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Kedra J, Dieudé P, Giboin C, Marotte H, Salliot C, Schaeverbeke T, Perdriger A, Soubrier M, Morel J, Constantin A, Dernis E, Royant V, Salmon JH, Pham T, Gottenberg JE, Pertuiset E, Dougados M, Devauchelle-Pensec V, Gaudin P, Cormier G, Goupille P, Mariette X, Berenbaum F, Alcaix D, Rouidi SA, Berthelot JM, Monnier A, Piroth C, Lioté F, Goëb V, Gaujoux-Viala C, Chary-Valckenaere I, Hajage D, Tubach F, Fautrel B. Towards the Lowest Efficacious Dose: Results From a Multicenter Noninferiority Randomized Open-Label Controlled Trial Assessing Tocilizumab or Abatacept Injection Spacing in Rheumatoid Arthritis in Remission. Arthritis Rheumatol 2024; 76:541-552. [PMID: 37942714 DOI: 10.1002/art.42752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 10/18/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE We assess the clinical and structural impact at two years of progressively spacing tocilizumab (TCZ) or abatacept (ABA) injections versus maintenance at full dose in patients with rheumatoid arthritis in sustained remission. METHODS This multicenter open-label noninferiority (NI) randomized clinical trial included patients with established rheumatoid arthritis in sustained remission receiving ABA or TCZ at a stable dose. Patients were randomized to treatment maintenance (M) at full dose (M-arm) or progressive injection spacing (S) driven by the Disease Activity Score in 28 joints every 3 months up to biologics discontinuation (S-arm). The primary end point was the evolution of disease activity according to the Disease Activity Score in 44 joints during the 2-year follow-up analyzed per protocol with a linear mixed-effects model, evaluated by an NI test based on the one-sided 95% confidence interval (95% CI) of the slope difference (NI margin 0.25). Other end points were flare incidence and structural damage progression. RESULTS Overall, 202 of the 233 patients included were considered for per protocol analysis (90 in S-arm and 112 in M-arm). At the end of follow-up, 16.2% of the patients in the S-arm could discontinue their biologic disease-modifying antirheumatic drug, 46.9% tapered the dose and 36.9% returned to a full dose. NI was not demonstrated for the primary outcome, with a slope difference of 0.10 (95% CI 0.10-0.31) between the two arms. NI was not demonstrated for flare incidence (difference 42.6%, 95% CI 30.0-55.1) or rate of structural damage progression at two years (difference 13.9%, 95% CI -6.7 to 34.4). CONCLUSION The Towards the Lowest Efficacious Dose trial failed to demonstrate NI for the proposed ABA or TCZ tapering strategy.
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Affiliation(s)
- Joanna Kedra
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Philippe Dieudé
- Université de Paris Cité, INSERM UMR 1152 and Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Caroline Giboin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Hubert Marotte
- Université Jean Monnet Saint-Étienne, Centre Hospitalier Universitaire de Saint-Etienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Étienne, France
| | | | | | | | - Martin Soubrier
- Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Jacques Morel
- Montpellier University Hospital and University of Montpellier, INSRM, CNRS, Montpellier, France
| | - Arnaud Constantin
- Pierre-Paul Riquet University Hospital, Toulouse III - Paul Sabatier University, and INSERM UMR 1291, Purpan University Hospital, Toulouse, France
| | | | | | - Jean-Hugues Salmon
- University of Reims Champagne-Ardenne, Faculty of Medicine, UR 3797 and Maison Blanche Hospital, Reims University Hospitals, Reims, France
| | - Thao Pham
- Sainte-Marguerite Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | | | | | - Maxime Dougados
- University of Paris, Hôpital Cochin. AP-HP, INSERM U1153, pôle de recherche et d'enseignement supérieur Sorbonne Paris-Cité, Paris, France
| | | | | | | | | | - Xavier Mariette
- Université Paris-Saclay, Hôpital Bicêtre, AP-HP, INSERM UMR1184, Le Kremlin Bicêtre, France
| | - Francis Berenbaum
- Sorbonne University-INSERM Centre De Recherche scientifique Saint-Antoine, AP-HP Saint-Antoine Hospital, Paris, France
| | | | | | | | | | | | - Frédéric Lioté
- Université de Paris and INSERM UMR1132 Bioscar (Centre Viggo Petersen), Hôpital Lariboisière, AP-HP, Paris, France
| | - Vincent Goëb
- University Hospital of Amiens, Université de Picardie Jules Verne, Amiens, France
| | - Cécile Gaujoux-Viala
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, University of Montpellier, INSERM, Centre Hospitalier Universitaire de Nîmes, Montpellier, France
| | | | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Bruno Fautrel
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
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Krankowska D, Flanczewski S, Gajek-Flanczewska W, Sapuła M, Cybula A, Wiercińska-Drapało A. Comparison between patients who interrupted ART and those with late HIV diagnosis. AIDS Care 2024; 36:374-381. [PMID: 37584430 DOI: 10.1080/09540121.2023.2237711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 07/12/2023] [Indexed: 08/17/2023]
Abstract
Early diagnosis of human immunodeficiency virus (HIV) and retention in care are cornerstones of better prognosis of people living with HIV (PLWH). The purpose of this study was to compare patients who discontinued antiretroviral treatment (ART) with those who were diagnosed late with HIV. In this retrospective analysis of PLWH under the care of one of the Infectious Diseases Clinics in Poland between 2020 and 2021, two sub-analyses were carried out. One comparing patients who relinked to care after treatment interruption ("Group A") with those who had late HIV diagnosis ("Group B"), another comparing group A to those who were adherent to ART ("Group C"). 215 patients were included in this study (Group A = 47, Group B = 53, Group C = 115). Those who discontinued ART more often used actively drugs (p = 0.001) in comparison to those with late HIV diagnosis. In both bivariate and multivariable analysis migrants were more often diagnosed late with HIV than interrupted ART (p = 0.004 and 0.015, respectively). In the second analysis, in the multivariable analysis female sex was not associated with treatment interruption, whereas active drug usage was. People using drugs have a higher risk of ART interruption. Migrants are more at risk of late HIV diagnosis. Adequate interventions should be made towards both groups.
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Affiliation(s)
- Dagny Krankowska
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warsaw, Poland
- Hospital for Infectious Diseases, Warsaw, Poland
| | - Sebastian Flanczewski
- Student's Scientific Society, Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Poland
| | - Wiktoria Gajek-Flanczewska
- Student's Scientific Society, Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Poland
| | - Mariusz Sapuła
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warsaw, Poland
- Hospital for Infectious Diseases, Warsaw, Poland
| | - Aneta Cybula
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warsaw, Poland
- Hospital for Infectious Diseases, Warsaw, Poland
| | - Alicja Wiercińska-Drapało
- Department of Infectious and Tropical Diseases and Hepatology, Medical University of Warsaw, Warsaw, Poland
- Hospital for Infectious Diseases, Warsaw, Poland
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Nguyen A, Drabo EF, Garland WH, Moucheraud C, Holloway IW, Leibowitz A, Suen SC. Are Unequal Policies in Pre-Exposure Prophylaxis Uptake Needed to Improve Equality? An Examination Among Men Who Have Sex with Men in Los Angeles County. AIDS Patient Care STDS 2022; 36:300-312. [PMID: 35951446 PMCID: PMC9419964 DOI: 10.1089/apc.2022.0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Racial and ethnic minority men who have sex with men (MSM) are disproportionately affected by HIV/AIDS in Los Angeles County (LAC), an important epicenter in the battle to end HIV. We examine tradeoffs between effectiveness and equality of pre-exposure prophylaxis (PrEP) allocation strategies among different racial and ethnic groups of MSM in LAC and provide a framework for quantitatively evaluating disparities in HIV outcomes. To do this, we developed a microsimulation model of HIV among MSM in LAC using county epidemic surveillance and survey data to capture demographic trends and subgroup-specific partnership patterns, disease progression, patterns of PrEP use, and patterns for viral suppression. We limit analysis to MSM, who bear most of the burden of HIV/AIDS in LAC. We simulated interventions where 3000, 6000, or 9000 PrEP prescriptions are provided annually in addition to current levels, following different allocation scenarios to each racial/ethnic group (Black, Hispanic, or White). We estimated cumulative infections averted and measures of equality, after 15 years (2021-2035), relative to base case (no intervention). By comparing allocation strategies on the health equality impact plane, we find that, of the policies evaluated, targeting PrEP preferentially to Black individuals would result in the largest reductions in incidence and disparities across the equality measures we considered. This result was consistent over a range of PrEP coverage levels, demonstrating that there are "win-win" PrEP allocation strategies that do not require a tradeoff between equality and efficiency.
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Affiliation(s)
- Anthony Nguyen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California Viterbi School of Engineering, Los Angeles, California, USA.,Address correspondence to: Anthony Nguyen, MEng, Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California Viterbi School of Engineering, 3715 McClintock Avenue, GER 240, Los Angeles, CA 90089-0001, USA
| | - Emmanuel Fulgence Drabo
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Wendy H. Garland
- Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Corrina Moucheraud
- Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health, Los Angeles, California, USA
| | - Ian W. Holloway
- Department of Social Welfare, University of California Los Angeles Luskin School of Public Affairs, Los Angeles, California, USA
| | - Arleen Leibowitz
- Department of Public Policy, University of California Los Angeles Luskin School of Public Affairs, Los Angeles, California, USA
| | - Sze-chuan Suen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California Viterbi School of Engineering, Los Angeles, California, USA
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Robinson CA, Lyddon TD, Gil HM, Evans DT, Kuzmichev YV, Richard J, Finzi A, Welbourn S, Rasmussen L, Nebane NM, Gupta VV, Ananthan S, Cai Z, Wonderlich ER, Augelli-Szafran CE, Bostwick R, Ptak RG, Schader SM, Johnson MC. Novel Compound Inhibitors of HIV-1 NL4-3 Vpu. Viruses 2022; 14:v14040817. [PMID: 35458546 PMCID: PMC9024541 DOI: 10.3390/v14040817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/06/2022] [Accepted: 04/09/2022] [Indexed: 12/14/2022] Open
Abstract
HIV-1 Vpu targets the host cell proteins CD4 and BST-2/Tetherin for degradation, ultimately resulting in enhanced virus spread and host immune evasion. The discovery and characterization of small molecules that antagonize Vpu would further elucidate the contribution of Vpu to pathogenesis and lay the foundation for the study of a new class of novel HIV-1 therapeutics. To identify novel compounds that block Vpu activity, we have developed a cell-based ‘gain of function’ assay that produces a positive signal in response to Vpu inhibition. To develop this assay, we took advantage of the viral glycoprotein, GaLV Env. In the presence of Vpu, GaLV Env is not incorporated into viral particles, resulting in non-infectious virions. Vpu inhibition restores infectious particle production. Using this assay, a high throughput screen of >650,000 compounds was performed to identify inhibitors that block the biological activity of Vpu. From this screen, we identified several positive hits but focused on two compounds from one structural family, SRI-41897 and SRI-42371. We developed independent counter-screens for off target interactions of the compounds and found no off target interactions. Additionally, these compounds block Vpu-mediated modulation of CD4, BST-2/Tetherin and antibody dependent cell-mediated toxicity (ADCC). Unfortunately, both SRI-41897 and SRI-42371 were shown to be specific to the N-terminal region of NL4-3 Vpu and did not function against other, more clinically relevant, strains of Vpu; however, this assay may be slightly modified to include more significant Vpu strains in the future.
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Affiliation(s)
- Carolyn A. Robinson
- Department of Molecular Microbiology and Immunology, University of Missouri, School of Medicine and the Christopher S. Bond Life Sciences Center, Columbia, MO 65211, USA; (C.A.R.); (T.D.L.); (S.W.)
| | - Terri D. Lyddon
- Department of Molecular Microbiology and Immunology, University of Missouri, School of Medicine and the Christopher S. Bond Life Sciences Center, Columbia, MO 65211, USA; (C.A.R.); (T.D.L.); (S.W.)
| | - Hwi Min Gil
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA; (H.M.G.); (D.T.E.)
| | - David T. Evans
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA; (H.M.G.); (D.T.E.)
| | - Yury V. Kuzmichev
- Infectious Disease Research, Drug Development Division, Southern Research, Frederick, MD 21701, USA; (Y.V.K.); (Z.C.); (E.R.W.); (R.G.P.); (S.M.S.)
| | - Jonathan Richard
- Centre de Recherche du CHUM, Montréal, QC HX2 0A9, Canada; (J.R.); (A.F.)
- Département de Microbiologie, Infectiologie et Immunologie, Université de Montréal, Montréal, QC HX2 0A9, Canada
| | - Andrés Finzi
- Centre de Recherche du CHUM, Montréal, QC HX2 0A9, Canada; (J.R.); (A.F.)
- Département de Microbiologie, Infectiologie et Immunologie, Université de Montréal, Montréal, QC HX2 0A9, Canada
| | - Sarah Welbourn
- Department of Molecular Microbiology and Immunology, University of Missouri, School of Medicine and the Christopher S. Bond Life Sciences Center, Columbia, MO 65211, USA; (C.A.R.); (T.D.L.); (S.W.)
| | - Lynn Rasmussen
- High-Throughput Screening Center, Drug Discovery Division, Southern Research, Birmingham, AL 35205, USA; (L.R.); (N.M.N.); (R.B.)
| | - N. Miranda Nebane
- High-Throughput Screening Center, Drug Discovery Division, Southern Research, Birmingham, AL 35205, USA; (L.R.); (N.M.N.); (R.B.)
| | - Vandana V. Gupta
- Department of Chemistry, Drug Discovery Division, Southern Research, Birmingham, AL 35205, USA; (V.V.G.); (S.A.); (C.E.A.-S.)
| | - Sam Ananthan
- Department of Chemistry, Drug Discovery Division, Southern Research, Birmingham, AL 35205, USA; (V.V.G.); (S.A.); (C.E.A.-S.)
| | - Zhaohui Cai
- Infectious Disease Research, Drug Development Division, Southern Research, Frederick, MD 21701, USA; (Y.V.K.); (Z.C.); (E.R.W.); (R.G.P.); (S.M.S.)
| | - Elizabeth R. Wonderlich
- Infectious Disease Research, Drug Development Division, Southern Research, Frederick, MD 21701, USA; (Y.V.K.); (Z.C.); (E.R.W.); (R.G.P.); (S.M.S.)
| | - Corinne E. Augelli-Szafran
- Department of Chemistry, Drug Discovery Division, Southern Research, Birmingham, AL 35205, USA; (V.V.G.); (S.A.); (C.E.A.-S.)
| | - Robert Bostwick
- High-Throughput Screening Center, Drug Discovery Division, Southern Research, Birmingham, AL 35205, USA; (L.R.); (N.M.N.); (R.B.)
| | - Roger G. Ptak
- Infectious Disease Research, Drug Development Division, Southern Research, Frederick, MD 21701, USA; (Y.V.K.); (Z.C.); (E.R.W.); (R.G.P.); (S.M.S.)
| | - Susan M. Schader
- Infectious Disease Research, Drug Development Division, Southern Research, Frederick, MD 21701, USA; (Y.V.K.); (Z.C.); (E.R.W.); (R.G.P.); (S.M.S.)
| | - Marc C. Johnson
- Department of Molecular Microbiology and Immunology, University of Missouri, School of Medicine and the Christopher S. Bond Life Sciences Center, Columbia, MO 65211, USA; (C.A.R.); (T.D.L.); (S.W.)
- Correspondence:
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Alebel A, Demant D, Petrucka P, Sibbritt D. Does undernutrition increase the risk of lost to follow-up in adults living with HIV in sub-Saharan Africa? Protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e048022. [PMID: 34907042 PMCID: PMC8671928 DOI: 10.1136/bmjopen-2020-048022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Undernutrition is considered a marker for poor prognosis among people living with HIV (PLHIV), particularly in sub-Saharan Africa (SSA), where undernutrition and HIV are both highly prevalent. Evidence suggests that undernutrition (body mass index <18.5 kg/m2) is one of the main factors that significantly increases the risk of lost to follow-up (LTFU) in PLHIV. However, primary studies in SSA have reported inconsistent findings on the relationship between undernutrition and LTFU among adults living with HIV. To the best of our knowledge, no systematic review which aimed to summarise the available evidence. Hence, this review aims to determine the pooled effect of undernutrition on LTFU among adults living with HIV in SSA. METHODS AND ANALYSIS PubMed, EMBASE, Web of Science, Scopus, and, for grey literature, Google Scholar will be systematically searched to include relevant articles published since 2005. Studies reporting the effect of undernutrition on LTFU in adults living with HIV in SSA will be included. The Newcastle-Ottawa Scale will be used for quality assessment. Data from eligible studies will be extracted using a standardised data extraction tool. Heterogeneity between included studies will be assessed using Cochrane Q-test and I2 statistics. The Egger's and Begg's tests at a 5% significance level will be used to evaluate publication bias. As heterogeneity is anticipated, the pooled effect size will be estimated using a random-effects model. The final effect size will be reported using the adjusted HR with a 95% CI. ETHICS AND DISSEMINATION Ethical approval is not required for a protocol for a systematic review. The results of this systematic review will be published in a peer-reviewed journal and will be publicly available. PROSPERO REGISTRATION NUMBER CRD42021277741.
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Affiliation(s)
- Animut Alebel
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
- School of Public Helath, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Daniel Demant
- School of Public Helath, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - Pammla Petrucka
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
| | - David Sibbritt
- School of Public Helath, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
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Stopping, starting, and sustaining HIV antiretroviral therapy: a mixed-methods exploration among African American/Black and Latino long-term survivors of HIV in an urban context. BMC Public Health 2021; 21:419. [PMID: 33639904 PMCID: PMC7912958 DOI: 10.1186/s12889-021-10464-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 02/18/2021] [Indexed: 11/30/2022] Open
Abstract
Background Although periods of HIV antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained. Yet, little is known about factors that contribute to such ART non-persistence among long-term HIV survivors. The present study applied a convergent parallel mixed-methods design to explore the phenomena of stopping/starting and sustaining ART, focusing on low-socioeconomic status African American or Black and Latino persons living with HIV (PLWH) who face the greatest challenges. Methods Participants (N = 512) had poor engagement in HIV care and detectable HIV viral load. All received structured assessments and N = 48 were randomly selected for in-depth interviews. Quantitative analysis using negative binomial regression uncovered associations among multi-level factors and the number of times ART was stopped/started and the longest duration of sustained ART. Qualitative data were analyzed using a directed content analysis approach and results were integrated. Results Participants were diagnosed 18.2 years ago on average (SD = 8.6), started ART a median five times (Q1 = 3, Q3 = 10), and the median longest duration of sustained ART was 18 months (Q1 = 6, Q3 = 36). Factors associated with higher rates of stops/starts were male sex, transgender identity, cannabis use at moderate-to-high-risk levels, and ART- and care-related stigma. Factors associated with lower rates of stops/starts were older age, more years since diagnosis, motivation for care, and lifetime injection drug use (IDU). Factors associated with longer durations of sustained ART were Latino/Hispanic ethnicity, motivation for ART and care, and recent IDU. Factors associated with a shorter duration were African American/Black race, alcohol use at moderate-to-high-risk levels, and social support. Qualitative results uncovered a convergence of intersecting risk factors for stopping/starting ART and challenges inherent in managing HIV over decades in the context of poverty. These included unstable housing, which contributed to social isolation, mental health distress, and substance use concerns, the latter prompting selling (“diverting”) ART. Primarily complementary quantitative and qualitative findings described mechanisms by which risk/protective factors operated and ways PLWH successfully restart and/or sustain ART. Conclusions The field focuses substantially on ART adherence, but greater attention to reducing the frequency of ART non-persistence is needed, along with creating social/structural conditions favorable for sustained ART. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10464-x.
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Fleming T, Collins AB, Bardwell G, Fowler A, Boyd J, Milloy MJ, Small W, McNeil R. A qualitative investigation of HIV treatment dispensing models and impacts on adherence among people living with HIV who use drugs. PLoS One 2021; 16:e0246999. [PMID: 33635886 PMCID: PMC7909635 DOI: 10.1371/journal.pone.0246999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 01/29/2021] [Indexed: 12/03/2022] Open
Abstract
Antiretroviral therapy (ART) dispensing is strongly associated with treatment adherence. Among illicit drug-using populations, whom experience greater structural barriers to adherence, directly administered antiretroviral therapy (DAAT) is often regarded as a stronger predictor of optimal adherence over self-administered medications. In Vancouver, Canada, people living with HIV (PLHIV) who use drugs and live in low-income housing are a critical population for treatment support. This group is typically able to access two key DAAT models, daily delivery and daily pickup, in addition to ART self-administration. This ethno-epidemiological qualitative study explores how key dispensing models impact ART adherence among PLHIV who use drugs living in low-income housing, and how this is framed by structural vulnerability. Semi-structured interviews lasting 30-45 minutes were conducted between February and May 2018 with 31 PLHIV who use drugs recruited from an ongoing prospective cohort of PLHIV who use drugs. Interviews were audio-recorded, transcribed verbatim, and analyzed using QSR International's NVivo 12 software. Interviews focused on housing, drug use, and HIV management. Models that constrained agency were found to have negative impacts on adherence and quality of life. Treatment interruptions were framed by structural vulnerabilities (e.g., housing vulnerability) that impacted ability to maintain adherence under certain dispensing models, and led participants to consider other models. Participants using DAAT models which accounted for their structural vulnerabilities (e.g., mobility issues, housing instability), credited these models for their treatment adherence, but also acknowledged factors that constrained agency, and the negative impacts this could have on both adherence, and quality of life. Being able to integrate ART into an established routine is key to supporting ART adherence. ART models that account for the structural vulnerability of PLHIV who use drugs and live in low-income housing are necessary and housing-based supports could be critical, but the impacts of such models on agency must be considered to ensure optimal adherence.
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Affiliation(s)
- Taylor Fleming
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, BC, Canada
| | - Alexandra B. Collins
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, Canada
| | - Al Fowler
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, Canada
| | - M. J. Milloy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, Canada
| | - Will Small
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Ryan McNeil
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
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Pons-Faudoa FP, Trani ND, Sizovs A, Shelton KA, Momin Z, Bushman LR, Xu J, Lewis DE, Demaria S, Hawkins T, Rooney JF, Marzinke MA, Kimata JT, Anderson PL, Nehete PN, Arduino RC, Sastry KJ, Grattoni A. Viral load Reduction in SHIV-Positive Nonhuman Primates via Long-Acting Subcutaneous Tenofovir Alafenamide Fumarate Release from a Nanofluidic Implant. Pharmaceutics 2020; 12:E981. [PMID: 33080776 PMCID: PMC7590004 DOI: 10.3390/pharmaceutics12100981] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
HIV-1 is a chronic disease managed by strictly adhering to daily antiretroviral therapy (ART). However, not all people living with HIV-1 have access to ART, and those with access may not adhere to treatment regimens increasing viral load and disease progression. Here, a subcutaneous nanofluidic implant was used as a long-acting (LA) drug delivery platform to address these issues. The device was loaded with tenofovir alafenamide (TAF) and implanted in treatment-naïve simian HIV (SHIV)-positive nonhuman primates (NHP) for a month. We monitored intracellular tenofovir-diphosphate (TFV-DP) concentration in the target cells, peripheral blood mononuclear cells (PBMC). The concentrations of TFV-DP were maintained at a median of 391.0 fmol/106 cells (IQR, 243.0 to 509.0 fmol/106 cells) for the duration of the study. Further, we achieved drug penetration into lymphatic tissues, known for persistent HIV-1 replication. Moreover, we observed a first-phase viral load decay of -1.14 ± 0.81 log10 copies/mL (95% CI, -0.30 to -2.23 log10 copies/mL), similar to -1.08 log10 copies/mL decay observed in humans. Thus, LA TAF delivered from our nanofluidic implant had similar effects as oral TAF dosing with a lower dose, with potential as a platform for LA ART.
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Affiliation(s)
- Fernanda P. Pons-Faudoa
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA; (F.P.P.-F.); (N.D.T.); (A.S.)
- School of Medicine and Health Sciences, Tecnologico de Monterrey, Monterrey 64710, NL, Mexico
| | - Nicola Di Trani
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA; (F.P.P.-F.); (N.D.T.); (A.S.)
- College of Materials Sciences and Opto-Electronic Technology, University of Chinese Academy of Science (UCAS), Shijingshan, Beijing 100049, China
| | - Antons Sizovs
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA; (F.P.P.-F.); (N.D.T.); (A.S.)
| | - Kathryn A. Shelton
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA; (K.A.S.); (P.N.N.); (K.J.S.)
| | - Zoha Momin
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA; (Z.M.); (J.T.K.)
| | - Lane R. Bushman
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-Anschutz Medical Campus, Aurora, CO 80045, USA; (L.R.B.); (P.L.A.)
| | - Jiaqiong Xu
- Center for Outcomes Research and DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston, TX 77030, USA;
- Weill Medical College of Cornell University, New York, NY 10065, USA
| | | | - Sandra Demaria
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, USA;
- Department of Pathology and Laboratory of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Trevor Hawkins
- Gilead Sciences, Inc., Foster City, CA 94404, USA; (T.H.); (J.F.R.)
| | - James F. Rooney
- Gilead Sciences, Inc., Foster City, CA 94404, USA; (T.H.); (J.F.R.)
| | - Mark A. Marzinke
- Departments of Pathology and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA;
| | - Jason T. Kimata
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA; (Z.M.); (J.T.K.)
| | - Peter L. Anderson
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-Anschutz Medical Campus, Aurora, CO 80045, USA; (L.R.B.); (P.L.A.)
| | - Pramod N. Nehete
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA; (K.A.S.); (P.N.N.); (K.J.S.)
- The University of Texas MD Anderson Cancer Center UTH Health Graduate School of Biomedical Sciences, Houston, TX 77030, USA
| | - Roberto C. Arduino
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX 77030, USA;
| | - K. Jagannadha Sastry
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA; (K.A.S.); (P.N.N.); (K.J.S.)
- Department of Thoracic Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Alessandro Grattoni
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA; (F.P.P.-F.); (N.D.T.); (A.S.)
- Department of Surgery, Houston Methodist Research Institute, Houston, TX 77030, USA
- Department of Radiation Oncology, Houston Methodist Research Institute, Houston, TX 77030, USA
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Law JKC, Butler LT, Hamill MM. Predictors of Discontinuation of Efavirenz as Treatment for HIV, Due to Neuropsychiatric Side Effects, in a Multi-Ethnic Sample in the United Kingdom. AIDS Res Hum Retroviruses 2020; 36:459-466. [PMID: 31931589 DOI: 10.1089/aid.2019.0193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Efavirenz (EFV) is one of the most commonly prescribed antiretroviral therapy (ART) medications for human immunodeficiency virus-infected adults because of its favorable pharmacokinetic profile and well-documented efficacy. Nonetheless, neuropsychiatric adverse events (AE) occur in almost half of the EFV users and it is the main reason for treatment discontinuation. To identify the sociodemographic characteristics and reported neuropsychiatric side effects that placed EFV users at an increased risk of discontinuation in a multi-ethnic sample in the United Kingdom. A retrospective medical records analysis of patients prescribed EFV-containing ART in an outpatient sexual health clinic between 2010 and 2016. One hundred forty-nine medical records were reviewed. Fifty-five patients discontinued EFV within the study period. About 55.7% of patients suffered from at least one neuropsychiatric AE, the most commonly recorded symptoms were depression, vivid dreams, dizziness, and sleep disturbance. There was an inverse relationship between number of AE and EFV continuation [adjust odds ratio (OR) = 0.12; confidence interval (95% CI) = 0.03-0.44, p < .05]. Furthermore, neuropsychiatric symptoms, including depression (adjust OR = 3.01; 95% CI = 1.30-6.96, p < .05), sleep disturbance (adjust OR = 3.00; 95% CI = 1.10-8.19, p < .05), and vivid dreams (adjust OR = 2.51; 95% CI = 1.05-6.00, p < .05), were independent predictors of EFV discontinuation. The findings revealed that patients who did not experience any neuropsychiatric side effects were eight times more likely to stay on an EFV-containing regimen than those who suffered from more than three symptoms. Additionally, patients who experienced depression or sleep disturbance were at threefold elevated risk of discontinuing an EFV-based regimen. The implications for clinical practice are discussed.
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Affiliation(s)
- Johnson Kai Chun Law
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, United Kingdom
| | - Laurie T Butler
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, United Kingdom
- Faculty of Science and Engineering, Anglia Ruskin University, Cambridge, United Kingdom
| | - Matthew M Hamill
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Sexual Health, Berkshire Healthcare NHS Foundation Trust, Bracknell, United Kingdom
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Abstract
OBJECTIVE To determine the incidence of antiretroviral therapy (ART) adherence among treatment-naive HIV-infected patients and to evaluate the impact of single-tablet regimen (STR) on ART adherence among this population. DESIGN Retrospective cohort study. METHODS We used a nationally representative sample of IQVIA LRx Lifelink individual level pharmacy claims database during 2011-2016, and defined adult patients with index date (first complete ART regimen prescription fill date) after 30 June 2011 as treatment naïve. We estimated ART adherence, measured as the proportion of days covered during 1 year following the index date. We conducted multivariable analysis to identify the factors associated with optimum adherence (≥90% proportion of days covered). We also compared adherence between patients prescribed STR and multiple-tablet regimens among those prescribed integrase strand transfer inhibitor-based or nonnucleoside reverse transcriptase inhibitor-based regimens. RESULTS Overall 42.9% of the patients were optimally adherent. Adherence was significantly lower among blacks, Hispanics and patients in low-income communities. Adjusting for the covariates, patients on STR had higher incidence of optimum adherence compared with those on multiple-tablet regimens among patients on integrase strand transfer inhibitor-based regimens [49 vs. 24%, relative risk, 2.16 (95% confidence interval: 1.96-2.26)], but no significant difference was observed among those on nonnucleoside reverse transcriptase inhibitor-based regimen [45 vs. 45%, relative risk, 1.12 (95% confidence interval: 0.99-1.26)]. CONCLUSION Low ART adherence observed among treatment-naive patients in this nationally representative study suggests the need for public health interventions to improve adherence among this population.
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Factors Associated With Gaps in Medicaid Enrollment Among People With HIV and the Effect of Gaps on Viral Suppression. J Acquir Immune Defic Syndr 2019; 78:413-420. [PMID: 29697594 DOI: 10.1097/qai.0000000000001702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Gaps in Medicaid enrollment may affect HIV outcomes. We evaluated factors associated with Medicaid enrollment gaps and their effect on viral suppression (VS) within the HIV Research Network. METHODS We used a combined data set with Medicaid enrollment files from 2006 to 2010 and HIV Research Network demographic and clinical data. A gap was defined as ≥1 month without Medicaid and gap length was determined. We used multivariable logistic regression to determine factors associated with a gap and multivariable logistic regression with generalized estimated equations to evaluate factors associated with VS after gap. RESULTS Of 5836 participants, the majority were male, of black race, and aged 25-50 years. More than half had a gap in Medicaid. Factors associated with a gap included male sex [adjusted odds ratio (aOR) 1.79, (1.53, 2.08)] and younger age (aORs ranging from 1.50 to 4.13 comparing younger age groups to age >50, P < 0.05 for all). About a quarter of gaps had VS information before and after gap. Of those, 53.7% had VS both before and after gap and 25.8% were unsuppressed both before and after gap. The strongest association with VS after gap was VS before gap [aOR 15.76 (10.48, 23.69)]. Transition into Ryan White HIV/AIDS Program coverage during Medicaid gaps was common (28% of all transitions). CONCLUSIONS Gaps in Medicaid enrollment were common and many individuals with pre-gap VS maintained VS after gap, possibly due to accessing other sources of antiretroviral therapy coverage. Implementing initiatives to maintain Medicaid enrollment and to expedite Medicaid reenrollment and having alternate resources available in gaps are important to ensure continuous antiretroviral therapy to optimize HIV outcomes.
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Balayan T, Oprea C, Yurin O, Jevtovic D, Begovac J, Lakatos B, Sedlacek D, Karpov I, Horban A, Kowalska JD. People who inject drugs remain hard-to-reach population across all HIV continuum stages in Central, Eastern and South Eastern Europe - data from Euro-guidelines in Central and Eastern Europe Network. Infect Dis (Lond) 2019; 51:277-286. [PMID: 30786803 DOI: 10.1080/23744235.2019.1565415] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND/OBJECTIVES Inadequate HIV care for hard-to-reach populations may result in failing the UNAIDS 90-90-90 goal. Therefore, we aimed to review the HIV continuum of care and hard-to-reach populations for each step of the continuum in Central, Eastern and South Eastern Europe. METHODS Euro-guidelines in Central and Eastern Europe (ECEE) Network Group were created in February 2016. The aim of the network was to review the standards of HIV care in the countries of the region. Information about each stage of HIV continuum of care and hard-to-reach populations for each stage was collected through on-line surveys. Respondents were ECEE members chosen based on their expertise and involvement in national HIV care. Data sources (year 2016) used by respondents included HIV Clinics electronic databases, Institutes of Public Health, Centres for AIDS Prevention, and HIV Programme Reviews. RESULTS The percentage of people living with HIV (PLHIV) linked to HIV care after HIV diagnosis was ranged between 80% and 96% in Central Europe, 51% and 92% in Eastern Europe and 80% and 100% in South-Eastern Europe. The percentage of PLHIV who are on ART was ranged from 80% to 93% in Central Europe, 18% to 92% in Eastern Europe and 80% to 100% in South-Eastern Europe. The percentage of people virologically suppressed while on ART was reported as 70-95%, 12-95% and 62-97% in Central, Eastern, and South Eastern Europe, respectively. All three regions reported people who inject drugs (PWID) as hard-to-reach population across all HIV continuum stages. Migrants were the second most reported hard-to-reach population. The proportion of late presenters among newly diagnosed ranged between 20% and 55%, 40% and 55% and 48% and 60% in Central, Eastern and South Eastern Europe, respectively. Four countries reported ARVs' delivery delays resulting in treatment interruptions in 2016: two (25%) in South-Eastern, one (20%) in Central and 1 (16.7%) in Eastern Europe. CONCLUSION Irrespective of the diversity in national HIV epidemics, countries from all three regions reported PWIDs as hard-to-reach population across all HIV continuum stages. Some countries are close to the UNAIDS 2020 goals, others need to strive for progress. However, differences in data sources and variations in definitions limit the utility of continuum of care as a comparative tool.
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Affiliation(s)
- Tatevik Balayan
- a National Center for Disease Control and Prevention , Yerevan , Armenia
| | - Cristiana Oprea
- b Victor Babes Clinical Hospital for Infectious Diseases, Carol Davila University of Medicine and Pharmacy , Bucharest , Romania
| | - Oleg Yurin
- c Central Research Institute of Epidemiology, Federal AIDS Centre , Moscow , Russian Federation
| | - Djorde Jevtovic
- d Belgrade University Medical School, Infectious Diseases Hospital , Belgrade Serbia
| | - Josip Begovac
- e University of Zagreb School of Medicine, University Hospital of Infectious Diseases , Zagreb , Croatia
| | - Botond Lakatos
- f Saint Laszlo Hospital National Center of HIV, Semmelweis University Faculty of Infectious Diseases , Budapest , Hungary
| | - Dalibor Sedlacek
- g Charles University Hospital in Pilsen , Pilsen , Czech Republic
| | - Igor Karpov
- h Belarus State Medical University , Minsk , Belarus
| | - Andrzej Horban
- i Hospital for Infectious Diseases Medical University of Warsaw , Warsaw , Poland
| | - Justyna D Kowalska
- i Hospital for Infectious Diseases Medical University of Warsaw , Warsaw , Poland
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Monroe AK, Lesko CR, Chander G, Lau B, Keruly J, Crane HM, Amico KR, Napravnik S, Quinlivan EB, Mugavero MJ. Ancillary service needs among persons new to HIV care and the relationship between needs and late presentation to care. AIDS Care 2019; 31:1131-1139. [PMID: 30776911 DOI: 10.1080/09540121.2019.1576840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Ancillary service needs likely influence time to diagnosis and presentation for HIV care. The effect of both met and unmet needs on late presentation to HIV care is not well understood. We used baseline data from 348 people with HIV (PWH) with no prior HIV care who enrolled in iENGAGE (a randomized controlled trial (RCT) of an intervention to support retention in care) at one of four HIV clinics in the US. A standardized baseline questionnaire collected information on ancillary service needs, and whether each need was presently unmet. We examined covariates known to be associated with disease stage at presentation to care and their association with needs. We subsequently assessed the relationship of needs with CD4 accounting for those other covariates by estimating prevalence ratios (PR) using inverse probability weights. Most patients enrolling in the RCT were male (79%) and the majority were Black (62%); median age was 34 years. Prevalence of any reported individual need was 69%. One-third of the sample had a baseline CD4 cell count <200, 42% between 200 and 499 and 27% ≥500. There was no statistically significant association between need or unmet need and baseline CD4. In general, psychiatric health and SU issues (depression, anxiety, and drug use) were consistently associated with higher prevalence of need (met and unmet). Additionally, the Black race was associated with higher basic resource needs (housing: PR 1.67, 95%CI 1.08-2.59; transportation: PR 1.65, 95% CI 1.12-2.45). Ancillary service needs (met and unmet) were common among patients new to HIV care and impacted vulnerable subgroups. However, we found no evidence that reporting a specific individual need, whether met or unmet, was associated with a timely presentation to HIV care. The impact of needs on subsequent steps of the HIV care continuum will be examined with longitudinal data.
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Affiliation(s)
- Anne K Monroe
- a Johns Hopkins University School of Medicine , Baltimore , MD , USA.,b Department of Epidemiology and Biostatistics , Milken Institute School of Public Health, George Washington University , Washington , DC , USA
| | - Catherine R Lesko
- c Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | | | - Bryan Lau
- c Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Jeanne Keruly
- d Adult Ryan White Services , Johns Hopkins University , Baltimore , MD , USA
| | - Heidi M Crane
- e Harborview Medical Center , University of Washington , Seattle , WA , USA
| | - K Rivet Amico
- f Department of Health Behavior and Health Education , School of Public Health, University of Michigan , Ann Arbor , MI , USA
| | | | - E Byrd Quinlivan
- h Institute for Global Health and Infectious Diseases , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Michael J Mugavero
- i Division of Infectious Diseases , University of Alabama at Birmingham (UAB) , Birmingham , AL , USA
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14
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Hines DM, Ding Y, Wade RL, Beaubrun A, Cohen JP. Treatment Adherence And Persistence Among HIV-1 Patients Newly Starting Treatment. Patient Prefer Adherence 2019; 13:1927-1939. [PMID: 31806941 PMCID: PMC6844203 DOI: 10.2147/ppa.s207908] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 08/01/2019] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To assess adherence and persistence with first-line single-tablet regimen (STR) and multi-tablet regimen (MTR) antiretroviral therapy (ART) in newly treated HIV-1 patients. METHODS Retrospective analysis of longitudinal pharmacy claims among US patients initiating ART between 1/1/2016 and 5/31/2016 (index date was defined by first ART claim for STRs, and fill date for the last therapy in the regimen for MTRs). Adherence was assessed over a 12-month period and reported as the proportion of adherent or non-adherent (defined as ≤5-day and > a 5-day gap between successive fills, respectively) patients. Sensitivity analysis using ≤7-day and ≤14-day gap thresholds to define adherence was performed. Persistence was assessed as the number of days on therapy from index until treatment discontinuation (>90 day gap in therapy). Kaplan-Meier curves and Cox Proportional Hazard models were generated to evaluate discontinuation rates. Assessments were performed on STRs vs MTRs overall and by regimen. RESULTS Patients initiating ART (STR: n=10,623; MTR: n=2504) had a mean age of 42.8 years; 76.0% were male. STR patients were >2 times more likely to be adherent over 12 months than MTR patients (24.9% vs 11.7%, respectively). Patients using EVG/COBI/FTC/TAF had greater adherence than those using other STRs. Among MTRs, patients were more adherent with FTC/TDF+DTG (15.1%) than other MTRs. Persistence was also greater with STRs, with MTR patients being 61% more likely to discontinue therapy. Persistence was best for FTC/TAF-based regimens. Predictors of treatment discontinuation included younger age, female gender, and Medicare or Medicaid insurance type. CONCLUSION Patients receiving STRs were significantly less likely to discontinue therapy and were more adherent with their regimens, providing further evidence of greater adherence and persistence with STRs versus MTRs. However, there was a large proportion of patients who interrupted or discontinued treatment. Further research examining treatment patterns beyond first line is warranted.
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Affiliation(s)
- Dionne M Hines
- Health Economics and Outcomes Research, IQVIA Inc, Plymouth Meeting, PA, USA
| | - Yao Ding
- Health Economics and Outcomes Research, IQVIA Inc, Plymouth Meeting, PA, USA
| | - Rolin L Wade
- Health Economics and Outcomes Research, IQVIA Inc, Plymouth Meeting, PA, USA
- Correspondence: Rolin L Wade IQVIA Inc., One IMS Drive, Plymouth Meeting, PA19462, USATel +1 215 434 812 2958 Email
| | - Anne Beaubrun
- Health Economics and Outcomes Research, Gilead Sciences Inc, Foster City, CA, USA
| | - Joshua P Cohen
- Institute for Clinical Research and Health Policy Studies, Tufts University, Boston, MA, USA
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15
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Tandon N, Mao J, Shprecher A, Anderson AJ, Cao F, Jiao X, Brown K. Compliance with clinical guidelines and adherence to antiretroviral therapy among patients living with HIV. Curr Med Res Opin 2019; 35:63-71. [PMID: 30173561 DOI: 10.1080/03007995.2018.1519499] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Evaluation of provider compliance with antiretroviral (ARV) treatment guidelines and patient adherence to ARVs is important for HIV care quality assessment; however, there are few current real-world data for guideline compliance and ARV adherence in the US. This study evaluated provider compliance with US Department of Health and Human Services (DHHS) guidelines and patient adherence to ARVs in a US population of patients with HIV.Methods: This was a retrospective claims study of adults with HIV-1 receiving ARV treatment between January 2010-December 2014. Follow-up began at first ARV treatment and ended at health plan disenrollment or study end. ARV regimens for treatment-naïve patients were categorized as "preferred/recommended", "alternative", or "non-preferred/recommended/alternative" according to DHHS guidelines. ARV adherence was evaluated using proportion of days covered (PDC) and medication possession ratio (MPR).Results: The analysis included 25,320 patients (84.4% male, mean age 45.3 years) and 39,071 regimens. Preferred/recommended regimens were most common during each study year, but the proportion of non-preferred/recommended/alternative regimens was substantial (15.9-20.6%). Only 53.6% of patients had optimal adherence by PDC ≥0.95, and 57.9% by MPR ≥0.95. Guideline non-compliance and sub-optimal adherence were more prevalent among female vs male patients (22.6% vs 14.8% [in 2014] and 65.9% vs 53.7%, respectively).Conclusions: Provider non-compliance with DHHS guidelines and sub-optimal ARV adherence among patients with HIV remain common in real-world practice, particularly for female patients. Healthcare providers should follow the latest clinical guidelines to ensure that patients receive recommended therapy, and address non-adherence when selecting ARV regimens.
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Affiliation(s)
- Neeta Tandon
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | | | | | | | - Xiaolong Jiao
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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Trends in antiretroviral therapy prescription, durability and modification: new drugs, more changes, but less failure. AIDS 2018; 32:347-355. [PMID: 29194118 DOI: 10.1097/qad.0000000000001708] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the real world durability of contemporary ART for treatment-naïve people living with HIV (PLWH). DESIGN A retrospective follow-up study in a multisite cohort. METHODS This study of the CNICS (CFAR Network of Integrated Clinical Systems) cohort integrates data from eight Center for AIDS Research (CFARs). PLWH initiating ART between 2007 and 2014 were included. Durability was defined as time from the initiation until discontinuation/modification using Kaplan-Meier survival curves. Cox Proportional Hazards measured associations with various sociodemographic and clinical characteristics. RESULTS Among 5373 PLWH, the initial regimen was modified in 2285 (43%) patients. Efavirenz/emtricitabine/tenofovir (n = 2173, 40%) was the most commonly prescribed initial ART regimen; elvitegravir/cobicistat/emtricitabine/tenofovir became more common after 2012. Median durability for all regimens was 48.6 months. There were statistically significant differences in median durability for NNRTI, InSTI, and protease inhibitor-based regimens, which lasted 61, 44, and 32 months, respectively. Female sex (aHR = 1.4; 95% CI 1.2-1.6), intravenous drug use (aHR = 1.6; 95% CI 1.3-1.9), and CD4 cell count less than 200 cells/μl (aHR = 1.2; 95% CI 1.1-1.3) were significantly associated with regimen modification. Compared with InSTI, those receiving an InSTI/protease inhibitor (aHR = 2.7; 95% CI 2.0-3.7) or protease inhibitor-based ART (aHR = 1.9; 95% CI 1.6-2.2) were significantly more likely to be modified; but those receiving NNRTI (aHR = 1.1; 95% CI 0.9-1.3) were not. CONCLUSION In treatment-naive PLWH, NNRTI and InSTI-based ART were most durable, relative to protease inhibitor and InSTI/protease inhibitor-based ART, and were least likely to be modified/discontinued. A greater understanding of reasons for regimen modification/discontinuation is needed to analyze contemporary regimen durability.
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Abstract
OBJECTIVE Whether the rate of HIV antiretroviral therapy (ART) persistence has improved over time in the United States is unknown. We examined ART persistence trends between 2001 and 2010, using non-HIV medications as a comparator. METHODS We conducted a retrospective cohort study using Medicaid claims. We defined persistence as the duration of treatment from the first to the last fill date before a 90-day permissible gap and used Kaplan-Meier curves and Cox proportional hazard models to assess crude and adjusted nonpersistence. The secular trends of ART persistence in 43 598 HIV patients were compared with the secular trends of persistence with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEI/ARB), statins, and metformin in non-HIV-infected patients and subgroups of HIV patients who started these control medications while using ART. RESULTS Median time to ART nonpersistence increased from 23.9 months in 2001-2003 to 35.4 months in 2004-2006 and was not reached for those starting ART in 2007-2010. In adjusted models, ART initiators in 2007-2010 had 11% decreased hazard of nonpersistence compared with those who initiated in 2001-2003 (P < 0.001). For non-HIV patients initiating angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), statins, and metformin, the hazard ratios for nonpersistence comparing 2007-2010 to 2001-2003 were 1.07, 0.94, and 1.02, respectively (all P < 0.001). For HIV patients initiating the three control medications, the hazard ratios of nonpersistence comparing 2007-2010 to 2001-2003 were 0.71, 0.65, and 0.63, respectively (all P < 0.001). CONCLUSION Persistence with ART improved between 2001 and 2010. Persistence with control medications improved at a higher rate among HIV patients using ART than HIV-negative controls.
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Edmonds A, Ludema C, Eron JJ, Cole SR, Adedimeji AA, Cohen MH, Cooper HL, Fischl M, Johnson MO, Krause DD, Merenstein D, Milam J, Wilson TE, Adimora AA. Effects of Health Insurance Interruption on Loss of Hypertension Control in Women With and Women Without HIV. J Womens Health (Larchmt) 2017; 26:1292-1301. [PMID: 28682658 DOI: 10.1089/jwh.2016.6308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Among low-income women with and without HIV, it is a priority to reduce age-related comorbidities, including hypertension and its sequelae. Because consistent health insurance access has been identified as an important factor in controlling many chronic diseases, we estimated the effects of coverage interruption on loss of hypertension control in a cohort of women in the United States. METHODS We analyzed prospective, longitudinal data from the Women's Interagency HIV Study. HIV-infected and HIV-uninfected women were included between 2005 and 2014 when they reported health insurance at consecutive biannual visits and had controlled hypertension, and were followed for any insurance break and loss of hypertension control. We estimated hazard ratios (HRs) by Cox proportional hazards regression with inverse-probability-of-treatment-and censoring weights (marginal structural models), and plotted the cumulative incidence of hypertension control loss. RESULTS Among 890 HIV-infected women, the weighted HR for hypertension control loss comparing health insurance interruption to uninterrupted coverage was 1.37 (95% confidence interval [CI], 0.99-1.91). Inclusion of AIDS Drug Assistance Program (ADAP) participation with health insurance modestly increased the HR (1.47; 95% CI, 1.04-2.07). Analysis of 272 HIV-uninfected women yielded a similar HR (1.39; 95% CI, 0.88-2.21). Additionally, there were indications of uninterrupted coverage having a protective effect on hypertension when compared with the natural course in HIV-infected (HR, 0.82; 95% CI, 0.61-1.11) and HIV-uninfected (HR, 0.78; 95% CI, 0.52-1.19) women. CONCLUSIONS This study provides evidence that health insurance continuity promotes hypertension control in key populations. Interventions that ensure coverage stability and ADAP access should be a policy priority.
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Affiliation(s)
- Andrew Edmonds
- 1 Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Christina Ludema
- 2 Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Joseph J Eron
- 2 Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Stephen R Cole
- 1 Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Adebola A Adedimeji
- 3 Department of Epidemiology and Population Health, Albert Einstein College of Medicine , Bronx, New York
| | - Mardge H Cohen
- 4 Department of Medicine, Cook County Health and Hospital System and Rush University , Chicago, Illinois
| | - Hannah L Cooper
- 5 Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University , Atlanta, Georgia
| | - Margaret Fischl
- 6 Division of Infectious Diseases, Department of Medicine, University of Miami School of Medicine , Miami, Florida
| | - Mallory O Johnson
- 7 Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Denise D Krause
- 8 Department of Biomedical Materials Science, School of Dentistry, University of Mississippi Medical Center , Jackson, Mississippi
| | - Dan Merenstein
- 9 Department of Family Medicine, Georgetown University Medical Center , Washington, District of Columbia
| | - Joel Milam
- 10 Department of Preventive Medicine, Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Tracey E Wilson
- 11 Department of Community Health Sciences, School of Public Health, State University of New York (SUNY) Downstate Medical Center , Brooklyn, New York
| | - Adaora A Adimora
- 1 Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
- 2 Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
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Corless IB, Hoyt AJ, Tyer-Viola L, Sefcik E, Kemppainen J, Holzemer WL, Eller LS, Nokes K, Phillips JC, Dawson-Rose C, Rivero-Mendez M, Iipinge S, Chaiphibalsarisdi P, Portillo CJ, Chen WT, Webel AR, Brion J, Johnson MO, Voss J, Hamilton MJ, Sullivan KM, Kirksey KM, Nicholas PK. 90-90-90-Plus: Maintaining Adherence to Antiretroviral Therapies. AIDS Patient Care STDS 2017; 31:227-236. [PMID: 28514193 DOI: 10.1089/apc.2017.0009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Medication adherence is the "Plus" in the global challenge to have 90% of HIV-infected individuals tested, 90% of those who are HIV positive treated, and 90% of those treated achieve an undetectable viral load. The latter indicates viral suppression, the goal for clinicians treating people living with HIV (PLWH). The comparative importance of different psychosocial scales in predicting the level of antiretroviral adherence, however, has been little studied. Using data from a cross-sectional study of medication adherence with an international convenience sample of 1811 PLWH, we categorized respondent medication adherence as None (0%), Low (1-60%), Moderate (61-94%), and High (95-100%) adherence based on self-report. The survey contained 13 psychosocial scales/indices, all of which were correlated with one another (p < 0.05 or less) and had differing degrees of association with the levels of adherence. Controlling for the influence of race, gender, education, and ability to pay for care, all scales/indices were associated with adherence, with the exception of Berger's perceived stigma scale. Using forward selection stepwise regression, we found that adherence self-efficacy, depression, stressful life events, and perceived stigma were significant predictors of medication adherence. Among the demographic variables entered into the model, nonwhite race was associated with double the odds of being in the None rather than in the High adherence category, suggesting these individuals may require additional support. In addition, asking about self-efficacy, depression, stigma, and stressful life events also will be beneficial in identifying patients requiring greater adherence support. This support is essential to medication adherence, the Plus to 90-90-90.
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Affiliation(s)
- Inge B Corless
- 1 MGH Institute of Health Professions School of Nursing , Boston, Massachusetts
| | - Alex J Hoyt
- 1 MGH Institute of Health Professions School of Nursing , Boston, Massachusetts
| | | | | | - Jeanne Kemppainen
- 4 University of North Carolina-Wilmington School of Nursing , Wilmington, North Carolina
| | | | | | - Kathleen Nokes
- 6 Hunter-Bellevue School of Nursing , CUNY, New York, New York
| | | | | | | | | | | | | | - Wei-Ti Chen
- 12 School of Nursing, Yale University , New Haven, Connecticut
| | - Allison R Webel
- 13 Bolton School of Nursing, Case Western University , Cleveland, Ohio
| | - John Brion
- 14 College of Nursing, The Ohio State University , Columbus, Ohio
| | | | - Joachim Voss
- 13 Bolton School of Nursing, Case Western University , Cleveland, Ohio
| | | | | | | | - Patrice K Nicholas
- 1 MGH Institute of Health Professions School of Nursing , Boston, Massachusetts
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20
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McNeil R, Kerr T, Coleman B, Maher L, Milloy MJ, Small W. Antiretroviral Therapy Interruption Among HIV Postive People Who Use Drugs in a Setting with a Community-Wide HIV Treatment-as-Prevention Initiative. AIDS Behav 2017; 21:402-409. [PMID: 27351192 DOI: 10.1007/s10461-016-1470-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
HIV Treatment as Prevention (TasP) initiatives promote antiretroviral therapy (ART) access and optimal adherence (≥95 %) to produce viral suppression among people living with HIV (PLHIV) and prevent the onward transmission of HIV. ART treatment interruptions are common among PLHIV who use drugs and undermine the effectiveness of TasP. Semi-structured interviews were conducted with 39 PLHIV who use drugs who had experienced treatment ART interruptions in a setting with a community-wide TasP initiative (Vancouver, Canada) to examine influences on these outcomes. While study participants attributed ART interruptions to "treatment fatigue," our analysis revealed individual, social, and structural influences on these events, including: (1) prior adverse ART-related experiences among those with long-term treatment histories; (2) experiences of social isolation; and, (3) breakdowns in the continuity of HIV care following disruptive events (e.g., eviction, incarceration). Findings reconceptualise 'treatment fatigue' by focusing attention on its underlying mechanisms, while demonstrating the need for comprehensive structural reforms and targeted interventions to optimize TasP among drug-using PLHIV.
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Affiliation(s)
- Ryan McNeil
- BC Centre for Excellence in HIV/AIDS, 608 - 1081 Burrard Street, Vancouver, BC, V6T 1Z1, Canada.
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Thomas Kerr
- BC Centre for Excellence in HIV/AIDS, 608 - 1081 Burrard Street, Vancouver, BC, V6T 1Z1, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bill Coleman
- BC Centre for Excellence in HIV/AIDS, 608 - 1081 Burrard Street, Vancouver, BC, V6T 1Z1, Canada
| | - Lisa Maher
- Kirby Institute of Infection and Immunity, UNSW Australia, Sydney, Australia
| | - M J Milloy
- BC Centre for Excellence in HIV/AIDS, 608 - 1081 Burrard Street, Vancouver, BC, V6T 1Z1, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Will Small
- BC Centre for Excellence in HIV/AIDS, 608 - 1081 Burrard Street, Vancouver, BC, V6T 1Z1, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Di Biagio A, Cozzi-Lepri A, Prinapori R, Angarano G, Gori A, Quirino T, De Luca A, Costantini A, Mussini C, Rizzardini G, Castagna A, Antinori A, dʼArminio Monforte A. Discontinuation of Initial Antiretroviral Therapy in Clinical Practice: Moving Toward Individualized Therapy. J Acquir Immune Defic Syndr 2016; 71:263-71. [PMID: 26871881 PMCID: PMC4770376 DOI: 10.1097/qai.0000000000000849] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Study aim was to estimate the rate and identify predictors of discontinuation of first combination antiretroviral therapy (cART) in recent years. Methods: Patients who initiated first cART between January 2008 and October 2014 were included. Discontinuation was defined as stop of at least 1 drug of the regimen, regardless of the reason. All causes of discontinuation were evaluated and 3 main endpoints were considered: toxicity, intolerance, and simplification. Predictors of discontinuation were examined separately for all 3 endpoints. Kaplan–Meier analysis was used for the outcome discontinuation of ≥1 drug regardless of the reason. Cox regression analysis was used to identify factors associated with treatment discontinuation because of the 3 reasons considered. Results: A total of 4052 patients were included. Main reason for stopping at least 1 drug were simplification (29%), intolerance (21%), toxicity (19%), other causes (18%), failure (8%), planned discontinuation (4%), and nonadherence (2%). In a multivariable Cox model, predictors of discontinuation for simplification were heterosexual transmission (P = 0.007), being immigrant (P = 0.017), higher nadir lymphocyte T CD4+ cell (P = 0.011), and higher lymphocyte T CD8+ cell count (P = 0.025); for discontinuation due to intolerance: the use of statins (P = 0.029), higher blood glucose levels (P = 0.050). About toxicity: higher blood glucose levels (P = 0.010) and the use of zidovudine/lamivudine as backbone (P = 0.044). Conclusions: In the late cART era, the main reason for stopping the initial regimen is simplification. This scenario reflects the changes in recommendations aimed to enhance adherence and quality of life, and minimize drug toxicity.
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Affiliation(s)
- Antonio Di Biagio
- *Infectious Diseases Unit, IRCCS AOU S. Martino-IST, National Institute for Cancer Research, Genoa, Italy;†Department of Infection and Population Health, Division of Population Health, UCL Medical School, Royal Free Campus, London, United Kingdom;‡Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy;§Clinic of Infectious Diseases, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy;‖Infectious Diseases Unit, Busto Arsizio Hospital, Busto Arsizio (VA), Italy;¶Infectious Diseases Unit, Siena University Hospital, Siena, Italy;#Department of Health Sciences, University of Ancona, Ancona, Italy;**Infectious Diseases Clinic, Policlinico of Modena, University of Modena and Reggio Emilia, Modena, Italy;††Infectious Diseases Unit, Sacco Hospital, Milan, Italy;‡‡Infectious Diseases Unit, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy;§§National Institute for Infectious Diseases IRCCS L. Spallanzani, Rome, Italy; and‖‖Clinic of Infectious and Tropical Diseases, Department of Health Sciences, S Paolo Hospital, University of Milan, Milan, Italy
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22
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Christopoulos KA, Olender S, Lopez AM, Lekas HM, Jaiswal J, Mellman W, Geng E, Koester KA. Retained in HIV Care But Not on Antiretroviral Treatment: A Qualitative Patient-Provider Dyadic Study. PLoS Med 2015; 12:e1001863. [PMID: 26263532 PMCID: PMC4532493 DOI: 10.1371/journal.pmed.1001863] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/03/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patients retained in HIV care but not on antiretroviral therapy (ART) represent an important part of the HIV care cascade in the United States. Even in an era of more tolerable and efficacious ART, decision making in regards to ART offer and uptake remains complex and calls for exploration of both patient and provider perspectives. We sought to understand reasons for lack of ART usage in patients meeting the Health Resources Services Administration definition of retention as well as what motivated HIV primary care appointment attendance in the absence of ART. METHODS AND FINDINGS We conducted a qualitative study consisting of 70 in-depth interviews with ART-naïve and ART-experienced patients off ART and their primary care providers in two urban safety-net HIV clinics in San Francisco and New York. Twenty patients and their providers were interviewed separately at baseline, and 15 dyads were interviewed again after at least 3 mo and another clinic visit in order to understand any ART use in the interim. We applied dyadic analysis to our data. Nearly all patients were willing to consider ART, and 40% of the sample went on ART, citing education on newer antiretroviral drugs, acceptance of HIV diagnosis, social support, and increased confidence in their ability to adhere as facilitators. However, the strength of the provider recommendation of ART played an important role. Many patients had internalized messages from providers that their health was too good to warrant ART. In addition, providers, while demonstrating patient-centered care through sensitivity to patients experiencing psychosocial instability, frequently muted the offer of ART, at times unintentionally. In the absence of ART, lab monitoring, provider relationships, access to social services, opiate pain medications, and acute symptoms motivated care. The main limitations of this study were that treatment as prevention was not explored in depth and that participants were recruited from academic HIV clinics in the US, making the findings most generalizable to this setting. CONCLUSIONS Provider communication with regard to ART is a key focus for further exploration and intervention in order to increase ART uptake for those retained in HIV care.
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Affiliation(s)
- Katerina A Christopoulos
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Susan Olender
- Columbia University Comprehensive HIV Program, Columbia University Medical Center, New York, New York, United States of America
| | - Andrea M Lopez
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Helen-Maria Lekas
- Division of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | - Jessica Jaiswal
- Division of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | - Will Mellman
- Division of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | - Elvin Geng
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Kimberly A Koester
- Center of AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America
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23
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Newman CE, Mao L, Persson A, Holt M, Slavin S, Kidd MR, Post JJ, Wright E, de Wit J. 'Not Until I'm Absolutely Half-Dead and Have To:' Accounting for Non-Use of Antiretroviral Therapy in Semi-Structured Interviews with People Living with HIV in Australia. AIDS Patient Care STDS 2015; 29:267-78. [PMID: 25806574 DOI: 10.1089/apc.2014.0301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Current debates regarding the use of antiretroviral therapy (ART) to promote both individual- and population-level health benefits underscore the importance of understanding why a subpopulation of people with diagnosed HIV and access to treatment choose not to use it. Semi-structured interviews were conducted between 2012 and 2014 with 27 people living with HIV in Australia who were not using ART at the time of interview. Analytic triangulation permitted an appreciation of not only the varied personal reasons for non-use of treatment, but also underlying views on HIV treatment, and the ideal conditions imagined necessary for treatment initiation. Policy goals to increase the number of people with HIV using ART must recognize the diverse explanations for non-use of ART, which include concerns about the various impacts of committing to lifelong pharmaceutical treatment use. Our research identified distinctive subgroups among people who are not using antiretroviral therapy, with a range of individual and social needs that may affect treatment decisions. These findings challenge assumptions about treatment non-use in resource-rich settings, revealing persistent consumer fears about the potent and unknown effects of HIV medications that deserve greater recognition in policy debate on treatment uptake.
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Affiliation(s)
- Christy E. Newman
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Limin Mao
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Asha Persson
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Martin Holt
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Sean Slavin
- Australian Federation of AIDS Organisations, Sydney, Australia
| | - Michael R. Kidd
- Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Jeffrey J. Post
- Department of Infectious Diseases, The Prince of Wales Hospital, Sydney, Australia
- Prince of Wales Clinical School, UNSW Australia, Sydney, Australia
| | - Edwina Wright
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Australia
- The Burnet Institute, Melbourne, Australia
| | - John de Wit
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
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Dombrowski JC, Simoni JM, Katz DA, Golden MR. Barriers to HIV Care and Treatment Among Participants in a Public Health HIV Care Relinkage Program. AIDS Patient Care STDS 2015; 29:279-87. [PMID: 25826007 DOI: 10.1089/apc.2014.0346] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Improving patient retention in HIV care and use of antiretroviral therapy (ART) are key steps to improving the HIV care continuum in the US. However, contemporary quantitative data on barriers to care and treatment from population-based samples of persons poorly engaged in care are sparse. We analyzed the prevalence of barriers to clinic visits, ART initiation, and ART continuation reported by 247 participants in a public health HIV care relinkage program in King County, WA. We identified participants using HIV surveillance data (N=188) and referrals from HIV/STD clinics and partner services (N=59). Participants most commonly reported insurance (50%), practical (26-34%), and financial (30%) barriers to care, despite residing in a state with essentially universal access to HIV care. Perceived lack of need for medical care was uncommon (<20%), but many participants (58%) endorsed a perceived lack of need for medication as a reason for not initiating ART. Depression and substance abuse were both highly prevalent (69% and 54%, respectively), and methamphetamine was the most commonly abused substance. Barriers to HIV care and treatment may be amenable to intervention by health department outreach in coordination with existing HIV medical and support services.
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Affiliation(s)
- Julia C. Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
| | - Jane M. Simoni
- Department of Psychology, University of Washington, Seattle, Washington
| | - David A. Katz
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
| | - Matthew R. Golden
- Department of Medicine, University of Washington, Seattle, Washington
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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25
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Oramasionwu C, Bailey SC, Johnson TL, Mao L. Engagement in outpatient care for persons living with HIV in the United States. AIDS Res Hum Retroviruses 2015; 31:177-82. [PMID: 25386831 DOI: 10.1089/aid.2014.0049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prior studies that have assessed engagement within the various stages of care for persons living with HIV (PLWH) studied patients receiving care in HIV medical care facilities. These data are not representative of care received throughout the United States, as not all PLWH receive care in HIV clinics. This study evaluated engagement in outpatient care and healthcare utilization for PLWH, beyond facilities that specialize in HIV. Cross-sectional data were from the 2009-2010 National Hospital Ambulatory Medical Care Survey. Levels of care included receiving any care, receiving HIV-related care, established in care, engaged in care, and prescribed antiretroviral therapy (ARV). Factors associated with ARV prescription were determined by logistic regression. We analyzed data for ∼2.6 million outpatient clinic visits for PLWH. Of these, 90% were receiving HIV-related care, 86% were established in care, 75% were engaged in care, and 65% were prescribed ARV. In stratified analysis, the proportion of PWLH who were engaged in care varied by race/ethnicity (p<0.001) and ARV prescription varied significantly across the three age groups (p=0.004). Clinic visits within the past year did not differ for those prescribed ARV vs. not prescribed ARV [median, IQR=3.3 visits (1.8-5.6) vs. 3.6 visits (1.3-5.9); p=0.7]. Seeing a physician was associated with ARV prescription (OR=0.27, 95% CI=0.15-0.51), whereas routine engagement in care was not associated with ARV prescription (OR=0.99, 95% CI=0.96-1.03). Given that non-ARV-treated PLWH utilized outpatient care services at rates similar to ARV-treated PLWH, these routine clinic visits are missed opportunities for increasing ARV prescription in untreated patients.
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Affiliation(s)
- Christine Oramasionwu
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Stacy Cooper Bailey
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Terence L. Johnson
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Lu Mao
- UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
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26
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Antiretroviral therapy uptake, attrition, adherence and outcomes among HIV-infected female sex workers: a systematic review and meta-analysis. PLoS One 2014; 9:e105645. [PMID: 25265158 PMCID: PMC4179256 DOI: 10.1371/journal.pone.0105645] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/16/2014] [Indexed: 11/19/2022] Open
Abstract
Purpose We aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally. Methods We systematically searched PubMed, Embase and MEDLINE in March 2014 to identify studies reporting on ART uptake, attrition, adherence, and outcomes (viral suppression or CD4 count improvements) among HIV-infected FSWs globally. When possible, available estimates were pooled using random effects meta-analyses (with heterogeneity assessed using Cochran's Q test and I2 statistic). Results 39 studies, reporting on 21 different FSW study populations in Asia, Africa, North America, South America, and Central America and the Caribbean, were included. Current ART use among HIV-infected FSWs was 38% (95% CI: 29%–48%, I2 = 96%, 15 studies), and estimates were similar between high-, and low- and middle-income countries. Ever ART use among HIV-infected FSWs was greater in high-income countries (80%; 95% CI: 48%–94%, I2 = 70%, 2 studies) compared to low- and middle-income countries (36%; 95% CI: 7%–81%, I2 = 99%, 3 studies). Loss to follow-up after ART initiation was 6% (95% CI: 3%–11%, I2 = 0%, 3 studies) and death after ART initiation was 6% (95% CI: 3%–11%, I2 = 0%, 3 studies). The fraction adherent to ≥95% of prescribed pills was 76% (95% CI: 68%–83%, I2 = 36%, 4 studies), and 57% (95% CI: 46%–68%, I2 = 82%, 4 studies) of FSWs on ART were virally suppressed. Median gains in CD4 count after 6 to 36 months on ART, ranged between 103 and 241 cells/mm3 (4 studies). Conclusions Despite global increases in ART coverage, there is a concerning lack of published data on HIV treatment for FSWs. Available data suggest that FSWs can achieve levels of ART uptake, retention, adherence, and treatment response comparable to that seen among women in the general population, but these data are from only a few research settings. More routine programme data on HIV treatment among FSWs across settings should be collected and disseminated.
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Gwadz M, Applegate E, Cleland C, Leonard NR, Wolfe H, Salomon N, Belkin M, Riedel M, Banfield A, Sanfilippo L, Wagner A, Mildvan D. HIV-Infected Individuals Who Delay, Decline, or Discontinue Antiretroviral Therapy: Comparing Clinic- and Peer-Recruited Cohorts. Front Public Health 2014; 2:81. [PMID: 25077137 PMCID: PMC4100062 DOI: 10.3389/fpubh.2014.00081] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/29/2014] [Indexed: 01/05/2023] Open
Abstract
A substantial proportion of persons living with HIV/AIDS (PLHA) delay, decline, or discontinue antiretroviral therapy (ART) when it is medically indicated (40–45%), largely African-Americans and Latinos/Hispanics. This study explores the feasibility of locating PLHA, who are not on ART (PLHA-NOA) through clinics and peer-referral; compares the two cohorts on multi-level barriers to ART; and examines readiness to initiate/reinitiate ART, a predictor of treatment outcomes. We recruited adult HIV-infected African-American and Latino/Hispanic PLHA-NOA through HIV hospital clinics and peer-referral in 2012–2013. Participants were engaged in structured 1-h assessments with reliable/valid measures on barriers to ART. We found that recruitment through peers (63.2%, 60/95) was more feasible than in clinics (36.8%, 35/90). Participants were 48.0 years old and had lived with HIV for 14.7 years on average, and 56.8% had taken ART previously. Most (61.1%) were male and African-American (76.8%), and 23.2% were Latino/Hispanic. Peer-recruited participants were older, had lived with HIV longer, were less engaged in HIV care, and were more likely to have taken ART previously. The cohorts differed in reasons for discontinuing ART. Levels of ART knowledge were comparable between cohorts (68.5% correct), and there were no differences in attitudes toward ART (e.g., mistrust), which were in the neutral range. In bivariate linear regression, readiness for ART was negatively associated with physician mistrust (B = −10.4) and positively associated with self-efficacy (B = 5.5), positive outcome expectancies (B = 6.3), beliefs about personal necessity of ART (B = 17.5), and positive internal norms (B = 7.9). This study demonstrates the feasibility of engaging this vulnerable population through peer-referral. Peer-recruited PLHA evidence particularly high rates of risk factors compared to those in hospital clinics. Interventions to support ART initiation and continuation are sorely needed for both subgroups.
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Affiliation(s)
- Marya Gwadz
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Elizabeth Applegate
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Charles Cleland
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Noelle Regina Leonard
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Hannah Wolfe
- Spencer Cox Center for Health, Mount Sinai St. Luke's-Roosevelt Hospital Center , New York, NY , USA
| | - Nadim Salomon
- Peter Kruger Clinic, Mount Sinai Beth Israel Medical Center , New York, NY , USA
| | - Mindy Belkin
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Marion Riedel
- School of Social Work, Columbia University , New York, NY , USA
| | - Angela Banfield
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Lisa Sanfilippo
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Andrea Wagner
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Donna Mildvan
- Department of Infectious Diseases, Mount Sinai Beth Israel Medical Center , New York, NY , USA
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28
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Achenbach CJ, Buchanan AL, Cole SR, Hou L, Mugavero MJ, Crane HM, Moore RD, Haubrich RH, Gopal S, Eron JJ, Hunt PW, Rodriguez B, Mayer K, Saag MS, Kitahata MM. HIV viremia and incidence of non-Hodgkin lymphoma in patients successfully treated with antiretroviral therapy. Clin Infect Dis 2014; 58:1599-606. [PMID: 24523217 PMCID: PMC4017888 DOI: 10.1093/cid/ciu076] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 01/31/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The incidence of non-Hodgkin lymphoma (NHL) in human immunodeficiency virus (HIV)-infected patients remains high despite treatment with antiretroviral therapy (ART). METHODS We evaluated NHL incidence in HIV-infected patients followed in the Centers for AIDS Research Network of Integrated Clinical Systems who started combination ART and achieved suppression of HIV. We estimated the hazard ratio for NHL by time-varying HIV viremia categories, accounting for time-varying CD4 cell count using marginal structural models. RESULTS We observed 37 incident NHL diagnoses during 21 607 person-years of follow-up in 6036 patients (incidence rate, 171 per 100 000 person-years; 95% confidence interval [CI], 124-236). NHL incidence was high even among patients with nadir CD4 cell count >200 cells/µL (140 per 100 000 person-years [95% CI, 80-247]). Compared with ≤50 copies/mL, hazard ratios (HRs) for NHL were higher among those with HIV viremia of 51-500 copies/mL (HR current = 1.66 [95% CI, .70-3.94]; HR 3-month lagged = 2.10 [95% CI, .84-5.22]; and HR 6-month lagged = 1.46 [95% CI, .60-3.60]) and >500 copies/mL (HR current = 2.39 [95% CI, .92-6.21]; HR 3-month lagged = 3.56 [95% CI, 1.21-10.49]; and HR 6-month lagged = 2.50 [95% CI, .91-6.84]). Current HIV RNA as a continuous variable was also associated with NHL (HR = 1.42 per log10 copies/mL [95% CI, 1.05-1.92]). CONCLUSIONS Our findings demonstrate a high incidence of NHL among HIV-infected patients on ART and suggest a role of HIV viremia in the pathogenesis of NHL. Earlier initiation of potent ART and maximal continuous suppression of HIV viremia may further reduce NHL risk.
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Affiliation(s)
- Chad J. Achenbach
- Department of Medicine, Center for Global Health, and The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Ashley L. Buchanan
- Gillings School of Global Public Health, Departments of Biostatistics and Epidemiology
| | - Stephen R. Cole
- Gillings School of Global Public Health, Departments of Biostatistics and Epidemiology
- Center for AIDS Research, University of North Carolina at Chapel Hill
| | - Lifang Hou
- Department of Preventive Medicine and The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Michael J. Mugavero
- Department of Medicine and Center for AIDS Research, University of Alabama at Birmingham
| | - Heidi M. Crane
- Department of Medicine and Center for AIDS Research, University of Washington, Seattle
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard H. Haubrich
- Department of Medicine and Center for AIDS Research, University of California, San Diego
| | - Satish Gopal
- Center for AIDS Research, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Joseph J. Eron
- Center for AIDS Research, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Peter W. Hunt
- Department of Medicine and Center for AIDS Research, University of California, San Francisco
| | - Benigno Rodriguez
- Department of Medicine and Center for AIDS Research, Case Western Reserve University, Cleveland, Ohio
| | - Kenneth Mayer
- Department of Medicine, Harvard Medical School and Fenway Community Health Center, Boston, Massachusetts
| | - Michael S. Saag
- Department of Medicine and Center for AIDS Research, University of Alabama at Birmingham
| | - Mari M. Kitahata
- Department of Medicine and Center for AIDS Research, University of Washington, Seattle
| | - for the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS)
- Department of Medicine, Center for Global Health, and The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
- Gillings School of Global Public Health, Departments of Biostatistics and Epidemiology
- Center for AIDS Research, University of North Carolina at Chapel Hill
- Department of Preventive Medicine and The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
- Department of Medicine and Center for AIDS Research, University of Alabama at Birmingham
- Department of Medicine and Center for AIDS Research, University of Washington, Seattle
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Medicine and Center for AIDS Research, University of California, San Diego
- Department of Medicine, University of North Carolina at Chapel Hill
- Department of Medicine and Center for AIDS Research, University of California, San Francisco
- Department of Medicine and Center for AIDS Research, Case Western Reserve University, Cleveland, Ohio
- Department of Medicine, Harvard Medical School and Fenway Community Health Center, Boston, Massachusetts
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