HIV virologic response better with single-tablet once daily regimens compared to multiple-tablet daily regimens

Viral load suppression and its predictor among HIV seropositive people who receive enhanced adherence counseling at public health institutions in Bahir Dar, Northwest Ethiopia. Retrospective follow-up study

BACKGROUND

For those HIV seropositive people with high viral loads, the World Health Organization recommends more counseling before changing ART regimens. A high viral load can lead to increased HIV transmission and lower survival rates. Clients with viral loads above 1000 copies/mL should receive enhanced adherence counseling for 3-6 months before switching. Despite enhanced adherence counseling programs, most countries struggle with viral load suppression. Little is known about viral load suppression in Ethiopia and the research area after counseling.

OBJECTIVE

This study aims to assess viral load suppression and its predictors among HIV-positive individuals receiving enhanced adherence counseling in Bahir Dar, Northwest Ethiopia, in 2022.

METHODS

An institution-based retrospective follow-up study was conducted among randomly selected 546 clients on Enhanced Adherence Counseling at public health facilities in Bahir Dar city. The Epicollect5 mobile application was used to collect the data, which was then exported to Stata version 14 for analysis. A Log-Binomial regression model was fitted for each explanatory variable. Variables having a p-value <0.25 in bivariate analysis were entered into a multivariable Log-Binomial regression model. Finally, an adjusted risk ratio with a 95% confidence interval and a p-value <0.05 was used to measure the strength of the prediction.

RESULTS

Following enhanced adherence counseling, 312 (57.1%) people had their viral load suppressed. Absence of recurrent OI (ARR 1.40; CI 1.03-1.91), EAC stay less than 3 months (ARR 1.54; CI 1.19-1.99), EAC stay 3-6 months (ARR 1.38; CI 1.12-1.69), once-daily ARV dose regimen (ARR 1.28; CI 1.03-1.58), baseline viral load of 2879.00 copies/ml (ARR 1.30, CI 1.06-1.60), being orthodox Tewahido Christian (ARR 0.37; CI 0.18-0.75) were significant predictors of viral load suppression after Enhanced Adherence Counseling.

CONCLUSION AND RECOMMENDATION

Most importantly, this study found that most people had suppressed viral loads after receiving enhanced adherence counseling. Significant predictors of viral load suppression included recurrent OI, length of stay on EAC, daily ARV dosing regimen, baseline viral load, and religion. Clients with a high baseline viral load and those who experience recurring opportunistic infections should get extra care during EAC sessions.

Trends and the associated factors of optimal immunological response and virological response in late anti-retroviral therapy initiation HIV cases in Taiwan from 2009 to 2020

BACKGROUND

Late cART initiation (CD4 count ≤200 cells/μL or AIDS-defining opportunistic illnesses [AOIs] at cART initiation) impedes CD4 count recovery and virologic suppression after cART initiation. However, studies to evaluate trends of and modifiable factors for optimal immunological response (IR) and virological response (VR) in people living with HIV (PLWH) with late cART initiation with the current HIV treatment strategies are limited.

METHODS

We retrospectively identified 475 PLWH with late cART initiation in 2009-2020. Patients were grouped based on the presence of IR (CD4 count ≥200 cells/μL) or VR (plasma viral load [PVL] ≤ 50 copies/mL) within 18 months after cART initiation (403 [84.8%] IR(+) and 72 [15.2%] IR(-); 422 [88.8%] VR(+) and 53 [11.2%] VR(-)). We used Joinpoint regression to identify IR (+) and VR(+) proportion changes.

RESULTS

From 2009 to 2020, the proportion of IR(+) patients remained unchanged (75% to 90%, P = 0.102), whereas that of VR(+) patients increased significantly (75% to 95%, P = 0.007). No join point was identified for either IR(+) or VR(+), and the annual percentage change was 0.56% (nonsignificant) and 1.35% (significant) for IR(+) and VR(+), respectively. Compared to IR(-) patients, IR(+) patients were more likely to have a higher pre-cART PVL, to start with a first-line INSTI-based regimen, or to start cART within 14 days of HIV diagnosis but were less likely to have chronic kidney disease, composite AOIs, or a lower pre-cART CD4 count. Compared to VR(-) patients, VR(+) patients were more likely to start a single-tablet regimen but were less likely to have a higher pre-cART PVL.

CONCLUSIONS

Our study identified several modifiable factors for optimal IR (rapid cART initiation and INSTI-based regimen initiation) and for optimal VR (STR initiation) among late initiators, which may guide early treatment modifications to reduce their AIDS-defining event incidence and mortality.

Improvements to Survey Design from Pilot Testing a Discrete-Choice Experiment of the Preferences of Persons Living with HIV for Long-Acting Antiretroviral Therapies

Background and Objective

Development of clear and effective discrete-choice experiment surveys is an important step toward ensuring accurate and usable preference results. Pretest interviews and pilot testing are common in the development of discrete-choice experiments, and it is important for researchers to report details of survey changes resulting from patient feedback elicited in pilot work. This paper details pilot testing of an online discrete-choice experiment to elicit preferences for long-acting antiretroviral therapies among patients with HIV.

Methods

The survey included an introduction to hypothetical treatment options, descriptions of attributes, comprehension questions, instructions for completing a discrete-choice experiment, a discrete-choice experiment with 17 choice tasks, and questions about personal characteristics. We piloted the survey with 50 respondents over ten waves. Each wave incorporated design improvements based on observations made during the previous wave. Respondents completed the online survey while screen sharing with a researcher, allowing interactive discussion. We developed a scheme for assessing and categorizing the survey changes.

Results

Changes to the pilot were categorized by ways they impacted aspects of the discrete-choice experiment or the likely quality of resulting data. The four categories of impact are: understanding of attributes, underlying discrete-choice experiment and understanding of the choice question, collection of individual characteristics hypothesized to affect preference, and changes that improved clarity and usability of the survey without directly affecting the other categories (e.g., survey navigation and instructional clarity, formatting changes).

Conclusions

Detailed attention to the respondent experience in this large pilot allowed survey improvements that will likely reduce ambiguity, ensure more accurate capture of patient preferences and, ultimately, improve product development for long-acting antiretroviral therapies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-022-00581-z.

The systematic development of attributes and levels for a discrete choice experiment of HIV patient preferences for long-acting antiretroviral therapies in the United States

INTRODUCTION

Patient preferences for long-acting antiretroviral therapies (LA-ART) should inform development of regimens with optimal adherence and acceptability. We describe a systematic process used to identify attributes and levels for a discrete choice experiment (DCE) designed to elicit preferences for potential LA-ART options in the US.

METHODS

Our approach was conducted in four stages: data collection, data reduction, removing inappropriate attributes, and optimizing wording. We started with 8 attributes defining potential LA-ART products based on existing literature and knowledge of products in development. We conducted 12 key informant interviews with experts in HIV treatment. The list of attributes, the set of plausible levels for each attribute, and restrictions on combinations of attribute levels were updated iteratively.

RESULTS

Despite uncertainty about which products will become available, key informant discussions converged on 4 delivery modes (infusions and patches were not considered immediately feasible) and 6 additional attributes. Treatment effectiveness and frequency of clinical monitoring were dropped. Oral lead-in therapy was split into two attributes: pre-treatment time undetectable and pre-treatment negative reaction testing. We omitted product-specific systemic and local side effects. In addition to mode, the final set of attributes included: frequency of dosing; location of treatment; pain; pre-treatment time undetectable; pre-treatment negative reaction testing; and late-dose leeway.

CONCLUSIONS

A systematic process successfully captured elements that are both feasible and relevant to evaluating the acceptability of potential LA-ART alternatives to patients.

Patient-reported outcomes among people living with HIV on single- versus multi-tablet regimens: Data from a real-life setting

BACKGROUND

The use of single-tablet regimens (STRs) in HIV treatment is ubiquitous. However, reintroducing the (generic) components as multi-tablet regimens (MTRs) could be an interesting cost-reducing strategy. It is essential to involve patient-reported outcome measures (PROs) to examine the effects of such an approach. Hence, this study compared PROs of people living with HIV taking an STR versus a MTR in a real world setting.

MATERIALS AND METHODS

This longitudinal study included 188 people living with HIV. 132 remained on a MTR and 56 switched to an STR. At baseline, months 1-3-6-12-18 and 24, participants filled in questionnaires on health-related quality of life (HRQoL), depressive symptoms, HIV symptoms, neurocognitive complaints (NCC), treatment satisfaction and adherence. Generalized linear mixed models and generalized estimation equations mixed models were built.

RESULTS

Clinical parameters and PROs of the two groups were comparable at baseline. Neurocognitive complaints and treatment satisfaction did differ over time among the groups. In the STR-group, the odds of having NCC increased monthly by 4,1% as compared to the MTR-group (p = 0.035). Moreover, people taking an STR were more satisfied with their treatment after 6 months: the median change score was high: 24 (IQR 7,5-29). Further, treatment satisfaction showed a contrary evolution in the groups: the estimated state score of the STR-group increased by 3,3 while it decreased by 0,2 in the MTR-group (p = 0.003). No differences over time between the groups were observed with regard to HRQoL, HIV symptoms, depressive symptoms and adherence.

CONCLUSIONS

Neurocognitive complaints were more frequently reported among people on an STR versus MTR. This finding contrasts with the higher treatment satisfaction in the STR-group over time. The long-term effects of both PROs should guide the decision-making on STRs vs. (generic) MTRs.

Cost-savings and potential cost-savings through the distribution of generic antiretroviral drugs within the statutory health insurance market of Germany between January 2017 and June 2019

Abstract

Background

Recent patent losses for antiretroviral drugs (ARV) have led to the debate of cost-saving through the replacement of patented drugs with generic drugs. The split of recommended single-tablet regimens (STR) into their single substance partners is one of the considerations mentioned in said debate. Particularly, generic tenofovir disoproxil/emtricitabine (TDF/FTC) is expected to hold untapped cost-saving potential, which may curb increasing overall expenditures for combined antiretroviral therapy (cART) within the statutory health insurance (SHI) of Germany.

Methods

Data of ARV reimbursed by the SHI were used to describe the trends of defined daily doses (DDD) as well as the revenue within the German ARV market. They were also used to determine the cost-savings of moving to generic drugs. The time period observed was between January 2017 and June 2019. The potential cost-savings were determined with following assumption in mind: the maximum possible use of generic ARV, including 1) the split of STR and replacing all substance partners with generic ones, and 2) replacing patented tenofovir alafenamide/emtricitabine (TAF/FTC) with generic TDF/FTC.

Results

Throughout the observation period, the DDD of generic ARV increased nearly five-fold while their revenue increased more than four-fold. Total cost-saving showed a sharp increase over the same period, with generic TDF/FTC accounting for a share of around 70%. The largest potential cost-saving could have been achieved through replacing patented TAF/FTC with generic TDF/FTC, peaking at nearly 10% of total revenue, but showing decreasing trends in general.

Conclusion

The progressive distribution of generic ARV ensured increasing cost-savings_, but consequently curbed the potential cost-savings. Unique price reductions of generic TDF/FTC have played a pivotal role for these effects. In any case, substituting with generic ARV should not fail to adhere to the treatment guidelines and continue to consider the medical requirements for the treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07390-4.

HIV pre-exposure prophylaxis and sexually transmitted infections: intersection and opportunity

Pre-exposure prophylaxis (PrEP) has revolutionized HIV prevention, but PrEP does not protect against other sexually transmitted infections (STIs). Rates of STIs are rising worldwide, with notably high incidences among PrEP-using men who have sex with men in high-income countries; in low-income and middle-income countries, data are sparse, but results from a limited number of studies among African women initiating and taking PrEP have shown high STI prevalence and incidence. Efforts aimed at markedly reducing HIV in populations worldwide include a major focus on increasing PrEP use, along with improving HIV testing and treatment in order to eliminate HIV transmission. Together, these efforts could augment continued expansion of the global STI epidemic, but they could alternatively create an opportunity to improve STI control, including the development of comprehensive sexual health programmes and research to develop new STI prevention strategies. The introduction of PrEP globally has been characterized by challenges and many successes, and its role as part of a range of robust strategies to reduce HIV infections is clear. Looking ahead, understanding rising rates of curable STIs and their relationship to HIV prevention, and considering the future directions for synergies in PrEP and STI prevention will be integral to improving sexual health.

Time to treatment disruption in children with HIV-1 randomized to initial antiretroviral therapy with protease inhibitors versus non-nucleoside reverse transcriptase inhibitors

BACKGROUND

Choice of initial antiretroviral therapy regimen may help children with HIV maintain optimal, continuous therapy. We assessed treatment-naïve children for differences in time to treatment disruption across randomly-assigned protease inhibitor versus non-nucleoside reverse transcriptase inhibitor-based initial antiretroviral therapy.

METHODS

We performed a secondary analysis of a multicenter phase 2/3, randomized, open-label trial in Europe, North and South America from 2002 to 2009. Children aged 31 days to <18 years, who were living with HIV-1 and treatment-naive, were randomized to antiretroviral therapy with two nucleoside reverse transcriptase inhibitors plus a protease inhibitor or non-nucleoside reverse transcriptase inhibitor. Time to first documented treatment disruption to any component of antiretroviral therapy, derived from treatment records and adherence questionnaires, was analyzed using Kaplan-Meier estimators and Cox proportional hazards models.

RESULTS

The modified intention-to-treat analysis included 263 participants. Seventy-two percent (n = 190) of participants experienced at least one treatment disruption during study. At 4 years, treatment disruption probabilities were 70% (protease inhibitor) vs. 63% (non-nucleoside reverse transcriptase inhibitor). The unadjusted hazard ratio (HR) for treatment disruptions comparing protease inhibitor vs. non-nucleoside reverse transcriptase inhibitor-based regimens was 1.19, 95% confidence interval [CI] 0.88-1.61 (adjusted HR 1.24, 95% CI 0.91-1.68). By study end, treatment disruption probabilities converged (protease inhibitor 81%, non-nucleoside reverse transcriptase inhibitor 84%) with unadjusted HR 1.11, 95% CI 0.84-1.48 (adjusted HR 1.13, 95% CI 0.84-1.50). Reported reasons for treatment disruptions suggested that participants on protease inhibitors experienced greater tolerability problems.

CONCLUSIONS

Children had similar time to treatment disruption for initial protease inhibitor and non-nucleoside reverse transcriptase inhibitor-based antiretroviral therapy, despite greater reported tolerability problems with protease inhibitor regimens. Initial pediatric antiretroviral therapy with either a protease inhibitor or non-nucleoside reverse transcriptase inhibitor may be acceptable for maintaining optimal, continuous therapy.

Impact of Pharmacy Type on HIV Viral Suppression: A Retrospective Cross-Sectional Cohort Study

Background

People with HIV (PWH) use various pharmacy types beyond traditional local pharmacies. Some specialized pharmacies offer additive adherence services such as refill reminders, expedited delivery, and adherence packaging.

Methods

This single-center, retrospective cohort study evaluated the impact of pharmacy type on the gain or loss of HIV viral suppression (VS; HIV RNA ≤50 copies/mL). Patients (≥19 years) were categorized by VS and pharmacy type: HIV-specialized (additive adherence/delivery services) vs traditional (without adherence/delivery services). Fisher exact tests examined the effect of pharmacy type on differences in VS between years, and logistic regression models identified possible predictors of gaining or losing VS.

Results

During 2017–2018, no differences were observed for the gain or loss of VS across pharmacy types (VS gain vs continued viremia, P = .393; VS loss vs continued VS, P = .064). Predictors for the gain of VS included antiretroviral therapy adherence as percentage of days covered (PDC; adjusted odds ratio [aOR], 1.05; P < .001) and Federal Poverty Level 100%–138% (FPL; aOR, 0.17; P = .032). Predictors for the loss of VS included use of protease inhibitor (aOR, 2.85; P = .013), ≥1 other illicit substance including tobacco (aOR, 2.96; P = .024), PDC (aOR, 0.95; P < .001), FPL 139%–200% (aOR, 0.09; P = .031), and CD4 >200 cells/ccm (aOR, 0.19; P = .013).

Conclusions

The gain or loss of VS among PWH in this retrospective cohort was not impacted by pharmacy transitions within the 2-year study period. However, PDC, FPL, illicit substance use, protease inhibitor use, and CD4 >200 cells/ccm were identified as factors associated with changes in VS.

The New NNRTI ACC007 Combined with Lamivudine and Tenofovir Disoproxil Fumarate Show Synergy Anti-HIV Activity In Vitro

BACKGROUND

Acquired immunodeficiency syndrome can hardly be cured currently and people with human immunodeficiency virus (HIV) need lifelong treatment that may result in the emergence of drug resistance which leads to failed treatment. Thus, the development of new anti- HIV drugs and new treatment regimens are necessary.

OBJECTIVE

The aim of this study is to analyze the combined anti-HIV activity of tenofovir disoproxil fumarate, lamivudine and ACC007, a new non-nucleoside reverse transcriptase inhibitor.

METHODS

The antiviral activity of tenofovir disoproxil fumarate, lamivudine and ACC007 alone or in combination against different HIV-1 strains was determined by the detection of HIV-1 p24 level through enzyme-linked immunosorbent assay.

RESULT

ACC007 showed EC50 of nanomolar range (from 3.03 nM to 252.59 nM) against all HIV-1 strains used in this study except the HIV-1A17, with EC50 of 1.57 μM. The combined antiviral activity of ACC007, lamivudine and tenofovir disoproxil fumarate showed synergy antiviral activity against all HIV-1 strains used in this study. The three-drug combination showed moderate synergism against HIV-1A17, HIV-14755-5, HIV-1K103N and HIV-1V106M, with a combination index value ranging from 0.71 to 0.87, and showed synergism against the other HIV-1 strains with combination index value from 0.35 to 0.67. The combination with ACC007 significantly increases the dose reduction index value of lamivudine and tenofovir disoproxil fumarate, compared with two-drug combination.

CONCLUSION

ACC007 exhibits potent antiviral activity alone or with 3TC and TDF, and exerts synergistic effect against all HIV strains used in our investigation in vitro.