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Importance of Routinely Taking Drug Therapy for HIV-1 Infection FREE

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The summary below is from the full report titled “Effect of Medication Adherence on Survival of HIV-Infected Adults Who Start Highly Active Antiretroviral Therapy When the CD4+ Cell Count Is 0.200 to 0.350 × 109 cells/L.” It is in the 18 November 2003 issue of Annals of Internal Medicine (volume 139, pages 810-816). The authors are E. Wood, R.S. Hogg, B. Yip, P.R. Harrigan, M.V. O'Shaughnessy, and J.S.G. Montaner.


Ann Intern Med. 2003;139(10):I-20. doi:10.7326/0003-4819-139-10-200311180-00003
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What is the problem and what is known about it so far?

HIV-1 infection is a serious chronic illness caused by a virus. The virus attacks the body's immune system and interferes with the body's ability to fight infection and certain types of cancer. Doctors use blood tests that measure immune function (CD4+ cell count) and the level of virus in the blood (viral load) to monitor patients with HIV-1 infection. As the disease advances, the CD4+ cell count drops and viral loads increase. Doctors treat HIV-1 infection with combinations of different drugs (antiretroviral agents). Combination therapy is difficult because patients need to take many pills several times a day and side effects are common. Doctors and patients wonder about the best time to start combination therapy. Guidelines recommend therapy in patients who have CD4+ cell counts less than 0.200 × 109 cells/L. Whether counts above these levels should guide the timing of therapy is unclear.

Why did the researchers do this particular study?

To see whether CD4+ cell count at the time of starting antiretroviral therapy or refilling drug therapy regularly (adherence) is more closely related to survival.

Who was studied?

1422 HIV-1–infected adults in Canada who began therapy between August 1996 and July 2000.

How was the study done?

CD4+ cell counts were measured before therapy began. Patients were then prescribed triple antiretroviral drug therapy. Drugs were dispensed through one center in British Columbia. The researchers assessed adherence to drugs according to whether patients refilled their prescriptions regularly during their first year of therapy. Patients were followed for 2 to 6 years. The researchers reviewed medical records and government vital statistics data to assess deaths that occurred during this time. The researchers then looked at whether the initial CD4+ cell count level or adherence to therapy best predicted survival.

What did the researchers find?

In general, patients with CD4+ cell counts greater than or equal to 0.200 × 109 cells/L who refilled their drug prescriptions regularly had low death rates. Among these patients, survival was similar regardless of whether therapy was started when counts were 0.200 to 0.349 × 109 cells/L or higher (≥ 0.350 × 109 cells/L). Patients with CD4+ cell counts of 0.200 to 0.349 × 109 cells/L and ≥ 350 × 109 cells/L who did not refill their drug prescriptions regularly had higher death rates than patients who refilled their prescriptions regularly.

What were the limitations of the study?

The study took place in a setting where health care, including drug therapy, was readily available and free. Results may not apply to other settings. Adherence to drug therapy was measured by numbers of dispensed prescriptions. Some patients may have refilled prescriptions regularly yet not have taken all of the prescribed pills. Potential differences in death rates between some groups may have been missed because few patients died.

What are the implications of the study?

Among patients with CD4+ cell counts greater than 0.200 × 109 cells/L, taking antiretroviral therapy regularly is probably more closely related to improved survival than is the CD4+ cell count (0.200 to 0.349 or ≥ 0.350 × 109 cells/L) when therapy is started.

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