Antiretroviral effects on HIV-1 RNA, CD4 cell count and progression to AIDS or death: a meta-regression analysis

Intravenous Mannitol Versus Placebo During Partial Nephrectomy in Patients with Normal Kidney Function: A Double-blind, Clinically-integrated, Randomized Trial

BACKGROUND

Mannitol is currently used as a renal protective agent to mitigate the effects of renal ischemia during nephron-sparing surgery (NSS). This routine practice lacks rigorous methodological study.

OBJECTIVE

To assess the effect on renal function outcomes after surgery of mannitol infusion prior to renal ischemia during NSS.

DESIGN, SETTING, PARTICIPANTS

This prospective, randomized, placebo-controlled, double-blind trial included 199 patients with a preoperative estimated glomerular filtration rate (eGFR) >45ml/min/1.73m² scheduled for NSS; the trial was conducted between July 2012 and July 2015.

INTERVENTION

Patients undergoing NSS were randomized to receive mannitol (12.5g) or placebo intravenously within 30min prior to renal vascular clamping.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the difference in eGFR (renal function) between the two groups at 6 mo following surgery assessed with an analysis of covariance model using preoperative eGFR, treatment group, and surgical approach as covariates.

RESULTS AND LIMITATIONS

At baseline, the median age of the patients was 58 yr, and the median eGFR was 88ml/min/1.73m². Comparing placebo with mannitol infusion, the adjusted difference of 0.2 eGFR units at 6 mo was not significant (p=0.9), with the upper bound of the 95% confidence interval (-3.1 to 3.5) excluding a clinically relevant effect of mannitol. Limitations include evaluation of a single mannitol dose and patients all had excellent preoperative renal function.

CONCLUSIONS

Intraoperative 12.5g mannitol infusion during NSS has no demonstrable clinical benefit when compared with standardized fluid hydration in patients with normal preoperative renal function, and its use in this setting is not warranted.

PATIENT SUMMARY

In this randomized trial, patients with normal kidney function who received mannitol during surgery to remove part of their kidney had no better kidney function 6 mo after surgery than those who did not receive mannitol. We conclude that this routine practice should be discontinued.

Predicting Malawian Women's Intention to Adhere to Antiretroviral Therapy

Background

With the increase in scaling up of antiretroviral therapy (ART), knowledge of the need for adherence to ART is pivotal for successful treatment outcomes.

Design and Methods

A cross-sectional study was carried out between October and December 2013. We administered theory of planned behaviour (TPB) and adherence questionnaires to 358 women aged 18-49 years, from a rural and urban ART-clinics in southern Malawi. Hierarchical linear regression models were used to predict intentions to adhere to ART.

Results

Regression models show that attitude (β=0.47), subjective norm (β=0.31) and perceived behavioural control (β=0.12) explain 55% of the variance in intentions to adhere to ART. The relationship between both food insecurity and perceived side effects with intentions to adhere to ART is mediated by attitude, subjective norm, and perceived behavioural control. Household (r=0.20) and individual (r=0.21) food insecurity were positively and significantly correlated with perceived behavioural control. Household food insecurity had a negative correlation with perceived side effects (r=-0.11). Perceived side effects were positively correlated with attitude (r=0.25). There was no statistically significant relationship between intentions to adhere to ART in the future and one month self-report of past month adherence. These interactions suggest that attitude predicted adherence only when food insecurity is high or perception of side effects is strong.

Conclusions

This study shows that modification might be needed when using TPB constructs in resource constraint environments.

Determinants of Antiretroviral Therapy Adherence among Women in Southern Malawi: Healthcare Providers' Perspectives

Background. The purpose of this study was to explore healthcare providers' perspectives on antiretroviral (ART) adherence in two ART clinics in southern Malawi. Nonadherence to ART is a significant hindrance to the success of HIV/AIDS treatment. Methods. A one-on-one semistructured interview was conducted with eight healthcare providers in two ART clinics in rural and urban southern Malawi. The interviews were focused on factors facilitating or hindering ART adherence and strategies to improve adherence. Interviews were audio-recorded, transcribed, and content-analyzed with the use of the constant comparison approach. Results. Of the eight participants, 63% were between the ages of 20 and 30 years and 37% were HIV counselors. Factors facilitating adherence include patients' belief and knowledge, HIV/AIDS education, and a supportive network. Barriers to adherence include discrimination, nondisclosure of HIV status, food insecurity, medication side effects, religion, misinformation, and staff and drug shortages. Strategies to improve adherence were identified by participants to include nutritional/food supplementation for malnourished or undernourished patients and patient counseling. Conclusions. There is a need for collaborative efforts between healthcare providers, patients, and faith-based organizations to identify and address hindrances and facilitators to patients' adherence. Further research is needed to develop strategies addressing religion, staff, and drug shortages.

The VACS index accurately predicts mortality and treatment response among multi-drug resistant HIV infected patients participating in the options in management with antiretrovirals (OPTIMA) study

Objectives

The VACS Index is highly predictive of all-cause mortality among HIV infected individuals within the first few years of combination antiretroviral therapy (cART). However, its accuracy among highly treatment experienced individuals and its responsiveness to treatment interventions have yet to be evaluated. We compared the accuracy and responsiveness of the VACS Index with a Restricted Index of age and traditional HIV biomarkers among patients enrolled in the OPTIMA study.

Methods

Using data from 324/339 (96%) patients in OPTIMA, we evaluated associations between indices and mortality using Kaplan-Meier estimates, proportional hazards models, Harrel’s C-statistic and net reclassification improvement (NRI). We also determined the association between study interventions and risk scores over time, and change in score and mortality.

Results

Both the Restricted Index (c = 0.70) and VACS Index (c = 0.74) predicted mortality from baseline, but discrimination was improved with the VACS Index (NRI = 23%). Change in score from baseline to 48 weeks was more strongly associated with survival for the VACS Index than the Restricted Index with respective hazard ratios of 0.26 (95% CI 0.14–0.49) and 0.39(95% CI 0.22–0.70) among the 25% most improved scores, and 2.08 (95% CI 1.27–3.38) and 1.51 (95%CI 0.90–2.53) for the 25% least improved scores.

Conclusions

The VACS Index predicts all-cause mortality more accurately among multi-drug resistant, treatment experienced individuals and is more responsive to changes in risk associated with treatment intervention than an index restricted to age and HIV biomarkers. The VACS Index holds promise as an intermediate outcome for intervention research.