Beyond efficacy: the impact of combination antiretroviral therapy on quality of life

Race explains substantial variance in whole blood thiamine diphosphate concentrations

Deficiency for thiamine (vitamin B1), traditionally assessed via the activity of the thiamine-dependent enzyme erythrocyte transketolase, has been reported in individuals with alcohol use disorder (AUD) and in people with HIV; concentrations of the metabolically active diphosphate form, however, have yet to be reported in HIV cohorts and results in AUD are equivocal. In this cross-sectional study, samples from 170 AUD, 130 HIV, and 100 healthy control individuals were analyzed to test the hypothesis that AUD and HIV groups relative to healthy controls would show low whole blood thiamine diphosphate (TDP) concentrations related to peripheral neuropathy. TDP concentrations were not different in the 3 study groups (P = .6141) but were lower in Black (n = 172) relative to White (n = 155) individuals (P < .0001) regardless of group. In a multiple regression, race relative to diagnoses explained more than 10 times the variance in whole blood TDP concentrations (F4,395 = 3.5, P = .0086; r2 = 15.1]. Performance on a measure of peripheral neuropathy (2-point discrimination) was worse in the HIV and AUD cohorts relative to the healthy control group (P < .0001) but was not associated with TDP concentrations. These findings suggest that Black individuals carry a heightened vulnerability for low whole blood TDP concentrations, but the clinical significance and mechanisms underlying these results remain to be determined.

How are women living with HIV in France coping with their perceived side effects of antiretroviral therapy? Results from the EVE study

OBJECTIVE

Side effects of antiretroviral therapy (ART) can have a negative impact on health-related quality of life threatening long-term retention in HIV care and adherence to ART. The aim of the French community-based survey EVE was to document personal experiences with side effects, the related physician-patient communication, and solutions found to deal with them.

DESIGN

Cross-sectional study of women between September 2013 to September 2014.

METHODS

An anonymous online questionnaire included the HIV Symptom Distress Module, which explores 20 symptoms.

RESULTS

In all, 301 women on ART participated in the study (median age: 49 years; median duration of ART: 14 years). They reported having experienced a median of 12 symptoms (Q1-Q3: 9-15) during the previous 12 months. Overall, 56% of them reported having found at least a partial solution to dealing with their symptoms. Women reporting financial difficulties were twice less likely to have found solutions to coping with their side effects (AOR: 0.5; 95% CI: 0.3-0.8). Feeling supported by the health-care provider (AOR: 2.1; 95% CI: 1.1-3.9) and being in contact with HIV/AIDS organisations (AOR: 1.9; 95% CI: 1.2-3.2) were positively associated with coping. Seventeen percent reported having modified their ART regimen to improve tolerance, with only 2 in 3 informing their physician afterwards. Reporting financial difficulties and living with more bothersome symptoms increased the risk of ART regimen modification without health-care provider consultation.

CONCLUSION

The EVE study has called attention to the large number of side effects experienced by WLWHIV, only half of whom have found self-care strategies to manage their symptoms. Modification of ART regimen by the women themselves was not uncommon.

Trends and determining factors associated with adherence to antiretroviral therapy (ART) in Cameroon: a systematic review and analysis of the CAMPS trial

BACKGROUND

The benefits of antiretroviral therapy (ART) cannot be experienced if they are not taken as prescribed. Yet, not all causes of non-adherence are dependent on the patient. Having to pay for medication reduces adherence rates. Non- adherence has severe public health implications which must be addressed locally and globally. This paper seeks to describe the trends in adherence rates reported in Cameroon and to investigate the determinants of adherence to ART in the Cameroon Mobile Phone SMS (CAMPS) trial.

METHODS

We conducted a systematic review of electronic databases (PubMed, Google Scholar, Web of Science, CINAHL, EMBASE and PSYCINFO) for publications on adherence to ART in Cameroon (from January 1999 to May 2012) and described the trend in reported adherence rates and the factors associated with adherence. Data were extracted in duplicate. We used multivariable analyses on the baseline data for 200 participants in the CAMPS trial to determine the factors associated with adherence in four models using different measures of adherence (more than 90% or 95% on the visual analogue scale, no missed doses and a composite measure: 100% on the visual analogue scale, no missed doses and all pills taken on time).

RESULTS

We identified nine studies meeting our inclusion criteria. Adherence to ART in Cameroon has risen steadily between 2000 and 2010, corresponding to reductions in the cost of medication. The factors associated with adherence to ART in Cameroon are grouped into patient, medication and disease related factors. We also identified factors related to the health system and the patient-provider relationship. In the CAMPS trial, education, side effects experienced and number of reminder methods were found to improve adherence, but only using multiple reminder methods was associated with better adherence in all the regression models (Adjusted Odds Ratio [AOR] 4.11, 95% Confidence Interval [CI] 1.89, 8.93; p<0.001; model IV).

CONCLUSIONS

Reducing the cost of ART is an important aspect of ensuring adequate adherence rates. Using multiple reminder methods may have a cumulative effect on adherence to ART, but should be investigated further.

Improved quality of life for opioid-dependent patients receiving buprenorphine treatment in HIV clinics

BACKGROUND

Opioid dependence and HIV infection are associated with poor health-related quality of life (HRQOL). Buprenorphine/naloxone (bup/nx) provided in HIV care settings may improve HRQOL.

METHODS

We surveyed 289 HIV-infected opioid-dependent persons treated with clinic-based bup/nx about HRQOL using the Short Form Health Survey (SF-12) administered at baseline, 3, 6, 9, and 12 months. We used normalized SF-12 scores, which correspond to a mean HRQOL of 50 for the general US population (SD 10, possible range 0-100). We compared mean normalized mental and physical composite and component scores in quarters 1, 2, 3, and 4 with baseline scores using generalized estimating equation models. We assessed the effect of clinic-based bup/nx prescription on HRQOL composite scores using mixed effects regression with site as random effect and time as repeated effect.

RESULTS

Baseline normalized SF-12 scores were lower than the general US population for all HRQOL domains. Average composite mental HRQOL improved from 38.3 (SE 12.5) to 43.4 (SE 13.2) [β 1.13 (95% CI: 0.72 to 1.54)] and composite physical HRQOL remained unchanged [β 0.21 (95% CI: -0.16 to 0.57)] over 12 months follow-up. Continued bup/nx treatment across all 4 quarters was associated with improvements in both physical [β 2.38 (95% CI: 0.63 to 4.12)] and mental [β 2.51 (95% CI: 0.42 to 4.60)] HRQOL after adjusting for other contributors to HRQOL.

CONCLUSIONS

Clinic-based bup/nx maintenance therapy is potentially effective in ameliorating some of the adverse effects of opioid dependence on HRQOL for HIV-infected populations.

Validation of the MOS-HIV as a measure of health-related quality of life in persons living with HIV and liver disease

BACKGROUND

Management of human immunodeficiency virus (HIV) infection with potent antiretroviral medication has transformed HIV into a chronic condition and has shifted much of the burden of disease to co-morbid conditions such as liver disease (LD). LD alone has been shown to have a significant effect on one's health-related quality of life (HRQOL). Clinical evidence suggests that the growing number of persons living with HIV+LD may have a poorer HRQOL than persons with HIV without LD. To date, the widely accepted instrument to assess HRQOL, Medical Outcomes Study-HIV Health Survey (MOS-HIV), has not been evaluated for reliability and validity in a population of HIV-infected persons with LD.

METHODS

HRQOL was prospectively assessed using the MOS-HIV in a sample of 532 HIV-infected adults on antiretroviral therapy (n=305 HIV and n=227 HIV+LD). In addition, participants completed standardized questionnaires of sociodemographics and co-morbid conditions.

RESULTS

The psychometric properties of the MOS-HIV were supported by testing reliability and construct, convergent, discriminative, and predictive validity. The MOS-HIV discriminated between those persons living with HIV with and without LD on the basis of the physical function subscale scores (p=0.018).

CONCLUSION

This study found the MOS-HIV valid and reliable instrument in persons with HIV+LD.

Multiple ways of targeting APOBEC3-virion infectivity factor interactions for anti-HIV-1 drug development

HIV-1 infections and the resulting AIDS pandemic remain a global challenge in the absence of a protective vaccine and because of rapid selection of drug-resistant viral variants in response to all currently available antiviral therapies. The development of new and highly active antiviral agents would greatly facilitate effective clinical management of HIV-1 infections and delay the onset of AIDS. Recent advances in our understanding of intracellular immunity conferred by host cytidine deaminases APOBEC3G (A3G) and APOBEC3F (A3F) and the mechanism by which the virally encoded virion infectivity factor (Vif) protein induces their proteasomal degradation provide fresh opportunities for the development of novel antiviral treatments. Interestingly, the Vif-A3G and Vif-A3F interactions that overcome this host defense mechanism are structurally distinct and provide two potential targets for antiviral drug development. This review provides an overview of current knowledge of APOBEC3-Vif interactions and recent efforts to target these interactions for antiviral drug development.

Impact of lipoatrophy on quality of life in HIV patients receiving anti-retroviral therapy

Metabolic and morphological side-effects occur in HIV-infected individuals receiving anti-retroviral treatment (ART). Peripheral fat loss that occurs particularly in the face, limbs and/or buttocks is referred to as lipoatrophy and has been found to be highly stigmatizing and to adversely impact the health-related quality of life (HRQL). Consumer Health Sciences Survey data collected between November 2003 and January 2006 were utilized to evaluate the impact of lipoatrophy on the HRQL in HIV-infected individuals receiving ART. This was evaluated using analysis of variance with item scores and mental component summary (MCS) and physical component summary (PCS) scores from the Medical Outcomes Trust questionnaire, SF-8 as dependent variables and lipoatrophy as the independent variable controlling for baseline age, sex and ethnicity. Clinical meaningfulness (mean difference divided by population standard deviation, delta/sigma) of differences between the groups with and without lipoatrophy was also evaluated. A cohort of 1124 subjects with at least six months of ART was selected based on the availability of data on whether or not lipoatrophy was present. Subjects were primarily male (80%), between the ages of 30 and 60 years (90%), Hispanic (37%) and about 25% each of African American and White. Overall, prevalence of lipoatrophy in this cohort of HIV patients was 18.9%. Statistically significant (p<0.001) differences in quality of life (as measured by SF-8 individual item scores and MCS and PCS scores) were observed between the two groups. The differences between the groups in item and summary scores were clinically meaningful in the small to near medium range (0.28-0.43). HIV-infected patients already experience a considerable deficiency in HRQL compared to general population; this study demonstrates that lipoatrophy further enhances that negative impact on HRQL.

Translating efficacy into effectiveness in antiretroviral therapy: beyond the pill count

Durable and sustained suppression of HIV replication can be achieved as demonstrated in several recent clinical trials of antiretroviral (ARV) regimens. However, the efficacy demonstrated in the experimental setting does not always translate to effectiveness in the clinical setting. The frequency and number of medications (conventionally referred to as the pill count) contribute to regimen effectiveness. However, clinicians and HIV-infected patients recognise that there are several other characteristics of an ARV regimen that are equally important contributors to its effectiveness. Potency and durability, the potential for drug-drug interactions, and the occurrence of adverse events also contribute to the effectiveness and complexity of a drug regimen. A comprehensive consideration of factors associated with efficacy will optimise the translation to effectiveness for the individual infected with HIV.

Feasibility of assessing autonomic dysregulation at a distance: the case of the HIV-positive patient

Alterations in lipid metabolism are a possible consequence of highly active antiretroviral therapies (HAART) for human immunodeficiency virus (HIV)-positive patients with consequent increase of cardiovascular risk. In this context we hypothesized that both acquired immunodeficiency syndrome (AIDS) and HAART might be associated to alterations in autonomic cardiovascular regulation. In this preliminary investigation we enrolled a total of 66 men, subdivided in two groups, 33 HIV-positive patients, and 33 healthy controls, and we tested the hypothesis that heart rate variability (HRV) of HIV positive patients can be assessed with a transtelephonic approach from the HIV clinic: 100% of the total of electrocardiograms (ECG) recordings that were sent from the distant site were successfully received and analyzed. Evaluation of the signal was subsequently performed in the centralized laboratory, and consisted in extracting the RR interval variability (RRV) series and afterward subjecting it to autoregressive spectral analysis. This study shows the feasibility of obtaining, from personnel without specific training, adequate RR variability data for further spectral analysis form a distant specialized autonomic laboratory. This feature is of critical importance in the context of possible large-scale application of this simple telemedicine approach.

Health-Related Quality of Life and Tolerability in Treatment-Experienced HIV-1–Infected Patients on Tipranavir versus Comparator Regimens

Background

Antiretroviral therapy including tipranavir boosted with ritonavir (TPV/r) has shown superior viral suppression and immunological response compared with comparator ritonavir-boosted protease inhibitor (CPI/r) regimens in treatment-experienced HIV-1-infected patients. This study assesses the influence of adverse events (AEs) on health-related quality of life (HRQOL) and change in HRQOL in patients treated with TPV/r versus CPI/r regimens.

Methods

Changes in HRQOL over 48 weeks were assessed using Medical Outcomes Study HIV Health Survey (MOS-HIV) data combined from two randomized, open-label, Phase III studies (RESIST-1 and RESIST-2). Generalized estimating equations (GEE) were used to compare physical health and mental health summary scores and 10 subscale scores, and to compare scores of patients with and without AEs. To compare AE incidences in the two treatment groups, AEs were exposure-adjusted.

Results

There were 984 patients in the HRQOL analysis. AE occurrence and severity resulted in significantly lower MOS-HIV scores across both treatment arms ( P<0.05). Overall incidence of AEs was higher in the CPI/r versus TPV/r group (562.8 versus 514.4 per 100 patient-exposure years); treatment-related AEs were more frequent in the TPV/r group (75.0 versus 56.6 per 100 patient-exposure years). HRQOL was maintained in patients on TPV/r over 48 weeks of treatment across all summary and subscale scores. Compared with CPI/r, TPV/r was associated with a significant but small (sd<0.2) improvement in pain scores (+4.8 points; P<0.05).

Conclusions

HRQOL was maintained across both summary and all subscale scores from baseline to 48 weeks in the TPV/r and CPI/r treatment arms, despite the incidence of treatment-related AEs.

Concomitant use of gastric acid-reducing agents is frequent among HIV-1-infected patients receiving protease inhibitor-based highly active antiretroviral therapy

OBJECTIVE

The aim of the study was to assess the frequency of the concurrent use of gastric acid-reducing agents among HIV-1-infected patients treated with highly active antiretroviral therapy (HAART) combinations.

METHODS

An anonymous, semistructured, self-administered questionnaire was consecutively distributed among HIV-1-infected patients at routine visits to specialized HIV clinics. The questionnaire contained 17 items asking specifically for information on current antiretroviral treatments and the use of gastric acid-reducing agents as well as demographic data.

RESULTS

A total of 424 patients in 12 centres participated in the study: 85% were male, 88% were of German nationality, 82% were >35 years of age and 201 (47.4%) were receiving a protease inhibitor (PI)-containing HAART regimen. Of these, 74 (37%) had received an acid-reducing drug within the previous 6 months and 43 (58%) were currently still on it. Two-thirds of patients (64.9%) were treated with proton-pump inhibitors (pantoprazole, omeprazole or esomeprazole) and 56% of patients on PI-containing regimens had been taking these drugs for longer than 2 months and up to a maximum of 3 years. The majority of patients (77%) had received the prescription for the acid-reducing drugs from their HIV specialist and the remaining patients had received over the counter (OTC) medication or prescriptions from other medical personnel.

CONCLUSIONS

A substantial subset of patients treated with HAART combinations, including those on PI-containing regimens, were using concomitant acid-reducing drugs, most often proton-pump inhibitors. As negative drug-drug interactions between some of the (boosted) PIs and gastric acid-reducing agents have recently been reported, HIV physicians should take this into account when prescribing PI-containing HAART combinations in order to avoid an additional risk of treatment failure.

Handling missing quality of life data in HIV clinical trials: what is practical?

AIMS

Missing health-related quality of life (HRQOL) data in clinical trials can impact conclusions but the effect has not been thoroughly studied in HIV clinical trials. Despite repeated recommendations to avoid complete case (CC) analysis and last observation carried forward (LOCF), these approaches are commonly used to handle missing data. The goal of this investigation is to describe the use of different analytic methods under assumptions of missing completely at random (MCAR), missing at random (MAR), and missing not at random (MNAR) using HIV as an empirical example.

METHODS

Medical Outcomes Study HIV (MOS-HIV) Health Survey data were combined from two large open-label multinational HIV clinical trials comparing treatments A and B over 48 weeks. Inclusion in the HRQOL analysis required completion of the MOS-HIV at baseline and at least one follow-up visit (weeks 8, 16, 24, 40, 48). Primary outcomes for the analysis were change from week 0 to 48 in mental health summary (MHS), physical health summary (PHS), pain and health distress scores analyzed using CC, LOCF, generalized estimating equations (GEE), direct likelihood and sensitivity analyses using joint mixed-effects model, and Markov chain Monte Carlo (MCMC) multiple imputation. Time and treatment were included in all models. Baseline and longitudinal variables (adverse event and reason for discontinuation) were only used in the imputation model.

RESULTS

A total of 511 patients randomized to treatment A and 473 to treatment B completed the MOS-HIV at baseline and at least one follow-up visit. At week 48, 71% of patients on treatment A and 31% on treatment B completed the MOS-HIV survey. Examining changes within each treatment group, CC and MCMC generally produced the largest or most positive changes. The joint model was most conservative; direct likelihood and GEE produced intermediate results; LOCF showed no consistent trend. There was greater spread for within-group changes than between-group differences (within MHS scores for treatment A: -0.1 to 1.6, treatment B: 0.4 to 2.0; between groups: -0.7 to 0.4; within PHS scores for treatment A: -1.5 to 0.4, treatment B: -1.7 to -0.2; between groups: 0.1 to 1.1). The size of within-group changes and between-group differences was of similar magnitude for the pain and health distress scores. In all cases, the range of estimates was small <0.2 SD (less than 2 points for the summary scores and 5 points for the subscale scores).

CONCLUSIONS

Use of the recommended likelihood-based models that do not require assumptions of MCAR was very feasible. Sensitivity analyses using auxiliary information can help to investigate the potential effect that missing data have on results but require planning to ensure that relevant data are prospectively collected.

Patient preferences among third agent HIV medications: a US and German perspective

The objective is to assess patient preferences for attributes associated with third agent HIV medications, including fosamprenavir/ritonavir (FPVr), fosamprenavir (FPV), lopinavir/ritonavir (LPVr), atazanavir (ATZ), and efavirenz (EFV). Subjects with HIV were recruited in the US and Germany to complete a computerized adaptive conjoint survey that assessed 13 attributes, including moderate to severe side effects, regimen convenience, drug resistance and efficacy. Literature on the target third-agent HIV drugs was used to identify percentage risk and severity level descriptions for each attribute. The derived preference (utility) weights for each attribute level informed the calculation of relative importance estimates for each attribute and the desirability of combinations of attributes matching the respective target third agents. The analysis included 288 HIV-positive participants (US: 132; Germany: 156), 205 of whom were treatment-experienced and 83 of whom were treatment-naïve. Of the 13 medication attributes evaluated, developing drug resistance, the risk of lipodystrophy, the risk of gastronitestinal side effects (diarrhoea, nausea and vomiting) and regimen convenience had the greatest impact on preferences. The profile based on FPVr was most preferred. Differences in the risk of developing drug resistance, risk of lipodystrophy, risk of gastrointestinal side effects and regimen convenience would likely be most influential in the perceived relative value of a third-agent medication. Physicians may wish to consider these features, especially when discussing HIV treatment options with their patients.

Social support and disclosure as predictors of mental health in HIV-positive youth

The purpose of this study was to describe mental health symptoms in a sample of 66 HIV-positive youth (ages 16-25) and to evaluate social support, disclosure, and physical status as predictors of symptoms. Data were collected from January 2002 to May 2003. As measured by the Brief Symptom Inventory (BSI), 50% of the youth scored above the cutoff for clinically significant mental health symptoms, thus highlighting the need for mental health services. Lower social support, higher viral load, HIV-status disclosure to acquaintances, and being gay/lesbian/bisexual (GLB) were all significantly correlated with more mental health symptoms, but disclosure to family and close friends and contact with service providers were not. Furthermore, regression analysis showed that social support, viral load, and disclosure to acquaintances predicted 32% of the variance in mental health symptoms. Being GLB was no longer significant, most likely because of shared variance with low social support. Results suggest the importance of mental health interventions, and the potential of social support interventions to improve mental health. Further research addressing the role of HIV-related stigma and homophobia is warranted.

Lipid lowering effects of Momordica charantia (Bitter Melon) in HIV-1-protease inhibitor-treated human hepatoma cells, HepG2

1. Hyperlipidemic effects of HIV-1-protease inhibitors (PI) are associated with increased hepatic production of triglyceride (TG)-rich lipoproteins, rather than lipoprotein clearance. PI are known to increase apolipoprotein B (apoB) secretion, apoC-III mRNA expression and decrease apoA-1 secretion. Nutritional therapy remains an important strategy to manage PI-associated hyperlipidemia. 2. This study investigated the in vitro efficacy of Asian vegetable, Momordica charantia or bitter melon (BM) to ameliorate PI-associated apoB and lipid abnormalities in HepG2 cells. 3. Our study demonstrates that bitter melon juice (BMJ) significantly reduced apoB secretion and apoC-III mRNA expression and normalized apoA-I expression in PI-treated HepG2 cells. BMJ also significantly reduced cellular TG and microsomal TG transfer protein, suggesting that lipid bioavailability and lipidation of apoB assembly may play a role in decreased apoB secretion. 4. Identifying molecular targets of BM may offer alternative dietary strategies to decrease PI-associated hyperlipidemia and improve quality of life among HIV-1-infected patients.

Economic models of antiretroviral therapy: searching for the optimal strategy

The diffusion of protease inhibitors and non-nucleoside reverse transcriptase inhibitors in the US in 1996 and 1997 reduced the number of deaths attributable to HIV disease and changed the way we think about the illness. Today, HIV disease may be deemed a fairly expensive chronic condition rather than an intolerably expensive fatal illness. Although most studies have found that patients receiving new drug therapies are hospitalised less frequently than patients who received early drug therapies, it is unclear whether the diffusion of new drug therapies has increased or decreased the annual cost of care. However, it is evident that the diffusion of new drug therapies has increased the lifetime cost of care. Analysts rely on models to simulate the course and cost of HIV disease. This study reviews the evolution of these models, paying particular attention to how these models estimate the cost of care. The primary findings of this review are that the economic data used in these models are often too imprecise to accurately identify the cost of each disease stage and are almost always outdated. Moreover, it was found that estimates of drug costs in these models may not accurately reflect actual expenditures.