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Else LJ, Dickinson L, Edick S, Zyhowski A, Ho K, Meyn L, Dilly-Penchala S, Thompson B, Shaw V, Khoo S, Brand RM. Tenofovir, emtricitabine, lamivudine and dolutegravir concentrations in plasma and urine following drug intake cessation in a randomized controlled directly observed pharmacokinetic trial to aid point-of-care testing. J Antimicrob Chemother 2024; 79:1597-1605. [PMID: 38758205 PMCID: PMC11215529 DOI: 10.1093/jac/dkae147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Poor adherence to ART and pre-exposure prophylaxis (PrEP) can impact patient and public health. Point-of-care testing (POCT) may aid monitoring and adherence interventions. OBJECTIVES We report the pharmacokinetics of tenofovir [dosed as tenofovir disoproxil (TDF) and tenofovir alafenamide (TAF)], emtricitabine (FTC), lamivudine (3TC) and dolutegravir (DTG) in plasma and urine following drug cessation to evaluate adherence targets in urine for POCT. METHODS Subjects were randomized (1:1) to receive DTG/FTC/TAF or DTG/3TC/TDF for 15 days. Plasma and spot urine were collected on Day 15 (0-336 h post final dose). Drug concentrations were quantified using LC-MS, and non-linear mixed-effects models applied to determine drug disposition between matrices and relationship with relevant plasma [dolutegravir protein-adjusted 90% inhibitory concentration (PA-IC90 = 64 ng/mL) and minimum effective concentration (MEC = 324 ng/mL)] and urinary thresholds [tenofovir disoproxil fumarate 1500 ng/mL]. RESULTS Of 30 individuals enrolled, 29 were included (72% female at birth, 90% Caucasian). Median (range) predicted time to plasma dolutegravir PA-IC90 and MEC were 83.5 (41.0-152) and 49.0 h (23.7-78.9), corresponding to geometric mean (90%) urine concentrations of 5.42 (4.37-6.46) and 27.4 ng/mL (22.1-32.7). Tenofovir in urine reached 1500 ng/mL by 101 h (58.6-205) with an equivalent plasma concentration of 6.20 ng/mL (4.21-8.18). CONCLUSIONS These data support use of a urinary tenofovir threshold of <1500 ng/mL (tenofovir disoproxil fumarate-based regimens) as a marker of three or more missed doses for a POCT platform. However, due to low dolutegravir concentrations in urine, POCT would be limited to a readout of recent dolutegravir intake (one missed dose).
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Affiliation(s)
- Laura J Else
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laura Dickinson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Stacey Edick
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Ken Ho
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Leslie Meyn
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sujan Dilly-Penchala
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Beth Thompson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Victoria Shaw
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Rhonda M Brand
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
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Spinelli M, Gandhi M. Point-of-care urine tenofovir monitoring of adherence to drive interventions for HIV treatment and prevention. Expert Rev Mol Diagn 2024; 24:169-175. [PMID: 38353417 DOI: 10.1080/14737159.2024.2312122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/26/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Although effective antiretroviral and pre-exposure prophylaxis/PrEP regimens are available globally, adherence challenges persist. Objective measures of adherence can both measure adherence accurately and can be used to drive interventions. The first point-of-care pharmacologic adherence measure, urine tenofovir testing using a lateral flow assay, is now available. AREAS COVERED This review examines the ability of pharmacologic metrics of adherence to predict HIV and PrEP clinical outcomes and the past use of pharmacologic metrics of adherence as tools to drive adherence interventions. The success of preliminary studies using point-of-care adherence metrics to guide interventions is then discussed. EXPERT OPINION Large randomized clinical trials are now needed to test the impact of point-of-care adherence interventions on HIV and PrEP clinical outcomes, given promising results of the pilot studies summarized here. Hybrid implementation-effectiveness studies will be needed to examine optimal approaches to incorporating point-of-care testing into routine clinical care delivery, including in guiding resistance testing, adherence counseling, and delivery of other evidence-based adherence interventions. Given the ability of point-of-care tenofovir testing to be implemented in settings where viral load testing is not available, and at more frequent intervals due to its low cost, urine-based tenofovir assays have the potential to be highly scalable in diverse clinical settings.
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Affiliation(s)
- Matthew Spinelli
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
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Zewdie K, Kiweewa FM, Ssebuliba T, Morrison SA, Muwonge TR, Boyer J, Bambia F, Badaru J, Stein G, Mugwanya KK, Wyatt C, Yin MT, Mujugira A, Heffron R. The effect of daily oral PrEP use during pregnancy on bone mineral density among adolescent girls and young women in Uganda. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 5:1240990. [PMID: 38260049 PMCID: PMC10801233 DOI: 10.3389/frph.2023.1240990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Oral pre-exposure prophylaxis (PrEP) is recommended during pregnancy for at-risk cisgender women. Pregnancy is known to impede bone growth and tenofovir-based PrEP may also yield detrimental changes to bone health. Thus, we evaluated the effect of PrEP use during pregnancy on bone mineral density (BMD). Methods We used data from a cohort of women who were sexually active, HIV-negative, ages 16-25 years, initiating DMPA or choosing condoms for contraception and enrolled in the Kampala Women's Bone Study. Women were followed quarterly with rapid testing for HIV and pregnancy, PrEP dispensation, and adherence counseling. Those who became pregnant were counseled on PrEP use during pregnancy per national guidelines. BMD of the neck of the hip, total hip, and lumbar spine was measured using dual-energy x-ray absorptiometry at baseline and annually. We compared the mean percent change in BMD from baseline to month 24. Results Among 499 women enrolled in the study, 105 pregnancies occurred in 90 women. At enrollment, the median age was 20 years (IQR: 19-21) and 89% initiated PrEP. During pregnancy, 67% of women continued using PrEP and PrEP was dispensed in 64% of visits. BMD declined significantly in women using PrEP during pregnancy compared to women who were not pregnant nor used PrEP: relative BMD change was -2.26% (95% CI: -4.63 to 0.11, p = 0.06) in the femoral neck, -2.57% (95% CI: -4.48 to -0.66, p = 0.01) in total hip, -3.06% (95% CI: -5.49 to -0.63, p = 0.001) lumbar spine. There was no significant difference in BMD loss when comparing PrEP-exposed pregnant women to pregnant women who never used PrEP. Women who became pregnant were less likely to continue PrEP at subsequent study visits than women who did not become pregnant (adjOR: 0.25, 95% CI: 0.16-0.37, p < 0.001). Based on pill counts, there was a 62% reduction in the odds of high PrEP adherence during pregnancy (adjOR = 0.38, 95% CI: 0.27-0.58, p < 0.001). Conclusion Women who used PrEP during pregnancy experienced a similar reduction in BMD as pregnant women with no PrEP exposure, indicating that BMD loss in PrEP-using pregnant women is largely driven by pregnancy and not PrEP.
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Affiliation(s)
- Kidist Zewdie
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Flavia M. Kiweewa
- MakerereUniversity-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Susan A. Morrison
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Jade Boyer
- Department of Medicine, Division of Infectious Disease, Columbia University, New York, NY, United States
| | - Felix Bambia
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Josephine Badaru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gabrielle Stein
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kenneth K. Mugwanya
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Christina Wyatt
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, United States
| | - Michael T. Yin
- Department of Medicine, Division of Infectious Disease, Columbia University, New York, NY, United States
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA, United States
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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4
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Mcinziba A, Wademan D, Viljoen L, Myburgh H, Jennings L, Decloed E, Orrell C, van Zyl G, van Schalkwyk M, Gandhi M, Hoddinott G. Perspectives of people living with HIV and health workers about a point-of-care adherence assay: a qualitative study on acceptability. AIDS Care 2023; 35:1628-1634. [PMID: 36781407 PMCID: PMC10423296 DOI: 10.1080/09540121.2023.2174928] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 01/22/2023] [Indexed: 02/15/2023]
Abstract
Current antiretroviral therapy (ART) adherence monitoring is premised on patients' self-reported adherence behaviour (prone to recall error) and verified by blood viral load measurement (which can delay results). A newly developed Urine Tenofovir Rapid Assay (UTRA) assesses tenofovir in urine at point-of-care and is a novel tool to test and immediately respond to adherence levels of people living with HIV (PLHIV). We explored PLHIV and health workers' initial perceptions about integrating the UTRA into routine medical care for adherence support. We conducted a series of once-off in-depth qualitative interviews with PLHIV (n = 25) and health workers (n = 5) at a primary care health facility in Cape Town, South Africa. Data analysis involved descriptive summaries of key emergent themes with illustrative case examples. We applied a deductive, outcomes-driven analytic approach to the summaries using the Implementation Outcomes Framework proffered by Proctor et al. (2011). The three relevant concepts from this framework that guided our evaluation were: acceptability, appropriateness, and feasibility. We found positive perceptions about the UTRA from many PLHIV and health worker participants. Many PLHIV reported that the immediate results offered by the UTRA could enable them to have constructive discussions with health workers on how to resolve adherence challenges in real-time. Few PLHIV reported concerns that drinking alcohol could affect their UTRA results. Many health workers reported that the UTRA could help them identify patients at risk of treatment failure and immediately intervene through counselling, though some relayed that they would support the UTRA's implementation if more staff members could be added in their busy facility. Overall, these findings show that the UTRA was widely perceived to be acceptable and actionable by many PLHIV and health workers in the study.
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Affiliation(s)
- Abenathi Mcinziba
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Dillon Wademan
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Lario Viljoen
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Hanlie Myburgh
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Lauren Jennings
- Desmond Tutu Health Foundation, Institute of Infectious Diseases & Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Eric Decloed
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Institute of Infectious Diseases & Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gert van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences and National Health Laboratory Service (NHLS) Tygerberg business unit, Stellenbosch University, Cape Town, South Africa
| | - Marije van Schalkwyk
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco (UCSF), San Francisco, United States of America
| | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
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Louart S, Hedible GB, Ridde V. Assessing the acceptability of technological health innovations in sub-Saharan Africa: a scoping review and a best fit framework synthesis. BMC Health Serv Res 2023; 23:930. [PMID: 37649024 PMCID: PMC10469465 DOI: 10.1186/s12913-023-09897-4] [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: 04/11/2022] [Accepted: 08/10/2023] [Indexed: 09/01/2023] Open
Abstract
Acceptability is a key concept used to analyze the introduction of a health innovation in a specific setting. However, there seems to be a lack of clarity in this notion, both conceptually and practically. In low and middle-income countries, programs to support the diffusion of new technological tools are multiplying. They face challenges and difficulties that need to be understood with an in-depth analysis of the acceptability of these innovations. We performed a scoping review to explore the theories, methods and conceptual frameworks that have been used to measure and understand the acceptability of technological health innovations in sub-Saharan Africa. The review confirmed the lack of common definitions, conceptualizations and practical tools addressing the acceptability of health innovations. To synthesize and combine evidence, both theoretically and empirically, we then used the "best fit framework synthesis" method. Based on five conceptual and theoretical frameworks from scientific literature and evidence from 33 empirical studies, we built a conceptual framework in order to understand the acceptability of technological health innovations. This framework comprises 6 determinants (compatibility, social influence, personal emotions, perceived disadvantages, perceived advantages and perceived complexity) and two moderating factors (intervention and context). This knowledge synthesis work has also enabled us to propose a chronology of the different stages of acceptability.
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Affiliation(s)
- Sarah Louart
- Univ. Lille, CNRS, UMR 8019 - CLERSE - Centre Lillois d'Etudes Et de Recherches Sociologiques Et Economiques, 59000, Lille, France.
- ALIMA, the Alliance for International Medical Action, Dakar, Senegal.
| | | | - Valéry Ridde
- Université Paris Cité, IRD, INSERM, Ceped, 75006, Paris, France
- Institut de Santé Et Développement, Université Cheikh Anta Diop, Dakar, Sénégal
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6
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Haberer JE, Mujugira A, Mayer KH. The future of HIV pre-exposure prophylaxis adherence: reducing barriers and increasing opportunities. Lancet HIV 2023:S2352-3018(23)00079-6. [PMID: 37178710 DOI: 10.1016/s2352-3018(23)00079-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/19/2023] [Accepted: 03/27/2023] [Indexed: 05/15/2023]
Abstract
The effectiveness of HIV pre-exposure prophylaxis (PrEP) hinges on adherence, which has been restricted by multifaceted barriers. Uptake of PrEP has been impeded by poor access resulting from high costs, provider uncertainty, discrimination, stigma, and poor understanding within the health-care community and the public of who can benefit from PrEP. Other important barriers to adherence and persistence over time relate to individuals (eg, depression) and their community, partners, and family (eg, poor support), and their effects vary substantially with each person, population, and setting. Despite these challenges, key opportunities for improving PrEP adherence exist, including novel delivery systems, tailored individual interventions, mobile health and digital health interventions, and long-acting formulations. Objective monitoring strategies will help to improve adherence interventions and alignment of PrEP use with the need for HIV prevention (ie, prevention-effective adherence). The future of PrEP adherence lies in person-centred approaches to service delivery that meet the needs of individuals while creating supportive environments and facilitating health-care access and delivery.
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Affiliation(s)
- Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth H Mayer
- Department of Medicine, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Graham SM, Okall DO, Mehta SD, Obondi E, Ng'ety G, Ochieng E, Jadwin-Cakmak L, Amico KR, Harper GW, Bailey RC, Otieno FO. Challenges with PrEP Uptake and Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kisumu, Kenya. AIDS Behav 2023; 27:1234-1247. [PMID: 36219270 PMCID: PMC10036412 DOI: 10.1007/s10461-022-03860-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 01/29/2023]
Abstract
Data on challenges with pre-exposure prophylaxis (PrEP) uptake and adherence among Kenyan gay, bisexual, and other men who have sex with men (GBMSM) are limited. In this mixed-methods sequential explanatory design study, our quantitative phase followed 157 at-risk, HIV-negative GBMSM who accepted PrEP and enrolled in a cohort with 12-month follow-up. Stored dried blood spots collected at two intervals were batch tested for tenofovir diphosphate (TFV-DP) concentrations at study end. Despite high self-reported adherence, only 14.6% of individuals had protective TFV-DP levels at any visit. Protective TFV-DP levels were positively associated with injection drug use and a self-assessed moderate risk of acquiring HIV, and negatively associated with time since enrolment. In our subsequent qualitative phase, an intensive workshop was conducted with the GBMSM community to identify barriers and facilitators to PrEP uptake and adherence. These data revealed numerous challenges with traditional PrEP programs that must be addressed through community collaborations.
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Affiliation(s)
- Susan M Graham
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, 325 Ninth Avenue, Box 139909, Seattle, WA, 98104, USA.
| | | | - Supriya D Mehta
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, IL, USA
| | - Eve Obondi
- Nyanza Reproductive Health Society, Kisumu, Kenya
| | | | - Elijah Ochieng
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Salina Youth Initiative, Kisumu, Kenya
| | - Laura Jadwin-Cakmak
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
| | - K Rivet Amico
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Gary W Harper
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Robert C Bailey
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, IL, USA
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Kiptinness C, Naik P, Thuo N, Malen RC, Dettinger JC, Pintye J, Rafferty M, Jomo E, Nyamasyo N, Wood T, Isabelli P, Morris S, Hattery D, Stergachis A, Were D, Sharma M, Ngure K, Mugambi ML, Ortblad KF. Online HIV prophylaxis delivery: Protocol for the ePrEP Kenya pilot study. Front Public Health 2023; 11:1054559. [PMID: 36908449 PMCID: PMC9998902 DOI: 10.3389/fpubh.2023.1054559] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Background Online pharmacies in Kenya provide sexual and reproductive health products (e.g., HIV self-testing, contraception) and could be leveraged to increase the reach of HIV pre-exposure and post-exposure prophylaxis (PrEP/PEP) to populations who do not frequently attend health facilities. To date, evidence is limited for operationalizing online PrEP/PEP delivery and the type of populations reached with this differential service delivery model. Methods The ePrEP Kenya Pilot will deliver daily oral PrEP and PEP via MYDAWA, a private online pharmacy retailer, to clients in Nairobi for 18 months. Potential clients will obtain information about PrEP/PEP on MYDAWA's sexual wellness page and self-screen for HIV risk. Individuals ≥18 years, identified as at HIV risk, and willing to pay for a blood-based HIV self-test and PrEP/PEP delivery will be eligible for enrollment. To continue with online PrEP/PEP initiation, eligible clients will purchase a blood-based HIV self-test for 250 KES (~USD 2) [delivered to their setting of choice for 99 KES (~USD 1)], upload an image of their self-test result, and attend a telemedicine visit with a MYDAWA provider. During the telemedicine visit, providers will screen clients for PrEP/PEP eligibility, including clinical concerns (e.g., kidney disease), discuss self-test results, and complete counseling on PrEP/PEP use and safety. Providers will refer clients who self-test HIV positive or report any existing medical conditions to the appropriate services at healthcare facilities that meet their preferences. Eligible clients will be prescribed PrEP (30-day PrEP supply at initiation; 90-day PrEP supply at follow-up visits) or PEP (28-day supply) for free and have it delivered for 99 KES (~USD 1). We will measure PrEP and PEP initiation among eligible clients, PEP-to-PrEP transition, PrEP continuation, and implementation outcomes (e.g., feasibility, acceptability, and costs). Discussion Establishing pathways to increase PrEP and PEP access is crucial to help curb new HIV infections in settings with high HIV prevalence. The findings from this study will provide evidence on the implementation of online pharmacy PrEP and PEP service delivery that can help inform guidelines in Kenya and similar settings.
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Affiliation(s)
- Catherine Kiptinness
- Partners in Health Research and Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Paulami Naik
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Nicholas Thuo
- Partners in Health Research and Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rachel C. Malen
- Public Health Science Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Biobehavioral Nursing and Health Informatics, Seattle, WA, United States
| | | | | | | | | | | | | | | | - Andy Stergachis
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Pharmacy, University of Washington, Seattle, WA, United States
| | | | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Katrina F. Ortblad
- Public Health Science Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
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Olanrewaju AO, Sullivan BP, Gim AH, Craig CA, Sevenler D, Bender AT, Drain PK, Posner JD. REverSe TRanscrIptase chain termination (RESTRICT) for selective measurement of nucleotide analogs used in HIV care and prevention. Bioeng Transl Med 2023; 8:e10369. [PMID: 36684094 PMCID: PMC9842053 DOI: 10.1002/btm2.10369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 01/25/2023] Open
Abstract
Sufficient drug concentrations are required for efficacy of antiretroviral drugs used in HIV care and prevention. Measurement of nucleotide analogs, included in most HIV medication regimens, enables monitoring of short- and long-term adherence and the risk of treatment failure. The REverSe TRanscrIptase Chain Termination (RESTRICT) assay rapidly infers the concentration of intracellular nucleotide analogs based on the inhibition of DNA synthesis by HIV reverse transcriptase enzyme. Here, we introduce a probabilistic model for RESTRICT and demonstrate selective measurement of multiple nucleotide analogs using DNA templates designed according to the chemical structure of each drug. We measure clinically relevant concentrations of tenofovir diphosphate, emtricitabine triphosphate, lamivudine triphosphate, and azidothymidine triphosphate with agreement between experiment and theory. RESTRICT represents a new class of activity-based assays for therapeutic drug monitoring in HIV care and could be extended to other diseases treated with nucleotide analogs.
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Affiliation(s)
- Ayokunle O. Olanrewaju
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
- Department of BioengineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Benjamin P. Sullivan
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Alicia H. Gim
- Department of Chemical EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Cosette A. Craig
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Derin Sevenler
- Center for Engineering in Medicine and SurgeryMassachusetts General HospitalBostonMassachusettsUSA
| | - Andrew T. Bender
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Paul K. Drain
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Jonathan D. Posner
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
- Department of Chemical EngineeringUniversity of WashingtonSeattleWashingtonUSA
- Department of Family MedicineUniversity of WashingtonSeattleWashingtonUSA
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Joseph Davey D, Nyemba DC, Castillo‐Mancilla J, Wiesner L, Norman J, Mvududu R, Mashele N, Johnson LF, Bekker L, Gorbach P, Coates TJ, Myer L. Adherence challenges with daily oral pre-exposure prophylaxis during pregnancy and the postpartum period in South African women: a cohort study. J Int AIDS Soc 2022; 25:e26044. [PMID: 36480171 PMCID: PMC9731362 DOI: 10.1002/jia2.26044] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. However, prevention effectiveness requires daily adherence prior to and during periods of sexual activity. Little is known about pharmacologic measures of PrEP adherence during pregnancy and postpartum and the factors related to optimal adherence during periods of sexual activity in this population. METHODS Between August 2019 and October 2021, we enrolled pregnant women without HIV at their first antenatal care visit followed-up through 12 months postpartum. Eligible women ≥16 years old received HIV prevention counselling and were offered oral PrEP (TDF-FTC). We quantified tenofovir-diphosphate (TFV-DP) in dried blood spots in women who reported taking PrEP in the past 30 days (at quarterly follow-up visits). We used regression models with generalized estimating equations to evaluate correlates of TFV-DP (any vs. none, and ≥2 vs. <2 doses/week), adjusting for maternal age and pregnancy status. RESULTS AND DISCUSSION In 382 women who started PrEP in pregnancy, returned for follow-up and reported PrEP use in the past 30 days, the median age was 27 years (interquartile range [IQR] = 23-32), and the median time on PrEP was 168 days (IQR = 84-252 days). Half of the samples had quantifiable TFV-DP at any time point (52%), declining from 67% of pregnant women 3 months post-initiation to 31% of postpartum women by 12 months. Overall, 72% had concentrations corresponding to <2 doses/week; 25% ≥2 doses/week; 3% 7 doses/week. Concentrations were lower in postpartum versus pregnancy (age-adjusted odds ratio [aOR] = 0.44; 95% confidence interval [CI] = 0.35-0.54). The correlation of self-reported adherence and TFV-DP ranged from -0.07 in pregnancy to 0.25 in postpartum women. Variables associated with having quantifiable TFV-DP included partner living with HIV/unknown serostatus (aOR = 1.50; 95% CI = 1.01-2.22), and reported frequency of sexual activity in the past month (aOR sex >5/month vs. no sex or <5 times/month = 2.11; 95% CI = 1.58-2.82) adjusting for age and pregnancy versus postpartum status. TFV-DP concentrations declined over follow-up time (aOR for 6 vs. 3 months = 0.49; 95% CI = 0.36-0.67). CONCLUSIONS Objectively measured adherence to PrEP was low overall and did not correlate with self-reported use. There is an urgent need for objective adherence measures to support clinical decision-making as well as adherence support interventions as part of PrEP services for pregnant and postpartum women at risk of HIV.
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Affiliation(s)
- Dvora Joseph Davey
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- The Desmond Tutu Health FoundationUniversity of Cape TownCape TownSouth Africa
| | - Dorothy C. Nyemba
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Jose Castillo‐Mancilla
- Division of Infectious DiseasesSchool of MedicineUniversity of Colorado‐Anschutz Medical CampusAuroraColoradoUSA
| | - Lubbe Wiesner
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jennifer Norman
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Rufaro Mvududu
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Nyiko Mashele
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and ResearchUniversity of Cape TownCape TownSouth Africa
| | - Linda‐Gail Bekker
- The Desmond Tutu Health FoundationUniversity of Cape TownCape TownSouth Africa
| | - Pamina Gorbach
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Thomas J. Coates
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
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11
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Jennings L, Kellermann T, Spinelli M, Nkantsu Z, Cogill D, van Schalkwyk M, Decloedt E, van Zyl G, Orrell C, Gandhi M. Drug Resistance, Rather than Low Tenofovir Levels in Blood or Urine, Is Associated with Tenofovir, Emtricitabine, and Efavirenz Failure in Resource-Limited Settings. AIDS Res Hum Retroviruses 2022; 38:455-462. [PMID: 34779228 PMCID: PMC9225825 DOI: 10.1089/aid.2021.0135] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The high cost of viral load (VL) testing limits its use for antiretroviral therapy (ART) adherence support. A low-cost lateral flow urine tenofovir (TFV) rapid assay predicts pre-exposure prophylaxis breakthroughs, but has not yet been investigated in HIV treatment. We therefore evaluated its utility in a pilot cross-sectional study of TFV-containing ART recipients at an increased risk of virologic failure (VF). Participants who had a treatment interruption ≥30 days or had ≥1 episode of viremia (VL ≥400 copies/mL) in the previous year were recruited from a public health setting in Cape Town, South Africa. Self-reported adherence data were collected, the urine TFV assay performed, and concurrent TFV-diphosphate analyzed in dried blood spots. VL testing was done concurrently and, if viremic, genotypic HIV drug resistance testing was performed. Of 48 participants, 18 (37.5%) had VL (>400 copies/mL) at the time of the study, including 16 of 39 receiving efavirenz (EFV), 2 of 6 receiving protease inhibitors, and 0 of 3 receiving dolutegravir. Resistance testing succeeded in 17/18, of which 14 had significant mutations compromising ≥2 agents of the current EFV-based regimen. Of these 14, all had detected urine TFV. Urine TFV was undetectable in two out of three without regimen-relevant resistance; p = .02. In participants on EFV-based regimens returning to care, VF was largely due to viral resistance, where detectable urine TFV had 100% sensitivity (14/14 participants) in predicting resistance. Conversely, when undetectable, the urine-based assay could be used to preclude participants with poor adherence from undergoing costly HIV drug resistance testing.
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Affiliation(s)
- Lauren Jennings
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | - Tracy Kellermann
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Matthew Spinelli
- Division of HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital, San Francisco, California, USA
| | - Zukiswa Nkantsu
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | - Dolphina Cogill
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | - Marije van Schalkwyk
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gert van Zyl
- Division of Medical Virology, Stellenbosch University, Faculty of Medicine and Health Sciences, Cape Town, South Africa
- National Health Laboratory Service, Tygerberg Business Unit, Cape Town, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital, San Francisco, California, USA
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12
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Haberer JE, Mugo N, Bukusi EA, Ngure K, Kiptinness C, Oware K, Garrison LE, Musinguzi N, Pyra M, Valenzuela S, Thomas KK, Anderson PL, Thirumurthy H, Baeten JM. Understanding Pre-Exposure Prophylaxis Adherence in Young Women in Kenya. J Acquir Immune Defic Syndr 2022; 89:251-260. [PMID: 35147580 PMCID: PMC8826617 DOI: 10.1097/qai.0000000000002876] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/21/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To present detailed analyses of long-term pre-exposure prophylaxis (PrEP) use and associated behaviors and perceptions among young Kenyan women. DESIGN Prospective, observational cohort. METHODS The Monitoring PrEP among Young Adult women Study involved 18 to 24-year-old women at high HIV risk initiating PrEP in Kisumu and Thika, Kenya. Visits for PrEP counseling and dispensing, HIV testing, and socio-behavioral data collection occurred at Month 1 and quarterly for 2 years. PrEP adherence was measured with pharmacy refill and real-time electronic monitoring, plus tenofovir diphosphate levels in 15% of participants. HIV risk behavior and perception were assessed by self-report in weekly short message service surveys from Months 6-24. Predictors of adherence were assessed with multivariable logistic regression analysis. RESULTS Three hundred forty-eight women (median age 21, VOICE risk score 7) were followed for 617 person-years. Pharmacy refills steadily declined from 100% (Month 0-1) to 54% (Months 22-24). Average electronically monitored adherence similarly declined from 65% (Month 0-1) to 15% (Months 22-24). Electronically monitored adherence had moderately high concordance with tenofovir diphosphate levels (67%). High average adherence (5+ doses/week) was seen at 385/1898 (20%) participant-visits and associated with low baseline VOICE risk score, >1 current sexual partner, ≤1-hour travel time to clinic, and the Kisumu site. short message service-reported behavior and risk perception were not associated with adherence. Four women acquired HIV (incidence 0.7/100 person-years). CONCLUSIONS PrEP adherence was modest and declined over time. HIV risk was inconsistently associated with adherence; clinic access and site-level factors were also relevant. Relatively low HIV incidence suggests participants may have achieved protection through multiple strategies.
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Affiliation(s)
- Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Nelly Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Thika, Kenya
- Department of Global Health, University of Washington, Seattle, WA
| | - Elizabeth Ann Bukusi
- Department of Global Health, University of Washington, Seattle, WA
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kenneth Ngure
- Center for Clinical Research, Kenya Medical Research Institute, Thika, Kenya
- Department of Community Heath, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Kevin Oware
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | | | - Maria Pyra
- Department of Medicine, University of Chicago, Chicago, IL
| | - Susie Valenzuela
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Denver, CO
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Jared M Baeten
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- HIV Clinical Development, Gilead Sciences, Foster City, CA
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13
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Joseph Davey DL, Dovel K, Mvududu R, Nyemba D, Mashele N, Bekker LG, Gorbach PM, Coates TJ, Myer L. Pre-exposure Prophylaxis Recent Adherence With Real-Time Adherence Feedback and Partner Human Immunodeficiency Virus Self-Testing: A Pilot Trial Among Postpartum Women. Open Forum Infect Dis 2021; 9:ofab609. [PMID: 35097151 PMCID: PMC8794072 DOI: 10.1093/ofid/ofab609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 12/01/2021] [Indexed: 12/13/2022] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) is safe and effective in postpartum women. Human immunodeficiency virus self-testing (HIVST) for male partners combined with biofeedback counseling through real-time adherence measures may improve PrEP use among postpartum women. Methods Between August 2020 and April 2021, we randomized postpartum women who initiated PrEP in pregnancy 1:1 to the intervention group (HIVST + biofeedback counseling after urine tenofovir test) or to standard of care ([SOC] facility-based human immunodeficiency virus [HIV] tests and routine counseling without biofeedback). The outcomes of interest were PrEP adherence in the past 48–72 hours via urine tenofovir tests and partner HIV testing, measured 1-month after randomization. Secondary outcomes included the proportion of partners who tested for HIV and the discrepancy between self-reported PrEP adherence and urine tenofovir result. Results We enrolled 106 women (median age = 26 years). At enrollment, 72% of women reported missing <2 doses in the past 7 days; 36% of women had tenofovir present in her urine. One month after enrollment, 62% (n = 33) of women in the intervention arm had tenofovir present in their urine compared to 34% (n = 18) in SOC (risk ratio [RR] = 1.83; 95% confidence interval [CI] = 1.19–2.82; P = .001). Two thirds of women in the intervention arm reported that her partner tested for HIV (66%; n = 35), compared to 17% (n = 9) in SOC (RR = 3.89; 95% CI = 2.08–7.27; P < .001). Self-reported PrEP adherence (took PrEP >5 of last week) with no tenofovir in urine test was lower in the intervention group (17% vs 46%; RR = 0.33; 95% CI = 0.17–0.67; P = .03). No social or clinical adverse events were reported in the intervention arm. Conclusions The HIVST for partners and biofeedback counseling increased levels of recent PrEP adherence, pointing to the importance of these interventions to support PrEP use in this population.
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Affiliation(s)
- Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Dorothy Nyemba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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14
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Vernon F, Morrow M, MaWhinney S, Coyle R, Coleman S, Ellison L, Zheng JH, Bushman L, Kiser JJ, Galárraga O, Anderson PL, Castillo-Mancilla J. Income Inequality Is Associated With Low Cumulative Antiretroviral Adherence in Persons With Human Immunodeficiency Virus. Open Forum Infect Dis 2020; 7:ofaa391. [PMID: 33072812 PMCID: PMC7539687 DOI: 10.1093/ofid/ofaa391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background The adherence biomarker tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is associated with viral suppression and predicts future viremia. However, its association with social determinants of health (SDoH) in people with human immunodeficiency virus (PWH) remains unknown. Methods Dried blood spots for TFV-DP were longitudinally collected from a clinical cohort of PWH receiving tenofovir disoproxil fumarate-based therapy (up to 3 visits over 48 weeks) residing in 5 Colorado counties. To assign SDoH, zip codes at enrollment were matched with SDoH data from AIDSVu (https://aidsvu.org/). The SDoH included household income, percentage living in poverty, education level, and income inequality (quantified using Gini coefficient, where 0 and 1 represent perfect income equality and inequality, respectively). Log-transformed TFV-DP concentrations were analyzed using a mixed-effects model to estimate percentage change (95% confidence interval) in TFV-DP for every significant change in the SDoH and adjusted for relevant covariates including age, gender, race, estimated glomerular filtration rate, body mass index, hematocrit, CD4+ T-cell count, antiretroviral drug class, and 3-month self-reported adherence. Results Data from 430 PWH totaling 950 person-visits were analyzed. In an adjusted analysis, income inequality was inversely associated with TFV-DP in DBS. For every 0.1 increase in the Gini coefficient, TFV-DP concentrations decreased by 9.2% (−0.5 to −17.1; P = .039). This remained significant after adjusting for human immunodeficiency virus viral suppression, where a 0.1 increase in Gini was associated with a decrease of 8.7% (−0.3 to −17.9; P = .042) in TFV-DP. Conclusions Higher income inequality was associated with lower cumulative antiretroviral adherence. These findings support the need for further research on how SDoH impact adherence and clinical care.
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Affiliation(s)
- Frances Vernon
- School of Medicine, University of Colorado-Anschutz Medical Campus (AMC), Aurora, Colorado, USA
| | - Mary Morrow
- Department of Biostatistics and Bioinformatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Samantha MaWhinney
- Department of Biostatistics and Bioinformatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Ryan Coyle
- Division of Infectious Diseases, School of Medicine, University of Colorado-AMC, Aurora, Colorado, USA
| | | | - Lucas Ellison
- Colorado Antiviral Pharmacology Laboratory and Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-AMC, Aurora, Colorado, USA
| | - Jia-Hua Zheng
- Colorado Antiviral Pharmacology Laboratory and Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-AMC, Aurora, Colorado, USA
| | - Lane Bushman
- Colorado Antiviral Pharmacology Laboratory and Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-AMC, Aurora, Colorado, USA
| | - Jennifer J Kiser
- Colorado Antiviral Pharmacology Laboratory and Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-AMC, Aurora, Colorado, USA
| | - Omar Galárraga
- Brown University, School of Public Health, Providence, Rhode Island, USA
| | - Peter L Anderson
- Colorado Antiviral Pharmacology Laboratory and Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-AMC, Aurora, Colorado, USA
| | - Jose Castillo-Mancilla
- Division of Infectious Diseases, School of Medicine, University of Colorado-AMC, Aurora, Colorado, USA
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