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Examining Why HIV Patients Discontinue ART

Examining Why HIV Patients Discontinue ART

Discontinuation of antiretroviral therapy (ART) among patients with HIV has been found to lead to virologic failure, drug resistance, and onward HIV transmission. “It’s imperative that we understand how many patients in the United States discontinue treatment, why they stop, and which patients are more likely to do this,” says Alison J. Hughes, MPH. “This information can allow us to more effectively target interventions to increase treatment persistence and optimize outcomes of people living with HIV.” New Data For a study published in the Journal of Acquired Immune Deficiency Syndromes, Hughes and colleagues conducted interviews with, and reviewed medical records for, a nationally representative sample of HIV-infected adults receiving HIV care from 2009 to 2010. The research team examined patient characteristics of ART discontinuation—defined as not currently taking ART—based on whether discontinuation was provider- or non–provider-initiated. “The good news was that 93% of patients in HIV care had initiated ART,” says Hughes. “However, of those who initiated ART, nearly 6% discontinued treatment, representing about 22,000 adults in the U.S.” Nearly half of patients reported that their healthcare provider had recommended treatment discontinuation. “We speculate that the high rate of provider-initiated discontinuation reflects treatment guidelines that were in place at the time, which recommended ART only for patients with a CD4 count less than 350 cells/mm3,” adds Hughes. The researchers also found that certain patients were more likely to stop treatment than others (Table). “Younger age, female gender, not having continuous health insurance, incarceration, injection drug use, and a high CD4 cell count were all associated with treatment discontinuation,” explains Hughes. “Unmet need for supportive services, no care in the...
Screening for HIV

Screening for HIV

In the United States, an estimated 1.2 million people are infected with HIV, and about 50,000 new cases emerge each year. Since the first cases of AIDS were reported in 1981, more than 1.1 million people have been diagnosed with the disease, and nearly 595,000 deaths have been attributed to it. About 20% to 25% of individuals living with HIV are unaware that they are infected with the virus. According to the U.S. Preventive Services Task Force (USPSTF), there is convincing evidence to suggest that identifying and treating HIV infection can markedly reduce the risk for HIV to progress to AIDS, AIDS-related events, and death in people who have immunologically advanced disease. Clinical data also show that initiating antiretroviral therapy (ART) earlier in patients with HIV—when they are most likely to be asymptomatic and detected by screening rather than clinical presentation—can decrease risks for AIDS-related events or death and transmission of HIV to uninfected people. Updated Recommendations In 2013, the USPSTF updated its 2005 recommendation statement on screening for HIV for adolescents, adults, and pregnant women. The USPSTF reviewed new evidence on the effectiveness of treatments for HIV in people with CD4 counts exceeding 0.200 × 109 cells/L. It also reviewed data on the effects of screening, counseling, and ART use on risky behaviors and HIV transmission risk as well as the long-term cardiovascular harms of ART. “The new USPSTF HIV screening guidelines now align more closely with recommendations that were released by the CDC back in 2006,” adds Dr. Volberding. According to the USPSTF recommendations, which were published in the Annals of Internal Medicine, all adults and adolescents...

Guidelines: Improving Retention & Treatment Adherence in HIV

Patient adherence to antiretroviral therapy (ART) is one of the most impor­tant factors associated with successful HIV outcomes. Following a diagnosis, timely entry into HIV medical care is essential to the provision of ART. However, of the approxi­mately 1.2 million people in the United States with HIV, only 69% are linked to care. For those who start care, only about 59% are retained in care. Among people with HIV who are on ART, just 28% have undetectable viral loads, which indicate high adherence to therapy. The varied and complex evidence base resulting from more than 20 years of research in these areas had until recently not been fully evaluated. In an effort to improve entry and retention in care as well as ART adherence in patients with HIV, a guidelines committee sponsored by the International Association of Physicians in AIDS Care and the NIH Office of AIDS Research published evidence-based guidelines in the Annals of Internal Medicine. Click here to view the full guidelines. Key Recommendations Melanie A. Thompson, MD, who was the lead author of the guideline document, says that the recommenda­tions set a high bar for meeting the standard of evidence. “We systematically reviewed literature from domestic and international studies that have been published since 1996,” she says. After reviewing 325 randomized controlled trials and observational studies that met stringent criteria for high-quality, comparative evidence, the expert panel arrived at 37 recommendations to assist clinicians in their care of people with HIV, several of which are particularly notable (Table 1). “All patients should receive some form of one-on-one ART education and adherence support.” According to Dr. Thompson,...

IDWeek 2012: EMRs Improve Treatment of ARV Recipients

The Particulars: Antiretroviral (ARV) medication errors may lead to toxicity and could decrease the efficacy of therapy over time. Such errors can also lead to the development of viral mutations to current ARV therapy and limit future treatments. Electronic medical record (EMR) use in the hospital may help reduce potential ARV errors and aid in medication reconciliation. Data Breakdown: Investigators implemented an intervention in a study that involved having all ARVs in a hospital EMR updated and continuously maintained with any changes from an HIV outpatient clinic. When compared with the period before the intervention, the ARV error rate decreased by 93% (16.0% vs 1.1%).  The costs associated with the decreased number of errors dropped by 85%. Take Home Pearl: Using EMRs to help maintain outpatient HIV clinic ARV regimens appears to significantly decrease medication errors and costs associated with these...

Making the Case for Earlier ART in HIV

The benefits of antiretroviral therapy (ART) during acute and early HIV infection remain unproven, despite several years of investigations into the topic. Studies have yielded conflicting results, with many having too few participants involved to make concrete, universal conclusions. It can also be challenging to identify patients who have been infected within the previous 6 months, making it difficult to conduct randomized trials in this population. As such, national guidelines currently recom­mend that ART be considered optional for acute and early HIV infection. Testing Early ART in Recently Infected Patients In the January 2012 Journal of Infectious Disease, researchers from the AIDS Clinical Trials Group Setpoint Study randomized patients with recent but not acute HIV infection to 36 weeks of ART followed by treatment discontinuation or to no treat­ment until pre-specified criteria for therapy initiation were met. “We aimed to deter­mine whether early treatment was associ­ated with a durable clinical benefit,” explains Christine M. Hogan, MD, lead author of the study. “To do that, we set out to demon­strate whether treatment during early infec­tion would lower the virologic set point (plasma HIV-1 RNA level)—an indepen­dent predictor of clinical outcome—after treatment was discontinued at 72 weeks.” The primary endpoint in the analysis was a composite of required treatment or retreat­ment and plasma HIV-1 RNA level at Week 72 for both groups and at Week 36 for the delayed-treatment group. The secondary end­point was the time to meeting guideline cri­teria—including CD4 count below 350 cells/mm3, clinical progression, or certain virologic criteria—for starting ART in the delayed-treatment arm or restarting ART after 36 weeks in the immediate-treatment arm. Unexpected Results from Delayed...
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