Socioeconomic factors explain suboptimal adherence to antiretroviral therapy among HIV-infected Australian adults with viral suppression

Life Instability Associated with Lower ART Adherence and Other Poor HIV-Related Care Outcomes in Older Adults with HIV

BACKGROUND

Life instability may be an important factor for HIV-related care outcomes in older adults living with HIV (OALWH). This study examined the degree to which an 11-item life instability index (LII) composed of individual- and community-level indicators was associated with HIV-related care outcomes-viral load, antiretroviral (ART) medication adherence, rates of detectable viral load, and HIV care appointment non-adherence among OALWH in the Miami area.

METHODS

Six hundred twenty-three OALWH completed an interviewer-administered assessment (English or Spanish), which was matched with medical record data.

RESULTS

Participants reported about six LII indicators each (M = 6.08, SD = 1.44). Greater index scores were associated with worse self-reported ART adherence (b =  - 1.14, p = 0.03), lower observed appointment adherence (b = 0.02, p < 0.01), higher viral load (b = 0.09, p = 0.02), and greater odds of viral detection (OR = 1.22, p = 0.01). Regarding health behaviors, life instability was significantly associated with increased illicit substance use among participants and not associated with depression or anxiety. The association of life instability to ART adherence remained significant (although attenuated) when controlling for the significant effects of substance use (b =  - 0.40, BSTP [- 0.87, - 0.09]).

CONCLUSION

This present study is the first to examine an additive life instability index and its association with HIV-related behavioral and biomedical health outcomes among a population of OALWH. Greater indicators of life instability among OALWH may lead to poorer HIV-related health outcomes above and beyond the net of the effects of depression, anxiety, and substance use.

HIV therapy adherence and outcomes in Peruvian military personnel over a 30-year period

<b>Objectives: </b>We aimed to describe the sociodemographic, clinical, and therapeutic characteristics of Peruvian military personnel diagnosed with HIV. Furthermore, we determined the frequency of highly active antiretroviral therapy (HAART) adherence, the complications and mortality.<br /> <b>Methods:</b> We retrospectively reviewed the medical records of patients diagnosed with HIV, confirmed by Western blot at a single institution from 1989-2020. Descriptive analyses were performed for all the variables using mean and standard deviation (SD) in the case of quantitative variables, and frequency and percentage for qualitative variables.<br /> <b>Results: </b>Of the 161 patients included, 95.7% were males and the mean age was 39.59 years (SD= 16.45 years). Most had college or higher education (67.7%) and were on active duty at diagnosis (77%). 35.4% had AIDS at diagnosis; 28.6% opportunistic infections; and 8.1% tuberculosis. The median follow-up was five years. 94.4% of the patients received HAART as the principal treatment; of these, 88.8% was adherent to treatment, and death was reported in 6.8%. There were no factors associated with adherence.<br /> <b>Conclusions: </b>Although the sociodemographic characteristics of Peruvian military personnel are similar to those of other countries, our findings suggest that Peruvian military personnel present higher adherence to HAART compared to previous studies in other military populations from South American countries. Further studies are recommended to assess specific factors attributed to these successful outcomes in the military personnel that can be applied in other hospitals.

Ageing with HIV: Medicine Optimisation Challenges and Support Needs for Older People Living with HIV: A Systematic Review

BACKGROUND

Older people living with HIV (PLWH) are at increased risks of co-morbidities and polypharmacy. However, little is known about factors affecting their needs and concerns about medicines. This systematic review aims to describe these and to identify interventions to improve medicine optimisation outcomes in older PLWH.

METHODS AND DATA SOURCES

Multiple databases and grey literature were searched from inception to February 2022 including MEDLINE, CINAHL, PsycInfo, PsychArticles, the Cochrane Database of Systematic Reviews and the Cochrane Controlled Register of Trials, Abstracts in Social Gerontology, and Academic Search Complete.

ELIGIBILITY CRITERIA

Studies reporting interventions/issues affecting older PLWH (sample populations with mean/median age ≥ 50 years; any aspect of medicine optimisation, or concerns). Quality assessments were completed by means of critical appraisal checklists for each study design. Title and abstract screening was led by one reviewer and a sample reviewed independently by two reviewers. Full-paper reviews were completed by one author and a 20% sample was reviewed independently by two reviewers.

SYNTHESIS

Data were extracted by three independent reviewers using standardised data extraction forms and synthesised according to outcomes or interventions reported. Data were summarised to include key themes, outcomes or concerns, and summary of intervention.

RESULTS

Seventy-nine (n = 79) studies met the eligibility criteria, most of which originated from the USA (n = 36). A few studies originated from Australia (n = 5), Canada (n = 5), Spain (n = 9), and the UK (n = 5). Ten studies originated from Sub-Saharan Africa (Kenya n = 1, South Africa n = 6, Tanzania n = 1, Uganda n = 1, Zimbabwe n = 1). The rest of the studies were from China (n = 1), France (n = 1), Germany (n = 1), Italy (n = 1), the Netherlands (n = 1), Pakistan (n = 1), Switzerland (n = 1), Saudi Arabia (n = 1) and Ukraine (n = 1). Publication dates ranged from 2002 to 2022. Sample sizes ranged from 10 to 15,602 across studies. The factors affecting older PLWH's experience of and issues with medicines were co-morbidities, health-related quality of life, polypharmacy, drug interactions, adverse drug reactions, adherence, medicine burden, treatment burden, stigma, social support, and patient-healthcare provider relationships. Nine interventions were identified to target older persons, five aimed at improving medication adherence, two to reduce drug interactions, and two for medicine self-management initiatives.

CONCLUSION

Further in-depth research is needed to understand older PLWH's experiences of medicines and their priority issues. Adherence-focused interventions are predominant, but there is a scarcity of interventions aimed at improving medicine experiences for this population. Multi-faceted interventions are needed to achieve medicine optimisation outcomes for PLWH.

TRIAL REGISTRATION

This study is registered with PROSPERO registration number: CRD42020188448.

Meaningful cognitive decline is uncommon in virally suppressed HIV, but sustained impairment, subtle decline and abnormal cognitive aging are not

BACKGROUND

High antiretroviral therapy (ART) coverage and viral suppression among people with HIV (PWH) in Australia provide a unique context to study individual cognitive trajectories, cognitive aging and factors associated with longitudinal cognitive function during chronic and stable HIV disease.

METHODS

Participants from the Predictors of Adherence to Antiretroviral Therapy study (n = 457, recruited between September 2013 and November 2015, median age = 52 years, and all with HIV RNA <50 copies mL) completed a cognitive assessment with CogState Computerized Battery (CCB) at baseline, Month-12, and Month-24. Demographics, psycho-social and socioeconomic factors, healthcare seeking behaviors, HIV disease characteristics and comorbidities were assessed. The CCB data were corrected for age, sex and practice effect and averaged into a global z-score (GZS). Cognitive impairment was defined with the global deficit score method (GDS>0.5). Meaningful cognitive change was statistically defined (decline or improvement versus stability, i.e., 90% CI, that is p < 0.05, 2-tailed) using a novel evidence-based change score: the linear mixed-effect regression (LMER)-based GZS change score. A separate LMER model with a top-down variable selection approach identified the independent effects of age and other demographic, HIV disease characteristics, socioeconomic and health-related factors on the demographically corrected GZS. The combined definitions of change and cross-sectional impairment enabled the identification of cognitive trajectories.

FINDINGS

At Month-12 and Month-24, 6% and 7% showed meaningful cognitive decline and 4% and 3% improved respectively. Only 1% showed sustained decline. Incident impairment due to subtle cognitive decline (i.e., below the threshold of meaningful cognitive decline) was 31% and 25% at Month-12 and Month-24, while 14% showed sustained impairment (i.e., cognitively impaired at all study visits). Older age (≥50 years) and time interaction was associated with lower demographically corrected GZS (β = -0.31, p < 0.001). Having a regular relationship, excellent English proficiency, and perceived stigma (avoidance) were associated with higher GZS (all p < 0.05). Relying on government subsidy, severe depression, and lower belief in ART necessity and higher concerns were associated with lower GZS (all p < 0.05). No HIV disease characteristics had a significant effect.

INTERPRETATIONS

Meaningful cognitive decline was not different from normal expectation in chronic stable HIV disease. Despite this, subtle cognitive decline, sustained cognitive impairment, and greater than normative-age cognitive aging were evident.

FUNDING

Funding for the PAART study was provided in part by unrestricted educational grants from Gilead Sciences (www.gilead.com) (Grant Number: IN-AU-264- 0131), the Balnaves Foundation (www.balnavesfoundation.com), the Victorian Department of Health and Human Services (Australia) (www.dhs.vic.gov.au/home), Western Australia Health (www.health.wa.gov.au), the ACT Ministry of Health (Australia) (www.health.act.gov.au), and in-kind support from the Queensland Department of Health (Australia) (www.health.qld.gov.au), and NHMRC Partnership grant APP1058474 (PI: Carr, Andrew).

A HIV diagnosis and treatment cascade for Aboriginal and Torres Strait Islander peoples of Australia

Aboriginal and Torres Strait Islander (hereafter Aboriginal) people are a priority population for HIV care in Australia; however, no HIV cascade exists for this population. We developed annual HIV cascades for 2010-2017 specific to Aboriginal peoples. By 2017, an estimated 595 Aboriginal people were living with HIV (PLWH); however, 14% remained undiagnosed. Cascade steps below global targets were: PLWH aware of their diagnosis (86%), and retention in care (81% of those who had received any care in previous two years in a sentinel network of clinics). For people retained in care, treatment outcomes surpassed global targets (92% receiving treatment, 93% viral suppression). Increases occurred across all HIV cascade steps over time; however, the least improvement was for retention in care, while the greatest improvement was achieving viral suppression. The HIV cascade for Aboriginal peoples highlights both gaps and strengths in the Australian HIV care system, and importantly highlights where potential interventions may be required to achieve the global UNAIDS targets.

Influence of Material Deprivation on Clinical Outcomes Among People Living with HIV in High-Income Countries: A Systematic Review and Meta-analysis

Despite developments in HIV treatment and care, disparities persist with some not fully benefiting from improvements in the HIV care continuum. We conducted a systematic review to explore associations between social determinants and HIV treatment outcomes (viral suppression and treatment adherence) in high-income countries. A random effects meta-analysis was performed where there were consistent measurements of exposures. We identified 83 observational studies eligible for inclusion. Social determinants linked to material deprivation were identified as education, employment, food security, housing, income, poverty/deprivation, socioeconomic status/position, and social class; however, their measurement and definition varied across studies. Our review suggests a social gradient of health persists in the HIV care continuum; people living with HIV who reported material deprivation were less likely to be virologically suppressed or adherent to antiretrovirals. Future research should use an ecosocial approach to explore these interactions across the lifecourse to help propose a causal pathway.

The Significance of Tumor Budding and Immunohistochemical Axl Expression in Gallbladder Adenocarcinomas

Background:

Tumor budding is a histopathological finding that is accepted as an indicator of epithelial-mesenchymal transformation in many solid tumors. Axl is a Receptor Tyrosine Kinase (RTK) family member and contributes to epithelial-mesenchymal transformation. It has been reported that its overexpression in various solid cancer cells is associated with a poor prognosis. It is claimed that Axl RTK may be the targeted molecule in treating some cancers due to its location in the cell membrane.

Aims:

To investigate the relationship between immunohistochemical (IHC) Axl expression with tumor budding on the histopathological level and their prognostic significance in patients with gallbladder carcinoma. Thus, it is aimed to contribute to the emergence of a molecular option for targeted, personalized therapy in these patients.

Study Design:

A retrospective cross-sectional study.

Methods:

Thirty-eight gallbladder cancer patients who underwent surgery between 2000 and 2017 were included in the study. The expressions of Axl RTK in tumor tissues were evaluated by the IHC method. Demographic data (age, sex) of patients, histopathological features (size, growth pattern), tumor differentiation, pathological T staging, lymphovascular invasion, perineural and serosal invasion, surgical margin, tumor infiltrated lymphocyte, and tumor budding were examined. The tumor budding of the tumor was made according to the International Tumor Budding Consensus Conference and was classified as low (0-4 buds), intermediate (5-9 buds), high (≥ 10 buds). The relationship between clinical pathologic features, the survival rate, and Axl expression was analyzed with Person’s chi-square, Cox regression tests, and the Kaplan-Meier method.

Results:

Tumor budding was determined as low in 12, intermediate in 10, and high in 16 cases. The increased degree of tumor budding was associated with focal-diffuse Axl expression (p = 0.018), infiltrative growth patterns (p = 0.031), poor differentiation (p = 0.006), advanced pathological stage (p = 0.002), and serosal (p = 0.040), perineural (p = 0.008), and lymphovascular invasion (p < 0.0001). Overall survival time was shorter in patients with intermediate to high tumor budding compared with those with low tumor budding (p = 0.011).

Conclusion:

Axl expression appears to be associated with tumor budding capacity, which may be a poor prognostic criterion for patients with gallbladder cancer. It may be a good target to prevent tumor budding to reduce tumor invasion and metastasis.

The effects of antidepressant medications on antiretroviral treatment adherence in HIV-positive individuals with depression

Background Extant literature has identified Major Depressive Disorder (MDD) as a comorbid disorder in individuals with seropositive human immunodeficiency disorder (HIV), and this may affect HIV-treatment efficacy. However, there is a paucity of literature evaluating the effects of antidepressant use on antiretroviral therapies (ART) in HIV-positive individuals. Herein, the following review assesses the effects of antidepressant medications on ART adherence in HIV-positive individuals with diagnosed MDD. Methods A systematic search on PubMed, Scopus, Web of Science, and Google Scholar search engines were conducted between database inception to June 12th, 2020 using the search and MeSH terms: (HIV) AND (antiretroviral or treatment) AND (depress*) AND (antidepressants) AND (adherence). Results We identified nine articles that evaluated ART adherence in HIV-positive individuals using antidepressants. Of the nine included articles, eight articles evaluated participants undergoing ART, and one article evaluated participants undergoing highly active antiretroviral therapy (HAART). Our primary findings suggest that patients who took antidepressant treatment for depression demonstrated greater adherence to HIV treatments and a reduction in missed HIV medication dosage. Limitations The heterogeneity of study design between the included studies was high. Conclusion The current review suggests that response to antidepressant medication may improve adherence to HIV treatments in HIV-positive individuals with comorbid depression. Further studies should expand the findings to explore the effects of disparate psychotropic agents on adherence behaviors among patients with HIV to identify the benefits of these agents on long-term health outcomes in this vulnerable clinical population.

Allopregnanolone and neuroHIV: Potential benefits of neuroendocrine modulation in the era of antiretroviral therapy

Forty years into the HIV pandemic, approximately 50% of infected individuals still suffer from a constellation of neurological disorders collectively known as 'neuroHIV.' Although combination antiretroviral therapy (cART) has been a tremendous success, in its present form, it cannot eradicate HIV. Reservoirs of virus reside within the central nervous system, serving as sources of HIV virotoxins that damage mitochondria and promote neurotoxicity. Although understudied, there is evidence that HIV or the HIV regulatory protein, trans-activator of transcription (Tat), can dysregulate neurosteroid formation potentially contributing to endocrine dysfunction. People living with HIV commonly suffer from endocrine disorders, including hypercortisolemia accompanied by paradoxical adrenal insufficiency upon stress. Age-related comorbidities often onset sooner and with greater magnitude among people living with HIV and are commonly accompanied by hypogonadism. In the post-cART era, these derangements of the hypothalamic-pituitary-adrenal and -gonadal axes are secondary (i.e., relegated to the brain) and indicative of neuroendocrine dysfunction. We review the clinical and preclinical evidence for neuroendocrine dysfunction in HIV, the capacity for hormone therapeutics to play an ameliorative role and the future steroid-based therapeutics that may have efficacy as novel adjunctives to cART.

Impact of the removal of patient co-payments for antiretroviral therapy (ART) on out-of-pocket expenditure, adherence and virological failure among Australian adults living with HIV

BACKGROUND

In 2015, New South Wales (Australia) removed patient co-payments for ART of HIV. We hypothesized the policy change would reduce overall out-of-pocket (OOP) healthcare expenditure, improve ART adherence, and better maintain HIV suppression.

METHODS

Using data from a national, 2-year prospective study of adults with HIV on ART (n=364) (2013-2017), we compared OOP healthcare expenditure, ART adherence, and virological failure (VF) in participants subject to the co-payment policy change with participants from other jurisdictions who never paid, and who always paid, co-payments. We used fixed effects regression models to compare outcomes, and incidence rates for VF.

RESULTS

Although ART co-payments declined, there was no significant change in total OOP healthcare expenditure in participants ceasing co-payments compared to those who continued (adjusted coefficient 0.09, 95% CI -0.31 to 0.48). Co-payment removal did not significantly reduce suboptimal ART adherence (from 17.5% to 16.3%) or VF (from 5.0 to 3.7 episodes per-100-person-years). Participants in the lowest income group but not receiving concessional government benefits incurred a non-significant increase in total OOP healthcare expenses; while concessional participants experienced a significant increase in non-ART HIV healthcare costs after the policy changed.

CONCLUSION

In this population, ART co-payments represented a small proportion of OOP healthcare expenditure. Its removal did not materially impact ART adherence or VF, although the study was not powered to detect these.

Europium sulfide nanoprobes predict antiretroviral drug delivery into HIV-1 cell and tissue reservoirs

Background: Delivery of long-acting nanoformulated antiretroviral drugs (ARVs) to human immunodeficiency virus type one cell and tissue reservoirs underlies next generation antiretroviral therapeutics. Nanotheranostics, comprised of trackable nanoparticle adjuncts, can facilitate ARV delivery through real-time drug tracking made possible through bioimaging platforms. Methods: To model HIV-1 therapeutic delivery, europium sulfide (EuS) nanoprobes were developed, characterized and then deployed to cells, tissues, and rodents. Tests were performed with nanoformulated rilpivirine (NRPV), a non-nucleoside reverse transcriptase inhibitor (NNRTI) used clinically to suppress or prevent HIV-1 infection. First, CD4+ T cells and monocyte-derived macrophages were EuS-treated with and without endocytic blockers to identify nanoprobe uptake into cells. Second, Balb/c mice were co-dosed with NRPV and EuS or lutetium177-doped EuS (177LuEuS) theranostic nanoparticles to assess NRPV biodistribution via mass spectrometry. Third, single photon emission computed tomography (SPECT-CT) and magnetic resonance imaging (MRI) bioimaging were used to determine nanotheranostic and NRPV anatomic redistribution over time. Results: EuS nanoprobes and NRPV entered cells through dynamin-dependent pathways. SPECT-CT and MRI identified biodistribution patterns within the reticuloendothelial system for EuS that was coordinate with NRPV trafficking. Conclusions: EuS nanoprobes parallel the uptake and biodistribution of NRPV. These data support their use in modeling NRPV delivery to improve treatment strategies.

A review of current strategies to improve HIV prevention and treatment in sexual and gender minority Latinx (SGML) communities

INTRODUCTION

The HIV epidemic continues to disproportionately impact sexual and gender minority Latinxs (SGML). Several syndemic conditions have been linked with HIV acquisition and transmission among SGML including immigration, discrimination, environmental racism, substance use, and mental health.

AREAS COVERED

We provide a summary of biomedical, behavioral, and social/structural interventions to reduce risks for acquiring HIV and improve outcomes along the HIV care continuum among SGML. We also discuss intervention approaches and opportunities that respond at the intersection of HIV and COVID-19 prevention and treatment.

EXPERT OPINION

There is a dire need for the combination of biomedical, behavioral, and social/structural interventions to reduce risks for acquiring HIV and improve outcomes along the HIV care continuum. Interventions and combination approaches should be driven by community-based participatory action research. The inclusion of community members in all stages of the research process can assure successful implementation of program activities and deliverables, including the provision of culturally and linguistically appropriate services. Given the current COVID-19 pandemic, which is disproportionately impacting individuals living with HIV and other comorbidities, the elderly, and under-resourced communities with a ferocity not seen in other communities, intervention approaches that respond at the intersection of HIV and COVID-19 prevention and treatment are also urgently needed.

Longitudinal Associations Between Neighborhood Factors and HIV Care Outcomes in the WIHS

Identifying structural determinants affecting HIV outcomes is important for informing interventions across heterogeneous geographies. Longitudinal hierarchical generalized mixed-effects models were used to quantify the associations between changes in certain structural-level factors on HIV care engagement, medication adherence, and viral suppression. Among women living with HIV in the WIHS, ten-unit increases in census-tract level proportions of unemployment, poverty, and lack of car ownership were inversely associated with viral suppression and medication adherence, while educational attainment and owner-occupied housing were positively associated with both outcomes. Notably, increased residential stability (aOR 5.68, 95% CI 2.93, 9.04) was positively associated with HIV care engagement, as were unemployment (aOR: 1.59, 95% CI 1.57, 1.60), lack of car ownership (aOR 1.14, 95% CI 1.13, 1.15), and female-headed households (aOR 1.23, 95% CI 1.22, 1.23). This underscores the importance of understanding neighborhood context, including factors that may not always be considered influential, in achieving optimal HIV-related outcomes.

Socioeconomic and psychosocial factors are associated with poor treatment outcomes in Australian adults living with HIV: a case-control study

Background A substantial minority of patients living with HIV refuse or cease antiretroviral therapy (ART), have virological failure (VF) or develop an AIDS-defining condition (ADC) or serious non-AIDS event (SNAE). It is not understood which socioeconomic and psychosocial factors may be associated with these poor outcomes.

METHODS

Thirty-nine patients with poor HIV treatment outcomes, defined as those who refused or ceased ART, had VF or were hospitalised with an ADC or SNAE (cases), were compared with 120 controls on suppressive ART. A self-report survey recorded demographics, physical health, life stressors, social supports, HIV disclosure, stigma or discrimination, health care access, treatment adherence, side effects, health and treatment perceptions and financial and employment status. Socioeconomic and psychosocial covariates significant in bivariate analyses were assessed with conditional multivariable logistic regression, adjusted for year of HIV diagnosis.

RESULTS

Cases and controls did not differ significantly with regard to sex (96.2% (n = 153) male) or age (mean (± s.d.) 51 ± 11 years). Twenty cases (51%) had refused or ceased ART, 35 (90%) had an HIV viral load >50 copies mL-1, 12 (31%) were hospitalised with an ADC and five (13%) were hospitalised with a new SNAE. Three covariates were independently associated with poor outcomes: foregoing necessities for financial reasons (adjusted odds ratio (aOR) 3.1, 95% confidence interval (95% CI) 1.3-7.6, P = 0.014), cost barriers to accessing HIV care (aOR 3.1, 95% CI 1.0-9.6, P = 0.049) and lower quality of life (aOR 3.8, 95% CI 1.5-9.7, P = 0.004).

CONCLUSIONS

Despite universal health care, socioeconomic and psychosocial factors are associated with poor HIV outcomes in adults in Australia. These factors should be addressed through targeted interventions to improve long-term successful treatment.

Socioeconomic and Demographic Statuses as Determinants of Adherence to Antiretroviral Treatment in HIV Infected Patients: A Systematic Review of the Literature

BACKGROUND

Socioeconomic and demographic statuses are associated with adherence to the treatment of patients with several chronic diseases. However, there is a controversy regarding their impact on adherence among HIV/AIDS patients. Thus, we performed a systematic review of the evidence regarding the association of socioeconomic and demographic statuses with adherence to antiretroviral therapy (ART) among HIV/AIDS patients.

METHODS

The PubMed database was used to search and identify studies concerning about socioeconomic and demographic statuses and HIV/AIDS patients. Data were collected on the association between adherence to ART and varies determinants factors of socioeconomic (income, education, and employment/occupation) and socio-demographic (sex and age).

FINDINGS

From 393 potentially-relevant articles initially identified, 35 original studies were reviewed in detail, which contained data that were helpful in evaluating the association between socioeconomic/ demographic statuses and adherence to ART among HIV patients. Two original research study has specifically focused on the possible association between socioeconomic status and adherence to ART. Income, level of education, and employment/occupational status were significantly and positively associated with the level of adherence in 7 studies (36.8%), 7 studies (28.0%), and 4 studies (23.5%) respectively out of 19, 25, and 17 studies reviewed. Sex (being male), and age (per year increasing) were significantly and positively associated with the level of adherence in 5 studies (14.3%), and 9 studies (25.7%) respectively out of 35 studies reviewed. However, the determinant of socioeconomic and demographic statuses was not found to be significantly associated with adherence in studies related to income 9(47.4%), education 17(68.0%), employment/ occupational 10(58.8%), sex 27(77.1%), and age 25(71.4%).

CONCLUSION

The majority of the reviewed studies reported that there is no association between socio- demographic and economic variables and adherence to therapy. Whereas, some studies show that age of HIV patients (per year increasing) and sex (being male) were positively associated with adherence to ART. Among socio-economic factors, the available evidence does not provide conclusive support for the existence of a clear association with adherence to ART among HIV patients. There seems to be a positive trend between socioeconomic factors and adherence to ART in some of the reviewed studies.

Time From HIV Diagnosis to Viral Suppression: Survival Analysis of Statewide Surveillance Data in Alabama, 2012 to 2014

BACKGROUND

Evaluation of the time from HIV diagnosis to viral suppression (VS) captures the collective effectiveness of HIV prevention and treatment activities in a given locale and provides a more global estimate of how effectively the larger HIV care system is working in a given geographic area or jurisdiction.

OBJECTIVE

This study aimed to evaluate temporal and geographic variability in VS among persons with newly diagnosed HIV infection in Alabama between 2012 and 2014.

METHODS

With data from the National HIV Surveillance System, we evaluated median time from HIV diagnosis to VS (<200 c/mL) overall and stratified by Alabama public health area (PHA) among persons with HIV diagnosed during 2012 to 2014 using the Kaplan-Meier approach.

RESULTS

Among 1979 newly diagnosed persons, 1181 (59.67%) achieved VS within 12 months of diagnosis; 52.6% (353/671) in 2012, 59.5% (377/634) in 2013, and 66.9% (451/674) in 2014. Median time from HIV diagnosis to VS was 8 months: 10 months in 2012, 8 months in 2013, and 6 months in 2014. Across 11 PHAs in Alabama, 12-month VS ranged from 45.8% (130/284) to 84% (26/31), and median time from diagnosis to VS ranged from 5 to 13 months.

CONCLUSIONS

Temporal improvement in persons achieving VS following HIV diagnosis statewide in Alabama is encouraging. However, considerable geographic variability warrants further evaluation to inform public health action. Time from HIV diagnosis to VS represents a meaningful indicator that can be incorporated into public health surveillance and programming.

Rapid initiation of antiretroviral therapy at HIV diagnosis: definition, process, knowledge gaps

Initiating antiretroviral therapy (ART) as early as the day of HIV diagnosis is a strategy of increasing global interest to control the HIV epidemic and optimize the health of people living with HIV (PLWH). No detrimental effects of rapid-start ART have been identified in randomized controlled trials undertaken in low- or middle-income countries, or in cohort studies performed in high-income countries. Rapid-start ART may be a key approach in reaching the 2020 Joint United Nations Programme on HIV/AIDS goal of 90% of all PLWH knowing their status, 90% of those diagnosed receiving sustained ART, and 90% of those receiving ART achieving viral suppression; it may also be important for achieving the suggested fourth "90%" goal: improving health-related quality-of-life in PLWH. Presently there is insufficient broad evidence for guidelines to recommend universal test-and-treat strategies for all people, in all settings, at HIV diagnosis; consequently, there is a pressing need to conduct high-quality studies that investigate immediate ART initiation. This article evaluates global evidence regarding rapid-start ART, including same-day start, with particular focus on the implementation of this strategy in high-income countries.

Adherence to Antiretroviral Regimens in Australia: A Nationwide Cohort Study

The lifetime use of combination antiretroviral therapy (cART) highlights the need to understand patterns of and factors associated with adherence to cART. In this cohort study using a 10% random sample of dispensing claims data for eligible Australians, we identified 2042 people dispensed cART between January 2016 and December 2017 (mean age 48.0 ± 12.0 years old, 88.6% male, and 85.9% treatment experienced). We considered people to be adherent if the proportion of treatment coverage days was ≥80% in the 360 days after their first observed cART dispensing. We also used group-based trajectory modeling (GBTM) to examine different patterns of adherence for 360 days from first observed cART dispensing. Most commonly, people receiving cART were treated with two nucleoside/nucleotide reverse transcriptase inhibitors with an integrase strand transfer inhibitors (INSTI-46.6%). Overall, 1708 people [83.6% (95% confidential interval 82.0-85.3%)] remained adherent over 360 days. GBTM identified three distinct adherence patterns: nearly always adherent [67.8% (63.7-71.9%) of the cohort], moderate adherence [26.6% (23.0-30.1%)], and low adherence [5.6% (4.1-7.2%)]. People were more likely to belong to the "nearly always adherent" trajectory if they were older (per additional year of age), treated with an INSTI regimen, and on treatment for more than 6 months. Our study demonstrates that the 360-day adherence to cART is generally high, but approximately one-third maintain a moderate or low adherence pattern. The use of INSTI regimens and additional support of treatment adherence, especially among younger people and those initiating therapy, may further improve adherence.

Genetic diversity and antiretroviral resistance-associated mutation profile of treated and naive HIV-1 infected patients from the Northwest and Southwest regions of Cameroon

BACKGROUND

Antiretroviral therapy (ART) has improved the survival of HIV infected persons. However, rapid scale-up of ART and the high HIV-1 genetic variability, has greatly influenced the emergence of drug-resistant strains. This constitutes a potential threat to achieving the UNAIDS' 90-90-90 goals by 2020. We investigated the prevalent HIV-1 genotypes, drug resistance-associated mutations and assessed some predictors of the occurrence of these mutations.

METHODS

This was a hospital-based cross-sectional study conducted between October 2010 and June 2012. Participants were consecutively enrolled from selected HIV treatment centers of the Southwest and Northwest regions of Cameroon. Viral load was determined with the automated Abbott Real-time HIV-1 m2000rt System. HIV genotyping and antiretroviral resistance mutations analysis were performed using Bayer's HIV-1 TRUGENE™ Genotyping Kit and OpenGene DNA Sequencing system. The drug resistance mutation was interpreted with the Stanford HIV database. Epidemiological data were obtained using pre-tested semi-structured questionnaires.

RESULTS

Of the 387 participants, 239 were successfully genotyped. The median age of these participants was 33 years (interquartile range, IQR: 28-40 years), and a majority (65.7%) were female. A total of 29.3% of the participants were receiving ART. The median duration of ART was 10.5 months (IQR: 4-17.25 months). The median CD4 count and log10 viral load of study participants were 353.5 cells/ml (IQR:145-471) and 4.89 copies/ml (IQR: 3.91-5.55) respectively. CRF02 (A/G) (69%) was the most prevalent subtype followed by G (8.2%) and F (6.7%). Overall, resistance mutations were present in 37.1% of ART-experienced and 10.7% of ART-naive patients. Nucleoside reverse transcriptase inhibitors (NRTI) mutations occurred in 30% of ART-experienced and 2.4% of ART-naïve patients, while non-nucleoside reverse transcriptase inhibitors (NNRTI) mutations occurred in 34.2% of ART-experienced and 10.1% of -naïve patients. M184V (8.4%, 20/239) and K103N (5.4%, 13/239) were the most prevalent mutations. Major protease inhibitor mutations occurred in 3 (1.3%) out of the 239 sequences. The duration of ART independently predicted the occurrence of resistance mutation among ART-experienced patients.

CONCLUSION

The high resistance to NNRTIs, which are the main support to the backbone (NRTIs) first-line antiretroviral regimen in Cameroon, has prompted the need to rollout an integrase strand transfer inhibitor regimen (containing Dolutegravir) with a higher genetic barrier to resistance as the preferred first line regimen.

Patient Self-Reported Adherence to Ritonavir-Boosted Darunavir Combined With Either Raltegravir or Tenofovir Disoproxil Fumarate/Emtricitabine in the NEAT001/ANRS143 Trial

Supplemental Digital Content is Available in the Text.

Background:

The NEAT001/ANRS143 trial demonstrated noninferiority of ritonavir-boosted darunavir combined with either raltegravir (RAL + DRV/r) or tenofovir disoproxil fumarate/emtricitabine (TDF/FTC + DRV/r) in HIV-positive, antiretroviral-naive adults. In post hoc analyses, however, RAL + DRV/r showed inferiority in patients with baseline CD4⁺ <200/mm³ and HIV-1 RNA ≥100,000 copies per milliliter. This preplanned ancillary study was conducted to assess whether differences in adherence might explain efficacy results.

Setting:

Phase III, open-label, randomized, multicenter study in 15 European countries (ClinicalTrials.gov, NCT01066962).

Methods:

Seven hundred seventy-four participants self-reported adherence (modified AIDS Clinical Trials Group questionnaire) over 96 weeks [383 RAL + DRV/r (twice daily; 5 pills/day), 391 TDF/FTC + DRV/r (once daily; 4 pills/day)]. Primary endpoint was ≥95% versus <95% adherence to prescribed doses recorded (1) over the last 4 days or (2) on the visual analogue scale over the last 30 days.

Results:

Characteristics, except age, were similar between arms; 9% had CD4⁺ <200 cells/mm³ and HIV-1 RNA ≥100,000 copies per milliliter. Adherence ≥95% in the last 4 days (P = 0.029) or at the visual analogue scale (P = 0.0072) was higher with TDF/FTC + DRV/r than with RAL + DRV/r. Adherence ≥95% over the last 4 days was associated with lower probability of virological failure (P = 0.015). Adherence in patients with baseline CD4⁺ <200 cells/mm³ and HIV-1 RNA ≥100,000 copies per milliliter was similar to the rest of the population, and not significantly associated with efficacy measures, with no significant differences between arms.

Conclusion:

Adherence was high and slightly better in the TDF/FTC + DRV/r than in the RAL + DRV/r arm. No convincing evidence was found that higher failure rate in the RAL + DRV/r arm in the subgroup with worse baseline viroimmunological status is caused by adherence differences.

Success and failure of initial antiretroviral therapy in adults: an updated systematic review

BACKGROUND

We updated a prior systematic review of initial antiretroviral therapy (ART) efficacy through week 144.

MATERIALS AND METHODS

Studies (1994 to July 2017) were drawn from PubMed, ClinicalTrials.gov, Cochrane Library, and major conferences; design, eligibility, patient, and ART data were abstracted. Outcomes are expressed as group size-weighted means. Mixed-effects meta-regression was used to identify sources of efficacy heterogeneity.

RESULTS

Within 354 groups (181 studies, 77 999 participants), principal backbones were tenofovir-emtricitabine (TDF/TAF-FTC) (44.2%), thymidine-based (27.7%), and abacavir-lamivudine (9.7%). Principal anchors were non-nucleoside analog (49.7%), boosted protease inhibitor (28.1%), and integrase inhibitor (INSTI; 11.5%). Mean intention-to-treat efficacy (RNA <50 copies/ml) was 71.3%, 63.5% (145 groups), and 61.8% (48 groups) at weeks 48, 96, and 144, respectively (for post-2010 studies, 83.8%, 79.9%, and 77.1%). TDF/TAF-FTC and INSTI were independent predictors of greater efficacy at weeks 48, 96, and 144. Additional independent predictors at week 48 were pre-ART resistance genotyping, higher baseline CD4 cell count, and once-daily ART. Fewer pills per day predicted greater efficacy at weeks 96 and 144. Phase 4 studies yielded progressively inferior efficacy than phase 3 studies (difference 5.1% at week 48, 15.8% at week 144). Cessation through week 144 overall (29.4%) and for adverse events (8.9%) declined over time, but cessation for virological failure (5.2%) did not.

CONCLUSIONS

Initial ART efficacy continues to improve, but more than 20% of post-2010 patients failed over 3 years. Real-world efficacy is lower than in phase 3 trials. Guidelines should list non-INSTI-based initial ART as nonpreferred. Strategies are needed to improve access to pre-ART genotyping and to increase early initiation of once-daily ART.

The Association of Material Hardship with Medication Adherence and Perceived Stress Among People Living with HIV in Rural Zambia

The intersection of poverty and HIV/AIDS has exacerbated socioeconomic inequalities in Zambia. For example, the downstream consequences of HIV/AIDS are likely to be severe among the poor. Current research has relied on multidimensional indicators of poverty, which encompass various forms of deprivation, including material. Although comprehensive measures help us understand what constitutes poverty and deprivation, their complexity and scope may hinder the development of appropriate and feasible interventions. These limitations prompted us to examine whether material hardship, a more practicable, modifiable aspect of poverty, is associated with medication adherence and perceived stress among people living with HIV (PLHIV) in Zambia. We used cross-sectional data from 101 PLHIV in Lundazi District, Eastern Province. Data were collected using a questionnaire and hospital records. Material hardship was measured using a five-item scale. Perceived stress was measured using the ten-item perceived stress scale. Adherence was a binary variable measured using a visual analog scale and medication possession ratio (MPR) obtained from pharmacy data. We analyzed the data with multivariable linear and logistic regressions using multiply imputed datasets. Results indicated that greater material hardship was significantly associated with MPR nonadherence (odds ratio = 0.83) and higher levels of perceived mental distress (β = 0.34). Our findings provide one of the first evidence on the association of material hardship with treatment and mental health outcomes among PLHIV. The findings also draw attention to the importance of economic opportunities for PLHIV and their implications for reducing material hardship and improving adherence and mental health status.

Beyond mere pill taking: SMS reminders for HIV treatment adherence delivered to mobile phones of clients in a community support network in Australia

SMS reminders sent to personal mobiles are increasingly used by clinical services to promote patient engagement, including adherence to antiretroviral treatment (ART) for HIV. From August to September 2015, a 6-week, randomised SMS reminder for ART adherence intervention was implemented among 98 HIV-positive clients of Australian's largest HIV charitable organisation located in Sydney. This was followed by a mixed-method evaluation, comprising a self-completed online survey and a one-to-one interview. Of the 62 survey participants, all being men, the majority were gay (85.5%) and living long-term with HIV (median year of HIV diagnosis = 1998). While everyone was on ART, a substantial proportion (n = 27, 43.5%) had interrupted treatment in the past. At the end of the intervention, based on the standard SMAQ measure, 82% had consistently adhered to ART in the previous week. While there was no statistically significant intervention effect, perceiving less stigma were independently associated with better ART adherence (adjusted odds ratio = 0.37; 95% CI 0.16-0.89; P = .026). Of the 11 interviewees, despite limited add-on effects on individual ART adherence, the campaign was well-received as a unique community support service. This study underscores the essential role of empowerment through enhancing disease self-management, increasing social support and reducing stigma, particularly for long-term HIV survivors. SMS messaging, part of mHealth, delivered by community services could have broader impacts on reducing health and social inequity.

Barriers to antiretroviral therapy adherence in developed countries: a qualitative synthesis to develop a conceptual framework for a new patient-reported outcome measure

Suboptimal adherence to antiretroviral therapy (ART) remains common. Patient-centered tools are needed to comprehensively assess adherence barriers in HIV clinical practice. Thus, we conducted a research synthesis to produce a conceptual framework for a new patient-reported outcome measure (PRO) for use in routine HIV care in Canada and France. A PRO's conceptual framework graphically represents the concepts to be measured and the potential relationships between them. Towards ensuring the framework's relevance to the target populations' concerns, qualitative studies with HIV-positive adults on barriers to ART adherence in developed countries were synthesized with thematic analysis, attending to the cross-study prevalence and interrelationships of barrier themes. In March 2016, searches within Medline, PsychINFO, and Embase produced 5,284 records. Two reviewers determined the final sample (n = 41). Analysis generated three levels of ART adherence barrier themes. Twenty Level 2 themes and their component subthemes (Level 3) were organized into 6 higher-order themes (Level 1): Cognitive and emotional aspects (100% of studies contributing content -prevalence), Lifestyle factors (95%), Social and material context (95%), Characteristics of ART (90%), Health experience and state (73%), and Healthcare services and system (66%). As to interrelationships, study authors articulated relationships between all higher-order themes (Level 3). Linkages between Level 2 barrier themes showed great variability, from 21% to 95%. Overall, this synthesis contributes an exceptionally detailed conceptual framework and report of ART adherence barriers, applicable to a wide range of PLHIV. It suggests that a key to understanding many barriers is through their interconnections. It also identifies gaps in barrier research. Concerning the new PRO's development, comprehensiveness will need to be weighed against other concerns (e.g., respondent burden) and the provision of barrier-specific guidance for clinically addressing its scores seems essential.

A tale of two countries: progress towards UNAIDS 90-90-90 targets in Botswana and Australia

UNAIDS 90-90-90 targets and Fast-Track commitments are presented as precursors to ending the AIDS epidemic by 2030, through effecting a 90% reduction in new HIV infections and AIDS-related deaths from 2010 levels (HIV epidemic control). Botswana, a low to middle-income country with the third-highest HIV prevalence, and Australia, a low-prevalence high-income country with an epidemic concentrated among men who have sex with men (MSM), have made significant strides towards achieving the UNAIDS 90-90-90 targets. These two countries provide lessons for different epidemic settings. This paper discusses the lessons that can be drawn from Botswana and Australia with respect to their success in HIV testing, treatment, viral suppression and other HIV prevention strategies for HIV epidemic control. Botswana and Australia are on target to achieving the 90-90-90 targets for HIV epidemic control, made possible by comprehensive HIV testing and treatment programmes in the two countries. As of 2015, 70% of all people assumed to be living with HIV had viral suppression in Botswana and Australia. However, HIV incidence remains above one per cent in the general population in Botswana and in MSM in Australia. The two countries have demonstrated that rapid HIV testing that is accessible and targeted at key and vulnerable populations is required in order to continue identifying new HIV infections. All citizens living with HIV in both countries are eligible for antiretroviral therapy (ART) and viral load monitoring through government-funded programmes. Notwithstanding their success in reducing HIV transmission to date, programmes in both countries must continue to be supported at current levels to maintain epidemic suppression. Scaled HIV testing, linkage to care, universal ART, monitoring patients on treatment over and above strengthened HIV prevention strategies (e.g. male circumcision and pre-exposure prophylaxis) will all continue to require funding. The progress that Botswana and Australia have made towards meeting the 90-90-90 targets is commendable. However, in order to reduce HIV incidence significantly towards 2030, there is a need for sustained HIV testing, linkage to care and high treatment coverage. Botswana and Australia provide useful lessons for developing countries with generalized epidemics and high-income countries with concentrated epidemics.

Concomitant medication polypharmacy, interactions and imperfect adherence are common in Australian adults on suppressive antiretroviral therapy

OBJECTIVES

We quantified concomitant medication polypharmacy, pharmacokinetic and pharmacodynamic interactions, adverse effects and adherence in Australian adults on effective antiretroviral therapy.

DESIGN

Cross-sectional.

METHODS

Patients recruited into a nationwide cohort and assessed for prevalence and type of concomitant medication (including polypharmacy, defined as ≥5 concomitant medications), pharmacokinetic or pharmacodynamic interactions, potential concomitant medication adverse effects and concomitant medication adherence. Factors associated with concomitant medication polypharmacy and with imperfect adherence were identified using multivariable logistic regression.

RESULTS

Of 522 participants, 392 (75%) took a concomitant medication (mostly cardiovascular, nonprescription or antidepressant). Overall, 280 participants (54%) had polypharmacy of concomitant medications and/or a drug interaction or contraindication. Polypharmacy was present in 122 (23%) and independently associated with clinical trial participation, renal impairment, major comorbidity, hospital/general practice-based HIV care (versus sexual health clinic) and benzodiazepine use. Seventeen participants (3%) took at least one concomitant medication contraindicated with their antiretroviral therapy, and 237 (45%) had at least one pharmacokinetic/pharmacodynamic interaction. Concomitant medication use was significantly associated with sleep disturbance and myalgia, and polypharmacy of concomitant medications with diarrhoea, fatigue, myalgia and peripheral neuropathy. Sixty participants (12%) reported imperfect concomitant medication adherence, independently associated with requiring financial support, foregoing necessities for financial reasons, good/very good self-reported general health and at least 1 bed day for illness in the previous 12 months.

CONCLUSION

In a resource-rich setting with universal healthcare access, the majority of this sample took a concomitant medication. Over half had at least one of concomitant medication polypharmacy, pharmacokinetic or pharmacodynamic interaction. Concomitant medication use was associated with several adverse clinical outcomes.

Bioequivalence of twice-daily oral tacrolimus in transplant recipients: More evidence for consensus?

In this Perspective on the clinical trial by Rita Alloway and colleagues, Simon Ball explains the benefits to healthcare systems and individual patients of the bioequivalence established between generic and brand-name formulations of an immunosuppressive drug in transplant recipients.

Creation of a nanoformulated cabotegravir prodrug with improved antiretroviral profiles

Long-acting parenteral (LAP) antiretroviral drugs have generated considerable interest for treatment and prevention of HIV-1 infection. One new LAP is cabotegravir (CAB), a highly potent integrase inhibitor, with a half-life of up to 54 days, allowing for every other month parenteral administrations. Despite this excellent profile, high volume dosing, injection site reactions and low body fluid drug concentrations affect broad use for virus infected and susceptible people. To improve the drug delivery profile, we created a myristoylated CAB prodrug (MCAB). MCAB formed crystals that were formulated into nanoparticles (NMCAB) of stable size and shape facilitating avid monocyte-macrophage entry, retention and reticuloendothelial system depot formulation. Drug release kinetics paralleled sustained protection against HIV-1 challenge. After a single 45 mg/kg intramuscular injection to BALB/cJ mice, the NMCAB pharmacokinetic profiles was 4-times greater than that recorded for CAB LAP. These observations paralleled replicate measurements in rhesus macaques. The results coupled with improved viral restriction in human adult lymphocyte reconstituted NOD/SCID/IL2Rγc^-/- mice led us to conclude that NMCAB can improve biodistribution and viral clearance profiles upon current CAB LAP formulations.