Sex-based differences in antiretroviral therapy initiation, switching and treatment interruptions: global overview from the International Epidemiologic Databases to Evaluate AIDS (IeDEA).

Michelle L Giles,Man Po Lee,Marco Luque,Michael John Gill,Catherine Mcgowan,Matthew Law,Renaud Becquet,Morna Cornell,Alison G Abraham,Paula Braitstein,Nathalie De Rekeneire,Kara Wools‐Kaloustian,Amit C Achhra,Andreas D Haas

doi:10.1002/jia2.25149

Abstract

IntroductionIn 2015, the World Health Organization recommended that all HIV‐infected individuals consider ART initiation as soon as possible after diagnosis. Sex differences in choice of initial ART regimen, indications for switching, time to switching and choice of second‐line regimens have not been well described. The aims of this study were to describe first‐line ART and CD4 count at ART initiation by sex, calendar year and region, and to analyse time to change or interruption in first‐line ART, according to sex in each region.MethodsParticipating cohorts included: Southern, East and West Africa (IeDEA‐Africa), North America (NA‐ACCORD), Caribbean, Central/South America (CCASAnet) and Asia‐Pacific including Australia (IeDEA Asia‐Pacific). The primary outcomes analysed for each region and according to sex were choice of initial ART, time to switching and time to discontinuation of the first‐line regimen.Results and DiscussionThe combined cohort data set comprised of 715,252 participants across seven regions from low‐ to high‐income settings. The median CD4 count at treatment initiation was lower in men compared with women in nearly all regions and time periods. Women from North America and Southern Africa were more likely to switch ART compared to men (p < 0.001) with approximately 90% of women reporting a major change after 10 years in North America. Overall, after 8 years on ART, >50% of HIV‐ positive men and women from Southern Africa, East Africa, South and Central America remained on their original regimen. Men were more likely to have a treatment interruption compared with women in low‐ and middle‐income countries from the Asia/Pacific region (p < 0.001) as were men from Southern Africa (p < 0.001). Greater than 75% of men and women did not report a treatment interruption after 10 years on ART from all regions except North America and Southern Africa.ConclusionsThere are regional variations in the ART regimen commenced at baseline and rates of major change and treatment interruption according to sex. Some of this is likely to reflect changes in local and international antiretroviral guideline recommendations but other sex‐specific factors such as pregnancy may contribute to these differences.

Highlights

In 2015, the World Health Organization recommended that all HIV-infected individuals consider antiretroviral therapy (ART) initiation as soon as possible after diagnosis
In the Asia-Pacific region nevirapine was the nucleoside reverse transcriptase inhibitor (NNRTI) more commonly prescribed in the first ART regimen in the earlier time period (2003 to 2005) for both men and women but this declined in the later time period (2010 to 2014) with efavirenz as the most commonly prescribed NNRTI
Our key findings are that there are regional variations in choice of initial ART regimen according to sex, and that the relative contribution from different antiretroviral classes has changed over time, which likely reflects changes in local, World Health Organization (WHO) and other guidelines, and availability of individual drugs

Summary

Introduction

In 2015, the World Health Organization recommended that all HIV-infected individuals consider ART initiation as soon as possible after diagnosis. Conclusions: There are regional variations in the ART regimen commenced at baseline and rates of major change and treatment interruption according to sex Some of this is likely to reflect changes in local and international antiretroviral guideline recommendations but other sex-specific factors such as pregnancy may contribute to these differences. In September 2015, the World Health Organization (WHO) announced that all persons infected with HIV should begin ART as soon as possible after diagnosis, thereby removing eligibility criteria for all populations and age groups (www.who.int) Accompanying these recommendations, expanded ART programmes and wider availability of virological monitoring [3] are making quality care more accessible globally, including lower income countries. Attention should be focused on understanding the factors that influence initial regimen choice, potentially harmful treatment interruptions, and the use of costly second- and third-line regimens

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