Risk factors and outcomes for late presentation for HIV-positive persons in Europe: results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE)

Late presentation for HIV remains a major health issue in Spain: Results from a multicenter cohort study, 2004-2018

OBJECTIVES

With the purpose of reducing the well-known negative impact of late presentation (LP) on people living with HIV (PLWH), guidelines on early HIV diagnosis were published in 2014 in Spain, but since then no data on LP prevalence have been published. To estimate prevalence and risk factors of LP and to evaluate their impact on the development of clinical outcomes in the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) during 2004-2018.

METHODS

CoRIS is an open prospective multicenter cohort of PLWH, adults, naive to ART at entry. LP was defined as HIV diagnosis with CD4 count ≤350 cells/μL or an AIDS defining event (ADE). Multivariable Poisson regression models were used to estimate both prevalence ratios (PR) for the association of potential risk factors with LP and Incidence rate ratios (IRRs) for its impact on the development of the composite endpoint (first ADE, first serious non-AIDS event [SNAE] or overall mortality).

RESULTS

14,876 individuals were included. Overall, LP prevalence in 2004-2018 was 44.6%. Risk factors for LP included older age, having been infected through injection drug use or heterosexual intercourse, low educational level and originating from non-European countries. LP was associated with an increased risk of the composite endpoint (IRR: 1.34; 95%CI 1.20, 1.50), ADE (1.39; 1.18, 1.64), SNAE (1.22; 1.01, 1.47) and mortality (1.71; 1.41, 2.08).

CONCLUSIONS

LP remains a health problem in Spain, mainly among certain populations, and is associated with greater morbidity and mortality. Public policies should be implemented to expand screening and early diagnosis of HIV infection, for a focus on those at greatest risk of LP.

Characteristics of heterosexually-acquired compared to homosexually-acquired HIV and implications for clinical practice: results from the Australian HIV Observational Database

Heterosexuals living with HIV report feeling additional HIV stigma compared to homosexual men, which may affect clinical outcomes. Yet, beyond routinely collected surveillance data, little is known about the characteristics of individuals who acquire HIV heterosexually and clinical outcomes by mode of sexual acquisition have not been directly compared. Using data from the Australian HIV Observational Database, we compared clinical characteristics of those with heterosexually-acquired (Het-HIV) to homosexually-acquired HIV (Hom-HIV) to investigate any differences and their implications for clinical management. 513 Het-HIV and 1467 Hom-HIV patients were included and contributed 3,127 and 9,457 person-years of follow-up, respectively. Compared with Hom-HIV, Het-HIV were more often born outside Australia (62.5% vs 39.9%, p<0.001), less likely to have Hepatitis C (4.8% vs 7.8%, p=0.029) and had lower median CD4 counts at diagnosis (292 vs 450 cells/µL, p<0.001) and cART initiation (270 vs 340 cells/µL, p<0.001). Despite these lower CD4 counts, there were no significant differences between groups for time to the major clinical endpoints of cART initiation, viral suppression, virological failure or all-cause mortality. Het-HIV had a lower risk of loss-to-follow-up than Hom-HIV (aHR 0.78; 95% CI 0.64-0.95). Further studies examining factors associated with, and interventions to inform retention in care are required.

Tracking missed opportunities for an early HIV diagnosis in a population of people living with HIV with known time of infection

PURPOSE

The goal of 90-90-90 first requires the expansion of access to HIV testing. Our aim was to record frequencies of HIV indicator conditions (ICs) and identify missed opportunities for an early HIV diagnosis.

METHODS

We retrospectively identified ICs in a population of 231 people living with HIV with known infection dates who attended our clinic. The study population was divided into four groups: (1) those self-tested pre-emptively (47/231, 20.3%), (2) those offered targeted testing based on risk factors (67/231, 29%), (3) those tested after an IC (73/231, 31.6%) and (4) those who were not offered testing after an IC (44/231, 19%). HIV acquisition dates were estimated by molecular clock analysis.

RESULTS

A total of 169 healthcare contacts (HCCs) were recorded. The most frequent HCC was mononucleosis-like syndrome (20.1%), unexplained weight loss (10.7%) and STIs (10.1%). AIDS-defining conditions were detected in 11.8%. Only 62.4% (73/117) of those with an IC were offered testing after their first HCC. Patients in group 4 had statistically significant delay in diagnosis compared with group 3 (109.1 weeks (IQR 56.4-238.6) vs 71.6 weeks (IQR 32.3-124.6)). The proportion of patients diagnosed as late presenters in each group was: (1) 16/47 (34%), (2) 37/67 (55.2%), (3) 43/73 (58.9%) and (4) 27/44 (61.4%) (p=0.027).

CONCLUSIONS

Our study uses a combination of molecular and clinical data and shows evidence that late presentation occurs in a high proportion of patients even in the presence of an IC. Given that risk-based targeted testing has low coverage, IC-guided testing provides a reasonable alternative to facilitate earlier HIV diagnosis and to improve late diagnosis across Europe and globally.

Late initiation of antiretroviral therapy: inequalities by educational level despite universal access to care and treatment

Background

Late antiretroviral treatment initiation for HIV disease worsens health outcomes and contributes to ongoing transmission. We investigated whether socioeconomic inequalities exist in access to treatment in a setting with universal access to care and treatment.

Methods

This study investigated the association of educational level, used as a proxy for socioeconomic status, with late treatment initiation and treatment initiation with advanced disease. Study participants included adults (≥25 years) who started treatment from 2005 to 2018 at Instituto Nacional de Infectologia Evandro Chagas of Fundação Oswaldo Cruz (INI/FIOCRUZ), Rio de Janeiro, Brazil. Educational level was categorized following UNESCO’s International Standard Classification of Education: incomplete basic education, basic education, secondary level, and tertiary level. We defined late treatment initiation as those initiating treatment with a CD4 < 350 cells/mL or an AIDS-defining event, and treatment initiation with advanced disease as those initiating treatment with a CD4 < 200 cells/mL or an AIDS-defining event. A directed acyclic graph (DAG) was constructed to represent the theoretical-operational model and to understand the involvement of covariates. Logistic regression models were used to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (95%CI). Multiple imputation using a chained equations approach was used to treat missing values and non-linear terms for continuous variables were tested.

Results

In total, 3226 individuals composed the study population: 876 (27.4%) had incomplete basic education, 540 (16.9%) basic, 1251 (39.2%) secondary level, and 525 (16.4%) tertiary level. Late treatment initiation was observed for 2076 (64.4%) while treatment initiation with advanced disease was observed for 1423 (44.1%). Compared to tertiary level of education, incomplete basic, basic and secondary level increased the odds of late treatment initiation by 89% (aOR:1.89 95%CI:1.47–2.43), 61% (aOR:1.61 95%CI:1.23–2.10), and 35% (aOR:1.35 95%CI:1.09–1.67). Likewise, the odds of treatment initiation with advanced disease was 2.5-fold (aOR:2.53 95%CI:1.97–3.26), 2-fold (aOR:2.07 95%CI:1.59–2.71), 1.5-fold (aOR:1.51 95%CI:1.21–1.88) higher for those with incomplete basic, basic and secondary level education compared to tertiary level.

Conclusion

Despite universal access to HIV care and antiretroviral treatment, late treatment initiation and social inequalities persist. Lower educational level significantly increased the odds of both outcomes, reinforcing the existence of barriers to “universal” antiretroviral treatment.

Impact of Advanced HIV Disease on Quality of Life and Mortality in the Era of Combined Antiretroviral Treatment

Currently, AIDS or severe immunodeficiency remains as a challenge for people with HIV (PWHIV) and healthcare providers. Our purpose was to analyze the impact of advanced HIV disease (AHD) on mortality, life expectancy and health-related quality of life (HRQoL). We reviewed cohort studies and meta-analyses conducted in middle- and high-income countries. To analyze HRQoL, we selected studies that reported overall health and/or physical/mental health scores on a validated HRQoL instrument. AIDS diagnosis supposes a higher risk of mortality during the first six months, remaining higher for 48 months. It has been reported that cancer and cardiovascular disease persist as frequent causes of mortality in PWHIV, especially those with previous or current AHD. PWHIV who initiate combination antiretroviral therapy (cART) with CD4 < 200 cells/µL have significantly lower estimated life expectancy than those with higher counts. AHD is associated with lower HRQoL, and a worse physical health or mental health status. AIDS and non-AIDS defining events are significant predictors of a lower HRQoL, especially physical health status. AHD survivors are in risk of mortality and serious comorbidities, needing special clinical attention and preventive programs for associated comorbidities. Their specific needs should be reflected in HIV guidelines.

Acquired immune deficiency syndrome (AIDS) and late presentation in Poland - data from Test and Keep in Care (TAK) Polska project

OBJECTIVES

Late presentation (LP) at HIV diagnosis is associated with worse prognosis and an increase in the number of new infections. We analyse the proportion of patients diagnosed late and factors related to LP in Poland in 2016-2017.

METHODS

Data were obtained from 13 out of 17 HIV centres in Poland from 2016 and 2017, including date of diagnosis, age, sex, transmission route, anti-hepatitis C virus (anti-HCV), Venereal Diseases Research Laboratory (VDRL) antibodies, AIDS diagnosis, baseline HIV viral load and CD4 count.

RESULTS

Out of 1522 patients, 88.9% were male with median age of 33.6 years. Men who have sex with men (MSM) comprised 69.4% of all new infections, heterosexual route of transmission (HTX) 18.2% and injecting drug use (IDU) 4.7%. Late presenters comprised 44.8% of the study group. Factors associated with LP were female sex [odds ratio (OR) = 1.5, 95% confidence interval (95% CI): 1.09-2.08], older age (OR = 1.59, 95% CI: 1.42-1.79 per decade), route of transmission (HTX: OR = 1.96, 95% CI: 1.50-2.56; IDU: OR = 3.17, 95% CI: 1.92-5.37), positive HCV results (OR = 1.90, 95% CI: 1.23-2.95) and syphilis diagnosis (OR = 2.06, 95% CI: 2.29-3.31). Adjusting for these factors, the only independent factors associated with LP were age (OR = 1.52, 95% CI: 1.35-1.71) and route of transmission (HTX: OR = 1.73, 95% CI: 1.23-2.44; IDU: OR = 2.24, 95% CI: 1.25-4.10).

CONCLUSIONS

Late presentation in Poland follows European trends. A total of 44.8% of all newly diagnosed patients in Poland continue to present late or at the AIDS stage. Independent factors associated with LP/AIDS were older age, IDU and HTX. Patients from these groups should be targeted to improve early diagnosis and medical care.

Impact of the COVID-19 pandemic on testing services for HIV, viral hepatitis and sexually transmitted infections in the WHO European Region, March to August 2020

We present preliminary results of a coronavirus disease (COVID-19) impact assessment on testing for HIV, viral hepatitis and sexually transmitted infections in the WHO European Region. We analyse 98 responses from secondary care (n = 36), community testing sites (n = 52) and national level (n = 10). Compared to pre-COVID-19, 95% of respondents report decreased testing volumes during March–May and 58% during June–August 2020. Reasons for decreases and mitigation measures were analysed.

Antiretroviral treatment outcomes among late HIV presenters initiating treatment with integrase inhibitors or protease inhibitors

OBJECTIVES

The aim of the study was to investigate the efficacy and safety of first-line antiretroviral therapy (ART) with integrase inhibitor (INI) or protease inhibitor (PI)-based regimens in patients with low CD4 cell counts and/or an AIDS-defining disease.

METHODS

We conducted a retrospective, multicentre analysis to investigate discontinuation proportions and virological response in patients with CD4 cell counts < 200 cells/µL and/or AIDS-defining disease when starting first-line ART. Proportions of those discontinuing ART were compared using univariate analysis. Virological response was analysed using the Food & Drug Administration (FDA) snapshot analysis (HIV-1 RNA < 50 HIV-1 RNA copies/mL at week 48).

RESULTS

Two hundred and eighteen late presenters were included in the study: 13.8% were women and 23.8% were of non-European ethnicity, and the mean baseline CD4 count was 91 cells/µL (standard deviation 112 cells/µL). A total of 131 late presenters started on INI- and 87 on PI-based treatment. It was found that 86.1% of patients treated with INIs and 81.1% of patients treated with PIs had a viral load < 50 copies/mL at week 48; proportions of discontinuation because of adverse events were 6.1% in the INI group and 11.5% in the PI group. No significant differences in discontinuation proportions were observed at week 12 or 48 between INI- and PI-based regimens (P = 0.76 and 0.52, respectively). Virological response was equally good in those receiving INIs and those receiving PIs (86.1% vs. 81.1%, respectively; P = 0.36).

CONCLUSIONS

In a European cohort of late presenters starting first-line INI or PI-based ART regimens, there were no significant differences in discontinuation proportions or virological response at week 48.

Estimating the burden of HIV late presentation and its attributable morbidity and mortality across Europe 2010-2016

BACKGROUND

Late presentation (LP), defined as a CD4 count < 350/mm3 or an AIDS-event at HIV-diagnosis, remains a significant problem across Europe. Linking cohort and surveillance data, we assessed the country-specific burden of LP during 2010-2016 and the occurrence of new AIDS events or deaths within 12 months of HIV-diagnosis believed to be attributable to LP.

METHODS

Country-specific percentages of LP and AIDS-events/death rates (assessed with Poisson regression) observed in The Collaboration of Observational HIV Epidemiological Research Europe (COHERE) and EuroSIDA cohorts, were applied to new HIV-diagnoses reported to the European Centre for Disease Prevention and Control. The estimated number of LP in the whole population was then calculated, as was the number of excess AIDS-events/deaths in the first 12 months following HIV-diagnosis assumed to be attributable to LP (difference in estimated events between LP and non-LP).

RESULTS

Thirty-nine thousand two hundred four persons were included from the COHERE and EuroSIDA cohorts, of whom 18,967 (48.4%; 95% Confidence Interval [CI] 47.9-48.9) were classified as LP, ranging from 36.9% in Estonia (95%CI 25.2-48.7) and Ukraine (95%CI 30.0-43.8) to 64.2% in Poland (95%CI 57.2-71.3). We estimated a total of > 320,000 LP and 12,050 new AIDS-events/deaths attributable to LP during 2010-2016, with the highest estimated numbers of LP and excess AIDS-events/deaths in Eastern Europe. Country-level estimates of excess events ranged from 17 AIDS-events/deaths (95%CI 0-533) in Denmark to 10,357 (95%CI 7768-147,448) in Russia.

CONCLUSIONS

Across countries in Europe, the burden of LP was high, with the highest estimated number of LP and excess AIDS-events/deaths being in Eastern Europe. Effective strategies are needed to reduce LP and the attributable morbidity and mortality that could be potentially avoided.

Prescription of antimicrobials in primary health care as a marker to identify people living with undiagnosed HIV infection, Denmark, 1998 to 2016

Background

Development of additional diagnostic strategies for earlier HIV diagnosis are needed as approximately 50% of newly diagnosed HIV-infected individuals continue to present late for HIV care.

Aim

We aimed to analyse antimicrobial consumption in the 3 years preceding HIV diagnosis, assess whether there was a higher consumption in those diagnosed with HIV compared with matched controls and whether the level of consumption was associated with the risk of HIV infection.

Methods

We conducted a nested case–control study, identifying all individuals (n = 2,784 cases) diagnosed with HIV in Denmark from 1998 to 2016 and 13 age-and sex-matched population controls per case (n = 36,192 controls) from national registers. Antimicrobial drug consumption was estimated as defined daily doses per person-year. We used conditional logistic regression to compute odds ratios and 95% confidence intervals.

Results

In the 3 years preceding an HIV diagnosis, we observed more frequent and higher consumption of antimicrobial drugs in cases compared with controls, with 72.4% vs 46.3% having had at least one prescription (p < 0.001). For all antimicrobial classes, the association between consumption and risk of subsequent HIV diagnosis was statistically significant (p < 0.01). The association was stronger with higher consumption and with shorter time to HIV diagnosis.

Conclusion

HIV-infected individuals have a significantly higher use of antimicrobial drugs in the 3 years preceding HIV diagnosis than controls. Prescription of antimicrobial drugs in primary healthcare could be an opportunity to consider proactive HIV testing. Further studies need to identify optimal prescription cut-offs that could endorse its inclusion in public health policies.

Prospective International Study of Incidence and Predictors of Immune Reconstitution Inflammatory Syndrome and Death in People Living With Human Immunodeficiency Virus and Severe Lymphopenia

BACKGROUND

Patients living with human immunodeficiency virus (PLWH) with low CD4 counts are at high risk for immune reconstitution inflammatory syndrome (IRIS) and death at antiretroviral therapy (ART) initiation.

METHODS

We investigated the clinical impact of IRIS in PLWH and CD4 counts <100 cells/μL starting ART in an international, prospective study in the United States, Thailand, and Kenya. An independent review committee adjudicated IRIS events. We assessed associations between baseline biomarkers, IRIS, immune recovery at week 48, and death by week 48 with Cox models.

RESULTS

We enrolled 506 participants (39.3% were women). Median age was 37 years, and CD4 count was 29 cells/μL. Within 6 months of ART, 97 (19.2%) participants developed IRIS and 31 (6.5%) died. Participants with lower hemoglobin at baseline were at higher IRIS risk (hazard ratio [HR], 1.2; P = .004). IRIS was independently associated with increased risk of death after adjustment for known risk factors (HR, 3.2; P = .031). Being female (P = .004) and having a lower body mass index (BMI; P = .003), higher white blood cell count (P = .005), and higher D-dimer levels (P = .044) were also significantly associated with increased risk of death. Decision-tree analysis identified hemoglobin <8.5 g/dL as predictive of IRIS and C-reactive protein (CRP) >106 μg/mL and BMI <15.6 kg/m2 as predictive of death.

CONCLUSIONS

For PLWH with severe immunosuppression initiating ART, baseline low BMI and hemoglobin and high CRP and D-dimer levels may be clinically useful predictors of IRIS and death risk.

Cascade Analysis of Anonymous Voluntary HIV Counseling and Testing Among Patients with HIV Infection in Taiwan

Despite successful implementation of anonymous voluntary human immunodeficiency virus (HIV) counseling and testing (aVCT) in Taiwan, the trend of late HIV presentation in sexually active populations has remained unchanged in Taiwan over the past decade. We evaluated the effect and acceptance of an aVCT cascade program among Taiwanese individuals by surveying 572 participants (mean age: 29.6 years; 99.3% men; and 79.5% same-sex sexual contact) diagnosed with HIV/acquired immune deficiency syndrome (AIDS) from 2015 to 2019. We designed a five-stage continuum based on acceptance of the program before HIV diagnosis: at high risk of HIV infection (Stage 1), heard of aVCT (Stage 2), wants to receive aVCT (Stage 3), has received aVCT (Stage 4), and regularly receives aVCT (Stage 5). Four domains established from exploratory factor analysis described reasons for inability to reach the next aVCT stage: low perceived HIV risk, fear of testing positive because of discrimination/stigmatization, and structural barriers to aVCT. Regular aVCT (vs. never receiving aVCT) protected against AIDS on diagnosis (p < 0.001). There were no significant differences in program acceptance across 2015-2019. However, uptake reduced markedly across the program; the largest reduction (37.4.0-61.0%) occurred from Stage 4 to Stage 5. Fear of testing positive because of discrimination/stigmatization was the main reason for not proceeding to the next aVCT stage. Although the findings indicate the benefits of regular aVCT for early HIV diagnosis, additional strategies to reduce fear of negative social consequences of HIV infection are prioritized to optimize aVCT in Taiwan.

"Stigma and HIV Are Like Brother and Sister!": The Experience of African-Born Persons Living with HIV in the US

Minnesota has seen an increase in the number of immigrants from Africa, notably in the mid-1990s, making up around 2% of Minnesota’s total population. This population also faces many impediments that cause important difficulties not only for HIV prevention but also for treatment and care options. The objectives of this study were to capture the experiences of Persons Living with HIV (PLWH) in Minnesota (US) and to elicit their stories about their diagnosis news and what management strategies they use for coping with the stigma associated with the disease. Participants were recruited via fliers in pharmacies, clinics, and HIV service centers located in Minnesota. Recruitment continued until thematic saturation was obtained. Fourteen subjects participated in audio-recorded, semi-structured interviews that were transcribed verbatim into written text. The transcriptions were analyzed using Thematic Analysis. Three themes emerged from the data. Theme 1: Cruel News: “HIV-Oooooo! I wish I was dead”, Theme 2: This is My Secret! and Theme 3: “Stigma and HIV are brother and sister”. The results demonstrate that stigma is an ever-present problem in African-born PLWH living in the US. Participants perceived the stigma associated with HIV status to affect their lives and culture at individual, familial, and societal levels.

Overlooked cases of HIV infection: An Italian tale of missed diagnostic opportunities

BACKGROUND

Late diagnoses are still a cause of increased HIV-related morbidity and mortality despite the availability of highly effective treatments. The aim of this study was to identify indicator conditions (ICs) in late presenters with HIV infection (LPs) that may represent missed opportunities of undertaking earlier HIV testing.

METHODS

The medical records of LPs referred to a specialist clinic in Milan, Italy, between 2011 and 2017 were reviewed to assess the frequency of ICs during the five years preceding diagnosis. Logistic regression analysis was used to investigate the factors associated with missed opportunities of making an earlier diagnosis.

RESULTS

The analysis considered 203 LPs (60.6% of the patients newly diagnosed as having HIV infection during the study period). Most had had ≥1 medical encounter in the five years before diagnosis, and 54 (26.6%) had been diagnosed as having ≥1 IC without undergoing HIV testing. The most frequent ICs were herpes zoster (19.8%), constitutional symptoms (17.4%) and lympho/thrombocytopenia (12.8%), and the missed opportunities for testing occurred in the settings of primary care (44.9%), specialist medical (38.2%) or surgical services (11.3%), and emergency departments (5.6%). Twenty-five (53.2%) of the 47 subjects with a non AIDS-defining IC had AIDS at the time of the diagnosis of HIV infection. Subjects aged >60 years were at increased risk of missed diagnostic opportunities (aOR 4.80, p = 0.008).

CONCLUSION

Implementing IC-guided HIV testing in non-specialist settings is an essential means of reducing late diagnoses of HIV infection even in the case of older subjects.

Determinants and Outcomes of Late Presentation of HIV Infection in Migrants in Catalonia, Spain: PISCIS Cohort 2004-2016

This study using the Catalan PISCIS cohort explores risk factors of migrants' late presentation and the impact of late presentation on their health outcomes. We analyse 9590 new HIV diagnoses enrolled in the cohort between 2004 and 2016. Univariate and multivariate logistic regression models are used to identify risk factors associated with late presentation among migrants, giving crude and adjusted odds ratios and their 95% confidence intervals. Cox regression models are estimated to identify risk factors associated with AIDS/death, and crude and adjusted hazard ratios and 95% confidence intervals are reported. Late presentation is higher in migrants than non-migrants. Among migrants, region of origin is associated with late presentation and AIDS/death during follow-up. The results highlight persisting inequalities in HIV diagnosis and care among migrants in Catalonia. Targeted interventions addressed to specific subgroups in the migrant population are needed.

Has Increased Rollout of Direct Acting Antiviral Therapy Decreased the Burden of Late Presentation and Advanced Liver Disease in Patients Starting Hepatitis C Virus Therapy in Germany?

GOALS AND BACKGROUND

International guidelines recommend prioritized treatment initiation in hepatitis C virus (HCV)-infected patients with advanced liver disease. We aimed to evaluate whether the widespread usage of direct acting antivirals (DAAs) has led to a decrease in late presentation for care.

STUDY

Data derived from the multicenter German Hepatitis C Cohort (GECCO) was analyzed. Treatment naive HCV-infected patients initiating DAA-based treatment between January 2014 and September 2017 were included. Advanced liver disease was defined by aspartate aminotransferase to platelet ratio index score ≥1.5, METAVIR≥F3, or FibroScan ≥9.5 kPa. Period prevalence and risk factors for late presentation were evaluated.

RESULTS

Six hundred fifty-three HCV-monoinfected and 210 HIV/HCV-coinfected patients (mean age, 48.6±12.7 y; 65.5% male) were included. Overall 32.5% of patients had advanced liver disease. In 2014 39.4% of patients presented with advanced liver disease, decreasing to 30.1%, 34.4%, and 26.4% in the years 2015, 2016, and 2017 (P=0.057), respectively. Patients with and without advanced liver disease differed in age (P<0.0001), CD4 ≤350/µL (P=0.027), genotype (P=0.005), transmission route (P=0.047), body mass index (P<0.001), and time since diagnosis (P=0.007). In the multivariable binary logistic regression analysis GT3, age above 45 years and being diagnosed >2 years ago were positively and HCV transmission through men who have sex with men was negatively associated with advanced liver disease.

CONCLUSIONS

Overall 32.5% of patients presented with advanced liver disease. We observed a trend toward a lower proportion of patients starting treatment late.GT3, age, years since HCV diagnosis and HCV transmission route were identified as risk factors for presentation with advanced liver disease.

Nationwide Cohort Study of Antiretroviral Therapy Timing: Treatment Dropout and Virological Failure in China, 2011-2015

Background

People living with human immunodeficiency virus (PLWH) are still being diagnosed late, rendering the benefits of "early" antiretroviral therapy (ART) unattainable. Therefore, we aimed to evaluate the benefits of "immediate" ART.

Methods

A nationwide cohort of PLWH in China who initiated ART January 1, 2011, to December 31, 2014 and had baseline CD4 results >200 cells/μL were censored at 12 months, dropout, or death, whichever came first. Treatment dropout and virological failure (viral load ≥400 copies/mL) were measured. Determinants were assessed by Cox and log-binomial regression.

Results

The cohort included 123605 PLWH. The ≤30 days group had a significantly lower treatment dropout rate of 6.72%, compared to 8.91% for the 91-365 days group and to 12.64% for the >365 days group. The ≤30 days group also had a significantly lower virological failure rate of 5.45% (31-90 days: 7.39%; 91-365 days: 9.64%; >365 days: 12.67%). Greater risk of dropout (91-365 days: adjusted hazard ratio [aHR] = 1.33, 95% confidence interval [CI] = 1.25-1.42; >365 days: aHR = 1.55, CI = 1.47-1.54), and virological failure (31-90 days: adjusted risk ratio [aRR] = 1.35, CI = 1.26-1.45; 91-365 days: aRR = 1.66, CI = 1.55-1.78; >365 days: aRR = 1.85, CI = 1.74-1.97) were observed for those who delayed treatment.

Conclusions

ART within 30 days of HIV diagnosis was associated with significantly reduced risk of treatment failure, highlighting the need to implement test-and-immediately-treat policies.

Human immunodeficiency disease in new diagnoses of head and neck squamous cell cancer: are we testing?

BACKGROUND

Human immunodeficiency virus infected patients have a three-fold increased risk of head and neck squamous cell carcinoma. The British HIV Association recommends human immunodeficiency virus testing in all new diagnoses of head and neck squamous cell carcinoma.

OBJECTIVES

This observational study aimed to examine the current routine practice of human immunodeficiency virus testing in patients with newly diagnosed head and neck squamous cell carcinoma, and to address the importance of this test in promoting the early diagnosis and treatment of human immunodeficiency virus.

METHODS

All head and neck cancer multidisciplinary teams in England were questioned on their protocol for human immunodeficiency virus testing in new diagnoses of head and neck squamous cell carcinoma.

RESULTS

Only 1 out of 30 hospitals leading head and neck multidisciplinary teams (3.3 per cent) routinely offered human immunodeficiency virus testing in this high-risk patient group.

CONCLUSION

This observational study highlights that head and neck specialists are not aware of, and are consequently not complying with, routine human immunodeficiency virus testing as recommended by the British HIV Association guidelines.

Correlates of Late Presentation to HIV care in a South Indian Cohort

Late presentation to healthcare by HIV infected patients' is common in India despite access to free combination antiretroviral therapy (cART). We assessed risk factors for late presentation among patients with a recent HIV diagnosis in an academic university-based antiretroviral treatment center. This retrospective study included 474 recently diagnosed HIV-infected patients registered for cART between 2012 and 2013. Subjects with CD4⁺ T-lymphocyte (CD4) count ≤ 350 cells/μL or with an AIDS defining event were defined as late presenters (LP) and patients with CD4 count ≤ 200 cells/μL or with an AIDS defining event were defined as LP with advanced HIV disease (LPAD). Multivariable logistic regression analysis was used to investigate factors associated with late presentation. Of the 474 patients, 356 (75.1%) were LP. Of these, 299 (83.99%) were LPAD and 57 (16.01%) LP were AIDS-free. Median CD4 count among LP was 134 cells/μL (interquartile range 72.25-219). Mean age of LP was 42.50 ± 8.88 years; 256 (71.9%) were males. Increasing age (> 51 years; Adjusted odds ratio [aOR] 4.19; P = 0.014) and rural residence (aOR 3.19; P = < 0.001) were independently associated with late presentation. HIV-positive housewives (aOR 0.34; P = 0.027), HIV-positive individuals with negative partners (aOR 0.48; P = 0.006), and partners with unknown HIV status (aOR 0.43; P = 0.007) were less likely to present late compared with positive partners of people living with HIV/AIDS (PLWHA). Most patients were LP despite free access to cART. Rural population and older PLWHA should be targeted while implementing HIV care. There is a need to strengthen the HIV care cascade by linking PLWHA to cART immediately after diagnosis.

Improving the evidence for indicator condition guided HIV testing in Europe: Results from the HIDES II Study - 2012 - 2015

BACKGROUND

It is cost-effective to perform an HIV test in people with specific indicator conditions (IC) with an undiagnosed HIV prevalence of at least 0.1%. Our aim was to determine the HIV prevalence for 14 different conditions across 20 European countries.

METHODS

Individuals aged 18-65 years presenting for care with one of 14 ICs between January 2012 and June 2014 were included and routinely offered an HIV test. Logistic regression assessed factors associated with testing HIV positive. Patients presenting with infectious mononucleosis-like syndrome (IMS) were recruited up until September 2015.

RESULTS

Of 10,877 patients presenting with an IC and included in the analysis, 303 tested positive (2.8%; 95% CI 2.5-3.1%). People presenting with an IC in Southern and Eastern Europe were more likely to test HIV positive as were people presenting with IMS, lymphadenopathy and leukocytopenia/ thrombocytopenia. One third of people diagnosed with HIV after presenting with IMS reported a negative HIV test in the preceding 12 months. Of patients newly diagnosed with HIV where data was available, 92.6% were promptly linked to care; of these 10.4% were reported lost to follow up or dead 12 months after diagnosis.

CONCLUSION

The study showed that 10 conditions had HIV prevalences > 0.1%. These 10 ICs should be adopted into HIV testing and IC specialty guidelines. As IMS presentation can mimic acute HIV sero-conversion and has the highest positivity rate, this IC in particular affords opportunities for earlier diagnosis and public health benefit.

CD4 recovery is associated with genetic variation in IFNγ and IL19 genes

Not all HIV-infected patients receiving cART are able to recover optimal CD4-T cell levels despite achieving undetectable viremia. We evaluated the potential association between polymorphisms (SNPs) in cytokines involved in immune response (IL15, IFNγ and IL19) and the failure to achieve optimal CD4 T-cells restoration after cART. For this, we carried out a retrospective study in 412 HIV-infected patients starting cART with CD4<200 cells/μL. These patients were classified as immunological non-responders (INR) if having a CD4 increase (ΔCD4) below 200 cells/μL after two years on successful cART. IL15, IFNγ and IL19 polymorphisms were genotyped using Sequenom's MassARRAY platform. We found 134 INR patients with a median [IQR] ΔCD4 = 133[73-174] cells/μL. In the multivariate analysis adjusted for age, sex, infection route, ethnic origin, hepatitis co-infection and HIV infection length, the AA genotype of the SNP rs2430561 in IFNγ (OR:2.01[1.13-3.56], p = 0.017) and the TT genotype of polymorphism rs2243191 in IL19 (OR:2.58 [1.17-5.68], p = 0.019) showed significant association with the INR status. Our results show that polymorphisms in IFNγ and IL19 genes significantly impacts in the probability of not achieving an optimal immune recovery in HIV-patients starting cART with CD4 T-cells <200 cells/μL. Thus, these SNPs could represent potential predictive markers of the immunodiscordant response.

An Internet-Based HIV Self-Testing Program to Increase HIV Testing Uptake Among Men Who Have Sex With Men in Brazil: Descriptive Cross-Sectional Analysis

BACKGROUND

Approximately 30% of people living with HIV worldwide are estimated to be unaware of their infection. HIV self-testing (HIVST) is a strategy recommended by the World Health Organization to increase access to and uptake of testing among key populations who are at high risk for HIV infection.

OBJECTIVE

This study aimed to describe the development and feasibility of a free, anonymous, internet-based HIVST strategy designed for men who have sex with men in Curitiba, Brazil (electronic testing [e-testing]).

METHODS

The project was developed under the scope of the "A Hora é Agora" (The Time is Now) program. Individuals aiming to request an HIVST package (two tests each) answered an anonymous 5-minute questionnaire regarding inclusion criteria and sexual risk behavior. Eligible individuals could receive one package every 6 months for free. Website analytics, response to online questionnaires, package distribution, and return of test results were monitored via a platform-integrated system.

RESULTS

Between February 2015 and January 2016, the website documented 17,786 unique visitors and 3218 completed online questionnaires. Most individuals self-reported being white (77.0%), young (median age: 25 years, interquartile range: 22-31 years), educated (87.3% completed secondary education or more), and previously tested for HIV (62.5%). Overall, 2526 HIVST packages were delivered; of those, 542 (21.4%) reported a result online or by mail (23 reactive and 11 invalid). During the study period, 37 individuals who reported using e-testing visited the prespecified health facility for confirmatory testing (30 positive, 7 negative).

CONCLUSIONS

E-testing proved highly feasible and acceptable in this study, thus supporting scale-up to additional centers for men who have sex with men in Brazil.

Outcome of an HIV education program for primary care providers: Screening and late diagnosis rates

Background

Late HIV diagnosis remains one of the challenges in combating the epidemic. Primary care providers play an important role in screening for HIV infection. Our study aims to evaluate the relationship between knowledge and barriers to HIV testing and screening outcomes. The impact of an education program for primary care providers, towards improving HIV testing and late diagnosis rates, is also assessed.

Methods

A self-administered questionnaire that was developed within the framework of the European project OptTEST was used to examine HIV knowledge and barriers to HIV testing scores before and after being involved in an HIV education program. A quasi-experimental design with pre- and post-intervention measures was performed to investigate its impact. We performed multivariable logistic regression analysis to assess the relationship between variables for the HIV testing offer.

Results

A total of 20 primary care centers and 454 primary care staff were included. Baseline OptTEST results showed that more knowledgeable staff offered an HIV test more frequently (OR 1.07; CI 95% 1.01–1.13; p = 0.027) and had lower barrier scores (OR 0.89; CI 95% 0.77–0.95; p = 0.005). Nurses had lower scores in knowledge-related items (OR 0.28; CI 95% 0.17–0.46; p<0.001), but higher scores in barrier-related items than physicians (OR 3.28; CI 95% 2.01–5.46; p<0.001). Specific centers with more knowledgeable staff members had a significant association with a greater level of new HIV diagnosis rates (OR 1.61; CI 95% 1.04–2.49; p = 0.032). After the intervention, we found that 12 out of 14 individual questions showed improved scores. In the 6 months after the training program, we similarly found a higher HIV testing rate (OR 1.19; CI 1.02–1.42; p = 0.036).

Conclusions

This study highlights the association between knowledge and barriers to HIV testing, including HIV testing rates. It shows that it is possible to modify knowledge and reduce perceived barriers through educational programs, subsequently improving HIV screening outcomes.

Long-term trends in HIV care entry: over 15 years of clinical experience from Poland

INTRODUCTION

Delay in HIV diagnosis and consequently late care entry with low CD4 counts remain a major challenge for the control of the HIV/AIDS epidemic. The aim of this study was to analyse the evolution of characteristics of the HIV epidemic in Poland.

METHODS

Cross-sectional data were collected for 3972 HIV-infected patients followed up in 14 of 17 Polish HIV treatment centres in the years 2000-2015. Clinical data were analysed and factors associated with late presentation (baseline CD4 count < 350 cells/μL or history of AIDS-defining illness) and advanced HIV disease (baseline CD4 count < 200 cells/μL or history of AIDS) were identified.

RESULTS

The majority (57.6%) of patients entered care late, while 35.6% presented with advanced HIV disease. The odds of being linked to care late or with advanced HIV disease increased consistently across age categories, increasing from 2.55 [95% confidence interval (CI) 1.46-4.47] for late presentation and 3.13 (95% CI 1.49-6.58) for advanced disease for the 21-30-year-old category to 5.2 (95% CI 1.94-14.04) and 8.15 (95% CI 2.88-23.01), respectively, for individuals > 60 years of age. Increased risks of late entry and advanced HIV disease were also observed for injecting drug users [adjusted odds ratio (aOR) 1.74 (95% CI 1.16-2.60) and 1.55 (95% CI 1.05-2.30), respectively], with lower aOR associated with the men who have sex with men transmission route [aOR 0.3 (95% CI 0.31-0.59) and 0.39 (95% CI 0.29-0.53), respectively]. The frequencies of cases in which patients were linked to care late and with advanced HIV disease decreased over time from 67.6% (2000) to 53.5% (2015) (P < 0.0001) and from 43.5% (2000) to 28.4% (2015) (P = 0.001), respectively.

CONCLUSIONS

Despite improvements over time, most patients diagnosed with HIV infection entered care late, with a third presenting with advanced HIV disease. Late care entry remains common among people who inject drugs and heterosexual groups.

Late presentation of HIV positive adults and its predictors to HIV/AIDS care in Ethiopia: a systematic review and meta-analysis

Introduction

Late presentation to HIV/AIDS care which is attended by problems like, poor treatment outcomes, early development of opportunistic infections, increased healthcare costs, and mortality is a major problem in Ethiopia. Although evidences are available on the prevalence and associated factors of late presentation to HIV/AIDS care, discrepancies among findings are appreciated. Thus, the country has faced difficulties of having a single estimated data.

Objective

This study aimed to estimate the pooled prevalence of late presentation of HIV positive adults to HIV/AIDS care and its predictors in Ethiopia.

Method

We searched all available articles through Google Scholar, PubMed, Web of Sciences, and EMBASE databases. Additionally, we accessed articles from the Ethiopian institutional online research repositories and reference lists of included studies. We included cohort, case- control, and cross-sectional studies in our review. Besides, we utilized the weighted inverse variance random-effects model. The total percentage of variation among studies due to heterogeneity was determined by I² statistic. Searching was limited to studies conducted in Ethiopia and published in the English language. Publication bias was checked by Egger’s regression test.

Results

A total of 8 studies with 7, 568 participants were included. The pooled prevalence of late presentation to HIV/AIDS care was 52.89% (95%CI: 35.37, 70.40). The odds of late presentation to HIV/AIDS care of frequent alcohol users [3.67(95% CI = 1.52–5.83)], high fear of stigma [3.90 (95% CI = 1.51–6.28)], chronic illness [3.34(95% CI = 1.52–5.16)], and the presence of symptoms at the time of HIV diagnosis [3.06 (95% CL = 1.18–4.94)] were higher compared to participants who did not experience the preceding.

Conclusion

The prevalence of late presentation of HIV positive adults to HIV/AIDS care was high in Ethiopia. Frequent alcohol use, high fear of stigma, chronic illness, and the presence of symptoms at the time of HIV diagnosis were associated with high odds of late presentation to HIV/AIDS care.

Trial registration

Registered in PROSPERO databases with the registration number of CRD42018081840.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4156-3) contains supplementary material, which is available to authorized users.

IL7RA rs6897932 Polymorphism is Associated with Better CD4+ T-Cell Recovery in HIV Infected Patients Starting Combination Antiretroviral Therapy

Interleukin-7 receptor subunit alpha (IL7RA) rs6897932 polymorphism IS related to CD4⁺ recovery after combination antiretroviral therapy (cART), but no studies so far have analyzed its potential impact in patients with very low CD4⁺ T-cells count. We aimed to analyze the association between IL7RA rs6897932 polymorphism and CD4⁺ T-cells count restoration in HIV-infected patients starting combination antiretroviral therapy (cART) with CD4⁺ T-cells count <200 cells/mm³. We performed a retrospective study in 411 patients followed for 24 months with a DNA sample available for genotyping. The change in CD4⁺ T-cells count during the follow-up was considered as the primary outcome. The rs6897932 polymorphism had a minimum allele frequency (MAF) >20% and was in Hardy–Weinberg equilibrium (p = 0.550). Of 411 patients, 256 carried the CC genotype, while 155 had the CT/TT genotype. The CT/TT genotype was associated with a higher slope of CD4⁺ T-cells recovery (arithmetic mean ratio; AMR = 1.16; p = 0.016), higher CD4⁺ T-cells increase (AMR = 1.19; p = 0.004), and higher CD4⁺ T-cells count at the end of follow-up (AMR = 1.13; p = 0.006). Besides, rs6897932 CT/TT was related to a higher odds of having a value of CD4⁺ T-cells at the end of follow-up ≥500 CD4⁺ cells/mm³ (OR = 2.44; p = 0.006). After multiple testing correction (Benjamini–Hochberg), only the increase of ≥ 400 CD4⁺ cells/mm³ lost statistical significance (p = 0.052). IL7RA rs6897932 CT/TT genotype was related to a better CD4⁺ T-cells recovery and it could be used to improve the management of HIV-infected patients starting cART with CD4⁺ T-cells count <200 cells/mm³.

Two decades of surveillance data show late presentation among a diverse group of women diagnosed with HIV in Victoria, Australia

OBJECTIVE

To develop an HIV response suited to women and to inform appropriate services, we describe the characteristics of women diagnosed and living with HIV using 22 years of high-quality surveillance data.

METHODS

Data on women newly diagnosed with HIV between 1994 and 2016 and women living with diagnosed HIV in Victoria at 31 December 2016 were extracted from the Victorian Public Health Surveillance System. Descriptive analysis by place of birth was performed and Poisson regression used to assess trends over time.

RESULTS

There were 465 new diagnoses among women in Victoria between 1994 and 2016 and 613 women living with HIV in 2016. Women were diagnosed late, and frequently reported no HIV testing history, AIDS-defining illness or other symptoms of HIV at diagnosis. These indicators of delayed diagnosis were even greater for non-Australian-born women. Conclusions and implications for public health: For Victoria to reach the ambitious targets for diagnosis, treatment and viral suppression in 95% of people living with HIV, prevention programs and efforts to increase early diagnosis as well as support services must consider the epidemiology and diversity of women.

Why do sub-Saharan Africans present late for HIV care in Switzerland?

OBJECTIVES

Late presentation (LP) to HIV care disproportionally affects individuals from sub-Saharan Africa (SSA). We explored the reasons for late presentation to care among this group of patients in the Swiss HIV Cohort Study.

METHODS

The prevalence of LP was compared between patients from Western Europe (WE) and those from SSA enrolled between 2009 and 2012. Patients were asked about HIV testing, including access to testing and reasons for deferring it, during face-to-face interviews.

RESULTS

The proportion of LP was 45.8% (435/950) among patients from WE, and 64.6% (126/195) among those from SSA (P < 0.001). Women from WE were slightly more likely to present late than men (52.6% versus 44.5%, respectively; P = 0.06), whereas there was no sex difference in patients from SSA (65.6% versus 63.2%, respectively; P = 0.73). Compared with late presenters from WE, those from SSA were more likely to be diagnosed during pregnancy (9.1% versus 0%, respectively; P < 0.001), but less likely to be tested by general practitioners (25.0% versus 44.6%, respectively; P = 0.001). Late presenters from SSA more frequently reported 'not knowing about anonymous testing possibilities' (46.4% versus 27.3%, respectively; P = 0.04) and 'fear about negative reaction in relatives' (39.3% versus 21.7%, respectively; P = 0.05) as reasons for late testing. Fear of being expelled from Switzerland was reported by 26.1% of late presenters from SSA.

CONCLUSIONS

The majority of patients from SSA were late presenters, independent of sex or education level. Difficulties in accessing testing facilities, lack of knowledge about HIV testing and fear-related issues are important drivers for LP in this population.

Epidemiological profile of individuals diagnosed with HIV: results from the preliminary phase of case-based surveillance in Kenya

Understanding the characteristics of individuals who are newly diagnosed with HIV is critical to controlling the HIV epidemic. Characterizing this population can improve strategies to identify undiagnosed positives and assist in targeting the provision of HIV services to improve health outcomes. We describe the characteristics of newly diagnosed HIV cases in western Kenya from 124 health facilities. The study cohort cases were matched to prevent duplication and patients newly diagnosed between January and June 2015 were identified and descriptive analysis performed. Among 8664 newly identified HIV cases, during the pilot timeframe, 3.1% (n=265) had retested for HIV after initial diagnosis. Linkage to care was recorded for approximately half (45.3%, n = 3930) and 28.0% (n = 2425) had a CD4 count available during the pilot timeframe. The median baseline CD4 count was 332 cells/mL (IQR: 156-544). Among the newly diagnosed age 15 years or older with a CD4 test, 53.0% (n = 1216) were diagnosed late, including 32.9% (n = 755) who had advanced HIV at diagnosis. Factors associated with late diagnosis included being male and in an age group older than 34 years. In western Kenya, continued efforts are needed in the area of testing to enhance early HIV diagnosis and epidemic control.

Primary health care: an opportunity for early identification of people living with undiagnosed HIV infection

OBJECTIVES

We aimed to determine the fraction of HIV-diagnosed individuals who had primary health care (PHC) contacts 3 years prior to HIV diagnosis and whether the risk of HIV diagnosis and degree of immunodeficiency were associated with the frequency of visits or procedures performed.

METHODS

We used data from national registries to conduct a population-based nested case-control study. Cases were individuals diagnosed with HIV infection in Denmark from 1998 to 2016. Population controls were extracted from the general population matched 13:1 on gender and age. We used conditional logistic regression. As there was a statistically significant interaction, analyses were further stratified by gender and Danish/non-Danish origin.

RESULTS

We identified 2784 cases and 36 192 controls. Ninety-three per cent of cases and 88% of controls attended PHC at least once in the 3 years prior to diagnosis, with a higher median number of visits to PHC (NVPC) for cases. We found a statistically significant positive association between NVPC and risk of subsequent HIV diagnosis in men and non-Danish women. A U-shaped association between NVPC and risk of HIV diagnosis among Danish women. No substantial association between NVPC and degree of immunodeficiency was found. Risk of HIV diagnosis and degree of immunodeficiency were weakly associated with type of procedures performed.

CONCLUSIONS

For most HIV-infected individuals, there seem to be many opportunities for earlier diagnosis in PHC. In men and non-Danish women, the risk of HIV diagnosis but not the degree of immunodeficiency was related to NVPC. The results suggest that the type of medical procedure performed cannot not be used as a guide by the primary physician to indicate which patients to test.

Co-morbid Non-communicable Diseases and Associated Health Service Use in African and Caribbean Immigrants with HIV

We sought to characterize non-communicable disease (NCD)-related and overall health service use among African and Caribbean immigrants living with HIV between April 1, 2010 and March 31, 2013. We conducted two population-based analyses using Ontario's linked administrative health databases. We studied 1525 persons with HIV originally from Africa and the Caribbean. Compared with non-immigrants with HIV (n = 11,931), African and Caribbean immigrants had lower rates of hospital admissions, emergency department visits and non-HIV specific ambulatory care visits, and higher rates of health service use for hypertension and diabetes. Compared with HIV-negative individuals from these regions (n = 228,925), African and Caribbean immigrants with HIV had higher rates of health service use for chronic obstructive pulmonary disease [rate ratio (RR) 1.78; 95% confidence interval (CI) 1.36-2.34] and malignancy (RR 1.20; 95% CI 1.19-1.43), and greater frequency of hospitalizations for mental health illness (RR 3.33; 95% CI 2.44-4.56), diabetes (RR 1.37; 95% CI 1.09-1.71) and hypertension (RR 1.85; 95% CI 1.46-2.34). African and Caribbean immigrants with HIV have higher rates of health service use for certain NCDs than non-immigrants with HIV. The evaluation of health services for African and Caribbean immigrants with HIV should include indicators of NCD care that disproportionately affect this population.

Lessons learned: Retrospective assessment of outcomes and management of patients with advanced HIV disease in a semi-urban polyclinic in Epworth, Zimbabwe

INTRODUCTION

HIV continues to be one of the leading causes of infectious death worldwide and presentation with advanced HIV disease is associated with increased morbidity and mortality. Recommendations for the management of advanced HIV disease include prompt screening and treatment of opportunistic infections, rapid initiation of ART and intensified adherence support. We present treatment outcomes of a cohort of patients presenting with advanced HIV disease in a semi-urban Zimbabwean polyclinic.

METHODS

Retrospective cohort analysis of adult patients enrolled for care at Epworth polyclinic, Zimbabwe between 2007 and end June 2016. Treatment outcomes at 6 and 12 months were recorded. Multivariate logistical regression analysis was undertaken to identify risk factors for presentation with advanced HIV Disease (CD4 count less than 200 cells/mm3 or WHO stage 3 or 4) and risks for attrition at 12 months.

RESULTS

16,007 anti-retroviral therapy naive adult patients were included in the final analysis, 47.4% of whom presented with advanced HIV disease. Patients presenting with advanced HIV disease had a higher mortality rate at 12 months following enrollment compared to early stage patients (5.11% vs 0.45%). Introduction of a package of differentiated care for patients with a CD4 count of less than 100 cells/mm3 resulted in diagnosis of cryptococcal antigenaemia in 7% of patients and a significant increase in the diagnosis of TB, although there was no significant difference in attrition at 6 or 12 months for these patients compared to those enrolled prior to the introduction of the differentiated care.

CONCLUSIONS

The burden of advanced HIV disease remained high over the study period in this semi-urban polyclinic in Zimbabwe. Introduction of a package of differentiated care for those with advanced HIV disease increased the diagnosis of opportunistic infections and represents a model of care which can be replicated in other polyclinics in the resource constrained Zimbabwean context.

A Patient-Centered Multicomponent Strategy for Accelerated Linkage to Care Following Community-Wide HIV Testing in Rural Uganda and Kenya

INTRODUCTION

As countries move toward universal HIV treatment, many individuals fail to link to care after diagnosis of HIV. Efficient and effective linkage strategies are needed.

METHODS

We implemented a patient-centered, multicomponent linkage strategy in the SEARCH "test-and-treat" trial (NCT 01864603) in Kenya and Uganda. After population-based, community-wide HIV testing, eligible participants were (1) introduced to clinic staff after testing, (2) provided a telephone "hot-line" for enquiries, (3) provided an appointment reminder phone call, (4) given transport reimbursement on linkage, and (5) tracked if linkage appointment was missed. We estimated the proportion linked to care within 1 year and evaluated factors associated with linkage at 7, 30, and 365 days after diagnosis.

RESULTS

Among 71,308 adults tested, 6811 (9.6%) were HIV-infected; of these, 4760 (69.9%) were already in HIV care, and 30.1% were not. Among 2051 not in care, 58% were female, median age was 32 (interquartile range 26-40) years, and median CD4 count was 493 (interquartile range 331-683) cells/µL. Half (49.7%) linked within 1 week, and 73.4% linked within 1 year. Individuals who were younger [15-34 vs. >35 years, adjusted Risk Ratio (aRR) 0.83, 95% confidence interval (CI): 0.74 to 0.94], tested at home vs. community campaign (aRR = 0.87, 95% CI: 0.81 to 0.94), had a high HIV-risk vs. low-risk occupation (aRR = 0.81, 95% CI: 0.75 to 0.88), and were wealthier (aRR 0.90, 95% CI: 0.83 to 0.97) were less likely to link. Linkage did not differ by marital status, stable residence, level of education, or having a phone contact.

CONCLUSIONS

Using a multicomponent linkage strategy, high proportions of people living with HIV but not in care linked rapidly after HIV testing.

Understanding the Time Needed to Link to Care and Start ART in Seven HPTN 071 (PopART) Study Communities in Zambia and South Africa

To achieve UNAIDS 90:90:90 targets at population-level, knowledge of HIV status must be followed by timely linkage to care, initiation and maintenance of antiretroviral therapy (ART) for all people living with HIV (PLHIV). Interpreting quantitative patterns using qualitative data, we investigate time taken to link to care and initiate ART amongst individuals aware of their HIV-status in high HIV-prevalence urban communities in the HPTN 071 (PopART) study, a community-randomised trial of a combination HIV prevention package, including universal testing and treatment, in 21 communities in Zambia and South Africa. Data are drawn from the seven intervention communities where immediate ART irrespective if CD4 count was offered from the trial-start in 2014. Median time from HIV-diagnosis to ART initiation reduced after 2 years of delivering the intervention from 10 to 6 months in both countries but varied by gender and community of residence. Social and health system realities impact decisions made by PLHIV about ART initiation.

Genetic variation in CCR2 and CXCL12 genes impacts on CD4 restoration in patients initiating cART with advanced immunesupression

OBJECTIVE

We investigated the association of genetic polymorphisms in chemokine and chemokine receptor genes with poor immunological recovery in HIV patients starting combined antiretroviral therapy (cART) with low CD4 T-cell counts.

METHODS

A case-control study was conducted in 412 HIV-infected patients starting cART with CD4 T-cell count <200 cells/μL and successful viral control for two years. CD4 count increase below 200 cells/μL after two years on cART was used to define INR (immunological non-responder) patients. Polymorphisms in CXCL12, CCL5 and CCR2 genes were genotyped using sequenom's MassARRAY platform.

RESULTS

Thirty two percent (134/412) of patients were classified as INR. After adjusting by age, route of HIV infection, length of infection before cART and viral hepatitis coinfection, CCR2 rs1799864-AG genotype was significantly associated with INR status (OR [95% CI]: 1.80 [1.04-3.11]; p = 0.04), and CXCL12 rs1801157-TT genotype showed a trend (OR [95% CI]: 2.47 [0.96-6.35]; p = 0.06).

CONCLUSIONS

CCR2 rs1799864-AG or CXCL12 rs1801157-TT genotypes influence on the probability of poor CD4 recovery in the population of HIV patients starting cART with low CD4 counts. Genotyping of these polymorphisms could be used to estimate the risk of poor CD4 restoration, mainly in patients who are diagnosed late in the course of infection.

The Continuing Value of CD4 Cell Count Monitoring for Differential HIV Care and Surveillance

The move toward universal provision of antiretroviral therapy and the expansion of HIV viral load monitoring call into question the ongoing value of CD4 cell count testing and monitoring. We highlight the role CD4 monitoring continues to have in guiding clinical decisions and measuring and evaluating the epidemiology of HIV. To end the HIV/AIDS epidemic, we require strategic information, which includes CD4 cell counts, to make informed clinical decisions and effectively monitor key surveillance indicators.

HIV late presentation and advanced HIV disease among patients with newly diagnosed HIV/AIDS in Southwestern China: a large-scale cross-sectional study

OBJECTIVE

This study aimed to investigate the prevalence of HIV late presentation and advanced HIV disease and to identify the factors associated with HIV late presentation and advanced HIV disease among patients with newly diagnosed HIV/AIDS in the Guangxi Zhuang Autonomous Region, in Southwestern China.

METHODS

Patients with newly diagnosed HIV registered in the HIV surveillance system of Guangxi Centers for Disease Control between January 2012 and December 2016 were included in this study.

RESULTS

Of 45,118 newly diagnosed patients, 70.2% had late presentation, and 45.1% had advanced HIV disease. A higher prevalence of late presentation and advanced HIV disease was found in male heterosexuals and female people who use drugs (PWID). Heterosexuals (OR 2.11 [95% CI 1.90-2.34]) and PWID (OR 1.55 [95% CI 1.30-1.84]) had a higher risk of late presentation than men who have sex with men (MSM). Blood testing of the blood receivers (OR 1.75 [95% CI 1.36-2.26]) and diagnosed in hospital (OR 1.74 [95% CI 1.65-1.84]) had an increased risk of late presentation compared to those who diagnosis in voluntary counseling and testing (VCT). Heterosexuals (OR 2.86 [95% CI 2.51-3.27]), PWID (OR 2.23 [95% CI 1.83-2.71]), blood testing of the blood receivers (OR 1.58 [95% CI 1.29-1.94]) and diagnosed in hospital (OR 1.85 [95% CI 1.76-1.94]) were also independent risk factors associated with advanced HIV disease. Older age, lower level of education and being divorced or widowed were also associated with late presentation and advanced HIV disease.

CONCLUSIONS

Late presentation and advanced HIV disease were very common among patients with newly diagnosed HIV in Guangxi, China during 2012-2016. Targeted programs are urgently required to reduce HIV late diagnosis in Guangxi, especially for male heterosexuals, PWID, and patients with characteristics such as older age, lower level of education, divorced or widowed.

Representations of people living with HIV: influences on the late diagnosis of infection

OBJECTIVE

To analyze the representations constructed by people living with HIV on the infection and their influence on the late search for diagnosis.

METHOD

A qualitative study, conducted through an open interview with people who had a late diagnosis of HIV infection. The theoretical framework adopted was the Theory of Social Representations based on a critical approach. For data analysis, was used the Structural Analysis of Narration method and the MAXQDA 12® software.

RESULTS

Eighteen people participated in the study. The following original representations were unveiled: AIDS as a transmissible and dangerous disease; disease of the other; severe, incurable and deadly disease; and denial of risk due to trust in a steady partner. These representations contributed to the late search for diagnosis, either because of the attitude of distance from susceptible people, or because they did not perceive or deny the risks to which they were exposed in their life trajectories.

CONCLUSION

Understanding the reasons that lead people to a late diagnosis of HIV is imperative in the current epidemic scenario for the planning and implementation of new strategies and policies for the timely diagnosis of the infection.

Barriers to health care services for migrants living with HIV in Spain

Background

In Spain, migrants are disproportionately affected by HIV and experience high rates of late diagnosis. We investigated barriers to health care access among migrants living with HIV (MLWH) in Spain.

Methods

Cross sectional electronic survey of 765 adult HIV-positive migrants recruited within 18 health care settings between July 2013 and July 2015. We collected epidemiological, demographic, behavioral and clinical data. We estimated the prevalence and risk factors of self-reported barriers to health care using multivariable logistic regression.

Results

Of those surveyed, 672 (88%) had information on health care access barriers: 23% were women, 63% from Latin America and Caribbean, 14% from Sub-Saharan Africa and 15% had an irregular immigration status. Men were more likely to report barriers than women (24% vs. 14%, P = 0.009). The main barriers were: lengthy waiting times for an appointment (9%) or in the clinic (7%) and lack of a health card (7%). Having an irregular immigration status was a risk factor for experiencing barriers for both men (OR: (4.0 [95%CI: 2.2-7.2]) and women (OR: 10.5 [95%CI: 3.1-34.8]). Men who experienced racial stigma (OR: 3.1 [95%CI: 1.9-5.1]) or food insecurity (OR: 2.1 [95%CI: 1.2-3.4]) were more likely to report barriers. Women who delayed treatment due to medication costs (6.3 [95%CI: 1.3-30.8]) or had a university degree (OR: 5.8 [95%CI: 1.3-25.1]) were more likely to report barriers.

Conclusion

Health care barriers were present in one in five5 MLWH, were more common in men and were associated to legal entitlement to access care, perceived stigma and financial constraints.

Early initiation of antiretroviral therapy for people newly diagnosed with HIV infection in Australia: trends and predictors, 2004-2015

OBJECTIVES

To determine trends in and predictors of early treatment for people newly diagnosed with human immunodeficiency virus (HIV) infection in Australia.

DESIGN, SETTING

Retrospective cohort analysis of routinely collected longitudinal data from 44 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) program.

PARTICIPANTS

Patients diagnosed with HIV infections, January 2004 - June 2015.

MAIN OUTCOME MEASURES

Commencement of antiretroviral therapy within 6 months of HIV diagnosis (early treatment); demographic, clinical, and risk group characteristics of patients associated with early treatment; trends in early treatment, by CD4⁺ cell count at diagnosis.

RESULTS

917 people were diagnosed with HIV infections, their median age was 34 years (interquartile range [IQR]: 27-43 years), and 841 (92%) were men; the median CD4⁺ cell count at diagnosis was 510 cells/μL (IQR, 350-674 cells/μL). The proportion of patients who received early treatment increased from 17% (15 patients) in 2004-06 to 20% (34 patients) in 2007-09, 34% (95 patients) in 2010-12, and 53% (197 patients) in 2013-15 (trend, P < 0.001). The probability of early treatment, which increased with time, was higher for patients with lower CD4⁺ cell counts and higher viral loads at diagnosis.

CONCLUSIONS

The proportion of people newly diagnosed with HIV in sexual health clinics in Australia who received treatment within 6 months of diagnosis increased from 17% to 53% during 2004-2015, reflecting changes in the CD4⁺ cell count threshold in treatment guidelines. Nevertheless, further strategies are needed to maximise the benefits of treatment to prevent viral transmission and morbidity.

Socio-demographic and clinical determinants of late presentation among patients newly diagnosed with HIV in the Eastern Cape, South Africa

South Africa recently implemented the 'test and treat' strategy for all HIV-infected individuals receiving diagnosis at the health facility level. However, the impact of this programme in terms of the prevention of HIV transmission, morbidity and mortality associated with HIV can only be maximized if patients are diagnosed early. This study determines the prevalence of late presentation among newly diagnosed HIV-infected individuals and also examines the socio-demographic and clinical determinants for late presentation in health facilities in the Eastern Cape Province, South Africa.In this cross-sectional study, a total of 335 newly diagnosed patients were recruited consecutively between August 2016 and July 2017. Late presenter for HIV care was defined in accordance with the European Late Presenter Consensus working group as a patient who reports for care when the CD4 count is below 350 cells/μL and/or when there is an established AIDS-defining clinical condition, irrespective of CD4 count. Adjusted and unadjusted logistic regression analysis was used to examine the determinants of late HIV diagnosis.Participants' mean age was 33.6 (SD: 10.6). Almost 96% of the participants believed their route of HIV infection was heterosexual sex. Most newly diagnosed HIV-infected patients (60%) were late presenters (CD4+ count ≤350 cells/μL and/or having an AIDS-defining illness in World Health Organisation (WHO)-defined stage III/IV), with 35% presenting with Acquired Immune Deficiency Syndrome (AIDS)-related complications. In the adjusted model, only male sex (AOR: 2.81; CI: 1.51-5.23), no formal education (AOR: 5.63; CI: 1.68-18.85), and overweight body mass category (AOR: 2.45; CI: 1.04-5.75) were independently associated with late HIV diagnosis.The majority of newly diagnosed HIV-infected individuals were late presenters. To maximize the impact of the 'test and treat' policy aimed at reducing new HIV transmissions and preventing the morbidity and mortality associated with HIV, there is a need for programmes to improve early detection of HIV in the study settings. This programme should target males and individuals with no formal education for maximum impact.

Social and structural factors and engagement in HIV care of sub-Saharan African migrants diagnosed with HIV in the Paris region

Migrants from sub-Saharan Africa (SSA) are often diagnosed at an advanced stage of HIV, and many of them have harsh living conditions. We aimed to evaluate the entry into care after HIV diagnosis and examine the related social determinants. The ANRS PARCOURS study is a life-event survey conducted in 2012-2013 in the Paris region among. Time between HIV diagnosis of SSA migrants living diagnosed HIV positive in France and HIV care and the determinants was assessed yearly by using mixed-effects logistic regression models. Among a total of 792 participants, 94.2% engaged in HIV care within the year of HIV diagnosis, 4.3% in the following year and 2.5% beyond the second year after diagnosis. The participants were more likely to engage in HIV care during years when they were effectively covered by health insurance and if the HIV test was carried out at the initiative of the doctor. Immigration for economic reasons or owing to threats in his/her country of origin was associated with delayed engagement in HIV care. Additionally, 4.3% of treated participants discontinued HIV care at least once at the time of the survey and more often if diagnosed at an advanced HIV disease stage and financially dependent.

Changing Spectrum of Opportunistic Illnesses among HIV-Infected Taiwanese Patients in Response to a 10-Year National Anti-TB Programme

The current trends and spectrum of acquired immunodeficiency syndrome (AIDS)-related opportunistic illnesses (AOIs) among newly diagnosed human immunodeficiency virus (HIV)-infected patients after the implementation of the 2006–2015 national anti-tuberculosis (TB) programmes in Taiwan remain unknown. We retrospectively reviewed 1757 patients at two centres in southern Taiwan between 2001 and 2015. Based on the anti-TB programme, patients were classified into periods 1 (2001–2005), 2 (2006–2010), and 3 (2011–2015). We further analysed factors associated with Mycobacterium tuberculosis (MTB) at presentation and during follow-up. The overall AOI incidence rate (23.6%) remained unchanged across the periods, with 81.4% of AOIs occurring at presentation. Pneumocystis jirovecii pneumonia was the leading AOI across the periods. MTB declined significantly from period 1 to period 3 (39.3% vs. 9.3%). Age and CD4+ cell count <200 cells/µL (vs. ≥501) were the risk factors associated with MTB at presentation, whereas period 2/3 (vs. period 1) was the protective factor. Intravenous drug use (vs. homosexual contact) was the risk factor associated with MTB during follow-up, and period 3 (vs. period 1) was the protective factor. AOI statistics in Taiwan must be closely monitored for fluctuations. Although MTB decreased substantially after implementation of the anti-TB programmes, additional efforts to reduce MTB are required.

Migrant women living with HIV in Europe: are they facing inequalities in the prevention of mother-to-child-transmission of HIV?: The European Pregnancy and Paediatric HIV Cohort Collaboration (EPPICC) study group in EuroCoord

Background

In pregnancy early interventions are recommended for prevention of mother-to-child-transmission (PMTCT) of HIV. We examined whether pregnant women who live with HIV in Europe and are migrants encounter barriers in accessing HIV testing and care.

Methods

Four cohorts within the European Pregnancy and Paediatric HIV Cohort Collaboration provided data for pooled analysis of 11 795 pregnant women who delivered in 2002-12 across ten European countries. We defined a migrant as a woman delivering in a country different from her country of birth and grouped the countries into seven world regions. We compared three suboptimal PMTCT interventions (HIV diagnosis in late pregnancy in women undiagnosed at conception, late anti-retroviral therapy (ART) start in women diagnosed but untreated at conception and detectable viral load (VL) at delivery in women on antenatal ART) in native and migrant women using multivariable logistic regression models.

Results

Data included 9421 (79.9%) migrant women, mainly from sub-Saharan Africa (SSA); 4134 migrant women were diagnosed in the current pregnancy, often (48.6%) presenting with CD4 count <350 cells/µl. Being a migrant was associated with HIV diagnosis in late pregnancy [OR for SSA vs. native women, 2.12 (95% CI 1.67, 2.69)] but not with late ART start if diagnosed but not on ART at conception, or with detectable VL at delivery once on ART.

Conclusions

Migrant women were more likely to be diagnosed in late pregnancy but once on ART virological response was good. Good access to antenatal care enables the implementation of PMTCT protocols and optimises both maternal and children health outcomes generally.

Effect of an Electronic Alert on Targeted HIV Testing Among High-Risk Populations

CONTEXT

Screening for HIV infection in medical settings remains suboptimal.

OBJECTIVE

To examine the real-world effectiveness of an electronic clinician alert on the same-day HIV testing rate and early diagnosis in high-risk populations.

DESIGN

We identified Kaiser Permanente Southern California Health Plan members aged 14 years or older who received tests for sexually transmitted infections.

MAIN OUTCOME MEASURES

Encounter-based same-day HIV testing rate, positive test result rate, and CD4⁺ cell count and HIV viral load at diagnosis.

RESULTS

We identified 1,800,948 patients who made 2,326,701 health care encounters eligible for HIV testing before implementation (January 1, 2008 - June 30, 2012) and 1,362,479 eligible encounters after implementation (January 1, 2013 - June 30, 2015). The same-day HIV testing rate increased from 36.7% to 44.1% (standardized mean difference = 0.15, significant difference). The alert was associated with a moderate difference and statistically significant increase in the HIV testing rate (adjusted odds ratio = 1.17, 95% confidence interval = 1.16-1.18). The positive test result rate increased from 0.02% to 0.04% (p < 0.001). During the postimplementation period, fewer HIV-infected patients had a CD4⁺ cell count below 200 and/or an HIV viral load of 10,000 copies/mL or higher at diagnosis.

CONCLUSION

Implementation of a targeted electronic alert embedded in the electronic medical record improved same-day HIV screening rate and positive test result rates among patients receiving tests for sexually transmitted infections in a large health organization. This intervention has potential for facilitating frequent screening and early identification of HIV infection in high-risk populations.

Routine HIV testing program in the University Infectious Diseases Centre in Lithuania: a four-year analysis

BACKGROUND

HIV transmission remains a major concern in Eastern Europe, and too many people are diagnosed late. Expanded testing strategies and early and appropriate access to care are required. Infectious disease departments might be targets for expanded HIV testing owing to the intense passage of key patient populations that carry indicators of HIV disease. Our objective was to evaluate the feasibility and clinical effectiveness of a fully integrated, opt-out routine, rapid HIV testing program.

METHODS

A retrospective four-year study of a screening program was conducted from 2010 through 2014. The program was divided into two periods: from 2010 to 2012 (pilot study) and from 2013 to 2014. The pilot study consisted of routine HIV testing of patients aged 18-55 that were hospitalized in one department. In the second period, all inpatients aged 18-65 were eligible. Targeted testing was conducted in the other inpatient department during the pilot study and the outpatient department during both periods.

RESULTS

During the pilot study, 2203 patients were hospitalized, 1314 (59.6%) were eligible, 954 (72.6%) were tested, and 3 (0.31%) were newly diagnosed HIV-positive. In the second period, 4911 patients were hospitalized, 3727 (75.9%) were eligible, 3303 (88.6%) were tested, and 7 (0.21%) were HIV-positive. In total, 2800 targeted tests were performed, and 4 (0.14%) patients tested positive with newly discovered HIV. All 14 newly diagnosed patients were provided with care. Comparing cumulative groups of routine and targeted testing, the HIV prevalence was 0.23% vs. 0.14% (p = 0.40) and was above the reported cost-effectiveness threshold of 0.1% (p = 0.012). A lower proportion of advanced disease and a higher proportion of heterosexually transmitted infection were found in the routine testing group.

CONCLUSION

Routine HIV testing in admissions of infectious diseases is acceptable, feasible, sustainable and clinically effective. Compared to targeted testing, routine testing helped to discover more patients in earlier stages and those with heterosexually transmitted HIV infection.

Low nadir CD4+ T-cell counts predict gut dysbiosis in HIV-1 infection

Human immunodeficiency virus (HIV)-1 infection causes severe gut and systemic immune damage, but its effects on the gut microbiome remain unclear. Previous shotgun metagenomic studies in HIV-negative subjects linked low-microbial gene counts (LGC) to gut dysbiosis in diseases featuring intestinal inflammation. Using a similar approach in 156 subjects with different HIV-1 phenotypes, we found a strong, independent, dose-effect association between nadir CD4+ T-cell counts and LGC. As in other diseases involving intestinal inflammation, the gut microbiomes of subjects with LGC were enriched in gram-negative Bacteroides, acetogenic bacteria and Proteobacteria, which are able to metabolize reactive oxygen and nitrogen species; and were depleted in oxygen-sensitive methanogenic archaea and sulfate-reducing bacteria. Interestingly, subjects with LGC also showed increased butyrate levels in direct fecal measurements, consistent with enrichment in Roseburia intestinalis despite reductions in other butyrate producers. The microbiomes of subjects with LGC were also enriched in bacterial virulence factors, as well as in genes associated with beta-lactam, lincosamide, tetracycline, and macrolide resistance. Thus, low nadir CD4+ T-cell counts, rather than HIV-1 serostatus per se, predict the presence of gut dysbiosis in HIV-1 infected subjects. Such dysbiosis does not display obvious HIV-specific features; instead, it shares many similarities with other diseases featuring gut inflammation.

Effects of Immunonutrition in Advanced Human Immunodeficiency Virus Disease: A Randomized Placebo-controlled Clinical Trial (Promaltia Study)

BACKGROUND

While nutritional interventions with prebiotics and probiotics seem to exert immunological effects, their clinical implications in human immunodeficiency virus (HIV)-infected subjects initiating antiretroviral therapy (ART) at advanced HIV disease remain unclear.

METHODS

This was a pilot multicenter randomized, placebo-controlled, double-blind study in which 78 HIV-infected, ART-naive subjects with <350 CD4 T cells/μL or AIDS were randomized to either daily PMT25341 (a mixture of synbiotics, omega-3/6 fatty acids and amino acids) or placebo for 48 weeks, each in combination with first-line ART. Primary endpoints were changes in CD4 T-cell counts and CD4/CD8 ratio from baseline to week 48 and safety. Secondary endpoints were changes in markers of T-cell activation, bacterial translocation, inflammation, and α and β microbiota diversity.

RESULTS

Fifty-nine participants completed the follow-up with a mean CD4+ T-cell count of 221 ± 108 cells/μL and mean CD4/CD8 ratio of 0.26 ± 0.19. PMT25341 was well tolerated, without grade 3-4 adverse effects attributable to the intervention. While most of the assessed biomarkers improved during the follow-up in both arms, PMT25341-treated subjects did not experience any significant change, compared to placebo-treated subjects, in mean CD4+ T-cell count change (278 vs 250 cells/μL, P = .474) or CD4/CD8 ratio change (0.30 vs 0.32, P = .854). Similarly, we did not detect differences between treatment arms in secondary endpoints.

CONCLUSIONS

In HIV-infected patients initiating ART at advanced disease, the clear immunological benefits of ART were not enhanced by this nutritional intervention targeting the gut-associated lymphoid tissue and microbiota.

CLINICAL TRIALS REGISTRATION

NCT00870363.