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Gap in ART Response Between Women and MSM Not Narrowing in London.....women and MSW have worse virologic responses to ART than MSM
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....women and MSW have worse virologic responses to ART than MSM..... women had 84% higher odds of 24-month virologic nonresponse than MSM......More than 20% of women interrupted ART by 24 month, about 15% of MSW and 10% of MSM.....treatment disruptions could explain much of the virologic nonresponse difference between women and MSM......evidence that this difference is narrowing in more recent years.....may reflect socioeconomic status, time in the UK, family circumstances, psychosocial factors, and comorbidities
from Jules: this is a disturbing reality ALSO reported among US women in the WAVES Study at EACS, which is a global study of TAF in women, where in this study only 68^ of women from the USA reported achieved viral load undetectable which was much lower than women from other parts of the globe where the study was conducted.
15th European AIDS Conference, October 21-24, 2015, Barcelona
Mark Mascolini
Rates of virologic nonresponse to first-line antiretroviral therapy (ART) have dropped over the years among men who have sex with men (MSM), men who have sex with women (MSW), and women in a large London HIV cohort [1]. But the nonresponse gap between MSM and women has not narrowed over the years.
Researchers working with the Royal Free HIV Cohort in London cited prior French research showing that women and MSW have worse virologic responses to ART than MSM [2]. Because of improvements in therapeutic safety and convenience, they wondered whether virologic outcomes based on gender and sexual orientation have changed over the years.
This study focused on 1675 members of the Royal Free HIV Cohort who started their first antiretroviral regimen between January 2001 and July 2013, who acquired HIV sexually, and who had at least 12 months of follow-up. The researchers determined how many people had virologic nonresponse at 12 months (a single viral load above 200 copies in the first viral load measure 12 to 18 months after ART began) and at 24 months (a single viral load above 200 copies in the first viral load measure 24 to 30 months after ART began). They conducted three analyses, one in which a missing viral load equals nonresponse, the second that excludes missing viral loads, and a third that excludes missing viral loads while not on ART. They considered three types of treatment disruption status in the first 12 months of therapy: (1) interrupted (stopped all antiretrovirals for a week or more), (2) switched (any antiretroviral change except for simplification), and (3) no disruptions.
The primary aim was to determine the proportion of MSM, MSW, and women with virologic nonresponse according to the year ART began. The Royal Free team used logistic regression models including an interaction term between gender/sexual orientation and year starting ART that they adjusted for ethnicity, age, initial ART regimen, and baseline viral load and CD4 count.
The analysis included 908 MSM (54% of the group), 292 MSM (17%), and 475 women (28%). Proportions of whites were 82% among MSM, 26% among MSW, and 15% among women, while proportions of black Africans were 2%, 52%, and 65%. Women included the highest proportion under 30 years old (24%) and MSW had the highest proportion over 49 (18%). Similar proportions in the 3 groups began ART with a nonnucleoside or a protease inhibitor. Median pretreatment CD4 count was higher in MSM (273) than in MSW (166) or women (205), while starting viral load were the same in MSM and MSW (5.0 log10 copies) but lower in women (4.8 log10 copies).
In the missing-equals-excluded analysis of everyone starting ART from 2000 through 2013, the virologic nonresponse rate at 12 months was significantly lower in MSM (7%) than in MSW (13%) or women (20%) (P < 0.0001). At 24 months MSM still had a significantly lower nonresponse rate (8%) than MSW (13%) or women (19%) (P < 0.0001).
Over time the missing-equals-excluded analysis showed that the 12-month virologic nonresponse rate dropped steadily in women (from about 37% to about 14%), in MSW (from about 23% to about 9%), and in MSM (from about 12% to about 3%). But the nonresponse gap between MSM and the other two groups persisted from 2001 through 2013. The gap between groups also persisted when the researchers figured 24-month virologic nonresponse. Logistic regression analysis showed similar changes in 12-month nonresponse per calendar year in MSM (adjusted odds ratio [aOR] 0.80), MSW (aOR 0.82), and women (aOR 0.83) (P = 0.77). Change in 24-month nonresponse per calendar year was better for MSM (aOR 0.72) than for MSW (aOR 0.83) or women (aOR 0.87) (P = 0.015).
Through the first 12 months of therapy, about 60% of MSM and MSW had no ART disruptions, while about 50% of women had no disruptions, a highly significant difference (P < 0.0001). At 24 months about 50% of MSM and MSW had no therapeutic disruptions, compared with about 40% of women (P < 0.0001). More than 20% of women interrupted ART by 24 months, compared with about 15% of MSW and 10% of MSM.
In a missing-equals-excluded analysis adjusted for gender/sexual orientation, calendar year, ethnicity, age, initial ART regimen, and baseline viral load and CD4 count, women had 84% higher odds of 24-month virologic nonresponse than MSM (aOR 1.84, 95% CI 1.09 to 3.12). Additional adjustment for ART disruptions weakened that association substantially and rendered it nonsignificant (aOR 1.25, 95% CI 0.67 to 2.35). That finding suggests treatment disruptions could explain much of the virologic nonresponse difference between women and MSM. Differences in nonresponse chances between MSW and MSM were not significant in either analysis.
Results were similar in a missing-equals-failure analysis, when the researchers defined nonresponse as a viral load above 50 copies instead of above 200 copies, and when the analysis excluded women pregnant at baseline.
The Royal Free team concluded that "women and MSW remain more likely to have virologic nonresponse than MSM and there is no evidence that this difference is narrowing in more recent years." They suggested that worse virologic outcome in women and MSW than in MSM may reflect socioeconomic status, time in the UK, family circumstances, psychosocial factors, and comorbidities. Among women but not MSW, disruptions to steady ART appeared to contribute to the worse virologic response than in MSM.
References
1. Burch LS, Smith CJ, Lampe FC, et al. Is the gender difference in viral load response to ART narrowing over time? 15th European AIDS Conference, October 21-24, 2015, Barcelona. Abstract PS6/3.
2. Fardet L, Mary-Krause M, Heard I, et al. Influence of gender and HIV transmission group on initial highly active antiretroviral therapy prescription and treatment response. HIV Med. 2006;7:520-529. http://www.ncbi.nlm.nih.gov/pubmed/17105511
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