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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,...

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...

International AIDS Society 2012 Meeting

New research was presented at AIDS 2012, the 19th International AIDS Conference, from July 22-27  in Washington, DC. The features below highlight just some of the studies that emerged from the conference. Multiple Benefits With Early HIV Treatment The Particulars: Research has indicated that early treatment of HIV helps prevent various adverse outcomes. A landmark trial (HPTN 052) recently found that effective early treatment of HIV appears to help prevent transmission among heterosexuals. Data Breakdown: Two analyses of HPTN 052 were conducted. The first reviewed HIV patients who underwent immediate therapy when compared with those whose treatment began after CD4 counts fell below 250 cells/mm3. Immediate therapy was associated with longer time to an AIDS-defining event and to tuberculosis. The second analysis, conducted in similar patients, found that early HIV treatment was cost-effective, and in some cases, perhaps less expensive than delaying therapy. Take Home Pearls: Early treatment of HIV appears to reduce the risk of AIDS-defining events and tuberculosis. Early treatment also appears to be cost-effective. HIV/HCV Co-Infection & Outcomes The Particulars: HIV has been shown in previous studies to accelerate hepatitis C virus (HCV) progression. Whether antiretroviral therapy (ART) slows this progression has not been explored in clinical trials. Data Breakdown: In a study, the outcomes of patients with HIV/HCV co-infection—all of whom were on ART—were compared with those of patients with HCV only. Co-infected patients had a 6.3% rate of hepatic decompensation, compared with 5.0% for those with HCV only. Hepatocellular carcinoma developed in 1.2% of co-infected patients, compared with 0.9% of HCV patients. The mortality rate was 32.9% for co-infected patients, compared with 15.4% for...
HIV: From Prevention to Care and Treatment

HIV: From Prevention to Care and Treatment

The incidence of HIV in the United States has remained stable over the last 15 years, while the number of people living with the disease has increased by about 60%. “As more people are living with HIV, it’s important to analyze and assess our efforts to identify people with the infection and ensure that they remain on treatment,” says Stacy M. Cohen, MPH. “With effective care and treatment, individuals with HIV can live long, healthy lives.” Intriguing New Findings on HIV Diagnoses Cohen and colleagues had a study published in the December 2011 issue of Morbidity and Mortality Weekly Report that highlights the importance of identifying persons with HIV and making sure they remain in medical care and receive treatment. The investigation estimated the overall proportion of persons with HIV in the U.S. who have achieved viral suppression (see also, The Role of Demographics in HIV Clinical Outcomes). To accomplish this, the research team looked at the estimated numbers of American adults living with and diagnosed with HIV, and evaluated the percentages of those diagnosed with the infection who: Are receiving HIV care. Have been prescribed antiretroviral therapy (ART). Achieved viral suppression. Received prevention counseling from healthcare providers. Approximately 77% of people diagnosed with HIV were linked to care within 3 to 4 months of diagnosis, but only 51% were retained in ongoing care. About 89% of adults with HIV who were in care had been prescribed ART. Of these, 77% had a suppressed viral load at their most recent test (Table). Despite effective tools for HIV treatment, only 28% of all HIV-infected people had a suppressed viral load...
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