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US ART Guideline Picks Linked to Better Viral Suppression, Fewer Side Effects
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IDSA/IDWeek 2015, October 7-11, San Diego
Mark Mascolini
Taking an antiretroviral therapy (ART) regimen recommended by US authorities improved chances of maintaining an undetectable viral load and avoiding side effects, according to a Centers for Disease Control and Prevention (CDC) analysis of a nationally representative sample of people in care for HIV infection [1]. People prescribed regimens not recommended in the Department of Health and Human Services (DHHS) guidelines [2] had worse antiretroviral adherence than those prescribed recommended regimens.
HIV treatment experts empaneled by the DHHS regularly update ART guidelines for people with HIV infection. Another study reported at IDWeek confirmed that US clinicians prescribe DHHS-recommended first-line combinations more often than alternative or other regimens [3]. But little is known about whether following guidelines affects outcomes in people with HIV. To address that issue, CDC researchers conducted this study of HIV-positive people in the Medical Monitoring Project (MMP).
The MMP group analyzed provides a nationally representative sample of people in care for HIV infection across the United States during the period 2009-2012. These 18,095 MMP participants were interviewed to gather sociodemographic and behavioral data, and their medical records were abstracted for relevant clinical data. This analysis focused on the most recent antiretroviral regimen in each person's medical record, which the investigators classified according to DHHS advice: (1) recommended, (2) alternative, (3) not recommended, and (4) other. They used multivariable logistic regression to figure adjusted prevalence ratios (APRs) assessing independent associations between the four regimen categories and three outcomes: (1) durable viral suppression, defined as all viral loads below 200 copies in the past year, (2) self-reported 100% dose adherence in the past 3 days, and (3) self-reported ART-related side effects.
A large majority of the MMP sample, 92%, had an ART prescription. Two thirds of the study group (66%) achieved durable viral suppression, 84% were dose adherent, and only 16% reported side effects. Almost three quarters of the group (73%) were men, 43% were 50 or older, and 41% were non-Hispanic black. A median of 10 years had passed since this group started ART, and only 5% began treatment in the past year.
Slightly more than half of MMP members, 52%, had a prescription for a combination on the 2014 list of preferred first-line regimens; 39% got one of two regimens--efavirenz plus tenofovir (TDF) and emtricitabine or lamivudine (XTC) (27%) or atazanavir/ritonavir plus TDF/XTC (11%). The highest sustained viral suppression rate came with efavirenz/abacavir/XTC (77%), followed by efavirenz/TDF/XTC (73%), atazanavir/ritonavir/abacavir/XTC (72%), then (all with TDF/XTC) atazanavir/ritonavir (65%), raltegravir (63%), darunavir/ritonavir (59%), and rilpivirine (52%). The CDC team noted these durable suppression rates are below those reported in most recent clinical trials.
In addition to the 52% who got a DHHS-recommended first-line regimen, 6% got alternative regimens, 29% got not-recommended regimens, and 13% got some other regimen. Compared with people prescribed a recommended regimen, people prescribed a not-recommended regimen were slightly but significantly less likely to achieve durable viral suppression (APR 0.98, 95% confidence interval [CI] 0.96 to 0.99) and those prescribed other regimens were even less likely to reach durable suppression (APR 0.92, 95% CI 0.88 to 0.96). Compared with people taking a recommended regimen, those two groups were also significantly less likely to be dose-adherent (APR 0.97, 95% CI 0.95 for 0.98 for not-recommended regimens; APR 0.93, 95% CI 0.91 to 0.95 for other regimens). And compared with the group on recommended ART, self-reported side effects proved significantly more likely with alternative regimens (APR 1.29, 95% CI 1.11 to 1.50), not-recommended regimens (APR 1.18, 95% CI 1.07 to 1.31), and other regimens (APR 1.18, 95% CI 1.05 to 1.33).
The CDC team concluded that "HIV providers should continue to be encouraged to prescribe ART according to established guidelines when clinically appropriate."
References
1. Tie Y, Frazier E, Skarbinski J. Effectiveness of antiretroviral therapy in HIV-infected adults receiving medical care in the United States. IDWeek 2015, October 7-11, San Diego. Abstract 122.
2. Department of Health and Human Services. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. https://aidsinfo.nih.gov/guidelines
3. Forlenza J, Brown K, Shprecher A, et al. Use of guideline-recommended antiretroviral regimens in a large US HIV treatment-naive population: findings from a 5-year analysis of payer claims data. IDWeek 2015, October 7-11, San Diego. Abstract 415. https://idsa.confex.com/idsa/2015/webprogram/Paper53584.html
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