The effect on survival of a multidimensional intervention project (SEAD) in HIV/AIDS patients with follow‐up and adherence (FUP/ADH) barriers

Abstract

Purpose of the study: Irregular FUP/ADH were associated with higher mortality and resource use [1]. SEAD was a multidimensional intervention project, designed from the patient's perspective, to specifically attend patients with poor FUP/ADH in an HIV/AIDS outpatient clinic. Methods: From Jan 2006 to May 2010, patients with poor FUP/ADH were offered SEAD inclusion, all were evaluated by a nurse or a psychologist (adherence collaborators) who assessed all the reasons and barriers precluding a correct FUP/ADH. For each identified problem, different interventions were planned, using our own resources or coordinating others. Follow-up was censored in Nov 2011. Time to death after being admitted to SEAD and the effect of SEAD program intervention were assessed with Kaplan-Meier curves, log-Rank test and a Cox regression model. Summary of results: Overall, 215 patients were assessed: mean age 45 years, 24% women, IDU 75%, with baseline ADH 90% in only 23%; median HIV-RNA and CD4 cell count were 377 copies/ml and 326 cell/mcL. Patients entered in SEAD due to poor ADH in 17%, FUP problems in 23%, and both 60%. Main reasons driving poor FUP/ADH were severe bio-psycho-social problems 28%, severe drug and/or alcohol abuse 26%, logistic problems 18%, other psychiatric disorders 13%, oversights 9%, unknown 4% and antiretroviral intolerance 2%. Only 54% of patients received;50% of planned interventions, due to population complexity. Cocaine/heroin and alcohol abuse were reported by 34% and 17% respectively. Afer a median follow-up of 3.7 [3.31-4.4] years 193 patients received a mean of 8 (2.5-12) interventions/year, achieving virological control in 64%. Probability of survival was 92%, 89% and 86% after 1, 2 and 3 years respectively. In Cox regression model an intervention of SEAD project higher than 50% of planned was an independent predictor of survival HR 0.336 (95% CI 0.156-0.725); p=0.005, after adjusting for age, alcohol or cocaine abuse, psychological attention, degree of adherence and follow-up, intravenous acquisition of HIV, and family support. Alcohol and cocaine abuse were associated with higher mortality HR 2.964 (95% CI 1.378-6.374); p=0.005 and HR 2.444 (95% CI 1.161-5.145); p=0.019. Conclusions: Being admitted to SEAD intervention project and receiving more than 50% of planned interventions increased survival expectancy.