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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3052 — Fewer Than a Quarter of HIV-Positive Veterans Adhere to Medications at Recommended Levels

LaFleur J (Salt Lake City VA), Nelson RE (Salt Lake City VA), Hayden C (Salt Lake City VA), Reimer L (University of Utah), Kone K (Salt Lake City VA), Nebeker J (Salt Lake City VA)

Objectives:
Best practice guidelines urge use of 3-4 drug regimens for treatment of human immunodeficiency virus (HIV) and recommend near-perfect levels of patient adherence (95%) to avoid treatment failure and development of drug-resistant infection. Veteran adherence to multi-drug regimens in HIV is not well-quantified; we report on veterans’ adherence to antiretroviral multi-drug therapy.

Methods:
Incident cases of HIV seropositive, antiretroviral-naïve patients initiating therapy from 1998-2006 were identified using data from the Veterans Health Administration (VHA) Clinical Case Registry (CCR). We defined antiretroviral-naïve as not having prior treatment in the VHA. Because patients often come to the VHA after receiving treatment outside the system, we also excluded patients if: (1) the first regimen was a ‘salvage’ regimen (composed of both a protease inhibitor [PI] and a non-nucleoside reverse transcriptase inhibitor [nNRTI] or composed of >= 5 agents), (2) HIV prognostic indices were not measured before the first ART prescription, and (3) all HIV-RNA levels before the first prescription were low enough to suggest prior treatment. The proportion of days covered (PDC) by 3 or more agents was calculated from pharmacy data over quarterly intervals between each patient’s first and last fill.

Results:
A total of 7,060 veterans met all inclusion criteria and were considered new starts. The mean age of the cohort was 56.3 (SD 9.4) and 97.6% were male. Average duration of therapy was 4.8 years (SD 2.6). Mean PDC was 20.9% (95% CI 20.2-21.7%) in quarter 1 among 7,060 veterans, which increased to 27.0% (95% CI 26.1-27.9%) in quarter 2 among 6,920 veterans. Mean PDC reached a maximum of 43.3% (95% CI 41.6-45.0) in quarter 26 among 2,451 veterans. The proportions of patients who adhered to at least 95% and 80% of 3 or more drugs ranged from 6.2% and 9.8% in quarter 1 to 23.0% and 32.2% in quarter 30 among 1,819 patients.

Implications:
Only a very small proportion of veterans with HIV had adherence to therapy in the “optimal” range.

Impacts:
To minimize risk of treatment failure and HIV drug resistance, interventions are needed to identify patients likely to be poorly adherent and to optimize adherence.


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