Optimizing HIV Care—Clarifying Treatment Interruptions and Meeting Unmet Patient Needs

A session at the 2018 ID Week Annual Meeting in San Francisco, CA, explored various strategies to optimize the delivery of care to those infected with HIV. Globally, almost 37 million people are living with HIV, with close to 2 million newly infected annually; about 22 million are treated using antiretroviral therapy.¹

Antiretroviral therapy can be interrupted for various reasons; however, whether this practice is wise is a contentious issue, and a trial that would directly address this is ethically dubious. To approach the issue in an ethically palatable way, investigators from the University Hospital of Cologne, Germany, and the German Center for Infection Research, also in Cologne, conducted a systematic review and meta-analysis of the literature to try to provide some clarity as to the safety and tolerability of treatment interruption.

“The meta-analysis was done to examine current evidence about treatment interruption,” explained presenter Melanie Stecher, MSc during the session attended by MD Magazine®. “These data might help in strategies for safe treatment interruption and in designing future clinical trials aimed at curing HIV infection.”

The meta-analysis involved 24 studies (n = 7135) that reported on treatment interruptions. Data that were examined included adverse events and severe adverse events, resistance, death, and disease progression. The studies featured various lengths of treatment interruption, and they were grouped as short treatment interruption (≤4 weeks) and long treatment interruption (>4 weeks). Patient examinations done while treatment was interrupted were categorized as narrow (≤14 days apart) and wide (>14 days apart).

More frequent patient examination was safer compared to longer times between examinations. For example, when the treatment interruption exceeded 4 weeks, only 1% (95% confidence interval [CI], 0-4, I² = 24.9%) of the patients who were examined relatively frequently developed problems compared to 10% (95% CI 5-117, I²= 95.1%) of those examined less often. The overall rate of adverse events was 5%.

The findings from the meta-analysis indicated that antiretroviral treatment interruption in patients with HIV is feasible with intense follow-up during the interruption.

“Adverse events have changed over time in the treatment of HIV. We tried to analyze the data concerning [antiretroviral] regimens, but this sort of data was not robust enough for us to really analyze meaningfully,” said Stecher.

Shifting gears from the provision of therapy, Dima Dandachi, MD, Baylor College of Medicine, Houston, Texas, spoke about unmet needs of HIV patients who have been hospitalized. “Some of these patients are really struggling in the daily lives. Just trying to get by may take precedence over health care. If they receive services tailored to their needs are more likely to enter and maintain regular medical care and have better health outcomes,” said Dandachi during her presentation.

She and her colleagues examined HIV patients being treated at Houston’s Ben-Taub Hospital to explore the association between unmet needs and the continuation of care and suppression of viral load. They also examined whether meeting the unmet needs made any difference in patient health.

The participants were randomized to sessions with a health educator that focused on safe sex and drug use, or to these interventions plus peer mentoring. Both groups were contacted by phone a number of times in consecutive months following discharge.

According to the study results, the 2 intervention schemes made no difference in whether the participants continued with their care or on the viral load. Therefore, the investigators shifted their gaze to what happened when unmet needs were dealt with or not resolved. The primary outcomes, both at 6 months, were the continuation of care and improvement in viral load (either a log₁₀ decrease or <400 copies/mL).

Of the 417 participants, 22% had no unmet needs, 34% had 1 or 2, and 44% had 3 or more. The unmet daily-life needs (subsistence needs) included transportation to and from medical visits (29%), housing (34%), and money for treatment (43%). Unmet medical needs included help for mental health and substance use difficulties, help in taking their medication, and, for 55% of participants, dental care.

Getting dental care increased the chance of improved viral load at 6 months (odds ratio [OR] 2.2, 95% CI 1.04-4.50 P = .03) and upped the likelihood that someone would still be seeking care at that time (OR 2.06, 95% CI 1.05-4.07; P = .04). Reliable access to transportation was another big boost to continued care (OR 0.5, 95% CI 0.34-0.94; P = .03).

Compared to participants with no need, those who reported ≥3 unmet subsistence needs were less likely to demonstrate viral load improvement (OR 0.5, 95% CI 0.28-0.92; P = .03) and to be retained in care (OR 0.52, 95% CI: 0.28-0.95; P = .03).

“People living with HIV are challenged. The face multiple barriers in obtaining care. These barriers can be complex and inter-related. Broader access to programs that assist in meeting subsistence needs could have significant individual and public health benefits,” said Dandachi.

REFERENCE:

1. Global HIV % AIDS statistics—2018 fact sheet. unaids.org/en/resources/fact-sheet. Accessed October 9, 2018. DISCLOSURES

Melanie Stecher, MSc: None

Dima Dandachi, MD: None

PRESENTATIONS

Oral Session: Optimizing HIV Treatment

Melanie Stecher, MSc. Public Health, University Hospital of Cologne, Cologne, Germany

1767. Structured Treatment Interruptions in HIV-infected Patients Receiving Antiretroviral Therapy — Implications for Future HIV Cure Trials: a systematic review and meta-analysis

Dima Dandachi, M.D., Baylor College of Medicine, Houston, Texas

1779 The Association of Unmet Needs with Subsequent Retention in Care and HIV Suppression Among Hospitalized Patients with HIV Who Are Out of Care

Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at hoyle@square-rainbow.com.