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Nonadherence to Triple Combination Therapy Is Predictive of AIDS Progression and Death in HIV-Positive Men and Women R. S. HOGG*, B. YIP, K. CHAN, M. V. O'SHAUGHNESSY, and J. S. G. MONTANER.
BC Ctr. for Excellence in HIV/AIDS, Vancouver, Canada Objective: To characterize the response to antiretroviral (ARV) therapy among participants enrolled in a population-based anti-HIV drug treatment program in British Columbia (BC).
Method: In BC antiretroviral therapies are distributed free of charge according to specific therapeutic guidelines. Study subjects were ARV naive, started triple therapy with 2 NRTIs and a PI or a NNRTI between 08/96-12/98, and had a baseline plasma viral load. The primary and secondary outcomes in this analysis were death, and a primary AIDS diagnosis or death respectively. K-M methods were used to estimate the hazard of death and AIDS-free survival from the initiation of antiretroviral therapy. Adherence was estimated by dividing the number of months of documented prescriptions dispensed by the number of months of follow-up in the first year of ARV therapy. All p-values are two-sided.
Results: A total of 950 subjects (815 men/135 women) were studied. The median time on antiretroviral therapy was 13 months (IQR 7-21 months). 807 persons (85%) initiated therapy with a PI-containing regimen and 143 (15%) with a NNRTI-containing regimen. A total of 64 deaths and 11 primary AIDS diagnoses were prospectively observed in this study. The cumulative mortality was 3.6% (+ 0.6) at 12 months. In a multivariate model, mortality was independently associated with being non-adherent to therapy [per 10% decline in adherence] (RR = 1.16; 95% CI: 1.06 – 1.26; p < 0.001), and having a lower CD4 cell count [per 100 cell X 106/L] (RR = 1.35; 95% CI: 1.13 - 1.61; p = 0.001) at baseline. The results were unchanged when AIDS-free survival was the outcome of interest. In this instance, the likelihood of death and/or AIDS was 1.17 times higher (95% CI: 1.08 – 1.28; p < 0.001) per 10% decline in adherence.
Conclusion: This study demonstrates that non-adherent participants are more likely to progress than adherent ones. In particular, we found that with every 10% decline in adherence among program participants there was a 16% increase in the rate of mortality.
Key Words: Adherence, AIDS-free survival, Survival
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