Tingting Zhang, PhD, on ART Discontinuation and Reinitiation

A new study published in the Journal of Infectious Diseases indicated that failure to initiate antiretroviral therapy (ART) within 18 months of discontinuation is common among Medicaid enrollees with HIV.

Researchers arrived at this conclusion after performing a retrospective cohort study of 45,409 Medicaid enrollees with HIV who had discontinued ART. The association of person-level characteristics with time from ART discontinuation to reinitiation within 18 months was assessed using Cox proportional hazard regression.

Of the 45,409 patients who had discontinued ART, 44% did not reinitiate ART, the study found. Factors associated with ART reinitiation included more outpatient visits (3+ vs 0 outpatient visits: adjusted hazard ratio [HR], 1.56) and hospitalization (adjusted HR, 1.18).

“Care engagement was associated with greater ART reinitiation,” the researchers wrote.

Infectious Diseases Consultant discussed these findings further with corresponding author Tingting Zhang, PhD, with the Department of Health Services, Policy and Practice at the Brown University School of Public Health in Providence, Rhode Island.

ID CON: What factors are associated with ART discontinuation among patients with HIV?

Dr Zhang: Many factors could contribute to the discontinuation of ART among people living with HIV, such as younger age, female gender, lower educational attainment, presence of substance abuse, care gaps, and lack of health insurance.

ID CON: You and your colleagues concluded that “failure to reinitiate ART within 18 months was common in this sample” and that “care engagement was associated with greater ART reinitiation.” Could you elaborate more on these findings?

Dr Zhang: We used prescription drug records and health service utilization records of Medicaid enrollees in 14 states in the United States with the highest HIV prevalence. We identified a group of people with HIV who discontinued their antiretroviral drug regimen for at least 90 days, and examined their prescription and health service utilization records for up to 18 months. We found that 44% of this group did not restart their HIV medication within the 18-month period. This percentage was highest in younger patients and females.

We looked at outpatient visits and presence of hospitalization after ART discontinuation, and we used statistical models to examine whether the presence of an outpatient visit or hospitalization, or greater number of outpatient visits would be linked to restarting ART. Outpatient visits and hospitalization could be for any health conditions/diagnosis. We found that the higher the number of outpatient visits after ART discontinuation, the more likely patients were to reinitiate ART. For instance, people with 3 or more outpatient visits for any diagnosis were 1.6 times more likely to restart their ART compared with those who did not have any outpatient visits. We also found that people with a hospitalization for any condition were 1.2 times more likely to reinitiate ART. 

ID CON: How do the findings from your study inform what steps need to be taken going forward to meet the Ending the HIV Epidemic by 2030 initiative in the United States?

Dr Zhang: Our study emphasizes the importance of keeping people living with HIV in care. HIV drug therapies benefit the majority of people who have HIV, but only high drug adherence can maximize treatment benefits. It is common for people with HIV to stop their drug therapy, but as our study shows, active follow-up and keeping patients in care (in particular, outpatient care) can bring those who stopped their HIV medication back into a treatment regimen.

ID CON: What key takeaways do you hope to leave with infectious disease specialists on this topic?

Dr Zhang: In this study, a large number of people with HIV had a treatment gap, which could result in disease progression and transmission. Retention in care is critical in restarting patients' HIV treatment after a discontinuation to shorten the gap of time without antiretroviral therapy.

ID CON: What is the next step in terms of future research in this area?

Dr Zhang: One next step is to develop an intervention program that traces patients who discontinue their drug therapy, and reengage these individuals in care.

—Christina Vogt

Reference:
Zhang T, Wilson IB, Youn B, Lee Y, Shireman TI. Factors associated with antiretroviral therapy reinitiation in Medicaid recipients with human immunodeficiency virus. J Infect Dis. 2020;221(10). doi:10.1093/infdis/jiz666