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Introduction: The transition from paediatric to adult HIV care is a particularly high‐risk time for disengagement among young adults; however, empirical data are lacking.
Methods: We reviewed medical records of 72 youth seen in both the paediatric and the adult clinics of the Grady Infectious Disease Program in Atlanta, Georgia, USA, from 2004 to 2014. We abstracted clinical data on linkage, retention and virologic suppression from the last two years in the paediatric clinic through the first two years in the adult clinic.
Results: Of patients with at least one visit scheduled in adult clinic, 97% were eventually seen by an adult provider (median time between last paediatric and first adult clinic visit = 10 months, interquartile range 2-18 months). Half of the patients were enrolled in paediatric care immediately prior to transition, while the other half experienced a gap in paediatric care and re‐enrolled in the clinic as adults. A total of 89% of patients were retained (at least two visits at least three months apart) in the first year and 56% in the second year after transition. Patients who were seen in adult clinic within three months of their last paediatric visit were more likely to be virologically suppressed after transition than those who took longer (Relative risk (RR): 1.76; 95% confidence interval (CI): 1.07-2.9; p = 0.03). Patients with virologic suppression (HIV‐1 RNA below the level of detection of the assay) at the last paediatric visit were also more likely to be suppressed at the most recent adult visit (RR: 2.3; 95% CI: 1.34-3.9; p = 0.002).
Conclusions: Retention rates once in adult care, though high initially, declined significantly by the second year after transition. Pre‐transition viral suppression and shorter linkage time between paediatric and adult clinic were associated with better outcomes post‐transition. Optimizing transition will require intensive transition support for patients who are not virologically controlled, as well as support for youth beyond the first year in the adult setting.
adolescent, transition, HIV, care engagement, continuum, engagement, youth
Transitioning young adults from paediatric to adult care and the HIV care continuum in Atlanta, Georgia, USA: a retrospective cohort study
Sophia A. Hussen,corresponding author*1,2 Rana Chakraborty,*3 Andrea Knezevic,*4 Andres Camacho‐Gonzalez,*3 Eugene Huang,*4 Rob Stephenson,*5 and Carlos del Rio*1,2
2017 Sep 1
There is limited comparative effectiveness evidence to guide approaches to managing diabetes in individuals failing metformin monotherapy. Our aim was to compare the incidence of all-cause mortality and major adverse cardiovascular events (MACEs) among new metformin monotherapy users initiating a dipeptidyl-peptidase-4 inhibitor (DPP4i), glucagon-like peptide-1 receptor agonist (GLP-1RA), sulfonylurea (SU), thiazolidinedione, or insulin.
We conducted a cohort study using the UK-based Clinical Practice Research Datalink. Participants included a cohort of 38,233 new users of metformin monotherapy who initiated a 2nd antidiabetic agent between January 1, 2007 and December 31, 2012 with follow-up until death, disenrollment, therapy discontinuation, or study end-date. A subcohort of 21,848 patients with linked hospital episode statistics (HES) and Office of National Statistics (ONS) data were studied to include MACE and cardiovascular-related death. The primary exposure contrasts, defined a priori, were initiation of a DPP4i versus an SU and initiation of a GLP-1RA versus an SU following metformin monotherapy. Cox proportional hazards models were used to assess the relative differences in time to mortality and MACE between exposure contrasts, adjusting for important baseline patient factors and comedications used during follow-up.
The main study cohort consisted of 6213 (16%) patients who initiated a DPP4i, 25,916 initiated an SU (68%), 4437 (12%) initiated a TZD, 487 (1%) initiated a GLP-1RA, 804 (2%) initiated insulin, and 376 (1%) initiated a miscellaneous agent as their 2nd antidiabetic agent. Mean age was 62 years, 59% were male, and mean glycated hemoglobin was 8.8% (92.6 mmol/mol). Median follow-up was 2.7 years (interquartile range 1.3-4.2). Mortality rates were 8.2 deaths/1000 person-years for DPP4i and 19.1 deaths/1000 person-years for SU initiators. Adjusted hazards ratio (aHR) for mortality in DPP4i versus SU initiators = 0.58, 95% CI 0.46 to 0.73, P < 0.001. MACE rates were 19.1/1000 person-years for DPP4i initiators, 15.9/1000 person-years for GLP1-RA initiators versus 33.1/1000 person-years for SU initiators (aHR: DPP4i vs SU initiators = 0.64, 95%CI 0.52-0.80; GLP1RA vs SU initiators = 0.73, 95% CI 0.34-1.55). In this cohort of metformin monotherapy users, 2nd-line DPP4i use was associated with a 42% relative reduction in all-cause mortality and 36% reduction in MACE versus SUs, the most common 2nd-line therapy in our study. GLP-1RAs were not associated with adverse events in this cohort.
antidiabetic drugs, cardiovascular diseases, cohort studies, dipeptidyl-peptidase IV inhibitors, mortality, sulfonylurea compounds, type 2 diabetes mellitus
Comparative effectiveness of incretin-based therapies and the risk of death and cardiovascular events in 38,233 metformin monotherapy users
John-Michael Gamble, PhD,a,∗ Jamie M. Thomas, BSc,a Laurie K. Twells, PhD,a,b William K. Midodzi, PhD,b and Sumit R. Majumdar, MD, MPHc
Nearly all newly infected children acquire Human Immunodeficiency virus (HIV) via mother-to-child transmission (MTCT) during pregnancy, labour or breastfeeding from untreated HIV-positive mothers. Antiretroviral therapy (ART) is the standard care for pregnant women with HIV. However, evidence of ART effectiveness and harms in infants and children of HIV-positive pregnant women exposed to ART has been largely inconclusive. The aim of our systematic review and network meta-analysis (NMA) was to evaluate the comparative safety and effectiveness of ART drugs in children exposed to maternal HIV and ART (or no ART/placebo) across different study designs.
We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (inception until December 7, 2015). Primary outcomes were any congenital malformations (CMs; safety), including overall major and minor CMs, and mother-to-child transmission (MTCT; effectiveness). Random-effects Bayesian pairwise meta-analyses and NMAs were conducted. After screening 6,468 citations and 1,373 full-text articles, 90 studies of various study designs and 90,563 patients were included.
The NMA on CMs (20 studies, 7,503 children, 16 drugs) found that none of the ART drugs examined here were associated with a significant increase in CMs. However, zidovudine administered with lamivudine and indinavir was associated with increased risk of preterm births, zidovudine administered with nevirapine was associated with increased risk of stillbirths, and lamivudine administered with stavudine and efavirenz was associated with increased risk of low birth weight. A NMA on MTCT (11 studies, 10,786 patients, 6 drugs) found that zidovudine administered once (odds ratio [OR] = 0.39, 95% credible interval [CrI]: 0.19-0.83) or twice (OR = 0.43, 95% CrI: 0.21-0.68) was associated with significantly reduced risk of MTCT.
Our findings suggest that ART drugs are not associated with an increased risk of CMs, yet some may increase adverse birth events. Some ART drugs (e.g., zidovudine) effectively reduce MTCT.
Comparative safety and effectiveness of perinatal antiretroviral therapies for HIV-infected women and their children: Systematic review and network meta-analysis including different study designs
Areti Angeliki Veroniki, Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Visualization, Writing - original draft, Writing - review & editing,1 Jesmin Antony, Data curation, Investigation, Project administration, Writing - review & editing,1 Sharon E. Straus, Conceptualization, Funding acquisition, Supervision, Validation, Writing - original draft, Writing - review & editing,1,2 Huda M. Ashoor, Data curation, Investigation, Project administration, Writing - review & editing,1 Yaron Finkelstein, Conceptualization, Writing - review & editing,3,4,5 Paul A. Khan, Conceptualization, Investigation, Writing - review & editing,1 Marco Ghassemi, Investigation, Writing - review & editing,1 Erik Blondal, Investigation, Writing - review & editing,1 John D. Ivory, Investigation, Writing - review & editing,1 Brian Hutton, Conceptualization, Writing - review & editing,6,7 Kevin Gough, Conceptualization, Writing - review & editing,1,2 Brenda R. Hemmelgarn, Conceptualization, Writing - review & editing,8 Erin Lillie, Investigation, Writing - review & editing,1 Afshin Vafaei, Investigation, Writing - review & editing,1 and Andrea C. Tricco, Conceptualization, Funding acquisition, Investigation, Methodology, Supervision, Validation, Writing - original draft, Writing - review & editing1,9,*