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Jopling R, Mutsvuke W, Fertig M, O'Cleirigh C, Mangezi W, Abas M. "What if I got rejected by the girl? I would rather stop the pills": barriers and facilitators of adherence to antiretroviral therapy for emerging adults aged 18-29 living with HIV in Zimbabwe. AIDS Care 2024; 36:168-178. [PMID: 38537178 PMCID: PMC11283961 DOI: 10.1080/09540121.2024.2332462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 03/14/2024] [Indexed: 05/12/2024]
Abstract
Emerging adults aged 18-29 have high rates of viral non-suppression, and poorer adherence to ART when compared to older adults. Semi-structured interviews were conducted with 24 emerging adults in Zimbabwe who had a recent history of viral non-suppression, to explore barriers and facilitators of adherence to ART. Interviews were coded using inductive thematic analysis. The mean age of participants was 23, 65% were male, and 79% reported acquiring HIV at birth. Twelve barriers to adherence were identified. Hiding HIV status due to the possible negative consequences of disclosure had a significant impact on adherence to ART. This was particularly important for emerging adults navigating starting intimate relationships. Being away from home, poverty, poor mental health, isolation, significant life events, alcohol, health systems barriers, and stigma were reported as barriers to adherence. Support from peers and family after disclosure of HIV status, phone-based reminders, problem-solving strategies to adhere, knowing others living with HIV, acted as facilitators to adherence to ART. Beliefs about medicines and relationships with health care providers acted as both barriers and facilitators to adherence. Interventions to reduce stigma, foster peer support, and therapy for common mental disorders could facilitate emerging adults aged 18-29 to adhere to ART.
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Affiliation(s)
- Rebecca Jopling
- Health Services and Population Research Department, King's College London, London, UK
| | | | - Madison Fertig
- Department of Psychological & Brain Sciences, Boston University, Boston, MA, USA
| | - Conall O'Cleirigh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Walter Mangezi
- Department of Primary Health Care Sciences, Unit of Mental Health, University of Zimbabwe, Harare, Zimbabwe
| | - Melanie Abas
- Health Services and Population Research Department, King's College London, London, UK
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Thielking AM, Fitzmaurice KP, Sewpaul R, Chrysanthopoulou SA, Dike L, Levy DE, Rigotti NA, Siedner MJ, Wood R, Paltiel AD, Freedberg KA, Hyle EP, Reddy KP. Tobacco smoking, smoking cessation and life expectancy among people with HIV on antiretroviral therapy in South Africa: a simulation modelling study. J Int AIDS Soc 2024; 27:e26315. [PMID: 38924347 PMCID: PMC11197963 DOI: 10.1002/jia2.26315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION As access to effective antiretroviral therapy (ART) has improved globally, tobacco-related illnesses, including cardiovascular disease, cancer and chronic respiratory conditions, account for a growing proportion of deaths among people with HIV (PWH). We estimated the impact of tobacco smoking and smoking cessation on life expectancy among PWH in South Africa. METHODS In a microsimulation model, we simulated 18 cohorts of PWH with virologic suppression, each homogenous by sex, initial age (35y/45y/55y) and smoking status (current/former/never). Input parameters were from data sources published between 2008 and 2022. We used South African data to estimate age-stratified mortality hazard ratios: 1.2-2.3 (females)/1.1-1.9 (males) for people with current versus never smoking status; and 1.0-1.3 (females)/1.0-1.5 (males) for people with former versus never smoking status, depending on age at cessation. We assumed smoking status remains unchanged during the simulation; people who formerly smoked quit at model start. Simulated PWH face a monthly probability of disengagement from care and virologic non-suppression. In sensitivity analysis, we varied smoking-associated and HIV-associated mortality risks. Additionally, we estimated the total life-years gained if a proportion of all virologically suppressed PWH stopped smoking. RESULTS Forty-five-year-old females/males with HIV with virologic suppression who smoke lose 5.3/3.7 life-years compared to PWH who never smoke. Smoking cessation at age 45y adds 3.4/2.4 life-years. Simulated PWH who continue smoking lose more life-years from smoking than from HIV (females, 5.3 vs. 3.0 life-years; males, 3.7 vs. 2.6 life-years). The impact of smoking and smoking cessation increase as smoking-associated mortality risks increase and HIV-associated mortality risks, including disengagement from care, decrease. Model results are most sensitive to the smoking-associated mortality hazard ratio; varying this parameter results in 1.0-5.1 life-years gained from cessation at age 45y. If 10-25% of virologically suppressed PWH aged 30-59y in South Africa stopped smoking now, 190,000-460,000 life-years would be gained. CONCLUSIONS Among virologically suppressed PWH in South Africa, tobacco smoking decreases life expectancy more than HIV. Integrating tobacco cessation interventions into HIV care, as endorsed by the World Health Organization, could substantially improve life expectancy.
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Affiliation(s)
- Acadia M. Thielking
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Kieran P. Fitzmaurice
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Ronel Sewpaul
- Human and Social Capabilities, Human Sciences Research CouncilCape TownSouth Africa
| | | | - Lotanna Dike
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Douglas E. Levy
- Harvard Medical SchoolBostonMassachusettsUSA
- Tobacco Research and Treatment CenterMassachusetts General HospitalBostonMassachusettsUSA
- Mongan Institute Health Policy Research CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Nancy A. Rigotti
- Harvard Medical SchoolBostonMassachusettsUSA
- Tobacco Research and Treatment CenterMassachusetts General HospitalBostonMassachusettsUSA
- Mongan Institute Health Policy Research CenterMassachusetts General HospitalBostonMassachusettsUSA
- Division of General Internal MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Mark J. Siedner
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Africa Health Research InstituteSomkheleSouth Africa
| | - Robin Wood
- Desmond Tutu Health Foundation, MowbrayCape TownSouth Africa
- Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - A. David Paltiel
- Public Health Modeling UnitYale School of Public HealthNew HavenConnecticutUSA
| | - Kenneth A. Freedberg
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Department of Health Policy and ManagementHarvard T. H. Chan School of Public HealthBostonMassachusettsUSA
| | - Emily P. Hyle
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
| | - Krishna P. Reddy
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Tobacco Research and Treatment CenterMassachusetts General HospitalBostonMassachusettsUSA
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
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Comfort AB, Asiimwe S, Amaniyre G, Orrell C, Moody J, Musinguzi N, Bwana MB, Bangsberg DR, Haberer JE, Tsai AC. Social networks and HIV treatment adherence among people with HIV initiating treatment in rural Uganda and peri-urban South Africa. SSM Popul Health 2024; 25:101593. [PMID: 38292051 PMCID: PMC10825562 DOI: 10.1016/j.ssmph.2023.101593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/24/2023] [Accepted: 12/28/2023] [Indexed: 02/01/2024] Open
Abstract
Timely initiation of and adherence to antiretroviral therapy (ART) is critical for improving HIV outcomes and reducing HIV transmissibility. Social networks, or the social relationships individuals have with each other, have been linked with positive health outcomes, but less is known about the extent to which social network composition and structure are associated with improved ART adherence among people living with HIV (PLWH). We conducted an ego-centric network study among 828 previously ART-naïve PLWH presenting for ART initiation at 11 clinics in Mbarara, Uganda (rural population) and Gugulethu, South Africa (peri-urban population). We collected social network data using name generator and name interpreter questions. ART adherence was monitored over 12 months using wireless monitors (Wisepill). Our primary outcome of interest was ART adherence during the 12-month follow-up period. We used generalized linear models to estimate the associations between network measures and ART adherence. PLWH at the Uganda site (compared with the South Africa site) were less isolated, had larger social networks, and had more social ties providing sufficient social support; they were also more likely to bridge different social groups whereby not all social ties were connected to each other. In Uganda, social isolation was associated with a 5.5 percentage point reduction in ART adherence (95% confidence interval [CI] -9.95 to -1.13; p = 0.014), while having more same gender social ties was associated with higher ART adherence (b = 0.13, 95% CI 0.02-0.25, p = 0.025). In South Africa, there was no association between social isolation and ART adherence, and having more friendship ties (vs. family ties) was associated with lower ART adherence (b = -2.20, 95% CI -3.56 to -0.84; p = 0.002). Identifying and supporting PLWH who are isolated may facilitate optimal adherence, but understanding how networks differentially affect ART adherence by country context is important.
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Affiliation(s)
- Alison B. Comfort
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94143-1224, USA
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, P. O. Box 1410, Mbarara, Uganda
| | - Gideon Amaniyre
- Makerere University Joint AIDS Program, Plot 4B P.O.Box 7072 Kololo Hill Dr, Kampala, Uganda
| | - Catherine Orrell
- Desmond Tutu Health Foundation, 3 Woodlands Rd, Woodstock, 7915, Cape Town, South Africa
| | - James Moody
- Department of Sociology, 268 Soc/Psych Building, Duke University, Durham, NC, 27708-0088, USA
| | - Nicholas Musinguzi
- Mbarara University of Science and Technology, P. O. Box 1410, Mbarara, Uganda
| | - Mwebesa Bosco Bwana
- Mbarara University of Science and Technology, P. O. Box 1410, Mbarara, Uganda
| | | | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
| | - Alexander C. Tsai
- Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
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Phillips T, Gomba Y, Myer L. Comparing a point-of-care urine tenofovir lateral flow assay to self-reported adherence and their associations with viral load suppression among adults on antiretroviral therapy. Trop Med Int Health 2024; 29:96-103. [PMID: 38084797 PMCID: PMC10872537 DOI: 10.1111/tmi.13953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
BACKGROUND Point-of-care (POC) lateral flow assays (LFA) to detect tenofovir (TFV) in urine have been developed to measure short-term ART adherence. Limited data exist from people living with HIV in routine care. METHODS Adults on TFV-containing regimens, having a routine viral load (VL) at an HIV clinic in Cape Town, South Africa were enrolled in a cross-sectional study. Patients recalled missed ART doses in the past three and 7 days and urine was tested using a POC TFV LFA. VL on the day was abstracted from medical records. RESULTS Among 314 participants, 293 (93%) had VL <1000 copies/mL, 20 (6%) had no TFV detected and 24 (8%) reported ≥1 missed dose in the past 3 days. Agreement between VL ≥1000 and undetectable TFV was higher compared to 3-day recall of ≥1 missed dose (Kappa 0.504 vs. 0.163, p = 0.015). The AUC to detect VL ≥1000 was 0.747 (95% CI 0.637-0.856) for undetectable TFV. This was statistically significantly better than for 7-day recall (0.571 95% CI 0.476-0.666, p = 0.040) but not for 3-day recall (0.587 95% CI 0.492-0.681, p = 0.071) of ≥1 missed dose. CONCLUSION In this largely virally suppressed cohort, TFV in urine had better agreement with VL than self-reported adherence and was a better predictor of viraemia on two of three self-report measures. Used in combination with VL, the POC urine TFV LFA could flag patients with viraemia in the presence of ART. Further research is needed to understand the potential application in different populations on ART, including pregnant women.
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Affiliation(s)
- Tamsin Phillips
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Yolanda Gomba
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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Kreniske P, Namuyaba OI, Kasumba R, Namatovu P, Ssewamala F, Wingood G, Wei Y, Ybarra ML, Oloya C, Tindyebwa C, Ntulo C, Mujune V, Chang LW, Mellins CA, Santelli JS. Mobile Phone Technology for Preventing HIV and Related Youth Health Problems, Sexual Health, Mental Health, and Substance Use Problems in Southwest Uganda (Youth Health SMS): Protocol for a Pilot Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e49352. [PMID: 38113102 PMCID: PMC10762611 DOI: 10.2196/49352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND East and Southern Africa have the highest HIV incidence and prevalence in the world, with adolescents and young adults being at the greatest risk. Despite effective combination prevention tools, including the recently available pre-exposure prophylaxis (PrEP), HIV incidence among adolescents and young adults in Uganda remains high, and PrEP use remains low. Mental health and substance use (behavioral health) play a role in sexual behavior and decision-making, contributing to an increase in the risk for acquiring HIV. Interventions that target multiple HIV risk factors, including sexual and mental health and problematic substance use, are crucial to ending the HIV epidemic. Yet few interventions addressing HIV related health disparities and comorbidities among adolescents and young adults in East and Southern Africa currently exist. OBJECTIVE This study aims to evaluate the acceptability and feasibility of Kirabo, an SMS text message intervention informed by the information, motivation, and behavior model and to be disseminated through secondary schools. The study will gather preliminary estimates of Kirabo's effectiveness in increasing HIV testing and linking users to mental health counselors. METHODS We identified Mobile 4 Reproductive Health for adaptation using the assessment, decision, administration, production, topical experts, integration, training, testing (ADAPT-ITT) framework. Mobile 4 Reproductive Health is an evidence-based automated 2-way SMS text messaging and interactive voice response platform that offers sexual and reproductive health information and links users to HIV clinics in East Africa. Through ADAPT-ITT we refined our approach and created Kirabo, an SMS text message-based intervention for linking adolescents and young adults to health services, including HIV testing and mental health counseling. We will conduct a 2-arm randomized controlled trial in Masaka, Uganda. Adolescents (N=200) will be recruited from local schools. Baseline sociodemographic characteristics, HIV test history, and behavioral health symptoms will be assessed. We will evaluate acceptability and feasibility using surveys, interviews, and mobile phone data. The preliminary efficacy of Kirabo in increasing HIV testing and linking users to mental health counselors will be evaluated immediately after the intervention and at the 3-month follow-up. We will also assess the intervention's impact on self-efficacy in testing for HIV, adopting PrEP, and contacting a mental health counselor. RESULTS Intervention adaptation began in 2019. A pretest was conducted in 2021. The randomized controlled trial, including usability and feasibility assessments and effectiveness measurements, commenced in August 2023. CONCLUSIONS Kirabo is a tool that assists in the efforts to end the HIV epidemic by targeting the health disparities and comorbidities among adolescents in Uganda. The intervention includes local HIV clinic information, PrEP information, and behavioral health screening, with referrals as needed. Increasing access to prevention strategies and mitigating factors that make adolescents and young adults susceptible to HIV acquisition can contribute to global efforts to end the HIV epidemic. TRIAL REGISTRATION ClinicalTrials.gov NCT05130151; https://clinicaltrials.gov/study/NCT05130151. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/49352.
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Affiliation(s)
- Philip Kreniske
- Community Health and Social Sciences Department, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
| | | | - Robert Kasumba
- Washington University in St Louis, St Louis, MO, United States
| | - Phionah Namatovu
- International Center for Child Development, Masaka, Uganda
- Washington University in St Louis, St Louis, MO, United States
| | - Fred Ssewamala
- International Center for Child Development, Masaka, Uganda
- Washington University in St Louis, St Louis, MO, United States
| | - Gina Wingood
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Ying Wei
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Michele L Ybarra
- Center for Innovative Public Health Research, San Clemente, CA, United States
| | | | | | | | | | - Larry W Chang
- Department of Epidemiology, School of Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, United States
| | - John S Santelli
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, United States
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6
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Beidelman ET, Bärnighausen T, Wing C, Tollman S, Phillips ML, Rosenberg M. Disease awareness and healthcare utilization in rural South Africa: a comparative analysis of HIV and diabetes in the HAALSI cohort. BMC Public Health 2023; 23:2202. [PMID: 37940928 PMCID: PMC10634006 DOI: 10.1186/s12889-023-17043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 10/21/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Studies from rural South Africa indicate that people living with HIV (PLHIV) may have better health outcomes than those without, potentially due to the frequent healthcare visits necessitated by infection. Here, we examined the association between HIV status and healthcare utilization, using diabetes as an illustrative comparator of another high-burden, healthcare-intensive disease. METHODS Our exposure of interest was awareness of positive disease status for both HIV and diabetes. We identified 742 individuals who were HIV-positive and aware of their status and 305 who had diabetes and were aware of their status. HIV-positive status was further grouped by viral suppression. For each disease, we estimated the association with (1) other comorbid, chronic conditions, (2) health facility visits, (3) household-level healthcare expenditure, and (4) per-visit healthcare expenditure. We used log-binomial regression models to estimate prevalence ratios for co-morbid chronic conditions. Linear regression models were used for all other outcomes. RESULTS Virally suppressed PLHIV had decreased prevalence of chronic conditions, increased public clinic visits [β = 0.59, 95% CI: 0.5, 0.7], and reduced per-visit private clinic spending [β = -60, 95% CI: -83, -6] compared to those without HIV. No differences were observed in hospitalizations and per-visit spending at hospitals and public clinics between virally suppressed PLHIV and non-PLHIV. Conversely, diabetic individuals had increased prevalence of chronic conditions, increased visits across facility types, increased household-level expenditures (β = 88 R, 95% CI: 29, 154), per-visit hospital spending (β = 54 R, 95% CI: 7, 155), and per-visit public clinic spending (β = 31 R, 95% CI: 2, 74) compared to those without diabetes. CONCLUSIONS Our results suggest that older adult PLHIV may visit public clinics more often than their HIV-negative counterparts but spend similarly on a per-visit basis. This provides preliminary evidence that the positive health outcomes observed among PLHIV in rural South Africa may be explained by different healthcare engagement patterns. Through our illustrative comparison between PLHIV and diabetics, we show that shifting disease burdens towards chronic and historically underfunded diseases, like diabetes, may be changing the landscape of health expenditure inequities.
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Affiliation(s)
- Erika T Beidelman
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA.
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Coady Wing
- O'Neill School of Public and Environmental Affairs, Indiana University-Bloomington, Bloomington, USA
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Meredith L Phillips
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA
| | - Molly Rosenberg
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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7
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Jennings L, Ferraris CM, Castillo-Mancilla JR, Robbins RN, Nguyen N, Leu CS, Dolezal C, Hsiao NY, Mgbako O, Joska J, Myer L, Anderson PL, Remien RH, Orrell C. Comparing Predictive Ability of Two Objective Adherence Measures in a Community-Based Cohort on Antiretroviral Therapy in South Africa: Tenofovir Diphosphate Concentrations and Electronic Adherence Monitors. J Acquir Immune Defic Syndr 2023; 93:327-332. [PMID: 36976520 PMCID: PMC10287050 DOI: 10.1097/qai.0000000000003198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/06/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Electronic adherence (EA) and tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) are objective measures of antiretroviral therapy (ART) adherence. We characterized the association between these measures in a prospective cohort of persons with HIV (PWH) on ART. SETTING Four primary health clinics in Cape Town, South Africa. METHODS We enrolled 250 virally suppressed PWH receiving tenofovir-based ART. We collected EA data, monthly viral load, and TFV-DP in DBS for 12 months. We used logistic regression to estimate the adjusted odds ratio (aOR) and 95% confidence intervals (CIs) for future viral breakthrough (VB) (>400 copies/mL) for each adherence measure. Receiver operating characteristics (ROCs) provided the predictive power of these measures. RESULTS Participants had a median (IQR) age of 34 (27-42); 78% were women. Twenty-one (8%) developed VB. Logistic regression showed that when percent EA and TFV-DP concentrations increased, the odds of VB decreased. This relationship was consistent at the time of VB (aOR of 0.41 [95% CI: 0.25 to 0.66] for TFV-DP and aOR of 0.64 [95% CI: 0.54 to 0.76] for EA) and for up to 2 months before VB. Both adherence measures predicted future VB at both 1 month and 2 months before viral load measurement. CONCLUSION We established that 2 objective adherence measures, EA and TFV-DP in DBS, have a positive association with, and are both strongly predictive of, VB in a community-based South African cohort on ART. Future research is needed to determine the feasibility of implementing these adherence measures in resource-limited settings to facilitate adherence interventions.
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Affiliation(s)
- Lauren Jennings
- Desmond Tutu Health Foundation, Institute of Infectious Diseases and Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Christopher M. Ferraris
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY
| | | | - Reuben N. Robbins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY
| | - Nadia Nguyen
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Cheng-Shiun Leu
- Columbia University Mailman School of Public Health, New York, NY
| | - Curtis Dolezal
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY
| | - Nei-yuan Hsiao
- National Health Laboratory Service, Cape Town, South Africa
| | - Ofole Mgbako
- Division of Infectious Diseases, Department of Medicine, NYU Langone Health, New York, NY
| | - John Joska
- HIV Mental Health Research Unit, University of Cape Town, Cape Town, South Africa; and
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Institute of Infectious Diseases and Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
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8
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Tassiopoulos K, Huo Y, Kacanek D, Malee K, Nichols S, Mellins CA, Kohlhoff S, Van Dyke RB. Association of Perceived Social Support with Viral Suppression Among Young Adults with Perinatally-Acquired HIV in the US-based Pediatric HIV/AIDS Cohort Study (PHACS). Clin Epidemiol 2023; 15:601-611. [PMID: 37193342 PMCID: PMC10182767 DOI: 10.2147/clep.s403570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/29/2023] [Indexed: 05/18/2023] Open
Abstract
Purpose To determine the relationship between perceived social support and viral suppression among young adults with perinatally-acquired HIV (YAPHIV). Participants and Methods We included YAPHIV ≥18 years enrolled in AMP Up, a study of PHACS (Pediatric HIV/AIDS Cohort Study), with social support evaluations and ≥1 HIV viral load (VL) measured over the next year. We evaluated emotional, instrumental, and friendship social support via the NIH Toolbox. We defined social support, measured at study entry and year 3 (if available), as low (T-score ≤40), average (41-59) or high (≥60). We defined viral suppression as all VL <50 copies/mL over the one year after social support measures. We fit multivariable Poisson regression models using generalized estimating equations, and evaluated transition from pediatric to adult care as an effect modifier. Results Among 444 YAPHIV, low emotional and instrumental support and friendship at entry were reported by 37%, 32% and 36%. Over the next year, 44% were virally suppressed. Of 136 with year 3 data, 45% were suppressed. Average or high levels of all three social support measures were associated with higher likelihood of viral suppression. Instrumental support was associated with viral suppression among those in pediatric (adjusted proportion suppressed among those with average/high vs low support=51.2% vs 28.9%; risk ratio (RR)=1.77, 95% confidence interval (CI)=1.37, 2.29), but not adult care (40.0% vs 40.8%; RR=0.98, 95% CI=0.67, 1.44). Conclusion Sufficient social support increases likelihood of viral suppression among YAPHIV. Strategies to enhance social support may promote viral suppression as YAPHIV prepare for adult clinical care transition.
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Affiliation(s)
| | - Yanling Huo
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Deborah Kacanek
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kathleen Malee
- Departments of Infectious Diseases and Psychiatry and Behavioral Science, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sharon Nichols
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - Claude A Mellins
- Psychiatry and Sociomedical Sciences, Columbia University, New York, NY, USA
| | - Stephan Kohlhoff
- Division of Pediatric Infectious Diseases, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Russell B Van Dyke
- Pediatric Infectious Diseases, Tulane University School of Medicine, New Orleans, LA, USA
| | - On behalf of the Pediatric HIV/AIDS Cohort Study
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Departments of Infectious Diseases and Psychiatry and Behavioral Science, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
- Psychiatry and Sociomedical Sciences, Columbia University, New York, NY, USA
- Division of Pediatric Infectious Diseases, SUNY Downstate Medical Center, Brooklyn, NY, USA
- Pediatric Infectious Diseases, Tulane University School of Medicine, New Orleans, LA, USA
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9
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Jennings L, West RL, Halim N, Kaiser JL, Gwadz M, MacLeod WB, Gifford AL, Haberer JE, Orrell C, Sabin LL. Protocol for an evaluation of adherence monitoring and support interventions among people initiating antiretroviral therapy in Cape Town, South Africa-a multiphase optimization strategy (MOST) approach using a fractional factorial design. Trials 2023; 24:310. [PMID: 37147725 PMCID: PMC10163747 DOI: 10.1186/s13063-023-07322-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/21/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND South Africa bears a large HIV burden with 7.8 million people with HIV (PWH). However, due to suboptimal antiretroviral therapy (ART) adherence and retention in care, only 66% of PWH in South Africa are virally suppressed. Standard care only allows for suboptimal adherence detection when routine testing indicates unsuppressed virus. Several adherence interventions are known to improve HIV outcomes, yet few are implemented in routinely due to the resources required. Therefore, determining scalable evidence-based adherence support interventions for resource-limited settings (RLS) is a priority. The multiphase optimization strategy (MOST) framework allows for simultaneous evaluation of multiple intervention components and their interactions. We propose to use MOST to identify the intervention combination with the highest levels of efficacy and cost-effectiveness that is feasible and acceptable in primary care clinics in Cape Town. METHODS We will employ a fractional factorial design to identify the most promising intervention components for inclusion in a multi-component intervention package to be tested in a future randomized controlled trial. We will recruit 512 participants initiating ART between March 2022 and February 2024 in three Cape Town clinics and evaluate acceptability, feasibility, and cost-effectiveness of intervention combinations. Participants will be randomized to one of 16 conditions with different combinations of three adherence monitoring components: rapid outreach following (1) unsuppressed virus, (2) missed pharmacy refill collection, and/or (3) missed doses as detected by an electronic adherence monitoring device; and two adherence support components: (1) weekly check-in texts and (2) enhanced peer support. We will assess viral suppression (<50 copies/mL) at 24 months as the primary outcome; acceptability, feasibility, fidelity, and other implementation outcomes; and cost-effectiveness. We will use logistic regression models to estimate intervention effects with an intention-to-treat approach, employ descriptive statistics to assess implementation outcomes, and determine an optimal intervention package. DISCUSSION To our knowledge, ours will be the first study to use the MOST framework to determine the most effective combination of HIV adherence monitoring and support intervention components for implementation in clinics in a RLS. Our findings will provide direction for pragmatic, ongoing adherence support that will be key to ending the HIV epidemic. TRIAL REGISTRATION ClinicalTrials.gov NCT05040841. Registered on 10 September 2021.
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Affiliation(s)
- Lauren Jennings
- Desmond Tutu Health Foundation, Institute of Infectious Diseases and Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Rebecca L West
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Marya Gwadz
- Silver School of Social Work, New York University, New York, NY, USA
| | - William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Allen L Gifford
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 72 E Concord Street, Boston, MA, 02118, USA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA, 02130, USA
- Department of Health Policy and Management, Boston University School of Public Health, Talbot Building, T348W, Boston, MA, 02118, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Institute of Infectious Diseases and Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lora L Sabin
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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10
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Nevrekar N, Butler K, Shapiro DE, Atuhaire P, Taha TE, Makanani B, Chinula L, Owor M, Moodley D, Chipato T, McCarthy K, Flynn PM, Currier J, Fowler MG, Gupta A, Suryavanshi N. Self-reported Antiretroviral Adherence: Association With Maternal Viral Load Suppression in Postpartum Women Living With HIV-1 From Promoting Maternal and Infant Survival Everywhere, a Randomized Controlled Trial in Sub-Saharan Africa and India. J Acquir Immune Defic Syndr 2023; 92:76-83. [PMID: 36170749 PMCID: PMC9722360 DOI: 10.1097/qai.0000000000003102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/06/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Optimal adherence to antiretroviral therapy (ART) is crucial to promoting maternal-infant health. SETTING Fourteen sites in 7 countries within sub-Saharan Africa and India. METHODS The multicomponent, open-label strategy PROMISE trial enrolled breastfeeding mother-infant pairs not meeting in-country criteria for maternal ART (mART) initiation in the postpartum component within 5 days of delivery. Randomization was to mART versus infant NVP (iNVP) prophylaxis. Infants in the mART arm also received 6 weeks of iNVP. Self-reported adherence was assessed in a secondary analysis. Time-to-event analyses were performed to explore the association between adherence and maternal viral load (mVL) in the mART arm. RESULTS Two thousand four hundred thirty-one mother-infant pairs were enrolled between 2011 and 2014; the baseline maternal median CD4 was 686 (IQR 553-869), and the median mVL was 322 copies/mL (IQR 40-1422). Self-reported adherence was lower in the mART arm compared with the iNVP arm (no missed doses within 4 weeks of all study visits: 66% vs 83%; within 2 weeks: 71% vs 85%; P < 0.0001). The iNVP adherence at week 6 was high in both arms: 97% in mART arm; 95% in iNVP arm. Time-to-event analyses showed that adherence to mART was associated with time to first mVL ≥400 copies/mL ( P < 0.0001). Missing 1 full day of doses over 3 days was associated with a 66% risk of mVL ≥1000 copies/mL (HR: 1.66; 95% CI: 1.37, 1.99). CONCLUSIONS Postpartum women were less adherent to their own ART than mothers providing their infant's nevirapine prophylaxis. The self-reported missed mART doses were associated with high mVL. Strategies to optimize postpartum mART adherence are urgently needed. CLINICAL TRIAL NUMBER ClinicalTrials.gov: NCT01061151; closed to follow-up.
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Affiliation(s)
- Neetal Nevrekar
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Kevin Butler
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Patience Atuhaire
- Makerere University–John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Taha E. Taha
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Bonus Makanani
- College of Medicine-Johns Hopkins Project, Blantyre, Malawi
| | | | - Maxensia Owor
- Makerere University–John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
- Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | | | - Patricia M. Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Judith Currier
- UCLA Centre for Clinical AIDS Research and Education, Los Angeles, CA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD; and
| | - Amita Gupta
- Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, India
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11
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Stanton AM, Hornstein BD, Musinguzi N, Dolotina B, Orrell C, Amanyire G, Asiimwe S, Cross A, Psaros C, Bangsberg D, Hahn JA, Haberer JE, Matthews LT. Factors Associated With Changes in Alcohol Use During Pregnancy and the Postpartum Transition Among People With HIV in South Africa and Uganda. J Int Assoc Provid AIDS Care 2023; 22:23259582231161029. [PMID: 36945860 PMCID: PMC10034296 DOI: 10.1177/23259582231161029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Identifying factors associated with alcohol use changes during pregnancy is important for developing interventions for people with HIV (PWH). Pregnant PWH (n = 202) initiating antiretroviral therapy in Uganda and South Africa completed two assessments, 6 months apart (T1, T2). Categories were derived based on AUDIT-C scores: "no use" (AUDIT-C = 0 at T1 and T2), "new use" (AUDIT-C = 0 at T1, >0 at T2), "quit" (AUDIT-C > 0 at T1, =0 at T2), and "continued use" (AUDIT-C > 0, T1 and T2). Factors associated with these categories were assessed. Most participants had "no use" (68%), followed by "continued use" (12%), "quit" (11%), and "new use" (9%). Cohabitating with a partner was associated with lower relative risk of "continued use." Borderline significant associations between food insecurity and higher risk of "new use" and between stigma and reduced likelihood of "quitting" also emerged. Alcohol use interventions that address partnership, food security, and stigma could benefit pregnant and postpartum PWH.
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Affiliation(s)
- Amelia M Stanton
- Department of Psychological and Brain Sciences, 1846Boston University, Boston, USA
- 446213The Fenway Institute, Boston, USA
- Department of Psychiatry, 2348Massachusetts General Hospital, Boston, USA
| | - Benjamin D Hornstein
- Department of Medicine, 9967University of Alabama at Birmingham, Birmingham, USA
| | - Nicholas Musinguzi
- Makerere-Mbarara Universities Joint AIDS Program (MJAP), Mbarara, Uganda
- 108123Mbarara University of Science and Technology, Mbarara, Uganda
| | - Brett Dolotina
- Department of Epidemiology, 33638Mailman School of Public Health, Columbia University, New York, USA
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gideon Amanyire
- Makerere-Mbarara Universities Joint AIDS Program (MJAP), Mbarara, Uganda
- 560159Africa Health Research Institute, Durban, South Africa
| | - Stephen Asiimwe
- Global Health Collaborative, Mbarara, Uganda
- Kabwohe Clinical Research Center (KCRC), Kabwohe, Uganda
| | - Anna Cross
- Desmond Tutu Health Foundation, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Christina Psaros
- Department of Psychiatry, 2348Massachusetts General Hospital, Boston, USA
- 1811Harvard Medical School, Boston, USA
| | - David Bangsberg
- School of Public Health, Oregon Health and Science University/Portland State, Portland, USA
| | - Judith A Hahn
- Department of Medicine, 8785University of California San Francisco, San Francisco, USA
| | - Jessica E Haberer
- 1811Harvard Medical School, Boston, USA
- Center for Global Health, 2348Massachusetts General Hospital, Boston, USA
| | - Lynn T Matthews
- Department of Medicine, 9967University of Alabama at Birmingham, Birmingham, USA
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12
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Tyagi A, Tong Y, Rabideau DJ, Reynolds Z, De Oliveira T, Lessells R, Amanyire G, Orrell C, Asiimwe S, Chimukangara B, Giandhari J, Pillay S, Haberer JE, Siedner MJ. Antiretroviral therapy adherence patterns, virological suppression, and emergence of drug resistance: A nested case–control study from Uganda and South Africa. Antivir Ther 2022; 27:13596535221114822. [DOI: 10.1177/13596535221114822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Relationships between distinct antiretroviral therapy (ART) adherence patterns and risk of drug resistance are not well understood. Methods We conducted a nested case–control analysis within a longitudinal cohort study of individuals initiating efavirenz-based ART. Primary outcomes of interest, measured at 6 and 12 months after treatment initiation, were: 1) virologic suppression, 2) virologic failure with resistance, and 3) virologic failure without resistance. Our primary exposure of interest was ART adherence, measured over the 6 months before each visit with electronic pill monitors, and categorized in three ways: 1) 6 months average adherence; 2) running adherence, defined as the proportion of days with average adherence over 9 days of less than or equal to 10%, 20%, and 30%; and 3) number of 3-, 7-, and 28-day treatment gaps in the prior 6 months Results We analyzed data from 166 individuals (107 had virologic failure during observation and 59 had virologic suppression at 6 and 12 months). Average adherence was higher among those with virologic suppression (median 83%, IQR 58–96%) versus those with virologic failure with resistance (median 35%, IQR 20–77%, pairwise P < 0.01) and those with virologic failure without resistance (median 21%, IQR 2–54%, pairwise P < 0.01). Although treatment gaps generally predicted virologic failure ( P < 0.01), they did not differentiate failure with and without drug resistance ( P > 0.6). Conclusions Average adherence patterns, but not the assessed frequency of treatment gaps, differentiated failure with versus without drug resistance among individuals initiating efavirenz-based ART. Future work should explore adherence-resistance relationships for integrase inhibitor-based regimens.
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Affiliation(s)
- Anisha Tyagi
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, MA, USA
| | - Yao Tong
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, MA, USA
| | - Dustin J Rabideau
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Biostatistics, Boston, MA, USA
| | - Zahra Reynolds
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, MA, USA
| | - Tulio De Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Richard Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Gideon Amanyire
- Africa Health Research Institute, Durban, South Africa
- Global Health Collaborative, Mbarara, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Stephen Asiimwe
- Global Health Collaborative, Mbarara, Uganda
- Kabwohe Clinical Research Center, Kabwohe, Uganda
| | - Benjamin Chimukangara
- KwaZulu-Natal Research Innovation and Sequencing Platform, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sureshnee Pillay
- KwaZulu-Natal Research Innovation and Sequencing Platform, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jessica E Haberer
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Mark J Siedner
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Africa Health Research Institute, Durban, South Africa
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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13
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Ghasabi F, Hashempour A, Khodadad N, Bemani S, Keshani P, Shekiba MJ, Hasanshahi Z. First report of computational protein-ligand docking to evaluate susceptibility to HIV integrase inhibitors in HIV-infected Iranian patients. Biochem Biophys Rep 2022; 30:101254. [PMID: 35368742 PMCID: PMC8968007 DOI: 10.1016/j.bbrep.2022.101254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 12/04/2022] Open
Abstract
Background Iran has recently included integrase (INT) inhibitors (INTIs) in the first-line treatment regimen in human immunodeficiency virus (HIV)-infected patients. However, there is no bioinformatics data to elaborate the impact of resistance-associated mutations (RAMs) and naturally occurring polymorphisms (NOPs) on INTIs treatment outcome in Iranian patients. Method In this cross-sectional survey, 850 HIV-1-infected patients enrolled; of them, 78 samples had successful sequencing results for INT gene. Several analyses were performed including docking screening, genotypic resistance, secondary/tertiary structures, post-translational modification (PTM), immune epitopes, etc. Result The average docking energy (E value) of different samples with elvitegravir (EVG) and raltegravir (RAL) was more than other INTIs. Phylogenetic tree analysis and Stanford HIV Subtyping program revealed HIV-1 CRF35-AD was the predominant subtype (94.9%) in our cases; in any event, online subtyping tools confirmed A1 as the most frequent subtype. For the first time, CRF-01B and BF were identified as new subtypes in Iran. Decreased CD4 count was associated with several factors: poor or unstable adherence, naïve treatment, and drug user status. Conclusion As the first bioinformatic report on HIV-integrase from Iran, this study indicates that EVG and RAL are the optimal INTIs in first-line antiretroviral therapy (ART) in Iranian patients. Some conserved motifs and specific amino acids in INT-protein binding sites have characterized that mutation(s) in them may disrupt INT-drugs interaction and cause a significant loss in susceptibility to INTIs. Good adherence, treatment of naïve patients, and monitoring injection drug users are fundamental factors to control HIV infection in Iran effectively.
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Key Words
- Antiretroviral therapy, ART
- Behavioral Diseases Consultation Center, BDCC
- Bictegravir, BIC
- C-terminal domain, CTD
- CRF35-AD
- Cabotegravir, CBT
- Catalytic core domain, CCD
- Dolutegravir, DTG
- Drug resistance
- Elvitegravir, EVG
- Grand average hydropathy, GRAVY
- HIV
- Human immunodeficiency virus, HIV
- INT, Integrase
- INTIs, Integrase inhibitors (INTIs)
- Injecting drug users, IDUs
- Integrase
- Integrase inhibitors
- Molecular docking
- N-terminal domain, NTD
- Naturally occurring polymorphisms, NOPs
- Post-translational modification, PTM
- Raltegravir, RAL
- Resistance-associated mutations, RAMs
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Affiliation(s)
- Farzane Ghasabi
- Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ava Hashempour
- Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nastaran Khodadad
- Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soudabeh Bemani
- Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parisa Keshani
- Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohamad Javad Shekiba
- Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Hasanshahi
- Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
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14
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Munseri P, Jassely L, Tumaini B, Hertzmark E. Body mass index, proteinuria and total lymphocyte counts in predicting treatment responses among ART naïve individuals with HIV initiated on antiretroviral treatment in Dar es Salaam, Tanzania, 2019: a cohort study. BMJ Open 2022; 12:e059193. [PMID: 35676009 PMCID: PMC9185589 DOI: 10.1136/bmjopen-2021-059193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To explore the potential use of body mass index (BMI), proteinuria and total lymphocyte count changes in predicting immunological and virological response in individuals with HIV initiated on antiretroviral treatment (ART). DESIGN Prospective cohort study. SETTING Three urban HIV care and treatment centres in Dar es Salaam. PARTICIPANTS Individuals with HIV initiating ART. OUTCOME MEASURES HIV viral load ≥1000 copies/mL (viral non-suppression) at 6 months after ART initiation. RESULTS Of 215 (out of 220 enrolled) participants who returned for evaluation at 6 months, 147 (66.8%) were women. At 6 months of follow-up, 89.4% (76/85) of participants with sustained weight gain were virally suppressed compared with 31.8% (7/22) with sustained loss, p<0.001. In participants who were lymphopaenic at baseline, an increase to normal total lymphocyte counts at 6 months was associated with an increase in CD4 count compared with participants who remained lymphopaenic, 96.2% (50/52) versus 54.8% (17/31), p<0.001. At baseline, 50.0% (110/220) had proteinuria. In participants without proteinuria from baseline to 6 months, 89.8% (79/88) were virally suppressed compared with participants with proteinuria at baseline and/or 3 months, 85.6% (77/90), those with persistent proteinuria, 30.8% (8/26), and proteinuria at 6 months only, 45.5% (5/11), p<0.001. In modified Poisson regression, the independent predictors other than CD4 cell counts for viral non-suppression at 6 months among individuals with HIV initiating on ART were BMI loss >5% from baseline to 6 months (adjusted RR 2.73, 95% CI (1.36 to 5.47)), lymphopaenia at 6 months (adjusted RR=4.54, 95% CI (2.19 to 9.39)) and proteinuria at 6 months (adjusted RR=2.63, 95% CI (1.25 to 5.54)). CONCLUSIONS Change in BMI, total lymphocyte count and presence of proteinuria can monitor and predict ART response and may be particularly helpful in settings when CD4 counts and viral load monitoring are unavailable.
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Affiliation(s)
- Patricia Munseri
- Internal Medicine, Muhimbili University of Health and Allied Sciences School of Medicine, Dar es Salaam, Tanzania
| | - Lazaro Jassely
- Internal Medicine, Muhimbili University of Health and Allied Sciences School of Medicine, Dar es Salaam, Tanzania
| | - Basil Tumaini
- Internal Medicine, Muhimbili University of Health and Allied Sciences School of Medicine, Dar es Salaam, Tanzania
| | - Ellen Hertzmark
- Global Health, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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15
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Perceptions About Local ART Adherence Norms and Personal Adherence Behavior Among Adults Living with HIV in Rural Uganda. AIDS Behav 2022; 26:1892-1904. [PMID: 35034237 DOI: 10.1007/s10461-021-03540-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 01/08/2023]
Abstract
Although misperceived norms often drive personal health behaviors, we do not know about this phenomenon in the context of antiretroviral therapy (ART) adherence. We conducted a cross-sectional study including all persons living with HIV (PLWH) on ART across eight villages in one parish in a rural region of southwestern Uganda. We used surveys to measure personal reports of ART adherence (not missing any doses of ART in the past 7 days was considered optimal adherence whereas missing doses was considered suboptimal adherence) and perceived norms about the local ART adherence norm (whether or not each individual thought 'most other PLWH on ART in this parish' missed any doses in the past 7 days). Multivariable Poisson regression models were used to estimate the association between perceived norms and personal adherence. Among 159 PLWH on ART (95% response rate), 142 (89%) reported no missed doses. However, 119 (75%) thought most individuals in this population of PLWH on ART were sub-optimally adherent. This misperception about the local ART adherence norm was prevalent in every subgroup of PLWH. Misperceiving the local ART adherence norm to be sub-optimal adherence was associated with a reduced likelihood of optimal adherence among married PLWH (adjusted relative risk [aRR] = 0.83; 95% confidence interval [CI] 0.71-0.97). The association was similar but imprecisely estimated for all PLWH (aRR = 0.91; 95% CI 0.82-1.01). Interventions to correct misperceived ART adherence norms as a stand-alone intervention or as a complement to other adherence promotion programs may influence ART adherence behavior and perhaps reduce HIV-related stigma.
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16
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Campbell LS, Masquillier C, Knight L, Delport A, Sematlane N, Dube LT, Wouters E. Stay-at-Home: The Impact of the COVID-19 Lockdown on Household Functioning and ART Adherence for People Living with HIV in Three Sub-districts of Cape Town, South Africa. AIDS Behav 2022; 26:1905-1922. [PMID: 34977957 PMCID: PMC8720535 DOI: 10.1007/s10461-021-03541-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Abstract
In March 2020, the South African government imposed a lockdown to control COVID-19 transmission. Lockdown may affect people living with HIV’s (PLWH) antiretroviral therapy (ART) adherence. Data from a cluster randomised control trial was collected from 152 PLWH in Cape Town sub-districts from October 2019–March 2020 when the lockdown halted collection. Subsequently, 83 PLWH were followed-up in June–July 2020. Random effects models were used to analyse: (1) changes between baseline and follow-up and (2) correlates of adherence during lockdown. At follow-up, there was an increase in the odds of being below the poverty line and the odds of experiencing violence decreased. Measures for well-being, household functioning, stigma and HIV competency improved. Violence, depression, food insecurity, and stigma were associated with poorer ART adherence; higher well-being scores were associated with better adherence. During lockdown, governments need to ensure financial support, access to (mental) health services, and services for those experiencing violence. Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.
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Affiliation(s)
- Linda S. Campbell
- Centre for Population, Family and Health, University of Antwerp, Prinsstraat 13, 2000 Antwerpen, Belgium
| | - Caroline Masquillier
- Centre for Population, Family and Health, University of Antwerp, Prinsstraat 13, 2000 Antwerpen, Belgium
| | - Lucia Knight
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- School of Public Health, Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Anton Delport
- School of Public Health, Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Neo Sematlane
- Centre for Population, Family and Health, University of Antwerp, Prinsstraat 13, 2000 Antwerpen, Belgium
- School of Public Health, Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Lorraine Tanyaradzwa Dube
- School of Public Health, Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Edwin Wouters
- Centre for Population, Family and Health, University of Antwerp, Prinsstraat 13, 2000 Antwerpen, Belgium
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
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Orievulu KS, Ayeb-Karlsson S, Ngema S, Baisley K, Tanser F, Ngwenya N, Seeley J, Hanekom W, Herbst K, Kniveton D, Iwuji CC. Exploring linkages between drought and HIV treatment adherence in Africa: a systematic review. Lancet Planet Health 2022; 6:e359-e370. [PMID: 35397224 PMCID: PMC7612934 DOI: 10.1016/s2542-5196(22)00016-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/11/2022] [Accepted: 01/21/2022] [Indexed: 06/14/2023]
Abstract
Climate change is directly and indirectly linked to human health, including through access to treatment and care. Our systematic review presents a systems understanding of the nexus between drought and antiretroviral therapy (ART) adherence in HIV-positive individuals in the African setting. Narrative synthesis of 111 studies retrieved from Web of Science, PubMed/MEDLINE, and PsycINFO suggests that livelihoods and economic conditions, comorbidities and ART regimens, human mobility, and psychobehavioural dispositions and support systems interact in complex ways in the drought-ART adherence nexus in Africa. Economic and livelihood-related challenges appear to impose the strongest impact on human interactions, actions, and systems that culminate in non-adherence. Indeed, the complex pathways identified by our systems approach emphasise the need for more integrated research approaches to understanding this phenomenon and developing interventions.
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Affiliation(s)
- Kingsley Stephen Orievulu
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Centre for Africa-China Studies, University of Johannesburg, Johannesburg, South Africa; Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Sonja Ayeb-Karlsson
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; United Nations University Institute for Environment and Human Security, Bonn, Germany; Institute for Risk and Disaster Reduction, University College London, London, UK; School of Global Studies, University of Sussex, Brighton, UK
| | - Sthembile Ngema
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Lincoln Institute for Health, University of Lincoln, Lincoln, UK
| | - Nothando Ngwenya
- Africa Health Research Institute, KwaZulu-Natal, South Africa; School of Nursing and Public Health, University of KwaZulu Natal, Durban, South Africa
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Global Health and Development Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Willem Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Division of Infection and Immunity, University College London, London, UK
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, South Africa; DSI-MRC South African Population Research Infrastructure Network, Durban, South Africa
| | | | - Collins C Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.
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18
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Sabin LL, Gifford AL, Haberer JE, Harvey K, Sarkisova N, Martin K, West RL, Stephens J, Killian C, Halim N, Berkowitz N, Jennings K, Jennings L, Orrell C. Patients' and Providers' Views on Optimal Evidence-Based and Scalable Interventions for Individuals at High Risk of HIV Treatment Failure: Sequential Explorations Among Key Stakeholders in Cape Town, South Africa. AIDS Behav 2022; 26:2783-2797. [PMID: 35190943 DOI: 10.1007/s10461-022-03623-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/25/2022]
Abstract
To support translation of evidence-based interventions into practice for HIV patients at high risk of treatment failure, we conducted qualitative research in Cape Town, South Africa. After local health officials vetted interventions as potentially scalable, we held 41 in-depth interviews with patients with elevated viral load or a 3-month treatment gap at community clinics, followed by focus group discussions (FGDs) with 20 providers (physicians/nurses, counselors, and community health care workers). Interviews queried treatment barriers, solutions, and specific intervention options, including motivational text messages, data-informed counseling, individual counseling, peer support groups, check-in texts, and treatment buddies. Based on patients' preferences, motivational texts and treatment buddies were removed from consideration in subsequent FGDs. Patients most preferred peer support groups and check-in texts while individual counseling garnered the broadest support among providers. Check-in texts, peer support groups, and data-informed counseling were also endorsed by provider sub-groups. These strategies warrant attention for scale-up in South Africa and other resource-constrained settings.
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Affiliation(s)
- Lora L Sabin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA.
| | - Allen L Gifford
- Section of General Internal Medicine, Boston University School of Medicine and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, 02118, USA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Jessica E Haberer
- Center of Global Health, Massachusetts General Hospital, Boston, MA, 02114, USA
- Department of Medicine, Harvard Medical School, Boston, MA, 02114, USA
| | - Kelsee Harvey
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Natalya Sarkisova
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Kyle Martin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Rebecca L West
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Jessie Stephens
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Clare Killian
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | | | - Karen Jennings
- City of Cape Town Health Department, Cape Town, South Africa
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19
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Zoungrana-Yameogo WN, Fassinou LC, Ngwasiri C, Samadoulougou S, Traoré IT, Hien H, Bakiono F, Drabo M, Kirakoya-Samadoulougou F. Adherence to HIV Antiretroviral Therapy Among Pregnant and Breastfeeding Women, Non-Pregnant Women, and Men in Burkina Faso: Nationwide Analysis 2019-2020. Patient Prefer Adherence 2022; 16:1037-1047. [PMID: 35444410 PMCID: PMC9013679 DOI: 10.2147/ppa.s354242] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Since the scale-up of antiretroviral therapy (ART) services in Burkina-Faso, achieving an AIDS-free generation depends on optimal ART adherence. However, no data exists on the population group differences on the level of ART adherence in Burkina-Faso. This study analyzes ART adherence among pregnant-and breastfeeding-women, non-pregnant women, and men in Burkina-Faso. METHODS From December 2019 to March 2020, a cross-sectional study among adult HIV-infected patients in Burkina-Faso, belonging either to the active file or the Prevention of Mother-To-Child Transmission programs was conducted. An analysis was performed and adherence was measured based on the number of times, patients did not meet the number of doses prescribed and did not take the ART treatment in the month prior to the survey. Logistic-regression models were used to identify factors associated with poor ART adherence and the adjusted odds ratios (aORs) with their 95% confidence intervals (95% CI) were reported. RESULTS The prevalence of good adherence was higher in the group of pregnant-and breastfeeding-women (86.6%, n = 112) compared to the other groups (73.1%, n=1017 in non-pregnant women and 72.0%, n = 318 in men). No association was found between ART adherence and the socio-demographic, clinical, and therapeutic characteristics of pregnant-and breastfeeding-women and men groups. However, non-pregnant women with a high level of education (aOR = 1.70; 95% CI: 1.16-2.49), having ever belonged to a support group (aOR= 1.47; 95% CI: 1.07-2.04), not having income-generating occupations (aOR= 1.53; 95% CI: 1.11-2.12), and in advanced clinical stage (aOR= 1.42; 95% CI: 1.06-1.91) were more susceptible to have poor adherence compared to their pairs. CONCLUSION Findings showed a large difference in ART adherence among pregnant-and breastfeeding-women, non-pregnant women and men and highlight the need for differentiated healthcare delivery according to population while specifically considering addressing the interest in early initiation of treatment and the benefit of support groups meeting.
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Affiliation(s)
| | - Lucresse Corine Fassinou
- Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
- Correspondence: Lucresse Corine Fassinou, Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso, Email
| | - Calypse Ngwasiri
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Sekou Samadoulougou
- Evaluation Platform on Obesity Prevention, Quebec Heart and Lung Institute, Quebec, QC, G1V 4G5, Canada
- Centre for Research on Planning and Development (CRAD), Université Laval, Quebec, QC, G1V 0A6, Canada
| | - Isidore Tiandiogo Traoré
- Service d’information et d’épidémiologie, Centre Hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
- Centre Muraz, Institut National de Santé Publique, Bobo-Dioulasso, Burkina Faso
| | - Hervé Hien
- Service d’information et d’épidémiologie, Centre Hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
- Centre Muraz, Institut National de Santé Publique, Bobo-Dioulasso, Burkina Faso
| | - Fidèle Bakiono
- Secrétariat Permanent du conseil national de lutte contre le SIDA et les infections sexuellement transmissible, ministère de la santé, Ouagadougou, Burkina Faso
| | - Maxime Drabo
- Département biomédical et santé publique, Institut de recherche en sciences de la santé, Ouagadougou, Burkina Faso
- Laboratoire de santé publique de l’Ecole doctorale des sciences de la santé (ED2S), Université Joseph Ki Zerbo Ouagadougou, Ouagadougou, Burkina Faso
| | - Fati Kirakoya-Samadoulougou
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
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20
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Orievulu K, Ayeb-Karlsson S, Ngwenya N, Ngema S, McGregor H, Adeagbo O, Siedner MJ, Hanekom W, Kniveton D, Seeley J, Iwuji C. Economic, social and demographic impacts of drought on treatment adherence among people living with HIV in rural South Africa: A qualitative analysis. CLIMATE RISK MANAGEMENT 2022; 36:100423. [PMID: 36923966 PMCID: PMC7614312 DOI: 10.1016/j.crm.2022.100423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The 2015 El Niño-triggered drought in Southern Africa caused widespread economic and livelihood disruption in South Africa, imposing multiple physical and health challenges for rural populations including people living with HIV (PLHIV). We examined the economic, social and demographic impacts of drought drawing on 27 in-depth interviews in two cohorts of PLHIV in Hlabisa, uMkhanyakude district, KwaZulu-Natal. Thematic analysis revealed how drought-enforced soil water depletion, dried-up rivers, and dams culminated in a continuum of events such as loss of livestock, reduced agricultural production, and insufficient access to water and food which was understood to indirectly have a negative impact on HIV treatment adherence. This was mediated through disruptions in incomes, livelihoods and food systems, increased risk to general health, forced mobility and exacerbation of contextual vulnerabilities linked to poverty and unemployment. The systems approach, drawn from interview themes, hypothesises the complex pathways of plausible networks of impacts from drought through varying socioeconomic factors, exacerbating longstanding contextual precarity, and ultimately challenging HIV care utilisation. Understanding the multidimensional relationships between climate change, especially drought, and poor HIV care outcomes through the prism of contextual vulnerabilities is vital for shaping policy interventions.
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Affiliation(s)
- Kingsley Orievulu
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
- Centre for Africa-China Studies, University of Johannesburg, Johannesburg, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Sonja Ayeb-Karlsson
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
- United Nations University Institute for Environment and Human Security, Bonn, Germany
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom
| | | | - Sthembile Ngema
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Oluwafemi Adeagbo
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Health Promotion, Education & Behaviour, University of South Carolina, USA
- Department of Sociology, University of Johannesburg, Johannesburg, South Africa
| | - Mark J. Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Harvard Medical School, Boston, MA 02114, USA
| | - Willem Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | | | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
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21
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Orievulu KS, Iwuji CC. Institutional Responses to Drought in a High HIV Prevalence Setting in Rural South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:434. [PMID: 35010691 PMCID: PMC8744984 DOI: 10.3390/ijerph19010434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/17/2022]
Abstract
In 2015, South Africa experienced one of the worst (El Niño-induced) droughts in 35 years. This affected economic activities, individual and community livelihoods and wellbeing especially in rural communities in northern KwaZulu-Natal. Drought's direct and indirect impacts on public health require urgent institutional responses, especially in South Africa's stride to eliminate HIV as a public health threat by 2030 in line with the UNAIDS goals. This paper draws on qualitative data from interviews and policy documents to discuss how the devastating effect of the 2015 drought experience in the rural Hlabisa sub-district of uMkhanyakude, a high HIV prevalence area, imposes an imperative for more proactive institutional responses to drought and other climate-related events capable of derailing progress made in South Africa's HIV/AIDS response. We found that drought had a negative impact on individual and community livelihoods and made it more difficult for people living with HIV to consistently engage with care due to economic losses from deaths of livestock, crop failure, food insecurity, time spent in search of appropriate water sources and forced relocations. It also affected government institutions and their interventions. Interviewed participants' reflections on drought-related challenges, especially those related to institutional and coordination challenges, showed that although current policy frameworks are robust, their implementation has been stalled due to complex reporting systems, and inadequate interdepartmental collaboration and information sharing. We thus argue that to address the gaps in the institutional responses, there is a need for more inclusive systems of drought-relief implementation, in which government departments, especially at the provincial and district levels, work with national institutions to better share data/information about drought-risks in order to improve preparedness and implementation of effective mitigation measures.
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Affiliation(s)
- Kingsley S. Orievulu
- Africa Health Research Institute, KwaZulu-Natal, Mtubatuba 3935, South Africa;
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
- Centre for Africa-China Studies, University of Johannesburg, Johannesburg 2006, South Africa
| | - Collins C. Iwuji
- Africa Health Research Institute, KwaZulu-Natal, Mtubatuba 3935, South Africa;
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
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22
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Reynolds Z, McCluskey SM, Moosa MYS, Gilbert RF, Pillay S, Aturinda I, Ard KL, Muyindike W, Musinguzi N, Masette G, Moodley P, Brijkumar J, Rautenberg T, George G, Johnson BA, Gandhi RT, Sunpath H, Marconi VC, Bwana MB, Siedner MJ. Who's slipping through the cracks? A comprehensive individual, clinical and health system characterization of people with virological failure on first-line HIV treatment in Uganda and South Africa. HIV Med 2021; 23:474-484. [PMID: 34755438 PMCID: PMC9010349 DOI: 10.1111/hiv.13203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES HIV virological failure remains a major threat to programme success in sub-Saharan Africa. While HIV drug resistance (HIVDR) and inadequate adherence are the main drivers of virological failure, the individual, clinical and health system characteristics that lead to poor outcomes are not well understood. The objective of this paper is to identify those characteristics among people failing first-line antiretroviral therapy (ART). METHODS We enrolled a cohort of adults in HIV care experiencing virological failure on first-line ART at five sites and used standard statistical methods to characterize them with a focus on three domains: individual/demographic, clinical, and health system, and compared each by country of enrolment. RESULTS Of 840 participants, 51% were women, the median duration on ART was 3.2 years [interquartile range (IQR) 1.1, 6.4 years] and the median CD4 cell count prior to failure was 281 cells/µL (IQR 121, 457 cells/µL). More than half of participants [53%; 95% confidence interval (CI) 49-56%] stated that they had > 90% adherence and 75% (95% CI 72-77%) took their ART on time all or most of the time. Conversely, the vast majority (90%; 95% CI 86-92%) with a completed genotypic drug resistance test had any HIV drug resistance. This population had high health system use, reporting a median of 3 (IQR 2.6) health care visits and a median of 1 (IQR 1.1) hospitalization in the preceding 6 months. CONCLUSIONS Patients failing first-line ART in sub-Saharan Africa generally report high rates of adherence to ART, have extremely high rates of HIV drug resistance and utilize significant health care resources. Health systems interventions to promptly detect and manage treatment failure will be a prerequisite to establishing control of the HIV epidemic.
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Affiliation(s)
| | - Suzanne M McCluskey
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | | | - Isaac Aturinda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Kevin L Ard
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Godfrey Masette
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Pravi Moodley
- University of KwaZulu-Natal, Durban, South Africa.,National Health Laboratory Service, KwaZulu-Natal, Durban, South Africa
| | | | | | - Gavin George
- University of KwaZulu-Natal, Durban, South Africa
| | - Brent A Johnson
- Department of Biostatistics and Computation Biology, University of Rochester, Rochester, NY, USA
| | - Rajesh T Gandhi
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Vincent C Marconi
- Emory University School of Medicine, Atlanta, GA, USA.,Department of Global Health, Emory University, Atlanta, GA, USA.,Emory Vaccine Center, Atlanta, GA, USA
| | | | - Mark J Siedner
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,University of KwaZulu-Natal, Durban, South Africa.,Mbarara University of Science and Technology, Mbarara, Uganda.,Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
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23
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Castillo-Mancilla JR, Musinguzi N, Asiimwe S, Siedner MJ, Orrell C, Bangsberg DR, Haberer JE. High residual inflammation despite HIV viral suppression: Lessons learned from real-time adherence monitoring among people with HIV in Africa. HIV Med 2021; 23:465-473. [PMID: 34704355 DOI: 10.1111/hiv.13200] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/22/2021] [Accepted: 10/10/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lower antiretroviral therapy (ART) adherence is associated with higher systemic inflammation in virally suppressed people with HIV (PWH); however, previous studies have mostly relied on subjective adherence measures and have not assessed this association by disease stage upon ART initiation. METHODS In the Monitoring Early Treatment Adherence study, adherence was monitored electronically in real time among adult, treatment-naïve PWH in Uganda and South Africa who initiated tenofovir disoproxil fumarate/emtricitabine/efavirenz during early-stage (CD4 > 350 cells/µL) or late-stage (CD4 < 200 cells/µL) disease. Participants who achieved viral suppression (< 400 copies/mL) at 6 months and remained suppressed after 12 months were analysed. The association between average ART adherence and plasma concentrations of interleukin 6 (IL-6), soluble CD14 (sCD14) and D-dimer was evaluated using adjusted multivariable linear regression, stratified by disease stage. RESULTS In all, 488 PWH (61% women, mean age 35 years) were included in the analysis. Median ART adherence overall was 87%. In adjusted models, every 10% increase in average adherence was associated with a 3.0% decrease in IL-6 [95% confidence interval (CI): -5.9 to -0.01, p = 0.05] at 12 months. This relationship was observed in PWH with both early-stage (5.9%, 95% CI: -10.1 to -1.6, p = 0.009) and late-stage disease (3.7%, 95% CI: -7.2 to -0.2, p = 0.039). No significant associations were found with sCD14 or D-dimer. CONCLUSIONS Objective ART adherence measurement was inversely associated with systemic inflammation in PWH who achieved viral suppression after ART initiation in sub-Saharan Africa, with a greater association in those with early-stage HIV. This finding underscores the importance of ART adherence beyond establishing viral suppression.
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Affiliation(s)
| | - Nicholas Musinguzi
- Mbarara University of Science and Technology-Massachusetts General Hospital Global Health Collaborative, Mbarara, Uganda
| | - Stephen Asiimwe
- Mbarara University of Science and Technology-Massachusetts General Hospital Global Health Collaborative, Mbarara, Uganda
| | - Mark J Siedner
- Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Africa Health Research Institute, Durban, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine & Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Jessica E Haberer
- Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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24
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Musinguzi N, Stanford FC, Boatin AA, Orrell C, Asiimwe S, Siedner M, Haberer JE. Association between obesity and combination antiretroviral therapy (cART) adherence among persons with early-stage HIV infection initiating cART. Int J Obes (Lond) 2021; 45:1855-1859. [PMID: 34007011 PMCID: PMC8316269 DOI: 10.1038/s41366-021-00837-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/23/2021] [Accepted: 04/23/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Obesity is common among people living with HIV (PLWH) and early-stage infection, yet associations with combination antiretroviral (cART) adherence are unclear. METHODS Among PLWH initiating cART in Uganda and South Africa, body mass index (BMI) was assessed at cART initiation, and cART adherence was monitored in real-time over 12 months. The association of obesity (BMI ≥ 30 kg/m2) with adherence was assessed among nonpregnant participants with CD4 > 350 cells/mm3 using fractional regression modeling. RESULTS Among 322 participants, median age was 32 years, 70% were female, and 54% were from Uganda. Prevalence of obesity was 12% in Uganda and 28% in South Africa. Mean overall cART adherence was 83% in Uganda and 66% in South Africa. Participants with obesity had higher adherence than those without obesity: +3.6% (p = 0.44) in Uganda and +11.4% (p = 0.02) in South Africa. CONCLUSION Obesity at cART initiation was common and associated with higher adherence, although only significantly in South Africa.
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Affiliation(s)
- Nicholas Musinguzi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Fatima Cody Stanford
- Department of Medicine- Neuroendocrine Unit, Department of Pediatrics- Endocrine, Nutrition Obesity Research Center at Harvard (NORCH) Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adeline A Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Department of Medicine & Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Stephen Asiimwe
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
- Kabwohe Clinical Research Centre, Kabwohe, Uganda
| | - Mark Siedner
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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25
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Lofgren SM, Nicol MR, Kandole TK, Castillo-Mancilla J, Anderson PL, Mpoza E, Tugume L, Bangdiwala AS, Ssebambulidde K, Hullsiek KH, Rhein J, Meya DB, Boulware DR. Short Communication: A Descriptive Analysis of Dried Blood Spot Adherence Testing Among Ugandans with HIV Presenting with Cryptococcal Meningitis. AIDS Res Hum Retroviruses 2021; 37:529-533. [PMID: 33677986 DOI: 10.1089/aid.2020.0202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Early antiretroviral therapy (ART) initiation after cryptococcal meningitis increases mortality, and those unmasking cryptococcosis after <2 weeks of ART have higher mortality. However, it is unknown if those presenting as ART experienced are actually adherent to their ART. Unknowingly, restarting ART in persons, who have discontinued ART, may be a fatal iatrogenic error. To evaluate ART adherence in an exploratory analysis, we collected dried blood spots on 44 HIV-infected persons presenting with cryptococcal meningitis. We quantified tenofovir diphosphate (TFV-DP) and lamivudine (3TC) from dried blood spots. We quantified cumulative ART adherence over the preceding 6-8 weeks based on TFV-DP concentrations and adherence over the last few days based on 3TC concentrations. Of 22 ART experienced, 20 (91%) had quantifiable concentrations. Of 18 receiving tenofovir, 15 (83%) had TFV-DP consistent with drug intake of ≥4 doses/week or moderate adherence. With 3TC, 72% (18/22) had detectable levels consistent with adherence over the last 3 days before measurement. Only three ART-experienced subjects were alive and virally suppressed at 4 months (n = 2 on ART for <30 days; n = 1 with undetectable antiretrovirals). Surprisingly, of 22 who reported not receiving ART, 4 (18%) had quantifiable tenofovir. Most ART-experienced subjects were taking their ART with moderate to good adherence with the majority likely having viral resistance given generally at good ART levels, receipt of intensive adherence counseling, and lack of subsequent viral suppression. The World Health Organization (WHO) guidelines recommend adherence counseling with ART continuation and repeat viral loads in 1-3 months before switching to second-line ART. These recommendations are likely inappropriate in those with central nervous system infections given the additional possible harm of central nervous system immune reconstitution syndrome. Further study to evaluate continuation of ART regimens when presenting with cryptococcosis has benefit, with checking blood levels at presentation potentially being a helpful option. ClinicalTrials.gov Identifier: NCT01802385.
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Affiliation(s)
- Sarah M. Lofgren
- Infectious Disease Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Melanie R. Nicol
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tadeo K. Kandole
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Jose Castillo-Mancilla
- Division of Infectious Diseases, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Peter L. Anderson
- Division of Infectious Diseases, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Edward Mpoza
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Ananta S. Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Katherine Huppler Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joshua Rhein
- Infectious Disease Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B. Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Glass TR, Günthard HF, Calmy A, Bernasconi E, Scherrer AU, Battegay M, Steffen A, Böni J, Yerly S, Klimkait T, Cavassini M, Furrer H. The Role of Human Immunodeficiency Virus (HIV) Asymptomatic Status When Starting Antiretroviral Therapy on Adherence and Treatment Outcomes and Implications for Test and Treat: The Swiss HIV Cohort Study. Clin Infect Dis 2021; 72:1413-1421. [PMID: 32157270 DOI: 10.1093/cid/ciaa239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/09/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Since the advent of universal test-and-treat , more people living with human immunodeficiency virus (PLHIV) initiating antiretroviral therapy (ART) are asymptomatic with a preserved immune system. We explored the impact of asymptomatic status on adherence and clinical outcomes. METHODS PLHIV registered in the Swiss HIV Cohort Study (SHCS) between 2003 and 2018 were included. We defined asymptomatic as Centers for Disease Control and Prevention stage A within 30 days of starting ART, non-adherence as any self-reported missed doses and viral failure as two consecutive viral load>50 copies/mL after >24 weeks on ART. Using logistic regression models, we measured variables associated with asymptomatic status and adherence and Cox proportional hazard models to assess association between symptom status and viral failure. RESULTS Of 7131 PLHIV, 76% started ART when asymptomatic and 1478 (22%) experienced viral failure after a median of 1.9 years (interquartile range, 1.1-4.2). In multivariable models, asymptomatic PLHIV were more likely to be younger, men who have sex with men, better educated, have unprotected sex, have a HIV-positive partner, have a lower viral load, and have started ART more recently. Asymptomatic status was not associated with nonadherence (odds ratio, 1.03 [95% confidence interval {CI}, .93-1.15]). Asymptomatic PLHIV were at a decreased risk of viral failure (adjusted hazard ratio, 0.87 [95% CI, .76-1.00]) and less likely to develop resistance (14% vs 27%, P < .001) than symptomatic PLHIV. CONCLUSIONS Despite concerns regarding lack of readiness, our study found no evidence of adherence issues or worse clinical outcomes in asymptomatic PLHIV starting ART.
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Affiliation(s)
- Tracy R Glass
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Huldrych F Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, University Hospital Geneva, Geneva, Switzerland
| | - Enos Bernasconi
- Division of Infectious Diseases, Regional Hospital Lugano, Lugano, Switzerland
| | | | - Manuel Battegay
- University of Basel, Basel, Switzerland.,Division of Infectious Diseases, University Hospital Basel, Basel, Switzerland
| | - Ana Steffen
- Division of Infectious Diseases, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Jürg Böni
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Sabine Yerly
- Laboratory of Virology, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Klimkait
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Matthias Cavassini
- Division of Infectious Diseases, University Hospital Lausanne, Lausanne, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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27
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Sok P, Mgbere O, Pompeii L, Essien EJ. Evaluation of the Sociodemographic, Behavioral and Clinical Influences on Complete Antiretroviral Therapy Adherence Among HIV-Infected Adults Receiving Medical Care in Houston, Texas. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2021; 13:539-555. [PMID: 34040451 PMCID: PMC8140896 DOI: 10.2147/hiv.s303791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/10/2021] [Indexed: 11/28/2022]
Abstract
Introduction Few studies have estimated complete antiretroviral therapy (ART) adherence following HIV infection since the advent of the new ART guidelines in 2012. This study determined the prevalence and influence of sociodemographic, behavioral, and clinical factors on complete ART adherence among people living with HIV (PLWH) receiving medical care in Houston/Harris County, Texas. Methods Data from the Houston Medical Monitoring Project survey collected from 2009 to 2014 among 1073 participants were used in this study. The primary outcome evaluated was combined adherence, defined as complete, partial, and incomplete combined adherence based on three ART adherence types—dose, schedule, and instruction adherence. The duration living since initial HIV diagnosis was classified as <5, 5–10 and >10 years. Rao–Scott Chi-square test and multivariable proportional-odds cumulative logit regression models were employed to identify the sociodemographic, behavioral, and clinical characteristics of complete combined adherence among the three groups of PLWH living with HIV infection. Results More than one-half (54.4%) of PLWH had complete, 37.4% had partial, and 8.3% had incomplete combined adherence. Among these PLWH, 52.2% had been infected with HIV for >10 years, and 26.5% and 21.4% were infected for <5 years and 5–10 years, respectively. PLWH who were diagnosed <5 and 5–10 years were two times (aOR=1.71, 95% CI=1.13–2.57; aOR=1.69, 95% CI=1.10–2.59; respectively) more likely to experience complete combined adherence than those with >10 years of infection. Multiple sociodemographic, behavioral, and clinical characteristics were significantly associated with complete adherence and varied by the duration of HIV infection. Conclusion Measures of adherence should include all adherence types (dose, schedule, instruction), as utilizing a single adherence type will overestimate adherence level in PLWH receiving medical care. Intervention efforts to maintain adherence should target recently infected PLWH, while those aimed at improving adherence should focus on longer infected PLWH.
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Affiliation(s)
- Pagna Sok
- The University of Texas School of Public Health, Texas Medical Center, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Texas Medical Center, Houston, TX, USA
| | - Osaro Mgbere
- Disease Prevention and Control Division, Houston Health Department, Houston, TX, USA.,Institute of Community Health, University of Houston, Texas Medical Center, Houston, TX, USA
| | - Lisa Pompeii
- The University of Texas School of Public Health, Texas Medical Center, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Texas Medical Center, Houston, TX, USA
| | - Ekere James Essien
- The University of Texas School of Public Health, Texas Medical Center, Houston, TX, USA.,Institute of Community Health, University of Houston, Texas Medical Center, Houston, TX, USA.,Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX, USA
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28
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Katz IT, Musinguzi N, Bell K, Cross A, Bwana MB, Amanyire G, Asiimwe S, Orrell C, Bangsberg DR, Haberer JE. Brief Report: The Impact of Disease Stage on Early Gaps in ART in the "Treatment for All" Era-A Multisite Cohort Study. J Acquir Immune Defic Syndr 2021; 86:562-567. [PMID: 33351529 PMCID: PMC7938906 DOI: 10.1097/qai.0000000000002605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/09/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Adoption of "Treat All" policies has increased antiretroviral therapy (ART) initiation in sub-Saharan Africa; however, unexplained early losses continue to occur. More information is needed to understand why treatment discontinuation continues at this vulnerable stage in care. METHODS The Monitoring Early Treatment Adherence Study involved a prospective observational cohort of individuals initiating ART at early-stage versus late-stage disease in South Africa and Uganda. Surveys and HIV-1 RNA levels were performed at baseline, 6, and 12 months, with adherence monitored electronically. This analysis included nonpregnant participants in the first 6 months of follow-up; demographic and clinical factors were compared across groups with χ2, univariable, and multivariable models. RESULTS Of 669 eligible participants, 91 (14%) showed early gaps of ≥30 days in ART use (22% in South Africa and 6% in Uganda) with the median time to gap of 77 days (interquartile range: 43-101) and 87 days (74, 105), respectively. Although 71 (78%) ultimately resumed care, having an early gap was still significantly associated with detectable viremia at 6 months (P ≤ 0.01). Multivariable modeling, restricted to South Africa, found secondary education and higher physical health score protected against early gaps [adjusted odds ratio (aOR) 0.4, 95% confidence interval (CI): 0.2 to 0.8 and (aOR 0.93, 95% CI: 0.9 to 1.0), respectively]. Participants reporting clinics as "too far" had double the odds of early gaps (aOR 2.2: 95% CI: 1.2 to 4.1). DISCUSSION Early gaps in ART persist, resulting in higher odds of detectable viremia, particularly in South Africa. Interventions targeting health management and access to care are critical to reducing early gaps.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard Global Health Institute, Cambridge, MA
| | | | - Kathleen Bell
- Massachusetts General Hospital Center for Global Health, Boston, MA
| | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | | | - Gideon Amanyire
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda
- Kabwohe Clinical Research Center, Kabwohe, Uganda; and
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - David R. Bangsberg
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
| | - Jessica E. Haberer
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Center for Global Health, Boston, MA
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29
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Siedner MJ, Moorhouse MA, Simmons B, de Oliveira T, Lessells R, Giandhari J, Kemp SA, Chimukangara B, Akpomiemie G, Serenata CM, Venter WDF, Hill A, Gupta RK. Reduced efficacy of HIV-1 integrase inhibitors in patients with drug resistance mutations in reverse transcriptase. Nat Commun 2020; 11:5922. [PMID: 33262331 PMCID: PMC7708638 DOI: 10.1038/s41467-020-19801-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/28/2020] [Indexed: 12/05/2022] Open
Abstract
Little is known about the impact of pretreatment drug resistance (PDR) on the efficacy of second generation integrase inhibitors. We sequenced pretreatment plasma specimens from the ADVANCE trial (NCT03122262). Our primary outcome was 96-week virologic success, defined as a sustained viral load <1000 copies/mL from 12 weeks onwards, <200 copies/mL from 24 weeks onwards, and <50 copies/mL after 48 weeks. Here we report how this outcome was impacted by PDR, defined by the World Health Organization (WHO) mutation list. Of 1053 trial participants, 874 (83%) have successful sequencing, including 289 (33%) randomized to EFV-based therapy and 585 (67%) randomized to DTG-based therapy. Fourteen percent (122/874) have ≥1 WHO-defined mutation, of which 98% (120/122) are NNRTI mutations. Rates of virologic suppression are lower in the total cohort among those with PDR 65% (73/112) compared to those without PDR (85% [605/713], P < 0.001), and for those on EFV-based treatment (60% [12/20] vs 86% [214/248], P = 0.002) and for those on DTG-based treatment (61/92 [66%] vs 84% [391/465] P < 0.001, P for interaction by regimen 0.49). Results are similar in multivariable models adjusted for clinical characteristics and adherence. NNRTI resistance prior to treatment is associated with long-term failure of integrase inhibitor-containing first-line regimens, and portends high rates of first-line failure in sub Saharan Africa.
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Affiliation(s)
- Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
- Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- University of KwaZulu-Natal, Durban, South Africa.
| | - Michelle A Moorhouse
- Ezintsha, Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Bryony Simmons
- Department of Infectious Disease, Imperial College, London, UK
| | - Tulio de Oliveira
- University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Richard Lessells
- University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Jennifer Giandhari
- University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | | | - Benjamin Chimukangara
- University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Celicia M Serenata
- Ezintsha, Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Willem D F Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | | | - Ravindra K Gupta
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
- University of KwaZulu-Natal, Durban, South Africa.
- University of Cambridge, Cambridge, UK.
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30
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Musinguzi N, Kidoguchi L, Mugo NR, Ngure K, Katabira E, Celum CL, Baeten JM, Heffron R, Haberer JE. Adherence to recommendations for ART and targeted PrEP use among HIV serodiscordant couples in East Africa: the "PrEP as a bridge to ART" strategy. BMC Public Health 2020; 20:1621. [PMID: 33115478 PMCID: PMC7594426 DOI: 10.1186/s12889-020-09712-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/15/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND PrEP use should be aligned with periods of risk for HIV acquisition. For HIV serodiscordant couples, PrEP can be used as a bridge until the partner living with HIV takes antiretroviral therapy (ART) long enough to achieve viral suppression (the "PrEP as a Bridge to ART" strategy). However, adherence to this strategy is unknown. METHODS In a demonstration project in Kenya and Uganda, HIV-uninfected partners of serodiscordant couples were advised to take PrEP until the partner living with HIV took ART for ≥ 6 months. PrEP discontinuation was then recommended unless there were concerns about ART adherence, immediate fertility intentions, or outside partners with unknown HIV/ART status. Electronic adherence monitoring and socio-behavioral questionnaire data were used in logistic regression models to explore completion of this strategy and continuation of PrEP beyond recommendations to stop its use. RESULTS Among 833 serodiscordant couples, 436 (52%) HIV-uninfected partners completed ≥ 6 months of PrEP as a bridge to ART. Strategy completion was associated with older age (aOR per 5 years = 1.1; p = 0.008) and having fewer children (aOR = 0.9; p = 0.019). Of the 230 participants encouraged to stop PrEP according to strategy recommendations, 170 (74%) did so. PrEP continuation among the remaining 60 participants was associated with more education (aOR = 1.1; p = 0.029), a preference for PrEP over ART (aOR = 3.6; p = 0.026), comfort with managing their serodiscordant relationship (aOR = 0.6; p = 0.046), and believing PrEP makes sex safe (aOR = 0.5; p = 0.026). CONCLUSION Half of participants completed the PrEP as a bridge to ART strategy and the majority stopped PrEP as recommended. These findings suggest that targeting PrEP to periods of risk is a promising approach; however, tailoring counseling around aligning PrEP use and HIV risk will be important for optimal strategy implementation.
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Affiliation(s)
- Nicholas Musinguzi
- grid.33440.300000 0001 0232 6272Global Health Collaborative, Mbarara University of Science and Technology, P. O Box 434, Mbarara, Uganda
| | - Lara Kidoguchi
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA
| | - Nelly R. Mugo
- grid.33058.3d0000 0001 0155 5938Centres for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA
| | - Kenneth Ngure
- grid.411943.a0000 0000 9146 7108School of Public Health, Jomo Kenyatta University of Agriculture and Technology Nairobi, Nairobi, Kenya
| | - Elly Katabira
- grid.11194.3c0000 0004 0620 0548Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Connie L. Celum
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Jared M. Baeten
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Renee Heffron
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Jessica E. Haberer
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital and Harvard Medical School, Boston, USA
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31
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Discussing Reproductive Plans with Healthcare Providers by Sexually Active Women Living with HIV in Western Ethiopia. AIDS Behav 2020; 24:2842-2855. [PMID: 32212068 DOI: 10.1007/s10461-020-02833-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Discussing reproductive plans with healthcare providers by women living with HIV (WLHIV) can assist in promoting safe reproductive health practices, but little research has been undertaken in this area. A cross-sectional survey was conducted in western Ethiopia in 2018 among 475 sexually active WLHIV. One hundred and twenty seven (26.8%) participants reported becoming pregnant in the last 5 years after being aware of their HIV-positive status; 33.6% reported their intention to have children in the future, and 26.9% were ambivalent about having children. WLHIV who reported general and personalized discussions of reproductive plans with healthcare providers were 30.7% and 16.8%, respectively. Unmarried sexually active women and WLHIV accessing health centers for antiretroviral therapy (ART) were less likely to report both general and personalized discussions than married women and women who accessed ART through hospitals, respectively. WLHIV are both having and intending to have children, highlighting discussions with healthcare providers can deliver support that reduces the risk of vertical and horizontal HIV transmission.
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32
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Ware NC, Wyatt MA, Pisarski EE, Bwana BM, Orrell C, Asiimwe S, Amanyire G, Musinguzi N, Bangsberg DR, Haberer JE. Influences on Adherence to Antiretroviral Therapy (ART) in Early-Stage HIV Disease: Qualitative Study from Uganda and South Africa. AIDS Behav 2020; 24:2624-2636. [PMID: 32140877 PMCID: PMC11091710 DOI: 10.1007/s10461-020-02819-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Realization of optimal treatment and prevention benefits in the era of universal antiretroviral therapy (ART) and "U=U" (undetectable = untransmittable) requires high adherence at all stages of HIV disease. This article draws upon qualitative interview data to characterize two types of influences on ART adherence for 100 Ugandans and South Africans initiating ART during early-stage HIV infection. Positive influences are: (a) behavioral strategies supporting adherence; (b) preserving health through adherence; (c) support from others; and (d) motivating effect of adherence monitoring. "De-stabilizing experiences" (mobility, loss, pregnancy) as barriers are posited to impact adherence indirectly through intervening consequences (e.g. exacerbation of poverty). Positive influences overlap substantially with adherence facilitators described for later-stage adherers in previous research. Adherence support strategies and interventions effective for persons initiating ART later in HIV disease are likely also to be helpful to individuals beginning treatment immediately upon confirmation of infection. De-stabilizing experiences merit additional investigation across varying populations.
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Affiliation(s)
- Norma C Ware
- Deparment of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Deparment of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, 02115, USA.
| | - Monique A Wyatt
- Deparment of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, 02115, USA
- Harvard Global, Cambridge, MA, USA
| | - Emily E Pisarski
- Deparment of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, 02115, USA
| | - Bosco M Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda
- Global Health Collaborative, Mbarara, Uganda
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, Cape Town, South Africa
- University of Cape Town, Cape Town, South Africa
| | - Stephen Asiimwe
- Global Health Collaborative, Mbarara, Uganda
- Kabwohe Clinical Research Centre, Kabwohe, Uganda
| | - Gideon Amanyire
- Global Health Collaborative, Mbarara, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - David R Bangsberg
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Jessica E Haberer
- Deparment of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, 02115, USA
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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33
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Matthews LT, Orrell C, Bwana MB, Tsai AC, Psaros C, Asiimwe S, Amanyire G, Musinguzi N, Bell K, Bangsberg DR, Haberer JE. Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12-month cohort study in urban South Africa and rural Uganda. J Int AIDS Soc 2020; 23:e25586. [PMID: 32820622 PMCID: PMC7441010 DOI: 10.1002/jia2.25586] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/18/2020] [Accepted: 07/01/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION We conducted a cohort study to understand patterns of anti-retroviral therapy (ART) adherence during pregnancy, postpartum and non-pregnancy follow-up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa. METHODS We collected survey data, continuously monitored ART adherence (Wisepill), HIV-RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow-up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non-pregnancy-related (neither pregnant nor postpartum). Fractional regression models included demographics and socio-behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV-RNA at 12 months by ever- versus never-pregnant status. RESULTS In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non-pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/mm3 ). HIV-RNA was suppressed among 91% (N = 135) ever-pregnant and 86% (N = 85) never-pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non-pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non-pregnancy-related follow-up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIV-RNA was suppressed among 57% (N = 47) ever-pregnant and 86% (N = 93) never-pregnant women. CONCLUSIONS Women in rural Uganda maintained high adherence with 91% of ever-pregnant and 86% of never-pregnant women suppressing HIV-RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow-up with median adherence of 40% and 57% of women with HIV-RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.
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Affiliation(s)
- Lynn T Matthews
- Department of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
- Department of MedicineMassachusetts General HospitalBostonMAUSA
| | | | | | - Alexander C Tsai
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Harvard Center for Population and Development StudiesBostonMAUSA
| | - Christina Psaros
- Department of PsychiatryMassachusetts General HospitalBostonMAUSA
| | - Stephen Asiimwe
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Kabwohe Clinical Research Center (KCRC)KabwoheUganda
| | - Gideon Amanyire
- Makerere‐Mbarara Universities Joint AIDS Program (MJAP)MbararaUganda
| | - Nicholas Musinguzi
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
| | - Kathleen Bell
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
| | - David R Bangsberg
- School of Public HealthOregon Health and Science University/Portland State UniversityPortlandORUSA
| | - Jessica E Haberer
- Department of MedicineMassachusetts General HospitalBostonMAUSA
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
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Digital Technology for Tuberculosis Medication Adherence: Promise and Peril. Ann Am Thorac Soc 2020; 17:421-423. [PMID: 32233860 DOI: 10.1513/annalsats.202001-027ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Alcohol Use and Antiretroviral Therapy Non-Adherence Among Adults Living with HIV/AIDS in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. AIDS Behav 2020; 24:1727-1742. [PMID: 31673913 DOI: 10.1007/s10461-019-02716-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Antiretroviral therapy (ART) is efficacious in improving clinical outcomes among people living with HIV (PLWH) and reducing HIV transmission when taken regularly. Research examining modifiable factors associated with ART non-adherence is critical for informing novel intervention development in settings with high HIV prevalence. Alcohol use has been linked with ART non-adherence in studies in sub-Saharan Africa; however, no review has pooled estimates across studies. We reviewed studies of alcohol use and ART non-adherence conducted in sub-Saharan Africa. We searched PubMed, CINAHL, EMBASE, and PsycINFO through August 2019 with terms related to ART non-adherence, alcohol use, and sub-Saharan Africa. One author reviewed titles/abstracts (n = 754) and two authors reviewed full texts (n = 308) for inclusion. Discrepancies were resolved by group consensus. Studies were retained if they quantitatively measured associations between alcohol use and ART non-adherence or viral non-suppression. We defined ART non-adherence using the definitions from each parent study (e.g., patients with > 5% missed ART doses during the previous four, seven or 30 days were considered non-adherent). A random effects meta-analysis was conducted to pool associations and we conducted additional analyses to assess between-study heterogeneity and publication bias and sensitivity analyses to determine robustness of our results when considering only certain study designs, alcohol use or ART scales, or studies that used viral non-suppression as their primary outcome. Of 56 articles meeting our inclusion criteria, 32 articles were included in the meta-analysis. All studies measured alcohol use via self-report. ART non-adherence was assessed using self-report, pill counts, or pharmacy records and definition of non-adherence varied depending on the measure used. Individuals who used alcohol had twice the odds of ART non-adherence compared with those who did not use alcohol (34% non-adherence among alcohol users vs. 18% among non-users; pooled odds ratio: 2.25; 95% confidence interval: 1.87-2.69; p < 0.001). We found evidence of a high degree of heterogeneity between studies (Cochrane Q statistic: 382.84, p< 0.001; I2 proportion: 91.9%) and evidence of publication bias. However, the magnitude of our pooled odds ratio was consistent across a number of sensitivity analyses to account for heterogeneity and publication bias. In a secondary analysis with studies using viral non-suppression as their primary outcome, we also estimated a statistically significant pooled effect of alcohol use on viral non-suppression (pooled odds ratio: 2.47; 95% confidence interval: 1.58-3.87). Evidence suggests alcohol use is associated with ART non-adherence in Sub-Saharan Africa, potentially hindering achievement of the UNAIDS 90-90-90 HIV treatment targets.
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Siedner MJ, Bwana MB, Asiimwe S, Amanyire G, Musinguzi N, Castillo-Mancilla J, Tracy RP, Katz IT, Bangsberg DR, Hunt PW, Orrell C, Haberer JE. Timing of Antiretroviral Therapy and Systemic Inflammation in Sub-Saharan Africa: Results From the META Longitudinal Cohort Study. J Infect Dis 2020; 220:1172-1177. [PMID: 31188451 PMCID: PMC6736121 DOI: 10.1093/infdis/jiz259] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/16/2019] [Indexed: 11/14/2022] Open
Abstract
Chronic inflammation predicts complications in persons with human immunodeficiency virus infection. We compared D-dimer, soluble CD14, and interleukin 6 levels before and 12 months after antiretroviral therapy (ART) initiation, among individuals starting ART during earlier-stage (CD4 T-cell count >350/µL) or late-stage disease (CD4 T-cell count <200/µL). Female sex, older age, viral load, and late-stage disease were associated with pre-ART biomarkers (n = 661; P < .05). However, there were no differences in biomarkers by disease stage after 12 months of ART (n = 438; P > .05), owing to loss from observation and greater declines in biomarkers in late-stage initiators (P < .001). Earlier initiation of ART is associated with decreased inflammation, but levels seem to converge between earlier and later initiators surviving to 12 months.
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Affiliation(s)
- Mark J Siedner
- Harvard Medical School, Boston.,Massachusetts General Hospital, Boston.,Mbarara University of Science and Technology, Uganda.,Africa Health Research Institute, Kwa-Zulu Natal, South Africa
| | | | - Stephen Asiimwe
- Mbarara University of Science and Technology, Uganda.,Kabwohe Clinical Research Center, Uganda
| | | | | | | | | | - Ingrid T Katz
- Harvard Medical School, Boston.,Brigham and Women's Hospital, Boston
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland
| | | | | | - Jessica E Haberer
- Harvard Medical School, Boston.,Massachusetts General Hospital, Boston
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Dorward J, Drain PK, Osman F, Sookrajh Y, Pillay M, Moodley P, Garrett N. Short Communication: Early Antiretroviral Therapy Is Associated with Better Viral Suppression and Less HIV Drug Resistance After Implementation of Universal Treatment in South Africa. AIDS Res Hum Retroviruses 2020; 36:297-299. [PMID: 31663368 DOI: 10.1089/aid.2019.0206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
All people living with HIV should receive antiretroviral therapy (ART), but those with CD4 counts >500 cells/mm3 at ART initiation ("early initiators") may be less motivated to adhere to treatment, compared with those with CD4 counts <200 cells/mm3 ("late initiators"). We performed a cross-sectional analysis among HIV-positive adults who had a viral load taken at 6 months after first-line ART initiation in a South African public clinic. Retrospective HIV drug resistance testing was performed on all samples with a viral load >1,000 copies/mL. We used Poisson regression models with robust variance to evaluate associations between early ART initiation and viral suppression <40 copies/mL. We assessed HIV drug resistance using descriptive statistics. Of 390 participants enrolled between February and August 2017, 60% were women and median age was 32 years [interquartile range (IQR) 27-38]. At ART initiation, median CD4 count was 366 cells/mm3 (IQR 204-546), and 30% were early initiators with CD4 > 500 cells/mm3. In multivariable analysis, early initiators were more likely to be virally suppressed compared with late initiators (adjusted risk ratio: 1.29, 95% confidence interval: 1.13-1.46). All 18 participants with viral load >1,000 copies/mL had successful genotyping, which identified drug resistance in 14/18 (77.8%). Among early initiators, drug resistance was detected in only 1/117 (0.9%), compared with 11/93 (11.8%) among late initiators. In conclusion, among people receiving ART in a South African public clinic, early initiators had better viral suppression after 6 months and less drug resistance than late initiators, which further supports universal treatment. Clinical trials registration: NCT03066128.
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Affiliation(s)
- Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul K. Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Farzana Osman
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Yukteshwar Sookrajh
- Prince Cyril Zulu Communicable Disease Centre, eThekwini Municipality, Durban, South Africa
| | - Melendhran Pillay
- Department of Virology, Inkosi Albert Luthuli Central Hospital, Cato Manor, Durban, South Africa
| | - Pravikrishnen Moodley
- Department of Virology, Inkosi Albert Luthuli Central Hospital, Cato Manor, Durban, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Benitez AE, Musinguzi N, Bangsberg DR, Bwana MB, Muzoora C, Hunt PW, Martin JN, Haberer JE, Petersen ML. Super learner analysis of real-time electronically monitored adherence to antiretroviral therapy under constrained optimization and comparison to non-differentiated care approaches for persons living with HIV in rural Uganda. J Int AIDS Soc 2020; 23:e25467. [PMID: 32202067 PMCID: PMC7086301 DOI: 10.1002/jia2.25467] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 01/27/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Real-time electronic adherence monitoring (EAM) systems could inform on-going risk assessment for HIV viraemia and be used to personalize viral load testing schedules. We evaluated the potential of real-time EAM (transferred via cellular signal) and standard EAM (downloaded via USB cable) in rural Uganda to inform individually differentiated viral load testing strategies by applying machine learning approaches. METHODS We evaluated an observational cohort of persons living with HIV and treated with antiretroviral therapy (ART) who were monitored longitudinally with standard EAM from 2005 to 2011 and real-time EAM from 2011 to 2015. Super learner, an ensemble machine learning method, was used to develop a tool for targeting viral load testing to detect viraemia (>1000 copies/ml) based on clinical (CD4 count, ART regimen), viral load and demographic data, together with EAM-based adherence. Using sample-splitting (cross-validation), we evaluated area under the receiver operating characteristic curve (cvAUC), potential for EAM data to selectively defer viral load tests while minimizing delays in viraemia detection, and performance compared to WHO-recommended testing schedules. RESULTS In total, 443 persons (1801 person-years) and 485 persons (930 person-years) contributed to standard and real-time EAM analyses respectively. In the 2011 to 2015 dataset, addition of real-time EAM (cvAUC: 0.88; 95% CI: 0.83, 0.93) significantly improved prediction compared to clinical/demographic data alone (cvAUC: 0.78; 95% CI: 0.72, 0.86; p = 0.03). In the 2005 to 2011 dataset, addition of standard EAM (cvAUC: 0.77; 95% CI: 0.72, 0.81) did not significantly improve prediction compared to clinical/demographic data alone (cvAUC: 0.70; 95% CI: 0.64, 0.76; p = 0.08). A hypothetical testing strategy using real-time EAM to guide deferral of viral load tests would have reduced the number of tests by 32% while detecting 87% of viraemia cases without delay. By comparison, the WHO-recommended testing schedule would have reduced the number of tests by 69%, but resulted in delayed detection of viraemia a mean of 74 days for 84% of individuals with viraemia. Similar rules derived from standard EAM also resulted in potential testing frequency reductions. CONCLUSIONS Our machine learning approach demonstrates potential for combining EAM data with other clinical measures to develop a selective testing rule that reduces number of viral load tests ordered, while still identifying those at highest risk for viraemia.
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Affiliation(s)
- Alejandra E Benitez
- Division of BiostatisticsSchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Nicholas Musinguzi
- Global Health CollaborativeMbarara University of Science and TechnologyMbararaUganda
| | - David R Bangsberg
- Oregon Health & Science University‐Portland State University School of Public HealthPortlandORUSA
| | - Mwebesa B Bwana
- Department of Internal MedicineMbarara University of Science & TechnologyMbararaUganda
| | - Conrad Muzoora
- Department of Internal MedicineMbarara University of Science & TechnologyMbararaUganda
| | - Peter W Hunt
- Division of Experimental MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jeffrey N Martin
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jessica E Haberer
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Maya L Petersen
- Division of BiostatisticsSchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
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Byonanebye DM, Semitala FC, Katende J, Bakenga A, Arinaitwe I, Kyambadde P, Musinguzi P, Biraro IA, Byakika-Kibwika P, Kamya MR. High viral suppression and low attrition in healthy HIV-infected patients initiated on ART with CD4 above 500 cells/µL in a program setting in Uganda. Afr Health Sci 2020; 20:132-141. [PMID: 33402901 PMCID: PMC7750048 DOI: 10.4314/ahs.v20i1.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The World Health Organization recommends antiretroviral therapy (ART) for all HIV-infected patients at all CD4 counts. However, there are concerns that asymptomatic patients may have poorer viral suppression and high attrition. OBJECTIVES We sought to determine attrition and viral suppression among healthy HIV-infected patients initiated on ART in program settings. METHODS This cross-sectional study enrolled ART-experienced patients attending two PEPFAR-supported, high-volume clinics in Kampala, Uganda. Eligible patients were >18 years and had completed at least six months on ART. Participants were interviewed on socio-demographics, ART history and plasma viral load (VL) determined using Abbott Real-time. Predictors of viral suppression (<75 copies/ml) were determined using multivariate logistic regression. RESULTS Overall, 267 participants were screened, 228 were eligible and 203 (89%) retained in care (visit within 90 days). Of the 203 participants, 115 (56.7%) were key-populations. Viral suppression was achieved in 173 patients (85%; 95% CI, 80.3%-90.1%). The factors associated with viral suppression were prior VL tests (AOR 6.98; p-value <0.001) and receiving care from a general clinic (AOR 5.41; p=0.009). CONCLUSION Asymptomatic patients initiated on ART with high baseline CD4 counts, achieve high viral suppression with low risk of attrition. VL monitoring and clinic type are associated with viral suppression.
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Affiliation(s)
| | - Fred C Semitala
- Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Alex Bakenga
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Irene Arinaitwe
- Makerere University College of Computing and Information Science
| | | | | | | | | | - Moses R Kamya
- Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala Uganda
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Time of HIV diagnosis, CD4 count and viral load at antenatal care start and delivery in South Africa. PLoS One 2020; 15:e0229111. [PMID: 32053679 PMCID: PMC7018033 DOI: 10.1371/journal.pone.0229111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/29/2020] [Indexed: 11/24/2022] Open
Abstract
Background Despite the success of prevention of mother to child transmission (PMTCT) program in South Africa, the 30% HIV prevalence among women of childbearing age requires the PMTCT program to be maximally efficient to sustain gains in the prevention of vertical HIV transmission. We aimed to determine the immunologic and virologic status at entry into antenatal care (ANC) and at childbirth among HIV positive women who conceived under the CD4<500 cells/μl antiretroviral therapy (ART) eligibility threshold and universal test and treat (UTT) policies in the Gauteng province of South Africa. Method We conducted a retrospective cohort study of 692 HIV positive adult (>18 years) postpartum women who gave birth between September 2016 and December 2017. Demographic, viral load (VL) and CD4 data at ANC start (3–9 months before delivery) and delivery (3 months before/after) were obtained from medical records of consenting women. We compared CD4≥500 cell/μl and viral load (VL) suppression (<400 copes/ml) rates at ANC start and delivery among women with a pre-pregnancy ART, women known HIV positive but with in-pregnancy ART and newly diagnosed women with in-pregnancy ART. Predictors of having a high CD4 and suppressed VL were assessed by log-binomial regression. Results Of the 692 participants, 394 (57.0%) had CD4 data and 326 (47.1%) had VL data. Overall women with a pre-pregnancy ART were more likely to start ANC with CD4 count≥500 cell/μl (46.3% vs 24.8%, adjusted risk ratio (aRR) = 1.9; 95% confidence interval (95% CI): 1.4–2.5), compared to newly diagnosed women. This difference was no longer apparent at the time of delivery (aRR 1.2 95% CI: 0.4–3.7). Similarly, viral suppression at delivery was higher among women with pre-pregnancy ART (87.2% vs 69.3%, aRR 1.3, 95% CI: 1.1–1.6) as compared to the newly diagnosed women. Viral suppression rate among newly diagnosed women increased substantially by the time of delivery from 43.5% to 69.3% (p = 0.001). Conclusion These results show that pre-pregnancy ART improves immunologic and virologic control during pregnancy and call for renewed efforts in HIV testing, linkage to ART and viral monitoring.
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Raggio GA, Psaros C, Fatch R, Goodman G, Matthews LT, Magidson JF, Amanyire G, Cross A, Asiimwe S, Hahn JA, Haberer JE. High Rates of Biomarker-Confirmed Alcohol Use Among Pregnant Women Living With HIV in South Africa and Uganda. J Acquir Immune Defic Syndr 2019; 82:443-451. [PMID: 31567551 PMCID: PMC6857734 DOI: 10.1097/qai.0000000000002156] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/22/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Alcohol use is common among people living with HIV and particularly harmful during pregnancy. However, objective data on alcohol use in pregnant women living with HIV (WLWH) are lacking. In areas with high levels of alcohol use generally, such as South Africa and Uganda, these data are needed to inform interventions. METHODS Pregnant and nonpregnant, antiretroviral therapy-naive WLWH were recruited from outpatient clinics in South Africa and Uganda. Women provided self-report data on previous three-month alcohol use and potential mental health correlates of alcohol use (depression and stigma). Blood samples were used to measure phosphatidylethanol (PEth), an objective biomarker of recent alcohol intake. We analyzed any alcohol use (ie, any self-reported use or PEth-positive [≥8 ng/mL]) and under-reporting of alcohol use (ie, no self-reported use with concurrent PEth-positive). RESULTS Among pregnant WLWH (n = 163, median age was 26 [interquartile range: 23-29], median gestational age was 20 weeks [interquartile range: 16-26]), 40% were using alcohol and 16% under-reported alcohol use. Neither any alcohol use nor under-reporting of alcohol use differed significantly between pregnant and nonpregnant women or by country (P > 0.05). Greater depression (but not greater stigma) was significantly associated with any alcohol use (adjusted odds ratio = 1.41, 95% confidence interval: [1.01 to 1.99]; P = 0.045). CONCLUSIONS Alcohol use was prevalent and under-reported among pregnant WLWH in South Africa and Uganda, similar to nonpregnant participants, and associated with depression. General health care and antenatal clinic settings present opportunities to provide integrated alcohol-based counseling and depression treatment.
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Affiliation(s)
- Greer A. Raggio
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- National Center for Weight and Wellness, Washington, DC
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robin Fatch
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Georgia Goodman
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lynn T. Matthews
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Infectious Disease, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa;
| | - Stephen Asiimwe
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda; and
- Kabwohe Clinical Research Center, Kabwohe, Uganda.
| | - Judith A. Hahn
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Inflammatory biomarkers prior to antiretroviral therapy as prognostic markers of 12-month mortality in South Africa and Uganda. AIDS 2019; 33:2043-2048. [PMID: 31274541 PMCID: PMC6774817 DOI: 10.1097/qad.0000000000002305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to determine the utility of biomarkers of immune activation, systemic inflammation and coagulopathy prior to antiretroviral therapy to predict mortality during the first year of antiretroviral therapy (ART) in sub-Saharan Africa. DESIGN A prospective, observational cohort. METHODS We measured soluble CD14, interleukin-6 and D-dimer in nonpregnant individuals initiating ART in South Africa and Uganda in the Measuring Early Treatment Adherence (META) Study. We used survival analysis methods to estimate their association with 12-month mortality, and fit receiver operator curves (ROC) to assess the prognostic value of each biomarker. RESULTS Six-hundred and sixty individuals were enrolled and had pretreatment biomarkers measured. Approximately 60% were women, with a median CD4 cell count of 187 cells/μl [interquartile range (IQR) 111-425] and approximately half were enrolled each from South Africa and Uganda. We observed 34 deaths for a crude mortality of 5.3 deaths/100 person-years (py) (95% confidence interval 3.8-7.4), which ranged from 0/100 py to 13.7/100 py in the lowest and highest tertile of pretreatment sCD14, respectively. In Cox models, all three biomarkers were strongly predictive of the hazard of death (adjusted hazard ratio 3-6, all P < 0.01). In multivariable models including biomarkers, both pretreatment CD4 cell count and pretreatment viral load became borderline or nonsignificantly associated with mortality. The c-statistic for area under ROC was higher for all three biomarkers than for CD4 cell count (P < 0.01). CONCLUSION Biomarkers of immune activation, systemic inflammation and coagulopathy prior to ART initiation are strongly predictive of early death on treatment after adjustment for CD4 cell count. Such biomarkers might serve as important prognostic indicators for patient triage in this population.
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