Discontinuation of ART Among Adults in HIV Care in the US
Discontinuation of ART Among Adults in HIV Care in the US
Background. Continuous antiretroviral therapy (ART) is important for maintaining viral suppression. This analysis estimates prevalence of and reason for ART discontinuation.
Methods. Three-stage sampling was used to obtain a nationally representative, cross-sectional sample of HIV-infected adults receiving HIV care. Face-to-face interviews and medical record abstractions were collected from June 2009 to May 2010. Data were weighted based on known probabilities of selection and adjusted for nonresponse. Patient characteristics of ART discontinuation, defined as not currently taking ART, stratified by provider-initiated versus non–provider-initiated discontinuation, were examined. Weighted logistic regression models predicted factors associated with ART discontinuation.
Results. Of adults receiving HIV care in the United States who reported ever initiating ART, 5.6% discontinued treatment. Half of those who discontinued treatment reported provider-initiated discontinuation. Provider-initiated ART discontinuation patients were more likely to have a nadir CD4 ≥200 cells per cubic millimeter. Non–provider-initiated ART discontinuation patients were more likely to have unmet need for supportive services and to have not received HIV care in the past 3 months. Among all patients who discontinued, younger age, female gender, not having continuous health insurance, incarceration, injection drug use, nadir CD4 count ≥200 cells per cubic millimeter, unmet need for supportive services, no care in the past 3 months and HIV diagnosis ≥5 years before interview were independently associated with ART discontinuation.
Conclusions. These findings inform development of interventions to increase ART persistence by identifying groups at increased risk of ART discontinuation. Evidence-based interventions targeting vulnerable populations are needed and are increasingly important as recent HIV treatment guidelines have recommended universal ART.
Combination antiretroviral therapy (ART) provides a range of benefits to HIV-infected patients such as increased survival, improved immune status and decreased morbidity, and opportunistic infections. Through viral suppression, ART reduces the likelihood of sexual transmission of HIV to uninfected partners. Recognition of these benefits has led to recent treatment guideline changes to recommend ART for all HIV-infected patients regardless of immune status. A major challenge of ART is that treatment must be continuous to receive benefits and in most cases requires a lifelong commitment. Many factors can affect a patient's ability to sustain treatment and may lead to ART discontinuation.
Treatment interruptions can be planned or unplanned, short or long term, or permanent. The decision to discontinue ART can be made by the patient or by the provider. Some reasons providers may recommend discontinuing treatment include severe drug toxicity, intervening illness, surgery that precludes oral therapy, or unavailability of antiretroviral medication. Patients may also choose to discontinue treatment due to factors such as personal beliefs (patient feels healthy and does not see the need to be on ART any longer), structural barriers (incarceration or transportation difficulties), or financial limitations or insurance status (loss of employment or insurance).
Although some therapy interruptions are clinically indicated, the negative effects of therapy discontinuation are well documented, with studies reporting that premature ART discontinuation results in decreased survival, lower CD4 count, increased viremia, and increased drug resistance. Moreover, sexual transmission of HIV has been documented in patients who discontinued ART regimens.
Previous research on ART utilization has focused primarily on adherence. Examinations of the prevalence and predictors of ART discontinuation have demonstrated that certain patients are more likely to discontinue ART. Substance use, injection drug use, disease severity, younger age, racial/ethnic minorities, female gender, unemployment, perceived HIV stigma, fear of discrimination, mental health, and side effects have been associated with ART discontinuation. However, these studies lack generalizability since they were conducted on subpopulations of HIV-infected patients, such as patients from 1 or a small group of clinics or hospitals, women only, or patients with a history of substance abuse. There are no population-based estimates of ART discontinuation nor has the distinction between provider-initiated and non–provider-initiated ART discontinuation been examined in previous literature. ART discontinuation and its effects will become an increasingly important issue as patients and providers come to adopt current universal treatment guidelines and the treatment eligible population increases. This analysis aims to estimate the weighted prevalence of ART initiation, current ART use and discontinuation, and to describe the main reason for discontinuation among a representative sample of HIV-infected adults receiving HIV care in the United States. In addition, we examined differences in the characteristics of patients who discontinued ART per provider recommendation versus those who self-initiated discontinuation or discontinued due to structural barriers. Finally, we investigated predictors of ART discontinuation. These findings can inform the development and evaluation of interventions to increase ART persistence among populations who are at increased risk of self-initiated ART discontinuation.
Abstract and Introduction
Abstract
Background. Continuous antiretroviral therapy (ART) is important for maintaining viral suppression. This analysis estimates prevalence of and reason for ART discontinuation.
Methods. Three-stage sampling was used to obtain a nationally representative, cross-sectional sample of HIV-infected adults receiving HIV care. Face-to-face interviews and medical record abstractions were collected from June 2009 to May 2010. Data were weighted based on known probabilities of selection and adjusted for nonresponse. Patient characteristics of ART discontinuation, defined as not currently taking ART, stratified by provider-initiated versus non–provider-initiated discontinuation, were examined. Weighted logistic regression models predicted factors associated with ART discontinuation.
Results. Of adults receiving HIV care in the United States who reported ever initiating ART, 5.6% discontinued treatment. Half of those who discontinued treatment reported provider-initiated discontinuation. Provider-initiated ART discontinuation patients were more likely to have a nadir CD4 ≥200 cells per cubic millimeter. Non–provider-initiated ART discontinuation patients were more likely to have unmet need for supportive services and to have not received HIV care in the past 3 months. Among all patients who discontinued, younger age, female gender, not having continuous health insurance, incarceration, injection drug use, nadir CD4 count ≥200 cells per cubic millimeter, unmet need for supportive services, no care in the past 3 months and HIV diagnosis ≥5 years before interview were independently associated with ART discontinuation.
Conclusions. These findings inform development of interventions to increase ART persistence by identifying groups at increased risk of ART discontinuation. Evidence-based interventions targeting vulnerable populations are needed and are increasingly important as recent HIV treatment guidelines have recommended universal ART.
Introduction
Combination antiretroviral therapy (ART) provides a range of benefits to HIV-infected patients such as increased survival, improved immune status and decreased morbidity, and opportunistic infections. Through viral suppression, ART reduces the likelihood of sexual transmission of HIV to uninfected partners. Recognition of these benefits has led to recent treatment guideline changes to recommend ART for all HIV-infected patients regardless of immune status. A major challenge of ART is that treatment must be continuous to receive benefits and in most cases requires a lifelong commitment. Many factors can affect a patient's ability to sustain treatment and may lead to ART discontinuation.
Treatment interruptions can be planned or unplanned, short or long term, or permanent. The decision to discontinue ART can be made by the patient or by the provider. Some reasons providers may recommend discontinuing treatment include severe drug toxicity, intervening illness, surgery that precludes oral therapy, or unavailability of antiretroviral medication. Patients may also choose to discontinue treatment due to factors such as personal beliefs (patient feels healthy and does not see the need to be on ART any longer), structural barriers (incarceration or transportation difficulties), or financial limitations or insurance status (loss of employment or insurance).
Although some therapy interruptions are clinically indicated, the negative effects of therapy discontinuation are well documented, with studies reporting that premature ART discontinuation results in decreased survival, lower CD4 count, increased viremia, and increased drug resistance. Moreover, sexual transmission of HIV has been documented in patients who discontinued ART regimens.
Previous research on ART utilization has focused primarily on adherence. Examinations of the prevalence and predictors of ART discontinuation have demonstrated that certain patients are more likely to discontinue ART. Substance use, injection drug use, disease severity, younger age, racial/ethnic minorities, female gender, unemployment, perceived HIV stigma, fear of discrimination, mental health, and side effects have been associated with ART discontinuation. However, these studies lack generalizability since they were conducted on subpopulations of HIV-infected patients, such as patients from 1 or a small group of clinics or hospitals, women only, or patients with a history of substance abuse. There are no population-based estimates of ART discontinuation nor has the distinction between provider-initiated and non–provider-initiated ART discontinuation been examined in previous literature. ART discontinuation and its effects will become an increasingly important issue as patients and providers come to adopt current universal treatment guidelines and the treatment eligible population increases. This analysis aims to estimate the weighted prevalence of ART initiation, current ART use and discontinuation, and to describe the main reason for discontinuation among a representative sample of HIV-infected adults receiving HIV care in the United States. In addition, we examined differences in the characteristics of patients who discontinued ART per provider recommendation versus those who self-initiated discontinuation or discontinued due to structural barriers. Finally, we investigated predictors of ART discontinuation. These findings can inform the development and evaluation of interventions to increase ART persistence among populations who are at increased risk of self-initiated ART discontinuation.