Virologic and Immunologic Response to Highly Active Antiretroviral Therapy in Indigenous and Nonindigenous HIV-1???Infected Patients in The Netherlands

Self-reported adherence and pharmacy refill adherence are both predictive for an undetectable viral load among HIV-infected migrants receiving cART

HIV-infected migrants were shown to have poorer treatment outcomes than Dutch HIV-infected patients, often due to worse treatment adherence. Self-reported adherence would be an easy way to monitor adherence, but its validity relative to pharmacy refill adherence has not been extensively evaluated in migrants. All HIV-infected migrants older than 18 years and in care at the two Rotterdam HIV-treatment centers were eligible. Refill data with leftover medication (PRL) (residual pill count) were obtained from their pharmacies up to 15 months prior to inclusion. Self-reported adherence to combination Antiretroviral Therapy was assessed by four questions about adherence at inclusion. Additionally, risk factors for pharmacy refill non-adherence were examined. In total, 299 HIV-infected migrants were included. Viral load (VL) was detectable in 11% of the patients. Specificity of PRL was 53% for patients with an adherence of 100% and decreased with lower cut-off values. Sensitivity and negative predictive value (NPV) were 68% and 15% and increased with lower cut-off values. Positive predictive value (PPV) was around 93% for all cut-off values. Using the self-reported questions, 139 patients (47%) reported to be adherent. Sensitivity was 49% and specificity was 72%. PPV and NPV were 95% and 13%. No risk factors for pharmacy refill non-adherence were found in multivariable analyses. Both PRL and self-reported adherence, can predict undetectable VL in HIV-infected migrants. PPV and NPV are similar for both methods. This study shows that using four self-reported items is sufficient to predict adherence which is crucial for optimal clinical outcome in HIV-infected migrants.

Effect of Legal Status on the Early Treatment Outcomes of Migrants Beginning Combined Antiretroviral Therapy at an Outpatient Clinic in Milan, Italy

OBJECTIVE

In a setting of free access to HIV care, we compared the early treatment outcomes of HIV-infected undocumented migrants (UMs), documented migrants (DMs), and Italian subjects.

METHODS

The clinical data of 640 Italians and 245 migrants who started combined antiretroviral therapy (cART) at an HIV clinic in Milan, Italy, were reviewed. The migrants were mainly Latin Americans (83 DMs and 56 UMs) or sub-Saharan Africans (52 DMs and 11 UMs), but a minority were of other origin (33 DMs and 10 UMs). Retention in follow-up and HIV suppression were compared between UMs, DMs, and natives 12 months ± 90 days after start of cART.

RESULTS

There were no significant between-group differences in the stage of HIV infection at the start of cART or the type of regimen received. The Latin American DMs and UMs included a higher proportion of transgender women than the other ethnic groups (P < 0.001). The UMs were less frequently followed up after 12 months than the DMs and natives (P = 0.004) and were more frequently permanently lost to follow-up (P < 0.001). UM status was an independent predictor of lost to follow-up (adjusted odds ratio 8.05, P < 0.001). The DMs and UMs were less frequently HIV suppressed after 12 months than the natives (78% and 80.7% vs 90.5%, P = 0.001), and Latin American migrants were significantly less likely to be virologically suppressed than the natives (adjusted odds ratio 0.30, P = 0.001).

CONCLUSIONS

Despite their free access to cART, subgroups of migrants facing multiple levels of vulnerability still have difficulties in gaining optimal HIV care.

Sub-Saharan African migrants have slower initial CD4+ cell recovery after combined antiretroviral treatment initiation than French natives

OBJECTIVE

Poorer immunologic responses to combined antiretroviral treatment (cART) have been reported among sub-Saharan African (SSA) migrants than among native Europeans. We studied whether differences in CD4 cell recovery between French natives and SSA migrants starting first-line cART could be explained by differences in socioeconomic conditions, inflammatory marker levels, and other established determinants.

METHODS

We compared 319 French natives and 175 SSA migrants (ANRS-COPANA cohort). Clinical, biological, and socioeconomic data (education, employment, income, and cohabiting partnership) were recorded at regular visits. A piecewise linear mixed-effects model was used to analyze CD4 cell count kinetics on cART.

RESULTS

Compared with French natives, SSA migrants were more frequently women, younger, less educated, living in more adverse conditions, and had more frequent symptoms of depression. The rate of CD4 cell recovery during the first 4 months on cART was significantly slower in SSA migrants, despite a similar virologic response, but did not differ significantly thereafter. The mean CD4 cell count rose from 251 cells/μl at baseline to 508 cells/μl at 36 months in migrants, and from 308 to 623 cells/μl in natives (additional mean gain of 58 cells/μl in natives). The difference persisted after adjustment for clinical, updated socioeconomic, and living conditions (-0.40√CD4 cells/month, P = 0.04); 25-hydroxyvitamin D, monocyte chemoattractant protein-1 and soluble tumor necrosis factor receptor 1 (sTNFR1) levels were lower in SSA migrants, but only sTNFR1 contributed to the difference in CD4 slope.

CONCLUSION

Initial CD4 cell recovery on cART was slower among SSA migrants than among French natives. This difference was not explained by established clinical and biological determinants or by socioeconomic status.

Risk Factors for Non-Adherence to cART in Immigrants with HIV Living in the Netherlands: Results from the ROtterdam ADherence (ROAD) Project

In the Netherlands, immigrant people living with HIV (PLWH) have poorer psychological and treatment outcomes than Dutch PLWH. This cross-sectional field study examined risk factors for non-adherence to combination Antiretroviral Therapy (cART) among immigrant PLWH. First and second generation immigrant PLWH attending outpatient clinics at two HIV-treatment centers in Rotterdam were selected for this study. Socio-demographic and clinical characteristics for all eligible participants were collected from an existing database. Trained interviewers subsequently completed questionnaires together with consenting participants (n = 352) to gather additional data on socio-demographic characteristics, psychosocial variables, and self-reported adherence to cART. Univariable and multivariable logistic regression analyses were conducted among 301 participants who had used cART ≥6 months prior to inclusion. Independent risk factors for self-reported non-adherence were (I) not having attended formal education or only primary school (OR = 3.25; 95% CI: 1.28–8.26, versus University), (II) experiencing low levels of social support (OR = 2.56; 95% CI: 1.37–4.82), and (III) reporting low treatment adherence self-efficacy (OR = 2.99; 95% CI: 1.59–5.64). Additionally, HIV-RNA >50 copies/ml and internalized HIV-related stigma were marginally associated (P<0.10) with non-adherence (OR = 2.53; 95% CI: 0.91–7.06 and OR = 1.82; 95% CI: 0.97–3.43). The findings that low educational attainment, lack of social support, and low treatment adherence self-efficacy are associated with non-adherence point to the need for tailored supportive interventions. Establishing contact with peer immigrant PLWH who serve as role models might be a successful intervention for this specific population.

[HIV infection and immigration]

Migrants represent around one third of patients newly diagnosed with HIV in Spain and they constitute a population with higher vulnerability to its negative consequences due to the socio-cultural, economical, working, administrative and legal contexts. Migrants are diagnosed later, which worsens their individual prognosis and facilitates the maintenance of the HIV epidemic. In spite of the different barriers they experience to access healthcare in general, and HIV-related services in particular, access to antiretroviral treatment has been similar to that of the autochthonous population. However, benefits of treatment have been not, with women in general and men from Sub-Saharan Africa exhibiting the worse response to treatment. We need to proactively promote earlier diagnosis of HIV infection, the adoption of preventive measures to avoid new infections, and to deliver accessible, adapted and high-quality health-care.

Impact of HIV care facility characteristics on the cascade of care in HIV-infected patients in the Netherlands

OBJECTIVE

Successful treatment of people infected with HIV requires that patients are retained in HIV care, use combination antiretroviral therapy (cART) and ultimately reach and sustain viral suppression. Our aim was to identify health facility characteristics associated with these steps in the cascade of HIV care.

DESIGN

Retrospective cohort study.

METHODS

We included data from all adult HIV-1-infected patients who entered care in the Netherlands between 2007 and 2013 (N = 7120). Multivariate logistic regression was used to examine the associations between health facility characteristics and the outcomes 'currently in care', 'initiated cART', and 'viral suppression'.

RESULTS

The proportion of patients 'currently in care' was high in all 26 treatment centres. cART initiation was positively associated with the accreditation of the health facility [OR (odds ratio): 1.62; 95% CI (confidence interval): 1.18-2.23] and the performance of an internal audit in the preceding 3 years (OR: 1.36; 95% CI: 1.02-1.81). The odds of cART initiation were higher in middle-sized (OR: 2.00; 95% CI: 1.25-3.21) and large HIV treatment centres (OR: 1.80; 95% CI: 1.14-2.84) compared with small centres (<300 HIV-infected patients). Viral suppression was negatively associated with the presence of a social worker in the HIV treatment team (OR: 0.62; 95% CI: 0.43-0.91).

CONCLUSIONS

Our results confirm that appointing expert HIV treatment centres facilitates retention in care and that a minimum volume requirement may be desirable. Our findings suggest that quality assessment through accreditation and the measurement of performance benefits the delivery of HIV care.

Increased risk of virologic failure to the first antiretroviral regimen in HIV-infected migrants compared to natives: data from the ICONA cohort

Migrant and Italian HIV-infected patients (n = 5773) enrolled in the ICONA cohort in 2004-2014 were compared for disparities in access to an initial antiretroviral regimen and/or risk of virologic failure (VF), and determinants of failure were evaluated. Variables associated with initiating antiretroviral therapy (ART) were analysed. Primary endpoint was time to failure after at least 6 months of ART and was defined as: VF, first of two consecutive virus loads (VL) >200 copies/mL; treatment discontinuation (TD) for any reason; and treatment failure as confirmed VL >200 copies/mL or TD. A Poisson multivariable analysis was performed to control for confounders. Migrants presented significantly lower CD4 counts and more frequent AIDS events at baseline. When adjusting for baseline confounders, migrants presented a lower likelihood to begin ART (odds ratio 0.80, 95% confidence interval (CI) 0.67-0.95, p 0.012). After initiating ART, the incidence VF rate was 6.4 per 100 person-years (95% CI 4.8-8.5) in migrants and 2.7 in natives (95% CI 2.2-3.3). Multivariable analysis confirmed that migrants had a higher risk of VF (incidence rate ratio 1.90, 95% CI 1.25-2.91, p 0.003) and treatment failure (incidence rate ratio 1.16, 95% CI 1.01-1.33, p 0.031), with no differences for TD. Among migrants, variables associated with VF were age, unemployment and use of a boosted protease inhibitor-based regimen versus nonnucleoside reverse transcriptase inhibitors. Despite the use of more potent and safer drugs in the last 10 years, and even in a universal health care setting, migrants living with HIV still present barriers to initiating ART and an increased risk of VF compared to natives.

Country of birth does not influence long-term clinical, virologic, and immunological outcome of HIV-infected children living in the Netherlands: a cohort study comparing children born in the Netherlands with children born in Sub-Saharan Africa

BACKGROUND

Immigrant HIV-infected adults in industrialized countries show a poorer clinical and virologic outcome compared with native patients. We aimed to investigate potential differences in clinical, immunological, and virologic outcome in Dutch HIV-infected children born in the Netherlands (NL) versus born in Sub-Saharan Africa (SSA) in a national cohort analysis.

METHODS

We included all HIV-infected children registered between 1996 and 2013. Descriptive statistics, mixed-effects models, and Cox proportional hazard models were used to investigate differences between groups.

RESULTS

In total, 319 HIV-infected children were registered. The majority of these children were born in SSA (n = 148, 47%) or NL (n = 113, 36%) and most were black (n = 158, 61%). Children born in NL were diagnosed at a median age of 1.2 years and initiated combination antiretroviral therapy (cART) at a median age of 2.6 years, compared with 3.7 and 5.3 years, respectively, for children born in SSA (HIV diagnosis: P < 0.001; cART initiation: P < 0.001). Despite a lower initial CD4 T-cell Z-score in children born in SSA, their immunological reconstitution was similar to children from NL. Virologic suppression was achieved in the majority of all cART-treated children (NL: 96%, SSA: 94%). There was no difference in the occurrence or timing of virologic failure.

CONCLUSIONS

Most immigrant HIV-infected children living in NL were born in SSA. Children born in SSA were diagnosed and initiated cART at an older age than children born in NL. Despite initial differences in CD4 T-cell counts and HIV viral load, the long-term immunological and virologic response to cART was similar in both groups.

Use of efavirenz or atazanavir/ritonavir is associated with better clinical outcomes of HAART compared to other protease inhibitors: routine evidence from the Italian MASTER Cohort

Randomized trials and observational cohorts reported higher rates of virological suppression after highly active antiretroviral therapy (HAART) including efavirenz (EFV), compared with boosted protease inhibitors (PIs). Correlations with immunological and clinical outcomes are unclear. Patients of the Italian MASTER cohort who started HAART from 2000 to 2010 were selected. Outstanding outcome (composite outcome for success (COS)) was introduced. We evaluated predictors of COS (no AIDS plus CD4+ count >500/mm(3)plus HIV-RNA <500 copies/mL) and of eight single outcomes either at month 6 or at year 3. Multivariable logistic regression was conducted. There were 6259 patients selected. Patients on EFV (43%) were younger, had greater CD4+ count, presented with AIDS less frequently, and more were Italians. At year 3, 90% of patients had HIV RNA <500 copies/mL, but only 41.4% were prescribed EFV, vs. 34.1% prescribed boosted PIs achieved COS (p <0.0001). At multivariable analysis, patients on lopinavir/ritonavir had an odds ratio of 0.70 for COS at year 3 (p <0.0001). Foreign origin and positive hepatitis C virus-Ab were independently associated with worse outcome (OR 0.54, p <0.0001 and OR 0.70, p 0.01, respectively). Patients on boosted PIs developed AIDS more frequently either at month 6 (13.8% vs. 7.6%, p <0.0001) or at year 3 (17.1% vs. 13.8%, p <0.0001). At year 3, deaths of patients starting EFV were 3%, vs. 5% on boosted PIs (p 0.008). In this study, naïve patients on EFV performed better than those on boosted PIs after adjustment for imbalances at baseline. Even when virological control is achieved, COS is relatively rare. Hepatitis C virus-positive patients and those of foreign origin are at risk of not obtaining COS.

Reducing the risk of bias in health behaviour change trials: improving trial design, reporting or bias assessment criteria? A review and case study

OBJECTIVE

It has been suggested that randomised controlled trials (RCTs) of health behaviour change (HBC) interventions are less rigorously designed than - for example- drug trials. This study presents an approach to clarifying whether this is due to poor trial design, incomplete trial reporting and/or the inappropriateness of commonly applied risk of bias assessment criteria.

DESIGN

First, a framework of key sources of bias and common strategies for reducing bias risk is developed based on a literature review. Second, we describe the design of a multi-site RCT evaluating the cost-effectiveness of an HIV-treatment adherence intervention (case study). The choices made by the multidisciplinary team trying to minimise the risk of bias are compared against the risk of bias framework.

MAIN OUTCOME MEASURES

Implementation of common strategies for reducing the risk of bias in the case study; alternative or additional strategies applied; a justification for each deviation from the risk of bias framework.

RESULTS

Most of the common strategies for reducing the risk of bias could be implemented. Alternative strategies were developed for minimising the risk of performance bias and contamination. Several additional, domain-specific risk of bias strategies were implemented.

CONCLUSIONS

The literature provides useful guidance for reducing the risk of bias in HBC trials. Yet, the case study suggests that HBC trial designers may face specific challenges that require alternative/additional measures for reducing the risk of bias. Using the risk of bias justification table (RATIONALE) could lead to better-designed HBC trials, more comprehensive trial reports and the data necessary for evaluating the appropriateness of commonly applied risk of bias assessment criteria to HBC trials.

Gender inequalities in the response to combination antiretroviral therapy over time: the Swiss HIV Cohort Study

OBJECTIVES

Gender-specific data on the outcome of combination antiretroviral therapy (cART) are a subject of controversy. We aimed to compare treatment responses between genders in a setting of equal access to cART over a 14-year period.

METHODS

Analyses included treatment-naïve participants in the Swiss HIV Cohort Study starting cART between 1998 and 2011 and were restricted to patients infected by heterosexual contacts or injecting drug use, excluding men who have sex with men.

RESULTS

A total of 3925 patients (1984 men and 1941 women) were included in the analysis. Women were younger and had higher CD4 cell counts and lower HIV RNA at baseline than men. Women were less likely to achieve virological suppression < 50 HIV-1 RNA copies/mL at 1 year (75.2% versus 78.1% of men; P = 0.029) and at 2 years (77.5% versus 81.1%, respectively; P = 0.008), whereas no difference between sexes was observed at 5 years (81.3% versus 80.5%, respectively; P = 0.635). The probability of virological suppression increased in both genders over time (test for trend, P < 0.001). The median increase in CD4 cell count at 1, 2 and 5 years was generally higher in women during the whole study period, but it gradually improved over time in both sexes (P < 0.001). Women also were more likely to switch or stop treatment during the first year of cART, and stops were only partly driven by pregnancy. In multivariate analysis, after adjustment for sociodemographic factors, HIV-related factors, cART and calendar period, female gender was no longer associated with lower odds of virological suppression.

CONCLUSIONS

Gender inequalities in the response to cART are mainly explained by the different prevalence of socioeconomic characteristics in women compared with men.

Higher rates of AIDS during the first year of antiretroviral therapy among migrants: the importance of tuberculosis

OBJECTIVE

In lower-income countries rates of AIDS-defining events (ADEs) and death are high during the first year of combination antiretroviral therapy (ART). We investigated differences between foreign-born (migrant) and native-born (nonmigrant) patients initiating ART in Europe, the US and Canada, and examined rates of the most common ADEs and mortality during the first year of ART.

DESIGN

Observational cohort study.

METHODS

We studied HIV-positive adults participating in one of 12 cohorts in the Antiretroviral Therapy Cohort Collaboration (ART-CC).

RESULTS

Of 48 854 patients, 25.6% were migrants: 16.1% from sub-Saharan Africa, 5.6% Latin America, 2.3% North Africa/Middle East, and 1.6% Asia. Incidence of ADEs during the first year of ART was 60.8 per 1000 person-years: 69.9 for migrants and 57.7 for nonmigrants [crude hazard ratio (HR) 1.18; 95% confidence interval (CI) 1.08-1.29], adjusted HR (for sex, age, CD4, HIV-1 RNA, ART regimen, prior ADE, probable route of infection and year of initiation, and stratified by cohort) 1.21 (95% CI 1.09-1.34). Rates of tuberculosis were substantially higher in migrants than nonmigrants (14.3 vs. 6.3; adjusted HR 1.94; 95% CI 1.53-2.46). In contrast, mortality was higher among nonmigrants than migrants (crude HR 0.71; 95% CI 0.61-0.84), although excess mortality was partially explained by patient characteristics at start of ART (adjusted HR 0.91; 95% CI 0.76-1.09).

CONCLUSIONS

During the first year of ART, HIV-positive migrants had higher rates of ADEs than nonmigrants. Tuberculosis was the most common ADE among migrants, highlighting the importance of screening for tuberculosis prior to ART initiation in this population.

Virologic, immunologic and clinical responses in foreign-born versus US-born HIV-1 infected adults initiating antiretroviral therapy: an observational cohort study

Introduction

Mortality rates within the first year of combination antiretroviral therapy (cART) initiation are several-fold higher in resource-limited countries than in resource-replete settings. However studies in western countries examining virologic, immunologic and clinical responses after cART initiation in indigenous versus non-indigenous populations have shown mixed results. This study aimed to determine whether there is a difference in these outcomes in a United States setting between foreign-born and US-born patients.

Methods

This retrospective observational cohort study of HIV-1 infected adults in one urban clinic in the United States compared virologic suppression, immune recovery and rates of AIDS defining events (ADEs) within the first year of cART using linear mixed effect models, log rank tests and Cox proportional hazard models. Data were analyzed for 94 foreign-born and 1242 US-born patients.

Results

Foreign-born patients were younger (31.7 years versus 38.5 years), more often female (38.3% versus 27.1%), less often injection drug users (3.2% versus 9.5%) or men who have sex with men (19.0% versus 54.5%), and had higher loss to follow-up rates (14.9% versus 6.2%). No significant differences were detected between the groups in suppression of plasma HIV-1 RNA, CD4+ cell recovery or development of ADEs.

Conclusions

During the first year on cART, virologic suppression, immune recovery and development of ADEs were comparable between foreign-born and US-born patients in care in a US clinic. Differential rates of loss to follow-up warrant further investigation in the foreign-born population.

HIV stigma and depressive symptoms are related to adherence and virological response to antiretroviral treatment among immigrant and indigenous HIV infected patients

We compared adherence to cART and virological response between indigenous and immigrant HIV-infected patients in the Netherlands, and investigated if a possible difference was related to a difference in the psychosocial variables: HIV-stigma, quality-of-life, depression and beliefs about medications. Psychosocial variables were assessed using validated questionnaires administered during a face-to-face interview. Adherence was assessed trough pharmacy-refill monitoring. We assessed associations between psychosocial variables and non-adherence and having detectable plasma viral load using logistic regression analyses. Two-hundred-two patients participated of whom 112 (55%) were immigrants. Viral load was detectable in 6% of indigenous patients and in 15% of the immigrants (P < 0.01). In multivariate analyses, higher HIV-stigma and prior virological failure were associated with non-adherence, and depressive symptoms, prior virological failure and non-adherence with detectable viral load. Our findings suggest that HIV-stigma and depressive symptoms may be targets for interventions aimed at improving adherence and virological response among indigenous and immigrant HIV-infected patients.

United Kingdom Collaborative HIV Cohort Study Group. Uptake and outcome of combination antiretroviral therapy in men who have sex with men according to ethnic group: the UK CHIC Study

BACKGROUND

We investigated differences in retention in HIV care and uptake of combination antiretroviral therapy (cART) and treatment outcomes between different ethnic men who have sex with men (MSM) groups.

METHODS

MSM subjects with known ethnicity and ≥1 day follow-up from 1996 to 2009 in the UK Collaborative HIV Cohort Study were included. Black and minority ethnic (BME) men were categorized as: black; Indian/Pakistani/Bangladeshi; other Asian/Oriental; and other/mixed. Logistic regression was used to identify factors associated with treatment initiation within the 6 months after each CD4 count. HIV viral load, CD4 counts, discontinuation/switch of a drug in the initial cART regimen, and development of a new AIDS event/death at 6 and 12 months were also analyzed.

RESULTS

Of 16,406 MSM, 1818 (11.0%) were BME; 892 (49.1%) black, 139 (7.6%) Indian/Pakistani/Bangladeshi, 254 (13.9%) other Asian/Oriental, 532 (29.2%) other/mixed. The proportion of MSM with no follow-up after HIV diagnosis was higher among BME than white MSM (3.4% vs. 2.2%, P = 0.002). Permanent loss to follow-up was highest in the other/mixed and lowest in Indian/Pakistani/Bangladeshi groups (P = 0.02). Six thousand three hundred thirty-eight MSM initiated first cART from January 1, 2000, to January 1, 2009. In multivariable analyses, BME MSM were 18% less likely to initiate cART than white MSM with similar CD4 counts [adjusted odds ratio 0.82 (95% confidence interval: 0.74 to 0.91), P = 0.0001]. However, once on cART, there were no differences in virological, immunological, and clinical outcomes.

CONCLUSIONS

This study demonstrates that despite BME MSM being a "minority within a minority" for those HIV infected, there are few ethnic disparities in access to and treatment outcomes in our setting.

Outcomes of antiretroviral therapy in the Swiss HIV Cohort Study: latent class analysis

An in-depth understanding of the different groups that make up the HIV-infected population should inform prevention and care. Using latent class analysis (LCA) we identified seven groups with similar socio-demographic and behavioral characteristics at enrolment in the Swiss HIV Cohort Study: older gay men, younger gay men, older heterosexual men, injection drug users, single migrants, migrant women in partnerships and heterosexual men and women. Outcomes of combination antiretroviral therapy (ART) were analyzed in 1,633 patients starting ART. Compared to older gay men, the probability of a virologic response to ART was reduced in single migrants, in older heterosexual men and in IDUs. Loss to follow-up was higher in single migrants and IDUs, and mortality was increased in older heterosexual men and IDUs. Socio-behavioral groups identified by LCA allow insights above what can be gleaned from traditional transmission groups, and may identify patients who could benefit from targeted interventions.

The efficacy of combination antiretroviral therapy in HIV type 1-infected patients treated in Curaçao compared with Antillean, Surinam, and Dutch HIV type 1-infected patients treated in The Netherlands

We compared the efficacy of combination antiretroviral therapy (cART) of Antillean HIV-1-infected patients treated on the Caribbean island of Curaçao (CUR-AN) with Antillean (NL-AN), Surinam (NL-SUR), and Dutch (NL-NL) patients treated in The Netherlands. In total 2118 therapy-naive patients who started cART between January 2005 and August 2008 were included in the comparison. The CUR-AN patients initiated cART at a median CD4 cell count of 141 cells/mm(3) and 63% had counts below 200 cells/mm(3). Within 12 months of the start of cART 76% of the CUR-AN patients achieved viral suppression, defined as HIV-1 RNA plasma levels below 80 copies/ml. The percentage achieving viral suppression was higher in patients treated in The Netherlands (NL-AN = 87%, NL-SUR = 93%, and NL-NL = 96%). Lost to follow-up after 30 months of cART was 10% among CUR-AN patients and was higher than observed among patients treated in The Netherlands (NL-AN = 8%, NL-SUR = 3%, and NL-NL = 2%). A similar pattern was found for progression to AIDS and death (10% of CUR-AN vs. 5%, 6%, and 7% of NL-AN, NL-SUR, and NL-NL patients, respectively). Late start of cART and limited viral suppression after the start of cART determine the higher rate of disease progression to AIDS and death among Antillean patients treated in Curaçao. The high percentage of lost to follow-up may result in an underestimation of AIDS and AIDS-related death among HIV-1-infected Antilleans treated in Curaçao.

Late initiation of HAART among HIV-infected patients in Spain is frequent and related to a higher rate of virological failure but not to immigrant status

PURPOSE

To determine whether immigrant status is associated with late initiation of highly active antiretroviral treatment (HAART) and/or poor response to antiretrovirals.

METHODS

GESIDA 5808 is a multicenter, retrospective cohort study (inclusion period January 2005 through December 2006) of treatment-naïve patients initiating HAART that compares HIV-infected patients who are immigrants with Spanish-born patients. A late starter (LS) was defined as any patient starting HAART with a CD4+ lymphocyte count <200 cells/μL and/or diagnosis of an AIDS-defining illness before or at the start of therapy. The primary endpoint was time to treatment failure (TTF), defined as virological failure (VF), death, opportunistic infection, treatment discontinuation/switch (D/S), or missing patient. Secondary endpoints were time to treatment failure as observed data (TTO; censoring missing patients) and time to virological failure (TVF; censoring missing patients and D/S not due to VF).

RESULTS

LS accounted for 56% of the patients. Lower educational and socioeconomic level and intravenous drug use (IVDU) were associated with categorization as LS, but immigrant status was not. Cox regression analysis (hazard ratio [HR]; 95% CI) between LS and non-LS patients showed no differences in TTF (0.97; 0.78-1.20) or TTO (1.18; 0.88-1.58), although it did reveal a difference in TVF (1.97; 1.18-3.29). CD4+ lymphocyte recovery was equivalent for both LS and non-LS patients (159 vs 173).

CONCLUSIONS

In our cohort, immigrant status was not shown to be related to late initiation of HAART. Although LS patients did not have a longer TTF for any reason, TVF was significantly shorter. Despite universal free access to HAART in Spain, measures to ensure early diagnosis and treatment of HIV infection are necessary.

Immune restoration and onset of new AIDS-defining events with combination antiretroviral therapy in HIV type-1-infected immigrants in the Netherlands

BACKGROUND

We investigated differences in immune restoration and onset of new AIDS-defining events on combination antiretroviral therapy (cART) among HIV type-1 (HIV-1)-infected patients of different regional origin now living in the Netherlands.

METHODS

Treatment-naive adults reaching plasma viral load (pVL)<400 copies/ml within 9 months of starting cART were selected from the Netherlands ATHENA cohort. CD4(+) T-cell response on cART was determined over 7 years using mixed models. CD4(+) T-cell counts were excluded from the analyses at the first of two consecutive measurements of pVL≥400 copies/ml following prior suppression to <400 copies/ml. Multivariate analyses included gender, age, CD4(+) T-cell count and pVL prior to cART, hepatitis coinfection, HIV-1 transmission and region of origin (Western Europe/North America [WN], sub-Saharan Africa [SSA], Southeast Asia [SEA], Latin America/Caribbean [LAC] or other).

RESULTS

For 6,057 selected patients (WN 3,947, SSA 989, SEA 237, LAC 695 and other 189), median follow-up was 3.2 years (WN 3.3, SSA 2.9, SEA 3.2, LAC 2.7 and other 2.7). CD4(+) T-cell increase in the first 6 months of cART was lower in males than females (-26 cells/mm(3); P<0.0001) and in patients from SSA compared with WN (-36 cells/mm(3); P<0.0001). Because men from SSA started with lower CD4(+) T-cell counts than men from WN, they continued to lag behind and had lower absolute CD4(+) T-cell counts after 7 years of cART. Furthermore, cumulative tuberculosis incidence after 7 years of cART was higher in SSA compared with WN (4.5% versus 0.5%, hazard ratio 5.08, 95% confidence interval 2.22-11.60).

CONCLUSIONS

HIV-1-infected immigrants from SSA have blunted immune restoration on fully suppressive cART and should be identified at an earlier disease stage. Our results call for more intensive screening for both latent and active tuberculosis in these patients.

Which method of adherence measurement is most suitable for daily use to predict virological failure among immigrant and non-immigrant HIV-1 infected patients?

In industrialized countries, virological failure occurs more often among HIV-infected immigrant patients. Non-adherence is the most credible explanation. We compared adherence of immigrant patients with that of non-immigrant patients in the Netherlands, and investigated which method of adherence measurement is most suitable for daily use to predict virological treatment failure: testing knowledge of the current regimen, a quantitative adherence interview, pharmacy prescription refill ratio (dispensed medication divided by prescribed medication, DM/PM), and plasma drug levels. Included were 61 immigrants and 81 non-immigrants. Virological failure did occur more often in immigrants than in non-immigrants (19.7% (12/61) versus 8.6% (7/81), p=0.056), especially among previously naive patients (19.6% (11/56) versus 0% (0/54), p<0.01). There were no differences between both groups on any of the four adherence measures. Virological failure was associated with reporting stopping medication when not feeling well (OR=12, 95%CI=1.9-77.7, p=0.02), and, among naive patients, also with a DM/PM < 0.85 (Odds Ratio=5.1, 95%Confidence Interval=1.2-22.3, p=0.03). Although our study confirmed a much higher virological failure rate among immigrants, we were unable to identify clear differences in adherence between immigrants and non-immigrant patient, although virological failure was associated with stopping medication when not feeling well and a low DM/PM. Unstructured treatment interruptions are a likely explanation of the findings. Interventions should be aimed at preventing patients to stop medication. A DM/PM below 0.85 can be indicative for patients who did stop medication and are at risk for virological failure.

Virologic response differences between African Americans and European Americans initiating highly active antiretroviral therapy with equal access to care

OBJECTIVE

Studies comparing virologic response to highly active antiretroviral therapy (HAART) between African Americans (AA) and European Americans (EA) have been confounded by differences in duration of HIV infection and access to health care. We evaluated virologic response to HAART between ethnicities in a large cohort with fewer confounders.

METHODS

The odds of attaining viral suppression at 6- and 12-months post-HAART were determined by multivariate logistic regression for HIV-infected AA and EA prospectively followed in a large US military cohort. Time-to-event methods were used to compare maintenance of suppression.

RESULTS

A total of 1363 subjects (51% AA, 92% men) with viral load results available 6 months after HAART initiation were included. There was no difference between ethnicities in time from seroconversion to HIV diagnosis or HAART initiation or in HAART regimens. Adjusted for multiple demographic and HIV-related factors, AA had significantly lower odds of obtaining undetectable viral loads after 6 (odds ratio 0.6, 95% confidence interval 0.4-0.8, P < 0.001) and 12 months (odds ratio 0.6, 95% confidence interval 0.4-0.8, P = 0.002) of HAART. Once undetectable, there was no difference in time to virologic failure between AA and EA.

CONCLUSIONS

Despite similar durations of HIV infection and equal access to health care, AAs were significantly less likely to achieve viral suppression compared with EA.

[Epidemiology of HIV infection in immigrants in Spain: information sources, characteristics, magnitude and tendencies]

Lately Spain, the proportion of immigrants has increased in both general and HIV-infected populations. Nevertheles, data on the temporal trends of the epidemic in immigrants and on their sociodemographic, epidemiologic and clinical characteristics are scarce and are scattered in various information sources that cover complementary aspects of this issue. The objectives of the present study were to analyze the available information sources that allow the epidemiology of HIV infection in immigrants in Spain to be studied, and to describe the current situation of HIV infection in immigrants, based on the available information sources.

Causes of death in HIV-infected women: persistent role of AIDS. The 'Mortalité 2000 & 2005' Surveys (ANRS EN19)

BACKGROUND

Little is known about the causes of death in human immunodeficiency virus (HIV)-infected women in the era of combination antiretroviral therapy (ART).

METHODS

In the French nationwide Mortalité 2000 and 2005 surveys, physicians reported causes of deaths in HIV-infected adults in 2000 and 2005, using a standardized questionnaire. We used multivariate logistic regression models to study the association between gender and AIDS-defining causes of death, adjusting for other characteristics.

RESULTS

Of the 1013 HIV-infected adults who died in 2005, 247 (24%) were women. Half of women were infected through heterosexual contacts, compared with 25% men. In 2005, the proportion of AIDS-defining causes of death was higher in women than in men (43 vs 34%; P = 0.01), whereas it had been the same in 2000 (47% in women and men). In 2005, women died less frequently than men from respiratory malignancies (lung, ear/nose/throat) and cardiovascular disease (9% of all causes of death in women compared with 16% in men; P = 0.004), and suicides or accidents (4 vs 9%; P = 0.02). Socio-economic precariousness, younger age, less alcohol and tobacco consumption and lack of prior ART explained the higher proportion of deaths from AIDS in women compared with men.

CONCLUSIONS

The higher proportion of AIDS-related deaths in women is probably explained by two factors: (i) some HIV-infected women, especially migrants in poor socio-economic conditions, may not have access to optimal care; and (ii) a lower prevalence of risk factors for respiratory, cardiovascular and violent deaths means that the risk of dying from non-AIDS causes may be lower in women.

[HIV infection in immigrants in Spain: Epidemiological characteristics and clinical presentation in the CoRIS Cohort (2004-2006)]

INTRODUCTION

A growing number of immigrants are using the public health services for HIV in Spain. We describe the sociodemographic, epidemiological, and clinical characteristics of a cohort of naïve HIV-infected subjects (CoRIS cohort) according to their place of origin.

METHODS

CoRIS is an open, hospital-based cohort of naïve, HIV-infected persons attended in 19 hospitals from 9 of the 19 autonomous regions in Spain. We describe the characteristics of the cohort members by place of origin, and compare them with the Spanish cases identified from January 2004 to October 2006, using the chi-square and Fisher exact tests.

RESULTS

Of 2507 patients, 76.3% were men and median age was 36 years. By origin, 71.5% were Spanish, 16.0% Latin Americans (LA), 5.8% sub-Saharan Africans (SSA), 3.7% Western Europeans (WE), 1.7% Eastern Europeans (EE) and 1.4% North Africans (NA). Compared to Spaniards, there were significant differences by origin in sex, age, and transmission category. Median CD4 count at cohort entry was 352 cell/microL, with no differences according to origin. Median viral load was 48 962 copies/mL and was significantly lower for SSA. Over 11.4 months of follow-up, 57.9% initiated HAART with no differences by origin. Hepatitis C prevalence was 29.9% in Spaniards, 7.3% in Latin Americans, 11.7% in SSA, and 45.7% in EE (P<0.05). Overall, 13.4% were Mantoux-positive (28.6% in SSA and 30.8% in NA). Tuberculosis was more common among cases from EE (9.5%) and SSA (8.3%) compared to Spaniards (4.8%) (P<0.05).

CONCLUSIONS

Almost one third of naïve HIV-infected patients in CoRIS are foreign-born. Their sociodemographic, epidemiological and clinical characteristics reflect the epidemic in their places of origin. However, their immunological status at cohort entry and initiation of HAART is no different from that of Spaniards.

Prevention of mother-to-child HIV transmission: similar access for sub-Sahara African immigrants and for French women?

OBJECTIVE

: To investigate whether mother-to-child transmission (MTCT) management and rate differed between African immigrants and French-born women delivering in France.

METHODS

: MTCT strategies were studied among human immunodeficiency virus type 1-infected women delivering between 1984 and 2007 in the multicenter French Perinatal Cohort, according to geographical origin.

RESULTS

: Among 9245 pregnancies (in 7090 women), the proportion of African mothers increased from 12% in 1984-1986 to 64% in 2003-2004. African women had later access to care than French women, even in recent years (1997-2004). They more often discovered their HIV infection during pregnancy (40.6 vs. 11.5%, P < 0.001), started prenatal care in the third trimester (14.1 vs. 9.8%, P < 0.001) and started antiretroviral therapy after 32 weeks gestation (7.6 vs. 4.1%, P < 0.001). The association with late treatment initiation disappeared when adjusted for late HIV diagnosis and prenatal care (adjusted odds ratio 1.0, 95% confidence interval 0.7-1.4). African and French women did not differ in terms of access to highly active antiretroviral therapy, nor for substandard management such as vaginal delivery with uncontrolled viral load, lack of intrapartum and postpartum treatment or breastfeeding. The MTCT rate was higher for African than for French women receiving antiretroviral therapy (1.8 vs. 0.8%, P = 0.02), but the difference was no longer significant after adjustment for main transmission risk factors (adjusted odds ratio = 1.7, 95% confidence interval 0.8-3.7, P = 0.17). MTCT did not differ among 2110 term deliveries with maternal viral load less than 400 copies/ml, (0.8 vs. 0.6%, P = 0.5).

CONCLUSION

: African immigrants more often had late HIV screening in pregnancy than French-born women, but had similar access to MTCT prevention, once the infection was diagnosed.

Initial therapy with nucleoside reverse transcriptase inhibitor-containing regimens is more effective than with regimens that spare them with no difference in short-term fat distribution: Hippocampe-ANRS 121 Trial

OBJECTIVES

The aim of this study was to evaluate the impact on body fat of nucleoside reverse transcriptase inhibitor (NRTI)-sparing regimens compared with NRTI-containing therapy in HIV-1-infected antiretroviral (ARV)-naive patients.

METHODS

A randomized, multicentre, open-label trial in ARV-naive patients. Subjects were randomized (2:1:1) to receive: (i) an NRTI-sparing regimen consisting of a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus a boosted protease inhibitor (PI/r); or (ii) an NRTI-containing regimen of (a) a PI/r plus two NRTIs or (b) an NNRTI plus two NRTIs. The primary endpoint was the change in subcutaneous limb fat measured by dual-energy X-ray absorptiometry at week (W) 96. Secondary endpoints included the proportion of patients with treatment failure, plasma HIV-RNA (pVL) <50 copies/mL and safety.

RESULTS

One hundred and seventeen patients were enrolled between November 2003 and May 2004: 26% female; 42% from sub-Saharan Africa; median plasma HIV-RNA (pVL) 5.1 log(10) copies/mL; median CD4 count 207 cells/mm(3). A planned interim analysis demonstrated significantly lower treatment and virological responses with the NRTI-sparing strategy, resulting in premature study termination on 19 July 2005. The proportion of patients who remained on their assigned treatment strategy and had pVL <50 copies/mL on the NRTI-sparing regimen was 60.0%, compared with 82.5% on the NRTI-containing regimen at W24 (P = 0.009) and 66.7% and 82.5%, respectively, at W48 (P = 0.059). Treatment failure was associated with the NRTI-sparing strategy in patients with suboptimal adherence and with being from sub-Saharan Africa. No differences in fat distribution were noted.

CONCLUSIONS

An initial NRTI-sparing regimen is less successful and virologically less potent than standard NRTI-containing regimen and should not therefore be used as the first line of treatment.

Screening and Management of HIV-2-Infected Individuals in Northern Italy

There is a lack of updated estimates of HIV-2 infection in Italy. Moreover, lack of standardized HIV-2 viral load (VL) and drug resistance tests challenges clinical practice. Among 2941 HIV-positive patients followed in our center (Brescia, Northern Italy), 220 (7.5%) were African at the beginning of the study period. We assessed a population of 151 HIV-Ab positive patients (141 of African origin), presenting for routine blood testing from January 2006 to May 2007. Those found infected with HIV-2 started an appropriate disease management with HIV-2 VL and genotypic drug resistance testing. Sixteen of 151 (10.6%) patients were positive for HIV-2. Of those 16 patients, 14 came from Africa. Among 7 experienced patients, 1 was responding to nelfinavir and 4 to lopinavir/ritonavir-containing regimens. Two patients were failing treatment: 1 patient was switched to a saquinavir/ritonavir-containing regimen and responded. The remaining patient switched to lamivudine + atazanavir + saquinavir + ritonavir did not respond, having had previous experience to multiple ineffective drugs, resulting in a very complex HIV-2 drug-resistance pattern. Accurate screening programs and integration of virological tools must be implemented urgently, given the high prevalence of HIV-2, particularly in immigrant patients.

An audit of viral load in one clinical population to describe features of viraemic patients on antiretroviral therapy

OBJECTIVES

To assess the prevalence of an undetectable viral load (VL) (<50 HIV-1 RNA copies/mL) in a clinical population and to identify those viraemic and at risk of failing antiretroviral therapy (ART).

METHODS

An audit of a complete clinical population on 1 January 2005 via a clinical database and clinical note review.

RESULTS

On 1 January 2005, 1910 patients were under care; 1229/1332 (92%) of those exposed to ART for >16 weeks had a VL of <50 copies/mL. We examined 49/56 case notes of viraemic patients to identify explanations for viraemia. Common reasons included previous initial mono- or dual therapy, adherence problems, more advanced HIV disease, concomitant medications, physical and mental health issues and being less well linked into the service. A review of these patients' current status on 1 April 2007 showed that six of the 49 had since died. However, of those still alive, 20 (47%) had a VL <500 copies/mL.

CONCLUSIONS

The proportion of patients on ART with detectable viraemia is low in current clinical practice. New drugs may help those who are failing because of resistance. However, there is a small minority of patients who, for various reasons, appear unable to maintain sufficient adherence to ART.

Demographic, clinical, and virologic characteristics of African-born persons with HIV/AIDS in a Minnesota hospital

Minnesota is currently home to the tenth largest African population and the second largest East African population in the United States. HIV is increasingly being diagnosed in African-born persons in Minnesota. A retrospective survey was conducted on all African-born patients in our HIV clinic between January 1994 and June 2005. We identified 237 patients who were African-born and HIV-positive. They constituted 12% of patients attending the clinic within the study timeframe. There was no significant difference in the ages of the African-born and non-African patients in the HIV clinic. African-born patients were more likely to be women compared with non-African patients (p < 0.001). Forty-three percent of the African-born patients presented with AIDS as defined by CD4(+) T cell counts less than 200 cells per milliliter compared to 33% of antiretroviral naïve non-African HIV patients in the clinic (p < 0.001). Most patients were infected through heterosexual contact and only 4% were diagnosed as a result of routine testing. Seven known HIV subtypes and four unique recombinant forms were identified. The most common opportunistic infection was pulmonary tuberculosis. African immigrants with HIV appear to: (1) access care at later stages of HIV disease than other patients in our clinic; (2) are often infected with non-B subtypes; (3) do not routinely get tested for HIV. Increased awareness to this growing trend is needed for health care providers and public health officials to tailor educational programs and prevention efforts for African immigrants in the United States.

Characteristics and response to antiretroviral therapy of HIV-1-infected patients born in Africa and living in France

BACKGROUND

The world-wide AIDS epidemic is reflected in Western Europe in an increasing number of HIV-infected persons who originate from Africa. We describe the characteristics and response to antiretroviral therapy (ART) of HIV-infected patients born in Africa and living in France.

METHODS

Analysis of data from the (Anti PROtéase COhorte APROCO) cohort study of HIV-infected patients initiating ART was carried out. Included in the study were 90 patients born in sub-Saharan Africa, 53 in North Africa and 771 in metropolitan France.

RESULTS

At baseline, there was a higher proportion of women and of the heterosexual transmission route of infection among patients born in sub-Saharan Africa, a higher proportion of injecting drug users among patients born in North Africa and a higher frequency of unemployment and of unstable housing conditions among patients born in both sub-Saharan and North Africa as compared with patients born in France. The median CD4 cell count was lower in patients born in both sub-Saharan and North Africa (sub-Saharan Africa: 197 cells/microL; North Africa: 222 cells/microL) than in patients born in France (307 cells/microL). Median HIV-1 viral loads were similar. After a median follow-up time of 36 months (2506 patient-years), the Kaplan-Meier estimations of probability of survival without new AIDS-defining events were not different. After 36 months of ART, in multivariate analysis, median CD4 cell count, CD4/CD8 ratio and viral load were not statistically different according to birthplace, but the median CD4 percentage was lower in patients born in both sub-Saharan and North Africa. The adherence profiles were similar.

CONCLUSIONS

Although clinical response and adherence to ART did not appear to differ in patients according to their birthplace, the reasons for the more advanced HIV infection observed at ART initiation among patients born in Africa should be further investigated.

Heterogeneous response to HAART across a diverse population of people living with HIV: results from the ANRS-EN12-VESPA Study

OBJECTIVES

Benefits from HAART may be heterogeneous across people living with HIV. We measured the differences in the rate of HAART failure across the various subgroups represented at the level of a country.

DESIGN

We used data from a national representative sample of people living with HIV and followed at hospital in France (ANRS-EN12-VESPA Study).

METHODS

Analyses were restricted to 896 participants on HAART for 6 months or more, who were antiretroviral naive at HAART initiation. Different indicators of treatment failure were defined: immunological failure (absence of an increase of 100 CD4 cells/microl or more); immunovirological failure (CD4 cell count of 200 cells/microl or less and detectable HIV-RNA); clinical failure (occurrence of an AIDS-defining illness more than 3 months after HAART initiation). Differences in the frequency of treatment failure were measured using logistic regression models adjusted for major established determinants of response to HAART.

RESULTS

Overall, 19.6% of the study participants experienced immunological failure, 3.4% immunovirological failure, and 3.0% clinical failure, with substantial variations across the various subgroups. Compared with homo/bisexual men, migrants had higher rates of immunological failure (adjusted odds ratio 2.27, 95% confidence interval 1.14-4.56 for migrant men and 2.19, 1.17-4.08 for migrant women), immunovirological failure (8.23, 1.77-38.33 and 6.91, 1.03-46.32), and clinical failure (4.60, 1.01-20.86 and 4.22, 0.84-21.17).

CONCLUSION

In France, migrants consistently appear to be at increased risk of treatment failure compared with other people with HIV. Understanding the reasons underlying such heterogeneity in terms of living conditions and educational/cultural background will be important.

Initial response to highly active antiretroviral therapy in HIV-1C-infected adults in a public sector treatment program in Botswana

OBJECTIVE

To describe the response to highly active antiretroviral treatment (HAART) in a public sector pilot antiretroviral (ARV) treatment program in Botswana.

METHODS

The response to HAART is described in adult HIV-infected ARV-naive patients initiating treatment from April 2001 to January 2002 at Princess Marina Hospital in Gaborone, Botswana. Patients had medical and laboratory evaluations before initiating ARV treatment and were followed longitudinally. For analysis, data were collected from charts and patient management records.

RESULTS

One hundred fifty-three ARV-naive patients initiated HAART. Most received didanosine plus stavudine (ddI + d4T) with efavirenz or nevirapine. The mean CD4 cell count increase was 149 cells/mm at 24 weeks and 204 cells/mm at 48 weeks. The percentage of patients with an HIV-1 RNA level < or =400 copies/mL was 87.0% at 24 weeks and 78.8% at 48 weeks. The Kaplan-Meier 1-year survival estimate was 84.7% (79.0%, 90.8%), with a 3.2-fold increased risk (P = 0.004) of mortality among patients with a CD4 cell count <50 cells/mm. The 1-year Kaplan-Meier estimate of toxicity-related drug switches was 32.2% (20.3%, 40.4%). The most common toxicity was peripheral neuropathy, occurring more frequently in patients with a preexisting diagnosis of peripheral neuropathy and among those placed on ddI + d4T-containing regimens.

CONCLUSIONS

An excellent response to HAART was observed among HIV-1C-infected patients, paralleling those seen elsewhere. Despite excellent responses, high rates of toxicity were observed for ddI + d4T-containing regimens.