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Maggiolo F, Valenti D, Teocchi R, Comi L, Filippo ED, Rizzi M. Adherence to and Forgiveness of 3TC/DTG in a Real-World Cohort. J Int Assoc Provid AIDS Care 2022; 21:23259582221101815. [PMID: 35695220 PMCID: PMC9203954 DOI: 10.1177/23259582221101815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: adherence and forgiveness are key factors for virologic success. We evaluated them for 3TC/DTG. Methods: pharmacy refills were used to calculate the proportion of days covered (PDC). Forgiveness was calculated as the achieved rate of HIV-RNA threshold by a given level of imperfect adherence. Results: 240 PLWH were included. The median follow-up was 819 days (IQR 450-1459) for a total of 681 person/years of follow-up. Adherence was very high with a median of 99% (IQR 95%-100%). Consequently, the virologic response was sustained with 83.8% of PLWH never exceeding a HIV RNA of 50 copies/ml and 95.8% of subjects with a steadily HIV-RNA < 200 copies/ml. A PDC lower than 80% was associated with a negative outcome irrespective of the HIV-RNA threshold considered. Conclusions: The extensive virologic efficacy of 3TC/DTG demonstrated both in clinical trials and real-world experiences seems to rely more on its friendliness than on its forgiveness.
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Affiliation(s)
- Franco Maggiolo
- UOC Infectious Diseases, 9333ASST Papa Giovanni XXII, Bergamo Italy
| | - Daniela Valenti
- UOC Infectious Diseases, 9333ASST Papa Giovanni XXII, Bergamo Italy.,FROM foundation, ASST Papa Giovanni XXII, Bergamo Italy
| | - Rodolfo Teocchi
- Informatics department, ASST Papa Giovanni XXII, Bergamo Italy
| | - Laura Comi
- UOC Infectious Diseases, 9333ASST Papa Giovanni XXII, Bergamo Italy
| | - Elisa Di Filippo
- UOC Infectious Diseases, 9333ASST Papa Giovanni XXII, Bergamo Italy
| | - Marco Rizzi
- UOC Infectious Diseases, 9333ASST Papa Giovanni XXII, Bergamo Italy
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Maggiolo F, Valenti D, Teocchi R, Comi L, Di Filippo E, Rizzi M. Real World Data on Forgiveness to Uncomplete Adherence to Bictegravir/ Emtricitabine/Tenofovir Alafenamide. J Int Assoc Provid AIDS Care 2022; 21:23259582221140208. [PMID: 36423244 PMCID: PMC9703486 DOI: 10.1177/23259582221140208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023] Open
Abstract
Background: forgiveness is the ability of a given regimen to maintain complete viral suppression despite a documented imperfect adherence. We explored forgiveness of bictegravir/emtricitabine/tenofovir alafenamide. Methods: drug refills were used to calculate the percent day covered (PDC) as a proxy of adherence. Forgiveness was calculated as the achieved rate of a selected HIV-RNA threshold by a given level of imperfect adherence. Results: 281 adult PLWH were followed for 343 patient/years. Adherence was very high with a median of 98% (IQR 95-100%). A PDC as low as 70% was sufficient to obtain 100% and maintain virologic suppression. According to probit analysis adherence was not related to the possibility to maintain an HIV-RNA TND or < 50 copies/ml. Conclusions: Long-term success of ART needs effective regimens that are the least intrusive of the patient's lifestyle, an elevated forgiveness may be considered as an additional feature that can further improve long-term outcomes.
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Affiliation(s)
- Franco Maggiolo
- UOC Infectious Diseases, ASST Papa Giovanni XXII, Bergamo, Italy
| | - Daniela Valenti
- UOC Infectious Diseases, ASST Papa Giovanni XXII, Bergamo, Italy
- FROM foundation, ASST Papa Giovanni XXII, Bergamo, Italy
| | - Rodolfo Teocchi
- Informatics department, ASST Papa Giovanni XXII, Bergamo, Italy
| | - Laura Comi
- UOC Infectious Diseases, ASST Papa Giovanni XXII, Bergamo, Italy
| | - Elisa Di Filippo
- UOC Infectious Diseases, ASST Papa Giovanni XXII, Bergamo, Italy
| | - Marco Rizzi
- UOC Infectious Diseases, ASST Papa Giovanni XXII, Bergamo, Italy
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Yan J, Ouyang J, Isnard S, Zhou X, Harypursat V, Routy JP, Chen Y. Alcohol Use and Abuse Conspires With HIV Infection to Aggravate Intestinal Dysbiosis and Increase Microbial Translocation in People Living With HIV: A Review. Front Immunol 2021; 12:741658. [PMID: 34975838 PMCID: PMC8718428 DOI: 10.3389/fimmu.2021.741658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/30/2021] [Indexed: 12/12/2022] Open
Abstract
The intestinal microbiome is an essential so-called human "organ", vital for the induction of innate immunity, for metabolizing nutrients, and for maintenance of the structural integrity of the intestinal barrier. HIV infection adversely influences the richness and diversity of the intestinal microbiome, resulting in structural and functional impairment of the intestinal barrier and an increased intestinal permeability. Pathogens and metabolites may thus cross the "leaky" intestinal barrier and enter the systemic circulation, which is a significant factor accounting for the persistent underlying chronic inflammatory state present in people living with HIV (PLWH). Additionally, alcohol use and abuse has been found to be prevalent in PLWH and has been strongly associated with the incidence and progression of HIV/AIDS. Recently, converging evidence has indicated that the mechanism underlying this phenomenon is related to intestinal microbiome and barrier function through numerous pathways. Alcohol acts as a "partner" with HIV in disrupting microbiome ecology, and thus impairing of the intestinal barrier. Optimizing the microbiome and restoring the integrity of the intestinal barrier is likely to be an effective adjunctive therapeutic strategy for PLWH. We herein critically review the interplay among HIV, alcohol, and the gut barrier, thus setting the scene with regards to development of effective strategies to counteract the dysregulated gut microbiome and the reduction of microbial translocation and inflammation in PLWH.
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Affiliation(s)
- Jiangyu Yan
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
| | - Jing Ouyang
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
| | - Stéphane Isnard
- Infectious Diseases and Immunity in Global Health Program, Research Institute, McGill University Health Centre, Montréal, QC, Canada
- Chronic Viral Illness Service, McGill University Health Centre, Montréal, QC, Canada
- Canadian HIV Trials Network (CTN), Canadian Institutes of Health Research (CIHR), Vancouver, BC, Canada
| | - Xin Zhou
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
| | - Vijay Harypursat
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
| | - Jean-Pierre Routy
- Infectious Diseases and Immunity in Global Health Program, Research Institute, McGill University Health Centre, Montréal, QC, Canada
- Chronic Viral Illness Service, McGill University Health Centre, Montréal, QC, Canada
- Division of Hematology, McGill University Health Centre, Montréal, QC, Canada
| | - Yaokai Chen
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
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Feder AF, Harper KN, Brumme CJ, Pennings PS. Understanding patterns of HIV multi-drug resistance through models of temporal and spatial drug heterogeneity. eLife 2021; 10:e69032. [PMID: 34473060 PMCID: PMC8412921 DOI: 10.7554/elife.69032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/03/2021] [Indexed: 01/09/2023] Open
Abstract
Triple-drug therapies have transformed HIV from a fatal condition to a chronic one. These therapies should prevent HIV drug resistance evolution, because one or more drugs suppress any partially resistant viruses. In practice, such therapies drastically reduced, but did not eliminate, resistance evolution. In this article, we reanalyze published data from an evolutionary perspective and demonstrate several intriguing patterns about HIV resistance evolution - resistance evolves (1) even after years on successful therapy, (2) sequentially, often via one mutation at a time and (3) in a partially predictable order. We describe how these observations might emerge under two models of HIV drugs varying in space or time. Despite decades of work in this area, much opportunity remains to create models with realistic parameters for three drugs, and to match model outcomes to resistance rates and genetic patterns from individuals on triple-drug therapy. Further, lessons from HIV may inform other systems.
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Affiliation(s)
- Alison F Feder
- Department of Integrative Biology, University of California, BerkeleyBerkeleyUnited States
- Department of Genome Sciences, University of WashingtonSeattleUnited States
| | - Kristin N Harper
- Harper Health and Science Communications, LLCSeattleUnited States
| | - Chanson J Brumme
- British Columbia Centre for Excellence in HIV/AIDSVancouverCanada
- Department of Medicine, University of British ColumbiaVancouverCanada
| | - Pleuni S Pennings
- Department of Biology, San Francisco State UniversitySan FranciscoUnited States
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5
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Cost-effectiveness of a novel strategy of HIV/AIDS care in Armed Forces: A stochastic model with Monte Carlo simulation. Med J Armed Forces India 2020; 76:284-292. [DOI: 10.1016/j.mjafi.2019.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/15/2019] [Indexed: 11/24/2022] Open
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Ruggles KV, Patel AR, Schensul S, Schensul J, Nucifora K, Zhou Q, Bryant K, Braithwaite RS. Betting on the fastest horse: Using computer simulation to design a combination HIV intervention for future projects in Maharashtra, India. PLoS One 2017; 12:e0184179. [PMID: 28873452 PMCID: PMC5584966 DOI: 10.1371/journal.pone.0184179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 08/18/2017] [Indexed: 11/18/2022] Open
Abstract
Objective To inform the design of a combination intervention strategy targeting HIV-infected unhealthy alcohol users in Maharashtra, India, that could be tested in future randomized control trials. Methods Using probabilistic compartmental simulation modeling we compared intervention strategies targeting HIV-infected unhealthy alcohol users on antiretroviral therapy (ART) in Maharashtra, India. We tested interventions targeting four behaviors (unhealthy alcohol consumption, risky sexual behavior, depression and antiretroviral adherence), in three formats (individual, group based, community) and two durations (shorter versus longer). A total of 5,386 possible intervention combinations were tested across the population for a 20-year time horizon and intervention bundles were narrowed down based on incremental cost-effectiveness analysis using a two-step probabilistic uncertainty analysis approach. Results Taking into account uncertainty in transmission variables and intervention cost and effectiveness values, we were able to reduce the number of possible intervention combinations to be used in a randomized control trial from over 5,000 to less than 5. The most robust intervention bundle identified was a combination of three interventions: long individual alcohol counseling; weekly Short Message Service (SMS) adherence counseling; and brief sex risk group counseling. Conclusions In addition to guiding policy design, simulation modeling of HIV transmission can be used as a preparatory step to trial design, offering a method for intervention pre-selection at a reduced cost.
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Affiliation(s)
- Kelly V. Ruggles
- Department of Medicine, New York University School of Medicine, New York, NY, United States of America
- * E-mail:
| | - Anik R. Patel
- Department of Experimental Medicine, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Stephen Schensul
- Department of Community Medicine and Health Care, University of Connecticut Health Center, Farmington, CT, United States of America
| | - Jean Schensul
- Institute for Community Research, Hartford, CT, United States of America
| | - Kimberly Nucifora
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - Qinlian Zhou
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States of America
| | - R. Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
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7
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Uyei J, Li L, Braithwaite RS. Is more research always needed? Estimating optimal sample sizes for trials of retention in care interventions for HIV-positive East Africans. BMJ Glob Health 2017; 2:e000195. [PMID: 29081993 PMCID: PMC5656134 DOI: 10.1136/bmjgh-2016-000195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 04/27/2017] [Accepted: 04/30/2017] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Given the serious health consequences of discontinuing antiretroviral therapy, randomised control trials of interventions to improve retention in care may be warranted. As funding for global HIV research is finite, it may be argued that choices about sample size should be tied to maximising health. METHODS For an East African setting, we calculated expected value of sample information and expected net benefit of sampling to identify the optimal sample size (greatest return on investment) and to quantify net health gains associated with research. Two hypothetical interventions were analysed: (1) one aimed at reducing disengagement from HIV care and (2) another aimed at finding/relinking disengaged patients. RESULTS When the willingness to pay (WTP) threshold was within a plausible range (1-3 × GDP; US$1377-4130/QALY), the optimal sample size was zero for both interventions, meaning that no further research was recommended because the pre-research probability of an intervention's effectiveness and value was sufficient to support a decision on whether to adopt the intervention and any new information gained from additional research would likely not change that decision. In threshold analyses, at a higher WTP of $5200 the optimal sample size for testing a risk reduction intervention was 2750 per arm. For the outreach intervention, the optimal sample size remained zero across a wide range of WTP thresholds and was insensitive to variation. Limitations, including not varying all inputs in the model, may have led to an underestimation of the value of investing in new research. CONCLUSION In summary, more research is not always needed, particularly when there is moderately robust prestudy belief about intervention effectiveness and little uncertainty about the value (cost-effectiveness) of the intervention. Users can test their own assumptions at http://torchresearch.org.
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Affiliation(s)
- Jennifer Uyei
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York City, New York, USA
| | - Lingfeng Li
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York City, New York, USA
| | - R Scott Braithwaite
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York City, New York, USA
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Gwadz MV, Collins LM, Cleland CM, Leonard NR, Wilton L, Gandhi M, Scott Braithwaite R, Perlman DC, Kutnick A, Ritchie AS. Using the multiphase optimization strategy (MOST) to optimize an HIV care continuum intervention for vulnerable populations: a study protocol. BMC Public Health 2017; 17:383. [PMID: 28472928 PMCID: PMC5418718 DOI: 10.1186/s12889-017-4279-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/21/2017] [Indexed: 12/10/2023] Open
Abstract
BACKGROUND More than half of persons living with HIV (PLWH) in the United States are insufficiently engaged in HIV primary care and not taking antiretroviral therapy (ART), mainly African Americans/Blacks and Hispanics. In the proposed project, a potent and innovative research methodology, the multiphase optimization strategy (MOST), will be employed to develop a highly efficacious, efficient, scalable, and cost-effective intervention to increase engagement along the HIV care continuum. Whereas randomized controlled trials are valuable for evaluating the efficacy of multi-component interventions as a package, they are not designed to evaluate which specific components contribute to efficacy. MOST, a pioneering, engineering-inspired framework, addresses this problem through highly efficient randomized experimentation to assess the performance of individual intervention components and their interactions. We propose to use MOST to engineer an intervention to increase engagement along the HIV care continuum for African American/Black and Hispanic PLWH not well engaged in care and not taking ART. Further, the intervention will be optimized for cost-effectiveness. A similar set of multi-level factors impede both HIV care and ART initiation for African American/Black and Hispanic PLWH, primary among them individual- (e.g., substance use, distrust, fear), social- (e.g., stigma), and structural-level barriers (e.g., difficulties accessing ancillary services). Guided by a multi-level social cognitive theory, and using the motivational interviewing approach, the study will evaluate five distinct culturally based intervention components (i.e., counseling sessions, pre-adherence preparation, support groups, peer mentorship, and patient navigation), each designed to address a specific barrier to HIV care and ART initiation. These components are well-grounded in the empirical literature and were found acceptable, feasible, and promising with respect to efficacy in a preliminary study. METHODS/DESIGN Study aims are: 1) using a highly efficient fractional factorial experimental design, identify which of five intervention components contribute meaningfully to improvement in HIV viral suppression, and secondary outcomes of ART adherence and engagement in HIV primary care; 2) identify mediators and moderators of intervention component efficacy; and 3) using a mathematical modeling approach, build the most cost-effective and efficient intervention package from the efficacious components. A heterogeneous sample of African American/Black and Hispanic PLWH (with respect to age, substance use, and sexual minority status) will be recruited with a proven hybrid sampling method using targeted sampling in community settings and peer recruitment (N = 512). DISCUSSION This is the first study to apply the MOST framework in the field of HIV prevention and treatment. This innovative study will produce a culturally based HIV care continuum intervention for the nation's most vulnerable PLWH, optimized for cost-effectiveness, and with exceptional levels of efficacy, efficiency, and scalability. TRIAL REGISTRATION ClinicalTrials.gov, NCT02801747 , Registered June 8, 2016.
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Affiliation(s)
- Marya Viorst Gwadz
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA.
| | - Linda M Collins
- The Methodology Center and Department of Human Development and Family Studies, Pennsylvania State University, State College, Pennsylvania, PA, USA
| | - Charles M Cleland
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Noelle R Leonard
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Leo Wilton
- Department of Human Development, State University of New York at Binghamton, Binghamton, NY, USA
- Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - David C Perlman
- Department of Infectious Diseases, Mount Sinai Beth Israel, New York, NY, USA
| | - Alexandra Kutnick
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Amanda S Ritchie
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
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Khademi A, Saure D, Schaefer A, Nucifora K, Braithwaite RS, Roberts MS. HIV Treatment in Resource-Limited Environments: Treatment Coverage and Insights. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:1113-1119. [PMID: 26686798 PMCID: PMC4686871 DOI: 10.1016/j.jval.2015.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 09/07/2015] [Accepted: 10/04/2015] [Indexed: 06/05/2023]
Abstract
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.
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Affiliation(s)
- Amin Khademi
- Department of Industrial Engineering, Clemson University, Clemson, SC, USA.
| | - Denis Saure
- Department of Industrial Engineering, University of Chile, Santiago, Chile
| | - Andrew Schaefer
- Department of Industrial Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kimberly Nucifora
- Section of Value and Comparative Effectiveness, NYU School of Medicine, New York, NY, USA
| | - R Scott Braithwaite
- Section of Value and Comparative Effectiveness, NYU School of Medicine, New York, NY, USA
| | - Mark S Roberts
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Industrial Engineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
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10
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Should expectations about the rate of new antiretroviral drug development impact the timing of HIV treatment initiation and expectations about treatment benefits? PLoS One 2014; 9:e98354. [PMID: 24963883 PMCID: PMC4070901 DOI: 10.1371/journal.pone.0098354] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 05/01/2014] [Indexed: 11/19/2022] Open
Abstract
Background Many analyses of HIV treatment decisions assume a fixed formulary of HIV drugs. However, new drugs are approved nearly twice a year, and the rate of availability of new drugs may affect treatment decisions, particularly when to initiate antiretroviral therapy (ART). Objectives To determine the impact of considering the availability of new drugs on the optimal initiation criteria for ART and outcomes in patients with HIV/AIDS. Methods We enhanced a previously described simulation model of the optimal time to initiate ART to incorporate the rate of availability of new antiviral drugs. We assumed that the future rate of availability of new drugs would be similar to the past rate of availability of new drugs, and we estimated the past rate by fitting a statistical model to actual HIV drug approval data from 1982–2010. We then tested whether or not the future availability of new drugs affected the model-predicted optimal time to initiate ART based on clinical outcomes, considering treatment initiation thresholds of 200, 350, and 500 cells/mm3. We also quantified the impact of the future availability of new drugs on life expectancy (LE) and quality-adjusted life expectancy (QALE). Results In base case analysis, considering the availability of new drugs raised the optimal starting CD4 threshold for most patients to 500 cells/mm3. The predicted gains in outcomes due to availability of pipeline drugs were generally small (less than 1%), but for young patients with a high viral load could add as much as a 4.9% (1.73 years) increase in LE and a 8% (2.43 QALY) increase in QALE, because these patients were particularly likely to exhaust currently available ART regimens before they died. In sensitivity analysis, increasing the rate of availability of new drugs did not substantially alter the results. Lowering the toxicity of future ART drugs had greater potential to increase benefit for many patient groups, increasing QALE by as much as 10%. Conclusions The future availability of new ART drugs without lower toxicity raises optimal treatment initiation for most patients, and improves clinical outcomes, especially for younger patients with higher viral loads. Reductions in toxicity of future ART drugs could impact optimal treatment initiation and improve clinical outcomes for all HIV patients.
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11
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Comparing adherence to two different HIV antiretroviral regimens: an instrumental variable analysis. AIDS Behav 2013; 17:160-7. [PMID: 22869102 DOI: 10.1007/s10461-012-0266-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The objective of this observational cohort study was to compare adherence to protease inhibitor (PI)-based regimens or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. HIV-seropositive, antiretroviral-naïve patients initiating therapy between 1998 and 2006 were identified using Veterans Health Administration databases. First-year adherence ratios were calculated as proportion of days covered (PDC). Multivariable regressions were run with an indicator for PDC >95, 90, 85, and 80 % as the dependent variable and an indicator for a PI-based regimen as the key independent variable. We controlled for residual unmeasured confounding by indication using an instrumental variable technique, using the physician's prescribing preference as the instrument. Out of 929 veterans on PI-based and 747 on NNRTI-based regimens, only 19.7 % of PI patients had PDC >80 %, compared to 35.1 % of NNRTI patients. In multivariable analysis, starting a PI regimen was significantly associated with poor adherence for all 4 adherence thresholds using conventional regressions and instrumental variable methods.
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12
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Roy U, McMillan J, Alnouti Y, Gautum N, Smith N, Balkundi S, Dash P, Gorantla S, Martinez-Skinner A, Meza J, Kanmogne G, Swindells S, Cohen SM, Mosley RL, Poluektova L, Gendelman HE. Pharmacodynamic and antiretroviral activities of combination nanoformulated antiretrovirals in HIV-1-infected human peripheral blood lymphocyte-reconstituted mice. J Infect Dis 2012; 206:1577-88. [PMID: 22811299 DOI: 10.1093/infdis/jis395] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Lack of adherence, inaccessibility to viral reservoirs, long-term drug toxicities, and treatment failures are limitations of current antiretroviral therapy (ART). These limitations lead to increased viral loads, medicine resistance, immunocompromise, and comorbid conditions. To this end, we developed long-acting nanoformulated ART (nanoART) through modifications of existing atazanavir, ritonavir, and efavirenz suspensions in order to establish cell and tissue drug depots to achieve sustained antiretroviral responses. NanoART's abilities to affect immune and antiviral responses, before or following human immunodeficiency virus type 1 infection were tested in nonobese severe combined immune-deficient mice reconstituted with human peripheral blood lymphocytes. Weekly subcutaneous injections of drug nanoformulations at doses from 80 mg/kg to 250 mg/kg, 1 day before and/or 1 and 7 days after viral exposure, elicited drug levels that paralleled the human median effective concentration, and with limited toxicities. NanoART treatment attenuated viral replication and preserved CD4(+) Tcell numbers beyond that seen with orally administered native drugs. These investigations bring us one step closer toward using long-acting antiretrovirals in humans.
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Affiliation(s)
- Upal Roy
- Department of Pharmacology and Experimental Neuroscience, College of Medicine, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
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13
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Cortes LMP, Zurakowski R. Resistance evolution in HIV - modeling when to intervene. PROCEEDINGS OF THE ... AMERICAN CONTROL CONFERENCE. AMERICAN CONTROL CONFERENCE 2012; 2012:4053-4058. [PMID: 25264400 PMCID: PMC4175725 DOI: 10.1109/acc.2012.6315693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The treatment of HIV is complicated by the evolution of antiviral drug resistant virus and the limited availability of antigenically independent antiviral regimens. The consequences to the patient of successive virological failures is such that many strategies to minimize the occurrence of such failures are being investigated. In this paper, a Markov chain-based model of virological failure is introduced. This model considers sequential failure events, and differentiates between several modes of virological failure. This model is then used to evaluate the resistance- targeted interventions by means of testing the impact of a viral load preconditioning strategy on total treatment regimen longevity in HIV patients. It is shown that a proposed intervention targeting pre-existing resistance has the potential to increase the expected time to three sequential virological failures by an average of 3.3 years per patient. When combined with an intervention targeting patient compliance, the total potential increase in the time to three sequential virological failures is as high as 11.2 years. The impact on patient and public health is discussed.
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Affiliation(s)
| | - Ryan Zurakowski
- Electrical and Computer Engineering, University of Delaware, Newark, DE 19716, USA
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Cahn P, Montaner J, Junod P, Patterson P, Krolewiecki A, Andrade-Villanueva J, Cassetti I, Sierra-Madero J, Casiró AD, Bortolozzi R, Lupo SH, Longo N, Rampakakis E, Ackad N, Sampalis JS. Pilot, randomized study assessing safety, tolerability and efficacy of simplified LPV/r maintenance therapy in HIV patients on the 1 PI-based regimen. PLoS One 2011; 6:e23726. [PMID: 21886816 PMCID: PMC3158782 DOI: 10.1371/journal.pone.0023726] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 07/25/2011] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES To compare the efficacy and safety of an individualized treatment-simplification strategy consisting of switching from a highly-active anti-retroviral treatment (HAART) with a ritonavir-boosted protease inhibitor (PI/r) and 2 nucleoside reverse-transcriptase inhibitors (NRTIs) to lopinavir/ritonavir (LPV/r) monotherapy, with intensification by 2 NRTIs if necessary, to that of continuing their HAART. METHODS This is a one-year, randomized, open-label, multi-center study in virologically-suppressed HIV-1-infected adults on their first PI/r-containing treatment, randomized to either LPV/r-monotherapy or continue their current treatment. Treatment efficacy was determined by plasma HIV-1 RNA viral load (VL), time-to-virologic rebound, patient-reported outcomes (PROs) and CD4+T-cell-count changes. Safety was assessed with the incidence of treatment-emergent adverse events (AE). RESULTS Forty-one patients were randomized to LPV/r and 39 to continue their HAART. No statistically-significant differences between the two study groups in demographics and baseline characteristics were observed. At day-360, 71(39:LPV/r;32:HAART) patients completed treatment, while 9(2:LPV/r;7:HAART) discontinued. In a Last Observation Carried Forward Intent-to-Treat analysis, 40(98%) patients on LPV/r and 37(95%) on HAART had VL<200 copies/mL (P = 0.61). Time-to-virologic rebound, changes in PROs, CD4+ T-cell-count and VL from baseline, also exhibited no statistically-significant between-group differences. Most frequent AEs were diarrhea (19%), headache (18%) and influenza (16%). Four (10%) patients on LPV/r were intensified with 2 NRTIs, all regaining virologic control. Eight serious AEs were reported by 5(2:LPV/r;3:HAART) patients. CONCLUSION At day-360, virologic efficacy and safety of LPV/r appears comparable to that of a PI+2NRTIs HAART. These results suggest that our individualized, simplified maintenance strategy with LPV/r-monotherapy and protocol-mandated NRTI re-introduction upon viral rebound, in virologically-suppressed patients merits further prospective long-term evaluation. TRIAL REGISTRATION ClinicalTrials.gov NCT00159224.
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Affiliation(s)
- Pedro Cahn
- Fundacion Huesped, Buenos Aires, Argentina
| | | | - Patrice Junod
- Clinique Médicale du Quartier Latin, Montréal, Canada
| | | | | | - Jaime Andrade-Villanueva
- Antiguo Hospital Civil de Guadalajara “Fray Antonio Alcalde”, CUCS, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | | | | | | | - Raul Bortolozzi
- División Estudios Clínicos, Centro Diagnóstico Médico de Alta Complejidad S.A. (CIBIC), Santa Fé, Argentina
| | | | | | | | | | - John S. Sampalis
- JSS Medical Research, Westmount, Canada
- McGill University, Montréal, Canada
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Nachega JB, Marconi VC, van Zyl GU, Gardner EM, Preiser W, Hong SY, Mills EJ, Gross R. HIV treatment adherence, drug resistance, virologic failure: evolving concepts. Infect Disord Drug Targets 2011; 11:167-74. [PMID: 21406048 DOI: 10.2174/187152611795589663] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 06/25/2010] [Indexed: 01/11/2023]
Abstract
Poor adherence to combined antiretroviral therapy (cART) has been shown to be a major determinant of virologic failure, emergence of drug resistant virus, disease progression, hospitalizations, mortality, and health care costs. While high adherence levels can be achieved in both resource-rich and resource-limited settings following initiation of cART, long-term adherence remains a challenge regardless of available resources. Barriers to optimal adherence may originate from individual (biological, socio-cultural, behavioral), pharmacological, and societal factors. Although patients and providers should continuously strive for maximum adherence to cART, there is accumulating evidence that each class of antiretroviral therapy has specific adherence-drug resistance relationship characteristics allowing certain regimens more flexibility than others. There is not a universally accepted measure for cART adherence, since each method has distinct advantages and disadvantages including cost, complexity, accuracy, precision, intrusiveness and bias. Development of a real-time cART adherence monitoring tool will enable the development of novel, pre-emptive adherence-improving strategies. The application of these strategies may ultimately prove to be the most cost-effective method to reduce morbidity and mortality for the individual and decrease the likelihood of HIV transmission and emergence of resistance in the community.
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Affiliation(s)
- Jean B Nachega
- Departments of International Health and Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA.
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Abstract
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.
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Braithwaite RS, Nucifora KA, Yiannoutsos CT, Musick B, Kimaiyo S, Diero L, Bacon MC, Wools-Kaloustian K. Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives? J Int AIDS Soc 2011; 14:38. [PMID: 21801434 PMCID: PMC3163507 DOI: 10.1186/1758-2652-14-38] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 07/30/2011] [Indexed: 12/11/2022] Open
Abstract
Background Updated World Health Organization guidelines have amplified debate about how resource constraints should impact monitoring strategies for HIV-infected persons on combination antiretroviral therapy (cART). We estimated the incremental benefit and cost effectiveness of alternative monitoring strategies for east Africans with known HIV infection. Methods Using a validated HIV computer simulation based on resource-limited data (USAID and AMPATH) and circumstances (east Africa), we compared alternative monitoring strategies for HIV-infected persons newly started on cART. We evaluated clinical, immunologic and virologic monitoring strategies, including combinations and conditional logic (e.g., only perform virologic testing if immunologic testing is positive). We calculated incremental cost-effectiveness ratios (ICER) in units of cost per quality-adjusted life year (QALY), using a societal perspective and a lifetime horizon. Costs were measured in 2008 US dollars, and costs and benefits were discounted at 3%. We compared the ICER of monitoring strategies with those of other resource-constrained decisions, in particular earlier cART initiation (at CD4 counts of 350 cells/mm3 rather than 200 cells/mm3). Results Monitoring strategies employing routine CD4 testing without virologic testing never maximized health benefits, regardless of budget or societal willingness to pay for additional health benefits. Monitoring strategies employing virologic testing conditional upon particular CD4 results delivered the most benefit at willingness-to-pay levels similar to the cost of earlier cART initiation (approximately $2600/QALY). Monitoring strategies employing routine virologic testing alone only maximized health benefits at willingness-to-pay levels (> $4400/QALY) that greatly exceeded the ICER of earlier cART initiation. Conclusions CD4 testing alone never maximized health benefits regardless of resource limitations. Programmes routinely performing virologic testing but deferring cART initiation may increase health benefits by reallocating monitoring resources towards earlier cART initiation.
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Affiliation(s)
- R Scott Braithwaite
- Section on Value and Comparative Effectiveness, Department of Medicine, New York University School of Medicine, USA.
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Gelman MA, Glenn JS. Mixing the right hepatitis C inhibitor cocktail. Trends Mol Med 2011; 17:34-46. [PMID: 21106440 PMCID: PMC3085044 DOI: 10.1016/j.molmed.2010.10.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 09/23/2010] [Accepted: 10/11/2010] [Indexed: 01/06/2023]
Abstract
Therapy for hepatitis C virus (HCV) infection is on the cusp of a new era. Until now, standard-of-care therapy has involved interferon (IFN) and ribavirin. With the first successful Phase III trials of specific targeted antiviral therapy for HCV (STAT-C) compounds, as well as three trials in progress giving the first glimpse of IFN-free combinations of STAT-C agents, this review looks ahead to the new classes of anti-HCV agents currently in clinical development. Successful pharmacologic control of HIV and TB frames the discussion, as well as consideration of the mutation frequency of HCV replication. Maximizing synergy between agents and minimizing cumulative toxicity will be critical to the design of future IFN-free STAT-C regimens.
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Affiliation(s)
- Michael A. Gelman
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Jeffrey S. Glenn
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
- Veterans Administration Medical Center, Palo Alto, California
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Braithwaite RS, Fiellin DA, Nucifora K, Bryant K, Roberts M, Kim N, Justice AC. Evaluating interventions to improve antiretroviral adherence: how much of an effect is required for favorable value? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:535-542. [PMID: 20345544 PMCID: PMC3032536 DOI: 10.1111/j.1524-4733.2010.00714.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
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.
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Using mechanistic models to simulate comparative effectiveness trials of therapy and to estimate long-term outcomes in HIV care. Med Care 2010; 48:S90-5. [PMID: 20473184 DOI: 10.1097/mlr.0b013e3181e2b744] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND In HIV care, it is difficult to decide when to initiate therapy, which drugs to use for initial treatment, and which drugs to use if drug resistance develops. With hundreds of possible drug regimens available and variable patterns of drug resistance, randomized controlled trials cannot answer all HIV treatment decisions. Mechanistic models of HIV infection can be used to conduct virtual therapeutic trials with the goal of predicting outcomes, some of which are long-term and may not fall within the time frame of a typical therapeutic trial. METHODS We used a previously developed and validated model of HIV infection to replicate 2 arms of an HIV initial treatment trial (ACTG A5142) and predict long-term outcomes. The model incorporated data about biologic processes involved in the development of drug resistance. RESULTS The model reproduced the proportion that developed AIDS (0.04 and 0.05 for the efavirenz arm and lopinavir arms, respectively, vs. 0.04 and 0.06 for the trial), the development of virologic failure (0.27 and 0.33 for the Efavirenz arm and lopinavir arms, respectively, vs. 0.24 and 0.37 for the trial), and drug resistance. The hazard ratio for the time to treatment failure, a combination of resistance and other causes (0.96 for the model vs. 0.75 for the trial; 95% confidence interval, 0.57-0.98), and changes in CD4 cell count, were less accurate. The model estimated longer-term life expectancy, quality-adjusted life expectancy, and HIV-related deaths. CONCLUSIONS Mechanistic models of HIV infections have the potential to be useful in comparative effectiveness research.
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Bazzoli C, Jullien V, Le Tiec C, Rey E, Mentré F, Taburet AM. Intracellular Pharmacokinetics of Antiretroviral Drugs in HIV-Infected Patients, and their Correlation with Drug Action. Clin Pharmacokinet 2010; 49:17-45. [DOI: 10.2165/11318110-000000000-00000] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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van den Berg-Wolf M, Hullsiek KH, Peng G, Kozal MJ, Novak RM, Chen L, Crane LR, Macarthur RD. Virologic, immunologic, clinical, safety, and resistance outcomes from a long-term comparison of efavirenz-based versus nevirapine-based antiretroviral regimens as initial therapy in HIV-1-infected persons. HIV CLINICAL TRIALS 2009; 9:324-36. [PMID: 18977721 DOI: 10.1310/hct0905-324] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To compare long-term virologic, immunologic, and clinical outcomes in antiretroviral-naïve persons starting efavirenz (EFV)- versus nevirapine (NVP)-based regimens. METHOD The FIRST study randomized patients into three strategy arms: PI+NRTI, NNRTI+NRTI, and PI+NNRTI+NRTI. NNRTI was determined by optional randomization (NVP or EFV) or by choice. For this randomized substudy, the primary endpoint was HIV RNA >50 copies/mL after 8 months or death. Genotypic resistance testing was done at virologic failure (VF; HIV RNA >1,000 copies/mL at or after 4 months). RESULTS 228 persons (111 randomized to EFV, 117 to NVP) were followed for median 5 years. Rates per 100 person years for the primary endpoint were 41.2 (EFV) and 42.8 (NVP; p = .59). The percent of persons with HIV RNA <50 copies/mL was similar throughout follow-up (p = .24), as were average increases in CD4+ cells (p = .30). 423 persons declining the substudy chose EFV; 264 chose NVP. There were 915 persons in the combined cohort (randomized and choice). In the combined cohort, the risk of VF and VF with any NNRTI or NRTI resistance or resistance of any class was significantly less for EFV compared to NVP. CONCLUSIONS EFV-based regimens as initial therapy resulted in a lower risk of VF and VF with resistance than did NVP-based regimens, although immunologic and clinical outcomes were similar.
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Braithwaite RS, Roberts MS, Goetz MB, Gibert CL, Rodriguez-Barradas MC, Nucifora K, Justice AC. Do benefits of earlier antiretroviral treatment initiation outweigh harms for individuals at risk for poor adherence? Clin Infect Dis 2009; 48:822-6. [PMID: 19210173 PMCID: PMC3032571 DOI: 10.1086/596768] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Clinicians may defer antiretroviral treatment for patients with suboptimal adherence. We used a validated computer simulation of HIV disease progression to compare alternative treatment thresholds for patients with suboptimal adherence. Earlier treatment increased life expectancy across a wide adherence range (50%-100% of doses taken). Delaying treatment for patients with suboptimal adherence may not always be appropriate.
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Affiliation(s)
- R Scott Braithwaite
- Department of Medicine, Section of General Internal Medicine, Yale University, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA.
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Rogowska-Szadkowska D, Chlabicz S. Perfect adherence in taking antiretroviral drugs – role of the doctors. HIV & AIDS REVIEW 2009. [DOI: 10.1016/s1730-1270(10)60029-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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The relationship between resistance and adherence in drug-naive individuals initiating HAART is specific to individual drug classes. J Acquir Immune Defic Syndr 2008; 49:266-71. [PMID: 18845950 DOI: 10.1097/qai.0b013e318189a753] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the relationship between HIV-1 drug resistance and adherence and the accumulation rate of resistance mutations in 1191 HIV-infected, antiretroviral-naive adults initiating highly active antiretroviral therapy in British Columbia, Canada. METHODS Plasma samples with plasma viral load >1,000 copies per milliliter collected within 30 months of follow-up were genotyped for drug resistance. Adherence was estimated using prescription refills and plasma drug levels. The primary outcome measure was time to detection of drug resistance. Cox proportional hazard regression was used to calculate hazard ratios (HRs) associated with baseline variables. RESULTS The accumulation rates of multiple primary and secondary mutations were similar in patients initiating highly active antiretroviral therapy with protease inhibitor versus nonnucleoside reverse transcriptase inhibitor (NNRTI). Rates decreased approximately 50% per additional mutation. At 80%-90% adherence based on refills, there was greater risk of detecting lamivudine (3TC) [HR 3.0, 95% confidence interval (CI): 1.9 to 4.7; P < 0.0001] and NNRTI mutations (HR 6.0, 95% CI: 3.3 to 10.9; P < 0.0001) compared with the >or=95% refill reference group. In a multivariate model, individuals with <95% refills and consistently detectable plasma drug levels were at increased risk for 3TC (HR 4.5, 95% CI: 2.6 to 7.9; P = 0.0001) and NNRTI resistance (HR 7.0, 95% CI: 3.4 to 14.5; P = 0.0001) compared with the reference group of >or=95% refills with consistently detectable drug levels. Adherence-resistance relationships were much weaker for protease inhibitors and nucleoside reverse transcriptase inhibitors as there was little variance in HRs among the different adherence strata compared with 3TC and NNRTIs. CONCLUSION The relationships between resistance, adherence, and mutation accumulation differ between HIV drug classes.
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Pontali E, Ventura A, Bruzzone B, Icardi G, Ferrari F. Unexpected High Rate of Wild-Type HIV-1 Genotype Among Inmates Failing Antiretroviral Therapy. HIV CLINICAL TRIALS 2008; 9:341-347. [DOI: 10.1310/hct0905-341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Lima V, Gill V, Yip B, Hogg R, Montaner J, Harrigan P. Increased Resilience to the Development of Drug Resistance with Modern Boosted Protease Inhibitor–Based Highly Active Antiretroviral Therapy. J Infect Dis 2008; 198:51-8. [DOI: 10.1086/588675] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Phillips AN, Pillay D, Miners AH, Bennett DE, Gilks CF, Lundgren JD. Outcomes from monitoring of patients on antiretroviral therapy in resource-limited settings with viral load, CD4 cell count, or clinical observation alone: a computer simulation model. Lancet 2008; 371:1443-51. [PMID: 18440426 DOI: 10.1016/s0140-6736(08)60624-8] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND In lower-income countries, WHO recommends a population-based approach to antiretroviral treatment with standardised regimens and clinical decision making based on clinical status and, where available CD4 cell count, rather than viral load. Our aim was to study the potential consequences of such monitoring strategies, especially in terms of survival and resistance development. METHODS A validated computer simulation model of HIV infection and the effect of antiretroviral therapy was used to compare survival, use of second-line regimens, and development of resistance that result from different strategies-based on viral load, CD4 cell count, or clinical observation alone-for determining when to switch people starting antiretroviral treatment with the WHO-recommended first-line regimen of stavudine, lamivudine, and nevirapine to second-line antiretroviral treatment. FINDINGS Over 5 years, the predicted proportion of potential life-years survived was 83% with viral load monitoring (switch when viral load >500 copies per mL), 82% with CD4 cell count monitoring (switch at 50% drop from peak), and 82% with clinical monitoring (switch when two new WHO stage 3 events or a WHO stage 4 event occur). Corresponding values over 20 years were 67%, 64%, and 64%. Findings were robust to variations in model specification in extensive univariable and multivariable sensitivity analyses. Although survival was slightly longer with viral load monitoring, this strategy was not the most cost effective. INTERPRETATION For patients on the first-line regimen of stavudine, lamivudine, and nevirapine the benefits of viral load or CD4 cell count monitoring over clinical monitoring alone are modest. Development of cheap and robust versions of these assays is important, but widening access to antiretrovirals-with or without laboratory monitoring-is currently the highest priority.
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Affiliation(s)
- Andrew N Phillips
- HIV Epidemiology and Biostatistics Group, Department of Primary Care and Population Sciences, and Royal Free Centre for HIV Medicine, Royal Free and University College Medical School, University College London, London, UK.
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Braithwaite RS, Roberts MS, Chang CCH, Goetz MB, Gibert CL, Rodriguez-Barradas MC, Shechter S, Schaefer A, Nucifora K, Koppenhaver R, Justice AC. Influence of alternative thresholds for initiating HIV treatment on quality-adjusted life expectancy: a decision model. Ann Intern Med 2008; 148:178-85. [PMID: 18252681 PMCID: PMC3124094 DOI: 10.7326/0003-4819-148-3-200802050-00004] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal threshold for initiating HIV treatment is unclear. OBJECTIVE To compare different thresholds for initiating HIV treatment. DESIGN A validated computer simulation was used to weigh important harms from earlier initiation of antiretroviral therapy (toxicity, side effects, and resistance accumulation) against important benefits (decreased HIV-related mortality). DATA SOURCES Veterans Aging Cohort Study (5742 HIV-infected patients and 11 484 matched uninfected controls) and published reports. TARGET POPULATION Individuals with newly diagnosed chronic HIV infection and varying viral loads (10,000, 30,000, 100,000, and 300,000 copies/mL) and ages (30, 40, and 50 years). TIME HORIZON Unlimited. PERSPECTIVE Societal. INTERVENTION Alternative thresholds for initiating antiretroviral therapy (CD4 counts of 200, 350, and 500 cells/mm3). OUTCOME MEASURES Life-years and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS Although the simulation was biased against earlier treatment initiation because it used an upper-bound assumption for therapy-related toxicity, earlier treatment increased life expectancy and QALYs at age 30 years regardless of viral load (life expectancies with CD4 initiation thresholds of 500, 350, and 200 cells/mm3 were 18.2 years, 17.6 years, and 17.2 years, respectively, for a viral load of 10,000 copies/mL and 17.3 years, 15.9 years, and 14.5 years, respectively, for a viral load of 300,000 copies/mL), and increased life expectancies at age 40 years if viral loads were greater than 30 000 copies/mL (life expectancies were 12.5 years, 12.0 years, and 11.4 years, respectively, for a viral load of 300,000 copies/mL). RESULTS OF SENSITIVITY ANALYSIS Findings favoring early treatment were generally robust. LIMITATIONS Results favoring later treatment may not be valid. The findings may not be generalizable to women. CONCLUSION This simulation suggests that earlier initiation of combination antiretroviral therapy is often favored compared with current recommendations.
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Affiliation(s)
- R Scott Braithwaite
- Yale University and Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516, USA.
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Braithwaite RS, Concato J, Chang CC, Roberts MS, Justice AC. A framework for tailoring clinical guidelines to comorbidity at the point of care. ACTA ACUST UNITED AC 2008; 167:2361-5. [PMID: 18039996 DOI: 10.1001/archinte.167.21.2361] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Evidence is accumulating to suggest that clinical guidelines should be modified for patients with comorbidities, yet there is no quantitative and objective approach that considers benefits together with risks. METHODS We outline a framework using a payoff time, which we define as the minimum elapsed time until the cumulative incremental benefits of a guideline exceed its cumulative incremental harms. If the payoff time of a guideline exceeds a patient's comorbidity-adjusted life expectancy, then the guideline is unlikely to offer a benefit and should be modified. We illustrate the framework by applying this method to colorectal cancer screening guidelines for 50-year-old men with human immunodeficiency virus (HIV) and 60-year-old women with congestive heart failure (CHF). RESULTS We estimated that colorectal cancer screening payoff times for 50-year-old men with HIV would range from 1.9 to 5.0 years and that colorectal cancer screening payoff times for 60-year-old women with CHF would range from 0.7 to 2.9 years. Because the payoff times for 50-year-old men with HIV were lower than their life expectancies (12.5-24.0 years), colorectal cancer screening may be beneficial for these patients. In contrast, because payoff times for 60-year-old women with CHF were sometimes greater than their life expectancies (0.6 to >5 years), colorectal cancer screening is likely to be harmful for some of these patients. CONCLUSION Use of a payoff time calculation may be a feasible framework to tailor clinical guidelines to the comorbidity profiles of individual patients.
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Affiliation(s)
- R Scott Braithwaite
- Section of General Internal Medicine, Yale University School of Medicine, West Haven Veterans Affairs Connecticut Healthcare System, VACS 11 ACSL-G, 950 Campbell Ave, West Haven, CT 06516, USA.
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Phillips AN, Leen C, Wilson A, Anderson J, Dunn D, Schwenk A, Orkin C, Hill T, Fisher M, Walsh J, Pillay D, Bansi L, Gazzard B, Easterbrook P, Gilson R, Johnson M, Sabin CA. Risk of extensive virological failure to the three original antiretroviral drug classes over long-term follow-up from the start of therapy in patients with HIV infection: an observational cohort study. Lancet 2007; 370:1923-8. [PMID: 18068516 DOI: 10.1016/s0140-6736(07)61815-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The long-term durability of viral-load suppression provided by the three original antiretroviral drugs is not well characterised. We estimated the proportion of patients who had extensive triple-class failure during long-term follow-up and examined characteristics associated with an increased rate of failure. METHODS 7916 patients who started antiretroviral therapy with three or more drugs were followed up from the time that therapy started until the last viral-load measure. Extensive triple-class virological failure was defined by failure of three subclasses of nucleoside reverse transcriptase inhibitors, a non-nucleoside reverse transcriptase inhibitor, and a ritonavir-boosted protease inhibitor. FINDINGS 167 patients developed extensive triple-class failure during 27 441 person-years of follow-up. The Kaplan-Meier estimate for the cumulative risk of extensive triple-class failure was 9.2% by 10 years (95% CI 5.0-13.4). There was evidence that this rate has decreased over time (adjusted hazard ratio 0.86 [0.77-0.96] per year more recent; p=0.006). Of the 167 patients with extensive triple-class failure, 101 (60%) subsequently had at least one viral load less than 50 copies per mL. The risk of death by 5 years from the time of extensive triple-class failure was 10.6% (2.4-18.8, nine deaths). INTERPRETATION We have shown that extensive virological failure of the three main classes of drugs occurs slowly in routine clinical practice. This finding has implications for the planning of treatment programmes in developing countries, where additional drugs outside these classes are unlikely to be available for some time.
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Affiliation(s)
- Andrew N Phillips
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK.
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Bangsberg DR, Kroetz DL, Deeks SG. Adherence-resistance relationships to combination HIV antiretroviral therapy. Curr HIV/AIDS Rep 2007; 4:65-72. [PMID: 17547827 DOI: 10.1007/s11904-007-0010-0] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Early views on the relationship between adherence and resistance postulated a bell-shaped relationship that balanced selective drug pressure and improved viral suppression along a continuum of adherence. Although this conceptual relationship remains valid, recent data suggest that each regimen class may have different adherence-resistance relationships. These regimen-specific relationships are a function of the capacities of resistant virus to replicate at different levels of drug exposure, which are largely, but not entirely, determined by the impact of mutations on susceptibility of the virus and the impact of the mutations on the inherent ability of the virus to replicate efficiently. Specific patterns of adherence, such as treatment discontinuations, may influence adherence-resistance relationship to combination regimens comprised of medications with differing half-lives. Host genomics that alters antiretroviral drug distribution and metabolism may also impact adherence-resistance relationships. Optimal antiretroviral regimens should be constructed such that there is little overlap in the window of adherence that selects for antiretroviral drug resistance.
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Affiliation(s)
- David R Bangsberg
- San Francisco General Hospital, UCSF, 1001 Potrero Avenue, Building 100, Room 301, San Francisco, CA 94110, USA.
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Braithwaite RS, Kozal MJ, Chang CCH, Roberts MS, Fultz SL, Goetz MB, Gibert C, Rodriguez-Barradas M, Mole L, Justice AC. Adherence, virological and immunological outcomes for HIV-infected veterans starting combination antiretroviral therapies. AIDS 2007; 21:1579-89. [PMID: 17630553 PMCID: PMC3460378 DOI: 10.1097/qad.0b013e3281532b31] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We aimed to determine adherence, virological, and immunological outcomes one year after starting a first combination antiretroviral therapy (ART) regimen. DESIGN Observational; synthesis of administrative, laboratory, and pharmacy data. Antiretroviral regimens were divided into efavirenz, nevirapine, boosted protease inhibitor (PI), and single PI categories. Propensity scores were used to control for confounding by treatment assignment. Adherence was estimated from pharmacy refill records. SETTING Veterans Affairs Healthcare System, all sites. PARTICIPANTS HIV-infected individuals starting combination ART with a low likelihood of previous antiretroviral exposure. INTERVENTIONS None. OUTCOMES The proportion of antiretroviral prescriptions filled as prescribed, a change in log HIV-RNA, the proportion with log HIV-RNA viral suppression, a change in CD4 cell count. RESULTS A total of 6394 individuals unlikely to have previous antiretroviral exposure started combination ART between 1996 and 2004, and were eligible for analysis. Adherence overall was low (63% of prescriptions filled as prescribed), and adherence with efavirenz (67%) and nevirapine (65%) regimens was significantly greater than adherence with boosted PI (59%) or single PI (61%) regimens (P < 0.001). Efavirenz regimens were more likely to suppress HIV-RNA at one year (74%) compared with nevirapine (62%), boosted PI (63%), or single PI (53%) regimens (all P < 0.001), and this superiority was maintained when analyses were adjusted for baseline clinical characteristics and propensity for treatment assignment. Efavirenz also yielded more favorable immunological outcomes. CONCLUSION HIV-infected individuals initiating their first combination ART using an efavirenz-based regimen had improved virological and immunological outcomes and greater adherence levels.
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Affiliation(s)
- R Scott Braithwaite
- Section of General Internal Medicine, Department of Medicine, Yale University, 950 Campbell Avenue, West Haven, CT 06516, USA.
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Abstract
Our objective was to illustrate the effects of using stricter standards for the quality of evidence used in decision analytic modeling. We created a simple 10-parameter probabilistic Markov model to estimate the cost-effectiveness of directly observed therapy (DOT) for individuals with newly diagnosed HIV infection. We evaluated quality of evidence on the basis of U.S. Preventive Services Task Force methods, which specified 3 separate domains: study design, internal validity, and external validity. We varied the evidence criteria for each of these domains individually and collectively. We used published research as a source of data only if the quality of the research met specified criteria; otherwise, we specified the parameter by randomly choosing a number from a range within which every number has the same probability of being selected (a uniform distribution). When we did not eliminate poor-quality evidence, DOT improved health 99% of the time and cost less than 100,000 dollars per additional quality-adjusted life-year (QALY) 85% of the time. The confidence ellipse was extremely narrow, suggesting high precision. When we used the most rigorous standards of evidence, we could use fewer than one fifth of the data sources, and DOT improved health only 49% of the time and cost less than 100,000 dollars per additional QALY only 4% of the time. The confidence ellipse became much larger, showing that the results were less precise. We conclude that the results of decision modeling may vary dramatically depending on the stringency of the criteria for selecting evidence to use in the model.
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Affiliation(s)
- R Scott Braithwaite
- Yale University School of Medicine and Connecticut Veterans Affairs Healthcare System, New Haven, Connecticut 06516, USA.
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Gange SJ, Kitahata MM, Saag MS, Bangsberg DR, Bosch RJ, Brooks JT, Calzavara L, Deeks SG, Eron JJ, Gebo KA, Gill MJ, Haas DW, Hogg RS, Horberg MA, Jacobson LP, Justice AC, Kirk GD, Klein MB, Martin JN, McKaig RG, Rodriguez B, Rourke SB, Sterling TR, Freeman AM, Moore RD. Cohort profile: the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Int J Epidemiol 2007; 36:294-301. [PMID: 17213214 PMCID: PMC2820873 DOI: 10.1093/ije/dyl286] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Richard D Moore
- Corresponding author. NA-ACCORD Coordinating Center, 1830 E. Monument St., Suite 8059, Baltimore, MD 21287, USA.
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