Although, single tablet regimen (STR) efavirenz, emtricibine, and tenofovir disoproxil fumarate (EFV/FTC/TDF) may be appealing in HIV infected persons who are at high risk for non-adherence, the degree to which this simplified formulation affects adherence is not known. The virologic effectiveness of this STR in a potentially non-adherent population remains a concern, given the rapid selection of drug-resistance seen with these drugs. We performed a prospective observational study assessing adherence and virologic response to EFV/FTC/TDF STR among a cohort of homeless and marginally housed individuals. We compared adherence and viral suppression to historical controls followed in the same cohort. Adherence was higher in EFV/FTC/TDF STR regimen compared to non-one-pill once daily therapy (p=0.0060) after controlling for multiple confounders. Viral suppression (HIV RNA <50 c/ml) was greater in EFV/FTC/TDF STR than non-one pill daily regimens (69.2% vs 46.5%; p=0.02), but there was no difference in viral suppression after controlling for adherence. Once daily EFV/TNF/FTC STR appears to be a reasonable option for individuals with multiple barriers to adherence. Randomized clinical trials addressing various therapeutic strategies for this patient population are needed.

BackgroundDespite advances in resuscitation care, mortality rates following cardiac arrest (CA) remain high. Between one-quarter (in-hospital CA) and two-thirds (out of hospital CA) of patients admitted comatose to intensive care die of neurological injury. Neuroprognostication determines an informed and timely withdrawal of life sustaining treatment (WLST), sparing the patient unnecessary suffering, alleviating family distress and allowing a more utilitarian use of resources. The latest Resuscitation Council UK (2015) guidance on post-resuscitation care provides the current multi-modal neuroprognostication strategy to predict neurological outcome. Its modalities include neurological examination, neurophysiological tests, biomarkers and radiology. Despite each of the current strategy’s predictive modalities exhibiting limitations, meta-analyses show that three, namely PLR (pupillary light reflex), CR (corneal reflex) and N20 SSEP (somatosensory-evoked potential), accurately predict poor neurological outcome with low false positive rates. However, the quality of evidence is low, reducing confidence in the strategy’s results. While infrared pupillometry (IRP) is not currently used as a prognostication modality, it can provide a quantitative and objective measure of pupillary size and PLR, giving a definitive view of the second and third cranial nerve activity, a predictor of neurological outcome.MethodsThe proposed study will test the hypothesis, “in those patients who remain comatose following return of spontaneous circulation (ROSC) after CA, IRP can be used early to help predict poor neurological outcome”. A comprehensive review of the evidence using a PRISMA-P (2015) compliant methodology will be underpinned by systematic searching of electronic databases and the two authors selecting and screening eligible studies using the Cochrane data extraction and assessment template. Randomised controlled trials and retrospective and prospective studies will be included, and the quality and strength of evidence will be assessed using the Grading  of Recommendation, Assessment and Evaluation (GRADE) approach.DiscussionIRP requires rudimentary skill and is objective and repeatable. As a clinical prognostication modality, it may be utilised early, when the strategy’s other modalities are not recommended. Corroboration in the evidence would promote early use of IRP and a reduction in ICU bed days.Systematic review registrationPROSPERO CRD42018118180

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