Do benefits of earlier antiretroviral treatment initiation outweigh harms for individuals at risk for poor adherence?

Impact of Cigarette Smoking and Smoking Cessation on Life Expectancy Among People With HIV: A US-Based Modeling Study

BACKGROUND

 In the United States, >40% of people infected with human immunodeficiency virus (HIV) smoke cigarettes.

METHODS

 We used a computer simulation of HIV disease and treatment to project the life expectancy of HIV-infected persons, based on smoking status. We used age- and sex-specific data on mortality, stratified by smoking status. The ratio of the non-AIDS-related mortality risk for current smokers versus that for never smokers was 2.8, and the ratio for former smokers versus never smokers was 1.0-1.8, depending on cessation age. Projected survival was based on smoking status, sex, and initial age. We also estimated the total potential life-years gained if a proportion of the approximately 248 000 HIV-infected US smokers quit smoking.

RESULTS

 Men and women entering HIV care at age 40 years (mean CD4⁺ T-cell count, 360 cells/µL) who continued to smoke lost 6.7 years and 6.3 years of life expectancy, respectively, compared with never smokers; those who quit smoking upon entering care regained 5.7 years and 4.6 years, respectively. Factors associated with greater benefits from smoking cessation included younger age, higher initial CD4⁺ T-cell count, and complete adherence to antiretroviral therapy. Smoking cessation by 10%-25% of HIV-infected smokers could save approximately 106 000-265 000 years of life.

CONCLUSIONS

 HIV-infected US smokers aged 40 years lose >6 years of life expectancy from smoking, possibly outweighing the loss from HIV infection itself. Smoking cessation should become a priority in HIV treatment programs.

HIV Treatment in Resource-Limited Environments: Treatment Coverage and Insights

BACKGROUND

The effects of antiretroviral treatment on the HIV epidemic are complex. HIV-infected individuals survive longer with treatment, but are less likely to transmit the disease. The standard coverage measure improves with the deaths of untreated individuals and does not consider the fact that some individuals may acquire the disease and die before receiving treatment, making it susceptible to overestimating the long-run performance of antiretroviral treatment programs.

OBJECTIVE

The objective was to propose an alternative coverage definition to better measure the long-run performance of HIV treatment programs.

METHODS

We introduced cumulative incidence-based coverage as an alternative to measure an HIV treatment program's success. To numerically compare the definitions, we extended a simulation model of HIV disease and treatment to represent a dynamic population that includes uninfected and HIV-infected individuals. Also, we estimated the additional resources required to implement various treatment policies in a resource-limited setting.

RESULTS

In a synthetic population of 600,000 people of which 44,000 (7.6%) are infected, and eligible for treatment with a CD4 count of less than 500 cells/mm(3), assuming a World Health Organization (WHO)-defined coverage rate of 50% of eligible people, and treating these individuals with a single treatment regimen, the gap between the current WHO coverage definition and our proposed one is as much as 16% over a 10-year planning horizon.

CONCLUSIONS

Cumulative incidence-based definition of coverage yields a more accurate representation of the long-run treatment success and along with the WHO and other definitions of coverage provides a better understanding of the HIV treatment progress.

Implementing tobacco use treatment guidelines in community health centers in Vietnam

Background

Vietnam has a smoking prevalence that is the second highest among Southeast Asian countries (SEACs). According to the World Health Organization (WHO), most reductions in mortality from tobacco use in the near future will be achieved through helping current users quit. Yet, largely due to a lack of research on strategies for implementing WHO-endorsed treatment guidelines in primary care settings, services to treat tobacco dependence are not readily available to smokers in low middle-income countries (LMICs) like Vietnam. The objective of this study is to conduct a cluster randomized controlled trial that compares the effectiveness of two system-level strategies for implementing evidence-based guidelines for the treatment of tobacco use in 26 public community health centers (CHCs) in Vietnam.

Methods/Design

The current study will use a cluster-randomized design and multiple data sources (patient exit interviews, provider and village health worker (VHW) surveys, and semi-structured provider/VHW interviews) to study the process of adapting and implementing clinical practice guidelines in Vietnam and theory-driven mechanisms hypothesized to explain the comparative effectiveness of the two strategies for implementation. CHCs will be randomly assigned to either of the following: (1) training plus clinical reminder system (TC) or (2) TC + referral to a VHW (TCR) for three in person counseling sessions. The primary outcome is provider adherence to tobacco use treatment guidelines. The secondary outcome is 6-month biochemically verified smoking abstinence.

Discussion

The proposed implementation strategies draw on evidence-based approaches and a growing literature that supports the effectiveness of integrating community health workers as members of the health care team to improve access to preventive services. We hypothesize that the value of these implementation strategies is additive and that incorporating a referral resource that allows providers to delegate the task of offering counseling (TCR) will be superior to TC alone in improving delivery of cessation assistance to smokers. The findings of this research have potential to guide large-scale adoption of promising strategies for implementing and disseminating tobacco use treatment guidelines throughout the public health system in Vietnam and will serve as a model for similar action in other LMICs.

Trial registration

NCT01967654

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0328-8) contains supplementary material, which is available to authorized users.

Asymptomatic stage of human immunodeficiency virus infection is the optimal timing for its management with Traditional Chinese Medicine

Acquired immune deficiency syndrome (AIDS) is a worldwide public health problem and an incurable disease. The roles of Traditional Chinese Medicine (TCM) on AIDS had been recognized and accepted by more and more people. Being a relatively long period, to initiate combination antiretroviral therapy (cART) for the asymptomatic human immunodeficiency virus (HIV) infection patient is not consensus. According to TCM theory, not only the imbalance of Yin and Yang but also the disharmony of internal body function and external natural environment had occurred in the body of the patient, the imbalance and the disharmony should be adjusted by the means of the treatment based on the patters identified among the symptoms in terms of TCM. We aimed to analyze the feature of patients with asymptomatic infection, and compare the advantages and disadvantages of the us- age of cART for asymptomatic infection, explored the possible mechanism underlying TCM treatment of the asymptomatic infection, by reviewing the TCM treatment progress on asymptomatic HIV infection.

Pharmacokinetics of darunavir after administration of an oral suspension with low-dose ritonavir and with or without food

This 2-part, phase 1, open-label, randomized, crossover study (NCT00752310) assessed ritonavir-boosted darunavir bioavailability (oral suspension vs. tablets), and steady-state darunavir pharmacokinetics (suspension). Part 1: 20 healthy adults randomly received 3 treatments with a ≥7-day washout between treatments; twice-daily ritonavir (100 mg, days 1-5) with darunavir (600 mg, day 3) as 2 × 300-mg tablets (fed, reference), or 6 mL of a 100-mg/mL suspension (fed or fasted, test). Part 2: 18 healthy volunteers received twice-daily darunavir (suspension, 600 mg days 1-6, one dose day 7) with twice-daily ritonavir (100 mg, days 1-9). Darunavir pharmacokinetics were evaluated (part 1 day 3; part 2 day 7). Safety/tolerability were assessed. In part 1, 90% confidence intervals for darunavir Cmax and AUC were all within 80-125% for suspension (fed or fasted) versus tablets (fed). Steady-state darunavir (suspension) pharmacokinetics in part 2 were similar to historic controls (tablets). No clinically relevant differences in adverse events or laboratory abnormalities occurred between treatments. Darunavir administered as an oral suspension or tablets (both with low-dose ritonavir) showed comparable bioavailability in healthy adults after a single dose. Steady-state darunavir pharmacokinetics (suspension, 600/100 mg twice daily) were consistent with historic controls; this formulation is considered suitable for pediatric use and for adults who cannot swallow tablets.

Modeling the cost-effectiveness of HIV treatment: how to buy the most 'health' when resources are limited

PURPOSE OF REVIEW

To summarize recent cost-effectiveness analyses (CEAs) that evaluate optimal treatment strategies for persons living with HIV/AIDS (PLWHA).

RECENT FINDINGS

Efforts to attain universal coverage of current treatment guidelines (e.g., initiation at CD4 cell count <350 cells/μl) are generally very costeffective. Expansion of access beyond current guidelines will additionally improve clinical outcomes and aversion of new HIV infections; however, cost-effectiveness is more uncertain. Increasing access to antiretroviral therapy (ART) offers greater health benefit than investing the same funds in intensive laboratory monitoring for those on ART, particularly in those settings in which universal coverage has not yet been attained. Recommended ART regimens (e.g., tenofovir) have favorable cost-effectiveness when compared with substitution of newer, more expensive agents (e.g., rilpivirine, darunavir) or substitution of older, cheaper alternatives that are more toxic (e.g., stavudine).

SUMMARY

There is increasing use of CEA to evaluate decisions regarding HIV treatment in order to buy the most 'health' with limited resources. Expansion of ART access provides substantial clinical and preventive benefit and offers favorable cost-effectiveness. Intensive laboratory monitoring may not be the highest priority in settings in which resources are constrained. Further work on the economic impact, clinical effectiveness, and feasibility of ART treatment for all (e.g., no CD4 cell initiation criteria) is needed.

Could early antiretroviral therapy entail more risks than benefits in sub-Saharan African HIV-infected adults? A model-based analysis

BACKGROUND

Initiation of antiretroviral therapy (ART) in all HIV-infected adults, regardless of CD4⁺ T-cell count, is a proposed strategy for reducing HIV transmission. We investigated the conditions under which starting ART early could entail more risks than benefits for patients with high CD4⁺ T-cell counts.

METHODS

We used a simulation model to compare ART initiation upon entry to care ('immediate ART') to initiation at CD4⁺ T-cell count ≤ 350 cells/μl ('WHO 2010 ART') in African adults with CD4⁺ T-cell counts >500 cells/μl. We varied inputs to determine the combination of parameters (population characteristics, conditions of care, treatment outcomes) that would result in higher 15-year mortality with immediate ART.

RESULTS

The 15-year mortality was 56.7% for WHO 2010 ART and 51.8% for immediate ART. In one-way sensitivity analysis, lower 15-year mortality was consistently achieved with immediate ART unless the rate of fatal ART toxicity was >1.0/100 person-years, the rate of withdrawal from care was >1.2-fold higher or the rate of ART failure due to poor adherence was >4.3-fold higher on immediate than on WHO 2010 ART. In multi-way sensitivity analysis, immediate ART led to higher mortality when moderate rates of fatal ART toxicity (0.25/100 person-years) were combined with rates of withdrawal from care >1.1-fold higher and rates of treatment failure >2.1-fold higher on immediate than on WHO 2010 ART.

CONCLUSIONS

In sub-Saharan Africa, ART initiation at entry into care would improve long-term survival of patients with high CD4⁺ T-cell counts, unless it is associated with increased withdrawal from care and decreased adherence. In early ART trials, a focus on retention and adherence will be crucial.

HIV/AIDS profile and realities at a regional antiretroviral therapy clinic in Jerusalem: 12 years analysis

The diagnosis of HIV, quality of follow-up, and treatment among immigrants are greatly influenced by cultural factors and access to the healthcare system. Israel, an immigrant-based society, features 3 cardinal HIV-positive patient groups, namely non-immigrant Israelis, legal immigrants (mainly from Ethiopia), and illegal African work-immigrants. While the first 2 groups are covered by a national health insurance, the latter group depends on an unstructured system of antiretroviral therapy (ART) supply. In the early 1990s, a national mentoring programme was implemented for legal immigrants. The programme involves community-based Ethiopian mentors who follow HIV-positive Ethiopians. In this retrospective cohort study we reviewed the files of HIV-positive patients diagnosed between 1995 and 2007, focusing on comparison between HIV-positive non-immigrant populations with both legal Ethiopian immigrants and the often overlooked illegal immigrants. Our results point to a substantial rate of loss to follow-up among the illegal immigrants. When comparing non-immigrants to legal immigrants, both feature similar adherence to follow-up, exposure and response to ART, despite profound cultural differences. Our results suggest that ethnic-related obstacles in HIV diagnosis and treatment may be overcome by 'cultural mediators', yet, addressing the silent mass of HIV-positive illegal work-immigrants, who are deprived of such programme benefits, poses a major challenge to Western health authorities.

Modelling the impact of treatment with individual antiretrovirals

PURPOSE OF REVIEW

The aim of this paper is to review the recent literature on HIV mathematical models that evaluate the effect of antiretroviral treatment on mortality, morbidity, HIV and other key outcomes. The focus of our attention is models which explicitly model specific effects of individual antiretroviral drugs.

RECENT FINDINGS

The number of studies that use mathematical models to evaluate the impact of antiretroviral drugs as a treatment or prevention strategy is increasing.Many mathematical models are deterministic compartmental models, and do not have the level of detail of specific effects of individual drugs. However, models that include specific antiretroviral drugs have been increasingly employed to assess the cost-effectiveness of prevention interventions, to evaluate benefits and harms (toxicities, side-effects, resistance development) of different regimens and different intervention timing and to predict long-term outcomes of randomized controlled trials (RCTs) that are not usually measured in the time frame of a trial.

SUMMARY

The number of models that consider specific antiretroviral drugs, with their own peculiarities, is limited. This factor is particularly the case for dynamic individual-based stochastic models. In order to address some research questions it is necessary to accurately take into consideration implications of toxicities, side-effects, and resistance acquisition, and hence to model specific drugs or at least specific drug classes.

A decision tree to help determine the best timing and antiretroviral strategy in HIV-infected patients

Optimal antiretroviral strategies for HIV-infected patients still need to be established. To this end a decision tree including different antiretroviral strategies that could be adopted for HIV-infected patients was built. A 10-year follow-up was simulated by using transitional probabilities estimated from a large cohort using a time-homogeneous Markov model. The desired outcome was for patients to maintain a CD4 cell count of >500 cells/mm3 without experiencing AIDS or death. For patients with a baseline HIV viral load ⩾5 log10 copies/ml, boosted protease inhibitor-based immediate highly active antiretroviral therapy (HAART) allowed them to spend 12% more time with CD4 ⩾500/mm3 than did delayed HAART (6·40 vs. 5·69 and 5·57 vs. 4·90 years for baseline CD4 ⩾500 and 350–499/mm3, respectively). In patients with a baseline HIV viral load ⩽3·5 log10 copies/ml, delayed HAART performed better than immediate HAART (6·43 vs. 6·26 and 5·95 vs. 5·18 for baseline CD4 ⩾500 and 350–499/mm3, respectively). Immediate HAART is beneficial in patients with a baseline HIV viral load ⩾5 log10 copies/ml, whereas deferred HAART appears to be the best option for patients with CD4 ⩾350/mm3 and baseline HIV viral load <3·5 log10 copies/ml.

When should antiretroviral therapy be started in HIV-positive persons?

Recommendations for the initiation of combination antiretroviral therapy in HIV-positive individuals are largely based on data from observational studies. Whilst all guidelines recommend immediate treatment in individuals with a CD4 count of less than 350 cells/mm(3), guidelines vary in their recommendations for treatment at higher CD4 counts. Several large cohort studies have published findings that contribute to the debate, although conclusions vary and results from these studies may be subject to bias.

Evaluating interventions to improve antiretroviral adherence: how much of an effect is required for favorable value?

OBJECTIVE

Uncertainty about the value of antiretroviral therapy (ARV) adherence interventions may be a barrier to implementation and evaluation. Our objective is to estimate the minimum effectiveness required for ARV adherence interventions to deliver acceptable value.

METHODS

We used a validated HIV computer simulation to estimate the impact of ARV adherence interventions on incremental costs and life expectancy. Across a wide range of intervention costs ($1000-10,000, one time or per year), we estimated the smallest effect size compatible with acceptable value (incremental cost-effective ratio < or =$100,000 per life-year). Effect sizes were measured using relative risk (RR) and absolute risk reduction (ARR), and these metrics were applied to nonadherence and nonadherence risk factors. Costs were estimated from a societal perspective ($2003) discounted at 3%.

RESULTS

To give acceptable value, a one-time $1000 intervention must reduce ARV nonadherence by RR < or = 0.82 (ARR > or = 0.04) for moderately nonadherent patients (20% of ARV doses missed) and RR < or = 0.90 (ARR > or = 0.05) for severely nonadherent patients (50% of ARV doses missed). A one-time $5000 intervention has an unacceptable value regardless of effect size for moderately nonadherent patients, and must reduce ARV nonadherence by RR <or = 0.31 (ARR > or = 0.69) for severely nonadherent patients. Interventions aimed at behavioral risk factors (e.g., unhealthy alcohol use) may confer acceptable value (e.g., if < or = $2000 and effect RR < or = 0.71 [ARR > or = 0.29]).

CONCLUSIONS

ARV adherence interventions with plausible effect sizes may offer favorable value if they cost <$5000 one time or per year. ARV adherence interventions with a favorable value should become more integral components of HIV care.

Adherence to antiretroviral therapy: the more you look, the more you see

PURPOSE OF REVIEW

There is evolving understanding of adherence to antiretroviral therapy (ART) and the consequences of nonadherence. The present review aims to discuss recent research findings that illuminate lingering clinical questions or contribute to the contextual framework for future research.

RECENT FINDINGS

Although some patients can achieve undetectable viral load at moderate adherence levels, studies confirmed that achieving very high adherence optimizes virological and clinical outcomes. In computer modeling, earlier initiation of ART despite suboptimal adherence was associated with improved survival and quality-adjusted life years. Better adherence and virological outcomes occurred when ART was initiated during hospitalization versus outpatient setting, and when depressed patients were treated with selective serotonin reuptake inhibitors. Differential adherence to individual drugs in an antiretroviral regimen appears to be common. Preliminary data from randomized studies designed to evaluate patient-selected treatment partners showed no clear benefit on long-term viral suppression.

SUMMARY

Earlier initiation of ART may be desirable even in some patients with suboptimal adherence. Adherence should be reinforced during periods of viral suppression, maximum adherence should be targeted, and attention paid to differential adherence and treatment of depression.