CROI: Treatment changes and breaks occur at high rate in Ugandan HIV patients

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Around a quarter of patients receiving antiretroviral therapy (ART) at two of Uganda’s largest treatment centres reported the need to change at least one of the drugs in their antiretroviral regimen, and one in seven had discontinued treatment for at least one month due to the cost of medicines, drug side-effects or drug stockouts. Given the limited number of drugs available in Uganda, researchers say, the findings pose a challenge for treatment delivery in resource-limited settings.

Ronald Kiguba and colleagues from Makerere University and the Joint Clinical Research Centre presented data on the practice of ART discontinuation and modification in people living with HIV/AIDS in Kampala at the Fourteenth Conference on Retroviruses and Opportunistic Infections in Los Angeles last month.

Adherence to the strict dosage regimes of antiretroviral therapy is vital in order to obtain optimal clinical treatment outcomes. The development of drug resistance is also invariably associated with poor adherence.

Glossary

opportunistic infection (OI)

An infection that occurs more frequently or is more severe in people with weakened immune systems, such as people with low CD4 counts, than in people with healthy immune systems. Opportunistic infections common in people with advanced HIV disease include Pneumocystis jiroveci pneumonia; Kaposi sarcoma; cryptosporidiosis; histoplasmosis; other parasitic, viral, and fungal infections; and some types of cancer. 

regression

Improvement in a tumour. Also, a mathematical model that allows us to measure the degree to which one of more factors influence an outcome.

drug resistance

A drug-resistant HIV strain is one which is less susceptible to the effects of one or more anti-HIV drugs because of an accumulation of HIV mutations in its genotype. Resistance can be the result of a poor adherence to treatment or of transmission of an already resistant virus.

cross-sectional study

A ‘snapshot’ study in which information is collected on people at one point in time. See also ‘longitudinal’.

pill burden

The number of tablets, capsules, or other dosage forms that a person takes on a regular basis. A high pill burden can make it difficult to adhere to an HIV treatment regimen.

The practices of ART discontinuation and modification contribute to poor adherence. However, there is a paucity of data on the prevalence and risk factors which are associated with these practices among African patients. It is against this background that the present study was undertaken in Kampala.

Discontinuation was defined as the simultaneous stopping of all ART for at least a month; modification was defined as the changing of at least one of the ART used as part of an initial ART regimen.

Patients receiving ART at two treatment centers were recruited into a cross-sectional study. Information about discontinuation and modification practices was obtained using sociological methods such as self-reporting using semi-structured quantitative and unstructured qualitative interviews.

Multivariate logistic regression was used to identify the factors which are independently associated with the discontinuation and modification of ART.

Six hundred and eighty-six individuals on ART were evaluated. Among these 94 (13.7%) had ever discontinued therapy and 175 (25.5 %) had ever modified their regimen. The commonest reason for discontinuation was drug cost as reported by 43 % of those who discontinued treatment for at least one month, and that for therapy modification was adverse events, reported in 71.8 % of the patients who modified at least one drug in their regimen.

Factors which were associated with discontinuation were ART experience (OR = 3.70, CI 2.13-6.25), use of alternative medicines (OR = 2.18, 95 % CI 1.06-4.47), history of hospitalisation (OR = 2.36, CI 1.32-4.20),

Factors which were associated with modification were more than three months’ duration of therapy (OR =3.13, CI 1.02-4.31), treatment initiation prior to 2004 (OR = 2.10, CI 1.02-4.31), unmarried vs married (OR = 1.67, CI 1.02-2.70), and high regimen pill burden (OR = 25.0, CI 12.50-50.00).

The authors conclude that rates of discontinuation and modification were significant and that this poses a challenge to the limited number of treatment options which can be provided to HIV/AIDS patients in the resource-limited setting of Uganda.

References

Kiguba R et al. Prevalence and factors associated with discontinuation and modification of highly active antiretroviral therapy among HIV-positive people in Kampala, Uganda. Fourteenth Conference on Retroviruses and Opportunistic Infections, Los Angeles, abstract 530, 2007.