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Endalamaw Alamneh D, Shiferaw MB, Getachew Demissie M, Emiru MA, Zemene Kassie T, Endaylalu Lakew K, Tadege TZ. Virological Outcomes Among Pregnant Women Receiving Antiretroviral Treatment in the Amhara Region, North West Ethiopia. HIV AIDS (Auckl) 2023; 15:209-216. [PMID: 37159581 PMCID: PMC10163878 DOI: 10.2147/hiv.s389506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 04/22/2023] [Indexed: 05/11/2023] Open
Abstract
Background Globally, approximately 35 million people are infected with HIV infection. Sub-Saharan countries contributed 71% of global burden. Women are the most affected groups accounting for 51% of global infection and 90% of HIV infections in children (<15 years) are a result of mother to child transmission. In the absence of any intervention, mother-to-child transmission has been estimated to 30-40% that could occur at various periods like during pregnancy, delivery, and post-partum, via breastfeeding. For future generations to be born HIV-free, evidences on the level of viremia and contributing factors in pregnant mothers is important. Objective The objective of this study is to determine the magnitude of viral non-suppression rate among pregnant women and identify the risk factors associated with viral non-suppression. Methods A cross-sectional study was conducted from July 01, 2021 to June 30, 2022, in pregnant women who are on antiretroviral treatment and attending HIV viral load testing in Amhara region viral load testing sites, North West Ethiopia. Socio-demographic, clinical, and HIV-1 RNA viral load data were collected from the excel database. The data were analyzed in SPSS 23.0 statistical software. Results Overall viral non-suppression rate was 9.1%. In other words, the viral suppression rate was 90.9%. Pregnant women being at AIDS stages III and IV and with fair treatment adherence and suspected testers were statistically associated with increased viral non-suppression rate. Conclusion Relatively low viral non-suppression rate among pregnant mothers that had almost met the third 90 of UNAIDS target. But, still, some mothers received a non-suppressed viral replication specifically the odds of having a non-suppressed viral load was higher in pregnant women with poor treatment adherence and WHO Stage III and IV and suspected testers.
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Affiliation(s)
- Demeke Endalamaw Alamneh
- Virology Department, Amhara Regional State Public Health Institute, Bahir Dar, Ethiopia
- Correspondence: Demeke Endalamaw Alamneh, Email
| | - Melashu Balew Shiferaw
- Infectious and Tropical diseases, Amhara Regional State Public Health Institute, Bahir Dar, Ethiopia
| | | | | | | | | | - Taye Zeru Tadege
- Neglected Tropical Diseases, Amhara Regional State Public Health Institute, Bahir Dar, Ethiopia
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Agegnehu CD, Merid MW, Yenit MK. Incidence and predictors of virological failure among adult HIV patients on first-line antiretroviral therapy in Amhara regional referral hospitals; Ethiopia: a retrospective follow-up study. BMC Infect Dis 2020; 20:460. [PMID: 32611405 PMCID: PMC7329399 DOI: 10.1186/s12879-020-05177-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 06/18/2020] [Indexed: 11/15/2022] Open
Abstract
Background Although the United Nations program on HIV/AIDS 90–90-90-targets recommends achieving 90% of viral suppression for patients on first-line antiretroviral therapy by 2020, virological failure is still high and it remains a global public health problem. Therefore, assessing the incidence and predictors of virological failure among adult HIV patients on first-line ART in Amhara regional referral hospitals, Ethiopia is vital to design appropriate prevention strategies for treatment failure and preventing the unnecessary switching to second-line regimens. Method An institution-based retrospective follow-up study was conducted on 490 adult HIV patients. The simple random sampling technique was used, and data were entered into Epi data Version 4.2.0.0 and was exported to Stata version 14 for analysis. The proportional hazard assumption was checked, and the Weibull regression was fitted. Cox-Snell residual was used to test the goodness of fit, and the appropriate model was selected by AIC/BIC. Finally, an adjusted hazard ratio with a 95% CI was computed, and variables with P-value < 0.05 in the multivariable analysis were taken as significant predictors of virological failure. Results The overall incidence rate of virological failure was 4.9 events per 1000 person-month observations (95%CI: 3.86–6.38). Users of CPT (AHR = 0.55, 95%CI: 0.31–0.97), poor adherence (AHR = 5.46, 95%CI: 3.07–9.74), CD4 Count <=200 cells/mm3 (AHR = 3.9, 95%CI: 1.07–13.9) and 201–350 cells/mm3 (AHR 4.1, 95%CI: 1.12–15) respectively, and NVP based first line drug regimen (AHR = 3.53, 95%CI: 1.73–7.21) were significantly associated with virological failure. Conclusion The incidence rate of virological failure was high. CPT, poor adherence, low baseline CD4 count and NVP based first-line drug regimen were independent risk factors associated with virological failure. Therefore, strengthening HIV care intervention and addressing these significant predictors is highly recommended in the study setting.
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Affiliation(s)
- Chilot Desta Agegnehu
- School of Nursing, College of Medicine and Health Sciences and Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia.
| | - Mehari Woldemariam Merid
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Melaku Kindie Yenit
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Bhagwat P, Kapadia SN, Ribaudo HJ, Gulick RM, Currier JS. Racial Disparities in Virologic Failure and Tolerability During Firstline HIV Antiretroviral Therapy. Open Forum Infect Dis 2019; 6:ofz022. [PMID: 30793009 PMCID: PMC6372057 DOI: 10.1093/ofid/ofz022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2019] [Indexed: 01/20/2023] Open
Abstract
Background Racial/ethnic disparities in HIV outcomes have persisted despite effective antiretroviral therapy. In a study of initial regimens, we found viral suppression varied by race/ethnicity. In this exploratory analysis, we use clinical and socioeconomic data to assess factors associated with virologic failure and adverse events within racial/ethnic groups. Methods Data were from AIDS Clinical Trial Group A5257, a randomized trial of initial regimens with either atazanavir/ritonavir, darunavir/ritonavir, or raltegravir (each combined with tenofovir DF and emtricitabine). We grouped participants by race/ethnicity and then used Cox-proportional hazards regression to examine the impact of demographic, clinical, and socioeconomic factors on the time to virologic suppression and time to adverse event reporting within each racial/ethnic group. Results We analyzed data from 1762 participants: 757 self-reported as non-Hispanic black (NHB), 615 as non-Hispanic white (NHW), and 390 as Hispanic. The proportion with virologic failure was higher for NHB (22%) and Hispanic (17%) participants compared with NHWs (9%). Factors associated with virologic failure were poor adherence and higher baseline HIV RNA level. Prior clinical AIDS diagnosis was associated with virologic failure for NHBs only, and unstable housing and illicit drug use for NHWs only. Factors associated with adverse events were female sex in all groups and concurrent use of medications for comorbidities in NHB and Hispanic participants only. Conclusions Clinical and socioeconomic factors that are associated with virologic failure and tolerability of antiretroviral therapy vary between and within racial and ethnic groups. Further research may shed light into mechanisms leading to disparities and targeted strategies to eliminate those disparities.
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Affiliation(s)
- Priya Bhagwat
- Center for HIV Identification, Prevention, and Treatment Services, University of California, Los Angeles, Los Angeles, California
| | - Shashi N Kapadia
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Heather J Ribaudo
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Roy M Gulick
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Judith S Currier
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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Tillison AS, Avery AK. Evaluation of the Impact of Routine HIV Screening in Primary Care. J Int Assoc Provid AIDS Care 2016; 16:18-22. [PMID: 27596961 DOI: 10.1177/2325957416666677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Since 2006, numerous testing initiatives have been launched across the United States to increase the number of individuals who know their HIV status. These initiatives are often venue based and reported in a variety of settings. However, the effectiveness of these initiatives has not been evaluated to determine if patients were identified earlier in the course of disease or would not have been otherwise tested. In 2010, a publicly funded teaching hospital implemented an electronic medical record prompt to improve the rate of routine HIV screening and diagnosis, focusing on primary care office visits. Both sex and CD4 count were found to be significantly related to being newly diagnosed after the intervention. Routine testing in primary care is an effective strategy to diagnose patients earlier in disease progression, particularly men who might otherwise not be tested and thus would remain undiagnosed until developing symptoms from advanced disease.
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Affiliation(s)
| | - Ann Keltner Avery
- 2 MetroHealth System, Case Western Reserve University, Cleveland, OH, USA
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Ngom-Gueye NF, Batista G, Ndiaye AA, Diouf A, Daye KA, Tall AB, Diouf A, Ndiaye K, Diop MN, Dia M, Diop CT, Gaye A, Ndour CT, Seydi M, Gueye L, Diop BM, Sow PS. Incidence and Factors Associated with the Switch to the Second Line Antiretroviral Treatment at the Ambulatory Treatment Center (CTA) in Dakar. Health (London) 2016. [DOI: 10.4236/health.2016.814154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sarfo FS, Sarfo MA, Norman B, Phillips R, Bedu-Addo G, Chadwick D. Risk of deaths, AIDS-defining and non-AIDS defining events among Ghanaians on long-term combination antiretroviral therapy. PLoS One 2014; 9:e111400. [PMID: 25340766 PMCID: PMC4207829 DOI: 10.1371/journal.pone.0111400] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 10/01/2014] [Indexed: 11/18/2022] Open
Abstract
Combination antiretroviral therapy (cART) has been widely available in Ghana since 2004. The aim of this cohort study was to assess the incidences of death, AIDS-defining events and non-AIDS defining events and associated risk factors amongst patients initiating cART in a large treatment centre. Clinical and laboratory data were extracted from clinic and hospital case notes for patients initiating cART between 2004 and 2010 and clinical events graded according to recognised definitions for AIDS, non-AIDS events (NADE) and death, with additional events not included in such definitions such as malaria also included. The cumulative incidence of events was calculated using Kaplan Meier analysis, and association of risk factors with events by Cox proportional hazards regression. Data were closed for analysis on 31st December, 2011 after a median follow-up of 30 months (range, 0-90 months). Amongst 4,039 patients starting cART at a median CD4 count of 133 cells/mm3, there were 324 (8%) confirmed deaths, with an event rate of 28.83 (95% CI 25.78-32.15) deaths per 1000-person follow-up years; the commonest established causes were pulmonary TB and gastroenteritis. There were 681 AIDS-defining events (60.60 [56.14-65.33] per 1000 person years) with pulmonary TB and chronic diarrhoea being the most frequent causes. Forty-one NADEs were recorded (3.64 [2.61-4.95] per 1000 person years), of which hepatic and cardiovascular events were most common. Other common events recorded outside these definitions included malaria (746 events) and respiratory tract infections (666 events). Overall 24% of patients were lost-to-follow-up. Alongside expected risk factors, stavudine use was associated with AIDS [adjusted HR of 1.08 (0.90-1.30)] and death (adjusted HR of 1.60 [1.21-2.11]). Whilst frequency of AIDS and deaths in this cohort were similar to those described in other sub-Saharan African cohorts, rates of NADEs were lower and far exceeded by events such as malaria and respiratory tract infections.
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Affiliation(s)
- Fred Stephen Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | | | - Richard Phillips
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - George Bedu-Addo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - David Chadwick
- The James Cook University Hospital, Middlesbrough, United Kingdom
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Cardoso SW, Luz PM, Velasque L, Torres T, Coelho L, Freedberg KA, Veloso VG, Walensky RP, Grinsztejn B. Effectiveness of first-line antiretroviral therapy in the IPEC cohort, Rio de Janeiro, Brazil. AIDS Res Ther 2014; 11:29. [PMID: 25206924 PMCID: PMC4158765 DOI: 10.1186/1742-6405-11-29] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 08/16/2014] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND While Brazil has had a long-standing policy of free access to antiretroviral therapy (ART) for all in need, the epidemiological impact of ART on human immunodeficiency virus (HIV) RNA suppression in this middle-income country has not been well evaluated. We estimate first-line ART effectiveness in a large Brazilian cohort and examine the socio-demographic, behavioral, clinical and structural factors associated with virologic suppression. METHODS Virologic suppression on first-line ART at 6, 12, and 24 months from start of ART was defined as having a viral load measurement ≤400 copies/mL without drug class modification and/or discontinuation. Drug class modification and/or discontinuation were defined based on the class of a particular drug. Quasi-Poisson regression was used to quantify the association of factors with virologic suppression. RESULTS From January 2000 through June 2010, 1311 patients started first-line ART; 987 (75%) patients used NNRTI-based regimens. Virologic suppression was achieved by 77%, 76% and 68% of patients at 6, 12 and 24 months, respectively. Factors associated with virologic suppression at 12 months were: >8 years of formal education (compared to <4 years, risk ratio (RR) 1.13, 95% confidence interval (95% CI) 1.03-1.24), starting ART in 2005-2010 (compared to 2000-2004, RR 1.25 95% CI 1.15-1.35), and clinical trial participation (compared to no participation, RR 1.08 95% CI 1.01-1.16). Also at 12 months, women showed less virologic suppression compared to heterosexual men (RR 0.90 95% CI 0.82-0.99). For the 24-month endpoint, in addition to higher education, starting ART in the later period, and clinical trial participation, older age and an NNRTI-based regimen were also independently associated with virologic suppression. CONCLUSIONS Our results show that in Brazil, a middle-income country with free access to treatment, over three-quarters of patients receiving routine care reached virologic suppression on first-line ART by the end of the first year. Higher education, more recent ART initiation and clinical trial participation were associated with improved outcomes both for the 12-month and the 24-month endpoints, suggesting that further studies are needed to understand what aspects relating to these factors lead to higher virologic suppression.
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Martin DA, Luz PM, Lake JE, Clark JL, Veloso VG, Moreira RI, Cardoso SW, Klausner JD, Grinsztejn B. Improved virologic outcomes over time for HIV-infected patients on antiretroviral therapy in a cohort from Rio de Janeiro, 1997-2011. BMC Infect Dis 2014; 14:322. [PMID: 24919778 PMCID: PMC4067376 DOI: 10.1186/1471-2334-14-322] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 06/04/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Previous cohort studies have demonstrated the beneficial effects of antiretroviral therapy (ART) on viral load suppression. We aimed to examine the factors associated with virologic suppression for HIV-infected patients on ART receiving care at the Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation in Rio de Janeiro, Brazil. METHODS HIV-1 RNA levels and CD4+ T-cell counts at the date closest to midyear (1 July) were evaluated for 1,678 ART-naïve patients ≥ 18 years of age initiating ART between 1997 and 2010. The odds ratios (OR) and 95% confidence intervals (CI) for having an undetectable viral load (≤ 400 copies/mL) were estimated using generalized estimating equations regression models adjusted for clinical and demographic factors. Time-updated covariates included age, years since HIV diagnosis, hepatitis C diagnosis and ART interruptions. RESULTS Between 1997 and 2011, the proportion of patients with an undetectable viral load increased from 6% to 78% and the median [interquartile range] CD4+ T-cell count increased from 207 [162, 343] to 554 [382, 743] cells/μL. Pre-treatment median CD4+ T-cell count significantly increased over the observation period from 114 [37, 161] to 237 [76, 333] cells/μL (p < .001). The per-year adjusted OR (aOR) for having undetectable viral load was 1.18 (95% CI = 1.16-1.21). ART interruptions >1 month per calendar significantly decreased the odds [aOR = 0.32 (95% CI = 0.27-0.38)] of having an undetectable viral load. Patients initiating on a protease inhibitor (PI)-based first-line regimen were less likely to have undetectable viral load [aOR = 0.72 (95% CI = 0.63-0.83)] compared to those initiating on a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. CONCLUSIONS Our results demonstrate significant improvements in virologic outcomes from 1997 to 2011, which persisted after adjusting for other factors. This may in part be due to improvements in care and new treatment options. NNRTI- versus PI-based first-line regimens were found to be associated with increased odds of having an undetectable viral load, consistent with previous studies. Treatment interruptions were found to be the most important determinant of not having an undetectable viral load. Studies are needed to characterize the reasons for treatment interruptions and to develop subsequent strategies for improving adherence to ART.
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Affiliation(s)
- David A Martin
- University of California, Los Angeles, Los Angeles, USA.
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Predictors of virologic response in persons who start antiretroviral therapy during recent HIV infection. AIDS 2014; 28:841-9. [PMID: 24401640 DOI: 10.1097/qad.0000000000000149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite evidence supporting antiretroviral therapy (ART) in recent HIV infection, little is known about factors that are associated with successful ART. We assessed demographic, virologic, and immunologic parameters to identify predictors of virologic response. DESIGN A 24-week observational study of ART on persons enrolled within 6 months of their estimated date of infection (EDI) evaluated baseline demographics and the collection of blood and gut specimens. METHODS Flow cytometry analyses of blood and gut lymphocytes allowed characterization of CD4 and CD8 T cells at study entry and end. Additional assessments included soluble CD14 (sCD14), lipopolysaccharide, CD4 T-cell counts, and HIV RNA levels. RESULTS Twenty-nine participants initiated ART, and 17 achieved undetectable HIV RNA by study end. A longer time from EDI to ART, older age, higher sCD14, lower proportions of central memory CD4 T cells, and higher proportions of activated CD8 T cells were associated with detectable viremia. Multivariable logistic regression found only older age and elevated sCD14 were independently associated with persistent viremia. Additionally, we observed that ART in recent infection did not result in discernible recovery of CD4 T cells in the gut. CONCLUSION In persons who started ART within 3-33 weeks from EDI, age and microbial translocation were associated with detectable HIV RNA. As observed in other cohorts, ART in recent infection did not improve proportions of total CD4 T cells in gut-associated lymphoid tissue (GALT). This lends support to further evaluate the use of more potent ART or regimens that protect the GALT in recent HIV infection.
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Fong R, Cheng AC, Vujovic O, Hoy JF. Factors associated with virological failure in a cohort of combination antiretroviral therapy-treated patients managed at a tertiary referral centre. Sex Health 2014; 10:442-7. [PMID: 24119435 DOI: 10.1071/sh13043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 08/01/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recent antiretroviral regimens are potent and better tolerated, resulting in a low prevalence of treatment failure. It is important to identify the drivers of virological failure, so that patients at risk can be identified early and prevention strategies implemented. METHODS We performed a retrospective case-control study of HIV-positive patients on antiretroviral therapy and managed at The Alfred Hospital during 2010 to evaluate the predictors of virological failure. Controls were matched 3:1 to cases by gender, and by clinical review in the same week as the diagnosis of virological failure in the case. Predictors of virological failure were identified by multivariate conditional logistic regression. RESULTS Thirty-nine patients were identified with treatment failure. In the multivariate model, characteristics associated with virological failure were missed clinic appointments in 1 year before virological failure (odds ratio (OR)=13.1, 95% confidence interval (CI): 2.8-61.1), multiple previous combined antiretroviral therapy regimens (OR =4.2, 95% CI:1.2-15.3), current hepatitis C infection (OR=8.6, 95% CI: 1.9-38.7), older age at HIV diagnosis (OR=1.1, 95% CI: 1.0-1.2), younger age at time of virological failure (OR=0.9, 95% CI: 0.8 to 1.0), and CD4 cell count at virological failure (OR=0.7, 95% CI: 0.5 to 0.9). CONCLUSIONS Targeted and appropriate adherence support should be provided to treatment-experienced patients, particularly those who have missed clinical appointments and those with hepatitis C coinfection. Further elucidation of the barriers to clinic attendance may optimise linkage and retention in care.
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Affiliation(s)
- Raymond Fong
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Vic. 3004, Australia
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Kassa D, Gebremichael G, Alemayehu Y, Wolday D, Messele T, van Baarle D. Virologic and immunologic outcome of HAART in Human Immunodeficiency Virus (HIV)-1 infected patients with and without tuberculosis (TB) and latent TB infection (LTBI) in Addis Ababa, Ethiopia. AIDS Res Ther 2013; 10:18. [PMID: 23842109 PMCID: PMC3718701 DOI: 10.1186/1742-6405-10-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 07/02/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND HIV/TB coinfection remains a major challenge even after the initiation of HAART. Little is known about Mycobacterium tuberculosis (Mtb) specific immune restoration in relation to immunologic and virologic outcomes after long-term HAART during co-infections with latent and active TB. METHODS A total of 232 adults, including 59 HIV patients with clinical TB (HIV + TB+), 125 HIV patients without clinical TB (HIV + TB-), 13 HIV negative active TB patients (HIV-TB+), and 10 HIV negative Tuberculin Skin TST positive (HIV-TST+), and 25 HIV-TST- individuals were recruited. HAART was initiated in 113 HIV + patients (28 TB + and 85 TB-), and anti-TB treatment for all TB cases. CD4+ T-cell count, HIV RNA load, and IFN-γ responses to ESAT-6/CFP-10 were measured at baseline, 6 months (M6), 18 months (M18) and 24 months (M24) after HAART initiation. RESULTS The majority of HIV + TB- (70%, 81%, 84%) as well as HIV + TB + patients (60%, 77%, 80%) had virologic success (HIV RNA < 50 copies/ml) by M6, M18 and M24, respectively. HAART also significantly increased CD4+ T-cell counts at 2 years in HIV + TB + (from 110.3 to 289.9 cells/μl), HIV + TB- patients (197.8 to 332.3 cells/μl), HIV + TST- (199 to 347 cells/μl) and HIV + TST + individuals (195 to 319 cells/μl). Overall, there was no significant difference in the percentage of patients that achieved virologic success and in total CD4+ counts increased between HIV patients with and without TB or LTBI. The Mtb specific IFN-γ response at baseline was significantly lower in HIV + TB + (3.6 pg/ml) compared to HIV-TB + patients (34.4 pg/ml) and HIV + TST + (46.3 pg/ml) individuals; and in HIV-TB + patients compared to HIV-TST + individuals (491.2 pg/ml). By M18 on HAART, the IFN-γ response remained impaired in HIV + TB + patients (18.1 pg/ml) while it normalized in HIV + TST + individuals (from 46.3 to 414.2 pg/ml). CONCLUSIONS Our data show that clinical and latent TB infections do not influence virologic and immunologic outcomes of ART in HIV patients. Despite this, HAART was unable to restore optimal TB responsiveness as measured by Mtb specific IFN-γ response in HIV/TB patients. Improvement of Mtb-specific immune restoration should be the focus of future therapeutic strategies.
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Affiliation(s)
- Desta Kassa
- Infectious and non-infectious diseases research directorate, Ethiopian Health and Nutrition Research Institute (EHNRI), P.O. Box 1242, Addis Ababa, Ethiopia
- Department of Internal Medicine and Infectious Diseases and Department of Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gebremedhin Gebremichael
- Infectious and non-infectious diseases research directorate, Ethiopian Health and Nutrition Research Institute (EHNRI), P.O. Box 1242, Addis Ababa, Ethiopia
| | - Yodit Alemayehu
- Infectious and non-infectious diseases research directorate, Ethiopian Health and Nutrition Research Institute (EHNRI), P.O. Box 1242, Addis Ababa, Ethiopia
| | - Dawit Wolday
- Medical Biotech Laboratory, Addis Ababa, Ethiopia
| | - Tsehaynesh Messele
- Infectious and non-infectious diseases research directorate, Ethiopian Health and Nutrition Research Institute (EHNRI), P.O. Box 1242, Addis Ababa, Ethiopia
| | - Debbie van Baarle
- Department of Internal Medicine and Infectious Diseases and Department of Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Zubaran C, Michelim L, Foresti K, Medeiros G, May W, Madi JM. Retention in medical care and antiretroviral treatment according to skin color in southern Brazil. J Int Assoc Provid AIDS Care 2013; 13:170-7. [PMID: 23697777 DOI: 10.1177/2325957413488178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to compare the retention in medical care and antiretroviral (ARV) treatment of individuals living with HIV and AIDS to antiretroviral therapy in southern Brazil according to their "race" or skin color. This study is part of a 225-day prospective trial, comprising 7 interviews, in which an intervention designed to improve adherence to treatment was tested. A convenience sample of 73 individuals living with HIV and/or AIDS enrolled in this follow-up procedure. The mean length of continuance in treatment was 161.5 (standard deviation [SD] = 18.6; 95% confidence interval [CI] = 125-198) and 138.4 (SD = 14.1; 95% C.I. = 111-166) days in the "nonwhite" and "white" categories, respectively. There was no significant difference between the 2 categories, χ(2)(1, n = 72) = 0.76, P = .38, which include similar levels of retention in medical care and treatment with ARV medications between groups of individuals categorized as white and nonwhite in this sample.
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Affiliation(s)
- Carlos Zubaran
- School of Medicine, University of Western Sydney, Australia
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Availability of volunteer-led home-based care system and baseline factors as predictors of clinical outcomes in HIV-infected patients in rural Zambia. PLoS One 2012; 7:e49564. [PMID: 23236351 PMCID: PMC3517597 DOI: 10.1371/journal.pone.0049564] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 10/14/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We assessed the impact of home-based care (HBC) for HIV+ patients, comparing outcomes between two groups of Zambians receiving antiretroviral therapy (ART) who lived in villages with and without HBC teams. METHODS We conducted a retrospective cohort study using medical charts from Macha Mission Hospital, a hospital providing HIV care in Zambia's rural Southern Province. Date of birth, date of ART initiation, place of residence, sex, body mass index (BMI), CD4+ cell count, and hemoglobin (Hgb) were abstracted. Logistic regression was used to test our hypothesis that HBC was associated with treatment outcomes. RESULTS Of 655 patients, 523 (80%) were eligible and included in the study. There were 428 patients (82%) with favorable outcomes (alive and on ART) and 95 patients (18%) with unfavorable outcomes (died, lost to follow-up, or stopped treatment). A minority of the 523 eligible patients (n = 84, 16%) lived in villages with HBC available. Living in a village with HBC was not significantly associated with treatment outcomes; 80% of patients in a village with HBC had favorable outcomes, compared to 82% of patients in a village without HBC (P = 0.6 by χ(2)). In bivariable analysis, lower BMI (P<0.001), low CD4+ cell count (P = 0.02), low Hgb concentration (P = 0.02), and older age at ART initiation (P = 0.047) were associated with unfavorable outcomes. In multivariable analysis, low BMI remained associated with unfavorable outcomes (P<0.001). CONCLUSIONS We did not find that living in a village with HBC available was associated with improved treatment outcomes. We speculate that the ART clinic's rigorous treatment preparation before ART initiation and continuous adherence counseling during ART create a motivated group of patients whose outcomes did not improve with additional HBC support. An alternative explanation is that the quality of the HBC program is suboptimal.
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Patients' demographic and clinical characteristics and level of care associated with lost to follow-up and mortality in adult patients on first-line ART in Nigerian hospitals. J Int AIDS Soc 2012; 15:17424. [PMID: 23010378 PMCID: PMC3494164 DOI: 10.7448/ias.15.2.17424] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 06/25/2012] [Accepted: 08/20/2012] [Indexed: 01/03/2023] Open
Abstract
Introduction Clinical outcome is an important determinant of programme success. This study aims to evaluate patients’ baseline characteristics as well as level of care associated with lost to follow-up (LTFU) and mortality of patients on antiretroviral treatment (ART). Methods Retrospective cohort study using routine service data of adult patients initiated on ART in 2007 in 10 selected hospitals in Nigeria. We captured data using an electronic medical record system and analyzed using Stata. Outcome measures were probability of being alive and retained in care at 12, 24 and 36 months on ART. Potential predictors associated with time to mortality and time to LTFU were assessed using competing risks regression models. Results After 12 months on therapy, 85% of patients were alive and on ART. Survival decreased to 81.2% and 76.1% at 24 and 36 months, respectively. Median CD4 count for patients at ART start, 12, 18 and 24 months were 152 (interquartile range, IQR: 75 to 242), 312 (IQR: 194 to 450), 344 (IQR: 227 to 501) and 372 (IQR: 246 to 517) cells/µl, respectively. Competing risk regression showed that patients’ baseline characteristics significantly associated with LTFU were male (adjusted sub-hazard ratio, sHR=1.24 [95% CI: 1.08 to 1.42]), ambulatory functional status (adjusted sHR=1.25 [95% CI: 1.01 to 1.54]), World Health Organization (WHO) clinical Stage II (adjusted sHR=1.31 [95% CI: 1.08 to 1.59]) and care in a secondary site (adjusted sHR=0.76 [95% CI: 0.66 to 0.87]). Those associated with mortality include CD4 count <50 cells/µl (adjusted sHR=2.84 [95% CI: 1.20 to 6.71]), WHO clinical Stage III (adjusted sHR=2.67 [95% CI: 1.26 to 5.65]) and Stage IV (adjusted sHR=5.04 [95% CI: 1.93 to 13.16]) and care in a secondary site (adjusted sHR=2.21 [95% CI: 1.30 to 3.77]). Conclusions Mortality was associated with advanced HIV disease and care in secondary facilities. Earlier initiation of therapy and strengthening systems in secondary level facilities may improve retention and ultimately contribute to better clinical outcomes.
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Genotype assays and third-line ART in resource-limited settings: a simulation and cost-effectiveness analysis of a planned clinical trial. AIDS 2012; 26:1083-93. [PMID: 22343964 DOI: 10.1097/qad.0b013e32835221eb] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To project the clinical and economic outcomes of a genotype assay for selection of third-line antiretroviral therapy (ART) in resource-limited settings, as per the planned international A5288 trial (MULTI-OCTAVE). METHODS We used the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-International Model to compare three strategies for patients who have failed second-line ART in South Africa: sustained second-line: no genotype assay, all patients remain on second-line ART; A5288: genotype to determine the resistance profile and assign an appropriate regimen; or population-based third-line: no genotype, all patients switch to a potent third-line regimen. Model inputs are from published data in South Africa. Resistance profiles, ART regimens, and efficacy data were those used for trial planning. RESULTS Projected life expectancy for sustained second-line, A5288, and population-based third-line are 61.1, 103.8, and 104.2 months. Compared to sustained second-line ($12 ,460), per person lifetime costs increase for the A5288 ($39, 250) and population-based ($44, 120) strategies. The incremental cost-effectiveness ratio of A5288, compared to sustained second-line, is $7500/year of life saved (YLS), and for population-based third-line, compared to A5288, is $154 ,500/YLS. In the A5288 strategy, very late presentation to care, coupled with lengthy delays to obtain the genotype, dramatically reduces 5-year survival, making the population-based third-line strategy more attractive. CONCLUSIONS We project that, whereas the public health approach to third-line therapy is unaffordable, genotype assays and third-line ART in resource-limited settings will increase survival and be cost-effective compared to the population-based approach, supporting the value of an efficacy study.
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Different baseline characteristics and different outcomes of HIV-infected patients receiving HAART through clinical trials compared with routine care in Mexico. J Acquir Immune Defic Syndr 2012; 59:155-60. [PMID: 22107816 DOI: 10.1097/qai.0b013e31823ff035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The efficacy of antiretroviral therapy (ART) has been established through clinical trials (CTs). However, selection bias and differences can limit their applicability to the general population. METHODS All treatment-naive HIV-infected patients who began ART in routine care (RC) between 2000 and 2008 were compared with all patients who initiated ART through a CT in terms of incidence of virological failure (VF), increase in CD4(+) count, mortality rate, and loss to follow-up (LTFU). RESULTS At baseline, the RC group had less years of education, higher unemployment rate, higher proportion of females (14.2 vs. 5.7%; P < 0.01), lower median CD4(+) (97 vs. 158 cells/μL; P < 0.01), and lower proportion of patients with hemoglobin >12 g/dL (74 vs. 83%, P = 0.04). VF at week 48 was less frequent in the CT compared with the RC group (1.8% vs. 6.21%, P = 0.02). In multivariate analysis, participation in CT [odds ratio (OR): 0.20, 95% confidence interval (CI): 0.04 to 0.91, P = 0.03], hemoglobin >12 g/dL (OR: 0.29, 95% CI 0.09-0.89, P = 0.03), and receiving an optimal highly active antiretroviral therapy regimen (OR: 0.09, 95% CI: 0.01 to 0.52, P < 0.01) remained associated with lower risk of VF. All cause mortality was 0.017 (95% CI: 0.002 to 0.122) versus 0.094 (95% CI: 0.053 to 0.17) deaths per 1000 person-days in the CT group and in the RC group, respectively (P = 0.05). No differences were found in the proportion of patients LTFU. CONCLUSIONS Receiving ART through CT was associated with lower probability of VF, lower mortality (probably related to less severe clinical characteristics at baseline), and similar rates of LTFU than RC.
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Khienprasit N, Chaiwarith R, Sirisanthana T, Supparatpinyo K. Incidence and risk factors of antiretroviral treatment failure in treatment-naïve HIV-infected patients at Chiang Mai University Hospital, Thailand. AIDS Res Ther 2011; 8:42. [PMID: 22060823 PMCID: PMC3238297 DOI: 10.1186/1742-6405-8-42] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 11/07/2011] [Indexed: 12/21/2022] Open
Abstract
Background The use of combination antiretroviral therapy (cART) has become a standard of care for the treatment of HIV infection. However, cost and resistance to cART are major obstacles for access to treatment especially in resource-limited settings. In this study, we aimed to determine the incidence and risk factors of treatment failure in a cohort of treatment-naïve Thai HIV-infected patients. Methods A retrospective cohort study was conducted among HIV-infected patients initiating their first cART at Chiang Mai University Hospital, Thailand. Results From January 2002 to December 2008, 788 patients were enrolled; 365 were male (46.3%), and the mean age was 37.9 ± 8.6 years. The median baseline CD4 count was 57.7 cells/mm3 (IQR 22, 127). GPO-VIR® (a fixed-dose combination of lamivudine, stavudine, and nevirapine) was the most common prescribed cART (657 patients, 83.4%). Seventy-six patients developed virological failure given the cumulative incidence of 9.6%. The incidence of virological failure was 2.79 (95% CI 2.47, 3.14) cases per 100 person years. Poor adherence was the strongest predictor for virological failure. Of 535 immunologically evaluable patients, 179 (33.5%) patients developed immunological failure. A low CD4 cell count at baseline (< 100 cells/mm3) and the increment of CD4 cell count of < 50 cell/mm3 after 6 months of cART were the predictors for immunological failure (p < 0.001). Conclusions This study demonstrated that even in resource-limited settings, the high rate of success could be expected in the cohort with good and sustainable drug adherence. Poor adherence, older age, and low baseline CD4 cell count are the predictors for unfavorable outcome of cART.
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CD4+ T-cell counts and plasma HIV-1 RNA levels beyond 5 years of highly active antiretroviral therapy. J Acquir Immune Defic Syndr 2011; 57:421-8. [PMID: 21602699 DOI: 10.1097/qai.0b013e31821e9f21] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The heterogeneity of CD4 T-cell counts and HIV-1 RNA at 5-12 years after the initiation of highly active antiretroviral therapy (HAART) remains largely uncharacterized. METHODS In the Multicenter AIDS Cohort Study, 614 men who initiated HAART contributed data 5-12 years subsequently. Multivariate regression was used to evaluate the predictors of CD4 counts and HIV-1 RNA levels. RESULTS At 5 to 12 years post-HAART, the median CD4 T-cell count was 586 (interquartile range, 421-791) cells per microliter and 78% of the HIV-1 RNA measurements were undetectable. Higher CD4 T-cell counts 5-12 years post HAART were predicted by higher CD4 T-cell counts and higher total lymphocyte count pre HAART, lack of hepatitis B or C virus coinfections, and greater CD4 T-cell change and suppressed HIV-1 RNA in the first 5 years after starting HAART. Men who were 50 years and older with 351-500 CD4 cells per microliter at HAART initiation had adjusted mean CD4 T-cell count of 643 cells per microliter at 10-12 years post HAART, which was similar to the adjusted mean CD4 T-cell count (670 cells/μL, P = 0.45) in this period for younger men starting HAART with lower CD4 T-cell counts. HIV-1 RNA suppression in the first 5 years post HAART predicted subsequent viral suppression. CONCLUSIONS Immunological and virological responses in the first 5 years post HAART predicted subsequent CD4 T-cell counts and HIV-1 RNA levels. The association between age and subsequent CD4 T-cell count supports incorporating age in the guidelines for use of HAART.
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Mossdorf E, Stoeckle M, Mwaigomole EG, Chiweka E, Kibatala PL, Geubbels E, Urassa H, Abdulla S, Elzi L, Tanner M, Furrer H, Hatz C, Battegay M. Improved antiretroviral treatment outcome in a rural African setting is associated with cART initiation at higher CD4 cell counts and better general health condition. BMC Infect Dis 2011; 11:98. [PMID: 21504595 PMCID: PMC3107177 DOI: 10.1186/1471-2334-11-98] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 04/19/2011] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data on combination antiretroviral therapy (cART) in remote rural African regions is increasing. METHODS We assessed prospectively initial cART in HIV-infected adults treated from 2005 to 2008 at St. Francis Designated District Hospital, Ifakara, Tanzania. Adherence was assisted by personal adherence supporters. We estimated risk factors of death or loss to follow-up by Cox regression during the first 12 months of cART. RESULTS Overall, 1,463 individuals initiated cART, which was nevirapine-based in 84.6%. The median age was 40 years (IQR 34-47), 35.4% were males, 7.6% had proven tuberculosis. Median CD4 cell count was 131 cells/μl and 24.8% had WHO stage 4. Median CD4 cell count increased by 61 and 130 cells/μl after 6 and 12 months, respectively. 215 (14.7%) patients modified their treatment, mostly due to toxicity (56%), in particular polyneuropathy and anemia. Overall, 129 patients died (8.8%) and 189 (12.9%) were lost to follow-up. In a multivariate analysis, low CD4 cells at starting cART were associated with poorer survival and loss to follow-up (HR 1.77, 95% CI 1.15-2.75, p=0.009; for CD4<50 compared to >100 cells/μl). Higher weight was strongly associated with better survival (HR 0.63, 95% CI 0.51-0.76, p<0.001 per 10 kg increase). CONCLUSIONS cART initiation at higher CD4 cell counts and better general health condition reduces HIV related mortality in a rural African setting. Efforts must be made to promote earlier HIV diagnosis to start cART timely. More research is needed to evaluate effective strategies to follow cART at a peripheral level with limited technical possibilities.
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Affiliation(s)
- Erik Mossdorf
- St. Francis Designated District Hospital, Ifakara, United Republic of Tanzania
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Pasquet A, Messou E, Gabillard D, Minga A, Depoulosky A, Deuffic-Burban S, Losina E, Freedberg KA, Danel C, Anglaret X, Yazdanpanah Y. Impact of drug stock-outs on death and retention to care among HIV-infected patients on combination antiretroviral therapy in Abidjan, Côte d'Ivoire. PLoS One 2010; 5:e13414. [PMID: 20976211 PMCID: PMC2955519 DOI: 10.1371/journal.pone.0013414] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Accepted: 09/04/2010] [Indexed: 12/04/2022] Open
Abstract
Background To evaluate the type and frequency of antiretroviral drug stock-outs, and their impact on death and interruption in care among HIV-infected patients in Abidjan, Côte d'Ivoire. Methods and Findings We conducted a cohort study of patients who initiated combination antiretroviral therapy (cART) in three adult HIV clinics between February 1, 2006 and June 1, 2007. Follow-up ended on February 1, 2008. The primary outcome was cART regimen modification, defined as at least one drug substitution, or discontinuation for at least one month due to drug stock-outs at the clinic pharmacy. The secondary outcome for patients who were on cART for at least six months was interruption in care, or death. A Cox regression model with time-dependent variables was used to assess the impact of antiretroviral drug stock-outs on interruption in care or death. Overall, 1,554 adults initiated cART and were followed for a mean of 13.2 months. During this time, 72 patients discontinued treatment and 98 modified their regimen because of drug stock-outs. Stock-outs involved nevirapine and fixed-dose combination zidovudine/lamivudine in 27% and 51% of cases. Of 1,554 patients, 839 (54%) initiated cART with fixed-dose stavudine/lamivudine/nevirapine and did not face stock-outs during the study period. Among the 975 patients who were on cART for at least six months, stock-out-related cART discontinuations increased the risk of interruption in care or death (adjusted hazard ratio [HR], 2.83; 95%CI, 1.25–6.44) but cART modifications did not (adjusted HR, 1.21; 95%CI, 0.46–3.16). Conclusions cART stock-outs affected at least 11% of population on treatment. Treatment discontinuations due to stock-outs were frequent and doubled the risk of interruption in care or death. These stock-outs did not involve the most common first-line regimen. As access to cART continues to increase in sub-Saharan Africa, first-line regimens should be standardized to decrease the probability of drug stock-outs.
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Affiliation(s)
- Armelle Pasquet
- Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Tourcoing, France.
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Muñoz M, Finnegan K, Zeladita J, Caldas A, Sanchez E, Callacna M, Rojas C, Arevalo J, Sebastian JL, Bonilla C, Bayona J, Shin S. Community-based DOT-HAART accompaniment in an urban resource-poor setting. AIDS Behav 2010; 14:721-30. [PMID: 19370409 DOI: 10.1007/s10461-009-9559-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Accepted: 03/29/2009] [Indexed: 12/01/2022]
Abstract
From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in a health district of Lima, Peru to receive community-based accompaniment with supervised antiretroviral (CASA). Paid community health workers performed twice-daily home visits to directly observe ART and offered additional medical, social and economic support to CASA participants. We matched 60 controls from a neighboring district by age, CD4 and primary referral criteria (TB status, female, neither). Using validated instruments at baseline and 12 months (time of DOT-HAART completion) we measured depression, social support, quality of life, HIV-related stigma and self-efficacy. We compared 12 month clinical and psychosocial outcomes among CASA versus control groups. CASA participants experienced better clinical and psychosocial outcomes at 12 months, including proportion with virologic suppression, increase in social support and reduction in HIV-associated stigma.
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Assessing the viorologic and adherence benefits of patient-selected HIV treatment partners in a resource-limited setting. J Acquir Immune Defic Syndr 2010; 54:85-92. [PMID: 20418724 DOI: 10.1097/01.qai.0000371678.25873.1c] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the efficacy of patient-selected treatment partners on virologic and adherence outcomes during first-line antiretroviral therapy. DESIGN Randomized controlled trial. SETTING AND ANALYTICAL APPROACH: Between June 2006 and December 2007, 499 HIV-infected adults in Jos, Nigeria, were randomized to standard of care (SOC) or patient-selected treatment partner-assisted therapy (TPA). Each patient was followed for 48 weeks. Virologic outcomes, adherence to drug pick-up, CD4 cell counts, and mortality are reported. RESULTS At week 24, undetectable viral load was achieved by 61.7% of patients in the TPA arm versus 50.2% of those receiving SOC [odds ratio (OR) = 1.58, 95% CI: 1.11 to 2.26, P < 0.05]. There was no significant difference at week 48: 65.3% versus 59.4% for TPA and SOC, respectively (OR = 1.28, 95% CI: 0.89 to 1.84, P > 0.05). The TPA group had more than 3 times the odds of at least 95% drug pickup adherence through week 24 (OR = 3.06, 95% CI: 1.89 to 4.94, P < 0.01) and almost twice the odds through week 48 (OR = 1.95, 95% CI: 1.29 to 2.93, P < 0.01). At week 48, there were no significant differences in CD4 cell count increases (t = -0.09, df = 404, P > 0.05) or mortality (10.6% vs. 6.1%) between TPA vs. SOC, respectively. Residence-to-clinic distance was significantly associated with virologic and adherence outcomes. CONCLUSIONS Use of patient-selected treatment partners was associated with improved drug pickup adherence and initial virologic success but had no durable effect on attaining undetectable viral load.
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Routman JS, Willig JH, Westfall AO, Abroms SR, Varshney M, Adusumilli S, Allison JJ, Savage KG, Saag MS, Mugavero MJ. Comparative efficacy versus effectiveness of initial antiretroviral therapy in clinical trials versus routine care. Clin Infect Dis 2010; 50:574-84. [PMID: 20067423 DOI: 10.1086/650004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The applicability of clinical trial findings (efficacy) to the routine care setting (effectiveness) may be limited because of study eligibility criteria and volunteer bias. Although well-chronicled in many conditions, the efficacy versus effectiveness of antiretroviral therapy (ART) remains understudied. METHODS A retrospective study of the University of Alabama at Birmingham 1917 Clinic Cohort evaluated ART-naive patients who started ART from 1 January 2000 through 31 December 2006. Patients received ART through clinical trials or routine care. Multivariable logistic and linear regression models were fit to evaluate factors associated with virological failure (virological failure was defined as a viral load >50 copies/mL) and change from baseline CD4+ cell count 6 and 12 months after ART initiation. Sensitivity analyses evaluated the impact of missing data on outcomes. RESULTS Among 570 patients starting ART during the study period, 121 (21%) enrolled in clinical trials, and 449 (79%) received ART via routine care. ART receipt through routine care was not associated with viral failure at either 6 months (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.54-1.86) or 12 months (OR, 1.56; 95% CI, 0.80-3.05) in primary analyses. No statistically significant differences in CD4+ cell count responses at 6 and 12 months were observed. CONCLUSIONS Although marked differences in efficacy versus effectiveness have been observed in the therapeutic outcomes of other conditions, our analyses found no evidence of such divergence among our patients who initiated antiretroviral therapy for human immunodeficiency virus infection.
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Affiliation(s)
- Justin S Routman
- Divisions of Infectious Diseases, Department of Medicine, University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-2050, USA
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Zaragoza-Macias E, Cosco D, Nguyen ML, del Rio C, Lennox J. Predictors of success with highly active antiretroviral therapy in an antiretroviral-naive urban population. AIDS Res Hum Retroviruses 2010; 26:133-8. [PMID: 20156096 DOI: 10.1089/aid.2009.0001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract Predictors of successful virologic, immunologic, and clinical response with combined antiretroviral therapy (cART) containing a boosted protease inhibitor or a nonnucleoside reverse transcriptase inhibitor were analyzed among an antiretroviral naive (ARV-naive) urban cohort. Measures of success included virologic suppression [HIV-1 viral load (VL) <400 copies/ml], an increase in CD4(+) T cells from baseline of >100 cells/microl, and lack of development of an AIDS-defining illness at 24 and 48 weeks after cART initiation. Two hundred and eighty-seven ARV-naive patients were included in this cohort, of which 76.7% were male and 86.8% were nonwhite. At the time of cART initiation their median age was 39 years, the geometric mean CD4(+) count was 42 cells/microl, and the mean viral load was 5.3 log(10) copies/ml. At 48 weeks, 72% of patients achieved virologic suppression, with > or =90% adherence and high school graduation predicting viral undetectability at 48 weeks. Baseline VL < or =100,000 copies/ml and a CD4(+) cell count >100 cells/microl were associated with viral suppression at 24 weeks [OR (95% CI) = 3.55 (1.29-9.81) and 3.96 (1.19-13.15), respectively]; female gender was associated with a greater increase in CD4(+) cell counts [OR (95% CI) = 7.41 (2.48-22.1)]. CDC stage A1-C2 at baseline predicted lack of clinical progression at 48 weeks. The results of this analysis of an ARV-naive cohort comprised predominantly of indigent, minority patients suggest that men who did not have a high school education and who had advanced HIV infection are less likely to have therapeutic success after cART initiation.
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Affiliation(s)
| | - Dominique Cosco
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303
| | - Minh Ly Nguyen
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303
| | - Carlos del Rio
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303
| | - Jeffrey Lennox
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303
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Ma Y, Zhao D, Yu L, Bulterys M, Robinson ML, Zhao Y, Dou Z, Chiliade P, Wei X, Zhang F. Predictors of virologic failure in HIV-1-infected adults receiving first-line antiretroviral therapy in 8 provinces in China. Clin Infect Dis 2010; 50:264-71. [PMID: 20017637 PMCID: PMC2805417 DOI: 10.1086/649215] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Despite poor primary health care systems, free antiretroviral therapy (ART) has been available in China for >5 years. Virologic outcomes in Chinese patients receiving ART have not been described on a national level. METHODS A multistage cluster design was used in 8 provinces to randomly select patients who had been receiving first-line ART for at least 6 months, who were stratified into 3 treatment-duration groups. Viral load testing and patient interviews were conducted, and data were linked with national treatment database information. Collected data were analyzed for association with viral suppression by means of multivariate modeling. Adequate viral suppression was defined as a viral load of <400 copies/mL. RESULTS Of 5256 patients receiving ART, 3894 met the eligibility criteria, among whom 1153 were analyzed. Overall, 72% demonstrated viral suppression, and 82%, 73%, and 67% of the participants receiving ART for 6-11, 12-23, and > or = 24 months, respectively, experienced viral suppression (P < .001). In a multivariate model, treatment given at locations other than county-level hospitals was less likely to achieve viral suppression, with greater odds for inadequate virologic response found at village clinics (odds ratio [OR], 5.4; 95% confidence interval [CI], 2.9-10.1), township health centers (OR, 3.1; 95% CI, 1.7-5.6), and public health clinics (OR, 3.1; 95% CI, 1.7-5.6). Patients receiving didanosine-based regimens were more likely to experience an inadequate virologic response than were those receiving lamivudine-based regimens (OR, 3.9; 95% CI, 2.7-5.7). CONCLUSIONS China's national ART program is largely successful at suppressing viral load. Care received outside of hospitals and regimens containing didanosine were associated with less favorable virologic outcomes.
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Affiliation(s)
- Ye Ma
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Decai Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Lan Yu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Marc Bulterys
- Global AIDS Program, Centers for Disease Control and Prevention, U.S. Embassy, Beijing, China
| | - Matthew L. Robinson
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Yan Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhihui Dou
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | | | - Xiaoyu Wei
- Global AIDS Program, Centers for Disease Control and Prevention, U.S. Embassy, Beijing, China
| | - Fujie Zhang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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Effect of incentives for medication adherence on health care use and costs in methadone patients with HIV. Drug Alcohol Depend 2009; 100:115-21. [PMID: 19054631 PMCID: PMC2715338 DOI: 10.1016/j.drugalcdep.2008.09.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Revised: 09/22/2008] [Accepted: 09/23/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND The potential benefits of anti-retroviral therapy for HIV is not fully realized because of difficulties in adherence with demanding treatment regimens, especially among injection drug users. METHODS HIV-positive methadone patients who were less than 80% adherent with their primary anti-retroviral therapy were randomized to a trial of incentives for on-time adherence. Adherence was rewarded with an escalating scale of vouchers redeemable for goods. Both intervention and control group visited a medication coach twice a month. The cost of the intervention was determined by micro-costing. Other costs were obtained from administrative data and patient report of out-of-system care. RESULTS During the 12-week intervention period, the incremental direct cost of the intervention, including treatment vouchers, was $942. The voucher group incurred $2572 in anti-retroviral drug cost, significantly more than the $1973 incurred by the comparison group (p<.01). Adherence, as measured by on-time openings of an electronically monitored vial, was 78% in the intervention group and 56% in the control group. CONCLUSIONS The incremental direct cost of voucher incentives was $292 per month. If the observed increase in adherence from voucher incentives can be sustained in the long-term, the literature suggests that disease progression will be slowed. Further research is needed to evaluate if the improvement can be sustained or achieved at lower cost. Mitigation of treatment resistance and reduction in HIV transmission are additional benefits that favor adoption.
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Long-term immunologic response to antiretroviral therapy in low-income countries: a collaborative analysis of prospective studies. AIDS 2008; 22:2291-302. [PMID: 18981768 DOI: 10.1097/qad.0b013e3283121ca9] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Few data are available on the long-term immunologic response to antiretroviral therapy (ART) in resource-limited settings, where ART is being rapidly scaled up using a public health approach, with a limited repertoire of drugs. OBJECTIVES To describe immunologic response to ART among ART patients in a network of cohorts from sub-Saharan Africa, Latin America, and Asia. STUDY POPULATION/METHODS: Treatment-naive patients aged 15 and older from 27 treatment programs were eligible. Multilevel, linear mixed models were used to assess associations between predictor variables and CD4 cell count trajectories following ART initiation. RESULTS Of 29 175 patients initiating ART, 8933 (31%) were excluded due to insufficient follow-up time and early lost to follow-up or death. The remaining 19 967 patients contributed 39 200 person-years on ART and 71 067 CD4 cell count measurements. The median baseline CD4 cell count was 114 cells/microl, with 35% having less than 100 cells/microl. Substantial intersite variation in baseline CD4 cell count was observed (range 61-181 cells/microl). Women had higher median baseline CD4 cell counts than men (121 vs. 104 cells/microl). The median CD4 cell count increased from 114 cells/microl at ART initiation to 230 [interquartile range (IQR) 144-338] at 6 months, 263 (IQR 175-376) at 1 year, 336 (IQR 224-472) at 2 years, 372 (IQR 242-537) at 3 years, 377 (IQR 221-561) at 4 years, and 395 (IQR 240-592) at 5 years. In multivariable models, baseline CD4 cell count was the most important determinant of subsequent CD4 cell count trajectories. CONCLUSION These data demonstrate robust and sustained CD4 response to ART among patients remaining on therapy. Public health and programmatic interventions leading to earlier HIV diagnosis and initiation of ART could substantially improve patient outcomes in resource-limited settings.
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Hacker MA, Kaida A, Hogg RS, Bastos FI. The first ten years: achievements and challenges of the Brazilian program of universal access to HIV/AIDS comprehensive management and care, 1996-2006. CAD SAUDE PUBLICA 2008; 23 Suppl 3:S345-59. [PMID: 17992341 DOI: 10.1590/s0102-311x2007001500003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 04/16/2007] [Indexed: 12/18/2022] Open
Abstract
A review was carried out of papers published between 1996 and 2006, documenting the introduction of highly active anti-retroviral therapy (HAART) in Brazil. Papers indexed in the MEDLINE and SciELO databases were retrieved using different combinations of keywords related to the management and care of AIDS in the post-HAART era: opportunistic diseases and co-infections, adherence to therapy, survival in the pre- and post-HAART eras, adverse events and side-effects, emergence and possible transmission of resistant viral strains, metabolic and cardiovascular disorders, and issues related to access to care and equity. The review documents the dramatic changes in HIV/AIDS disease progression in the post-HAART era, including an increase in survival and quality of life and a pronounced decrease in the episodes of opportunistic diseases. Notwithstanding such major achievements, new challenges have emerged, including slow evolving co-infections (such as hepatitis C, metabolic and cardiovascular disorders), the emergence of viral resistance, with consequences at the individual level (virological failure) and the community level (primary/secondary resistance at the population level), and impacts on the cost of new therapeutic regimens.
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Affiliation(s)
| | - Angela Kaida
- University of British Columbia, Canada; BC Centre for Excellence in HIV/AIDS, Canada
| | - Robert S. Hogg
- BC Centre for Excellence in HIV/AIDS, Canada; Simon Fraser University, Canada
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Badri M, Lawn SD, Wood R. Utility of CD4 cell counts for early prediction of virological failure during antiretroviral therapy in a resource-limited setting. BMC Infect Dis 2008; 8:89. [PMID: 18601727 PMCID: PMC2459184 DOI: 10.1186/1471-2334-8-89] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Accepted: 07/04/2008] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Viral load monitoring is not available for the vast majority of patients receiving antiretroviral therapy in resource-limited settings. However, the practical utility of CD4 cell count measurements as an alternative monitoring strategy has not been rigorously assessed. METHODS In this study, we used a novel modelling approach that accounted for all CD4 cell count and VL values measured during follow-up from the first date that VL suppression was achieved. We determined the associations between CD4 counts (absolute values and changes during ART), VL measurements and risk of virological failure (VL > 1,000 copies/ml) following initial VL suppression in 330 patients in South Africa. CD4 count changes were modelled both as the difference from baseline (DeltaCD4 count) and the difference between consecutive values (CD4 count slope) using all 3-monthly CD4 count measurements during follow-up. RESULTS During 7093.2 patient-months of observation 3756 paired CD4 count and VL measurements were made. In patients who developed virological failure (n = 179), VL correlated significantly with absolute CD4 counts (r = - 0.08, P = 0.003), DeltaCD4 counts (r = - 0.11, P < 0.01), and most strongly with CD4 count slopes (r = - 0.30, P < 0.001). However, the distributions of the absolute CD4 counts, DeltaCD4 counts and CD4 count slopes at the time of virological failure did not differ significantly from the corresponding distributions in those without virological failure (P = 0.99, P = 0.92 and P = 0.75, respectively). Moreover, in a receiver operating characteristic (ROC) curve, the association between a negative CD4 count slope and virological failure was poor (area under the curve = 0.59; sensitivity = 53.0%; specificity = 63.6%; positive predictive value = 10.9%). CONCLUSION CD4 count changes correlated significantly with VL at group level but had very limited utility in identifying virological failure in individual patients. CD4 count is an inadequate alternative to VL measurement for early detection of virological failure.
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Affiliation(s)
- Motasim Badri
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Sprinz E, Bay MB, Lazzaretti RK, Jeffman MW, Mattevi VS. Lopinavir/ritonavir monotherapy as maintenance treatment in HIV-infected individuals with virological suppression: results from a pilot study in Brazil. HIV Med 2008; 9:270-6. [DOI: 10.1111/j.1468-1293.2008.00558.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Keiser O, Anastos K, Schechter M, Balestre E, Myer L, Boulle A, Bangsberg D, Touré H, Braitstein P, Sprinz E, Nash D, Hosseinipour M, Dabis F, May M, Brinkhof MWG, Egger M. Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America. Trop Med Int Health 2008; 13:870-9. [PMID: 18373510 DOI: 10.1111/j.1365-3156.2008.02078.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe temporal trends in baseline clinical characteristics, initial treatment regimens and monitoring of patients starting antiretroviral therapy (ART) in resource-limited settings. METHODS We analysed data from 17 ART programmes in 12 countries in sub-Saharan Africa, South America and Asia. Patients aged 16 years or older with documented date of start of highly active ART (HAART) were included. Data were analysed by calculating medians, interquartile ranges (IQR) and percentages by regions and time periods. Not all centres provided data for 2006 and 2005 and 2006 were therefore combined. RESULTS A total of 36,715 patients who started ART 1996-2006 were included in the analysis. Patient numbers increased substantially in sub-Saharan Africa and Asia, and the number of initial regimens declined, to four and five, respectively, in 2005-2006. In South America 20 regimes were used in 2005-2006. A combination of 3TC/D4T/NVP was used for 56% of African patients and 42% of Asian patients; AZT/3TC/EFV was used in 33% of patients in South America. The median baseline CD4 count increased in recent years, to 122 cells/microl (IQR 53-194) in 2005-2006 in Africa, 134 cells/microl (IQR 72-191) in Asia, and 197 cells/microl (IQR 61-277) in South America, but 77%, 78% and 51%, respectively, started with <200 cells/microl in 2005-2006. In all regions baseline CD4 cell counts were higher in women than men: differences were 22cells/microl in Africa, 65 cells/microl in Asia and 10 cells/microl in South America. In 2005-2006 a viral load at 6 months was available in 21% of patients Africa, 8% of Asian patients and 73% of patients in South America. Corresponding figures for 6-month CD4 cell counts were 74%, 77% and 81%. CONCLUSIONS The public health approach to providing ART proposed by the World Health Organization has been implemented in sub-Saharan Africa and Asia. Although CD4 cell counts at the start of ART have increased in recent years, most patients continue to start with counts well below the recommended threshold. Particular attention should be paid to more timely initiation of ART in HIV-infected men.
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Affiliation(s)
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- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland.
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Carvalho CVD, Merchán-Hamann E, Matsushita R. [Determinants of antiretroviral treatment adherence in Brasília, Federal District: a case-control study]. Rev Soc Bras Med Trop 2008; 40:555-65. [PMID: 17992413 DOI: 10.1590/s0037-86822007000500013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 08/17/2007] [Indexed: 11/21/2022] Open
Abstract
We sought to evaluate factors relating to adherence to antiretroviral treatment in the Federal District. Out of 150 patients interviewed at seven reference centers; 35 non-adherent subjects were considered to be cases; we selected 70 age-matched adherent individuals as controls. Variables relating to sociodemographics, habits, social support, quality of life, disease-related issues, clinical conditions, treatment and healthcare services were evaluated. Bivariate analysis showed that adherence was associated with race/color, educational level, the reference center where the patient was followed up and familial income. After adjustments, mixed race (parda), reference center location in central Brasília, high educational level and friends support for needs remained associated with adherence. After excluding race/color from the model, the reference center location, educational level, profession, income, support (being able to count on someone who demonstrably likes you) and satisfaction with the service at the pharmacy remained related to adherence. In addition to the factors already established in the literature, questions relating to support within the microsocial environment and the healthcare services were shown to be associated with therapeutic compliance.
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Pacheco AG, Tuboi SH, Faulhaber JC, Harrison LH, Schechter M. Increase in non-AIDS related conditions as causes of death among HIV-infected individuals in the HAART era in Brazil. PLoS One 2008; 3:e1531. [PMID: 18231611 PMCID: PMC2211396 DOI: 10.1371/journal.pone.0001531] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 01/02/2008] [Indexed: 01/16/2023] Open
Abstract
Background In 1996, Brazil became the first developing country to provide free and universal access to HAART. Although a decrease in overall mortality has been documented, there are no published data on the impact of HAART on causes of death among HIV-infected individuals in Brazil. We assessed temporal trends of mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM) and other conditions generally not associated with HIV-infection among persons with and without HIV infection in Brazil between 1999 and 2004. Methodology/Principal Findings Odds ratios were used to compare causes of death in individuals who had HIV/AIDS listed on any field of the death certificate with those who did not. Logistic regression models were fitted with generalized estimating equations to account for spatial correlation; co-variables were added to the models to control for potential confounding. Of 5,856,056 deaths reported in Brazil between 1999 and 2004 67,249 (1.15%) had HIV/AIDS listed on the death certificate and non-HIV-related conditions were listed on 16.3% in 1999, increasing to 24.1% by 2004 (p<0.001). The adjusted average yearly increases were 8% and 0.8% for CVD (p<0.001), and 12% and 2.8% for DM (p<0.001), for those who had and did not have HIV/AIDS listed on the death certificate, respectively. Similar results were found for these conditions as underlying causes of death. Conclusions/Significance In Brazil between 1999 and 2004 conditions usually considered not to be related to HIV-infection appeared to become more likely causes of death over time than reported causes of death among individuals who had HIV/AIDS listed on the death certificate than in those who did not. This observation has important programmatic implications for developing countries that are scaling-up access to antiretroviral therapy.
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Affiliation(s)
- Antonio G Pacheco
- Department of Epidemiology and Quantitative Methods in Health, National School of Public Health/Scientific Computing Program, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil.
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Celentano DD, Lucas G. Optimizing Treatment Outcomes in HIV-Infected Patients with Substance Abuse Issues. Clin Infect Dis 2007; 45 Suppl 4:S318-23. [DOI: 10.1086/522557] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Long-term psychosocial challenges for people living with HIV: let's not forget the individual in our global response to the pandemic. AIDS 2007; 21 Suppl 5:S55-63. [PMID: 18090270 DOI: 10.1097/01.aids.0000298104.02356.b3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Since the beginning of the HIV epidemic, people living with HIV have faced numerous psychological and behavioral challenges. With the advent of antiretroviral therapy (ART) there have been dramatic shifts in some of these key challenges and new ones have come to the forefront. This paper highlights several critical psychological and behavioral aspects of HIV disease, a few of which require focused attention, including mental health, stigma and disclosure, adherence, and sexual behavior. Although the focus is primarily on adults living with HIV, we also comment on some of the additional challenges for children and young people. Our critical examination in these areas draws upon the lessons learned in contexts in which ART has been available for a decade, and we explore what is currently happening in settings with more recent treatment access. In the end we offer our insights into what we may expect in the future, and provide recommendations for ongoing prevention and care initiatives with adults, children, and young people affected by this disease.
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McGowan CC, Cahn P, Gotuzzo E, Padgett D, Pape JW, Wolff M, Schechter M, Masys DR. Cohort Profile: Caribbean, Central and South America Network for HIV research (CCASAnet) collaboration within the International Epidemiologic Databases to Evaluate AIDS (IeDEA) programme. Int J Epidemiol 2007; 36:969-76. [PMID: 17846055 DOI: 10.1093/ije/dym073] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
In 1996, Brazil became the first developing country to provide universal access to antiretroviral therapy (ART), based on a strategy that utilizes an individualized approach to treatment and an open formulary. At the time, the number of patients in need of treatment was less than 15% of what it is today, there were six approved drugs for the treatment of HIV infection (compared with 25 today), and the life expectancy of patients was measured in months and years, not in decades. In recent years, preventable and treatable conditions such as cardiovascular diseases increased significantly faster as causes of death among HIV-infected individuals than in the general population. In the near future there will be a substantial increase in the number of patients in need of therapy and in the number of patients using more complex regimens who also have co-morbidities that impact prognosis. Brazil will thus need to expand its network of treatment facilities, increase its capacity to manage more complex clinical conditions, and decide on the proper balance of sophistication that will be required. As the Brazilian scientific output is not commensurate with its successes in the treatment and prevention of HIV infection, there is little empirical basis to inform decisions on how best to allocate finite resources. The Brazilian response to the HIV/AIDS epidemic, universal access to ART in particular, is an example to other developing countries. The Brazilian experience also shows that operational research should be an integral part of programmes of access to treatment, if their long-term sustainability is to be ensured.
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Affiliation(s)
- Mauro Schechter
- Hospital Universitario Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco no, 255, Ilha do Fundão, CEP 21941.590 Rio de Janeiro, SP, Brazil.
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Diazgranados CA, Silva A, Bermudez A, Roncancio D, Diruggiero P, Mantilla M. Rate and predictors of optimal virologic response to antiretroviral therapy in Colombia. Int J Infect Dis 2007; 11:531-5. [PMID: 17512234 DOI: 10.1016/j.ijid.2007.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Revised: 02/23/2007] [Accepted: 03/06/2007] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To estimate the rate of optimal response to antiretroviral therapy and its predictors in Colombia. METHODS A retrospective cohort study was performed. The medical records of all patients at three major HIV clinics in different areas of Colombia, South America, were reviewed. Eligible patients met the following criteria: (1) viral load test available while on therapy; and (2) patients must have been on a stable first antiviral regimen for at least 1 year (48 weeks). Optimal virologic response was defined as a viral load <400 copies/ml. RESULTS Two hundred and twenty patients were eligible for the study. The optimal virologic response rate was 40% (95% confidence interval 34-46%). Younger age (p=0.02) and western region of the country (p=0.026) were the only significant predictors of non-optimal response in bivariate analysis. Multivariate logistic regression analysis confirmed younger age (p=0.0054) and geographic area (p=0.0468) as independent predictors of non-optimal response. CONCLUSIONS The optimal response rate in some areas of Colombia seems lower than that reported for other areas of the developing world. Poorer virologic responses were observed in younger patients and in those from the western region of the country.
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Tuboi SH, Brinkhof MWG, Egger M, Stone RA, Braitstein P, Nash D, Sprinz E, Dabis F, Harrison LH, Schechter M. Discordant Responses to Potent Antiretroviral Treatment in Previously Naive HIV-1-Infected Adults Initiating Treatment in Resource-Constrained Countries. J Acquir Immune Defic Syndr 2007; 45:52-9. [PMID: 17460471 DOI: 10.1097/qai.0b013e318042e1c3] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the frequency of and risk factors for discordant responses at 6 months on highly active antiretroviral therapy (HAART) in previously treatment-naive HIV patients from resource-limited countries. METHODS The Antiretroviral Therapy in Low-Income Countries Collaboration is a network of clinics providing care and treatment to HIV-infected patients in Africa, Latin America, and Asia. Patients who initiated therapy between 1996 and 2004, were aged 16 years or older, and had a baseline CD4 cell count were included in this analysis. Responses were defined based on plasma viral load (PVL) and CD4 cell count at 6 months as complete virologic and immunologic (VR(+)IR(+)), virologic only (VR(+)IR(-)), immunologic only (VR(-)IR(+)), and nonresponse (VR(-)IR(-)). Multinomial logistic regression was used to assess the association between therapy responses and clinical and demographic variables. RESULTS Of the 3111 patients eligible for analysis, 1914 had available information at 6 months of therapy: 1074 (56.1%) were VR(+)IR(+), 364 (19.0%) were VR(+)IR(-), 283 (14.8%) were (VR(-)IR(+)), and 193 (10.1%) were VR(-)IR(-). OF THE 3111 patients eligible for analysis, 1914 had available information at 6 months of therapy: 1074 (56.1%) were VRIR, 364 (19.0%) were VRIR, 283 (14.8%) were (VRIR), and 193 (10.1%) were VRIR. Compared with complete responders, virologic-only responders were older, had a higher baseline CD4 cell count, had a lower baseline PVL, and were more likely to have received a nonstandard HAART regimen; immunologic-only responders were younger, had a lower baseline CD4 cell count, had a higher baseline PVL, and were more likely to have received a protease inhibitor-based regimen. CONCLUSIONS The frequency of and risk factors for discordant responses were comparable to those observed in developed countries. Longer follow-up is needed to assess the long-term impact of discordant responses on mortality in these resource-limited settings.
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Affiliation(s)
- Suely H Tuboi
- Infectious Diseases Epidemiology Research Unit, Graduate School of Public Health and School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
Despite the unprecedented pace of development of drugs for the treatment of a viral disease and the unquestionable efficacy of antiretroviral therapy, there is a need for less toxic and cheaper regimens that could simplify the treatment of HIV infection without sacrificing efficacy. The favorable pharmacokinetic profile and the high genetic barrier of boosted protease inhibitors make them ideal candidates for use as monotherapy. Given the encouraging results of available studies on lopinavir/ritonavir monotherapy in patients with no prior failure with protease inhibitors, it may be warranted to conduct trials to investigate the cost-effectiveness of lopinavir/ritonavir monotherapy as second-line therapy in resource-constrained settings where virologic monitoring is not feasible. In addition, larger trials with longer follow up, with particular attention to the potential consequences of viral replication in sites where the penetration of protease inhibitors may be poor, are needed before this strategy can be considered for routine use.
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Affiliation(s)
- Mauro Schechter
- Projeto Praça Onze, Universidade Federal do Rio de Janeiro, Brazil.
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May SB, Barroso PF, Nunes EP, Barcaui HS, Almeida MMT, Costa MD, Faulhaber JC, Santoro-Lopes G, Schechter M. Effectiveness of highly active antiretroviral therapy using non-brand name drugs in Brazil. Braz J Med Biol Res 2007; 40:551-5. [PMID: 17401499 DOI: 10.1590/s0100-879x2007000400014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2006] [Accepted: 02/02/2007] [Indexed: 11/22/2022] Open
Abstract
In Brazil, HIV-infected individuals receive drugs (including non-brand name drugs which comprise locally produced generics and drugs that have not been tested in bioequivalence trials) free of charge from the government. The objective of the present study was to evaluate the effectiveness of highly active antiretroviral therapy (HAART) in Rio de Janeiro, Brazil, where non-brand drugs are widely used. For this purpose, we estimated the proportion of subjects with virologic failure (plasma HIV viral load greater than 400 copies/mL at 6 months after initiation of treatment). This was a retrospective cohort study of drug-naive HIV-infected subjects who initiated HAART. Subjects were included in the analysis if they were 18 years of age or older, were treatment naive, started HAART with a minimum of 3 drugs, and had available information on blood plasma HIV-1 viral load after 6 months on therapy. All subjects used antiretrovirals in dosing regimens recommended by the Brazilian National Advisory Committee for Antiretroviral Therapy. Chart reviews were conducted in three settings: at two public health outpatient units, at one clinical trial unit and at one private office. No comparisons of the effectiveness of non-brand name with the effectiveness of brand name drugs were made. We present results for 485 patients; of these, 354 (73%), 55 (11%), and 76 (16%) were seen at the public health outpatient units, private office, and clinical trial unit, respectively. Virologic failure was observed in 119 (25%) of the subjects. This study demonstrates the effectiveness of HAART in a setting where non-brand name drugs are widely used.
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Affiliation(s)
- S B May
- Serviço de Doenças Infecciosas e Parasitárias, Departamento de Medicina Preventiva, Hospital Universitário Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Bunupuradah T, Wannachai S, Chuamchaitrakool A, Intasan J, Nuchapong T, Neiss W, Kramm K, Pancharoen C, Burger D, Ananworanich J. Use of taste-masking product, FLAVORx, to assist Thai children to ingest generic antiretrovirals. AIDS Res Ther 2006; 3:30. [PMID: 17194311 PMCID: PMC1770927 DOI: 10.1186/1742-6405-3-30] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 12/29/2006] [Indexed: 11/10/2022] Open
Abstract
We evaluated whether FLAVORx helped thirty Thai children take opened capsule, crushed tablets and liquid generic ARVs with more ease. All children had excellent adherence, evaluated by PACTG Standard International Questionnaire and interviewing, before and after one month of FLAVORx. Eighty percent took ARV with more ease and wish to continue FLAVORx. Strawberry was the most popular flavor.
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Affiliation(s)
- Torsak Bunupuradah
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
| | - Siripan Wannachai
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
| | - Arpa Chuamchaitrakool
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
| | - Jintana Intasan
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
| | - Thantip Nuchapong
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
| | | | | | | | | | - Jintanat Ananworanich
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
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Affiliation(s)
- Mauro Schechter
- Hospital Universitario Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, AIDS Research Laboratory, Av Brigadeiro Trompowski s/n lha do Fundão, Rio de Janeiro, RJ, 21941–590 Brazil
| | - Esper Georges Kallas
- Universidade Federal de São Paulo, Department of Medicine, Rua Mirassol 207, São Paulo, SP, 04044–010, Brazil
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Bastos FI, Hacker MA. Pesquisas brasileiras biomédicas e epidemiológicas face às metas da UNGASS. Rev Saude Publica 2006; 40 Suppl:31-41. [PMID: 16729157 DOI: 10.1590/s0034-89102006000800006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O foco do estudo é a resposta brasileira em Ciência, Tecnologia e Inovação às metas formuladas no documento da UNGASS. Foram analisados os itens 70-73 que integram o documento Draft Declaration of Commitment for the UNGASS on HIV/AIDS, 2001, que definem metas para a Ciência, Tecnologia e Inovação em HIV/Aids. Os principais tópicos listados nesses itens foram operacionalizados sob a forma de "palavras-chave", de modo a orientar buscas sistemáticas nos bancos de dados padrão em biomedicina, incluindo ainda o Web of Science, nas suas subdivisões referentes às ciências naturais e sociais. O sucesso da pesquisa brasileira no âmbito da caracterização e isolamento do HIV-1 é inegável. Estudos vacinais fases II/III têm sido desenvolvidos no Rio de Janeiro, Belo Horizonte e São Paulo. O monitoramento da resistência primária teve estudos empíricos desenvolvidos em populações específicas, por meio da "Rede Brasileira em Monitoramento da Resistência do HIV". No âmbito do monitoramento da resistência secundária, destacaram-se iniciativas como a Rede Nacional de Genotipagem. Dois sistemas nacionais, o Sistema de Informações de Mortalidade e o Sistema de Informações de Agravos de Notificação - Aids e alguns estudos de maior abrangência têm dado origem a trabalhos sobre tendências da epidemia. A produção de medicamentos genéricos de qualidade e sua distribuição gratuita aos pacientes foram destacadas. O Brasil tem implementado uma resposta consistente e diversificada no âmbito do HIV/Aids, com estudos referentes ao desenvolvimento de vacinas, novos medicamentos e monitoramento da epidemia.
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Affiliation(s)
- Francisco Inácio Bastos
- Departamento de Informações em Saúde, Centro de Informação Científica e Tecnológica, Fundação Oswaldo Cruz, 21040-900 Rio de Janeiro, RJ, Brazil.
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