Clinical Impact and Cost of Laboratory Monitoring Need Review Even in Resource-Rich Setting

Losses to follow-up of HIV-infected people in the Spanish VACH cohort over the period between 2013 and 2014: The importance of sociodemographic factors

OBJECTIVE

To determine the proportion of people infected by HIV or AIDS under follow-up in the VACH Cohort in 2012 who were lost to follow-up from 2013 to 2014, and to establish the sociodemographic features relating to this loss.

METHODS

We considered subjects with less than one recorded consultation per year studied to be lost to follow-up. We built logistic regression models to calculate the odds ratios (OR) and their 95% confidence intervals (95% CI), of the variables relating to loss to follow-up.

RESULTS

The overall percentage of losses to follow-up was 15.5% (95% CI 14.9-16-1). The variables associated with loss to follow up were: not receiving antiretroviral treatment (ART) (OR: 1.948, 95% CI: 1.651 -2.298), being an immigrant (OR: 1.746; 95%CI: 1.494-2.040), intravenous drug consumption being the mechanism for HIV transmission (OR: 1.498, 95% CI: 1.312-1.711), being unemployed (OR: 1.331; 95% CI: 1.179-1.503), being without a partner (OR: 1.948, 95% CI: 1.651-1.298), belonging to a low socioeconomic class (OR: 1.279; 95% CI: 1.143-1.431), and being attended in a hospital with fewer than 1000 patients under follow-up (OR: 1.257, 95% CI: 1.121-1.457), as well as being under age and having spent less time under follow-up in the Cohort.

CONCLUSIONS

15.5% of the patients were lost to follow-up over a period of 2years in the VACH Cohort. This was associated with a series of sociodemographic and epidemiological variables that it might be useful to identify to design initiatives targeting the populations most likely to abandon the circuits of care, and guide strategies towards achieving Objective 90-90-90.

[GESIDA/National AIDS Plan: Consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (Updated January 2015)]

OBJECTIVE

This consensus document is an update of combined antiretroviral therapy (cART) guidelines and recommendations for HIV-1 infected adult patients.

METHODS

To formulate these recommendations, a panel composed of members of the AIDS Study Group and the AIDS National Plan (GeSIDA/Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, and cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations, and the evidence that supports them, are based on modified criteria of the Infectious Diseases Society of America.

RESULTS

In this update, cART is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and level of the recommendation depends on the CD4+T-lymphocyte count, the presence of opportunistic diseases or comorbid conditions, age, and prevention of transmission of HIV. The objective of cART is to achieve an undetectable plasma viral load. Initial cART should always comprise a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors, and a third drug from a different family. Three out of the ten recommended regimes are regarded as preferential (all of them with an integrase inhibitor as the third drug), and the other seven (based on a non-nucleoside reverse transcriptase inhibitor, a ritonavir-boosted protease inhibitor, or an integrase inhibitor) as alternatives. This update presents the causes and criteria for switching cART in patients with undetectable plasma viral load, and in cases of virological failure where rescue cART should comprise 3 (or at least 2) drugs that are fully active against the virus. An update is also provided for the specific criteria for cART in special situations (acute infection, HIV-2 infection, and pregnancy) and with comorbid conditions (tuberculosis or other opportunistic infections, kidney disease, liver disease, and cancer).

CONCLUSIONS

These new guidelines update previous recommendations related to cART (when to begin and what drugs should be used), how to monitor and what to do in case of viral failure or drug adverse reactions. cART specific criteria in comorbid patients and special situations are equally updated.

Determinants of HIV outpatient service utilization: a systematic review

Demands on HIV services are increasing as a consequence of the increased life-expectancy of HIV patients in the highly active antiretroviral therapy era. Understanding the factors that influence utilization of ambulatory HIV services is useful for planning service provision. This study reviewed factors associated with utilization of hospital based HIV out-patient services. Studies reporting person-based utilization rates of HIV-specific outpatient services broken down by patient or healthcare characteristics were eligible for inclusion. The Andersen Behavioral Model was used to organize the information extracted into pre-disposing, enabling and need components. Ten studies were included in the final review. Older age, private insurance, urban residence, lower CD4 counts, a diagnosis of AIDS, or anti-retroviral treatment were associated with higher utilization rates. The results of this review are consistent with existing knowledge regarding HIV patients' use of health services. Little information was identified on the influence of health service characteristics on utilization of out-patient services.

[GeSIDA/National AIDS Plan: Consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (Updated January 2014)]

OBJECTIVE

This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients.

METHODS

To formulate these recommendations a panel composed of members of the Grupo de Estudio de Sida and the Plan Nacional sobre el Sida reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. Recommendations strength and the evidence in which they are supported are based on modified criteria of the Infectious Diseases Society of America.

RESULTS

In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and grade of the recommendation varies with the clinical circumstances: CDC stage B or C disease (A-I), asymptomatic patients (depending on the CD4+ T-lymphocyte count: <350cells/μL, A-I; 350-500 cells/μL, A-II, and >500 cells/μL, B-III), comorbid conditions (HIV nephropathy, chronic hepatitis caused by HBV or HCV, age >55years, high cardiovascular risk, neurocognitive disorders, and cancer, A-II), and prevention of transmission of HIV (mother-to-child or heterosexual, A-I; men who have sex with men, A-III). The objective of ART is to achieve an undetectable plasma viral load. Initial ART should always comprise a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors and a third drug from a different family (non-nucleoside reverse transcriptase inhibitor, protease inhibitor, or integrase inhibitor). Some of the possible initial regimens have been considered alternatives. This update presents the causes and criteria for switching ART in patients with undetectable plasma viral load and in cases of virological failure where rescue ART should comprise 2 or 3 drugs that are fully active against the virus. An update is also provided for the specific criteria for ART in special situations (acute infection, HIV-2 infection, and pregnancy) and with comorbid conditions (tuberculosis or other opportunistic infections, kidney disease, liver disease, and cancer).

CONCLUSIONS

These new guidelines updates previous recommendations related to cART (when to begin and what drugs should be used), how to monitor and what to do in case of viral failure or drug adverse reactions. cART specific criteria in comorbid patients and special situations are equally updated.

Advances in detection and monitoring of plasma viremia in HIV-infected individuals receiving antiretroviral therapy

PURPOSE OF REVIEW

This review will describe advances in detection and results of monitoring persistent viremia in patients on long-term suppressive therapy. In addition, the review explores the usefulness of these methods in determining the effectiveness of new HIV-1 eradication strategies in purging persistent HIV-1 reservoirs.

RECENT FINDINGS

Quantification of plasma HIV-1 RNA levels remains essential for determining the success of combination antiretroviral therapy (cART) in treated patients. Recently, several new platforms with improved sensitivity for quantifying HIV-1 RNA have been developed and the application of these assays has revealed that low-level viremia persists in patients on suppressive therapy. In addition, new technological advances such as digital PCR have been proposed to increase the sensitivity of measuring and characterizing persistent HIV-1 viremia. The application of these assays will be important in determining the effectiveness of future HIV-1 eradication strategies.

SUMMARY

The level of HIV-1 RNA in patient plasma remains an important marker for determining the success of cART. New sensitive assays have found that HIV-1 persists in the plasma of patients on suppressive therapy that may have implications for the clinical management of this disease and strategies for eliminating HIV-1 infection.