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Alhassan RK, Ketor CE, Ashinyo A, Ashinyo ME, Nutor JJ, Adjadeh C, Sarkodie E. Quality of antiretroviral therapy services in Ghana: Implications for the HIV response in resource-constrained settings. SAGE Open Med 2021; 9:20503121211036142. [PMID: 34377475 PMCID: PMC8326618 DOI: 10.1177/20503121211036142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
Objective Number of People Living with Human Immune-deficiency Virus in Ghana is over 300,000 and unmet need for antiretroviral therapy is approximately 60%. This study sought to determine the quality of antiretroviral therapy services in selected ART sites in Ghana using the input-process-outcome approach. Methods This is a descriptive cross-sectional case study that employed modified normative evaluation to assess quality of antiretroviral therapy services in the Oti and Volta regions of Ghana among People Living with HIV (n = 384) and healthcare providers (n = 16). The study was conducted from 11 March to 9 May 2019. Results Resources for managing HIV clients were largely available with the exception of viral load machines, reagents for CD4 counts, and antifungals such as Fluconazole and Cotrimoxazole. Patients enrolled on antiretroviral therapy within 2 weeks was 71% and clients retained in care within 2 weeks of enrolment was 90%. Approximately 26% of enrolled clients recorded viral load suppression; 33% of People Living with HIV who were not insured with the National Health Insurance Scheme paid for some antiretrovirals and cotrimoxazole. Adherence to ART and Cotrimoxazole were 95% and 88%, respectively, using pill count on their last three visits. Time spent with clinical team was among the worst rated (mean = 2.98, standard deviation = 0.54) quality indicators by patients contrary to interpersonal relationship with health provider which was among the best rated (mean = 3.25, standard deviation = 0.41) indicators. Conclusion Observed quality care gaps could potentially reverse gains made in HIV prevention and control in Ghana if not addressed timely; an important value addition of this study is the novel application of input-process-outcome approach in the context of antiretroviral therapy services in Ghana. There is also the need for policy dialogue on inclusion of medications for prophylaxis in antiretroviral therapy on the National Health Insurance Scheme to promote adherence and retention.
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Affiliation(s)
- Robert Kaba Alhassan
- Centre for Health Policy and Implementation Research, Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
| | - Courage Edem Ketor
- Pharmacy Department, Jasikan District Hospital, Ghana Health Service, Jasikan, Ghana
| | - Anthony Ashinyo
- National AIDS/STI Control Programme, Ghana Health Service, Accra, Ghana
| | - Mary Eyram Ashinyo
- Department of Quality Assurance and Safety, Ghana Health Service, Accra, Ghana
| | - Jerry John Nutor
- Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Conrad Adjadeh
- Pharmacy Department, Margaret Marquart Catholic Hospital Kpando, Kpando, Ghana
| | - Emmanuel Sarkodie
- Pharmacy Department, Kwame Nkrumah University of Science and Technology (KNUST) Hospital, Kumasi, Ghana
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Fusco J, Henegar C, Quinlivan EB, Vannappagari V, Aboud M, Smith K, Fusco G. Integrase Inhibitor-Based Antiretroviral Therapy Among Women Living with HIV: Data from the OPERA Cohort. Curr HIV Res 2020; 17:266-276. [PMID: 31560291 DOI: 10.2174/1570162x17666190927161537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Women face unique complexities in HIV treatment yet are underrepresented in antiretroviral therapy (ART) studies. OBJECTIVE This analysis assessed the one-year durability of the first integrase strand transfer inhibitor (INSTI)-based regimens prescribed to women in a large cohort of patients living with HIV in care. METHODS Women with HIV who initiated their first INSTI-containing regimen between 08/12/2013 and 11/30/2015 were identified in the OPERA cohort, a collaboration of 79 US outpatient clinics. Discontinuation within the first year of treatment with an INSTI was compared between dolutegravir (DTG), raltegravir (RAL) and elvitegravir (EVG), using multivariable Cox regression and Kaplan- Meier estimates. Virologic response and regimen modifications were described and compared across INSTIs. RESULTS A total of 537 treatment-naïve (DTG: 39%, EVG: 48%, RAL: 13%) and 878 treatmentexperienced (DTG: 57%, EVG: 29%, RAL: 13%) women were analyzed. In the first twelve months after initiation, women taking EVG or RAL were more likely to discontinue their initial INSTI than those taking DTG among both treatment-naïve (adjusted hazard ratio EVG vs. DTG: 1.59 (95% CI: 1.09, 2.39); RAL vs. DTG: 2.46 (1.49, 4.05)) and treatment-experienced women (EVG vs. DTG: 1.39 (1.02, 1.88); RAL vs. DTG: 2.17 (1.51, 3.12)). Following discontinuation of the initial INSTI, women commonly switched to a regimen containing a different drug from the INSTI class (treatment-naïve DTG: 34%, RAL: 33% EVG: 41%; treatment-experienced DTG: 23%, RAL: 19% EVG: 41%). CONCLUSION In treatment-naïve and treatment-experienced women living with HIV, women taking DTG had the lowest risk for early (≤1 year) discontinuation.
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Affiliation(s)
| | | | | | | | | | - Kimberly Smith
- ViiV Healthcare, Research Triangle Park, NC, United States
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Treatment modification after starting cART in people living with HIV: retrospective analysis of the German ClinSurv HIV Cohort 2005-2017. Infection 2020; 48:723-733. [PMID: 32613529 PMCID: PMC7519003 DOI: 10.1007/s15010-020-01469-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 06/21/2020] [Indexed: 11/23/2022]
Abstract
Objective Combination antiretroviral therapy (cART) has markedly increased survival and quality of life in people living with HIV. With the advent of new treatment options, including single-tablet regimens, durability and efficacy of first-line cART regimens are evolving. Methods We analyzed data from the prospective multicenter German Clinical Surveillance of HIV Disease (ClinSurv) cohort of the Robert-Koch Institute. Kaplan–Meier and Cox proportional hazards models were run to examine the factors associated with treatment modification. Recovery after treatment initiation was analyzed comparing pre-cART viral load and CD4+ T-cell counts with follow-up data. Results We included 8788 patients who initiated cART between 2005 and 2017. The sample population was predominantly male (n = 7040; 80.1%), of whom 4470 (63.5%) were reporting sex with men as the transmission risk factor. Overall, 4210 (47.9%) patients modified their first-line cART after a median time of 63 months (IQR 59–66). Regimens containing integrase strand transfer inhibitors (INSTI) were associated with significantly lower rates of treatment modification (adjusted hazard ratio 0.44; 95% CI 0.39–0.50) compared to protease inhibitor (PI)-based regimens. We found a decreased durability of first-line cART significantly associated with being female, a low CD4+ T-cell count, cART initiation in the later period (2011–2017), being on a multi-tablet regimen (MTR). Conclusions Drug class and MTRs are significantly associated with treatment modification. INSTI-based regimens showed to be superior compared to PI-based regimens in terms of durability. Electronic supplementary material The online version of this article (10.1007/s15010-020-01469-6) contains supplementary material, which is available to authorized users.
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Eaton EF, Gravett RM, Tamhane AR, Mugavero MJ. Antiretroviral Therapy Initiation and Changes in Self-Reported Depression. Clin Infect Dis 2018; 64:1791-1794. [PMID: 28419238 DOI: 10.1093/cid/cix217] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/23/2017] [Indexed: 12/14/2022] Open
Abstract
In this retrospective study of treatment-naive PLWH initiating antiretroviral therapy, the score for the depression scale of the Patient Health Questionnaire (PHQ-9) was significantly higher at baseline (median, 6.0; interquartile range, 2-11) than at 12 months (3.0; 0-8; P < .001). Baseline depression and lack of insurance are associated with 12-month depression, but receipt of efavirenz-based antiretroviral therapy is not.
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Affiliation(s)
- Ellen F Eaton
- Department of Medicine, Division of Infectious Disease and
| | - Ronnie M Gravett
- Department of Medicine, University of Alabama at Birmingham, Alabama
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Trends in antiretroviral therapy prescription, durability and modification: new drugs, more changes, but less failure. AIDS 2018; 32:347-355. [PMID: 29194118 DOI: 10.1097/qad.0000000000001708] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the real world durability of contemporary ART for treatment-naïve people living with HIV (PLWH). DESIGN A retrospective follow-up study in a multisite cohort. METHODS This study of the CNICS (CFAR Network of Integrated Clinical Systems) cohort integrates data from eight Center for AIDS Research (CFARs). PLWH initiating ART between 2007 and 2014 were included. Durability was defined as time from the initiation until discontinuation/modification using Kaplan-Meier survival curves. Cox Proportional Hazards measured associations with various sociodemographic and clinical characteristics. RESULTS Among 5373 PLWH, the initial regimen was modified in 2285 (43%) patients. Efavirenz/emtricitabine/tenofovir (n = 2173, 40%) was the most commonly prescribed initial ART regimen; elvitegravir/cobicistat/emtricitabine/tenofovir became more common after 2012. Median durability for all regimens was 48.6 months. There were statistically significant differences in median durability for NNRTI, InSTI, and protease inhibitor-based regimens, which lasted 61, 44, and 32 months, respectively. Female sex (aHR = 1.4; 95% CI 1.2-1.6), intravenous drug use (aHR = 1.6; 95% CI 1.3-1.9), and CD4 cell count less than 200 cells/μl (aHR = 1.2; 95% CI 1.1-1.3) were significantly associated with regimen modification. Compared with InSTI, those receiving an InSTI/protease inhibitor (aHR = 2.7; 95% CI 2.0-3.7) or protease inhibitor-based ART (aHR = 1.9; 95% CI 1.6-2.2) were significantly more likely to be modified; but those receiving NNRTI (aHR = 1.1; 95% CI 0.9-1.3) were not. CONCLUSION In treatment-naive PLWH, NNRTI and InSTI-based ART were most durable, relative to protease inhibitor and InSTI/protease inhibitor-based ART, and were least likely to be modified/discontinued. A greater understanding of reasons for regimen modification/discontinuation is needed to analyze contemporary regimen durability.
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Saag LA, Tamhane AR, Batey DS, Mugavero MJ, Eaton EF. Mental health service utilization is associated with retention in care among persons living with HIV at a university-affiliated HIV clinic. AIDS Res Ther 2018; 15:1. [PMID: 29338735 PMCID: PMC5771035 DOI: 10.1186/s12981-018-0188-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/02/2018] [Indexed: 11/25/2022] Open
Abstract
Background Mental health (MH) comorbidities reduce retention in care for persons living with HIV (PLWH) and are associated with poor health outcomes. Optimizing retention in primary care is vital, as poor retention is associated with delayed receipt of antiretroviral (ARV) therapy, ARV non-adherence, and poor health outcomes, including failure to suppress viral load, decreased CD4 counts, and clinically significant ARV drug resistance. We hypothesized that MH service utilization would be associated with improved retention in care for patients with HIV and MH comorbidities. Methods This is a retrospective analysis of PLWH initiating outpatient HIV health care at a university-affiliated HIV clinic between January 2007 and December 2013. We examined the association between MH service utilization and retention in care, the outcome of interest, using univariate and multivariable logistic regression. Results Overall, 627 (84.4%) out of 743 patients were retained in care using the Health Resources & Services Administration HIV/AIDS Bureau (HRSA/HAB) metric. A multivariable model adjusted for several sociodemographic factors, MH comorbidities, and MH service utilization. The results suggest that lack of health insurance (public ORadj = 0.3, p < 0.01; no insurance ORadj = 0.4, p < 0.01) and ≥ 3 MH comorbidities (ORadj = 0.3, P = 0.01) were associated with decreased retention in care. Conversely, older age (> 45 years, ORadj. = 1.6, p = 0.14) and ≥ 3 MH service utilization visits (ORadj. = 6.8, p < 0.01) were associated with increased retention in care. Conclusions Even in the absence of documented MH comorbidities, improved retention in care was observed with increasing MH service utilization. In order to achieve the US-based National HIV/AIDS Strategy goal of 90% retention in care for PLWH, MH service utilization should be considered along with other evidence-based interventions to improve retention for PLWH newly engaged in care.
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Virologic suppression and CD4+ cell count recovery after initiation of raltegravir or efavirenz-containing HIV treatment regimens. AIDS 2018; 32:261-266. [PMID: 29112076 DOI: 10.1097/qad.0000000000001668] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To explore the effectiveness of raltegravir-based antiretroviral therapy (ART) on treatment response among ART-naive patients seeking routine clinical care. DESIGN Cohort study of adults enrolled in HIV care in the United States. METHODS We compared virologic suppression and CD4 cell count recovery over a 2.5 year period after initiation of an ART regimen containing raltegravir or efavirenz using observational data from a US clinical cohort, generalized to the US population of people with diagnosed HIV. We accounted for nonrandom treatment assignment, informative censoring, and nonrandom selection from the US target population using inverse probability weights. RESULTS Of the 2843 patients included in the study, 2476 initiated the efavirenz-containing regimen and 367 initiated the raltegravir-containing regimen. In the weighted intent-to-treat analysis, patients spent an average of 74 (95% confidence interval: 41, 106) additional days alive with a suppressed viral load on the raltegravir regimen than on the efavirenz regimen over the 2.5-year study period. CD4 cell count recovery was also superior under the raltegravir regimen. CONCLUSION Patients receiving raltegravir spent more time alive and suppressed than patients receiving efavirenz, but the probability of viral suppression by 2.5 years after treatment was similar between groups. Optimizing the amount of time spent in a state of viral suppression is important to improve survival among people living with HIV and to reduce onward transmission.
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Bengtson AM, Pence BW, Eaton EF, Edwards JK, Eron JJ, Mathews WC, Mollan K, Moore RD, O’Cleirigh C, Geng E, Mugavero MJ. Patterns of efavirenz use as first-line antiretroviral therapy in the United States: 1999-2015. Antivir Ther 2018; 23:363-372. [PMID: 29424697 PMCID: PMC6085156 DOI: 10.3851/imp3223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Efavirenz has been a mainstay of antiretroviral therapy (ART) for over 15 years in the US. Its association with neuropsychiatric side effects may influence clinical prescribing and management. METHODS We included HIV-infected adults enrolled in care at seven sites across the US, who initiated combination ART between 1999 and 2015. We examined the proportion initiating and continuing on efavirenz, overall and by mental health status. Log binomial and Cox models were used to estimate associations between mental health, clinical and sociodemographic characteristics and initiating or switching from efavirenz as first-line ART. RESULTS Of the 8,230 participants included, 3,710 (45%) initiated efavirenz. In multivariable analyses, prior mono- or dual-ART, ART initiation after 2006, being female, intravenous drug use, antidepressant prescription, previous mental health diagnosis and baseline CD4+ T-cell count >350 cells/mm3 were inversely associated with initiating efavirenz. Participants initiating efavirenz had a faster time to a regimen switch, compared with those initiating an efavirenz-free regimen (P-value <0.01). Among efavirenz initiators, starting efavirenz in more recent time periods and a previous mental health diagnosis were associated with faster time to switching from efavirenz. Despite this, 40-50% of participants with a previous mental health diagnosis initiated and continued on efavirenz for much of the follow-up period. CONCLUSIONS Multiple clinical factors, including mental health diagnoses, appeared to influence efavirenz use. While mental health diagnosis status and more recent treatment starts were associated with shorter duration of efavirenz therapy, a previous mental health diagnosis did not preclude efavirenz initiation or continuation in many participants.
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Affiliation(s)
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ellen F Eaton
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph J Eron
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William C Mathews
- Department of Medicine, University of California at San Diego, San Diego, CA, USA
| | - Katie Mollan
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Richard D Moore
- School of Medicine and Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Connall O’Cleirigh
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- The Fenway Institute, Boston, MA, USA
| | - Elvin Geng
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Michael J Mugavero
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
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Effectiveness and tolerance of single tablet versus once daily multiple tablet regimens as first-line antiretroviral therapy - Results from a large french multicenter cohort study. PLoS One 2017; 12:e0170661. [PMID: 28152047 PMCID: PMC5289500 DOI: 10.1371/journal.pone.0170661] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 01/09/2017] [Indexed: 11/20/2022] Open
Abstract
Objectives Pill burden during antiretroviral treatment (ART) is associated with worse adherence and impaired virological suppression. We compared the effectiveness, tolerance, and persistence on treatment of single tablet regimens (STRs) with non-STR once-daily regimens in patients receiving first-line ART. Methods Retrospective analysis of naïve HIV-1 infected patients prospectively enrolled in the French Dat’AIDS cohort and initiating first-line ART with STRs or once-daily non-STRs from 2004 to 2013. The primary outcome was time to treatment discontinuation defined by any change in the treatment regimen. STR and non-STR groups were compared controlling for baseline risk factors by inverse probability weighted treatment Cox analysis (IPWT) and propensity-score matching (PSM). Results Overall, 3212 patients (STR 499, non-STR 2713) were included. Median time to treatment discontinuation was shorter in non-STR patients than in STR patients, both in the IPWT (HR = 0.61, p<0.0001) and the PSM cohort (HR = 0.55, p<0.0001). This difference disappeared when censoring ART modification for simplification, both in the IPWT (HR = 0.97, p = 0.65) and the PSM cohort (HR = 0.91, p = 0.33). A lower rate of virological failure was observed with STRs than with non-STRs in both cohorts (HR = 0.23; p = 0.002 and HR = 0.22, p = 0.003, respectively). A lower rate of treatment modification for adverse event was observed with non-STRs in the IPWT cohort (HR = 1.46, p<0.0001), but not in the PSM cohort (HR = 1.22, p = 0.11). Conclusion First-line therapy with STRs was associated with a longer time to treatment discontinuation than with non-STRs. However, when ART modification for simplification was not considered as a failure, STRs and non-STRs were similar.
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Eaton EF, McDavid C, Banasiewicz MK, Mugavero MJ, Knight SJ. Patient preferences for antiretroviral therapy: effectiveness, quality of life, access and novel delivery methods. Patient Prefer Adherence 2017; 11:1585-1590. [PMID: 29075105 PMCID: PMC5609802 DOI: 10.2147/ppa.s142643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to understand patient preferences for contemporary antiretroviral therapy (ART) by focusing on three areas that have been understudied: minority patients (racial/ethnic and sexual minorities), experience with novel single-tablet regimens made available in the last 10 years, and patient concerns related to ART. The rationale was that identifying ART characteristics that are most desirable could inform provider prescribing practices, increase the use of patient-centered ART, maximize durability and ART adherence, and ultimately improve HIV outcomes, such as viral suppression and AIDS-related comorbidities. METHODS We recruited English- and Spanish-speaking persons living with HIV (PLWH) who were ≥19 years of age or older and had initiated ART after January 1, 2006, until saturation was reached (n=28). We excluded patients who had started on ART more than 10 years earlier, in order to ensure responses were relevant to more contemporary ART regimens. We recruited racial/ethnic and sexual minorities, including men who have sex with men and transgender participants, to reflect the current HIV epidemic. Nominal group technique was used to identify and prioritize preferences and concerns. Multi-voting analysis was used to quantify responses from most important (5 points) to least important (1 point). RESULTS For 28 diverse participants, clinical outcomes (162 points) and quality of life (120 points) were preferred. Hispanic participants were more concerned about accessibility than non-Hispanic (3.8 vs 1.9 average points/participant). DISCUSSION HIV-infected persons prioritize access, clinical outcomes, and quality of life when considering contemporary ART treatment. Providers, insurers and policy makers should incorporate these preferences when making decisions about ART.
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Affiliation(s)
- Ellen F Eaton
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Correspondence: Ellen F Eaton, Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, THT 229, 1720 2nd Ave South, Birmingham, AL 35294, USA, Tel +1 205 975 0661, Email
| | - Chastity McDavid
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary Katy Banasiewicz
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael J Mugavero
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sara J Knight
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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