Almost a quarter of American women who started anti-HIV therapy between 1995 and 2000 later discontinued this treatment, according to a study published in the April 1st edition of the Journal of Acquired Immune Deficiency Syndromes. The investigators also found that women who started HAART after the spring of 1998 were significantly more likely to discontinue than women commencing treatment before that date, probably because discontinuation has become more acceptable as knowledge about long-term side-effects has developed.
Investigators from the US Women’s Interagency HIV Study (WIHS) had previously demonstrated that the rate of HAART discontinuation increased from 3% in 1996 to 9% in 1999. The investigators wished to characterise more precisely the temporal trends in the discontinuation of HAART over three calendar periods and the factors associated with risk of stopping HAART.
The study population consisted of 936 women. All had started HAART after 1995 and had then received at least six months of anti-HIV therapy and were followed-up at six monthly intervals. According to the date of HAART initiation, the women were divided into one of three consecutive time periods (Ocober 1995 to March 1998; April 1998 – June 1999; and, July 1999 to September 2000). Factors examined for an association with HAART discontinuation included ethnicity: pre-HAART CD4 cell count and viral load; pre-HAART depressive symptoms; pre-HAART self-reported physical health; a pre-HAART AIDS diagnosis; pre-HAART report of injecting drug use; and, immunological and virological changes on HAART.
Of the 936 women who initiated HAART between 1995 and September 2000, 220 (24%) discontinued HAART in five years of follow-up.
Compared with women who remained on HAART, individuals who discontinued were more likely to be Latina (35% versus 24%) and less likely to be white (10% versus 21%, p
Compared with women who started treatment in the period between 1995 and March 1998, patients commencing HAART between April 1998 and June 1999 (p = 0.026) and July 1998 and September 2000 (p = 0.07), were more likely to stop HAART.
A multivariate analysis found that high viral load (p
In further analysis, the investigators found that for the first time period African American ethnicity relative to white ethnicity (risk hazard 4.11) and injecting drug use prior to HAART initiation were significantly associated with discontinuation. In the second period, African American ethnicity (hazard ratio 2.86), Latina ethnicity (hazard ratio 5) were significantly associated with stopping HAART. In the third period, no significant associations were found.
“Our findings emphasise that access to treatment for depression may have important implications for the management of HIV-infected individuals on antiretroviral therapy”, comment the investigators.
The investigators believe the increased hazard associated with commencing HAART in the later two calendar periods examined could be because “discontinuation has become more acceptable as the burden of frequently associated side-effects has been more recognised.”
The association between high viral load and discontinuation is explained, the investigators suggest, by patients stopping regimens that are not successfully suppressing HIV.
Ahdieh-Grant L et al. Factors and temporal trends associated with highly active antiretroviral therapy discontinuation in the women’s interagency HIV study. J Acquir Immune Defic Syndr: 38 (4): 500 – 503, 2005.