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ABSTRACT: Antiretroviral therapy for the treatment of HIV infection requires high levels of adherence to both maintain plasma HIV RNA at undetectable levels and prevent the emergence of drug resistance. As adherence to treatment is a major criterion for the evaluation of therapeutic outcomes, randomized clinical trials (RCTs) conducted among HIV-infected patients commonly include an assessment of adherence. However, there is still no gold-standard tool for assessing adherence behaviors in HIV RCTs. The methods currently used to collect and analyze adherence data are varied, which makes the comparison of results between studies difficult. The scope of this article is to review and discuss the range of adherence measures currently used in RCTs conducted among HIV-infected adults.
Expert Review of Anticancer Therapy 03/2013; 11(3):239-50. · 3.28 Impact Factor
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Fabienne Marcellin,
Caroline Lions,
Maria Winnock,
Dominique Salmon,
Jacques Durant, Bruno Spire,
Marion Mora,
Marc-Arthur Loko,
François Dabis,
Stéphanie Dominguez,
Perrine Roux,
Maria Patrizia Carrieri
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ABSTRACT: AIMS: Studying alcohol abuse impact, as measured by physicians' perceptions and patients' self-reports, on HIV virological rebound among patients chronically co-infected with HIV and hepatitis C virus (HCV). DESIGN: Cohort study. SETTING: Seventeen French hospitals. PARTICIPANTS: 512 patients receiving antiretroviral therapy (ART) with an undetectable initial HIV viral load and at least two viral load measures during follow-up. MEASUREMENTS: Medical records and self-administered questionnaires. HIV virological rebound defined as HIV viral load above the limit of detection of the given hospital's laboratory test. Alcohol abuse defined as reporting to have drunk regularly at least 4 (for men) or 3 (for women) alcohol units per day during the previous six months. Correlates of time to HIV virological rebound identified using Cox proportional hazards models. FINDINGS: At enrolment, nine percent of patients reported alcohol abuse. Physicians considered 14.8% of all participants as alcohol abusers. Self-reported alcohol abuse was independently associated with HIV virological rebound (hazard ratio [95% confidence interval]: 2.04 [1.13-3.67]; p=0.02), after adjustment for CD4 count, time since ART initiation and hospital HIV caseload. No significant relationship was observed between physician-reported alcohol abuse and virological rebound (p=0.87). CONCLUSIONS: In France, the assessment of alcohol abuse in patients co-infected with HIV and hepatitis C virus should be based on patients' self-reports, rather than physicians' perceptions. Baseline screening of self-reported alcohol abuse may help identify co-infected patients at risk of subsequent HIV virological rebound.
Addiction 02/2013; · 4.31 Impact Factor
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Mégane Meresse,
Maria Patrizia Carrieri,
Christian Laurent,
Charles Kouanfack,
Camelia Protopopescu,
Jérôme Blanche,
Julien Cohen,
Gabrièle Laborde-Balen,
Avelin F Aghokeng, Bruno Spire,
Jean-Paul Moatti,
Eric Delaporte,
Sylvie Boyer
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ABSTRACT: BACKGROUND: Although treatment adherence is a major challenge in sub-Saharan Africa, it is still unknown which longitudinal patterns of adherence are the most detrimental to long-term virological response to non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens. This analysis aimed to study the influence of different time patterns of adherence on virological failure after 24 months of treatment in Cameroon. METHODS: Antiretroviral therapy (ART) adherence data were collected using face-to-face questionnaires administered at months 1, 3, 6, 12, 18 and 24. Virological failure was defined as viral load >40 copies/ml at month 18 and/or 24. Two combined indicators of early adherence (months 1, 3 and 6) and adherence during the maintenance phase (months 12, 18 and 24) were designed to classify patients as always adherent during the early or maintenance phase, non-adherent at least once and having interrupted ART for >2 days at least once at any visit during either of these two phases. RESULTS: Virological failure occurred in 107 (42%) of the 254 patients included in the analysis. In the early and maintenance phases, 84% and 76%, respectively, were always adherent, 5% and 5% were non-adherent and 11% and 20% experienced ≥1 treatment interruption. Early non-adherence was independently associated with virological failure (adjusted OR 7.2 [95% CI 1.5, 34.6]), while only treatment interruptions had a significant impact on virological failure during the maintenance phase (adjusted OR 2.1 [95% CI 1.1, 4.4]). CONCLUSIONS: ART NNRTI-regimens used in sub-Saharan Africa seem to 'forgive' deviations from good adherence during the maintenance phase. Optimizing adherence in the early months of treatment remains crucial, especially in a setting of poor health care infrastructure and resources.
Antiviral therapy 01/2013; · 3.16 Impact Factor
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Charlotte Boullé,
Charles Kouanfack,
Gabrièle Laborde-Balen,
Maria Patrizia Carrieri,
Marlise Dontsop,
Sylvie Boyer,
Avelin Fobang Aghokeng, Bruno Spire,
Sinata Koulla-Shiro,
Eric Delaporte,
Christian Laurent
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ABSTRACT: BACKGROUND:: Task shifting to nurses for antiretroviral therapy (ART) is promoted by WHO to compensate for the severe shortage of physicians in Africa. We assessed the effectiveness of task shifting from physicians to nurses in rural district hospitals in Cameroon. METHODS:: We performed a cohort study using data from the Stratall trial, designed to assess monitoring strategies in 2006-2010. ART-naive patients were followed-up for 24 months after treatment initiation. Clinical visits were performed by nurses or physicians. We assessed the associations between the consultant ratio (i.e. the ratio of the number of nurse-led visits to the number of physician-led visits) and HIV virological success, CD4 recovery, mortality, and disease progression to death or to WHO clinical stage 4 in multivariate analyses. RESULTS:: Of the 4,141 clinical visits performed in 459 patients (70.6% female, median age 37 years), a quarter was task shifted to nurses. The consultant ratio was not significantly associated with virological success (odds ratio 1.00, 95%CI 0.59-1.72, p=0.990), CD4 recovery (coefficient -3.6, 95%CI -35.6; 28.5, p=0.827), mortality (time ratio 1.39, 95%CI 0.27-7.06, p=0.693) or disease progression (time ratio 1.60, 95%CI 0.35-7.37, p=0.543). CONCLUSION:: This study brings important evidence about the comparability of ART-related outcomes between HIV models of care based on physicians or nurses in resource-limited settings. Investing in nursing resources for the management of non-complex patients should help reduce costs and patient waiting lists while freeing up physician time for the management of complex cases, for mentoring and supervision activities, as well as for other health interventions.
JAIDS Journal of Acquired Immune Deficiency Syndromes 01/2013; · 4.43 Impact Factor
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ABSTRACT: The continued scaling-up of antiretroviral therapy (ART) in Sub-Saharan Africa provides an opportunity to further study its impact on sexual behaviors among people living with HIV/AIDS (PLWHA). We explored time trend and correlates of sexual activity among PLWHA initiating ART in Cameroon and compared sexual risk behaviors between patients sexually active before and after initiating ART and those resuming sexual activity after ART initiation. Analyses were based on longitudinal data collected within the randomized trial (n=459) conducted in nine rural district hospitals in Cameroon. Sexual activity was defined as reporting at least one sexual partner during the previous 3 months. Inconsistent condom use (ICU) was defined as reporting to have "never," "sometimes," or "nearly always" used condoms at least once with a partner(s) either HIV-negative or of unknown HIV status during the same period. Mc Nemar tests were used to assess time trend, while mixed-effect logistic regressions were conducted to analyze the effect of time since ART initiation on sexual activity. The proportion of sexually active patients significantly increased over time: from 31.8% at baseline to 40.2 and 47.1% after 6 and 12 months of ART, respectively (p=0.001), to 55.9% after 24 months (p=0.02). After adjustment for behavioral and psychosocial factors, time since ART initiation was independently associated with reporting sexual activity (AOR [95% CI]=1.30 [1.17-1.46] per 6-month increase, p=0.001). ICU was more frequent among patients sexually active both before and after ART initiation than among those who resumed sexual activity after ART initiation (82 vs. 59%, p<B0.001). To conclude, while ART initiation fosters resumption of sexual activity in patients who are inactive before starting treatment; unsafe sexual behaviors remain less frequent in this population than in patients who are already sexually active before starting ART. Risk reduction programs should be reinforced among PLWHA in the context of ART scaling-up.
AIDS Care 01/2013; 25(3):347-55. · 1.60 Impact Factor
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ABSTRACT: This work aimed to analyze the rate of disclosure to relatives and friends over time and to identify factors affecting disclosure among seropositive adults initiating antiretroviral therapy (ART) in rural district hospitals in the context of decentralized, integrated HIV care and task-shifting to nurses in Cameroon. Stratall was a 24-month, randomized, open-label trial comparing the effectiveness of clinical monitoring alone with laboratory plus clinical monitoring on treatment outcomes. It enrolled 459 HIV-infected ART-naive adults in 9 rural district hospitals in Cameroon. Participants in both groups were sometimes visited by nurses instead of physicians. Patients with complete data both at enrolment (M0) and at least at one follow-up visit were included in the present analysis. A mixed Poisson regression was used to estimate predictors of the evolution of disclosure index over 24 months (M24).The study population included 385 patients, accounting for 1733 face-to-face interviews at follow-up visits from M0 to M24. The median [IQR] number of categories of relatives and friends to whom patients had disclosed was 2 [1]-[3] and 3 [2]-[5] at M0 and M24 (p-trend<0.001), respectively. After multiple adjustments, factors associated with disclosure to a higher number of categories of relatives and friends were as follows: having revealed one's status to one's main partner, time on ART, HIV diagnosis during hospitalization, knowledge on ART and positive ratio of follow-up nurse-led to physician-led visits measuring task-shifting. ART delivered in the context of decentralized, integrated HIV care including task-shifting was associated with increased HIV serological status disclosure.
PLoS ONE 01/2013; 8(1):e55225. · 4.09 Impact Factor
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ABSTRACT: A cross-sectional survey, using self-sampled finger-prick blood on blotting paper and anonymous behavioral self-administrated questionnaires was conducted in Paris in 2009 among MSM attending gay venues. Paired biological results and questionnaires were available for 886 participants. HIV seroprevalence was 17.7 % (95 % CI: 15.3-20.4). Four groups were identified according to their knowledge of their HIV biological status. Among the 157 found to be seropositive, 31 (19.7 %) were unaware of their status and reported high levels of sexual risk behaviors and frequent HIV testing in the previous 12 months. Among the 729 MSM diagnosed HIV-negative, 183 were no longer sure whether they were still HIV-negative, or had never been tested despite the fact that they engaged in at-risk sexual behaviors. This study provides the first estimate of HIV seroprevalence among MSM in Paris and underlines the specific need for combined prevention of HIV infection in this MSM population.
AIDS and Behavior 09/2012; · 3.49 Impact Factor
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ABSTRACT: BACKGROUND: In France, the rapid scale-up of buprenorphine, an opioid maintenance treatment (OMT), in primary care for drug users has led to an impressive reduction in HIV prevalence among injecting drug users (IDU) but has had no major effect on Hepatitis C incidence. To date, patients willing to start methadone can only do so in a methadone clinic (a standard centre for drug and alcohol dependence (CSAPA) or a hospital setting) and are referred to primary care physicians after dose stabilization. This study aims to assess the effectiveness of methadone in patients who initiated treatment in primary care compared with those who initiated it in a CSAPA, by measuring abstinence from illicit opioid use after one year of treatment. METHODS: The ANRS-Methaville study is a randomized multicenter non-inferiority control trial comparing methadone initiation (lasting approximately 2 weeks) in primary care and in CSAPA. The model of care chosen for methadone initiation in primary care was based on study-specific pre-training of all physicians, exclusion criteria and daily supervision of methadone during the initiation phase. Between January 2009 and January 2011, 12 sites each having one CSAPA and several primary care physicians, were identified to recruit patients to be randomized into two groups, one starting methadone in primary care (n=147), the other in CSAPA (n=49). The primary outcome of the study is the proportion of participants not using street opioids after 1 year of treatment i.e. non-inferiority of primary care model in terms of the proportion of patients not using street opioids compared with the proportion observed in those starting methadone in a CSAPA. DISCUSSION: The ANRS-Methaville study is the first in France to use an interventional trial to improve access to OMT for drug users. Once the non-inferiority results become available the Ministry of Health and agency for the safety of health products may change the law regarding legal prescription of methadone and make methadone initiation by trained primary care physicians possible. Clinical Trials: Number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397 and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.
BMC Public Health 06/2012; 12(1):488. · 2.00 Impact Factor
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ABSTRACT: Abstract Men who have sex with men (MSM) recruited in sex venues have been shown to be interested in accessing HIV home-tests if reliable and authorised tests were available. To what extent is this true for MSM recruited online? In an online survey in French on the use of unauthorised HIV home-tests purchased online, MSM previously unaware of the existence of these tests were asked if they would be interested in accessing them if these tests were authorised. Among 5908 non-HIV positive respondents, 86.5% expressed interest. Independent variables associated with interest included: being younger, living in smaller towns, having a job but not tertiary education and living in a conventional family with one's parents or a wife and family. Interested men were also more likely to have never done the standard HIV test or not in the last year, to have casual sex partners but on average not more than once a week, to take sexual risks with these partners, to live their sex-lives with men in absolute secrecy and yet often to try to make a date to see their sex partners again. Of the 5109 respondents interested in accessing self-tests purchasable online, 4362 (85.4%) answered an open question on their reasons for being interested. Using thematic analysis, principle themes identified proved to be similar to those found in earlier studies with MSM recruited in sex venues: convenience, rapidity accessing results and privacy. In answer to a closed question, men not interested chose as reasons: satisfaction with current method, doubts about reliability, not wanting to be alone when discovering results and fear of incorrect use. In conclusion, although the online questionnaire may have introduced selection bias over-representing men already interested, many Internet-using MSM are interested in accessing self-tests available for purchase online.
AIDS Care 06/2012; · 1.60 Impact Factor
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ABSTRACT: Psychiatric disorders are relatively common among HIV-infected patients. However, there are few studies about their potential risk factors. This analysis aimed to measure the incidence of severe psychiatric events (PE) among patients receiving combination antiretroviral therapy (cART) of the French APROCO-COPILOTE (ANRS CO8) cohort, and to identify the medical and socio-behavioural correlates of their first episode of depression, suicide or suicide attempt (D/S/SA).
APROCO-COPILOTE is a cohort of patients started on a protease inhibitor regimen between 1997 and 1999, with prospective medical standardized records and self-administered questionnaires collecting socio-demographic and socio-behavioural data. This analysis included all 11-year follow-up visits for 1,095 patients having completed baseline self-administered questionnaires. A proportional hazard Cox model was used to identify the correlates of a first D/S/SA event.
The overall prevalence of severe PE remained low: 50 patients experienced 67 events (incidence rate [95% CI] =1.04 [0.82, 1.32] per 100 person-years). Depression (n=16), suicides (n=5) and suicide attempts (n=14) were the most frequently diagnosed PE (0.54 [0.39, 0.76] per 100 person-years) among 25 patients. Multivariate results showed that unemployment, unstable housing, detectable viral load and smoking more than 20 cigarettes/day were independently associated with D/S/SA.
Although the incidence of severe PE remained relatively low among the patients of APROCO-COPILOTE cohort, this study's results underline a clinically important problem in HIV-infected patients receiving cART. Furthermore, our findings not only emphasize the importance of comprehensive care, especially for socially vulnerable patients, but may also help future studies designed to assess the effectiveness of interventions in reducing the risk of PE during cART.
Antiviral therapy 04/2012; 17(6):1079-83. · 3.16 Impact Factor
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ABSTRACT: The last international consensus conference about hepatitis C virus (HCV) treatment emphasized the importance of treatment
for persons coinfected with HCV and human immunodeficiency virus (HIV). As liver biopsy precedes treatment, we aimed to identify
factors associated with the performance of liver biopsy among HIV-HCV coinfected drug users during a 5-year follow-up to study
their access to HCV treatment. Of the 296 patients followed in the HIV hospital departments of Nice and Marseilles and with
retrievable records about HCV diagnosis and care, 166 were eligible for analysis having had detectable HCV RNA at least once
during the study period. Overall, 45.2% of patients underwent liver biopsy during follow-up. Using proportional hazard models,
predictors of having had a liver biopsy were high social support, complete abstinence from drug injection, and lack of immunosuppression
as well as male gender, no history of multiple incarcerations, more recent onset of drug use, and an increase of liver enzyme
levels. These results suggest that specific efforts should be devoted to HIV-HCV coinfected drug users to assist with stabilizing
these patients to optimize their access to HCV care whenever possible.
Journal of Urban Health 04/2012; 81(1):48-57. · 2.13 Impact Factor
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Hepatology 04/2012; · 11.66 Impact Factor
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ABSTRACT: In low- and middle-income countries, men who have sex with men (MSM) are 19 times more likely to be HIV positive compared with background populations. Criminalisation and social rejection of homosexuality in most sub-Saharan African countries reinforce stigma and exclude MSM from prevention activities, including HIV testing. This paper's purpose is to identify factors associated with never having been HIV tested (NHT), among a sample of Cameroonian MSM. In 2008, a community-based study was conducted in Douala, the economic capital city of Cameroon, by a local NGO Alternatives-Cameroun, recruiting participants through the snowball technique and administering a questionnaire during face-to-face interviews. Proximity to HIV was investigated according to the following criteria: knowing at least one person living with HIV and having been exposed to HIV prevention interventions. NHT was defined as reporting to have never been HIV tested. A logistic regression was used to identify factors associated with NHT. Among the 165 MSM of our study group who reported that they were not HIV positive, 19% reported NHT. Factors independently associated with NHT were as follows: being younger, being Muslim, not having a steady male partner, not knowing any person living with HIV and never having been exposed to HIV prevention interventions. In this MSM population, a small proportion reported that they had never been HIV tested and among these, the percentage was higher among individuals not in proximity to HIV. Despite the hostile context of sub-Saharan African countries towards MSM, local and national HIV testing campaigns to date may have played a substantial role in raising HIV awareness in the MSM population living in Douala, and peer-based counselling may have educated those in contact with Alternatives-Cameroun regarding the positive value of HIV testing. This result is a further argument for continuing community-based prevention and extending it to difficult-to-reach MSM.
AIDS Care 04/2012; 24(8):1020-7. · 1.60 Impact Factor
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Nicolas Lorente,
Marie Suzan-Monti,
Chantal Vernay-Vaisse,
Marion Mora,
Jérôme Blanche,
Lionel Fugon,
Philippe Dhotte,
Jean-Marie Le Gall,
Patrick Rovera,
Maria Patrizia Carrieri,
Marie Préau, Bruno Spire
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ABSTRACT: In France, HIV testing can be easily performed in free and anonymous voluntary counselling testing (VCT) centres. The recent national study among French men who have sex with men (MSM) showed that 73% of those already tested for HIV had been tested in the previous two years. Nothing is known about the risk behaviours of MSM attending VCT centres. This study aimed to characterize sexual risk behaviours of MSM tested for HIV in such centres and identify factors associated with inconsistent condom use (ICU). A cross-sectional study was conducted from March to December 2009 in four VCT centres where a self-administered questionnaire was proposed to all MSM about to have a HIV test. ICU was defined as reporting non-systematic condom use during anal intercourse with casual male partners. Among the 287 MSM who fully completed their questionnaire, 44% reported ICU in the previous six months. Among those who had been already tested, 63% had had their test in the previous two years. Factors independently associated with ICU included: never avoiding one-night stands, not having been recently HIV tested, experiencing difficulty in using condoms when with a HIV negative partner or when under the influence of drugs or alcohol and finally, reporting to have had a large number of casual male partners in the previous six months. The rate of recently tested MSM was high in our study. Nevertheless, this rate was lower than that found in the last national study. Furthermore those not recently tested were significantly more likely to report high risk behaviours. We therefore recommend that further efforts be made to adapt the offer of both HIV testing and counselling to meet the specific needs of hard-to-reach MSM. Accordingly, an additional community-based offer of HIV testing to reach most-at-risk MSM is forthcoming in France.
AIDS Care 04/2012; 24(8):1039-45. · 1.60 Impact Factor
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ABSTRACT: We analysed sexual difficulties in a nationally representative sample of HIV-infected outpatients in France. Analyses were
restricted to the 1,812 HIV-treated participants who reported at least one sexual partner during the 12months prior to the
study. The sample included 40.6% homosexual men and 24.4% women; 68.1% had a steady partner and 48.2% reported casual partners.
Sexual difficulties were reported by 33.3% of the selected individuals and were more frequent in those with low sexual activity.
Immuno-virological outcomes were not associated with sexual difficulties. After multiple adjustment for sexual frequency and
antidepressant consumption, it was found that a larger HIV-network, reporting HIV-discrimination from friends and/or sexual
partners, suffering from lipodystrophy and reporting very disturbing HIV-related symptoms were all significantly associated
with sexual difficulties. HIV and HIV-treatment experience are associated with sexual difficulties. Psychological support
focused on HIV-experience should be tested as a possible tool for improving sexual quality of life.
AIDS and Behavior 04/2012; 12(4):670-676. · 3.49 Impact Factor
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Expert Review of Anticancer Therapy 04/2012; 10(4):403-6. · 3.28 Impact Factor
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ABSTRACT: Although not authorised in France, HIV self-tests are easily available online. The authors questioned French-speaking internet-using men who have sex with men (MSM) concerning their access to and use of such tests.
Online questionnaire on sex websites and gay and HIV community websites. A multivariate logistic regression for rare events was used to identify factors associated with accessing self-tests.
9169 MSM completed the questionnaire. 2748 (30%) were aware of online self-tests, but only 82 of those aware and not already HIV positive (3.5%) declared having accessed one and only 69 using it. In the multivariate model, living one's sex-life with men in absolute secrecy (odds ratio (OR)=3.90, 95% CI 1.73 to 8.76), knowing of the tests via a sex partner (OR=3.42, CI 1.39 to 8.41) or an internet search engine (OR=2.18, CI 1.26 to 3.74) but not through the general (OR=0.21, CI 0.11 to 0.42) or the gay press (OR=0.34, CI 0.16 to 0.73), having unprotected anal intercourse with a casual partner in the preceding year (OR=1.90, CI 1.17 to 3.06), using self-tests for other diseases (OR=2.66, CI 1.43 to 4.90), using poppers (OR=2.23, CI 1.35 to 3.67) and doping products (OR=3.53, CI 1.55 to 8) in the preceding year, having done a traditional HIV test but not in the preceding year (OR=1.93, CI 1.14 to 3.32), never having had suicidal thoughts (OR=0.54, CI 0.32 to 0.90) and living in the provinces (OR=1.80, CI 1.01 to 3.25) were all independently associated with accessing self-tests.
Although readiness to admit use of unauthorised medical products may have influenced results, few MSM aware of the existence of self-tests actually declared having accessed one. Accessing the self-test was independently associated with both living one's sex-life with men in total secrecy and having had unprotected anal intercourse in the last 12 months, indicating that autonomous self-testing may reduce barriers to testing for this vulnerable population.
Sexually transmitted infections 03/2012; 88(5):368-74. · 2.18 Impact Factor
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Dominique Salmon-Ceron,
Julien Cohen,
Maria Winnock,
Perrine Roux,
Firouze Bani Sadr,
Eric Rosenthal,
Isabelle Poizot Martin,
Marc-Arthur Loko,
Marion Mora,
Philippe Sogni, Bruno Spire,
François Dabis,
Maria Patrizia Carrieri
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ABSTRACT: Treatment for the hepatitis C virus (HCV) may be delayed significantly in HIV/HCV co-infected patients. Our study aims at identifying the correlates of access to HCV treatment in this population.
We used 3-year follow-up data from the HEPAVIH ANRS-CO13 nationwide French cohort which enrolled patients living with HIV and HCV. We included pegylated interferon and ribavirin-naive patients (N = 600) at enrolment. Clinical/biological data were retrieved from medical records. Self-administered questionnaires were used for both physicians and their patients to collect data about experience and behaviors, respectively.
Median [IQR] follow-up was 12[12-24] months and 124 patients (20.7%) had started HCV treatment. After multiple adjustment including patients' negative beliefs about HCV treatment, those followed up by a general practitioner working in a hospital setting were more likely to receive HCV treatment (OR[95%CI]: 1.71 [1.06-2.75]). Patients followed by general practitioners also reported significantly higher levels of alcohol use, severe depressive symptoms and poor social conditions than those followed up by other physicians.
Hospital-general practitioner networks can play a crucial role in engaging patients who are the most vulnerable and in reducing existing inequities in access to HCV care. Further operational research is needed to assess to what extent these models can be implemented in other settings and for patients who bear the burden of multiple co-morbidities.
BMC Health Services Research 03/2012; 12:59. · 1.66 Impact Factor
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ABSTRACT: It is well established that high adherence to HIV-infected patients on highly active antiretroviral treatment (HAART) is a major determinant of virological and immunologic success. Furthermore, psychosocial research has identified a wide range of adherence factors including patients' subjective beliefs about the effectiveness of HAART. Current statistical approaches, mainly based on the separate identification either of factors associated with treatment effectiveness or of those associated with adherence, fail to properly explore the true relationship between adherence and treatment effectiveness. Adherence behavior may be influenced not only by perceived benefits-which are usually the focus of related studies-but also by objective treatment benefits reflected in biological outcomes.
Our objective was to assess the bidirectional relationship between adherence and response to treatment among patients enrolled in the ANRS CO8 APROCO-COPILOTE study. We compared a conventional statistical approach based on the separate estimations of an adherence and an effectiveness equation to an econometric approach using a 2-equation simultaneous system based on the same 2 equations.
Our results highlight a reciprocal relationship between adherence and treatment effectiveness. After controlling for endogeneity, adherence was positively associated with treatment effectiveness. Furthermore, CD4 count gain after baseline was found to have a positive significant effect on adherence at each observation period. This immunologic parameter was not significant when the adherence equation was estimated separately. In the 2-equation model, the covariances between disturbances of both equations were found to be significant, thus confirming the statistical appropriacy of studying adherence and treatment effectiveness jointly.
Our results, which suggest that positive biological results arising as a result of high adherence levels, in turn reinforce continued adherence and strengthen the argument that patients who do not experience rapid improvement in their immunologic and clinical statuses after HAART initiation should be prioritized when developing adherence support interventions. Furthermore, they invalidate the hypothesis that HAART leads to "false reassurance" among HIV-infected patients.
Medical care 02/2012; 50(5):410-8. · 3.24 Impact Factor
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Archives of Sexual Behavior 02/2012; 41(3):525-7. · 3.53 Impact Factor
