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Persistence of antiretroviral therapy regimens among veterans with HIV newly initiating treatment in the US
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Best Treatment Persistence With BIC/FTC/TAF in 3300 US Veterans
HIV Drug Therapy/Glasgow 2020, October 5-8, 2020
Mark Mascolini
Among 3319 US veterans starting antiretroviral therapy in 2016-2019, those starting single-tablet bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) stopped treatment less often in 1 year than veterans starting any other single-tablet or multitablet regimen studied [1]. As a group, single-tablet combinations had greater persistence (fewer discontinuations) than multitablet regimens.
Noting the established advantages of single-tablet antiretroviral combinations [2], researchers in the Columbia (South Carolina) VA Health Care System and collaborators at other centers analyzed veterans starting their first antiretroviral combination to compare persistence of single-tablet versus multitablet medleys as well as persistence of individual regimens. They focused on veterans starting a US guideline-recommended initial regimen between January 1, 2016 and July 30, 2019.
The researchers set the index date as the date of the first antiretroviral claim for single-tablet regimens or the prescription fill claim date of the last drug in a multitablet regimen. Persistence equaled the percentage of veterans who stayed on their initial regimen for 6 months and 1 year after the index date. Treatment discontinuation meant at least a 90-day gap between prescription refills for the initial regimen. The VA team used adjusted Cox proportional hazards models to identify independent risks of discontinuation for regimens studied.
The analysis involved 2591 antiretroviral-naive veterans starting a single-tablet combination and 728 starting a multitablet regimen. The single-tablet group was younger (average 49.4 vs 53.3 years, P < 0.001) and had a higher CD4 count (37.9% vs 30.2% above 250, P < 0.001) than the multitablet group. About 95% of each group were men, and almost two thirds in each group had a pretreatment viral load below 500 copies. The comorbidity rate gauged by the Charlson Comorbidity Index was lower (better) in the single-tablet group (1.7 vs 2.4, P < 0.001), and they took fewer non-HIV drugs than the multitablet group (average 4.9 vs 7.4, P < 0.001).
Six months after starting treatment, 85.5% of the single-tablet group versus 76.4% of the multitablet group remained on their starting regimen. After 12 months those rates were 56.9% versus 40.8%. Median persistence measured 421 days with single-tablet combinations and 293 days with multitablet combinations. The researchers did not tabulate reasons for stopping a regimen.
A proportional hazards model adjusted for age group, gender, geographic region, number of unique drugs filled on index date, Charlson Comorbidity Index, and pretreatment CD4 count and viral load determined that risk of discontinuation was 30% lower with single-tablet than multitablet combinations (adjusted hazard ratio [aHR] 0.70, 95% confidence interval [CI 0.61 to 0.81].
Compared with BIC/FTC/TAF, risk of stopping a combination was about 50% greater with elvitegravir/cobicistat/FTC/TAF (aHR 1.49, 95% CI 1.03 to 2.14, P < 0.001), 60% higher with dolutegravir/abacavir/lamivudine (aHR 1.59, 95% CI 1.10 to 2.30, P < 0.001), more than twice higher with multitablet dolutegravir plus FTC/TAF (aHR 2.10, 95% CI 1.32 to 3.34, P < 0.001), and 2.5-fold higher with multitablet dolutegravir plus FTC/tenofovir disoproxil fumarate (TDF) (aHR 2.49, 95% CI 1.14 to 5.42, P < 0.001). Compared with BIC/FTC/TAF, discontinuation was also independently greater with the single-tablet combos efavirenz/FTC/TDF, rilpivirine/FTC/TDF, and elvitegravir/cobicistat/FTC/TDF, and with the multitablet regimens boosted darunavir plus FTC/TAF and boosted atazanavir plus FTC/TAF.
References
1. Sutton S, Wang X, Diaz-Cuervo H, Magagnoli J. Persistence of antiretroviral therapy regimens among veterans with HIV newly initiating treatment in the US. HIV Drug Therapy/Glasgow 2020, October 5-8, 2020. Abstract P032.
2. Altice F, Evuarherhe O, Shina S, et al. Adherence to HIV treatment regimens: systematic literature review and meta-analysis. Patient Prefer Adherence. 2019;13:475-490
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