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Canadian Journal of Public Health

, Volume 109, Issue 5–6, pp 800–809 | Cite as

The impact of drug coverage on viral suppression among people living with HIV in Ontario, Canada

  • Beth RachlisEmail author
  • Lucia Light
  • Sandra Gardner
  • Ann N. Burchell
  • Janet Raboud
  • Claire Kendall
  • Michael A. McIsaac
  • James Murray
  • Anita Rachlis
  • Sean B. Rourke
Quantitative Research
  • 123 Downloads

Abstract

Objectives

We investigated the effect of drug coverage on viral suppression (sVL) in Ontario, Canada, where there is no universal coverage of prescription drugs, including antiretroviral therapy (ART).

Methods

Ontarians without employment coverage may be eligible for varying degrees of coverage through government-sponsored programs. Remaining individuals pay all expenses entirely out of pocket. Among participants on ART enrolled in the Ontario HIV Treatment Network Cohort Study (OCS) who were interviewed in 2008–2013 with known or imputable drug coverage, we estimated the prevalence with sVL (< 200 copies/mL) as of their last viral load each year. We calculated prevalence ratios (PR) according to time-updated socio-economic and behavioural factors using multivariable generalized estimating equations with a log-link function. Multiple imputation was used to assess the sensitivity of these findings to different assumed missing data models.

Results

One thousand two hundred forty-seven participants were included (3463 person-years). Compared to study participants with employer coverage, individuals covered through the Ontario Drug Benefit (ODB) were less likely to be suppressed (PR, 95% confidence interval (CI) 0.96, 0.93–0.98). After multivariable adjustment, ODB remained independently associated with less success in achieving sVL (adjusted PR, 95% CI 0.98, 0.95–0.99). These findings were robust to different assumptions about the missing data.

Conclusion

Our findings suggest that drug coverage can affect viral suppression in our setting. Further research is needed to identify the mechanisms by which coverage interacts with individual patient factors to affect viral suppression. Mechanisms to improve access and coverage for ART are needed.

Keywords

HIV Viral suppression Prescription drug coverage 

Résumé

Objectifs

Nous avons étudié l’effet de la couverture médicamenteuse sur la suppression virale (sVL) en Ontario, au Canada, où il n’y a pas de couverture universelle des médicaments sur ordonnance, y compris les traitements antirétroviraux (ART).

Méthodes

Les Ontarien(ne)s sans couverture d’emploi peuvent être admissibles à divers degrés de couverture dans le cadre de programmes parrainés par le gouvernement. Les personnes restantes paient toutes les dépenses de leur poche. Parmi les participants sous médicaments ARV à l’étude de cohorte du Réseau ontarien de traitement du VIH (SCO) qui ont été interviewés en 2008–2013 avec une couverture médicamenteuse connue ou imputable, nous avons estimé la prévalence de sVL (<200 copies / mL) à partir de leur dernière charge virale à chaque année. Nous avons calculé les ratios de prévalence (PR) en fonction de facteurs socio-économiques et comportementaux mis à jour, en utilisant des équations d’estimation généralisées multivariées avec une fonction de liaison logarithmique. L’imputation multiple a été utilisée pour évaluer la sensibilité de ces résultats aux différents modèles de données manquantes supposées.

Résultats

1247 participants ont été inclus (3463 années-personnes). Comparativement aux participants à l’étude ayant une couverture d’employeur, les personnes couvertes par le Programme de médicaments de l’Ontario (PMO) étaient moins susceptibles d’être réprimées (Rapport de prévalence (PR), Intervalle de confiance (IC) 95%: 0,96, 0,93-0,98). Après ajustement multivariable, PMO est demeuré indépendamment associé avec moins de succès dans la réalisation de sVL (PR ajusté, IC à 95%: 0,98, 0,95-0,99). Ces résultats étaient robustes à différentes hypothèses concernant les données manquantes.

Conclusion

Nos résultats suggèrent que la couverture médicamenteuse peut affecter la suppression virale dans notre cadre. Des recherches supplémentaires sont nécessaires pour identifier les mécanismes par lesquels la couverture interagit avec les facteurs individuels du patient pour affecter la suppression virale. Des mécanismes visant à améliorer l’accès et la couverture des traitements antirétroviraux sont nécessaires.

Mots-clés

VIH Suppression virale Couverture des médicaments sur ordonnance 

Notes

Acknowledgements

The OHTN Cohort Study Team consists of Drs. Abigail Kroch (Principal Investigator), OHTN; Beth Rachlis, OHTN, Dignitas International and University of Toronto; Ann Burchell, St. Michael’s Hospital and University of Toronto; Kevin Gough, St. Michael’s Hospital; Jeffrey Cohen, Windsor Regional Hospital; Curtis Cooper, Ottawa General Hospital; Don Kilby, University of Ottawa Health Services; Fred Crouzat and Mona Loutfy, Maple Leaf Medical Clinic; Anita Rachlis, Nisha Andany, and Nicole Mittmann, Sunnybrook Health Sciences Centre; Irving Salit, Toronto General Hospital; Michael Silverman, St. Joseph’s Health Care; and Roger Sandre, Sudbury Regional Hospital.

We gratefully acknowledge all of the people living with HIV who volunteer to participate in the OHTN Cohort Study. We also acknowledge the work and support of OCS Governance Committee and Scientific Steering Committee members: Patrick Cupido, Joanne Lindsay, Adrian Betts, Les Bowman, Lisungu Chieza, Tracey Conway, Mark McCallum, John McTavish, Colleen Price, Rosie Thein, Claire Kendall, Breklyn Bertozzi, Barry Adam, David Brennan, Tony Antoniou, Ann Burchell, Curtis Cooper, Trevor Hart, Mona Loutfy, Kelly O’Brien, Sergio Rueda, and Anita Rachlis. The OHTN Cohort Study also acknowledges the work of past Governance Committee and Scientific Steering Committee members.

We thank all interviewers, data collectors, research associates, coordinators, nurses, and physicians who provide support for data collection. The authors wish to thank OCS staff for data management, IT support, and study coordination: Madison Kopansky-Giles, Robert Hudder, Lucia Light, Veronika Moravan, Nahid Qureshi, and Tsegaye Bekele. The OHTN Cohort Study is supported by the Ontario Ministry of Health and Long-Term Care.

We also acknowledge Public Health Ontario for supporting linkage with the HIV viral load database.

Funding statement

The Ontario HIV Treatment Network (OHTN) Cohort Study is funded by the AIDS Bureau, Ontario Ministry of Health and Long-Term Care. JR was supported by an OHTN Chair in Biostatistics. CK is supported by a CIHR-OHTN New Investigator Award.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

41997_2018_104_MOESM1_ESM.doc (116 kb)
ESM 1 (DOC 116 kb)

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Copyright information

© The Canadian Public Health Association 2018

Authors and Affiliations

  • Beth Rachlis
    • 1
    • 2
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  • Lucia Light
    • 1
  • Sandra Gardner
    • 2
    • 3
  • Ann N. Burchell
    • 4
    • 5
  • Janet Raboud
    • 2
    • 6
  • Claire Kendall
    • 7
    • 8
  • Michael A. McIsaac
    • 9
  • James Murray
    • 10
  • Anita Rachlis
    • 11
    • 12
  • Sean B. Rourke
    • 5
    • 13
  1. 1.The Ontario HIV Treatment NetworkTorontoCanada
  2. 2.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  3. 3.Baycrest Health SciencesTorontoCanada
  4. 4.Department of Family and Community MedicineUniversity of TorontoTorontoCanada
  5. 5.Department of Family and Community MedicineSt. Michael’s HospitalTorontoCanada
  6. 6.Toronto General Hospital Research InstituteUniversity Health NetworkTorontoCanada
  7. 7.Bruyère Research InstituteOttawaCanada
  8. 8.Department of Family MedicineUniversity of OttawaOttawaCanada
  9. 9.Department of Public Health SciencesQueens UniversityKingstonCanada
  10. 10.AIDS BureauOntario Ministry of Health and Long-Term CareTorontoCanada
  11. 11.Sunnybrook Health Sciences CentreTorontoCanada
  12. 12.Department of MedicineUniversity of TorontoTorontoCanada
  13. 13.Department of PsychiatryUniversity of TorontoTorontoCanada

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