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Antiretroviral Adherence and HIV-1 Drug Resistance in the US
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Reported by Jules Levin
CROI 2019 March 4-7 Seattle
Download the PDF here
Carmela Benson,1 Xiaotian Wang,2 Keith J. Dunn,1,* Nicole Li,2 Laura Mesana,3 Johnny Lai,4 Eric Y. Wong,1 Kimberley Brown5
1Janssen Scientific Affairs, LLC, Titusville, NJ, USA; 2Amaris, Toronto, ON, Canada; 3Amaris, Jersey City, NJ, USA; 4Monogram Biosciences, San Francisco, CA, USA; 5Janssen Research & Development, LLC, Titusville, NJ, USA
'Social Determinants of Health Predict non-adherence'
'poor adherence at the state level
was also correlated with higher HIV-1 mortality and higher HIV-1
prevalence rates'
This study at CROI reports: At least 40% of patients had poor adherence to ART in the majority of states, and those states with more than half of patients with poor adherence were mostly clustered in the South region of the US......Overall in the US, the mean PDC was 73.1% (median: 73.0%)......Lower education level, poverty, unemployment, female gender, and non-white race were associated with poor ART adherence......Lower education level, unemployment, and non-white race were associated with a higher prevalence of poor/suboptimal adherence-----Adherence: Adherence to ART was defined as the proportion of days covered (PDC), which is the sum of days during the observation period covered by either ≤2 ARTs or 1 single-tablet regimen, divided by a fixed number of available days in the observation period (365 days without any gaps); on the state level, poor adherence was defined as the percentage of the patient population studied with PDC <80% and suboptimal adherence was defined as the percentage of patients with 80% ≤PDC <95%.....Across all states, 20.0% to 53.8% of isolates tested showed HIV-1 drug resistance.
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Overestimated Viral Suppression in the USA [from Jules--many like to say 90% or 85% are virally suppressed, this overstates viral suppression. There are many different sources accumulating data on rates of viral suppression which often includes only certain patient populations and does not include many of the most marginalized HIV+ in care who are not be in their database. When people say this they use data that does not include these gaps & pockets of people in care who are not virally suppressed.]
Our primary analysis sample included 12,776 patients who completed at least one PRO. The sample was largely male (84%) and identified as white non-Hispanic (49%) (Table 1). The majority of patients were currently taking ART (89%), had a CD4 count > 500 (55%), and had an undetectable viral load (72%) within 6 months prior to their most recent PRO completion.[ If the overall rte is 72% for undetectable viral load that means there are pockets & groups of individuals with detectable viral load < 72%.] pdf for this study attached above
CDC-2014: Among 651,811 persons with HIV infection diagnosed through 2013 and who were alive through 2014 in 38 jurisdictions with complete laboratory reporting, a lower percentage of blacks had sustained viral suppression (40.8%), than had Hispanics (50.1%) and whites (56.3%). Among persons who were in care (i.e., had at least one viral load test in 2014) and had not achieved sustained viral suppression in 2014, blacks experienced longer periods (52.1% of the 12-month period) with viral loads >1,500 copies/mL, than did Hispanics (47.2%) and white (40.8%). Blacks aged 13–24 years had the lowest prevalence of sustained viral suppression, a circumstance that might increase transmission risk potential. Strengthening interventions that improve access to ART, promote adherence, and address barriers to clinical care and supportive services for all persons with diagnosed HIV infection is important for achieving the national goal of reducing health disparities.
Viral suppression is essential to maintaining the health of persons living with HIV infection and reducing the likelihood of HIV transmission. National treatment guidelines recommend that all persons with diagnosed HIV infection, regardless of their viral load or CD4 level, take ART to achieve viral suppression.† However, only 40.8% of blacks living with diagnosed HIV infection in 38 jurisdictions with complete laboratory reporting had sustained viral suppression in 2014, a percentage lower than that among Hispanics (50.1%) and whites (56.3%). The remaining 59.2% of blacks included 25.3% who were in care but did not have sustained viral suppression in 2014 (i.e., partial suppression or not suppressed) and 33.9% with no viral load tests in 2014. The latter is an indication of not receiving adequate HIV care and presumably not having suppressed viral load. Among those in care, blacks experienced a longer period (i.e., half of the time during the 12-month period) with a viral load >1,500 copies/mL, a circumstance which can adversely affect health outcomes and pose a risk for further transmission. Although prescription of ART increased among blacks who received HIV clinical care from 2009 to 2013, fewer blacks received an ART prescription (92.9%) than did Hispanics (95.2%) and whites (95.2%) (3). These findings highlight areas for improvement in care retention and offering of ART to all persons with HIV infection according to the national treatment guidelines.
https://www.cdc.gov/mmwr/volumes/67/wr/mm6704a2.htm?s_cid=mm6704a2_w#contribAff
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Note: Poor adherence was defined as the percentage of patients with PDC <80%, obtained from 2015 to 2017 through the Symphony Health Solutions claims database (shown as values in the map; no value is shown for states with insufficient data). HIV-1 prevalence was described using the rate of HIV-1 prevalence per 100,000 population, based on 2015 data obtained from the CDC. Boundaries were outlined for the Northeast, Midwest, South, and West regions. The adherence and prevalence data were from 2 independent sources; thus, no causal relationships were investigated.
Note: The prevalence of HIV-1 drug resistance was defined as the percentage of isolates submitted to Monogram Biosciences with a genotypic assessment for resistance to any commercially available NRTI, NNRTI, PI, and/or INI, based on the Monogram Biosciences database from 2015 to 2017 (shown as values in the map); prevalence is not shown if a state had <10 isolates available. Poor adherence was defined as the percentage of patients with PDC <80%, obtained from 2015 to 2017 through the Symphony Health Solutions claims database. Boundaries were outlined for the Northeast, Midwest, South, and West regions. The adherence and resistance data were from 2 independent sources; thus, no causal relationships were investigated.
social determinants of health (SDoH)
*Education was defined as the percentage of the population 25 years of age and older without a high school diploma per state, based on the 2016 ACS.
†Poverty was defined as the percentage of households living below the federal poverty level per state, based on the 2016 ACS.
Employment was defined as the unemployment rate for the population 16 years of age and over per state, based on the 2016 ACS.
Gender was defined as the percentage of males per state, based on the 2016 ACS.
‖Race was defined as the percentage of non-Caucasians per state, based on the 2016 ACS.
HIV-1 mortality was defined as the rate of HIV-1 deaths per 100,000 population in 2015, reported by the CDC.
#HIV-1 viral suppression was defined as the percentage of HIV-1 viral suppression among patients living with HIV-1 infection in 2014, reported by the CDC.
Note: The percentage of the population with poor/suboptimal adherence to ART was 74.9%.
*Education was defined as the percentage of the population 25 years of age and older without a high school diploma per state, based on the 2016 ACS.
†Poverty was defined as the percentage of households living below the federal poverty level per state, based on the 2016 ACS.
Employment was defined as the unemployment rate for the population 16 years of age and over per state, based on the 2016 ACS.
Gender was defined as the percentage of males per state, based on the 2016 ACS.
||Race was defined as the percentage of non-Caucasians per state, based on the 2016 ACS.
HIV-1 mortality was defined as the rate of HIV-1 deaths per 100,000 population in 2015, reported by the CDC.
#HIV-1 viral suppression was defined as the percentage of HIV-1 viral suppression among patients living with HIV-1 infection in 2014, reported by the CDC.
References
1. Rhee SY, et al. Clin Infect Dis. 2019;68(2):213-221.
2. Rhee SY, et al. PLoS Med. 2015;12(6):e1001845.
3. Kleeberger CA, et al. J Acquir Immune Defic Syndr. 2001;26(1):82-92.
4. Do HM, et al. BMC Infect Dis. 2013;13:154.
5. Poles G, et al. J Int Assoc Provid AIDS Care. 2014;13(1):78-84.
6. Onoya D, et al. AIDS Patient Care STDS. 2017;31(5):205-212.
7. Beer L, Skarbinski J. AIDS Educ Prev. 2014;26(6):521-537.
8. CDC. Today's HIV/AIDS Epidemic. CDC Fact Sheet. August 2016.
https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/todaysepidemic-508.pdf.
Accessed January 13, 2019.
9. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Division of HIV/AIDS Prevention. Understanding the HIV Care Continuum. June 2018.
https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf. Accessed January 13, 2019.
10. Nachega JB, et al. Infect Disord Drug Targets. 2011;11(2):167-174.
11. Healthypeople.org.
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed January 13, 2019.
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