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Background Plasma viral load (pVL) is a key indicator of therapeutic response in HIV-infected patients receiving combination antiretroviral therapy (cART), but is often unavailable in routine clinical care in resource-limited settings. Previous model-based simulation studies have suggested that the benefits of routine pVL monitoring among patients on first-line regimens in resource-limited settings are modest, but this needs corroboration in well-defined study populations.Methods We investigated virological suppression levels and identified predictors of detectable viraemia among 870 randomly selected patients who started cART between May 2009 and April 2012 in 10 health-care facilities in Addis Ababa, Ethiopia. A total of 656 (75.4%) patients, who were alive, were retained in HIV care and receiving cART for at least 6 months provided a blood sample for pVL measurement. Predictors of detectable viraemia were identified in a multivariate logistic regression model.Results In on-treatment analysis, 94.5% (95% CI 92.5, 96.1) of the patients achieved virological suppression below 400 copies/ml after a median (IQR) of 26 (17–35) months on cART. When patients who were lost to follow-up, dead or stopped were assumed to have had detectable viraemia, the proportion of patients with virological suppression =400 copies/ml decreased to 74.6% (95% CI 71.5%, 77.4%). Younger age, lower educational status, =95% medication adherence, lower CD4+T-cell count at cART initiation and/ or the diagnosis of immunological failure thereafter significantly predicted detectable viraemia.Conclusions Virological suppression levels can be high in an established ART programme in a resource-limited setting, even without the availability of routine pVL monitoring. Efforts to improve treatment outcomes should focus on younger and illiterate patients, earlier detection of HIV-positive status and cART initiation before patients are severely immunocompromised, and improving retention in care.

Background Self-report is the most commonly used measure of adherence to highly active antiretroviral therapy, but typically shows weaker associations with virological treatment outcome than more objective adherence assessment methods. Socially desirable responding might hamper the validity of self-reported adherence. We investigated whether stratifying patients according to their socially desirable response set might improve the prediction of virological treatment response by self-reported adherence.Methods Patients enrolled in the focus group of the Dutch national cohort ATHENA completed a social desirability scale, four self-report adherence questions, and had their plasma HIV type-1 (HIV-1) RNA concentrations measured. We calculated odds ratios and 95% confidence intervals for self-reported non-adherence to predict HIV-1 RNA>50 copies/ml among patients with a lower or a higher tendency towards socially desirable responding.Results A total of 331 patients were included. Self- reported non-adherence was significantly predictive of HIV-1 RNA>50 copies/ml on three out of four questions among patients with lower socially desirable responding (n=198). Self-reported non-adherence did not predict HIV-1 RNA>50 copies/ml among patients with higher socially desirable responding (n=132).Conclusions Stratifying patients according to their socially desirable response set improved the prediction of virological treatment response by self-reported adherence. This finding emphasizes the importance of discussing medication adherence with patients in a non-threatening and non-judgemental way that normalizes non-adherence in order to reduce socially desirable responding.

First, to compare the quality of life (QL) and perceived self-competence of children and adolescents with anorectal malformations or Hirschsprung disease with that of reference groups. Second, to identify predictors of QL. A total of 491 patients with anorectal malformations or Hirschsprung disease were sent a questionnaire, which assessed QL (mental, physical), disease-specific functioning (defecation-related), perceived self-competence (self-esteem, athletic competencies, school attitude), and demographic characteristics (sex, age). The clinical characteristics (disease severity, presence of congenital anomalies) were extracted from medical records. More than 50% (316, 64%) of patients with anorectal malformations or Hirschsprung disease completed the questionnaire. On average, children and adolescents in both patient groups reported no differences in QL domains compared with the reference groups. However, standard deviations revealed considerable individual variation, indicating the presence of patients with high levels of QL as well as patients with low levels of QL. Children and adolescents in both patient groups reported psychosocial problems in all domains, compared with the reference groups. Females, older patients, and those with a severe form of the disease reported lower levels of perceived self-competence and global disease-specific functioning, which in turn predicted QL. Our results should alert clinicians to patients who are at risk for QL problems and may therefore be in need of extra care. Our findings illustrate the importance of both global disease-specific functioning and perceived psychosocial competencies for enhancing the QL of these patients.

First, to compare the quality of life (QL) and perceived self-competence of children and adolescents with anorectal malformations or Hirschsprung disease with that of reference groups. Second, to identify predictors of QL.

Objective In patients with a chronic asymptomatic HIV-1 infection and >200 CD4+T-cells/µl, the optimal timing of highly active antiretroviral therapy (HAART) initiation is unclear. It involves a trade-off between a potentially reduced risk of mortality, when started earlier in the course of infection, and an earlier exposure to pill burden and potential toxicities. We investigated patients’ preferences for immediate HAART initiation relative to delaying HAART for 1 year.Methods Consecutive patients were asked for their preference during an interview. A hypothetical difference in 3-year mortality risk between both options was systematically varied between 0% and 10% to determine the threshold at which preference would switch to HAART initiation.Results About 30% of patients preferred HAART initiation even if the mortality risk would be equal for both options. Almost 25% always preferred delaying HAART even if this would result in a 10% greater mortality risk. Most treatment guidelines recommend delaying HAART >350 CD4+T-cells/µl However, at a risk difference between starting and delaying HAART that corresponds with this CD4+T-cell count, about 50% would prefer to start HAART immediately. Most guidelines recommend starting HAART below 200 CD4+T-cells/µl However, at a risk difference between both options corresponding with this CD4+T-cell count, about 40% preferred delaying HAART.Conclusions We found large variation in patients’ preferences. Some patients were more inclined to initiate HAART earlier than the recommended guidelines, whereas others were more inclined to delay HAART. These findings emphasize the need for shared decision-making when deciding on the most optimal timing of HAART initiation in chronic asymptomatic HIV-1 infection.