Relationship Between Single Tablet Antiretroviral Regimen and Adherence to Antiretroviral and Non-Antiretroviral Medications Among Veterans' Affairs Patients with Human Immunodeficiency Virus

Factors associated with incomplete adherence to integrase strand transfer inhibitor-containing single-tablet regimen among Japanese people living with HIV

BACKGROUND

People living with human immunodeficiency virus (PLWH) require high rates of medication adherence to antiretroviral therapy (ART) for a successful treatment outcome. Understanding the factors associated with incomplete adherence among those receiving integrase strand transfer inhibitor-containing single-tablet regimens (INSTI-STRs) is crucial for improving treatment outcomes. This study aimed to identify the factors contributing to incomplete ART adherence among Japanese PLWH receiving INSTI-STRs.

METHODS

This multicenter cross-sectional study was conducted at 11 Japanese institutions as an anonymous survey. ART adherence was assessed using a self-reported questionnaire. We defined incomplete ART adherence as missing ≥ 1 dose of antiretroviral drugs (ARVs) over the past month. The factors associated with incomplete ART adherence were assessed using logistic regression analysis. Additionally, we investigated the associations between patients' satisfaction score with and need for ARVs and their adherence to ART.

RESULTS

The final analysis included data of 387 patients who were treated with INSTI-STRs. Multivariate logistic regression demonstrated significant association of younger age (adjusted odds ratio [aOR], 0.79; 95%confidence interval [CI]: 0.64-0.99 for each 10-year increment) with incomplete ART adherence. Additionally, female sex (aOR, 3.98; 95%CI: 1.36-11.60); depressive symptoms (mild depression: aOR, 1.68; 95%CI: 1.001-2.82, moderate depression: aOR, 2.98; 95%CI: 1.35-6.53, and severe depression: aOR, 8.73; 95%CI: 1.38-55.00 vs. minimal depression); were also significantly associated with incomplete ART adherence when compared with the reference categories. Concomitant medication usage was significantly associated with a lower rate of incomplete ART adherence (1-4 medications: aOR, 0.53; 95%CI: 0.31-0.89 and ≥ 5 medications: aOR, 0.30; 95%CI: 0.13-0.70 vs. no concomitant medication usage). In the incomplete ART adherence group, satisfaction scores for various aspects were significantly lower. Furthermore, a lower proportion of patients in the incomplete ART adherence group preferred the option of "taking tablets daily and visiting the hospital every 3 months," compared to those in the complete ART adherence group (p = 0.008).

CONCLUSIONS

This study demonstrated that factors associated with incomplete ART adherence include younger age, female sex, no concomitant medication, and depressive symptoms. Despite ART simplification, incomplete adherence among PLWH receiving INSTI-STRs, remains a challenge, requiring additional actions.

Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era

Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.

Antiretroviral stewardship in a tertiary academic hospital: The need for a clinical pharmacist

Background

South Africa has the highest prevalence of people living with HIV globally. Although antiretroviral therapy provides solutions, evidence of antiretroviral resistance emerged, requiring the application of antiretroviral-stewardship programmes to curb medication-related problems.

Aim

Identify and describe antiretroviral-stewardship pharmacist interventions in an active antiretroviral-stewardship programme.

Setting

HIV-positive adults admitted to medical wards at a tertiary academic hospital in South Africa.

Methods

A descriptive quantitative study was performed, utilising an antiretroviral-stewardship assessment tool to determine antiretroviral-related recommendations in the treatment of HIV-positive adults. The study employed purposive sampling. Treatment charts were evaluated to identify antiretroviral-stewardship recommendations. The number of recommendations highlighted the need for a clinical pharmacist in an active antiretroviral-stewardship programme. Descriptive data analysis with Pearson correlations was employed to display the data.

Results

Medication-related problems were identified in 100% of study patients (n = 41), with an average of 2.46 interventions per patient. One-hundred-and-one medication-related problems were identified by using the antiretroviral-stewardship assessment tool. The identified problems included a lack of viral load testing (41, 100%), lack of CD4 count monitoring (15; 36.6%) and lack of prophylactic treatment against opportunistic infections (10; 24.4%). Medication-related problems included the presence of clinically significant drug-drug interactions and serious side effects, CD4 count decline despite being on antiretroviral therapy, unnecessary treatment interruptions including risk for IRIS, inappropriate antiretroviral therapy regimen, non-adherence and absence of treating tuberculosis as co-morbidity.

Conclusion

Present study demonstrates the need of an active antiretroviral-stewardship programme's benefits. The possible role of the clinical pharmacist as active participant and leader in this programme is highlighted.

Contribution

Highlight the role of clinical pharmacists in antiretroviral stewardship.

Adherence to antiretroviral therapy and viral suppression: Analysis of three periods between 2011 and 2017 at an HIV-AIDS center, Brazil

The increased effectiveness of antiretroviral therapy (ART) in the last 30 years is a scientific landmark, and viral suppression is directly associated with treatment adherence. The aim of this study was to compare the results of ART adherence and viral load suppression with the evolution of the protocols and other associated factors, in people living with HIV. A panel analysis of three descriptive longitudinal studies investigating ART adherence and viral load suppression was conducted in people with HIV treated at a drug dispensing unit in the Federal District. The studies were carried out during periods of 2011, 2013, and 2017, coinciding with the three different recommended treatment schemes for the country. Adherence was assessed using drug dispensing records. Viral load data were obtained from the Ministry of Healthʼs Laboratory Examination Information System. Analysis of the data of 522 individuals in the three periods showed sociodemographic differences such as a decline in the percentage of women (from 33% in period 1 to 4% in period 3) and an increase in the percentage of young people. ART adherence was higher in period 2 (tenofovir/lamivudine/efavirenz scheme). Viral load suppression was greater in period 3 (tenofovir/lamivudine/dolutegravir scheme). The relative detectable viral load risk was nearly two-fold higher (RR 1.83) in people living with HIV with less than 80% adherence when compared to those above 80%. With respect to the different schemes recommended in Brazil during the periods studied, ART containing dolutegravir was the most effective in achieving viral load suppression. By contrast, there was better ART adherence in the daily combined fixed dose consisting of tenofovir/lamivudine/efavirenz in tablet form. Adherence to ART above 80% seemed to be enough to promote an effective treatment in therapeutic schemes including efavirenz or dolutegravir.

Structure based design and evaluation of benzoheterocycle derivatives as potential dual HIV-1 protease and reverse transcriptase inhibitors

The development of dual inhibitors of HIV-1 protease and reverse transcriptase is an attractive strategy for multi-target therapeutic of AIDS, which may be privileged in delaying the occurrence of drug resistance. We herein designed a novel kind of dual inhibitors with benzofuran or indole cores. Biological results showed that a number of inhibitors displayed significant activity against both HIV-1 protease and reverse transcriptase. Among which, inhibitor 10f exhibited a good correlation with an approximate ratio of 1: 2 between the two enzymes. Furthermore, the dual inhibitors illustrated similar potency against both the wild-type virus and drug-resistant mutant. In addition, the molecular dynamic simulation studies verified the dual actions of such inhibitors.

Medication adherence with fixed-dose versus free-equivalent combination therapies: Systematic review and meta-analysis

Objective: We conducted a large-scale meta-analysis and subgroup analysis to compare the effect of fixed-dose combination (FDC) therapy with that of free-equivalent combination (FEC) therapy on medication adherence. Methods: Studies published in Web of Science, PubMed, Cochrane Library, ScienceDirect, and Embase up to May 2022 were identified according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary assessed outcomes were the medication possession ratio (MPR) and proportion of days covered (PDC). We investigated the probability of being adherent to the prescribed treatment (MPR or PDC ≥80%) or the average estimate of these two parameters. Studies reporting such results were included in this meta-analysis. The summary measures were reported as the risk ratio (RR) and the weighted mean difference (MD) with 95% of confidence interval (CI) using the random-effects model of DerSimonian and Laird. The quality of the cohort studies was assessed using the Newcastle-Ottawa scale. Results: Of the 1,814 screened studies, 61 met the predefined inclusion criteria. The meta-analysis of the results showed that compared to FEC, FDC significantly improved the medication compliance of patients by 1.29 times (95% CI:1.23-1.35, p < 0.00001). I² of 99% represent high heterogeneity across studies. The mean difference in medication adherence between FDC and FEC was 0.10 (95% CI: 0.06-0.14, p < 0.00001) with an I² estimate of 100%. Subgroup analyses were performed for studies that reported adherence outcomes according to disease type, period of evaluation and compliance indicators. A sensitivity analysis was conducted to exclude the results of low-quality studies, as well as studies in which there was ambiguity in the method of calculating the estimator. Conclusion: Analysis of the assessed parameters for the intention-to-treat and subgroup populations suggests that FDC can improve adherence to treatment and its advantages over FEC may increase over time. Further research is needed to better understand how medical conditions affect the impact of reduced pill burden on adherence, particularly in diseases other than cardiovascular disease and type 2 diabetes mellitus.

Barriers and facilitators to maintaining a high level of polypharmacy adherence in people living with HIV: A scoping review

Objectives: With the prolongation of life span and increasing incidence of comorbidities, polypharmacy has become a challenge for people living with HIV/AIDS (PLWH). This review aimed to identify barriers and facilitators to maintaining a high level of polypharmacy adherence in people living with HIV/AIDS. Methods: Nine electronic databases were searched for studies from 1996 to October 2021. Studies were included if they were conducted with adults living with HIV/AIDS and reported barriers and facilitators to maintaining a high level of polypharmacy adherence. This review presents a conceptual framework model to help understand the barriers and facilitators. Results: Twenty-nine studies were included. The majority of publications were observational studies. Eighty specific factors were identified and further divided into five categories, including individual factors, treatment-related factors, condition-related factors, healthcare provider-related factors, and socioeconomic factors, based on the multidimensional adherence model (MAM). Conclusion: Eighty factors associated with polypharmacy adherence among people living with HIV/AIDS were identified and grouped into five major categories. Healthcare providers can make decisions based on the five categories of relevant factors described in this paper when developing interventions to enhance polypharmacy adherence. It is recommended that medications be evaluated separately and that an overall medication evaluation be conducted at the same time to prevent inappropriate polypharmacy use.

Cumulative tenofovir diphosphate exposure in persons with HIV taking single- vs. multiple-tablet regimens

BACKGROUND

We assessed cumulative antiretroviral exposure-using tenofovir diphosphate (TFV-DP) in dried blood spots (DBS)-in persons with HIV (PWH) receiving tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy (ART) as single-tablet regimens (STR) or multiple-tablet regimens (MTR).

METHODS

Blood for DBS was prospectively collected in PWH on TDF during 1144 person visits (n = 523). Linear mixed-effects models, adjusted for baseline characteristics, were used to compare TFV-DP in STR versus MTR. Models adjusted for ART regimen using either anchor drug class, pharmacokinetic booster status (unboosted [u/] or boosted [b/]), or a combined STR/MTR and booster categorical variable.

RESULTS

In the anchor class-adjusted model, STR had 19% (95% confidence interval [CI]: 3%-37%; p = 0.02) higher TFV-DP concentrations than MTR. However, in the booster-adjusted model, STR was not significantly higher than MTR (estimate 5%, 95% CI: -9% to 21%; p = 0.48), although PWH on b/ART had 35% (95% CI: 16%-58%; p = 0.0001) higher TFV-DP than u/ART. In the STR/MTR-boosted variable model, when compared to u/MTR, b/STR, b/MTR, and u/STR had 25% (95% CI: 7%-47%; p = 0.005), 37% (95% CI: 17%-59%; p < 0.0001), and 7% (95% CI: -7% to 24%; p = 0.34) higher TFV-DP, respectively. Compared with b/MTR, b/STR had 9% (95% CI: -31% to 10%; p = 0.37) lower TFV-DP. In a sensitivity analysis of PWH with HIV viral load <20 copies/ml at all visits, b/STR and b/MTR had 34% (95% CI: 16%-55%; p < 0.0001) and 12% (95% CI: -2% to 27%; p = 0.09) higher TFV-DP, respectively, compared with u/MTR, while u/STR had 4% (95% CI: -15% to 8%; p = 0.50) lower TFV-DP. Compared with b/MTR, b/STR had 17% (95% CI: 2%-30%; p = 0.03) higher TFV-DP.

CONCLUSIONS

Persons with HIV on b/TDF-based ART had higher TFV-DP than u/ART, regardless of STR or MTR use. No significant differences in TFV-DP between regimens of the same boosting status (i.e., b/STR vs. b/MTR; u/STR vs. u/MTR) were observed in the full cohort. Future research should examine the clinical utility of these findings in patient-tailored ART selection.

Real-World Adherence to Antiretroviral Therapy Among HIV-1 Patients Across the United States

Introduction

Recent changes in antiretroviral therapies (ARTs) may have affected medication adherence of people living with human immunodeficiency virus-1 (HIV-1). In this study adherence to ART regimens among patients with HIV-1 (PWH) across the US during a recent time period was examined and study findings were stratified by US region and state.

Methods

A retrospective observational study using the Symphony Health Solution Integrated Dataverse database was conducted. Patients ≥ 18 years of age who had a diagnosis of HIV-1 (without an HIV-2 diagnosis) and who were treated with ART between July 2017 and September 2018 (first pharmacy record: index date) were selected from the data source. Both patients who had not been previously treated with ART and those who were treatment experienced were included. Patients were required to have ≥ 1 medical/pharmacy record ≥ 12 months after their index date (follow-up period). Patient characteristics were examined during a 12-month pre-index period. During the follow-up, medication adherence, measured as the proportion of days covered (PDC), was examined for all patients and stratified by US region and state.

Results

Among 206,474 adult PWH treated with ART, mean age was 47.9 years, 73.4% were male, and 30.0% were Caucasian. The most prevalent comorbid conditions were hyperlipidemia (25.1%), depressive disorders (14.8%), and type 2 diabetes (12.1%). During the follow-up period, mean (standard deviation) PDC was 74.1% (25.9%) among PWH across the US [Midwest: 74.4% (25.5%); Northeast: 74.3% (26.1%); South: 73.2% (26.3%); West: 76.4% (24.8%)]. Across all US regions, > 60% of PWH had adherence < 90% and > 40% had adherence < 80%; the West had the highest adherent population.

Conclusions

Among PWH treated with ART across the US, a majority had suboptimal adherence. Implementation of strategies to improve ART adherence, including clinical consideration of ARTs with high genetic barriers to resistance, is needed in the US.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01883-8.

Effect of pharmacist care on clinical outcomes among people living with HIV/AIDS: A systematic review and meta-analysis

BACKGROUND

Pharmacists play a significant role in the multidisciplinary care of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA). However, there is less evidence to clarify the impact of pharmacist as an individual team member on HIV care.

OBJECTIVE

This study aims to determine the effects of pharmacist intervention on improving adherence to antiretroviral therapy (ART), viral load (VL) suppression, and change in CD4-T lymphocytes in PLWHA.

METHODS

We identified relevant records from six databases (Pubmed, EMBASE, ProQuest, Scopus, Cochrane, and EBSCOhost) from inception till June 2020. We included studies that evaluated the impact of pharmacist care activities on clinical outcomes in PLWHA. A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and mean difference (MD) for continuous data] with 95% confidence intervals (CIs). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to evaluate the quality of evidence. The review protocol was published on PROSPERO (CRD42020167994).

RESULTS

Twenty-five studies involving 3206 PLWHA in which pharmacist-provided intervention either in the form of education with or without pharmaceutical-care either alone or as an interdisciplinary team member were included. Eight studies were randomized controlled trials (RCTs), while 17 studies were non-RCTs. Pooled-analyses showed a significant impact of pharmacist care compared to usual care group on adherence outcome (OR: 2.70 [95%, CI 1.80, 4.05]), VL suppression (OR: 4.13 [95% CI 2.27, 7.50]), and rise of CD4-T lymphocytes count (MD: 66.83 cells/mm³ [95% CI 44.08, 89.57]). The strength of evidence ranged from moderate, low to very low.

CONCLUSION

The findings suggest that pharmacist care improves adherence, VL suppression, and CD4-T lymphocyte improvement in PLWHA; however, it should be noted that the majority of the studies have a high risk of bias. More research with more rigorous designs is required to reaffirm the impact of pharmacist interventions on clinical and economic outcomes in PLWHA.

Failure to eradicate Helicobacter pylori infection is more frequent among HIV-positive patients

OBJECTIVES

Helicobacter pylori is a worldwide infection, but little is known about the efficacy of treatment for H. pylori infection in HIV-positive patients. The goal of this work was to evaluate outcomes after first-line H. pylori treatment and identify risk factors for failure in HIV-positive patients.

METHODS

This registry study of unmatched H. pylori-infected HIV-positive patients and HIV-negative obese pre-bariatric surgery controls was performed in a tertiary university hospital. Cases were enrolled from 2006 to 2017, controls from 2007 to 2014, and both received standard of care. An additional 'optimal' subgroup of cases was enrolled prospectively from 2017 to 2019 which was treated only on the basis of antibiogram, drug interaction search and additional support by one referent physician. Helicobacter pylori eradication failure rates were compared according to clinical, microbiological and pathological parameters and treatment.

RESULTS

We analysed 258 HIV-positive patients and 204 HIV-negative control patients. Helicobacter pylori eradication failure rates were markedly greater in cases (24.1%) than in controls (8.8%). The proportions of levofloxacin and metronidazole resistance were greater in cases than in controls (P < 0.05). Among cases treated with H. pylori triple therapy (S3T), the 'optimal' subgroup experienced a 9.5% failure rate vs. 28.6% with other strategies (P = 0.01). Risk factors for failure were H. pylori treatment strategy, exposure to antiretroviral treatment, and alcohol status. Overall, positive HIV status was a risk factor for S3T eradication failure.

CONCLUSIONS

Patients co-infected with H. pylori and HIV frequently failed to eradicate H. pylori and this was related to treatment strategy, antiretroviral exposure and lifestyle.

Cabotegravir-Rilpivirine: The First Complete Long-Acting Injectable Regimen for the Treatment of HIV-1 Infection

Objective:

To review the efficacy and safety of cabotegravir (CAB) with rilpivirine (RPV) in the treatment of HIV-1 infection.

Data Sources:

A literature search was performed using PubMed and Google Scholar (2010 to January 2021) with the search terms cabotegravir and rilpivirine. Other resources included abstracts presented at recent conferences and the manufacturer’s website and prescribing information.

Study Selection:

All English-language articles of studies assessing the efficacy and safety of CAB with RPV were included.

Data Synthesis:

The combination of CAB, a new integrase strand transfer inhibitor, and RPV, an established nonnucleoside reverse transcriptase inhibitor, is the first long-acting dual therapy approved for the treatment of HIV-1 infection in adults who have achieved viral suppression on a standard antiretroviral therapy (ART). This regimen demonstrated comparable maintenance of viral suppression evaluated up to 160 weeks, with low rates of virological failure. CAB and RPV are available as suspension given intramuscularly in 2 separate injections every 4 weeks. Common adverse effects include injection site reactions, pyrexia, fatigue, and headache. CAB and RPV are also available as tablets given orally for bridging therapy.

Relevance to Patient Care and Clinical Practice:

This long-acting dual therapy represents an attractive option with a high barrier to resistance for adults who have achieved viral suppression on standard ART and who prefer monthly injections over daily oral therapy.

Conclusions:

CAB-RPV is the first complete long-acting injectable that provides a convenient way to maintain viral suppression with no negative effects on renal and bone health and few drug interactions.

Adherence after treatment switch from a multiple tablet antiretroviral regimen to a single tablet antiretroviral regimen

OBJECTIVES

To evaluate adherence after treatment switch from a multiple-tablet regimen (MTR) to a single-tablet regimen (STR) in a national cohort of human immunodeficiency virus (HIV) patients.

METHODS

This retrospective observational cohort, with data spanning January 1, 2000 to March 1, 2019, consisted of HIV infected patients receiving treatment from the Veterans Affairs (VA) health system. Patients were required to have a complete MTR regimen after January 1, 2006 and before December 31, 2018 with at least 60 days of treatment. Medical and pharmacy data were analyzed from the Veterans Affairs Informatics and Computing Infrastructure (VINCI) database. Statistical analyses examined differences in adherence when patients switched to a STR. Patients who switched to a STR were propensity score matched to those who never switched. Descriptive statistics and multivariable linear mixed effects models were utilized to evaluate differences in adherence between MTR and STR treatment in both the matched and unmatched samples.

RESULTS

A total of 5021 patients met the study criteria, 3906 patients in the MTR only cohort and 1115 patients in the switch to STR cohort. The unmatched cohorts were similar in terms of sex, index year, drug/alcohol abuse, and viral load but differed in terms of race, Charlson comorbidity and mental health conditions. The one to one propensity score matched cohort included 2230 patients, 1115 patients in each cohort. Among patients that switched from a MTR to STR, adherence increased on average from 65.9% to 78.12%. We find overall adherence is higher with STRs than with MTR HIV regimens in both the matched and unmatched sample and adherence declines with time for both STR and MTR regimens.

CONCLUSIONS

Switching to a STR is associated with higher adherence compared to MTR among patients with HIV treated with antiretrovirals. However, adherence declines over time with both STR and MTR regimens.

A comparison of medication adherence and viral suppression in antiretroviral treatment-naïve patients with HIV/AIDS depending on the drug formulary

Antiretroviral treatment (ART) adherence is highlighted in management of patients living with human immunodeficiency virus. In South Korea, ART medication research has rarely been conducted due to the low economic burden associated with government-funded treatment. This cross-sectional study aimed to compare the pill burden impact between ART regimen compliance and HIV-RNA viral load suppression. Data were collected from 2008 to 2016 at a general hospital in South Korea. A total of 210 HIV/AIDS treatment-naïve patients were grouped as follows: single-tablet regimen (STR, one tablet/day), mild pill burden (two-four tablets/day), and heavy pill burden (≥ five tablets/day). Patients were analyzed according to gender, age at index date, medical insurance type, comorbidities, depression, HIV/AIDS disease burden as indicated by HIV-RNA viral load and CD4, and laboratory variables. In a multivariate logistic regression model, the STR group demonstrated adherence 5.10 times more often than the heavy pill burden group. Females and patients with an initial viral load of 500,000 or more were 0.090- and 0.040-fold less adherent to the ART regimen. Among these patients, 95% or more of the MPR group were 7.38 times more likely to have a lower limit of detection (LLOD) of viral load suppression. The highest initial viral load group was 0.090-fold less likely to have an LLOD than the reference group. These results suggest that a single-tablet regimen could improve medication adherence and the clinical virologic outcome. Therefore, general population research on ART adherence and polypharmacy is needed.

Does the Polypill Improve Patient Adherence Compared to Its Individual Formulations? A Systematic Review

Many patients, especially those with a high pill burden and multiple chronic illnesses, are less adherent to medication. In medication treatments utilizing polypills, this problem might be diminished since multiple drugs are fused into one formulation and, therefore, the therapy regimen is simplified. This systematic review summarized evidence to assess the effect of polypills on medication adherence. The following databases were searched for articles published between 1 January 2000, and 14 May 2019: PubMed, Web of Science, Cochrane Library, and Scopus. Medication adherence was the only outcome assessed, regardless of the method of measuring it. Sixty-seven original peer-reviewed articles were selected. Adherence to polypill regimens was significantly higher in 56 articles (84%) compared to multiple pill regimens. This finding was also supported by the results of 13 out of 17 selected previously published systematic reviews and meta-analyses dealing with this topic. Adherence can be improved through the formulation of polypills, which is probably why the interest in researching them is growing. There are many polypills on the market, but the adherence studies so far focused mainly on a small range of medical conditions.

Treatment Patterns and Predictors of Adherence in HIV Patients Receiving Single- or Multiple-Tablet Darunavir, Cobicistat, Emtricitabine, and Tenofovir Alafenamide

PURPOSE

Darunavir, cobicistat, emtricitabine, and tenofovir alafenamide can be used as a single-tablet regimen (STR, DRV/c/FTC/TAF) or multiple-tablet regimen (MTR, DRV/c+FTC/TAF) to treat patients with human immunodeficiency virus (HIV). This study described treatment patterns and predictors of adherence among patients with HIV initiated on DRV/c/FTC/TAF or DRV/c+FTC/TAF.

PATIENTS AND METHODS

A retrospective longitudinal study was conducted using linked claims and electronic medical records from Decision Resources Group's Real World Data Repository (7/17/2017-6/1/2019). Treatment-naïve and treatment-experienced virologically suppressed adults with HIV-1 prescribed DRV/c/FTC/TAF or DRV/c+FTC/TAF (index date) were included. Six-month persistence (no treatment gaps >60 and >90 days) and adherence (proportion of days covered [PDC]) to the index regimen were evaluated among patients with ≥6 months of observation post-index. Predictors of low adherence (PDC<80%) were evaluated using a logistic regression model.

RESULTS

Among 2633 eligible patients (49.5 years old, 29% female, 37% African American/Black), 12% were treatment-naïve pre-index and 88% switched from a previous antiretroviral therapy; 84% initiated DRV/c/FTC/TAF and 16% initiated DRV/c+FTC/TAF. Among 822 DRV/c/FTC/TAF patients with ≥6 months of observation post-index, 80% and 86% had no >60- and >90-day gaps in DRV/c/FTC/TAF coverage, respectively, while among 204 DRV/c+FTC/TAF patients with ≥6 months of observation post-index, 69% and 75% had no >60- and >90-day gaps in DRV/c+FTC/TAF coverage, respectively. Mean (median) PDC for the index regimen was 81% (93%) for patients treated with DRV/c/FTC/TAF and 73% (83%) for patients treated with DRV/c+FTC/TAF. Predictors of low adherence included younger age (odds ratio [OR]=2.36, p=0.017), higher Quan-Charlson comorbidity index (OR=1.32, p=0.012), use of MTR regimen at index (OR=1.69, p=0.022), and prior low adherence (OR=2.56, p<0.001).

CONCLUSION

Among patients initiating a DRV/c-based regimen, those initiating STR had higher 6-month adherence/persistence than those initiating MTR, highlighting the potential benefits of the STR formulation, particularly among younger patients with multiple comorbidities and prior low adherence.

Depression Prevalence, Antidepressant Treatment Status, and Association with Sustained HIV Viral Suppression Among Adults Living with HIV in Care in the United States, 2009-2014

Previous research indicates a high burden of depression among adults living with HIV and an association between depression and poor HIV clinical outcomes. National estimates of diagnosed depression, depression treatment status, and association with HIV clinical outcomes are lacking. We used 2009-2014 data from the Medical Monitoring Project to estimate diagnosed depression, antidepressant treatment status, and associations with sustained viral suppression (all viral loads in past year < 200 copies/mL). Data were obtained through interview and medical record abstraction and were weighted to account for unequal selection probabilities and non-response. Of adults receiving HIV medical care in the U.S. and prescribed ART, 27% (95% confidence interval [CI] 25-29%) had diagnosed depression during the surveillance period; the majority (65%) were prescribed antidepressants. The percentage with sustained viral suppression was highest among those without depression (72%, CI 71-73%) and lowest among those with untreated depression (66%, CI 64-69%). Compared to those without depression, those with a depression diagnosis were less likely to achieve sustained viral suppression (aPR 0.95, CI 0.93-0.97); this association held for persons with treated depression compared to no depression (aPR 0.96, CI 0.94-0.99) and untreated depression compared to no depression (aPR 0.92, CI 0.89-0.96). The burden of depression among adults living with HIV in care is high. While in our study depression was only minimally associated with a lower prevalence of sustained viral suppression, diagnosing and treating depression in persons living with HIV remains crucial in order to improve mental health and avoid other poor health outcomes.

DSM-5 substance use disorder symptom clusters and HIV antiretroviral therapy (ART) adherence

This study examines self-reported 30-day antiretroviral therapy (ART) adherence among 101 people living with HIV and substance use disorders (SUD) in New York City in terms of Diagnostic and Statistical Manual - 5th Edition (DSM-5) SUD symptom clusters: impaired control, social impairment, risky use and pharmacological criteria. Overall, 60.4% met DSM-5 criteria for stimulant, 55.5% for alcohol, 34.7% for cannabis and 25.7% for opioid SUD. Of the 76 participants with a current ART prescription, 75.3% reported at least 90% 30-day adherence. Participants with vs. without alcohol SUD were significantly less likely to report ART adherence (64.3% vs. 88.2%, p = .017). Endorsement of social impairment significantly differed among adherent vs. non-adherent participants with alcohol SUDs (74.1% vs. 100%, p = .038) and with opioid SUDs (94.1% vs. 50.0%, p = .040). Understanding specific SUD symptom clusters may assist providers and patients in developing strategies to improve ART adherence.

Which antiretroviral regimen is associated with higher adherence in Brazil? A comparison of single, multi, and dolutegravir-based regimens

We evaluated adherence to highly active antiretroviral therapy (HAART) and its associated factors according to the type of regimen in patients initiating treatment in Belo Horizonte, Minas Gerais State, Brazil. We measured adherence using the eight items Morisky Therapeutic Adhesion Scale (MMAS-8) and compared the use of "backbone" tenofovir/lamivudine plus efavirenz one tablet once-daily (STR) or dolutegravir in multi-tablet once-daily (MTR-DTG), or other multi-tablet regimens (MTR-other). We conducted a multivariate logistic regression analysis to address factors associated with adherence. A total of 393 patients were included, 254 used STR, 106 MTR-DTG, and 33 MTR-other. The overall adhesion rate was 44.8% (95%CI: 39.4; 50.1), 50% for MTR-DTG, 43.3% for STR and 39.4% for MTR-other. Multivariate analysis showed a higher chance of adherence among patients using MTR-DTG, those who received and understood counseling about their treatment and with a higher quality of life. Prior use of illicit drugs in the lifetime was associated with poorer adherence. Overall adherence was low, highlighting the need for strategies focusing on counseling about medicines and substance use. Pill burden was not an issue for patients using MTR-DTG once-daily, who achieved better results.

The Incidence and Severity of Drug Interactions Before and After Antiretroviral Therapy Simplification in Treatment-Experienced Patients With HIV Infection

Background: Current guidelines advocate for antiretroviral therapy (ART) simplification in patients on complicated regimens. Simplifying ART improves patient adherence and quality of life, but changes in drug interactions (DIs) are uncertain. Objective: This study assessed changes in DIs following ART simplification in patients with HIV. Methods: This was an observational, retrospective cohort study of patients attending an urban HIV clinic. Patients were included if they had ART simplification (a decreased number of daily tablets) and ≥1 concomitant medication (CM). Total DI scores were generated for each patient pre-ART simplification and post-ART simplification using an online DI database. Each ART-CM pair labeled as "do not co-administer" was given a score of 2, "potential interaction" a score of 1, or "no interaction" a score of 0. Differences in total DI scores following simplification were analyzed with a Wilcoxon Signed-Rank test. Predictors of DI score reductions were examined with linear regression. Results: A total of 99 patients were included. Their median age was 54 years, and 79% were male. The median durations of HIV infection and ART were 16 and 10 years, respectively. Patients were receiving an average of 4.5 CMs. Median interaction scores presimplification and postsimplification were 3 (interquartile range [IQR], 1-6) and 1 (IQR, 0-2) respectively (P < 0.001). Predictors of score reductions were the patient's number of CMs, discontinuing a protease inhibitor, and switching to a dolutegravir-based regimen. Conclusion and Relevance: ART simplification decreased the incidence of DIs in this analysis of patients with advanced age who had ART experience and polypharmacy.

Long-Term Effects of Psychological Interventions to Improve Adherence to Antiretroviral Treatment in HIV-Infected Persons: A Systematic Review and Meta-Analysis

We examined the efficacy of psychological adherence-enhancing interventions (AEIs) compared with usual care in HIV-infected adults under antiretroviral treatment (ART) by focusing on adherence and clinical HIV markers as outcomes in the short term and long term. We searched relevant databases for controlled studies that compared psychological AEIs with usual care. We included 31 comparisons from 27 individual studies in our meta-analyses. Psychological AEIs were significantly superior to usual care in improving adherence [standardized mean difference (SMD) 0.30, 95% CI 0.20-0.40] and reducing HIV viral load (SMD 0.15, 0.07-0.23) at the end of treatment. At the last follow-up, we found no difference between psychological AEIs and usual care, neither on adherence (SMD 0.07, -0.11-0.24) nor on clinical markers (SMD 0.06, -0.03-0.15). After excluding outliers from the analyses, between-study heterogeneity was small, and we did not identify any relevant moderators of intervention effects. In summary, psychological AEIs may significantly improve ART adherence and HIV viral load compared with usual care in the short term, but fail to be superior in achieving long-lasting improvements on ART adherence and clinical HIV markers as compared with usual care. Owing to limited quality and the majority of studies being conducted in the United States or Europe, our results have to be interpreted with caution, and are most relevant to the United States and Europe. The consistently reported difficulties to achieve sustained ART adherence improvements in previous and the present meta-analyses highlight the need to focus on maintaining ART adherence improvements in future research.

Abacavir/lamivudine/dolutegravir single tablet regimen in patients with human immunodeficiency virus and end-stage renal disease on hemodialysis

No single-tablet antiretroviral (ARV) regimens (STRs) are approved for patients with human immunodeficiency virus (HIV) and end-stage renal disease (ESRD) on hemodialysis (HD). Based on known pharmacokinetic (PK) properties, abacavir (ABC)/lamivudine (3TC)/dolutegravir (DTG) STR may represent a promising option. This case series presents the safety and efficacy of ABC/3TC/DTG STR in patients with HIV and ESRD on HD. Patients were included if they were HIV-positive, maintained on intermittent HD for ESRD, switched to an ARV regimen containing ABC/3TC/DTG, and had at least one set of virologic data before and after the switch. Average age (±standard deviation) was 59 (±8) years. The majority of patients were cis-gender male and non-Hispanic Black. Only one demonstrated clinically significant resistance at baseline. All were on multiple-tablet regimens prior to the switch. Five patients (83%) achieved undetectable HIV-RNA after the switch while only four patients (46%) were undetectable immediately prior. No decline in immune function was noted. ABC/3TC/DTG STR was well tolerated. Only one patient self-reported an adverse event (nausea), which resolved without drug discontinuation. Based on these data, it appears that ABC/3TC/DTG may be a safe and effective ARV-STR option for patients with HIV and ESRD on HD. A larger trial including a PK analysis is needed to confirm these findings.

Efficacy and safety of switching to fixed-dose bictegravir, emtricitabine, and tenofovir alafenamide from boosted protease inhibitor-based regimens in virologically suppressed adults with HIV-1: 48 week results of a randomised, open-label, multicentre, phase 3, non-inferiority trial

BACKGROUND

Switching from therapy based on a boosted protease inhibitor to bictegravir, emtricitabine, and tenofovir alafenamide could avoid drug interactions and unwanted side-effects in virologically suppressed adults with HIV-1 infection, while maintaining a high barrier to resistance and providing a simplified once-daily, single-tablet regimen. Here, we report 48 week results of a phase 3 study investigating this switch.

METHODS

In this multicentre, randomised, open-label, active-controlled, non-inferiority, phase 3 trial, adults with HIV-1 infection were enrolled at 121 outpatient centres in ten countries. Eligible participants were aged 18 years or older, had an estimated glomerular filtration rate of 50 mL per min or higher, had been virologically suppressed (plasma HIV-1 RNA <50 copies per mL) for 6 months or more before screening, and were on a regimen consisting of boosted atazanavir or darunavir plus either emtricitabine and tenofovir disoproxil fumarate or abacavir and lamivudine. We randomly assigned participants (1:1), using a computer-generated randomisation sequence, to switch to co-formulated once-daily bictegravir (50 mg), emtricitabine (200 mg), and tenofovir alafenamide (25 mg), herein known as the bictegravir group, or to remain on their baseline boosted protease inhibitor regimen, herein known as the boosted protease inhibitor group, for 48 weeks. Randomisation was stratified by use of tenofovir disoproxil fumarate or abacavir at screening. The primary endpoint was the proportion of participants with plasma HIV-1 RNA of 50 copies per mL or higher at week 48 (by US Food and Drug Administration snapshot algorithm), with a prespecified non-inferiority margin of 4%. Efficacy and safety analyses included all participants who received at least one dose of study drug. This study is ongoing but not actively recruiting patients and is registered with ClinicalTrials.gov, number NCT02603107.

FINDINGS

Between Dec 2, 2015, and July 15, 2016, 578 participants were randomly assigned and 577 were treated (290 in the bictegravir group and 287 in the boosted protease inhibitor group). At week 48, five participants (2%) in the bictegravir group and five (2%) in the boosted protease inhibitor group had plasma HIV-1 RNA of 50 copies per mL or higher (difference 0·0%, 95·002% CI -2·5 to 2·5), thus switching to the bictegravir regimen was non-inferior to continued boosted protease inhibitor therapy. The overall incidence and severity of adverse events was similar between groups, although headache occurred more frequently in the bictegravir group than in the boosted protease inhibitor group. 233 (80%) participants in the bictegravir group and 226 (79%) in the boosted protease inhibitor group had an adverse event. Only two (1%) participants in the bictegravir group and one (<1%) in the boosted protease inhibitor group discontinued treatment because of adverse events. 54 participants (19%) in the bictegravir group had drug-related adverse events compared with six (2%) in the protease inhibitor group.

INTERPRETATION

Fixed-dose bictegravir, emtricitabine, and tenofovir alafenamide might be a safe and efficacious alternative to continued boosted protease inhibitor therapy in adults with HIV-1 infection.

FUNDING

Gilead Sciences.

Next generation fixed dose combination pharmacotherapies for treating HIV

INTRODUCTION

Treatment options for patients with HIV-1 infection have grown over the past two decades to include multiple fixed-dose combination pharmacotherapies that have greatly simplified administration of antiretroviral therapy (ART) for both patients and providers. Effective virologic control can often be achieved with once-daily use of a single-tablet regimen. Over the past three years, ART drug development has focused on the next generation of fixed-dose combinations for initial and maintenance therapy with improved efficacy, safety and tolerability.

AREAS COVERED

This review covers pre-clinical and clinical data searched through PubMed and presented at major conferences through November 2017.

EXPERT OPINION

Currently available single-tablet regimens have clinical limitations related to adverse event profiles, drug-drug and drug-food interactions and variable barriers to resistance. Anticipated advances in ART fixed-dose combinations promise combinations of current multiple tablet regimens into single tablets, as well as combinations with novel drugs with improved safety and tolerability. The traditional dogma of effective ART containing at least three active antiretroviral drugs is being challenged by promising data to support efficacy of certain regimens containing two drugs. Implementation of next generation ART will bring to light issues of clinical preference and cost-effectiveness as patents of existing drugs expire and more generic formulations become available.