云南省HIV-1感染儿童一线抗病毒治疗病毒学反弹影响因素研究

目的 观察云南省艾滋病病毒(HIV-1)感染儿童抗病毒治疗(ART)的疗效,探讨ART过程中出现病毒学反弹的影响因素.方法 通过"国家艾滋病抗病毒治疗信息系统"收集资料,并进行描述性分析,采用COX比例风险回归模型分析发生病毒学反弹的影响因素.结果 2005年1月1日至2015年12月31日,云南省随访治疗1年以上且在...     

History of viral suppression on combination antiretroviral therapy as a predictor of virological failure after a treatment change*

Objectives

HIV‐infected persons experience different patterns of viral suppression after initiating combination antiretroviral therapy (cART). The relationship between such differences and risk of virological failure after starting a new antiretroviral could help with patient monitoring strategies.

Methods

A total of 1827 patients on cART starting at least one new antiretroviral from 1 January 2000 while maintaining a suppressed viral load were included in the analysis. Poisson regression analysis identified factors predictive of virological failure after baseline in addition to traditional demographic variables. Baseline was defined as the date of starting new antiretrovirals.

Results

Four hundred and fifty‐one patients (24.7%) experienced virological failure, with an incidence rate (IR) of 7.3 per 100 person‐years of follow‐up (PYFU) [95% confidence interval (CI) 6.7–8.0]. After adjustment, patients who had rebounded in the year prior to baseline had a 2.4‐times higher rate of virological failure after baseline (95% CI 1.77–3.26; P<.0001), while there was no increased incidence in patients whose last viral rebound was >3 years prior to baseline [Incidence rate ratio (IRR) 1.06; 95% CI 0.75–1.50; P=0.73] compared with patients who had never virally rebounded. Patients had an 86% (95% CI 1.36–2.55; P<.0001), 53% (95% CI 1.06–2.04; P=0.02) and 5% (95% CI 0.80–1.38; P=0.72) higher virological failure rate after baseline if they were virally suppressed <50%, 50–70% and 70–90% of the time they were on cART prior to baseline, respectively, compared with those virally suppressed >90% of the time.

Discussion

Intensive monitoring after a treatment switch is required in patients who have rebounded recently or have a low percentage of time suppressed while on cART. Consideration should be given to increasing the provision of adherence counselling.     

Poor retention in care one-year after viral suppression: a significant predictor of viral rebound

Optimal retention in care should be continuously monitored even after suppression to prevent the risk of viral rebound. The purpose of this study is to assess the association between retention in care and viral rebound 12 months after viral suppression. A retrospective medical chart review study was conducted at an academic clinic in Lexington, KY, to determine an association between retention in care and viral rebound. A total of 658 patients, who were virally suppressed at any time between 2003 and 2009, were followed for 12 months after viral suppression. Retention in care was defined as having at least one clinic visit every three months (visit constancy) and viral rebound was defined as a viral load >400 copies/ml. Of the 658 patients included in the study, 43% were less than optimally retained in care and 26% had a viral rebound 12 months after suppression. In the multivariable logistic regression model, the odds of a viral rebound were much greater for suboptimal (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.44–3.63) and poor (OR: 15.1; 95% CI: 6.82–33.41) retainers compared to optimal retainers. The results of the study suggest that retention in HIV care plays a central role in maintaining optimal outcomes such as viral suppression. Interventions that target improvement in retention in care among those who are poorly retained must be set in place in order to reduce the risk of a viral rebound.     

Impact of adherence on duration of virological suppression among patients receiving combination antiretroviral therapy

Objective

To assess the effect of adherence to antiretroviral therapy on the duration of virological suppression after controlling for whether or not the patient ever attained a plasma viral load below the limit of detection of sensitive HIV‐1 RNA assays.

Methods

Data were combined from three randomized, blinded clinical trials (INCAS, AVANTI‐2, and AVANTI‐3) that compared the antiviral effects of two‐ and three‐drug antiretroviral regimens. Virological suppression was defined as maintaining a plasma viral load below 1000 copies/mL. Adherence was defined prospectively and measured by patient self‐report.

Results

Adherence did not have a major impact on the probability of achieving virological suppression for patients receiving dual therapy. However, for patients receiving triple therapy, adherence increased the probability of virological suppression, whether the plasma viral load nadir was above or below the lower limit of quantification. Compared to adherent patients with a plasma viral load nadir below the lower limit of quantification, the relative risk of virological failure was 3.0 for non‐adherent patients with a nadir below the limit, 18.1 for adherent patients with a nadir above the limit, and 32.1 for non‐adherent patients with a nadir above the limit.

Conclusion

For patients receiving current three‐drug antiretroviral regimens, adherence to therapy and plasma viral load nadir are important factors determining the duration of virological suppression.

     

Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users

Despite a burgeoning literature on adherence to HIV therapies, few studies have examined the impact of ongoing drug use on adherence and viral suppression, and none of these have utilized electronic monitors to quantify adherence among drug users. We used 262 electronic monitors to measure adherence with all antiretrovirals in 85 HIV-infected current and former drug users, and found that active cocaine use, female gender, not receiving Social Security benefits, not being married, screening positive for depression, and the tendency to use alcohol or drugs to cope with stress were all significantly associated with poor adherence. The strongest predictor of poor adherence and, in turn, failure to maintain viral suppression, was active cocaine use. Overall adherence among active cocaine users was 27%, compared to 68% among subjects who reported no cocaine use during the 6-month study period. Consequently, 13% of active cocaine users maintained viral suppression, compared to 46% of nonusers. Interventions to improve adherence should focus on reducing cocaine use, developing adaptive coping skills, and identifying and treating depression.     

Relationship between hunger,adherence to antiretroviral therapy and plasma HIV RNA suppression among HIV-positive illicit drug users in a Canadian setting

Food insecurity may be a barrier to achieving optimal HIV treatment-related outcomes among illicit drug users. This study therefore, aimed to assess the impact of severe food insecurity, or hunger, on plasma HIV RNA suppression among illicit drug users receiving antiretroviral therapy (ART). A cross-sectional Multivariate logistic regression model was used to assess the potential relationship between hunger and plasma HIV RNA suppression. A sample of n = 406 adults was derived from a community-recruited open prospective cohort of HIV-positive illicit drug users, in Vancouver, British Columbia (BC), Canada. A total of 235 (63.7%) reported “being hungry and unable to afford enough food,” and 241 (59.4%) had plasma HIV RNA < 50 copies/ml. In unadjusted analyses, self-reported hunger was associated with lower odds of plasma HIV RNA suppression (Odds Ratio = 0.59, 95% confidence interval [CI]: 0.39–0.90, p = 0.015). In multivariate analyses, this association was no longer significant after controlling for socio-demographic, behavioral, and clinical characteristics, including 95% adherence (Adjusted Odds Ratio [AOR] = 0.65, 95% CI: 0.37–1.10, p = 0.105). Multivariate models stratified by 95% adherence found that the direction and magnitude of this association was not significantly altered by the adherence level. Hunger was common among illicit drug users in this setting. Although, there was an association between hunger and lower likelihood of plasma HIV RNA suppression, this did not persist in adjusted analyses. Further research is warranted to understand the social-structural, policy, and physical factors shaping the HIV outcomes of illicit drug users.     

Predictors of viral suppression among youth living with HIV in the southern United States

ABSTRACT

Youth living with HIV (YLH) in the United States (U.S.) face significant problems with achieving viral suppression, especially in the South. To examine this issue, YLH with a detectable viral load (N?=?61) were recruited from the southern U.S and assessed over 16 weeks for health and treatment factors. Participants were part of a smartphone-based intervention trial. Analyses focused on predictors of viral suppression controlling for intervention effects. Fifty-three percent achieved suppression. In univariate models, YLH who engaged in condomless sex four to 16 weeks into the study (odds ratio [OR]?=?4.00; compared to those who did not) and self-reported?≥?90% antiretroviral adherence in the first four weeks of the study (OR?=?25.00; compared to youth with <90%) had a higher likelihood of suppression. Shifts in adherence-related social support (OR?=?4.98) and appointments kept (OR?=?2.72) were also associated with suppression. YLH endorsing illicit drug use had a lower likelihood of suppression (OR?=?0.16; compared to those without use). Effects (except drug use) remained significant or approached significance in a multivariate model. Adherence promotion efforts should consider this population’s adherence-related social support, drug use, and risk for sexually transmitted infections.     

Correlates of antiretroviral adherence and viral load among transgender women living with HIV

Transgender women are 49 times more likely to become HIV infected than other groups, yet they are drastically underserved by current treatment efforts and report lower rates of treatment adherence then other groups. The objective of this study was to explore correlates of antiretroviral (ART) adherence and viral load among HIV-positive transgender women on ART utilizing a cross-sectional survey of a convenience sample of 59 transgender women. In multivariate models of ART adherence, correlates were age, stress appraisal of transphobic experiences, importance of gender affirmation, and adherence to hormone therapy. In multivariate models of self-reported viral load, correlates were stress appraisal of transphobic experiences and being in a relationship. This study provides preliminary evidence of transgender-relevant correlates of ART adherence and viral load.     

Adherence to antiretroviral therapy: factors independently associated with reported difficulty taking antiretroviral therapy in a national sample of HIV-positive Australians

Objectives

Given the importance of adherence to combination antiretroviral therapy (cART) for the reduced morbidity and improved mortality of people living with HIV infection (PLWH), we set out to determine which of a number of previously investigated personal, socioeconomic, treatment‐related and disease‐related factors were independently associated with self‐reported difficulty taking antiretroviral therapy (ART) in an Australian sample of PLWH.

Methods

Using data from a national cross‐sectional survey of 1106 PLWH, we conducted bivariate and multivariable analyses to assess the association of over 70 previously investigated factors with self‐reported difficulty taking ART. Factors that maintained an association with reported difficulty taking ART at the level of α=0.05 in the multivariable logistic regression analysis were considered to be independently associated with reported difficulty taking ART.

Results

A total of 867 (78.4%) survey respondents were taking antiretroviral medication at the time of completing the HIV Futures 6 survey. Overall, 39.1% of these respondents reported difficulty taking ART. Factors found to be independently associated with reported difficulty taking ART included younger age, alcohol and party drug use, poor or fair self‐reported health, diagnosis of a mental health condition, living in a regional centre, taking more than one ART dose per day, experiencing physical adverse events or health service discrimination, certain types of ART regimen and specific attitudes towards ART and HIV.

Conclusions

Thirteen previously investigated factors were found to be independently associated with reported difficulty taking ART, reaffirming the dynamic nature of adherence behaviour and the ongoing importance of addressing adherence behaviour in the clinical management of PLWH.     

Impact of weight gain with dolutegravir on antiretroviral adherence and viral suppression in four African countries

Objective

We hypothesized that total body weight (TBW) gain after switching antiretroviral therapy (ART) regimen to tenofovir disoproxil fumarate/lamivudine/dolutegravir (TLD) may negatively impact ART adherence and viral load (VL) and therefore sought to examine these associations.

Methods

The ongoing African Cohort Study (AFRICOS) enrols people with HIV at 12 facilities in Kenya, Nigeria, Tanzania and Uganda supported by The US President's Emergency Plan for AIDS Relief. Among ART-experienced participants who switched to TLD, we used multivariable multinomial logistic regression to examine associations between pre−/post-TLD changes in percentage TBW (≥5% gain, <5% change, ≥5% loss) and changes in self-reported ART adherence (0, 1–2, ≥3 days missed doses in past 30 days) and VL [(<50 copies/mL (undetectable), 50–999 copies/mL (detectable, but suppressed), ≥1000 copies/mL (unsuppressed)].

Results

Among 1508 participants, median time from starting TLD to follow-up was 9 months (interquartile range: 7–11). Overall, 438 (29.1%) participants experienced a TBW gain ≥5%, which was more common among females than among males (32.2% vs 25.2%, p = 0.005) and participants switching from efavirenz [32.0% vs nevirapine (19.9%) and boosted protease inhibitor (20.0%); p < 0.001]. Compared with a TBW change <5% [950 (63.0%) participants], TBW gain ≥5% was not significantly associated with more days with missed ART doses [adjusted odds ratio (aOR) = 0.77, 95% confidence interval (CI): 0.48–1.23] or VL becoming detectable and/or unsuppressed (aOR = 0.69, 95% CI: 0.41–1.16).

Conclusions

Although a substantial proportion of participants experienced weight gain after switching to TLD, we did not identify a significant impact on adherence or virological outcomes.