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Nwosu EC, Holmes MJ, Cotton MF, Dobbels E, Little F, Laughton B, van der Kouwe A, Meintjes EM, Robertson F. Cortical structural changes related to early antiretroviral therapy (ART) interruption in perinatally HIV-infected children at 5 years of age. IBRO Neurosci Rep 2021; 10:161-170. [PMID: 34179869 PMCID: PMC8211921 DOI: 10.1016/j.ibneur.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/03/2021] [Indexed: 12/21/2022] Open
Abstract
ART interruption in children can occur especially in resource-limited settings for reasons including poor adherence, stock-outs, ART intolerance of non-pediatric formulas and pill size, as well as ultimately to test for HIV remission. Although early ART initiation is now standard of care in pediatric HIV management, very little is known on the effect of early ART initiation or subsequent interruption on brain development. This study aimed to investigate the effect of ART interruption on brain cortical thickness (CT) and folding in a subset of children from the Children with HIV Early antiRetroviral therapy (CHER) trial cohort who all started ART before 18 months of age. CHER participants in the neuroimaging follow-up study had magnetic resonance (MRI) scans on a 3T Siemens Allegra brain scanner at age 5.44 ± 0.37 years. MR images were processed using the automated cross-sectional stream in FreeSurfer v6.0 and vertex wise comparisons of CT and local gyrification indices (LGIs) were performed between HIV+ children and HIV- controls, as well as between HIV+ children on interrupted or continuous ART and controls. HIV+ children (n = 46) showed thicker cortex than HIV- children (n = 29) in bilateral frontal and left temporo-insular regions but lower LGIs in left superior and bilateral medial orbitofrontal cortex extending into rostral anterior cingulate. Children on interrupted ART (n = 21) had thicker cortex than HIV- controls in left frontal and right insular regions, but children on continuous treatment (n = 25) showed no difference from controls. Children on both interrupted and continuous ART showed region-specific alterations in LGI relative to controls. Cortical folding appears more sensitive than CT to early life events including early ART and interruption. However, immune health resilience in children can translate to long term preservation of morphometric brain development, especially for those on early and continuous treatment.
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Affiliation(s)
- Emmanuel C. Nwosu
- UCT Medical Imaging Research Unit, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
- Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Martha J. Holmes
- UCT Medical Imaging Research Unit, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
- Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Mark F. Cotton
- Family Centre for Research with Ubuntu, Department of Paediatrics & Child Health, Tygerberg Children’s Hospital and Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Els Dobbels
- Family Centre for Research with Ubuntu, Department of Paediatrics & Child Health, Tygerberg Children’s Hospital and Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Francesca Little
- Department of Statistical Sciences, Faculty of Sciences, University of Cape Town, South Africa
| | - Barbara Laughton
- Family Centre for Research with Ubuntu, Department of Paediatrics & Child Health, Tygerberg Children’s Hospital and Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Andre van der Kouwe
- A.A. Martinos Centre for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Ernesta M. Meintjes
- UCT Medical Imaging Research Unit, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
- Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Frances Robertson
- UCT Medical Imaging Research Unit, Division of Biomedical Engineering, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
- Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, South Africa
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Brummel SS, Taha TE, Angelidou K(N, Saidi F, Atuhaire P, Dula D, Moodley D, Matubu A, Chareka G, Nevrekar N, Vhembo T, Fairlie L, Theron G, Mlay P, George K, Basar M, Chakhtoura N, Browning R, Fowler MG, Currier JS. Brief Report: Impact of ART on Maternal Health After Cessation of Breastfeeding. J Acquir Immune Defic Syndr 2021; 86:450-454. [PMID: 33273210 PMCID: PMC8143379 DOI: 10.1097/qai.0000000000002586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/26/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT IMPAACT PROMISE 1077BF/FF was a sequentially randomized study of pregnant and postpartum women living with HIV to investigate the efficacy and safety of antiretroviral therapy (ART). This Maternal Health Component investigated efficacy for the risk of developing AIDS or death; and safety among women randomized to continue ART (CTART: N = 289) or discontinue ART (N = 268) after cessation of breastfeeding or after confirmation of infant infection. No AIDS-defining illnesses were reported during follow-up in either arm. Adverse events of grade 3 or higher were more frequent in the CTART arm [hazard ratio = 1.78, 95% confidence interval: (1.05 to 3.02), P-value = 0.03]. The difference in adverse events in the 2 groups was mostly driven by moderate weight loss for women on the CTART arm.
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Affiliation(s)
- Sean S. Brummel
- The Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Taha E. Taha
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Friday Saidi
- University of North Carolina (UNC) Project—Malawi, Kamuzu Central Hospital, Malawi
| | - Patience Atuhaire
- Makerere University –John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Dingase Dula
- Johns Hopkins-College of Medicine Research Project, Blantyre, Malawi
| | - Dhayendre Moodley
- Centre for AIDS Research in South Africa and Department of Obstetrics and Gynecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Allen Matubu
- Department of Obstetrics and Gynecology, UZ-UCSF Collaborative Project, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Gift Chareka
- Department of Obstetrics and Gynecology, UZ-UCSF Collaborative Project, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Neetal Nevrekar
- Byramjee Jeejeebhoy Government Medical College and Clinical Research Site, Pune, India
| | - Tichaona Vhembo
- University of Zimbabwe College of Health Sciences—Clinical Trials Research Centre, Harare, Zimbabwe
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Pendo Mlay
- Kilimanjaro Christian Medical Center, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Michael Basar
- Frontier Science and Technology Research Foundation, Amherst, NY
| | - Nahida Chakhtoura
- National Institute for Child Health and Human Development, Washington, D.C
| | - Renee Browning
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | | | - Judith S. Currier
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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Chang H. A mathematical study on the drug resistant virus emergence with HIV/AIDS treatment cases. Heliyon 2021; 7:e05883. [PMID: 33490667 PMCID: PMC7809186 DOI: 10.1016/j.heliyon.2020.e05883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/01/2020] [Accepted: 12/24/2020] [Indexed: 11/17/2022] Open
Abstract
HIV/AIDS drug treatments, one of which is highly active anti-retroviral ther-apy (HAART), often fail by the emergence of drug resistant virus. In this paper we study a quantitative method to evaluate the chance of resistant virus gen-eration. To this end we develop a mathematical description of the possibility of the emergence of resistant virus species against drug treatments, depend-ing on the trajectories of the state variables of HIV infection dynamic model. By simulation studies of mathematical models we apply the proposed analy-sis method to HIV/AIDS drug therapies, improved gradual dosage reduction (iGDR) and structured treatment interruption (STI). Based on the analysis it can be explained the reason why STI therapy often fails. Moreover it is con-cluded that iGDR is desirable particularly by decreasing the threat of resistant virus emergence.
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Stecher M, Claßen A, Klein F, Lehmann C, Gruell H, Platten M, Wyen C, Behrens G, Fätkenheuer G, Vehreschild JJ. Systematic Review and Meta-analysis of Treatment Interruptions in Human Immunodeficiency Virus (HIV) Type 1-infected Patients Receiving Antiretroviral Therapy: Implications for Future HIV Cure Trials. Clin Infect Dis 2021; 70:1406-1417. [PMID: 31102444 DOI: 10.1093/cid/ciz417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/17/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Safety and tolerability of analytical treatment interruptions (ATIs) as a vital part of human immunodeficiency virus type 1 (HIV-1) cure studies are discussed. We analyzed current evidence for the occurrence of adverse events (AEs) during TIs. METHODS Our analysis included studies that reported on AEs in HIV-1-infected patients undergoing TIs. All interventional and observational studies were reviewed, and results were extracted based on predefined criteria. The proportion of AEs was pooled using random-effects models. Metaregression was used to explore the influence of baseline CD4+ T-cell count, viral load, study type, previous time on combined antiretroviral therapy, and follow-up interval during TIs. RESULTS We identified 1048 studies, of which 22 studies including 7104 individuals fulfilled the defined selection criteria. Included studies had sample sizes between 6 and 5472 participants, with durations of TI cycles ranging from 7 days to 27 months. The intervals of HIV-1-RNA testing varied from 2 days to 3 months during TIs. The overall proportion of AEs during TIs >4 weeks was 3% (95% confidence interval [CI], 0%-7%) and was lower in studies with follow-up intervals ≤14 days (0%; 95% CI, 0%-1%) than in studies with wider follow-up intervals (6%; 95% CI, 2%-13%; P value for interaction = .01). CONCLUSIONS We found moderate-quality evidence indicating that studies with narrow follow-up intervals did not show a substantial increase in AEs during TIs. Our findings indicate that ATI may be a safe strategy as part of HIV-1 cure trials by closely monitoring for HIV-1 rebound.
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Affiliation(s)
- Melanie Stecher
- Department I for Internal Medicine, University Hospital of Cologne.,German Center for Infection Research, Partner Site Bonn-Cologne
| | - Annika Claßen
- Department I for Internal Medicine, University Hospital of Cologne.,German Center for Infection Research, Partner Site Bonn-Cologne
| | - Florian Klein
- German Center for Infection Research, Partner Site Bonn-Cologne.,Laboratory of Experimental Immunology, Institute of Virology.,Center for Molecular Medicine Cologne, University of Cologne
| | - Clara Lehmann
- Department I for Internal Medicine, University Hospital of Cologne.,German Center for Infection Research, Partner Site Bonn-Cologne
| | - Henning Gruell
- Department I for Internal Medicine, University Hospital of Cologne.,German Center for Infection Research, Partner Site Bonn-Cologne.,Laboratory of Experimental Immunology, Institute of Virology
| | | | - Christoph Wyen
- Department I for Internal Medicine, University Hospital of Cologne.,Praxis am Ebertplatz, Cologne
| | - Georg Behrens
- Department for Clinical Immunology and Rheumatology Hannover Medical School.,German Center for Infection Research, Partner Site Hannover
| | - Gerd Fätkenheuer
- Department I for Internal Medicine, University Hospital of Cologne.,German Center for Infection Research, Partner Site Bonn-Cologne
| | - Jörg Janne Vehreschild
- Department I for Internal Medicine, University Hospital of Cologne.,German Center for Infection Research, Partner Site Bonn-Cologne.,Medical Department II, University Hospital of Frankfurt, Germany
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Freguja R, Bamford A, Zanchetta M, Del Bianco P, Giaquinto C, Harper L, Dalzini A, Cressey TR, Compagnucci A, Saidi Y, Riault Y, Ford D, Gibb D, Klein N, De Rossi A. Long-term clinical, virological and immunological outcomes following planned treatment interruption in HIV-infected children. HIV Med 2020; 22:172-184. [PMID: 33124144 PMCID: PMC8436743 DOI: 10.1111/hiv.12986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 08/22/2020] [Accepted: 09/23/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Planned treatment interruption (PTI) of antiretroviral therapy (ART) in adults is associated with adverse outcomes. The PENTA 11 trial randomized HIV-infected children to continuous ART (CT) vs. CD4-driven PTIs. We report 5 years' follow-up after the end of main trial. METHODS Post-trial, all children resumed ART. Clinical, immunological, virological and treatment data were collected annually. A sub-study investigated more detailed immunophenotype. CT and PTI arms were compared using intention-to-treat. Laboratory parameters were compared using linear regression, adjusting for baseline values; mixed models were used to include all data over time. RESULTS In all, 101 children (51 CT, 50 PTI) contributed a median of 7.6 years, including 5.1 years of post-trial follow-up. Post-trial, there were no deaths, one pulmonary tuberculosis and no other CDC stage B/C events. At 5 years post-trial, 90% of children in the CT vs. 82% in the PTI arm had HIV RNA < 50 copies/mL (P = 0.26). A persistent increase in CD8 cells was observed in the PTI arm. The sub-study (54 children) suggested that both naïve and memory populations contributed to higher CD8 cells following PTI. Mean CD4/CD8 ratios at 5 years post-trial were 1.22 and 1.08 in CT and PTI arms, respectively [difference (CT - PTI) = -0.15; 95% CI: -0.34-0.05), P = 0.14]. The sub-study also suggested that during the trial and at early timepoints after the end of the trial, reduction in CD4 in the PTI arm was mainly from loss of CD4 memory cells. CONCLUSIONS Children tolerated PTI with few long-term clinical, virological or immunological consequences.
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Affiliation(s)
- R Freguja
- Section of Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - A Bamford
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,MRC Clinical Trials Unit, London, UK
| | - M Zanchetta
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - P Del Bianco
- Clinical Trials and Biostatistic Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - C Giaquinto
- Department of Mother and Child Health, University of Padova, Padova, Italy
| | - L Harper
- MRC Clinical Trials Unit, London, UK
| | - A Dalzini
- Section of Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - T R Cressey
- PHPT/IRD 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.,Department of Immunology & Infectious Diseases, Harvard T.H Chan School of Public Health, Boston, MA, USA.,Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - A Compagnucci
- INSERMSC10-US019, Essais thérapeutiques et maladies Infectieuses, Villejuif, France
| | - Y Saidi
- INSERMSC10-US019, Essais thérapeutiques et maladies Infectieuses, Villejuif, France
| | - Y Riault
- INSERMSC10-US019, Essais thérapeutiques et maladies Infectieuses, Villejuif, France
| | - D Ford
- MRC Clinical Trials Unit, London, UK
| | - D Gibb
- MRC Clinical Trials Unit, London, UK
| | - N Klein
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - A De Rossi
- Section of Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
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Time to viral rebound and safety after antiretroviral treatment interruption in postpartum women compared with men. AIDS 2019; 33:2149-2156. [PMID: 31373919 DOI: 10.1097/qad.0000000000002334] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE(S) The short-term safety of treatment interruptions, a necessary part of cure studies, is not well established, particularly in women. We explored viral rebound kinetics and safety in a group of postpartum women discontinuing ART and compared results to men in historical interruption trials. DESIGN Prospective evaluation of time to virologic rebound. METHODS One thousand and seventy-six asymptomatic, virally suppressed, postpartum women living with HIV enrolled in the PROMISE trial with baseline CD4 cell counts at least 350 cells/μl underwent antiretroviral treatment (ART) discontinuation. Proportion with virologic suppression at weeks 4 and 12 were compared with participants in ACTG treatment interruption trials (91% male population). RESULTS In PROMISE, using interval censored methods, the estimated median time to HIV viral rebound was 2 weeks. An estimated 6% of women would remain virally suppressed at 30 weeks. Of those who had viral rebound by 30 weeks (N = 993), less than 4% experienced grade 3 or higher laboratory events, and 1% experienced WHO stage 2 or higher clinical events. Overall, less than 1% of participants progressed from WHO Stage 1 to Stage 2 or higher after discontinuation of ART, and 3.9% experienced a decline in CD4 cell count to less than 350 cells/μl or local treatment guidelines. A significantly higher proportion of women in PROMISE (25.4%) were virologically suppressed (<400 copies/ml) at 12 weeks compared with ACTG NWCS 371 participants (6.4%). CONCLUSION Temporary treatment interruptions in healthy, HIV-infected women with high CD4 cell counts can be well tolerated. Potential sex differences need to be considered in cure studies examining time to virologic rebound.
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Cost-effectiveness and budget impact of immediate antiretroviral therapy initiation for treatment of HIV infection in Côte d'Ivoire: A model-based analysis. PLoS One 2019; 14:e0219068. [PMID: 31247009 PMCID: PMC6597104 DOI: 10.1371/journal.pone.0219068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/14/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction The Temprano and START trials provided evidence to support early ART initiation recommendations. We projected long-term clinical and economic outcomes of immediate ART initiation in Côte d’Ivoire. Methods We used a mathematical model to compare three potential ART initiation criteria: 1) CD4 <350/μL (ART<350/μL); 2) CD4 <500/μL (ART<500/μL); and 3) ART at presentation (Immediate ART). Outcomes from the model included life expectancy, 10-year medical resource use, incremental cost-effectiveness ratios (ICERs) in $/year of life saved (YLS), and 5-year budget impact. We simulated people with HIV (PWH) in care (mean CD4: 259/μL, SD 198/μL) and transmitted cases. Key input parameters to the analysis included first-line ART efficacy (80% suppression at 6 months) and ART cost ($90/person-year). We assessed cost-effectiveness relative to Côte d’Ivoire’s 2017 per capita annual gross domestic product ($1,600). Results Immediate ART increased life expectancy by 0.34 years compared to ART<350/μL and 0.17 years compared to ART<500/μL. Immediate ART resulted in 4,500 fewer 10-year transmissions per 170,000 PWH compared to ART<350/μL. In cost-effectiveness analysis, Immediate ART had a 10-year ICER of $680/YLS compared to ART<350/μL, ranging from cost-saving to an ICER of $1,440/YLS as transmission rates varied. ART<500/μL was “dominated” (an inefficient use of resources), compared with Immediate ART. Immediate ART increased the 5-year HIV care budget from $801.9M to $812.6M compared to ART<350/μL. Conclusions In Côte d’Ivoire, immediate compared to later ART initiation will increase life expectancy, decrease HIV transmission, and be cost-effective over the long-term, with modest budget impact. Immediate ART initiation is an appropriate, high-value standard of care in Côte d’Ivoire and similar settings.
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CD4 recovery following antiretroviral treatment interruptions in children and adolescents with HIV infection in Europe and Thailand. HIV Med 2019; 20:456-472. [PMID: 31099155 DOI: 10.1111/hiv.12745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The aim of the study was to explore factors associated with CD4 percentage (CD4%) reconstitution following treatment interruptions (TIs) of antiretroviral therapy (ART). METHODS Data from paediatric HIV-infected cohorts across 17 countries in Europe and Thailand were pooled. Children on combination ART (cART; at least three drugs from at least two classes) for > 6 months before TI of ≥ 30 days while aged < 18 years were included. CD4% at restart of ART (r-ART) and in the long term (up to 24 months after r-ART) following the first TI was modelled using asymptotic regression. RESULTS In 779 children with at least one TI, the median age at first TI was 10.1 [interquartile range (IQR) 6.4, 13.6] years and the mean CD4% was 27.3% [standard deviation (SD) 11.0%]; the median TI duration was 9.0 (IQR 3.5, 22.5) months. In regression analysis, the mean CD4% was 19.2% [95% confidence interval (CI) 18.3, 20.1%] at r-ART, and 27.1% (26.2, 27.9%) in the long term, with half this increase in the first 6 months. r-ART and long-term CD4% values were highest in female patients and in children aged < 3 years at the start of TI. Long-term CD4% was highest in those with a TI lasting 1 to <3 months, those with r-ART after year 2000 and those with a CD4% nadir ≥ 25% (all P < 0.001). The effect of CD4% nadir during the TI differed significantly (P = 0.038) by viral suppression at the start of the TI; in children with CD4% nadir < 15% during TI, recovery was better in those virally suppressed prior to the TI; viral suppression was not associated with recovery in children with CD4% nadir ≥ 25%. CONCLUSIONS After restart of ART following TI, most children reconstituted well immunologically. Nevertheless, several factors predicted better immunological reconstitution, including younger age and higher nadir CD4% during TI.
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Lau JS, Smith MZ, Lewin SR, McMahon JH. Clinical trials of antiretroviral treatment interruption in HIV-infected individuals. AIDS 2019; 33:773-791. [PMID: 30883388 DOI: 10.1097/qad.0000000000002113] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
: Despite the benefits of antiretroviral therapy (ART) for people living with HIV, there has been a long-standing research interest in interrupting ART as a strategy to minimize adverse effects of ART as well as to test interventions aiming to achieve a degree of virological control without ART. We performed a systematic review of HIV clinical studies involving treatment interruption from 2000 to 2017 to describe the differences between treatment interruption in studies that contained and didn't contain an intervention. We assessed differences in monitoring strategies, threshold to restart ART, duration and adverse outcomes of treatment interruption, and factors aimed at minimizing transmission. We found that treatment interruption has been incorporated into 159 clinical studies since 2000 and is increasingly being included in trials to assess the efficacy of interventions to achieve sustained virological remission off ART. Great heterogeneity was noted in immunological, virological and clinical monitoring strategies, as well as in thresholds to recommence ART. Treatment interruption in recent intervention studies were more closely monitored, had more conservative thresholds to restart ART and had a shorter treatment interruption duration, compared with older treatment interruption studies that didn't include an intervention.
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Boyd A, Moh R, Maylin S, Abdou Chekaraou M, Mahjoub N, Gabillard D, Anglaret X, Eholié SP, Danel C, Delaugerre C, Zoulim F, Lacombe K. Effect of hepatitis B virus (HBV) surface-gene variability on markers of replication during treated human immunodeficiency virus-HBV infection in Western Africa. Liver Int 2019; 39:280-289. [PMID: 30257068 DOI: 10.1111/liv.13975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 08/18/2018] [Accepted: 09/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Replication markers exhibit substantial variation during chronic hepatitis B virus (HBV) infection, part of which can be explained by mutations on the surface (S) gene. We aimed to identify S-gene mutations possibly influencing the quantification of HBV replication markers (MUPIQH) in HBV genotype E infection, common to Western Africa. METHODS Seventy-three antiretroviral treatment (ART)-naïve human immunodeficiency virus (HIV)-HBV co-infected patients from Côte d'Ivoire, initiating anti-HBV-containing ART, had available HBV S-gene sequences. S-gene MUPIQHs were screened at ART initiation based on lower HBV-DNA or HBsAg quantification (qHBsAg) compared to wildtype. Their association with HBV virological response and qHBsAg slope during treatment was evaluated. RESULTS Genotype E was predominant (95.9%). At ART initiation, median HBV-DNA was 7.27 log10 copies/mL (IQR = 5.26-8.33) and qHBsAg 4.08 log10 IU/mL (IQR = 3.49-4.61). Twelve S-gene MUPIQHs were identified among 21 patients (28.8%): sS140L (n = 4), sD144A (n = 1), sS167L (n = 2), sS174N (n = 6), sP178Q (n = 2), sG185L (n = 2), sW191L (n = 2), sP203Q/R (n = 2), sS204N/I/R/K/T/G (n = 7), sN207T (n = 2), sF212C (n = 1) and sV224A/Y (n = 7). MUPIQHs at positions s185+s191+s224 and s178+s204 were within highly covarying networks of S-gene mutations. Older age (P = 0.02), elevated transaminases (P = 0.03) and anti-hepatitis B "e" antibody-positive serology (P = 0.009) were significantly associated with prevalent MUPIQHs at ART initiation. During treatment, baseline MUPIQHs were not associated with time-to-undetectable HBV-DNA (P = 0.7) and qHBsAg levels decreased at similar rates between those with vs without MUPIQHs (P = 0.5). CONCLUSION Several novel S-gene mutations were associated with reductions in replication markers among West African co-infected patients. These mutations, however, do not affect response during antiviral treatment. Their diagnostic and clinical consequences need clarification.
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Affiliation(s)
- Anders Boyd
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Saint Antoine Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Raoul Moh
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire
| | - Sarah Maylin
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France
| | | | - Nadia Mahjoub
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Delphine Gabillard
- INSERM U1219, Bordeaux, France.,ISPED, University of Bordeaux, Bordeaux, France
| | - Xavier Anglaret
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire.,INSERM U1219, Bordeaux, France.,ISPED, University of Bordeaux, Bordeaux, France
| | - Serge Paul Eholié
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire
| | - Christine Danel
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire.,INSERM U1219, Bordeaux, France.,ISPED, University of Bordeaux, Bordeaux, France
| | - Constance Delaugerre
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France.,INSERM U941, Paris, France
| | - Fabien Zoulim
- INSERM U1052-Centre de Recherche sur le Cancer de Lyon (CRCL), Lyon, France.,UMR_S1052, CRCL, University of Lyon, Lyon, France.,Department of Hepatology, Hospices Civils de Lyon, Lyon, France
| | - Karine Lacombe
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Saint Antoine Hospital, AP-HP, Sorbonne Université, Paris, France.,Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, AP-HP, Paris, France
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11
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Gossez M, Martin GE, Pace M, Ramjee G, Premraj A, Kaleebu P, Rees H, Inshaw J, Stöhr W, Meyerowitz J, Hopkins E, Jones M, Hurst J, Porter K, Babiker A, Fidler S, Frater J. Virological remission after antiretroviral therapy interruption in female African HIV seroconverters. AIDS 2019; 33:185-197. [PMID: 30325764 DOI: 10.1097/qad.0000000000002044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION There are few data on the frequency of virological remission in African individuals after treatment with antiretroviral therapy (ART) in primary HIV infection (PHI). METHODS We studied participants (n = 82) from South Africa and Uganda in Short Pulse Antiretroviral Treatment at HIV-1 Seroconversion, the first trial of treatment interruption in African individuals with PHI randomized to deferred ART or 48 weeks of immediate ART. All were female and infected with non-B HIV subtypes, mainly C. We measured HIV DNA in CD4+ T cells, CD4+ cell count, plasma viral load (pVL), cell-associated HIV RNA and T-cell activation and exhaustion. We explored associations with clinical progression and time to pVL rebound after treatment interruption (n = 22). Data were compared with non-African Short Pulse Antiretroviral Treatment at HIV-1 Seroconversion participants. RESULTS Pretherapy pVL and integrated HIV DNA were lower in Africans compared with non-Africans (median 4.16 vs. 4.72 log10 copies/ml and 3.07 vs. 3.61 log10 copies/million CD4+ T cells, respectively; P < 0.001). Pre-ART HIV DNA in Africans was associated with clinical progression (P = 0.001, HR per log10 copies/million CD4+ T cells increase (95% CI) 5.38 (1.95-14.79)) and time to pVL rebound (P = 0.034, HR per log10 copies/ml increase 4.33 (1.12-16.84)). After treatment interruption, Africans experienced longer duration of viral remission than non-Africans (P < 0.001; HR 3.90 (1.75-8.71). Five of 22 African participants (22.7%) maintained VL less than 400 copies/ml over a median of 188 weeks following treatment interruption. CONCLUSION We find evidence of greater probability of virological remission following treatment interruption among African participants, although we are unable to differentiate between sex, ethnicity and viral subtype. The finding warrants further investigation.
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Affiliation(s)
- Morgane Gossez
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | | | - Matthew Pace
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Gita Ramjee
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Anamika Premraj
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Pontiano Kaleebu
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Helen Rees
- Wits Reproductive Health and HIV Institute of the University of the Witwatersrand, Johannesburg, South Africa
| | - Jamie Inshaw
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology
| | - Wolfgang Stöhr
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology
| | - Jodi Meyerowitz
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Emily Hopkins
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Mathew Jones
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Jacob Hurst
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | | | - Abdel Babiker
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology
| | - Sarah Fidler
- Division of Medicine, Wright Fleming Institute, Imperial College, London
| | - John Frater
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
- The Oxford Martin School
- Oxford National Institute of Health Research Biomedical Research Centre, Oxford, UK
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12
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Boyd A, Moh R, Maylin S, Abdou Chekaraou M, Mahjoub N, Gabillard D, Anglaret X, Eholié SP, Delaugerre C, Danel C, Zoulim F, Lacombe K. Precore G1896A mutation is associated with reduced rates of HBsAg seroclearance in treated HIV hepatitis B virus co-infected patients from Western Africa. J Viral Hepat 2018; 25:1121-1131. [PMID: 29660214 DOI: 10.1111/jvh.12914] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/20/2018] [Indexed: 12/22/2022]
Abstract
The nucleotide substitution G1896A on the precore (pc) region has been implicated in virological and serological responses during treatment in hepatitis B virus (HBV)-infected patients. Whether this mutation affects the therapeutic course of HIV-HBV co-infected patients, especially from Western Africa, is unknown. In this prospective cohort study, 86 antiretroviral (ARV)-naïve HIV-HBV co-infected patients from Côte d'Ivoire, initiating ARV-treatment containing lamivudine (n = 53) or tenofovir (n = 33), had available baseline pc sequences. Association of the pcG1896A mutation with time to undetectable HBV-DNA, hepatitis B "e" antigen (HBeAg) seroclearance (in HBeAg-positive patients), and hepatitis B surface antigen (HBsAg) seroclearance was evaluated using Cox proportional hazards regression. At ARV-initiation, median HBV-DNA was 6.04 log10 copies/mL (IQR = 3.70-7.93) with 97.7% harbouring HBV genotype E. Baseline pcG1896A mutation was identified in 51 (59.3%) patients, who were more commonly HBeAg-negative (P < .001) and had basal core promotor A1762T/G1764A mutations (P < .001). Patients were followed for a median 36 months (IQR = 24-36). Cumulative proportion of undetectable HBV-DNA was significantly higher in patients with baseline mutation (pcG1896A = 86.6% vs no pcG1896A = 66.9%, P = .04), but not after adjusting for baseline HBV-DNA levels and anti-HBV agent (P = .2). No difference in cumulative proportion of HBeAg seroclearance was observed between mutation groups (pcG1896A = 57.1% vs no pcG1896A = 54.3%, P = .7). Significantly higher cumulative proportion of HBsAg seroclearance was observed in patients without this mutation (pcG1896A = 0% vs no pcG1896A = 36.9%, P < .001), even after adjusting for baseline HBsAg quantification and anti-HBV agent (P < .001). In conclusion, lacking the pcG1896A mutation before ARV initiation appeared to increase HBsAg seroclearance rates during treatment. The therapeutic implications of this mutation need further exploration in this setting.
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Affiliation(s)
- A Boyd
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, Paris, France
| | - R Moh
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire
| | - S Maylin
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France
| | | | - N Mahjoub
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France
| | - D Gabillard
- INSERM, U1219, Bordeaux, France.,University of Bordeaux, ISPED, Bordeaux, France
| | - X Anglaret
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire.,INSERM, U1219, Bordeaux, France.,University of Bordeaux, ISPED, Bordeaux, France
| | - S P Eholié
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire
| | - C Delaugerre
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France.,INSERM U941, Paris, France
| | - C Danel
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire.,INSERM, U1219, Bordeaux, France.,University of Bordeaux, ISPED, Bordeaux, France
| | - F Zoulim
- INSERM U1052- Cancer Research Center of Lyon (CRCL), Lyon, France.,University of Lyon, UMR_S1052, CRCL, Lyon, France.,Department of Hepatology, Hospices Civils de Lyon, Lyon, France
| | - K Lacombe
- Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, AP-HP, Paris, France.,INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Hôpital Saint Antoine, AP-HP, Sorbonne Université, Paris, France
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13
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Churchill D, Waters L, Ahmed N, Angus B, Boffito M, Bower M, Dunn D, Edwards S, Emerson C, Fidler S, Fisher M, Horne R, Khoo S, Leen C, Mackie N, Marshall N, Monteiro F, Nelson M, Orkin C, Palfreeman A, Pett S, Phillips A, Post F, Pozniak A, Reeves I, Sabin C, Trevelion R, Walsh J, Wilkins E, Williams I, Winston A. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015. HIV Med 2018; 17 Suppl 4:s2-s104. [PMID: 27568911 DOI: 10.1111/hiv.12426] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | - Mark Bower
- Chelsea and Westminster Hospital, London, UK
| | | | - Simon Edwards
- Central and North West London NHS Foundation Trust, UK
| | | | - Sarah Fidler
- Imperial College School of Medicine at St Mary's, London, UK
| | | | | | | | | | | | | | | | - Mark Nelson
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Caroline Sabin
- Royal Free and University College Medical School, London, UK
| | | | - John Walsh
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Ian Williams
- Royal Free and University College Medical School, London, UK
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14
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Schreiber-Stainthorp W, Sinharay S, Srinivasula S, Shah S, Wang J, Dodd L, Lane HC, Di Mascio M, Hammoud DA. Brain 18F-FDG PET of SIV-infected macaques after treatment interruption or initiation. J Neuroinflammation 2018; 15:207. [PMID: 30007411 PMCID: PMC6046092 DOI: 10.1186/s12974-018-1244-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/29/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Although rates of severe HIV-associated neurocognitive disorders have declined in the post-antiretroviral treatment (ART) era, subtle deficits persist, possibly exacerbated by treatment non-adherence. The actual effects of ART interruption/initiation on brain glucose metabolism as a reflection of viral replication and neuroinflammation remain unclear. Our study investigates how treatment initiation and interruption alter brain glucose metabolism in SIV-infected macaques, using 18F-FDG PET in correlation with plasma and CSF viral loads (VL) and cytokine levels. METHODS SIV-infected macaques (n = 7) underwent ART initiation only, ART interruption only, or both. Five uninfected animals served as controls. 18F-FDG PET imaging was performed at baseline and 1, 3, and 6 months after treatment modification. Mean and maximum standardized uptake values (SUV) for the whole-brain and subregions were calculated. Plasma and CSF VL and cytokine levels were measured. Paired t tests evaluated acute changes in whole-brain SUV from baseline to 1 month, while mixed-effect linear regression models evaluated changes over multiple timepoints and correlated SUV values with disease markers. RESULTS ART interruption was associated with increased SUVmean and SUVmax acutely, after 1 month (SUVmean 95% CI [0.044-0.786 g/ml], p = 0.037; SUVmax 95% CI [0.122-3.167 g/ml], p = 0.041). The correlation between SUV and time, however, was not significant when evaluated across all timepoints. Increased SUVmean and SUVmax correlated with decreased CD4+ and CD8+ T-cell counts and increased plasma VL. SUVmax was positively associated with increases in CSF VL, and there were borderline positive associations between SUVmax and IL-2, and between SUVmean and IL-15. The treatment initiation group showed no associations between imaging and disease biomarkers despite viral suppression, reduced cytokine levels, and increased CD4+ and CD8+ T-cell counts. CONCLUSIONS ART interruption is associated with increased brain glucose metabolism within 1 month of treatment cessation, which, in concert with increased levels of pro-inflammatory cytokines in the CSF, may reflect neuroinflammation in the setting of viral rebound. Although we cannot assert neurologic damage in association with cerebral hypermetabolism, it is a concerning outcome of ART non-adherence. Treatment initiation, meanwhile, did not result in significant changes in brain metabolism. HIV-induced neuroinflammation may require a longer period to abate than our follow-up period allowed.
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Affiliation(s)
| | - Sanhita Sinharay
- Center for Infectious Disease Imaging, Clinical Center, National Institutes of Health, Bethesda, MD USA
| | - Sharat Srinivasula
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., National Cancer Institute Campus at Frederick, Frederick, MD USA
| | - Swati Shah
- Center for Infectious Disease Imaging, Clinical Center, National Institutes of Health, Bethesda, MD USA
| | - Jing Wang
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., National Cancer Institute Campus at Frederick, Frederick, MD USA
| | - Lori Dodd
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD USA
| | - H. Clifford Lane
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD USA
| | - Michele Di Mascio
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD USA
| | - Dima A. Hammoud
- Center for Infectious Diseases Imaging (CIDI), Clinical Center, National Institutes of Health (NIH), 10 Center Drive, Building 10, Room 1C-368, Bethesda, MD 20892 USA
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15
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Houghtaling L, Moh R, Abdou Chekaraou M, Gabillard D, Anglaret X, Eholié SP, Zoulim F, Danel C, Lacombe K, Boyd A. CD4+ T Cell Recovery and Hepatitis B Virus Coinfection in HIV-Infected Patients from Côte d'Ivoire Initiating Antiretroviral Therapy. AIDS Res Hum Retroviruses 2018; 34:439-445. [PMID: 29466862 DOI: 10.1089/aid.2017.0272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Immunorecovery could be attenuated in HIV-hepatitis B virus (HBV) coinfection versus HIV monoinfection during antiretroviral therapy (ART), yet, whether it also occurs in individuals from sub-Saharan Africa without severe comorbidities is unknown. In this study, 808 HIV-infected patients in Côte d'Ivoire initiating continuous ART were included. Six-month CD4+ count trajectories and the proportion reaching CD4+ T cell counts >350/mm3, HIV-RNA <300 copies/mL, still alive and not lost to follow-up within 18 months ("optimal immunorecovery") were compared between coinfected groups. At inclusion, 80 (9.9%) patients were HIV-HBV coinfected, 40 (50.0%) of whom had high HBV-DNA viral load (VL) (>104 copies/mL). Coinfected patients with high HBV-DNA replication initiated ART with significantly lower median CD4+ T cell counts [216/mm3, interquartile range (IQR) = 150-286] compared to coinfection with low HBV-DNA replication (268/mm3, IQR = 178-375) or HIV monoinfection (257/mm3, IQR = 194-329) (p = .003). These patients had significantly faster rates of CD4+ cell count increase from baseline after adjusting for baseline age, World Health Organization stage III/IV, and CD4+ cell counts (p = .04), yet, were not more likely to exhibit optimal immunorecovery (82.5% vs. 80.0% and 77.9%, respectively) (p = .8). In conclusion, change in CD4+ cell counts after ART-initiation was accelerated in coinfected patients with high HBV DNA VLs, but this did not lead to increased rates of optimal immunorecovery.
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Affiliation(s)
- Laura Houghtaling
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Raoul Moh
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
- Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire
- Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire
| | | | - Delphine Gabillard
- INSERM, U1219, Epidémiologie-Biostatistique, Bordeaux, France
- University of Bordeaux, ISPED, Bordeaux, France
| | - Xavier Anglaret
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
- INSERM, U1219, Epidémiologie-Biostatistique, Bordeaux, France
- University of Bordeaux, ISPED, Bordeaux, France
| | - Serge Paul Eholié
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
- Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire
- Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire
| | - Fabien Zoulim
- Cancer Research Center of Lyon, INSERM, Unité 1052, CNRS, UMR 5286, Lyon, France
| | - Christine Danel
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
- INSERM, U1219, Epidémiologie-Biostatistique, Bordeaux, France
- University of Bordeaux, ISPED, Bordeaux, France
| | - Karine Lacombe
- Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, AP-HP, Paris, France
- INSERM, Sorbonne Universités, Institut Pierre Louis d'épidémiologie et de Santé Publique, F75012, Paris, France
| | - Anders Boyd
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F75012, Paris, France
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16
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Song A, Liu X, Huang X, Meyers K, Oh DY, Hou J, Xia W, Su B, Wang N, Lu X, Xia H, Yang X, Chen H, Wu H. From CD4-Based Initiation to Treating All HIV-Infected Adults Immediately: An Evidence-Based Meta-analysis. Front Immunol 2018; 9:212. [PMID: 29487595 PMCID: PMC5816781 DOI: 10.3389/fimmu.2018.00212] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 01/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background The World Health Organization (WHO) Consolidated antiretroviral therapy (ART) guidelines set the CD4+ T-cell counts threshold to 500 cells/mm3 in 2013, and 2015 guidelines recommend treating all HIV-infected adults regardless of their CD4+ T-cell counts. To inform the decision-making around ART guidelines for people living with HIV, we systematically reviewed the literature to estimate differences in clinical benefits between individuals starting treatment with baseline CD4+ T-cell counts ≥500 cells/mm3 (early initiation) as compared to <500 cells/mm3 (deferred initiation). Methods We systematically searched the electronic databases and abstracts for randomized controlled trials (RCT) and observational studies. Outcomes were mortality, AIDS progression, AIDS or death, immunologic recovery, and virologic suppression. We pooled data across studies and performed analyses of effect sizes. Results We identified 13 studies comparing early and deferred treatment. The pooled risk ratio (RR) of mortality of 11 observational studies was 0.90 (95% CI 0.82–0.99), with moderate heterogeneity (I2 = 53%). The pooled RR for progression to AIDS from two observational studies was 0.77 (95% CI 0.47–1.24). Five observational studies found a pooled RR of death or AIDS of 0.94 (95% CI 0.93–0.95). For the outcome of immunologic recovery, defined as CD4+ T-cell counts reaching at least 800 cells/mm3 after ART, one observational study found early initiation of ART had an HR (hazard ratio) of 2.39 (95% CI 1.93–2.96). The pooled RR of viral suppression (a viral load <50 copies/ml) after 9 months from one cohort was 1.04 (95% CI 0.99–1.09). Conclusion Mortality risk and risk for AIDS appear to be reduced among people living with HIV with early initiation of ART, based on current WHO guidelines, as compared to those with deferred initiation of ART (<500 cells/mm3).
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Affiliation(s)
- Aixin Song
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xinchao Liu
- Infectious Diseases Department, Peking Union Medical College Hospital, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Kathrine Meyers
- The Aaron Diamond AIDS Research Center, New York, NY, United States
| | - Djin-Ye Oh
- The Aaron Diamond AIDS Research Center, New York, NY, United States
| | - Jianhua Hou
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Wei Xia
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Bin Su
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Ni Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Xiaofan Lu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Huan Xia
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaodong Yang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
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17
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Boyd A, Houghtaling L, Moh R, Chekaraou MA, Gabillard D, Eholié SP, Anglaret X, Zoulim F, Danel C, Lacombe K, For The Anrs Trivacan And Anrs VarBVA Studies. Clinical Outcomes during Treatment Interruptions in Human Immunodeficiency Virus-Hepatitis B Virus Co-infected Patients from Sub-Saharan Africa. Am J Trop Med Hyg 2017; 97:1936-1942. [PMID: 29141712 DOI: 10.4269/ajtmh.16-1016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Antiretroviral treatment (ART) interruptions increase the risk of severe morbidity/mortality in human immunodeficiency virus (HIV)-infected individuals from subSaharan Africa. We aimed to determine whether the risk is further increased among HIV-hepatitis B virus (HBV) co-infected patients in this setting. In this sub-analysis of a randomized-control trial, 632 participants from Côte d'Ivoire randomized to receive continuous-ART (C-ART), structured ART interruptions of 2-months off, 4-months on (2/4-ART), and CD4-guided ART interruptions (CD4GT, interruption at 350/mm3 and reintroduction at 250/mm3) were analyzed. Incidence rates (IR) of serious HIV- and non-HIV-related morbidity were compared between patients stratified on hepatitis B surface antigen (HBsAg) status. Overall, 65 (10.3%) were HBsAg-positive, 29 (44.6%) of whom had HBV-DNA levels > 10,000 copies/mL. After a median 2.0 year (range = 0.2-3.1) follow-up, ≥ 1 serious HIV-related events occurred in 101 HIV mono-infected and 15 HIV-HBV co-infected patients (IR = 10.0 versus 13.2/100 person/years, respectively, P = 0.3), whereas the highest incidence was observed in co-infected patients with baseline HBV-replication > 10,000 copies/mL (IR = 24.0/100 person/years, P versus HIV mono-infected = 0.002). Incidence of bacterial infections was also highest in the co-infected group with HBV-replication > 10,000 copies/mL (IR = 12.9 versus 3.3/100 person/years in HIV mono-infected patients, P = 0.001). The relative effect of CD4GT or 2/4-ART versus C-ART was not different between infection groups (P for interaction = 0.4). No increase in the incidence of non-HIV-related morbidity was observed for co-infected patients (P = 0.5), even at HBV-replication levels > 10,000 copies/mL (P = 0.7). In conclusion, co-infected patients with elevated HBV-replication at ART-initiation are more susceptible to HIV-related morbidity, especially invasive bacterial diseases, during treatment interruption.
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Affiliation(s)
- Anders Boyd
- INSERM, UMR_S1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Laura Houghtaling
- Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota
| | - Raoul Moh
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Mariama Abdou Chekaraou
- Centre de Recherche sur le Cancer de Lyon, Equipes 15 et 16, INSERM, Unité 1052, CNRS, UMR 5286, Lyon, France
| | - Delphine Gabillard
- University of Bordeaux, ISPED, Bordeaux, France.,Epidémiologie-Biostatistique, INSERM, U1219, Bordeaux, France
| | - Serge Paul Eholié
- Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Xavier Anglaret
- University of Bordeaux, ISPED, Bordeaux, France.,Epidémiologie-Biostatistique, INSERM, U1219, Bordeaux, France.,Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Fabien Zoulim
- Centre de Recherche sur le Cancer de Lyon, Equipes 15 et 16, INSERM, Unité 1052, CNRS, UMR 5286, Lyon, France
| | - Christine Danel
- University of Bordeaux, ISPED, Bordeaux, France.,Epidémiologie-Biostatistique, INSERM, U1219, Bordeaux, France.,Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Karine Lacombe
- Sorbonne Universités, INSERM, UPMC Univ Paris 06, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France.,Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, AP-HP, Paris, France
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18
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Lewis J, Payne H, Walker AS, Otwombe K, Gibb DM, Babiker AG, Panchia R, Cotton MF, Violari A, Klein N, Callard RE. Thymic Output and CD4 T-Cell Reconstitution in HIV-Infected Children on Early and Interrupted Antiretroviral Treatment: Evidence from the Children with HIV Early Antiretroviral Therapy Trial. Front Immunol 2017; 8:1162. [PMID: 28979264 PMCID: PMC5611383 DOI: 10.3389/fimmu.2017.01162] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 09/01/2017] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Early treatment of HIV-infected children and adults is important for optimal immune reconstitution. Infants' immune systems are more plastic and dynamic than older children's or adults', and deserve particular attention. This study aimed to understand the response of the HIV-infected infant immune system to early antiretroviral therapy (ART) and planned ART interruption and restart. METHODS Data from HIV-infected children enrolled the CHER trial, starting ART aged between 6 and 12 weeks, were used to explore the effect of ART on immune reconstitution. We used linear and non-linear regression and mixed-effects models to describe children's CD4 trajectories and to identify predictors of CD4 count during early and interrupted ART. RESULTS Early treatment arrested the decline in CD4 count but did not fully restore it to the levels observed in HIV-uninfected children. Treatment interruption at 40 or 96 weeks resulted in a rapid decline in CD4 T-cells, which on retreatment returned to levels observed before interruption. Naïve CD4 T-cell count was an important determinant of overall CD4 levels. A strong correlation was observed between thymic output and the stable CD4 count both before and after treatment interruption. CONCLUSION Early identification and treatment of HIV-infected infants is important to stabilize CD4 counts at the highest levels possible. Once stabilized, children's CD4 counts appear resilient, with good potential for recovery following treatment interruption. The naïve T-cell pool and thymic production of naive cells are key determinants of children's CD4 levels.
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Affiliation(s)
- Joanna Lewis
- CoMPLEX, University College London, London, United Kingdom
- NIHR Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Helen Payne
- Institute of Child Health, University College London, London, United Kingdom
| | - A. Sarah Walker
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diana M. Gibb
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Abdel G. Babiker
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Ravindre Panchia
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark F. Cotton
- Children’s Infectious Diseases Clinical Research Unit, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Avy Violari
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nigel Klein
- Institute of Child Health, University College London, London, United Kingdom
| | - Robin E. Callard
- CoMPLEX, University College London, London, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
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Ghehi C, Gabillard D, Moh R, Badje A, Kouamé GM, Oouttara E, Ahibo H, N’Takpé JB, Lecarrou J, Eholié SP, Anglaret X, Danel C. High correlation between Framingham equations with BMI and with lipids to estimate cardiovascular risks score at baseline in HIV-infected adults in the Temprano trial, ANRS 12136 in Côte d'Ivoire. PLoS One 2017; 12:e0177440. [PMID: 28582393 PMCID: PMC5459337 DOI: 10.1371/journal.pone.0177440] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 04/27/2017] [Indexed: 01/14/2023] Open
Abstract
Context Data on cardiovascular risk (CVR) score among HIV-infected patients in sub-Saharan Africa are scarce. Our first objective was to compare the CVR score of Framingham utilizing BMI and lipids at baseline, and secondary to assess evolution of CVR score over time at Month 30 in the Temprano trial. Methods HIV-infected adults with CD4 <800/mm3 without criteria for initiating ART were included and followed for 30 months in the Temprano trial, which assessed the benefits and risks of early antiretroviral treatment (ART) vs deferred ART. CVR score was estimated at baseline and Month-30 using Framingham equations with either BMI or lipids and classified as high (>20%), moderate (10–20%), and low risk (<10%). At baseline, we compare these two estimations utilizing the Pearson correlation test and analyze the increasing CV risk score over time by Proportional odds cumulative logit models for people attending the Month-30 (M30) visit. Results Among the 2056 patients, 78% were women, median age was 35 years, and median CD4 count was 464/mm3, 6.8% were obese, 6.3% had hypertension, 7.8% were smokers (1.8% women, 26.8% men), 19% had Total Cholesterol (TC) >5mmol/L, and 1% diabetes at baseline. At baseline the concordance between the two Framingham equations was excellent (r = 0.95; p<0.0001). Among the 1700 patients who attended M30 visit and with available data, 1.3% had a high CV risk score at baseline and 3.1% at M30 visit using Framingham equation with BMI. Adjusted odds ratio (aOR) of being at a higher CV risk score at M30 visit compared to a higher CV risk score at M0 visit was 1.35 (CI 95% 1.17–1.57). Stratified by sex, the increasing CV risk score was OR 1.73 (CI 95%: 1.30–2.29) for women and OR 1.24 (CI 95%: 1.02–1.50) for men. Early ART was not associated with an increasing CV risk score (p = 0.88). Results for the 1422 patients with Framingham equation using lipids were similar. Conclusion In a large trial evaluating early ART for HIV infection in Côte d’Ivoire, Framingham equation with BMI and lipids were highly correlated and CV risk score increases over time. Early ART was not significantly associated with this increasing CV risk score.
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Affiliation(s)
- Calixte Ghehi
- Programme PACCI - ANRS research site, Abidjan, Côte d’Ivoire
- Inserm U1219, Université de Bordeaux, Bordeaux, France
- Unité de Soins Ambulatoire et de Conseil (USAC), Abidjan, Côte d’Ivoire
| | | | - Raoul Moh
- Programme PACCI - ANRS research site, Abidjan, Côte d’Ivoire
- Inserm U1219, Université de Bordeaux, Bordeaux, France
- Service des Maladies Infectieuses et Tropicales, CHU de Treichville, Abidjan, Côte d’Ivoire
| | - Anani Badje
- Programme PACCI - ANRS research site, Abidjan, Côte d’Ivoire
- Inserm U1219, Université de Bordeaux, Bordeaux, France
| | | | - Eric Oouttara
- Inserm U1219, Université de Bordeaux, Bordeaux, France
| | - Hugues Ahibo
- Centre de Recherche et Diagnostic sur le SIDA, (Cedres) CHU de Treichville, Abidjan, Côte d’Ivoire
| | | | | | - Serge Paul Eholié
- Programme PACCI - ANRS research site, Abidjan, Côte d’Ivoire
- Inserm U1219, Université de Bordeaux, Bordeaux, France
- Service des Maladies Infectieuses et Tropicales, CHU de Treichville, Abidjan, Côte d’Ivoire
| | - Xavier Anglaret
- Programme PACCI - ANRS research site, Abidjan, Côte d’Ivoire
- Inserm U1219, Université de Bordeaux, Bordeaux, France
| | - Christine Danel
- Programme PACCI - ANRS research site, Abidjan, Côte d’Ivoire
- Inserm U1219, Université de Bordeaux, Bordeaux, France
- * E-mail:
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20
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Ahonkhai AA, Adeola J, Banigbe B, Onwuatuelo I, Adegoke AB, Bassett IV, Losina E, Freedberg KA, Okonkwo P, Regan S. Impact of Unplanned Care Interruption on CD4 Response Early After ART Initiation in a Nigerian Cohort. J Int Assoc Provid AIDS Care 2016; 16:98-104. [PMID: 28084189 PMCID: PMC5289066 DOI: 10.1177/2325957416672010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors conducted a retrospective cohort study of unplanned care interruption (UCI) among adults initiating antiretroviral therapy (ART) from 2009 to 2011 in a Nigerian clinic. The authors used repeated measures regression to model the impact of UCI on CD4 count upon return to care and rate of CD4 change on ART. Among 2496 patients, 83% had 0, 15% had 1, and 2% had ≥2 UCIs. Mean baseline CD4 for those with 0, 1, or ≥2 UCIs was 228/cells/mm3, 355/cells/mm3, and 392/cells/mm3 ( P < .0001), respectively. The UCI was associated with a 62 CD4 cells/mm3 decrease (95% confidence interval [CI]: -78 to -45) at next measurement. In months 1 to 6 on ART, patients with 0 UCI gained 10 cells/µL/mo (95% CI: 7-4). Those with 1 and ≥2 UCIs lost 2 and 5 cells/µL/mo (95% CI: -18 to 13 and -26 to 16). Patients with UCI did not recover from early CD4 losses associated with UCI. Preventing UCI is critical to maximize benefits of ART.
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Affiliation(s)
- Aimalohi A. Ahonkhai
- Division of infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Juliet Adeola
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria
| | - Bolanle Banigbe
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria
| | | | | | - Ingrid V. Bassett
- Division of infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Kenneth A. Freedberg
- Division of infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Susan Regan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
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Eholié SP, Badje A, Kouame GM, N’takpe JB, Moh R, Danel C, Anglaret X. Antiretroviral treatment regardless of CD4 count: the universal answer to a contextual question. AIDS Res Ther 2016; 13:27. [PMID: 27462361 PMCID: PMC4960900 DOI: 10.1186/s12981-016-0111-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 07/12/2016] [Indexed: 02/06/2023] Open
Abstract
After a period where it was recommended to start antiretroviral therapy (ART) early, the CD4 threshold for treating asymptomatic adults dropped to 200/mm3 at the beginning of the 2000s. This was mostly due to a great prudence with regards to drug toxicity. The ART-start CD4 threshold in most international guidelines was then raised to 350/mm3 in 2006–2009 and to 500/mm3 in 2009–2013. Between 2012 and 2015, international guidelines went the last step further and recommended treating all HIV-infected adults regardless of their CD4 count. This ultimate step was justified by the results of three randomized controlled trials, HPTN 052, Temprano ANRS 12136 and START. These three trials assessed the benefits and risks of starting ART immediately upon inclusion (“early ART”) versus deferring ART until the current starting criteria were met (“deferred ART”). Taken together, they recruited 8427 HIV-infected adults in 37 countries. The primary outcome was severe morbidity, a composite outcome that included all-cause deaths, AIDS diseases, and non-AIDS cancers in the three trials. The trial results were mutually consistent and reinforcing. The overall risk of severe morbidity was significantly 44–57 % lower in patients randomized to early ART as compared to deferred ART. Early ART also decreased the risk of AIDS, tuberculosis, invasive bacterial diseases and Kaposi’s sarcoma considered separately. The incidence of severe morbidity was 3.2 and 3.5 times as high in HPTN052 and Temprano as in START, respectively. This difference is mostly due to the geographical context of morbidity. The evidence is now strong that initiating ART at high CD4 counts entails individual benefits worldwide, and that this is all the more true in low resource contexts where tuberculosis and other bacterial diseases are highly prevalent. These benefits in addition to population benefits consisting of preventing HIV transmission demonstrated in HPTN052, justify the recommendation that HIV-infected persons should initiate ART regardless of CD4 count. This recommendation faces many challenges, including the fact that switching from “treat at 500 CD4/mm3” to “treat everyone” not only requires more tests and more drugs, but also more people to support patients and help them remain in care.
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The impact of transient combination antiretroviral treatment in early HIV infection on viral suppression and immunologic response in later treatment. AIDS 2016; 30:879-88. [PMID: 26636925 PMCID: PMC4794189 DOI: 10.1097/qad.0000000000000991] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: Effects of transient combination antiretroviral treatment (cART) initiated during early HIV infection (EHI) remain unclear. We investigate whether this intervention affects viral suppression and CD4+ cell count increase following its reinitiation in chronic infection (CHI). Design: Longitudinal observational study. Methods: We identified adult patients from Concerted Action of Seroconversion to AIDS and Death in Europe who seroconverted after 1/1/2000, had a 12 months or less HIV test interval and initiated cART from naive. We classified individuals as ‘pretreated in EHI’ if treated within 6 months of seroconversion, interrupted for at least 12 weeks, and reinitiated during CHI. Statistical analysis was performed using survival analysis methods and mixed models. Results: Pretreated and initiated in CHI groups comprised 202 and 4263 individuals, with median follow-up after CHI treatment 4.5 and 3 years, respectively. Both groups had similar virologic response and relapse rates (P = 0.585 and P = 0.206) but pretreated individuals restarted treatment with higher baseline CD4+ cell count (∼80 cells/μl; P < 0.001) and retained significantly higher CD4+ cell count for more than 3 years after treatment (re)initiation. Assuming common baseline CD4+ cell count, differences in CD4+ cell count slopes were nonsignificant. Immunovirologic response to CHI treatment was not associated with timing or duration of the transient treatment. Conclusion: Although treatment interruptions are not recommended, stopping cART initiated in EHI does not seem to reduce the chance of a successful outcome of treatment in CHI.
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23
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Ouattara EN, Robine M, Eholié SP, MacLean RL, Moh R, Losina E, Gabillard D, Paltiel AD, Danel C, Walensky RP, Anglaret X, Freedberg KA. Laboratory Monitoring of Antiretroviral Therapy for HIV Infection: Cost-Effectiveness and Budget Impact of Current and Novel Strategies. Clin Infect Dis 2016; 62:1454-1462. [PMID: 26936666 DOI: 10.1093/cid/ciw117] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/24/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Optimal laboratory monitoring of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) remains controversial. We evaluated current and novel monitoring strategies in Côte d'Ivoire, West Africa. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications -International model to compare clinical outcomes, cost-effectiveness, and budget impact of 11 ART monitoring strategies varying by type (CD4 and/or viral load [VL]) and frequency. We included "adaptive" strategies (biannual then annual monitoring for patients on ART/suppressed). Mean CD4 count at ART initiation was 154/μL. Laboratory test costs were CD4=$11 and VL=$33. The standard of care (SOC; biannual CD4) was the comparator. We assessed cost-effectiveness relative to Côte d'Ivoire's 2013 per capita GDP ($1500). RESULTS Discounted life expectancy was 16.69 years for SOC, 16.97 years with VL confirmation of immunologic failure, and 17.25 years for adaptive VL. Mean time on failed first-line ART was 3.7 years for SOC and <0.9 years for all routine/adaptive VL strategies. VL failure confirmation was cost-saving compared with SOC. Adaptive VL had an incremental cost-effectiveness ratio (ICER) of $4100/year of life saved compared with VL confirmation and increased the 5-year budget by $310/patient compared with SOC. Adaptive VL achieved an ICER <1× GDP if second-line ART and VL costs simultaneously decreased to $156 and $13, respectively. CONCLUSIONS VL confirmation of immunologic failure is more effective and less costly than CD4 monitoring in Côte d'Ivoire. Adaptive VL monitoring reduces time on failing ART, is cost-effective, and should become standard in Côte d'Ivoire and similar settings.
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Affiliation(s)
- Eric N Ouattara
- Institut National de la Santé et de la Recherche Médicale Centre 897.,Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.,Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.,Interdepartmental Centre of Tropical Medicine and Clinical International Health, Division of Infectious and Tropical Diseases, Department of Medicine, University Hospital Centre, Bordeaux, France
| | - Marion Robine
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Serge P Eholié
- Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Rachel L MacLean
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Raoul Moh
- Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire.,Department of Infectious and Tropical Diseases, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Elena Losina
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Delphine Gabillard
- Institut National de la Santé et de la Recherche Médicale Centre 897.,Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France
| | | | - Christine Danel
- Institut National de la Santé et de la Recherche Médicale Centre 897.,Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.,Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire
| | - Rochelle P Walensky
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School.,Division of Infectious Diseases, Brigham and Women's Hospital
| | - Xavier Anglaret
- Institut National de la Santé et de la Recherche Médicale Centre 897.,Institut de Santé Publique d'Epidémiologique et de Développement, University of Bordeaux, France.,Programme PACCI/Agence Nationale de Recherche sur le SIDA et les hépatites virales Research Site, Treichville University Hospital Center, Abidjan, Côte d'Ivoire
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School.,Department of Epidemiology, Boston University School of Public Health.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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24
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Boyd A, Maylin S, Moh R, Mahjoub N, Gabillard D, Eholié SP, Danel C, Anglaret X, Zoulim F, Girard PM, Delaugerre C, Lacombefor K. Hepatitis B surface antigen quantification as a predictor of seroclearance during treatment in HIV-hepatitis B virus coinfected patients from Sub-Saharan Africa. J Gastroenterol Hepatol 2016; 31:634-44. [PMID: 26313291 DOI: 10.1111/jgh.13156] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM In Sub-Saharan Africa, seroclearance of hepatitis B surface antigen (HBsAg) and hepatitis B "e" antigen (HBeAg), including their quantifiable markers, have rarely been evaluated during long-term antiviral treatment among patients coinfected with HIV and hepatitis B virus (HBV). METHODS In this prospective cohort study from two randomized-control trials in Côte d'Ivoire, 161 antiretroviral-naïve HIV-HBV coinfected patients starting lamivudine (n = 76) or tenofovir/emtricitabine (n = 85) containing antiretroviral therapy were included. HBV DNA was quantified using an in-house assay (detection limit = 12 copies/mL) and HBsAg quantification (qHBsAg) using the Elecsys assay. RESULTS Overall, 33 (20.5%) patients were HBeAg positive, 121 (75.2%) had detectable HBV DNA, and 92/93 (98.9%) harbored HBV genotype E. Median treatment duration was 35.5 months (interquartile range: 24.3-36.4). Among HBeAg-positive patients, cumulative proportion with HBeAg seroclearance was 46.3% (n = 14). Overall, cumulative proportion of HBsAg seroclearance was 6.6% (n = 10). Lower baseline qHBsAg levels and strong 12-month declines in qHBsAg were significantly associated with HBsAg seroclearance for both HBeAg-negative and HBeAg-positive patients. When taken at certain levels, these determinants provided moderate sensitivity (Se) and specificity (Sp) in predicting HBsAg seroclearance at month 36 (≤ 1000 IU/mL at baseline, Se = 0.80, Sp = 0.80; ≥ 1.0 log10 IU/mL drop at month 12, Se = 0.57, Sp = 1.00). Instead, qHBsAg levels ≤ 100 or ≤ 10 IU/mL at month 12 were optimal (both Se = 0.90 and Sp = 1.00). Detectable HBV-DNA provided fairly high Se and Sp when evaluated at baseline (Se = 1.00, Sp = 0.80), but not at month 12 (Se = 0.80, Sp = 0.40). CONCLUSIONS HBsAg seroclearance rates are not common in patients from Sub-Saharan Africa treated with anti-HBV containing antiretroviral therapy. qHBsAg levels at 12 months of treatment may accurately predict HBsAg seroclearance.
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Affiliation(s)
- Anders Boyd
- INSERM, UMR_S1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Sarah Maylin
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France.,INSERM U941, Paris, France.,Université Paris-Diderot, Paris, France
| | - Raoul Moh
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Ivory Coast
| | - Nadia Mahjoub
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France.,INSERM U941, Paris, France
| | - Delphine Gabillard
- Epidémiologie-Biostatistique, INSERM, U897.,ISPED, University of Bordeaux, Bordeaux, France
| | - Serge Paul Eholié
- Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire.,Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Ivory Coast.,Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Ivory Coast
| | - Christine Danel
- Epidémiologie-Biostatistique, INSERM, U897.,ISPED, University of Bordeaux, Bordeaux, France.,Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Ivory Coast
| | - Xavier Anglaret
- Epidémiologie-Biostatistique, INSERM, U897.,ISPED, University of Bordeaux, Bordeaux, France.,Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Ivory Coast
| | - Fabien Zoulim
- Centre de Recherche sur le Cancer de Lyon, Equipes 15 et 16, INSERM, Unité 1052, Lyon, France
| | - Pierre-Marie Girard
- Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, Paris, France.,Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Universités, UPMC Univ Paris 06, UMR S 1136, Paris, France
| | - Constance Delaugerre
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France.,INSERM U941, Paris, France.,Université Paris-Diderot, Paris, France
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25
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Implementation and Operational Research: Integration of PMTCT and Antenatal Services Improves Combination Antiretroviral Therapy Uptake for HIV-Positive Pregnant Women in Southern Zambia: A Prototype for Option B+? J Acquir Immune Defic Syndr 2016; 70:e123-9. [PMID: 26181813 DOI: 10.1097/qai.0000000000000760] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Early initiation of combination antiretroviral therapy (cART) for HIV-positive pregnant women can decrease vertical transmission to less than 5%. Programmatic barriers to early cART include decentralized care, disease-stage assessment delays, and loss to follow-up. INTERVENTION Our intervention had 3 components: integrated HIV and antenatal services in 1 location with 1 provider, laboratory courier to expedite CD4 counts, and community-based follow-up of women-infant pairs to improve prevention of mother-to-child transmission attendance. Preintervention HIV-positive pregnant women were referred to HIV clinics for disease-stage assessment and cART initiation for advanced disease (CD4 count <350 cells/μL or WHO stage >2). METHODS We used a quasi-experimental design with preintervention/postintervention evaluations at 6 government antenatal clinics (ANCs) in Southern Province, Zambia. Retrospective clinical data were collected from clinic registers during a 7-month baseline period. Postintervention data were collected from all antiretroviral therapy-naive, HIV-positive pregnant women and their infants presenting to ANC from December 2011 to June 2013. RESULTS Data from 510 baseline women-infant pairs were analyzed and 624 pregnant women were enrolled during the intervention period. The proportion of HIV-positive pregnant women receiving CD4 counts increased from 50.6% to 77.2% [relative risk (RR) = 1.81; 95% confidence interval (CI): 1.57 to 2.08; P < 0.01]. The proportion of cART-eligible pregnant women initiated on cART increased from 27.5% to 71.5% (RR = 2.25; 95% CI: 1.78 to 2.83; P < 0.01). The proportion of eligible HIV-exposed infants with documented 6-week HIV PCR test increased from 41.9% to 55.8% (RR = 1.33; 95% CI: 1.18 to 1.51; P < 0.01). CONCLUSIONS Integration of HIV care into ANC and community-based support improved uptake of CD4 counts, proportion of cART-eligible women initiated on cART, and infants tested.
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de Ruiter A, Taylor GP, Clayden P, Dhar J, Gandhi K, Gilleece Y, Harding K, Hay P, Kennedy J, Low-Beer N, Lyall H, Palfreeman A, O'Shea S, Tookey P, Tosswill J, Welch S, Wilkins E. British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review). HIV Med 2015; 15 Suppl 4:1-77. [PMID: 25604045 DOI: 10.1111/hiv.12185] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Boyd A, Maylin S, Moh R, Gabillard D, Menan H, Mahjoub N, Danel C, Anglaret X, Eholié SP, Girard PM, Zoulim F, Delaugerre C, Lacombe K. Identifying patients infected with hepatitis B virus in sub-Saharan Africa: potential for misclassification. Diagn Microbiol Infect Dis 2015; 83:248-51. [PMID: 26283522 DOI: 10.1016/j.diagmicrobio.2015.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 07/07/2015] [Accepted: 07/16/2015] [Indexed: 11/17/2022]
Abstract
Most research in sub-Saharan Africa establishes hepatitis B infection via one-time hepatitis B surface antigen (HBsAg) testing. Of 237 HIV-infected patients from two clinical trials testing HBsAg positive (MiniVidas®), 206 (86.9%) had validated serological tests using another assay (Architect). Discrepancies could be due to inactive infection, highlighting the importance of assessing hepatitis B virus infection phase.
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Affiliation(s)
- Anders Boyd
- INSERM, UMR_S1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France.
| | - Sarah Maylin
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France; Université Paris-Diderot, Paris, France
| | - Raoul Moh
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire
| | - Delphine Gabillard
- INSERM, U897, Epidémiologie-Biostatistique, Bordeaux, France; University of Bordeaux, ISPED, Bordeaux, France
| | - Hervé Menan
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire; Centre de Diagnostic et de Recherche sur le SIDA et les Maladies Opportunistes (CeDReS), Centre Hospitalier Universitaires (CHU) de Treichville, Abidjan, Côte d'Ivoire
| | - Nadia Mahjoub
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France; Université Paris-Diderot, Paris, France
| | - Christine Danel
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire; INSERM, U897, Epidémiologie-Biostatistique, Bordeaux, France; University of Bordeaux, ISPED, Bordeaux, France
| | - Xavier Anglaret
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire; INSERM, U897, Epidémiologie-Biostatistique, Bordeaux, France; University of Bordeaux, ISPED, Bordeaux, France
| | - Serge Paul Eholié
- Programme PAC-CI, ANRS Research Site, Treichville University Hospital, Abidjan, Côte d'Ivoire; Department of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire; Medical School, University Felix Houphouet Boigny, Abidjan, Côte d'Ivoire
| | - Pierre-Marie Girard
- Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, AP-HP, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Fabien Zoulim
- Centre de Recherche sur le Cancer de Lyon, Equipes 15 et 16, INSERM, Unité 1052, CNRS, UMR 5286, Lyon, France
| | - Constance Delaugerre
- Laboratoire de Virologie, Hôpital Saint-Louis, AP-HP, Paris, France; INSERM U941, Paris, France; Université Paris-Diderot, Paris, France
| | - Karine Lacombe
- Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, AP-HP, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
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Tang B, Xiao Y, Cheke RA, Wang N. Piecewise virus-immune dynamic model with HIV-1 RNA-guided therapy. J Theor Biol 2015; 377:36-46. [PMID: 25908208 DOI: 10.1016/j.jtbi.2015.03.040] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 02/03/2015] [Accepted: 03/24/2015] [Indexed: 12/22/2022]
Abstract
Clinical studies have used CD4 T cell counts to evaluate the safety or risk of plasma HIV-1 RNA-guided structured treatment interruptions (STIs), aimed at maintaining CD4 T cell counts above a safe level and plasma HIV-1 RNA below a certain level. However, quantifying and evaluating the impact of STIs on the control of HIV replication and on activation of the immune response remains challenging. Here we extend the virus-immune dynamic system by including a piecewise smooth function to describe the elimination of HIV viral loads and the activation of effector cells under plasma HIV-1 RNA-guided therapy, in order to quantitatively explore the STI strategies. We theoretically investigate the global dynamics of the proposed Filippov system. Our main results indicate that HIV viral loads could either go to infinity or be maintained below a certain level or stabilize at a previously given level, depending on the threshold level and initial HIV virus loads and effector cell counts. This suggests that proper combinations of threshold and initial HIV virus loads and effector cell counts, based on threshold policy, can successfully preclude exceptionally high growth of HIV virus and, in particular, maximize the controllable region.
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Affiliation(s)
- Biao Tang
- School of Mathematics and Statistics, Xi׳an Jiaotong University, Xi׳an, 710049, PR China
| | - Yanni Xiao
- School of Mathematics and Statistics, Xi׳an Jiaotong University, Xi׳an, 710049, PR China.
| | - Robert A Cheke
- Natural Resources Institute, University of Greenwich at Medway, Chatham Maritime, Chatham, Kent ME4 4TB, UK
| | - Ning Wang
- National Center for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, PR China
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Cohen C. Low-Level Viremia in HIV-1 Infection: Consequences and Implications for Switching to a New Regimen. HIV CLINICAL TRIALS 2015; 10:116-24. [DOI: 10.1310/hct1002-116] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Clinical impact and cost-effectiveness of making third-line antiretroviral therapy available in sub-Saharan Africa: a model-based analysis in Côte d'Ivoire. J Acquir Immune Defic Syndr 2014; 66:294-302. [PMID: 24732870 DOI: 10.1097/qai.0000000000000166] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In sub-Saharan Africa, HIV-infected adults who fail second-line antiretroviral therapy (ART) often do not have access to third-line ART. We examined the clinical impact and cost-effectiveness of making third-line ART available in Côte d'Ivoire. METHODS We used a simulation model to compare 4 strategies after second-line ART failure: continue second-line ART (C-ART2), continue second-line ART with an adherence reinforcement intervention (AR-ART2), immediate switch to third-line ART (IS-ART3), and continue second-line ART with adherence reinforcement, switching patients with persistent failure to third-line ART (AR-ART3). Third-line ART consisted of a boosted-darunavir plus raltegravir-based regimen. Primary outcomes were 10-year survival and lifetime incremental cost-effectiveness ratios (ICERs), in $/year of life saved (YLS). ICERs below $3585 (3 times the country per capita gross domestic product) were considered cost-effective. RESULTS Ten-year survival was 6.0% with C-ART2, 17.0% with AR-ART2, 35.4% with IS-ART3, and 37.2% with AR-ART3. AR-ART2 was cost-effective ($1100/YLS). AR-ART3 had an ICER of $3600/YLS and became cost-effective if the cost of third-line ART decreased by <1%. IS-ART3 was less effective and more costly than AR-ART3. Results were robust to wide variations in the efficacy of third-line ART and of the adherence reinforcement, as well as in the cost of second-line ART. CONCLUSIONS Access to third-line ART combined with an intense adherence reinforcement phase, used as a tool to distinguish between patients who can still benefit from their current second-line regimen and those who truly need third-line ART would provide substantial survival benefits. With minor decreases in drug costs, this strategy would be cost-effective.
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Claborn KR, Meier E, Miller MB, Leffingwell TR. A systematic review of treatment fatigue among HIV-infected patients prescribed antiretroviral therapy. PSYCHOL HEALTH MED 2014; 20:255-65. [PMID: 25110152 DOI: 10.1080/13548506.2014.945601] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV treatment requires lifelong adherence to medication regimens that comprise inconvenient scheduling, adverse side effects, and lifestyle changes. Antiretroviral adherence and treatment fatigue have been inextricably linked. Adherence in HIV-infected populations has been well investigated; however, little is known about treatment fatigue. This review examines the current state of the literature on treatment fatigue among HIV populations and provides an overview of its etiology and potential consequences. Standard systematic research methods were used to gather published papers on treatment fatigue and HIV. Five databases were searched using PRISMA criteria. Of 1557 studies identified, 21 met the following inclusion criteria: (a) study participants were HIV-infected; (b) participants were prescribed antiretroviral medication; (c) the article referenced treatment fatigue; (d) the article was published in a peer-reviewed journal; and (e) text was available in English. Only seven articles operationally defined treatment fatigue, with three themes emerging throughout the definitions: (1) pill burden; (2) loss of desire to adhere to the regimen; and (3) nonadherence to regimens as a consequence of treatment fatigue. Based on these studies, treatment fatigue may be defined as "decreased desire and motivation to maintain vigilance in adhering to a treatment regimen among patients prescribed long-term protocols." The cause and course of treatment fatigue appear to vary by developmental stage. To date, only structured treatment interruptions have been examined as an intervention to reduce treatment fatigue in children and adults. No behavioral interventions have been developed to reduce treatment fatigue. Further, only qualitative studies have examined treatment fatigue conceptually. Studies designed to systematically assess treatment fatigue are needed. Increased understanding of the course and duration of treatment fatigue is expected to improve adherence interventions, thereby improving clinical outcomes for individuals living with HIV.
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Affiliation(s)
- Kasey R Claborn
- a Center for Alcohol and Addiction Studies and the Alcohol Research Center on HIV , Brown University , Providence , RI , USA
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Immunologic status and virologic outcomes in repeat pregnancies to HIV-positive women not on antiretroviral therapy at conception: a case for lifelong antiretroviral therapy? AIDS 2014; 28:1369-72. [PMID: 24685820 PMCID: PMC4032213 DOI: 10.1097/qad.0000000000000282] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
During their second pregnancy with diagnosed HIV (n = 1177), two-fifths of women in the UK/Ireland not on antiretroviral therapy (ART) at conception had an immunological indication for treatment (CD4+ <350 cells/μl), of whom nearly half had CD4+ at least 350 cells/μl in their previous pregnancy. Those initiating ART during pregnancy had a 4.3-fold increased odds of detectable viral load at delivery compared with those conceiving on treatment, suggesting that continuation of ART after pregnancy may be beneficial for many women.
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6.0 Supporting patients on therapy. HIV Med 2013. [DOI: 10.1111/hiv.12119_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Biomarkers from late pregnancy to 6 weeks postpartum in HIV-infected women who continue versus discontinue antiretroviral therapy after delivery. J Acquir Immune Defic Syndr 2013; 63:593-601. [PMID: 23714738 DOI: 10.1097/qai.0b013e31829b0b9f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Women who use antiretroviral therapy (ART) solely for the prevention of mother-to-child transmission of HIV discontinue postpartum. We hypothesized that women discontinuing ART by 6 weeks postpartum ("discontinuers") would have elevated postpartum inflammatory biomarker levels relative to women remaining on ART postpartum ("continuers"). METHODS Data from HIV-infected pregnant women enrolled in the International Maternal Pediatric Adolescent AIDS Clinical Trials Group P1025 with CD4 counts >350 cells per cubic millimeter before initiating ART or first pregnancy CD4 counts >400 cells per cubic millimeter after starting ART and with available stored plasma samples at >20 weeks of gestation, delivery, and 6 weeks postpartum were analyzed. Plasma samples were tested for highly sensitive C-reactive protein, D-dimer, and interleukin-6. We used longitudinal linear spline regression to model biomarkers over time. RESULTS Data from 128 women (65 continuers and 63 discontinuers) were analyzed. All biomarkers increased from late pregnancy to delivery, then decreased postpartum (slopes different from 0, P < 0.001). Continuers had a steeper decrease in log D-dimer between delivery and 6 weeks postpartum than discontinuers (P = 0.002). CONCLUSIONS In contrast to results from treatment interruption studies in adults, both ART continuers and ART discontinuers had significant decreases in the levels of D-dimer, highly sensitive C-reactive protein, or interleukin-6 postpartum. Continuation was associated with a more rapid decline in D-dimer levels compared with discontinuation.
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No clinically significant drug-resistance mutations in HIV-1 subtype C-infected women after discontinuation of NRTI-based or PI-based HAART for PMTCT in Botswana. J Acquir Immune Defic Syndr 2013; 63:572-7. [PMID: 23542639 DOI: 10.1097/qai.0b013e31829308f8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Risk of developing drug resistance after stopping antiretroviral regimens to prevent mother-to-child HIV-1 transmission is unknown. The Mma Bana Study randomized treatment-naive pregnant women with CD4 ≥200 cells per cubic millimeter to receive either abacavir/zidovudine/lamivudine [triple nucleoside reverse transcriptase inhibitor (NRTI) arm] or lopinavir/ritonavir/zidovudine/lamivudine [protease inhibitor (PI) arm]. Drugs were discontinued after 6 months of breastfeeding. One month after discontinuation, 29 NRTI arm samples and 25 PI arm samples were successfully genotyped. No clinically significant antiretroviral resistance mutations were detected. Eight minor resistance mutations were found among 11 (20%) women (3 from NRTI arm and 8 from PI arm), occurring at similar frequencies to those reported in HIV-1 subtype C treatment-naive cohorts.
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Klein N, Sefe D, Mosconi I, Zanchetta M, Castro H, Jacobsen M, Jones H, Bernardi S, Pillay D, Giaquinto C, Walker AS, Gibb DM, De Rossi A. The immunological and virological consequences of planned treatment interruptions in children with HIV infection. PLoS One 2013; 8:e76582. [PMID: 24194841 PMCID: PMC3806774 DOI: 10.1371/journal.pone.0076582] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 08/26/2013] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To evaluate the immunological and viral consequences of planned treatment interruptions (PTI) in children with HIV. DESIGN This was an immunological and virological sub-study of the Paediatric European Network for Treatment of AIDS (PENTA) 11 trial, which compared CD4-guided PTI of antiretroviral therapy (ART) with continuous therapy (CT) in children. METHODS HIV-1 RNA and lymphocyte subsets, including CD4 and CD8 cells, were quantified on fresh samples collected during the study; CD45RA, CD45RO and CD31 subpopulations were evaluated in some centres. For 36 (18 PTI, 18 CT) children, immunophenotyping was performed and cell-associated HIV-1 DNA analysed on stored samples to 48 weeks. RESULTS In the PTI group, CD4 cell count fell rapidly in the first 12 weeks off ART, with decreases in both naïve and memory cells. However, the proportion of CD4 cells expressing CD45RA and CD45RO remained constant in both groups. The increase in CD8 cells in the first 12 weeks off ART in the PTI group was predominantly due to increases in RO-expressing cells. PTI was associated with a rapid and sustained increase in CD4 cells expressing Ki67 and HLA-DR, and increased levels of HIV-1 DNA. CONCLUSIONS PTI in children is associated with rapid changes in CD4 and CD8 cells, likely due to increased cell turnover and immune activation. However, children off treatment may be able to maintain stable levels of naïve CD4 cells, at least in proportion to the memory cell pool, which may in part explain the observed excellent CD4 cell recovery with re-introduction of ART.
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Affiliation(s)
- Nigel Klein
- Institute of Child Health, University College London, London, United Kingdom
- * E-mail:
| | - Delali Sefe
- Institute of Child Health, University College London, London, United Kingdom
| | - Ilaria Mosconi
- AIDS Reference Center, University of Padova, Padova, Italy
| | | | - Hannah Castro
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Marianne Jacobsen
- Institute of Child Health, University College London, London, United Kingdom
| | - Hannah Jones
- Institute of Child Health, University College London, London, United Kingdom
| | | | - Deenan Pillay
- University College London/Medical Research Council Centre for Medical Molecular Virology, University College London Medical School, London, United Kingdom
| | - Carlo Giaquinto
- Department of Paediatrics, University of Padova, Padova, Italy
| | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Anita De Rossi
- AIDS Reference Center, University of Padova, Padova, Italy
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Doherty K, Ciaranello A. What is needed to eliminate new pediatric HIV infections: the contribution of model-based analyses. Curr Opin HIV AIDS 2013; 8:457-66. [PMID: 23743788 PMCID: PMC3799993 DOI: 10.1097/coh.0b013e328362db0d] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Computer simulation models can identify key clinical, operational, and economic interventions that will be needed to achieve the elimination of new pediatric HIV infections. In this review, we summarize recent findings from model-based analyses of strategies for prevention of mother-to-child HIV transmission (MTCT). RECENT FINDINGS In order to achieve elimination of MTCT (eMTCT), model-based studies suggest that scale-up of services will be needed in several domains: uptake of services and retention in care (the PMTCT 'cascade'), interventions to prevent HIV infections in women and reduce unintended pregnancies (the 'four-pronged approach'), efforts to support medication adherence through long periods of pregnancy and breastfeeding, and strategies to make breastfeeding safer and/or shorter. Models also project the economic resources that will be needed to achieve these goals in the most efficient ways to allocate limited resources for eMTCT. Results suggest that currently recommended PMTCT regimens (WHO Option A, Option B, and Option B+) will be cost-effective in most settings. SUMMARY Model-based results can guide future implementation science, by highlighting areas in which additional data are needed to make informed decisions and by outlining critical interventions that will be necessary in order to eliminate new pediatric HIV infections.
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Affiliation(s)
- Katie Doherty
- The Medical Practice Evaluation Center, Divisions of General Medicine bInfectious Disease, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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CD4 count slope and mortality in HIV-infected patients on antiretroviral therapy: multicohort analysis from South Africa. J Acquir Immune Defic Syndr 2013; 63:34-41. [PMID: 23344547 DOI: 10.1097/qai.0b013e318287c1fe] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In many resource-limited settings monitoring of combination antiretroviral therapy (cART) is based on the current CD4 count, with limited access to HIV RNA tests or laboratory diagnostics. We examined whether the CD4 count slope over 6 months could provide additional prognostic information. METHODS We analyzed data from a large multicohort study in South Africa, where HIV RNA is routinely monitored. Adult HIV-positive patients initiating cART between 2003 and 2010 were included. Mortality was analyzed in Cox models; CD4 count slope by HIV RNA level was assessed using linear mixed models. RESULTS About 44,829 patients (median age: 35 years, 58% female, median CD4 count at cART initiation: 116 cells/mm) were followed up for a median of 1.9 years, with 3706 deaths. Mean CD4 count slopes per week ranged from 1.4 [95% confidence interval (CI): 1.2 to 1.6] cells per cubic millimeter when HIV RNA was <400 copies per milliliter to -0.32 (95% CI: -0.47 to -0.18) cells per cubic millimeter with >100,000 copies per milliliter. The association of CD4 slope with mortality depended on current CD4 count: the adjusted hazard ratio (aHRs) comparing a >25% increase over 6 months with a >25% decrease was 0.68 (95% CI: 0.58 to 0.79) at <100 cells per cubic millimeter but 1.11 (95% CI: 0.78 to 1.58) at 201-350 cells per cubic millimeter. In contrast, the aHR for current CD4 count, comparing >350 with <100 cells per cubic millimeter, was 0.10 (95% CI: 0.05 to 0.20). CONCLUSIONS Absolute CD4 count remains a strong risk for mortality with a stable effect size over the first 4 years of cART. However, CD4 count slope and HIV RNA provide independently added to the model.
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Time to End the Ban on Pregnancy and Breastfeeding in Antiretrovirals Strategy Trials. J Acquir Immune Defic Syndr 2013; 62:e156-8. [DOI: 10.1097/qai.0b013e318282a1c1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Assessment, diagnosis, and treatment of HIV-associated neurocognitive disorder: a consensus report of the mind exchange program. Clin Infect Dis 2013; 56:1004-17. [PMID: 23175555 PMCID: PMC3657494 DOI: 10.1093/cid/cis975] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 11/13/2012] [Indexed: 01/02/2023] Open
Abstract
Many practical clinical questions regarding the management of human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND) remain unanswered. We sought to identify and develop practical answers to key clinical questions in HAND management. Sixty-six specialists from 30 countries provided input into the program, which was overseen by a steering committee. Fourteen questions were rated as being of greatest clinical importance. Answers were drafted by an expert group based on a comprehensive literature review. Sixty-three experts convened to determine consensus and level of evidence for the answers. Consensus was reached on all answers. For instance, good practice suggests that all HIV patients should be screened for HAND early in disease using standardized tools. Follow-up frequency depends on whether HAND is already present or whether clinical data suggest risk for developing HAND. Worsening neurocognitive impairment may trigger consideration of antiretroviral modification when other causes have been excluded. The Mind Exchange program provides practical guidance in the diagnosis, monitoring, and treatment of HAND.
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Outcomes after reinitiating antiretroviral therapy in children randomized to planned treatment interruptions. AIDS 2013; 27:579-89. [PMID: 23135172 DOI: 10.1097/qad.0b013e32835c1181] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Excess risks for death/opportunistic disease in adults randomized to CD4-driven planned treatment interruption (PTI) in the Strategies for Management of Antiretroviral Therapy (SMART) trial remained after antiretroviral therapy (ART) re-initiation. Risks for children following PTI were evaluated in long-term follow-up of children in the PENTA 11 trial. METHODS Children with HIV RNA below 50 copies/ml and CD4 at least 30% (2-6 years) or at least 500 cells/μl (7-15 years) were randomized to continuous ART (cART) or PTI in PENTA 11 (ISRCTN 36694210). After the end of the trial, all were recommended to resume ART. Data were collected annually and analysed up to the second year of visit. RESULTS One hundred and one (51 cART, 50 PTI; median baseline age 9.2 years) children had median overall follow-up 4.6 (range 3.7-5.0) years. During 2-year post-trial period, there were no deaths or new Centers for Disease Control and Prevention (CDC) stage B/C events. Rate of clinical grade of at least two events was similar between PTI and cART [relative risk (RR) 1.03; 95% confidence interval (CI) 0.43, 2.50; P = 0.94]. At 2 years, difference in absolute CD4% between PTI and cART was -1.6% (-4.5%; 1.3%; P = 0.27), and proportions with HIV RNA below 50 copies/ml were 82 versus 86% (P = 0.57), respectively; no differences in growth or fasting lipids were observed. Key predictors of greater CD4% recovery after re-initiating ART were higher CD4% at baseline (P < 0.001) and longer time since ART re-initiation (P < 0.001). During overall follow-up, 4 (8%) PTI versus 5 (10%) CT children switched ART for failure (P = 0.75) and 9 (18%) versus 1 (2%) (P = 0.008) substituted ART for simplification. CONCLUSIONS No adverse clinical, immunological or virological consequences of PTI were observed 2 years after the end of PENTA 11 trial. Although ART interruption is not generally recommended, it may be an acceptable option for children, particularly when there is high risk of unplanned treatment interruptions.
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Ciaranello AL, Perez F, Engelsmann B, Walensky RP, Mushavi A, Rusibamayila A, Keatinge J, Park JE, Maruva M, Cerda R, Wood R, Dabis F, Freedberg KA. Cost-effectiveness of World Health Organization 2010 guidelines for prevention of mother-to-child HIV transmission in Zimbabwe. Clin Infect Dis 2013; 56:430-46. [PMID: 23204035 PMCID: PMC3540037 DOI: 10.1093/cid/cis858] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 07/17/2012] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe. METHODS We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4). Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE. RESULTS Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to $5710 per mother-infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother-infant pair). Option B+ (LE, 39.04 years; lifetime cost, $6620 per mother-infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B. CONCLUSIONS Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions.
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Affiliation(s)
- Andrea L Ciaranello
- Medical Practice Evaluation Center, Divisions of Infectious Disease, Massachusetts General Hospital, Boston, MA 02114, USA.
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Harrison L, Ananworanich J, Hamadache D, Compagnucci A, Penazzato M, Bunupuradah T, Mazza A, Ramos JT, Flynn J, Rampon O, Mellado Pena MJ, Floret D, Marczynska M, Puga A, Forcat S, Riault Y, Lallemant M, Castro H, Gibb DM, Giaquinto C. Adherence to antiretroviral therapy and acceptability of planned treatment interruptions in HIV-infected children. AIDS Behav 2013; 17:193-202. [PMID: 22584916 PMCID: PMC3548111 DOI: 10.1007/s10461-012-0197-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There have been no paediatric randomised trials describing the effect of planned treatment interruptions (PTIs) of antiretroviral therapy (ART) on adherence, or evaluating acceptability of such a strategy. In PENTA 11, HIV-infected children were randomised to CD4-guided PTIs (n = 53) or continuous therapy (CT, n = 56). Carers, and children if appropriate, completed questionnaires on adherence to ART and acceptability of PTIs. There was no difference in reported adherence on ART between CT and PTI groups; non-adherence (reporting missed doses over the last 3 days or marking <100 % adherence since the last clinical visit on a visual analogue scale) was 18 % (20/111) and 14 % (12/83) on carer questionnaires in the CT and PTI groups respectively (odds ratios, OR (95 % CI) = 1.04 (0.20, 5.41), χ2 (1) = 0.003, p = 0.96). Carers in Europe/USA reported non-adherence more often (31/121, 26 %) than in Thailand (1/73, 1 %; OR (95 % CI) = 54.65 (3.68, 810.55), χ2 (1) = 8.45, p = 0.004). The majority of families indicated they were happy to have further PTIs (carer: 23/36, 64 %; children: 8/13, 62 %), however many reported more clinic visits during PTI were a problem (carer: 15/36, 42 %; children: 6/12, 50 %).
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Yeh RF, Gupta SA, Sangani DN, Sansgiry SS. The association of pharmacy drug-delivery services with adherence in an urban HIV population†. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2012. [DOI: 10.1111/j.1759-8893.2012.00099.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Objective
The aim of this study was to examine the effect of drug-distribution methods on antiretroviral medication adherence in HIV-positive patients.
Methods
This was a longitudinal, retrospective study of an independent retail pharmacy providing complementary delivery services. Patients of 18 years of age or older receiving antiretroviral therapy were evaluated from 1 January to 30 June 2004. Patients were included if they had a minimum of one prescription claim for any antiretroviral medication during the study period and received state medication assistance. Using data obtained from computerized pharmacy records a medication possession ratio was calculated to assess adherence measured by pharmacy refill history over 6 months. To assess the consistency of adherence over time a modified medication possession ratio, termed the compliance/non-compliance index (CNI) at each refill, was developed and compared between each group.
Key findings
Of the 181 patients included in the study, those who had medications delivered had significantly better adherence (90.3% compared with 82.6%, P = 0.001) and CNI value (73.5% compared with 57.9%, P = 0.001) in comparison with those who picked up their medications. After controlling for age, gender, drug class, insurance type and time and distance from the pharmacy, use of medication-delivery services was significantly associated with adherence (P < 0.0001) and CNI score (P = 0.012).
Conclusion
Complementary medication-delivery services by pharmacies significantly increased adherence at each refill for antiretroviral therapy in HIV-positive patients. Further research is needed on how medication-distribution strategies can be implemented universally and the economic impact on cost of care to increase medication adherence in this high-risk population.
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Affiliation(s)
- Rosa F Yeh
- Department of Clinical Sciences and Administration, University of Houston, College of Pharmacy, Houston, TX, USA
| | | | | | - Sujit S Sansgiry
- Department of Clinical Sciences and Administration, University of Houston, College of Pharmacy, Houston, TX, USA
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Becquet R, Dabis F. Editorial commentary: turning the tide on HIV in women and children: preventing breast-milk HIV transmission while increasing maternal life expectancy. Clin Infect Dis 2012; 56:140-2. [PMID: 22997213 DOI: 10.1093/cid/cis813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Lifson AR, Demissie W, Tadesse A, Ketema K, May R, Yakob B, Metekia M, Slater L, Shenie T. Barriers to retention in care as perceived by persons living with HIV in rural Ethiopia: focus group results and recommended strategies. J Int Assoc Provid AIDS Care 2012; 12:32-8. [PMID: 22993233 DOI: 10.1177/1545109712456428] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inability to retain HIV-infected patients in care undermines the benefits of starting millions in low-income countries on antiretroviral therapy (ART). In a hospital HIV clinic in rural southern Ethiopia, we conducted focus groups of HIV-infected men and women to learn more about experiences with and barriers to attending clinic appointments. Respondents reported multiple barriers, including those that were patient related (eg, misunderstandings about ART, mistaken belief in AIDS cures, and drug/alcohol use), clinic related (eg, negative provider interactions, lack of familiarity with patients' medical situation, and overcrowding), medication related (eg, side effects), social (eg, stigma and discrimination and lack of support), and situational/resource related (eg, distance to clinic, lack of funds, competing domestic/work priorities, and lack of food). Based on the lessons learned from these focus groups, we implemented a community intervention to improve retention, using trained community support workers who provide patient education, counseling, social support, problem-solving assistance, needed referrals, and improved communication/linkage to the patients' HIV clinic.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55454, USA.
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Kalmar EMN, Sanabani SS, Charlys da Costa A, Ferreira S, Barreto CC, Chen S, Sabino EC. Evaluation of HIV-1 resistance to antiretroviral drugs among 150 patients after six months of therapeutic interruption. Int J STD AIDS 2012; 23:120-5. [PMID: 22422687 DOI: 10.1258/ijsa.2011.011124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Most of the antiretroviral (ARV) studies in Brazil have been reported in treatment-experienced and naive patients rather than in the setting of treatment interruption (TI). In this study, we analysed reasons given for TI and resistance mutations occurring in 150 HIV-1-infected patients who underwent TI. Of the patients analysed, 110 (73.3%) experienced TI following medical advice, while the remaining patients stopped antiretroviral therapy (ART) of their own accord. The main justifications for TI were: ARV-related toxicities (38.7%), good laboratory parameters (30%) and poor adherence (20%). DNA sequencing of the partial pol gene was successful in 137 (91.3%) patients, of whom 38 (27.7%) presented mutations conferring ARV resistance. A higher viral load prior to TI correlated with drug resistance (P < 0.05). Our results demonstrate that there are diverse rationales for TI and that detection of resistant strains during TI most likely indicates a fitter virus than the wild type. High viral loads coupled with unprotected sex in this group could increase the likelihood of transmission of drug-resistant virus. Thus, treating physicians should be alerted to this problem when the use of ARVs is interrupted.
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Affiliation(s)
- E M N Kalmar
- Department of Infectious Disease, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
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11.0 References. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.1030_12.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Prague M, Commenges D, Drylewicz J, Thiébaut R. Treatment Monitoring of HIV-Infected Patients based on Mechanistic Models. Biometrics 2012; 68:902-11. [DOI: 10.1111/j.1541-0420.2012.01749.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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