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Risk Factors for Low CD4+ Count Recovery Despite Viral Suppression Among Participants Initiating Antiretroviral Treatment With CD4+ Counts > 500 Cells/mm3: Findings From the Strategic Timing of AntiRetroviral Therapy (START) Trial. J Acquir Immune Defic Syndr 2019; 81:10-17. [PMID: 30664075 DOI: 10.1097/qai.0000000000001967] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Low CD4 recovery among HIV-positive individuals who achieve virologic suppression is common but has not been studied among individuals initiating treatment at CD4 counts of >500 cells/mm. SETTING United States, Africa, Asia, Europe and Israel, Australia, Latin America. METHODS Among participants randomized to immediate antiretroviral therapy (ART) in the Strategic Timing of AntiRetroviral Therapy trial, low CD4 recovery was defined as a CD4 increase of <50 cells/mm from baseline after 8 months despite viral load of ≤200 copies/mL. Risk factors for low recovery were investigated with logistic regression. RESULTS Low CD4 recovery was observed in 39.7% of participants. Male sex [odds ratio (OR), 1.53; P = 0.007], lower screening CD4 cell counts (OR, 1.09 per 100 fewer cells/mm; P = 0.004), higher baseline CD8 cell counts (OR, 1.05 per 100 more cells/mm; P < 0.001), and lower HIV RNA levels (OR, 1.93 per log10 decrease; P < 0.001) were associated with low CD4 recovery. D-dimer had a quadratic association with low CD4 recovery, with lowest odds occurring at 0.32 μg/mL. At lower HIV RNA levels, the odds of low CD4 recovery were elevated across the levels of screening CD4 count; but at higher HIV RNA levels, the odds of low CD4 recovery were higher among those with lower vs. higher screening CD4. CONCLUSIONS Low CD4 recovery is frequent among participants starting ART at high CD4 counts. Risk factors include male sex, lower screening CD4 cell counts, higher CD8 cell counts, and lower HIV RNA levels. More follow-up is required to determine the impact of low CD4 recovery on clinical outcomes.
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Arenas-Pinto A, Grund B, Sharma S, Martinez E, Cummins N, Fox J, Klingman KL, Sedlacek D, Collins S, Flynn PM, Chasanov WM, Kedem E, Katlama C, Sierra-Madero J, Afonso C, Brouwers P, Cooper DA. Risk of Suicidal Behavior With Use of Efavirenz: Results from the Strategic Timing of Antiretroviral Treatment Trial. Clin Infect Dis 2019. [PMID: 29538636 DOI: 10.1093/cid/ciy051] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Randomized trials have shown increased risk of suicidality associated with efavirenz (EFV). The START (Strategic Timing of Antiretroviral Treatment) trial randomized treatment-naive human immunodeficiency virus (HIV)-positive adults with high CD4 cell counts to immediate vs deferred antiretroviral therapy (ART). Methods The initial ART regimen was selected prior to randomization (prespecified). We compared the incidence of suicidal and self-injurious behaviours (suicidal behavior) between the immediate vs deferred ART groups using proportional hazards models, separately for those with EFV and other prespecified regimens, by intention to treat, and after censoring participants in the deferred arm at ART initiation. Results Of 4684 participants, 271 (5.8%) had a prior psychiatric diagnosis. EFV was prespecified for 3515 participants (75%), less often in those with psychiatric diagnoses (40%) than without (77%). While the overall intention-to-treat comparison showed no difference in suicidal behavior between arms (hazard ratio [HR], 1.07, P = .81), subgroup analyses suggest that initiation of EFV, but not other ART, is associated with increased risk of suicidal behavior. When censoring follow-up at ART initiation in the deferred group, the immediate vs deferred HR among those who were prespecified EFV was 3.31 (P = .03) and 1.04 (P = .93) among those with other prespecified ART; (P = .07 for interaction). In the immediate group, the risk was higher among those with prior psychiatric diagnoses, regardless of prespecified treatment group. Conclusions Participants who used EFV in the immediate ART group had increased risk of suicidal behavior compared with ART-naive controls. Those with prior psychiatric diagnoses were at higher risk.
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Affiliation(s)
- Alejandro Arenas-Pinto
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
| | | | - Shweta Sharma
- Division of Biostatistics, University of Minnesota, Minneapolis
| | | | | | - Julie Fox
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Karin L Klingman
- Division of AIDS, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | - Eynat Kedem
- Clinical Immunology Unit, Rambam Health Care Center, Haifa, Israel
| | | | - Juan Sierra-Madero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, México
| | | | - Pim Brouwers
- Division of AIDS, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - David A Cooper
- The Kirby Institute, University of New South Wales, Sydney, Australia
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Zablotska IB, Vaccher SJ, Bloch M, Carr A, Foster R, Grulich AE, Guy R, McNulty A, Ooi C, Pell C, Poynten IM, Prestage G, Ryder N, Templeton D. High Adherence to HIV Pre-exposure Prophylaxis and No HIV Seroconversions Despite High Levels of Risk Behaviour and STIs: The Australian Demonstration Study PrELUDE. AIDS Behav 2019; 23:1780-1789. [PMID: 30284653 DOI: 10.1007/s10461-018-2290-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PrELUDE study evaluated daily pre-exposure prophylaxis (PrEP) in high-risk individuals in Australia. This open-label, single-arm study tested participants for HIV/STI and collected behavioural information three-monthly. We report trends over 18 months in medication adherence, side-effects, HIV/STI incidence and behaviour. 320 gay/bisexual men (GBM), 4 women and 3 transgender participants, followed on average 461 days, reported taking seven pills/week on 1,591 (88.5%) occasions and 4-6 pills/week on 153 (8.5%) occasions. No HIV infections were observed. STI incidence was high and stable, while gonorrhoea infections declined from 100.0 to 25.8/100 person-years between 6 and 15 months (p < 0.001). The number of HIV-positive and unknown-status sex partners, and condomless anal intercourse, significantly increased. In this high-risk cohort of mainly GBM, increases in risk behaviours and high STI incidence were not accompanied by HIV infections due to high adherence to daily PrEP. The study informed policy and further PrEP implementation among Australian GBM.
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Zablotska IB, O'Connor CC. Preexposure Prophylaxis of HIV Infection: the Role of Clinical Practices in Ending the HIV Epidemic. Curr HIV/AIDS Rep 2018; 14:201-210. [PMID: 29071519 DOI: 10.1007/s11904-017-0367-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to summarise the recent evidence from high-income settings about providers' ability to deliver on the UNAIDS goal of at least three million people at substantial risk of HIV infection with PrEP by 2020, including awareness and knowledge about PrEP, willingness to prescribe PrEP, current levels of prescribing and service delivery models and issues. RECENT FINDINGS Awareness about PrEP among health providers is growing, but at different pace depending on provider type. HIV and sexual health specialists are more likely to have knowledge about PrEP than generalists, and to be willing to prescribe it, mainly because of their closer contact with people at high risk for HIV and better risk assessment skills. There is still no consensus as to who should be responsible for providing PrEP, but clearly all hands on deck will be useful in delivering on the international target of three million people at substantial risk for HIV on PrEP by 2020. Only about 5% of the target has been reached so far. Local guidance and large-scale education and information programs for clinicians will be necessary to upskill health providers. High cost of PrEP is still a major barrier for its broad implementation, even in countries were PrEP roll-out has started. Health services are facing major structural challenges due to implementation of PrEP services to a substantial volume of patients. The early implementation experiences demonstrated that PrEP can be successfully delivered across a variety of settings, and a broad range of strategies and models of care can streamline PrEP delivery. Education of the providers and PrEP cost solutions will be essential for rapid roll-out of PrEP.
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Affiliation(s)
- Iryna B Zablotska
- The Kirby Institute, University of New South Wales Sydney, Sydney, 2052, Australia.
| | - Catherine C O'Connor
- The Kirby Institute, University of New South Wales Sydney, Sydney, 2052, Australia
- Sexual Health Service, Sydney Local Health District, Camperdown, 2050, Australia
- Central Clinical School, University of Sydney, Sydney, 2006, Australia
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Kunisaki KM, Niewoehner DE, Collins G, Aagaard B, Atako NB, Bakowska E, Clarke A, Corbelli GM, Ekong E, Emery S, Finley EB, Florence E, Infante RM, Kityo CM, Madero JS, Nixon DE, Tedaldi E, Vestbo J, Wood R, Connett JE. Pulmonary effects of immediate versus deferred antiretroviral therapy in HIV-positive individuals: a nested substudy within the multicentre, international, randomised, controlled Strategic Timing of Antiretroviral Treatment (START) trial. THE LANCET RESPIRATORY MEDICINE 2016; 4:980-989. [PMID: 27773665 DOI: 10.1016/s2213-2600(16)30319-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Observational data have been conflicted regarding the potential role of HIV antiretroviral therapy (ART) as a causative factor for, or protective factor against, COPD. We therefore aimed to investigate the effect of immediate versus deferred ART on decline in lung function in HIV-positive individuals. METHODS We did a nested substudy within the randomised, controlled Strategic Timing of Antiretroviral Treatment (START) trial at 80 sites in multiple settings in 20 high-income and low-to-middle-income countries. Participants were HIV-1 infected individuals aged at least 25 years, naive to ART, with CD4 T-cell counts of more than 500 per μL, not receiving treatment for asthma, and without recent respiratory infections (baseline COPD was not an exclusion criterion). Participants were randomly assigned to receive ART (an approved drug combination derived from US Department of Health and Human Services guidelines) either immediately, or deferred until CD4 T-cell counts decreased to 350 per μL or AIDS developed. The randomisation was determined by participation in the parent START study, and was not specific to the substudy. Because of the nature of our study, site investigators and participants were not masked to the treatment group assignment; however, the assessors who reviewed the outcomes were masked to the treatment group. The primary outcome was the annual rate of decline in lung function, expressed as the FEV1 slope in mL/year; spirometry was done annually during follow-up for up to 5 years. We analysed data on an intention-to-treat basis, and planned separate analyses in smokers and non-smokers because of the known effects of smoking on FEV1 decline. The substudy was registered at ClinicalTrials.gov number NCT01797367. FINDINGS Between March 11, 2010, and Aug 23, 2013, we enrolled 1026 participants to our substudy, who were then randomly assigned to either immediate (n=518) or deferred (n=508) ART. Median baseline characteristics included age 36 years (IQR 30-44), CD4 T-cell count 648 per μL (583-767), and HIV plasma viral load 4·2 log10 copies per mL (3·5-4·7). 29% were female and 28% were current smokers. Median follow-up time was 2·0 years (IQR 1·9-3·0). We noted no differences in FEV1 slopes between the immediate and deferred ART groups either in smokers (difference of -3·3 mL/year, 95% CI -38·8 to 32·2; p=0·86) or in non-smokers (difference of -5·6 mL/year, -29·4 to 18·3; p=0·65) or in pooled analyses adjusted for smoking status at each study visit (difference of -5·2 mL/year, -25·1 to 14·6; p=0·61). INTERPRETATION The timing of ART initiation has no major short-term effect on rate of lung function decline in HIV-positive individuals who are naive to ART, with CD4 T-cell counts of more than 500 per μL. In light of updated WHO recommendations that all HIV-positive individuals should be treated with ART, regardless of their CD4 T-cell count, our results suggest an absence of significant pulmonary harm with such an approach. FUNDING US National Heart Lung and Blood Institute, US National Institute of Allergy and Infectious Diseases, Division of AIDS, Agence Nationale de Recherches sur le SIDA et les Hipatites Virales (France), Australian National Health and Medical Research Council, Danish National Research Foundation, European AIDS Treatment Network, German Ministry of Education and Research, UK Medical Research Council and National Institute for Health Research, and US Veterans Health Administration Office of Research and Development.
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Affiliation(s)
- Ken M Kunisaki
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA.
| | - Dennis E Niewoehner
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA
| | | | - Bitten Aagaard
- Copenhagen HIV Programme, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nafisah B Atako
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | | | | | | | - Ernest Ekong
- Institute of Human Virology-Nigeria, Abuja, Nigeria
| | - Sean Emery
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Rosa M Infante
- Asociación Civil Impacta Salud y Educación, Barranco, Lima, Perú
| | | | - Juan Sierra Madero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Infectious Diseases Department, Mexico City, Mexico
| | | | - Ellen Tedaldi
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Robin Wood
- Desmond Tutu HIV Foundation, Cape Town, South Africa
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Denning E, Sharma S, Smolskis M, Touloumi G, Walker S, Babiker A, Clewett M, Emanuel E, Florence E, Papadopoulos A, Sánchez A, Tavel J, Grady C. Reported consent processes and demographics: a substudy of the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial. HIV Med 2015; 16 Suppl 1:24-9. [PMID: 25711320 DOI: 10.1111/hiv.12230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Efforts are needed to improve informed consent of participants in research. The Strategic Timing of AntiRetroviral Therapy (START) study provides a unique opportunity to study the effect of length and complexity of informed consent documents on understanding and satisfaction among geographically diverse participants. METHODS Interested START sites were randomized to use either the standard consent form or the concise consent form for all of the site's participants. RESULTS A total of 4473 HIV-positive participants at 154 sites world-wide took part in the Informed Consent Substudy, with consent given in 11 primary languages. Most sites sent written information to potential participants in advance of clinic visits, usually including the consent form. At about half the sites, staff reported spending less than an hour per participant in the consent process. The vast majority of sites assessed participant understanding using informal nonspecific questions or clinical judgment. CONCLUSIONS These data reflect the interest of START research staff in evaluating the consent process and improving informed consent. The START Informed Consent Substudy is by far the largest study of informed consent intervention ever conducted. Its results have the potential to impact how consent forms are written around the world.
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Affiliation(s)
- E Denning
- Coordinating Centers for Biometric Research, Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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