for Health Care Providers
Chapter 5 - Antiretroviral Therapy
5.1 Veterans Receiving Antiretroviral Therapy
Potent combinations of antiretroviral medications have transformed HIV from an illness with uniformly high rates of fatality to one that more closely resembles a chronic disease. In VHA all 28 currently available Food and Drug Administration (FDA)--approved antiretroviral medications are included on the national VHA formulary and are available to Veterans with HIV/AIDS. HIV infected Veterans fill over one million VHA prescriptions annually, one-third of which are for antiretrovirals. Antiretrovirals are prescribed at all local VHA healthcare systems and uptake of newly introduced antiretroviral medications is generally rapid across the system. In 2008, 80% of HIV infected Veterans had an outpatient prescription for an antiretroviral medication. Antiretroviral treatment rates across VISNs in 2008 ranged from 71% to 85%.
Between 2005 and 2008, the proportion of Veterans prescribed antiretrovirals rose steadily from 71% to 80%. The proportion of Veterans receiving their first ever VHA prescribed antiretroviral has decreased slightly over the same period from 6.3% to 5.7% of those in care. The high percentage of HIV infected Veterans on antiretroviral therapy demonstrates that access to antiretroviral therapy is widespread for Veterans receiving care from the VHA. Table 6 presents the number of Veterans with HIV/AIDS on antiretroviral therapy nationally and at each VISN in 2008.
|Number in Care||Number with Antivirals||Percent with Antivirals|
|VA New England Healthcare System (1)||636||482||76%|
|VA Healthcare Network Upstate New York (2)||354||252||71%|
|VA NY/NJ Veterans Healthcare Network (3)||1,910||1,481||78%|
|VA Healthcare - VISN 4 (4)||1,055||827||78%|
|VA Capitol Health Care Network (5)||1,559||1,186||76%|
|VA Mid-Atlantic Health Care Network (6)||1,535||1,203||78%|
|VA Southeast Network (7)||2,459||1,959||80%|
|VA Sunshine Healthcare Network (8)||3,100||2,509||81%|
|VA MidSouth Healthcare Network (9)||852||672||79%|
|VA Healthcare System of Ohio (10)||544||427||79%|
|Veterans in Partnership - VISN 11 (11)||775||660||85%|
|VA Great Lakes Health Care System (12)||787||606||77%|
|VA Heartland Network (15)||550||450||82%|
|South Central VA Health Care Network (16)||2,060||1,726||84%|
|VA Heart of Texas Health Care Network (17)||1,197||981||82%|
|VA Southwest Health Care Network (18)||749||627||84%|
|VA Rocky Mountain Network (19)||424||360||85%|
|VA Northwest Network (20)||719||586||82%|
|VA Sierra Pacific Network (21)||1,182||939||79%|
|VA Desert Pacific Healthcare Network (22)||2,025||1,617||80%|
|VA Midwest Health Care Network (23)||369||304||82%|
5.2 Antiretroviral Therapy by Class
Antiretroviral medications are categorized into six classes which include nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), protease inhibitors (PI), fusion inhibitors (FI), CCR5 antagonists (CCR5), and integrase inhibitors (INTEGRASE). Department of Health and Human Services (DHHS) guidelines recommend a combination of two NRTIs plus either one NNRTI or a PI (with or without ritonavir for boosting).1 In accordance with these guidelines, at least 92% of Veterans on antiretrovirals in 2008 received NRTIs; the backbone of all DHHS preferred regimens. Fifty-seven percent of Veterans received PIs in 2008, 49% received NNRTIs, 6% received an integrase inhibitor, and less than one percent received a fusion inhibitor or CCR5 antagonist. Though the use of individual products within some classes fluctuated, the number of Veterans with HIV/AIDS receiving either a NRTI, PI or NNRTI has slowly increased since 2005 as shown in Figure 6.
Figure 6. Number of HIV Infected Veterans Receiving Antiretroviral Therapy by Class.
5.3 Trends in Specific Antiretroviral Product and Ingredient Use
Of Veterans with HIV/AIDS who were prescribed a PI in 2008, 39% received atazanavir, 33% received lopinavir/ritonavir, and less than 10% received each of the other available PIs. Use of nelfinavir, the third most widely prescribed PI in 2005, fell by 54% between 2005 and 2008. Forty-eight percent of Veterans prescribed a PI in 2008 received ritonavir; it is likely that most received ritonavir as a pharmacologic booster to increase the concentrations of the concomitant PI. This represents a 45% increase in ritonavir use since 2005 and is consistent with the literature showing the benefits of boosted PI regimens compared to unboosted PI regimens in attaining undetectable viral loads.3, 4, 5 All of the current DHHS preferred PI regimens are ritonavir boosted regimens.
Efavirenz is the most widely prescribed NNRTI; 80% of Veterans who received an NNRTI in 2008 were prescribed this agent; 15% received nevirapine and 5% received etravirine. Between 2005 and 2008 there was a 24% increase in the use of efavirenz containing products and a 29% decrease in the use of nevirapine. This is consistent with DHHS treatment guidelines which, since 2004, have recommended efavirenz as the preferred NNRTI.2
With regard to NRTIs, VHA providers appear to have shifted from zidovudine to tenofovir in accordance with 2008 DHHS guidelines. In 2008, use of zidovudine-containing products had decreased to 27% of those on antiretrovirals compared to 44% in 2005 while use of tenofovir containing products had increased from 46% in 2005 to 67% of those on antiretrovirals in 2008. Didanosine and stavudine use have dramatically decreased since 2005. Abacavir use has remained relatively constant at 24% of all Veterans on antiretrovirals in 2005 and 21% in 2008. Numbers of Veterans with HIV/AIDS prescribed each of the 28 currently available FDA approved products is shown in Table 7 while Figure 7 shows selected antiretroviral ingredient use over the past 12 years.
|Total Number of Veterans on ARV Therapy||16,830||17,312||18,054||18,670|
Figure 7. Number of HIV Infected Veterans Receiving Selected Antiretroviral Ingredients from VHA by Year
- Antiretroviral therapy. All FDA approved antiretroviral medications are included in this report. Information on use of antiretroviral medication was obtained from the CCR outpatient prescription files.
- Medication Use by Product. Data for amprenavir and zalcitabine are not presented as these two antiretroviral are no longer available from the manufacturer and neither was used in 2008.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. November 3, 2008; 1-139. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed July 22, 2009
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. March 23, 2004; 1-128. Available at http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL03232004003.pdf. Accessed July 22, 2009. Page 53.
- Shulman N, Zolopa A, Havlir D, et al. Virtual inhibitory quotient predicts response to ritonavir boosting of indinavir based therapy in human immunodeficiency virus-infected patients with ongoing viremia. Antimicrob Agents & Chemother, 2002. 46:3907-16. Available at http://www.ncbi.nlm.nih.gov/pubmed/12435695
- Dragsted UB, Gerstoft J, Youle M, et al. A randomized trial to evaluate lopinavir/ritonavir versus saquinavir/ritonavir in HIV-1 infected patients: the MaxCmin2 trial. Antivir Ther 2005. 10:735-743. Available at http://www.ncbi.nlm.nih.gov/pubmed/16218173
- Malan DR, Krantz E, David N, et al. Efficacy and safety of atazanavir with or without ritonavir as part of once-daily highly active antiretroviral therapy regimens in antiretroviral-naive patients. JAIDS 2008. 47:161-167. Available at http://www.ncbi.nlm.nih.gov/pubmed/17971713