Clinical care of HIV-patients: evaluating progress and future challenges

Since the introduction of combination therapy in 1996, Human Immunodeficiency Virus (HIV) treatment has changed substantially. Over twenty new antiretroviral drugs have been licensed for the treatment of HIV-infection and HIV has been transformed into a long-term chronic infection for many patients. Yet it remains unclear how improved efficacy of new antiretrovirals reported in clinical trials has translated to population-level effectiveness in general clinical care. Nor is it clear how the increasingly chronic nature of HIV-infection, characterised by an ageing HIV-population increasingly suffering from age-related non-infectious co-morbidities and drug-drug interactions, will affect HIV care. Such an evaluation is important not just to measure progress, but also to address future challenges for clinical care in order to develop evidence-based changes to clinical guidelines and ensure continued high-quality care. By analysing a dataset that collects data from all HIV-infected patients in clinical care in the Netherlands it was shown that the use of combination antiretroviral therapy (cART) regimens in the Netherlands closely follows changes in guidelines, to the benefit of patients. While there was no significant improvement in mortality, newer drugs with better tolerability and simpler dosing resulted in improved immunological and virological recovery and reduced incidence of switching due to toxicity and virological failure. An individual-based model of the ageing HIV-population in the Netherlands was constructed and used to quantify and evaluate the future challenges posed by an ageing HIV-population. The model showed that the age-structure of HIV-patients in the Netherlands is rapidly shifting to older age. By 2030, almost three quarters of patients will be aged 50 or over. This will result in an increased burden of co-morbidity, polypharmacy and an increasing proportion of patients who will experience potential complications with their HIV-treatment. Cardiovascular disease (CVD) in particular will become a major burden of co-morbid disease. Integrating a smoking cessation programme or changing HIV-treatment guidelines to recommend prescribing a polypill for CVD to all HIV-patients aged 45 or 55 years and over could improve the burden of CVD, improve patient outcome and be cost saving in the long-term.Open Acces

Projections of non-communicable disease and health care costs among HIV-positive persons in Italy and the U.S.A.: A modelling study.

BACKGROUND: Country-specific forecasts of the growing non-communicable disease (NCD) burden in ageing HIV-positive patients will be key to guide future HIV policies. We provided the first national forecasts for Italy and the Unites States of America (USA) and quantified direct cost of caring for these increasingly complex patients. METHODS AND SETTING: We adapted an individual-based model of ageing HIV-positive patients to Italy and the USA, which followed patients on HIV-treatment as they aged and developed NCDs (chronic kidney disease, diabetes, dyslipidaemia, hypertension, non-AIDS malignancies, myocardial infarctions and strokes). The models were parameterised using data on 7,469 HIV-positive patients from the Italian Cohort Naïve to Antiretrovirals Foundation Study and 3,748 commercially-insured patients in the USA and extrapolated to national level using national surveillance data. RESULTS: The model predicted that mean age of HIV-positive patients will increase from 46 to 59 in Italy and from 49 to 58 in the USA in 2015-2035. The proportion of patients in Italy and the USA diagnosed with ≥1 NCD is estimated to increase from 64% and 71% in 2015 to 89% and 89% by 2035, respectively, driven by moderate cardiovascular disease (CVD) (hypertension and dyslipidaemia), diabetes and malignancies in both countries. NCD treatment costs as a proportion of total direct HIV costs will increase from 11% to 23% in Italy and from 40% to 56% in the USA in 2015-2035. CONCLUSIONS: HIV patient profile in Italy and the USA is shifting to older patients diagnosed with multiple co-morbidity. This will increase NCD treatment costs and require multi-disciplinary patient management

Clinical decision support systems to guide healthcare providers on HIV testing

OBJECTIVE: To understand the impact of clinical decision support systems (CDSSs) on improving HIV testing and diagnosis. DESIGN: An original global systematic review (PROSPERO Number: CRD42020175576) of peer-reviewed articles reporting on electronic CDSSs that generate triggers encouraging healthcare providers to perform an HIV test. METHODS: Medline, Embase, Cochrane CENTRAL and CINAHL EBSCOhost were searched up to 17 November 2020 and reference lists of included articles were checked. Qualitative and quantitative syntheses (using meta-analyses) of identified studies were performed. RESULTS: The search identified 1424 records. Twenty-two articles met inclusion criteria (19 of 22 non-HIV endemic settings); 18 clinical and four laboratory-driven reminders. Reminders promoted 'universal' HIV testing for all patients without a known HIV infection and no recent documented HIV test, or 'targeted' HIV testing in patients with clinical risk-factors or specific diagnostic tests. CDSSs increased HIV testing in hospital and nonhospital setting, with the pooled risk-ratio amongst studies reporting comparable outcome measures in hospital settings (n = 3) of 2.57 [95% confidence interval (CI) 1.53-4.33, random-effect model] and in nonhospital settings (n = 4) of 2.13 (95% CI 1.78-4.14, random effect model). Results of the clinical impact of CDSSs on HIV diagnosis were mixed. CONCLUSION: CDSSs improve HIV testing and may, potentially, improve diagnosis. The data support the broader study of CDSSs in low- and high prevalent HIV settings to determine their precise impact on UNAIDS goals to reach universal HIV testing and treatment coverage

Adjusted hazard ratio (95% Confidence intervals) of switching from first-line to second-line due to virological failure.

<p>Adjusted hazard ratio (95% Confidence intervals) of switching from first-line to second-line due to virological failure.</p

Demographic characteristics of the 10,278 patients in the study population by calendar time of treatment initiation.

<p>Demographic characteristics of the 10,278 patients in the study population by calendar time of treatment initiation.</p

Rate of switching per 100 person-years. Calendar time refers to time of switching.

<p>Rate of switching per 100 person-years. Calendar time refers to time of switching.</p

Rates of CD4 recovery and VL suppression.

<p>Unadjusted Kaplan-Meier curves for A) Rates of CD4 recovery of 150 cells/mm³ by 12 months and B) Rates of VL suppression to below 1,000 copies/ml by 12 months.</p

Adjusted hazard ratio (95% Confidence intervals) of switching from first-line to second-line due to toxicity.

<p>Adjusted hazard ratio (95% Confidence intervals) of switching from first-line to second-line due to toxicity.</p