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Manzanares M, Ramos-Martín F, Rodríguez-Mora S, Casado-Fernández G, Sánchez-Menéndez C, Simón-Rueda A, Mateos E, Cervero M, Spivak AM, Planelles V, Torres M, García-Gutiérrez V, Coiras M. Sustained antiviral response against in vitro HIV-1 infection in peripheral blood mononuclear cells from people with chronic myeloid leukemia treated with ponatinib. Front Pharmacol 2024; 15:1426974. [PMID: 39380908 PMCID: PMC11460598 DOI: 10.3389/fphar.2024.1426974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 09/09/2024] [Indexed: 10/10/2024] Open
Abstract
HIV-1 infection cannot be cured due to long-lived viral reservoirs formed by latently infected CD4+ T cells. "Shock and Kill" strategy has been considered to eliminate the viral reservoir and achieve a functional cure but the stimulation of cytotoxic immunity is necessary. Ponatinib is a tyrosine kinase inhibitor (TKI) clinically used against chronic myeloid leukemia (CML) that has demonstrated to be effective against HIV-1 infection in vitro. Several TKIs may induce a potent cytotoxic response against cancer cells that makes possible to discontinue treatment in people with CML who present long-term deep molecular response. In this longitudinal study, we analyzed the capacity of ponatinib to induce an antiviral response against HIV-1 infection in peripheral blood mononuclear cells (PBMCs) obtained from people with CML previously treated with imatinib for a median of 10 years who changed to ponatinib for 12 months to boost the anticancer response before discontinuing any TKI as part of the clinical trial NCT04043676. Participants were followed-up for an additional 12 months in the absence of treatment. PBMCs were obtained at different time points and then infected in vitro with HIV-1. The rate of infection was determined by quantifying the intracellular levels of p24-gag in CD4+ T cells. The levels of p24-gag+ CD4+ T-cells were lower when these cells were obtained during and after treatment with ponatinib in comparison with those obtained during treatment with imatinib. Cytotoxicity of PBMCs against HIV-infected target cells was significantly higher during treatment with ponatinib than during treatment with imatinib, and it was maintained at least 12 months after discontinuation. There was a significant negative correlation between the lower levels of p24-gag+ CD4+ T-cells and the higher cytotoxicity induced by PBMCs when cells were obtained during and after treatment with ponatinib. This cytotoxic immunity was mostly based on higher levels of Natural Killer and Tγδ cells seemingly boosted by ponatinib. In conclusion, transient treatment with immunomodulators like ponatinib along with ART could be explored to boost the antiviral activity of cytotoxic cells and contribute to the elimination of HIV-1 reservoir.
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Affiliation(s)
- Mario Manzanares
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- PhD Program in Biomedical Sciences and Public Health, Universidad Nacional de Educación a Distancia (UNED), Madrid, Spain
| | - Fernando Ramos-Martín
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Sara Rodríguez-Mora
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Guiomar Casado-Fernández
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- Faculty of Sciences, Universidad de Alcalá, Madrid, Spain
| | - Clara Sánchez-Menéndez
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- PhD Program in Biomedical Sciences and Public Health, Universidad Nacional de Educación a Distancia (UNED), Madrid, Spain
- Hematology and Hemotherapy Service, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alicia Simón-Rueda
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- PhD Program in Biomedical Sciences and Public Health, Universidad Nacional de Educación a Distancia (UNED), Madrid, Spain
| | - Elena Mateos
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Miguel Cervero
- Internal Medicine Service, Hospital Universitario Severo Ochoa, Madrid, Spain
- School of Medicine, Universidad Alfonso X El Sabio, Madrid, Spain
| | - Adam M. Spivak
- Division of Microbiology and Immunology, Department of Pathology, University of Utah School of Medicine, Salt LakeCity, UT, United States
| | - Vicente Planelles
- Division of Microbiology and Immunology, Department of Pathology, University of Utah School of Medicine, Salt LakeCity, UT, United States
| | - Montserrat Torres
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Valentín García-Gutiérrez
- Hematology and Hemotherapy Service, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Mayte Coiras
- Immunopathology and Viral Reservoir Unit, National Center of Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Kim JH, Seong JE, Ahn S, Lee Y, Lee JA, Ahn JY, Jeong SJ, Ku NS, Yeom JS, Choi JY. Antiretroviral Therapy during Long-term Surgical Care: 'Exploring Difficult Cases in HIV Clinics' of the Korean Society for AIDS Conference in 2023. Infect Chemother 2024; 56:287-299. [PMID: 39231503 PMCID: PMC11458491 DOI: 10.3947/ic.2024.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 06/24/2024] [Indexed: 09/06/2024] Open
Abstract
With advancements in antiretroviral therapy (ART), the average lifespan of people with human immunodeficiency virus (HIV) is increasing, as is the number of older adults with HIV. Accordingly, the number of patients with HIV who undergo surgery or require critical care for various reasons is increasing. Since the prognosis of people with HIV depends on the continuous and effective maintenance of ART, there is a need to consider effectively maintaining ART in people with HIV in these conditions. This case involved a 55-year-old patient with well-controlled HIV who received ART and presented to the emergency room with acute abdominal pain. He was diagnosed with extensive bowel infarction and panperitonitis and received critical care in the intensive care unit, including mechanical ventilation and continuous renal replacement therapy. The patient was administered enteral nutrition via a nasogastric tube. The patient subsequently underwent extensive small bowel resection and developed short bowel syndrome. The patient maintained ART during that period. A literature review related to the use of ART under these conditions is included in this study. This case was discussed at the [Exploring Difficult Cases in HIV Clinics] of the Korean Society for AIDS Conference held in 2023.
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Affiliation(s)
- Jung Ho Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Eun Seong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sangmin Ahn
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yongseop Lee
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Ah Lee
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Ahn
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Su Ku
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Joon-Sup Yeom
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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3
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Trickey A, Zhang L, Rentsch CT, Pantazis N, Izquierdo R, Antinori A, Leierer G, Burkholder G, Cavassini M, Palacio-Vieira J, Gill MJ, Teira R, Stephan C, Obel N, Vehreschild JJ, Sterling TR, Van Der Valk M, Bonnet F, Crane HM, Silverberg MJ, Ingle SM, Sterne JA. Care interruptions and mortality among adults in Europe and North America. AIDS 2024; 38:1533-1542. [PMID: 38742863 PMCID: PMC11239093 DOI: 10.1097/qad.0000000000003924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE Interruptions in care of people with HIV (PWH) on antiretroviral therapy (ART) are associated with adverse outcomes, but most studies have relied on composite outcomes. We investigated whether mortality risk following care interruptions differed from mortality risk after first starting ART. DESIGN Collaboration of 18 European and North American HIV observational cohort studies of adults with HIV starting ART between 2004 and 2019. METHODS Care interruptions were defined as gaps in contact of ≥365 days, with a subsequent return to care (distinct from loss to follow-up), or ≥270 days and ≥545 days in sensitivity analyses. Follow-up time was allocated to no/preinterruption or postinterruption follow-up groups. We used Cox regression to compare hazards of mortality between care interruption groups, adjusting for time-updated demographic and clinical characteristics and biomarkers upon ART initiation or re-initiation of care. RESULTS Of 89 197 PWH, 83.4% were male and median age at ART start was 39 years [interquartile range (IQR): 31-48)]. 8654 PWH (9.7%) had ≥1 care interruption; 10 913 episodes of follow-up following a care interruption were included. There were 6104 deaths in 536 334 person-years, a crude mortality rate of 11.4 [95% confidence interval (CI): 11.1-11.7] per 1000 person-years. The adjusted mortality hazard ratio (HR) for the postinterruption group was 1.72 (95% CI: 1.57-1.88) compared with the no/preinterruption group. Results were robust to sensitivity analyses assuming ≥270-day (HR 1.49, 95% CI: 1.40-1.60) and ≥545-day (HR 1.67, 95% CI: 1.48-1.88) interruptions. CONCLUSIONS Mortality was higher among PWH reinitiating care following an interruption, compared with when PWH initially start ART, indicating the importance of uninterrupted care.
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Affiliation(s)
- Adam Trickey
- Population Health Sciences, University of Bristol, UK
| | - Lei Zhang
- School of Public Finance and Management, Yunnan University of Finance and Economics, China
| | - Christopher T. Rentsch
- Yale School of Medicine, New Haven, CT, USA; London School of Hygiene & Tropical Medicine, London, UK
| | - Nikos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Rebeca Izquierdo
- National Center for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain; Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Carlos III Health Institute, Madrid, Spain
| | - Andrea Antinori
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Gisela Leierer
- Department of Dermatology and Venereology, Medical University of Innsbruck, Innsbruck, Austria
| | - Greer Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matthias Cavassini
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - M. John Gill
- Dept of Medicine, University of Calgary, Alberta, Canada
| | - Ramon Teira
- Servicio de Medicina Interna, Hospital Universitario de Sierrallana, Torrelavega, Cantabria, Spain
| | - Christoph Stephan
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jorg-Janne Vehreschild
- Department I for Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Timothy R. Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Marc Van Der Valk
- Stichting HIV Monitoring, Amsterdam, the Netherlands. Amsterdam University Medical Centers, Dept of Infectious diseases, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Fabrice Bonnet
- Université de Bordeaux, INSERM U1219, Bordeaux Population Health and CHU de Bordeaux, Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, Bordeaux, France
| | - Heidi M. Crane
- Department of Medicine, University of Washington, Seattle, WA
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MOOLLA H, DAVIES MA, DAVIES C, EUVRARD J, PROZESKY HW, FOX MP, ORRELL C, VON GROOTE P, JOHNSON LF. The effect of care interruptions on mortality in adults resuming antiretroviral therapy. AIDS 2024; 38:1198-1205. [PMID: 38814712 PMCID: PMC11141523 DOI: 10.1097/qad.0000000000003859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To estimate the relative rate of all-cause mortality amongst those on antiretroviral treatment (ART) with a history of interruptions compared with those with no previous interruptions in care. DESIGN Retrospective cohort study. METHODS We used data from four South African cohorts participating in the International epidemiology Databases to Evaluate AIDS Southern Africa collaboration. We included adults who started ART between 2004 and 2019. We defined a care interruption as a gap in contact longer than 180 days. Observation time prior to interruption was allocated to a 'no interruption' group. Observation time after interruption was allocated to one of two groups based on whether the first interruption started before 6 months of ART ('early interruption') or later ('late interruption'). We used Cox regression to estimate hazard ratios. RESULTS Sixty-three thousand six hundred and ninety-two participants contributed 162 916 person-years of observation. There were 3469 deaths. Most participants were female individuals (67.4%) and the median age at ART initiation was 33.3 years (interquartile range: 27.5-40.7). Seventeen thousand and eleven (26.7%) participants experienced care interruptions. Those resuming ART experienced increased mortality compared with those with no interruptions: early interrupters had a hazard ratio of 4.37 (95% confidence interval (CI) 3.87-4.95) and late interrupters had a hazard ratio of 2.74 (95% CI 2.39-3.15). In sensitivity analyses, effect sizes were found to be proportional to the length of time used to define interruptions. CONCLUSION Our findings highlight the need to improve retention in care, regardless of treatment duration. Programmes to encourage return to care also need to be strengthened.
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Affiliation(s)
- Haroon MOOLLA
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Mary-Ann DAVIES
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Claire DAVIES
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Jonathan EUVRARD
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Hans W. PROZESKY
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Matthew P. FOX
- Department of Epidemiology and Department of Global Health, Boston University, Boston, Massachusetts, USA
| | | | - Per VON GROOTE
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Leigh F. JOHNSON
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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Nemphos SM, Green HC, Prusak JE, Fell SL, Goff K, Varnado M, Didier K, Guy N, Moström MJ, Tatum C, Massey C, Barnes MB, Rowe LA, Allers C, Blair RV, Embers ME, Maness NJ, Marx PA, Grasperge B, Kaur A, De Paris K, Shaffer JG, Hensley-McBain T, Londono-Renteria B, Manuzak JA. Elevated Inflammation Associated with Markers of Neutrophil Function and Gastrointestinal Disruption in Pilot Study of Plasmodium fragile Co-Infection of ART-Treated SIVmac239+ Rhesus Macaques. Viruses 2024; 16:1036. [PMID: 39066199 PMCID: PMC11281461 DOI: 10.3390/v16071036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024] Open
Abstract
Human immunodeficiency virus (HIV) and malaria, caused by infection with Plasmodium spp., are endemic in similar geographical locations. As a result, there is high potential for HIV/Plasmodium co-infection, which increases the pathology of both diseases. However, the immunological mechanisms underlying the exacerbated disease pathology observed in co-infected individuals are poorly understood. Moreover, there is limited data available on the impact of Plasmodium co-infection on antiretroviral (ART)-treated HIV infection. Here, we used the rhesus macaque (RM) model to conduct a pilot study to establish a model of Plasmodium fragile co-infection during ART-treated simian immunodeficiency virus (SIV) infection, and to begin to characterize the immunopathogenic effect of co-infection in the context of ART. We observed that P. fragile co-infection resulted in parasitemia and anemia, as well as persistently detectable viral loads (VLs) and decreased absolute CD4+ T-cell counts despite daily ART treatment. Notably, P. fragile co-infection was associated with increased levels of inflammatory cytokines, including monocyte chemoattractant protein 1 (MCP-1). P. fragile co-infection was also associated with increased levels of neutrophil elastase, a plasma marker of neutrophil extracellular trap (NET) formation, but significant decreases in markers of neutrophil degranulation, potentially indicating a shift in the neutrophil functionality during co-infection. Finally, we characterized the levels of plasma markers of gastrointestinal (GI) barrier permeability and microbial translocation and observed significant correlations between indicators of GI dysfunction, clinical markers of SIV and Plasmodium infection, and neutrophil frequency and function. Taken together, these pilot data verify the utility of using the RM model to examine ART-treated SIV/P. fragile co-infection, and indicate that neutrophil-driven inflammation and GI dysfunction may underlie heightened SIV/P. fragile co-infection pathogenesis.
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Affiliation(s)
- Sydney M. Nemphos
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Hannah C. Green
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - James E. Prusak
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Sallie L. Fell
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Kelly Goff
- Division of Microbiology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Megan Varnado
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Kaitlin Didier
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Natalie Guy
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Matilda J. Moström
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Coty Tatum
- Division of Microbiology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Chad Massey
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Mary B. Barnes
- Division of Microbiology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Lori A. Rowe
- Division of Microbiology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Carolina Allers
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Robert V. Blair
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Monica E. Embers
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Nicholas J. Maness
- Division of Microbiology, Tulane National Primate Research Center, Covington, LA 70433, USA
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Preston A. Marx
- Division of Microbiology, Tulane National Primate Research Center, Covington, LA 70433, USA
- Department of Tropical Medicine and Infectious Disease, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA;
| | - Brooke Grasperge
- Division of Veterinary Medicine, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Amitinder Kaur
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Kristina De Paris
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC 27559, USA
| | - Jeffrey G. Shaffer
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA
| | | | - Berlin Londono-Renteria
- Department of Tropical Medicine and Infectious Disease, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA;
| | - Jennifer A. Manuzak
- Division of Immunology, Tulane National Primate Research Center, Covington, LA 70433, USA
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA 70112, USA
- Department of Tropical Medicine and Infectious Disease, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA;
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Molemans M, Reis R, Shabalala F, Dlamini N, Masilela N, Simelane N, Pell C, Chao A, Spiegelman D, Vernooij E, van Leth F. Reasons for using traditional and complementary care by people living with HIV on antiretroviral therapy and association with interrupted care: a mixed methods study in Eswatini. BMC Complement Med Ther 2023; 23:350. [PMID: 37794359 PMCID: PMC10548651 DOI: 10.1186/s12906-023-04184-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
The use of traditional, complementary, and alternative medicine (TCAM) can lead to delays and interruptions in the HIV continuum of care. This study explores reasons for TCAM use in people living with HIV on antiretroviral therapy (ART) in Eswatini and compares interrupted care between different types of TCAM users. Data were collected using surveys in the MaxART study (a test-and-treat trial) between 2014 and 2017 to assess the exposure, namely visiting a TCAM provider. Additionally, visit dates were retrieved from clinic records to assess the outcome, interrupted care. Open-ended questions were analysed with qualitative content analysis (n = 602) and closed questions with bivariable and multivariable analysis (n = 202). Out of 202 participants, 145 (72%) never used TCAM, 40 (20%) ever used, and 17 (8%) is currently using TCAM (diviners, herbalists, and religious healers). No differences in interrupted care were found comparing never (reference category), past (Odds Ratio: 1.31, 95% confidence interval: 0.63-2.72), and current users (1.34, 0.47-3.77), while adjusting for gender, time since HIV diagnosis, and time on ART. Contextual factors affecting the choice for TCAM were the influence of family, advice from the health facility, and religious beliefs. Individual factors include trust in biomedical care, type of illness, no need for additional care, and practical reasons such as financial means. In conclusion, individual and contextual factors influence the choice for TCAM. Interrupted care does not differ between never, past, and current users.
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Affiliation(s)
- Marjan Molemans
- Amsterdam Institute for Social Science Research, Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Ria Reis
- Amsterdam Institute for Social Science Research, Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
- The Children's Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Fortunate Shabalala
- Department of Community Health Nursing, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini, Swaziland
| | - Njabuliso Dlamini
- National Emergency Response Council on HIV and AIDS (NERCHA), Mbabane, Eswatini, Swaziland
| | - Nelisiwe Masilela
- Department of Community Health Nursing, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini, Swaziland
| | - Njabulo Simelane
- Ministry of Foreign Affairs and Trade, Mbabane, Eswatini, Swaziland
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Ariel Chao
- Yale School of Public Health, New Haven, USA
| | | | - Eva Vernooij
- Amsterdam Institute for Social Science Research, Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
- Department of Interdisciplinary Social Sciences, Utrecht University, Utrecht, The Netherlands
| | - Frank van Leth
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Health Sciences, Vrije Universiteit, Amsterdam, The Netherlands
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7
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Van Zandt AR, MacLean AG. Advances in HIV therapeutics and cure strategies: findings obtained through non-human primate studies. J Neurovirol 2023; 29:389-399. [PMID: 37635184 DOI: 10.1007/s13365-023-01162-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023]
Abstract
Human immunodeficiency virus (HIV), the main contributor of the ongoing AIDS epidemic, remains one of the most challenging and complex viruses to target and eradicate due to frequent genome mutation and immune evasion. Despite the development of potent antiretroviral therapies, HIV remains an incurable infection as the virus persists in latent reservoirs throughout the body. To innovate a safe and effective cure strategy for HIV in humans, animal models are needed to better understand viral proliferation, disease progression, and therapeutic response. Nonhuman primates infected with simian immunodeficiency virus (SIV) provide an ideal model to study HIV infection and pathogenesis as they are closely related to humans genetically and express phenotypically similar immune systems. Examining the clinical outcomes of novel treatment strategies within nonhuman primates facilitates our understanding of HIV latency and advances the development of a true cure to HIV.
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Affiliation(s)
- Alison R Van Zandt
- Tulane National Primate Research Center, Covington, LA, USA
- Biomedical Sciences Training Program, Tulane University School of Medicine, New Orleans, LA, USA
| | - Andrew G MacLean
- Tulane National Primate Research Center, Covington, LA, USA.
- Biomedical Sciences Training Program, Tulane University School of Medicine, New Orleans, LA, USA.
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, USA.
- Tulane Brain Institute, New Orleans, LA, USA.
- Tulane Center for Aging, New Orleans, LA, USA.
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8
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Ma J, Jin Y, Jiao K, Wang Y, Gao L, Li X, Ma W. Antiretroviral treatment interruption and resumption within 16 weeks among HIV-positive adults in Jinan, China: a retrospective cohort study. Front Public Health 2023; 11:1137132. [PMID: 37228714 PMCID: PMC10203161 DOI: 10.3389/fpubh.2023.1137132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/10/2023] [Indexed: 05/27/2023] Open
Abstract
Background Treatment interruption has been found to increase the risk of opportunistic infections and death among HIV-positive adults, posing a challenge to fully realizing antiretroviral therapy (ART). However, it has been observed that short-term interruption (<16 weeks) was not associated with significant increases in adverse clinical events. There remains a dearth of evidence concerning the interruption and resumption of ART after short-term discontinuation in China. Methods HIV-positive adults who initiated ART in Jinan between 2004 and 2020 were included in this study. We defined ART interruption as more than 30 consecutive days off ART and used Cox regression to identify predictors of interruption. ART resumption was defined as a return to ART care within 16 weeks following discontinuation, and logistic regression was used to identify barriers. Results A total of 2,506 participants were eligible. Most of them were male [2,382 (95%)] and homosexual [2,109 (84%)], with a median age of 31 (IQR: 26-40) years old. Of all participants, 312 (12.5%) experienced a treatment interruption, and the incidence rate of interruption was 3.2 (95% CI: 2.8-3.6) per 100 person-years. A higher risk of discontinuation was observed among unemployed individuals [adjusted hazard ratio (aHR): 1.45, 95% CI: 1.14-1.85], with a lower education level (aHR: 1.39, 95% CI: 1.06-1.82), those with delayed ART initiation (aHR: 1.43, 95% CI: 1.10-1.85), receiving Alafenamide Fumarate Tablets at ART initiation (aHR: 5.19, 95% CI: 3.29-8.21). About half of the interrupters resumed ART within 16 weeks, and participants who delayed ART initiation, missed the last CD4 test before the interruption and received the "LPV/r+NRTIs" regimen before the interruption were more likely to discontinue treatment for the long term. Conclusion Antiretroviral treatment interruption remains relatively prevalent among HIV-positive adults in Jinan, China, and assessing socioeconomic status at treatment initiation will help address this issue. While almost half of the interrupters returned to care within 16 weeks, further focused measures are necessary to reduce long-term interruptions and maximize the resumption of care as soon as possible to avoid adverse clinical events.
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Affiliation(s)
- Jing Ma
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yan Jin
- Institution for Acquired Immunodeficiency Syndrome (AIDS)/Sexually Transmitted Diseases (STD) Control and Prevention, Jinan Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Kedi Jiao
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Yao Wang
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Lijie Gao
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xinrui Li
- Institution for Acquired Immunodeficiency Syndrome (AIDS)/Sexually Transmitted Diseases (STD) Control and Prevention, Jinan Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Wei Ma
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
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9
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Fauk NK, Gesesew HA, Seran AL, Ward PR. Barriers to access to antiretroviral therapy by people living with HIV in an indonesian remote district during the COVID-19 pandemic: a qualitative study. BMC Infect Dis 2023; 23:296. [PMID: 37147599 PMCID: PMC10161978 DOI: 10.1186/s12879-023-08221-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 04/04/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Coronavirus disease (COVID-19) pandemic has a significant influence on the access to healthcare services. This study aimed to understand the views and experiences of people living with HIV (PLHIV) about barriers to their access to antiretroviral therapy (ART) service in Belu district, Indonesia, during the COVID-19 pandemic. METHODS This qualitative inquiry employed in-depth interviews to collect data from 21 participants who were recruited using a snowball sampling technique. Data analysis was guided by a thematic framework analysis. RESULTS The findings showed that fear of contracting COVID-19 was a barrier that impeded participants' access to ART service. Such fear was influenced by their awareness of their vulnerability to the infection, the possibility of unavoidable physical contact in public transport during a travelling to HIV clinic and the widespread COVID-19 infection in healthcare facilities. Lockdowns, COVID-19 restrictions and lack of information about the provision of ART service during the pandemic were also barriers that impeded their access to the service. Other barriers included the mandatory regulation for travellers to provide their COVID-19 vaccine certificate, financial difficulty, and long-distance travel to the HIV clinic. CONCLUSIONS The findings indicate the need for dissemination of information about the provision of ART service during the pandemic and the benefits of COVID-19 vaccination for the health of PLHIV. The findings also indicate the need for new strategies to bring ART service closer to PLHIV during the pandemic such as a community-based delivery system. Future large-scale studies exploring views and experiences of PLHIV about barriers to their access to ART service during the COVID-19 pandemic and new intervention strategies are recommended.
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Affiliation(s)
- Nelsensius Klau Fauk
- Research Centre on Public Health, Equity and Human Flourishing (PHEHF), Torrens University, 88 Wakefield Street, 5000, Adelaide, South Australia, Australia
- Institute of Resource Governance and Social Change, 85227, Kupang, Indonesia
| | - Hailay Abrha Gesesew
- Research Centre on Public Health, Equity and Human Flourishing (PHEHF), Torrens University, 88 Wakefield Street, 5000, Adelaide, South Australia, Australia.
- College of Health Sciences, Mekelle University, P.O. Box 231, Mekelle, Tigray, Ethiopia.
| | - Alfonsa Liquory Seran
- Health Department of Belu District, Atapupu Public Health Centre, 85752, Atambua, Belu, Indonesia
| | - Paul Russell Ward
- Research Centre on Public Health, Equity and Human Flourishing (PHEHF), Torrens University, 88 Wakefield Street, 5000, Adelaide, South Australia, Australia
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10
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Ta TM, Malik S, Anderson EM, Jones AD, Perchik J, Freylikh M, Sardo L, Klase ZA, Izumi T. Insights Into Persistent HIV-1 Infection and Functional Cure: Novel Capabilities and Strategies. Front Microbiol 2022; 13:862270. [PMID: 35572626 PMCID: PMC9093714 DOI: 10.3389/fmicb.2022.862270] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/21/2022] [Indexed: 12/23/2022] Open
Abstract
Although HIV-1 replication can be efficiently suppressed to undetectable levels in peripheral blood by combination antiretroviral therapy (cART), lifelong medication is still required in people living with HIV (PLWH). Life expectancies have been extended by cART, but age-related comorbidities have increased which are associated with heavy physiological and economic burdens on PLWH. The obstacle to a functional HIV cure can be ascribed to the formation of latent reservoir establishment at the time of acute infection that persists during cART. Recent studies suggest that some HIV reservoirs are established in the early acute stages of HIV infection within multiple immune cells that are gradually shaped by various host and viral mechanisms and may undergo clonal expansion. Early cART initiation has been shown to reduce the reservoir size in HIV-infected individuals. Memory CD4+ T cell subsets are regarded as the predominant cellular compartment of the HIV reservoir, but monocytes and derivative macrophages or dendritic cells also play a role in the persistent virus infection. HIV latency is regulated at multiple molecular levels in transcriptional and post-transcriptional processes. Epigenetic regulation of the proviral promoter can profoundly regulate the viral transcription. In addition, transcriptional elongation, RNA splicing, and nuclear export pathways are also involved in maintaining HIV latency. Although most proviruses contain large internal deletions, some defective proviruses may induce immune activation by expressing viral proteins or producing replication-defective viral-like particles. In this review article, we discuss the state of the art on mechanisms of virus persistence in the periphery and tissue and summarize interdisciplinary approaches toward a functional HIV cure, including novel capabilities and strategies to measure and eliminate the infected reservoirs and induce immune control.
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Affiliation(s)
- Tram M. Ta
- Department of Biological Sciences, Misher College of Arts and Sciences, University of the Sciences in Philadelphia, Philadelphia, PA, United States
| | - Sajjaf Malik
- Department of Biological Sciences, Misher College of Arts and Sciences, University of the Sciences in Philadelphia, Philadelphia, PA, United States
| | - Elizabeth M. Anderson
- Office of the Assistant Secretary for Health, Region 3, U.S. Department of Health and Human Services, Washington, DC, United States
| | - Amber D. Jones
- Department of Biological Sciences, Misher College of Arts and Sciences, University of the Sciences in Philadelphia, Philadelphia, PA, United States,Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Jocelyn Perchik
- Department of Biological Sciences, Misher College of Arts and Sciences, University of the Sciences in Philadelphia, Philadelphia, PA, United States
| | - Maryann Freylikh
- Department of Biological Sciences, Misher College of Arts and Sciences, University of the Sciences in Philadelphia, Philadelphia, PA, United States
| | - Luca Sardo
- Department of Infectious Disease and Vaccines, Merck & Co., Inc., Kenilworth, NJ, United States
| | - Zackary A. Klase
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA, United States,Center for Neuroimmunology and CNS Therapeutics, Institute of Molecular Medicine and Infectious Diseases, Drexel University of Medicine, Philadelphia, PA, United States
| | - Taisuke Izumi
- Department of Biological Sciences, Misher College of Arts and Sciences, University of the Sciences in Philadelphia, Philadelphia, PA, United States,*Correspondence: Taisuke Izumi,
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11
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Psaros C, Stanton AM. Patterns of post-partum HIV care engagement. Lancet HIV 2021; 8:e730-e731. [PMID: 34762837 PMCID: PMC10929616 DOI: 10.1016/s2352-3018(21)00270-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | - Amelia M Stanton
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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12
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Schwiebert E, Wang Y, Xi R, Choma K, Streiff J, Flammer LJ, Rivers N, Ozdener MH, Margolskee RF, Christensen CM, Rawson NE, Jiang P, Breslin PAS. Inhibition of Bitter Taste from Oral Tenofovir Alafenamide. Mol Pharmacol 2021; 99:319-327. [PMID: 33824185 DOI: 10.1124/molpharm.120.000071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 03/01/2021] [Indexed: 11/22/2022] Open
Abstract
Children have difficulty swallowing capsules. Yet, when presented with liquid formulations, children often reject oral medications due to their intense bitterness. Presently, effective strategies to identify methods, reagents, and tools to block bitterness remain elusive. For a specific bitter-tasting drug, identification of the responsible bitter receptors and discovery of antagonists for those receptors can provide a method to block perceived bitterness. We have identified a compound (6-methylflavone) that can block responses to an intensely bitter-tasting anti-human immunodeficiency virus (HIV) drug, tenofovir alafenamide (TAF), using a primary human taste bud epithelial cell culture as a screening platform. Specifically, TAS2R39 and TAS2R1 are the main type 2 taste receptors responding to TAF observed via heterologously expressing specific TAS2R receptors into HEK293 cells. In this assay, 6-methylflavone blocked the responses of TAS2R39 to TAF. In human sensory testing, 8 of 16 subjects showed reduction in perceived bitterness of TAF after pretreating (or "prerinsing") with 6-methylflavone and mixing 6-methylflavone with TAF. Bitterness was completely and reliably blocked in two of these subjects. These data demonstrate that a combined approach of human taste cell culture-based screening, receptor-specific assays, and human psychophysical testing can successfully discover molecules for blocking perceived bitterness of pharmaceuticals, such as the HIV therapeutic TAF. Our hope is to use bitter taste blockers to increase medical compliance with these vital medicines. SIGNIFICANCE STATEMENT: Identification of a small molecule that inhibits bitter taste from tenofovir alafenamide may increase the compliance in treating children with human immunodeficiency virus infections.
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Affiliation(s)
- Erik Schwiebert
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Yi Wang
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Ranhui Xi
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Katarzyna Choma
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - John Streiff
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Linda J Flammer
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Natasha Rivers
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Mehmet Hakan Ozdener
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Robert F Margolskee
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Carol M Christensen
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Nancy E Rawson
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Peihua Jiang
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
| | - Paul A S Breslin
- Discovery Biomed, Birmingham, Alabama (E.S., J.S.); Monell Chemical Senses Center, Philadelphia, Pennsylvania (Y.W., R.X., K.C., L.J.F., N.R., M.H.O., R.F.M., C.M.C., N.E.R., P.J., P.A.S.B.); and Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey (P.A.S.B.)
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13
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Piwowarek M, Siennicka K, Mikuła T, Wiercińska-Drapało A. Cerebral Toxoplasmosis, CMV and Bacterial Pneumonia with Decreasing CD4+ T-Cell Count as Results of Antiretroviral Therapy Discontinuation-A Case Report. Pathogens 2021; 10:pathogens10040497. [PMID: 33924043 PMCID: PMC8073605 DOI: 10.3390/pathogens10040497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 11/16/2022] Open
Abstract
Cerebral toxoplasmosis occurs mainly in immunocompromised hosts as a reactivation of latent Toxoplasma gondii infection. In the diagnostic process, magnetic resonance imaging (MRI), serum testing, and biopsy are used. We describe a case of a 43-year-old HIV-positive patient presenting with altered levels of consciousness, aphasia, and hemiparesis. The patient had a history of antiretroviral therapy discontinuation for about 3 years. MRI revealed lesions, suggesting cerebral toxoplasmosis and subacute hemorrhage, serum tests for Toxoplasma gondii were positive. Antiparasitics and glycocorticosteroids were administered. A decline in viral load and clinical improvement were observed, however CD4+ T-cell count continued to decrease. The patient’s state worsened, he developed CMV and bacterial pneumonia, which led to his death. What is crucial in the management of an HIV-infected patient is effective and continuous antiretroviral therapy. Discontinuation of the treatment may result in AIDS and lead to poor recovery of the CD4+ T-cell population, even after reimplementation of antiretroviral therapy and a decrease in viral load.
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Affiliation(s)
- Marta Piwowarek
- Students’ Science Society of the Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Wolska 37 Street, 01-201 Warsaw, Poland;
- Correspondence:
| | - Katarzyna Siennicka
- Students’ Science Society of the Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Wolska 37 Street, 01-201 Warsaw, Poland;
| | - Tomasz Mikuła
- The Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Wolska 37 Street, 01-201 Warsaw, Poland; (T.M.); (A.W.-D.)
| | - Alicja Wiercińska-Drapało
- The Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Wolska 37 Street, 01-201 Warsaw, Poland; (T.M.); (A.W.-D.)
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14
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Walker CK, Shaw CM, Moss Perry MV, Claborn MK. Antiretroviral Therapy Management in Adults With HIV During ICU Admission. J Pharm Pract 2021; 35:952-962. [PMID: 33858244 DOI: 10.1177/08971900211000692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The extended lifespan of people living with human immunodeficiency (HIV) and acquired immune deficiency syndrome (AIDS) (PLWHA) has increased the potential for ICU admissions unrelated to HIV infection. The objective of this review is to guide continued management of antiretroviral therapy (ART) recommended by the United States Department of Health and Human Services Antiretroviral Guidelines in critically ill adult PLWHA admitted to the intensive care unit (ICU). Pharmacists are uniquely positioned to mitigate these concerns, including whether to continue ART in the ICU, drug interactions with common ICU drugs, renal and hepatic dosing considerations, and alternative methods of administration. Despite these concerns, the original ART regimen should be continued or modified in conjunction with an HIV specialist. Discontinuation greater than 2 weeks should be avoided due to potential resistance and future HIV treatment failure. Use of ART in critically ill patients presents challenges that pharmacists are best equipped to address to prevent adverse events, administration errors, and treatment failure.
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Affiliation(s)
- Cheri K Walker
- 8452Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
| | - Cassie M Shaw
- 8452Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
| | | | - Melanie K Claborn
- 8452Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
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15
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Sarca AD, Sardo L, Fukuda H, Matsui H, Shirakawa K, Horikawa K, Takaori-Kondo A, Izumi T. FRET-Based Detection and Quantification of HIV-1 Virion Maturation. Front Microbiol 2021; 12:647452. [PMID: 33767685 PMCID: PMC7985248 DOI: 10.3389/fmicb.2021.647452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/18/2021] [Indexed: 01/27/2023] Open
Abstract
HIV-1 infectivity is achieved through virion maturation. Virus particles undergo structural changes via cleavage of the Gag polyprotein mediated by the viral protease, causing the transition from an uninfectious to an infectious status. The majority of proviruses in people living with HIV-1 treated with combination antiretroviral therapy are defective with large internal deletions. Defective proviral DNA frequently preserves intact sequences capable of expressing viral structural proteins to form virus-like particles whose maturation status is an important factor for chronic antigen-mediated immune stimulation and inflammation. Thus, novel methods to study the maturation capability of defective virus particles are needed to characterize their immunogenicity. To build a quantitative tool to study virion maturation in vitro, we developed a novel single virion visualization technique based on fluorescence resonance energy transfer (FRET). We inserted an optimized intramolecular CFP-YPF FRET donor-acceptor pair bridged with an HIV-1 protease cleavage sequence between the Gag MA-CA domains. This system allowed us to microscopically distinguish mature and immature virions via their FRET signal when the FRET donor and acceptor proteins were separated by the viral protease during maturation. We found that approximately 80% of the FRET labeled virus particles were mature with equivalent infectivity to wild type. The proportion of immature virions was increased by treatment of virus producer cells with a protease inhibitor in a dose-dependent manner, which corresponded to a relative decrease in infectivity. Potential areas of application for this tool are assessing maturation efficiency in different cell type settings of intact or deficient proviral DNA integrated cells. We believe that this FRET-based single-virion imaging platform will facilitate estimating the impact on the immune system of both extracellular intact and defective viruses by quantifying the Gag maturation status.
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Affiliation(s)
- Anamaria D Sarca
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Luca Sardo
- Department of Biological Sciences, University of the Sciences, Philadelphia, PA, United States
| | - Hirofumi Fukuda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroyuki Matsui
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kotaro Shirakawa
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuki Horikawa
- Department of Optical Imaging, Advanced Research Promotion Center, Tokushima University, Tokushima, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Taisuke Izumi
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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16
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Li M, Liang S, Zhou C, Chen M, Liang S, Liu C, Zuo Z, Liu L, Feng Y, Song C, Xing H, Ruan Y, Shao Y, Liao L. HIV Drug Resistance Mutations Detection by Next-Generation Sequencing during Antiretroviral Therapy Interruption in China. Pathogens 2021; 10:pathogens10030264. [PMID: 33668946 PMCID: PMC7996606 DOI: 10.3390/pathogens10030264] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/17/2021] [Accepted: 02/20/2021] [Indexed: 11/24/2022] Open
Abstract
Patients with antiretroviral therapy interruption have a high risk of virological failure when re-initiating antiretroviral therapy (ART), especially those with HIV drug resistance. Next-generation sequencing may provide close scrutiny on their minority drug resistance variant. A cross-sectional study was conducted in patients with ART interruption in five regions in China in 2016. Through Sanger and next-generation sequencing in parallel, HIV drug resistance was genotyped on their plasma samples. Rates of HIV drug resistance were compared by the McNemar tests. In total, 174 patients were included in this study, with a median 12 (interquartile range (IQR), 6–24) months of ART interruption. Most (86.2%) of them had received efavirenz (EFV)/nevirapine (NVP)-based first-line therapy for a median 16 (IQR, 7–26) months before ART interruption. Sixty-one (35.1%) patients had CRF07_BC HIV-1 strains, 58 (33.3%) CRF08_BC and 35 (20.1%) CRF01_AE. Thirty-four (19.5%) of the 174 patients were detected to harbor HIV drug-resistant variants on Sanger sequencing. Thirty-six (20.7%), 37 (21.3%), 42 (24.1%), 79 (45.4%) and 139 (79.9) patients were identified to have HIV drug resistance by next-generation sequencing at 20% (v.s. Sanger, p = 0.317), 10% (v.s. Sanger, p = 0.180), 5% (v.s. Sanger, p = 0.011), 2% (v.s. Sanger, p < 0.001) and 1% (v.s. Sanger, p < 0.001) of detection thresholds, respectively. K65R was the most common minority mutation, of 95.1% (58/61) and 93.1% (54/58) in CRF07_BC and CRF08_BC, respectively, when compared with 5.7% (2/35) in CRF01_AE (p < 0.001). In 49 patients that followed-up a median 10 months later, HIV drug resistance mutations at >20% frequency such as K103N, M184VI and P225H still existed, but with decreased frequencies. The prevalence of HIV drug resistance in ART interruption was higher than 15% in the survey. Next-generation sequencing was able to detect more minority drug resistance variants than Sanger. There was a sharp increase in minority drug resistance variants when the detection threshold was below 5%.
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Affiliation(s)
- Miaomiao Li
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
| | - Shujia Liang
- Guangxi Center for Disease Control and Prevention, Nanning 530028, China;
| | - Chao Zhou
- Chongqing Center for Disease Control and Prevention, Chongqing 400042, China;
| | - Min Chen
- Yunnan Center for Disease Control and Prevention, Kunming 650022, China;
| | - Shu Liang
- Sichuan Center for Disease Control and Prevention, Chengdu 610041, China;
| | - Chunhua Liu
- Henan Center for Disease Control and Prevention, Zhengzhou 450016, China;
| | - Zhongbao Zuo
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
| | - Lei Liu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
| | - Yi Feng
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
| | - Chang Song
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
| | - Hui Xing
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
| | - Yuhua Ruan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
| | - Yiming Shao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
| | - Lingjie Liao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (M.L.); (Z.Z.); (L.L.); (Y.F.); (C.S.); (H.X.); (Y.R.); (Y.S.)
- Correspondence:
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17
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Psaros C, Stanton AM, Bedoya CA, Mosery N, Evans S, Matthews LT, Haberer J, Vangel M, Safren S, Smit JA. Protocol for a prospective evaluation of postpartum engagement in HIV care among women living with HIV in South Africa. BMJ Open 2020; 10:e035465. [PMID: 31924641 PMCID: PMC6955573 DOI: 10.1136/bmjopen-2019-035465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION KwaZulu-Natal (KZN), South Africa (SA) has the highest prevalence of pregnant women living with HIV in the world. Pregnancy and the postpartum period offer opportunities to engage women in HIV care, to prevent perinatal transmission and to optimise maternal and infant well-being. However, research suggests that remaining engaged in HIV care during this time can be challenging. METHODS AND ANALYSIS We are conducting a 5-year prospective cohort study among pregnant women living with HIV in KZN to estimate the rates and factors associated with attrition from HIV care during this critical period. To determine who is most likely to fall out of care, we are examining a range of relevant variables informed by a socioecological model of HIV care, including individual, relational, community and healthcare system variables. We are enrolling 18-45-year-old women, at 28 weeks or more of pregnancy, who are living with HIV and currently taking antiretroviral therapies. Participants complete quantitative assessments at baseline (pregnancy) and at 6, 12, 18 and 24 months postpartum. A subset of women and their partners are invited to complete qualitative interviews to further explore their experiences in HIV care. The main study outcomes are suppressed HIV RNA and retention in care at each study assessment. Our understanding of the factors that drive postpartum attrition from HIV care will ultimately inform the development of interventions to facilitate continued engagement in postpartum HIV care. ETHICS AND DISSEMINATION This protocol has been approved by the Human Research Ethics Committee (Medical) at The University of the Witwatersrand (Johannesburg, SA) and the Partners Human Research Committee at Partners HealthCare (Boston, Massachusetts, USA). Site support and approval were obtained from the District Hospital and the KZN Provincial Department of Health. Results will be disseminated through peer-reviewed manuscripts, reports and both local and international presentations (Ethics Registration #170 212).
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Affiliation(s)
- Christina Psaros
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amelia M Stanton
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - C Andres Bedoya
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nzwakie Mosery
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Shannon Evans
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Lynn Turner Matthews
- Department of Medicine, Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jessica Haberer
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark Vangel
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven Safren
- Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - Jennifer A Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
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18
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San C, Lê MP, Matheron S, Mourvillier B, Caseris M, Timsit JF, Wolff M, Yazdanpanah Y, Descamps D, Peytavin G. Management of oral antiretroviral administration in patients with swallowing disorders or with an enteral feeding tube. Med Mal Infect 2019; 50:537-544. [PMID: 31722864 DOI: 10.1016/j.medmal.2019.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/14/2018] [Accepted: 10/18/2019] [Indexed: 02/07/2023]
Abstract
HIV infection has evolved into a chronic disease with comorbidities since the combination antiretroviral therapy era. Complications still occur and patients may need to be admitted to an intensive care unit. Acute respiratory failure is the first cause of these admissions, questioning the administration of solid oral dosage formulations. This issue is also observed in geriatric units where the prevalence of dysphagia is high and underestimated. The problem of antiretroviral administration is critical: altered solid oral dosage formulations and/or administration via enteral feeding tubes are sometimes the only option. The aim is to help manage antiretroviral treatment in unconscious or intubated patients and those with swallowing disorders who are hospitalized in intensive care units or geriatric units. This review provides information on the main antiretroviral regimens and on practical and legal aspects of manipulating solid oral dosage formulations and administration via enteral feeding tubes. Alternatives to the solid formulation are available for most of the 27 oral antiretrovirals available, or manufacturers provide recommendations for patients who are unable to swallow. Manipulation of solid oral dosage formulations such as crushing tablets or opening capsules and administration via feeding tubes are frequently reported but should be the last option for safety and liability issues. Before any off-label administration of a drug, physicians should consider alternatives to the solid oral dosage formulation and check whether the drug can be altered. Therapeutic monitoring is important in this particular setting as the pharmacokinetic profile of drugs is difficult to predict.
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Affiliation(s)
- Carine San
- Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M P Lê
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France.
| | - S Matheron
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - B Mourvillier
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Caseris
- Service de pédiatrie, AP-HP, Hôpital Robert Debré, 75019 Paris, France
| | - J-F Timsit
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Wolff
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - Y Yazdanpanah
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - D Descamps
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de virologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - G Peytavin
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
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19
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Risk factors for antiretroviral therapy (ART) discontinuation in a large multinational trial of early ART initiators. AIDS 2019; 33:1385-1390. [PMID: 30932953 DOI: 10.1097/qad.0000000000002210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We aimed to investigate potential causes of higher risk of treatment interruptions within the multicountry Strategic Timing of AntiRetroviral Treatment (START) trial in 2015. METHODS We defined baseline as the date of starting antiretroviral therapy (ART) and a treatment interruption as discontinuing ART for at least 2 weeks. Participants were stratified by randomization arm and followed from baseline to earliest end date of the initial phase of START, death, date of consent withdrawn or date of first treatment interruption. Cox regression was used to calculate hazard ratios and 95% confidence intervals for factors that may predict treatment interruptions in each arm. RESULTS Of the 3438 participants who started ART, 2286 were in the immediate arm and 1152 in the deferred arm. 12.9% of people in the immediate arm and 10.5% of people in the deferred arm experienced at least one treatment interruption by 3 years after starting ART. In adjusted analyses, age [hazard ratio for 35-50 years: 0.75 (95% confidence interval: 0.59-0.97) and >50 years: 0.53 (0.33-0.80) vs. <35 years], education status [hazard ratio for postgraduate education vs. less than high-school education (0.23 (0.10-0.50))] and region [hazard ratio for United States vs. Europe/Israel (3.16 (2.09-4.77))] were significantly associated with treatment interruptions in the immediate arm. In the deferred arm, age and education status were significantly associated with treatment interruptions. CONCLUSION Within START, we identified younger age and lower educational attainment as potential causes of ART interruption. There is a need to strengthen adherence advice and wider social support in younger people and those of lower education status.
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20
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Gonzalo-Gil E, Rapuano PB, Ikediobi U, Leibowitz R, Mehta S, Coskun AK, Porterfield JZ, Lampkin TD, Marconi VC, Rimland D, Walker BD, Deeks S, Sutton RE. Transcriptional down-regulation of ccr5 in a subset of HIV+ controllers and their family members. eLife 2019; 8:e44360. [PMID: 30964004 PMCID: PMC6456299 DOI: 10.7554/elife.44360] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/01/2019] [Indexed: 11/13/2022] Open
Abstract
HIV +Elite and Viremic controllers (EC/VCs) are able to control virus infection, perhaps because of host genetic determinants. We identified 16% (21 of 131) EC/VCs with CD4 +T cells with resistance specific to R5-tropic HIV, reversed after introduction of ccr5. R5 resistance was not observed in macrophages and depended upon the method of T cell activation. CD4 +T cells of these EC/VCs had lower ccr2 and ccr5 RNA levels, reduced CCR2 and CCR5 cell-surface expression, and decreased levels of secreted chemokines. T cells had no changes in chemokine receptor mRNA half-life but instead had lower levels of active transcription of ccr2 and ccr5, despite having more accessible chromatin by ATAC-seq. Other nearby genes were also down-regulated, over a region of ~500 kb on chromosome 3p21. This same R5 resistance phenotype was observed in family members of an index VC, also associated with ccr2/ccr5 down-regulation, suggesting that the phenotype is heritable.
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Affiliation(s)
- Elena Gonzalo-Gil
- Section of Infectious Diseases, Department of Internal MedicineYale University School of MedicineNew HavenUnited States
| | - Patrick B Rapuano
- Section of Infectious Diseases, Department of Internal MedicineYale University School of MedicineNew HavenUnited States
| | - Uchenna Ikediobi
- Section of Infectious Diseases, Department of Internal MedicineYale University School of MedicineNew HavenUnited States
| | - Rebecca Leibowitz
- Section of Infectious Diseases, Department of Internal MedicineYale University School of MedicineNew HavenUnited States
| | - Sameet Mehta
- Yale Center for Genome Analysis Bioinformatics groupYale University School of MedicineNew HavenUnited States
| | - Ayse K Coskun
- Section of Infectious Diseases, Department of Internal MedicineYale University School of MedicineNew HavenUnited States
| | - J Zachary Porterfield
- Section of Infectious Diseases, Department of Internal MedicineYale University School of MedicineNew HavenUnited States
| | - Teagan D Lampkin
- Infectious Diseases SectionDallas VA Medical CenterDallasUnited States
| | - Vincent C Marconi
- Atlanta VA Medical Center, Emory University School of MedicineAtlantaUnited States
| | - David Rimland
- Atlanta VA Medical Center, Emory University School of MedicineAtlantaUnited States
| | - Bruce D Walker
- Ragon Institute of MGHMIT and Harvard UniversityCambridgeUnited States
| | - Steven Deeks
- Department of MedicineUniversity of California San FranciscoSan FranciscoUnited States
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoUnited States
| | - Richard E Sutton
- Section of Infectious Diseases, Department of Internal MedicineYale University School of MedicineNew HavenUnited States
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21
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Hwang B, Shroufi A, Gils T, Steele SJ, Grimsrud A, Boulle A, Yawa A, Stevenson S, Jankelowitz L, Versteeg-Mojanaga M, Govender I, Stephens J, Hill J, Duncan K, van Cutsem G. Stock-outs of antiretroviral and tuberculosis medicines in South Africa: A national cross-sectional survey. PLoS One 2019; 14:e0212405. [PMID: 30861000 PMCID: PMC6413937 DOI: 10.1371/journal.pone.0212405] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/02/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND HIV and TB programs have rapidly scaled-up over the past decade in Sub-Saharan Africa and uninterrupted supplies of those medicines are critical to their success. However, estimates of stock-outs are largely unknown. This survey aimed to estimate the extent of stock-outs of antiretroviral and TB medicines in public health facilities across South Africa, which has the world's largest antiretroviral treatment (ART) program and a rising multidrug-resistant TB epidemic. METHODS We conducted a cross-sectional telephonic survey (October-December 2015) of public health facilities. Facilities were asked about the prevalence of stock-outs on the day of the survey and in the preceding three months, their duration and impact. RESULTS Nationwide, of 3547 eligible health facilities, 79% (2804) could be reached telephonically. 88% (2463) participated and 4% (93) were excluded as they did not provide ART or TB treatment. Of the 2370 included facilities, 20% (485) reported a stock-out of at least 1 ARV and/or TB-related medicine on the day of contact and 36% (864) during the three months prior to contact, ranging from 74% (163/220) of health facilities in Mpumalanga to 12% (32/261) in the Western Cape province. These 864 facilities reported 1475 individual stock-outs, with one to fourteen different medicines out of stock per facility. Information on impact was provided in 98% (1449/1475) of stock-outs: 25% (366) resulted in a high impact outcome, where patients left the facility without medicine or were provided with an incomplete regimen. Of the 757 stock-outs that were resolved 70% (527) lasted longer than one month. INTERPRETATION There was a high prevalence of stock-outs nationwide. Large interprovincial differences in stock-out occurrence, duration, and impact suggest differences in provincial ability to prevent, mitigate and cope within the same framework. End-user monitoring of the supply chain by patients and civil society has the potential to increase transparency and complement public sector monitoring systems.
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Affiliation(s)
- Bella Hwang
- Médecins Sans Frontières South Africa, Operational Control Centre Brussels, Cape Town, South Africa
- * E-mail:
| | - Amir Shroufi
- Médecins Sans Frontières South Africa, Operational Control Centre Brussels, Cape Town, South Africa
| | - Tinne Gils
- Médecins Sans Frontières South Africa, Operational Control Centre Brussels, Cape Town, South Africa
| | - Sarah Jane Steele
- Médecins Sans Frontières South Africa, Operational Control Centre Brussels, Cape Town, South Africa
| | | | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Anele Yawa
- Treatment Action Campaign, Johannesburg, South Africa
| | | | | | | | - Indira Govender
- Rural Doctors Association of Southern Africa, Johannesburg, South Africa
| | | | - Julia Hill
- Médecins Sans Frontières South Africa, Operational Control Centre Brussels, Cape Town, South Africa
| | - Kristal Duncan
- Médecins Sans Frontières South Africa, Operational Control Centre Brussels, Cape Town, South Africa
| | - Gilles van Cutsem
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
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22
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Finocchio T, Coolidge W, Johnson T. The ART of Antiretroviral Therapy in Critically Ill Patients With HIV. J Intensive Care Med 2018; 34:897-909. [PMID: 30309292 DOI: 10.1177/0885066618803871] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The management of patients with human immunodeficiency virus (HIV) can be a complicated specialty within itself, made even more complex when there are so many unanswered questions regarding the care of critically ill patients with HIV. The lack of consensus on the use of antiretroviral medications in the critically ill patient population has contributed to an ongoing clinical debate among intensivists. This review focuses on the pharmacological complications of antiretroviral therapy (ART) in the intensive care setting, specifically the initiation of ART in patients newly diagnosed with HIV, immune reconstitution inflammatory syndrome (IRIS), continuation of ART in those who were on a complete regimen prior to intensive care unit admission, barriers of drug delivery alternatives, and drug-drug interactions.
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Affiliation(s)
- Tyler Finocchio
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
| | - William Coolidge
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
| | - Thomas Johnson
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
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23
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Wang L, Min JE, Zang X, Sereda P, Harrigan RP, Montaner JSG, Nosyk B. Characterizing Human Immunodeficiency Virus Antiretroviral Therapy Interruption and Resulting Disease Progression Using Population-Level Data in British Columbia, 1996-2015. Clin Infect Dis 2018; 65:1496-1503. [PMID: 29048508 DOI: 10.1093/cid/cix570] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 06/28/2017] [Indexed: 11/12/2022] Open
Abstract
Background Suboptimal retention is among the biggest challenges to realize the full benefits of combination antiretroviral therapy (ART). We aimed to describe ART interruption patterns and identify determinants of disease progression while off ART in British Columbia, Canada. Methods With population-level data on ART utilization and laboratory testing in British Columbia (1996-2015), we described the timing, frequency, and duration of ART interruptions (a gap of ≥90 days in ART dispensation records). A 4-state continuous-time Markov model was implemented to identify determinants of disease progression during individuals' first ART interruption episode. Disease progression was measured according to CD4-based state transitions (cells/μL: ≥500 to 200-499; 200-499 to <200; ≥500 to death; 200-499 to death; and <200 to death). Results Among individuals initiating ART, 3129 (38.6%) interrupted ART over a median 8-year follow-up (interquartile range [IQR], 4.3-13.5 years). Those interrupting ART had a median of 1 interruption (IQR, 1.0-3.0), with the first interruption occurring 12.8 (IQR, 4.0-36.1) months after ART initiation, lasting for 7.5 (IQR, 4.1-20.3) months. The proportion of individuals interrupting ART within the first year of ART initiation decreased over time; however, the absolute number of individuals interrupting ART remained high. In a multivariable analysis, age, historical plasma viral load, and ART regimen changes prior to interruption were associated with increased hazard of CD4 decline and death. Conclusions Our results demonstrate that ART interruptions are common even in a high-resource setting with universal free access to human immunodeficiency virus care. Further efforts are needed to promote ART reengagement and may consider prioritizing individuals with poorer prognostic factors.
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Affiliation(s)
- Linwei Wang
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | | | - Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | - Paul Sereda
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | - Richard P Harrigan
- BC Centre for Excellence in HIV/AIDS, Vancouver.,Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, Vancouver.,Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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24
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Belenky N, Pence BW, Cole SR, Dusetzina SB, Edmonds A, Oberlander J, Plankey MW, Adedimeji A, Wilson TE, Cohen J, Cohen MH, Milam JE, Golub ET, Adimora AA. Associations Between Medicare Part D and Out-of-Pocket Spending, HIV Viral Load, Adherence, and ADAP Use in Dual Eligibles With HIV. Med Care 2018; 56:47-53. [PMID: 29227443 PMCID: PMC5728680 DOI: 10.1097/mlr.0000000000000843] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The implementation of Medicare part D on January 1, 2006 required all adults who were dually enrolled in Medicaid and Medicare (dual eligibles) to transition prescription drug coverage from Medicaid to Medicare part D. Changes in payment systems and utilization management along with the loss of Medicaid protections had the potential to disrupt medication access, with uncertain consequences for dual eligibles with human immunodeficiency virus (HIV) who rely on consistent prescription coverage to suppress their HIV viral load (VL). OBJECTIVE To estimate the effect of Medicare part D on self-reported out-of-pocket prescription drug spending, AIDS Drug Assistance Program (ADAP) use, antiretroviral adherence, and HIV VL suppression among dual eligibles with HIV. METHODS Using 2003-2008 data from the Women's Interagency HIV Study, we created a propensity score-matched cohort and used a difference-in-differences approach to compare dual eligibles' outcomes pre-Medicare and post-Medicare part D to those enrolled in Medicaid alone. RESULTS Transition to Medicare part D was associated with a sharp increase in the proportion of dual eligibles with self-reported out-of-pocket prescription drug costs, followed by an increase in ADAP use. Despite the increase in out-of-pocket costs, both adherence and HIV VL suppression remained stable. CONCLUSIONS Medicare part D was associated with increased out-of-pocket spending, although the increased spending did not seem to compromise antiretroviral therapy adherence or HIV VL suppression. It is possible that increased ADAP use mitigated the increase in out-of-pocket spending, suggesting successful coordination between Medicare part D and ADAP as well as the vital role of ADAP during insurance transitions.
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Affiliation(s)
- Nadya Belenky
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Brian W. Pence
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephen R. Cole
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stacie B. Dusetzina
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan Oberlander
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael W. Plankey
- Division of Infectious Diseases and Travel Medicine, Department of Medicine, Georgetown University, Washington, DC
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Tracey E. Wilson
- Department of Community Health Sciences School of Public Health, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Jennifer Cohen
- Department of Clinical Pharmacy, University of California, San Francisco, California
| | - Mardge H. Cohen
- Departments of Medicine, Stroger Hospital and Rush University, Chicago, Illinois
| | - Joel E. Milam
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Elizabeth T. Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Adaora A. Adimora
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, NC
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25
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Mavhu W, Willis N, Mufuka J, Mangenah C, Mvududu K, Bernays S, Mangezi W, Apollo T, Araya R, Weiss HA, Cowan FM. Evaluating a multi-component, community-based program to improve adherence and retention in care among adolescents living with HIV in Zimbabwe: study protocol for a cluster randomized controlled trial. Trials 2017; 18:478. [PMID: 29052529 PMCID: PMC5649065 DOI: 10.1186/s13063-017-2198-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 09/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND World Health Organization (WHO) adolescent HIV-testing and treatment guidelines recommend community-based interventions to support antiretroviral therapy (ART) adherence and retention in care, while acknowledging that the evidence to support this recommendation is weak. This cluster randomized controlled trial aims to evaluate the effectiveness and cost-effectiveness of a psychosocial, community-based intervention on HIV-related and psychosocial outcomes. METHODS/DESIGN We are conducting the trial in two districts. Sixteen clinics were randomized to either enhanced ART-adherence support or standard of care. Eligible individuals (HIV-positive adolescents aged 13-19 years and eligible for ART) in both arms receive ART and adherence support provided by adult counselors and nursing staff. Adolescents in the intervention arm additionally attend a monthly support group, are allocated to a designated community adolescent treatment supporter, and followed up through a short message service (SMS) and calls plus home visits. The type and frequency of contact is determined by whether the adolescent is "stable" or in need of enhanced support. Stable adolescents receive a monthly home visit plus a weekly, individualized SMS. An additional home visit is conducted if participants miss a scheduled clinic appointment or support-group meeting. Participants in need of further, enhanced, support receive bi-weekly home visits, weekly phone calls and daily SMS. Caregivers of adolescents in the intervention arm attend a caregiver support group. Trial outcomes are assessed through a clinical, behavioral and psychological assessment conducted at baseline and after 48 and 96 weeks. The primary outcome is the proportion who have died or have virological failure (viral load ≥1000 copies/ml) at 96 weeks. Secondary outcomes include virological failure at 48 weeks, retention in care (proportion of missed visits) and psychosocial outcomes at both time points. Statistical analyses will be conducted and reported in line with CONSORT guidelines for cluster randomized trials, including a flowchart. DISCUSSION This study provides a unique opportunity to generate evidence of the impact of the on-going Zvandiri program, for adolescents living with HIV, on virological failure and psychosocial outcomes as delivered in a real-world setting. If found to reduce rates of treatment failure, this would strengthen support for further scale-up across Zimbabwe and likely the region more widely. TRIAL REGISTRATION Pan African Clinical Trial Registry database, registration number PACTR201609001767322 (the Zvandiri trial). Retrospectively registered on 5 September 2016.
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Affiliation(s)
- Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), 9 Monmouth Road, Avondale West, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Juliet Mufuka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), 9 Monmouth Road, Avondale West, Harare, Zimbabwe
| | - Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), 9 Monmouth Road, Avondale West, Harare, Zimbabwe
| | - Kudzanayi Mvududu
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), 9 Monmouth Road, Avondale West, Harare, Zimbabwe
| | - Sarah Bernays
- School of Public Health, University of Sydney, Sydney, NSW Australia
| | - Walter Mangezi
- Department of Psychiatry, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Tsitsi Apollo
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Ricardo Araya
- Health Services and Population Research Department, King’s College London, London, UK
| | - Helen A. Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances M. Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), 9 Monmouth Road, Avondale West, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Krubiner CB, Merritt MW. Which strings attached: ethical considerations for selecting appropriate conditionalities in conditional cash transfer programmes. JOURNAL OF MEDICAL ETHICS 2017; 43:167-176. [PMID: 27707877 DOI: 10.1136/medethics-2016-103386] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 08/16/2016] [Accepted: 09/14/2016] [Indexed: 06/06/2023]
Abstract
Conditional cash transfers (CCTs) present a promising approach to simultaneously tackle chronic poverty and poor health. While these programmes clearly embody beneficent aims, questions remain regarding the ethical design of CCTs. Limited guidance exists for the ethical evaluation of the defining feature of these programmes: the conditionalities. Drawing upon prominent public health ethics frameworks and social justice theories, this paper outlines five categories of morally relevant considerations that CCT programme designers should consider when assessing which behaviours or outcomes they select as conditionalities for payment: (1) likelihood of yielding desired health outcomes, (2) risks and burdens, (3) receptivity, (4) attainability and (5) indirect impacts and externalities. When evaluating potential conditionalities across these five categories of considerations, it is important to recognise that not all beneficiaries or subgroups of beneficiaries will fare equally on each. Given that most CCTs aim to reduce inequities and promote long-term health and prosperity for the most disadvantaged, it is critical to apply these considerations with due attention to how different segments of the beneficiary population will be differentially affected. Taken on balance, with due reflection on distributional effects, these five categories represent a comprehensive set of considerations for the moral analysis of specific conditionalities and will help ensure that CCT designers structure programmes in a way that is both morally sound and effective in achieving their goals.
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Affiliation(s)
| | - Maria W Merritt
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Dalhatu I, Onotu D, Odafe S, Abiri O, Debem H, Agolory S, Shiraishi RW, Auld AF, Swaminathan M, Dokubo K, Ngige E, Asadu C, Abatta E, Ellerbrock TV. Outcomes of Nigeria's HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004-2012. PLoS One 2016; 11:e0165528. [PMID: 27829033 PMCID: PMC5102414 DOI: 10.1371/journal.pone.0165528] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 10/13/2016] [Indexed: 12/20/2022] Open
Abstract
Background The Nigerian Antiretroviral therapy (ART) program started in 2004 and now ranks among the largest in Africa. However, nationally representative data on outcomes have not been reported. Methods We evaluated retrospective cohort data from a nationally representative sample of adults aged ≥15 years who initiated ART during 2004 to 2012. Data were abstracted from 3,496 patient records at 35 sites selected using probability-proportional-to-size (PPS) sampling. Analyses were weighted and controlled for the complex survey design. The main outcome measures were mortality, loss to follow-up (LTFU), and retention (the proportion alive and on ART). Potential predictors of attrition were assessed using competing risk regression models. Results At ART initiation, 66.4 percent (%) were females, median age was 33 years, median weight 56 kg, median CD4 count 161 cells/mm3, and 47.1% had stage III/IV disease. The percentage of patients retained at 12, 24, 36 and 48 months was 81.2%, 74.4%, 67.2%, and 61.7%, respectively. Over 10,088 person-years of ART, mortality, LTFU, and overall attrition (mortality, LTFU, and treatment stop) rates were 1.1 (95% confidence interval (CI): 0.7–1.8), 12.3 (95%CI: 8.9–17.0), and 13.9 (95% CI: 10.4–18.5) per 100 person-years (py) respectively. Highest attrition rates of 55.4/100py were witnessed in the first 3 months on ART. Predictors of LTFU included: lower-than-secondary level education (reference: Tertiary), care in North-East and South-South regions (reference: North-Central), presence of moderate/severe anemia, symptomatic functional status, and baseline weight <45kg. Predictor of mortality was WHO stage higher than stage I. Male sex, severe anemia, and care in a small clinic were associated with both mortality and LTFU. Conclusion Moderate/Advanced HIV disease was predictive of attrition; earlier ART initiation could improve program outcomes. Retention interventions targeting men and those with lower levels of education are needed. Further research to understand geographic and clinic size variations with outcome is warranted.
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Affiliation(s)
- Ibrahim Dalhatu
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Dennis Onotu
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Solomon Odafe
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
- * E-mail:
| | - Oseni Abiri
- School of Biomedical Informatics, University of Texas, Houston, Texas, United States of America
| | - Henry Debem
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Simon Agolory
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Ray W. Shiraishi
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Andrew F. Auld
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Mahesh Swaminathan
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Kainne Dokubo
- School of Biomedical Informatics, University of Texas, Houston, Texas, United States of America
| | - Evelyn Ngige
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Chukwuemeka Asadu
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Emmanuel Abatta
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Tedd V. Ellerbrock
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
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McMahon JH, Spelman T, Ford N, Greig J, Mesic A, Ssonko C, Casas EC, O’Brien DP. Risk factors for unstructured treatment interruptions and association with survival in low to middle income countries. AIDS Res Ther 2016; 13:25. [PMID: 27408611 PMCID: PMC4940870 DOI: 10.1186/s12981-016-0109-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/30/2016] [Indexed: 12/17/2022] Open
Abstract
Background Antiretroviral therapy (ART) treatment interruptions lead to poor clinical outcomes with unplanned or unstructured TIs (uTIs) likely to be underreported. This study describes; uTIs, their risk factors and association with survival. Methods Analysis of ART programmatic data from 11 countries across Asia and Africa between 2003 and 2013 where an uTI was defined as a ≥90-day patient initiated break from ART calculated from the last day the previous ART prescription would have run out until the date of the next ART prescription. Factors predicting uTI were assessed with a conditional risk-set multiple failure time-to-event model to account for repeated events per subject. Association between uTI and mortality was assessed using Cox proportional hazards, with a competing risks extension to test for the influence of lost to follow-up (LTFU). Results 40,632 patients were included from 11 countries across 33 sites (17 Africa, 16 Asia). Median duration of follow-up was 1.61 years (IQR 0.54–3.31 years), 3386 (8.3 %) patients died, and 3453 (8.5 %) were LTFU. There were 14,817 uTIs, with 10,162 (25 %) patients having more than one uTI. In the adjusted model males were at lower risk of uTI (aHR 0.94, p < 0.01, and age 20–59 was protective compared to <20 years (20–39 years aHR 0.87, p < 0.01; 40–59 years aHR 0.86, p < 0.01). Preserved immune function, as measured by higher CD4 cell count, was associated with a reduced rate of uTI compared to CD4 <200 cells/μL (CD4 200–350 cells/μL aHR 0.89, p < 0.01; CD4 >350 cells/μL aHR 0.87, p < 0.01), whereas advanced clinical disease was associated with increased uTI rate (WHO stage 3 aHR 1.10, p < 0.01; WHO stage 4 aHR 1.21, p < 0.01). There was no relationship between uTI and mortality after adjusting for disease status and considering LTFU as a competing risk. Conclusions uTIs were frequent in people in ART programs in low-middle income countries and associated with younger age, female gender and advanced HIV. uTI did not predict survival when loss to follow-up was considered a competing risk. Further evaluation of uTI predictors and interventions to reduce their occurrence is warranted.
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D'Almeida KW, Lert F, Spire B, Dray-Spira R. Determinants of virological response to antiretroviral therapy: socio-economic status still plays a role in the era of cART. Results from the ANRS-VESPA 2 study, France. Antivir Ther 2016; 21:661-670. [PMID: 27355137 DOI: 10.3851/imp3064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Disparities in combined antiretroviral therapy (cART) outcomes have been consistently reported among people living with HIV (PLWHIV). The present study aims at investigating the mechanisms underlying those disparities among PLWHIV in France. METHODS We used data from the Vespa2 survey, a large national cross-sectional survey, representative of HIV-infected people followed at hospitals in 2011. Among participants diagnosed ≥1996, HIV treatment-naive at the time of cART initiation and on cART for at least 12 months, the frequency of sustained virological suppression (SVS; undetectable viral load [<50 copies/ml] for at least 6 months) at the time of the survey, was assessed and its social determinants were measured through logistic regression, accounting for clinical and biological determinants of response to cART. RESULTS Among 1,246 participants, 77.7% had achieved SVS. SVS was less frequent among those unemployed (0.6 [range 0.3-1.0]) and those with the lowest level of education (0.4 [range 0.2-0.9]). The late presenters, diagnosed at a CD4+ T-cell count <200/mm3 (0.5 [range 0.3-0.9]) and the late starters, diagnosed at a CD4+ T-cell count >200 but initiating cART at CD4+ T-cell count <200 (0.3 [range 0.1-0.8]) were less likely than the ideal starters (≥350 CD4+ T-cells/mm3 at cART initiation) to achieve SVS, as were those who reported suboptimal adherence versus those reporting optimal adherence (0.4 [range 0.2-0.7]). In bivariate analyses, material deprivation, discrimination and a weak social network were also associated with a poorer treatment response. CONCLUSIONS Structural social factors remain strong determinants of treatment response and should be addressed in a broad approach of care, but wider political issues should also be investigated.
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Affiliation(s)
- Kayigan W D'Almeida
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136) - Équipe de recherche en épidémiologie sociale, Paris, France.,Centre de recherche en Epidemiologie et Sante des Populations Ringgold standard institution, Villejuif, Île-de-France, France
| | - France Lert
- Centre de recherche en Epidemiologie et Sante des Populations Ringgold standard institution, Villejuif, Île-de-France, France
| | - Bruno Spire
- INSERM, UMR912, Economics and Social Sciences Applied to Health and Analysis of Medical Information (SESSTIM), Marseille, France.,Aix Marseille University, UMRS912, IRD, Marseille, France.,ORS PACA, Southeastern Health Regional Observatory, Marseille, France
| | - Rosemary Dray-Spira
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136) - Équipe de recherche en épidémiologie sociale, Paris, France.,Centre de recherche en Epidemiologie et Sante des Populations Ringgold standard institution, Villejuif, Île-de-France, France
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Low Non-structured Antiretroviral Therapy Interruptions in HIV-Infected Persons Who Inject Drugs Receiving Multidisciplinary Comprehensive HIV Care at an Outpatient Drug Abuse Treatment Center. AIDS Behav 2016; 20:1068-75. [PMID: 26427376 DOI: 10.1007/s10461-015-1211-y] [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: 12/13/2022]
Abstract
Continuous HIV treatment is necessary to ensure successful combined antiretroviral therapy (cART). The aim of this study was to evaluate the incidence of patient-initiated non-structured treatment interruptions in HIV-infected persons who inject drugs and who received a multidisciplinary comprehensive program, including medical HIV care, drug-dependence treatment and psychosocial support, at a drug outpatient addiction center. Non-structured treatment interruptions were defined as ≥30 consecutive days off cART without medical indication. During a median follow-up of 53.8 months, 37/132 (28 %) patients experienced the first non-structured treatment interruptions. The cumulative probability of cART interruption at 5 years was 31.2 % (95 % CI 22.4-40.0). Current drug use injection ≥1/day (HR 14.77; 95 % CI 5.90-36.96) and cART naive patients (HR 0.35, 95 % CI 0.14-0.93) were predictive factors for non-structured treatment interruptions. HIV care provided at a drug addiction center is a useful strategy to sustain continuous cART, however, drug abstinence is essential for the long-term maintenance of cART.
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Jiamsakul A, Kerr SJ, Ng OT, Lee MP, Chaiwarith R, Yunihastuti E, Van Nguyen K, Pham TT, Kiertiburanakul S, Ditangco R, Saphonn V, Sim BLH, Merati TP, Wong W, Kantipong P, Zhang F, Choi JY, Pujari S, Kamarulzaman A, Oka S, Mustafa M, Ratanasuwan W, Petersen B, Law M, Kumarasamy N. Effects of unplanned treatment interruptions on HIV treatment failure - results from TAHOD. Trop Med Int Health 2016; 21:662-74. [PMID: 26950901 DOI: 10.1111/tmi.12690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Treatment interruptions (TIs) of combination antiretroviral therapy (cART) are known to lead to unfavourable treatment outcomes but do still occur in resource-limited settings. We investigated the effects of TI associated with adverse events (AEs) and non-AE-related reasons, including their durations, on treatment failure after cART resumption in HIV-infected individuals in Asia. METHODS Patients initiating cART between 2006 and 2013 were included. TI was defined as stopping cART for >1 day. Treatment failure was defined as confirmed virological, immunological or clinical failure. Time to treatment failure during cART was analysed using Cox regression, not including periods off treatment. Covariables with P < 0.10 in univariable analyses were included in multivariable analyses, where P < 0.05 was considered statistically significant. RESULTS Of 4549 patients from 13 countries in Asia, 3176 (69.8%) were male and the median age was 34 years. A total of 111 (2.4%) had TIs due to AEs and 135 (3.0%) had TIs for other reasons. Median interruption times were 22 days for AE and 148 days for non-AE TIs. In multivariable analyses, interruptions >30 days were associated with failure (31-180 days HR = 2.66, 95%CI (1.70-4.16); 181-365 days HR = 6.22, 95%CI (3.26-11.86); and >365 days HR = 9.10, 95% CI (4.27-19.38), all P < 0.001, compared to 0-14 days). Reasons for previous TI were not statistically significant (P = 0.158). CONCLUSIONS Duration of interruptions of more than 30 days was the key factor associated with large increases in subsequent risk of treatment failure. If TI is unavoidable, its duration should be minimised to reduce the risk of failure after treatment resumption.
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Affiliation(s)
| | - Stephen J Kerr
- The Kirby Institute, UNSW Australia, Sydney, Australia.,HIV-NAT, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Department of Global Health, Academic Medical Center, University of Amsterdame, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Oon Tek Ng
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore City, Singapore
| | - Man Po Lee
- Queen Elizabeth Hospital, Hong Kong, China
| | - Romanee Chaiwarith
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Evy Yunihastuti
- Working Group on AIDS, Faculty of Medicine, University of Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | | | | | | | | | - Vonthanak Saphonn
- National Center for HIV/AIDS, Dermatology & STDs and University of Health Sciences, Phnom Penh, Cambodia
| | | | | | - Wingwai Wong
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Fujie Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | | | | | - Shinichi Oka
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Winai Ratanasuwan
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Matthew Law
- The Kirby Institute, UNSW Australia, Sydney, Australia
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Masroori N, Merindol N, Berthoux L. The interferon-induced antiviral protein PML (TRIM19) promotes the restriction and transcriptional silencing of lentiviruses in a context-specific, isoform-specific fashion. Retrovirology 2016; 13:19. [PMID: 27000403 PMCID: PMC4802722 DOI: 10.1186/s12977-016-0253-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/15/2016] [Indexed: 01/09/2023] Open
Abstract
Background The promyelocytic leukemia (PML) protein, a type I interferon (IFN-I)-induced gene product and a member of the tripartite motif (TRIM) family, modulates the transcriptional activity of viruses belonging to various families. Whether PML has an impact on the replication of HIV-1 has not been fully addressed, but recent studies point to its possible involvement in the restriction of HIV-1 in human cells and in the maintenance of transcriptional latency in human cell lines in which HIV-1 is constitutively repressed. We investigated further the restriction of HIV-1 and a related lentivirus, SIVmac, by PML in murine cells and in a lymphocytic human cell line. In particular, we studied the relevance of PML to IFN-I-mediated inhibition and the role of individual human isoforms. Results We demonstrate that both human PML (hPML) and murine PML (mPML) inhibit the early post-entry stages of the replication of HIV-1 and a related lentivirus, SIVmac. In addition, HIV-1 was transcriptionally silenced by mPML and by hPML isoforms I, II, IV and VI in MEFs. This PML-mediated transcriptional repression was attenuated in presence of the histone deacetylase inhibitor SAHA. In contrast, depletion of PML had no effect on HIV-1 gene expression in a human T cell line. PML was found to contribute to the inhibition of HIV-1 by IFN-I. Specifically, IFN-α and IFN-β treatments of MEFs enhanced the PML-dependent inhibition of HIV-1 early replication stages. Conclusions We show that PML can inhibit HIV-1 and other lentiviruses as part of the IFN-I-mediated response. The restriction takes place at two distinct steps, i.e. reverse transcription and transcription, and in an isoform-specific, cellular context-specific fashion. Our results support a model in which PML activates innate immune antilentiviral effectors. These data are relevant to the development of latency reversal-inducing pharmacological agents, since PML was previously proposed as a pharmacological target for such inhibitors. This study also has implications for the development of murine models of HIV-1. Electronic supplementary material The online version of this article (doi:10.1186/s12977-016-0253-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nasser Masroori
- Laboratory of Retrovirology, Department of Medical Biology and BioMed Research Group, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Natacha Merindol
- Laboratory of Retrovirology, Department of Medical Biology and BioMed Research Group, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Lionel Berthoux
- Laboratory of Retrovirology, Department of Medical Biology and BioMed Research Group, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada.
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Arnet I, Kooij MJ, Messerli M, Hersberger KE, Heerdink ER, Bouvy M. Proposal of Standardization to Assess Adherence With Medication Records: Methodology Matters. Ann Pharmacother 2016; 50:360-8. [PMID: 26917817 DOI: 10.1177/1060028016634106] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Medication adherence is the process by which patients take their medication as prescribed and is an umbrella term that encompasses all aspects of medication use patterns. Ambiguous terminology has emerged to describe a deviation from prescribed regimen, forcing the European ABC Project to define 3 phases of medication use: initiation, implementation, and discontinuation. However, different measures of medication adherence using medication records are currently available that do not always distinguish between these phases. The literature is lacking standardization and operationalization of the assessment methods. OBJECTIVE To propose a harmonization of standards as well as definitions of distinct measures and their operationalization to quantify adherence to medication from medication records. METHODS Group discussions and consensus process among all coauthors. The propositions were generated using the authors' experiences and views in the field of adherence, informed by theory. RESULTS The concepts of adherence measures within the new taxonomy were harmonized, and the standards necessary for the operationalization of adherence measures from medication records are proposed. Besides percentages and time-to values, the addition of a dichotomous value for the reinitiation of treatment is proposed. Methodological issues are listed that should be disclosed in studies on adherence. CONCLUSIONS The possible impact of the measures in adherence research is discussed. By doing this, the results of future adherence research should gain in accuracy. Finally, studies will become more transparent, enabling comparison between studies.
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Mûnene E, Ekman B. Socioeconomic and clinical factors explaining the risk of unstructured antiretroviral therapy interruptions among Kenyan adult patients. AIDS Care 2016; 28:1110-8. [PMID: 26846424 DOI: 10.1080/09540121.2016.1140890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
A cross-sectional study was conducted to assess the extent of unstructured HIV treatment interruptions (TIs) and investigate the effects of socioeconomic, socio-demographic, HIV treatment-related and clinical factors on the magnitude and rate of the same among adult patients at a Kenyan regional referral center. Four hundred and twenty-one adult patients actively receiving antiretroviral therapy at Nyeri County Referral Hospital since 2003 were randomly selected to complete a health survey questionnaire. Electronic records were used to obtain their HIV treatment utilization history. The marginal effects of selected determinants on prevalence and rate of TI were assessed by fitting multiple Poisson log-linear regression models. In total, 392 patients participated in the study. HIV TI was prevalent with 64.5% having had at least one TI of 3 months or more during treatment. The risk of TI was significantly higher in those longer on treatment (prevalence ratio = 1.2, 95% confidence interval [CI] 1.12-1.28). Greater risk of TI was also associated with lower income (prevalence rate ratio [PRR] = 0.9, 95% CI 0.83-1.00), low medication adherence (PRR = 0.3, 95% CI 0.13-0.72), inconsistent treatment engagement (PRR = 0.4, 95% CI 0.19-0.75) and, contrarily, fewer adverse drug reactions (PRR = 0.9, 95% CI 0.90-0.97). Unstructured HIV TIs appear to be fairly common at the study site. The results suggest that efforts to minimize HIV TI could benefit from treatment-continuity monitoring strategies that target the high-risk sub-samples identified.
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Affiliation(s)
- Edwin Mûnene
- a Department of Pharmacy , Nyeri County Referral Hospital , Nyeri Town , Nyeri County , Kenya
| | - Björn Ekman
- b Division of Social Medicine and Global Health , Lund University , Malmö City , Skåne County , Sweden
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Karetnikov A. Commentary: Questioning the HIV-AIDS Hypothesis: 30 Years of Dissent. Front Public Health 2015; 3:193. [PMID: 26301215 PMCID: PMC4528088 DOI: 10.3389/fpubh.2015.00193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/23/2015] [Indexed: 01/09/2023] Open
Affiliation(s)
- Alexey Karetnikov
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
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Ogbuagu O, Villanueva M. Extensive Central Nervous System Cryptococcal Disease Presenting as Immune Reconstitution Syndrome in a Patient with Advanced HIV: Report of a Case and Review of Management Dilemmas and Strategies. Infect Dis Rep 2014; 6:5576. [PMID: 25568756 PMCID: PMC4274402 DOI: 10.4081/idr.2014.5576] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 08/13/2014] [Accepted: 08/14/2014] [Indexed: 12/18/2022] Open
Abstract
One of the complications of the use of antiretroviral therapy (ART), immune reconstitution inflammatory syndrome (IRIS), is particularly problematic in the management of cryptococcal meningitis. We present the case of a 35-year-old male with acquired immune deficiency syndrome diagnosed with extensive central nervous system (CNS) cryptococcal disease, including meningitis and multiple intracranial cysts, diagnosed eight weeks after the initiation of ART. The patient experienced a relapsing and remitting clinical course despite repeated courses of potent antifungal therapy and aggressive management of raised intracranial pressure. This review highlights therapeutic dilemmas and strategies in the management of CNS cryptococcosis complicated with IRIS and highlights gaps in available treatment guidelines.
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Affiliation(s)
- Onyema Ogbuagu
- Yale HIV/AIDS Program, Section of Infectious Diseases, Yale University School of Medicine , New Haven, CT, USA
| | - Merceditas Villanueva
- Yale HIV/AIDS Program, Section of Infectious Diseases, Yale University School of Medicine , New Haven, CT, USA
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Samji H, Chen Y, Salters K, Montaner JSG, Hogg RS. Correlates of unstructured antiretroviral treatment interruption in a cohort of HIV-positive individuals in British Columbia. AIDS Behav 2014; 18:2240-8. [PMID: 24781638 DOI: 10.1007/s10461-014-0776-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Treatment interruptions (TIs) limit the therapeutic success of combination antiretroviral therapy and are associated with higher morbidity and mortality. HIV-positive individuals dealing with concurrent health issues, access challenges and competing life demands are hypothesized to be more likely to interrupt treatment. Individuals were included if they initiated cART ≥1 year prior to interview date and had a CD4 cell count and initial regimen recorded at initiation. Using pharmacy recording, a TI was defined as a patient-initiated gap in treatment ≥90 consecutive days during the 12 months preceding or following the study interview. 117 (15.2 %) of 768 participants included in this study had a TI during the study window. 76.0 % of participants were male, 27.5 % were of Aboriginal ancestry and the median age was 46 (interquartile range 40-52). In multivariable logistic regression, TIs were significantly associated with current illicit drug use (adjusted odds ratio [aOR] 1.68, 95 % confidence interval [CI] 1.05-2.68); <95 % adherence in the first year of treatment (aOR 2.68, 95 % CI 1.67-4.12); living with at least one person (aOR 1.95; 95 % CI 1.22-3.14) or living on the street (aOR 5.08, 95 % CI 1.72-14.99) compared to living alone; poor perception of overall health (aOR 1.64 95 % CI 1.05-2.55); being unemployed (aOR: 2.22, 95 % CI 1.16-4.23); and younger age at interview (aOR 0.57, 95 % CI 0.44-0.75, per 10 year increase). Addressing socioeconomic barriers to treatment retention is vital for supporting the continuous engagement of patients in care.
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Samji H, Taha TE, Moore D, Burchell AN, Cescon A, Cooper C, Raboud JM, Klein MB, Loutfy MR, Machouf N, Tsoukas CM, Montaner JSG, Hogg RS. Predictors of unstructured antiretroviral treatment interruption and resumption among HIV-positive individuals in Canada. HIV Med 2014; 16:76-87. [PMID: 25174373 DOI: 10.1111/hiv.12173] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Sustained optimal use of combination antiretroviral therapy (cART) has been shown to decrease morbidity, mortality and HIV transmission. However, incomplete adherence and treatment interruption (TI) remain challenges to the full realization of the promise of cART. We estimated trends and predictors of treatment interruption and resumption among individuals in the Canadian Observational Cohort (CANOC) collaboration. METHODS cART-naïve individuals ≥ 18 years of age who initiated cART between 2000 and 2011 were included in the study. We defined TIs as ≥ 90 consecutive days off cART. We used descriptive analyses to study TI trends over time and Cox regression to identify factors predicting time to first TI and time to treatment resumption after a first TI. RESULTS A total of 7633 participants were eligible for inclusion in the study, of whom 1860 (24.5%) experienced a TI. The prevalence of TI in the first calendar year of cART decreased by half over the study period. Our analyses highlighted a higher risk of TI among women [adjusted hazard ratio (aHR) 1.59; 95% confidence interval (CI) 1.33-1.92], younger individuals (aHR 1.27; 95% CI 1.15-1.37 per decade increase), earlier treatment initiators (CD4 count ≥ 350 vs. <200 cells/μL: aHR 1.46; 95% CI 1.17-1.81), Aboriginal participants (aHR 1.67; 95% CI 1.27-2.20), injecting drug users (aHR 1.43; 95% CI 1.09-1.89) and users of zidovudine vs. tenofovir in the initial cART regimen (aHR 2.47; 95% CI 1.92-3.20). Conversely, factors predicting treatment resumption were male sex, older age, and a CD4 cell count <200 cells/μL at cART initiation. CONCLUSIONS Despite significant improvements in cART since its advent, our results demonstrate that TIs remain relatively prevalent. Strategies to support continuous HIV treatment are needed to maximize the benefits of cART.
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Affiliation(s)
- H Samji
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
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Abstract
In human immunodeficiency virus (HIV)-infected persons, the incidence of hematologic malignancies, including leukemia and lymphoma, is increased despite the use of successful antiretroviral therapy. Hematopoietic stem cell transplantation (SCT) is emerging as a safe and effective therapy for HIV-infected persons with hematologic malignancies. Management of these patients is complicated by drug-drug interactions involving antiretroviral therapy (ART) that may impact conditioning agent efficacy and metabolism of immunosuppressive medications and potentiate drug toxicities. As such, optimal strategies for ART remain controversial. We discuss recent advances, controversies, and future directions related to SCT in HIV-infected persons, including the investigation of allogeneic SCT as a strategy for HIV cure.
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Affiliation(s)
- Ignacio A Echenique
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave, Suite 900, Chicago, IL, 60611, USA,
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Role of P-glycoprotein in the distribution of the HIV protease inhibitor atazanavir in the brain and male genital tract. Antimicrob Agents Chemother 2013; 58:1713-22. [PMID: 24379203 DOI: 10.1128/aac.02031-13] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The blood-testis barrier and blood-brain barrier are responsible for protecting the male genital tract and central nervous system from xenobiotic exposure. In HIV-infected patients, low concentrations of antiretroviral drugs in cerebrospinal fluid and seminal fluid have been reported. One mechanism that may contribute to reduced concentrations is the expression of ATP-binding cassette drug efflux transporters, such as P-glycoprotein (P-gp). The objective of this study was to investigate in vivo the tissue distribution of the HIV protease inhibitor atazanavir in wild-type (WT) mice, P-gp/breast cancer resistance protein (Bcrp)-knockout (Mdr1a-/-, Mdr1b-/-, and Abcg2-/- triple-knockout [TKO]) mice, and Cyp3a-/- (Cyp) mice. WT mice and Cyp mice were pretreated with a P-gp/Bcrp inhibitor, elacridar (5 mg/kg of body weight), and the HIV protease inhibitor and boosting agent ritonavir (2 mg/kg intravenously [i.v.]), respectively. Atazanavir (10 mg/kg) was administered i.v. Atazanavir concentrations in plasma (Cplasma), brain (Cbrain), and testes (Ctestes) were quantified at various times by liquid chromatography-tandem mass spectrometry. In TKO mice, we demonstrated a significant increase in atazanavir Cbrain/Cplasma (5.4-fold) and Ctestes/Cplasma (4.6-fold) ratios compared to those in WT mice (P<0.05). Elacridar-treated WT mice showed a significant increase in atazanavir Cbrain/Cplasma (12.3-fold) and Ctestes/Cplasma (13.5-fold) ratios compared to those in vehicle-treated WT mice. In Cyp mice pretreated with ritonavir, significant (P<0.05) increases in atazanavir Cbrain/Cplasma (1.8-fold) and Ctestes/Cplasma (9.5-fold) ratios compared to those in vehicle-treated WT mice were observed. These data suggest that drug efflux transporters, i.e., P-gp, are involved in limiting the ability of atazanavir to permeate the rodent brain and genital tract. Since these transporters are known to be expressed in humans, they could contribute to the low cerebrospinal and seminal fluid antiretroviral concentrations reported in the clinic.
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Antiretroviral treatment interruptions induced by the Kenyan postelection crisis are associated with virological failure. J Acquir Immune Defic Syndr 2013; 64:220-224. [PMID: 24047971 DOI: 10.1097/qai.0b013e31829ec485] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antiretroviral treatment interruptions (TIs) cause suboptimal clinical outcomes. Data on TIs during social disruption are limited. METHODS We determined effects of unplanned TIs after the 2007-2008 Kenyan postelection violence on virological failure, comparing viral load (VL) outcomes in HIV-infected adults with and without conflict-induced TI. RESULTS Two hundred and one patients were enrolled, median 2.2 years after conflict and 4.3 years on treatment. Eighty-eight patients experienced conflict-related TIs and 113 received continuous treatment. After adjusting for preconflict CD4, patients with TIs were more likely to have detectable VL, VL >5,000 and VL >10,000. CONCLUSIONS Unplanned conflict-related TIs are associated with increased likelihood of virological failure.
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Tinago W, O'Halloran JA, O'Halloran RM, Macken A, Lambert JS, Sheehan GJ, Mallon PWG. Characterization of associations and development of atazanavir resistance after unplanned treatment interruptions. HIV Med 2013; 15:224-32. [DOI: 10.1111/hiv.12107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2013] [Indexed: 12/30/2022]
Affiliation(s)
- W Tinago
- HIV Molecular Research Group; School of Medicine and Medical Science; University College Dublin; Dublin Ireland
- Department of Community Medicine; College of Health Sciences; University of Zimbabwe; Harare Zimbabwe
| | - JA O'Halloran
- Department of Infectious Diseases; Mater Misericordiae University Hospital; Dublin Ireland
| | - RM O'Halloran
- Department of Infectious Diseases; Mater Misericordiae University Hospital; Dublin Ireland
| | - A Macken
- HIV Molecular Research Group; School of Medicine and Medical Science; University College Dublin; Dublin Ireland
| | - JS Lambert
- Department of Infectious Diseases; Mater Misericordiae University Hospital; Dublin Ireland
| | - GJ Sheehan
- Department of Infectious Diseases; Mater Misericordiae University Hospital; Dublin Ireland
| | - PWG Mallon
- HIV Molecular Research Group; School of Medicine and Medical Science; University College Dublin; Dublin Ireland
- Department of Infectious Diseases; Mater Misericordiae University Hospital; Dublin Ireland
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O'Connor JL, Gardner EM, Mannheimer SB, Lifson AR, Esser S, Telzak EE, Phillips AN. Factors associated with adherence amongst 5295 people receiving antiretroviral therapy as part of an international trial. J Infect Dis 2012. [PMID: 23204161 DOI: 10.1093/infdis/jis731] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND We assessed factors associated with antiretroviral therapy (ART) adherence, including specific ART medications. METHODS The Strategies for Management of Antiretroviral Therapy study was an international antiretroviral therapy (ART) strategy trial that compared intermittent ART, using CD4(+) T-cell count as a guide, to continuous ART. Adherence during the 7 days before each visit was measured using self-report. We defined high adherence as self-report of taking "all" pills for each prescribed ART medication; all other reports were defined as suboptimal adherence. Factors associated with adherence were assessed using logistic regression with generalized estimating equations. RESULTS Participants reported suboptimal adherence at 6016 of 35 695 study visits (17%). Factors independently associated with suboptimal adherence were black race, protease inhibitor-containing regimens, greater pill burden, higher maximum number of doses per day, and smoking. Factors independently associated with higher adherence were older age, higher education, region of residence, episodic treatment, higher latest (at the time of adherence) CD4(+) T-cell count, and being prescribed concomitant drugs (ie, medications for comorbidities). Of specific drugs investigated, atazanavir, atazanavir/ritonavir, fosamprenavir, indinavir, indinavir/ritonavir, and lopinavir/ritonavir were associated with suboptimal adherence, and tenofovir disoproxil fumarate/emtricitabine was associated with higher adherence. CONCLUSIONS In this, the largest analysis of ART adherence to date, some protease inhibitor-containing regimens and regimens with >1 dose per day were associated with suboptimal adherence.
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Affiliation(s)
- Jemma L O'Connor
- Research Department of Infection and Population Health, University College London, UCL Royal Free Campus, Rowland Hill St, London, United Kingdom. jemma.o'
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Zugna D, Geskus RB, De Stavola B, Rosinska M, Bartmeyer B, Boufassa F, Chaix ML, Babiker A, Porter K. Time to virological failure, treatment change and interruption for individuals treated within 12 months of HIV seroconversion and in chronic infection. Antivir Ther 2012; 17:1039-48. [PMID: 22910338 DOI: 10.3851/imp2312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Estimates of treatment failure, change and interruption are lacking for individuals treated in early HIV infection. METHODS Using CASCADE data, we compared the effect of treatment in early infection (within 12 months of seroconversion) with that seen in chronic infection on risk of virological failure, change and interruption. Failure was defined as two subsequent measures of HIV RNA>1,000 copies/ml following suppression (<500 copies/ml), or >500 copies/ml 6 months following initiation. Treatment change and interruption were defined as modification or interruption lasting >1 week. In multivariable competing risks proportional subdistribution hazards models, we adjusted for combination antiretroviral therapy (cART) class, sex, risk group, age, CD4(+) T-cell count, HIV RNA and calendar period at treatment initiation. RESULTS Of 1,627 individuals initiating cART early (median 1.8 months from seroconversion), 159, 395 and 692 failed, changed and interrupted therapy, respectively. For 2,710 individuals initiating cART in chronic infection (median 35.9 months from seroconversion), the corresponding values were 266, 569 and 597. Adjusted hazard ratios (HRs; 95% CIs) for treatment failure and change were similar between the two treatment groups (0.93 [0.72, 1.20] and 1.06 [0.91, 1.24], respectively). There was an increasing trend in rates of interruption over calendar time for those treated early, and a decreasing trend for those starting treatment in chronic infection. Consequently, compared with chronic infection, treatment interruption was similar for early starters in the early cART period, but the relative hazard increased over calendar time (1.54 [1.33, 1.79] in 2000). CONCLUSIONS Individuals initiating treatment in early HIV infection are more likely to interrupt treatment than those initiating later. However, rates of failure and treatment change were similar between the two groups.
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Affiliation(s)
- Daniela Zugna
- Cancer Epidemiology Unit, CeRMS and CPO-Piemonte, University of Turin, Turin, Italy
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Prevalence of Drug Resistance and Associated Mutations in a Population of HIV-1(+) Puerto Ricans: 2006-2010. AIDS Res Treat 2012; 2012:934041. [PMID: 22593823 PMCID: PMC3347695 DOI: 10.1155/2012/934041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 01/30/2012] [Accepted: 02/13/2012] [Indexed: 11/30/2022] Open
Abstract
This is a continuation of our efforts to maintain a record of the evolution of HIV-1 infection in Puerto Rico by monitoring the expression levels of antiretroviral drug-resistance-associated mutations. Samples from 2,500 patients from 2006–2010 were analyzed using the TruGene HIV-1 genotyping kit and the OpenGene DNA sequencing system. Results show that 58.8% of males and 65.3% of females had HIV-1 with resistance to at least one medication. The average number of HIV mutations was 6.0 in males and 6.1 in females. Statistically significant differences between men and women were recorded in the levels of HIV-1 expressed mutations and antiretroviral drug resistance. The most prevalent antiretroviral medication resistance shifted from zalcitabine to nevirapine and efavirenz in the five-year period. M184V and L63P were the dominant mutations for the reverse transcriptase and the protease genes, respectively, but an increase in the incidence of minority mutations was observed.
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Minzi OM, Buma D, Kagashe GA. Self-initiation of antiretroviral therapy in the developing world: the involvement of private pharmacies in an HIV program. DRUG HEALTHCARE AND PATIENT SAFETY 2012; 4:27-31. [PMID: 22570571 PMCID: PMC3345878 DOI: 10.2147/dhps.s23653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Self-initiation to antiretroviral treatment (ART) exposes the patient to the risk of drug toxicity, poor adherence to treatment, and escalates the development of drug resistance. Objectives To determine the sources of antiretroviral (ARV) drugs by unregistered human immunodeficiency virus (HIV)-infected patients and the extent of ARV self-medication. Methods Simulated clients were used to investigate availability and ARV dispensing practice in the private pharmacies in Dar Es Salaam, Tanzania. A total of 480 HIV-infected patients qualifying to start ART were interviewed to find out their previous use of ARV drugs prior to visiting the HIV clinics. Venous blood (2 mL) was collected from each patient who indicated not to have used ARVs in the past (n = 450). Blood samples were analyzed for the presence and levels of nevirapine (NVP). Results Only 5.1% (23/451) of pharmacies were found stocking ARVs drugs, among which 4.0% were retail. Drug dispensers in nearly all (15/18) retail pharmacies which stocked ARVs were willing to sell ARVs without prescription. Out of 450 enrolled patients, only 2.7% (12) stated that they had been receiving ARV drugs from HIV clinics but interrupted the ART treatment due to various reasons. From 450 patients, only 10% had quantifiable NVP concentrations in the blood, despite stating in an interview that they had not recently used ARVs. Conclusion Prior use of ARV drugs outside HIV clinics was rare among patients attending those centers. However, the results show that some patients could access and use ARV drugs from private pharmacies without undergoing ART eligibility assessment in HIV clinics.
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Affiliation(s)
- Omary Mashiku Minzi
- Unit of Pharmacology and Therapeutics, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
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Critical illness in HIV-infected patients in the era of combination antiretroviral therapy. Ann Am Thorac Soc 2011; 8:301-7. [PMID: 21653532 DOI: 10.1513/pats.201009-060wr] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
As HIV-infected persons on combination antiretroviral therapy (ART) are living longer and rates of opportunistic infections have declined, serious non-AIDS-related diseases account for an increasing proportion of deaths. Consistent with these changes, non-AIDS-related illnesses account for the majority of ICU admissions in more recent studies, in contrast to earlier eras of the AIDS epidemic. Although mortality after ICU admission has improved significantly since the earliest HIV era, it remains substantial. In this article, we discuss the current state of knowledge regarding the impact of ART on incidence, etiology, and outcomes of critical illness among HIV-infected patients. In addition, we consider issues related to administration of ART in the ICU and identify important areas of future research.
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Ncaca LN, Kranzer K, Orrell C. Treatment interruption and variation in tablet taking behaviour result in viral failure: a case-control study from Cape Town, South Africa. PLoS One 2011; 6:e23088. [PMID: 21858001 PMCID: PMC3152560 DOI: 10.1371/journal.pone.0023088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 07/11/2011] [Indexed: 01/05/2023] Open
Abstract
Background Understanding of the impact of non-structured treatment interruption (TI) and variation in tablet-taking on failure of first-line antiretroviral therapy (ART) is limited in a resource-poor setting. Methods A retrospective matched case-control analysis. Individuals failing ART were matched by time on ART with 4 controls. Viral load (VL) and CD4 count were completed 4-monthly. Adherence percentages, from tablet returns, were calculated 4-monthly (interval) and from ART start (cumulative). Variation between intervals and TI (>27 days off ART) were recorded. Conditional multivariate logistic regression analysis was performed to estimate the effect of cumulative adherence <90%, at least one episode of adherence variation >10% and TI on virological failure. Age, gender, baseline log VL and CD4 were included as possible confounders in the multivariate model. Results 244 patients (44 cases, 200 controls) were included. Median age was 32 years (IQR28–37), baseline CD4 108 cells/mm3 (IQR56–151), VL 4.82 log (IQR4.48–5.23). 94% (96% controls, 86% failures) had cumulative adherence >90%. The odds of failure increased 3 times (aOR 3.01, 95%CI 0.81–11.21) in individuals with cumulative adherence <90%, 2.2 times (aOR 2.20, 95%CI 1.04–4.64) in individuals with at least one episode of fluctuating adherence of >10% and 4.01 times (aOR 4.01, 95%CI 1.45–11.10) in individuals with TIs. For individuals with TI and cumulative adherence >95%, the odds of failing were 5.65 (CI 1.40–22.85). Conclusion It is well known that poor cumulative adherence increases risk of virological failure, but less well understood that TI and variations in tablet-taking also play a key role, despite otherwise excellent adherence.
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Affiliation(s)
- Lisa-Noelle Ncaca
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Katharina Kranzer
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Kranzer K, Ford N. Unstructured treatment interruption of antiretroviral therapy in clinical practice: a systematic review. Trop Med Int Health 2011; 16:1297-313. [PMID: 21718394 DOI: 10.1111/j.1365-3156.2011.02828.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To characterize the frequency, reasons, risk factors, and consequences of unstructured anti-retroviral treatment interruptions. METHOD Systematic review. RESULTS Seventy studies were included. The median proportion of patients interrupting treatment was 23% for a median duration of 150 days. The most frequently reported reasons for interruptions were drug toxicity, adverse events, and side-effects; studies from developing countries additionally cited treatment costs and pharmacy stock-outs as concerns. Younger age and injecting drug use was a frequently reported risk factor. Other risk factors included CD4 count, socioeconomic variables, and pharmacy stock outs. Treatment interruptions increased the risk of death, opportunistic infections, virologic failure, resistance development, and poor immunological recovery. Proposed interventions to minimize interruptions included counseling, mental health services, services for women, men, and ethnic minorities. One intervention study found that the use of short message service reminders decrease the prevalence of treatment interruption from 19% to 10%. Finally, several studies from Africa stressed the importance of reliable and free access to medication. CONCLUSION Treatment interruptions are common and contribute to worsening patient outcomes. HIV/AIDS programmes should consider assessing their causes and frequency as part of routine monitoring. Future research should focus on evaluating interventions to address the most frequently reported reasons for interruptions.
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Affiliation(s)
- Katharina Kranzer
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.
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