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Di Biagio A, Lorenzini P, Gustinetti G, Rusconi S, De Luca A, Lapadula G, Lo Caputo S, Cicalini S, Castelli F, Marchetti G, Antinori A, Monforte AD. Durability of Second Antiretroviral Regimens in the Italian Cohort Naive Antiretrovirals Foundation Study and Factors Associated with Discontinuation. AIDS Patient Care STDS 2017; 31:487-494. [PMID: 29211512 DOI: 10.1089/apc.2017.0140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The study was designed to investigate the median duration of second antiretroviral regimens and factors associated with early discontinuation in HIV patients who switched with an undetectable viral load. We conducted a retrospective analysis of the Italian Cohort Naive Antiretrovirals Foundation Study (ICONA), which collects data throughout the country. Patients who started first antiretroviral therapy (ART) after January 1, 2008 in any center involved in this cohort and then switched to a second regimen were included in the study. Second ART failure was described as two HIV-RNA >200 copies/mL or the discontinuation of any drug. Statistical analysis was performed utilizing Kaplan-Meier curves and Cox regression model. The study population included 835 patients and the median duration of first ART regimens was 16 months with HIV-RNA undetectable for 13 months. The main causes of switch to second ART regimens were toxicity (42.5%) and simplification (37.5%). The switch mostly involved the third drug (63.5%) and almost one third of the population received a single-tablet regimen (STR) as second treatment (30.6%). The median duration of second ART regimens was 9.2 months and the probabilities of treatment discontinuation at 12, 24, and 36 months were 21%, 35%, and 48.2%, respectively. STR formulations had a protective effect against second ART discontinuation. Almost half of our population needed a third regimen within 3 years, but STR could improve second ART durability.
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Affiliation(s)
- Antonio Di Biagio
- Infectious Diseases Unit, Department of Internal Medicine, Ospedale Policlinico S. Martino, Genoa, Italy
| | - Patrizia Lorenzini
- National Institute for Infectious Diseases, IRCCS L. Spallanzani, Rome, Italy
| | - Giulia Gustinetti
- Infectious Diseases Unit, Department of Internal Medicine, Ospedale Policlinico S. Martino, Genoa, Italy
| | - Stefano Rusconi
- Infectious Diseases Unit, Sacco Hospital, Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, Milan, Italy
| | - Andrea De Luca
- Malattie Infettive Universitarie, ed Epatologia, Dipartimento di Medicina Interna e Specialistica, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | | | - Stefania Cicalini
- National Institute for Infectious Diseases, IRCCS L. Spallanzani, Rome, Italy
| | - Francesco Castelli
- University Department of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, Brescia, Italy
| | - Giulia Marchetti
- Division of Infectious Diseases, San Paolo Hospital, University of Milan, Milan, Italy
| | - Andrea Antinori
- National Institute for Infectious Diseases, IRCCS L. Spallanzani, Rome, Italy
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HIV-infection and psychiatric illnesses - A double edged sword that threatens the vision of a contained epidemic: The Greater Stockholm HIV Cohort Study. J Infect 2016; 74:22-28. [PMID: 27717780 DOI: 10.1016/j.jinf.2016.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/11/2016] [Accepted: 09/16/2016] [Indexed: 01/20/2023]
Abstract
CONTEXT The Greater Stockholm HIV Cohort Study is an initiative to provide longitudinal information regarding the health of people living with HIV. OBJECTIVE Our aim was to explore the prevalence of HIV and its association with psychiatric co-morbidities. DESIGN, SETTING AND PARTICIPANTS All patients with a recorded diagnosis of HIV (any position of the ICD-10 codes B20-B24) were identified during the period 2007-2014 and related to the total population in Stockholm by January 1, 2015, N = 2.21 million. The age at diagnosis, gender, and first occurrence of an HIV diagnosis was recorded. Analyses were done by age and gender. Prevalence of psychiatric co-morbidities amongst HIV patients were recorded. MAIN OUTCOME MEASURES Age-adjusted odds ratios with 95% confidence intervals were calculated with logistic regression for prevalent psychiatric co-morbidities in HIV infected individuals compared to the prevalence in the general population. RESULTS The total prevalence of HIV was 0.16%; females 0.10% (n = 1134) and males 0.21% (n = 2448). HIV-infected people were more frequently diagnosed with psychiatric illnesses and drug abuse. In females and males with HIV-diagnosis respectively, drug dependence disorder was 7.5 (7.76% vs 1.04%) and 5.1 (10.17% vs 1.98%) times higher, psychotic disorders were 6.3 (2.65% vs 0.42%) and 2.9 (1.43% vs 0.49%) times higher, bipolar disorder was 2.5 (1.41% vs 0.57%) and 3 (1.02% vs 0.34%) times higher, depression diagnosis was 1.5 (8.47% vs 5.82%) and 3.4 (10.17% vs 2.97%) higher, trauma-related disorder was 1.5 (6.00% vs 4.10%) respectively 2.9 (4.45% vs 1.56%) times higher, anxiety disorder was 1.2 (6.88% vs 5.72%) and 2.2 (6.54% vs 2.93%) times higher than in their non-infected peers. CONCLUSION Despite effective ART, many individuals with HIV have an impaired mental health and a history of drug abuse that may threaten the vision of a contained epidemic.
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Abstract
BACKGROUND Antiretroviral therapy (ART) adherence is critical for successful HIV treatment outcomes. Once-daily dosing could improve adherence. Plasma concentrations of once-daily vs twice-daily abacavir + lamivudine are bioequivalent in children, but no randomized trial has compared virological outcomes. METHODS Children taking abacavir + lamivudine-containing first-line regimens twice daily for more than 36 weeks in the ARROW trial (NCT02028676, ISRCTN24791884) were randomized to continue twice-daily vs move to once-daily abacavir + lamivudine (open-label). Co-primary outcomes were viral load suppression at week 48 (12% noninferiority margin, measured retrospectively) and lamivudine or abacavir-related grade 3/4 adverse events. RESULTS Six hundred and sixty-nine children (median 5 years, range 1-16) were randomized to twice daily (n = 333) vs once daily (n = 336) after median 1.8 years on twice-daily abacavir + lamivudine-containing first-line ART. Children were followed for median 114 weeks. At week 48, 242/331 (73%) twice daily vs 236/330 (72%) once daily had viral load less than 80 copies/ml [difference -1.6% (95% confidence interval -8.4,+5.2%) P = 0.65]; 79% twice daily vs 78% once daily had viral load less than 400 copies/ml (P = 0.76) (week 96 results similar). One grade 3/4 adverse event was judged uncertainly related to abacavir + lamivudine (hepatitis; once daily). At week 48, 9% twice daily vs 10% once daily reported missing one or more ART pills in the last 4 weeks (P = 0.74) and 8 vs 8% at week 96 (P = 0.90). Carers strongly preferred once-daily dosing. There was no difference between randomized groups in postbaseline drug-resistance mutations or drug-susceptibility; WHO 3/4 events; ART-modifying, grade 3/4 or serious adverse events; CD4% or weight-for-age/height-for-age (all P > 0.15). CONCLUSION Once-daily abacavir + lamivudine was noninferior to twice daily in viral load suppression, with similar resistance, adherence, clinical, immunological and safety outcomes. Abacavir + lamivudine provides the first once-daily nucleoside backbone across childhood that can be used to simplify ART.
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Jayaweera D, DeJesus E, Nguyen KL, Grimm K, Butcher D, Seekins DW. Virologic Suppression, Treatment Adherence, and Improved Quality of Life on a Once-Daily Efavirenz-Based Regimen in Treatment-Naïve HIV-1–Infected Patients Over 96 Weeks. HIV CLINICAL TRIALS 2015; 10:375-84. [DOI: 10.1310/hct1006-375] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Cruciani M, Malena M. Combination dolutegravir-abacavir-lamivudine in the management of HIV/AIDS: clinical utility and patient considerations. Patient Prefer Adherence 2015; 9:299-310. [PMID: 25733823 PMCID: PMC4337619 DOI: 10.2147/ppa.s65199] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Mario Cruciani
- Center of Community Medicine and HIV Outpatient Clinic, Infectious Diseases Unit, San Bonifacio Hospital, Verona, Italy
- Correspondence: Mario Cruciani, Center of Community Medicine and HIV Outpatient Clinic, ULSS 20 Verona, Via Germania, 20-37135 Verona, Italy, Email
| | - Marina Malena
- Center of Community Medicine and HIV Outpatient Clinic, Infectious Diseases Unit, San Bonifacio Hospital, Verona, Italy
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Jallow A, Ljunggren G, Wändell P, Carlsson AC. Prevalence, incidence, mortality and co-morbidities amongst human immunodeficiency virus (HIV) patients in Stockholm County, Sweden - the Greater Stockholm HIV Cohort Study. AIDS Care 2014; 27:142-9. [PMID: 25277328 DOI: 10.1080/09540121.2014.963012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Our aim was to study the prevalence and incidence of patients with human immunodeficiency virus (HIV) in the general population in Stockholm, Sweden. We also aimed to study mortality among individuals with HIV and to explore co-morbidities. The study population included all living persons who resided in Stockholm County, Sweden, as of 31 December 2012 (N = 2,212,435). Information on all consultations between 2007 and 2012 was obtained from primary health care, specialist outpatient care and inpatient care. Analyses were done by age and gender. All patients with a recorded diagnosis of HIV were included. The prevalence of HIV was calculated using 2012 data. The prevalence of HIV in Stockholm area as per end of December 2012 was as low as 0.1% in females and 0.2% in males, and the annual incidence of HIV continued to decline over the years. In recent years, cancers, diabetes and hypertension were about as common in individuals with HIV as in the general population. Males with HIV had 3- to 4-fold higher age-adjusted odds of being diagnosed with depression and 3-fold higher odds of anxiety disorders and women had 1.6 to 2-fold higher age-adjusted odds of depression and anxiety disorders, than males and females in the general population, respectively. The relatively good somatic health observed in this study could be attributed to nearly optimal HIV therapy in Sweden. The mental health of HIV patients was significantly worse than that in the general population and needs further attention.
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Identification and assessment of adherence-enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: a systematic literature review and meta-analysis. Drugs 2014; 73:545-62. [PMID: 23588595 PMCID: PMC3647098 DOI: 10.1007/s40265-013-0041-3] [Citation(s) in RCA: 215] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Non-adherence to medications is prevalent across all medical conditions that include ambulatory pharmacotherapy and is thus a major barrier to achieving the benefits of otherwise effective medicines. Objective The objective of this systematic review was to identify and to compare the efficacy of strategies and components thereof that improve implementation of the prescribed drug dosing regimen and maintain long-term persistence, based on quantitative evaluation of effect sizes across the aggregated trials. Data sources MEDLINE, EMBASE, CINAHL, the Cochrane Library, and PsycINFO were systematically searched for randomized controlled trials that tested the efficacy of adherence-enhancing strategies with self-administered medications. The searches were limited to papers in the English language and were included from database inception to 31 December 2011. Study selection Our review included randomized controlled trials in which adherence was assessed by electronically compiled drug dosing histories. Five thousand four hundred studies were screened. Eligibility assessment was performed independently by two reviewers. A structured data collection sheet was developed to extract data from each study. Study appraisal and synthesis methods The adherence-enhancing components were classified in eight categories. Quality of the papers was assessed using the criteria of the Cochrane Handbook for Systematic Reviews of Interventions guidelines to assess potential bias. A combined adherence outcome was derived from the different adherence variables available in the studies by extracting from each paper the available adherence summary variables in a pre-defined order (correct dosing, taking adherence, timing adherence, percentage of adherent patients). To study the association between the adherence-enhancing components and their effect on adherence, a linear meta-regression model, based on mean adherence point estimates, and a meta-analysis were conducted. Results Seventy-nine clinical trials published between 1995 and December 2011 were included in the review. Patients randomized to an intervention group had an average combined adherence outcome of 74.3 %, which was 14.1 % higher than in patients randomized to the control group (60.2 %). The linear meta-regression analysis with stepwise variable selection estimated an 8.8 % increase in adherence when the intervention included feedback to the patients of their recent dosing history (EM-feedback) (p < 0.01) and a 5.0 % increase in adherence when the intervention included a cognitive-educational component (p = 0.02). In addition, the effect of interventions on adherence decreased by 1.1 % each month. Sensitivity analysis by selecting only high-quality papers confirmed the robustness of the model. The random effects model in the meta-analysis, conducted on 48 studies, confirmed the above findings and showed that the improvement in adherence was 19.8 % (95 % CI 10.7–28.9 %) among patients receiving EM-feedback, almost double the improvement in adherence for studies that did not include this type of feedback [10.3 % (95 % CI 7.5–13.1 %)] (p < 0.01). The improvement in adherence was 16.1 % (95 % CI 10.7–21.6 %) in studies that tested cognitive-educational components versus 10.1 % (95 % CI 6.6–13.6 %) in studies that did not include this type of intervention (p = 0.04). Among 57 studies measuring clinical outcomes, only 8 reported a significant improvement in clinical outcome. Limitations Despite a common measurement, the meta-analysis was limited by the heterogeneity of the pooled data and the different measures of medication adherence. The funnel plot showed a possible publication bias in studies with high variability of the intervention effect. Conclusions Notwithstanding the statistical heterogeneity among the studies identified, and potential publication bias, the evidence from our meta-analysis suggests that EM-feedback and cognitive-educational interventions are potentially effective approaches to enhance patient adherence to medications. The limitations of this research highlight the urgent need to define guidelines and study characteristics for research protocols that can guide researchers in designing studies to assess the effects of adherence-enhancing interventions. Electronic supplementary material The online version of this article (doi:10.1007/s40265-013-0041-3) contains supplementary material, which is available to authorized users.
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Nachega JB, Parienti JJ, Uthman OA, Gross R, Dowdy DW, Sax PE, Gallant JE, Mugavero MJ, Mills EJ, Giordano TP. Lower pill burden and once-daily antiretroviral treatment regimens for HIV infection: A meta-analysis of randomized controlled trials. Clin Infect Dis 2014; 58:1297-307. [PMID: 24457345 PMCID: PMC3982838 DOI: 10.1093/cid/ciu046] [Citation(s) in RCA: 255] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Once-daily compared with twice-daily antiretroviral therapy regimens increased adherence; however, the difference was modest and not associated with a difference in virological suppression. In addition, higher pill burden was associated with lower rates of virological suppression, whether once- or twice-daily regimens. Background. Contemporary antiretroviral treatment regimens are simpler than in the past, with lower pill burden and once-daily dosing frequency common. We performed a meta-analysis of randomized controlled trials (RCTs) to investigate the impact of pill burden and once-daily vs twice-daily dosing on ART adherence and virological outcomes. Methods. A literature search of 4 electronic databases through 31 March 2013 was used. RCTs comparing once-daily vs twice-daily ART regimens that also reported on adherence and virological suppression were included. Study design, study population characteristics, intervention, outcome measures, and study quality were extracted. Study quality was rated using the Cochrane risk-of-bias tool. Results. Nineteen studies met our inclusion criteria (N = 6312 adult patients). Higher pill burden was associated with both lower adherence rates (P = .004) and worse virological suppression (P < .0001) in both once-daily and twice-daily subgroups, although the association with adherence in the once-daily subgroup was not statistically significant. The average adherence was modestly higher in once-daily regimens than twice-daily regimens (weighted mean difference = 2.55%; 95% confidence interval [CI], 1.23 to 3.87; P = .0002). Patients on once-daily regimens did not achieve virological suppression more frequently than patients on twice-daily regimens (relative risk [RR] = 1.01; 95% CI, 0.99 to 1.03; P = .50). Both adherence and viral load suppression decreased over time, but adherence decreased less with once-daily dosing than with twice-daily dosing. Conclusions. Lower pill burden was associated with both better adherence and virological suppression. Adherence, but not virological suppression, was slightly better with once- vs twice-daily regimens.
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Affiliation(s)
- Jean B Nachega
- Department of Epidemiology, Pittsburgh University Graduate School of Public Health, Pennsylvania
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Balfour L, Spaans JN, Fergusson D, Huff H, Mills EJ, la Porte CJ, Walmsley S, Singhal N, Rosenes R, Tremblay N, Gill MJ, Loemba H, Conway B, Rachlis A, Ralph E, Loutfy M, Mallick R, Moorhouse R, William Cameron D. Micronutrient deficiency and treatment adherence in a randomized controlled trial of micronutrient supplementation in ART-naïve persons with HIV. PLoS One 2014; 9:e85607. [PMID: 24465617 PMCID: PMC3897458 DOI: 10.1371/journal.pone.0085607] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 12/02/2013] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The MAINTAIN study is an on-going RCT comparing high-dose micronutrient and anti-oxidant supplementation versus recommended daily allowance (RDA) vitamins in slowing HIV immune deficiency progression in ART-naïve people with HIV infection. OBJECTIVE We planned analysis of the first 127 participants to determine the baseline prevalence of serum micronutrient deficiencies and correlates, as well as tolerance and adherence to study interventions. METHODS Participants receive eight capsules twice daily of 1) high-dose or 2) RDA supplements for two years and are followed-up quarterly for measures of immune deficiency progression, safety and tolerability. Regression analysis was used to identify correlates of micronutrient levels at baseline. Adherence was measured by residual pill count, self-report using the General Treatment Scale (GTS) and short-term recall HIV Adherence Treatment Scale (HATS). RESULTS Prior micronutrient supplementation (within 30 days) was 27% at screening and 10% of study population, and was not correlated with baseline micronutrient levels. Low levels were frequent for carotene (24%<1 nmol/L), vitamin D (24%<40 nmol/L) and serum folate (20%<15 nmol/L). The proportion with B12 deficiency (<133 pmol/L) was 2.4%. Lower baseline levels of B12 correlated lower baseline CD4 count (r = 0.21, p = 0.02) with a 21 pmol/L reduction in B12 per 100 cells/µL CD4. Vitamin D levels were higher in men (p<0.001). After a median follow-up of 1.63 years, there were 19 (15%) early withdrawals from the study treatment. Mean treatment adherence using pill count was 88%. Subjective adherence by the GTS was 81% and was moderately but significantly correlated with pill count (r = 0.29, p<0.001). Adherence based on short-term recall (HATS) was >80% in 75% of participants. CONCLUSION Micronutrient levels in asymptomatic HIV+ persons are in keeping with population norms, but micronutrient deficiencies are frequent. Adherence levels are high, and will permit a valid evaluation of treatment effects. TRIAL REGISTRATION ClinicalTrials.gov NCT00798772.
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Affiliation(s)
- Louise Balfour
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Ottawa at the Ottawa Hospital, Ottawa, Ontario, Canada
| | - Johanna N. Spaans
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Clinical Epidemiology Program, University of Ottawa at The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, University of Ottawa at The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Harold Huff
- Canadian College of Naturopathic Medicine, Toronto, Ontario, Canada
| | - Edward J. Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Charles J. la Porte
- Division of Infectious Diseases, Department of Medicine, University of Ottawa at the Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, University of Ottawa at The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Sharon Walmsley
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Neera Singhal
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Clinical Epidemiology Program, University of Ottawa at The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Ron Rosenes
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
| | - Nancy Tremblay
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Ottawa at the Ottawa Hospital, Ottawa, Ontario, Canada
| | - M. John Gill
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Hugues Loemba
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Department of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Conway
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anita Rachlis
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Edward Ralph
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Mona Loutfy
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ranjeeta Mallick
- Ottawa Methods Centre, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rika Moorhouse
- Clinical Epidemiology Program, University of Ottawa at The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - D. William Cameron
- CIHR Canadian HIV Trials Network (CTN), Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Department of Medicine, University of Ottawa at the Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, University of Ottawa at The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
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Colombo GL, Castagna A, Di Matteo S, Galli L, Bruno G, Poli A, Salpietro S, Carbone A, Lazzarin A. Cost analysis of initial highly active antiretroviral therapy regimens for managing human immunodeficiency virus-infected patients according to clinical practice in a hospital setting. Ther Clin Risk Manag 2013; 10:9-15. [PMID: 24379676 PMCID: PMC3872009 DOI: 10.2147/tcrm.s49428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective In the study reported here, single-tablet regimen (STR) versus (vs) multi-tablet regimen (MTR) strategies were evaluated through a cost analysis in a large cohort of patients starting their first highly active antiretroviral therapy (HAART). Adult human immunodeficiency virus (HIV) 1-naïve patients, followed at the San Raffaele Hospital, Milan, Italy, starting their first-line regimen from June 2008 to April 2012 were included in the analysis. Methods The most frequently used first-line HAART regimens (>10%) were grouped into two classes: 1) STR of tenofovir disoproxil fumarate (TDF) + emtricitabine (FTC) + efavirenz (EFV) and 2) MTR including TDF + FTC + EFV, TDF + FTC + atazanavir/ritonavir (ATV/r), TDF + FTC + darunavir/ritonavir (DRV/r), and TDF + FTC + lopinavir/ritoavir (LPV/r). Data were analyzed from the point of view of the Lombardy Regional Health Service. HAART, hospitalizations, visits, medical examinations, and other concomitant non-HAART drug costs were evaluated and price variations included. Descriptive statistics were calculated for baseline demographic, clinical, and laboratory characteristics; associations between categorical variables and type of antiretroviral strategy (STR vs MTR) were examined using chi-square or Fisher’s exact tests. At multivariate analysis, the generalized linear model was used to identify the predictive factors of the overall costs of the first-line HAART regimens. Results A total of 474 naïve patients (90% male, mean age 42.2 years, mean baseline HIV-RNA 4.50 log 10 copies/mL, and cluster of differentiation 4 [CD4+] count of 310 cells/μL, with a mean follow-up of 28 months) were included. Patients starting an STR treatment were less frequently antibody-hepatitis C virus positive (4% vs 11%, P=0.040), and had higher mean CD4+ values (351 vs 297 cells/μL, P=0.004) than MTR patients. The mean annual cost per patient in the STR group was €9,213.00 (range: €6,574.71–€33,570.00) and €14,277.00 (range: €5,908.89–€82,310.30) among MTR patients. At multivariate analysis, after adjustment for age, sex, antibody-hepatitis C virus status, HIV risk factors, baseline CD4+, and HIV-RNA, the cost analysis was significantly lower among patients starting an STR treatment than those starting an MTR (adjusted mean: €12,096.00 vs €16,106.00, P=0.0001). Conclusion STR was associated with a lower annual cost per patient than MTR, thus can be considered a cost-saving strategy in the treatment of HIV patients. This analysis is an important tool for policy makers and health care professionals to make short- and long-term cost projections and thus assess the impact of these on available budgets.
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Affiliation(s)
- Giorgio L Colombo
- Department of Drug Sciences, School of Pharmacy, University of Pavia, Italy ; Studi Analisi Valutazioni Economiche (S.A.V.E.), Milan, Italy
| | | | | | - Laura Galli
- Infectious Diseases Department, San Raffaele Hospital, Milan, Italy
| | - Giacomo Bruno
- Studi Analisi Valutazioni Economiche (S.A.V.E.), Milan, Italy
| | - Andrea Poli
- Infectious Diseases Department, San Raffaele Hospital, Milan, Italy
| | | | - Alessia Carbone
- Infectious Diseases Department, San Raffaele Hospital, Milan, Italy
| | - Adriano Lazzarin
- Infectious Diseases Department, San Raffaele Hospital, Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy
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Blydt-Hansen TD, Pierce CB, Cai Y, Samsonov D, Massengill S, Moxey-Mims M, Warady BA, Furth SL. Medication treatment complexity and adherence in children with CKD. Clin J Am Soc Nephrol 2013; 9:247-54. [PMID: 24262500 DOI: 10.2215/cjn.05750513] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES The complexity of CKD management in children is increased by the number of comorbid conditions. This study assessed the prevalence of comorbidities in pediatric CKD and the frequency with which multiple comorbidities present together by assessing prevalent medication use by CKD stage and diagnosis and their association with clinical or sociodemographic factors. The association between number and frequency of dosing of medications prescribed and self-report of nonadherence was also assessed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this cross-sectional analysis of the Chronic Kidney Disease in Children study, medication use at study entry grouped by indication was examined by CKD stage, diagnosis, age, race, ethnicity, income, and CKD duration. Multivariate adjusted predictors of medication use and clustering were examined. Nonadherence was assessed by self-report of missed medications in the past 7 days. RESULTS The 558 eligible participants had a median age of 11 years and median GFR of 44 ml/min per 1.73 m(2); 62% of participants were male and 78% had nonglomerular kidney disease. The number of medications for treatment of CKD comorbidities increased with advanced CKD stage (2.5-fold for stages IV versus II; P<0.001) and glomerular disease (1.4-fold versus nonglomerular; P<0.001). Three distinct medication clusters were identified that corresponded to treatment of glomerular disease, advanced renal tubular dysfunction, and proteinuric complications, respectively. Nonadherence was associated with increased medication dosing frequency (administration >2 times/d; P<0.001) but not the number of medications. CONCLUSIONS Medical therapy for children with CKD is complex and is affected by glomerular diagnosis, CKD stage, and medication frequency. The need for CKD-related medication treatment cannot be easily predicted by CKD staging alone. Poorer adherence was associated with increased medication frequency, but not with the number of medical problems needing treatment. Consolidating medical treatment and reducing medication frequency may improve adherence rates in children with CKD.
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Affiliation(s)
- Tom D Blydt-Hansen
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Langebeek N, Sprenger HG, Gisolf EH, Reiss P, Sprangers MAG, Legrand JC, Richter C, Nieuwkerk PT. A simplified combination antiretroviral therapy regimen enhances adherence, treatment satisfaction and quality of life: results of a randomized clinical trial. HIV Med 2013; 15:286-90. [DOI: 10.1111/hiv.12112] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 12/20/2022]
Affiliation(s)
- N Langebeek
- Department of Internal and Infectious Diseases; Rijnstate Hospital; Arnhem the Netherlands
| | - HG Sprenger
- Department of Internal Medicine, Section Infectious Diseases; University of Groningen, University Medical Centre Groningen; Groningen the Netherlands
| | - EH Gisolf
- Department of Internal and Infectious Diseases; Rijnstate Hospital; Arnhem the Netherlands
| | - P Reiss
- Department of Internal Medicine; Department of Global Health; Academic Medical Center; Amsterdam the Netherlands
| | - MAG Sprangers
- Department of Medical Psychology; Academic Medical Center; Amsterdam the Netherlands
| | - JC Legrand
- Teaching Hospital of Charleroi; Brussels Belgium
| | - C Richter
- Department of Internal and Infectious Diseases; Rijnstate Hospital; Arnhem the Netherlands
| | - PT Nieuwkerk
- Department of Medical Psychology; Academic Medical Center; Amsterdam the Netherlands
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Simpson KN, Hanson KA, Harding G, Haider S, Tawadrous M, Khachatryan A, Pashos CL, Wu AW. Patient reported outcome instruments used in clinical trials of HIV-infected adults on NNRTI-based therapy: a 10-year review. Health Qual Life Outcomes 2013; 11:164. [PMID: 24090055 PMCID: PMC3852266 DOI: 10.1186/1477-7525-11-164] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 09/05/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) may provide valuable information to clinicians and patients when choosing initial antiretroviral therapy. OBJECTIVE To identify and classify PRO instruments used to measure treatment effects in clinical trials evaluating NNRTIs. METHODS We conducted a structured literature review using PubMed to identify NNRTI trials published from March 2003 to February 2013. Studies identified--based on disease, instrument, PRO, and NNRTI medication terms were reviewed--to identify PRO instruments. Domains measured within each instrument were recorded to understand key areas of interest in NNRTIs. RESULTS Of 189 articles reviewed, 27 validated instruments were administered in 26 unique trials, with a mean of 1.9 instruments (median: 1; range: 1-7) per trial. The Medical Outcomes Study HIV Health Survey (MOS-HIV) was the most commonly used instrument (n = 8 trials). Seventeen trials (65%) included at least one multidimensional health-related quality of life (HRQL) instrument (HIV-targeted, n = 11; general, n = 8). Other validated instruments measured sleep (n = 5), depression (n = 5), anxiety (n = 4), psychiatric symptoms (n = 2), beliefs about HIV medications (n = 2), HIV symptoms (n = 1), and stress (n = 1). CONCLUSIONS Although review of recent NNRTI trials suggests a lack of consensus on the optimal PRO instruments, a typical battery is comprised of a multidimensional HRQL measure coupled with one or more symptom measures. Further work is needed to clarify advantages and disadvantages of using specific PRO instruments to measure relevant constructs and to identify the most useful batteries of instruments for NNRTI trials.
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Affiliation(s)
- Kit N Simpson
- Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Kristin A Hanson
- UBC: An Express Scripts Company, 185 Dorval Ave, Suite 500, Dorval, QC H9S 5J9, Canada
| | - Gale Harding
- Evidera, 7101 Wisconsin Avenue, Suite 600, Bethesda, MD 20814, USA
| | - Seema Haider
- Pfizer Inc., 558 Eastern Point Road, Groton, CT 06340, USA
| | | | | | - Chris L Pashos
- UBC: An Express Scripts Company, 430 Bedford Street, Lexington, MA 02420, USA
| | - Albert W Wu
- Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
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Marcellin F, Spire B, Carrieri MP, Roux P. Assessing adherence to antiretroviral therapy in randomized HIV clinical trials: a review of currently used methods. Expert Rev Anti Infect Ther 2013; 11:239-50. [PMID: 23458765 DOI: 10.1586/eri.13.8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antiretroviral therapy for the treatment of HIV infection requires high levels of adherence to both maintain plasma HIV RNA at undetectable levels and prevent the emergence of drug resistance. As adherence to treatment is a major criterion for the evaluation of therapeutic outcomes, randomized clinical trials (RCTs) conducted among HIV-infected patients commonly include an assessment of adherence. However, there is still no gold-standard tool for assessing adherence behaviors in HIV RCTs. The methods currently used to collect and analyze adherence data are varied, which makes the comparison of results between studies difficult. The scope of this article is to review and discuss the range of adherence measures currently used in RCTs conducted among HIV-infected adults.
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Mateo MG, Gutierrez MDM, Vidal F, Domingo P. Stavudine extended release (once-daily, Bristol-Myers Squibb) for the treatment of HIV/AIDS. Expert Opin Pharmacother 2013; 14:1055-64. [PMID: 23510448 DOI: 10.1517/14656566.2013.782285] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Stavudine extended release (d4T XR) was a formulation which tried to solve the two main problems associated with the use of stavudine immediate release (d4T IR). These were twice daily dosing schema at a time when most formulations were long-life allowing once daily dosing; and that the use of d4T IR was associated with long-term toxicity through mitochondrial toxicity clinically expressed as peripheral neuropathy, pancreatitis and above all, lipodystrophy. The link between stavudine exposure and lipodystrophy had a great negative impact on its use in clinical practice. AREAS COVERED The authors cover the most relevant papers related to the efficacy and safety of d4T XR-based antiretroviral therapy. EXPERT OPINION The development of d4T XR has only been partially successful with regard to its objectives. Improved pharmacokinetic properties allow its once daily dosing, and although it exhibits less mitochondrial toxicity it is still hampered by its development in a significant proportion of patients. This has caused its use to be almost residual in industrialised countries. As of now, d4T XR has not been made available in developing countries, despite the extended use of the immediate-release formulation. Currently, if there is no other chance of starting combination antiretroviral therapy, d4T XR could play a role in the treatment of HIV infection.
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Affiliation(s)
- Ma Gracia Mateo
- Infectious Diseases Unit, Hospital de Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Colombo GL, Di Matteo S, Maggiolo F. Antiretroviral therapy in HIV-infected patients: a proposal to assess the economic value of the single-tablet regimen. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:59-68. [PMID: 23430273 PMCID: PMC3575123 DOI: 10.2147/ceor.s38977] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the economic value of a reduced number of pills in patients infected with the immunodeficiency virus (HIV) and on highly active antiretroviral therapy by a cost-effectiveness model. METHODS An incremental cost-effectiveness analysis of efavirenz, tenofovir, and emtricitabine (TDF-FTC-EFV) as a single-tablet regimen versus a multipill regimen, with reference to untreated HIV-infected patients, was carried out from the perspective of the Italian National Health Service. The comparisons were performed with the help of a Markov decision model over a 10-year time horizon. Based on the ADONE (ADherence to ONE pill) study, it was then possible to identify the utility score increment in patients switching from a multipill regimen of TDF-FTC + EFV therapy to a single-tablet regimen. RESULTS The single-tablet regimen (0.755 quality-adjusted life-years [QALYs]/year) resulted in better patient quality of life, with a higher number of QALYs than for the TDF-FTC + EFV multipill regimen (0.716 QALYs/year). The single-tablet regimen was the most cost-effective treatment strategy, with an incremental cost-effectiveness ratio of €22,017.00 versus €26,558.00 for the multipill regimen. A 24% decrease in cost of the multipill regimen determined equivalence with the single-tablet regimen in terms of the incremental cost-effectiveness ratio. Univariate sensitivity and probabilistic analysis carried out on the main variables did not highlight significant variations with respect to the base case scenario. CONCLUSION The single-tablet regimen resulted in better adherence, and therefore better quality of life as perceived by patients, corresponding to a €4541.00 lower cost-effectiveness ratio per QALY versus the multipill regimen, with a 17% lower cost in favor of the single-tablet regimen. The value determined could be used to identify a maximum potential "premium price" of 29% to be assigned to therapeutic regimens proposing a single-tablet regimen for HIV-infected patients.
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Affiliation(s)
- Giorgio L Colombo
- University of Pavia, Department of Drug Sciences, School of Pharmacy, Pavia, Italy ; Studi Analisi Valutazioni Economiche, Milan, Italy
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Bonafede M, Juday T, Lenhart G, Pan K, Hebden T, Correll T. Cost-effectiveness of efavirenz vs rilpivirine in HIV patients initiating first-line combination antiretroviral therapy. J Med Econ 2013; 16:552-9. [PMID: 23391157 DOI: 10.3111/13696998.2013.774280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE In US treatment guidelines, efavirenz (EFV) is the preferred non-nucleoside reverse transcriptase inhibitor (NNRTI) for first-line HIV treatment. In the ECHO and THRIVE trials comparing EFV with another NNRTI, rilpivirine (RPV), both medications had similar virologic suppression rates at 96-weeks; however, RPV had higher rates of virologic failure and drug resistance and lower rates of discontinuation due to adverse events. This study compared the cost-effectiveness of EFV to RPV in first-line HIV treatment in the US. METHODS A Markov model with 14 health states was constructed to estimate 10-year costs and clinical outcomes from a US payer perspective for antiretroviral naïve HIV patients initiating EFV or RPV. First-line efficacy data came from 96-week results of the ECHO and THRIVE trials, which compared EFV and RPV, both in combination with two nucleos(t)ide reverse transcriptase inhibitors. Other clinical inputs, mortality rates, and costs (2011 US$) came from published sources. Subsequent therapy lines (second, third, non-suppressive) were based on US treatment guidelines and common to both treatment arms. Robustness of study results was assessed in sensitivity analyses varying model inputs by ±25%. Potential limitations of the model center on the ability of any model to capture the clinical complexity of HIV treatment. RESULTS In the base case, 10-year costs were lower for EFV compared to RPV ($214,031 vs $222,090). Life expectancy (8.44 years) and years without AIDS (8.40 years) were equal; years in virologic suppression were similar (EFV = 7.87 years, RPV = 7.86 years). EFV had modest cost savings compared to RPV in terms of incremental cost-effectiveness per life-year gained, life-year gained in viral suppression, and life-year gained without AIDS. In sensitivity analyses, EFV remained cost-saving compared to RPV in over 90% of scenarios, demonstrating the robustness of study results. CONCLUSIONS EFV was predicted to be modestly cost-saving compared with RPV over 10 years in US patients initiating first-line HIV treatment. Sensitivity analyses suggest that results may hold across multiple settings.
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Smets E, Brogan AJ, Hill A, Adriaenssen I, Sawyer AW, Domingo-Pedrol P, Gostkorzewicz J, Ledesma F. [Comparative cost-effectiveness analysis between darunavir/ritonavir and other protease inhibitors in treatment-naive human immunodeficiency syndrome type 1-infected patients in Spain]. Enferm Infecc Microbiol Clin 2012; 31:430-6. [PMID: 23260386 DOI: 10.1016/j.eimc.2012.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 10/10/2012] [Accepted: 11/06/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION GESIDA (AIDS Study Group) has proposed preferred regimens of antiretroviral treatment as initial therapy in HIV infected patients. The objective of this analysis is to compare the costs and effectiveness of darunavir/r QD and other ritonavir-boosted (/r) protease inhibitors (PIs) currently recommended in GESIDA guidelines for treatment-naïve patients. METHODS A cost-efficacy model compared the boosted PIs recommended as preferred or alternative treatment choices, each used with a nucleoside reverse transcriptase inhibitor backbone. Efficacy was measured by 48-week virological response (viral load < 50 copies/mL) adjusted by baseline viral load and CD4 cell count. To generate efficiency frontiers and cost-efficacy ratios, one-year antiretroviral therapy costs in Spain, and 48-week efficacy values were used. RESULTS The model estimated that starting treatment with darunavir/r QD was the most cost-effective choice compared with the other preferred PI/r based therapies. The average cost per patient with a virological response was lower for darunavir/r QD (13,420€) than for atazanavir/r QD (14,000€), or lopinavir/r BID (13,815€). Among the preferred PI/r-based therapies, darunavir/r QD also was estimated to be the most efficient option for treatment-naïve patients. Atazanavir/r QD and lopinavir/r BID were found to be «dominated» by darunavir/r) and, consequently, were outside the efficiency frontier of PI/r-based first-line treatment. Given a fixed budget of 10 million euros for PI/r-based first-line therapy, the model estimated that darunavir/r QD would yield more responders (745) than atazanavir/r QD (714), or lopinavir/r BID (724). At the same time, darunavir/r QD would reduce the number of individuals failing treatment (150) compared with atazanavir/r QD (172) and lopinavir/r BID (286). CONCLUSIONS In this model, darunavir/r QD was found to be the most cost-effective choice, among the preferred PI/r-based therapies recommended in the Spanish guidelines for treatment-naïve patients.
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Affiliation(s)
- Erik Smets
- Johnson & Johnson Pharmaceutical Services LLC, Beerse, Bélgica
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Helleberg M, Kronborg G, Larsen CS, Pedersen G, Pedersen C, Nielsen L, Laursen AL, Obel N, Gerstoft J. Decreasing rate of multiple treatment modifications among individuals who initiated antiretroviral therapy in 1997-2009 in the Danish HIV Cohort Study. Antivir Ther 2012; 18:345-354. [PMID: 23072939 DOI: 10.3851/imp2436] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND We hypothesized that rates and reasons for treatment modifications have changed since the implementation of combination antiretroviral therapy (cART) due to improvements in therapy. METHODS From a nationwide population-based cohort study we identified all HIV-1-infected adults who initiated cART in Denmark 1997-2009 and were followed ≥1 year. Incidence rate ratios (IRRs) and reasons for treatment modifications were estimated and compared between patients, who initiated treatment in 1997-1999, 2000-2004 and 2005-2009. Rates of discontinuation of individual antiretroviral drugs (ARVs) were evaluated. RESULTS A total of 3,107 patients were followed for a median of 7.3 years (IQR 3.8-10.8). Rates of first treatment modification ≤1 year after cART initiation did not change (IRR 0.88 [95% CI 0.78, 1.01] and 1.03 [95% CI 0.90, 1.18] in 2000-2004 and 2005-2009, respectively, compared with 1997-1999). Rates of multiple modifications decreased markedly (2000-2004 IRR 0.60 [95% CI 0.53, 0.67] and 2005-2009 IRR 0.38 [95% CI 0.32, 0.46]). Rates of treatment modifications due to virological failure, toxicity and other/unknown reasons decreased (IRR 0.25 [95% CI 0.14, 0.45], 0.69 [95% CI 0.56, 0.83] and 0.45 [95% CI 0.36, 0.57], respectively, in 2005-2009 compared with 1997-1999), whereas the rate of modifications with the aim of simplification increased (IRR 1.85 [95% CI 1.52, 2.25]). CONCLUSIONS Rates of first treatment modification ≤1 year after cART initiation have not changed since the early cART era, whereas the risk of multiple modifications has decreased markedly. Modifications due to virological failure and toxicity have decreased substantially, whereas rates of switch to simpler and less toxic regimens have increased.
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Affiliation(s)
- Marie Helleberg
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Gitte Kronborg
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - Carsten S Larsen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Gitte Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Lars Nielsen
- Department of Infectious Diseases, Hillerød Hospital, Hillerød, Denmark
| | - Alex L Laursen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jan Gerstoft
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
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García-Ramos SE, Santolaya Perrín MR, Fernández-Pacheco García-Valdecasas M. [Analysis of adherence and efficiency when replacing an antiretroviral therapy with efavirenz-emtricitabine-tenofovir in a single daily dose]. FARMACIA HOSPITALARIA 2012; 36:315-20. [PMID: 22858089 DOI: 10.1016/j.farma.2011.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 02/21/2011] [Accepted: 03/01/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To analyse whether the change of antiretroviral therapy to efavirenz/emtricitabine/tenofovir in a single daily dose (EETu) increases adherence and maintains effectiveness, and establish the cost increase caused by the change. METHODS An observational, retrospective, and intra-subject study, performed in the outpatient dispensing unit. The study period was 1 year (6 months before and 6 months after the change). Computer dispensing records and days of hospitalisation during the study period were reviewed, and the difference in treatment adherence calculated. To determine the effectiveness of treatment, viral load and CD4 lymphocytes data before and after the change were reviewed. The cost before and after treatment for each patient was determined, and therefore the annual cost increase and the incremental cost per patient. RESULTS The study included 127 patients. The difference in adherence was 0.6%. The percentage of poor adherence was 35.4% and 40.9% before and after the treatment change, respectively. The levels of CD4 lymphocytes and viral load did not change significantly with treatment. The economic analysis revealed an annual increase of 25,374.60 and €199.80 per patient. CONCLUSIONS The use of EETu did not improve the control of HIV infection in terms of effectiveness and adherence, and resulted in increased economic costs. Therefore, its choice as antiretroviral treatment will have to be based on criteria other than those described above.
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Affiliation(s)
- S E García-Ramos
- Servicio de Farmacia, Hospital Universitario Príncipe de Asturias, Madrid, España.
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Thompson MA, Mugavero MJ, Amico KR, Cargill VA, Chang LW, Gross R, Orrell C, Altice FL, Bangsberg DR, Bartlett JG, Beckwith CG, Dowshen N, Gordon CM, Horn T, Kumar P, Scott JD, Stirratt MJ, Remien RH, Simoni JM, Nachega JB. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med 2012; 156:817-33, W-284, W-285, W-286, W-287, W-288, W-289, W-290, W-291, W-292, W-293, W-294. [PMID: 22393036 PMCID: PMC4044043 DOI: 10.7326/0003-4819-156-11-201206050-00419] [Citation(s) in RCA: 481] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
DESCRIPTION After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV. METHODS A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation. RECOMMENDATIONS Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.
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Schapira AHV, Barone P, Hauser RA, Mizuno Y, Rascol O, Busse M, Debieuvre C, Fraessdorf M, Poewe W. Patient-reported convenience of once-daily versus three-times-daily dosing during long-term studies of pramipexole in early and advanced Parkinson’s disease. Eur J Neurol 2012; 20:50-6. [DOI: 10.1111/j.1468-1331.2012.03712.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Krentz HB, Cosman I, Lee K, Ming JM, Gill MJ. Pill burden in HIV infection: 20 years of experience. Antivir Ther 2012; 17:833-40. [PMID: 22358155 DOI: 10.3851/imp2076] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND New antiretroviral (ARV) drugs and improved formulations and coformulations of existing ARVs are actively promoted to diminish a patient's pill burden and to minimise the opportunity for mismatched dosing, although the effect of these advances is poorly understood. We determine how these changes affect the total daily pill burden (TDPB) for ARV and other drug use over a 20-year period. METHODS Using our in-house pharmacy database, we calculated the daily number and associated pill burden of oral ARV and non-ARV (prescription and over-the-counter) medications taken by every patient within the Southern Alberta Cohort (SAC) between 1990 and 2010. We compared the mean TDPB with the patients' sociodemographic and clinical characteristics. RESULTS Mean TDPB for ARV-experienced patients increased from 4.9 in 1990 to 12.1 in 1998 but decreased to 6.7 in 2010. By 2010, new ARVs and newer formulations had decreased ARV pill burden by 50% over five years. In 1990, however, 95% of the TDPB consisted of ARVs but by 2010 it fell to 51% as non-ARV daily drugs increased from 0.2 in 1990 to 2.6 in 2010. Variation in TDPB was attributable to four main factors: patient's age, risk factor, nadir CD4(+) T-cell count and duration of known HIV infection. CONCLUSIONS While new ARV formulations and coformulations have simplified regimens, this reduction in ARV pill burden has been counterbalanced by increases in non-ARV drugs required for managing comorbidities. Discussions on merits of coformulations in decreasing ARV pill burden need to include the non-ARV pill burden.
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Adler LA, Lynch LR, Shaw DM, Wallace SP, Ciranni MA, Briggie AM, Kulaga A, O'Donnell KE, Faraone SV. Medication adherence and symptom reduction in adults treated with mixed amphetamine salts in a randomized crossover study. Postgrad Med 2011; 123:71-9. [PMID: 21904088 DOI: 10.3810/pgm.2011.09.2461] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The study objectives were to 1) evaluate medication adherence for adults with attention-deficit/hyperactivity disorder (ADHD) treated with 3 times daily (TID) mixed amphetamine salts immediate release (MAS IR) versus once-daily (qAM) MAS extended release (MAS XR) in a randomized, crossover study; and 2) to examine the associations between adherence and efficacy for MAS IR and MAS XR. METHODS Sixty-two adults with ADHD were enrolled and 49 completed the study. The treatment condition order (TID-qAM or qAM-TID) was counterbalanced across participants, with an intervening washout period of ≥ 7 days. Adherence was assessed via 3 measures: 1) self-report, 2) pill count, and 3) the Medication Event Monitoring System (MEMS(®)). The primary efficacy measure was the ADHD Rating Scale (ADHD-RS); secondary measures included the Time-Sensitive ADHD Symptom Scale (TASS) and Clinical Global Impressions-Severity of Illness (CGI-S) scale. RESULTS Adherence to treatment as measured by self-report and pill count was not significantly different between MAS XR and MAS IR. Adherence was significantly better for MAS XR than MAS IR for all of the MEMS(®) measures. The mean change in ADHD-RS, TASS, and CGI-S scores at endpoint was significantly improved for both MAS IR and MAS XR and did not differ significantly between groups. There was not a significant adherence by efficacy interaction. CONCLUSION Adults with ADHD adhered equally well with MAS IR as with MAS XR when assessed by pill count and self-report, but not by the MEMS(®) measures. Both treatments significantly reduced ADHD symptoms, and efficacy was not significantly different between groups. Adherence was not associated with treatment outcome.
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Affiliation(s)
- Lenard A Adler
- Department of Psychiatry, NYU School of Medicine, New York, NY 10016, USA.
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Raboud J, Li M, Walmsley S, Cooper C, Blitz S, Bayoumi AM, Rourke S, Rueda S, Rachlis A, Mittmann N, Smieja M, Collins E, Loutfy MR. Once daily dosing improves adherence to antiretroviral therapy. AIDS Behav 2011; 15:1397-409. [PMID: 20878227 DOI: 10.1007/s10461-010-9818-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We studied the association of once-daily dosing with self-reported adherence among participants of the Ontario Cohort Study who were currently taking ART and who had completed a 90-min interviewer-administered questionnaire. Suboptimal adherence was defined as missing ≥1 dose of ART in the 4 days prior to the interview. Participants (n = 779) were 85% male, 69% men having sex with men, 67% white, median age 48 years (IQR 42-54), median years of ART 9 (IQR 5-13) and median CD4 count 463 cells/mm(3) (IQR 320-638). Fifteen percent of participants reported suboptimal adherence in the 4 days prior to the interview. In a multivariable logistic regression model, participants on once daily regimens were half as likely to miss a dose during the 4 days prior to the interview. Other independent correlates of suboptimal adherence were younger age, lower positive social interaction and increased frequency of consuming > 6 alcoholic drinks on one occasion.
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Rosso R, Di Biagio A, Maggiolo F, Nulvesu L, Callegaro AP, Taramasso L, Bruzzone B, Viscoli C. Patient-reported outcomes and low-level residual HIV-RNA in adolescents perinatally infected with HIV-1 after switching to one-pill fixed-dose regimen. AIDS Care 2011; 24:54-8. [PMID: 21800951 DOI: 10.1080/09540121.2011.596511] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Raffaella Rosso
- a Clinica Malattie Infettive, Ospedale San Martino , Università degli Studi di Genova , Genova , Italy
| | - Antonio Di Biagio
- a Clinica Malattie Infettive, Ospedale San Martino , Università degli Studi di Genova , Genova , Italy
| | - Franco Maggiolo
- b Divisione di Malattie Infettive , Ospedali Riuniti, Bergamo , Italy
| | - Loredana Nulvesu
- a Clinica Malattie Infettive, Ospedale San Martino , Università degli Studi di Genova , Genova , Italy
| | | | - Lucia Taramasso
- a Clinica Malattie Infettive, Ospedale San Martino , Università degli Studi di Genova , Genova , Italy
| | - Bianca Bruzzone
- d Laboratorio di Igiene , Ospedale San Martino, Genova , Italy
| | - Claudio Viscoli
- a Clinica Malattie Infettive, Ospedale San Martino , Università degli Studi di Genova , Genova , Italy
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Juday T, Gupta S, Grimm K, Wagner S, Kim E. Factors associated with complete adherence to HIV combination antiretroviral therapy. HIV CLINICAL TRIALS 2011; 12:71-8. [PMID: 21498150 DOI: 10.1310/hct1202-71] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess factors associated with adherence, particularly pill burden, to combination antiretroviral therapy (cART) using multivariate models. METHOD A cross-sectional survey of US adults with a self-reported diagnosis of HIV/AIDS was conducted between April and May 2007. Respondents on a cART regimen of at least 2 nucleoside reverse transcriptase inhibitors plus at least 1 protease inhibitor or non-nucleoside reverse transcriptase inhibitor (n = 461) were included in the analytic sample. Multiple logistic regression models determined independent predictors of complete adherence (defined as never missing or skipping an antiretroviral dose). RESULTS Fifty-four percent of respondents reported complete adherence to cART. Adherent respondents reported a lower percentage of hospitalizations (11% vs 28%; P < .0001) and emergency room visits (26% vs 34%; P < .09). Respondents taking the single tablet efavirenz/emtricitabine/tenofovir fixed-dose regimen were significantly more likely to have complete adherence than respondents taking other cART regimens (odds ratio [OR] 2.1, P < .05), and higher imputed daily HIV pill count was associated with lower likelihood of complete adherence (OR 0.93, P < .05). CONCLUSION This study shows the negative impact of higher pill burden on medication adherence, an important factor associated with treatment outcomes in patients with HIV/AIDS.
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Nachega JB, Mugavero MJ, Zeier M, Vitória M, Gallant JE. Treatment simplification in HIV-infected adults as a strategy to prevent toxicity, improve adherence, quality of life and decrease healthcare costs. Patient Prefer Adherence 2011; 5:357-67. [PMID: 21845035 PMCID: PMC3150164 DOI: 10.2147/ppa.s22771] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Indexed: 11/30/2022] Open
Abstract
Since the advent of highly active antiretroviral therapy (HAART), the treatment of human immunodeficiency virus (HIV) infection has become more potent and better tolerated. While the current treatment regimens still have limitations, they are more effective, more convenient, and less toxic than regimens used in the early HAART era, and new agents, formulations and strategies continue to be developed. Simplification of therapy is an option for many patients currently being treated with antiretroviral therapy (ART). The main goals are to reduce pill burden, improve quality of life and enhance medication adherence, while minimizing short- and long-term toxicities, reducing the risk of virologic failure and maximizing cost-effectiveness. ART simplification strategies that are currently used or are under study include the use of once-daily regimens, less toxic drugs, fixed-dose coformulations and induction-maintenance approaches. Improved adherence and persistence have been observed with the adoption of some of these strategies. The role of regimen simplification has implications not only for individual patients, but also for health care policy. With increased interest in ART regimen simplification, it is critical to study not only implications for individual tolerability, toxicity, adherence, persistence and virologic efficacy, but also cost, scalability, and potential for dissemination and implementation, such that limited human and financial resources are optimally allocated for maximal efficiency, coverage and sustainability of global HIV/AIDS treatment.
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Affiliation(s)
- Jean B Nachega
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Nachega JB, Rosenkranz B, Pham PA. Twice-daily versus once-daily antiretroviral therapy and coformulation strategies in HIV-infected adults: benefits, risks, or burden? Patient Prefer Adherence 2011; 5:645-51. [PMID: 22259241 PMCID: PMC3259079 DOI: 10.2147/ppa.s27558] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The recent development of once-daily antiretroviral agents and fixed-dose combination formulations has been an important development in antiretroviral regimen simplification. Recent studies indicate that once-daily antiretroviral regimens improve adherence, especially in antiretroviral-naïve patients and in difficult-to-treat populations, such as the homeless or marginally housed. However, there are potential risks with the higher peak and lower trough plasma drug concentrations that may result from certain once-daily formulations. Due to the multifactorial and complex nature of adherence behavior, clinicians' efforts to improve patient adherence should not be limited to prescribing once-daily regimens, but should also consider social support, side effect management, and adherence support tools, such as pillbox organizers and other targeted interventions. Additional research will clarify the benefits of once-daily and fixed-dose combination regimens on clinical and virologic outcomes. Comprehensive cost-benefit analysis of regimen simplification could help facilitate evidence-based decisions regarding antiretroviral regimen choices.
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Affiliation(s)
- Jean B Nachega
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine and Centre for Infectious Diseases, University of Stellenbosch, Capetown, South Africa
- Correspondence: Jean B Nachega, Johns Hopkins University, Bloomberg, School of Public Health, Department of International Health, Global Disease Epidemiology and Control Program, 615 N Wolfe St, Suite W5031, Baltimore, MD 21205, USA, Tel +1 410 955 2378, Fax +1 410 502 6733, Email
| | - Bernd Rosenkranz
- Division of Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Stellenbosch, Capetown, South Africa
| | - Paul A Pham
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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A single tablet regimen is associated with higher adherence and viral suppression than multiple tablet regimens in HIV+ homeless and marginally housed people. AIDS 2010; 24:2835-40. [PMID: 21045636 DOI: 10.1097/qad.0b013e328340a209] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although, single-tablet regimen (STR) efavirenz, emtricibine, and tenofovir disoproxil fumarate (EFV/FTC/TDF) may be appealing in HIV-infected persons who are at high risk for nonadherence, the degree to which this simplified formulation affects adherence is not known. The virologic effectiveness of this STR in a potentially nonadherent population remains a concern, given the rapid selection of drug resistance seen with these drugs. METHOD We performed a prospective observational study assessing adherence and virologic response to EFV/FTC/TDF STR among a cohort of homeless and marginally housed individuals. We compared adherence and viral suppression to historical controls followed in the same cohort. RESULTS Adherence was higher in EFV/FTC/TDF STR regimen compared to non-one-pill-once-daily therapy (P = 0.006) after controlling for multiple confounders. Viral suppression (HIV RNA <50 copies/ml) was greater in EFV/ FTC/TDF STR than non-one-pill-once-daily regimens (69.2 versus 46.5%; P = 0.02), but there was no difference in viral suppression after controlling for adherence. CONCLUSION Once-daily EFV/TNF/FTC STR appears to be a reasonable option for individuals with multiple barriers to adherence. Randomized clinical trials addressing various therapeutic strategies for this patient population are needed.
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Brogan AJ, Mrus J, Hill A, Sawyer AW, Smets E. Comparative cost-efficacy analysis of darunavir/ritonavir and other ritonavir-boosted protease inhibitors for first-line treatment of HIV-1 infection in the United States. HIV CLINICAL TRIALS 2010; 11:133-44. [PMID: 20736150 DOI: 10.1310/hct1103-133] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE A comprehensive study comparing the costs and efficacies of darunavir/ritonavir 800/100 mg qd and the other ritonavir-boosted (/r) protease inhibitors (PIs) recommended for treatment-naïve individuals with HIV-1 infection would help health care decision makers identify the value of each boosted PI. METHODS A cost-efficacy model was developed to compare the five recommended boosted PIs, each used with a tenofovir-based nucleotide/nucleoside reverse transcriptase inhibitor backbone. Efficacy was measured by virologic response (ie, HIV-1 ribonucleic acid < 50 copies/mL) at 48 weeks, based on a systematic review and meta-analysis of recent clinical trials. One-year antiretroviral therapy costs and 48-week efficacy values were used to generate the efficiency frontier and cost-efficacy ratios. RESULTS Darunavir/r was the most efficacious boosted PI, with an incremental cost-efficacy ratio of $27,390 per additional individual with virologic response, compared with fosamprenavir/r. All other regimens were dominated. Darunavir/r combination therapy also had one of the lowest average costs ($26,287) per individual with virologic response, resulting in a maximal number of individuals successfully treated within a fixed budget. The model results were robust in variability and sensitivity analyses. CONCLUSION Darunavir/r 800/100 mg qd combination therapy represents a cost-efficacious option for treatment-naïve individuals with HIV-1 infection in the United States.
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Affiliation(s)
- Anita J Brogan
- RTI Health Solutions, Research Triangle Park, North Carolina 27709, USA.
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Goldman D, Lakdawalla D, Philipson TJ, Yin W. Valuing health technologies at NICE: recommendations for improved incorporation of treatment value in HTA. HEALTH ECONOMICS 2010; 19:1109-16. [PMID: 20842680 DOI: 10.1002/hec.1654] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Dana Goldman
- Schaeffer Center for Health Policy and Economics, University of Southern California and RANDCorporation, CA, USA
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Friedman RJ. Simplifying thromboprophylaxis could improve outcomes in orthopaedic surgery. THROMBOSIS 2010; 2010:108049. [PMID: 22084657 PMCID: PMC3211076 DOI: 10.1155/2010/108049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Revised: 05/27/2010] [Accepted: 08/18/2010] [Indexed: 11/17/2022]
Abstract
Venous thromboembolism is a serious complication after total hip or knee surgery, and there is a well-established clinical need for thromboprophylaxis. However, in a large number of cases adequate administration of thromboprophylaxis does not seem to occur after total joint arthroplasty. A major challenge in the management of thromboprophylaxis is to balance the benefits of treatment with the risks, including bleeding complications. Another potential barrier to the optimal use of thromboprophylaxis could be the inconvenience of currently available agents. Many surgeons therefore adopt a conservative approach towards thromboprophylaxis. Simplifying therapy with more convenient, efficacious, and safe anticoagulants could change attitudes to anticoagulant use and improve adherence to thromboprophylactic guidelines.
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Affiliation(s)
- Richard J Friedman
- Department of Orthopaedic Surgery, Roper Hospital, Charleston Orthopaedic Associates, 1012 Physicians Drive, Charleston, SC 29414, USA
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Alam I, Stainbrook T, Cecil B, Kistler KD. Enhanced adherence to HCV therapy with higher dose ribavirin formulation: final analyses from the ADHERE registry. Aliment Pharmacol Ther 2010; 32:535-42. [PMID: 20500732 DOI: 10.1111/j.1365-2036.2010.04381.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Poor adherence to Hepatitis C virus (HCV) treatment is an important cause of treatment failure. Traditional ribavirin 200 mg (RBV) treatment is associated with a significant daily pill burden. RibaPak (RBP), available as 400 mg and 600 mg ribavirin tablets, offers simplified dosing at two pills daily. AIM To examine whether improved adherence was associated with RBP vs. RBV. METHODS Accurate Dosing in Hepatitis C: Examining the RibaPak Experience (ADHERE) was a U.S., multi-centre, prospective registry capturing data on adherence with RBP vs. RBV in adults with HCV. Adherence was measured by the proportion of subjects remaining on treatment at weeks 4, 12 and 24; by pill counts; and by the proportion of subjects who took > or = 80% of their prescribed dose. RESULTS A total of 503 patients (RBP = 346, RBV = 157) from 33 sites were included. A greater proportion of RBV vs. RBP subjects prematurely discontinued treatment. At 12 and 24 weeks, a greater proportion of RBP vs. RBV subjects took > or = 80% of their prescribed doses (P < 0.05). For patients who remained on treatment, the mean milligrams missed per day was significantly greater for RBV vs. RBP at 24 weeks. CONCLUSIONS First line treatment with RBP may offer the best prospect for less discontinuation and improved treatment adherence.
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Affiliation(s)
- I Alam
- Austin Hepatitis Center, Austin, TX, USA
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Similar safety and efficacy of once- and twice-daily lopinavir/ritonavir tablets in treatment-experienced HIV-1-infected subjects at 48 weeks. J Acquir Immune Defic Syndr 2010; 54:143-51. [PMID: 20134330 DOI: 10.1097/qai.0b013e3181cbd21e] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the safety and antiviral activity of once (QD) or twice (BID) daily lopinavir/ritonavir (LPV/r) in combination with investigator-selected nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) in treatment-experienced subjects. METHODS Subjects failing treatment with HIV-1 RNA > 1000 copies per milliliter received LPV/r tablets 800/200 mg QD (n = 300) or 400/100 mg BID (n = 299) with investigator-chosen nucleoside/nucleotide reverse transcriptase inhibitors. Efficacy was determined by the intent-to-treat time to loss of virologic response (ITT-TLOVR) algorithm. Safety, tolerability, adherence, impact of baseline protease mutations on virologic response, and emergence of resistance on therapy were assessed. RESULTS Demographics were comparable across groups. By intent-to-treat time to loss of virologic response, 166 QD subjects (55.3%) and 155 BID subjects (51.8%) were responders at week 48 (P = 0.413), with similar mean increases in CD4 T-cell count. QD subjects demonstrated better adherence than BID subjects. The occurrence of treatment-related moderate/severe adverse events was comparable for all events except nausea, which was reported more frequently among BID-treated subjects. Emergence of new protease resistance mutations on treatment was similarly infrequent in both groups. CONCLUSION LPV/r dosed QD resulted in increased treatment adherence and was as efficacious as BID LPV/r while providing similar safety, tolerability, and limited resistance evolution.
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Airoldi M, Zaccarelli M, Bisi L, Bini T, Antinori A, Mussini C, Bai F, Orofino G, Sighinolfi L, Gori A, Suter F, Maggiolo F. One-pill once-a-day HAART: a simplification strategy that improves adherence and quality of life of HIV-infected subjects. Patient Prefer Adherence 2010; 4:115-25. [PMID: 20517472 PMCID: PMC2875721 DOI: 10.2147/ppa.s10330] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of the ADONE (ADherence to ONE pill) study was to verify the effect of a reduced number of pills on adherence and quality of life (QoL) in HIV-infected patients on highly active antiretroviral therapy (HAART). DESIGN Prospective, multicenter, study. METHODS Patients chronically treated with emtricitabine (FTC) + tenofovir (TDF) + efavirenz (EFV) or lamivudine (3TC) +TDF +EFV and with a HIV-RNA < 50 copies/mL were switched to the single-pill fixed-dose regimen (FDR) of FTC +TDF +EFV. Data were collected with SF-36 using visual analog scales. Results of the final (6 months) primary as-treated analysis are reported. RESULTS 212 patients (77.4% males) of mean age 45.8 years were enrolled; 202 completed the study. One month post switch to FDR the adherence rate increased significantly to 96.1% from a baseline value of 93.8% (P < 0.01). The increase was steadily maintained throughout the study (96.2% at 6 months). QoL improved over time from 68.8% to 72.7% (P = 0.042) as well, and was significantly associated with the perception of health status, presence of adverse events (AEs) and number of reported AEs (P < 0.0001). QoL significantly influenced adherence (P < 0.0001). During FDR use the mean CD4 count increased from 556 to 605 cells/muL (P < 0.0001). At the end of follow-up 98% of patients maintained HIV-RNA level < 50 copies/mL and 100% <400 copies/mL. Four patients stopped therapy because they were lost to follow-up and 6 because of AEs (insomnia/nervousness 4, allergy 1, difficulties swallowing pills 1). CONCLUSION By substituting a one-pill once-a-day HAART, we observed an improvement of both adherence and QoL while maintaining high virologic and immunologic efficacy. HAART simplicity is an added value that favors adherence and may improve long-term success.
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Affiliation(s)
- Monica Airoldi
- Division of Infectious Diseases, Ospedali Riuniti, Bergamo
- Division of Infectious Diseases, Ospedale San Gerardo, Monza
| | | | - Luca Bisi
- Division of Infectious Diseases, Università, Modena
| | - Teresa Bini
- Division of Infectious Diseases, Ospedale San Paolo, Milano
| | | | | | - Francesca Bai
- Division of Infectious Diseases, Ospedale San Paolo, Milano
| | | | - Laura Sighinolfi
- Division of Infectious Diseases, Ospedale Sant’Anna, Ferrara, Italy
| | - Andrea Gori
- Division of Infectious Diseases, Ospedale San Gerardo, Monza
| | - Fredy Suter
- Division of Infectious Diseases, Ospedali Riuniti, Bergamo
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Jacobson JM, Thompson MA, Lalezari JP, Saag MS, Zingman BS, D'Ambrosio P, Stambler N, Rotshteyn Y, Marozsan AJ, Maddon PJ, Morris SA, Olson WC. Anti-HIV-1 activity of weekly or biweekly treatment with subcutaneous PRO 140, a CCR5 monoclonal antibody. J Infect Dis 2010; 201:1481-7. [PMID: 20377413 DOI: 10.1086/652190] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND PRO 140 is a humanized CCR5 monoclonal antibody that has demonstrated potent antiviral activity when it is administered intravenously to adults infected with CCR5-tropic (R5) human immunodeficiency virus type 1 (HIV-1). This study is the first to evaluate subcutaneous administration. METHODS A randomized, double-blind, placebo-controlled study was conducted among 44 subjects with HIV-1 RNA levels of >5000 copies/mL, CD4(+) cell counts of >300 cells/microL, no receipt of antiretroviral therapy for >or=12 weeks, and only R5 HIV-1 detectable. Subjects received placebo, 162 mg of PRO 140, or 324 mg of PRO 140 weekly for 3 weeks or 324 mg of PRO 140 every other week for 2 doses by means of subcutaneous infusion. Subjects were monitored for 58 days for safety, antiviral effects, and PRO 140 serum concentrations. RESULTS Subcutaneous PRO 140 demonstrated potent and prolonged antiretroviral activity. Mean log(10) reductions in HIV-1 RNA level were 0.23, 0.99 (P=.009), 1.37 (P<.001), and 1.65 (P<.001) for the placebo, 162 mg weekly, 324 mg biweekly, and 324 mg weekly dose groups, respectively. Viral loads remained suppressed between successive doses. Treatment was generally well tolerated. CONCLUSIONS This trial demonstrates proof of concept for a monoclonal antibody administered subcutaneously in HIV-1 infected individuals. Subcutaneous PRO 140 offers the potential for significant dose-dependent HIV-1 RNA suppression and infrequent patient self-administration. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00642707 .
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Affiliation(s)
- Jeffrey M Jacobson
- Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Bubalo J, Clark RK, Jiing SS, Johnson NB, Miller KA, Clemens-Shipman CJ, Sweet AL. Medication adherence: Pharmacist perspective. J Am Pharm Assoc (2003) 2010; 50:394-406. [DOI: 10.1331/japha.2010.08180] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Hodder SL, Mounzer K, DeJesus E, Ebrahimi R, Grimm K, Esker S, Ecker J, Farajallah A, Flaherty JF. Patient-reported outcomes in virologically suppressed, HIV-1-Infected subjects after switching to a simplified, single-tablet regimen of efavirenz, emtricitabine, and tenofovir DF. AIDS Patient Care STDS 2010; 24:87-96. [PMID: 20156091 DOI: 10.1089/apc.2009.0259] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A randomized, open-label, multicenter study was conducted to evaluate the therapeutic switch to a single-tablet formulation of efavirenz/emtricitabine/tenofovir DF (EFV/FTC/TDF) among virologically suppressed, HIV-1-infected subjects. Eligible subjects on stable antiretroviral therapy (ART) with HIV-1 RNA less than 200 copies per milliliter for 3 months or more were stratified by prior protease inhibitor (PI)- or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based therapy and randomized (2:1) to EFV/FTC/TDF or to stay on their baseline regimen (SBR). Patient-reported measures were quality of life (QOL; SF-36 [version 2]), treatment adherence (visual analogue scale), preference of medication (POM), perceived ease of the regimen for condition (PERC), and a 20-item HIV symptom index. Overall, 203 subjects were randomized to EFV/FTC/TDF and 97 to SBR. Fifty-three percent of subjects had previously received a PI-based regimen; 47% an NNRTI-based therapy. Throughout the study, SF-36 summary scores did not differ significantly from baseline, regardless of previous ART or treatment allocation. Adherence was 96% or more in both groups at baseline and all subsequent study visits. At study conclusion, the EFV/FTC/TDF regimen was considered easier to follow than prior regimens by 97% and 96% of subjects previously receiving PI-based and NNRTI-based therapies, respectively. Overall, 91% of subjects switched to EFV/FTC/TDF indicated a preference over their prior therapy. Switching to EFV/FTC/TDF was associated with transient worsening/emergence of dizziness and sustained improvements in several other HIV-related symptoms. In conclusion, switching virologically suppressed, HIV-1-infected subjects from PI-based or NNRTI-based regimens to EFV/FTC/TDF was associated with maintained QOL and treatment adherence, and improved ease of use and treatment satisfaction.
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Affiliation(s)
- Sally L. Hodder
- University of Medicine and Dentistry of New Jersey, Newark, New Jersey
| | - Karam Mounzer
- Philadelphia FIGHT, Philadelphia, Pennsylvania
- University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | | | - Janet Ecker
- Gilead Sciences, Inc., Foster City, California
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Atkinson MJ, Petrozzino JJ. An evidence-based review of treatment-related determinants of patients' nonadherence to HIV medications. AIDS Patient Care STDS 2009; 23:903-14. [PMID: 19642921 DOI: 10.1089/apc.2009.0024] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Patients' adherence to antiretroviral medications is a primary determinant of both the effectiveness of treatment and the clinical course of HIV/AIDS. This empirical review is intended to compare the relative importance of patient and treatment characteristics on nonadherence behavior and the impact of nonadherence on treatment failure. Articles cited in PubMed and published between 2006 and June 2008 (n = 200) were reviewed to select those that address patient or treatment characteristics associated with nonadherence. Twenty-two articles were selected that provided odds ratio or hazard ratio statistics that quantified predictors of patients' level of nonadherence (e.g., <80%, 80%-95% and >95%). Results were summarized using random effects meta-analytic models. Predictors of nonadherence were divided into four predictive clusters (clinical predictors, comorbid predictors, treatment competence predictors, and dosing predictors). The summary odds ratios (ORs) of nonadherence for each cluster (in order of strength) were treatment competence 2.0 (95% confidence interval [CI]: 1.6-2.6), clinical predictors 1.6 (95% CI: 1.4-1.8), comorbid predictors 1.6 (95% CI: 1.4-1.8), and dosing predictors 1.5 (95% CI: 1.3-1.7). The effect of nonadherence on treatment failure supported the findings of two prior empirical reviews (OR 2.0, 95% CI: 1.6-2.5). Within dosing predictors, a pill burden of more versus less than 10 pills per day was associated with a much higher odds of nonadherence than twice versus once daily dosing or small differences in the number of types of antiretroviral treatments in a regimen. These results provide insight into the relative importance of various determinants of patient nonadherence that may inform the design of patient educational initiatives and initiatives to simplify treatment regimens.
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Affiliation(s)
- Mark J. Atkinson
- PRO-Spectus LLC, San Diego, California
- Health Services Research Center, University of California at San Diego, San Diego, California
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Grant PM, Palmer S, Bendavid E, Talbot A, Slamowitz DC, Cain P, Kobayashi SS, Balamane M, Zolopa AR. Switch from enfuvirtide to raltegravir in virologically suppressed HIV-1 infected patients: effects on level of residual viremia and quality of life. J Clin Virol 2009; 46:305-8. [PMID: 19819183 DOI: 10.1016/j.jcv.2009.09.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 09/16/2009] [Accepted: 09/19/2009] [Indexed: 02/01/2023]
Abstract
BACKGROUND Raltegravir is a potential treatment option for virologically suppressed HIV-1 infected patients on enfuvirtide with injection site reactions. OBJECTIVES To characterize safety and efficacy of an enfuvirtide to raltegravir switch including changes in T-cells, quality of life, and residual viremia. STUDY DESIGN In patients with viral load <50 copies/mL and injection site reactions, enfuvirtide was switched to raltegravir without additional changes to the antiretroviral regimen. Virologic failure was defined as a viral load >1000 copies/mL or two consecutive viral load measurements between 50 and 1000 copies/mL (low-level viremia). Over the 24 week study, we compared changes in T-cells, injection site reactions, quality of life, and residual viremia, as measured through the single-copy assay which can detect plasma virus down to a single copy, using paired t-tests. RESULTS Fourteen patients with a median CD4+ T-cell count of 420 cells/microL were enrolled. After the switch, two patients experienced virologic failure due to confirmed low-level viremia. However, both patients subsequently were re-suppressed, one without any changes to his regimen. There was no change in CD4+ T-cell count. Injection site reactions resolved. However, there was little reported change in quality of life. The baseline median level of residual viremia was 6 copies/mL and did not change after the switch to raltegravir. CONCLUSIONS A switch to raltegravir in virologically suppressed patients on enfuvirtide is effective in maintaining immunologic and virologic control at 24 weeks but did not result in a change in residual viremia.
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Affiliation(s)
- Philip M Grant
- Stanford University, Division of Infectious Diseases, Palo Alto, CA 94305-5107, USA.
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Parienti JJ, Bangsberg DR, Verdon R, Gardner EM. Better adherence with once-daily antiretroviral regimens: a meta-analysis. Clin Infect Dis 2009; 48:484-8. [PMID: 19140758 DOI: 10.1086/596482] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Once-daily regimens of antiretroviral therapy are simpler than other regimens, but whether such regimens are associated with better adherence to treatment is controversial. We performed a meta-analysis of 11 randomized, controlled trials (total number of subjects, 3029), which revealed that the adherence rate was better with once-daily regimens (+2.9%; 95% confidence interval, 1.0%-4.8%; P < .003) than with twice-daily regimens. This modest effect was more pronounced at the time of treatment initiation and for regimens for which all medications were taken once per day.
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Affiliation(s)
- Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research, Côte de Nacre University Hospital, Caen, France.
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WEISS JJ, BRÄU N, STIVALA A, SWAN T, FISHBEIN D. Review article: adherence to medication for chronic hepatitis C - building on the model of human immunodeficiency virus antiretroviral adherence research. Aliment Pharmacol Ther 2009; 30:14-27. [PMID: 19416131 PMCID: PMC3102513 DOI: 10.1111/j.1365-2036.2009.04004.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of hepatitis C virus (HCV) infection with pegylated interferon/ribavirin achieves sustained virological response in up to 56% of HCV mono-infected patients and 40% of HCV/human immunodeficiency virus (HIV)-co-infected patients. The relationship of patient adherence to outcome warrants study. AIM To review comprehensively research on patient-missed doses to HCV treatment and discuss applicable research from adherence to HIV antiretroviral therapy. METHODS Publications were identified by PubMed searches using the keywords: adherence, compliance, hepatitis C virus, interferon and ribavirin. RESULTS The term 'non-adherence' differs in how it is used in the HCV from the HIV literature. In HCV, 'non-adherence' refers primarily to dose reductions by the clinician and early treatment discontinuation. In contrast, in HIV, 'non-adherence' refers primarily to patient-missed doses. Few data have been published on the rates of missed dose adherence to pegylated interferon/ribavirin and its relationship to virological response. CONCLUSIONS As HCV treatment becomes more complex with new classes of agents, adherence will be increasingly important to treatment success as resistance mutations may develop with suboptimal dosing of HCV enzyme inhibitors. HIV adherence research can be applied to that on HCV to establish accurate methods to assess adherence, investigate determinants of non-adherence and develop strategies to optimize adherence.
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Affiliation(s)
- J. J. WEISS
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
| | - N. BRÄU
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
,Veterans Affairs Medical Center, Infectious Disease Section, Bronx, NY, USA
| | - A. STIVALA
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - T. SWAN
- Treatment Action Group, New York, NY, USA
| | - D. FISHBEIN
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
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