Socioeconomic Position Associated With Effectiveness Of HIV Drugs
Socioeconomic position is a determinant of antiretroviral treatment effectiveness during initial therapy for HIV-1 infection. The effect was found in a study from Harvard School of Public Health (HSPH), Massachusetts General Hospital, Stanford University Medical School, and the American Psychological Association, even among subjects with high rates of drug adherence, according to a study published in the August 1 issue of the Journal of Psychosomatic Research. One probably has to live in Harvard to wonder how this is possible. And one does not have to wonder that there are means for such amazing research, as the study was supported by grants from GlaxoSmithKline, Pfizer, and Novartis. In case you wonder why those companies are interested in behavioral factors influencing patient’s compliance see: with adequate profit, capital is very bold – HIV market to top $10 billion
The researchers used data from a clinical trial that recruited HIV-positive men and women in the U.S. and Italy who had not previously taken any HIV medications. The study participants were being treated with highly active antiretroviral treatment (HAART), a combination of antiretroviral drugs sometimes referred to as an AIDS “cocktail.”
Scientific literature suggests that stress and emotional distress predict a faster decline in the immune system cells that can fight HIV progression. Previous studies have shown that people at lower socioeconomic positions often report chronic life stressors. The HSPH team and its collaborators wanted to examine whether socioeconomic position would influence immune functioning and response to antiretroviral treatments, even if patients adhered to their antiretroviral drugs. The researchers used the educational level of subjects as a measure for socioeconomic position.
The study’s authors documented the length of time until a participant first experienced a regimen failure, meaning that the drug combination had failed to maintain low HIV levels in the bloodstream or that HIV drugs had been changed or stopped. The researchers found that participants with lower levels of education reached initial regimen failure faster than participants with a college- or graduate-level degree.
However, participants with high levels of so-called “adherence self-efficacy,” despite lower education levels, experienced a reduction in initial regimen failure by 15 to 17 percent. Adherence self-efficacy was described by the authors as a coping resource that reflected the strength of the patient’s belief in the effectiveness of their medication and their ability to adhere to their treatment regimen. The authors suggest that one reason behind this association may be that coping styles are known to be associated with better immune functioning in individuals with HIV disease.
“These findings support health promotion programs focusing on psychological and behavioral aspects associated with therapeutic regimens, which might not otherwise be considered in the treatment of HIV,” said Linda Marc, who led the research project while a Doctor of Science candidate in the Department of Society, Human Development, and Health at HSPH. Marc is now a lecturer at Yale School of Public Health and chair of the HIV/AIDS Special Interest Group for the International Society for Quality of Life Research.
Marc and her team also point out that the study’s results may be particularly relevant to HIV care in the developing world. However, Marc noted, it is unknown if these results can be extrapolated to resource-poor settings because the trial was conducted with participants who live in developed nations. Marc added that since little is known about the impact of stressors on immune functioning in resource-poor settings, she believes there is a need to promote research methods in these parts of the world that simultaneously examine biological and social factors.
“In this way, researchers can better understand the variations of immune functioning and determine what proportion of treatment failure is modifiable through social variables, in contrast to known biological factors of HIV treatment effectiveness,” she said.
J Psychosom Res. 2007 Aug;63(2):207-16.
Educational attainment and response to HAART during initial therapy for HIV-1 infection.
Marc LG, Testa MA, Walker AM, Robbins GK, Shafer RW, Anderson NB, Berkman LF; for the ACTG Data Analysis Concept Sheet Study Team.
Cornell HIV Clinical Trials Unit, New York, NY, USA; Department of Psychiatry, Weill Medical College of Cornell, White Plains, NY, USA; Harvard School of Public Health, Boston, MA, USA.
OBJECTIVE: Previous research has demonstrated an association between educational attainment (EA) and negative physical and psychological outcomes. This study investigated whether EA is associated with regimen failure during initial therapy with highly active antiretroviral treatment (HAART) and whether adherence self-efficacy (ASE), a coping resource, moderates the relationship between EA and regimen failure. METHODS: A secondary analysis of AIDS Clinical Trial Group Protocol 384, an international, multicenter, randomized, partially double-blinded trial, included 799 male and 181 female antiretroviral-naïve subjects (age, 37.0+/-9.5 years). Participants were recruited from 1998 to 1999 and followed for a median of 2.3 years across 81 centers. The dependent variable was “time to first regimen failure.” Covariates include baseline HIV-1 log(10)RNA and CD4(+) counts, self-reported adherence, study site, ASE, age, sex, race, treatment assignment, and baseline use of nonantiretroviral medications. RESULTS: ASE significantly moderated the relationship between EA and regimen failure. Results showed that for every 10-unit increase in ASE, individuals with “less than high school” education had a 17% reduction in regimen failure (hazard ratio=0.83; 95% confidence interval=0.70-0.98) when compared to the reference group “college/graduate,” even after adjusting for baseline factors known to contribute to regimen failure. The time to first regimen failure was shorter with decreasing EA, trending toward significance (P=.08). CONCLUSIONS: There is a social gradient in HAART effectiveness, and ASE reduces the deleterious effects of lower EA on regimen failure. We recommend designing controlled interventions to evaluate the effectiveness of programs that increase ASE prior to initiation with HAART, particularly for those with lower EA.
AIDS Behav. 2004 Jun;8(2):141-50.
Factors influencing medication adherence beliefs and self-efficacy in persons naive to antiretroviral therapy: a multicenter, cross-sectional study.
Reynolds NR, Testa MA, Marc LG, Chesney MA, Neidig JL, Smith SR, Vella S, Robbins GK; Protocol Teams of ACTG 384, ACTG 731 and A5031s.
Ohio State University, Columbus 43210, USA. firstname.lastname@example.org
It is widely recognized that adherence to antiretroviral therapy is critical to long-term treatment success, yet rates of adherence to antiretroviral medications are frequently subtherapeutic. Beliefs about antiretroviral therapy and psychosocial characteristics of HIV-positive persons naive to therapy may influence early experience with antiretroviral medication adherence and therefore could be important when designing programs to improve adherence to antiretroviral therapy. As part of a multicenter AIDS Clinical Trial Group (ACTG 384) study, 980 antiretroviral-naive subjects (82% male, 47% White, median age 36 years, and median CD4 cell count 278 cells/mm3) completed a self-administered questionnaire prior to random treatment assignment of initial antiretroviral medications. Measures of symptom distress, general health and well-being, and personal and situational factors including demographic characteristics, social support, self-efficacy, depression, stress, and current adherence to (nonantiretroviral) medications were recorded. Associations among variables were explored using correlation and regression analyses. Beliefs about the importance of antiretroviral adherence and ability to take antiretroviral medications as directed (adherence self-efficacy) were generally positive. Fifty-six percent of the participants were “extremely sure” of their ability to take all medications as directed and 48% were “extremely sure” that antiretroviral nonadherence would cause resistance, but only 37% were as sure that antiretroviral therapy would benefit their health. Less-positive beliefs about antiretroviral therapy adherence were associated with greater stress, depression, and symptom distress. More-positive beliefs about antiretroviral therapy adherence were associated with better scores on health perception, functional health, social-emotional-cognitive function, social support, role function, younger age, and higher education (r values = 0.09-0.24, all p < .001). Among the subset of 325 participants reporting current use of medications (nonantiretrovirals) during the prior month, depression was the strongest correlate of nonadherence ( r = 0.33, p < .001). The most common reasons for nonadherence to the medications were “simply forgot” (33%), “away from home” (27%), and “busy” (26%). In conclusion, in a large, multicenter survey, personal and situational factors, such as depression, stress, and lower education, were associated with less certainty about the potential for antiretroviral therapy effectiveness and one’s perceived ability to adhere to therapy. Findings from these analyses suggest a role for baseline screening for adherence predictors and focused interventions to address modifiable factors placing persons at high risk for poor adherence prior to antiretroviral treatment initiation.