Determinants of adherence to highly active antiretroviral therapy among HIV-1-infected patients in Côte d'Ivoire

OBJECTIVE: To assess adherence to HAART and to determine factors associated with poor adherence among HIV-1-infected patients in Abidjan, C?te d'Ivoire. METHODS: A prospective observational study of 614 consecutive patients attending an HIV/AIDS outpatient clinic. Adherence was measured twice at 3-month intervals by self-report of missing doses over 4 days. An adherence level of less than 95% was defined as poor adherence. We used generalized estimating equation models for binomial distribution with repeated measures for data analysis. RESULTS: Of the 591 subjects who completed the study, 74.3% reported adherence levels of 95% or greater. Six factors were independently related to poor adherence: age less than 35 years [relative risk (RR) 1.45; 95% confidence interval (CI) 1.17-1.79], absence of social support (RR 1.66; 95% CI 1.24-2.24), number of daily pills 10 or more (RR 1.47; 95% CI 1.14-1.91), time of adherence assessment (first versus second time assessment RR 1.36; 95% CI 1.12-1.66), CD4 cell count of 250 cells/mul or greater (RR 1.43; 95% CI 1.10-1.88), and not being less worried about HIV infection now that treatments have improved (RR 1.26; 95% CI 1.01-1.58). Drug supply interruptions in the pharmacies were reported by 10.0% of the non-adherent patients as the reason for missing pills. CONCLUSION: Psychosocial factors were found to impact adherence and should be analysed in more detail by further studies. Scaling up antiretroviral therapy in sub-Saharan Africa should be preceded by reliable drug supply and distribution systems.     

A new decline in preventive behaviours among homosexual men : the role of highly active antiretroviral therapy?

The articles published in this issue of Eurosurveillance on recent trends of preventive behaviours in homosexual men in Spain, Switzerland, and the Netherlands, all conclude that the practice of safer sex is declining. They emphasise increases in anal penetration (regardless of the nature of the relationship), non-protected anal intercourse, and ejaculation in the mouth, in particular among casual partners. The increase of diagnoses of acute sexually transmitted diseases (such as gonorrhoea and syphilis) in different European countries - illustrated in this issue by the data from the Netherlands - is the first tangible consequence of this decline.     

Human immunodeficiency virus infection unresponsive to highly active antiretroviral therapy: denial of poor medication adherence or recalcitrant infection?

Poor clinical and virologic response to combination antiretroviral therapy for human immunodeficiency virus (HIV) infection may stem from a variety of factors including poor medication adherence, development of drug-resistant HIV strains, drug interactions, efflux pumps, and unfavorable pharmacokinetics. Diagnosing nonadherence to medication is particularly challenging. We present a case of lack of response to antiretroviral therapy in a patient who denied problems with medication adherence. The patient underwent a variety of objective examinations, all of which suggested poor medication adherence was responsible for his nonresponse to antiretrovirals. An approach to evaluating patients for causes of poor response to antiretroviral therapy and nonadherence and implications for clinical practice are discussed.     

Does immune reconstitution syndrome promote active tuberculosis in patients receiving highly active antiretroviral therapy?

OBJECTIVES: To assess whether highly active anti-retroviral therapy (HAART) contributes to the presentation of active tuberculosis (TB). DESIGN: Retrospective single-centre cohort study. METHODS: A total of 111 HIV-infected individuals with active TB were identified at an urban teaching hospital between February 1997 and April 2004. Those receiving HAART at the time of TB diagnosis were assessed. RESULTS: Nineteen of 111 (17%) were receiving HAART when TB developed. Within this group there appeared to be two distinct populations. Thirteen of 19, 12 from ethnic or social groups with high background rates of TB, developed disease a median of 41 days (range, 7-109) after starting HAART ('early TB' group). In six of 19 ('late TB' group), TB occurred a median of 358 days after HAART initiation (range, 258-598). The 'early TB' group had lower CD4 cell counts when starting HAART in comparison with the 'late TB' group (median; 87 versus 218 x 10 cells/l; P = 0.04); however no difference was observed in the rate of change of CD4 cell count (P = 0.5) or HIV load. Paradoxical reaction rate in the 'early TB' group was significantly greater than in the 'late-TB' group (62 versus 0%, P = 0.02) and greater than in a similar control population who started HAART while taking anti-TB therapy (62 versus 30%, P = 0.05). CONCLUSIONS: These data suggest anti-HIV treatment may amplify the presentation of active TB. This has implications for antiretroviral programmes in countries with high TB rates and warrants prospective investigation of a larger cohort.     

National review of first treatment change after starting highly active antiretroviral therapy in antiretroviral-naïve patients

Objectives

The aim of the study was to explore the factors surrounding modification of the first antiretroviral (ARV) regimen where drug switch occurred 3 months or more after initiation. Reference was made to the British HIV Association (BHIVA) guidelines on HIV management.

Methods

A case note and questionnaire‐based audit was carried out.

Results

Toxicity was the single most important reason for ARV change and was the only, or a contributory, cause in over half the patients. Virological failure, adherence issues, requirement for treatment simplification, and patient request were other significant reasons cited. In one‐third of those with virological failure, six or more months had elapsed between first detection and the time of switching to a new ARV regimen.

Conclusions

This audit demonstrated broad adherence to the BHIVA guidelines, although the long time before switching ARVs in the setting of virological failure was of some concern, particularly given the continuing and significant occurrence of primary ARV resistance in the UK.

     

Atherosclerosis and HIV in the highly active antiretroviral therapy era: towards an epidemic of cardiovascular disease?

Whether the atherogenic metabolic side effects of highly active antiretroviral therapy (HAART) (lipid disorders and glucose intolerance/diabetes) will translate, in the long term, into an increased incidence of cardiovascular events that would offset the survival benefits of this type of therapy is a matter of intense concern. This concern has been substantiated by a series of case reports of HIV-infected patients who had experienced unexplained cardiovascular disease. However, in the absence of prospective, large cohort studies, the answer to this question at present remains elusive. Indirect evidence, from retrospective cohort analyses and non-invasive imaging of peripheral arteries, indicates that HIV-infected persons are at higher risk for atherosclerosis than HIV-negative individuals. However, this risk does not appear to be attributable to HAART. Pending the availability of further data, a global assessment of the risk for heart disease should be performed in all HAART-treated HIV-infected patients, taking into account age and the presence of major risk factors. There is so far no evidence, from a cardiovascular standpoint, to limit administration of HAART. However, interventions on modifiable risk factors, including smoking cessation, are strongly recommended, particularly in high-risk patients.     

Secondary hyperparathyroidism in HIV patients: is there any responsibility of highly active antiretroviral therapy?

Secondary hyperparathyroidism may develop in the presence of hypovitaminosis D in order to maintain calcium homeostasis. We conducted a cross-sectional analysis in a cohort of 371 patients, identifying secondary hyperparathyroidism in 65 patients. This high prevalence (17.5%) was in part justified by the high prevalence of hypovitaminosis D (77.4%) in the whole sample, but we also identified an independent association with the use of tenofovir.