Tracy R. Glass

Correlates of self-reported nonadherence to antiretroviral therapy in HIV-infected patients: the Swiss HIV Cohort Study

Background: Adherence is one of the most crucial issues in the clinical management of HIV-infected patients receiving antiretroviral therapy (ART). Methods: A 2-item adherence questionnaire was introduced into the Swiss HIV Cohort Study in July 2003. All 3607 eligible patients were on ART for ≥6 months and their current regimen for ≥1 month. Three definitions of nonadherence were considered: missing ≥1 dose, missing ≥2 doses, and taking <95% of doses in the past 4 weeks. Results: Over 30% of patients reported missing ≥1 dose, 14.9% missed ≥2 doses, and 7.1% took <95% of doses in the previous 4 weeks. The rate of drug holidays was 5.8%. Whether using more or less conservative definitions of nonadherence, younger age, living alone, number of previous regimens, and boosted protease inhibitor regimens were independent factors associated with nonadherence. There was a significant association between optimal viral suppression and nonadherence as well as a significant linear trend in optimal viral suppression by missed doses. Conclusions: Younger age, lack of social support, and complexity of therapy are important factors that are related to nonadherence with ART. Investment in behavioral dimensions of HIV is crucial to improve adherence in ART recipients.

Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study

OBJECTIVE To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire. DESIGN Multi-hospital cross-sectional surveys of patients and nurses. SETTING Eight Swiss acute care hospitals PARTICIPANTS Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units. MAIN OUTCOME MEASURES Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year. RESULTS Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones. CONCLUSION As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.

Prevalence of risk factors for cardiovascular disease in HIV‐infected patients over time: the Swiss HIV Cohort Study

Metabolic changes caused by antiretroviral therapy (ART) may increase the risk of coronary heart disease (CHD). We evaluated changes in the prevalence of cardiovascular risk factors (CVRFs) and 10‐year risk of CHD in a large cohort of HIV‐infected individuals.

Longitudinal analysis of patterns and predictors of changes in self-reported adherence to antiretroviral therapy: Swiss HIV Cohort Study

Background:Adherence to combination antiretroviral therapy (cART) is a dynamic process, however, changes in adherence behavior over time are insufficiently understood. Methods:Data on self-reported missed doses of cART was collected every 6 months in Swiss HIV Cohort Study participants. We identified behavioral groups associated with specific cART adherence patterns using trajectory analyses. Repeated measures logistic regression identified predictors of changes in adherence between consecutive visits. Results:Six thousand seven hundred nine individuals completed 49,071 adherence questionnaires [median 8 (interquartile range: 5-10)] during a median follow-up time of 4.5 years (interquartile range: 2.4-5.1). Individuals were clustered into 4 adherence groups: good (51.8%), worsening (17.4%), improving (17.6%), and poor adherence (13.2%). Independent predictors of worsening adherence were younger age, basic education, loss of a roommate, starting intravenous drug use, increasing alcohol intake, depression, longer time with HIV, onset of lipodystrophy, and changing care provider. Independent predictors of improvements in adherence were regimen simplification, changing class of cART, less time on cART, and starting comedications. Conclusions:Treatment, behavioral changes, and life events influence patterns of drug intake in HIV patients. Clinical care providers should routinely monitor factors related to worsening adherence and intervene early to reduce the risk of treatment failure and drug resistance.

Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania

BackgroundEarly and frequent antenatal care attendance during pregnancy is important to identify and mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit from its preventive and curative services. This study assesses the timing of adult and adolescent pregnant womens first antenatal care visit and identifies factors influencing early and late attendance.MethodsThe study was conducted in the Ulanga and Kilombero rural Demographic Surveillance area in south-eastern Tanzania in 2008. Qualitative exploratory studies informed the design of a structured questionnaire. A total of 440 women who attended antenatal care participated in exit interviews. Socio-demographic, social, perception- and service related factors were analysed for associations with timing of antenatal care initiation using regression analysis.ResultsThe majority of pregnant women initiated antenatal care attendance with an average of 5 gestational months. Belonging to the Sukuma ethnic group compared to other ethnic groups such as the Pogoro, Mhehe, Mgindo and others, perceived poor quality of care, late recognition of pregnancy and not being supported by the husband or partner were identified as factors associated with a later antenatal care enrolment (p < 0.05). Primiparity and previous experience of a miscarriage or stillbirth were associated with an earlier antenatal care attendance (p < 0.05). Adolescent pregnant women started antenatal care no later than adult pregnant women despite being more likely to be single.ConclusionsFactors including poor quality of care, lack of awareness about the health benefit of antenatal care, late recognition of pregnancy, and social and economic factors may influence timing of antenatal care. Community-based interventions are needed that involve men, and need to be combined with interventions that target improving the quality, content and outreach of antenatal care services to enhance early antenatal care enrolment among pregnant women.

Validation of the basel extent of rationing of nursing care instrument

Background: Financial constraints and other forces affecting health care in many countries have led to nurses implicitly limiting their care in some instances. In the absence of an accepted definition and theoretical framework of implicit rationing of nursing care, a framework and the Basel Extent of Rationing of Nursing Care (BERNCA) instrument were developed. This instrument was used in the Swiss part of the International Hospital Outcome Study, in which implicit rationing of nursing care was studied. Objective: To examine the validity and reliability of the newly developed BERNCA instrument. Methods: Psychometric analysis was performed on data from 957 nurses in five Swiss acute care hospitals enrolled in a larger hospital organization study. An explanatory factor analysis with varimax rotation was used to investigate the instruments internal structure, Spearman correlations were used to test relationships between implicit rationing and two related concepts, and Cronbachs alpha and interitem correlations were used to test the reliability of the scale. Results: Expert feedback confirmed that the BERNCA covered the implicit rationing of nursing care domain adequately and that its questions were fully comprehensible. The single-factor solution confirmed the instruments unidimensional internal structure. A moderate to strong correlation in the expected direction was found between the BERNCA implicit rationing data and the quality of the nurse work environment as measured by the Nursing Work Index-Revised, particularly the perceived adequacy of nursing resources, although a significant but low correlation was also shown with patient-to-nurse ratios. Cronbachs alphas (.93) and interitem correlations indicated internal consistency and homogeneity. Discussion: Initial evidence of the validity and reliability of the BERNCA instrument was provided.

Resurgence of HIV infection among men who have sex with men in Switzerland: mathematical modelling study

Background New HIV infections in men who have sex with men (MSM) have increased in Switzerland since 2000 despite combination antiretroviral therapy (cART). The objectives of this mathematical modelling study were: to describe the dynamics of the HIV epidemic in MSM in Switzerland using national data; to explore the effects of hypothetical prevention scenarios; and to conduct a multivariate sensitivity analysis. Methodology/Principal Findings The model describes HIV transmission, progression and the effects of cART using differential equations. The model was fitted to Swiss HIV and AIDS surveillance data and twelve unknown parameters were estimated. Predicted numbers of diagnosed HIV infections and AIDS cases fitted the observed data well. By the end of 2010, an estimated 13.5% (95% CI 12.5, 14.6%) of all HIV-infected MSM were undiagnosed and accounted for 81.8% (95% CI 81.1, 82.4%) of new HIV infections. The transmission rate was at its lowest from 1995–1999, with a nadir of 46 incident HIV infections in 1999, but increased from 2000. The estimated number of new infections continued to increase to more than 250 in 2010, although the reproduction number was still below the epidemic threshold. Prevention scenarios included temporary reductions in risk behaviour, annual test and treat, and reduction in risk behaviour to levels observed earlier in the epidemic. These led to predicted reductions in new infections from 2 to 26% by 2020. Parameters related to disease progression and relative infectiousness at different HIV stages had the greatest influence on estimates of the net transmission rate. Conclusions/Significance The model outputs suggest that the increase in HIV transmission amongst MSM in Switzerland is the result of continuing risky sexual behaviour, particularly by those unaware of their infection status. Long term reductions in the incidence of HIV infection in MSM in Switzerland will require increased and sustained uptake of effective interventions.

Describing the evolution of medication nonadherence from pretransplant until 3 years post-transplant and determining pretransplant medication nonadherence as risk factor for post-transplant nonadherence to immunosuppressives: the Swiss Transplant Cohort Study.

Although medication nonadherence (MNA) is a major risk factor for poor outcomes, the evolution of MNA from pre‐ to 3 years post‐transplant among the four major organ transplant groups remains unknown. Therefore, this study described this evolution and investigated whether pretransplant MNA predicts post‐transplant immunosuppressive medication nonadherence (IMNA). Adult participants (single transplant, pretransplant and ≤1 post‐transplant assessment, using medications pretransplant) in the Swiss Transplant Cohort Study (a prospective nation‐wide cohort study) were included. Nonadherence, defined as any deviation from dosing schedule, was assessed using two self‐report questions pretransplant and at 6, 12, 24 and 36 months post‐transplant. Nonadherence patterns were modelled using generalized estimating equations. The sample included 1505 patients (average age: 52.5 years (SD: 13.1); 36.3% females; 924 renal, 274 liver, 181 lung, 126 heart). The magnitude and variability of self‐reported MNA decreased significantly from pretransplant to 6 months post‐transplant (OR = 0.21; 95% CI: 0.16–0.27). Post‐transplant IMNA increased continuously from 6 months to 3 years post‐transplant (OR = 2.75; 95% CI: 1.97–3.85). Pretransplant MNA was associated with threefold higher odds of post‐transplant IMNA (OR = 3.10; 95% CI: 2.29–4.21). As pretransplant MNA predicted post‐transplant IMNA and a continuous increase in post‐transplant IMNA was observed, early adherence‐supporting interventions are indispensible.

Association of Alcohol Consumption and HIV Surrogate Markers in Participants of the Swiss HIV Cohort Study

Background:Alcohol consumption may affect the course of HIV infection and/or antiretroviral therapy (ART). The authors investigated the association between self-reported alcohol consumption and HIV surrogate markers in both treated and untreated individuals. Design:Prospective cohort study. Methods:Over a 7-year period, the authors analyzed 2 groups of individuals in the Swiss HIV Cohort Study: (1) ART-naïve individuals remaining off ART and (2) individuals initiating first ART. For individuals initiating first ART, time-dependent Cox proportional hazards models were used to assess the association between alcohol consumption, virological failure, and ART interruption. For both groups, trajectories of log-transformed CD4 cell counts were analyzed using linear mixed models with repeated measures. Results:The authors included 2982 individuals initiating first ART and 2085 ART naives. In individuals initiating first ART, 241 (8%) experienced virological failure. Alcohol consumption was not associated with virological failure. ART interruption was noted in 449 (15%) individuals and was more prevalent in severe compared with none/light health risk drinkers [hazard ratio: 2.24, 95% confidence interval: 1.42 to 3.52]. The association remained significant even after adjusting for nonadherence. The authors did not find an association between alcohol consumption and change in CD4 cell count over time in either group. Conclusions:No effect of alcohol consumption on either virological failure or CD4 cell count in both groups of ART-initiating and ART-naive individuals was found. However, severe drinkers were more likely to interrupt ART. Efforts on ART continuation should be especially implemented in individuals reporting high alcohol consumption.

Contribution of Genetic Background, Traditional Risk Factors, and HIV-Related Factors to Coronary Artery Disease Events in HIV-Positive Persons

BACKGROUND Persons infected with human immunodeficiency virus (HIV) have increased rates of coronary artery disease (CAD). The relative contribution of genetic background, HIV-related factors, antiretroviral medications, and traditional risk factors to CAD has not been fully evaluated in the setting of HIV infection. METHODS In the general population, 23 common single-nucleotide polymorphisms (SNPs) were shown to be associated with CAD through genome-wide association analysis. Using the Metabochip, we genotyped 1875 HIV-positive, white individuals enrolled in 24 HIV observational studies, including 571 participants with a first CAD event during the 9-year study period and 1304 controls matched on sex and cohort. RESULTS A genetic risk score built from 23 CAD-associated SNPs contributed significantly to CAD (P = 2.9 × 10(-4)). In the final multivariable model, participants with an unfavorable genetic background (top genetic score quartile) had a CAD odds ratio (OR) of 1.47 (95% confidence interval [CI], 1.05-2.04). This effect was similar to hypertension (OR = 1.36; 95% CI, 1.06-1.73), hypercholesterolemia (OR = 1.51; 95% CI, 1.16-1.96), diabetes (OR = 1.66; 95% CI, 1.10-2.49), ≥ 1 year lopinavir exposure (OR = 1.36; 95% CI, 1.06-1.73), and current abacavir treatment (OR = 1.56; 95% CI, 1.17-2.07). The effect of the genetic risk score was additive to the effect of nongenetic CAD risk factors, and did not change after adjustment for family history of CAD. CONCLUSIONS In the setting of HIV infection, the effect of an unfavorable genetic background was similar to traditional CAD risk factors and certain adverse antiretroviral exposures. Genetic testing may provide prognostic information complementary to family history of CAD.