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"Treatment partners" improve short-term virologic outcomes in those starting HIV therapy
Michael Carter, 2012-08-27 12:20:00

The use of “treatment partners” boosts the chances of achieving an early undetectable viral load, investigators in Nigeria report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

However, the virologic benefits of treatment partners were not sustained in the long term, and the use of partners had no effect on CD4 cell gains or mortality risk.

Adherence is a major factor contributing to the success of antiretroviral therapy. The best outcomes are seen in people who take all or nearly all of their doses correctly. In contrast, poor adherence is associated with a failure to suppress viral load and the emergence of drug-resistant strains of HIV.

Many people, including individuals in resource-limited settings, achieve and sustain impressive levels of adherence. However, there is an ongoing need to develop new resources to support adherence.

One possible strategy is the use of treatment partners. This involves the selection of a family member, friend or neighbour, by a person who is starting HIV therapy, as a treatment partner.

Treatment partners support adherence by observing the person taking their HIV treatment, assist in the reporting and management of side-effects and also provide reminders about clinic appointments and pharmacy refills.

In a small, unrandomised study, investigators in Jos, Nigeria, found treatment partners beneficial. The same team of researchers wanted to evaluate their use in a larger, randomised study. Their aim was to see if the use of patient-selected treatment partners affected patient outcomes, including adherence, the chances of achieving an undetectable viral load, increases in CD4 cell count and rates of serious illness and death.

They therefore designed a study involving 499 adults who were starting HIV therapy for the first time. The participants were recruited between 2006 and 2007 and were randomised into two arms.

All the participants received information about adherence from a trained counsellor and a pharmacist. Individuals who did not have an undetectable viral load six months after starting therapy received further adherence counselling. This package of adherence counselling was the standard of care.

Half the people in the study were randomised to receive a treatment partner. The participant was allowed to select his or her treatment partner, who could be a spouse, other family member, friend or neighbour.

Outcomes were monitored at weeks twelve, 24 and 48.

Similar proportions of people in the two study arms experienced a 1 log reduction in viral load after twelve weeks of therapy (78% treatment-partners arm vs 76% standard of care).

By week 24, people with treatment partners were significantly more likely to have an undetectable viral load (62 vs 50%; OR = 1.58; 95% CI, 1.11-2.26; p < 0.05).

Virologic outcomes at week 48 continued to favour the use of treatment partners. Almost two-thirds (64%) of people with treatment partners had an undetectable viral load at this time point compared to 56% of those who received the standard of care. However, this difference was not significant (OR = 1.44; 95% CI, 0.99-2.09).

“Nondurability of initial virologic benefit in treatment-partnered patients may be related to the fact that all patients who were viremic at week 24 received focused adherence retraining, regardless of study arm,” suggest the authors. “In addition, it is possible that some treatment-partner fatigue occurred, and enthusiasm for intervening in another individual’s ART waned over time.”

Increases in CD4 cell count were similar between the two groups, as was the mortality rate (11 vs 6%).

Living near the clinic (less than 20km vs over 100km) was associated with better levels of adherence and improved virologic outcomes.

“Use of patient-selected treatment partners…had no durable impact on viral suppression, CD4 replenishment, or mortality,” conclude the investigators. “The relationship between residence-to-clinic distance and patient outcomes requires further exploration because it may have implications for the ongoing scale-up of ART in resource-limited settings.”

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