title: Impact of recommendation updates in well-controlled patients on nonrecommended antiretroviral therapies: the Swiss HIV cohort study.
abstract: BACKGROUND
  HIV treatment recommendations are updated as clinical trials are published. Whether recommendations drive clinicians to change antiretroviral therapy in well-controlled patients is unexplored.
  
  
  METHODS
  We selected patients with undetectable viral loads (VLs) on nonrecommended regimens containing double-boosted protease inhibitors (DBPIs), triple-nucleoside reverse transcriptase inhibitors (NRTIs), or didanosine (ddI) plus stavudine (d4T) at publication of the 2006 International AIDS Society recommendations. We compared demographic and clinical characteristics with those of control patients with undetectable VL not on these regimens and examined clinical outcome and reasons for treatment modification.
  
  
  RESULTS
  At inclusion, 104 patients were in the DBPI group, 436 in the triple-NRTI group, and 19 in the ddI/d4T group. By 2010, 28 (29%), 204 (52%), and 1 (5%) patient were still on DBPIs, triple-NRTIs, and ddI plus d4T, respectively. 'Physician decision,' excluding toxicity/virological failure, drove 30% of treatment changes. Predictors of recommendation nonobservance included female sex [adjusted odds ratio (aOR) 2.69, 95% confidence interval (CI) 1 to 7.26; P = 0.01] for DPBIs, and undetectable VL (aOR 3.53, 95% CI 1.6 to 7.8; P = 0.002) and lack of cardiovascular events (aOR 2.93, 95% CI 1.23 to 6.97; P = 0.02) for triple-NRTIs. All patients on DBPIs with documented diabetes or a cardiovascular event changed treatment. Recommendation observance resulted in lower cholesterol values in the DBPI group (P = 0.06), and more patients having undetectable VL (P = 0.02) in the triple-NRTI group.
  
  
  CONCLUSIONS
  The physician's decision is the main factor driving change from nonrecommended to recommended regimens, whereas virological suppression is associated with not switching. Positive clinical outcomes observed postswitch underline the importance of observing recommendations, even in well-controlled patients.
authors.affiliation: Department of Medicine, Infectious Diseases Service, University Hospital and University of Lausanne, Lausanne, Switzerland. noemie.boillat@chuv.ch
authors.forename: Noémie
authors.initials: N
authors.lastname: Boillat-Blanco
authors.forename: Katharine E A
authors.initials: KE
authors.lastname: Darling
authors.forename: Patrick
authors.initials: P
authors.lastname: Taffe
authors.forename: Regina
authors.initials: R
authors.lastname: Osih
authors.forename: Carol
authors.initials: C
authors.lastname: Strahm
authors.forename: Maddalena
authors.initials: M
authors.lastname: Adami
authors.forename: Luigia
authors.initials: L
authors.lastname: Elzi
authors.forename: Samira
authors.initials: S
authors.lastname: Daou
authors.forename: Jan
authors.initials: J
authors.lastname: Fehr
authors.forename: Gilles
authors.initials: G
authors.lastname: Wandeler
authors.forename: Matthias
authors.initials: M
authors.lastname: Cavassini
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000139:chemically induced / Q000517:prevention & control; D016009:Chi-Square Distribution; D002784:Cholesterol / Q000097:blood; D048909:Diabetes Complications / Q000150:complications; D016049:Didanosine / Q000627:therapeutic use; D004359:Drug Therapy, Combination / Q000592:standards; D005260:Female; D019983:Guideline Adherence; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy*; D017320:HIV Protease Inhibitors / Q000627:therapeutic use*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D018894:Reverse Transcriptase Inhibitors / Q000627:therapeutic use*; D012737:Sex Factors; D018709:Statistics, Nonparametric; D018119:Stavudine / Q000627:therapeutic use; D013557:Switzerland; D019562:Viral Load
chemical_list: D017320:HIV Protease Inhibitors; D018894:Reverse Transcriptase Inhibitors; D002784:Cholesterol; D018119:Stavudine; D016049:Didanosine