Allison L. Agwu

Antiretroviral treatment, management challenges and outcomes in perinatally HIV-infected adolescents

Three decades into the HIV/AIDS epidemic there is a growing cohort of perinatally HIV‐infected adolescents globally. Their survival into adolescence and beyond represent one of the major successes in the battle against the disease that has claimed the lives of millions of children. This population is diverse and there are unique issues related to antiretroviral treatment and management. Drawing from the literature and experience, this paper discusses several broad areas related to antiretroviral management, including: 1) diverse presentation of HIV, (2) use of combination antiretroviral therapy including in the setting of co‐morbidities and rapid growth and development, (3) challenges of cART, including nonadherence, resistance, and management of the highly treatment‐experienced adolescent patient, (4) additional unique concerns and management issues related to PHIV‐infected adolescents, including the consequences of longterm inflammation, risk of transmission, and transitions to adult care. In each section, the experience in both resource‐rich and limited settings are discussed with the aim of highlighting the differences and importantly the similarities, to share lessons learnt and provide insight into the multi‐faceted approaches that may be needed to address the challenges faced by this unique and resilient population.

Comparing Different Measures of Retention in Outpatient HIV Care

Objectives:The US National HIV/AIDS Strategy identifies retention in care as an important quality performance measure. There is no gold standard to measure retention in care. This study is the first to compare different measures of retention, using a large geographically diverse sample. Design:A prospective cohort of 17 425 HIV-infected adults enrolled in care at 12 US HIV clinics between 2001 and 2008. Methods:We compared three measures of retention for each patient: proportion of time not spent in a gap of more than 6 months between successive outpatient visits; proportion of 91-day quarters in which at least one visit occurred; proportion of years in which two or more visits separated by at least 90 days occurred. Associations among measures and effects of sociodemographic and clinical characteristics were examined. Results:The three measures of retention were moderately to strongly correlated. Averaging across patients, 71% of time in care was not spent in a gap more than 6 months; 73% of all quarters had at least one visit; and 75% of all years had at least two visits separated by at least 90 days. For all measures, retention was significantly higher for women, whites, older individuals, men who had sex with men (MSM)-related HIV transmission, and initial CD4 cell counts 50 cell/&mgr;l or less. Conclusions:This is one of the first studies to provide a national estimate of retention in HIV care in the US, which ranged from 71 to 75% using any of the accepted retention measures. Future studies should assess how well different measures predict clinical outcomes and establish acceptable target levels for retention.

A World Wide Web–Based Antimicrobial Stewardship Program Improves Efficiency, Communication, and User Satisfaction and Reduces Cost in a Tertiary Care Pediatric Medical Center

BACKGROUND Antimicrobial stewardship programs aim to reduce inappropriate hospital antimicrobial use. At the Johns Hopkins Childrens Medical and Surgical Center (Baltimore, MD), we implemented a World Wide Web-based antimicrobial restriction program to address problems with the existing restriction program. METHODS A user survey identified opportunities for improvement of an existing antimicrobial restriction program and resulted in subsequent design, implementation, and evaluation of a World Wide Web-based antimicrobial restriction program at a 175-bed, tertiary care pediatric teaching hospital. The program provided automated clinical decision support, facilitated approval, and enhanced real-time communication among prescribers, pharmacists, and pediatric infectious diseases fellows. Approval status, duration, and rationale; missing request notifications; and expiring approvals were stored in a database that is accessible via a secure Intranet site. Before and after implementation of the program, user satisfaction, reports of missed and/or delayed doses, antimicrobial dispensing times, and cost were evaluated. RESULTS After implementation of the program, there was a

Impact of age on retention in care and viral suppression

370,069 reduction in projected annual cost associated with restricted antimicrobial use and an 11.6% reduction in the number of dispensed doses. User satisfaction increased from 22% to 68% and from 13% to 69% among prescribers and pharmacists, respectively. There were 21% and 32% reductions in the number of prescriber reports of missed and delayed doses, respectively, and there was a 37% reduction in the number of pharmacist reports of delayed approvals; measured dispensing times were unchanged (P = .24). In addition, 40% fewer restricted antimicrobial-related phone calls were noted by the pharmacy. CONCLUSION The World Wide Web-based antimicrobial approval program led to improved communication, more-efficient antimicrobial administration, increased user satisfaction, and significant cost savings. Integrated tools, such as this World Wide Web-based antimicrobial approval program, will effectively enhance antimicrobial stewardship programs.

Sustained Savings from a Longitudinal Cost Analysis of an Internet-Based Preapproval Antimicrobial Stewardship Program

Background:Retention in care is important for all HIV-infected persons and is strongly associated with initiation of antiretroviral therapy and viral suppression. However, it is unclear how retention in care and age interact to affect viral suppression. We evaluated whether the association between retention and viral suppression differed by age at entry into care. Methods:Cross-sectional analysis (2006–2010) involving 17,044 HIV-infected adults in 14 clinical cohorts across the United States and Canada. Patients contributed 1 year of data during their first full-calendar year of clinical observation. Poisson regression examined associations between retention measures [US National HIV/AIDS Strategy (NHAS), US Department of Health and Human Services (DHHS), 6-month gap, and 3-month visit constancy] and viral suppression (HIV RNA ⩽200 copies/mL) by age group: 18–29 years, 30–39 years, 40–49 years, 50–59 years, and 60 years or older. Results:Overall, 89% of patients were retained in care using the NHAS measure, 74% with the DHHS indicator, 85% did not have a 6-month gap, and 62% had visits in 3–4 quarters of the year; 54% achieved viral suppression. For each retention measure, the association with viral suppression was significant for only the younger age groups (18–29 and 30–39 years): 18–29 years [adjusted prevalence ratio (APR) = 1.33, 95% confidence interval (CI): 1.03 to 1.70]; 30–39 years (APR = 1.23, 95% CI: 1.01 to 1.49); 40–49 years (APR = 1.06, 95% CI: 0.90 to 1.22); 50–59 (APR = 0.92, 95% CI: 0.75 to 1.13); ≥60 years (APR = 0.99, 95% CI: 0.63 to 1.56) using the NHAS measure as a representative example. Conclusions:These results have important implications for improving viral control among younger adults, emphasizing the crucial role retention in care plays in supporting viral suppression in this population.

Disparities in receipt of antiretroviral therapy among HIV-infected adults (2002-2008).

OBJECTIVE To evaluate an internet-based preapproval antimicrobial stewardship program for sustained reduction in antimicrobial prescribing and resulting cost savings. DESIGN Retrospective cohort study and cost analysis. METHODS Review of all doses and charges of antimicrobials dispensed to patients over 6 years (July 1, 2005-June 30, 2011) at a tertiary care pediatric hospital. RESULTS Restricted antimicrobials account for 26% of total doses but 81% of total antimicrobial charges. Winter months (November-February) and the oncology and infant and toddler units were associated with the highest antimicrobial charges. Five restricted drugs accounted for the majority (54%) of charges but only 6% of doses. With an average approval rate of 91.5% (95% confidence interval [CI], 91.1%-91.9%), the preapproval antibiotic stewardship program saved

Retention in care is more strongly associated with viral suppression in HIV-infected patients with lower versus higher CD4 counts.

103,787 (95% CI,

The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression

98,583-

Disparities in Antiretroviral Treatment: A Comparison of Behaviorally-HIV-Infected Youth and Adults in the HIV Research Network

109,172) per year, or

Analyses of HIV-1 Drug-Resistance Profiles Among Infected Adolescents Experiencing Delayed Antiretroviral Treatment Switch After Initial Nonsuppressive Highly Active Antiretroviral Therapy

14,156 (95% CI,