Understanding early HIV-1 rebound dynamics following antiretroviral therapy interruption: The importance of effector cell expansion

Most people living with HIV-1 experience rapid viral rebound once antiretroviral therapy is interrupted; however, a small fraction remain in viral remission for an extended duration. Understanding the factors that determine whether viral rebound is likely after treatment interruption can enable the development of optimal treatment regimens and therapeutic interventions to potentially achieve a functional cure for HIV-1. We built upon the theoretical framework proposed by Conway and Perelson to construct dynamic models of virus-immune interactions to study factors that influence viral rebound dynamics. We evaluated these models using viral load data from 24 individuals following antiretroviral therapy interruption. The best-performing model accurately captures the heterogeneity of viral dynamics and highlights the importance of the effector cell expansion rate. Our results show that post-treatment controllers and non-controllers can be distinguished based on the effector cell expansion rate in our models. Furthermore, these results demonstrate the potential of using dynamic models incorporating an effector cell response to understand early viral rebound dynamics post-antiretroviral therapy interruption.

Healthcare Resource Consumption and Related Costs in Patients on Antiretroviral Therapies: Findings from Real-World Data in Italy

This real-world analysis conducted on administrative databases of a sample of Italian healthcare entities was aimed at describing the role of therapeutic pathways and drug utilization in terms of adherence, persistence, and therapy discontinuation in HIV-infected patients under antiretroviral therapies (ART) and Tenofovir Alafenamide (TAF)-based regimens on healthcare resource consumption and related direct healthcare costs. Between 2015 and 2019, adults (≥18 years) prescribed with TAF-based therapies were identified and characterized in the year prior to the first prescription (index-date) for TAF-based therapies and followed-up until the end of data availability. Overall, 2658 ART-treated patients were included, 1198 of which were under a TAF-based regimen. TAF-based therapies were associated with elevated percentages of adherence (83.3% patients with proportion of days covered, PDC > 95% and 90.6% with PDC > 85%) and persistence (78.5%). The discontinuation rate was low in TAF-treated patients, ranging from 3.3% in TAF-switchers to 5% in naïve. Persistent patients had lower overall mean annual healthcare expenditures (EUR 11,106 in persistent vs. EUR 12,380 in non-persistent, p = 0.005), and this trend was statistically significant also for costs related to HIV hospitalizations. These findings suggest that a better therapeutic management of HIV infection might result in positive clinical and economic outcomes.

Drivers of HIV-1 drug resistance to non-nucleoside reverse-transcriptase inhibitors (NNRTIs) in nine southern African countries: a modelling study

INTRODUCTION

The rise of HIV-1 drug resistance to non-nucleoside reverse-transcriptase inhibitors (NNRTI) threatens antiretroviral therapy's long-term success (ART). NNRTIs will remain an essential drug for the management of HIV-1 due to safety concerns associated with integrase inhibitors. We fitted a dynamic transmission model to historical data from 2000 to 2018 in nine countries of southern Africa to understand the mechanisms that have shaped the HIV-1 epidemic and the rise of pretreatment NNRTI resistance.

METHODS

We included data on HIV-1 prevalence, ART coverage, HIV-related mortality, and survey data on pretreatment NNRTI resistance from nine southern Africa countries from a systematic review, UNAIDS and World Bank. Using a Bayesian hierarchical framework, we developed a dynamic transmission model linking data on the HIV-1 epidemic to survey data on NNRTI drug resistance in each country. We estimated the proportion of resistance attributable to unregulated, off-programme use of ART. We examined each national ART programme's vulnerability to NNRTI resistance by defining a fragility index: the ratio of the rate of NNRTI resistance emergence during first-line ART over the rate of switching to second-line ART. We explored associations between fragility and characteristics of the health system of each country.

RESULTS

The model reliably described the dynamics of the HIV-1 epidemic and NNRTI resistance in each country. Predicted levels of resistance in 2018 ranged between 3.3% (95% credible interval 1.9-7.1) in Mozambique and 25.3% (17.9-33.8) in Eswatini. The proportion of pretreatment NNRTI resistance attributable to unregulated antiretroviral use ranged from 6% (2-14) in Eswatini to 64% (26-85) in Mozambique. The fragility index was low in Botswana (0.01; 0.0-0.11) but high in Namibia (0.48; 0.16-10.17), Eswatini (0.64; 0.23-11.8) and South Africa (1.21; 0.83-9.84). The combination of high fragility of ART programmes and high ART coverage levels was associated with a sharp increase in pretreatment NNRTI resistance.

CONCLUSIONS

This comparison of nine countries shows that pretreatment NNRTI resistance can be controlled despite high ART coverage levels. This was the case in Botswana, Mozambique, and Zambia, most likely because of better HIV care delivery, including rapid switching to second-line ART of patients failing first-line ART.

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.

Predominance of positive epistasis among drug resistance-associated mutations in HIV-1 protease

Drug-resistant mutations often have deleterious impacts on replication fitness, posing a fitness cost that can only be overcome by compensatory mutations. However, the role of fitness cost in the evolution of drug resistance has often been overlooked in clinical studies or in vitro selection experiments, as these observations only capture the outcome of drug selection. In this study, we systematically profile the fitness landscape of resistance-associated sites in HIV-1 protease using deep mutational scanning. We construct a mutant library covering combinations of mutations at 11 sites in HIV-1 protease, all of which are associated with resistance to protease inhibitors in clinic. Using deep sequencing, we quantify the fitness of thousands of HIV-1 protease mutants after multiple cycles of replication in human T cells. Although the majority of resistance-associated mutations have deleterious effects on viral replication, we find that epistasis among resistance-associated mutations is predominantly positive. Furthermore, our fitness data are consistent with genetic interactions inferred directly from HIV sequence data of patients. Fitness valleys formed by strong positive epistasis reduce the likelihood of reversal of drug resistance mutations. Overall, our results support the view that strong compensatory effects are involved in the emergence of clinically observed resistance mutations and provide insights to understanding fitness barriers in the evolution and reversion of drug resistance.

Association between HIV stigma and antiretroviral therapy adherence among adults living with HIV: baseline findings from the HPTN 071 (PopART) trial in Zambia and South Africa

OBJECTIVES

Adherence to antiretroviral therapy (ART) leads to viral suppression for people living with HIV (PLHIV) and is critical for both individual health and reducing onward HIV transmission. HIV stigma is a risk factor that can undermine adherence. We explored the association between HIV stigma and self-reported ART adherence among PLHIV in 21 communities in the HPTN 071 (PopART) trial in Zambia and the Western Cape of South Africa.

METHODS

We conducted a cross-sectional analysis of baseline data collected between 2013 and 2015, before the roll-out of trial interventions. Questionnaires were conducted, and consenting participants provided a blood sample for HIV testing. Poor adherence was defined as self-report of not currently taking ART, missing pills over the previous 7 days or stopping treatment in the previous 12 months. Stigma was categorised into three domains: community, health setting and internalised stigma. Multivariable logistic regression was used for analysis.

RESULTS

Among 2020 PLHIV self-reporting ever taking ART, 1888 (93%) were included in multivariable analysis. Poor ART adherence was reported by 15.8% (n = 320) of participants, and 25.7% (n = 519) reported experiencing community stigma, 21.5% (n = 434) internalised stigma, and 5.7% (n = 152) health setting stigma. PLHIV who self-reported previous experiences of community and internalised stigma more commonly reported poor ART adherence than those who did not (aOR 1.63, 95% CI 1.21 -2.19, P = 0.001 and aOR 1.31, 95% CI 0.96-1.79, P = 0.09).

CONCLUSIONS

HIV stigma was associated with poor ART adherence. Roll-out of universal treatment will see an increasingly high proportion of PLHIV initiated on ART. Addressing HIV stigma could make an important contribution to supporting lifelong ART adherence.

Antiretroviral Adherence Level Necessary for HIV Viral Suppression Using Real-World Data

BACKGROUND

A benchmark of near-perfect adherence (≥95%) to antiretroviral therapy (ART) is often cited as necessary for HIV viral suppression. However, given newer, more effective ART medications, the threshold for viral suppression may be lower. We estimated the minimum ART adherence level necessary to achieve viral suppression.

SETTINGS

The Patient-centered HIV Care Model demonstration project.

METHODS

Adherence to ART was calculated using the proportion of days covered measure for the 365-day period before each viral load test result, and grouped into 5 categories (<50%, 50% to <80%, 80% to <85%, 85% to <90%, and ≥90%). Binomial regression analyses were conducted to determine factors associated with viral suppression (HIV RNA <200 copies/mL); demographics, proportion of days covered category, and ART regimen type were explanatory variables. Generalized estimating equations with an exchangeable working correlation matrix accounted for correlation within subjects. In addition, probit regression models were used to estimate adherence levels required to achieve viral suppression in 90% of HIV viral load tests.

RESULTS

The adjusted odds of viral suppression did not differ between persons with an adherence level of 80% to <85% or 85% to <90% and those with an adherence level of ≥90%. In addition, the overall estimated adherence level necessary to achieve viral suppression in 90% of viral load tests was 82% and varied by regimen type; integrase inhibitor- and nonnucleoside reverse transcriptase inhibitor-based regimens achieved 90% viral suppression with adherence levels of 75% and 78%, respectively.

CONCLUSIONS

The ART adherence level necessary to reach HIV viral suppression may be lower than previously thought and may be regimen-dependent.

Analysis of Systematic Reviews of Medication Adherence Interventions for Persons with HIV, 1996-2017

This overview of reviews summarizes the evidence from systematic reviews (SR) on the effectiveness of antiretroviral therapy (ART) adherence interventions for people with HIV (PWH) and descriptively compares adherence interventions among key populations. Relevant articles published during 1996-2017 were identified by comprehensive searches of CDC's HIV/acquired immunodeficiency syndrome (AIDS) Prevention Research Synthesis Database and manual searches. Included SRs examined primary interventions intended to improve ART adherence, focused on PWH, and assessed medication adherence or biologic outcomes (e.g., viral load). We synthesized the qualitative data and used the Assessment of Multiple Systematic Reviews (AMSTAR) for quality assessment. Forty-one SRs met inclusion criteria. Average quality was high. SRs that evaluated text-messaging interventions (n = 9) consistently reported statistically significant improvements in adherence and biologic outcomes. Other ART adherence strategies [e.g., behavioral, directly administered antiretroviral therapy (DAART)] reported improvements, but did not report significant effects for both outcomes, or intervention effects that did not persist postintervention. In the review focused on people who inject drugs (n = 1), DAART alone or in combination with medication-assisted therapy improved both outcomes. In SRs focused on children or adolescents aged <18 years (n = 5), regimen-related and hospital-based DAART improved biologic outcomes. ART adherence interventions (e.g., text-messaging) improved adherence and biologic outcomes; however, results differed for other intervention strategies, populations, and outcomes. Because few SRs reported evidence for populations at high risk (e.g., men who have sex with men), the results are not generalizable to all PWH. Future implementation studies are needed to examine medication adherence interventions in specific populations and address the identified gaps.

The Potential Protective Role of Vitamin D Supplementation on HIV-1 Infection

HIV infection remains a global and public health issue with the incidence increasing in some countries. Despite the fact that combination antiretroviral therapy (cART) has decreased mortality and increased the life expectancy of HIV-infected individuals, non-AIDS conditions, mainly those associated with a persistent inflammatory state, have emerged as important causes of morbidity, and mortality despite effective antiviral therapy. One of the most common comorbidities in HIV-1 patients is Vitamin D (VitD) insufficiency, as VitD is a hormone that, in addition to its physiological role in mineral metabolism, has pleiotropic effects on immune regulation. Several reports have shown that VitD levels decrease during HIV disease progression and correlate with decreased survival rates, highlighting the importance of VitD supplementation during infection. An extensive review of 29 clinical studies of VitD supplementation in HIV-infected patients showed that regardless of cART, when VitD levels were increased to normal ranges, there was a decrease in inflammation, markers associated with bone turnover, and the risk of secondary hyperparathyroidism while the anti-bacterial response was increased. Additionally, in 3 of 7 studies, VitD supplementation led to an increase in CD4+ T cell count, although its effect on viral load was inconclusive since most patients were on cART. Similarly, previous evidence from our laboratory has shown that VitD can reduce the infection of CD4+ T cells in vitro. The effect of VitD supplementation on other HIV-associated conditions, such as cardiovascular diseases, dyslipidemia or hypertension, warrants further exploration. Currently, the available evidence suggests that there is a potential role for VitD supplementation in people living with HIV-1, however, comprehensive studies are required to define an adequate supplementation protocol for these individuals.

Adherence Measurements in HIV: New Advancements in Pharmacologic Methods and Real-Time Monitoring

PURPOSE OF REVIEW

In this review, we present new developments in antiretroviral adherence, focusing on pharmacological measures and real-time adherence monitoring. In addition, new strategies on how to incorporate these new measures into research and clinical care are proposed.

RECENT FINDINGS

Antiretroviral drug concentrations in hair and dried blood spots are two novel pharmacological measures of cumulative drug adherence and exposure that have been recently evaluated in HIV treatment and pre-exposure prophylaxis. Real-time adherence monitoring using electronic devices has also proven highly informative, feasible, and well accepted, offering the possibility for an immediate intervention when non-adherence is detected. Both approaches offer considerable advantages over traditional adherence measures in predicting efficacy. New methods to objectively monitor adherence in real-time and over long time periods have been developed. Further research is required to better understand how these measures can optimize adherence and, ultimately, improve clinical outcomes in HIV treatment and prevention.

Tenofovir Diphosphate in Dried Blood Spots Is Strongly Associated With Viral Suppression in Individuals With Human Immunodeficiency Virus Infections

BACKGROUND

Although tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is a predictor of adherence and pre-exposure prophylaxis efficacy, its utility in human immunodeficiency virus (HIV) treatment remains unknown.

METHODS

DBS for TFV-DP were collected up to 3 times over 48 weeks in persons living with HIV (PLWH) who were receiving TFV disoproxil fumarate (TDF)-based therapy. Log-transformed baseline TFV-DP was compared using t-tests or analyses of variance; generalized estimating equations were used to estimate the adjusted odds ratio (aOR) of viral suppression (<20 copies/mL) based on the TFV-DP concentration at the study visit.

RESULTS

We analyzed 1199 DBS from 532 participants (76 female; 101 Black, 101 Hispanic). Among the virologically-suppressed participants at baseline (n = 347), TFV-DP was lower in Blacks (geometric mean 1453, 95% confidence interval [CI] 1291-1635) vs Whites (1793, 95% CI 1678-1916; P = .002) and Hispanics (1760, 95% CI 1563-1982; P = .025); in non-boosted (1610, 95% CI 1505-1723) vs. boosted (1888, 95% CI 1749-2037; P = .002) regimens; and in non-nucleoside reverse transcription inhibitor-based (1563, 95% CI 1432-1707) vs. boosted protease inhibitor-based (1890, 95% CI 1704-2095; P = .006) and multiclass-based (1927, 95% CI 1650-2252; P = .022) regimens. The aOR of virologic suppression, after adjusting for age, gender, race, body mass index, estimated glomerular filtration rate, CD4+ T-cell count, antiretroviral drug class and duration of therapy, was 73.5 (95% CI 25.7-210.5; P < .0001) for a TFV-DP concentration ≥1850 fmol/punch compared to <350 fmol/punch.

CONCLUSIONS

TFV-DP in DBS is strongly associated with virologic suppression in PLWH on TDF-based therapy and is associated with certain participant characteristics. Further research is required to evaluate this drug adherence and exposure measure in clinical practice.

CLINICAL TRIALS REGISTRATION

NCT02012621.

Switching strategies in the recent era of antiretroviral therapy

INTRODUCTION

Although antiretroviral therapy is highly effective, many patients may benefit from switching strategies. Rapid advances in the development of new antiretroviral drugs could enhance the success of these approaches. In this review, we build on a previous review from 2014 and summarize the current options for switching strategies in virologically suppressed HIV-infected patients. Areas covered: We conduct a critical analysis of scientific evidence for various switching strategies used in the modern era of antiretroviral therapy, as well as reasons for these approaches, other considerations to be taken into account, and alternative strategies. Expert opinion: Current antiretroviral regimens are effective and well tolerated in HIV patients. A number of options may provide benefit to patients, even virologically suppressed patients, possibly enhancing adherence and avoiding adverse effects and toxicities. Cost reduction may also be an important goal of switching strategies. The present scenario is excellent, as many good antiretroviral compounds and regimens allow clinicians to further improve on effective treatments now used in routine practice. Even the current paradigm of triple-drug regimens as the standard of care could change, at least in some patients.

Moderately High Tenofovir Diphosphate in Dried Blood Spots Indicates Drug Resistance in Viremic Persons Living with HIV

BACKGROUND

Tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is a strong predictor of viral suppression in persons living with HIV (PLWH). Its association with antiretroviral therapy (ART) resistance remains unknown.

METHODS

Blood was collected in PLWH receiving TDF-containing ART enrolled in a 48-week study. Tenofovir diphosphate/emtricitabine triphosphate (FTC-TP) were quantified from the same sample as HIV viral load (VL) in PLWH who developed resistance within ≤12 months.

RESULTS

The study enrolled 807 participants, of whom 10 had new resistance-conferring mutations. Among these, median (interquartile range) TFV-DP and HIV VL were 956 (407-1510) fmol/punch and 9840 (513-68,200) copies/mL, respectively. Five had quantifiable FTC-TP in DBS. Based on previously published data, a TFV-DP concentration of 956 fmol/punch would have an adjusted odds of virologic suppression of 32.8 versus TFV-DP <350 fmol/punch, making viremia of ∼10,000 copies/mL an unexpected outcome.

CONCLUSION

Moderately high TFV-DP in DBS (700-1249 fmol/punch) in PLWH with high viremia suggest that antiretroviral drug resistance might be present.

Compliance with clinical guidelines and adherence to antiretroviral therapy among patients living with HIV

Objective: Evaluation of provider compliance with antiretroviral (ARV) treatment guidelines and patient adherence to ARVs is important for HIV care quality assessment; however, there are few current real-world data for guideline compliance and ARV adherence in the US. This study evaluated provider compliance with US Department of Health and Human Services (DHHS) guidelines and patient adherence to ARVs in a US population of patients with HIV.Methods: This was a retrospective claims study of adults with HIV-1 receiving ARV treatment between January 2010-December 2014. Follow-up began at first ARV treatment and ended at health plan disenrollment or study end. ARV regimens for treatment-naïve patients were categorized as "preferred/recommended", "alternative", or "non-preferred/recommended/alternative" according to DHHS guidelines. ARV adherence was evaluated using proportion of days covered (PDC) and medication possession ratio (MPR).Results: The analysis included 25,320 patients (84.4% male, mean age 45.3 years) and 39,071 regimens. Preferred/recommended regimens were most common during each study year, but the proportion of non-preferred/recommended/alternative regimens was substantial (15.9-20.6%). Only 53.6% of patients had optimal adherence by PDC ≥0.95, and 57.9% by MPR ≥0.95. Guideline non-compliance and sub-optimal adherence were more prevalent among female vs male patients (22.6% vs 14.8% [in 2014] and 65.9% vs 53.7%, respectively).Conclusions: Provider non-compliance with DHHS guidelines and sub-optimal ARV adherence among patients with HIV remain common in real-world practice, particularly for female patients. Healthcare providers should follow the latest clinical guidelines to ensure that patients receive recommended therapy, and address non-adherence when selecting ARV regimens.

A Systematic Review of Medication Adherence Thresholds Dependent of Clinical Outcomes

Background: In pharmacotherapy, the achievement of a target clinical outcome requires a certain level of medication intake or adherence. Based on Haynes's early empirical definition of sufficient adherence to antihypertensive medications as taking ≥80% of medication, many researchers used this threshold to distinguish adherent from non-adherent patients. However, we propose that different diseases, medications and patient's characteristics influence the cut-off point of the adherence rate above which the clinical outcome is satisfactory (thereafter medication adherence threshold). Moreover, the assessment of adherence and clinical outcomes may differ greatly and should be taken into consideration. To our knowledge, very few studies have defined adherence rates linked to clinical outcomes. We aimed at investigating medication adherence thresholds in relation to clinical outcomes.

Method: We searched for studies that determined the relationship between adherence rates and clinical outcomes in the databases PubMed, Embase^Ⓡ and Web of Science™ until December 2017, limited to English-language. Our outcome measure was any threshold value of adherence. The inclusion criteria of the retrieved studies were (1) any measurement of medication adherence, (2) any assessment of clinical outcomes, and (3) any method to define medication adherence thresholds in relation to clinical outcomes. We excluded articles considered as a tutorial. Two authors (PB and IA) independently screened titles and abstracts for relevance, reviewed full-texts, and extracted items. The results of the included studies are presented qualitatively.

Result: We analyzed 6 articles that assessed clinical outcomes linked to adherence rates in 7 chronic disease states. Medication adherence was measured with Medication Possession Ratio (MPR, n = 3), Proportion of Days Covered (PDC, n = 1), both (n = 1), or Medication Event Monitoring System (MEMS). Clinical outcomes were event free episodes, hospitalization, cortisone use, reported symptoms and reduction of lipid levels. To find the relationship between the targeted clinical outcome and adherence rates, three studies applied logistic regression and three used survival analysis. Five studies defined adherence thresholds between 46 and 92%. One study confirmed the 80% threshold as valid to distinguish adherent from non-adherent patients.

Conclusion: The analyzed studies were highly heterogeneous, predominantly concerning methods of calculating adherence. We could not compare studies quantitatively, mostly because adherence rates could not be standardized. Therefore, we cannot reject or confirm the validity of the historical 80% threshold. Nevertheless, the 80% threshold was clearly questioned as a general standard.

Distance to HIV care and treatment adherence: Adjusting for socio-demographic and geographical heterogeneity

Distance to health services plays an important role in determining access to care and an individual's health. This study aims to examine the relationship between distance to antiretroviral therapy (ART) prescribing physician and adherence to HIV treatment in British Columbia, Canada. Only participants who provided highly accurate locational data for both place of residence and their physician were used in the analysis. Using logistic regression, a multivariable confounder model was created to assess the association between distance and adherence. A geographically weighted logistic regression was also performed to adjust for spatial dependency. There were 1528 participants in the analysis, for a median distance of 17.85km. The final model showed further away from ART prescribing physician had a higher chance of incomplete adherence to ART (adjusted odds ratio 1.31; 95% Confidence Interval 1.04-1.65). Mobile services could potentially increase adherence rates for population residing further away from their ART prescribing physician.

The use of illustrated medication diaries to improve outcomes for children initiated on highly active antiretroviral therapy

Background: Human immunodeficiency virus (HIV) represents a huge burden of disease in South Africa. Highly active antiretroviral therapy (HAART) is effective in reducing HIV-related morbidity and mortality. Simple, inexpensive methods like adherence diaries to optimise effects of HAART would be useful.Methods: This quasi-experimental study was performed at a paediatric antiretroviral clinic in KwaZulu-Natal, South Africa. Children, from birth to 15 years, initiated on HAART from 01 August 2015 to 31 July 2016 were given illustrated medication diaries to be completed by caregivers. Viral load suppression and improvement in growth parameters and CD4+ percentage were determined at six months and one year. These outcomes were compared to those of a group of children who had been initiated on HAART from 01 August 2014 to 31 July 2015 and who had not received diaries.Results: Ninety-nine children were included in the historical control group and 35 children in the intervention group. Viral load suppression (HIV-1 RNA of < 400 copies/mL) was 72% in the control group and 71% in the diary group at 6 months (p = 0.6). At 12 months, 73% of children in the control group and 57% of the diary group had suppressed viral loads (p = 0.18). At 6 months, 63% of children in the control group and 57% of the diary group had improved weight for height z-scores (p = 0.09). At 12 months, when compared with baseline weight for height z-scores, there was improvement in 34% and 41% of the control and diary groups, respectively (p = 0.6). CD4+ percentages improved in 51% of the control group and 50% of the diary group at 6 months (p = 0.70); improvement was noted in 44% and 49%, respectively, at 12 months (p = 0.33).Conclusion: The addition of an illustrated medication diary to routine adherence counselling did not improve outcomes for children initiated on HAART.

Single tablet HIV regimens facilitate virologic suppression and retention in care among treatment naïve patients

Newer HIV regimens are typically taken once daily but vary in the number of pills required. Whether the number of pills in a once-daily HIV regimen affects clinical outcomes is unknown. We retrospectively compared adherence, retention in care, and virologic outcomes between patients starting a once daily single-tablet regimen (STR) to patients starting a once-daily multi-tablet regimen (MTR) in a publicly funded clinic in the United States. Outcomes were measured in the year after starting ART and included retention in care, virologic suppression, and medication possession ratio of at least 80%. Data from patients initiating therapy from 1 January 2008 to 31 December 2011 were analyzed with both unadjusted and propensity-score adjusted regression. Overall, 622 patients started with an STR (100% efavirenz-based) and 406 with an MTR (65% atazanavir-based and 35% darunavir-based) regimen. Retention in care was achieved in 80.7% of STR patients vs. 72.7% of MTR patients (unadjusted OR 1.57, 95% CI 1.17-2.11; adjusted OR 1.49, 95% CI 1.10-2.02). Virologic suppression occurred among 84.4% of STR patients vs. 77.6% of MTR patients (unadjusted OR 1.56; 95% CI 1.14-2.15; adjusted OR 1.41; 95% CI 1.02-1.96). There was no difference in the proportion of patients achieving at least 80% adherence, as measured by medication possession ratio (33.0% of STR patients and 30.1% of MTR patients; unadjusted OR 1.14; 95% CI 0.87-1.50; adjusted OR 1.04, CI 0.79-1.38). While it is difficult to eliminate confounding in this observational study, retention in care and virologic outcomes were better in patients prescribed STRs.

Adherence and virologic outcomes among treatment-naïve veteran patients with human immunodeficiency virus type 1 infection

Many studies have estimated the association between the adherence to antiretroviral therapies and human immunodeficiency virus (HIV) patients' virologic/immunologic outcomes. However, evidence is lacking on the causal effect of adherence on the outcomes. The goal of this study is to understand whether near perfect adherence is necessary to achieve optimal virologic outcome and also to investigate the effect of initial adherence to antiretroviral therapies on initial viral suppression by different regimens. A cohort study was conducted on HIV veterans initiating antiretroviral therapies in 1999 to 2015. The primary outcome was the first viral suppression occurred within 30 to 60 days since the index date. Multiple imputation was used to impute the missing value of virologic outcomes. The inverse probability of treatment weighting (IPTW) method was applied to estimate the viral suppression rate at each specific adherence category for each regimen category. Marginal structural models with IPTW were used to estimate the risk of viral suppression in lower-adherence categories in comparison to near-perfect adherence level ≥95%. Data showed that lower adherence caused lower viral suppression rate, with the association differentiated by the regimen. Patients on integrase strand transfer had the highest viral suppression rate, with patients on protease inhibitors having the lowest rate. Regardless of regimens, the viral suppression rate among patients at initial adherence of 75 to <95% was not statistically different from patients at adherence of ≥95%; however, the differences might be clinically significant.

Predicting poor adherence to antiretroviral therapy among treatment-naïve veterans infected with human immunodeficiency virus

Previous studies suggested that human immunodeficiency virus (HIV) infected patients at risk of poor adherence were not distinguishable only based on the baseline characteristics. This study is to identify patient characteristics that would be consistently associated with poor adherence across regimens and to understand the associations between initial and long-term adherence. HIV treatment-naïve patients initiated on protease inhibitors, nonnucleoside reverse transcriptase inhibitors, or integrase strand transfer inhibitors were identified from the Veteran Health Administration system. Initial adherence measured as initial coverage ratio (ICR) and long-term adherence measured as thereafter 1-year proportion days covered (PDC) of base agent and complete regimen were estimated for each patient. The patients most likely to exhibit poor adherence were African-American, with lower socioeconomic status, and healthier. The initial coverage ratio of base agent and complete regimen were highly correlated, but the correlations between ICR and thereafter 1-year PDC were low. However, including initial adherence as a predictor in predictive model would substantially increase predictive accuracy of future adherence.

Reporting quality of randomized controlled trials in patients with HIV on antiretroviral therapy: a systematic review

BACKGROUND

To allow for correct evaluation of clinical trial results, readers require comprehensive, clear, and highly transparent information on the methodology used and the results obtained. This study aimed to evaluate the quality of reporting in articles on randomized controlled trials (RCTs) of antiretroviral therapy (ART) in the field of HIV/AIDS.

METHODS

We searched for original articles on RCTs of ART developed in the field of HIV/AIDS in PubMed database by 5 April 2016. Searched articles were divided into three groups based on the revision year in which the Consolidated Standards of Reporting Trials (CONSORT) guidelines were published: Period 1 (1996-2001); Period 2 (2002-2010); and Period 3 (2011-2016). We evaluated the articles using the reporting rates of the 37 items in the CONSORT 2010 checklist, five items in the protocol deviation, and the three items in the ethics.

RESULTS

Fifty-two articles were extracted and included in this study. Many of the reporting rates calculated using the CONSORT 2010 checklist showed a significantly increasing trend over the successive periods (65% in Period 1, 67% in Period 2, 79% in Period 3; p < 0.0001). The items with reporting rates < 50% were "the presence or absence of a protocol change and the reason for such a change," "randomization and blinding," and "where the full trial protocol can be accessed." Reporting rates of deviations were as low as < 30%, while the reporting rates for patient compliance were the highest (>80% in Period 3) among the five items. The reporting rates for obtaining informed consent and approval by the ethics committee or institutional review board were high (>88%), regardless of the time period assessed.

CONCLUSION

In terms of representative RCT articles in the field of HIV/AIDS, the reporting rate of the items defined by CONSORT was approximately 70%, improving over the successive CONSORT statement revision periods.

Reduced adherence to antiretroviral therapy is associated with residual low-level viremia

The source and significance of residual low-level viremia (LLV) during combinational antiretroviral therapy (cART) remain a matter of controversy. It is unclear whether residual viremia depends on ongoing release of HIV from the latent reservoir or if viral replication contributes to LLV. We examined the relationship between adherence and LLV. Adherence was estimated by pharmacy refill and dichotomized as ≥95% or <95%. Plasma HIV-RNA was determined, with an ultrasensitive test having a limit of detection of 3 copies/mL at least 2 times over the follow-up period. Patients were grouped according to HIV-RNA over time as K<3: constantly <3 copies/mL; V<3: sometimes below or above the cutoff limit but always <50 copies/mL; K>3: constantly between 3 and 50 copies/mL; and V>50: a measure of >50 copies/mL minimum. Overall, 2789 patients were included. At each time point approximately 92% of the patients presented an HIV-RNA <50 copies/mL and two-thirds of those <3 copies/mL, 34.6% of patients had <3 copies/mL constantly, 32.7% sometimes below or above the cutoff limit but always <50 copies/mL, 9.5% constantly between 3 and 50 copies/mL, and 23.2% a measure of >50 copies/mL minimum. The mean adherence rate was 92.1% (95% confidence interval [CI] from 91.1% to 93.1%) in K<3 patients, similar in V<3 patients (91.9%), but lowered to 88.8% in K>3 patients and to 88.4% in V>50 patients (P<0.0001). Approximately 55% of patients in groups K<3 and V<3 showed an adherence rate ≥95%; this proportion lowered to ~51% in K>3 and to 48% in V>50. Moreover, 34% of patients with a steady adherence <95% were categorized as K>3, whereas 21.7% of those with a drug holiday (21.7%) were observed in the V>50 group (P=0.002). A steady viral suppression can occur despite moderate cART non-adherence, but reduced adherence is associated with low-level residual viremia, which could reflect new rounds of HIV replication. However, a detectable HIV-RNA could also be detected in patients with optimal cART adherence, indicating additional mechanisms favoring HIV persistence.

Stressful and traumatic life events as disruptors to antiretroviral therapy adherence

Stressful and traumatic life events (STLEs) are common among HIV-infected individuals and may affect health behaviors such as adherence to antiretroviral (ARV) therapy, with important implications for treatment outcomes. We examined the association between STLEs and ARV adherence among 289 US-based participants enrolled between 7/1/2010 and 9/1/2013 in a study of depression treatment for HIV-infected patients. Participants received monthly telephone calls to assess STLEs and pill count-based ARV adherence. Inverse probability of observation weighting was combined with multiple imputation to address missing data. Participants were mostly male (71%) and black (63%), with a median age of 45 years. Median monthly adherence was 96% (interquartile range (IQR): 85-100%). Participants experienced a mean of 2.48 STLEs (range: 0-14) in the previous month. The presence of ≥2 STLEs was associated with a mean change in adherence of -3.67% (95% confidence interval (CI): -7.12%, -0.21%) and decreased likelihood of achieving ≥95% adherence (risk ratio (95% CI) = 0.82 (0.71, 0.95)). For each additional STLE, the mean adherence change was -0.90% (95% CI: -1.79%, 0.00%). STLEs were associated with poorer ARV adherence, including decreased likelihood of adhering to ≥95% of ARV doses. This level of adherence has a critical role in regimen effectiveness and prevention of resistance.

The adherence gap: a longitudinal examination of men's and women's antiretroviral therapy adherence in British Columbia, 2000-2014

OBJECTIVE

The aim of this study was to observe the effect of sex on attaining optimal adherence to combination antiretroviral therapy (cART) longitudinally while controlling for known adherence confounders - IDU and ethnicity.

DESIGN

Using the population-based HAART Observational Medical Evaluation and Research cohort, data were collected from HIV-positive adults, aged at least 19 years, receiving cART in British Columbia, Canada, with data collected between 2000 and 2014. cART adherence was assessed using pharmacy refill data. The proportion of participants reaching optimal (≥95%) adherence by sex was compared per 6-month period from initiation of therapy onward. Generalized linear mixed models with logistic regression examined the effect of sex on cART adherence.

RESULTS

Among 4534 individuals followed for a median of 65.9 months (interquartile range: 37.0-103.2), 904 (19.9%) were women, 589 (13.0%) were Indigenous, and 1603 (35.4%) had a history of IDU. A significantly lower proportion of women relative to men were optimally adherent overall (57.0 vs. 77.1%; P < 0.001) and in covariate analyses. In adjusted analyses, female sex remained independently associated with suboptimal adherence overall (adjusted odds ratio: 0.55; 95% confidence interval: 0.48-0.63).

CONCLUSION

Women living with HIV had significantly lower cART adherence rates then men across a 14-year period overall, and by subgroup. Targeted research is required to identify barriers to adherence among women living with HIV to tailor women-centered HIV care and treatment support services.

High levels of virological failure with major genotypic resistance mutations in HIV-1-infected children after 5 years of care according to WHO-recommended 1st-line and 2nd-line antiretroviral regimens in the Central African Republic: A cross-sectional study

A large cohort of 220 HIV-1-infected children (median [range] age: 12 [4-17] years) was cared and followed up in the Central African Republic, including 198 in 1st-line and 22 in 2nd-line antiretroviral regimens. Patients were monitored clinically and biologically for HIV-1 RNA load and drug resistance mutations (DRMs) genotyping. A total of 87 (40%) study children were virological responders and 133 (60%) nonresponders. In children with detectable viral load, the majority (129; 97%) represented a virological failure. In children receiving 1st-line regimens in virological failure for whom genotypic resistance test was available, 45% displayed viruses harboring at least 1 DRM to NNRTI or NRTI, and 26% showed at least 1 major DRM to NNRTI or NRTI; more than half of children in 1st-line regimens were resistant to 1st-generation NNRTI and 24% of the children in 1st-line regimens had a major DRMs to PI. Virological failure and selection of DRMs were both associated with poor adherence. These observations demonstrate high rate of virological failure after 3 to 5 years of 1st-line or 2nd-line antiretroviral treatment, which is generally associated with DRMs and therapeutic failure. Overall, more than half (55%) of children receiving 1st-line antiretroviral treatment for a median of 3.4 years showed virological failure and antiretroviral-resistance and thus eligible to 2nd-line treatment. Furthermore, two-third (64%) of children under 2nd-line therapy were eligible to 3rd-line regimen. Taken together, these observations point the necessity to monitor antiretroviral-treated children by plasma HIV-1 RNA load to diagnose as early as possible the therapeutic failure and operate switch to a new therapeutic line.

Odds of Viral Suppression by Single-Tablet Regimens, Multiple-Tablet Regimens, and Adherence Level in HIV/AIDS Patients Receiving Antiretroviral Therapy

STUDY OBJECTIVE

To evaluate the odds of achieving viral suppression in human immunodeficiency virus (HIV) patients using antiretroviral therapy as a single-tablet regimen (STR) or multiple-tablet regimen (MTR).

DESIGN

Retrospective cohort study.

DATA SOURCES

South Carolina Medicaid medical and pharmacy paid claims data were obtained from the South Carolina Revenue and Fiscal Affairs Office; laboratory data were obtained from the South Carolina Department of Health and Environmental Control.

PATIENTS

A total of 1536 patients who were dispensed a complete STR (477 patients) or MTR (1059 patients) regimen lasting at least 60 days between January 1, 2006, and December 31, 2013.

MEASUREMENTS AND MAIN RESULTS

The analysis examined adherence levels and regimen type on odds of viral load suppression. Regimen adherence levels (90-94%, 85-89%, 80-84%, and less than 80%) were compared with the gold standard adherence for HIV of 95% or greater. Patients were followed from index date until the earliest date of regimen discontinuation, treatment switch, end of study period, last date of eligibility, or death. Differences in outcomes were evaluated by χ² , Wilcoxon rank sum statistical tests, and multivariate regression models controlling for covariates. For STR regimens we find that, when compared with 95% or greater adherence, there is no statistical difference in the odds of viral suppression with adherence levels greater than or equal to 80%. However, adherence levels greater than or equal to 95% were associated with a greater odds of viral suppression when compared with less than 80% STR adherence (odds ratio [OR] 2.57, Dunnett 95% confidence interval [CI] 1.04-6.32). For MTR regimens, there was no statistical difference in the odds of viral suppression for the adherence level 90-94% compared with the 95% or greater adherence (OR 3.59, Dunnett 95% CI 0.805-16.043). However, the 95% or greater adherence has greater odds of viral suppression compared with all other MTR adherence levels. In addition, no difference was found in the odds of viral suppression between STR and MTR for all adherence levels.

CONCLUSIONS

Compared with 95% or greater adherence, STR regimens achieve viral suppression with adherence levels of 80% or greater, whereas MTR regimens require adherence levels of 90% or greater to achieve viral suppression in South Carolina Medicaid patients with HIV/AIDS.

Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV

BACKGROUND

Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care.

OBJECTIVE

To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support.

DISCUSSION

Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps.

CONCLUSION

It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.

Characteristics of Transmitted Drug-Resistant HIV-1 in Recently Infected Treatment-Naive Patients in Japan

OBJECTIVES

Progress in antiretroviral treatment has led to fewer virological failure cases, but 10%-20% of treatment-naive HIV/AIDS cases are reported to harbor drug-resistant strains, suggesting transmission of drug-resistant HIV. We aimed to determine the trend in prevalence of transmitted drug-resistant (TDR) HIV in Japan, particularly in recently infected patients.

METHODS

Drug-resistance test was performed on 3904 HIV-1-infected cases newly diagnosed between 2007 and 2012. The number of cases infected within 6 months [recent seroconverters (RS)] was estimated by BED assay of 2700 plasma samples. Characteristics of RS cases were further analyzed.

RESULTS

The overall prevalence of TDR was 9.1%, ranging from 7.3% in 2008% to 12.5% in 2010. Among 1403 subtype B/E/D cases with >50 CD4 T cell counts and >1000 HIV copies per milliliter, 468 (33.4%) were estimated to be RS. The prevalence of RS was significantly higher among cases who were male, Japanese, and men who have sex with men. The prevalence of TDR did not differ significantly between recent and long-term seroconverters (8.5% vs. 9.2%, respectively, P = 0.68). Common mutations in both groups were M46I/L and T215 revertants. Furthermore, sequences with these mutations, K103N and D30N/N88D formed clusters on phylogenetic trees.

CONCLUSION

Our study clarified an increase in prevalence of TDR in Japan from 2007 to 2012. The phylogenetic clustering of cases with M46I/L or T215 revertants suggests that HIV with these mutations have become circulating strains. Furthermore, detailed analyses showed that Japanese men who have sex with men are more aware of their risk of HIV infection.

Predictors and Profiles of Antiretroviral Therapy Adherence Among African American Adolescents and Young Adult Males Living with HIV

Adherence to antiretroviral therapy (ART) is crucial for thwarting HIV disease progression and reducing secondary HIV transmission, yet youth living with HIV (YLH) struggle with adherence. The highest rates of new HIV infections in the United States occur in young African American men. A sample of 387 HIV-positive young African American males on ART was selected from a cross-sectional assessment of (YLH) receiving medical care within the Adolescent Trials Network for HIV/AIDS Interventions (ATN) from 2010 to 2012 (12-24 years old, median 22.00, SD 2.08). Participants completed self-reported adherence, demographic, health, and psychosocial measures. Sixty-two percent self-reported 100% ART adherence. Optimal data analysis identified frequency of cannabis use during the past 3 months as the strongest independent predictor of adherence, yielding moderate effect strength sensitivity (ESS) = 27.1, p < 0.001. Among participants with infrequent cannabis use, 72% reported full adherence; in contrast, only 45% of participants who used cannabis frequently reported full adherence. Classification tree analysis (CTA) was utilized to improve classification accuracy and to identify the pathways of ART adherence and nonadherence. The CTA model evidenced a 38% improvement above chance for correctly classifying participants as ART adherent or nonadherent. Participants most likely to be adherent were those with low psychological distress and minimal alcohol use (82% were adherent). Participants least likely to be adherent were those with higher psychological distress and engaged in weekly cannabis use (69% were nonadherent). Findings suggest multiple profiles of ART adherence for young African American males living with HIV and argue for targeted psychosocial interventions.

Getting less of what you want: reductions in statistical power and increased bias when categorizing medication adherence data

Medication adherence is thought to be the principal clinical predictor of positive clinical outcomes, not only for serious mental illnesses such as schizophrenia, bipolar disorder, or depression, but also for physical conditions such as diabetes. Consequently, research on medication often looks not only at medication condition (e.g., placebo, standard medication, investigative medication), but also at adherence in taking those medications within each medication condition. The percentage (or proportion) scale is one of the more frequently employed and easily interpretable measures. Patients can be 0 % adherent, 100 % adherent, or somewhere in between. For simplicity, many reported adherence analyses dichotomize or trichotomize the adherence predictor when estimating its effect on outcomes of interest. However, the methodological literature shows that the practice of categorizing continuously distributed predictors reduces statistical power at best and, at worst, can severely bias parameter estimates. This can result in inflated Type I errors (false positive acceptance of null adherence effects) or Type II errors (false negative rejection of true adherence effects). We extend the methodological literature on categorization to the construct of adherence. The measurement scale of adherence leads to a diverse family of potential distributions including uniform, n-shaped, u-shaped (i.e., bimodal), positively skewed, and negatively skewed. Using a simulation study, we generated negative, null, and positive "true" effects of adherence on simulated continuous and binary outcomes. We then estimated the adherence effect with and without categorizing the adherence variable. We show how parameter estimates and standard errors can be severely biased when categorizing adherence. The categorization of adherence is shown to cause null effects to become positive or negative depending on the distribution of the simulated adherence variable, inflating Type I errors. When the adherence effect was significantly different from zero, categorization can render the effect null, inflating Type II errors. We recommend that adherence be measured continuously and analyzed without categorization when using it as a predictor in regression models.

Adherence and HIV RNA Suppression in the Current Era of Highly Active Antiretroviral Therapy

BACKGROUND

We examined trends in adherence to highly active antiretroviral therapy (HAART) and HIV RNA suppression and estimated the minimum cutoff of adherence to newer HAART formulations needed for HIV RNA suppression by regimen type.

METHODS

We used Veterans Affairs pharmacy dispensing data from the Veterans Aging Cohort Study Virtual Cohort between October 2000 and September 2010 and defined adherence as the duration of time the patient had the medications available, relative to the total number of days between refills for all antiretrovirals in a year. Temporal trends in adherence and viral load suppression were examined by the patient's most frequently used HAART regimen in the year. The minimum needed adherence was defined as the level at which the odds of suppression was not significantly different than that observed with ≥ 95% adherence using repeated-measures logistic regression.

RESULTS

A total of 21,865 HAART users contributed 82,217 person-years of follow-up. There was a significant increase (P(trend) < 0.001) in the proportion virally suppressed even among those with <95% adherence (2001: 38% to 2010: 84%), and the trend was similar when restricting to their first HAART regimen. For nonnucleoside reverse transcriptase inhibitor multi-pill users, the odds of suppression did not differ for 85%-89% adherence compared to those with ≥ 95% adherence [odds ratios: 0.82 (0.64-1.04)], but for protease inhibitor users, the odds of suppression significantly differed if adherence levels were <95% compared to ≥ 95% adherence.

CONCLUSIONS

Although all HIV-infected persons should be instructed to achieve perfect adherence, concerns of slightly lower adherence should not hinder prescribing new HAART regimens early in HIV infection.

The path of least resistance: aggressive or moderate treatment?

The evolution of resistance to antimicrobial chemotherapy is a major and growing cause of human mortality and morbidity. Comparatively little attention has been paid to how different patient treatment strategies shape the evolution of resistance. In particular, it is not clear whether treating individual patients aggressively with high drug dosages and long treatment durations, or moderately with low dosages and short durations can better prevent the evolution and spread of drug resistance. Here, we summarize the very limited available empirical evidence across different pathogens and provide a conceptual framework describing the information required to effectively manage drug pressure to minimize resistance evolution.

De-novo design, synthesis and evaluation of novel 6,7-dimethoxy-1,2,3,4-tetrahydroisoquinoline derivatives as HIV-1 reverse transcriptase inhibitors

Background

Acquired Immune Deficiency Syndrome (AIDS) is the advanced stage of infection caused by Human Immunodeficiency Virus (HIV). HIV/AIDS had a great impact on society, both as an illness and as a source of discrimination. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) are structurally diverse group of compounds which binds to Reverse Transcriptase (RT) enzyme of HIV. Like other anti-HIV drugs, long-term clinical effectiveness of approved NNRTIs has been hampered due to the rapid development of drug resistance. So, there is an urgent need to discover the NNRTIs, which can be effective against the drug sensitive as well as drug resistant strains of HIV-1 RT.

Results

Two series of novel thirty, 6,7-dimethoxy-1,2,3,4-tetrahydroisoquinoline analogues (5a-o) and (8a-o) were designed and synthesized as inhibitor of HIV-1 reverse transcriptase. All the synthesized compounds were characterized by infrared spectroscopy, proton nuclear magnetic resonance spectroscopy, mass spectroscopy and evaluated for in-vitro RT inhibitory activity. Among the tested compounds, eighteen compounds exhibited more than 50 % inhibition at tested 100 μM concentration, in which two compounds 8h and 8l showed promising inhibition (74.82 and 72.58 %) respectively. The preliminary structure–activity relationship (SAR) of the test compounds and docking studies of the two significantly active compounds 8h and 8l were performed to examine their putative binding with HIV-RT. Predicted physiochemical parameters of the synthesized compounds were within the acceptable range of drugable properties.

Conclusion

The results obtained from this investigation revealed that, the synthesized compounds (5a-o) and (8a-o) showed moderate to promising HIV-1 RT inhibition activity. The overall SAR studies can help in identification of further lead as well as in designing of newer potential inhibitor of HIV-1 RT.

Graphical Abstract

Drug use patterns associated with risk of non-adherence to antiretroviral therapy among HIV-positive illicit drug users in a Canadian setting: a longitudinal analysis

BACKGROUND

Among people living with HIV/AIDS, illicit drug use is a risk for sub-optimal treatment outcomes. However, few studies have examined the relative contributions of different patterns of drug use on adherence to antiretroviral therapy (ART). We sought to estimate the effect of different types of illicit drug use on adherence in a setting of universal free HIV/AIDS treatment and care.

METHODS

Using data from ongoing prospective cohorts of HIV-positive illicit drug users linked to comprehensive pharmacy dispensation records in Vancouver, Canada, we examined factors associated with ≥95% prescription refill adherence using generalized estimating equations (GEE) logistic regression.

RESULTS

Between 1996 and 2013, 692 ART-exposed individuals were followed for a median of 42.7 months (Interquartile Range: 29.1-71.7). In multivariable GEE analyses, heroin injection (Adjusted Odds Ratio [AOR] = 0.75, 95% Confidence Interval [CI]: 0.66-0.85) as well as cocaine injection (AOR = 0.80, 95% CI: 0.72-0.90) were associated with lower likelihoods of optimal adherence. Methadone maintenance therapy (AOR = 1.88, 95% CI: 1.68-2.11) was associated with a greater likelihood of adherence.

CONCLUSIONS

Periods of heroin and cocaine injection appeared to have the most deleterious impact upon antiretroviral adherence. The findings point to the need for improved access to treatment for heroin use disorder, particularly methadone, and highlight the need to identify strategies to support ART adherence among cocaine injectors.

Short communication: Tenofovir diphosphate in dried blood spots as an objective measure of adherence in HIV-infected women

Simple and reproducible tools to assess antiretroviral adherence are needed. A level of tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) <1,250 fmol/punch is predicted to identify imperfect adherence. Herein we evaluated TFV-DP in DBS as a measure of adherence among HIV-infected women. DBS and peripheral blood mononuclear cells (PBMCs) were collected twice (∼1 week apart) in 35 well-controlled HIV-infected women [median age 42 years, 14 African American/black (AA)] receiving daily coformulated tenofovir/emtricitabine and either atazanavir/ritonavir (n=20) or raltegravir (n=16). TFV-DP in DBS and PBMCs was quantified by LC-MS/MS. Six-month adherence was measured as average days between monthly pharmacy refills. Data were loge transformed for analysis and presented as median (range); the correlation between continuous variables was analyzed using the Pearson correlation coefficient. The average TFV-DP between the two visits (aTFV-DP) in DBS and PBMCs was 1,874 (706-3,776) fmol/punch and 125 (1-278) fmol/10(6) cells, respectively. AA women had lower levels of aTFV-DP in DBS compared to whites (1,660 vs. 1,970 fmol/punch; p=0.04), with a viremic patient having the lowest drug levels (706 fmol/punch). Days between pharmacy refills were 34 (30-54) vs. 30 (26-40) in women with TFV-DP in DBS <1,250 vs. ≥1,250 fmol/punch (p=0.006). TFV-DP in DBS was negatively correlated with an increasing number of days between refills (r=-0.56, p=0.002). TFV-DP DBS was a reliable and objective measure of adherence in HIV-infected women based on a strong inverse relationship with pharmacy refill adherence.

Level of adherence and HIV RNA suppression in the current era of highly active antiretroviral therapy (HAART)

The need to achieve ≥95 % adherence to HAART for treatment effectiveness may be a barrier for universal initiation at early stages of HIV. Using longitudinal data collected from 2006 to 2011 from cohort studies of MSM (MACS) and IDUs (ALIVE study), we estimated the minimum adherence needed to achieve HIV RNA suppression (<50 copies/mL), defined as the level at which at least 80 % were virally suppressed, and the odds of suppression was not significantly different than that observed with ≥95 % adherence. In the MACS, ≥80 % suppression was observed with 80-84 % adherence and the odds ratio for suppression (vs. ≥95 % adherence) was 1.43 (0.61, 3.33). In the ALIVE study where <35 % were on newer drugs, only 71.4 % were suppressed among those who reported ≥95 % adherence. Although IDUs on older HAART regimens may need to be ≥95 % adherent, concerns related to non-adherence may be less of a barrier to initiation of modern HAART regimens.

The cost-effectiveness of monitoring strategies for antiretroviral therapy of HIV infected patients in resource-limited settings: software tool

Background

The cost-effectiveness of routine viral load (VL) monitoring of HIV-infected patients on antiretroviral therapy (ART) depends on various factors that differ between settings and across time. Low-cost point-of-care (POC) tests for VL are in development and may make routine VL monitoring affordable in resource-limited settings. We developed a software tool to study the cost-effectiveness of switching to second-line ART with different monitoring strategies, and focused on POC-VL monitoring.

Methods

We used a mathematical model to simulate cohorts of patients from start of ART until death. We modeled 13 strategies (no 2^nd-line, clinical, CD4 (with or without targeted VL), POC-VL, and laboratory-based VL monitoring, with different frequencies). We included a scenario with identical failure rates across strategies, and one in which routine VL monitoring reduces the risk of failure. We compared lifetime costs and averted disability-adjusted life-years (DALYs). We calculated incremental cost-effectiveness ratios (ICER). We developed an Excel tool to update the results of the model for varying unit costs and cohort characteristics, and conducted several sensitivity analyses varying the input costs.

Results

Introducing 2^nd-line ART had an ICER of US$1651-1766/DALY averted. Compared with clinical monitoring, the ICER of CD4 monitoring was US$1896-US$5488/DALY averted and VL monitoring US$951-US$5813/DALY averted. We found no difference between POC- and laboratory-based VL monitoring, except for the highest measurement frequency (every 6 months), where laboratory-based testing was more effective. Targeted VL monitoring was on the cost-effectiveness frontier only if the difference between 1^st- and 2^nd-line costs remained large, and if we assumed that routine VL monitoring does not prevent failure.

Conclusion

Compared with the less expensive strategies, the cost-effectiveness of routine VL monitoring essentially depends on the cost of 2^nd-line ART. Our Excel tool is useful for determining optimal monitoring strategies for specific settings, with specific sex-and age-distributions and unit costs.

Antiretroviral Non-Adherence is Associated With a Retrieval Profile of Deficits in Verbal Episodic Memory

HIV-associated deficits in verbal episodic memory are commonly associated with antiretroviral non-adherence; however, the specific aspects of memory functioning (e.g., encoding, consolidation, or retrieval) that underlie this established relationship are not well understood. This study evaluated verbal memory profiles of 202 HIV+ participants who underwent a 30-day electronic monitoring of antiretroviral adherence. At the group level, non-adherence was significantly associated with lower scores on immediate and delayed passage recall and word list learning. Retention and recognition of passages and word lists were not related to adherence. Participants were then classified as having either a normal verbal memory profile, a "subcortical" retrieval profile (i.e., impaired free recall with relatively spared recognition), or a "cortical" encoding profile (e.g., cued recall intrusions) based on the Massman et al. ( 1990 ) algorithm for the California Verbal Learning Test. HIV+ participants with a classic retrieval deficit had significantly greater odds of being non-adherent than participants with a normal or encoding profile. These findings suggest that adherence to prescribed antiretroviral regimens may be particularly vulnerable to disruption in HIV+ individuals due to deficits in the complex process of efficiently accessing verbal episodic information with minimal cues. A stronger relationship between non-adherence and passage (vs. word list) recall was also found and may reflect the importance of contextual features in remembering to take medications. Targeted interventions for enhancing and supporting episodic memory retrieval processes may improve antiretroviral adherence and overall health outcomes among persons living with HIV.

Barriers to antiretroviral therapy adherence and plasma HIV RNA suppression among AIDS clinical trials group study participants

We conducted a secondary data analysis of 11 AIDS Clinical Trials Group (ACTG) studies to examine longitudinal associations between 14 self-reported antiretroviral therapy (ART) adherence barriers (at 12 weeks) and plasma HIV RNA (at 24 weeks) and to discern the relative importance of these barriers in explaining virologic detectability. Studies enrolled from 1997 to 2003 and concluded between 2002 and 2012. We included 1496 (54.2% of the original sample) with complete data. The most commonly selected barriers were "away from home" (21.9%), "simply forgot" (19.6%), "change in daily routine" (19.5%), and "fell asleep/slept through dosing time" (18.9%). In bivariate analyses, "too many pills to take" (OR=0.43, p<0.001), "wanted to avoid side effects" (OR=0.54, p=0.001), "felt drug was toxic/harmful" (OR=0.44, p<0.001), "felt sick or ill" (OR=0.49, p<0.001), "felt depressed/overwhelmed" (OR=0.58, p=0.004), and "problem taking pills at specified time" (OR=0.71, p=0.04) were associated with a lower odds of an undetectable HIV RNA. "Too many pills to take," "wanted to avoid side effects," "felt drug was toxic/harmful," "felt sick/ill,", and "felt depressed/overwhelmed" had the highest relative importance in explaining virologic detectability. "Simply forgot" was not associated with HIV RNA (OR=0.99, p=0.95) and was ninth in its relative importance. Adherence interventions should prioritize barriers with highest importance in explaining virologic outcomes rather than focusing on more commonly reported barriers.

HIV viral suppression among persons with varying levels of engagement in HIV medical care, 19 US jurisdictions

BACKGROUND

Ongoing HIV medical care is vital in achieving and maintaining viral suppression. We examined viral suppression applying retention in care definitions used by various federal agencies.

METHODS

Using National HIV Surveillance System data from 19 US jurisdictions with complete CD4 and viral load reporting, we determined viral suppression among persons who met the National HIV/AIDS Strategy retention in care definition (≥2 visits ≥3 months apart; "retained in continuous care") and among those who had evidence of care but did not meet the definition ("engaged in care"). We also examined viral suppression among persons who met the Health and Human Services Core Indicator definition for retention.

RESULTS

Of 338,959 persons living with diagnosed HIV infection in 19 areas in 2010, 63.7% received any care; of these, 19.7% were "engaged in care" and 80.3% were "retained in continuous care." Of those "engaged in care," 47.7% achieved viral suppression compared with 73.6% of persons "retained in continuous care." Significant differences were evident for all subpopulations within each care category; younger persons and blacks/African Americans had lower levels of viral suppression than their counterparts. Persons "engaged in care," regardless of sex, age, race/ethnicity, and transmission category, had significantly lower percentages of viral suppression than persons "retained in continuous care." Similar patterns of viral suppression were found for persons meeting the Health and Human Services definition compared with persons "retained in continuous care."

CONCLUSIONS

Higher levels of engagement in care, including more frequent monitoring of CD4 and viral load, were associated with viral suppression.

Predictors of early mortality in a cohort of HIV-infected children receiving high active antiretroviral treatment in public hospitals in Ethiopia

Highly active antiretroviral therapy (HAART) is the breakthrough in care and treatment of people living with HIV, leading to a reduction in mortality and an improvement in the quality of life. Without antiretroviral treatment, most HIV-infected children die before their fifth birthday. So the objective of this study is to determine the mortality and associated factors in a cohort of HIV-infected children receiving ART in Ethiopia. A multicentre facility-based retrospective cohort study was done in selected pediatric ART units in hospitals found in Addis Ababa, Ethiopia. The probability of survival was estimated using the Kaplan-Meier method, and multivariate analysis by Cox proportional hazards regression models was conducted to determine the independent predictor of survival. A total of 556 children were included in this study. Of the total children, 10.4% were died in the overall cohort. More deaths (70%) occurred in the first 6 months of ART initiation, and the remaining others were still on follow-up at different hospitals. Underweight (moderate and severe; HR: 10.10; 95% CI: 2.08, 28.00; P = 0.004; and HR: 46.69; 95% CI: 9.26, 200.45; P < 0.01, respectively), advanced disease stage (WHO clinical stages III and IV; HR: 10.13: 95% CI: 2.25, 45.58; P = 0.003), poor ART adherence (HR: 11.72; 95% CI: 1.60, 48.44; P = 0.015), and hemoglobin level less than 7 g/dl (HR: 4.08: 95% CI: 1.33, 12.56; P = 0.014) were confirmed as significant independent predictors of death after controlling for other factors. Underweight, advanced disease stage, poor adherence to ART, and anemia appear to be independent predictor of survival in HIV-infected children receiving HAART at the pediatric units of public hospitals in Ethiopia. Nutritional supplementations, early initiation of HAART, close supervision, and monitoring of patients during the first 6 months, the follow up period is recommended.

Combination dolutegravir-abacavir-lamivudine in the management of HIV/AIDS: clinical utility and patient considerations

The current standard of care for human immunodeficiency virus (HIV) treatment is a three-drug regimen containing a nonnucleoside reverse transcriptase inhibitor, a protease inhibitor, or an integrase strand transfer inhibitor (INSTI) plus two nucleoside/tide reverse transcriptase inhibitors. Given their potency, safety, and distinctive mechanism of action, INSTIs represent an important advance in HIV type 1 (HIV-1) therapy. Dolutegravir (DTG) is a new-generation INSTI recently approved for the treatment of HIV-1-infected adult patients, with distinct advantages compared with other available antiretroviral agents. In well-designed, large clinical trials, DTG-containing regimens have demonstrated either noninferiority or superiority to current first-line agents such as raltegravir-, darunavir/ritonavir-, and efavirenz-containing regimens. The favorable safety profile, low potential for drug interactions, minimal impact on lipids, good tolerability, and high resistance barrier of DTG makes this compound one of the preferred choices for HIV therapy in multiple clinical scenarios, including treatment-naïve and treatment-experienced patients. DTG is the only antiretroviral drug not yet associated with de novo emergence of resistance mutations in treatment-naïve individuals. However, data from in vitro studies and clinical trial suggest the possibility of cross-resistance between first- and second-generation INSTIs. Even though these profiles are infrequent at the moment, they need to be monitored in all current patients treated with INSTIs. With its potent activity, good tolerability, simplicity of dosing, and minimal drug interaction profile, DTG will likely play a major role in the management of patients with HIV-1 infection. On the basis of clinical trial data, current guidelines endorse DTG in combination with nucleoside/tide reverse transcriptase inhibitors as one of the recommended regimens in antiretroviral therapy-naïve patients. Most of the favorable clinical experiences from clinical trials are based on the combination of DTG with abacavir/lamivudine, and DTG is planned to be coformulated with abacavir/lamivudine. This will provide a further advantage, given that single tablet regimens are associated with higher adherence rates as well as improvement in quality of life and enhanced patient preference.

Adherence to extended postpartum antiretrovirals is associated with decreased breast milk HIV-1 transmission

OBJECTIVE

Estimate association between postpartum antiretroviral adherence and breast milk HIV-1 transmission.

DESIGN

Prospective cohort study.

METHODS

Mother-infant pairs were randomized after delivery to immediately begin receiving 28 weeks of either triple maternal antiretrovirals (zidovudine, lamivudine, and either nevirapine, nelfinavir, or lopinavir-ritonavir) or daily infant nevirapine as part of the Breastfeeding, Antiretrovirals, and Nutrition (BAN) study. Associations between postpartum antiretroviral adherence and rate of breast milk HIV-1 transmission were estimated using Cox models. We measured adherence over four postpartum time intervals using pill count, suspension bottle weight, and maternal self-report. Adherence was categorized and lagged by one interval. Missing adherence measures were multiply imputed. Infant HIV-1 infection was determined by DNA PCR every 2-6 weeks. The primary endpoint was infant HIV-1 infection by 38 weeks of age among infants alive and uninfected at 5 weeks.

RESULTS

Analyses included 1479 mother-infant pairs and 45 transmission events. Using pill count and bottle weight information, 22-40% of mother-infant pairs at any given interval were less than 90% adherent. Having at least 90% adherence was associated with a 52% [95% confidence interval (CI) 3-76] relative reduction in the rate of breast milk HIV-1 transmission, compared with having less than 90% adherence when controlling for study arm, breastfeeding status, and maternal characteristics. Complete case analysis rendered similar results (n = 501; relative reduction 59%, 95% CI 6-82).

CONCLUSION

Nonadherence to extended postpartum antiretroviral regimens in 'real world' settings is likely to be higher than that seen in BAN. Identifying mothers with difficulty adhering to antiretrovirals, and developing effective adherence interventions, will help maximize benefits of antiretroviral provision throughout breastfeeding.

Depression, adherence and attrition from care in HIV-infected adults receiving antiretroviral therapy

BACKGROUND

A better understanding of the relationship between depression and HIV-related outcomes, particularly as it relates to adherence to treatment, is critical to guide effective support and treatment of individuals with HIV and depression. We examined whether depression was associated with attrition from care in a cohort of 610 HIV-infected adults in rural Rwanda and whether this relationship was mediated through suboptimal adherence to treatment.

METHODS

The association between depression and attrition from care was evaluated with a Cox proportional hazard model and with mediation methods that calculate the direct and indirect effects of depression on attrition and are able to account for interactions between depression and suboptimal adherence. Depression was assessed with the Hopkins Symptom Checklist-15; attrition was defined as death, treatment default, or loss to follow-up.

RESULTS

Baseline depression was significantly associated with time to attrition after adjustment for receipt of community-based accompaniment, physical functioning quality of life score, and CD4 cell count (HR=2.40, 95% CI 1.27 to 4.52, p=0.005). In multivariable mediation analysis, we found no evidence that the association between depression and attrition after 3 months was mediated by suboptimal adherence (direct effect of depression on attrition: OR=3.90 (1.26 to 12.04), p=0.02; indirect effect: OR=1.07 (0.92 to 1.25), p=0.38).

CONCLUSIONS

Even in the context of high antiretroviral therapy adherence, depression may adversely influence HIV outcomes through a pathway other than suboptimal adherence. Treatment of depression is critical to achieving good mental health and retention in HIV-infected individuals with depression.

Adherence among rural HIV-infected patients in the deep south: a comparison between single-tablet and multi-tablet once-daily regimens

BACKGROUND

Once-daily (QD), combination antiretroviral therapy (ART) can impact the willingness and ability of patients to take medications as directed. The impact of antiretroviral (ARV) drug adherence influenced by single-tablet (STR) versus multi-tablet regimens (MTR) among patients enrolled in the AIDS Drug Assistance Program (ADAP) in a rural environment has not yet been assessed.

MATERIAL AND METHODS

A retrospective chart review evaluated adherence and outcomes in adult HIV-infected patients enrolled in the ADAP at 2 ambulatory clinics in the Southeast, taking either a QD STR (efavirenz [EFV]/emtricitabine/tenofovir [TDF]) or a QD protease inhibitor (PI)-based, MTR (atazanavir [ATV], ritonavir [RTV], and emtricitabine/TDF) by evaluating pharmacy refill records, patient self-reported adherence, and virologic response.

RESULTS

A total of 389 patient records were analyzed (STR, n = 165 versus MTR, n = 224). There were more males, a higher percentage of treatment-naive patients, and more patients with a baseline CD4 count of >200 cells/mm(3) in the MTR group. Based on refill records, more patients on MTR were >90% adherent (61.6% versus 51.5%, P = .047). In a multivariable analysis, being treatment experienced was a negative predictor (odds ratio [OR] = 0.48, 0.29-0.78) for adherence. Regimen choice was not associated with adherence. More patients taking MTR were virologically suppressed at the end of the observation period. Regardless of the regimen, being >90% adherent was a significant predictor of virologic suppression (OR = 3.51, 1.98-6.23).

CONCLUSION

Treatment-experienced patients enrolled in ADAP are less likely to be adherent. A QD PI-based MTR may result in comparable adherence to an STR in a rural HIV-infected population.

Association of first-line and second-line antiretroviral therapy adherence

Adherence to first-line ART is an important predictor of adherence to second-line ART. Improving adherence prior to switch is critical to improve patient outcomes.

Background

 Adherence to first-line antiretroviral therapy (ART) may be an important indicator of adherence to second-line ART. Evaluating this relationship may be critical to identify patients at high risk for second-line failure, thereby exhausting their treatment options, and to intervene and improve patient outcomes.

Methods

 Adolescents and adults (n = 436) receiving second-line ART were administered standardized questionnaires that captured demographic characteristics and assessed adherence. Optimal and suboptimal cumulative adherence were defined as percentage adherence of ≥90% and <90%, respectively. Bivariable and multivariable binomial regression models were used to assess the prevalence of suboptimal adherence percentage by preswitch adherence status.

Results

 A total of 134 of 436 (30.7%) participants reported suboptimal adherence to second-line ART. Among 322 participants who had suboptimal adherence to first-line ART, 117 (36.3%) had suboptimal adherence to second-line ART compared with 17 of 114 (14.9%) who had optimal adherence to first-line ART. Participants who had suboptimal adherence to first-line ART were more likely to have suboptimal adherence to second-line ART (adjusted prevalence ratio, 2.4; 95% confidence interval, 1.5–3.9).

Conclusions

 Adherence to first-line ART is an important predictor of adherence to second-line ART. Targeted interventions should be evaluated in patients with suboptimal adherence before switching into second-line therapy to improve their outcomes.

Single-Tablet Regimens in HIV Therapy

Combined antiretroviral therapy (cART) has evolved considerably over the past decades leading to a better control of human immunodeficiency virus replication. Recently, regimens have evolved so as to simplify dosing frequency and reduce pill burden to improve adherence. Several national and international guidelines suggest antiretroviral (ARV) regimen simplification as a method of improving adherence. Decreased cART adherence has been associated with both patient-related factors and regimen-related factors. Adherence rates are statistically higher when simpler, once-daily (OD) regimens are combined with smaller daily regimen pill burdens. The avoidance of selective non-adherence, where a patient takes part of a regimen but not the full regimen, is a further potential benefit offered by single-tablet regimens (STRs). Simplification of cART has been associated with a better quality of life (QoL). Although tempered by other factors, better adherence, higher QoL and patients' preferences are all key points which might combine to assure long-lasting efficacy and durability of cART. All studies underlined the favorable tolerability profile of newer STRs. Three STRs are currently available. Tenofovir (TDF) plus emtricitabine (FTC)/efavirenz (EFV) was the first OD complete ARV regimen available as a STR. TDF plus FTC/rilpivirine is a second-generation STR. The most recently approved STR, TDF plus FTC/cobicistat/elvitegravir, is the first non-nucleoside reverse transcriptase inhibitor-based STR. All of them have shown excellent efficacy; safety and tolerability have been improved by more recent formulations. Several other STRs are anticipated both combining completely different drugs, abacavir (ABC) plus lamivudine (3TC)/dolutegravir, utilizing innovative formulations of older drugs, tenofovir alafenamide fumarate, or taking advance of bioequivalent drugs, lamivudine (3TC) plus ABC/EFV. The future challenge would be to develop completely alternative STRs (including for example protease inhibitors or new molecules) to extend the advantages of simplicity to heavily pre-treated individuals.

Determinants of adherence in a cohort of Belgian HIV patients: a pilot study

Since the era of highly active antiretroviral therapy (HAART), HIV is considered a chronic disease. Adherence to HAART is crucial for effectiveness. Non-adherence negatively impacts patient outcome and the larger economy. However, data on adherence among the Belgian HIV cohort are scarce. Therefore, the purpose of this pilot study was to identify determinants of adherence among HIV patients treated in Belgium. The study was conducted at the Aids Reference Centre of Ghent University Hospital between 1 January and 31 December 2012. Sociodemographic data were collected, along with the Simplified Medication Adherence Questionnaire (SMAQ), the Center for Adherence Support Evaluation (CASE) Adherence Index, the EuroQol-6D, the Medical Outcomes Study-HIV (MOS-HIV), the Beck Depression Inventory-II, and three neurocognitive complaints screening questions. To date, 218 patients participated in the study, among whom 173 (79·4%) were male. Mean age was 46·0±10·6 years and 133 patients (63·9%) were homosexual. According to the SMAQ and the CASE, 78·5% and 93·5% of the patients were adherent to antiretroviral therapy. Logistic regression analysis revealed that smoking, neurocognitive complaints, and female sex were independent determinants of non-adherence. In conclusion, there is an elevated risk for non-adherence in smokers, people experiencing neurocognitive problems, and women in our sample. The latter could reflect differences between male and female HIV patients in Belgium. Adherence improving initiatives should be tailored to these three risk groups.