Uptake of antiretroviral treatment among people living with HIV in London: ethnicity, gender and sexual orientation

Differences in HIV clinical outcomes amongst heterosexuals in the United Kingdom by ethnicity

OBJECTIVE

We investigated differences in clinical outcomes in heterosexual participants, by ethnicity in the UK Collaborative HIV Cohort Study from 2000 to 2017.

DESIGN

Cohort analysis.

METHODS

Logistic/proportional hazard regression assessed ethnic group differences in CD4+ cell count at presentation, engagement-in-care, combination antiretroviral therapy (cART) initiation, viral suppression and rebound.

RESULTS

Of 12 302 participants [median age: 37 (interquartile range: 31-44) years, 52.5% women, total follow-up: 85 846 person-years], 64.4% were black African, 19.1% white, 6.3% black Caribbean, 3.6% black other, 3.3% South Asian/other Asian and 3.4% other/mixed. CD4+ cell count at presentation amongst participants from non-white groups were lower than the white group. Participants were engaged-in-care for 79.6% of follow-up time; however, black and other/mixed groups were less likely to be engaged-in-care than the white group (adjusted odds ratios vs. white: black African: 0.70 (95% confidence interval (CI) 0.63-0.79], black Caribbean: 0.74 (0.63-0.88), other/mixed: 0.78 (0.62-0.98), black other: 0.81 (0.64-1.02)). Of 8867 who started cART, 79.1% achieved viral suppression, with no differences by ethnicity in cART initiation or viral suppression. Viral rebound (22.2%) was more common in the black other [1.95 (1.37-2.77)], black African [1.85 (1.52-2.24)], black Caribbean [1.73 (1.28-2.33)], South Asian/other Asian [1.35 (0.90-2.03)] and other/mixed [1.09 (0.69-1.71)] groups than in white participants.

CONCLUSION

Heterosexual people from black, Asian and minority ethnic (BAME) groups presented with lower CD4+ cell counts, spent less time engaged-in-care and were more likely to experience viral rebound than white people. Work to understand and address these differences is needed.

Beliefs in Antiretroviral Treatment and Self-Efficacy in HIV Management are Associated with Distinctive HIV Treatment Trajectories

An online survey was conducted among people living with HIV (PLHIV) in Australia to discern key factors associated with distinctive ART use patterns. The sample (N = 358), was further divided into three groups: those on ART continuously since initiation (n = 208, 58.1%); those on ART intermittently (n = 117, 32.7%); and those not on ART at the time of survey (n = 33, 9.2%). ART non-users were the most likely to hold serious concerns about ART that outweighed perceived necessities (benefits) from ART (AOR = 0.13; 95% CI 0.06-0.29; p < 0.001). They were also the least self-efficacious in HIV disease management (AOR = 0.29; 95% CI 0.09-0.87; p = 0.028). Intermittent ART users were more likely to receive their HIV diagnosis prior to 2003 (AOR = 0.38; 95% CI 0.28-0.53; p < 0.001) and perceive lower HIV management self-efficacy (AOR = 0.50, 95% CI 0.28-0.87; p = 0.015) than continuous users. ART-related beliefs and perceived self-efficacy in HIV self-management play an important role in achieving universal treatment uptake and sustained high levels of adherence.

Later cART initiation in migrant men from sub-Saharan Africa without advanced HIV disease in France

Objective

To compare the time from entry into care for HIV infection until combination antiretroviral therapy (cART) initiation between migrants and non migrants in France, excluding late access to care.

Methods

Antiretroviral-naïve HIV-1-infected individuals newly enrolled in the FHDH cohort between 2002–2010, with CD4 cell counts &gt;200/μL and no previous or current AIDS events were included. In three baseline CD4 cell count strata (200–349, 350-499, ≥500/μL), we examined the crude time until cART initiation within three years after enrolment according to geographic origin, and multivariable hazard ratios according to geographic origin, gender and HIV-transmission group, with adjustment for baseline age, enrolment period, region of care, plasma viral load, and HBV/HBC coinfection.

Results

Among 13338 individuals, 9605 (72.1%) were French natives (FRA), 2873 (21.4%) were migrants from sub-Saharan Africa/non-French West Indies (SSA/NFW), and 860 (6.5%) were migrants from other countries. Kaplan-Meier probabilities of cART initiation were significantly lower in SSA/NFW than in FRA individuals throughout the study period, regardless of the baseline CD4 stratum. After adjustment, the likelihood of cART initiation was respectively 15% (95%CI, 1–28) and 20% (95%CI, 2–38) lower in SSA/NFW men than in FRA men who had sex with men (MSM) in the 350-499 and ≥500 CD4 strata, while no difference was observed between other migrant groups and FRA MSM.

Conclusion

SSA/NFW migrant men living in France with CD4 &gt;350/μL at entry into care are more likely to begin cART later than FRA MSM, despite free access to treatment. Administrative delays in obtaining healthcare coverage do not appear to be responsible.

Uptake and outcome of combination antiretroviral therapy in men who have sex with men according to ethnic group: the UK CHIC Study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes in the first year after initiation of first-line HAART among heterosexual men and women in the UK CHIC Study

BACKGROUND

We analysed the influence of gender on use and outcomes of first-line HAART in a UK cohort.

METHODS

Analyses included heterosexuals starting HAART from 1998-2007 with pre-treatment CD4(+) T-cell count<350 cells/mm(3) and viral load (VL)>500 copies/ml. Virological suppression (<50 copies/ml), virological rebound (>500 copies/ml), CD4(+) T-cell counts at 6 and 12 months, clinical events and treatment discontinuation/switch in the first year of HAART were compared using linear, logistic and Cox regression.

RESULTS

Compared with women (n=2,179), men (n=1,487) were older and had lower CD4(+) T-cell count and higher VL at start of HAART. Median follow-up was 3.8 years (IQR 2.0-6.2). At 6 and 12 months, 72.7% and 75.3% had VL≤50 copies/ml, with no large differences between genders at either time after adjustment for confounders (6 months, OR 0.92 [95% CI 0.76-1.13]; 12 months, OR 1.06 [95% CI 0.85-1.31]). Overall, 79.4% patients achieved virological suppression and 19.2% experienced virological rebound, without gender differences, although men had an increased risk of rebound after excluding pregnant women (adjusted relative hazard [RH] 1.33 [95% CI 1.04-1.71]). Mean CD4(+) T-cell count increases at 6 and 12 months were, respectively, 112 and 156 cells/mm(3) overall, with mean differences between men and women of -14.6 cells/mm(3) (95% CI -24.6--4.5) and -12.1 cells/mm(3) (95% CI -24.4-0.2) at 6 and 12 months, respectively. Clinical progression was similar in men and women, but men were less likely to experience treatment discontinuation/switch (adjusted RH 0.72 [95% CI 0.63-0.83]).

CONCLUSIONS

Despite higher discontinuation rates among women, men had an increased risk of virological rebound and slightly poorer CD4(+) T-cell count responses. Identifying the reasons underlying treatment discontinuation/switch may help optimize treatment strategies for both genders.

Differences in national antiretroviral prescribing patterns between black and white patients with HIV/AIDS, 1996-2006

OBJECTIVES

The benefit of improved health outcomes for blacks receiving highly active antiretroviral therapy (HAART) lags behind that of whites. This project therefore sought to determine whether the reason for this discrepancy in health outcomes could be attributed to disparities in use of antiretroviral therapy between black and white patients with HIV.

MATERIALS AND METHODS

The 1996-2006 National Hospital Ambulatory Medical Care Surveys were used to identify hospital outpatient visits that documented antiretrovirals. Patients younger than 18 years, of nonblack or nonwhite race, and lacking documentation of antiretrovirals were excluded. A multivariable logistic regression model was constructed with race as the independent variable and use of HAART as the dependent variable.

RESULTS

Approximately 3 million HIV/AIDS patient visits were evaluated. Blacks were less likely than whites to use HAART and protease inhibitors (odds ratio, 95% CI 0.81 [0.81-0.82] and 0.67 [0.67-0.68], respectively). More blacks than whites used non-nucleoside reverse transcriptase inhibitors (odds ratio, 95% CI 1.18 [1.17-1.18]). In 1996, the crude rates of HAART were relatively low for both black and white cohorts (5% vs 6%). The rise in HAART for blacks appeared to lag behind that of whites for several years, until 2002, when the proportion of blacks receiving HAART slightly exceeded the proportion of whites receiving HAART. In later years, the rates of HAART were similar for blacks and whites (81% vs 82% in 2006). Blacks appeared less likely than whites to use protease inhibitors and more likely than whites to use non-nucleoside reverse transcriptase inhibitors from 2000 to 2004.

CONCLUSIONS

Blacks experienced a lag in the use of antiretrovirals at the beginning of the study; this discrepancy dissipated in more recent years.

Immunological profile in persons under antiretroviral therapy in a rural Nigerian hospital

Human immunodeficiency virus (HIV) contributes significantly to morbidity and mortality in sub-Saharan Africa, with Nigeria having the third highest burden of HIV infection globally; efforts are made to increases access to HIV/AIDS care and treatment. This has currently reached rural areas with limited manpower and laboratory evaluation capacity. This review is necessitated by the paucity of interim report on treatment profile in Nigerian rural areas. We report on the immunological profile of patients on antiretroviral therapy (ART) in Otukpo General Hospital, a rural Nigerian hospital. This is a retrospective cohort study of patients receiving ART treatment and care, on April 2009, when 2347 patients were under ART therapy. Out of these, 96 patients were selected by simple random sampling from hospital register, with their data abstracted from standardized Ministry of Health registers and facility documents kept at the hospital, and analyzed for descriptive and biometric measures. Ninty-six patients (29% males) with a median age of 35 years, median baseline CD4 lymphocyte count 221 cells/mL, median one year CD4 lymphocyte count of 356 cells/mL and median one year CD4 lymphocyte increment of 124 cells/mL were studied. There is no statistically significant difference in baseline CD4 lymphocyte count when data is disaggregated by type of drug regimen (AZT, D4T and TDF). Fourty-four percent, 23% and 33% of patients were on TDF, D4T & AZT based regimen, respectively (P=0.66). Increment of >100 cells/mL was seen in 64.58% of the reviewed patients. There was a higher CD4 lymphocyte count increment in patients on TDF & D4T compared with those in AZT based regimens (ANOVA; P<0.0003). Multivariate linear regression model showed one year CD4 lymphocyte count, one year increment in CD4 lymphocyte count, WBC count, and absolute neutrophil count to be significant correlates of baseline CD4 lymphocyte count (P<0.0001). Equally, multivariate logistic regression found age, platelet count and CD4 lymphocyte count at 12 months showed to be significant predictors of CD4 lymphocyte increment above 100 cells/µL (P<0.0001). Despite advanced disease presentation and a very large-scale program, high quality HIV/AIDS care was achieved as indicated by good short-term, immunologic outcomes, while TDF & D4T induce higher immunological recovery compared with AZT. This report suggests that quality HIV care and treatment can be effective despite the challenges of a resource-limited setting.

Disparities in antiretroviral prescribing for blacks and whites in the United States

PURPOSE

The health benefits for blacks on highly active antiretroviral therapy (HAART) lags behind that of whites. We therefore investigated whether this discrepancy in health outcomes is attributable to disparities in the receipt of appropriate HAART between black and white human immunodeficiency virus (HIV) patients.

METHODS

The 2000-2005 National Ambulatory Medical Care Surveys were used to identify patients receiving antiretrovirals. Regimens were evaluated for appropriateness according to national antiretroviral guideline recommendations. A multivariable logistic regression model was used to assess black race as a predictor for appropriate HAART.

RESULTS

An estimated 4.1 million HIV-related visits with antiretroviral therapy were identified. Eighty-six percent of visits were associated with appropriate therapy; inappropriate therapy was often due to antiretroviral monotherapy. Interestingly, blacks were more likely to receive appropriate therapy in comparison to white patients (94% vs 83%, P < .001). Multivariable analysis revealed black race as an independent predictor for an appropriate regimen (chi2 likelihood ratio, 12.3, P < .001) when controlling for age, gender, insurance status, and geographic region.

CONCLUSIONS

Health outcome disparities between black and white HIV patients do not appear to be attributable to differences in receipt of appropriate HAART. Further investigations are warranted to identify factors responsible for these outcome disparities.