Antiretroviral therapy: a key component of a comprehensive HIV prevention strategy

Providing anti-retroviral treatment did not achieve the ambition of 'Joint united nations program on HIV/AIDS (UNAIDS) among HIV positive patient in Ethiopia': a systematic review and meta-analysis

Introduction

Antiretroviral Treatment (ART) has great importance in reducing viral load. Though a global effort was made to suppress viral load, the level of viral load suppression among ART patients is still high in Ethiopia.

Objective

This study aims to assess the magnitude and contributing factors for viral load suppression among patients attending ART clinics in Ethiopia.

Methods

The articles were searched using different databases using the guideline of reporting systematic review and meta-analysis (PRISMA). A random effect model was used to ascertain the pooled prevalence of viral load suppression in Ethiopia using STATA 14 software.

Results

The pooled prevalence of suppressed viral load was 75.25% (95% CI: 68.61-81.89). Having good adherence (OR: 2.71, 95% CI 2.27, 3.15), baseline CD4 count (OR: 1.74, 95% CI 1.53, 1.96), and being female (OR: 1.41, 95% CI 1.04, 1.79) were determinants of pooled estimates of suppressed viral load.

Conclusion

The pooled prevalence of suppressed viral load was 75% which is lower than the targeted level by the sustainable development goal (SDG) 2020, which was 90%. Therefore, the stakeholders should be focused on the existing strategies to decrease viral load among ART patients. They should work to adhere to patients for ART treatment.

Unsuppressed Viral Load Level in Public Health Facilities: Nonvirological Predictors among Adult Antiretroviral Therapy Users in Southwestern Ethiopia

BACKGROUND

Unsuppressed viral load in patients on antiretroviral (ARV) therapy occurs when treatment fails to suppress a patient's viral load, and is associated with decreased survival and increased HIV transmission. Identifying the level of unsuppressed viral load with its associated factors has benefits in controlling transmission and reducing burden. Therefore, this study aimed to assess unsuppressed viral load (>1,000 copies/mL) and associated factors among HIV patients taking first-line antiretroviral treatment at public health facilities in Jimma, Ethiopia.

METHODS

A facility-based cross-sectional study was conducted on 669 patients on first-line ARV therapy (at least 6 months) in public health facilities in Jimma. Sociodemographic, treatment, clinical, immunological, and viral load data were extracted from medical records, entered into EpiData 3.1, and analyzed with SPSS 20. Multivariate logistic regression analysis was performed to identify factors independently associated with viral nonsuppression, considering a 95% CI with P<0.05 statistically significant.

RESULTS

Among the participants, 258 (38.6%) were aged 25-34 years. Median age was 35 years. Prevalence of unsuppressed viral load was 20.3%. Risk of unsuppressed viral loads was 91% lower among ARV therapy patients who had been taking ARV therapy <2 years (AOR 0.09, 95% CI 0.01-0.83), lower baseline BMI (AOR 4.44, 95% CI 1.56-12.64), lower baseline CD4 (AOR 2.76, 95% CI 1.45-5.29), poor adherence to ARV therapy medication (AOR 3.19, 95% CI 1.29-7.89), and immunological failure (AOR 4.26, 95% CI 2.56-7.09) were the independent predictors of unsuppressed viral load.

CONCLUSION

This study revealed that there is a high level of virological failure among adult HIV patients, and confirms the need to develop close follow-up strategies of targeted interventions for patients in care who are at high risk of unsuppressed viral load.

Smartphone-based incentives for promoting adherence to antiretroviral therapy: A randomized controlled trial

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Contingency management (CM) intervention can promote adherence to ART.

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CM for ART adherence can be delivered via a smartphone platform.

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Smartphone CM reduces barriers to adoption of CM relative to in-person CM.

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Low-income people with HIV found smartphone CM to be acceptable and easy to use.

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CM produced detectable ART adherence improvements despite high baseline levels.

Antiretroviral therapy can improve the lives of people living with HIV and reduce the rate of transmission. However, high levels of adherence are required. Some people living with HIV, including people who use drugs, are at elevated risk for non-adherence. Contingency management is a promising intervention for promoting adherence to antiretroviral therapy. Barriers to adoption of contingency management include lack of provider expertise and implementation effort. To address these barriers, a smartphone-based adherence intervention was developed. HIV + people with a substance use disorder were required to submit video selfies of medication consumption that met validity criteria. Monetary incentives were delivered to participants via reloadable debit cards, contingent upon a valid video. The intervention was evaluated in a small (n = 50) randomized controlled trial. Intervention participants submitted 75% of possible videos, and 81% of videos met validity criteria, indicating a high level of usability. Participants also rated the intervention as highly acceptable. Adherence was measured as the percent of participants who achieved a 95% adherence threshold, and also as the overall percent of days in which participants were adherent to their antiretroviral therapy. The former showed a significant effect for group, (p = .034) but this was not maintained when adjusting for stratification variables as covariates (p = .094). The latter measure showed a significant group × time interaction. Smartphone-based contingency management is a promising method for promoting adherence to antiretroviral therapy. Assessing the cost-benefit of the intervention and development of strategies for long-term adherence are priorities for future research.

Current Computational Approaches for the Development of Anti-HIV Inhibitors: An Overview

BACKGROUND

Today, HIV-1 infection has become an extensive problem to public health and a greater challenge to all working researchers throughout the world. Since the beginning of HIV-1 virus, several antiviral therapeutic agents have been developed at various stages to combat HIV-1 infection. But, many of antiviral drugs are on the platform of drug resistance and toxicology issues, needs an urgent constructive investigation for the development of productive and protective therapeutics to make an improvement of individual life suffering with viral infection. As developing a novel agent is very costly, challenging and time taking route in the recent times.

METHODS

The review summarized about the modern approaches of computational aided drug discovery to developing a novel inhibitor within a short period of time and less cost.

RESULTS

The outcome suggests on the premise of reported information that the computational drug discovery is a powerful technology to design a defensive and fruitful therapeutic agents to combat HIV-1 infection and recover the lifespan of suffering one.

CONCLUSION

Based on survey of the reported information, we concluded that the current computational approaches is highly supportive in the progress of drug discovery and controlling the viral infection.

Development Of Saquinavir Mesylate Nanoemulsion-Loaded Transdermal Films: Two-Step Optimization Of Permeation Parameters, Characterization, And Ex Vivo And In Vivo Evaluation

Background

Saquinavir mesylate (SQR) tablets are widely used against human immunodeficiency virus. SQR has bioavailability issues owing to its poor aqueous solubility, extensive first-pass metabolism, and even low gastrointestinal tract permeability and absorption.

Objective

An in-depth optimization process was carried out using factorial design to improve the permeation parameters and thereby the bioavailability of SQR by formulating self-nanoemulsifying drug delivery system (SNEDDS)-loaded polymeric transdermal films.

Methods

The solubility of SQR in different nanoemulsion components was examined. Various combinations of selected components were prepared in an extreme vertices mixture design to identify the useful nanoemulsion zone and to develop SNEDDS with minimum globule size. The optimized SQR-SNEDDS was loaded in polyvinyl alcohol (PVA)-based transdermal films. The Box-Behnken design was used to optimize and evaluate SQR permeability. The prepared films were characterized for thickness, tensile strength, elongation, folding endurance, and accelerated stability studies. The optimized film was examined for ex vivo skin permeation and in vivo pharmacokinetic parameters.

Results

The optimized SQR-SNEDDS was prepared in proportions of 0.1, 0.55, and 0.35 of clove oil, labrasol, and Transcutol, respectively. The implemented Box-Behnken design indicated the optimized film consisted of 1.0% PVA, 0.25% propylene glycol, and clove oil as the oil phase. The tensile strength, thickness, percent elongation, and folding endurance of the optimized SQR-SNEDDS film were 0.93 ± 0.013 kg/cm², 0.22 ± 0.006 mm, 43.1 ± 0.022%, and >200 times, respectively. A higher Cmax and double the AUC were observed for SQR-SNEDDS–loaded film in comparison to pure SQR-loaded films.

Conclusion

Implementation of a two-step design to optimize and control experimental factors in the preparation of SQR-SNEDDS and its loading onto PVA-based transdermal films was achieved. The films indicated improved ex vivo skin permeation, enhanced bioavailability, and overcame the limitations of the oral dosage form.

Near Full-length Genomic Sequencing and Molecular Analysis of HIV-Infected Individuals in a Network-based Intervention (TRIP) in Athens, Greece: Evidence that Transmissions Occur More Frequently from those with High HIV-RNA

Background:

TRIP (Transmission Reduction Intervention Project) was a network-based, contact tracing approach to locate and link to care, mostly people who inject drugs (PWID) with recent HIV infection.

Objective:

We investigated whether sequences from HIV-infected participants with high viral load cluster together more frequently than what is expected by chance.

Methods:

Paired end reads were generated for 104 samples using Illumina MiSeq next-generation se-quencing.

Results:

63 sequences belonged to previously identified local transmission networks of PWID (LTNs) of an HIV outbreak in Athens, Greece. For two HIV-RNA cut-offs (105 and 106 IU/mL), HIV transmissions were more likely between PWID with similar levels of HIV-RNA (p<0.001). 10 of the 14 sequences (71.4%) from PWID with HIV-RNA >106 IU/mL were clustered in 5 pairs. For 4 of these clusters (80%), there was in each one of them at least one sequence from a recently HIV-infected PWID.

Conclusion:

We showed that transmissions are more likely among PWID with high viremia.

Efficacy of a Small-Group Intervention for Post-Incarcerated Black Men Who Have Sex with Men and Women (MSMW)

We conducted a randomized controlled trial of a six-session behavioral intervention designed to reduce frequency of condomless sex and numbers of sex partners among recently incarcerated, bisexual Black men. One hundred participants were assigned to the small-group intervention, Men in Life Environments (MILE), and 112 were assigned to the control condition. Among those assigned to MILE, 69% attended at least one session, 88% of whom attended all sessions. At 3-months' follow-up, large reductions in risk behaviors were reported by both groups. Means for episodes of condomless sex in the previous 3 months declined from 27.7 to 8.0 for the intervention and 25.6 to 6.7 for the control group. Reductions were not greater for the intervention than those of the control group. Regression to the mean, respondent burden, and implementation issues, such as moving from office-based to field-based survey administration at follow-up, may have contributed to the large declines reported by both groups.

Description and Demonstration of Cognitive Behavioral Therapy to Enhance Antiretroviral Therapy Adherence and Treat Depression in HIV-Infected Adults

There are an estimated 1.1 million individuals living with HIV/AIDS in the United States. In addition to the various medical comorbidities of HIV infection, depression is one of the most frequently co-occurring psychiatric conditions among HIV-infected individuals. Furthermore, depression has been found to be associated with nonadherence to antiretroviral therapy (ART), as well as HIV disease progression. Cognitive behavioral therapy (CBT) has repeatedly been found to effectively treat depression in adult populations, and CBT for adherence and depression (CBT-AD) is an effective treatment for improving depressive symptoms and medication adherence in the context of various chronic health conditions, including diabetes and HIV-infection. This paper provides a description of the CBT-AD approach to treat depression and ART adherence in HIV-infected adults, which we have developed and tested in our clinic, and for which detailed therapist and client guides exist. To augment the description of treatment, the present article provides video component demonstrations of several core modules that highlight important aspects of this treatment, including Life-Steps for medication adherence, orientation to CBT-AD and psychoeducation, and suggestions for adaptation of core CBT modules for HIV-infected adults. Discussion of video demonstrations highlights differences in patient presentations and course of treatment between HIV-infected adults receiving CBT-AD and HIV-uninfected adults receiving traditional CBT for depression. This description and the accompanying demonstrations are intended as a practical guide to assist therapists wishing to conduct such a treatment in the outpatient setting.

Treatment as prevention--where next?

Uptake of antiretroviral regimens with associated durable virologic suppression has been shown to reduce the risk of HIV transmission. Expanding antiretroviral therapy (ART) programs at a population level may serve as a vital strategy in the elimination of the AIDS epidemic. The global expansion of ART programs has greatly improved access to life-saving therapies and is likely to achieve the target of 15 million individuals on therapy set by UNAIDS. In addition to the incontrovertible gains in terms of life expectancy, growing evidence demonstrates that durable virologic suppression is associated with significant reductions in HIV transmission amongst heterosexual couples and men who have sex with men. Expansion of successful ART programs, best monitored by a program-level continuum of care cascade to assess progress in diagnosis, retention in care, and virologic suppression, is associated with reductions in HIV incidence at a population level. Expanding and sustaining successful ART delivery at a global level is a key component in a comprehensive approach to combating the HIV epidemic over the next two decades.

Incarceration is associated with used syringe lending among active injection drug users with detectable plasma HIV-1 RNA: a longitudinal analysis

Background

Informed by recent studies demonstrating the central role of plasma HIV-1 RNA viral load (VL) on HIV transmission, interventions to employ HIV antiretroviral treatment as prevention (TasP) are underway. To optimize these efforts, evidence is needed to identify factors associated with both non-suppressed VL and HIV risk behaviours. Thus, we sought to assess the possible role played by exposure to correctional facilities on VL non-suppression and used syringe lending among HIV-seropositive people who use injection drugs (PWID).

Methods

We used data from the ACCESS study, a community-recruited prospective cohort. We used longitudinal multivariate mixed-effects analyses to estimate the relationship between incarceration and plasma HIV-1 RNA > 500 copies/mL among antiretroviral therapy (ART)-exposed active PWID and, during periods of non-suppression, the relationship between incarceration and used syringe lending.

Results

Between May 1996 and March 2012, 657 ART-exposed PWID were recruited. Incarceration was independently associated with higher odds of VL non-suppression (Adjusted Odds Ratio [AOR] = 1.54, 95% Confidence Interval [95% CI]: 1.10, 2.16). In a separate multivariate model restricted to periods of VL non-suppression, incarceration was independently associated with lending used syringes (AOR = 1.81, 95% CI: 1.03, 3.18).

Conclusions

The current findings demonstrate that incarceration is associated with used syringe lending among active PWID with detectable plasma HIV-1 RNA. Our results provide a possible pathway for the commonly observed association between incarceration and increased risk of HIV transmission. Our results suggest that alternatives to incarceration of non-violent PWID and evidence-based combination HIV prevention interventions for PWID within correctional facilities are urgently needed.

HIV treatment as prevention: the key to an AIDS-free generation

The presence of elevated HIV viral load within blood and genital secretions is a critical driver of transmission events. Long-term suppression of viral load to undetectable levels through the use of antiretroviral therapy is now standard practice for clinical management of HIV. Antiretroviral therapy therefore can play a key role as a means to curb HIV transmission. Results of a randomized clinical trial, in conjunction with several observational studies, have now confirmed that antiretroviral therapy markedly decreases HIV transmission risk. Mathematical models and population-based ecologic studies suggest that further expansion of antiretroviral coverage within current guidelines can play a major role in controlling the spread of HIV. Expansion of so-called "Treatment as Prevention" initiatives relies upon maximal uptake of the HIV continuum-of-care cascade to allow for successful identification of those not yet known to be HIV-infected, engagement of patients in appropriate care, and subsequently achieving sustained virologic suppression in patients with the use of antiretroviral therapy. Since 2010, the Joint United Nations AIDS (UNAIDS) program has called for the inclusion of antiretroviral treatment as a key pillar in the global strategy to control the spread of HIV infection. This has now been invigorated by the release of the World Health Organization's 2013 Consolidated Antiretroviral Therapy Guidelines, recommending treatment to be offered to all HIV-infected individuals with CD4 cell counts below 500/mm³, and, regardless of CD4 cell count, to serodiscordant couples, TB and HBV co-infected individuals, pregnant women, and children below the age of 5 years.

Prevention, Rehabilitation, and Mitigation Strategies of Cognitive Deficits in Aging with HIV: Implications for Practice and Research

Highly active antiretroviral therapy has given the chance to those living with HIV to keep on living, allowing them the opportunity to age and perhaps age successfully. Yet, there are severe challenges to successful aging with HIV, one of which is cognitive deficits. Nearly half of those with HIV experience cognitive deficits that can interfere with everyday functioning, medical decision making, and quality of life. Given that cognitive deficits develop with more frequency and intensity with increasing age, concerns mount that as people age with HIV, they may experience more severe cognitive deficits. These concerns become especially germane given that by 2015, 50% of those with HIV will be 50 and older, and this older cohort of adults is expected to grow. As such, this paper focuses on the etiologies of such cognitive deficits within the context of cognitive reserve and neuroplasticity. From this, evidence-based and hypothetical prevention (i.e., cognitive prescriptions), rehabilitation (i.e., speed of processing training), and mitigation (i.e., spaced retrieval method) strategies are reviewed. Implications for nursing practice and research are posited.

Time patterns of adherence and long-term virological response to non-nucleoside reverse transcriptase inhibitor regimens in the Stratall ANRS 12110/ESTHER trial in Cameroon

BACKGROUND

Although treatment adherence is a major challenge in sub-Saharan Africa, it is still unknown which longitudinal patterns of adherence are the most detrimental to long-term virological response to non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens. This analysis aimed to study the influence of different time patterns of adherence on virological failure after 24 months of treatment in Cameroon.

METHODS

Antiretroviral therapy (ART) adherence data were collected using face-to-face questionnaires administered at months 1, 3, 6, 12, 18 and 24. Virological failure was defined as viral load >40 copies/ml at month 18 and/or 24. Two combined indicators of early adherence (months 1, 3 and 6) and adherence during the maintenance phase (months 12, 18 and 24) were designed to classify patients as always adherent during the early or maintenance phase, non-adherent at least once and having interrupted ART for >2 days at least once at any visit during either of these two phases.

RESULTS

Virological failure occurred in 107 (42%) of the 254 patients included in the analysis. In the early and maintenance phases, 84% and 76%, respectively, were always adherent, 5% and 5% were non-adherent and 11% and 20% experienced ≥ 1 treatment interruption. Early non-adherence was independently associated with virological failure (adjusted OR 7.2 [95% CI 1.5, 34.6]), while only treatment interruptions had a significant impact on virological failure during the maintenance phase (adjusted OR 2.1 [95% CI 1.1, 4.4]).

CONCLUSIONS

ART NNRTI-regimens used in sub-Saharan Africa seem to 'forgive' deviations from good adherence during the maintenance phase. Optimizing adherence in the early months of treatment remains crucial, especially in a setting of poor health care infrastructure and resources.

Substance use disorders and HIV/AIDS prevention and treatment intervention: research and practice considerations

Social workers are often on the front lines of the HIV/AIDS epidemic delivering prevention education and interventions, offering or linking individuals to HIV testing, and working to improve treatment access, retention, and adherence, especially among vulnerable populations. Individuals with substance use disorders face additional challenges to reducing sexual and drug risk behaviors, as well as barriers to testing, treatment, and antiretroviral therapy adherence. This article presents current data on HIV transmission and research evidence on prevention and intervention with substance abusers and highlights how individual social workers can take advantage of this knowledge in practice and through adoption and implementation within organizations.

Impact of highly active antiretroviral therapy on the molecular epidemiology of newly diagnosed HIV infections

OBJECTIVE

To evaluate HIV-1 transmission trends and the impact of highly active antiretroviral therapy (HAART) on newly diagnosed HIV infections in Geneva, Switzerland.

DESIGN

Retrospective molecular epidemiology analysis of all newly HIV-diagnosed individuals between 2008 and 2010.

METHODS

Phylogenetic analyses were performed using pol sequences of 780 newly HIV-1 diagnosed individuals between 2000 and 2010 (mandatory reporting) and 1058 individuals diagnosed before 2000. All clusters (bootstrap value >98%) including individuals diagnosed in 2008-2010 were analyzed. Recent HIV infections (<1 year) were determined by documented seroconversion and/or fraction of ambiguous nucleotides. Median viral load and HAART coverage during the study period were obtained from patients included in the Swiss HIV Cohort Study (SHCS).

RESULTS

Among 142 newly diagnosed individuals during 2008-2010, 49% had a recent infection and 42% were included in transmission clusters. Among the latter, two-thirds were included in new clusters and one-third expanded previously known clusters. MSM carrying resistant strains were more frequently included in clusters. Only 1.8% of individuals diagnosed before 2000 and 10.8% diagnosed during 2000-2008 were included in clusters involving individuals diagnosed between 2008 and 2010. During 2008-2010, the median population viral load of SHCS-enrolled individuals was significantly lower for individuals diagnosed before 2000 than for those diagnosed during 2000-2008 and 2008-2010 and HAART coverage significantly higher.

CONCLUSIONS

MSM with recent HIV infection are a significant source of onward transmission. Individuals diagnosed before 2000 were only exceptionally related to newly diagnosed infections between 2008 and 2010. Prevention campaigns need to be focused on improving diagnosis for recently infected individuals.

Antiretroviral drugs: critical issues and recent advances

Human immunodeficiency virus (HIV) infection is now recognized as a chronic illness. Although the success of highly active antiretroviral therapy is beyond question, several issues still persist. Since the drugs cannot eradicate the virus, cure is not yet possible, and patients have to maintain a lifelong adherence with the risk of toxic effects, drug-drug interactions and drug resistance. A clear understanding of the viral replication and its interaction with host cell factors has led to the development of a large number of effective antiretroviral drugs (ARVs). New drugs in the existing class such as apricitabine, elvucitabine and etravirine have shown promising results against HIV isolates resistant to first line drugs. These drugs have offered a new choice for patients with drug resistant disease. However, the impact of their long term use on safety is yet to be assessed. Novel drugs with unique mechanism of action such as CD4 receptor attachment inhibitors, maturation inhibitors, pharmacokinetic enhancers, capsid assembly inhibitors and lens epithelium derived growth factor inhibitors are still under development. Currently, ARVs, especially tenofovir and emtricitabine, are also being evaluated for prevention of sexual transmission of HIV-1. The initial results of an HIV prevention trial network are encouraging and have recommended the use of ARVs for pre-exposure prophylaxis. Thus, ARVs form the key component of HIV prevention and treatment strategy. This article discusses the challenges associated with HIV-1 treatment and updates several major advances in the development of ARVs.

Cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected injection drug users: a randomized controlled trial

OBJECTIVE

Depression and substance use, the most common comorbidities with HIV, are both associated with poor treatment adherence. Injection drug users comprise a substantial portion of individuals with HIV in the United States and globally. The present study tested cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with HIV and depression in active substance abuse treatment for injection drug use.

METHOD

This is a 2-arm, randomized controlled trial (N = 89) comparing CBT-AD with enhanced treatment as usual (ETAU). Analyses were conducted for two time-frames: (a) baseline to post-treatment and (b) post-treatment to follow-up at 3 and 6 months after intervention discontinuation.

RESULTS

At post-treatment, the CBT-AD condition showed significantly greater improvement than ETAU in MEMS (electronic pill cap) based adherence, γslope = 0.8873, t(86) = 2.38, p = .02; dGMA-raw = 0.64, and depression, assessed by blinded assessor: Mongomery-Asberg Depression Rating Scale, F(1, 79) = 6.52, p < .01, d = 0.55; clinical global impression, F(1, 79) = 14.77, p < .001, d = 0.85. After treatment discontinuation, depression gains were maintained, but adherence gains were not. Viral load did not differ across condition; however, the CBT-AD condition had significant improvements in CD4 cell counts over time compared with ETAU, γslope = 2.09, t(76) = 2.20, p = .03, dGMA-raw = 0.60.

CONCLUSIONS

In patients managing multiple challenges including HIV, depression, substance dependence, and adherence, CBT-AD is a useful way to integrate treatment of depression with an adherence intervention. Continued adherence counseling is likely needed, however, to maintain or augment adherence gains in this population.