Is there a baseline CD4 cell count that precludes a survival response to modern antiretroviral therapy?

Effectiveness of intensive adherence counselling in achieving an undetectable viral load among people on antiretroviral therapy with low-level viraemia in Uganda

INTRODUCTION

Uganda was using a threshold of 1000 copies/mL to determine viral non-suppression for antiretroviral therapy monitoring among people living with HIV, prior to this study. It was not clear whether people living with HIV with low-level viraemia (LLV, ≥50 to <1000 copies/mL) would benefit from intensive adherence counselling (IAC). The purpose of this study was to determine the effectiveness of IAC among people living with HIV, receiving antiretroviral therapy, and with LLV in Uganda, to guide key policy decisions in HIV care, including the review of the viral load (VL) testing algorithm.

METHODS

This cluster-randomized clinical trial comprised adults from eight HIV clinics who were living with HIV, receiving ART, and had recent VL results indicating LLV (tested from July 2022 to October 2022). Participants in the intervention arm clinics received three once-monthly sessions of IAC, and those in the comparison non-intervention arm clinics received the standard of care. At the end of the study, all participants were re-tested for VL to determine the proportions of those who then had an undetectable VL (<50 copies/mL). We assessed the statistical association between cross-tabulated variables using Fisher's exact test and then modified Poisson regression.

RESULTS

A total of 136 participants were enrolled into the study at eight HIV clinics. All 68 participants in the intervention arm completed all IAC sessions. Only one participant in the non-intervention arm was lost to follow-up. The average follow-up time was 3.7 months (standard deviation [SD] 0.2) and 3.5 months (SD 0.1) in the intervention and non-intervention arms, respectively. In total, 59 (43.7%) of 135 people living with HIV achieved an undetectable VL during the study follow-up period. The effect of IAC on attaining an undetectable VL among people with LLV was nearly twice as high in the intervention arm (57.4%) than in the non-intervention arm (29.9%): adjusted risk ratio 1.9 (95% confidence interval 1.0-3.5), p = 0.037.

CONCLUSION

IAC doubled the likelihood of an undetectable VL among people living with HIV with LLV. Therefore, IAC has been instituted as an intervention to manage people living with HIV with LLV in Uganda, and this should also be adopted in other Sub-Saharan African countries with similar settings.

CLINICALTRIALS

GOV IDENTIFIER

NCT05514418.

Two strains and drug adherence: An HIV model in the paradigm of community transmission

A two-strain model, comprising of drug-sensitive and drug-resistant strains, is proposed for the dynamics of Human Immunodeficiency Virus (HIV) spread in a community. A treatment model is introduced by taking drug adherence into account. The treatment-free model is analyzed for the effect of treatment availability and drug adherence on disease dynamics. The analysis revealed that for the treatment-free model, at least one strain faces competitive exclusion, and co-existence of both strains is not possible. On the contrary, both strains may co-exist in presence of treatment. The analysis carried out was both local, as well as global. A comprehensive bifurcation analysis showed periodic behaviour and all solutions approached a stable limit cycle for a wide range of parametric values. Overall, we concluded that the treatment availability and drug adherence play a significant role in determining the dynamics of HIV spread. Numerical simulations are performed to validate the analytical results using MATLAB.

Characteristics of psychosocial interventions to improve ART adherence in people living with HIV: A systematic review

The HIV/AIDS pandemic continues to be a significant global public health crisis. The main HIV/AIDS treatment is the antiretroviral therapy (ART), which is highly effective but depends on the patient's adherence to be successful. However, the adherence to antiretroviral therapy remains unsatisfactory across different populations, which raises considerable difficulties at both individual and collective levels. Suboptimal adherence to ART can be overcome through multidisciplinary management that includes evidence-based psychosocial interventions. Existing reviews on these interventions have focused mainly on studies with experimental designs, overlooking valuable interventions whose evidence comes from different study designs. Here, we aimed to carry out a comprehensive review of the current research on psychosocial interventions for ART adherence and their characteristics including studies with different designs. We conducted a systematic review following PRISMA guidelines. We searched five databases (Pubmed, EBSCO, LILACS, WoS and SCIELO) for articles reporting a psychosocial intervention to improve treatment adherence for people living with HIV (adults). The quality of each study was analyzed with standardized tools, and data were summarized using a narrative synthesis method. Twenty-three articles were identified for inclusion, and they demonstrated good to fair quality. Individual counseling was the most frequent intervention, followed by SMS reminders, education, and group support. Most interventions combined different strategies and self-efficacy was the most common underlying theoretical framework. This review provides insight into the main characteristics of current psychosocial interventions designed to improve ART treatment adherence. PROSPERO number: CRD42021252449.

HIV Disclosure to Family Members and Medication Adherence: Role of Social Support and Self-efficacy

Although antiretroviral therapy (ART) is vital to people living with HIV (PLWH) by suppressing the virus and in turn preventing onward HIV transmission and reducing AIDS-related morbidity and mortality, the rates of optimal ART adherence continuously remain low. Disclosure of HIV status is considered to be a critical predictor of ART adherence. However, few studies have explored the mechanisms underlying the association between disclosure and medication adherence. The current study aims to examine the mediating role of social support and self-efficacy underlying the relationship between HIV disclosure to family members and ART adherence. PLWH in China provided data on HIV disclosure, ART adherence, perceived social support on medication adherence, adherence self-efficacy, and social-demographic information. The path analyses revealed that disclosure to family members had significant indirect effects on adherence via social support and self-efficacy. Our findings suggested that HIV disclosure might positively affect ART adherence through two psychosocial pathways: social support and self-efficacy. Future intervention to improve medication adherence among PLWH should consider targeting these two factors.

Development and content validation of measures assessing adherence barriers and behaviors for use in clinical care

BACKGROUND

Providers are often unaware of poor adherence to prescribed medications for their patients with chronic diseases.

OBJECTIVE

To develop brief, computer-administered patient-reported measures in English and Spanish assessing adherence behaviors and barriers. Design, Participants, and Main Measures: Item pools were constructed from existing measures of medication adherence behaviors and barriers, which informed development of a patient concept elicitation interview guide to identify medication adherence behavior and barrier-related concepts. Two hundred six patients either living with HIV (PLWH) or without were interviewed. Interviews were coded, concepts matched to item pool content, and new items were developed for novel concepts. A provider/investigator team highlighted clinically relevant items. Cognitive interviews were conducted with patients on final candidate items (n = 37). The instruments were administered to 2081 PLWH.

KEY RESULTS

Behavioral themes from concept elicitation interviews included routines incorporating time of day, placement, visual cues, and intentionality to miss or skip doses. Barrier themes included health-related (e.g. depressed mood, feeling ill), attitudes/beliefs (e.g., need for medication), access (e.g., cost/insurance problems), and circumstantial barriers (e.g., lack of privacy, disruption of daily routine). The final instruments included 6 behavior items, and 1 barrier item with up to 23 response options. PLWH endorsed a mean (SD) of 3.5 (1.1) behaviors. The 201 PLWH who missed ≥2 doses in the previous week endorsed a mean (SD) of 3.1 (2.5) barriers. The intraclass correlation coefficient (ICC) for the numbers of behaviors endorsed in 61 PLWH after 4-16 days was 0.54 and for the number of barriers for the 20 PLWH with ≥2 missed doses the ICC was 0.89, representing fair and excellent test-retest reliability.

CONCLUSION

Measures of medication adherence behaviors and barriers were developed for use with patients living with chronic diseases focusing on clinical relevance, brevity, and content validity for use in clinical care.

Implementation and evaluation of a therapeutic patient education programme during a clinical trial in Yaoundé, Cameroon - Trial ANRS-12286/MOBIDIP

OBJECTIVES

High adherence is needed to maintain antiretroviral therapy efficacy. Few attempts at therapeutic patient education (TPE) have been made in sub-Saharan Africa. We describe patients' achievements before intervention and identified needs, TPE programme implementation and evaluation, and patients' satisfaction.

METHODS

The TPE programme was proposed to patients in the ANRS-12286/MOBIDIP trial. Beforehand, a directory of competences to manage HIV infection was designed. Patients' HIV-related knowledge and skills assessment was realised, leading to an educational contract. Evaluation was performed using a standardised collection form and a satisfaction survey.

RESULTS

Of 154 patients, 146 underwent TPE. During a median of 1.8 years, 47% of patients had ≥3 consultations. Educational assessment revealed limited knowledge about HIV disease. Conversely, patients had frequently managed issues of adherence or disclosure. A median of 12 objectives were considered per patient, and 75% were attained. Objectives from the cognitive domain were less frequently attained. Patients appeared satisfied with the intervention: more emphasis was placed on psycho-affective aspects or experience-sharing than on the acquisition of knowledge.

CONCLUSION

Active listening, know-how and a space for discussion appear more important for patients than knowledge on disease or treatments.

PRACTICE IMPLICATIONS

In HIV care, the directory of learning objectives should be revised to include more objectives concerning practical skills for disease management.

The association of therapeutic versus recreational marijuana use and antiretroviral adherence among adults living with HIV in Florida

PURPOSE

Marijuana use is common among people living with HIV (PLWH), but its association with antiretroviral therapy (ART) adherence is unclear. This study examined the association between reason for marijuana use and ART adherence in a sample of adults living with HIV.

PATIENTS AND METHODS

Participants (N=703) recruited from seven community health centers in Florida completed a 45-minute questionnaire assessing demographics, symptoms of anxiety and depression, ART adherence, and substance use, including reasons for marijuana use. ART adherence was defined as the proportion of days in the last 30 days participants did not miss any medication and dichotomized as optimal (≥95%) and suboptimal (<95%). Multivariate logistic regression analysis assessed the association between therapeutic marijuana use to manage HIV symptoms (ie, improve appetite/gain weight, induce sleep, relieve nausea/vomiting, relieve pain, relieve anxiety/depression/stress) versus recreational marijuana use and ART adherence.

RESULTS

Approximately one third (33.2%) of the participants reported using marijuana in the past 3 months. Of marijuana users, 21.8% reported using marijuana only for therapeutic purposes to manage HIV-associated medical symptoms, while 78.2% reported recreational use. After controlling for covariates, therapeutic use of marijuana was not associated with ART adherence (AOR =1.19, 95% CI =0.60-2.38, p=0.602) while recreational marijuana users showed significantly greater odds of suboptimal ART adherence compared to nonusers (AOR =1.80, 95% CI =1.18-2.72, p=0.005).

CONCLUSION

Our results suggest differences in ART adherence between individuals who report recreational versus therapeutic marijuana use. Continued research examining the health implications of marijuana use among adults living with HIV is important as legalization of recreational and medical marijuana proliferates in the United States.

Landmark estimation of survival and treatment effects in observational studies

Clinical studies aimed at identifying effective treatments to reduce the risk of disease or death often require long term follow-up of participants in order to observe a sufficient number of events to precisely estimate the treatment effect. In such studies, observing the outcome of interest during follow-up may be difficult and high rates of censoring may be observed which often leads to reduced power when applying straightforward statistical methods developed for time-to-event data. Alternative methods have been proposed to take advantage of auxiliary information that may potentially improve efficiency when estimating marginal survival and improve power when testing for a treatment effect. Recently, Parast et al. (J Am Stat Assoc 109(505):384-394, 2014) proposed a landmark estimation procedure for the estimation of survival and treatment effects in a randomized clinical trial setting and demonstrated that significant gains in efficiency and power could be obtained by incorporating intermediate event information as well as baseline covariates. However, the procedure requires the assumption that the potential outcomes for each individual under treatment and control are independent of treatment group assignment which is unlikely to hold in an observational study setting. In this paper we develop the landmark estimation procedure for use in an observational setting. In particular, we incorporate inverse probability of treatment weights (IPTW) in the landmark estimation procedure to account for selection bias on observed baseline (pretreatment) covariates. We demonstrate that consistent estimates of survival and treatment effects can be obtained by using IPTW and that there is improved efficiency by using auxiliary intermediate event and baseline information. We compare our proposed estimates to those obtained using the Kaplan-Meier estimator, the original landmark estimation procedure, and the IPTW Kaplan-Meier estimator. We illustrate our resulting reduction in bias and gains in efficiency through a simulation study and apply our procedure to an AIDS dataset to examine the effect of previous antiretroviral therapy on survival.

A Comparison of Adherence Timeframes Using Missed Dose Items and Their Associations with Viral Load in Routine Clinical Care: Is Longer Better?

Questions remain regarding optimal timeframes for asking about adherence in clinical care. We compared 4-, 7-, 14-, 30-, and 60-day timeframe missed dose items with viral load levels among 1099 patients on antiretroviral therapy in routine care. We conducted logistic and linear regression analyses examining associations between different timeframes and viral load using Bayesian model averaging (BMA). We conducted sensitivity analyses with subgroups at increased risk for suboptimal adherence (e.g. patients with depression, substance use). The 14-day timeframe had the largest mean difference in adherence levels among those with detectable and undetectable viral loads. BMA estimates suggested the 14-day timeframe was strongest overall and for most subgroups although findings differed somewhat for hazardous alcohol users and those with current depression. Adherence measured by all missed dose timeframes correlated with viral load. Adherence calculated from intermediate timeframes (e.g. 14-day) appeared best able to capture adherence behavior as measured by viral load.

Fosamprenavir: Drug Development for Adherence

Objective:

To review the pharmacology, pharmacokinetics, virology, safety, efficacy, and clinical use of fosamprenavir.

Data Sources:

A MEDLINE (1966–July 2005) search was conducted using fosamprenavir, Lexiva, amprenavir, and GW433908 as key words. Abstracts from infectious diseases and HIV scientific meetings were identified. Bibliographies of cited articles were reviewed.

Study Selection and Data Extraction:

All publications, meeting abstracts, and unpublished information were reviewed and relevant items included. Information from in vitro, preclinical, and Phase II and III clinical trials was included.

Data Synthesis:

Fosamprenavir is a protease inhibitor (PI) prodrug used for the treatment of HIV-1 infection. The active moiety, amprenavir, is extensively metabolized by CYP3A4. In clinical trials, fosamprenavir was at least as effective as amprenavir, with a reduced pill burden. Fosamprenavir was developed with the intention of reducing the pill burden associated with amprenavir. It has demonstrated comparable safety and efficacy with comparator Pls and is associated with limited cross-resistance to other Pls.

Conclusions:

Fosamprenavir is a promising antiretroviral agent with favorable efficacy and tolerability. At this time, data indicate the utility of fosamprenavir in treatment-naïve and PI-experienced HIV-infected patients.

A Randomized Controlled Trial Protocol to Evaluate the Effectiveness of an Integrated Care Management Approach to Improve Adherence Among HIV-Infected Patients in Routine Clinical Care: Rationale and Design

BACKGROUND

Adherence to antiretroviral medications is a key determinant of clinical outcomes. Many adherence intervention trials investigated the effects of time-intensive or costly interventions that are not feasible in most clinical care settings.

OBJECTIVE

We set out to evaluate a collaborative care approach as a feasible intervention applicable to patients in clinical care including those with mental illness and/or substance use issues.

METHODS

We developed a randomized controlled trial (RCT) investigating an integrated, clinic-based care management approach to improve clinical outcomes that could be integrated into the clinical care setting. This is based on the routine integration and systematic follow-up of a clinical assessment of patient-reported outcomes targeting adherence, depression, and substance use, and adapts previously developed and tested care management approaches. The primary health coach or care management role is provided by clinic case managers allowing the intervention to be generalized to other human immunodeficiency virus (HIV) clinics that have case managers. We used a stepped-care approach to target interventions to those at greatest need who are most likely to benefit rather than to everyone to maintain feasibility in a busy clinical care setting.

RESULTS

The National Institutes of Health funded this study and had no role in study design, data collection, or decisions regarding whether or not to submit manuscripts for publication. This trial is currently underway, enrollment was completed in 2015, and follow-up time still accruing. First results are expected to be ready for publication in early 2017.

DISCUSSION

This paper describes the protocol for an ongoing clinical trial including the design and the rationale for key methodological decisions. There is a need to identify best practices for implementing evidence-based collaborative care models that are effective and feasible in clinical care. Adherence efficacy trials have not led to sufficient improvements, and there remains little guidance regarding how adherence interventions should be implemented into clinical care. By focusing on improving adherence within care settings using existing staff, routine assessment of key domains, such as depression, adherence, and substance use, and feasible interventions, we propose to evaluate this innovative way to improve clinical outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01505660; http://clinicaltrials.gov/ct2/show/NCT01505660 (Archived by WebCite at http://www.webcitation/ 6ktOq6Xj7).

Mortality According to CD4 Count at Start of Combination Antiretroviral Therapy Among HIV-infected Patients Followed for up to 15 Years After Start of Treatment: Collaborative Cohort Study

BACKGROUND

CD4 count at start of combination antiretroviral therapy (ART) is strongly associated with short-term survival, but its association with longer-term survival is less well characterized.

METHODS

We estimated mortality rates (MRs) by time since start of ART (<0.5, 0.5-0.9, 1-2.9, 3-4.9, 5-9.9, and ≥10 years) among patients from 18 European and North American cohorts who started ART during 1996-2001. Piecewise exponential models stratified by cohort were used to estimate crude and adjusted (for sex, age, transmission risk, period of starting ART [1996-1997, 1998-1999, 2000-2001], and AIDS and human immunodeficiency virus type 1 RNA at baseline) mortality rate ratios (MRRs) by CD4 count at start of ART (0-49, 50-99, 100-199, 200-349, 350-499, ≥500 cells/µL) overall and separately according to time since start of ART.

RESULTS

A total of 6344 of 37 496 patients died during 359 219 years of follow-up. The MR per 1000 person-years was 32.8 (95% confidence interval [CI], 30.2-35.5) during the first 6 months, declining to 16.0 (95% CI, 15.4-16.8) during 5-9.9 years and 14.2 (95% CI, 13.3-15.1) after 10 years' duration of ART. During the first year of ART, there was a strong inverse association of CD4 count at start of ART with mortality. This diminished over the next 4 years. The adjusted MRR per CD4 group was 0.97 (95% CI, .94-1.00; P = .054) and 1.02 (95% CI, .98-1.07; P = .32) among patients followed for 5-9.9 and ≥10 years, respectively.

CONCLUSIONS

After surviving 5 years of ART, the mortality of patients who started ART with low baseline CD4 count converged with mortality of patients with intermediate and high baseline CD4 counts.

Are there differences in disease progression and mortality among male and female HIV patients on antiretroviral therapy? A meta-analysis of observational cohorts

Studies examining the sex differences in morbidity and mortality among HIV/AIDS patients have yielded inconsistent results. We conducted a meta-analysis of sex differences in disease progression and mortality among HIV/AIDS patients. Medical literature databases from inception to August 2014 were searched for published observational studies assessing sex differences in immunologic and virologic response, disease progression and mortality among HIV-infected patients. Random effects meta-analyses of 115 eligible studies were conducted to obtain pooled estimates of outcomes and heterogeneity was explored in sub-group analyses. Pooled estimates showed an increased risk of progression to AIDS (relative risk [RR]=1.11,95% CI=1.02-1.21) and all-cause mortality (RR=1.23, 95% CI=1.17-1.29) among males compared to females. All-cause mortality differed by sex only in low and middle income countries. The risk of AIDS-related mortality (RR=1.03, 95% CI=0.82-1.30), immunologic failure (RR=1.19,95% CI: 0.97-1.47), virologic suppression (RR=0.98, 95% CI=0.84-1.14), virologic failure (RR=1.26, 95% CI=0.99-1.61) and the change in CD4 cell count (Weighted mean difference [WMD] = -5.15, 95% CI= -13.57 to 3.28) did not differ by sex. These findings were modified by disease severity, adherence and use of highly active antiretroviral therapy. We conclude that HIV-related disease progression and survival outcomes are poorer in males.

Dose-response relationship between methadone dose and adherence to antiretroviral therapy among HIV-positive people who use illicit opioids

BACKGROUND AND AIMS

For HIV-positive individuals who use illicit opioids, engagement in methadone maintenance therapy (MMT) can contribute to improved HIV treatment outcomes. However, to our knowledge, the role of methadone dosing in adherence to antiretroviral therapy (ART) has not yet been investigated. We sought to examine the relationship between methadone dose and ART adherence among a cohort of people who use illicit opioids.

DESIGN AND SETTING

We used data from the AIDS Care Cohort to Evaluate Access to Survival Services (ACCESS) study, an ongoing prospective observational cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, linked confidentially to comprehensive HIV treatment data in a setting of universal no-cost medical care, including medications. We evaluated the longitudinal relationship between methadone dose and the likelihood of ≥ 95% adherence to ART among ART-exposed participants during periods of engagement in MMT.

PARTICIPANTS

Two hundred and ninety-seven ART-exposed individuals on MMT were recruited between December 2005 and May 2013 and followed for a median of 42.1 months.

MEASUREMENTS

We measured methadone dose at ≥ 100 versus < 100 mg/day and the likelihood of ≥ 95% adherence to ART.

FINDINGS

In adjusted generalized estimating equation (GEE) analyses, MMT dose ≥ 100 mg/day was associated independently with optimal adherence to ART [adjusted odds ratio (AOR) = 1.38; 95% confidence interval (CI) = 1.08-1.77). In a subanalysis, we observed a dose-response relationship between increasing MMT dose and ART adherence (AOR = 1.06 per 20 mg/day increase, 95% CI = 1.00-1.12).

CONCLUSION

Among HIV-positive individuals in methadone maintenance therapy, those receiving higher doses of methadone (≥ 100 mg/day) are more likely to achieve ≥ 95% adherence to antiretroviral therapy than those receiving lower doses.

High-intensity cannabis use and adherence to antiretroviral therapy among people who use illicit drugs in a Canadian setting

Cannabis is increasingly prescribed clinically and utilized by people living with HIV/AIDS (PLWHA) to address symptoms of HIV disease and to manage side effects of antiretroviral therapy (ART). In light of concerns about the possibly deleterious effect of psychoactive drug use on adherence to ART, we sought to determine the relationship between high-intensity cannabis use and adherence to ART among a community-recruited cohort of HIV-positive illicit drug users. We used data from the ACCESS study, an ongoing prospective cohort study of HIV-seropositive illicit drug users linked to comprehensive ART dispensation records in a setting of universal no-cost HIV care. We estimated the relationship between at least daily cannabis use in the last 6 months, measured longitudinally, and the likelihood of optimal adherence to ART during the same period, using a multivariate linear mixed-effects model accounting for relevant socio-demographic, behavioral, clinical and structural factors. From May 2005 to May 2012, 523 HIV-positive illicit drug users were recruited and contributed 2,430 interviews. At baseline, 121 (23.1 %) participants reported at least daily cannabis use. In bivariate and multivariate analyses we did not observe an association between using cannabis at least daily and optimal adherence to prescribed HAART (Adjusted Odds Ratio = 1.12, 95 % Confidence Interval [95 % CI]: 0.76-1.64, p value = 0.555.) High-intensity cannabis use was not associated with adherence to ART. These findings suggest cannabis may be utilized by PLWHA for medicinal and recreational purposes without compromising effective adherence to ART.

Database-Supported Teleconferencing: An Additional Clinical Mentoring Tool to Assist a Multinational Company HIV/AIDS Treatment Program in Africa

BACKGROUND

The lack of human resources for health is presently recognized as a major factor limiting scale-up of antiretroviral treatment (ART) programs in resourcelimited settings. The mobilization of public and private partners, the decentralization of care, and the training of non-HIV specialist nurses and general practitioners could help increase the number of HIV-infected patients receiving ART. In addition to other forms of training, scheduled teleconferences (TCs) have been organized to support a comprehensive HIV treatment program delivered by a private company's health team.

OBJECTIVE

To describe the role of the TC as an additional tool in mentoring a company's health care workers (HCWs).

METHOD

For this study, all TC reports were retrospectively reviewed and the questions classified by topic. Participating Heineken physicians evaluated the technical quality and scientific relevance of the TCs through an anonymous survey.

RESULTS

From October 2001 to December 2003, 10 HCWs working in 14 operating companies in 5 African countries raised 268 problems during 45 TCs. A total of 79 questions (29%) were asked about antiretroviral (ARV) therapy, 53 (20%) about the diagnosis and treatment of opportunistic infection, 43 (16%) about ARV toxicity, 40 (15%) about care organization and policy, 32 (12%) about laboratory or drug supply, and 21 (8%) about biological parameters. The mean TC attendance rate was 70%. The level of satisfaction among local company physicians was 65% for logistics, 89% for scientific relevance, 84% for applicability of advice, and 85% overall. The most common complaints concerned the poor quality of the telephone connection and language problems for francophone participants.

CONCLUSION

Database-supported teleconferencing could be an additional tool to mentor company HCWs in their routine care of HIV-infected workers and family members. The role and costeffectiveness of telemedicine in improving health outcomes should be further studied.

Unannounced telephone-based pill counts: a valid and feasible method for monitoring adherence

Phone-based unannounced pill counts to measure medication adherence are much more practical and less expensive than home-based unannounced pill counts, but their validity has not been widely assessed. We examined the validity of phone versus home-based pill counts using a simplified protocol streamlined for studies embedded in clinical care settings. A total of 100 paired counts were used to compare concordance between unannounced phone and home-based pill counts using interclass correlations. Discrepancy analyses using χ(2) tests compared demographic and clinical characteristics across patients who were concordant between phone and home-based pill counts and patients who were not concordant. Concordance was high for phone-based and home-based unannounced total pill counts, as well as individual medication counts and calculated adherence. This study demonstrates that a simplified phone-based pill count protocol can be implemented among patients from a routine clinical care setting and is a feasible means of monitoring medication adherence.

Sex differences in HIV outcomes in the highly active antiretroviral therapy era: a systematic review

To assess sex disparities in AIDS clinical and laboratory outcomes in the highly active antiretroviral therapy (HAART) era we conducted a systematic review of the published literature on mortality, disease progression, and laboratory outcomes among persons living with HIV and starting HAART. We performed systematic PubMed and targeted bibliographic searches of observational studies published between January, 1998, and November, 2013, that included persons starting HAART and reported analyses of mortality, progression to AIDS, or virologic or immunologic treatment outcomes by sex. Risk ratios (relative risks, odd ratios, and hazard ratios) and 95% confidence intervals were obtained. Sixty-five articles were included in this review. Thirty-nine studies were from North America and Europe and 26 were from Latin America, Asia, and Africa. Forty-four studies (68%) showed no statistically significant difference in risk of mortality, progression to AIDS, or virologic or immunologic treatment outcomes by sex. Decreased risk of death among females compared to males was observed in 24 of the 25 articles that included mortality analyses [pooled risk ratio 0.72 (95% confidence interval=0.69-0.75)], and decreased risk of death or AIDS was observed in 9 of the 13 articles that examined the composite outcome [pooled risk ratio=0.91 (0.84-0.98)]. There was no significant effect of sex on the risk of progression to AIDS [pooled risk ratio=1.15 (0.99-1.31)]. In this systematic review, females starting HAART appeared to have improved survival compared to males. However, this benefit was not associated with decreased progression to either AIDS or to differences in virologic or immunologic treatment outcomes.

Methadone maintenance therapy decreases the rate of antiretroviral therapy discontinuation among HIV-positive illicit drug users

We sought to examine whether methadone maintenance therapy (MMT) decreased rates of antiretroviral therapy (ART) discontinuation and was associated with plasma HIV RNA responses among a cohort of illicit drug users. Cumulative ART discontinuation rates were estimated using Kaplan-Meier methods and factors independently associated with ART discontinuation were identified using Cox proportional hazards regression. Engagement in MMT was negatively and independently associated with ART discontinuation [Adjusted Relative Hazard = 0.67 (95 % CI 0.54-0.83); p < 0.001]. Among participants receiving ART and MMT, 81.6 % of plasma HIV-1 RNA assessments were <500 copies/mL, while 65.81 % of HIV-1 RNA assessments among those prescribed ART without MMT were <500 copies/mL (p < 0.001). These results demonstrate that engagement in MMT conferred a protective benefit against ART discontinuation and was associated with a significant increase in plasma HIV RNA suppression among HIV-infected opioid-dependent drug users.

Predictors of CD4:CD8 ratio normalization and its effect on health outcomes in the era of combination antiretroviral therapy

Background

HIV leads to CD4:CD8 ratio inversion as immune dysregulation progresses. We examined the predictors of CD4:CD8 normalization after combination antiretroviral therapy (cART) and determined whether normalization is associated with reduced progression to AIDS-defining illnesses (ADI) and death.

Methods

A Canadian cohort of HIV-positive adults with CD4:CD8<1.2 prior to starting cART from 2000–2010 were analyzed. Predictors of (1) reaching a CD4:CD8 ≥1.2 on two separate follow-up visits >30 days apart, and (2) ADI and death from all causes were assessed using adjusted proportional hazards models.

Results

4206 patients were studied for a median of 2.77 years and 306 (7.2%) normalized their CD4:CD8 ratio. Factors associated with achieving a normal CD4:CD8 ratio were: baseline CD4+ T-cells >350 cells/mm³, baseline CD8+ T-cells <500 cells/mm³, time-updated HIV RNA suppression, and not reporting sex with other men as a risk factor. There were 213 ADIs and 214 deaths in 13476 person-years of follow-up. Achieving a normal CD4:CD8 ratio was not associated with time to ADI/death.

Conclusions

In our study, few individuals normalized their CD4:CD8 ratios within the first few years of initiating modern cART. This large study showed no additional short-term predictive value of the CD4:CD8 ratio for clinical outcomes after accounting for other risk factors including age and HIV RNA.

Trauma history and depression predict incomplete adherence to antiretroviral therapies in a low income country

Background

As antiretroviral therapy (ART) for HIV becomes increasingly available in low and middle income countries (LMICs), understanding reasons for lack of adherence is critical to stemming the tide of infections and improving health. Understanding the effect of psychosocial experiences and mental health symptomatology on ART adherence can help maximize the benefit of expanded ART programs by indicating types of services, which could be offered in combination with HIV care.

Methodology

The Coping with HIV/AIDS in Tanzania (CHAT) study is a longitudinal cohort study in the Kilimanjaro Region that included randomly selected HIV-infected (HIV+) participants from two local hospital-based HIV clinics and four free-standing voluntary HIV counselling and testing sites. Baseline data were collected in 2008 and 2009; this paper used data from 36 month follow-up interviews (N = 468). Regression analyses were used to predict factors associated with incomplete self-reported adherence to ART.

Results

Incomplete ART adherence was significantly more likely to be reported amongst participants who experienced a greater number of childhood traumatic events: sexual abuse prior to puberty and the death in childhood of an immediate family member not from suicide or homicide were significantly more likely in the non-adherent group and other negative childhood events trended toward being more likely. Those with incomplete adherence had higher depressive symptom severity and post-traumatic stress disorder (PTSD). In multivariable analyses, childhood trauma, depression, and financial sacrifice remained associated with incomplete adherence.

Discussion

This is the first study to examine the effect of childhood trauma, depression and PTSD on HIV medication adherence in a low income country facing a significant burden of HIV. Allocating spending on HIV/AIDS toward integrating mental health services with HIV care is essential to the creation of systems that enhance medication adherence and maximize the potential of expanded antiretroviral access to improve health and reduce new infections.

The patient-provider relationship as experienced by a diverse sample of highly adherent HIV-infected people

Qualitative interviews with 23 HIV-infected people who self-reported high-level adherence to antiretroviral therapy were used to examine the process by which they came to accept their HIV infection and engage in high-level adherence behaviors. A major theme that emerged during data analysis was the importance of the patient-provider relationship. The quality of the relationship between patient and provider emerged as an important component of working through early struggles with diagnosis and the on-going struggles of living with a chronic illness. A variety of factors impacting the patient-provider relationship emerged as subthemes. What can be taken from this study is the importance of the patient-provider relationship in the effective self-management of HIV infection. Additionally, several specific behaviors can enhance the patient-provider relationship and help assure movement toward patient acceptance of the illness and engagement in high-level adherence behaviors.

Injection drug use and HIV antiretroviral therapy discontinuation in a Canadian setting

We investigated whether drug-related behaviors predicted antiretroviral therapy (ART) discontinuation among a cohort of injection drug users (IDU) in a Canadian setting. Cox regression analyses were used to investigate the impact of drug use patterns on rates of ART discontinuation among a sample of HIV-positive IDU in Vancouver, Canada between May 1996 and April 2008. In total, 408 HIV-positive IDU initiated ART during the study period, among whom 257 (63.0%) discontinued ART at least once. Rates of ART discontinuation were not significantly elevated among those who reported ongoing injection of heroin, cocaine, or other illicit drugs in comparison to those who reported not injecting drugs. However, public drug use was significantly predictive of ART discontinuation. Our findings may contribute to a reconsideration of the role of active drug use in determining retention in ART programs among IDU.

Evaluation of the single-item self-rating adherence scale for use in routine clinical care of people living with HIV

The self-rating scale item (SRSI) is a single-item self-report adherence measure that uses adjectives in a 5-point Likert scale, from "very poor" to "excellent," to describe medication adherence over the past 4 weeks. This study investigated the SRSI in 2,399 HIV-infected patients in routine care at two outpatient primary HIV clinics. Correlations between the SRSI and four commonly used adherence items ranged from 0.37 to 0.64. Correlations of adherence barriers, such as depression and substance use, were comparable across all adherence items. General estimating equations suggested the SRSI is as good as or better than other adherence items (p's <0.001 vs. <0.001-0.99) at predicting adherence-related clinical outcomes, such as HIV viral load and CD4(+) cell count. These results and the SRSI's low patient burden suggest its routine use could be helpful for assessing adherence in clinical care and should be more widespread, particularly where more complex instruments may be impractical.

Differences between self-reported and electronically monitored adherence among patients receiving antiretroviral therapy in a resource-limited setting

BACKGROUND

Measurement of adherence to antiretroviral therapy (ART) by patient self-report is common in resource-limited settings but widely believed to overstate actual adherence. The extent to which these measures overstate adherence has not been examined among a large patient population.

METHODS

HIV-infected adult patients in Kenya who initiated ART within the past 3 months were followed for 6 months. Adherence was measured by participants' self-reports of doses missed in the past 7 days during monthly clinic visits and by continuous Medication Event Monitoring System (MEMS) in participants' pill bottles. Seven-day self-reported adherence was compared to 7-day MEMS adherence, 30-day MEMS adherence, and adherence more than 90% during each of the first 6 months.

RESULTS

Self-reported and MEMS adherence measures were linked for 669 participants. Mean 7-day self-reported adherence was 98.7% and mean 7-day MEMS adherence was 86.0%, a difference of 12.7% (P < 0.01). The difference between the two adherence measures increased over time due to a decline in 7-day MEMS adherence. However, patients with lower MEMS adherence were in fact more likely to self-report missed doses and the difference between self-reported and MEMS adherence was similar for each number of self-reported missed doses. When analysis was limited to patients who reported rarely or never removing multiple doses at the same time, mean difference was 10.5% (P < 0.01).

CONCLUSION

There is a sizable and significant difference between self-reported and MEMS adherence. However, a strong relationship between the measures suggests that self-reported adherence is informative for clinical monitoring and program evaluation.

Immune reconstitution kinetics as an early predictor for mortality using various hematopoietic stem cell sources in children

The severity of complications of allogeneic hematopoietic stem cell transplantation (HSCT) is governed mainly by the status of immune reconstitution. In this study, we investigated differences in immune reconstitution with different cell sources and the association between the kinetics of immune reconstitution and mortality. Immunophenotyping was performed every 2 weeks in children who had undergone HSCT between 2004 and 2008 at University Medical Center Utrecht. Lymphocyte reconstitution in the first 90 days after HSCT was studied in relation to mortality in 3 HSCT groups: matched sibling bone marrow (BM) recipients (35 patients), unrelated BM recipients (32 patients), and unrelated cord blood recipients (36 patients). The median age of recipients was 5.9 years (range, 0.1-21 years). The nature and speed of T cell, B cell, and natural killer (NK) cell reconstitution were highly dependent on the cell source. In the first 90 days after HSCT, faster B cell and NK cell reconstitution and delayed T cell reconstitution were shown in unrelated cord blood recipients compared with matched sibling BM and unrelated BM recipients. Of the lymphocyte subsets investigated, a large number of NK cells and a more rapid CD4(+) immune reconstitution over time, resulting in sustained higher CD4(+) counts, were the only predictors of a lower mortality risk in all cell sources. The final model showed that during the first 90 days, patients with an area under the CD4(+) cell receiver- operating curve of >4,300 cells/day and no peak in CD4(+) cell counts had the highest likelihood of survival (hazard ratio for mortality, 0.2; 95% confidence interval, 0.06-0.5). Our data indicate that CD4(+) kinetics may be used to identify patients at greatest risk for mortality early after HSCT.

Evaluation of the effectiveness of an outreach clinical mentoring programme in support of paediatric HIV care scale-up in Botswana

Clinical mentoring by providers skilled in HIV management has been identified as a cornerstone of scaling-up antiretroviral treatment in Africa, particularly in settings where expertise is limited. However, little data exist on its effectiveness and impact on improving the quality-of-care and clinical outcomes, especially for HIV-infected children. Since 2008, the Botswana-Baylor Children's Clinical Centre of Excellence (COE) has operated an outreach mentoring programme at clinical sites around Botswana. This study is a retrospective review of 374 paediatric charts at four outreach mentoring sites (Mochudi, Phutadikobo, Molepolole and Thamaga) evaluating the effectiveness of the programme as reflected in a number of clinically-relevant areas. Charts from one visit prior to initiation of mentoring and from one visit after approximately one year of mentoring were assessed for statistically-significant differences (p<0.05) in the documentation of clinically-relevant indicators. Mochudi showed notable improvements in all indicators analysed, with particular improvements in documentation of pill count, viral load (VL) results, correct laboratory monitoring and correct antiretroviral therapy (ART) dosing (p<0.0001, p<0.0001, p<0.0001 and p<0.0001, respectively). Broad and substantial improvements were also seen in Molepolole, with the most improvement in disclosure documentation of all four sites. At Thamaga, improvements were restricted to CD4 documentation (p<0.001), recent VL and documented pill count (p<0.05 and p<0.05, respectively). Phuthadikobo showed the least amount of improvement across indicators, with only VL documentation and correct ART dosing showing statistically-significant improvements (p<0.05 and p<0.0001, respectively). These findings suggest that clinical mentoring may assist improvements in a number of important areas, including ART dosing and monitoring; adherence assessment and assurance; and disclosure. Clinical mentoring may be a valuable tool in scale-up of quality paediatric HIV care-and-treatment outside specialised centres. Further study will help refine approaches to clinical mentoring, including assuring mentoring translates into improved clinical outcomes for HIV-infected children.

Predicting trends in HIV-1 sexual transmission in sub-Saharan Africa through the Drug Resource Enhancement Against AIDS and Malnutrition model: antiretrovirals for 5 reduction of population infectivity, incidence and prevalence at the district level

BACKGROUND

The use of antiretrovirals to reduce the incidence of human immunodeficiency virus (HIV) infection has been evaluated in mathematical models as potential strategies for curtailing the epidemic. Cohort data from the Drug Resource Enhancement Against AIDS and Malnutrition (DREAM) Program was used to generate a realistic model for the HIV epidemic in sub-Saharan Africa.

METHODS

Two combined stochastic models were developed: patient and epidemic models. Models were combined using virus load as a parameter of infectivity. DREAM data that assessed patient care in Mozambique and Malawi were used to generate measures of infectivity, survival, and adherence. The Markov chain prediction model was used for the analysis of disease progression in treated and untreated patients. A partnership model was used to assess the probability that an infected individual would transmit HIV.

RESULTS

Data from 26565 patients followed up from January 2002 through July 2009 were analyzed with the model; 63% of patients were female, the median age was 35 years, and the median observation time was 25 months. In the model, a 5-fold reduction in infectivity (from 1.6% to 0.3%) occurred within 3 years when triple ART was used. The annual incidence of HIV infection declined from 7% to 2% in 2 years, and the prevalence was halved, from 12% to 6%, in 11 years. Mortality in HIV-infected individuals declined by 50% in 5 years. A cost analysis demonstrated economic efficiency after 4 years.

CONCLUSIONS

Our model, based on patient data, supports the hypothesis that treatment of all infected individuals translates into a drastic reduction in incident HIV infections. A targeted implementation strategy with massive population coverage is feasible in sub-Saharan Africa.

Physician experience and rates of plasma HIV-1 RNA suppression among illicit drug users: an observational study

Background

Despite the availability of antiretroviral therapy (ART), suboptimal treatment outcomes have been observed among HIV-seropositive illicit drug users. As there is an urgent need to improve responses to antiretroviral therapy among this population, we undertook this study to evaluate the role of physician experience on rates of plasma HIV-1 RNA suppression following initiation of ART.

Methods

Using data from a community-recruited cohort of HIV-positive illicit drug users, we used Cox proportional hazards regression to model the time to plasma viral HIV RNA < 500 copies/mL among antiretroviral-naïve subjects initiating ART. Physician experience was defined as a continuous variable measured per 100 HIV-infected patients previously enrolled in the province-wide HIV treatment registry by that physician at the time a patient was enrolled.

Results

Between May 1996 and December 2008, 267 individuals initiated ART among whom 227 (85%) achieved a plasma HIV RNA < 500 copies/mL during the study period. In a multivariate analysis, greater physician experience was independently associated with higher rates of plasma HIV RNA suppression (adjusted hazard ratio [AHR] = 1.17, 95% confidence interval [CI]: 1.03-1.34) after adjustment for adherence to ART. Other factors associated with viral suppression included engagement in methadone maintenance therapy (AHR = 1.61, 95% CI: 1.23-2.09), ≥ 95% adherence to ART (AHR = 2.42, 95% CI: 1.80-3.26), baseline CD4 count (AHR = 0.89, 95% CI: 0.83-0.96) and baseline plasma HIV-1 RNA (AHR = 0.65, 95% CI: 0.53-0.81).

Conclusions

In this setting of universal HIV/AIDS care, illicit drug users with more experienced physicians exhibited faster rates of plasma viral load suppression. These findings argue for specialized services to help optimize HIV treatment outcomes among this population.

Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting

Despite the advent of effective antiretroviral therapy (ART), HIV-seropositive injection drug users (IDU) continue to suffer from elevated levels of morbidity and mortality. Evidence is needed to identify social- and structural-level barriers to effective ART. We investigated the impact of homelessness on plasma HIV RNA response among illicit drug users initiating ART in a setting with free and universal access to HIV care. We accessed data from a long-running prospective cohort of community-recruited IDU linked to comprehensive HIV clinical monitoring and ART dispensation records. Using Cox proportional hazards with recurrent events modeling, we estimated the independent effect of homelessness on time to plasma HIV viral load suppression. Between May 1996 and September 2009, 247 antiretroviral naïve individuals initiated ART and contributed 1755 person-years of follow-up. Among these individuals, the incidence density of plasma HIV RNA suppression less than 500 copies/mm(3) was 56.7 (95% confidence interval [CI]: 46.9-66.0) per 100 person-years. In unadjusted analyses, homelessness was strongly associated with lower rates suppression (hazard ratio = 0.56, 95% CI: 0.40-0.78, p = 0.001), however, after adjustment for adherence this association was no longer significant (adjusted hazard ratio = 0.79, 95% CI: 0.56-1.11, p = 0.177). Homelessness poses a significant structural barrier to effective HIV treatment. However, since this relationship appears to be mediated by lower levels of ART adherence, interventions to improve adherence among members of this vulnerable population are needed.

Normal Range of CD4 Cell Counts and Temporal Changes in Two HIVNegative Malawian Populations

Longitudinal studies were carried out to determine trends in CD4 cell counts over a four year period in healthy HIV-negative adults in a rural (134 individuals) and an urban (80 individuals) site in Malawi, using TruCountTM and FACScountTM platforms. At baseline, median counts and 95% ranges were 890 (359-1954) cells per microlitre (μl) and 725 (114-1074) cells/μl respectively. 1.5% and 6% respectively had baseline counts below 350 cells/μl and 1.5% and 2.5% below 250 cells per μl. Transient dips to below 250 cells/μl were observed in seven individuals, with two individuals having persistently low CD4 counts over more than one year. Women and individuals from the urban site were significantly more likely to have "low CD4 count" (< 500 cells/μl) even when adjusted for other factors. In common with neighbouring countries, HIV-negative populations in Malawi have CD4 counts considerably lower than European reference ranges, and healthy individuals may have persistently or transiently low counts. Within Malawi, ranges differ according to the selected population.

Social factors affecting ART adherence in rural settings in Zambia

The purpose of this study was to assess the factors that influence ART adherence arising in rural settings in Zambia. A survey was conducted with face-to-face interviews using a semi-structured questionnaire and written informed consent was obtained at ART sites in Mumbwa District in rural Zambia. The questionnaire included items such as the socio-demographic characteristics of respondents, support for adherence, ways to remember when to take ARVs at scheduled times, and the current status of adherence. Valid responses were obtained from 518 research participants. The mean age of the respondents was 38.3 years and the average treatment period was 12.5 months. More than half of the respondents (51%) were farmers, about half (49%) did not own a watch, and 10% of them used the position of the sun to remember when to take ARVs. Sixteen percent of respondents experienced fear of stigma resulting from taking ARVs at work or home, and 10% felt pressured to share ARVs with someone. Eighty-eight percent of the participants reported that they had never missed ARVs in the past four days. Multivariable logistic regression analysis identified age (38 years old or less, odds ratio (OR) = 2.5, 95% confidence interval (CI): 1.3–4.8, p = 0.005), “remembering when to take ARVs based on the position of the sun” (OR = 3.3, 95% CI: 1.3–8.8, p = 0.016), and “feeling pressured to share ARVs with someone” (OR = 4.4, 95% CI: 1.6–12.0, p = 0.004) as independent factors for low adherence. As ART services expand to rural areas, program implementers should pay more attention to more specific factors arising in rural settings since they may differ from those in urban settings.

Cost-effectiveness of early treatment with first-line NNRTI-based HAART regimens in the UK, 1996-2006

Aim

Calculate time to first-line treatment failure, annual cost and cost-effectiveness of NNRTI versus PIboosted first-line HAART regimens in the UK, 1996–2006.

Background

Population costs for HIV services are increasing in the UK and interventions need to be effective and efficient to reduce or stabilize costs. 2NRTIs + NNRTI regimens are cost-effective regimens for first-line HAART, but these regimens have not been compared with first-line PI_boosted regimens.

Methods

Times to first-line treatment failure and annual costs were calculated for first-line HAART regimens by CD4 count when starting HAART (2006 UK prices). Cost-effectiveness of 2NRTIs+NNRTI versus 2NRTIs+PI_boosted regimens was calculated for four CD4 strata.

Results

55% of 5,541 people living with HIV (PLHIV) started HAART with CD4 count ≤200 cells/mm3, many of whom were Black Africans. Annual treatment cost decreased as CD4 count increased; most marked differences were observed between starting HAART with CD4 ≤200 cells/mm3 compared with CD4 count >200 cells/mm3. 2NRTI+PI_boosted and 2NRTI+NNRTI regimens were the most effective regimens across the four CD4 strata; 2NRTI+NNRTI was cost-saving or cost-effective compared with 2NRTI + PI_boosted regimens.

Conclusion

To ensure more effective and efficient provision of HIV services, 2NRTI+NNRTI should be started as first-line HAART regimen at CD4 counts ≤350 cell/mm3, unless specific contra-indications exist. This will increase the number of PLHIV receiving HAART and will initially increase population costs of providing HIV services. However, starting PLHIV earlier on cost-effective regimens will maintain them in better health and use fewer health or social services, thereby generating fewer treatment and care costs, enabling them to remain socially and economically active members of society. This does raise a number of ethical issues, which will have to be acknowledged and addressed, especially in countries with limited resources.

Livelihood security and adherence to antiretroviral therapy in low and middle income settings: a systematic review

INTRODUCTION

We sought to examine the association between livelihood security and adherence to antiretroviral therapy (ARVs) in low- and middle-income countries (LIMC).

METHODS

Performing a systematic review, we searched, independently and in duplicate, 7 electronic databases and 2 conference websites for quantitative surveys that examined the association between indicators of livelihood security and adherence to ARVs in LIMC between 2000-2010. Criteria for relevance were applied to complete papers (quantitative study with estimates of associations) and quality assessment was conducted on those deemed relevant. We performed three regressions to measure the association between each type of livelihood and adherence.

RESULTS

Twenty original studies and 6 conference abstracts were included, the majority from Africa (n = 16). Seventeen studies and 3 conference abstracts were cross-sectional and 3 studies and 3 abstracts were prospective clinical cohort studies, with considerable variation in quality for studies of each design type. Among the diverse populations represented, we observed considerable variation in associations between measurements of livelihood indicators and increasingly accepted adherence measures, irrespective of study design or quality. A financial capital indicator, financial constraints/payment for ARV medication, was more commonly associated with non-adherence (3/5 studies). A human capital indicator, educational level, was most commonly associated with adherence (11/20 studies).

DISCUSSION

Additional better quality research examining livelihood security is required to inform provision of optimal supports for adherence and mitigation of the impacts of HIV/AIDS.

Density of healthcare providers and patient outcomes: evidence from a nationally representative multi-site HIV treatment program in Uganda

OBJECTIVE

We examined the association between density of healthcare providers and patient outcomes using a large nationally representative cohort of patients receiving combination antiretroviral therapy (cART) in Uganda.

DESIGN

We obtained data from The AIDS Support Organization (TASO) in Uganda. Patients 18 years of age and older who initiated cART at TASO between 2004 and 2008 contributed to this analysis. The number of healthcare providers per 100 patients, the number of patients lost to follow-up per 100 person years and number of deaths per 100 person years were calculated. Spearman correlation was used to identify associations between patient loss to follow-up and mortality with the healthcare provider-patient ratios.

RESULTS

We found no significant associations between the number of patients lost to follow-up and physicians (p = 0.45), nurses (p = 0.93), clinical officers (p = 0.80), field officers (p = 0.56), and healthcare providers overall (p = 0.83). Similarly, no significant associations were observed between mortality and physicians (p = 0.65), nurses (p = 0.49), clinical officers (p = 0.73), field officers (p = 0.78), and healthcare providers overall (p = 0.73).

CONCLUSIONS

Patient outcomes, as measured by loss to follow-up and mortality, were not significantly associated with the number of doctors, nurses, clinical officers, field officers, or healthcare providers overall. This may suggest that that other factors, such as the presence of volunteer patient supporters or broader political or socioeconomic influences, may be more closely associated with outcomes of care among patients on cART in Uganda.

Physician's manual reporting underestimates mortality: evidence from a population-based HIV/AIDS treatment program

BACKGROUND

In clinical and cohort research, mortality estimates are often derived from manual reports generated by physicians or electronic reports from vital event registries. We examined the rate of underreporting of deaths by manual methods as compared with electronic reports from a vital event registry.

METHODS

The retrospective analyses included deaths among participants registered in an observational cohort who initiated highly-active antiretroviral therapy (HAART) between August 1, 1996 and June 30, 2006. Deaths were routinely reported manually by physicians and through annual electronic record linkages with a population-based vital event registry. Multivariate logistic regression was carried out to assess independent predictors of death reporting by manual methods.

RESULTS

Of the 3,116 individuals included in the analyses, 622 (20.0%) died during follow-up. Manual reporting by physicians only identified 377 (60.6%), while electronic linkages captured 598 (96.1%) of all deaths. Multivariate analysis indicated that deaths among individuals with lower CD4 cell count, higher HIV plasma viral load, a history of injection drug use, and under the care of an HIV-experienced physicians were more likely to be reported manually. Furthermore, non-accidental deaths were more likely to be reported manually, and manual reporting of deaths increased over time.

CONCLUSIONS

Relying only on manual reports to ascertain deaths significantly underestimates the total number of deaths in the population. This can generate important biases when evaluating the impact of therapeutic interventions in the populational setting.

Specific eradication of HIV-1 from infected cultured cells

A correlation between increase in the integration of Human Immunodeficiency virus-1 (HIV-1) cDNA and cell death was previously established. Here we show that combination of peptides that stimulate integration together with the protease inhibitor Ro 31-8959 caused apoptotic cell death of HIV infected cells with total extermination of the virus. This combination did not have any effect on non-infected cells. Thus it appears that cell death is promoted only in the infected cells. It is our view that the results described in this work suggest a novel approach to specifically promote death of HIV-1 infected cells and thus may eventually be developed into a new and general anti-viral therapy.

Expanding access to HAART: a cost-effective approach for treating and preventing HIV

OBJECTIVE

HIV continues to present a substantial global health burden. Given the high direct medical costs associated with the disease, prevention of new transmission is an important element in limiting economic burden. In addition to providing therapeutic benefit, treatment with HAART has potential to prevent transmission of HIV. The objective in this study was to perform an economic evaluation of the incremental net benefit associated with an intervention to expand treatment with HAART in British Columbia, Canada.

DESIGN

A mathematical model describing transmission of HIV, integrated with a microsimulation model describing the clinical and economic course of HIV.

METHODS

The primary outcome was the incremental net benefit of expanding treatment with HAART from 50 to 75% of clinically eligible individuals in British Columbia, assuming a willingness-to-pay threshold of US$ 50,000 per quality-adjusted life year. Direct medical costs included were antiretroviral and nonantiretroviral medications, hospitalizations, physician visits, and laboratory tests. The mathematical and microsimulation models were based on patient characteristics observed in British Columbia. Longitudinal data described health services utilization, clinical progression, and survival for all individuals receiving treatment for HIV in British Columbia.

RESULTS

Over 30 years, the HAART expansion scenario was associated with a net benefit of US$ 900 million (95% confidence interval US$ 493 million to 1.45 billion).

CONCLUSION

Increasing the HAART treatment rate from 50 to 75% of clinically eligible individuals in British Columbia appears to be a cost-effective strategy based on this model. These cost-effectiveness results are consistent with public health objectives: all individuals who are eligible for an established life-saving treatment should receive it.

Differential survival benefit of universal HAART access in Brazil: a nation-wide comparison of injecting drug users versus men who have sex with men

OBJECTIVE

Brazil accounts for approximately 70% of injection drug users (IDUs) receiving highly active antiretroviral therapy (HAART) in low-income/middle-income countries. We evaluated the impact of HAART availability/access on AIDS-related mortality among IDUs versus men who have sex with men (MSM).

DESIGN

Nation-wide analysis on Brazilian IDU and MSM diagnosed with AIDS in 2000-2006.

METHODS

Four national information systems were linked, and Cox regression was used to assess impact of HAART availability/access on differential AIDS-related mortality.

RESULTS

Among 28,426 patients, 6777 died during 87,792 person-years of follow-up. Compared with MSM, IDU were significantly less likely to be receiving HAART, to have ever had determinations for CD4 or viral load. After controlling for confounders, IDU had a significantly higher risk of death (adjusted hazard ratio: 1.94; 95% confidence interval: 1.84 to 2.05). Among the subset that had at least 1 CD4 and viral load determination, higher risk of death among IDU persisted (hazard ratio: 1.82; 95% confidence interval: 1.58 to 2.11). Nonwhite ethnicity significantly increased this risk, whereas prompt HAART uptake after AIDS diagnosis reduced the risk of death. After controlling for spatially correlated survival data, AIDS-related mortality remained higher in IDU than in MSM.

CONCLUSIONS

Despite free/universal HAART access, differential AIDS-related mortality exists in Brazil. Efforts are needed to identify and eliminate these health disparities.

Piloting a peer-driven intervention model to increase access and adherence to antiretroviral therapy and HIV care among street-entrenched HIV-positive women in Vancouver

A peer-driven intervention (PDI) was developed to support uptake and adherence to highly active antiretroviral therapy (HAART) among women sex workers who use illicit substances in Vancouver, because uptake and adherence continues to be suboptimal. Trends of adherence were examined among women in this program by (1) exposure to the intervention and (2) risk behaviors including drug use and unstable housing. Between January 2007 and January 2008, 20 HIV-positive women were enrolled into the PDI on a rolling basis. PDI participation included weekly peer support meetings, a health advocate (buddy) system, peer outreach service, and onsite nursing care. Adherence was measured directly with pharmacy records (PR) and indirectly with self-report and viral load (VL) outcomes. Participants attended an average of 50 (21-70) PDI meetings. Overall self-reported adherence was high (92%) and most women (11) reported increased adherence from the first to the last 13 PDI meetings attended (average increase = 18%). The number of viral load tests <or=50 copies/mL increased by 40% from the pre-PDI period (1 year before enrollment), to the PDI period (duration enrolled). PR adherence and improvements in VL outcomes were higher among participants with greater housing instability and frequency of injecting/smoking drugs. Despite a very difficult environment to provide HIV care, there is evidence to suggest that the PDI may have had a positive impact on adherence outcomes. Although this would not predict long-term treatment success, the PDI approach to HIV treatment support is a promising program for women who might otherwise be excluded from treatment altogether.

Mortality is influenced by locality in a major HIV/AIDS epidemic

OBJECTIVES

The aim of the study was to compare the risks of death among HIV-infected patients on highly active antiretroviral therapy (HAART) in two proximate, yet distinct neighbourhoods: a neighbourhood with a high concentration of gay men, and a neighbourhood with a high concentration of injecting drug users.

METHODS

We compared the clinical and socioeconomic characteristics of HIV-infected patients from the two neighbourhoods entering the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program from 1 September 1997 to 30 November 2005, using contingency table statistics. Cox survival models and Kaplan-Meier methods were used to estimate the cumulative mortality rates.

RESULTS

We found significant differences between patients from the two neighbourhoods for all socioeconomic variables. Patients in the neighbourhood with a high concentration of injecting drug users were more likely to be female, have a history of injecting drug use, have a less HIV-experienced physician and be less adherent. Patients in the neighbourhood with a high concentration of gay men were more likely to have AIDS. Mortality was significantly higher for patients in the neighbourhood with a high concentration of injecting drug users [hazard ratio (HR) 3.01; 95% confidence interval (CI) 1.73, 5.24].

CONCLUSIONS

A threefold increase was observed in the risk of death among HIV-infected individuals on HAART in the neighbourhood with a high concentration of injecting drug users relative to the neighbourhood with a high concentration of gay men. The implications of this study should be assessed in similar HIV/AIDS epicentres.

Spiritual and mind-body beliefs as barriers and motivators to HIV-treatment decision-making and medication adherence? A qualitative study

We examined spiritual/mind-body beliefs related to treatment decision-making and adherence in 79 HIV-positive people (35% female, 41% African American, 22% Latino, 24% White) who had been offered antiretroviral treatment by their physicians. Interviews (performed in 2003) identified spiritual/mind-body beliefs; the Adult AIDS Clinical Trials Group (ACTG) questionnaire assessed adherence and symptoms/side effects. Decision-making was influenced by health-related spiritual beliefs (e.g., calling on God/Higher Power for help/protection, God/Higher Power controls health) and mind-body beliefs (e.g., mind controls body, body tells when medication is needed). Participants believing God/Higher Power controls health were 4.75 times more likely to refuse, and participants with mind-body beliefs related to decision-making were 5.31 times more likely to defer antiretrovirals than those without those beliefs. Participants believing spirituality helps coping with side effects reported significantly better adherence and fewer symptoms/side effects. Fewer symptoms/side effects were significantly associated with the beliefs mind controls body, calling on God/Higher Power for help/protection, and spirituality helps adherence. Spiritual/mind-body beliefs as barriers or motivators to taking or adhering to treatment are important, since they may affect survival and quality of life of HIV-positive people.

Effect of incentives for medication adherence on health care use and costs in methadone patients with HIV

BACKGROUND

The potential benefits of anti-retroviral therapy for HIV is not fully realized because of difficulties in adherence with demanding treatment regimens, especially among injection drug users.

METHODS

HIV-positive methadone patients who were less than 80% adherent with their primary anti-retroviral therapy were randomized to a trial of incentives for on-time adherence. Adherence was rewarded with an escalating scale of vouchers redeemable for goods. Both intervention and control group visited a medication coach twice a month. The cost of the intervention was determined by micro-costing. Other costs were obtained from administrative data and patient report of out-of-system care.

RESULTS

During the 12-week intervention period, the incremental direct cost of the intervention, including treatment vouchers, was $942. The voucher group incurred $2572 in anti-retroviral drug cost, significantly more than the $1973 incurred by the comparison group (p<.01). Adherence, as measured by on-time openings of an electronically monitored vial, was 78% in the intervention group and 56% in the control group.

CONCLUSIONS

The incremental direct cost of voucher incentives was $292 per month. If the observed increase in adherence from voucher incentives can be sustained in the long-term, the literature suggests that disease progression will be slowed. Further research is needed to evaluate if the improvement can be sustained or achieved at lower cost. Mitigation of treatment resistance and reduction in HIV transmission are additional benefits that favor adoption.

Incomplete reconstitution of T cell subsets on combination antiretroviral therapy in the AIDS Clinical Trials Group protocol 384

BACKGROUND

Initiation of combination antiretroviral therapy (ART) results in higher total CD4 cell counts, a surrogate for immune reconstitution. Whether the baseline CD4 cell count affects reconstitution of immune cell subsets has not been well characterized.

METHODS

Using data from 978 patients (621 with comprehensive immunological assessments) from the AIDS [Acquired Immunodeficiency Syndrome] Clinical Trials Group protocol 384, a randomized trial of initial ART, we compared reconstitution of CD4(+), CD4(+) naive and memory, CD4(+) activation, CD8(+), CD8(+) activation, B, and natural killer cells among patients in different baseline CD4(+) strata. Reference ranges for T cell populations in control patients negative for human immunodeficiency virus (HIV) infection were calculated using data from AIDS Clinical Trials Group protocol A5113.

RESULTS

Patients in the lower baseline CD4(+) strata did not achieve total CD4(+) cell counts similar to those of patients in the higher strata during 144 weeks of ART, although CD4(+) cell count increases were similar. Ratios of CD4(+) naive-memory cell counts and CD4(+):CD8(+) cell counts remained significantly reduced in patients with lower baseline CD4(+) cell counts (

CONCLUSIONS

After nearly 3 years of ART, T cell subsets in patients with baseline CD4(+) cell counts >350 cells/mm(3) achieved or approached the reference range those of control individuals without HIV infection. In contrast, patients who began ART with Collapse

Key Words Collapse

MESH Headings

• Acquired Immunodeficiency Syndrome/drug therapy
• Acquired Immunodeficiency Syndrome/immunology
• Adult
• Antiretroviral Therapy, Highly Active
• B-Lymphocytes/immunology
• CD4 Lymphocyte Count
• CD4-CD8 Ratio
• Female
• Humans
• Killer Cells, Natural/immunology
• Male
• Middle Aged
• T-Lymphocyte Subsets/immunology

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Grants

• AI25879 NIAID NIH HHS
• AI066992 NIAID NIH HHS
• K01 AI062435-02 NIAID NIH HHS
• R01 AI066992 NIAID NIH HHS
• U01 AI038858 NIAID NIH HHS
• AI27659 NIAID NIH HHS
• AI38855 NIAID NIH HHS
• IP30AI060354 NIAID NIH HHS
• U01 AI025879 NIAID NIH HHS
• K01 AI062435 NIAID NIH HHS
• AI27666 NIAID NIH HHS
• AI38858 NIAID NIH HHS
• K01 AI062435-04 NIAID NIH HHS
• U01 AI038855 NIAID NIH HHS
• K01 AI062435-03 NIAID NIH HHS
• K01AI062435 NIAID NIH HHS
• U01 AI027666 NIAID NIH HHS
• K01 AI062435-01A1 NIAID NIH HHS
• U01 AI027659 NIAID NIH HHS
• P30 AI060354 NIAID NIH HHS

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Affiliation(s)

Gregory K Robbins Infectious Diseases Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
John G Spritzler
Ellen S Chan
David M Asmuth
Rajesh T Gandhi
Benigno A Rodriguez
Gail Skowron
Paul R Skolnik
Robert W Shafer
Richard B Pollard

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Impact of baseline health and community support on antiretroviral treatment outcomes in HIV patients in South Africa

The importance of community support when scaling-up antiretroviral treatment (ART) in resource-limited settings is poorly understood. We assessed the impact of baseline health, patient characteristics and community support on ART outcomes at 6 and 12 months in a representative sample of 268 patients enrolled in the Free State public sector ART program (South Africa). Delayed ART initiation reduced ART response, whereas support from treatment buddies, community health workers and support groups significantly improved treatment outcomes.