.0001), AIDS-defining cancers (55% decline; P trend <0.0001), nonAIDS-defining cancers (NADC; 15% decline; P trend = 0.0003), and nonvirus-related NADC (20% decline; P trend <0.0001); significant IRR declines for all cancer (from 2.0 to 1.6; P trend <0.0001), AIDS-defining cancers (from 19 to 5.5; P trend <0.0001), and nonvirus-related NADC (from 1.4 to 1.2; P trend = 0.049); and borderline significant IRR declines for NADC (from 1.6 to 1.4; P trend = 0.078) and virus-related NADC (from 4.9 to 3.5; P trend = 0.071). CONCLUSION Improved HIV care resulting in improved immune function most likely contributed to the HIV+ incidence rate and the IRR declines. Further promotion of early and sustained ART, improved ART regimens, reduction of traditional cancer risk factor (e.g. smoking) prevalence, and evidence-based screening could contribute to future cancer incidence declines among HIV+ persons.
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Affiliation(s)
| | - Janet P. Tate
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Yale School of Medicine, New Haven, CT
| | - Keith Sigel
- Icahn School of Medicine at Mt. Sinai, New York, NY
| | - David Rimland
- Atlanta Veterans Affairs Medical Center, Atlanta, GA; Emory University School of Medicine, Atlanta, GA
| | | | - Cynthia Gibert
- Washington DC Veterans Affairs Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Roger J. Bedimo
- Veterans Affairs North Texas Healthcare System, Dallas, TX; University of Texas Southwestern Medical Center, Dallas, TX
| | - Sheldon T. Brown
- Icahn School of Medicine at Mt. Sinai, New York, NY
- James J. Peters Veterans Affairs Medical Center, New York, NY
| | - Amy C. Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Yale School of Medicine, New Haven, CT
| | - Robert Dubrow
- Yale School of Medicine, New Haven, CT
- Yale School of Public Health, New Haven, CT
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Scott Sutton S, Magagnoli J, Hardin JW. Impact of Pill Burden on Adherence, Risk of Hospitalization, and Viral Suppression in Patients with HIV Infection and AIDS Receiving Antiretroviral Therapy. Pharmacotherapy 2016; 36:385-401. [PMID: 26923931 DOI: 10.1002/phar.1728] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
STUDY OBJECTIVE To evaluate the impact of pill burden on outcomes in patients with human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) receiving antiretroviral therapy (ART) as a single-tablet regimen (STR) or multiple-tablet regimen (MTR). DESIGN Retrospective cohort study. DATA SOURCES South Carolina Medicaid medical and pharmacy paid claims data were obtained from the South Carolina Revenue and Fiscal Affairs Office; laboratory data were obtained from the South Carolina Department of Health and Environmental Control. PATIENTS A total of 2174 patients covered by South Carolina Medicaid who were dispensed a complete ART STR (580 patients) or MTR (1594 patients) lasting at least 60 days between January 1, 2006, and December 31, 2013. MEASUREMENTS AND MAIN RESULTS Outcomes were ART adherence; risk of, time to, and total number of hospitalizations; and viral load suppression. Patients were followed from the index date (start date of their complete ART regimen) until the earliest date of one of the following: treatment discontinuation; treatment switch from MTR to STR, or vice versa; end of study period; last date of Medicaid eligibility; or death. Differences in outcomes were evaluated by using bivariate χ(2) and Wilcoxon rank sum tests, as well as multivariate regression models controlling for covariates measured during a 6-month baseline period. The STR and MTR cohorts were, on average, similar in terms of age at index date, Charlson Comorbidity Index score, sex, drug abuse, and mental health diagnoses, but they differed significantly in racial composition, index year of regimen, previous treatment, baseline viral load, and CD4 measures. The bivariate analysis revealed that the STR cohort was more adherent (p<0.0001), had a lower risk of hospitalization (p=0.0076), and had a higher proportion of patients with viral suppression (64.5% vs 49.5%, p<0.0001). In addition, multivariate regression models revealed that the STR cohort was more adherent and was associated with a lower risk of hospitalization (hazard ratio 0.71, 95% confidence interval 0.59-0.86), but no significant difference in viral load suppression was noted between the STR and MTR cohorts. CONCLUSION The STR was associated with higher adherence rates and a lower risk of hospitalization (both in the adjusted and unadjusted analyses) in South Carolina Medicaid patients with HIV infection and AIDS. A higher proportion of patients in the STR cohort had viral suppression during the follow-up period in the unadjusted analysis compared with the MTR cohort; however, no significant difference in viral suppression was observed when controlling for adherence.
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Affiliation(s)
- S Scott Sutton
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, South Carolina College of Pharmacy, Columbia, South Carolina
| | - Joseph Magagnoli
- Health and Demographics, South Carolina Revenue and Fiscal Affairs Office, Columbia, South Carolina
| | - James W Hardin
- Department of Epidemiology & Biostatistics, University of South Carolina, Columbia, South Carolina
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Bezabhe WM, Chalmers L, Bereznicki LR, Peterson GM. Adherence to Antiretroviral Therapy and Virologic Failure: A Meta-Analysis. Medicine (Baltimore) 2016; 95:e3361. [PMID: 27082595 PMCID: PMC4839839 DOI: 10.1097/md.0000000000003361] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The often cited need to achieve ≥95% (nearly perfect) adherence to antiretroviral therapy (ART) for successful virologic outcomes in HIV may present a barrier to initiation of therapy in the early stages of HIV. This meta-analysis synthesized 43 studies (27,905 participants) performed across >26 countries, to determine the relationship between cut-off point for optimal adherence to ART and virologic outcomes. Meta-analysis was performed using a random-effect model to calculate pooled odds ratios with corresponding 95% confidence intervals. The mean rate of patients reporting optimal adherence was 63.4%. Compared with suboptimal adherence, optimal adherence was associated with a lower risk of virologic failure (0.34; 95% CI: 0.26-0.44). There were no significant differences in the pooled odds ratios among different optimal adherence thresholds (≥98-100%, ≥95%, ≥80-90%). Study design (randomized controlled trial vs observational study) (regression coefficient 0.74, 95% CI: 0.04-1.43, P < 0.05) and study region (developing vs developed countries; regression coefficient 0.56, 95% CI: 0.01-1.12, P < 0.05) remained as independent predictors of between-study heterogeneity, with more patients with optimal adherence from developing countries or randomized controlled trials experiencing virologic failure. The threshold for optimal adherence to achieve better virologic outcomes appears to be wider than the commonly used cut-off point (≥95% adherence). The cut-off point for optimal adherence could be redefined to a slightly lower level to encourage the prescribing ART at an early stage of HIV infection.
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Pellowski JA, Kalichman SC, Kalichman MO, Cherry C. Alcohol-antiretroviral therapy interactive toxicity beliefs and daily medication adherence and alcohol use among people living with HIV. AIDS Care 2016; 28:963-70. [PMID: 26964014 DOI: 10.1080/09540121.2016.1154134] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Alcohol-antiretroviral therapy (ART) interactive toxicity beliefs reflect perceived adverse outcomes of mixing alcohol and ART. Previous research has shown a significant relationship between alcohol-ART interactive toxicity beliefs and ART non-adherence, over and above other correlates of non-adherence such as human immunodeficiency virus (HIV)symptoms and frequency of alcohol use. Most past studies have collected data over extended periods and have not determined if alcohol use and missed medications occur at the day-level among people holding interactive toxicity beliefs. Previous daily analyses, however, have been limited by self-reported adherence and relatively short periods of observation. To address these gaps in the literature, men and women living with HIV in Atlanta, GA, were enrolled in a 45-day observational cohort study. Daily alcohol use was collected using two-way interactive text message surveys and daily adherence was collected via the Wisepill device. Fifty-seven participants completed a measure of alcohol-ART interactive toxicity beliefs and contributed 2565 days of daily data. Participants who endorsed high levels of interactive toxicity beliefs had significantly more days when they missed doses of medication. Alcohol-antiretroviral toxicity beliefs predicted missing doses of medication on days when participants were drinking and on days when they were not drinking. Multilevel multivariate regressions showed that these toxicity beliefs predicted daily missed doses of medication over and above quantity of alcohol consumed, depression and general medication concerns. This study replicates and extends previous literature and indicates the necessity of addressing alcohol-ART toxicity beliefs within adherence interventions.
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Affiliation(s)
- Jennifer A Pellowski
- a Department of Psychiatry and Human Behavior , The Warren Alpert Medical School of Brown University , Providence , RI , USA
| | - Seth C Kalichman
- b Department of Psychology , University of Connecticut , Storrs , CT , USA
| | - Moira O Kalichman
- b Department of Psychology , University of Connecticut , Storrs , CT , USA
| | - Chauncey Cherry
- b Department of Psychology , University of Connecticut , Storrs , CT , USA
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Pasternak AO, de Bruin M, Bakker M, Berkhout B, Prins JM. High Current CD4+ T Cell Count Predicts Suboptimal Adherence to Antiretroviral Therapy. PLoS One 2015; 10:e0140791. [PMID: 26468956 PMCID: PMC4607457 DOI: 10.1371/journal.pone.0140791] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 09/30/2015] [Indexed: 11/18/2022] Open
Abstract
High levels of adherence to antiretroviral therapy (ART) are necessary for achieving and maintaining optimal virological suppression, as suboptimal adherence leads to therapy failure and disease progression. It is well known that adherence to ART predicts therapy response, but it is unclear whether clinical outcomes of ART predict adherence. To examine the predictive power of current CD4+ T cell count for adherence of HIV-infected individuals to ART, we performed a cross-sectional analysis of 133 Dutch HIV patients with electronically measured adherence. In a multivariate analysis adjusting for a number of sociodemographic and clinical variables, high current CD4+ T cell count (>660 cells/mm3) was most strongly associated with lower adherence to ART (assessed as a continuous variable) during a two-month period immediately following the measurements of variables (P = 0.008). The twice-per-day (versus once-per-day) dosing regimen was also significantly associated with lower adherence (P = 0.014). In a second multivariate analysis aimed at determining the predictors of suboptimal (<100% of the doses taken) adherence, high current CD4+ T cell count was again the strongest independent predictor of suboptimal adherence to ART (P = 0.015), and the twice-per-day dosing regimen remained associated with suboptimal adherence (P = 0.025). The association between suboptimal adherence and virological suppression was significant in patients with high CD4+ T cell counts, but not in patients with low or intermediate CD4+ T cell counts (P = 0.036 and P = 0.52, respectively; P = 0.047 for comparison of the effects of adherence on virological suppression between patients with high vs. low or intermediate CD4+ T cell counts), suggesting that apart from promoting suboptimal adherence, high CD4+ T cell count also strengthens the effect of adherence on virological suppression. Therefore, sustained efforts to emphasize continued adherence are necessary, especially for patients with high CD4+ T cell counts.
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Affiliation(s)
- Alexander O. Pasternak
- Laboratory of Experimental Virology, Department of Medical Microbiology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | - Marijn de Bruin
- Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Margreet Bakker
- Laboratory of Experimental Virology, Department of Medical Microbiology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands
| | - Ben Berkhout
- Laboratory of Experimental Virology, Department of Medical Microbiology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands
| | - Jan M. Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands
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Peng S, Tafazzoli A, Dorman E, Rosenblatt L, Villasis-Keever A, Sorensen S. Cost-effectiveness of DTG + ABC/3TC versus EFV/TDF/FTC for first-line treatment of HIV-1 in the United States. J Med Econ 2015; 18:763-76. [PMID: 25934146 DOI: 10.3111/13696998.2015.1046878] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Data from the SINGLE trial demonstrated that 88% of treatment-naïve HIV-1 patients treated with dolutegravir and abacavir/lamivudine (DTG + ABC/3TC) achieved viral suppression at 48 weeks compared with 81% of patients treated with efavirenz/tenofovir disoproxil fumarate/emtricitabine (EFV/TDF/FTC). It is unclear how this difference in short-term efficacy impacts long-term cost-effectiveness of these regimens. This study sought to evaluate long-term cost-effectiveness of DTG + ABC/3TC vs EFV/TDF/FTC from a US payer perspective. METHODS This study is an individual discrete-event simulation which tracked the disease status and treatment pathway of HIV-1 patients. The model simulated treatment over a lifetime horizon by tracking change in patients' CD4 count, clinical events occurrence (opportunistic infections, cancer, and cardiovascular events), treatment switch, and death. The model included up to four lines of treatment. Baseline patient characteristics, efficacy, and safety of DTG + ABC/3TC and EFV/TDF/FTC were informed by data from the SINGLE trial. The efficacy of subsequent treatment lines, clinical event risks, mortality, cost, and utility inputs were based on literature and expert opinion. Outcomes were lifetime discounted medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). RESULTS Compared with EFV/TDF/FTC, DTG + ABC/3TC increased lifetime costs by $19,153 and per person survival by 0.12 QALYs, resulting in an ICER of $158,890/QALY. ICERs comparing DTG + ABC/3TC to EFV/TDF/FTC remained above the traditional, US willingness-to-pay threshold of $50,000/QALY gained in all scenarios, and above $100,000 or $150,000/QALY gained in most scenarios. LIMITATIONS Due to data limitations, the treatment patterns, CD4 count during viral rebound and treatment switch, viral rebound after trial end, and long-term adverse event-related treatment discontinuation were based on assumptions, presented to and approved by clinical experts. CONCLUSIONS Compared with EFV/TDF/FTC, DTG + ABC/3TC resulted in higher cost and only slightly increased QALYs over a lifetime, with an ICER that exceeded the standard cost-effectiveness threshold. This indicates that the incremental benefit in effectiveness associated with DTG + ABC/3TC may not be worth the incremental increase in costs.
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Teshome W, Belayneh M, Moges M, Endriyas M, Mekonnen E, Ayele S, Misganaw T, Shiferaw M, Chinnakali P, Hinderaker SG, Kumar AMV. Who takes the medicine? Adherence to antiretroviral therapy in Southern Ethiopia. Patient Prefer Adherence 2015; 9:1531-7. [PMID: 26604706 PMCID: PMC4631418 DOI: 10.2147/ppa.s90816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Treatment adherence is critical for the success of antiretroviral therapy (ART) for people living with HIV. There is limited representative information on ART drug adherence and its associated factors from Southern Ethiopia. We aimed at estimating the level of adherence to ART among people living with HIV and factors associated with it in 20 randomly selected ART clinics of Southern Ethiopia. METHODS In this cross-sectional study, we interviewed consecutive HIV patients on first-line antiretroviral regimen attending the clinics in June 2014 using a pretested and structured questionnaire. For measuring adherence, we used 4-day recall method based on "The AIDS Clinical Trial Group adherence assessment tool". Patients were classified as "Incomplete adherence" if they missed any of the doses in the last 4 days. Data were singly entered using EpiData and descriptive analysis, and unadjusted odds ratios were calculated using EpiDataStat software. Multivariate logistic regression analysis was performed using Stata v12.0. RESULTS Of 974 patients interviewed, 539 (56%) were females, and mean age was 35 years. The proportion of patients with incomplete adherence was 13% (95% confidence interval: 11%-15%). In multivariate analysis, factors significantly associated with incomplete adherence included young age, being Protestant Christian, consuming alcohol, being single, and being a member of an HIV association. Psychosocial factors like stigma, depression, and satisfaction to care were not associated with incomplete adherence in the current context. CONCLUSION The overall adherence to ART was good. However, there were certain subgroups with incomplete adherence who need special attention. The health care providers (especially counselors) need to be aware of these subgroups and tailor their counseling to improve adherence among these groups. Exploratory qualitative studies may help uncover the exact reasons for incomplete adherence.
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Affiliation(s)
- Wondu Teshome
- School of Public and Environmental Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Correspondence: Wondu Teshome, PO Box 898, Hawassa, Ethiopia, Tel +251 91 176 1805, Email
| | - Mihretu Belayneh
- School of Public and Environmental Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Mathewos Moges
- School of Public and Environmental Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Misganu Endriyas
- Research Technology Transfer Process Unit, SNNP Regional Health Bureau, Hawassa, Ethiopia
| | - Emebet Mekonnen
- Research Technology Transfer Process Unit, SNNP Regional Health Bureau, Hawassa, Ethiopia
| | - Sinafiksh Ayele
- Research Technology Transfer Process Unit, SNNP Regional Health Bureau, Hawassa, Ethiopia
| | - Tebeje Misganaw
- Research Technology Transfer Process Unit, SNNP Regional Health Bureau, Hawassa, Ethiopia
| | - Mekonnen Shiferaw
- Research Technology Transfer Process Unit, SNNP Regional Health Bureau, Hawassa, Ethiopia
| | - Palanivel Chinnakali
- Department of Preventive and Social Medicine, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | | | - Ajay MV Kumar
- The International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India
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