HIV This Week

Marcellin F, Boyer S, Protopopescu C, Dia A, Ongolo-Zogo P, Koulla-Shiro S, Abega SC, Abé C, Moatti JP, Spire B, Carrieri MP; the EVAL Study Group*. Determinants of unplanned antiretroviral treatment interruptions among people living with HIV in Yaoundé, Cameroon (EVAL survey, ANRS 12-116). Trop Med Int Health. 2008;13(12):1470-8

This study’s objective was to identify correlates of self-reported antiretroviral treatment interruptions among people living with HIV in Cameroon. Analyses were based on data collected in the national survey EVAL (ANRS 12-116) among 533 ART-treated people living with HIV in Yaoundé, the capital city of Cameroon, and its neighbourhood. Logistic regression models were used to identify factors associated with self-reported antiretroviral treatment interruptions longer than two consecutive days during the previous 4 weeks. Antiretroviral treatment interruptions were reported by 68 patients (12.8%). After adjustment for gender, education, and household income, characteristics independently associated with interruptions were pharmacy stock shortages [OR (95%CI):3.25 (1.78-5.90)], binge drinking [2.87 (1.39-5.91)], and the number of self-reported slimming symptoms [1.23 (1.02-1.48)]. In poor-resource settings where access to second and third-line regimens is still limited, food supply programmes and interventions to minimise antiretroviral treatment shortage may reduce the risk of antiretroviral treatment interruptions.

Editors’ note: Supply chain management to reduce pharmacy stock shortages and prevention of hazardous alcohol use can help reduce the frequency of the more-than-two-days antiretroviral treatment interruptions that are associated with risk of viral resistance. Food supply programmes are a critical adjunct in the first 6 months of antiretroviral treatment to prevent malnutrition related to advanced HIV disease at treatment initiation and to address the poor social conditions that may undermine adherence.

The prevalence of HIV infection in older patients (> or =50 years) is increasing due to highly active antiretroviral therapy, and new HIV infections in older patients. Some earlier studies suggest that older patients respond differently to highly active antiretroviral therapy than younger patients. The objective of this study is to compare the effectiveness of highly active antiretroviral therapy in older and younger HIV patients by conducting a retrospective analysis of an observational clinical cohort. Virologic and immunologic response, progression to AIDS, and mortality were compared between 670 younger patients (<40 years) and 149 older patients (> or =50 years) by t-test, Kaplan-Meier methods, and multivariate Cox proportional hazards analysis. Compared with younger patients, older patients were more likely to be on non-nucleoside reverse transcriptase inhibitors based versus protease inhibitor based regimens (42 vs. 29%, P < 0.01). Time to HIV-1 RNA virologic suppression was less in older than in younger patients (3.2 vs. 4.4 months, P < 0.01). Immunologic response did not differ by age. Older patients had fewer AIDS-defining opportunistic infections (22 vs. 31%, P < 0.01), but higher mortality (36 vs. 27%, P = 0.04) and shorter survival (25th percentile survivor function 36.2 vs. 58.5 months, P = 0.02) than younger patients. Older age was associated with more rapid virologic suppression [adjusted hazard ratio = 1.33 (1.09-1.63)] and earlier mortality [adjusted hazard ratio = 1.56 (1.14-2.14)]. Non-nucleoside reverse transcriptase inhibitors based regimens were associated with more rapid virologic suppression [adjusted hazard ratio = 1.22 (1.03-1.44)]. Time to virologic suppression after highly active antiretroviral therapy initiation was shorter in older patients, although CD4 response did not differ by age. Older patients had fewer opportunistic infections, but survival was shorter. The authors’ data suggest a need to better understand causes of mortality in older patients.

Editors´note: Multiple studies reported worse HIV outcomes among older compared to younger patients before the advent of antiretroviral treatment. This study contributes to the body of conflicting literature on the comparative effect of antiretroviral treatment by age. Its findings are interesting but the sample size is small, the high proportion of patients of minority race and injecting drug use status may limit generalisability, adherence data were available for only a limited number of patients, and the older age group included those infected recently as well as those who have aged with AIDS. Nonetheless, age-specific treatment recommendations to start older patients on antiretroviral treatment at higher CD4 counts may be warranted given their shorter survival time despite good immunologic responses.