Findings from the first national clinical audit of treatment for people with HIV.
ABSTRACT We reviewed the impact of and assessed adherence to British HIV Association (BHIVA) guidelines in routine clinical practice. Feedback has been provided to clinical centres to facilitate any necessary change.
We used a questionnaire to gauge clinicians' views on the guidelines and availability of antiretroviral therapy (ART) drugs and specialized tests. A case note review of 2044 patients was conducted to assess adherence to guideline recommendations plus patterns of use of HIV resistance testing.
Most clinicians (74.1%) report that BHIVA guidelines have influenced care at their centres. A significant minority report problems with access to specialized tests. Most patients who started ART did so at CD4 counts lower than guidelines recommend but in most cases this reflected the CD4 count at diagnosis of HIV. Of patients on ART, an overwhelming majority (97.6%) were receiving three or more drugs. Of those on three or more drugs, 58.9% had latest viral load (VL) below 50 HIV-1 RNA copies/mL and a further 18.1% below 500 copies/mL. Only 19.3% of patients had been tested for HIV resistance, of whom more than half showed resistance to more than one class of drugs.
This clinical audit provides encouraging evidence of the quality of care offered to people with diagnosed HIV in the UK. However late diagnosis means most people start ART at a more advanced stage than guidelines recommend.
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ABSTRACT: Objectives and Retrospective study of all patients who started antiretroviral therapy (ART) in 2007 in a single center in Paris, with baseline characteristics and 1-year outcome, to assess adherence to national guidelines. We analyzed 118 patients. Time of ART initiation was in agreement with the guidelines for only 64 (54.2%) patients. Fifty patients (42%) started ART with AIDS or a CD4 count <200 cells/mm(3). In all, 62 (52%) and 47 patients (40%) received a combination of 2 nucleoside analogues with efavirenz (EFV) and 1 ritonavir-boosted protease inhibitor (PI/r), respectively. Treatment regimens were in accordance with the guidelines for 114 patients (97%). At 1 year, 16 patients (13.5%) were lost to follow-up, only 5 (4.9%) experienced HIV disease progression or death, but 19 (18.6%) required hospitalization. Antiretroviral therapy was changed in 21 patients (21%). Ten patients (8.4%) experienced virologic failure. Antiretroviral therapy was in agreement with guidelines for the choice of combination but was often initiated too late.Journal of the International Association of Physicians in AIDS Care (JIAPAC) 08/2011; 11(1):40-6.
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ABSTRACT: There are limited data on adherence to HIV treatment guidelines. We assessed adherence to US Department of Health and Human Services guidelines with Australian Commentary for adults initiating antiretroviral therapy (ART). Data were recorded regarding "when to start", "what to start" and pre-ART comorbid disease assessment for consecutive adults initiating ART at primary care and hospital clinics in Sydney and Melbourne from 2004 through 2008. Independent predictors of adherence to guidelines were calculated by stepwise logistic regression. For the 500 subjects (95.9% male, mean 40.2 years, median CD4 count 270 cells/μL) "when to start" adherence was 87.6%, and was less likely with initiation in a clinical trial [0.25 (95% CI: 0.13 to 0.49); P < 0.0001] and previous, short-term nontherapeutic antiretroviral exposure [0.08 (0.03 to 0.25); P < 0.0001]. "What to start" adherence was 69.0% for guideline-"preferred" regimens (85.8% for guideline-"preferred" or "alternative" regimens) and more likely with ART initiated in 2008 versus pre-2008 [OR: 2.69 (1.64 to 4.61); P = 0.0001]. Median comorbid disease assessment adherence was 56.8%, ranging from 25.6% for urinalysis to 99.2% for white blood cell count, and was more likely in patients with AIDS, and initiating ART in hospital or in a clinical trial. Hospital clinics were more likely to perform antiretroviral resistance testing (71.2% vs. 46.4%, P < 0.0001), to use "preferred" ART regimens (76.8% vs. 62.2%, P = 0.0002) but less likely to promote healthy diet and lifestyle (63.4% vs. 36.4%, P < 0.0001). "When to start" and "what to start" guidelines have been largely adhered to in Australia, but pre-ART comorbid disease assessment requires greater attention.JAIDS Journal of Acquired Immune Deficiency Syndromes 02/2012; 59(5):478-88. · 4.65 Impact Factor
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ABSTRACT: Objectives The aim of the study was to assess the adequacy of initial antiretroviral therapy (ART), in terms of its timing and the choice of regimens, according to the Spanish national treatment guidelines [Spanish AIDS Study Group−National Plan for AIDS (GeSIDA-PNS) Guidelines] for treatment-naïve HIV-infected patients. MethodsA prospective cohort study of HIV-positive ART-naïve subjects attending 27 centres in Spain from 2004 to 2010 was carried out. Regimens were classified as recommended, alternative or nonrecommended according to the guidelines. Delayed start of treatment was defined as starting treatment later than 12 months after the patient had fulfilled the treatment criteria. Multivariate logistic and Cox regression analyses were performed. ResultsA total of 6225 ART-naïve patients were included in the study. Of 4516 patients who started treatment, 91.5% started with a recommended or alternative treatment. The use of a nonrecommended treatment was associated with a CD4 count > 500 cells/μL [odds ratio (OR) 2.03; 95% confidence interval (CI) 1.14–3.59], hepatitis B (OR 2.23; 95% CI 1.50–3.33), treatment in a hospital with 5 log HIV-1 RNA copies/ml. The use of a nonrecommended regimen was significantly associated with mortality [hazard ratio (HR) 1.61; 95% CI 1.03–2.52; P = 0.035] and lack of virological response. Conclusions Compliance with the recommendations of Spanish national guidelines was high with respect to the timing and choice of initial ART. The use of nonrecommended regimens was associated with a lack of virological response and higher mortality.HIV Medicine 02/2014; 15(2). · 3.16 Impact Factor