High levels of viral load monitoring and viral suppression under Treat All in Rwanda - a cross-sectional study

The viral load monitoring cascade in HIV treatment programmes in sub-Saharan Africa: a systematic review

BACKGROUND

The United Nations' 95-95-95 (95% of people with HIV being aware of their diagnosis, 95% of those aware of their diagnosis being on treatment and 95% achieving viral suppression) target aims to reduce morbidity and mortality of HIV. However, with 60% of new HIV infections occurring in sub-Saharan Africa (SSA), achieving this target in the region is challenging. Viral load (VL) monitoring is the gold-standard approach of assessing treatment efficacy, and its implementation into national health systems is a global health priority if elimination of HIV as a public health threat is to be achieved by 2030. This systematic review aims to investigate VL monitoring outcomes in SSA, and to identify gaps and possible interventions to help nations meet their 2030 targets.

METHODS

A literature search of three electronic platforms (MEDLINE, EMBASE and Global Health) was undertaken from 1 January to 9 August 2024 to identify studies published in English and conducted in SSA. The primary outcome was the proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART) with routine VL monitoring at the recommended time points (initially, 6 months, 12 months and annually). Secondary outcomes reported proportions of PLHIV who received routine VL monitoring who went on to complete the cascade of care after identified virological failure [enhanced adherence counselling (EAC), switch to second-line ART, and finally viral suppression].

RESULTS

The initial search identified 342 papers, of which 35 studies were included for narrative synthesis. Included studies reported on findings from 14 African countries and demonstrated extensive variation in rates of VL monitoring (range: 24.3-99.7%, mean: 63.8%). Results were more unfavourable in the latter steps of the viral load monitoring cascade, with a range of 0-88%, and a switch to second-line ART mean of 42% (range: 4.4-93%). Studies with additional support, and those with community-based models of care, had higher rates of VL testing and viral suppression.

CONCLUSIONS

VL monitoring and management of virological failure are suboptimal in many SSA countries due to individual and health system-related challenges. Health system strengthening is vital to ensure the sustainability of HIV treatment programmes and the achievement of 95-95-95 targets by 2030.

Beliefs affecting ART adherence in newly diagnosed HIV-positive participants in Manzini, Eswatini

Background

Achieving optimal adherence to antiretroviral therapy (ART) is challenging. Consistency in HIV care and treatment is crucial for achieving viral load suppression and preventing HIV-related illnesses, disease progression to AIDS, mortality, drug resistance, and onward transmission.

Objectives

The purpose of this research was to gain a comprehensive understanding of the beliefs that play a role in determining the level of ART adherence among individuals newly diagnosed with HIV. By examining these beliefs, the researchers aimed to identify potential barriers and facilitators to adherence, ultimately contributing to the development of effective interventions and strategies to improve ART adherence.

Method

An exploratory qualitative approach was employed in this study, utilising the Theory of Planned Behaviour (TPB) as its theoretical framework. To gather insights, in-depth interviews were conducted with 19 participants recruited post diagnosis, who shared their beliefs regarding ART adherence. Thematic analysis identified beliefs, categorised under TPB precursors, namely behavioural outcomes, subjective norms, and perceived behavioural control.

Results

Participants emphasised health improvement, treatment effectiveness, and disease prevention as advantages to ART adherence, while disadvantages included fear of lifelong commitment, side effects, and stigma. ART adherence was enhanced by family support but impeded by a number of social factors. Participants expressed confidence in creating personal reminders or seeking external help, but anticipated various challenges.

Conclusion

The research has shown that the beliefs affecting ART adherence in individuals recently diagnosed with HIV but not yet on treatment are like those that have been reported to influence adherence in HIV-positive participants currently receiving treatment.

Development and calibration of a mathematical model of HIV outcomes among Rwandan adults: informing equitable achievement of targets in Rwanda

Background

We developed and calibrated the Central Africa-International epidemiology Databases to Evaluate AIDS (CA-IeDEA) HIV policy model to inform equitable achievement of global goals, overall and across sub-populations, in Rwanda.

Methods

We created a deterministic dynamic model to project adult HIV epidemic and care continuum outcomes, overall and for 25 subpopulations (age group, sex, HIV acquisition risk, urbanicity). Data came from the Rwanda cohort of CA-IeDEA, 2004-2020; Rwanda Demographic and Health Surveys, 2005, 2010, 2015; Rwanda Population-based HIV Impact Assessment, 2019; and the literature and reports. We calibrated the model to 47 targets by selecting the 50 best-fitting parameter sets among 20,000 simulations. Calibration targets reflected epidemic (HIV prevalence, incidence), global goals (percentage on antiretroviral therapy (ART) among diagnosed, percentage virally suppressed among on ART) and other (number on ART, percentage virally suppressed) indicators, overall and by sex. Best-fitting sets minimized the summed absolute value of the percentage deviation (AVPD) between model projections and calibration targets. Good model performance was mean AVPD ≤5% across the 50 best-fitting sets and/or projections within the target confidence intervals; acceptable was mean AVPD >5% and ≤15%.

Results

Across indicators, 1,841 of 2,350 (78.3%) model projections were a good or acceptable fit to calibration targets. For HIV epidemic indicators, 256 of 300 (85.3%) projections were a good fit to targets, with the model performing better for women (83.3% a good fit) than for men (71.7% a good fit). For global goals indicators, 96 of 100 (96.0%) projections were a good fit; model performance was similar for women and men. For other indicators, 653 of 950 (68.7%) projections were a good or acceptable fit. Fit was better for women than for men (percentage virally suppressed only) and when restricting targets for number on ART to 2013 and beyond.

Conclusions

The CA-IeDEA HIV policy model fits historical data and can inform policy solutions for equitably achieving global goals to end the HIV epidemic in Rwanda. High-quality, unbiased population-based data, as well as novel approaches that account for calibration target quality, are critical to ongoing use of mathematical models for programmatic planning.

Low birth weight among infants and pregnancy outcomes among women living with HIV and HIV-negative women in Rwanda

Introduction

In utero exposure to HIV and/or triple antiretroviral therapy (ART) have been shown to be associated with preterm births and low birth weight (LBW), but data from low-resources settings with high burden of HIV remain limited. This study utilized retrospective data to describe pregnancy outcomes among Rwandan women living with HIV (WLHIV) and HIV-negative women and to assess the association of HIV and ART with LBW.

Methods

This study used data from a large cohort of WLHIV and HIV-negative women in Rwanda for a cross-sectional analysis. Retrospective data were collected from antenatal care (ANC), delivery, and Prevention of Mother to Child Transmission (PMTCT) registries within the Central Africa International Epidemiology Databases to Evaluate AIDS (CA-IeDEA) in Rwanda. Data from women with documented HIV test results and known pregnancy outcomes were included in the analysis. Analyses for predictors of LBW (< 2,500 g) were restricted to singleton live births. Logistic models were used to identify independent predictors and estimate the odd ratios (OR) and 95% confidence intervals (CI) measuring the strength of their association with LBW.

Results and discussion

Out of 10,608 women with known HIV status and with documented pregnancy outcomes, 9.7% (n = 1,024) were WLHIV. We restricted the sample to 10,483 women who had singleton live births for the analysis of the primary outcome, LBW. Compared with HIV-negative women, WLHIV had higher rates of stillbirth, preterm births, and LBW babies. Multivariable model showed that WLHIV and primigravidae had higher odds of LBW. Lower maternal weight and primigravidae status were associated with greater odds of LBW. Among WLHIV, the use of ART was associated with significantly lower odds of LBW in a bivariate analysis. Even in a sample of relatively healthier uncomplicated pregnancies and women who delivered in low-risk settings, WLHIV still had higher rates of poor pregnancy outcomes and to have LBW infants compared to women without HIV. Lower maternal weight and primigravidae status were independently associated with LBW. Given that supplementary nutrition to malnourished pregnant women is known to decrease the incidence of LBW, providing such supplements to lower-weight WLHIV, especially primigravidae women, might help reduce LBW.

Attrition one year after starting antiretroviral therapy before and after the programmatic implementation of HIV "Treat All" in Sub-Saharan Africa: a systematic review and meta-analysis

INTRODUCTION

Evidence on the real-world effects of "Treat All" on attrition has not been systematically reviewed. We aimed to review existing literature to compare attrition 12 months after antiretroviral therapy (ART) initiation, before and after "Treat All" was implemented in Sub-Saharan Africa and describe predictors of attrition.

METHODS

We searched Embase, Google Scholar, PubMed, and Web of Science in July 2020 and created alerts up to the end of June 2023. We also searched for preprints and conference abstracts. Two co-authors screened and selected the articles. Risk of bias was assessed using the modified Newcastle-Ottawa Scale. We extracted and tabulated data on study characteristics, attrition 12 months after ART initiation, and predictors of attrition. We calculated a pooled risk ratio for attrition using random-effects meta-analysis.

RESULTS

Eight articles and one conference abstract (nine studies) out of 8179 screened records were included in the meta-analysis. The random-effects adjusted pooled risk ratio (RR) comparing attrition before and after "Treat All" 12 months after ART initiation was not significant [RR = 1.07 (95% Confidence interval (CI): 0.91-1.24)], with 92% heterogeneity (I2). Being a pregnant or breastfeeding woman, starting ART with advanced HIV, and starting ART within the same week were reported as risk factors for attrition both before and after "Treat All".

CONCLUSIONS

We found no significant difference in attrition before and after "Treat All" one year after ART initiation. While "Treat All" is being implemented widely, differentiated approaches to enhance retention should be prioritised for those subgroups at risk of attrition.

PROSPERO NUMBER

CRD42020191582 .

Immediate and long-term outcomes after treat-all among people living with HIV in China: an interrupted time series analysis

BACKGROUND

In 2003, China implemented free antiretroviral therapy (ART) for people living with HIV (PLHIV), establishing an eligibility threshold of CD4 < 200 cells/μl. Subsequently, the entry criteria were revised in 2012 (eligibility threshold: CD4 ≤ 350 cells/μl), 2014 (CD4 ≤ 500 cells/μl), and 2016 (treat-all). However, the impact of treat-all policy on HIV care and treatment indicators in China is unknown. We aimed to elucidate the immediate and long-term impact of the implementation of treat-all policy in China.

METHODS

Anonymized programmatic data on ART initiation and collection in PLHIV who newly started ART were retrieved between 1 January 2015 and 31 December 2019, from two provincial and municipal Centers for Disease Control and Prevention and ten major infectious disease hospitals specialized in HIV care in China. We used Poisson and quasi-Poisson segmented regression models to estimate the immediate and long-term impact of treat-all on three key indicators: monthly proportion of 30-day ART initiation, mean CD4 counts (cells/μl) at ART initiation, and mean estimated time from infection to diagnosis (year). We built separate models according to gender, age, route of transmission and region.

RESULTS

Monthly data on ART initiation and collection were available for 75,516 individuals [gender: 83.8% males; age: median 39 years, interquartile range (IQR): 28-53; region: 18.5% Northern China, 10.9% Northeastern China, 17.5% Southern China, 49.2% Southwestern China]. In the first month of treat-all, compared with the contemporaneous counterfactual, there was a significant increase in proportion of 30-day ART initiation [+ 12.6%, incidence rate ratio (IRR) = 1.126, 95% CI: 1.033-1.229; P = 0.007] and mean estimated time from infection to diagnosis (+ 7.0%, IRR = 1.070, 95% CI: 1.021-1.120; P = 0.004), while there was no significant change in mean CD4 at ART initiation (IRR = 0.990, 95% CI: 0.956-1.026; P = 0.585). By December 2019, the three outcomes were not significantly different from expected levels. In the stratified analysis, compared with the contemporaneous counterfactual, mean CD4 at ART initiation showed significant increases in Northern China (+ 3.3%, IRR = 1.033, 95% CI: 1.001-1.065; P = 0.041) and Northeastern China (+ 8.0%, IRR = 1.080, 95% CI: 1.003-1.164; P = 0.042) in the first month of treat-all; mean estimated time from infection to diagnosis showed significant increases in male (+ 5.6%, IRR = 1.056, 95% CI: 1.010-1.104; P = 0.016), female (+ 14.8%, IRR = 1.148, 95% CI: 1.062-1.240; P < 0.001), aged 26-35 (+ 5.3%, IRR = 1.053, 95% CI: 1.001-1.109; P = 0.048) and > 50 (+ 7.8%, IRR = 1.078, 95% CI: 1.000-1.161; P = 0.046), heterosexual transmission (+ 12.4%, IRR = 1.124, 95% CI: 1.042-1.213; P = 0.002) and Southwestern China (+ 12.9%, IRR = 1.129, 95% CI: 1.055-1.208; P < 0.001) in the first month of treat-all.

CONCLUSIONS

The implementation of treat-all policy in China was associated with a positive effect on HIV care and treatment outcomes. To advance the work of rapid ART, efforts should be made to streamline the testing and ART initiation process, provide comprehensive support services, and address the issue of uneven distribution of medical resources.

Poor adherence to antiretroviral therapy among adult people living with HIV initiated during the COVID-19 epidemic waves – observations at the University Teaching Hospital in Lusaka, Zambia

Background

Coronavirus disease 2019 (COVID-19)-related disruptions in healthcare services and clinical outcomes have been predicted and documented. However, little is known about how antiretroviral therapy (ART) adherence disruptions caused by the COVID-19 pandemic have manifested amidst the ‘Undetectable = Untransmittable' campaign initiative. Using a patient's viral load as a proxy for medication adherence, our study aimed to determine the adherence to ART on first-line medications among adult people living with human immunodeficiency virus (PLWHIV) at the University Teaching Hospital in Lusaka, Zambia during the pandemic.

Methods

This was a hospital-based cross-sectional study. Secondary data of PLWHIV registered to receive ART from the Adult Infectious Disease Centre was extracted from the SmartCare® electronic health record system to constitute a resultant data set that this study used. The data extraction form was used to extract values of dependent (ART adherence measured by viral load detectability) and independent variables and imported them into the statistical analysis tool, STATA version 16.1 MP. Descriptive statistics of individual characteristics, testing for associations using Pearson's chi-square test, and stratified and combined multivariable logistic regression were performed.

Results

Of the 7,281 adult PLWHIV included in this study, 9.0% (95% CI 8.3–9.6%) were virally detectable. Estimates of the odds ratios of detectable viral load remained significantly higher among adult PLWHIV who were initiated on ART after the U=U campaign was launched in Zambia and were on a monthly 2.51 (1.31–9.03) or 6-monthly 4.75 (3.52–6.41) dispensing of a dolutegravir-based regimen and those on 6-monthly dispensing of an efavirenz-based regimen 4.67 (2.16–10.08) compared to their counterparts. Overall estimates showed us the same picture 4.14 (3.22–5.31), having adjusted for all other predictor variables.

Conclusion

We found that a high proportion of people with detectable viral load in the study population, irrespective of medication refill interval and type of regimen, was concentrated among adult PLWHIV who started treatment during the COVID-19 epidemic waves, as compared to those who started treatment before the pandemic. This observed disparity suggests the inherent impact of the pandemic on the adherence to ART among adult PLWHIV in Lusaka, Zambia. This further illustrates how exposed program responses are to external shocks, especially in already weakened health systems, and the need to create program response buffers and resilient program-specific strategies to minimize the effect of external disruptions.

Incidence and factors associated with being lost to follow-up among people living with HIV and receiving antiretroviral therapy in Nyarugenge the central business district of Kigali city, Rwanda

BACKGROUND

Lost to follow-up (LTFUP) continues to threaten the sustainability of antiretroviral therapy (ART) benefits and success of ART programs. We determined the incidence and predictors of LTFUP among people living with HIV (PLHIV) on ART in Nyarugenge the Central Business District of Kigali city.

METHODS

A cohort of PLHIV who initiated ART in 2018 was retrospectively studied for 24 months. Using health facility records, a person who had no record of contact with the health facility for at least three consecutive months was considered LTFUP. LTFUP incidence rates were computed, and the Fine-Gray's competing risk regression models were used to determine factors associated with time to first LTFUP. Generalized estimating equations (GEEs) were used to analyze repeated measurement outcomes of LTFUP and predictors of LTFUP.

RESULTS

Of 950 participants, 581 (61.2%) were females and 866 (91.2%) were 15 to 49 years old. From 1,586.1 person years of observation (pyo), 148 participants got LTFUP for 451 times. The incidence rate to first event was 9.4 per 100 pyo (95%CI:7.9-10.9) and 31.8 per 100 pyo (95%CI:29.0-34.4) to multiple events. WHO stage, marital status, employment status and person to contact when PLHIV is not reachable were associated with time to first LTFUP event. However, an average participant with a contact person who was not a Community Health Worker (CHW) or a peer educator had higher incidence of LTUP (aIRR = 2.69, 95%CI: 1.43-5.06), an average single patients had higher incidence of LTFUP (aIRR = 1.74, 95%CI: 1.28-2.34) compared to married/co-habiting, and an average self-employed had higher incidence of LTFUP (aIRR = 1.51, 95%CI: 1.14-2.01) compared to participants employed by others. Furthermore, an average PLHIV living out-of-the health facility catchment area had higher incidence of LTFUP (aIRR = 1.55, 95%CI: 1.19-2.01) compared to an average PLHIV living in the health facility catchment area whereas, an average children initiated on first line had lower incidence of LTUP (aIRR = 0.43, 95%CI: 0.21-0.86) compared to adults.

CONCLUSION

Using CHW and peer educators as contact persons can help to reduce LTFUP while, targeted sensitization and service delivery are needed for single, self-employed and, patients living out of the health facility catchment area.

Characteristics and clinical outcomes of patients presenting with advanced HIV disease in the "treat all" era: a retrospective cohort study from rural Rwanda

Background

In 2016 Rwanda adopted “treat all” where all patients with HIV are immediately eligible for ART regardless of disease progression. Despite widespread availability of treatment, it is unknown whether presentation with advanced HIV persists.

Methods

We conducted a retrospective cohort among patients aged ≥ 15 who enrolled in care between July 2016 and July 2018 in three rural Rwandan districts. We estimated the prevalence of advanced HIV, defined as presenting with CD4 count < 200 cells/mm³ or WHO stage 3 or 4, and compared baseline characteristics of patients with and without advanced HIV. We compared cumulative incidences and time to events using Chi squared tests and Cox proportional hazards models, respectively, for (a) viral load tests; (b) viral suppression; (c) death; and (d) treatment failure (a composite of death, lost to follow up, or virologic failure).

Results

Among 957 patients, 105 (11.0%) presented with advanced HIV. These patients were significantly more likely to have low body mass index, come from Burera district, be older, and be identified through inpatient settings rather than through voluntary or prenatal testing. Patients with advanced HIV had significantly higher risks of death at 12-months (9.5% vs 1.5%, p < 0.001) and 18-months (10.5% vs 1.9%, p < 0.001) and significantly higher risk of treatment failure at 12-months (21.9% vs. 14.2%, p = 0.037). After adjusting for confounders, patients with advanced HIV had still higher rates of death (adjusted Hazard ratio [aHR] = 4.4, 95% CI: 1.9, 10.2, p < 0.001) and treatment failure (aHR = 1.7, 95% CI: 1.1, 2.5, p = 0.017), but no difference in viral load testing (aHR = 1.1, 95% CI: 0.8, 1.5, p = 0.442) or viral suppression (aHR = 1.0, 95% CI: 0.8, 1.4, p = 0.949). When allowing for the hazard ratio to vary over time, patients with advanced HIV experienced elevated rates of treatment failure in the first six of enrollment, but not after nine months.

Conclusion

Presenting with advanced HIV remains common and is still associated with poor patient outcomes. Sensitization of the community to the benefits of early ART initiation, identification of patients with advanced HIV, and holistic support programs for the first 6 months of treatment may be needed to improve outcomes.

Factors associated with HIV viral suppression among children and adults receiving antiretroviral therapy in Malawi in 2021: Evidence from the Laboratory Management Information System

OBJECTIVE

To describe the prevalence of HIV viral suppression and assess the factors associated with HIV viral suppression among persons receiving antiretroviral therapy (ART) in Malawi in 2021.

METHODS

Implementation study using routinely collected patient-level HIV RNA-PCR test result data extracted from the national Laboratory Management Information System (LIMS) database managed by the Department of HIV/AIDS in 2021. We calculated frequencies, proportions and odds ratios (OR) of HIV viral suppression with their associated 95% confidence intervals (95%CIs). We performed a random-effects logistic regression to determine the risk factors associated with HIV viral suppression among ART patients, controlling for the spatial autocorrelation between districts and adjusting for other variables.

RESULTS

We evaluated 515,797 adults and children receiving ART and having a viral load test in 2021. Of these, 92.8% had HIV viral suppression. ART patients living in urban areas had lower likelihood of HIV viral suppression than those living in rural areas (adjusted OR [aOR] = 0.95, 95%CI: 0.92-0.99, p = 0.01). There was an increasing trend in HIV viral suppression with increasing ART duration. Routine VL monitoring samples were 39% more likely to have suppressed VL values than confirmatory HIV VL monitoring samples (aOR = 1.39; 95%CI: 1.34-1.43, p < 0.001).

CONCLUSION

This is the first national analysis of Malawi HIV VL data from LIMS. Our findings show the need to particularly consider the urban residents, those below 20 years, males, those on ART for less than a year as well as those on specific ARV regimens in order to persistently suppress HIV VL and consequently achieve the goal of achieving HIV VL suppression by 2030.

Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis

INTRODUCTION

Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement.

METHODS

We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis.

RESULTS AND DISCUSSION

We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty.

CONCLUSIONS

Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.

HIV Viral Suppression among People Living with HIV on Antiretroviral Therapy in Haut-Katanga and Kinshasa Provinces of Democratic Republic of Congo

Human immunodeficiency virus (HIV) infections and less-than-optimal care of people living with HIV (PLHIV) continue to challenge public health and clinical care organizations in the communities that are most impacted by HIV. In the era of evidence-based public health, it is imperative to monitor viral load (VL) in PLHIV according to global and national guidelines and assess the factors associated with variation in VL levels. Purpose: This study had two objectives—(a) to describe the levels of HIV VL in persons on antiretroviral therapy (ART), and (b) to analyze the significance of variation in VL by patients’ demographic and clinical characteristics, outcomes of HIV care, and geographic characteristics of HIV care facilities. Methods: The study population for this quantitative study was 49,460 PLHIV in the Democratic Republic of Congo (DRC) receiving ART from 241 CDC-funded HIV/AIDS clinics in the Haut-Katanga and Kinshasa provinces of the DRC. Analysis of variance (ANOVA) was performed, including Tamhane’s T2 test for pairwise comparisons using de-identified data on all patients enrolled in the system by the time the data were extracted for this study by the HIV programs in May 2019. Results: The VL was undetectable (<40 copies/mL) for 56.4% of the patients and 24.7% had VL between 40 copies/mL and less than 1000 copies per mL, indicating that overall, 81% had VL < 1000 and were virologically suppressed. The remaining 19% had a VL of 1000 copies/mL or higher. The mean VL was significantly (p < 0.001) higher for males than for females (32,446 copies/mL vs. 20,786, respectively), persons <15 years of age compared to persons of ages ≥ 15 years at the time of starting ART (45,753 vs. 21,457, respectively), patients who died (125,086 vs. 22,090), those who were lost to follow-up (LTFU) (69,882 vs. 20,018), those with tuberculosis (TB) co-infection (64,383 vs. 24,090), and those who received care from urban clinics (mean VL = 25,236) compared to rural (mean VL = 3291) or semi-rural (mean VL = 26,180) clinics compared to urban. WHO clinical stages and duration on ART were not statistically significant at p ≤ 0.05 in this cohort. Conclusions: The VL was >1000 copies/mL for 19% of PLHIV receiving ART, indicating that these CDC-funded clinics and programs in the Haut-Katanga and Kinshasa provinces of DRC have more work to do. Strategically designed innovations in services are desirable, with customized approaches targeting PLHIV who are younger, male, those LTFU, with HIV/TB co-infection, and those receiving care from urban clinics.

Continuum of Care UNAIDS Fast-Track Targets Evaluation of Patients Living with Human Immunodeficiency Virus Infection

The current study evaluated the progress of continuum healthcare for patients living with human immunodeficiency virus (HIV) infection from Cluj County in two moments, 2016 and 2020, and compared the results to the Fast-Track targets (FTTs) proposed by the Joint United Nations Programme (UNAIDS) on HIV/AIDS. By the end of 2020, 368 out of 385 confirmed HIV-positive patients from Cluj County were under surveillance in our center, representing almost 95% of the patients living with HIV and knowing their diagnosis, compared to 87.9% in 2016. Nearly 97% of those in active follow-up from Cluj County were under antiretroviral therapy (ART) in 2020, compared to 89% in 2016. The number of virally suppressed patients from those under ART was almost 94% in 2020, compared to 82.7% in 2016, and the increase is observed regardless of the ART regime. A shift towards integrase strand transfer inhibitors, with a higher efficacy, fewer adverse effects, and fewer drug interactions, is observed, which could contribute to the decrease in HIV transmission.

Virologic outcomes of people living with human immunodeficiency virus who started antiretroviral treatment on the same-day of diagnosis in Ethiopia: A multicenter observational study

INTRODUCTION

There have been tremendous achievements in scaling-up antiretroviral therapy (ART) for treatment of human immunodeficiency virus (HIV), following universal "test and treat" policy implementation in low- and middle-income countries. However, its effects on virologic outcomes is not yet well investigated. We compared low viral load status in people living with HIV between those who were initiated on ART on the same-day and after 7 days of being diagnosed with HIV infection.

METHODS

We conducted a retrospective cohort study of persons age ≥15 years-old who were newly diagnosed and started on ART between October 2016 and July 2018 at 11 public health facilities in northwest Ethiopia. Exposure was initiation of ART on the same-day of HIV diagnosis. The outcome was low viral load at 12-months following ART initiation. We used double-robust estimator using inverse-probability-weighted regression adjustment to compare the groups.

RESULTS

A total of 398 people who started ART on the same-day of HIV diagnosis and 479 people who started 7 days after the initial diagnosis were included in this study. By 12-months following ART initiation, 73.4% (292) in the same-day group vs 83.7% (401) in the >7 days group achieved low viral load (absolute difference = 10.3% (95% CI: 4.9%, 15.8%)). After adjusting for baseline and follow-up covariates, there was statistically significant difference in low viral load status (adjusted difference = 8.3% (95% CI: 3.5%, 13.0%)) between the same-day group and the >7 days group.

CONCLUSIONS

Achievement of low viral load by 12-months post-initiation of ART was not optimal among participants who started ART on the same-day of HIV diagnosis. Efforts should be made to reinforce treatment adherence while initiating same-day ART.

The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions

INTRODUCTION

The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade.

METHODS

We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero.

RESULTS AND DISCUSSION

Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care.

CONCLUSIONS

The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.

Reducing time to differentiated service delivery for newly diagnosed people living with HIV in Kigali, Rwanda: study protocol for a pilot, unblinded, randomised controlled study

INTRODUCTION

Current HIV guidelines recommend differentiated service delivery (DSD) models that allow for fewer health centre visits for clinically stable people living with HIV (PLHIV). Newly diagnosed PLHIV may require more intensive care early in their treatment course, yet frequent appointments can be burdensome to patients and health systems. Determining the optimal parameters for defining clinical stability and transitioning to less frequent appointments could decrease patient burden and health system costs. The objectives of this pilot study are to explore the feasibility and acceptability of (1) reducing the time to DSD from 12 to 6 months after antiretroviral therapy (ART) initiation,and (2) reducing the number of suppressed viral loads required to enter DSD from two to one.

METHODS AND ANALYSES

The present study is a pilot, unblinded trial taking place in three health facilities in Kigali, Rwanda. Current Rwandan guidelines require PLHIV to be on ART for ≥12 months with two consecutive suppressed viral loads in order to transition to less frequent appointments. We will randomise 90 participants to one of three arms: entry into DSD at 6 months after one suppressed viral load (n=30), entry into DSD at 6 months after two suppressed viral loads (n=30) or current standard of care (n=30). We will measure feasibility and acceptability of this intervention; clinical outcomes include viral suppression at 12 months (primary outcome) and appointment attendance (secondary outcome).

ETHICS AND DISSEMINATION

This clinical trial was approved by the institutional review board of Albert Einstein College of Medicine and by the Rwanda National Ethics Committee. Findings will be disseminated through conferences and peer-reviewed publications, as well as meetings with stakeholders.

TRIAL REGISTRATION NUMBER

NCT04567693.

Recording of HIV viral loads and viral suppression in South African patients receiving antiretroviral treatment: a multicentre cohort study

BACKGROUND

Viral suppression in patients on antiretroviral treatment (ART) is critical to reducing HIV transmission and HIV-related mortality. Although many studies have evaluated factors associated with viral suppression, few have assessed the extent to which missing viral load data may bias results.

METHODS

We included data on all patients starting ART from 2005 to 2019 in eight South African cohorts participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) collaboration. Multivariable logistic regression models were used to determine factors associated with having a viral load measurement within 2 months of a scheduled testing date and having a viral load <400 RNA copies/ml ('viral suppression'). In a sensitivity analysis, missing viral loads were imputed based on patients' clinical and demographic characteristics and outcomes.

RESULTS

Viral load tests were scheduled in 603,549 and 77,423 intervals in adults and children, respectively, but test results were recorded in only 40.7% and 41.2%, respectively. The proportion of recorded results suppressed was 85.7% in adults and 72.4% in children. After imputation of missing viral load measurements, viral suppression reduced slightly in adults (85.3%) and increased in children (73.2%). Predictors of virological suppression in adults, which included female sex, older age, higher baseline CD4⁺ T-cell count and recent testing year, were similar in the main analysis and after imputing missing viral loads.

CONCLUSIONS

Although viral load information was frequently missing in the South African setting, estimates of viral suppression and predictors of viral suppression did not change substantially after adjusting for missing data.