Publications
Association of ART Type and Adherence with Viral Suppression: An Observational Study of a Clinical Population of People with HIV
2023
Manalel, J., Kaufman, J., Wu, Y., Fusaris, E., Correa, A., Ernst, J., & Brennan-Ing, M. (2023). Association of ART Type and Adherence with Viral Suppression: An Observational Study of a Clinical Population of People with HIV. Poster presented at the Society for Behavioral Medicine Annual Meeting, Phoenix, AZ, April 26-29.
Jasmine Manalel, Jennie Kaufman, Yiyi Wu and Mark Brennan-Ing
Abstract
Background: Adherence to antiretroviral therapy (ART) is essential to effective management of HIV, which includes suppressing HIV viral load to undetectable levels. Some formulations of ART are more “forgiving” of poor adherence, allowing people living with HIV (PLWH) to be virally suppressed at lower adherence levels (i.e., <90%). The primary objective of this study was to determine how ART forgiveness varies depending on ART type and adherence.
Methods: Data came from the claims and clinical records of 3,552 HIV-positive members of a Medicaid managed care plan who were 18 years or older and continuously enrolled from 2017 through 2019. Pharmacy fill data were used to characterize ART medication usage using latent class analysis (LCA). This approach captures the complexity of real-world ART usage, including multiple medications and ART switching. We eliminated low frequency ART prescriptions (< 1% of fills each year) from over 1,100 unique combinations. Logistic regression models were estimated for each ART pattern to determine whether odds of viral suppression differed by ART adherence level (< 50%, 50% to <8 0%, 80% to < 85%, 85% to < 90%, and >= 90%).
Results: Among members with valid pharmacy data, 66% were men, 54% were Black, and average age was 45 years. Two-thirds of members were over 90% adherent to their ART medications. LCA yielded five ART medication patterns (i.e., latent classes) over three years, all of which were characterized by more recent ART formulations, though they varied in number of tablets and in medication class. After adjusting for demographics, multimorbidity, nadir CD4 count, and ART switches, ART medication patterns did not differ significantly in odds of maintaining viral suppression with at least 80% adherence. For example, patterns characterized by boosted protease inhibitor (PI) medications were generally as effective as patterns characterized by medications containing integrase strand transfer inhibitors (INSTIs).
Conclusions: These findings add to a growing body of evidence suggesting that ART adherence required for viral suppression may be lower than the 90% + standard used in clinical settings. The clinical implications of these findings can guide provider-patient communication for PLWH, especially those who have difficulty maintaining near-perfect adherence. This includes those experiencing unstable housing, mental health conditions, or substance use. Providers might use these findings to inform clinical care for patients in these vulnerable groups.