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Shet A.,St Johns Medical College Hospital | Shet A.,Karolinska Institutet | Neogi U.,Karolinska Institutet | Kumarasamy N.,Center for Research and Education | And 3 more authors.
Tropical Medicine and International Health | Year: 2015

Objective: Combination antiretroviral therapy (ART) has improved in efficacy, durability and tolerability. Virological efficacy studies in India are limited. We determined incidence and predictors of virological failure among patients initiating first-line ART and described virological resuppression after confirmed failure, with the goal of informing national policy. Methods: Therapy-naïve patients initiated on first-line ART as per national guidelines were monitored every 3 months for adherence and virological response over 2 years. Genotyping on baseline samples was performed to assess primary drug resistance. Multivariate Cox regression analysis was used to assess predictors of virological failure. Results: Virological failure rate among 599 eligible patients was 10.7 failures per 100 person-years. Cumulative failure incidence was 13.2% in the first year and 16.5% over 2 years. Patients initiated on tenofovir had a significantly lower rate of virological failure than those on stavudine or zidovudine (6.7 vs. 11.9 failures per 100 person-years, P = 0.013). Virological failure was independently associated with age <40 years, mean adherence <95%, non-tenofovir-containing regimens and presence of primary drug resistance. In a subset of 311 patients who were reassessed after treatment failure, 19% (11/58) patients resuppressed their viral load to <400 copies/ml after confirmed virological failure. Conclusions: Our results support the inclusion of tenofovir as first-line ART in resource-limited settings and a role for regular adherence counselling and virological monitoring for enhanced treatment success. Detection of early virological failure should provide an opportunity to augment adherence counselling and repeat viral load testing before therapy switch is considered. © 2015 John Wiley & Sons Ltd Source


Jakobsen F.,Orthopaedic Research Unit | Hansen J.,Center for Research and Education
Journal of Interprofessional Care | Year: 2014

In a Danish Interprofessional Training Unit (ITU), the clinical tutors have succeeded in developing a safe learning environment combined with challenging the students by giving them responsibility for the patient's care and rehabilitation. In the ITU, students improved their uniprofessional and interprofessional knowledge and capability while strengthening their professional identity. It was, therefore, decided to make an attempt to transfer these interprofessional learning and teaching methods to another setting. The aims of this study were to evaluate whether the students learned about interprofessional collaboration and strengthened their professional identity and whether the clinical tutors could create a safe and challenging learning environment. Clinical tutors from the professions occupational therapy, physiotherapy, and nursing together planned the pedagogical approach and practical organization of two pilot studies in an orthopedic ward. After the intervention, focus group interviews of students and clinical tutors were performed and analyzed. The findings indicated that a one-week interprofessional clinical placement can contribute to students learning about interprofessional collaboration and to their development of professional identity. The data from the clinical tutors indicated that they needed to create a safe and challenging learning environment but emphasized that a thorough planning and continuous monitoring and adjusting of the clinical placement is necessary for success. The study documents that it is possible to create successful interprofessional learning opportunities in a normal ward environment in a restricted time frame. This knowledge can be applied to other ward settings where interprofessional clinical training is a natural possibility. © 2014 Informa UK Ltd. Source


Shet A.,St Johns Medical College Hospital | Shet A.,Karolinska Institutet | De Costa A.,Karolinska Institutet | Kumarasamy N.,Center for Research and Education | And 6 more authors.
BMJ (Online) | Year: 2014

Objective To assess whether customised mobile phone reminders would improve adherence to therapy and thus decrease virological failure among HIV infected patients starting antiretroviral treatment, (ART).Design Randomised controlled trial among HIV infected patients initiating antiretroviral treatment,.Setting Three diverse healthcare delivery settings in south India: two ambulatory clinics within the Indian national programme and one private HIV healthcare clinic.Participants 631 HIV infected, ART naïve, adult patients eligible to initiate first line ART were randomly assigned to mobile phone intervention (n=315) or standard care (n=316) and followed for 96 weeks..Intervention The intervention consisted of customised, interactive, automated voice reminders, and a pictorial message that were sent weekly to the patients' mobile phones for the duration of the study.Main outcome measures The primary outcome was time to virological failure (viral load >400 copies/mL on two consecutive measurements). Secondary outcomes included ART adherence measured by pill count, death rate, and attrition rate. Suboptimal adherence was defined as mean adherence <95%.Results Using an intention-to-treat approach we found no observed difference in time to virological failure between the allocation groups: failures in the intervention and standard care arms were 49/315 (15.6%) and 49/316 (15.5%) respectively (unadjusted hazard ratio 0.98, 95% confidence interval 0.67 to 1.47, P=0.95). The rate of virological failure in the intervention and standard care groups were 10.52 and 10.73 per 100 person years respectively. Comparison of suboptimal adherence was similar between both groups (unadjusted incidence rate ratio 1.24, 95% CI 0.93 to 1.65, P=0.14). Incidence proportion of patients with suboptimal adherence was 81/300 (27.0%) in the intervention arm and 65/299 (21.7%) in the standard care arm. The results of analyses adjusted for potential confounders were similar, indicating no significant difference between the allocation groups. Other secondary outcomes such as death and attrition rates, and subgroup analysis also showed comparable results across allocation groups.Conclusions In this multicentre randomised controlled trial among ART naïve patients initiating first line ART within the Indian national programme, we found no significant effect of the mobile phone intervention on either time to virological failure or ART adherence at the end of two years of therapy.Trial ragistration Current Controlled Trial ISRCTN79261738. Source


Phanuphak P.,Red Cross | Phanuphak P.,Chulalongkorn University | Sirivichayakul S.,Chulalongkorn University | Jiamsakul A.,University of New South Wales | And 13 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

BACKGROUND: We compared treatment outcomes of transmitted drug resistance (TDR) in patients on fully or partially sensitive drug regimens. METHODS: Factors associated with survival and failure were analyzed using Cox proportional hazards and discrete time conditional logistic models. RESULTS: TDR, found in 60 (4.1%) of 1471 Asian treatment-naive patients, was one of the significant predictors of failure. Patients with TDR to >1 drug in their regimen were >3 times as likely to fail compared to no TDR. CONCLUSIONS: TDR was associated with failure in the context of non-fully sensitive regimens. Efforts are needed to incorporate resistance testing into national treatment programs. © 2013 by Lippincott Williams and Wilkins. Source


Thio C.L.,Johns Hopkins University | Smeaton L.,Harvard University | Saulynas M.,Johns Hopkins University | Hwang H.,Johns Hopkins University | And 11 more authors.
AIDS | Year: 2013

OBJECTIVE: To understand the HIV-hepatitis B virus (HBV) epidemic from a global perspective by clinically and virologically characterizing these viruses at the time of antiretroviral therapy (ART) initiation in a multinational cohort. METHODS AND DESIGN: HIV-infected patients enrolled in two international studies were classified as HIV-HBV coinfected or HIV monoinfected prior to ART. HIV-HBV coinfected patients were tested for HBV characteristics, hepatitis D virus (HDV), a novel noninvasive marker of liver disease, and drug-resistant HBV. Comparisons between discrete covariates used χ or Fisher's exact tests (and Jonchkheere-Terpstra for trend tests), whereas continuous covariates were compared using Wilcoxon Rank-Sum Test. RESULTS: Of the 2105 HIV-infected patients from 11 countries, the median age was 34 years and 63% were black. The 115 HIV-HBV coinfected patients had significantly higher alanine aminotransferase and aspartate aminotransferase values, lower BMI, and lower CD4 T-cell counts than HIV monoinfected patients (median 159 and 137cells/μl, respectively, P=0.04). In the coinfected patients, 49.6% had HBeAg-negative HBV, 60.2% had genotype A HBV, and 13% were HDV positive. Of the HBeAg-negative patients, 66% had HBV DNA 2000IU/ml or less compared to 5.2% of the HBeAg-positive individuals. Drug-resistant HBV was not detected. CONCLUSION: Screening for HBV in HIV-infected patients in resource-limited settings is important because it is associated with lower CD4 T-cell counts. In settings in which HBV DNA is not available, HBeAg may be useful to assess the need for HBV treatment. Screening for drug-resistant HBV is not needed prior to starting ART in settings in which this study was conducted. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Source

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