Long-term quality of life outcomes in three antiretroviral treatment strategies for HIV-1 infection

Predictors of health-related quality of life among older adults living with HIV in Thailand: results from the baseline and follow-up surveys

The current longitudinal study consisted of baseline and follow-up surveys among older adults living with HIV (OALHIV) in Thailand. The health-related quality of life (HRQoL) was assessed using the Medical Outcomes Study HIV (MOS-HIV) questionnaire. We performed multiple linear regression analysis to document correlates of HRQoL at baseline and the predictors of the changes in HRQoL at follow-up. Of the 364 participants recruited at baseline; 327 (89.9%) completed the follow-up survey. The mean (SD) Physical Health Summary (PHS) and Mental Health Summary (MHS) scores were respectively 49.8 (7.3) and 53.2 (6.4). There was a significant increase in the mean score of most of the MOS-HIV domains, ranging between 1.3 for the PHS and 26.9 for the energy/fatigue dimension. In contrast, the mean score significantly decreased by 4.1 and 10.3 points, respectively for the cognitive and social functioning. Female gender was a predictor of the decline in social (β = -11.37; P = 0.031) and cognitive (β = -8.05; P = 0.002) functioning at follow-up, while being married was related to an increase of in the score of energy/fatigue (vitality) (β = 5.98; P = 0.011) at follow-up. Physical exercise was associated with an increase in social functioning (β = 9.38; p = 0.042). Overall the HRQoL of OALHIV improved or was maintained over time.

Effect of Health Care on Quality of Life among Human Immunodeficiency Virus Infected Adults With and Without Visceral Leishmaniasis in northwest Ethiopia: A Longitudinal Follow-Up Study

There has been a scarcity of data on the effect of health care on the quality of life (QoL) of human immunodeficiency virus (HIV)- and visceral leishmaniasis (VL)- coinfected patients over time. We sought to assess the change that health care brings about in the QoL of HIV patients with and without VL and its predictors in 6 months. A total of 465 HIV patients without VL and 125 HIV-VL-coinfected patients were enrolled in the longitudinal follow-up study from October 2015 to September 2016. Data on QoL at baseline and in 6 months were collected by trained nurses through face-to-face interviews using a short Amharic version of World Health Organization QoL instrument for HIV clients. Multiple linear regressions were used to assess the predictors of health-related QoL. There was an improvement in all of the domains of QoL at the sixth month follow-up compared with the baseline for both groups of patients (P < 0.001). Lack of social support and income were associated with the low improvement in QoL in most of the domains in both groups. Compared with patients having severe acute malnutrition, patients having moderate acute malnutrition and normal nutritional status were better in most of the QoL domains in both groups of patients. Both antiretroviral and anti-VL treatments showed improvement in all dimensions of QoL. Income, social support, and nutritional status were the predictors for most of the QoL domains.

A study of neuropsychological profile of human immunodeficiency virus-positive children and adolescents on antiretroviral therapy

AIMS

The aim is to study the neuropsychological and functional profile of children and adolescents with human immunodeficiency virus (HIV) infection on antiretroviral therapy (ART) and the association between the neuropsychological status and medical illness variables, treatment variables, and functional status in the cases of the sample and compare with normal controls.

MATERIALS AND METHODS

Forty-two HIV-positive children and adolescents on ART were evaluated and compared with 40 matched controls not known to be HIV-positive. The tools used were the Wechsler Intelligence Scale for Children-III R for neuropsychological evaluation, the Brief Impairment Scale to assess functional impairment, and a semi-structured questionnaire to obtain other relevant details.

RESULTS

There were significant differences between the verbal, performance intelligence quotients (IQs), global IQ score, and several individual subtests between cases and controls. The HIV group was also found to have a significant functional impairment.

CONCLUSION

Our findings show that HIV infection is associated with significant cognitive and functional impairment. The role of ART in these impairments requires further study. Such understanding can help to introduce wholesome and relatively safer management strategies for youngsters with HIV infection and improve their quality of life.

Usefulness of Patient-Generated Index for HIV to Measure Individual Quality of Life: A Study from Thailand

OBJECTIVES

To measure health-related quality of life (HRQOL) in Thai HIV patients using the patient-generated index for HIV (PGI-HIV) and to compare the psychometric properties of the PGI-HIV with those of the EuroQol five-dimensional (EQ-5D) questionnaire and the Medical Outcome Study HIV Health Survey in terms of practicality, reliability, validity, and responsiveness.

METHODS

In this study, two rounds of interviews were carried out in HIV outpatients who met the eligibility criteria and attended the HIV Clinic of Warinchamrap Hospital between January and March 2010. The patients were interviewed using a data collection form and three HRQOL measures (the PGI-HIV, the EQ-5D questionnaire, and the Medical Outcome Study HIV Health Survey) to assess the practicality and validity. The second interview was performed to check the test-retest reliability and responsiveness.

RESULTS

A total of 210 patients completed the study. They were mostly women (69.5%), with a mean age of 39.2 ± 11.1 years. The majority with the US Centers for Disease Control and Prevention clinical stage C took the current antiretroviral drugs within 1 year. The average PGI score was about 0.60, implying HIV/AIDS and antiretroviral drug therapy decreased the patients' quality of life by 40% from their healthy life. Three mostly cited impact domains were hyperlipidemia, lipid maldistribution and lipodystrophy, and hepatitis. The PGI-HIV was considered as practical, with a mean difficulty score of 3.7 ± 0.8, highly reliable (intraclass correlation coefficient = 0.75; P < 0.001), and responsive to HRQOL changes (effect size = 0.81; standardized response mean = 0.99), but not valid when compared with CD4 levels and viral loads (all Pearson' r < 0.2; P > 0.05).

CONCLUSIONS

The PGI-HIV was used to measure the individual HRQOL in a Thai sample of HIV-positive patients. It proves to be practical, highly reliable, and very responsive to changes in patients' HRQOL.

Rural residence and adoption of a novel HIV therapy in a national, equal-access healthcare system

Rural persons with HIV face barriers to care that may influence adoption of advances in therapy. We performed a retrospective cohort study to determine rural-urban variation in adoption of raltegravir-the first HIV integrase inhibitor-in national Veterans Affairs (VA) healthcare. There were 1,222 veterans with clinical indication for raltegravir therapy at time of its FDA approval in October 2007, of whom 223 (19.1%) resided in rural areas. Urban persons were more likely than rural to initiate raltegravir within 180 days (17.3% vs. 11.2%, P = 0.02) and 360 days (27.5% vs. 19.7%, P = 0.02), but this gap narrowed slightly at 720 days (36.3% vs. 31.8%, P = 0.19). In multivariable analysis adjusting for patient characteristics, urban residence predicted raltegravir adoption within 180 days (odds ratio 1.72, 95% CI 1.09-2.70) and 360 days (OR 1.63, 95% CI 1.13-2.34), but not 720 days (OR 1.26, 95% CI 0.84-1.87). Efforts are needed to reduce geographic variation in adoption of advances in HIV therapy.

Antiretroviral adherence among rural compared to urban veterans with HIV infection in the United States

Rural-dwelling persons with HIV infection face barriers to maintaining high levels of antiretroviral adherence. We compared adherence among 1,782 rural and 18,519 urban veterans initiating antiretroviral therapy in the Veterans Affairs (VA) healthcare system in the United States between 1998 and 2007. Residence was determined using rural urban commuting area codes and adherence using pharmacy-based refill measures. The median proportion of days covered (PDC) by combination antiretroviral therapy in the first year of treatment ranged from 0.72 among urban residents to 0.79 among rural-small town/remote residents (p < 0.0001). In multivariable logistic regression, predictors of high adherence (PDC greater than 0.90) were residence in a rural-small town/remote setting (odds ratio 1.24, 95 % CI 1.09-1.56, relative to urban), increasing age, white race, absence of an alcohol or substance use disorder, and absence of hepatitis C infection. Results may differ outside VA healthcare, where there may be fewer resources to support adherence among rural-dwelling persons with HIV.

Assessing the association between self-report items for HIV pill adherence and biological measures

Sub-optimal pill adherence to antiretroviral treatment among HIV-infected persons may have serious consequences, including a decline in health status, eventually leading to death. We developed an instrument to assess self-reported pill adherence to antiretroviral therapy (ART) among patients attending a public health clinic in South Africa. The instrument, based on previously published guidelines, consisted of five questions and a visual analogue scale assessing pill adherence behaviour and was administered to 101 patients living with HIV who commenced ART at least six months prior to data collection. The scale showed fair but not excellent internal consistency (alpha reliability=0.63). Participants reported generally high levels of pill adherence. One question on the scale was able to distinguish between a detectable and a lower than detectable viral load (p<0.01). Yet, the combined items did not predict biologically measured adherence. Despite good comprehensibility of items, the study may have been vulnerable to recall and social desirability bias and was conducted only among clinic attenders rather than those with varied levels of clinic attendance, which is potentially a matter for further study.

Longitudinal change in cognitive function and medication adherence in HIV-infected adults

Neuropsychological (NP) dysfunction has been linked to poor medication adherence among HIV-infected adults. However, there is a dearth of research examining longitudinal changes in the relationship between NP status and adherence rates. We hypothesized that declines in NP functioning would be associated with a corresponding decline in medication adherence while stable NP functioning would be associated with stable or improving adherence rates. Participants included 215 HIV-infected adults who underwent cognitive testing at study entry and six months later. Compared to the NP stable group, the NP decline group showed a greater drop in adherence rates. Further analysis revealed that, beyond global NP, learning and memory was significantly associated with changes in adherence rates. These findings further support the link between cognitive functioning and medication adherence and illustrates the importance of documenting changes in cognitive abilities for identifying individuals at risk for poor adherence.

Quality of life and needs assessment on people living with HIV and AIDS in Malawi

PURPOSE

Malawi is a sub-Saharan African nation with a severe HIV epidemic. The quality of life (QoL) has never been investigated among people living with HIV and AIDS (PLWHA) in Malawi. This study examines the QoL and associated factors including life needs among PLWHA at different stages of their illness in the northern region of Malawi.

METHODS

Survey analysis of consecutive outpatient participants receiving highly active antiretroviral therapy at the Rainbow Clinic and non-HIV patients receiving care at the affiliated Mzuzu Central Hospital during a one-month period was performed. Laboratory testing and clinical diagnosis were used to determine HIV status, determine CD4 count, and classify WHO clinical stage. A total of 267 HIV-infected patients and 598 non-HIV participants completed a needs assessment and a Short Form-36 (SF-36) questionnaire, which contained a QoL subscale. SF-36 subscales and needs assessment scores were analyzed using t-test, ANOVA test, and Generalized Linear Model-Tukey's test.

RESULTS

HIV-positive patients had significantly lower physical functioning (p=0.0365), mental health (p=0.001), social functioning (p<0.0001), and mental component summary (p=0.0069) scores than HIV-negative patients. Further, WHO Stage III HIV patients had significantly lower vitality (p=0.0439) and mental health (p=0.0022) scores than WHO Stages I and II patients; and WHO Stage IV patients had significantly lower vitality (p=0.0015), mental health (p=0.0006), and physical component summary (p=0.0443) scores than WHO Stages I and II patients. Finally, AIDS patients, as determined by CD4 count, had significantly lower bodily pain (p=0.0423) and physical component summary (p=0.0148) scores than non-AIDS, HIV-positive patients.

CONCLUSION

HIV patients undergoing treatment in Malawi have a significantly lower QoL, both mentally and physically, than their non-HIV counterparts. Further, HIV patients at more advanced stages, both by the WHO definition and by CD4 count, have a significantly lower QoL than HIV patients at earlier stages of the disease.

The impact of highly active antiretroviral therapy on activities of daily living in HIV-infected adults in South Africa

This study investigated the relationship between highly active antiretroviral therapy (HAART) and instrumental activities of daily living (IADLs) among two clinical cohorts in South Africa. Between 2003 and 2008 structured questionnaires were administered to HIV-positive patients attending outpatient clinics at an urban hospital (Soweto, n = 3,081) and a rural hospital (Acornhoek, n = 1,247). Among those receiving help, an average of 4.8 and 5.1 h of assistance with IADLs daily was reported (rural and urban participants, respectively), with the patient's mother and children assisting the most. Participants on HAART were 17 and 41% less likely to receive assistance with IADLs in the rural and urban cohorts, respectively, after adjusting for demographic characteristics, healthcare utilization, and CD4 counts. HAART significantly decreased the IADL assistance among patients in South Africa. Alongside clinical benefits, HAART has the potential to reduce the burden of HIV-related care, potentially extending wider social and economic gains to other family members.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of life in HIV-infected individuals receiving antiretroviral therapy is related to adherence

This study assesses changes in quality of life (QoL) over time among HIV-infected individuals receiving antiretroviral therapy (ART) and evaluates how this relates to ARTadherence. Prospective, longitudinal data were examined from 1050 participants in two large, randomized, multi-centre antiretroviral clinical trials. QoL was assessed by the SF-12; adherence by the Terry Beirn Community Programs for Clinical Research on AIDS Antiretroviral Medication Self-report. Participants included 20% women, 53% African Americans, 16% Latinos; mean age was 39 years; mean baseline CD4+ cell count 230 cells/mm3; 89% were ART-naïve at entry. Baseline physical and mental health summary QoL scores were 45.4 and 42.9, comparable to scores reported in other advanced HIV populations. Significant improvements in mean QoL scores were seen for the group as a whole after 1 to 4 months on new ART regimens, and persisted for 12 months. Participants reporting 100% ART adherence achieved significantly higher QoL scores at 12 months compared to those with poorer adherence, particularly if 100% adherence was consistent (p < 0.001). Those with at least 80% ART adherence had smaller gains in QoL at 12 months when compared to baseline, while those with < 80% adherence had worsening of QoL. In this analysis, ART adherence was associated with improved QoL, particularly if adherence was sustained.

Stavudine or zidovudine in three-drug combination therapy for initial treatment of HIV infection in antiretroviral-naïve individuals

BACKGROUND

The introduction of highly active antiretroviral therapy (ART) as treatment for HIV infection has greatly improved mortality and morbidity for adults and children living with HIV around the world. Two common medications given in first-line antiretroviral therapy are the nucleoside reverse transcriptase inhibitors (NRTI) stavudine (d4T) or zidovudine (AZT).

OBJECTIVES

To assess the efficacy of d4T compared to AZT in combination with one NRTI and one non-nucleoside reverse transcriptase inhibitor (NNRTI), two additional NNRTIs, or one NRTI and one protease inhibitor (PI), as part of first-line ART for HIV-infected people in low-resource settings.

SEARCH STRATEGY

Standard Cochrane methods were used to search electronic databases and conference proceedings with relevant search terms without limits to language.

SELECTION CRITERIA

Randomised controlled trials of HIV-infected patients 5 years of age and older were included. Primary outcomes of interest included mortality, severe adverse events, virologic response to ART, and adherence/tolerance/retention. Secondary outcomes included immunologic response to ART, development of ART drug resistance, and prevention of sexual transmission of HIV.

DATA COLLECTION AND ANALYSIS

Two authors assessed each reference for inclusion and exclusion criteria established a priori. Data were abstracted independently using a standardised abstraction form.

MAIN RESULTS

Nine randomised controlled trials were identified as meeting the inclusion criteria. The nine trials enrolled 2,159 participants but looked at a multiplicity of drug combinations. Despite this, a reasonably robust literature suggests no statistically significant difference between the two drug combinations, including severe adverse events and adherence/tolerance/retention. The quality of the literature was found overall to be low to very low for all key outcomes. Only one study reported on drug resistance, and no studies reported on sexual transmission of HIV. The length of follow-up time and study settings varied greatly.

AUTHORS' CONCLUSIONS

While ideally future research would focus on direct comparison of standard therapeutic combinations of d4T+3TC+an NNRTI and AZT+3TC+an NNRTI to compare these regimens more directly, it is unlikely that additional trials will be mounted. Observational studies should focus on understanding outcomes, including toxicity and tolerability, in low- and middle-income countries.

Adherence to antiretroviral therapy in patients participating in a graduated cost recovery program at an HIV care center in South India

In resource-constrained settings, the most frequently cited barrier to optimal antiretroviral therapy (ART) adherence among HIV-infected patients has been the cost of medications. In recent years many subsidized medication programs have been developed to improve ART affordability. A Graduated Cost Recovery program at the largest care center in South India has enrolled 839 eligible patients into four tiers based on an evaluation of their financial information and willingness to pay, of these patients 635 consented to participate in this study. Patients in Tier 1 receive first-line ART at no cost, whereas patients in Tiers 2, 3, and 4 pay 50, 75, and 100%, respectively of the cost of first-line medications based on an assessment of their means. Adherence rates of 95% or greater on 3-day recall were achieved by 84.6% of Tier 1 (n = 156), 71.6% of Tier 2 (n = 141), 72.3% of Tier 3 (n = 242), and 79.2% of Tier 4 (n = 96). These findings suggest patients are highly motivated and that the provision of no-cost ART can promote higher rates of optimal adherence.

Optimal management of HIV-infected women during pregnancy and delivery: an audit of compliance with recommendations

BACKGROUND

The improvement in quality of life of HIV-infected patients and a reduced risk of vertical transmission have led to an increase in the desire for pregnancy among infected women. We assessed whether local recommendations were followed by HIV-infected mothers and their reasons for noncompliance.

METHODS

Data on HIV-infected women who delivered between 2002 and 2006 in a large public university hospital in Brussels were collected and analyzed for compliance with recommendations and outcomes.

RESULTS

The evidence suggests that current recommendations were followed in two thirds of the 203 recorded deliveries, as the patients in question (n = 140) came to term with an undetectable viral load and an uninfected newborn. About half of these women delivered vaginally, and 67% had ruptured membranes for less than 4 hours and required no instrumental delivery. Among those for whom optimal conditions for delivery were not met, two newborns were infected.

CONCLUSIONS

The current recommendations were followed in only two thirds of the recorded deliveries. To improve results for the future, we have adapted our protocol both by starting antiviral therapy earlier and by assigning nurses to the patients' follow-up to try to promote better compliance to treatment during pregnancy.

96-Week Efficacy and Safety of Atazanavir, With and Without Ritonavir, in a HAART Regimen in Treatment-Naive Patients

This study assesses virologic response, safety, tolerability, and changes in health-related quality of life (HRQoL) in antiretroviral (ARV)-naive patients treated with 2 atazanavir (ATV)-based regimens over 96 weeks. Treatment-naive adult patients (n = 200) were randomized to receive either ATV 300 mg with ritonavir (RTV) 100 mg (ATV300/r, n = 95) or ATV 400 mg (ATV400; n = 105). At week 96, 75% of ATV300/r-treated and 70% of ATV400-treated patients achieved viral loads <400 copies/mL (difference estimate [95% confidence interval, CI] = 5.1 [-7.1 to 17.2]). Five and 20 patients, respectively, experienced virologic failure. Adverse event-related discontinuations occurred among 8% receiving ATV300/r and 3% receiving ATV400. Plasma lipid elevations were generally low. Both regimens were well tolerated and associated with sustained improvements in HRQoL. These findings demonstrate long-term efficacy, tolerability, and safety of both ATV300/r and ATV400 in ARV-naive patients through 96 weeks with improvements in HRQoL.

Human immunodeficiency virus serodiscordant couples on highly active antiretroviral therapies with undetectable viral load: conception by unprotected sexual intercourse or by assisted reproduction techniques?

Until recently, only assisted reproduction was proposed to serodiscordant couples wishing to conceive. Nevertheless, recent publications have proposed unprotected sexual intercourse, targeting fertile days, for couples where antiretroviral treatment has lowered blood viral load to an undetectable level. Available data and the arguments for and against conception by safe sex versus the use of a strategy of unprotected sexual intercourse targeting fertile days are reviewed and analyzed. Although the rate of transmission of human immunodeficiency virus in serodiscordant couples in precise conditions (such as an undetectable viral load on treatment by highly active antiretroviral therapies and sexual intercourse limited to the fertile days) is very low, not zero, here we stress the various factors which can increase the risk of seroconversion in this particular population. In this context, it seems less cautious to abandon the recommendations of safe sex in serodiscordant couples desiring a child. The recourse to medically assisted procreation is advised, as long as evidence from further studies does not show that unprotected sexual intercourse, targeted to fertile days, does not have unexpected harmful consequences.

HIV testing practices and attitudes on prevention efforts in six diverse Chicago communities

Data describing local level HIV testing practices and attitudes regarding HIV prevention are rarely available, yet would be useful for HIV policy and evaluation. A comprehensive health survey was conducted in six community areas of Chicago (n = 1,699) in 2002-2003. The HIV prevention module of this survey was used for this analysis. The proportion that ever tested for HIV ranged from 40 to 75% and 11 to 38% were tested in the past 12 months. Residents favored: needle exchange programs (59-77%), HIV information in high schools (95-100%) and elementary schools (85-94%), and condom distribution in high schools (74-93%). Attitudes were less favorable regarding pharmacies selling clean needles (37-58%) and condom distribution in elementary schools (22-66%). Adults in these areas are over three times more likely to have been tested recently than adults nationally. Residents strongly favor community based HIV prevention initiatives such as needle exchange programs, condom distribution in high schools, and HIV prevention taught in schools. These evidence-based observations may be valuable in planning HIV prevention programs and in shaping policy.

Factors influencing quality of life of people living with HIV in Estonia: a cross-sectional survey

Background

Identification of factors that determine quality of life is important in order to better tailor health and social care services, and thereby improve the functioning and well being of people living with HIV. The estimated number of people living with HIV in eastern Europe and central Asia is 1.6 million. Little is known about the quality of life of people living with HIV in this region. The main purpose of the present study was to identify the factors influencing quality of life in a sample of HIV-infected persons in Estonia.

Methods

A convenient sample of 451 patients attending three infectious diseases clinics for routine HIV clinical care visits was recruited for a cross-sectional survey. The World Health Organization's Quality of Life HIV instrument was used to measure quality of life of the participants and medical data was abstracted from clinical records.

Results

Good overall quality of life was reported by 42.6% (95% CI: 38.0–47.2%) of the study participants (53% men, 60% self-identify as injecting drug users, 82% <30 years of age, 30% with CD4+ T cell count <300 cells/mm³, and 22% on antiretroviral treatment). We identified the following variables as independent predictors of good overall quality of life: being currently employed or studying (AOR: 2.27, 95% CI: 1.18–4.38); and the absence of HIV-related symptoms (AOR: 2.31, 95% CI: 1.24–4.29).

Conclusion

A comprehensive and competent care system, including health care providers and social workers, is required for an effective response. In addition, social interventions should seek to enhance the economic and employment opportunities for people living with HIV in the region.

Factors associated with health-related quality-of-life in HIV-infected Brazilians

Acquired immunodeficiency syndrome HIV/(AIDS) infection has become a chronic disease. This change led to a growing interest in outcomes focusing on the individual, such as health-related quality-of-life (QoL), to assess the impact of treatments. Our study evaluated the impact of the use of antiretroviral drugs, factors related to the infection and socioeconomic factors on the HQoL of HIV-infected patients. A total of 367 patients answered the questionnaire based on the World Health Organization QoL for HIV brief version. According to the modified-Poisson regression approach, the use of antiretroviral drugs was associated with worse QoL in the domain of the level of independence (P = 0.016). Being unemployed was associated with a worse QoL (P < 0.05) in five out of six domains; the only exception was the domain of spirituality (P > 0.05). Among the factors assessed, the socioeconomic aspects were most significant in determining the HQoL of the patients studied.

Psychosocial predictors of medication adherence among persons living with HIV

BACKGROUND

Since the introduction of highly active antiretroviral therapy (HAART), many have learned to live with HIV as a chronic illness. Adherence to medical regimens is extremely important for HIV patients.

PURPOSE

To examine the extent to which medication adherence among HIV patients is related to social and psychological variables.

METHOD

Data were gathered among 127 HIV patients (aged from 18-65 years) recruited at their quarterly consultation at Metz Hospital (France). Subjects completed a self-report adherence to medication scale, the Illness Perception Questionnaire (IPQ), the Beliefs about Medicine Questionnaire (BMQ), a French Value System Scale, a treatment satisfaction scale, and sociodemographic measures.

RESULTS

Analyses revealed significant associations between adherence and patients' beliefs about treatment, satisfaction with treatment, confidence in the physician, some values ("other people," "god and children"), and duration of treatment and illness.

CONCLUSION

The data suggest that patients' beliefs about treatment are formed to a certain degree in the patients' relationship with the physician. Furthermore, adherence seems to be related to personal values.

InforMatrix nucleoside/nucleotide reverse transcriptase inhibitor 'backbones'

InforMatrix is an interactive decision matrix technique. This paper describes the use of InforMatrix to determine an order of merit within the various nucleoside and nucleotide reverse transcriptase inhibitors. In the order of merit, six criteria (effectiveness, safety, tolerance, convenience, usability and costs) are weighted against each other. Data necessary for this weighting process are derived from literature as well as personal practical experience. This article gives an overview of the most relevant information from clinical trials, cohort studies and databases concerning backbones consisting of two nucleoside/nucleotide reverse transcriptase inhibitors in the treatment of HIV infections, as well as a description of the interactive decision matrix technique. By using this interactive matrix technique, a rational consideration of the treatment options for backbones consisting of two nucleoside/nucleotide reverse transcriptase inhibitors becomes possible.

Health-related quality of life outcomes in HIV-infected patients starting different combination regimens in a randomized multinational trial: the INITIO-QoL substudy

The health-related quality of life (HRQoL) outcomes in HIV-infected, treatment-naive patients starting different HAART regimens in a 3-year, randomized, multinational trial were compared. HRQoL was measured in a subgroup of patients enrolled in the INITIO study (153/911), using a modified version of the MOS-HIV questionnaire. The regimens compared in the INITIO trial were composed by two NRTIs (didanosine + stavudine) plus either an NNRTI (efavirenz) or a PI (nelfinavir), or both (efavirenz + nelfinavir). Primary HRQoL outcomes were Physical and Mental Health Summary scores (PHS and MHS, respectively). During follow-up, an increase of PHS score was observed in all treatment arms. The MHS score remained substantially unchanged with the four-drug combination and showed with both NNRTI- and PI-based three-drug regimens a marked trend toward improvement, which became statistically significant when a multiple imputation method was used to adjust for missing data. Overall, starting all the combination regimens compared in the INITIO study was associated with a maintained or slightly improved HRQOL status, consistently with the positive immunological and virological changes observed in the main study. The observed differences in the MHS indicate a possible HRQoL benefit associated to the use of three-drug, two-class regimens and no additional benefit for the use of four-drug, three-class regimens, confirming that three-drug, two-class regimens that include two NRTIs plus either an NNRTI or a PI should be preferred as initial treatment of HIV infection.

Are retrospective measures of change in quality of life more valid than prospective measures?

BACKGROUND

Adaptation to changing health presents a challenge to measuring change in quality of life (QoL). Previous studies have shown that different methods for measuring change yield different results, but it is unclear which method provides a more valid measurement of change. We investigated which of 3 commonly used methods for measuring change in QoL yielded the strongest associations with clinical measures of change in health status.

METHODS

A total of 268 human immunodeficiency virus (HIV)-1-infected patients starting highly active antiretroviral therapy completed QoL measures at baseline and after 36 weeks. We calculated Pearson correlation coefficients between change in QoL according to a prospective baseline and prospective follow-up measurement, a retrospective baseline and prospective follow-up measurement, or retrospective transition questions and change in CD4-cell count, plasma viral-load, body mass index, and hemoglobin concentration.

RESULTS

Patients evaluated their QoL significantly worse on the retrospective than on the prospective baseline measurement (P<0.01). These results may indicate that patients' reference value by which they evaluate their QoL changed over time, which would invalidate prospective serial QoL measurements. The retrospective baseline measurement method yielded strongest associations with clinical measures of change (P=0.02 to P<0.01). Distinguishing between the change inferred from the conventional prospective and the retrospective baseline measurement method was meaningful because the prospective method did not lead to changes that would be considered clinically significant, whereas the retrospective baseline measurement method did.

CONCLUSIONS

A method for measuring change in QoL incorporating a retrospective baseline-measurement showed strongest associations with change in clinical indicators of health status, suggesting a more valid measurement of change in QoL than a conventional prospective method.

Using cost-effectiveness analyses to inform policy: the case of antiretroviral therapy in Thailand

Background:

Much emphasis is put on providing evidence to assist policymakers in priority setting and investment decisions. Assessing the cost-effectiveness of interventions is one technique used by policymakers in their decisions around the allocation of scarce resources. However, even where such evidence is available, other considerations may also be taken into account, and even over-ride technical evidence. Antiretroviral therapy (ART) is the most effective intervention to reduce HIV-related morbidity and prolong mortality. However, treatment provision in the developing world has been hindered by the high costs of services and drugs, casting doubts on its cost-effectiveness. This paper looks at Thailand's publicly-funded antiretroviral initiative which was first introduced in 1992, and explores the extent to which cost-effectiveness evidence influenced policy.

Methods:

This article reviews the development of the national ART programme in Thailand between 1992 and 2004. It examines the roles of cost-effectiveness information in treatment policy decisions. Qualitative approaches including document analysis and interview of key informants were employed.

Results:

Two significant policy shifts have been observed in government-organised ART provision. In 1996, service-based therapy for a few was replaced by a research network to support clinical assessments of antiretroviral medication in public hospitals. This decision was taken after a domestic study illustrated the unaffordable fiscal burden and inefficient use of resources in provision of ART. The numbers of treatment recipients was maintained at 2,000 per year throughout the 1990s. It was not until 2001 that a new government pledged to extend the numbers receiving the service, as part of its commitment to universal coverage. Several elements played a role in this decision: new groups of dominant actors, drug price reductions, a pro-active civil society movement, lessons from experience on treatment benefits, and global treatment advocacy. Unlike previous policy discourse, human rights, ethics and equity notions were explicitly raised to support therapy extension.

Conclusion:

In the early decision, moving from a relatively limited ART service to a research network was clearly influenced by cost-effectiveness data. But in the 2001 decision to include ART in the universal coverage package, cost-effectiveness arguments were over-ruled by other considerations. Thai ART policy was shaped by many factors, and was not a simple rational process which relied on evidence.

A randomized trial of the impact of a programmable medication reminder device on quality of life in patients with AIDS

This 6-month randomized controlled trial evaluated the impact on quality of life (QOL) of a medication reminder device for patients with HIV. Patients were eligible if they had taken three or fewer highly active antiretroviral therapy (HAART) regimens or were treatment naïve. The intervention group received the Disease Management Assistance System (DMAS), a prompting device that verbally reminds patients at medication times and electronically records doses, and a monthly 30 minute adherence educational session. Controls received education only. QOL was measured at baseline and 6 months using the Centers for Epidemiologic Studies Depression Scale (CES-D), Instrumental Activities of Daily Living (IADLs), and the Medical Outcomes Study HIV Health Survey (MOS-HIV). At baseline, 62 patients completed surveys (31 control, 31 DMAS); at month 6, 48 patients completed surveys (23 control, 25 DMAS). At month 6, controls had improved QOL scores for CES-D, IADLs, physical health, general health, pain, QOL, and role functioning, while participants in the DMAS arm had some deterioration in QOL scores. These differences persisted after controlling for demographics, baseline CD4, and adherence. DMAS was associated with improved adherence but decreased QOL.

[Clinical status, adherence to HAART and quality of life in HIV-infected patients receiving antiretroviral treatment]

INTRODUCTION

Quality of life is one of the most frequently used subjective measures in chronic health problems. The aim of this study is to analyze the association between clinical and therapeutic parameters, and 11 quality of life domains in HIV-infected patients.

METHODS

A cross-sectional survey of 320 patients on antiretroviral treatment was conducted in four Andalusian hospitals (Spain). A semi-structured questionnaire was administered by health care professionals. Health-related quality of life was assessed with the MOS-HIV questionnaire, an instrument designed specifically for HIV-infected patients.

RESULTS

Almost three-quarters of the population were men (73.4%); 35.6% had developed aids, and 88.1% were considered adherent to treatment. Patients with greater viral load presented lower quality of life scores for all the domains, except cognitive functioning. Patients who had developed aids showed poorer quality of life for 10 of the 11 domains. Patients with adequate adherence to antiretroviral treatment showed better quality of life for 10 domains. No statistically significant differences in the domain scores except for quality of life were found between patients with a treatment regimen including protease inhibitors and those without.

CONCLUSION

The patient's clinical status and adherence affect not only survival, but also quality of life.

Effect of long-cycle structured intermittent versus continuous HAART on quality of life in patients with chronic HIV infection

OBJECTIVE

To examine the effect of repeated, long-cycle structured intermittent versus continuous HAART on health-related quality of life (HRQL) and symptom distress in patients with chronic HIV infection and plasma HIV RNA of less than 50 copies/ml.

DESIGN

Prospective survey of adult patients (n = 46) enrolled in a randomized clinical trial evaluating intermittent versus continuous HAART on immunological and virologic parameters. Patients (n = 23) randomized to structured intermittent therapy received serial cycles of 4 weeks on/8 weeks off HAART.

OUTCOME MEASURES

HRQL was measured by the physical and mental health summary scores of the Medical Outcomes Study HIV Health Survey (MOS-HIV). Symptom distress was measured by the Symptom Distress Scale. Patients completed initial questionnaires prior to randomization and at weeks 4, 12, and 40 of the trial via a touch screen computer in an outpatient clinic.

RESULTS

Baseline demographic and clinical characteristics were equivalent in both treatment groups. Although the mental health summary score declined significantly over time for the structured intermittent group, linear mixed modeling ANOVA indicated no significant difference across time for MOS-HIV summary and Symptom Distress Scale scores between the two treatment arms.

CONCLUSION

In this small sample, repeated long-cycle structured intermittent therapy may not provide HRQL or symptom distress advantage compared to continuous HAART in patients with chronic HIV infection over 10 months of treatment. Further research in a heterogenous chronic HIV population and longer follow-up period is warranted.

Assessing the effect of HAART on change in quality of life among HIV-infected women

Background

The impact of highly active antiretroviral therapy (HAART) on health-related quality of life (QOL) of HIV-1 infected individuals in large prospective cohorts has not been well studied.

Objective

To assess the effect of HAART on QOL by comparing HIV-infected women using HAART with HIV-infected women remaining HAART naïve in the Women's Interagency HIV Study (WIHS), a multicenter prospective cohort study begun in 1994 in the US.

Methods

A 1:1 matching with equivalent (≤ 0.1%) propensity scores for predicting HAART initiation was implemented and 458 pairs were obtained. HAART effects were assessed using pattern mixture models. The changes of nine QOL domain scores and one summary score derived from a shortened version of the MOS-HIV from initial values were used as study outcomes.

Results

The background covariates of the treatment groups were well-balanced after propensity score matching. The 916 matched subjects had a mean age of 38.5 years and 42% had a history of AIDS diagnosis. The participants contributed a total of 4,292 person visits with a median follow-up time of 4 years. In the bivariate analyses with only HAART use and time as covariates, HAART was associated with short-term improvements of 4 QOL domains: role functioning, social functioning, pain and perceived health index. After adjusting for demographic, socioeconomic, biological and clinical variables, HAART had small but significant short-term improvements on changes in summary QOL (mean change: 3.25; P = 0.02), role functioning (6.99; P < 0.01), social functioning (5.74; P < 0.01), cognitive functioning (3.59; P = 0.03), pain (6.73; P < 0.01), health perception (3.67; P = 0.03) and perceived health index (4.87; P < 0.01). These QOL scores typically remained stable or declined over additional follow-up and there was no indication that HAART modified these trends.

Conclusion

Our study demonstrated significant short-term HAART effects on most QOL domains, but additional use of HAART did not modify long-term trends. These changes could be attributed to the direct effect of HAART and indirect HAART effect mediated through clinical changes.

A single-item measure of health-related quality-of-life for HIV-infected patients in routine clinical care

Measurement of health-related quality-of-life (HRQL) captures dimensions of health not otherwise assessed. However, HRQL measurement is time-consuming and difficult to incorporate into a routine clinical care setting. The purpose of this study was to assess the construct validity, discriminative ability, and feasibility of administering a single-item health status measure (EVGGFP) of HRQL rating health as excellent, very good, good, fair, or poor among HIV-infected patients in routine clinical care. Patients attending an urban HIV specialty clinic completed a survey assessing their current symptom burden, HRQL as measured by EVGGFP and by a 7-domain, 21-item HRQL instrument (HRQL-21), and sociodemographic factors (n = 269). Patients were predominantly men (91%), 27% reported a history of intravenous drug use, and over half had some college education. We used multiple regression analysis to examine the association between HRQL assessed by EVGGFP and the HRQL-21. We compared the discriminative ability of EVGGFP and the HRQL-21 to detect differences in CD4 cell count, plasma HIV-1 RNA level, and symptom burden. We found that HRQL scores determined by EVGGFP were significantly associated with domain scores from the HRQL-21 (adjusted R2 0.42-0.69). The discriminative ability of EVGGFP was equivalent to that of the HRQL-21. EVGGFP had high sensitivity and low to moderate specificity in identifying patients with poor overall HRQL who might benefit from more comprehensive evaluation of multiple HRQL domains. EVGGFP can be used to assess health status among HIV-infected patients in routine clinical care and may be useful in settings in which comprehensive HRQL assessment is not practical.

Better quality of life with neuropsychological improvement on HAART

BACKGROUND

Successful highly active antiretroviral therapy (HAART) regimens have resulted in substantial improvements in the systemic health of HIV infected persons and increased survival times. Despite increased systemic health, the prevalence of minor HIV-associated cognitive impairment appears to be rising with increased longevity, and it remains to be seen what functional outcomes will result from these improvements. Cognitive impairment can dramatically impact functional ability and day-to-day productivity. We assessed the relationship of quality of life (QOL) and neuropsychological functioning with successful HAART treatment.

METHODS

In a prospective longitudinal study, subjects were evaluated before instituting HAART (naïve) or before changing HAART regimens because current therapy failed to maintain suppression of plasma viral load (treatment failure). Subjects underwent detailed neuropsychological and neurological examinations, as well as psychological evaluation sensitive to possible confounds. Re-evaluation was performed six months after institution of the new HAART regimen and/or if plasma viral load indicated treatment failure. At each evaluation, subjects underwent ultrasensitive HIV RNA quantitative evaluation in both plasma and cerebrospinal fluid.

RESULTS

HAART successes performed better than failures on measures exploring speed of mental processing (p < .02). HAART failure was significantly associated with increased self-reports of physical health complaints (p < .01) and substance abuse (p < .01). An interesting trend emerged, in which HAART failures endorsed greater levels of psychological and cognitive complaints (p = .06). Analysis between neuropsychological measures and QOL scores revealed significant correlation between QOL Total and processing speed (p < .05), as well as flexibility (p < .05).

CONCLUSION

Our study investigated the relationship between HIV-associated neurocognitive impairment and quality of life. HAART failures experienced slower psychomotor processing, and had increased self-reports of physical health complaints and substance abuse. Contrariwise, HAART successes experienced improved mental processing, demonstrating the impact of successful treatment on functioning. With increasing life expectancy for those who are HIV seropositive, it is important to measure cognitive functioning in relation to the actual QOL these individuals report. The study results have implications for the optimal management of HIV-infected persons. Specific support or intervention may be beneficial for those who have failed HAART in order to decrease substance abuse and increase overall physical health.

Spiritual well-being, sleep disturbance, and mental and physical health status in HIV-infected individuals

A growing body of evidence demonstrates a significant relationship between spirituality and health. HIV-infected individuals often find new meaning and purpose for their lives while establishing new connections and strengthening old ones. This descriptive, correlational study examined the relationships among spiritual well-being, sleep quality, and health status in 107 HIV-infected men and women. Spiritual well-being was found to be a significant factor related to both sleep quality and mental and physical health status. Every study participant reported sleep disturbance. The findings suggest that spiritual well-being and sleep quality need to be assessed so appropriate interventions can be implemented to improve health outcomes in this population.

[A study of initial antiretroviral therapy effectiveness, survival and safety in HIV+ patients]

OBJECTIVE

To study initial antiretroviral therapies indicated for HIV-infected patients during the 2001-2003 period regarding effectiveness, survival and safety.

METHOD

A descriptive, retrospective study of clinical and drug-related variables of naïve HIV-infected patients through pharmacotherapeutic history.

RESULTS

Mean CD4+ lymphocytes counts were 209.6 cells/mm3. Pneumonia by Pneumocystis carinii was the most commonly found condition at antiretroviral treatment onset. Most commonly used therapies included those based on a non-nucleoside reverse transcriptase inhibitor (NNRTI) combined with two nucleoside reverse transcriptase inhibitors (NRTIs). The longest mean survival was achieved by using combinations of three nucleoside reverse transcriptase inhibitors. The primary reason for initial antiretroviral therapy discontinuation were adverse effects, with stavudine exhibiting the poorest tolerability.

CONCLUSIONS

Therapies based on non-nucleoside reverse transcriptase inhibitors and protease inhibitors (PIs) have shown similar effectiveness to increase CD4+ cell counts. Regarding viral load decreases, protease inhibitors were most effective. Therapies using three nucleoside reverse transcriptase inhibitors resulted in peak survival.

Retrospective analysis of suspending HAART in selected patients with controlled HIV replication

We sought to determine the consequences of stopping highly active antiretroviral therapy (HAART) in a group of 41 HIV-infected individuals with undetectable HIV viral loads and CD4+ counts greater than 500 cells per microliter for 6 months or more. Clinical and laboratory parameters were monitored, as was the time to HAART reinitiation. Three months after HAART interruption, the median CD4+ count declined by 162 cells per microliter and HIV viral load increased by 24,000 copies per milliliter. Over the next year, CD4+ counts continued to decrease by an average of 11 cells per microliter per 3-month intervals. In contrast, HIV viral loads remained stable over the same period. Five of 7 patients (71%) with elevated cholesterol levels and 6 of 13 patients (46%) with elevated triglyceride levels had these values normalize after stopping HAART. After a median of 21 months follow-up, 26 of 41 patients (63%) have restarted HAART. Patients with Centers for Disease Control (CDC) HIV/AIDS C classification were more likely to restart HAART than those with A or B classification (p = 0.008). Reasons for HAART restart included clinical events in 8 patients. Fifteen patients restarted HAART for immunologic reasons: CD4+ count less than 300 cells per microliter (n = 7); HIV viral load greater than 55,000 copies per milliliter (n = 3); or both (n = 5). Three patients restarted HAART because of personal preference. Within 4 months, all 26 patients who restarted HAART achieved HIV viral loads less than 50 copies per milliliter. Although patients were able to rapidly achieve nondetectable HIV viral loads after restarting HAART, the inability to foresee clinical events among 8 patients (20%) is disconcerting. We advise caution before HAART interruption, particularly for those patients with a preceding history of significant HIV-related complications.

A stress and coping model of medication adherence and viral load in HIV-positive men and women on highly active antiretroviral therapy (HAART)

The authors tested a structural model that incorporated age, time since diagnosis, social support, coping, and negative mood as predictors of medication adherence and HIV viral load on 188 men and 134 women on highly active antiretroviral therapy (HAART). The authors used psychosocial latent factors formed from baseline measures to predict latent factors of adherence, as assessed by electronic monitoring and self-report, and viral load defined by indicators assessed over a 15-month period. Results from the model indicate that greater negative mood and lower social support are related to greater use of avoidance-oriented coping strategies. Use of these coping strategies by patients on HAART is related to poorer medication adherence and, subsequently, higher viral load. This model advances researchers' understanding of the contribution of psychosocial variables in predicting treatment adherence and disease progression in HIV-positive men and women.

The two-year impact of first generation protease inhibitor based antiretroviral therapy (PI-ART) on health-related quality of life

BACKGROUND

Protease inhibitor based antiretroviral therapy (PI-ART) was introduced in 1996 and has greatly reduced the incidence of HIV-related morbidity and mortality in the industrialised world. PI-ART would thus be expected to have a positive effect on health-related quality of life (HRQL). On the other hand, HRQL might be negatively affected by strict adherence requirements as well as by short and long-term adverse effects. The aim of this study was to assess the influence of two years of first generation PI-ART on HRQL in patients with a relatively advanced state of HIV-infection. Furthermore, we wanted to investigate the relation between developments in HRQL and viral response, self-reported adherence and subjective experience of adverse effects in patients with PI-ART.

METHODS

HRQL was measured by the Swedish Health-Related Quality of Life Questionnaire (SWED-QUAL). Sixty-three items from the SWED-QUAL forms two single-item and 11 multi-item dimension scales. For this study, two summary SWED-QUAL scores (physical HRQL composite score and emotional HRQL composite score) were created through a data reduction procedure. At the 2-year follow-up measurement (see below), items were added to measure adherence and subjective experience of adverse effects. Demographic and medical data were obtained from specific items in the questionnaires and from the medical files. Seventy-two patients who were among the first to receive PI-ART (indinavir or ritonavir based) responded to the questionnaire before the start of PI-ART. Of these, 54 responded to the same instrument after two years of treatment (13 had died, four had changed clinic and one did not receive the questionnaire).

RESULTS

The main findings were that the emotional HRQL deteriorated during two years of PI-ART, while the physical HRQL remained stable. Multiple linear regression analyses showed that experience of adverse effects contributed most to the deterioration of emotional HRQL.

CONCLUSION

In this sample of patients with relatively advanced state of HIV-infection, our data suggested that a negative development of physical HRQL had been interrupted by the treatment and that the emotional dimension of HRQL deteriorated during two years after start of PI-ART. Subjective experience of adverse effects made a major contribution to the decrease in emotional HRQL. The results underline the importance of including HRQL measures in the evaluation of new life prolonging therapies.

The physical, emotional and interpersonal impact of HAART: exploring the realities of HIV seropositive individuals on combination therapy

The purpose of this qualitative study was to understand the impact of HAART on the lives of HIV seropositive men and women. The data demonstrate that the demands of these treatments are substantial, but that renewed health and hope for the future due to the implementation of HAART often overshadows the stress of the treatments on the physical, emotional and social well-being of the individuals. Practitioners should be keenly aware of the struggles faced by those on HAART, and provide multidimensional support to assure maximum effectiveness of these treatments in light of the realities of their clients' lives.

Comparison of WHOQOL-BREF and SF-36 in patients with HIV infection

The purpose of the study was to evaluate the reliability and validity of the two generic instruments, the WHOQOL and the SF-36, for assessing health-related quality of life in 224 patients with HIV infection. The internal consistency ranged from 0.75 to 0.86 across the WHOQOL-BREF domains and from 0.72 to 0.93 across the SF-36 scales. The scores of all WHOQOL-BREF domains and SF-36 scales correlated positively with the measure of happiness, Sat-HRQOL and self-perceived health status, and correlated negatively with the number and intensity of symptoms. Patients with higher CD4 cell counts scored significantly higher on G4 (general health), three WHOQOL-BREF domains, seven SF-36 scales, and PCS (physical component summary). Patients with fewer symptoms and with less intensity of symptoms had significantly higher scores on all four domains of WHOQOL-BREF, eight scales, PCS, and MCS (mental component summary) of the SF-36 scale. The correlations between the physical, psychological, and social domains of the WHOQOL-BREF and PF (physical functioning), MH (mental health), and SF (social functioning) of the SF-36 were 0.51, 0.75, and 0.54, respectively. There is also good correlation between PCS of the SF-36 and the physical domain of the WHOQOL-BREF (r = 0.48), and between MCS and all four domains of the WHOQOL-BREF (r range = 0.60-0.75). The WHOQOL-BREF domains showed fewer floor or ceiling effect than the SF-36 scales. We concluded that both the WHOQOL-BREF and the SF-36 are reliable and valid health related quality-of-life instruments in patients with HIV infection.

Pharmacologic Perspectives for Once-Daily Antiretroviral Therapy

OBJECTIVE

To contrast available once-daily antiretroviral agents and combinations of these agents from a clinical pharmacologic viewpoint.

DATA SOURCES

Data were extracted from publications and major HIV conference proceedings cited in MEDLINE (1966–March 2004) using the search terms antiretroviral therapy, combination therapy, once-daily therapy, and pharmacokinetics. Additional references were obtained from the bibliographies of these sources.

STUDY SELECTION AND DATA EXTRACTION

Information pertaining to pharmacologic perspectives for once-daily antiretroviral agents was selected.

DATA SYNTHESIS

Maximal and durable suppression of plasma HIV RNA, the principal goal of therapy, depends on the intrinsic antiviral activity of the antiretroviral regimen. A favorable tolerability/toxicity profile is also fundamentally important. All once-daily agents exhibit some pharmacologic limitations or lack adequate long-term follow-up. Of available agents, efavirenz has a long and distinguished efficacy record, with reasonable safety and moderate tolerability. Lamivudine, and newer agents such as atazanavir (or atazanavir/ritonavir), emtricitabine, fosamprenavir/ritonavir, and tenofovir, may offer pharmacologic advantages in the current state of once-daily therapy. Important considerations exist for coadministering once-daily agents including drug–drug interactions, drug–food incompatibilities, and synergistic toxicities. Few controlled studies have compared once-daily regimens with conventional regimens.

CONCLUSIONS

Progress has been made toward once-daily therapy, but more clinical experience with available agents is needed, including comparative studies of entirely once-daily regimens versus conventional regimens. Limitations of currently available agents signify a need for improved antiretroviral utilization or new alternative agents.

Factors associated with efavirenz discontinuation in a large community-based sample of patients

Efavirenz (EFV) is a potent antiretroviral drug; its use may be limited, however, by psychiatric symptoms that require its discontinuation. We sought to identify the characteristics that placed patients at an elevated risk of discontinuation. Data for this cross-sectional study came from a self-administered questionnaire distributed by French AIDS community associations; it collected information about sociodemographic characteristics, addictive behaviours, treatment regimens, EFV history and depression. Patients remaining on EFV for more than six months were compared with those who stopped taking it. Of the 828 patients who completed the questionnaire, 175 had taken EFV for at least six months, and 152 had discontinued it (median months [IQR] of exposure=4[2-10]). Of these 327 patients (median age=42), 23% were women, 46% were unemployed, 38% had a steady sexual partner and 24% reported a history of multiple depressive episodes. Logistic regression showed that the factors independently associated with EFV discontinuation were female gender (OR[95%CI]=2.2[1.2-3.8]), unemployment (1.8[1.1-2.8]), a steady sexual partner (1.7[1-2.5]) and multiple episodes of depression (2.6[1.5-4.5]). Clinicians should keep in mind the neuropsychiatric risks of EFV during the first year, especially among patients with a history of multiple depressive episodes.

Pitfalls of assessing hepatotoxicity in trials and observational cohorts

The relationship between the use of antiretroviral drugs and the development of hepatic abnormalities has been documented in both randomized controlled trials (RCTs) and observational database studies. Both types of study design are known to have limitations when addressing this issue. Whereas RCTs may enroll a population that is at lower risk for the development of hepatotoxicity, thus underestimating the possible effect of antiretroviral therapy on hepatic abnormalities, observational databases may encompass information from a more heterogeneous group of patients, allowing the drugs to be assessed in a more realistic situation. However, a number of possible biases associated with the use of observational data may limit the conclusions that can be drawn from such studies. I describe some of the benefits and limitations of RCTs and observational data sets when drawing conclusions about the relationship between antiretroviral therapy and the development of hepatic abnormalities.

Health-related quality of life of patients with HIV disease: impact of hepatitis C coinfection

Health-related quality of life (HRQOL) is diminished in patients infected with both hepatitis C virus (HCV) and human immunodeficiency virus (HIV), but the effect of HIV/HCV coinfection on HRQOL is unknown. We compared the HRQOL of urban HIV/HCV coinfected patients with that of patients infected with either HCV or HIV alone. We then compared the 3 groups with a US population sample, adjusting for demographic characteristics. HRQOL for the group of HIV/HCV coinfected patients was statistically similar to that of HRQOL in patients with either HCV or HIV alone, but the 3 groups had a significantly decreased HRQOL than did the adjusted US population. Using multivariate techniques, we determined that age, unemployment, injection drug use, and depression were associated with impaired HRQOL. These findings underscore the importance of a multidisciplinary approach to the treatment of these patient populations.

[Economic and socio-behavioural issues related to highly active antiretroviral therapies for HIV infection: the contribution of social science research]

This article presents a synthesis of the main topics covered by social science research (SSR) on HIV/AIDS, since the advent of highly active antiretroviral therapies (HAART) in 1996. SSR has shown that non-adherence cannot be reliably <<predicted>> on the sole basis of a few a priori patient characteristics that clinicians could easily identify before initiation of HAART, and that a dynamic approach to adherence, continuously monitoring the impact of patients' subjective experience with HAART is needed. In relationship with the evolution of HIV infection toward a <<chronic disease>>, SSR has dealt with the impact of HAART on all aspects of patients' daily lives (from employment and professional status to sexuality). It has also emphasised the potential contradictions between the hopes generated by these cost-effective therapeutic advances, on the one hand, and the high social vulnerability of a growing proportion of people living with HIV-AIDS, on the other hand. Finally, SSR suggests recommendations for <<normalising>> AIDS public policies without losing the potential for innovations that the fight against this epidemic has introduced in health care and <<Social Security>> systems, as well as physician-patient's relationships.

Impact of a Patient Education Program on Adherence to HIV Medication

Patients' knowledge of their HIV condition and its treatment, which has been recognized as a factor that influences adherence to antiretroviral therapy, can be improved through educational programs. This prospective, randomized, controlled trial compared an experimental group that participated in an educational program and a control group with standard care. The study evaluated the impact of an educational intervention on adherence to antiretroviral therapy, patients' knowledge, quality of life, and therapeutic response in patients treated with highly active antiretroviral therapy. Three hundred twenty-six patients were analyzed at inclusion. A higher level of adherence was associated with patients who were older, had higher incomes, and did not smoke. CD4 cell count and plasma viral load were correlated with adherence at entry. The educational intervention had an impact on adherence and knowledge in the experimental group at 6 months, which was maintained at 12 and 18 months. A delayed increase in adherence was observed in the control group at 12 months. No significant impact on quality of life was observed over time. The patients' health status improved in 56% of the experimental group subjects and 50% of the control subjects. However, no significant impact was shown on CD4 cell count and plasma viral load. This study shows that an educational intervention improves adherence to antiretroviral regimens and health status and suggests that it should be initiated early in therapy.

Personality, quality of life and HAART adherence among men and women living with HIV/AIDS

Very few studies have documented relations between personality traits and quality of life among individuals living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS). Some have shown that poor perceived quality of life as determined by a sense of purpose may be associated with inadequate adherence to highly active antiretroviral treatment (HAART) in this population. Although adequate HAART adherence is critical to achieve the full therapeutic effects of newly and highly effective regimens, very little is known of how both personality factors and HIV-specific quality of life may impact adherence to these medication regimens. This study evaluated relations among personality traits, quality of life and HAART adherence among 116 men and women living with HIV/AIDS. Results showed that personality traits such as neuroticism were significantly associated with poorer quality of life, whereas conscientiousness and extraversion were associated with better quality of life. In contrast, personality traits were not directly related to HAART adherence. Both higher overall functioning and lower medication worries scores were significantly associated with HAART adherence. Findings suggest that personality traits are associated with HIV-specific quality of life on the one hand, and that HIV-specific quality of life is related to HAART adherence on the other. Future studies assessing the efficacy of psychosocial interventions in improving quality of life and HAART adherence should consider the role of personality traits in promoting better quality of life.