Trends in discharges from the HIV/AIDS ward at a tertiary Canadian Hospital from 2005 to 2014.

Advances in HIV therapies have transformed HIV infection into a manageable chronic disease. Accordingly, hospital admission trends among people living with HIV may have evolved over time. This study describes discharge diagnoses from the dedicated HIV/AIDS ward at St. Paul's Hospital in Vancouver, Canada. A retrospective database review of admissions to the HIV/AIDS ward between 1 July 2005 and 30 June 2014 was conducted. Primary discharge diagnoses were manually categorized by condition and reviewed by two physicians. Data were analysed in 12-month intervals. Trends were fitted using generalized estimating equations. A total of 1595 individuals with 3919 admissions were included. The median age was 46 years, 77.1% identified as male, 63.6% had a history of injection drug use (IDU) and 61.8% had a history of hepatitis C virus exposure. The most common reasons for admission included non-opportunistic respiratory tract infections (18.2%), cellulitis (7.3%), gastroenteritis (6.0%), endocarditis/bacteremia (4.9%) and bone/joint infections (3.5%). The proportion of admissions attributable to opportunistic infections declined from 16.2% in 2005 to 5.5% in 2014. Over this period, the proportion of individuals on antiretroviral therapy and with virologic suppression increased (odds ratio 1.19 [95% confidence interval 1.16, 1.23] and 1.22 [95% confidence interval 1.17, 1.26], respectively). These results demonstrate a decline in admissions related to opportunistic infections but increased admissions due to other infections among people living with HIV. Preventive and outpatient care for respiratory infections and complications of IDU may further improve health care outcomes and decrease hospital admissions in this setting.

The impact of HCV co-infection status on healthcare-related utilization among people living with HIV in British Columbia, Canada: a retrospective cohort study.

BACKGROUND: The burden of HCV among those living with HIV remains a major public health challenge. We aimed to characterize trends in healthcare-related visits (HRV) of people living with HIV (PLW-HIV) and those living with HIV and HCV (PLW-HIV/HCV), in British Columbia (BC), and to identify risk factors associated with the highest HRV rates over time. METHODS: Eligible individuals, recruited from the BC Seek and Treat for Optimal Prevention of HIV/AIDS population-based retrospective cohort (N = 3955), were ≥ 18 years old, first started combination antiretroviral therapy (ART) between 01/01/2000-31/12/2013, and were followed for ≥6 months until 31/12/2014. The main outcome was HRV rate. The main exposure was HIV/HCV co-infection status. We built a confounder non-linear mixed effects model, adjusting for several demographic and time-dependent factors. RESULTS: HRV rates have decreased since 2000 in both groups. The overall age-sex standardized HRV rate (per person-year) among PLW-HIV and PLW-HIV/HCV was 21.11 (95% CI 20.96-21.25) and 41.69 (95% CI 41.51-41.88), respectively. The excess in HRV in the co-infected group was associated with late presentation for ART, history of injection drug use, sub-optimal ART adherence and a higher number of comorbidities. The adjusted HRV rate ratio for PLW-HIV/HCV in comparison to PLW-HIV was 1.18 (95% CI 1.13-1.24). CONCLUSIONS: Although HRV rates have decreased over time in both groups, PLW-HIV/HCV had 18% higher HRV than those only living with HIV. Our results highlight several modifiable risk factors that could be targeted as potential means to minimize the disease burden of this population and of the healthcare system.

Is there a rural/urban gap in the quality of HIV care for treatment-naïve HIV-positive individuals initiating antiretroviral therapy in British Columbia?

Rurally located people living with HIV (PLWH) face unique challenges associated with remoteness that may negatively affect their HIV care outcomes. The Programmatic Compliance Score (PCS) has been used previously as a quality of care metric, and is predictive of mortality for treatment-naïve individuals initiating combination antiretroviral therapy (cART). This study looked at whether the rurality of PLWH impacted their PCS. PCS was calculated for PLWH (≥19 years old) initiating cART in British Columbia between 2000 and 2013. Rurality was determined at the time of cART initiation using two methodologies: (1) a categorical postal code method; and (2) the General Practice Rurality Index (GPRI), a score representing an individual's degree of rurality. Ordinal logistic regression modeling was used to assess the relationship between rurality and PCS. Among 4616 PLWH with an evaluable PCS, 176 were classified as rural and 3512 as urban (928 had an unknown postal code). After adjusting for age, sex, hepatitis C status, Indigenous ancestry, and year of cART initiation, categorical rurality was not associated with a worse PCS (adjusted odds ratio (AOR) 1.04; 95% CI: 0.77-1.39). However, an increasing degree of rurality was associated with a worse PCS (AOR (per 10 increase in GPRI) 1.13; 95% CI: 1.06-1.20). Given that a poor PCS has been shown to be predictive of all-cause mortality for individuals initiating cART, strategies to improve access to HIV care for rural individuals should be evaluated.

Continuing professional development in HIV chronic disease management for primary care providers.

Primary care providers need continuing professional development (CPD) in order to improve their knowledge and confidence in the care of patients with chronic conditions. We developed an intensive modular CPD program in the chronic disease management of HIV for primary care providers. The program combines self-directed learning, interactive tutorials with experts, small group discussions, case studies, clinical training, one-on-one mentoring and individualized learning objectives. We trained 27 family physicians and 7 nurse practitioners between 2011 and 2013. The trainees reported high levels of satisfaction with the program. There was a 136.76% increase in the number of distinct HIV-positive patients receiving HIV-related medication refills that were prescribed by the trainees.

Temporal trends in the discontinuation of first-line antiretroviral therapy.

OBJECTIVES: The aim of this study was to describe the rates and predictors of discontinuing first-line antiretroviral therapy in the different eras of treatment over a nearly 20 year period initiated in British Columbia between 1992 and 2010. METHODS: All naive adults who started antiretroviral therapy (first-line antiretroviral therapy) at any hospital or clinic in British Columbia (Canada) in 1992-2010 were included in this population-based retrospective cohort study. We were primarily interested in whether the era of treatment (1992-95, 1996-2000, 2001-05 and 2006-10) was associated with discontinuation (stopping or switching of initial treatment) within 3 years of starting therapy. Weibull survival analysis was used to model the era of treatment and its association with time to discontinuation. RESULTS: The study included 7901 patients. Overall, the probability of discontinuing at 12, 24 and 36 months of treatment was 52%, 68% and 76%, respectively. In the adjusted model, variables associated with discontinuing were earlier treatment era, younger age, low adherence and lower baseline CD4 count. Regarding the 2006-10 period, the probability of discontinuing at 12, 24 and 36 months was 36%, 47% and 53%, respectively. In the adjusted model, the variables associated with discontinuation were younger age, female gender, AIDS-defining illnesses at baseline, low adherence and a protease inhibitor (PI)-based regimen. CONCLUSIONS: Discontinuation rates of first-line therapy have decreased over time, but are still quite high even for the latest drug combinations. In the most recent era, younger women on a PI regimen and those not achieving optimal adherence had the highest risk of discontinuing first-line antiretroviral therapy.

Antiretroviral drug costs and prescription patterns in British Columbia, Canada: 1996-2011.

INTRODUCTION: Treatment options and therapeutic guidelines have evolved substantially since highly active antiretroviral treatment (HAART) became the standard of HIV care in 1996. We conducted the present population-based analysis to characterize the determinants of direct costs of HAART over time in British Columbia, Canada. METHODS: We considered individuals ever receiving HAART in British Columbia from 1996 to 2011. Linear mixed-effects regression models were constructed to determine the effects of demographic indicators, clinical stage, and treatment characteristics on quarterly costs of HAART (in 2010$CDN) among individuals initiating in different temporal periods. The least-square mean values were estimated by CD4 category and over time for each temporal cohort. RESULTS: Longitudinal data on HAART recipients (N = 9601, 17.6% female, mean age at initiation = 40.5) were analyzed. Multiple regression analyses identified demographics, treatment adherence, and pharmacological class to be independently associated with quarterly HAART costs. Higher CD4 cell counts were associated with modestly lower costs among pre-HAART initiators [least-square means (95% confidence interval), CD4 > 500: 4674 (4632-4716); CD4: 350-499: 4765 (4721-4809) CD4: 200-349: 4826 (4780-4871); CD4 <200: 4809 (4759-4859)]; however these differences were not significant among post-2003 HAART initiators. Population-level mean costs increased through 2006 and stabilized post-2003 HAART initiators incurred quarterly costs up to 23% lower than pre-2000 HAART initiators in 2010. CONCLUSIONS: Our results highlight the magnitude of the temporal changes in HAART costs, and disparities between recent and pre-HAART initiators. This methodology can improve the precision of economic modeling efforts by using detailed cost functions for annual, population-level medication costs according to the distribution of clients by clinical stage and era of treatment initiation.

Factors predictive of 30-day postoperative mortality in HIV/AIDS patients in the era of highly active antiretroviral therapy.

BACKGROUND: Factors that predict HIV (human immunodeficiency virus)/AIDS patient postoperative mortality have remained poorly defined. OBJECTIVES: The primary objective of this study was to identify factors predictive of short-term, postoperative mortality in HIV/AIDS patients. The secondary objective of this study was to develop a scoring system that would predict short-term postoperative mortality in HIV/AIDS patients. METHODS: We retrospectively reviewed all HIV/AIDS patients who underwent surgical procedures in British Columbia, Canada, between April 1995 and March 2002. The primary outcome evaluated was 30-day postoperative mortality. Demographic, clinical, and hospitalization-related data were obtained and utilized to predict outcomes using a logistic regression model. RESULTS: A total of 2305 procedures were carried out on 1322 patients during the study period. Admissions were classified as urgent/emergent for 1311 procedures (57%) and the overall 30-day postoperative mortality was 9.5% (126 deaths). Urgent/emergent admission, older age, prior surgery, a CD4 cell count of ≤ 50 cells/mm, a hemoglobin level ≤ 120 g/L, and a white blood cell count >11 g/L within 90 days before the surgical procedure was predictive of an increased 30-day postoperative mortality in a multivariate model. Using these variables, we formulated the HIV Surgical Mortality Score (HSMS) to obtain the median-estimated probability of postoperative death. CONCLUSIONS: For accurate preoperative mortality risk stratification for HIV/AIDS patients, we have found that several clinical and laboratory variables must be evaluated. If appropriately validated, our proposed HSMS could be utilized to estimate the probability of short-term postoperative death among HIV/AIDS patients.

Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study.

BACKGROUND: Results of cohort studies and mathematical models have suggested that increased coverage with highly active antiretroviral therapy (HAART) could reduce HIV transmission. We aimed to estimate the association between plasma HIV-1 viral load, HAART coverage, and number of new cases of HIV in the population of a Canadian province. METHODS: We undertook a population-based study of HAART coverage and HIV transmission in British Columbia, Canada. Data for number of HIV tests done and new HIV diagnoses were obtained from the British Columbia Centre for Disease Control. Data for viral load, CD4 cell count, and HAART use were extracted from the British Columbia Centre for Excellence in HIV/AIDS population-based registries. We modelled trends of new HIV-positive tests and number of individuals on HAART using generalised additive models. Poisson log-linear regression models were used to estimate the association between new HIV diagnoses and viral load, year, and number of individuals on HAART. FINDINGS: Between 1996 and 2009, the number of individuals actively receiving HAART increased from 837 to 5413 (547% increase; p=0.002), and the number of new HIV diagnoses fell from 702 to 338 per year (52% decrease; p=0.001). The overall correlation between number of individuals on HAART and number of individuals newly testing positive for HIV per year was -0.89 (p<0.0001). For every 100 additional individuals on HAART, the number of new HIV cases decreased by a factor of 0.97 (95% CI 0.96-0.98), and per 1 log(10) decrease in viral load, the number of new HIV cases decreased by a factor of 0.86 (0.75-0.98). INTERPRETATION: We have shown a strong population-level association between increasing HAART coverage, decreased viral load, and decreased number of new HIV diagnoses per year. Our results support the proposed secondary benefit of HAART used within existing medical guidelines to reduce HIV transmission. FUNDING: Ministry of Health Services and Ministry of Healthy Living and Sport, Province of British Columbia; US National Institute on Drug Abuse; US National Institutes of Health; Canadian Institutes of Health Research.

Trends in reported AIDS defining illnesses (ADIs) among participants in a universal antiretroviral therapy program: an observational study.

BACKGROUND: We examined trends in AIDS-defining illnesses (ADIs) among individuals receiving highly active antiretroviral therapy (HAART) in British Columbia (BC), Canada to determine whether declines in ADIs could be contributing to previously observed improvements in life-expectancy among HAART patients in BC since 1996. METHODS: HAART-naïve individuals aged ≥ 18 years who initiated treatment in BC each of the following time-periods 1996 - 1998; 1999 - 2001; 2002 - 2004; 2005 - 2007 were included. The proportion of participants with reported ADIs were examined for each time period and trends were analyzed using the Cochran-Armitage Trend Test. Cox proportional hazards models were used to examine factors associated with ADIs. RESULTS: A total of 3721 individuals (81% male) initiated HAART during the study period. A total of 251 reports of ADIs were received from 214 unique patients. These occurred in a median of 4 months (IQR = 1-19 months) from HAART initiation. The proportion of individuals with a reported ADI did not change significantly from 4.6% in the earliest time period to 5.8% in the latest period (p = 0.181 for test of trend). There were no significant declines in any specific ADI over the study period. Multivariable Cox models found that individuals initiating HAART during 2002-04 were at an increased risk of ADIs (AHR = 1.55; 95% CI 1.04-2.32) in comparison to 1996 - 98, but there were no significant differences in other time periods. CONCLUSIONS: Trends in reported ADIs among individuals receiving HAART since 1996 in BC do not appear to parallel improvements in life-expectancy over the same period.

Improved virological outcomes in British Columbia concomitant with decreasing incidence of HIV type 1 drug resistance detection.

BACKGROUND: There have been limited studies evaluating temporal changes in the incidence of detection of drug resistance among human immunodeficiency virus type 1 (HIV-1) isolates and concomitant changes in plasma HIV load for treated individuals in a population-wide setting. METHODS: Longitudinal plasma viral load and genotypic resistance data were obtained from patients receiving antiretroviral therapy from the British Columbia Drug Treatment Program from July 1996 through December 2008. A total of 24,652 resistance tests were available from 5422 individuals. The incidence of successful plasma viral load suppression and of resistance to each of 3 antiretroviral categories (nucleoside/nucleotide reverse-transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors) was calculated for the population receiving therapy. RESULTS: There has been a drastic decrease in the incidence of new cases of HIV-1 drug resistance in individuals followed during 1996-2008. In 1997, the incidence rate of any newly detected resistance was 1.73 cases per 100 person-months of therapy, and by 2008, the incidence rate had decreased >12-fold, to 0.13 cases per 100 person-months of therapy. This decrease in the incidence of resistance has occurred at an exponential rate, with half-times on the order of 2-3 years. Concomitantly, the proportion of individuals with plasma viral load suppression has increased linearly over time (from 64.7% with HIV RNA levels <50 copies/mL in 2000 to 87.0% in 2008; R2=0.97; P<.001). CONCLUSIONS: Our results suggest an increasing effectiveness of highly active antiretroviral therapy at the populational level. The vast majority of treated patients in British Columbia now have either suppressed plasma viral load or drug-susceptible HIV-1, according to their most recent test results.

Epidemiology of antiretroviral multiclass resistance.

Given the recent evolution of therapeutic trends, the frequency and determinants of multiclass-resistant HIV infection in the modern combination highly active antiretroviral therapy (HAART) era are less well understood. In this study, the authors characterize the epidemiology of antiretroviral multiclass resistance among HAART-naïve patients enrolled in a province-wide HAART distribution program in British Columbia, Canada. HAART and resistance testing are free to eligible individuals in British Columbia. This study was based on patients who initiated naïve on HAART and were followed during January 1, 2000-June 30, 2007. Explanatory logistic and survival models were built to identify those factors most influential in the emergence of multiclass resistance. Among the 1,820 individuals in our study, 833 (46%) were tested for antiretroviral resistance at least once during their follow-up. Multiclass resistance was observed in 142 individuals (n = 833; 17%) during a median follow-up of 14 months (interquartile range, 3-34 months) (incidence rate, 0.8 cases/1,000 person-months). The authors found that initial nonnucleoside reverse transcriptase inhibitor-based HAART was the main determinant of multiclass resistance. Given that these inhibitors are still widely used, priority should be given to make resistance testing and viral load monitoring a standard part of human immunodeficiency virus care to maximize the long-term efficacy and efficiency of HAART.

Physician's manual reporting underestimates mortality: evidence from a population-based HIV/AIDS treatment program.

BACKGROUND: In clinical and cohort research, mortality estimates are often derived from manual reports generated by physicians or electronic reports from vital event registries. We examined the rate of underreporting of deaths by manual methods as compared with electronic reports from a vital event registry. METHODS: The retrospective analyses included deaths among participants registered in an observational cohort who initiated highly-active antiretroviral therapy (HAART) between August 1, 1996 and June 30, 2006. Deaths were routinely reported manually by physicians and through annual electronic record linkages with a population-based vital event registry. Multivariate logistic regression was carried out to assess independent predictors of death reporting by manual methods. RESULTS: Of the 3,116 individuals included in the analyses, 622 (20.0%) died during follow-up. Manual reporting by physicians only identified 377 (60.6%), while electronic linkages captured 598 (96.1%) of all deaths. Multivariate analysis indicated that deaths among individuals with lower CD4 cell count, higher HIV plasma viral load, a history of injection drug use, and under the care of an HIV-experienced physicians were more likely to be reported manually. Furthermore, non-accidental deaths were more likely to be reported manually, and manual reporting of deaths increased over time. CONCLUSIONS: Relying only on manual reports to ascertain deaths significantly underestimates the total number of deaths in the population. This can generate important biases when evaluating the impact of therapeutic interventions in the populational setting.

Safety and efficacy of once-daily nevirapine dosing: a multicohort study.

BACKGROUND: Nevirapine (NVP) is often prescribed once daily in clinical practice in combination with a once daily nucleoside backbone. We investigated the relationship of NVP dosing with safety and efficacy. METHODS: Patients from the Dutch AIDS Therapy Evaluation in the Netherlands (ATHENA) cohort study, Canadian HAART Observational Medical Evaluation and Research (HOMER) cohort and Swiss HIV Cohort Study (SHCS) using NVP-based combination therapy either once daily or twice daily were included. Risk factors for discontinuing NVP because of hypersensitivity reactions (HSRs) were investigated using multivariate logistic regression. Risk factors for virological failure 96 weeks after NVP initiation were identified using logistic regression and Cox models. RESULTS: Of 5,636 patients (774 once daily and 4,862 twice daily), 268 (4.8%) discontinued NVP because of HSR between 2 and 18 weeks. Logistic regression showed that, compared with patients with detectable HIV type-1 (HIV-1) RNA starting twice-daily NVP, there was a significantly higher risk of discontinuation of once-daily NVP because of HSR in patients with detectable HIV-1 RNA at the start of NVP (odds ratio [OR] 1.52; P=0.04), whereas the risk was actually significantly lower in patients starting once-daily NVP with undetectable HIV-1 RNA (OR 0.44; P=0.04). Cox models showed that risk of virological failure was not different for twice- versus once-daily NVP in treatment-naive patients (twice-daily versus once-daily hazard ratio [HR] 1.01; P=0.95), treatment-experienced patients experiencing treatment failure (twice-daily versus once-daily HR 1.22; P=0.30) or patients with undetectable HIV-1 RNA simplifying treatment with NVP (twice-daily versus once-daily HR 1.29; P=0.30). CONCLUSIONS: Initiation of a once-daily NVP-based regimen in patients with suppressed viraemia carries a low risk of treatment-limiting HSR. Once- or twice-daily NVP-based regimens appear to have similar antiretroviral efficacy.

Association between HIV-1 RNA level and CD4 cell count among untreated HIV-infected individuals.

OBJECTIVES: We examined the significance of plasma HIV-1 RNA levels (or viral load alone) in predicting CD4 cell decline in untreated HIV-infected individuals. METHODS: Data were obtained from the British Columbia Centre for Excellence in HIV/AIDS. Participants included all residents who ever had a viral load determination in the province and who had never taken antiretroviral drugs (N = 890). We analyzed a total of 2074 viral load measurements and 2332 CD4 cell counts. Linear mixed-effects models were used to predict CD4 cell decline over time. RESULTS: Longitudinal viral load was strongly associated with CD4 cell decline over time; an average of 1 log(10) increase in viral load was associated with a 55-cell/mm(3) decrease in CD4 cell count. CONCLUSIONS: Our results support the combined use of CD4 cell count and viral load as prognostic markers in HIV-infected individuals before the introduction of antiretroviral therapy.

Retention in care and mortality trends among patients receiving comprehensive care for HIV infection: a retrospective cohort study.

BACKGROUND: Studies examining the relation between comprehensive care and health outcomes associated with comorbidities unrelated to HIV infection have focused mainly on the health outcomes of HIV-infected people and comorbid substance use disorders. We aimed to assess the impact of retention in comprehensive HIV infection care on overall, AIDS-related and non-AIDS-related mortality. METHODS: Using a retrospective cohort design, we collected data for HIV-infected patients aged 19 years or more who first visited a comprehensive HIV infection clinic in Vancouver between Jan. 1, 2004, and Dec. 31, 2014. We defined retention in care as visit constancy (whether the patient attended the clinic at least once per given period) of 75% or greater. We used Poisson regression modelling to examine mortality trends. We performed Cox proportional hazards modelling to assess survival by retention during the first year of follow-up and identify factors associated with death. RESULTS: A total of 2101 patients were included in the study. Of the 2101, 1340 (63.8%) were retained in the first year of care, and 271 (12.9%) died during the study period. Among the 264 cases in which the cause of death was known, although the primary underlying cause of death (74 [28.0%]) was AIDS-related, half of all AIDS-related deaths (37/74 [50%]) occurred early in the study (2004-2007). In later years, most deaths (147/184 [79.9%]) were non-AIDS-related. Overall mortality was significantly reduced among patients with higher retention in care during the first year of follow-up (per 20% increase in visit constancy; adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.79-0.96). Higher retention was also associated with reduced risk of AIDS-related death (adjusted HR 0.79, 95% CI 0.64-0.97). INTERPRETATION: Although there was an overall trend toward decreased AIDS-related mortality over time, retention in care markedly decreased the likelihood of death. Maintaining patient engagement in comprehensive ancillary care is a patient-centred way of decreasing mortality rates among HIV-infected people.

Prevalence of Human Immunodeficiency Virus-1 Integrase Strand Transfer Inhibitor Resistance in British Columbia, Canada Between 2009 and 2016: A Longitudinal Analysis.

BACKGROUND: Integrase strand transfer inhibitors (INSTIs) are highly efficacious and well tolerated antiretrovirals with fewer adverse side-effects relative to other classes of antiretrovirals. The use of INSTIs raltegravir, elvitegravir, and dolutegravir has increased dramatically over recent years. However, there is limited information about the evolution and prevalence of INSTI resistance mutations in clinical human immunodeficiency virus populations. METHODS: Human immunodeficiency virus-1-positive individuals ≥19 years were included if they received ≥1 dispensed prescription of antiretroviral therapy (ART) in British Columbia between 2009 and 2016 (N = 9358). Physician-ordered drug resistance tests were analyzed and protease inhibitor (PI), reverse-transcriptase inhibitor (RT), and INSTI resistance were defined as having ≥1 sample with a combined, cumulative score ≥30 by Stanford HIV Drug Resistance Algorithm version 7.0.1. RESULTS: Although most ART-treated individuals were tested for PI and RT resistance, INSTI resistance testing lagged behind the uptake of INSTIs among INSTI-treated individuals (11% in 2009; 34% in 2016). The prevalence of INSTI resistance was relatively low, but it increased from 1 to 7 per 1000 ART-treated individuals between 2009 and 2016 (P < .0001, R2 = 0.98). Integrase strand transfer inhibitor resistance mutations increased at integrase codons 66, 97, 140, 148, 155, and 263. CONCLUSIONS: The prevalence of INSTI resistance remains low compared with PI and RT resistance in ART-treated populations but is expanding with increased INSTI use.

Physicians' patient base composition and mortality among people living with HIV who initiated antiretroviral therapy in a universal care setting.

OBJECTIVES: To assess the impact of physicians' patient base composition on all-cause mortality among people living with HIV (PLHIV) who initiated highly active antiretroviral therapy (HAART) in British Columbia (BC), Canada. DESIGN: Observational cohort study from 1 January 2000 to 31 December 2013. SETTING: BC Centre for Excellence in HIV/AIDS' (BC-CfE) Drug Treatment Program, where HAART is available at no cost. PARTICIPANTS: PLHIV aged ≥ 19 who initiated HAART in BC in the HAART Observational Medical Evaluation and Research (HOMER) Study. OUTCOME MEASURES: All-cause mortality as determined through monthly linkages to the BC Vital Statistics Agency. STATISTICAL ANALYSIS: We examined the relationships between patient characteristics, physicians' patient base composition, the location of the practice, and physicians' experience with PLHIV and all-cause mortality using unadjusted and adjusted Cox proportional hazards models. RESULTS: A total of 4 445 PLHIV (median age = 42, Q1, Q3 = 34-49; 80% male) were eligible for our study. Patients were seen by 683 prescribing physicians with a median experience of 77 previously treated PLHIV in the past 2 years (Q1, Q3 = 23-170). A multivariable Cox model indicated that the following factors were associated with all-cause mortality: age (aHR = 1.05 per 1-year increase, 95% CI = 1.04 to 1.06), year of HAART initiation (2004-2007: aHR = 0.65, 95% CI = 0.53 to 0.81, 2008-2011: aHR = 0.46, 95% CI = 0.35 to 0.61, Ref: 2000-2003), CD4 cell count at baseline (aHR = 0.88 per 100-unit increase in cells/mm3, 95% CI = 0.82 to 0.94), and < 95% adherence in first year on HAART (aHR = 2.28, 95% CI = 1.88 to 2.76). In addition, physicians' patient base composition, specifically, the proportion of patients who have a history of injection drug use (aHR = 1.11 per 10% increase in the proportion of patients, 95% CI = 1.07 to 1.15) or Indigenous ancestry (aHR = 1.07 per 10% increase , 95% CI = 1.03-1.11) and being a patient of a physician who primarily serves individuals outside of the Vancouver Coastal Health Authority region (aHR = 1.22, 95% CI = 1.01 to 1.47) were associated with mortality. CONCLUSIONS: Our findings suggest that physicians with a higher proportion of individuals who face potential barriers to care may need additional supports to decrease mortality among their patients. Future research is required to examine these relationships in other settings and to determine strategies that may mitigate the associations between the composition of physicians' patient bases and survival.

Predicting hospitalization among HIV-infected antiretroviral naïve patients starting HAART: determining clinical markers and exploring social pathways.

In the era of highly active antiretroviral therapy (HAART), hospitalization as a measure of morbidity has become of increasing interest. The objectives of this study were to determine clinical predictors of hospitalization among HIV-infected persons initiating HAART and to explore the impact of gender and drug use on hospitalization. The analysis was based on a cohort of HIV-positive individuals initiating HAART between 1996 and 2001. Information on hospitalizations was obtained through data linkage with the BC Ministry of Health. Cox-proportional hazard models were used to assess variables associated with time to hospitalization. A total of 1,605 people were eligible and 672 (42%) were hospitalized for one or more days. The final multivariate model indicated that there was an increased risk of hospitalization among those with high baseline HIV RNA (HR for > 100,000 copies/mL: 1.26; 95%CI: 1.16-1.59) or low CD4 cell counts (HR [95% CI] compared to > or = 200 cells/mm3: 1.62 [1.28-2.06] and 1.29 [1.07-1.56] for < 50 and 50-199 cells/mm(3), respectively). Other factors, including adherence, previous hospitalization, gender and injection drug use remained predictive of hospitalization. These findings highlight the importance of closely monitoring patients starting therapy with low CD4 cell counts in order to mediate or prevent outcomes requiring hospitalization.

Validity of self-reported adherence among injection drug users.

BACKGROUND: In Vancouver, the availability of prescription refill data for all HIV-infected individuals plus a prospective cohort of injection drug users (IDUs) permitted an examination of the validity of self-reported highly active antiretroviral therapy (HAART) adherence among IDUs. METHODS: Self-reported HAART adherence among Vancouver Injection Drug Users Study participants was compared with pharmacy refill rates from the British Columbia Drug Treatment Program database. Pearson's correlation coefficient and Pearson's chi(2) test were used to assess associations between adherence as measured by self-report and pharmacy refill data. RESULTS: Among 88 HIV-infected IDUs, 48 (55%) had an adherence rate of > or =75% as measured by pharmacy refill adherence, whereas 81 (92%) had an adherence rate of > or =75% as measured by self-report. Self-reported adherence was not statistically associated with pharmacy refill adherence (P > .1). CONCLUSION: These findings suggest that the validity of self-report measures may be limited when applied to community-recruited IDUs.

Nonadherence increases the risk of hospitalization among HIV-infected antiretroviral naive patients started on HAART.

BACKGROUND: Since the advent of highly active antiretroviral therapy (HAART), AIDS-related hospitalizations have decreased. The objective of this study was to assess the impact of adherence on hospitalization among antiretroviral-naïve HIV-infected persons initiating HAART. METHODS: Analysis was based on a cohort of individuals initiating HAART between 1996 and 2001. The primary outcome was hospitalization for one or more days. Survival methods were used to assess the impact of adherence on hospitalization. RESULTS: Of 1605 eligible participants, 672 (42%) were hospitalized for one or more days after initiating HAART. Median adherence levels were 92 (IQR: 58, 100) and 100 (IQR: 83, 100) among those ever and never hospitalized, respectively. After controlling for confounders, those with <95% adherence had 1.88 times (95% CI: 1.60, 2.21) higher risk for hospitalization. CONCLUSIONS: Suboptimal adherence among HIV-infected patients taking HAART predicts hospitalization. Identifying and addressing factors contributing to poor adherence early in treatment could improve patient care and lower hospitalization costs.