Statins Utilization in Adults With HIV: The Treatment Gap and Predictors of Statin Initiation

BACKGROUND

We characterized trends in statin eligibility and subsequent statin initiation among people with HIV (PWH) from 2001 to 2017 and identified predictors of statin initiation between 2014 and 2017.

SETTING

PWH participating in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) enrolled in 12 US cohorts collecting data on statin eligibility criteria/prescriptions from 2001 to 2017.

METHODS

We determined the annual proportion eligible for statins, initiating statins, and median waiting time (from statin eligibility to initiation). Eligibility was defined using ATP III guidelines (2001-2013) and ACC/AHA guidelines (2014-2017). We assessed initiation predictors in 2014-2017 among statin-eligible PWH using Poisson regression, estimating adjusted prevalence ratios (aPRs) with 95% confidence intervals (95% CIs).

RESULTS

Among 16,409 PWH, 7386 (45%) met statin eligibility criteria per guidelines (2001-2017). From 2001 to 2013, statin eligibility ranged from 22% to 25%. Initiation increased from 13% to 45%. In 2014, 51% were statin-eligible, among whom 25% initiated statins, which increased to 32% by 2017. Median waiting time to initiation among those we observed declined over time. Per 10-year increase in age, initiation increased 46% (aPR 1.46, 95% CI: 1.29 to 1.67). Per 1-year increase in calendar year from 2014 to 2017, there was a 41% increase in the likelihood of statin initiation (aPR 1.41, 95% CI: 1.25 to 1.58).

CONCLUSIONS

There is a substantial statin treatment gap, amplified by the 2013 ACC/AHA guidelines. Measures are warranted to clarify reasons we observe this gap, and if necessary, increase statin use consistent with guidelines including efforts to help providers identify appropriate candidates.

1704. Regional and Racial Disparities in Response to Antiretroviral Therapy (ART) among People Living with Human Immunodeficiency Virus (PLWH)

Background

This study evaluated differences in viral suppression by race and region among PLWH in care at 10 community practices.

Methods

PLWH (≥18 yrs) starting a new ART between Jan’15-Sept’19 with viral load at regimen prescription (Rx) and ≥6 months (mo) of prior history were selected from Trio Health HIV EMR database. Logistic regression [LR] estimated the association of covariates with outcome “viremic” (viral load >50 cells/ml) among those with viral load recorded 12-15 mo after baseline (BSL). Sensitivity analyses were conducted using viral loads at 9-15 mo, in patients (pts) on their BSL regimens for ≥12 mo, and pts with dispensing data. Covariates: BSL suppression, gender, race, age, payer, region (South vs non-South), BSL single vs multi-tablet regimen (STR vs MTR), and switch status from BSL regimen. Multicollinearity was not present.

Results

Of 20271 PLWH, 10373 (51%) were treated in South (41% not suppressed at BSL including 30% treatment-naïve [TN]) and 9898 (49%) in non-South (32% not suppressed including 26% TN). The following groups had higher suppression rates at 12-15 mo: males (83%) vs females (80%) p=0.003; white (85%) vs black (78%) and other known race (78%) p< 0.001; insured by commercial or Medicare insurance (both 85%) vs Medicaid (76%) or uninsured (71%) p< 0.001; treated in non-South (88%) vs South (77%) p< 0.001; age ≥50 (87%) vs < 50 (80%) p< 0.001, those who did not switch from BSL regimen (84%) vs switchers (82%) p< 0.001; on STR (84%) vs MTR (81%) p< 0.001.

In LR, pts less likely to be suppressed at 12-15 mo were: < 50 adjusted odds ratio (aOR)=0.76 (0.67-0.88), unspecified gender vs female aOR=0.51 (0.28-0.92), black vs white aOR=0.65 (0.56-0.74), other race (Asian, etc.) vs white aOR=0.73 (0.59-0.91), insured by Medicaid vs commercially aOR=0.64 (0.50-0.82), uninsured vs commercially insured aOR=0.63 (0.53-0.75), treated in South aOR=0.43 (0.38-0.50), switched from BSL regimen aOR=0.75 (0.66-.086), on MTR vs STR aOR=0.81 (0.72-0.92), viremic at BSL aOR=0.41 (0.36-0.47). Sensitivity analyses results were similar.

Conclusion

Our findings highlighted higher rates of viremia among younger, black or other non-white race, pts treated in the South, on Medicaid or uninsured, on MTR, even after accounting for other characteristics.

Disclosures

Keith M. Rawlings, MD, ViiV Healthcare (Employee) Joseph J. Eron, MD, Gilead Sciences (Consultant, Research Grant or Support)Janssen (Consultant, Research Grant or Support)Merck (Consultant)ViiV Healthcare (Consultant, Research Grant or Support) Julie Priest, MSPH, GlaxoSmithKline (Employee, Shareholder) Janna Radtchenko, MBA, Trio Health (Employee) Joseph Mrus, MD, MSc, ViiV Healthcare (Employee) Moti Rampogal, MD, Gilead Sciences (Consultant, Research Grant or Support, Speaker’s Bureau)Janssen (Consultant, Research Grant or Support, Speaker’s Bureau)Merck (Consultant, Research Grant or Support)ViiV Healthcare (Consultant, Research Grant or Support, Speaker’s Bureau) Alan Oglesby, MPH, ViiV Healthcare (Employee) Richard A. Elion, MD, Gilead Sciences (Advisor or Review Panel member, Research Grant or Support, Speaker’s Bureau)Jannssen (Speaker’s Bureau)Proteus (Research Grant or Support)Trio Health (Employee)ViiV Healthcare (Advisor or Review Panel member, Research Grant or Support)

Estimated Impact of Targeted Pre-Exposure Prophylaxis: Strategies for Men Who Have Sex with Men in the United States

Pre-exposure prophylaxis (PrEP) effectively reduces human immunodeficiency virus (HIV) transmission. We aimed to estimate the impact of different PrEP prioritization strategies among Black and Latino men who have sex with men (MSM) in the United States, populations most disproportionately affected by HIV. We developed an agent-based simulation to model the HIV epidemic among MSM. Individuals were assigned an HIV incidence risk index (HIRI-MSM) based on their sexual behavior. Prioritization strategies included PrEP use for individuals with HIRI-MSM ≥10 among all MSM, all Black MSM, young (≤25 years) Black MSM, Latino MSM, and young Latino MSM. We estimated the number needed to treat (NNT) to prevent one HIV infection, reductions in prevalence and incidence, and subsequent infections in non-PrEP users avoided under these strategies over 5 years (2016-2020). Young Black MSM eligible for PrEP had the lowest NNT (NNT = 10) followed by all Black MSM (NNT = 33) and young Latino MSM (NNT = 35). All Latino MSM and all MSM had NNT values of 63 and 70, respectively. Secondary infection reduction with PrEP was the highest among young Latino MSM (53.2%) followed by young Black MSM (37.8%). Targeting all MSM had the greatest reduction in prevalence (14.7% versus 2.9%-3.9% in other strategies) and incidence (49.4% versus 9.4%-13.9% in other groups). Using data representative of the United States MSM population, we found that a strategy of universal PrEP use by MSM was most effective in reducing HIV prevalence and incidence of MSM. Targeted use of PrEP by Black and Latino MSM, however, especially those ≤25 years, had the greatest impact on HIV prevention.

Increased Risk of Myocardial Infarction in HIV-Infected Individuals in North America Compared With the General Population

BACKGROUND

Previous studies of cardiovascular disease (CVD) among HIV-infected individuals have been limited by the inability to validate and differentiate atherosclerotic type 1 myocardial infarctions (T1MIs) from other events. We sought to define the incidence of T1MIs and risk attributable to traditional and HIV-specific factors among participants in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and compare adjusted incidence rates (IRs) to the general population Atherosclerosis Risk in Communities (ARIC) cohort.

METHODS

We ascertained and adjudicated incident MIs among individuals enrolled in 7 NA-ACCORD cohorts between 1995 and 2014. We calculated IRs, adjusted incidence rate ratios (aIRRs), and 95% confidence intervals of risk factors for T1MI using Poisson regression. We compared aIRRs of T1MIs in NA-ACCORD with those from ARIC.

RESULTS

Among 29,169 HIV-infected individuals, the IR for T1MIs was 2.57 (2.30 to 2.86) per 1000 person-years, and the aIRR was significantly higher compared with participants in ARIC [1.30 (1.09 to 1.56)]. In multivariable analysis restricted to HIV-infected individuals and including traditional CVD risk factors, the rate of T1MI increased with decreasing CD4 count [≥500 cells/μL: ref; 350-499 cells/μL: aIRR = 1.32 (0.98 to 1.77); 200-349 cells/μL: aIRR = 1.37 (1.01 to 1.86); 100-199 cells/μL: aIRR = 1.60 (1.09 to 2.34); <100 cells/μL: aIRR = 2.19 (1.44 to 3.33)]. Risk associated with detectable HIV RNA [<400 copies/mL: ref; ≥400 copies/mL: aIRR = 1.36 (1.06 to 1.75)] was significantly increased only when CD4 was excluded.

CONCLUSIONS

The higher incidence of T1MI in HIV-infected individuals and increased risk associated with lower CD4 count and detectable HIV RNA suggest that early suppressive antiretroviral treatment and aggressive management of traditional CVD risk factors are necessary to maximally reduce MI risk.

Rilpivirine versus efavirenz with emtricitabine/tenofovir disoproxil fumarate in treatment-naïve HIV-1-infected patients with HIV-1 RNA ≤100,000 copies/mL: week 96 pooled ECHO/THRIVE subanalysis

The once daily, single-tablet regimen (STR) combining rilpivirine (RPV), emtricitabine (FTC), and tenofovir disoproxil fumarate (TDF) provides a simplified treatment option for antiretroviral therapy (ART)-naïve patients with baseline HIV-1 RNA (BLVL) of ≤100,000 copies/mL. The aim of this analysis is to compare long-term efficacy, safety, and tolerability of RPV+FTC/TDF vs. efavirenz (EFV)+FTC/TDF as individual components in subjects with BLVL ≤100,000 copies/mL. Week 96 efficacy and safety data from subjects with BLVL ≤100,000 copies/mL, who received daily RPV 25 mg or EFV 600 mg with FTC/TDF in the phase 3, randomized, double-blind, double-dummy, active-controlled, registrational trials ECHO and THRIVE, were analyzed. Virologic response was evaluated by intent-to-treat, time to loss of virological response (ITT-TLOVR), and Snapshot algorithms. Through Week 96, RPV+FTC/TDF demonstrated non-inferior efficacy to EFV+FTC/TDF (84% vs. 81%, respectively; ITT-TLOVR) in 543 subjects with BLVL ≤100,000 copies/mL, and overall rates of virologic failure (VF) were 5.9% vs. 2.4%, respectively. Resistance development was lower in Year 2 than Year 1. Subjects in both arms with suboptimal adherence (≤95%) had lower virologic responses (63% vs. 62%, respectively). Treatment with RPV+FTC/TDF was associated with significantly fewer treatment-related adverse events (AEs), grade 2-4 AEs, neurological and psychiatric AEs (including dizziness and abnormal dreams/nightmares), and rash. Additionally, grade 2-4 treatment-emergent laboratory abnormalities and grade 1-3 lipid abnormalities were significantly less common with RPV+FTC/TDF than EFV+FTC/TDF. RPV+FTC/TDF demonstrated non-inferior efficacy to EFV+FTC/TDF in ART-naïve subjects with BLVL ≤100,000 copies/mL and was associated with a higher rate of VF but a more favorable safety and tolerability profile through Week 96.

Considerations in selecting protease inhibitor therapy

Over the past 10 years, highly active antiretroviral therapy that included a protease inhibitor has played a significant role in reducing morbidity and mortality among HIV-infected individuals. The early protease inhibitors were associated, however, with some significant limitations that posed major obstacles to their use--limited potency, difficult side effects, high regimen complexity and potential for cross-resistance. Important advances in the protease inhibitor class, including ritonavir boosting and the approval of two new protease inhibitors with the potential for once daily dosing, have led to simpler, better-tolerated protease-inhibitor therapy with the potential for improved efficacy, less toxicity and a reduced risk of the development of HIV resistance. Protease inhibitor characteristics and patient preferences should be considered in selecting the protease inhibitor that maximizes the opportunity for long-term efficacy and tolerability of highly active antiretroviral therapy.

Once-daily antiretroviral therapies for HIV infection: Consensus Statement of an Advisory Committee of the International Association of Physicians in AIDS Care

OBJECTIVE

Adherence is essential to successful virologic outcome of highly active antiretroviral therapy (HAART). Documented factors contributing to poor adherence include toxicity, food requirements, and pill burden. Once-daily antiretroviral therapies for HIV infection offer potential benefit by decreasing pill burden and dosing frequency, which may subsequently improve treatment adherence. This Consensus Statement is intended to offer guidance to physicians actively involved in HIV/AIDS care.

PARTICIPANTS

Eight physicians with expertise in HIV medicine were invited by the International Association of Physicians in AIDS Care (IAPAC) to serve on an ad hoc Advisory Committee.

CONSENSUS PROCESS

IAPAC convened the Advisory Committee in June 2002 to develop a draft Consensus Statement. Scientific and clinical research, and other data in published literature and abstracts from scientific conferences were considered by strength of evidence. A Subcommittee updated the Consensus Statement in October 2002 to reflect relevant data presented at the XIV International AIDS Conference and the 42nd Interscience Conference on Antimicrobial Agents and Chemotherapy. This document represents consensus agreement of the Advisory Committee. CONFLICT OF INTEREST DISCLOSURE: The International Association of Physicians in AIDS Care sponsored and coordinated the development of this Consensus Statement with an unrestricted educational grant from Bristol-Myers Squibb. The opinions expressed in this Consensus Statement represent only those of the Advisory Committee.

Weight loss as a predictor of survival and disease progression in HIV infection. Terry Beirn Community Programs for Clinical Research on AIDS

Severe weight loss in HIV is associated with decreased length of survival. It is unclear whether mild weight loss is associated with an increased risk of death or opportunistic complications of HIV. Participants in four interventional studies (n = 2382) conducted by a community-based clinical trials network were evaluated for percentage change in weight during their first 4 months in the study. Proportional hazards models were performed for the occurrence of opportunistic complications and death subsequent to the 4-month visit. The relative risk of death and opportunistic complications for those with 5% to 10% weight loss over 4 months was 2.22 (p < .001) and 1.89 (p < .001), respectively, and 1.26 (p < .01) and 1.19 (p < .01) among those who lost 0% to 5% of their body weight, respectively, when compared with those with no weight loss. Among those who lost 5% to 10% of their body weight, the relative risk of individual opportunistic complications increased significantly, including Pneumocystis carinii pneumonia (PCP) (1.61; p < .01), cytomegalovirus (CMV) (2.33; p < .001), and Mycobacterium avium complex (MAC) (1.81; p < .01). As little as 5%t weight loss over a 4-month period is associated with increased risk of death and opportunistic complications in HIV. A weight loss of 5% to 10% is also associated with an increased risk of individual opportunistic complications.

Complementary medicine and HIV infection

The social role of alternative medicine is critical in empowering the large proportion of HIV-positive patients who choose to use nontraditionally prescribed medicines. Working toward an open scientific dialogue with HIV-related complementary therapies is a worthy goal for all providers.