Efficacy and safety of ritonavir-boosted and unboosted atazanavir among antiretroviral-naïve patients.

PURPOSE: Evaluate responses and safety of ritonavir-boosted atazanavir ("boosted atazanavir") compared to unboosted atazanavir among antiretroviral-naïve patients in the clinical managed care setting. METHOD: Observational cohort analysis of atazanavir use (comparing ritonavir-boosted to non-boosted) at Kaiser Permanente and Group Health Cooperative from 2003 to 2006. Antiretroviral-naïve patients initiating atazanavir were followed through 52 weeks of treatment. RESULTS: 443 patients were prescribed atazanavir (69 non-boosted; 15.5%). Boosted and non-boosted atazanavir groups were similar with respect to gender and age. Boosted atazanavir use was associated with greater odds achieving HIV RNA <400 c/mL (odds ratio [OR] = 3.24, p = .008), greater decrease in HIV RNA (-0.37 log10/mL, p = .03), greater increase in CD4 T-cell count (+59 cells/microL, p = .01), and greater increase in total bilirubin (+1.21 mg/dL as opposed to +0.56 mg/dL, p .001). There were no statistically significant differences for glucose, liver transaminases, total cholesterol, or LDL cholesterol elevations. There were greater odds of maximal viral control when atazanavir was combined with tenofovir or zidovudine in combination with lamivudine (or emtricitabine). CONCLUSIONS: Ritonavir-boosted atazanavir is associated with greater virologic control and immune response through 52 weeks compared to non-boosted atazanavir, without greater risk of adverse events except elevated bilirubin. Thus, ritonavir-boosted atazanavir is the preferred method of prescribing atazanavir.

Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients.

OBJECTIVES: To determine the impact of depression on highly active antiretroviral therapy (HAART) adherence and clinical measures and investigate if selective serotonin reuptake inhibitors (SSRIs) improve these measures. DESIGN: Retrospective cohort study. METHODS: In 2 large health maintenance organizations, we measured the effects of depression (with and without SSRI use) on adherence and changes in viral and immunologic control among HIV-infected patients starting a new HAART regimen. HAART adherence, HIV RNA levels, and changes in CD4 T-cell counts through 12 months were measured. RESULTS: A total of 3359 patients were evaluated; 42% had a depression diagnosis, and 15% used SSRIs during HAART. Depression without SSRI use was associated with significantly decreased odds of achieving > or =90% adherence to HAART (odds ratio [OR] = 0.81, 95% confidence interval [CI]: 0.70 to 0.98; P = 0.03). Depression was associated with significantly lower odds of an HIV RNA level <500 copies/mL (OR = 0.77, 95% CI: 0.62 to 0.95; P = 0.02). Depressed patients compliant with SSRI medication (>80% adherence to SSRI) had HAART adherence and viral control statistically similar to nondepressed HIV-infected patients taking HAART. Comparing depressed with nondepressed HIV-infected patients, CD4 T-cell responses were statistically similar; among depressed patients, those compliant with SSRI had statistically greater increases in CD4 cell responses. CONCLUSIONS: Depression significantly worsens HAART adherence and HIV viral control. Compliant SSRI use is associated with improved HIV adherence and laboratory parameters.

Primary care delivery is associated with greater physician experience and improved survival among persons with AIDS.

OBJECTIVE: It has been shown that greater physician experience in the care of persons with AIDS prolongs survival, but how more experienced primary care physicians achieve better outcomes is not known. DESIGN/SETTING/PATIENTS: Retrospective cohort study of HIV-infected patients enrolled in a large staff-model health maintenance organization from 1990 through 1999. MEASUREMENTS: Adjusted odds of medical service delivery and adjusted hazard ratio of death by physician experience level (least, moderate, most) and service utilization. MAIN RESULTS: Primary care delivery by physicians with greater AIDS experience was associated with improved survival. After controlling for disease severity, patients cared for by the most experienced physicians were twice as likely to receive a primary care visit in a given month compared with patients of the least and moderately experienced physicians (P <.01). Patients of the least experienced physicians received the lowest level of outpatient pharmacy and laboratory services (P <.001) and were half as likely to have a specialty care visit compared with patients of the most and moderately experienced physicians (P <.05). Patients who received infrequent primary care visits by the least experienced physicians were 15.3 times more likely to die than patients of the most experienced physicians (P =.02). There was a significant increase in primary care services delivered to the population of HIV-infected patients receiving care in 1999, when highly active antiretroviral therapy (HAART) was in general use, compared with the time period prior to the introduction of HAART. CONCLUSIONS: Primary care delivery by physicians with greater HIV experience contributes to improved patient outcomes.