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BETTER EFFECTIVENESS OF HERPES ZOSTER VACCINE IN PREVENTING HERPES ZOSTER OPHTHALMICUS WITH OCULAR INVOLVEMENT
A212
VA L U E I N H E A LT H 1 9 ( 2 0 1 6 ) A 1 - A 3 1 8
low- socioeconomic memory care assisted living facility is being conducted to evaluate the diagnosis and the appropriate treatment UTIs. Data collected from charts include demographic characteristics, serum creatinine and estimated clearance, medications, memory assessment scores, date of diagnosis of UTI, relevant laboratory testing, antibiotic regimen, and any complications. Results: The preliminary results showed that there were a total of 24 cases of documented uncomplicated UTI in the year 2014-2015. Out of these, urine analysis and culture were done on only 33% of the patients. Among the patients evaluated through urine analysis and culture, 20% of them reported to have positive urine culture. 25 % of the patients without urine analysis or positive urine culture did not receive any antibiotic therapy. Sulfamethoxazole-trimethoprim double strength was used as a treatment regimen in 75% patients with no urine analysis and negative urine culture. Amoxicillinclavulanate is prescribed in patients with a positive urine culture. Conclusions: Sulfamethoxazole-trimethoprim double strength was used as a therapy regimen in majority of the patients which is in accordance with the Infectious Diseases Society of America (IDSA) guidelines for treating acute non-complicated cystitis (UTI). The appropriateness of amoxicillin-clavulanate as the therapy agent of choice in patients with positive urine culture needs further analysis. PIN3 SYSTEMATIC REVIEW OF NOVEL THERAPEUTIC AGENTS FOR TREATMENT OF HEPATITIS C VIRUS INFECTION IN THE UNITED STATES Menges B L , Deitelzweig C , Lin J , Lingohr-Smith M , Lin G Novosys Health, Green Brook, NJ, USA .
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Objectives: Recently, there have been several novel therapeutic agents approved in the US for treatment of hepatitis C virus (HCV) infection. How these agents compare with each other is of important value to healthcare providers and US payers. Methods: A systematic literature search of PubMed and ClinicalTrials.gov between 2005 and 2015 was conducted. Publications describing phase III clinical trials evaluating the HCV treatment regimens ledispavir–sofosbuvir (LS), sofosbuvir (S), ombitasvir-paritaprevir-ritonavir-dasabuvir (OPRD), and grazoprevir–elbasvir (GE) were included. Data were extracted and reviewed by two independent researchers. Descriptive statistics were used to compare the results of the trials. Results: 19 publications (22 trials) were identified (LS= 4, S= 10, OPRD= 6 and GE= 2). Among the 2287 patients from LS trials, 66% (n= 1515) were male, 2267 patients had HCV genotype 1, and 13% (n= 291) had cirrhosis. Of the 2973 patients from S trials, 43% (n= 1291) were male, a majority had HCV genotype 3 (n= 1660), and 23% (n= 681) had cirrhosis. The OPRD trials included 2315 patients, of which 57% (n= 1331) were male, all patients had HCV genotype 1 and 16% (n= 380) had cirrhosis. The GE trials included 656 patients of which, 61% were male (n= 399), 616 had HCV genotype 1 and 18% had cirrhosis (n= 117). Among the treatment regimens, the sustained virologic response rates measured at 12 weeks post treatment (SVR12) were 94%-99%, 67%97%, 92%-99.5%, and 95% for LS, S, OPRD and GE, respectively. Conclusions: All HCV treatment regimens reviewed had relatively high SVR12 rates which were superior to historical control rates (60% for treatment naïve). The majority of the HCV treatment regimens evaluated were used for treating patients with HCV genotype 1. Further study is needed to determine the most effective therapies for the different HCV genotypes and how these treatments compare in the real-world setting. PIN4 BETTER EFFECTIVENESS OF HERPES ZOSTER VACCINE IN PREVENTING HERPES ZOSTER OPHTHALMICUS WITH OCULAR INVOLVEMENT Tseng H F , Zheng C , Luo Y , Sy L S , Mercado C , Jacobsen S J Kaiser Permanente Southern California, Pasadena, CA, USA .
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Objectives: Herpes zoster ophthalmicus (HZO) occurs when the varicella-zoster virus is reactivated in the ophthalmic division of the trigeminal nerve, either with or without ocular involvement. Serious sequelae, including chronic ocular inflammation, vision loss, and disabling pain can occur in patients with ocular involvement. Our previous study reported that herpes zoster (HZ) vaccine was effective in protecting against HZO with ocular involvement. The aim was to confirm this observation by taking advantage of a novel natural language processing (NLP) algorithm to identify HZO patients with ocular involvement avoiding time-consuming chart review Methods: This study included Kaiser Permanente Southern California members who were at least 60 years old. The vaccinated cohort included 176,078 members who received HZ vaccine during 01/01/2007 through 12/31/2014. Each vaccinated member was matched to three unvaccinated members on age, sex, and length of membership. Individuals were passively followed through their electronic health records to identify incident HZ cases, who were further classified into HZO with ocular involvement, HZO without ocular involvement, and other HZ using a validated NLP algorithm applied to free-text clinical records. Cox regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) associated with vaccination. Results: The number of HZO cases with ocular involvement was 293 in 653,734 person-years (0.4 per 1,000 person-years; 95% CI, 0.4-0.5) among the vaccinated and 1,258 in 1,400,716 person-years (0.9 per 1,000 person-years; 95% CI, 0.8-0.9) among the unvaccinated. HZ vaccination was associated with a reduced risk of HZO with ocular involvement (adjusted HR= 0.41; 95% CI, 0.35-0.48). The reduced risk was more prominent compared to HZO without ocular involvement (adjusted HR= 0.65; 95% CI, 0.58-0.73) and other HZ (adjusted HR= 0.50; 95% CI, 0.480.52). Conclusions: This large scale study confirms our previous observation that HZ vaccine provides better protection against HZO with ocular involvement than against other HZ or against HZO without ocular involvement. PIN5 SUSCEPTIBILITY PROFILE OF CLINICAL ISOLATES OF ESCHERICHIA COLI TO THIRD-GENERATION CEPHALOSPORINS M 1, Hussain T 2, Waqas
M3
Zubair Medical and Dental College, Peshawar, Pakistan, 2National University of Sciences and Technology, Islamabad, Pakistan, 3Abdul Wali Khan University, Mardan, Pakistan .
1Peshawar
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Objectives: Escherichia coli is the most frequently encountered pathogen in community and hospital acquired infections. Cephalosporins are broad spectrum antibiotics commonly administered in empiric therapy for treatment of infections caused by gram negative pathogens including Escherichia coli. The aim of this study was to investigate the susceptibility profile of clinical isolates of Escherichia coli to third generation cephalosporin antibiotics. Methods: Fifty seven isolates of Escherichia coli were collected from the microbiology laboratory of Khyber Teaching Hospital during the summer of 2015. Susceptibility profile of the isolates to third-generation cephalosporins was determined by the Kirby-Bauer disc diffusion tests. Results: All of the Escherichia coli isolates showed resistance to various third-generation cephalosporins tested. Fifteen percent of the isolates were resistant to cefotaxime, 24% to ceftriaxone, 22% to ceftizoxime, 19% to ceftazidime, 13% to cefixime, 16% to ceftibuten and 7% to cefoperazone. Conclusions: The results show that resistance to third-generation cephalosporins is booming in clinical isolates of Escherichia coli. Inappropriate use of these antibiotics is the common reason for rendering bacteria resistant. To preserve the effectiveness of cephalosporins, proper administration and preparation of more advanced generations of cephalosporins is warranted. PIN6 EFFICACY, SAFETY, AND COST-EFFECTIVENESS OF 13-VALENT PNEUMOCOCCAL VACCINE: OVERVIEW OF THE LITERATURE FOR INCORPORATION PURPOSES Godói I P 1, Nascimento R C 2, Lemos L L 3, Almeida A M 4, Acurcio F A 3, Guerra Júnior A A 3 1Federal University of Minas Gerais; CCATES, Belo Horizonte, Brazil, 2College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil, 3CCATES, Federal University of Minas Gerais, Belo Horizonte, Brazil, 4College of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil .
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Objectives: Until recently two conjugated pneumococcal vaccines were available, PCV7 and PCV10. This study evaluated the efficacy, safety and cost-effectiveness of 13-valent pneumococcal vaccine (PCV13), a vaccine licensed in 2010 for the prevention against Streptococcus pneumoniae infections, as a first step in the evaluation of possible incorporation into health systems. Methods: Medline, The Cochrane Library, Lilacs and the Centre for Reviews Dissemination were searched for systematic reviews (SR) with meta-analysis evaluating the efficacy and safety of PCV13 in the prevention of pneumococcal disease in children, and for pharmacoeconomic studies evaluating the use of PCV13 compared to PCV10 and/or PCV7. The quality of evidence was assessed using the modified GRADE system. Results: We included one SR with meta-analysis comparing PCV7 to PCV13, and 11 pharmacoeconomic studies, including ten cost-effectiveness analyses of PCV7, PCV10 and PCV13. The SR, of moderate quality, demonstrated similar safety profile between therapeutic alternatives and superior efficacy of PCV13. The pharmacoeconomic studies showed different results of cost-effectiveness: PCV10 was dominated in four (Argentina; Japan; Colombia; and Sweden in a study sponsored by GSK); PCV13 in three (Germany and Greece; Mexico; Singapore); and no preference in three (Holland; Australia; and Denmark and Sweden in a study sponsored by Pfizer). Neither PCV10 nor PCV13 was cost-effective in Thailand (cost-utility analysis). Conclusions: In general, PCV13 and PCV10 presented similar safety and efficacy profiles. PCV13 provides protection for three additional serotypes associated with pneumonia, however these are not commonly found in the community. PCV10, on the other hand, provides better result for otitis. Individual countries should take this into account when assessing incorporation. Also, economic studies show that the cost of the technology is the main factor to be considered, indicating that PCV13 will have a favorable ratio only if the cost of the vaccination schedule is equivalent or lower than PCV10. PIN7 ASSOCIATION OF INTERFERON-BASED THERAPY AND CARDIOVASCULAR DISEASE IN CHRONIC HEPATITIS C PATIENTS IN THE UNITED STATES Wang W , Park H University of Florida, Gainesville, FL, USA .
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Objectives: A recent meta-analysis found that individuals infected with hepatitis C virus (HCV) had increased risks of cardiovascular disease (CVD) and CVD-related mortality. This study aimed to examine whether antiviral therapy for HCV infection was associated with improved CVD outcomes. Methods: A retrospective cohort study was conducted using administrative claims from Truven Health MarketScan Commercial Claims Database (2008-2013). Patients > = 18 years old with newly diagnosed HCV by ICD-9-CM codes, who initiated interferon-based therapy (treated cohort) and matched untreated controls (untreated cohort), had no prior history of CVD at least 12 months were included. Patient who had > = 1 prescription of IBT will be counted as treated person. The index date was defined as the first date of prescription claim for interferon. Patients were followed up for the occurrence of the first CVD including Coronary Heart Disease (CHD), Cerebrovascular Disease (CCV), Peripheral Arterial Disease (PAD), and Congestive Heart Failure (CHF). Cox proportional hazard models with propensity score matching (1:1) were employed. Results: In the propensity score-matched cohorts, a total of 11,232 HCV patients were identified to meet the inclusion criteria (treated cohort: n= 5616, mean age= 52yrs, 61.20% male; untreated cohort: n= 5616, mean age= 51yrs, 58.56% male). During 8,695.6 person-years of treated cohort follow-up, 302 CVD cases happened (crude incidence: 34.73/1000 person-yrs), while 365 events occurred during the 8,557.6 person-years of follow up time in untreated cohort (crude incidence: 42.65/1000 person-yrs). After multivariate adjustment, antiviral therapy was associated with the decreased risk of CVD compared to untreated cohort, although this was not statistically significant (HR= 0.931 95%CI 0.797-1.088). Conclusions: Our findings suggest that antiviral treatment for HCV infection was associated with reduced CVD risk in HCV patients, although this was not statistically significant. Further study are needed to examine the effects of adherence to antiviral therapy on CVD outcomes. PIN8 ANTIRETROVIRALS AND CO-PRESCRIBED DRUGS FOR PEOPLE LIVING WITH HIV/AIDS IN A UNIVERSITY TEACHING HOSPITAL, SOUTH WEST NIGERIA Oreagba I A , Usman S O , Akanmu S University of Lagos, Lagos, Nigeria .
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VA L U E I N H E A LT H 1 9 ( 2 0 1 6 ) A 1 - A 3 1 8
low- socioeconomic memory care assisted living facility is being conducted to evaluate the diagnosis and the appropriate treatment UTIs. Data collected from charts include demographic characteristics, serum creatinine and estimated clearance, medications, memory assessment scores, date of diagnosis of UTI, relevant laboratory testing, antibiotic regimen, and any complications. Results: The preliminary results showed that there were a total of 24 cases of documented uncomplicated UTI in the year 2014-2015. Out of these, urine analysis and culture were done on only 33% of the patients. Among the patients evaluated through urine analysis and culture, 20% of them reported to have positive urine culture. 25 % of the patients without urine analysis or positive urine culture did not receive any antibiotic therapy. Sulfamethoxazole-trimethoprim double strength was used as a treatment regimen in 75% patients with no urine analysis and negative urine culture. Amoxicillinclavulanate is prescribed in patients with a positive urine culture. Conclusions: Sulfamethoxazole-trimethoprim double strength was used as a therapy regimen in majority of the patients which is in accordance with the Infectious Diseases Society of America (IDSA) guidelines for treating acute non-complicated cystitis (UTI). The appropriateness of amoxicillin-clavulanate as the therapy agent of choice in patients with positive urine culture needs further analysis. PIN3 SYSTEMATIC REVIEW OF NOVEL THERAPEUTIC AGENTS FOR TREATMENT OF HEPATITIS C VIRUS INFECTION IN THE UNITED STATES Menges B L , Deitelzweig C , Lin J , Lingohr-Smith M , Lin G Novosys Health, Green Brook, NJ, USA .
.
.
.
.
.
Objectives: Recently, there have been several novel therapeutic agents approved in the US for treatment of hepatitis C virus (HCV) infection. How these agents compare with each other is of important value to healthcare providers and US payers. Methods: A systematic literature search of PubMed and ClinicalTrials.gov between 2005 and 2015 was conducted. Publications describing phase III clinical trials evaluating the HCV treatment regimens ledispavir–sofosbuvir (LS), sofosbuvir (S), ombitasvir-paritaprevir-ritonavir-dasabuvir (OPRD), and grazoprevir–elbasvir (GE) were included. Data were extracted and reviewed by two independent researchers. Descriptive statistics were used to compare the results of the trials. Results: 19 publications (22 trials) were identified (LS= 4, S= 10, OPRD= 6 and GE= 2). Among the 2287 patients from LS trials, 66% (n= 1515) were male, 2267 patients had HCV genotype 1, and 13% (n= 291) had cirrhosis. Of the 2973 patients from S trials, 43% (n= 1291) were male, a majority had HCV genotype 3 (n= 1660), and 23% (n= 681) had cirrhosis. The OPRD trials included 2315 patients, of which 57% (n= 1331) were male, all patients had HCV genotype 1 and 16% (n= 380) had cirrhosis. The GE trials included 656 patients of which, 61% were male (n= 399), 616 had HCV genotype 1 and 18% had cirrhosis (n= 117). Among the treatment regimens, the sustained virologic response rates measured at 12 weeks post treatment (SVR12) were 94%-99%, 67%97%, 92%-99.5%, and 95% for LS, S, OPRD and GE, respectively. Conclusions: All HCV treatment regimens reviewed had relatively high SVR12 rates which were superior to historical control rates (60% for treatment naïve). The majority of the HCV treatment regimens evaluated were used for treating patients with HCV genotype 1. Further study is needed to determine the most effective therapies for the different HCV genotypes and how these treatments compare in the real-world setting. PIN4 BETTER EFFECTIVENESS OF HERPES ZOSTER VACCINE IN PREVENTING HERPES ZOSTER OPHTHALMICUS WITH OCULAR INVOLVEMENT Tseng H F , Zheng C , Luo Y , Sy L S , Mercado C , Jacobsen S J Kaiser Permanente Southern California, Pasadena, CA, USA .
.
.
.
.
.
.
.
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Objectives: Herpes zoster ophthalmicus (HZO) occurs when the varicella-zoster virus is reactivated in the ophthalmic division of the trigeminal nerve, either with or without ocular involvement. Serious sequelae, including chronic ocular inflammation, vision loss, and disabling pain can occur in patients with ocular involvement. Our previous study reported that herpes zoster (HZ) vaccine was effective in protecting against HZO with ocular involvement. The aim was to confirm this observation by taking advantage of a novel natural language processing (NLP) algorithm to identify HZO patients with ocular involvement avoiding time-consuming chart review Methods: This study included Kaiser Permanente Southern California members who were at least 60 years old. The vaccinated cohort included 176,078 members who received HZ vaccine during 01/01/2007 through 12/31/2014. Each vaccinated member was matched to three unvaccinated members on age, sex, and length of membership. Individuals were passively followed through their electronic health records to identify incident HZ cases, who were further classified into HZO with ocular involvement, HZO without ocular involvement, and other HZ using a validated NLP algorithm applied to free-text clinical records. Cox regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) associated with vaccination. Results: The number of HZO cases with ocular involvement was 293 in 653,734 person-years (0.4 per 1,000 person-years; 95% CI, 0.4-0.5) among the vaccinated and 1,258 in 1,400,716 person-years (0.9 per 1,000 person-years; 95% CI, 0.8-0.9) among the unvaccinated. HZ vaccination was associated with a reduced risk of HZO with ocular involvement (adjusted HR= 0.41; 95% CI, 0.35-0.48). The reduced risk was more prominent compared to HZO without ocular involvement (adjusted HR= 0.65; 95% CI, 0.58-0.73) and other HZ (adjusted HR= 0.50; 95% CI, 0.480.52). Conclusions: This large scale study confirms our previous observation that HZ vaccine provides better protection against HZO with ocular involvement than against other HZ or against HZO without ocular involvement. PIN5 SUSCEPTIBILITY PROFILE OF CLINICAL ISOLATES OF ESCHERICHIA COLI TO THIRD-GENERATION CEPHALOSPORINS M 1, Hussain T 2, Waqas
M3
Zubair Medical and Dental College, Peshawar, Pakistan, 2National University of Sciences and Technology, Islamabad, Pakistan, 3Abdul Wali Khan University, Mardan, Pakistan .
1Peshawar
.
.
Objectives: Escherichia coli is the most frequently encountered pathogen in community and hospital acquired infections. Cephalosporins are broad spectrum antibiotics commonly administered in empiric therapy for treatment of infections caused by gram negative pathogens including Escherichia coli. The aim of this study was to investigate the susceptibility profile of clinical isolates of Escherichia coli to third generation cephalosporin antibiotics. Methods: Fifty seven isolates of Escherichia coli were collected from the microbiology laboratory of Khyber Teaching Hospital during the summer of 2015. Susceptibility profile of the isolates to third-generation cephalosporins was determined by the Kirby-Bauer disc diffusion tests. Results: All of the Escherichia coli isolates showed resistance to various third-generation cephalosporins tested. Fifteen percent of the isolates were resistant to cefotaxime, 24% to ceftriaxone, 22% to ceftizoxime, 19% to ceftazidime, 13% to cefixime, 16% to ceftibuten and 7% to cefoperazone. Conclusions: The results show that resistance to third-generation cephalosporins is booming in clinical isolates of Escherichia coli. Inappropriate use of these antibiotics is the common reason for rendering bacteria resistant. To preserve the effectiveness of cephalosporins, proper administration and preparation of more advanced generations of cephalosporins is warranted. PIN6 EFFICACY, SAFETY, AND COST-EFFECTIVENESS OF 13-VALENT PNEUMOCOCCAL VACCINE: OVERVIEW OF THE LITERATURE FOR INCORPORATION PURPOSES Godói I P 1, Nascimento R C 2, Lemos L L 3, Almeida A M 4, Acurcio F A 3, Guerra Júnior A A 3 1Federal University of Minas Gerais; CCATES, Belo Horizonte, Brazil, 2College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil, 3CCATES, Federal University of Minas Gerais, Belo Horizonte, Brazil, 4College of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil .
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Objectives: Until recently two conjugated pneumococcal vaccines were available, PCV7 and PCV10. This study evaluated the efficacy, safety and cost-effectiveness of 13-valent pneumococcal vaccine (PCV13), a vaccine licensed in 2010 for the prevention against Streptococcus pneumoniae infections, as a first step in the evaluation of possible incorporation into health systems. Methods: Medline, The Cochrane Library, Lilacs and the Centre for Reviews Dissemination were searched for systematic reviews (SR) with meta-analysis evaluating the efficacy and safety of PCV13 in the prevention of pneumococcal disease in children, and for pharmacoeconomic studies evaluating the use of PCV13 compared to PCV10 and/or PCV7. The quality of evidence was assessed using the modified GRADE system. Results: We included one SR with meta-analysis comparing PCV7 to PCV13, and 11 pharmacoeconomic studies, including ten cost-effectiveness analyses of PCV7, PCV10 and PCV13. The SR, of moderate quality, demonstrated similar safety profile between therapeutic alternatives and superior efficacy of PCV13. The pharmacoeconomic studies showed different results of cost-effectiveness: PCV10 was dominated in four (Argentina; Japan; Colombia; and Sweden in a study sponsored by GSK); PCV13 in three (Germany and Greece; Mexico; Singapore); and no preference in three (Holland; Australia; and Denmark and Sweden in a study sponsored by Pfizer). Neither PCV10 nor PCV13 was cost-effective in Thailand (cost-utility analysis). Conclusions: In general, PCV13 and PCV10 presented similar safety and efficacy profiles. PCV13 provides protection for three additional serotypes associated with pneumonia, however these are not commonly found in the community. PCV10, on the other hand, provides better result for otitis. Individual countries should take this into account when assessing incorporation. Also, economic studies show that the cost of the technology is the main factor to be considered, indicating that PCV13 will have a favorable ratio only if the cost of the vaccination schedule is equivalent or lower than PCV10. PIN7 ASSOCIATION OF INTERFERON-BASED THERAPY AND CARDIOVASCULAR DISEASE IN CHRONIC HEPATITIS C PATIENTS IN THE UNITED STATES Wang W , Park H University of Florida, Gainesville, FL, USA .
.
Objectives: A recent meta-analysis found that individuals infected with hepatitis C virus (HCV) had increased risks of cardiovascular disease (CVD) and CVD-related mortality. This study aimed to examine whether antiviral therapy for HCV infection was associated with improved CVD outcomes. Methods: A retrospective cohort study was conducted using administrative claims from Truven Health MarketScan Commercial Claims Database (2008-2013). Patients > = 18 years old with newly diagnosed HCV by ICD-9-CM codes, who initiated interferon-based therapy (treated cohort) and matched untreated controls (untreated cohort), had no prior history of CVD at least 12 months were included. Patient who had > = 1 prescription of IBT will be counted as treated person. The index date was defined as the first date of prescription claim for interferon. Patients were followed up for the occurrence of the first CVD including Coronary Heart Disease (CHD), Cerebrovascular Disease (CCV), Peripheral Arterial Disease (PAD), and Congestive Heart Failure (CHF). Cox proportional hazard models with propensity score matching (1:1) were employed. Results: In the propensity score-matched cohorts, a total of 11,232 HCV patients were identified to meet the inclusion criteria (treated cohort: n= 5616, mean age= 52yrs, 61.20% male; untreated cohort: n= 5616, mean age= 51yrs, 58.56% male). During 8,695.6 person-years of treated cohort follow-up, 302 CVD cases happened (crude incidence: 34.73/1000 person-yrs), while 365 events occurred during the 8,557.6 person-years of follow up time in untreated cohort (crude incidence: 42.65/1000 person-yrs). After multivariate adjustment, antiviral therapy was associated with the decreased risk of CVD compared to untreated cohort, although this was not statistically significant (HR= 0.931 95%CI 0.797-1.088). Conclusions: Our findings suggest that antiviral treatment for HCV infection was associated with reduced CVD risk in HCV patients, although this was not statistically significant. Further study are needed to examine the effects of adherence to antiviral therapy on CVD outcomes. PIN8 ANTIRETROVIRALS AND CO-PRESCRIBED DRUGS FOR PEOPLE LIVING WITH HIV/AIDS IN A UNIVERSITY TEACHING HOSPITAL, SOUTH WEST NIGERIA Oreagba I A , Usman S O , Akanmu S University of Lagos, Lagos, Nigeria .
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