Antihypertensive medication adherence and blood pressure control among central Alabama veterans

Medication nonadherence is associated with adverse outcomes. To evaluate antihypertensive medication adherence and its association with blood pressure (BP) control, the authors described population adherence to prescribed antihypertensive medication (proportion of days covered ≥80%) and BP control (mean BP <140/90 mm Hg) among central Alabama veterans during the fiscal year 2015. Overall, 75.1% of patients receiving antihypertensive medication were considered adherent, and 66.1% had adequate BP control. Patients adherent to antihypertensive medication were more likely to have adequate BP control compared with patients classified as nonadherent (67.4% vs 62.0%; adjusted odds ratio 1.33; 95% confidence interval, 1.22–1.44 [P<.0001]). Among patients who had uncontrolled BP, 73.6% were considered adherent to medication. Adherence to antihypertensive medication was associated with adequate BP control; however, a substantial proportion of patients with inadequate BP control were also considered adherent. Interventions to increase BP control could address more aggressive medication management to achieve BP goals.     

Hypertension Control and Its Correlates Among Adults Attending a Hypertension Clinic in Tanzania

Hypertension control rates are low in sub‐Saharan Africa. Population‐specific determinants of blood pressure (BP) control have not been adequately described. The authors measured BP and conducted interviews to determine factors associated with BP control among adults attending a hypertension clinic in Tanzania. Three hundred adults were enrolled. BP was controlled in 47.7% of patients at the study visit but only 28.3% over three consecutive visits. Demographic and socioeconomic factors were not associated with control. Obesity and higher medication cost were associated with decreased control. Their effect was mediated through adherence. Good knowledge of (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.0–6.1; P=.047), attitudes towards (OR, 2.7; 95% CI, 1.0–7.1; P=.04), and practices concerning (OR, 5.4; 95% CI, 2.3–13.0; P<.001) hypertension were independently associated with increased control, even after adjusting for mediation through adherence. Good adherence had the strongest association with control (OR, 14.6; 95% CI, 5.8–37.0; P<.001). Strategies to reduce hypertension‐related morbidity and mortality in sub‐Saharan Africa should target these factors. Interventional studies of such strategies are needed.     

The association between medication adherence and treatment intensification with blood pressure control in resistant hypertension

Patients with resistant hypertension are at risk for poor outcomes. Medication adherence and intensification improve blood pressure (BP) control; however, little is known about these processes or their association with outcomes in resistant hypertension. This retrospective study included patients from 2002 to 2006 with incident hypertension from 2 health systems who developed resistant hypertension or uncontrolled BP despite adherence to ≥3 antihypertensive medications. Patterns of hypertension treatment, medication adherence (percentage of days covered), and treatment intensification (increase in medication class or dose) were described in the year after resistant hypertension identification. Then, the association between medication adherence and intensification with 1-year BP control was assessed controlling for patient characteristics. Of the 3550 patients with resistant hypertension, 49% were male, and mean age was 60 years. One year after resistance hypertension determination, fewer patients were taking diuretics (77.7% versus 92.2%; P<0.01), β-blockers (71.2% versus 79.4%; P<0.01), and angiotensinogen-converting enzyme inhibitor/angiotensin receptor blocker (64.8% versus 70.1%; P<0.01) compared with baseline. Rates of BP control improved over 1 year (22% versus 55%; P<0.01). During this year, adherence was not associated with 1-year BP control (adjusted odds ratio, 1.18 [95% CI: 0.94-1.47]). Treatment was intensified in 21.6% of visits with elevated BP. Increasing treatment intensity was associated with 1-year BP control (adjusted odds ratio, 1.64 [95% CI, 1.58-1.71]). In this cohort of patients with resistant hypertension, treatment intensification but not medication adherence was significantly associated with 1-year BP control. These findings highlight the need to investigate why patients with uncontrolled BP do not receive treatment intensification.     

Does medication adherence itself confer fracture protection? An investigation of the healthy adherer effect in observational data

Objective

Prior observational studies have shown an association between bisphosphonate adherence and fewer fractures. It is unclear if such studies reflect pharmacologic benefits or behavioral attributes, i.e., the healthy adherer effect. Our objective was to examine the association of therapy adherence and fracture risk among patients initiating therapies hypothesized to be favorable, unfavorable, or neutral toward fracture risk, in order to evaluate for a healthy adherer effect.

Methods

In this observational study, we identified patients within Medicare 2006–2009 data who initiated any of 3 medication groups within 9 months after an osteoporotic fracture as follows: 1) oral bisphosphonates (n = 2,507), 2) selective serotonin reuptake inhibitors (SSRIs; n = 2,420), or 3) angiotensin‐converting enzyme (ACE) inhibitor or calcium‐channel blocker (CCB; n = 2,178). Cox regression analysis, adjusting for covariates, was used to compare fracture rates at the hip and major osteoporotic fracture sites (including hip, clinical vertebral, humerus, and wrist) during followup, comparing patients with high adherence versus low adherence within each medication group.

Results

There were few baseline differences between those who had high adherence versus lower adherence. High adherence with bisphosphonates decreased fracture risk at both hip (hazard ratio [HR] 0.53, 95% confidence interval [95% CI] 0.32–0.96) and major fracture sites (HR 0.61, 95% CI 0.45–0.80). High adherence with SSRIs suggested increased fracture risk at both hip (HR 1.58, 95% CI 0.97–2.57) and major fracture sites (HR 1.32, 95% CI 0.96–1.83). High adherence with ACE inhibitors/CCBs was neutral toward fracture risk at both hip (HR 1.27, 95% CI 0.67–2.41) and major fracture sites (HR 1.00, 95% CI 0.67–1.49).

Conclusion

In this observational cohort of older individuals, the association between medication adherence and fracture risk differed by medication exposure, suggesting a limited role for the healthy adherer effect in observational studies of osteoporosis medications.     

Predictors of compliance with a mass drug administration programme for lymphatic filariasis in Orissa State,India 2008

Objectives To assess the performance of an educational campaign to increase adherence to a mass‐administered DEC regimen against lymphatic filariasis (LF) in Orissa, and to identify factors that could enhance future campaigns. Method Randomized cluster survey, comparing areas that did and did not receive the educational campaign, using a household coverage survey and knowledge, attitudes and practices (KAP) survey. Results LF MDA coverage for the entire population (n = 3449) was 56% (95% CI: 50.0–61.9). There was no statistical difference between the areas that did and did not receive the educational campaign. The most common barriers to adherence were fear of medication side effects (47.4%) and lack of recognition of one’s risk for LF (15.8%). Modifiable, statistically significant, multivariable predictors of adherence were knowing that DEC prevents LF (aOR = 2.6, 95% CI: 1.4–5.1), knowing that mosquitoes transmit LF (aOR = 1.9, 95% CI: 1.1–3.2), and knowing both about the mass drug administration (MDA) in advance and that mosquitoes transmit LF (aOR = 5.4, 95% CI: 2.8–10.4). Conclusions India needs to increase compliance with MDA programmes to reach its goal of interrupting LF transmission. Promoting a simple public health message before MDA distribution, which takes into account barriers to and predictors of adherence, could raise compliance with the LF MDA programme.     

Medication adherence and stroke/TIA risk in treated hypertensives: Results from the REGARDS study

BackgroundThe extent to which low medication adherence in hypertensive individuals contributes to disparities in stroke and transient ischemic attack (TIA) risk is poorly understood.MethodsInvestigators examined the relationship between self-reported medication adherence and blood pressure (BP) control (<140/90 mm Hg), Framingham Stroke Risk Score, and physician-adjudicated stroke/TIA incidence in treated hypertensive subjects (n = 15,071; 51% black; 57% in Stroke Belt) over 4.9 years in the national population-based REGARDS cohort study.ResultsMean systolic BP varied from 130.8 ± 16.2 mm Hg in those reporting high adherence to 137.8 ± 19.5 mm Hg in those reporting low adherence (P for trend < .0001). In logistic regression models, each level of worsening medication adherence was associated with significant and increasing odds of inadequately controlled BP (≥140/90 mm Hg; score = 1, odds ratio [95% confidence interval], 1.20 [1.09–1.30]; score = 2, 1.27 [1.08–1.49]; score = 3 or 4, 2.21 [1.75–2.78]). In hazard models using systolic BP as a mediator, those reporting low medication adherence had 1.08 (1.04–1.14) times greater risk of stroke and 1.08 (1.03–1.12) times greater risk of stroke or TIA.ConclusionLow medication adherence was associated with inadequate BP control and an increased risk of incident stroke or TIA.     

Incidence and Risk of Sorafenib‐Induced Hypertension: A Systematic Review and Meta‐Analysis

Hypertension is one of the major side effects of sorafenib, and reported incidences vary substantially among clinical trials. A systematic review was conducted using Medline, PubMed, Embase, and the Cochrane Library for all longitudinal studies to investigate the incidence and risk of hypertension events in cancer patients treated with sorafenib. A total of 14 randomized controlled trials and 39 prospective single‐arm trials involving 13,555 patients were selected for the meta‐analysis. The relative risk of all‐grade and high‐grade hypertension associated with sorafenib were 3.07 (95% confidence interval [CI], 2.05–4.60; P<.01) and 3.31 (95% CI, 2.21–4.95; P<.01), respectively. The overall incidence of sorafenib‐induced all‐grade and high‐grade hypertension were 19.1% (95% CI, 15.8%–22.4%) and 4.3% (95% CI, 3.0%–5.5%), respectively. A significantly higher incidence of hypertension was noted in patients with renal cell carcinoma (RCC) compared with those with non‐RCC malignancies (all‐grade: 24.9% [95% CI, 19.7%–30.1%] vs 15.7% [95% CI, 12.1%–19.3%]; P<.05; high‐grade:8.6% [95% CI, 6.0%–11.2%] vs 1.8% [95% CI, 0.9%–2.6%]; P<.05). The trials with median progression‐free survival (PFS) longer than 5.3 months (mean PFS) demonstrated a significantly higher incidence of high‐grade hypertension than trials with shorter PFS (6.3% [95% CI, 4.1%–8.5%] vs 2.6% [95% CI, 1.4%–3.8%]; P<.05). Findings of the meta‐analysis indicated a significantly high risk of sorafenib‐induced hypertension. Patients with RCC have a significantly higher incidence of hypertension and the occurrence of hypertension may be associated with improved prognosis.     

Patient preferences and assessment of likely adherence to hepatitis C virus treatment

Summary. To estimate patient preferences for attributes of hepatitis C virus (HCV) treatment and patients’ assessment of the likely effect of treatment attributes on treatment adherence, HCV patients ≥18 years old completed an online survey that included nine 2‐alternative choice questions. Each choice question was defined by the probability of sustained viral response (Efficacy), injection frequency (Frequency), duration of flu‐like symptoms after every injection (Flu), injection device (Device), average number of days of work missed each week (Lost Work Days), probability of reversible hair thinning while on treatment (Alopecia) and probability of developing clinical depression while on treatment (Depression). We estimated a mean relative importance weight for each attribute. Patients also answered three rating questions to assess the extent to which treatment attributes might affect adherence. Hundred and fifty patients completed the survey. Efficacy was the most important attribute with a mean relative importance weight of 10 [95% CI: 7.9–12.1]. The remaining attributes were ranked in order of importance as follows: Depression (4.4 [95% CI: 3.6–5.1]), Flu Days (Frequency × Flu) (3.7 [95% CI: 2.2–5.3]), Lost Work Days (2.9 [95% CI: 2.3–3.5]), Alopecia (1.3 [95% CI: 0.7–1.9]) and Device (1.2 [95% CI: 0.4–2.0]). Patients with prior treatment experience were less likely to indicate that treatment attributes would affect adherence. Patients also indicated that increases in the number of flu days would increase the likelihood of nonadherence to treatment. Sustained viral response is the most important treatment attribute to patients but treatment side effects might affect treatment adherence.     

Cardiovascular disease knowledge, medication adherence, and barriers to preventive action in a minority population

Lack of knowledge and awareness of cardiovascular disease may contribute to disproportionately higher risk in minorities. The authors studied minorities in Harlem, New York (N=214), to evaluate knowledge and preventive behaviors. More than half of the participants did not know optimal blood pressure (BP) (52%) and cholesterol (60%) goals. Lack of health insurance (odds ratio, 2.1; 95% confidence interval, 1.0-4.5) and less than a high school education (odds ratio, 2.0;95% confidence interval, 1.02-3.87) were associated with not knowing optimal BP. Among those with BP >/=140/90 mm Hg, 34% were unaware that they had high BP, and age younger than 55 years was predictive of lack of awareness that they had high BP (odds ratio, 8.5; 95% confidence interval, 2.6-28.1). Predictors of medication nonadherence included age younger than 45 years vs age 45 years or older (P=.004) and no health insurance vs health insurance (P=.01). Younger, less educated, uninsured patients should be targeted for educational interventions regarding cardiovascular disease prevention goals, personal risk, and the importance of medication adherence.     

Risk factors for Raynaud's phenomenon in the workforce

Objective

To assess the prevalence of and risk factors for Raynaud's phenomenon (RP) in a French working population characterized by various levels of exposure to work‐related constraints.

Methods

The study population comprised 3,710 workers (2,161 men and 1,549 women) who were followed up by 83 occupational physicians and were representative of the region's workforce. RP, as diagnosed by a questionnaire and a standardized interview, was defined as the occurrence of at least occasional attacks of finger blanching triggered by exposure to environmental cold during the previous 12 months. Personal factors and work exposure were assessed by self‐administered questionnaires. The associations between RP and personal and occupational factors were analyzed using logistic regression modeling.

Results

A total of 87 cases of RP (56 women and 31 men) were diagnosed. The population‐based annual prevalence rates of RP were 3.6% (95% confidence interval [95% CI] 2.7–4.5%) for women and 1.4% (95% CI 0.9–1.9%) for men. Women had a higher risk of RP (odds ratio [OR] 2.1 [95% CI 1.3–3.4]) and the risk decreased continuously with body mass index (OR for 1‐kg/m² increment 0.87 [95% CI 0.81–0.94]). The risk of RP increased consistently but moderately with age after 35 years (ORs ranging from 2.0 [95% CI 1.1–3.8] to 2.9 [95% CI 1.6–5.2]). Among the work‐related factors studied, RP was associated with an exposure to a cold environment or objects (OR 2.2 [95% CI 1.0–4.6]), a high repetitiveness of a task (OR 1.7 [95% CI 1.0–2.7]), a high psychological demand at work (OR 1.7 [95% CI 1.0–2.7]), and low support from supervisors (OR 2.4 [95% CI 1.5–3.8]).

Conclusion

Personal and work‐related factors were associated with RP, with a clear difference between the sexes. Work‐related psychosocial stressors played a significant role independently of biomechanical and environmental exposure.     

Adherence to disease‐modifying antirheumatic drugs and the effects of exposure misclassification on the risk of hospital admission

Objective

To describe the effect of different exposure classification strategies for disease‐modifying antirheumatic drugs (DMARDs) on drug‐outcome associations.

Methods

We studied the association between DMARD initiation and all‐cause hospitalizations in patients with rheumatoid arthritis (RA), 1995–2005. Initiators of DMARDs and oral glucocorticoids were followed for ≤180 days. We compared 2 strategies for exposure classification: a persistent exposure required (PER) approach, in which followup stopped when the regimen changed; and a persistent exposure ignored (PEI) approach, in which followup continued despite regimen changes. For PEI, adherence was assessed using the medication possession ratio. All‐cause hospitalization risk was compared among RA regimen initiators using Cox models and methotrexate as the reference.

Results

We identified 28,906 episodes of medication initiation. In PER analyses, tumor necrosis factor α antagonists did not increase hospitalization risk compared with methotrexate, whereas leflunomide did (hazard ratio [HR] 1.36, 95% confidence interval [95% CI] 1.1–1.67). Glucocorticoids increased hospitalization risk (HR 1.29, 1.54, and 2.03 for low, medium, and high doses, respectively). PEI results were similar to PER except that infliximab initiation increased the risk of hospitalization compared with methotrexate (HR 1.46, 95% CI 1.19–1.8), and most other effects were closer to the null. In PEI, adherence ranged from 73% for etanercept to 6% for glucocorticoids and adherence to methotrexate was 59%.

Conclusion

Compared with methotrexate initiation, leflunomide or glucocorticoid initiation consistently increased all‐cause hospitalizations in the first 180 days of use. Most PER and PEI estimates were similar; observed differences in risk between these methods were likely due to differences in adherence.     

Depression,medication adherence,and service utilization in systemic lupus erythematosus

Objective

Forgetting to take medications is an important cause of nonadherence. This study evaluated factors associated with forgetting to take medications in a large cohort of persons with systemic lupus erythematosus (SLE) participating in the University of California, San Francisco Lupus Outcomes Study (LOS). Relationships among adherence problems and service utilization (outpatient visits, emergency department visits, and hospitalizations) were also evaluated.

Methods

The cohort consisted of 834 LOS participants who provided self‐reported frequency of forgetting to take medications as directed. Predictors of adherence and service utilization patterns included self‐reported sociodemographics, disease‐related characteristics (e.g., disease activity, recent SLE flare), and mental health characteristics (Center for Epidemiologic Studies Depression Scale and cognitive function screen). Health care utilization patterns included the presence and quantity of visits to rheumatologists, primary care physicians, other care providers, emergency departments, and hospitalizations.

Results

Forty‐six percent of the LOS cohort reported forgetting to take medications at least some of the time. Depressive symptom severity was a strong predictor of adherence difficulties (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02–1.05; P < 0.0001) after accounting for all other predictors. Persons reporting adherence difficulties had significantly greater numbers of outpatient rheumatology and primary care visits, and were more likely to visit the emergency department (OR 1.45, 95% CI 1.04–2.04; P = 0.03).

Conclusion

Depression may be an important cause of medication adherence problems, and difficulties with adherence are significantly associated with high‐cost service utilization, specifically emergency department visits. In an era of rapidly evolving treatments for lupus, identifying patients at risk for adherence problems may decrease medical expenditures and improve patient outcomes in SLE.     

Direct assessment of adherence and drug interactions in patients with hypertensive crisis—A cross‐sectional study in the Emergency Department

Though drug adherence is supposed to be low in hypertensive crisis (HTN‐C), there are no data available from direct adherence assessments. The aim of the present study was to evaluate adherence to prescribed antihypertensives and potential interactions of concomitant drugs and foods with prescribed antihypertensives in patients with HTN‐C by a direct evaluation via biochemical urine analysis. In the present cross‐sectional study, 100 patients with HTN‐C, admitted to the emergency department (ED), were included. A biochemical urine analysis using gas chromatography‐tandem mass spectrometry was performed. Out of 100 patients, 86 received antihypertensives. Urine analyses could be evaluated unambiguously in 62 patients. In 15 of these 62 patients (24%), a nonadherence could be demonstrated, and in 21 patients (34%), a partial nonadherence could be demonstrated. Patients with nonadherence or partial nonadherence showed a longer hypertension history (15[5‐22] vs 10[3‐15] years, P = 0.04) were prescribed more general medication (number 7.1 ± 3.4 vs 3.4 ± 1.8; P < 0.01) as well as antihypertensive drugs (number 2.8 ± 1.1 vs 1.5 ± 0.7, P < 0.01). A potential BP‐raising trigger by medications or food interaction was frequently detectable, predominantly with nonsteroidal anti‐inflammatory drugs (NSAIDs; n = 38), glucocorticoids (n = 8), antidepressants (n = 10), and licorice (n = 10). Nonadherence and partial nonadherence to prescribed antihypertensives might play a crucial role for the occurrence of HTN‐C. However, further case‐controlled studies are needed to confirm the present findings. Ingestion of concurrent over‐the‐counter drugs such as NSAIDs but also prescribed drugs as well as aliments may lead to critical BP elevation. In order to prevent HTN‐C, the present findings emphasize the importance for clinicians to pay attention to the issue of adherence and co‐medication.     

Predictors of decline in medication adherence: results from the cohort study of medication adherence among older adults

Few data are available on the predictors of decline in antihypertensive medication adherence and the association of decline in adherence with subsequent blood pressure (BP) control. The current analysis included 1965 adults from the Cohort Study of Medication Adherence Among Older Adults recruited between August 2006 and September 2007. Decline in antihypertensive medication adherence was defined as a ≥2-point decrease on the 8-item Morisky Medication Adherence Scale assessed during telephone surveys 1 and 2 years after baseline. Risk factors for decline in adherence were collected using telephone surveys and administrative databases. BP was abstracted from outpatient records. The annual rate for a decline in adherence was 4.3% (159 participants experienced a decline). After multivariable adjustment, a decline in adherence was associated with an odds ratio (OR) for uncontrolled BP (≥140/90 mm Hg) at follow-up of 1.68 (95% CI: 1.01-2.80). Depressive symptoms (OR: 1.84 [95% CI: 1.20-2.82]) and a high stressful life events score (OR: 1.68 [95% CI: 1.19-2.38]) were associated with higher ORs for a decline in adherence. Female sex (OR: 0.61 [95% CI: 0.42-0.88]), being married (OR: 0.68 [95% CI: 0.47-0.98]), and calcium channel blocker use (OR: 0.68 [95% CI: 0.48-0.97]) were associated with lower ORs for decline. In summary, a decline in antihypertensive medication adherence was associated with uncontrolled BP. Modifiable factors associated with decline were identified. Further research is warranted to determine whether interventions can prevent the decline in antihypertensive medication adherence and improve BP control.     

Effects of cigarette smoking and nicotine dependence on adherence to antiretroviral therapy among HIV-positive patients in Vietnam

Cigarette smoking is increasingly recognized as an indicator for inferior adherence to antiretroviral therapy (ART) among HIV-positive patients. Given the limited body of work on this issue, we aimed to explore the relations between cigarette smoking, nicotine dependence, and ART adherence in Vietnam. A cross-sectional study of 1050 HIV-positive people was conducted from January to September 2013 in Hanoi (the capital) and Nam Dinh (a rural city). Adherence to ART during the last 30 days was measured by the 100-point visual analog scale (VAS). Smoking history and nicotine dependence (Fagerstrom Test of Nicotine Dependence) were self-reported by participants. Multiple logistic regression was performed to examine the association of current smoking and nicotine dependence with ART nonadherence. Using the established VAS cut point of 95 to indicate adequate adherence, the prevalence of ART nonadherence was 30.9%. Approximately 35.5% of the sample reported current smoking. No association between smoking status and ART nonadherence was found. However, participants with greater nicotine dependence (OR?=?1.1, 95%CI?=?1.0–1.2 per unit increase) were more likely to be nonadherent. Also, individuals who were female (OR?=?1.70, 95%CI?=?1.19–2.42), receiving ART in Nam Dinh (OR?=?1.6, 95%CI?=?1.1–2.4), and currently feeling anxiety (OR?=?1.6, 95% CI?=?1.2–2.1) had a higher likelihood of ART nonadherence. Additionally, current smokers reporting current pain (OR?=?1.9, 95%CI?=?1.2–3.1) were more likely to be nonadherent. Conversely, protective factors included living with a spouse/partner (OR?=?0.5, 95%CI?=?0.3–0.7) and having more than a high school education (OR?=?0.4, 95%CI?=?0.1–1.0). Given the high prevalence of suboptimal adherence and current smoking among HIV-positive patients, screening for smoking status and nicotine dependence during ART treatment may help to improve patients’ adherence to medication. More efforts should be targeted to women, patients with mental health problems, and ART clinics in rural areas.     

Association of social stress,illicit drug use,and health beliefs with nonadherence to antiretroviral therapy

OBJECTIVE: To assess the roles of socioeconomic status, social stability, social stress, health beliefs, and illicit drug use with nonadherence to antiretroviral therapy. DESIGN: Cross-sectional study. SETTING: Urban hospital clinic. PARTICIPANTS: One hundred ninety-six consecutive HIV-infected patients taking at least 1 antiretroviral medication, awaiting a visit with their primary care provider. METHODS: Patients were interviewed while waiting for a clinic appointment and were asked to fill out a 4-part survey with questions regarding antiretroviral adherence, illicit drug use, health beliefs, and social situation. Adherence was defined as the percentage of doses taken, i.e., the number of doses taken divided by the number of doses prescribed over a 2-week interval. Univariate and multivariate logistic regressions were performed to identify factors associated with nonadherence in different patient subgroups. MAIN RESULTS: Nonadherence to antiretroviral therapy was associated with active illicit drug use (adjusted odds ratio [AOR], 2.31; 95% confidence interval [95% CI], 1.17 to 4.58), eating fewer than 2 meals per day (AOR, 3.31; 95% CI, 1.11 to 9.92), and feeling as though pressures outside of the clinic affected patient's ability to take antiretroviral medications as prescribed (AOR, 2.22; 95% CI, 0.99 to 4.97). In patients with a history of injection drug use, nonadherence to antiretroviral therapy was independently associated with eating fewer than 2 meals per day (AOR, 17.54; 95% CI, 1.92 to 160.4) and active illicit drug use (AOR, 4.18; 95% CI, 1.68 to 10.75). In patients without any injection drug use, nonadherence was only associated with feeling as though pressures outside of clinic affected patient's ability to take antiretroviral medications as prescribed (AOR, 3.55; 95% CI, 1.07 to 11.76). Male-to-male sexual contact was associated with lower nonadherence in patients with an HIV risk factor other than injection drug use (AOR, 0.35; 95% CI, 0.13 to 0.95). A history of drug use but no illicit drug use within 6 months of the interview was not associated with an increased rate of nonadherence. CONCLUSIONS: Although our sample size was limited and variables that are not significant in subgroup analysis may still be associated with adherence, our results suggest that correlates of nonadherence are HIV risk factor specific. Strategies to increase antiretroviral adherence in HIV-infected patients should include social support interventions targeted at different risk factors for different patient groups.     

The association of hypertension,hypertension duration,and control with incident heart failure in black and white adults

Associations between hypertension and some cardiovascular diseases are stronger in black vs white adults. We examined associations of hypertension, hypertension duration, and control with incident heart failure (HF) in black and white REasons for Geographic And Racial Differences in Stroke study participants (n = 25 770) who were followed for incident HF hospitalization (n = 947) from enrollment in 2003‐2007 through 2015. Hypertension was defined, using updated US guidelines, as systolic or diastolic blood pressure (BP) ≥130/80 mm Hg or antihypertensive medication use. Duration was assessed at baseline, and control was defined as treated BP < 130/80 mm Hg. Compared with no hypertension, hypertension was associated with higher risk of incident HF (HR_whites 1.90 [95% CI 1.49, 2.41], HR_blacks 2.36 [95% CI 1.53, 3.65]), HF with preserved ejection fraction (HR_whites 2.01 [95% CI 1.34, 3.01], HR_blacks 2.70 [95% CI 1.25, 2.53]), and HF with reduced/mid‐range ejection fraction (HR_whites 1.69 [95% CI 1.23, 2.33], HR_blacks 2.29 [95% CI 1.26, 4.15]). Hypertension duration <10 years and ≥10 years were associated with higher risk for incident HF compared with no hypertension. Although risk of incident HF was highest among participants with uncontrolled BP, even controlled BP vs no hypertension was associated with increased risk of HF (HR_whites 1.93 [95% CI 1.44, 2.58], HR_blacks 2.01 [95% CI 1.22, 3.29]). Interactions with race were not statistically significant. The risk of HF associated with hypertension, even with shorter duration or controlled BP, suggests that both prevention and therapeutic management of hypertension are important in reducing HF risk.     

Association of the HLA–DRB1 gene with premature death,particularly from cardiovascular disease,in patients with rheumatoid arthritis and inflammatory polyarthritis

Objective

To examine the role of the variants of the PTPN22 and HLA–DRB1 genes as predictors of mortality in inflammatory polyarthritis (IP) and rheumatoid arthritis (RA).

Methods

Patients were recruited from a primary care–based inception cohort of patients with IP and were followed up prospectively. For patients who died, the cause and date of death was obtained. Cox proportional hazards regression models were used to assess the association of the HLA–DRB1 (including the shared epitope [SE]) and PTPN22 genes with the risk of death from all causes and from cardiovascular disease (CVD) and to assess the interactions between SE, smoking, and anti–cyclic citrullinated peptide (anti‐CCP) status, adjusted by age at symptom onset and sex.

Results

DNA samples were available from 1,022 IP patients. During followup, 751 of them (74%) satisfied the American College of Rheumatology 1987 criteria for RA, and 242 of them (24%) died. Carriage of 2 copies of SE alleles predicted death from all causes (hazard ratio [HR] 1.57 [95% confidence interval (95% CI) 1.1–2.2]) and from CVD (HR 1.68 [95% CI 1.1–2.7]). This effect was most marked for individuals with the HLA–DRB1*01/*04 combination. An interaction of smoking, SE alleles, and anti‐CCP antibodies was observed and was associated with the greatest risk of death from CVD (HR 7.81 [95% CI 2.6–23.2]). No association of the PTPN22 gene with mortality was detected.

Conclusion

SE alleles, particularly compound heterozygotes, are associated with death from all causes and from CVD, independently of autoantibody status. However, the combination of SE, smoking, and anti‐CCP antibodies is associated with a high risk of premature death in patients with IP and RA, which raises the possibility of a targeted strategy to prevent CVD in these patients.

     

Alcohol use and non‐adherence to antiretroviral therapy in HIV‐infected patients in West Africa

Aim To investigate the association between alcohol use and adherence to highly active antiretroviral treatment (HAART) among human immunodeficiency virus (HIV)‐infected patients in subSaharan Africa. Design and setting Cross‐sectional survey conducted in eight adult HIV treatment centres from Benin, Côte d'Ivoire and Mali. Participants and measurements During a 4‐week period, health workers administered the Alcohol Use Disorders Identification Test to HAART‐treated patients and assessed treatment adherence using the AIDS Clinical Trials Group follow‐up questionnaire. Findings A total of 2920 patients were enrolled with a median age of 38 years [interquartile range (IQR) 32–45 years] and a median duration on HAART of 3 years (IQR 1–4 years). Overall, 91.8% of patients were identified as adherent to HAART. Non‐adherence was associated with current drinking [odds ratio (OR) 1.4; 95% confidence interval (CI) 1.1–2.0], hazardous drinking (OR 4.7; 95% CI 2.6–8.6) and was associated inversely with a history of counselling on adherence (OR 0.7; 95% CI 0.5–0.9). Conclusions Alcohol consumption and hazardous drinking is associated with non‐adherence to HAART among HIV‐infected patients from West Africa. Adult HIV care programmes should integrate programmes to reduce hazardous and harmful drinking.