艾滋病患者抗病毒治疗依从现状的调查分析

目的 调查我国某农村地区艾滋病患者抗病毒治疗的服药依从性现状,并分析影响服药依从性的相关因素.方法 采用问卷对安徽省阜阳市70例艾滋病患者进行匿名调查,内容包括患者服药情况及其社会人口学资料、治疗情况、副反应、服药知识.采用SPSS 13.0统计软件对数据进行整理分析.结果 70例患者过去4 d内服药依从率为50%～100%,平均85.51%,服药依从(服药依从率≥95%)的患者占42.9%.患者漏服药物的主要原因包括外出或干农活而不在家、忘记、怕被注意到服药和应服药时睡着了.经分析发现,患者的年龄、子女个数和服药知识是影响其服药依从性的相关因素.结论 所调查艾滋病患者抗病毒治疗的服药依从性为中等水平,有待于进一步提高.针对患者漏服药物的常见原因和主要相关因素,可通过对患者提醒、督导,提高和改善患者的服药知识,从而提高艾滋病患者的服药依从性,保证其治疗效果并促进艾滋病治疗和预防工作.     

Factors affecting patient adherence to highly active antiretroviral therapy

OBJECTIVE: To determine the clinical and demographic variables related to adherence to highly active antiretroviral therapy (HAART) in patients treated in our hospital and identify the characteristics of nonadherent patients. METHODS: Outpatients receiving treatment with HAART (n = 283) were asked about variables related to adherence and to complete the APGAR (family support), State-Trait Anxiety questionnaire (STAI) (emotional situation), and IAS (social support) questionnaires. Patients were classified in 2 groups depending on whether adherence was > or =95% or <95%. Adherence was defined as the percentage of dosage forms prescribed that were obtained by the patient at the hospital pharmacy. A multivariate analysis was created to analyze how each significant variable affected adherence. RESULTS: Our data showed significant nonadherence for patients with the following factors: low level of education, unemployed, emotional situation, and abuse of substances including intravenous drugs. All significant variables were included in a logistic regression model to optimize the results. This model considered 4 variables: age (95% CI 0.89 to 0.99), number of antiretroviral drugs (95% CI 1.05 to 2.11), STAI Anxiety/Trait test (95% CI 2.02 to 6.02), and abuse of drugs (95% CI 1.20 to 3.95). CONCLUSIONS: We recommended special intervention to reinforce adherence for younger patients, patients taking a high number of antiretroviral drugs, those who have a history of intravenous drug use, and those with high anxiety status.     

Outpatient patterns of care and longitudinal intensity of antiretroviral therapy for HIV-infected drug users

OBJECTIVE: To examine the association of drug users' outpatient patterns of care with subsequent intensity of antiretroviral therapy (ART). MATERIALS AND METHODS: Annual types of ART in 8897 New York State Medicaid drug users who were prescribed ART for > or =6 months in 1996 or 1997 were determined. From pharmacy claims, intensity was classified from changes in annual type of ART in 1996 to 97 and 1997 to 98 as: optimal (ie, on or starting highly active ART [HAART]), acceptable (ie, on or starting 2+ non-HAART drugs), or suboptimal (ie, none, <6 months, one drug, or change from HAART to non-HAART). In both 1996 and 1997, outpatient pattern of care was defined including regular medical care, regular drug treatment, both, and neither and categories of visits for HIV-focused care. Predictors of adequate ART intensity were examined among the group with suboptimal or adequate intensity (model 1) and predictors of optimal ART intensity among the group with adequate or optimal intensity (model 2). RESULTS: The adjusted odds ratios (AOR) of acceptable ART intensity in model 1 were increased for those with HIV-focused care (AOR, 2.9; 95% CI, 2.6, 3.3 for 4+ visits 1.7; 95% CI, 1.5, 1.9 for 1-3 visits) or regular medical care (AOR, 1.2 [1.1, 1.4]. Adjusted odds ratios (AOR) of optimal intensity in model 2 were increased for those with regular substance abuse care with (AOR, 1.4 [1.2, 1.7]) or without (AOR, 1.2 [1.1, 1.4]) regular medical care whereas HIV-focused visits had no effect. CONCLUSION: Care from an HIV-focused provider was predictive of a drug user receiving at least adequate intensity of ART for more than 2 years whereas regular drug abuse treatment, especially with regular medical care, was associated with optimal intensity of ART.     

Impact of a Rural Village Women (Asha) Intervention on Adherence to Antiretroviral Therapy in Southern India

BACKGROUND:: Despite the increased prevalence of HIV in the rural female population of India, adherence to antiretroviral therapy continues to be low because of several barriers that discourage rural women. OBJECTIVES:: This study aims to assess the effectiveness of an intervention (Asha-Life) delivered by Accredited Social Health Activists (Asha) to improve antiretroviral therapy adherence of rural women living with AIDS in India compared with that of a usual care group. METHODS:: Sixty-eight rural women living with AIDS, aged 18-45 years, participated in a prospective, randomized pilot clinical trial and were assessed for several factors affecting adherence, such as sociodemographic characteristics, health history, CD4 cell count, enacted stigma, depressive symptomology, help getting antiretroviral therapy, and perceived therapy benefits. RESULTS:: Findings at 6 months revealed that, although both groups improved their adherence to antiretroviral therapy, there was greater improvement in the Asha-Life group (p < .001), who reported a greater reduction in barriers to antiretroviral therapy than those in the usual care group. DISCUSSION:: Antiretroviral therapy adherence showed significant increase in the Asha-Life cohort in which basic education on HIV/AIDS, counseling on antiretroviral therapy, support from Ashas, financial assistance, and better nutrition, was provided. The Asha-Life intervention may have great potential in improving antiretroviral therapy adherence and decreasing barriers among rural women living with AIDS in India.     

The role of social support and negative affect in medication adherence for HIV-infected men who have sex with men

Combinations of medications that control HIV viral replication are called antiretroviral therapy (ART). Regimens can be complex, so medication adherence is often suboptimal, although high rates of adherence are necessary for ART to be effective. Social support, which has been directly and indirectly associated with better treatment adherence in HIV-infected individuals, influences negative affect, including depression and anxiety. Our study assessed whether current anxious and depressive symptoms mediated the relationship between general social support and recent self-reported medication adherence in HIV-infected men who have sex with men (N= 136; 65% White, 15% Black/African American). Results revealed no direct effect, but an indirect effect of depressive (95% CI [-.011, -.0011]) and anxious symptoms (95% CI [-.0097, -.0009]), between social support and medication adherence. Greater levels of social support were associated with lower levels of depression and anxiety, which in turn were associated with lower ART adherence.     

The effect of depressive symptoms at ART initiation on HIV clinical progression and mortality: implications in clinical practice

BACKGROUND: Depression is common in HIV-infected patients receiving antiretroviral therapy. However, longitudinal studies addressing the role that depression might play in HIV clinical progression and mortality remain rare. This is especially true for those studies that also consider the possible confounding influence of patient's adherence to treatment. METHODS: The ANRS CO-8 APROCO-COPILOTE cohort study enrolled 1,281 individuals at the initiation of a protease-inhibitor-containing regimen between 1997 and 1999. Adherence, depressive symptoms and other psychosocial factors were measured using self-administered questionnaires. Predictors of progression to AIDS or death were studied using Cox models. RESULTS: Out of 1,028 individuals eligible for the present analysis, 92 individuals either died or had an AIDS-defining event during a median follow up of 54 months. At baseline, 377 individuals (41%) reported depressive symptoms and 124 (12%) reported non-adherence at month 4. Depressive symptoms at baseline were associated with progression (hazard ratio [HR] 2.1; P = 0.001). Despite the association between depressive symptoms and nonadherence, depressive symptoms remained a predictor of clinical progression (adjusted HR [aHR] [95% confidence interval (CI)] 1.6 [1.0-2.5]) after adjustment for several factors: initial non-adherence (aHR [95% CI] 2.0 [1.1-3.6]), having a steady partner (aHR [95% CI] 0.5 [0.3-0.7]), older age (aHR [95% CI] 1.40 [1.12-1.74] per 10-year increment), HIV clinical stage C (aHR [95% CI] 2.5 [1.6-4.0]), plasma HIV RNA > or = 100,000 copies/ml (aHR [95% CI] 1.7 [1.1-2.87]) and more than 8 years since HIV diagnosis (aHR [95% CI] 1.8 [1.1-2.8]). CONCLUSION: Depressive symptoms and non-adherence are independent predictors of HIV clinical progression and mortality. Screening and appropriate treatment of depressive symptoms at antiretroviral treatment initiation should be included in the standard care of HIV-infected patients.     

The Impact of Alcohol Use on Antiretroviral Therapy Adherence in Koreans Living with HIV

Purpose

This study aimed to examine the impact of alcohol use on the antiretroviral therapy (ART) adherence of Koreans living with human immunodeficiency virus (HIV).

Social networks of substance users with HIV infection: application of the Norbeck Social Support Scale

The role of social support networks in medication adherence among HIV-infected substance users remains understudied. In this secondary data analysis, the authors sought to determine the relationship between social support networks and antiretroviral adherence among HIV-infected substance abusers receiving methadone. They analyzed data collected in a 24-week study of 76 methadone-maintained, HIV-infected substance abusers randomized to directly observed antiretroviral therapy or treatment as usual. The authors used logistic regression to examine the relationship between social support networks and self-reported antiretroviral adherence. Their results showed that study participants had an average of 1.36 social network members (SD = 1.4); 34% of participants had at least one drug user and 25% had at least one HIV-infected person in their network. The presence of network drug users and HIV-infected network members was associated with less antiretroviral medication adherence (p < .05). The authors conclude that both social network density and characteristics of network members have implications for medication adherence.     

Limited impact of immunosuppression and HAART on the incidence of cervical squamous intraepithelial lesions in HIV-positive women

BACKGROUND: Although highly active antiretroviral therapy (HAART) has lowered the incidence of various opportunistic diseases, its impact on cervical squamous intraepithelial lesions (SILs) is unclear. Our objective was to compare the incidence of SILs in HIV-infected women receiving HAART versus those not receiving HAART and to determine the role of risk factors including immunosuppression in the pathogenesis of SIL. METHODS: A total of 298 HIV-infected women with normal Papanicolaou (Pap) smear and normal colposcopic findings at enrollment were followed-up until incident SIL or last follow-up visit. Cox regression modelling was used to assess risks factors for incident SIL. RESULTS: Eighty-eight women developed SILs, including 75 low-grade lesions, during a median follow-up of 28 months (16-52; incidence of 8.7 cases per 100 person-years). No invasive cervical cancers were identified. Incidence decreased from 10.7 to 6.5 per 100 person-years in non-receiving versus receiving HAART women (relative risk [RR]: 0.7; 95% confidence interval [CI]: 0.4-1.2, P=0.15, from the adjusted Cox model). Incident SIL was not associated to low CD4+ T-cell count (P=0.54). In multivariate analysis, the only significant risk factor for incident lesion was the age between 30-39 compared with over 40 (RR: 3.5; 95% CI: 1.4-8.9; P=0.02). CONCLUSION: No impact in the development of SIL was evidenced for CD4+ T-cell counts, but we cannot exclude a modest impact of HAART. All HIV-positive women should be offered to participate in cervical cancer screening programmes whether or not they receive effective antiretroviral therapy.     

Adverse events to antiretrovirals in the Swiss HIV Cohort Study: effect on mortality and treatment modification

BACKGROUND: Antiretroviral therapy (ART) decreases morbidity and mortality in HIV-infected patients but is associated with considerable adverse events (AEs). METHODS: We examined the effect of AEs to ART on mortality, treatment modifications and drop-out in the Swiss HIV Cohort Study. A cross-sectional evaluation of prevalence of 13 clinical and 11 laboratory parameters was performed in 1999 in 1,078 patients on ART. AEs were defined as abnormalities probably or certainly related to ART. A score including the number and severity of AEs was defined. The subsequent progression to death, drop-out and treatment modification due to intolerance were evaluated according to the baseline AE score and characteristics of individual AEs. RESULTS: Of the 1,078 patients, laboratory AEs were reported in 23% and clinical AEs in 45%. During a median follow up of 5.9 years, laboratory AEs were associated with higher mortality with an adjusted hazard ratio (HR) of 1.3 (95% confidence interval [CI] 1.2-1.5; P < 0.001) per score point. For clinical AEs no significant association with increased mortality was found. In contrast, an increasing score for clinical AEs (HR 1.11,95% CI 1.04-1.18; P = 0.002), but not for laboratory AEs (HR 1.07, 95% CI 0.97-1.17; P = 0.17), was associated with antiretroviral treatment modification. AEs were not associated with a higher drop-out rate. CONCLUSIONS: The burden of laboratory AEs to antiretroviral drugs is associated with a higher mortality. Physicians seem to change treatments to relieve clinical symptoms, while accepting laboratory AEs. Minimizing laboratory drug toxicity seems warranted and its influence on survival should be further evaluated.     

Long-term virological outcome and resistance mutations at virological rebound in HIV-infected adults on protease inhibitor-sparing highly active antiretroviral therapy

OBJECTIVE: To assess the durability of the undetectability of HIV plasma viraemia (pV) and to determine the factors associated with virological rebound (VR) in HIV-infected adults on protease inhibitor (PI)-sparing highly active antiretroviral therapy (HAART). The development of resistance mutations during virologically successful therapy and VR was also analysed. MATERIALS AND METHODS: One hundred and twenty-six HIV-infected adults on PI-sparing HAART were prospectively followed from April 1998 to December 2002: Group 1, naive for antiretroviral drugs (n = 26); Group 2, previously PI-HAART-exposed patients (n = 19); Group 3, previously exposed to suboptimal therapy (n = 81). Genotypic resistance tests on peripheral blood mononuclear cells or on plasma RNA (when feasible) were carried out when undetectable HIV pV was demonstrated for at least 48 weeks. Additionally, patients showing a therapy adherence >95% developing VR were also tested at rebound, at simplification and during previous suboptimal therapy exposure. RESULTS: The median follow-up time was 630 [329-903] days. VR was considered as two consecutive pV levels >50 copies/mL. Twenty-two (17.5%) patients developed VR. Only therapy adherence <95% was independently associated with VR (adjusted hazard ratio: 8.42; 95% CI: 3.33-21.27). Twenty (40%) of the 50 patients with pV < 50 copies/mL for at least 48 weeks showed at least one thymidine-associated mutation (TAM) but none had NNRTI-resistance mutations. Ten (83.3%) of 12 available adherent patients showing VR harboured NNRTI-resistance-associated mutations; 50% of them were considered as wild-type strains at simplification time. However, the TAM number and resistance mutations profile found on suboptimal exposure were very similar to those found at VR on simplification therapy. CONCLUSIONS: PI-sparing HAART allows maintenance of successful long-term control of HIV replication, adherence to therapy being the main factor associated with VR. However, a small proportion of patients on simplification regimen may develop VR regardless of therapy compliance. VR on PI-sparing HAART is characterized by the emergence of NNRTI cross-resistance mutations. Finally, TAMs 'archived' during previous suboptimal exposures are partially involved in subsequent VR on simplification HAART.     

血药浓度监测在儿童艾滋病患者抗病毒治疗依从性评价中的应用

目的 探讨血药浓度监测在儿童艾滋病患者抗病毒治疗依从性评价中的应用价值.方法 收集2009年3-10月河南省上蔡县CDC诊治的87例患儿连续3次随访的治疗相关信息及261份血浆标本,建立高效液相色谱-质谱联用的方法,测定血浆中抗病毒药物浓度.对治疗方案、患儿年龄、性别、父母情况、治疗经历和治疗时间等可能影响依从性的相关因素采用单因素Logistic回归分析.结果 以血药浓度是否低于LLTR 1000 ng/ml为标准判断患者是否漏服药物,发现28份标本血药浓度

Abstract：

Objective To evaluate the application of plasma drug monitoring in pediatric HIV/AIDS patient antiretroviral therapy adherence monitoring.Methods Totally 261 plasma samples and related information were collected from three consecutive follow-up visits of 87 HIV-infected children treated in Shangcai county CDC of Henan province from March to October 2009.The plasma concentrations of antiretroviral drugs were measured by a developed high performance liquid chromatography-mass spectrometry method.Potential adherence influencing factors, such as regimen, age, gender, parent conditions, previous ART exposure and therapy duration, were analyzed by univariate logistic regression.Results Plasma concentration of antiretroviral drugs lower than LLTR (1 000 ng/ml) was the criteria to identify missed dose.The concentrations of 28 plasma samples were lower than LLTR, which meant missing dose.There were 17 patients (19.5%) with their concentrations lower than LLTR at least once in three follow-up visits.Logistic regression analysis of adherence related factors showed that compared with the children whose parents were both alive, the children whose mother and (or) father died were more likely to miss dose.The odds ratio was 4.13(95% credibility interval:1.37-12.46, P values was 0.012).Conclusions HIV-infected children have adherence problems when receiving antiretroviral therapy.Plasma therapeutic drug monitoring can be one of the effective methods to monitor the adherence.     

Continuation of postpartum antiretroviral therapy in a cohort of women infected with human immunodeficiency virus.

A common dilemma for HIV-positive pregnant women is the issue of continuation or cessation of antiretroviral therapy (ART) postpartum. Current guidelines for ART during pregnancy offer no specific recommendations for postpartum ART care. The objective of this study was to ascertain characteristics that would predict cessation or continuation of ART postpartum. In this study, prenatal and medical clinic records were reviewed retrospectively for a cohort of 29 HIV-infected pregnant women who were seen in the Temple University High Risk obstetrics practice from 1997 to 1998. All women took ART during pregnancy, except for one who received i.v. AZT and nevirapine during labor. HIV-specific medical care was provided concurrently during the time of the woman's obstetrics visit by a nurse practitioner and a clinical nurse specialist in consultation with the physician. Factors that were included for review included race, age, use of ART at the time of pregnancy diagnosis, type of ART during pregnancy, CD4 count, HIV-1 ribonucleic acid polymerase chain reaction (RNA PCR) levels, current substance use, disclosure of HIV status to current partner, years of HIV infection, prior HIV infected child, and whether this was a first pregnancy. The two groups of women were divided between those who discontinued ART postpartum and those who continued ART. The data were analyzed with the Kruskal-Wallis test for two groups, or calculations of risk ratios with Fisher's exact test. Study results indicated that 15 out of 29 women (51%) continued ART postpartum. The significant factors for continuation included Latina ethnicity (risk ratio = 0.24, confidence interval = 0.06-0.87), CD4 < 200 mm3 (p = .04), and a greater number of drugs in the antiretroviral regimen 3 versus 2 (p = .05). This study showed that postpartum continuation of ART was associated with identified Latina ethnicity, lower CD4 counts, and a greater number of drugs in the pregnancy regimen. Further study is recommended to understand the clinical impact of intermittent ART, the strategies for postpartum therapy adherence, and clinical follow-up.     

Medication-based Refill Adherence Among Pregnant Women Living With HIV in Nigeria

PurposeA major global public health challenge is the continuance of new pediatric HIV infections primarily because of mother to child transmission of HIV occurring mainly in sub-Saharan African countries. The purpose of this study was to examine antiretroviral therapy (ART) refill adherence and its determinants among pregnant women living with HIV in Nigeria.MethodsA retrospective review of pharmacy refill records was undertaken to examine adherence data on 275 pregnant women undergoing ART in 4 high-volume HIV treatment sites in Nigeria. A pharmacy refill adherence measure was used to assess medication refill behavior of pregnant women living with HIV who had received an ART refill during a period of 3 months. Medication-based ART refill adherence was categorized as % adherence (100% adherence) or % nonadherence (<100% adherence) to the ART refill scheduled dates. Refill appointments were scheduled on a 28-day cycle. Multivariable logistic regression analysis was performed.FindingsOf the 275 women, 59.3% (95% CI, 53.1%–65.5%) were adherent to their ART refill schedule. Women who initiated ART during the third trimester of their current pregnancy had the lowest adherence rate of 30.8% (95% CI, 7.7%–53.8%) compared with women who commenced ART before conception or during the first or second trimester. The availability of a treatment support person was significantly associated with ART refill adherence. The odds of medication-based refill adherence were 2.9 times higher for participants who had a treatment support person (odds ratio = 2.9; 95% CI, 1.6–5.2; p = 0.001).ImplicationsResults indicate that having a treatment support person could contribute to improving ART adherence in pregnant women living in Nigeria.     

Sex issues in HIV-1-infected persons during highly active antiretroviral therapy: a systematic review

BACKGROUND: Since the introduction of highly active antiretroviral therapy (HAART), morbidity and mortality rates have sharply decreased among HIV-infected patients. Studies of possible differences between men and women in the course of HIV infection give conflicting results. The objective of this study was to assess sex differences during HAART. METHODS: A literature search by using the MEDLINE database between March 2002 and February 2007 was performed to identify all published studies on the sex-specific differences on the impact of HAART. All articles with measures of effect (preferably adjusted odds ratio, relative risk or hazard ratio with 95% CI) of sex on viroimmunological and clinical parameters during HAART were included. Five different topics of interest in our research were selected: time of initiation of HAART, adherence, viroimmunological response, clinical response and adverse reactions during HAART. RESULTS: US data report an initiation of HAART at an earlier disease stage in men compared with women. After initiation of HAART, most authors do not report any viroimmunological difference, although a few clinical studies showed a significantly better virological response in women compared with men. Nevertheless, women were more likely to be less adherent to antiretrovirals and to have non-structured treatment interruptions than men. This is likely to be related to the higher number of adverse reactions they experience during HAART. Finally, discordant opinions with regard to clinical benefits during HAART exist, but recent clinical and observational trials suggest a better clinical outcome for women. CONCLUSIONS: We found little evidence of sex differences during antiretroviral treatment. Nevertheless, most of these studies were underpowered to detect sex differences and had limited follow-up at 6 or 12 months. Design of new gender-sensitive clinical trials with both prolonged follow-up and sample size representative of the current HIV prevalence among women are strongly needed to detect the likely sex differences of antiretroviral agents during HIV infection.     

Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money

CONTEXT: Current Israeli guidelines for the empiric treatment of uncomplicated urinary tract infection (UTI) in women recommend nitrofurantoin for 5 days. Some physicians nevertheless opt for ofloxacin, which should be prescribed for 3 days according to universally accepted guidelines. OBJECTIVE: To evaluate the economic consequences of longer than recommended durations of antibiotic therapy in the empiric treatment of uncomplicated UTI in women. DESIGN, SETTING AND PATIENTS: Data were derived from the electronic records of one of the four health maintenance organizations in Israel. The sample included all women aged 18-75 years who were diagnosed with acute cystitis or UTI from January 2001 to June 2002 and were empirically treated with antibiotics. Of the 7738 patients identified, 1138 received nitrofurantoin and 1054 ofloxacin. The excess expenditure accrued due to longer than recommended therapy with these drugs was evaluated. RESULTS: The rate of adherence was 22.23% for nitrofurantoin (95% CI=19.81%, 24.65%), and 4.08% for ofloxacin (95% CI=2.88%, 5.28%). The average excess expenditure per case was 5.78 USD (US Dollar) with ofloxacin and 3.43 USD with nitrofurantoin, resulting in an annual loss to the health maintenance organizations of approximately 19,000 USD. When extrapolated to the national population of 6.5 million, the loss due to inappropriate treatment of adult women is 190,000 USD. CONCLUSIONS: The lack of adherence to national and international guidelines with regard to the recommended duration of antibiotic treatment of UTI in women resulted in a significant and avoidable waste of health system resources. This study suggests that drug utilization analyses that concentrate solely on the choice of drug may be overlooking important information.