Use of protease inhibitors among persons with AIDS in Los Angeles County

Conspiracy beliefs about HIV are related to antiretroviral treatment nonadherence among african american men with HIV

BACKGROUND

Medical mistrust is prevalent among African Americans and may influence health care behaviors such as treatment adherence. We examined whether a specific form of medical mistrust-HIV conspiracy beliefs (eg, HIV is genocide against African Americans)-was associated with antiretroviral treatment nonadherence among African American men with HIV.

METHODS

On baseline surveys, 214 African American men with HIV reported their agreement with 9 conspiracy beliefs, sociodemographic characteristics, depression symptoms, substance use, disease characteristics, medical mistrust, and health care barriers. Antiretroviral medication adherence was monitored electronically for one month postbaseline among 177 men in the baseline sample.

RESULTS

Confirmatory factor analysis revealed 2 distinct conspiracy belief subscales: genocidal beliefs (eg, HIV is manmade) and treatment-related beliefs (eg, people who take antiretroviral treatments are human guinea pigs for the government). Both subscales were related to nonadherence in bivariate tests. In a multivariate logistic regression, only treatment-related conspiracies were associated with a lower likelihood of optimal adherence at one-month follow-up (odds ratio = 0.60, 95% confidence interval = 0.37 to 0.96, P < 0.05).

CONCLUSIONS

HIV conspiracy beliefs, especially those related to treatment mistrust, can contribute to health disparities by discouraging appropriate treatment behavior. Adherence-promoting interventions targeting African Americans should openly address such beliefs.

Factors associated with use of HIV primary care among persons recently diagnosed with HIV: Examination of variables from the behavioural model of health-care utilization

The delay between testing positive for human immunodeficiency virus (HIV) and entering medical care can be better understood by identifying variables associated with use of HIV primary care among persons recently diagnosed with the virus. We report findings from 270 HIV-positive persons enrolled in the Antiretroviral Treatment Access Study (ARTAS). 74% had not seen an HIV care provider before enrollment; 26% had one prior visit only. Based on Andersen's behavioural model of health care utilization, several variables reflecting demographic, healthcare, illness, behavioural, and psychosocial dimensions were assessed and used to predict the likelihood that participants had seen an HIV care provider six months after enrollment. Overall, 69% had seen an HIV care provider by six months. In multivariate analysis, the likelihood of seeing a provider was significantly (p<.05) higher among men, Hispanics (vs. non-Hispanic Blacks), those with higher education, those who did not use injection drugs, those with three or more HIV-related symptoms, those with public health insurance (vs. no insurance), and those who received short-term case management (vs. passive referral). The findings support several conceptual categories of Andersen's behavioural model of health services utilization as applied to the use of HIV medical care among persons recently diagnosed with HIV.

Relationship Between Antiretroviral Prescribing Patterns and Treatment Guidelines in Treatment-Naive HIV-1-Infected US Veterans (1992-2004)

OBJECTIVE

To analyze temporal patterns of antiretroviral (ARV) prescribing practices relative to nationally defined guidelines in treatment-naive patients with HIV-1 infection.

DESIGN

Retrospective cohort study.

METHODS

We evaluated ARV prescribing patterns among ARV treatment-naive veterans who were receiving care within the US Department of Veterans Affairs (VA) from 1992 through 2004 in comparison to evolving adult HIV-1 treatment guidelines.

RESULTS

A total of 15,934 patients initiated ARV treatment. Since 1999, >94% of patients initiated at least a 3-ARV medication combination, although the percentage of patients who initiated a guideline "preferred" or "alternative" regimen never rose to greater than 72% and was significantly associated with being black and with region of care. After 1999, 20% of patients started 4 or more active ARV agents in combination, which was significantly associated with lower baseline CD4 cell count, higher viral load, and receiving care in the western United States. The proportion of patients receiving guideline "not recommended" regimens (virologically undesirable or overlapping toxicities) was <1% after 1997. VA prescribing trends generally predated guideline recommendations by 6 to 12 months.

CONCLUSIONS

VA prescribing patterns for ARV initiation adhere to treatment guidelines that maximize safety. Guidelines designed to maximize efficacy were not followed as stringently. Evaluating clinical practice patterns against contemporary treatment guidelines can inform guideline development.

HIV behavioral surveillance in the U.S.: a conceptual framework

This article describes a conceptual framework for HIV behavioral surveillance in the United States. The framework includes types of behaviors to monitor, such as risk behaviors, HIV testing behaviors, adherence to HIV treatment, and care-seeking for HIV/AIDS. The framework also describes the population groups in which specific behaviors should be monitored. Because the framework is multifaceted in terms of behaviors and populations, behavioral data from multiple surveillance systems are integrated to achieve HIV behavioral surveillance program objectives. Defining surveillance activities more broadly to include behavioral surveillance in multiple populations will provide more comprehensive data for prevention planning, and lead to a more effective response to HIV/AIDS in the United States.

Hormonal contraceptive use and the effectiveness of highly active antiretroviral therapy

The role of hormonal contraceptive use in the effectiveness of highly active antiretroviral therapy (HAART) was examined among participants in the Women's Interagency HIV Study who were followed from HAART initiation to 2001. Propensity score selection was used to match 77 hormonal contraceptive users with 77 nonusers on age, race, and pre-HAART CD4-positive T-lymphocyte (CD4+ cell) count and viral load. The authors compared hormonal contraceptive users and nonusers with regard to the CD4+ cell count and viral load responses to HAART upon initiation. Proportional hazards analyses were used to assess the effect of hormonal contraceptive use on times to increases in CD4+ cell count of 50 cells/mm(3) and 100 cells/mm(3) and achievement of an undetectable viral load. There were no statistically significant differences in CD4+ cell counts and log viral load responses by hormone use after HAART initiation, except in log viral load at the third visit after initiation (p = 0.047). Time-dependent hormonal contraceptive use was not a statistically significant predictor of achieving increases in CD4+ cell count of 50 cells/mm(3) and 100 cells/mm(3) or an undetectable viral load (p = 0.517, p = 0.751, and p = 0.218, respectively) after HAART initiation. In conclusion, the authors did not find substantial evidence that use of hormonal contraceptives strongly affected responses to HAART.

Racial and Gender Disparities in Receipt of Highly Active Antiretroviral Therapy Persist in a Multistate Sample of HIV Patients in 2001

BACKGROUND

National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization.

METHODS

Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART.

RESULTS

In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm received HAART; and 77% of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART.

CONCLUSIONS

Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).

Factors affecting adherence to antiretroviral therapy in people living with HIV/AIDS

Antiretroviral treatments have given hope to people living with HIV/AIDS and play a role in improving their quality of life. However, the effectiveness of these treatments is directly related to the level of adherence and commitment to them. Researchers have demonstrated that there are many factors that play an important role in adopting and maintaining adherence behavior. In this article, the authors present an indepth review of the literature and from this, enumerate the factors that link adherence behavior to the individual, the treatment, the illness, and the relationship with the health professional. An understanding of these factors is essential to develop interventions that will improve adherence to therapeutic regimens among people with HIV/AIDS.

Factors associated with accelerated atherosclerosis in HIV-1-infected persons treated with protease inhibitors

Recent evidence suggests that as a group protease inhibitors (PIs) may accelerate certain factors associated with atherosclerosis. The objective of this study was to evaluate the effect of individual PIs (indinavir, lopinavir, nelfinavir, ritonavir, and saquinavir) on certain factors associated with atherosclerosis. Persons who took saquinavir and/or ritonavir were compared with those on other PIs. Between May 2000 and July 2001, the lipid profiles, C-reactive protein (CRP) levels, coronary artery calcium (CAC) scores, and blood cell morphologic parameters were measured in 98 black adult participants aged 25 to 45 years with HIV-1 infection in Baltimore, Maryland. Among these 98, there were 55 (56.1%) taking PIs. Students' t-test and chi2 test were used to detect the between-group differences. Study participants in both the PI and non-PI groups were similar in age, sex, body mass index, blood pressure, red and white blood cell counts, time since HIV diagnosis, and duration on anti-retroviral therapy. Compared with those who took non-PI regimens, those who took indinavir, nelfinavir, or saquinavir had significantly higher levels of mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH). Those taking any PI had significantly higher total cholesterol and low-density lipoprotein. Those taking nelfinavir, ritonavir, or saquinavir were more likely to have a higher CAC score (>5) than those on non-PI regimens. There were no differences in the lipid profiles, MCV, MCH, CRP, and CAC between those taking saquinavir and/or ritonavir and those taking other PIs. Overall, the changes noted might lead to anticipation of clinical changes linked to accelerated atherosclerosis in patients on PIs.

Differences in prescription of antiretroviral therapy in a large cohort of HIV-infected patients

The objective of this study was to determine factors associated with prescription of highly active antiretroviral therapy (HAART). The authors observed 9530 patients eligible for antiretroviral therapy (ART) in more than 100 hospitals and clinics in 10 US cities. Multiple logistic regression analysis was used to assess factors associated with HAART prescription, stratifying patients by no history versus history of ART to assess the association between prescription and CD4, viral load, and outpatient visits. Overall, female gender (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.60-0.76) and alcoholism (OR, 0.85; 95% CI, 0.74-0.99) were associated with decreased likelihood of HAART prescription. Enrollment at a private facility (OR, 1.33; 95% CI, 1.14-1.56), heterosexual exposure (OR, 1.34; 95% CI, 1.13-1.58), and Hispanic ethnicity (OR, 1.19; 95% CI, 1.04-1.37) were associated with prescription. For patients with no history of prescribed ART, CD4 <500 cells/microL (OR, 3.94; 95% CI, 2.02-7.66), and high viral load were associated with increased likelihood of prescription; for patients with history of ART prescription, those whose outpatient visits averaged > or =2 per 6-month interval (OR, 1.30; 95% CI, 1.10-1.54) were more likely and those with high viral load were less likely to be prescribed HAART (OR, 0.50; 95% CI, 0.44-0.56). The authors found differences in HAART prescription by gender, race, exposure mode, alcoholism, and provider type for all patients, by CD4 and viral load for patients with no history of ART prescription, and by average number of outpatient visits and viral load for patients with history of ART prescription.

Factors associated with the use of highly active antiretroviral therapy in patients newly entering care in an urban clinic

Ethnic minority, female, and drug-using patients may be less likely to receive highly active antiretroviral therapy (HAART), despite its proven benefits. We reviewed the medical records of a consecutive population of 354 patients entering care in 1998 at the Thomas Street Clinic, an academically affiliated, public, HIV-specialty clinic in Houston, to determine the factors associated with not receiving HAART as recorded in pharmacy records. Ninety-two patients (26.0%) did not receive HAART during at least 6 months of follow-up. Patients who did not receive HAART were more likely to be women and to have missed more than two physician appointments and were less likely to have a CD4 count <200 cells/microL or a viral load > or = 10 copies/mL. In multivariate logistic analysis, missed appointments (OR = 5.85, p<.0001), female sex (OR = 2.53, =.001), and CD4 count > or = 200 cells/microL (OR = 2.50, p=.001) were independent predictors of not receiving HAART. More than half the patients who never received HAART never returned to the clinic after their first appointment. Among patients new to care, women and those with poor appointment adherence were less likely to receive HAART. Efforts to improve clinic retention and further study of the barriers to HAART use in women are needed.

AIDS in the HAART era: New York's heterogeneous geography

During the 1990s, the number of new AIDS cases in New York City, USA, declined precipitously. The declines, beginning before highly active antiretroviral therapy (HAART) was introduced, were geographically heterogeneous across two New York City boroughs analyzed. From 1993 to 1998, zip codes in Lower Manhattan, with large white and affluent populations, had declines as much as 55% more than the rest of Manhattan. Bronx zip codes underwent still lesser declines. Declines also differed within zip codes among subpopulations. White zip code populations tended to have greater declines than Latino populations, which in turn tended to have greater declines than black populations. According to bivariate and stepwise regressions, an array of socioeconomic and community stress variables acted in combination on the decline in New York AIDS. Manhattan's declines in total AIDS incidence were primarily defined by changes in AIDS incidence for whites and for men who have sex with men, racial segregation, and the proportions of households in upper income classes and under rent stress. Bronx declines in total AIDS are principally explained by a broader range of income classes, and social instability as marked by housing overcrowding and cirrhosis and drug mortalities. Whatever the combination of proximate causes for the decline in AIDS incidence in 1990s New York (educational campaigns, HAART, demographic stochasticity), the decline was shaped by the city's socioeconomic structure and political and ecological history. That structure and history generates the geographically defined aggregates of behaviors that promote or impede AIDS decline. Such spatial heterogeneity may provide for HIV refugia, areas where the virus can weather the epidemic's contraction, a troubling possibility with the accelerating microbicidal failures of combination therapies.

Coronary artery calcification, atherogenic lipid changes, and increased erythrocyte volume in black injection drug users infected with human immunodeficiency virus-1 treated with protease inhibitors

BACKGROUND

Protease inhibitors (PIs) may be associated with accelerated atherosclerosis in individuals infected with human immunodeficiency virus (HIV). We assessed the effects of HIV PIs on subclinical atherosclerosis.

METHODS

The lipid profiles, C-reactive protein (CRP) levels, coronary artery calcification (CAC) scores, and blood cell morphologic changes were quantified in 98 black adult participants, aged 25 to 45 years, with HIV-1 infection in Baltimore, Md. Fifty-five participants (56.1%) were taking PIs; 43 participants (43.9%) were not. The Student t and chi(2) tests were used as a means of detecting the between-group differences.

RESULTS

Participants in both the PI and non-PI groups were similar in age, sex, body mass index, blood pressure, heart rate, and red and white blood cell counts. Compared with the non-PI group, the PI group had significantly higher serum total cholesterol (4.8 +/- 1.0 vs 3.8 +/- 0.7 mmol/L, P <.001) and LDL cholesterol (2.9 +/- 0.8 vs 2.1 +/- 0.7 mmol/L, P <.001) levels and red blood cell mean corpuscular volume (92.2 +/- 9.3 vs 86.8 +/- 7.2 microm3, P =.048). The CAC scores in the PI group were also higher than those in the non-PI group (11.0 +/- 28.6 [n = 43] vs 1.7 +/- 5.8, P =.043). CAC scores were marginally associated with log-transformed duration of the PI therapy (P =.055). Serum CRP levels remained unchanged (5.5 +/- 13.6 mg/L [n = 45] vs 3.9 +/- 5.5 mg/L, P =.467). Serum total cholesterol level, LDL cholesterol level, red blood cell mean corpuscular volume, and CAC scores were indicated by means of regression analyses to be associated with log-transformed duration of the PI therapy.

CONCLUSIONS

The use of PIs is associated with coronary artery calcification, atherogenic lipid changes, and increased erythrocyte volume in individuals infected with HIV-1.

Association of medical insurance and other factors with receipt of antiretroviral therapy

OBJECTIVES

This study was designed to assess sociodemographic and medical insurer factors associated with receipt of highly active antiretroviral therapy (HAART).

METHODS

Patients included (n = 959) were enrolled in the Johns Hopkins HIV Clinic after April 1, 1996, received > or = 90 days of care, and had a CD4 count > or = 500 cells/mm3 or HIV-1 RNA > 20 000 copies/mL. We assessed the associations of sociodemographic factors and medical insurance with receipt of HAART, stratified by 2 time periods (April 1996 through March 1997 versus April 1997 through March 1999).

RESULTS

HAART was more likely to be used in patients who were > 39 years, White, had CD4 counts < 350 cells/mm3, had fewer missed clinic visits, and did not have intravenous drug use as their risk factor for HIV transmission. In period 1 (April 1996 through March 1997), HAART was more likely to be used in patients who were commercially insured than in other payer groups; differences between payers narrowed in period 2 (April 1997 through March 1999), however, as did differences by race.

CONCLUSIONS

Differences in use of HAART on the basis of payer have narrowed since 1996. This encouraging finding may demonstrate the importance of programs that lower economic barriers to medical care.

Predictors of use of highly active antiretroviral therapy (HAART) among persons with AIDS in San Francisco, 1996-1999

Highly active antiretroviral therapy (HAART) has contributed to a decrease in AIDS-related morbidity and mortality. This study used population-based AIDS surveillance data to evaluate the prevalence and predictors of HAART use among persons with AIDS in San Francisco. Use of HAART among persons living with AIDS increased from 41% in 1996 to 72% in 1999. Fourteen percent of persons diagnosed with AIDS between 1996 and 1999 initiated HAART before their AIDS diagnosis. Use of HAART before an AIDS diagnosis increased from 5% in 1996 to 26% in 1999. In the multivariable analysis, African Americans, injection drug users, and those without insurance at the time of AIDS diagnosis were less likely to use HAART before AIDS diagnosis. Delayed initiation of HAART after AIDS was more likely to occur among African Americans, injection drug users, homeless persons, those with public insurance, and those with higher CD4 counts. Although the overall prevalence of HAART use was high, disparity in use of HAART existed by race and risk group, patient's insurance status, and facility of diagnosis. Barriers in use of treatment should be identified so all persons with AIDS can benefit from improved therapies.

Use of protease inhibitors and non-nucleoside reverse transcriptase inhibitors among Medicaid beneficiaries with AIDS

OBJECTIVES

This study compared the use of new antiretroviral treatments across sociodemographic subgroups during the 3 years after the introduction of these treatments and examined diffusion of the therapies over time.

METHODS

Merged surveillance and claims data were used to examine use of protease inhibitors and non-nucleoside reverse transcriptase inhibitors (PI/NNRTIs) among New Jersey Medicaid beneficiaries with AIDS.

RESULTS

In 1996, there were sharp disparities in use of PI/NNRTI therapy among racial minorities and injection drug users, even after control for other patient characteristics. These gaps had decreased by 1998. Higher PI/NNRTI treatment rates were also observed among beneficiaries enrolled in a statewide HIV/AIDS-specific home- and community-based Medicaid waiver program.

CONCLUSIONS

Even within a population of individuals similar in regard to health coverage, there were substantial sociodemographic differences in use of PI/NNRTIs during the early years after their introduction. These differences narrowed as new treatments became standard. Participation in a case-managed Medicaid waiver program seems to be associated with a more appropriate pattern of use. These results suggest a need to address nonfinancial barriers to care.

Impact of medical and nonmedical factors on physician decision making for HIV/AIDS antiretroviral treatment

To examine influences of medical factors (e.g., viral load) and nonmedical factors (e.g., patient characteristics) on treatment decisions for highly active antiretroviral therapy (HAART), we sent a survey to a random sample of 995 infectious disease physicians who treat patients with HIV/AIDS in the United States in August, 1998. The response rate was 53%. Respondents were asked to report their current practices with respect to antiretroviral treatment and the extent to which each of three medical and 17 nonmedical factors would influence them for or against prescribing HAART to a hypothetical HIV-positive patient. Most reported initiating HAART with findings of low CD4+ cell counts and high viral loads, and weighing CD4+ cell counts, viral load, and opportunistic infection heavily in their decisions to prescribe HAART. Patients' prior history of poor adherence was weighed very much against initiating HAART. Patient homelessness, heavy alcohol use, injection drug use, and prior psychiatric hospitalization were cited by most physicians as weighing against HAART initiation. Thus, most physicians in this sample follow guidelines for the use of HAART, and nonmedical factors related to patients' life situations are weighed as heavily as disease severity in treatment decisions. As HIV increasingly becomes a disease associated with economic disadvantage and other social health problems, it will be essential to develop interventions and care support systems to enable patients experiencing these problems to benefit from HIV treatment advances.