Prevalence of nonsuppressed viral load and associated factors among HIV-positive adults receiving antiretroviral therapy in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017): results from population-based nationally representative surveys

Courier delivery of antiretroviral therapy: a cohort study of a South African private-sector HIV programme

INTRODUCTION

Courier delivery has become a popular antiretroviral therapy (ART) distribution method in some HIV care settings, yet data on ART courier delivery and how it relates to ART outcomes are scarce. We studied the differences in viral suppression rates between individuals from a South African private sector HIV programme receiving ART by courier delivery and those receiving ART through traditional retail dispensing.

METHODS

Individuals aged 15 years or older who were actively enrolled in the Aid for AIDS programme between January 2011 and July 2022 were eligible for the analysis. The outcome of interest was viral suppression defined as a viral load (VL) <400 copies per ml. We calculated adjusted odds ratios (OR) for the association between the ART distribution method and viral suppression, comparing those receiving refills through courier pharmacies versus retail dispensing at the time of the VL testing. We used generalized estimating equations to account for repeated VL testing of the same individual. The models were adjusted for age, sex, calendar year, ART regimen, history of mental illness and medical insurance scheme. We computed adjusted ORs for the calendar periods 2011-2013, 2014-2016, 2017-2019, 2020-2022 and overall.

RESULTS

We extracted 442,619 VL measurements from 68,720 eligible individuals, 39,406 (57.3%) were women. The median number of VL measurements per individual was 6 (IQR 3-10). VL suppression was detected in 398,901 (90.1%) tests, and 185,701 (42.0%) of the tests were taken while the individual was receiving ART by courier delivery. Overall, courier delivery was associated with 5% higher odds of viral suppression than retail dispensing (adjusted OR 1.05, 95% CI 1.02-1.08). The strength and direction of this association varied by calendar period, with an adjusted OR of 1.37 (95% CI 1.27-1.48) in 2011-2013 and 1.02 (95% CI 0.97-1.07) in 2020-2022.

CONCLUSIONS

Courier delivery of ART is a viable alternative to retail dispensing in the South African private sector, as it was associated with higher viral suppression until 2016 and similar suppression rates in recent years. Further research is needed to investigate the potential benefits and drawbacks of courier delivery of ART in both private and public healthcare settings.

Determinants of viral load suppression failure among HIV adults on ARV attending health care facilities: a retrospective study in Tanga region, Tanzania

BACKGROUND

Availability and accessibility of Antiretroviral drugs (ARV's) improve the lives of People living with HIV (PLHIV) by improving client's immune system to overcome infections and prevent the development of AIDS and other HIV complications. Combination therapy, early initiation of ART, newer ART drugs, single dosage and drug affordability significantly contribute in the reduction of viral multiplication and suppression of HIV to undetectable plasma levels.

METHODS

A retrospective longitudinal study design study was conducted from 1st October, 2018 to 30th June 2022 in all supported HIV care and treatment health facilities in Tanga region which were supported by Amref Health Africa, Tanzania. The participants were HIV adult patients aged 15 years and above on ART and attended the clinic at least once after ART initiation. Viral load suppression levels are defined with viral load <1,000 HIV RNA copies/ml (viral load suppression). Cox proportional hazard regression models were employed to identify risk factors for virological failure. P values were two-sided, and we considered a P<0.05 to be statistically significant.

RESULTS

Fifty-nine thousand five hundred three adult clients >15 years whom were on ART were included in the analysis to determine the level of plasma Viral Load suppression after being on ART. Female 41,304 (69.4%) and male 18,199 (30.6%). Only four percent (2,290) were found to be unsuppressed i.e having plasma Viral Load >1,000cp/ml while 96% (57,213) were virally suppressed. Several factors were independently associated with virologic failure that included; age between 15 - <25 years (HR: 2.82, 95% CI 1.96 - 4.04), BMI <18.5 (HR: 1.69, 95% CI 1.23 - 2.30), advanced WHO stage IV (HR: 1.60, 95% CI 1.12 - 2.24), CD4 cell count <350 (HR: 2.61, 95% CI 2.12 - 3.23), poor adherence (HR: 1.98, 95% CI 1.80 - 2.18) and not using DTG based drug (HR: 11.8, 95% CI 9.74 - 14.3).

CONCLUSION

Virologic failure was observed in this study among clients with young age, advanced WHO stage IV, not using DTG based regimen, poor drug adherence and second line regime. To improve Viral Load Suppression among these clients; the existing HIV intervention strategies should be taken care by targeting the identified risk factors.

Differentiated care for youth in Zimbabwe: Outcomes across the HIV care cascade

Youth living with HIV are at higher risk than adults of disengaging from HIV care. Differentiated models of care such as community delivery of antiretroviral therapy (ART) may improve treatment outcomes. We investigated outcomes across the HIV cascade among youth accessing HIV services in a community-based setting. This study was nested in a cluster-randomised controlled trial (CHIEDZA: Clinicaltrials.gov, Registration Number: NCT03719521) conducted in three provinces in Zimbabwe and aimed to investigate the impact of a youth-friendly community-based package of HIV services, integrated with sexual and reproductive health services for youth (16-24 years), on population-level HIV viral load (VL). HIV services included HIV testing, ART initiation and continuous care, VL testing, and adherence support. Overall 377 clients were newly diagnosed with HIV at CHIEDZA, and linkage to HIV care was confirmed for 265 (70.7%, 234 accessed care at CHIEDZA and 31 with other providers); of these 250 (94.3%) started ART. Among those starting ART at CHIEDZA who did not transfer out and had enough follow up time (>6 months), 38% (68/177) were lost-to-follow-up within six months. Viral suppression (HIV Viral Load <1000 copies/ml) among those who had a test at 6 months was 90% (96/107). In addition 1162 clients previously diagnosed with HIV accessed CHIEDZA; 714 (61.4%) had a VL test, of whom 565 (79.1%) were virally suppressed. This study shows that provision of differentiated services for youth in the community is feasible. Linkage to care and retention during the initial months of ART was the main challenge and needs concerted attention to achieve the ambitious 95-95-95 UNAIDS targets.

Trend and factors associated with non-suppression of viral load among adolescents on ART in Tanzania: 2018-2021

Background

Tanzania is one of the countries with a high burden of HIV. It has an estimated 1.4 million people living with HIV in 2021. Adolescents living with HIV on antiretroviral therapy (ART) have worse treatment adherence, viral suppression, and mortality rates compared to adults. This study aim was to determine the trend of non-suppression among adolescents on ART in Tanzania from 2018 to 2021 and latest associated predictors.

Methodology

The study utilized data of adolescents (10-19 years) receiving ART in Tanzania mainland for the period of 2018-2021 from the National Care and Treatment Centers database. The primary outcome of interest was non-suppression of viral load, defined as a VL above 1,000 copies/ml. The study employed multivariable logistic regression models to identify factors associated with non-suppression of VL. STATA 15 statistical software was used to analyze the data.

Results

Records of 65,942 adolescents present in the CTC database Tanzania were analyzed. Approximately more than half were female 38,544 (58.5%). The proportion of non-suppression was 34.5%, 23.3%, 12.1%, and 9.7% for the years 2018-2021, respectively. After adjusting for other factors, adolescents with a history of poor adherence to ART in the last six months had higher odds of non-suppression (OR = 1.95, 95% CI = 1.64, 2.31). Adolescents on second or third line ART regimens were almost two times more likely to be non-suppressed compared to those on first-line regimens (OR = 2.85, 95% CI = 2.52, 3.23). Girls had lower odds of non-suppression compared to boys (OR = 0.91, 95% CI = 0.84, 0.98), and similarly, patients attending hospitals had lower odds compared to those attending dispensaries (OR = 0.79, 95% CI = 0.72, 0.87).

Conclusion

Being female, having good history of adherence over the last six months, and attending hospital level was significantly associated with lower levels of non-suppression, while being on second line ART or attending lower health facilities increased the odds of non-suppression. Efforts to enhance the quality and capacity of health services at lower-level facilities (dispensaries and health centers) should be prioritized, as well as promoting gender-sensitive approaches that take into account the unique needs and experiences of adolescent girls and boys are needed to improve VL suppression among this population.

Factors associated with HIV-positive status awareness among adults with long term HIV infection in four countries in the East and Southern Africa region: A multilevel approach

Antiretroviral treatment (ART) appropriately and regularly used decreases the human immunodeficiency virus (HIV) viral load in the bloodstream, preventing HIV-infected people from spreading the infection to others. Disparities in ART adoption persists in East and Southern Africa, with low HIV-positive status knowledge being the primary factor. We investigated individual and household characteristics of HIV-positive status awareness among adults with long-term HIV infection in four East and Southern African countries: Eswatini, Malawi, Tanzania, and Zimbabwe. The study analyzed data from surveys conducted in Eswatini, Malawi, Tanzania, and Zimbabwe in 2015-2016. Only individuals who tested positive for HIV through rapid tests were included in the analysis. Those who already knew they were HIV-positive were categorized as aware, while those who reported being negative, never tested, or didn't know their status were categorized as unaware. Statistical models were used to examine various factors related to HIV awareness. Pooled and country-specific odds ratios were computed. The percentage of people who knew they had HIV ranged from 58% (Tanzania and Malawi) to 87% (Eswatini). After adjusting for other variables, young persons in all countries were less likely to be aware of their HIV-positive status. Gender, marital status, education, working status, household wealth, and urbanization level of households were also associated with HIV-positive status awareness but inconsistent across countries. HIV-positive status awareness in these four East and Southern African nations remained unsatisfactory as compared to the United Nations' 95% guideline, indicating that testing and knowledge of HIV testing in this region still has a lot of potential for improvement. The observed variations among nations may be attributable to differences in HIV pandemic culture and policies. The findings of this study will assist governments determining which subpopulations to target to boost adoption of HIV testing services, as well as in designing and development of policies.

Differences between persons with and without disability in HIV prevalence, testing, treatment, and care cascade in Tanzania: a cross-sectional study using population-based data

BACKGROUND

Persons with disability may have a higher HIV prevalence and be less likely than persons without disability to know their HIV-positive status, access antiretroviral therapy (ART), and suppress their HIV viral load (HIV care cascade). However, studies examining differences between persons with and without disability in HIV prevalence and the HIV care cascade are lacking. Using the Tanzania HIV Impact Survey (THIS) data collected between October 2016 and August 2017, we assessed differences in HIV prevalence and progress towards achieving the 2020 HIV care cascade target between persons with and without disability.

METHODS

Using the Washington Group Short Set (WG-SS) Questions on Disability, we defined disability as having a functional difficulty in any of the six life domains (seeing, hearing, walking/climbing, remembering/ concentrating, self-care, and communicating). We classified respondents as disabled if they responded having either "Some Difficulty", "A lot of difficulties" or "Unable to" in any of the WG-SS Questions. We presented the sample characteristics by disability status and analyzed the achievement of the cascade target by disability status, and sex. We used multivariable logistic regressions, and adjusted for age, sex, rural-urban residence, education, and wealth quintile.

RESULTS

A total of 31,579 respondents aged 15 years and older had HIV test results. Of these 1,831 tested HIV-positive, corresponding to an estimated HIV prevalence of 4.9% (CI: 4.5 - 5.2%) among the adult population in Tanzania. The median age of respondents who tested HIV-positive was 32 years (with IQR of 21-45 years). HIV prevalence was higher (5.7%, 95% CI: 5.3-7.4%) among persons with disability than persons without disability (4.3%, 95% CI: 4.0 - 4.6%). Before adjustment, compared to women without disability, more women with disability were aware of their HIV-positive status (n = 101, 79.0%, 95% CI: 68.0-87.0% versus n = 703, 63.0%, 95% CI: 59.1-66.7%) and accessed ART more frequently (n = 98, 98.7%, 95% CI: 95.3-99.7% versus n = 661, 94.7%, 95% CI: 92.6-96.3%). After adjusting for socio-demographic characteristics, the odds of having HIV and of accessing ART did not differ between persons with and without disability. However, PLHIV with disability had higher odds of being aware of their HIV-positive status (aOR 1.69, 95% 1.05-2.71) than PLHIV without disability. Men living with HIV and with disability had lower odds (aOR = 0.23, 95% CI: 0.06-0.86) to suppress HIV viral loads than their counterparts without disability.

CONCLUSION

We found no significant differences in the odds of having HIV and of accessing ART between persons with and without disability in Tanzania. While PLHIV and disability, were often aware of their HIV-positive status than their non-disabled counterparts, men living with HIV and with disability may have been disadvantaged in having suppressed HIV viral loads. These differences are correctable with disability-inclusive HIV programming. HIV surveys around the world should include questions on disability to measure potential differences in HIV prevalence and in attaining the 2025 HIV care cascade target between persons with and without disability.

Assessing sex differences in viral load suppression and reported deaths using routinely collected program data from PEPFAR-supported countries in sub-Saharan Africa

BACKGROUND

In sub-Saharan Africa, more women than men access HIV testing and treatment and may have better viral load suppression (VLS). We utilized routinely reported aggregated HIV program data from 21 sub-Saharan African countries to examine sex differences in VLS and death rates within antiretroviral therapy (ART) programs supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR).

METHODS

We included VLS and reported death data for persons aged 15 + years on ART from October-December 2020 disaggregated by sex and age for each subnational unit (SNU). We used linear mixed-model regression to estimate VLS proportion and negative binomial mixed-model regression to estimate the rates of death and death plus interruptions in treatment (IIT). All models were weighted for SNU-level ART population size and adjusted for sex, age, HIV/tuberculosis coinfection, country, and SNU; models for reported deaths and deaths plus IIT were also adjusted for SNU-level VLS.

RESULTS

Mean VLS proportion was higher among women than men (93.0% vs. 92.0%, p-value < 0.0001) and 50 + than 15-49 age group (93.7% vs. 91.2%, p-value < 0.0001). The mean rate of reported deaths was higher among men than women (2.37 vs. 1.51 per 1000 persons, p-value < 0.0001) and 50 + than 15-49 age group (2.39 vs. 1.50 per 1000, p-value < 0.0001); the mean rate of reported deaths plus IIT was higher among men (30.1 in men vs. 26.0 in women per 1000, p-value < 0.0001) and higher among 15-49 than 50 + age group (34.7 vs. 22.6 per 1000, p-value < 0.0001).

CONCLUSIONS

The mean rate of reported deaths was higher among men in most models despite adjusting for VLS. Further exploration into differences in care-seeking behaviors; coverage of screening, prophylaxis, and/or treatment of opportunistic infections; and more extensive testing options for men to include CD4 is recommended.

Human Immunodeficiency Virus Viral Load Monitoring and Rate of Virologic Suppression Among Patients Receiving Antiretroviral Therapy in Democratic Republic of the Congo, 2013-2020

Background

Antiretroviral therapy (ART) expansion and viral load as a treatment monitoring approach have increased the demand for viral load testing. Many hurdles affect the coverage, quality, and use of viral load results. Estimates of viral load monitoring and viral suppression rates are needed to assess the performance of ART programs and improve human immunodeficiency virus (HIV) management outcomes.

Methods

People with HIV (PWH) viral load monitoring data were routinely collected in 84 health facilities in Kinshasa, Democratic Republic of the Congo (DRC), between 2013 and 2020. The number of PWH under ART, the number of participants with at least 1 viral load test result, the rate of viral suppression (defined as ≤1000 HIV ribonucleic acid copies per mL), and the mean turnaround time from sample collection to release of viral load test results were collected together with clinical data.

Results

A total of 14 057 PWH were included in the analysis. People with HIV were mainly enrolled after the "test and treat" implementation. The patients were followed for a median period of 27 months. The proportion of PWH with at least 1 available viral load largely increased in recent years. The delay from sample collection to release of viral load test results decreased overtime, from 35 days in 2018 to 16 days in 2020. Pregnancy and advanced HIV disease were associated with a lower chance of viral suppression.

Conclusions

There has been considerable success in increasing viral load access for all PWH under therapy in DRC. Nevertheless, viral load testing should be intensified with a particular effort to be made in groups at higher risk of viral failure.

Mental Health, ART Adherence, and Viral Suppression Among Adolescents and Adults Living with HIV in South Africa: A Cohort Study

We followed adolescents and adults living with HIV aged older than 15 years who enrolled in a South African private-sector HIV programme to examine adherence and viral non-suppression (viral load > 400 copies/mL) of participants with (20,743, 38%) and without (33,635, 62%) mental health diagnoses. Mental health diagnoses were associated with unfavourable adherence patterns. The risk of viral non-suppression was higher among patients with organic mental disorders [adjusted risk ratio (aRR) 1.55, 95% confidence interval (CI) 1.22-1.96], substance use disorders (aRR 1.53, 95% CI 1.19-1.97), serious mental disorders (aRR 1.30, 95% CI 1.09-1.54), and depression (aRR 1.19, 95% CI 1.10-1.28) when compared with patients without mental health diagnoses. The risk of viral non-suppression was also higher among males, adolescents (15-19 years), and young adults (20-24 years). Our study highlights the need for psychosocial interventions to improve HIV treatment outcomes-particularly of adolescents and young adults-and supports strengthening mental health services in HIV treatment programmes.

Associations Between Mobility, Food Insecurity, and Transactional Sex Among Women in Cohabitating Partnerships: An Analysis From 6 African Countries 2016-2017

BACKGROUND

Mobile women are at risk of HIV infection in sub-Saharan Africa, although we lack evidence for HIV risk among women in mobile partnerships, especially in the context of household food insecurity, a growing concern in the region.

SETTING

Women aged 15-59 years with a cohabitating male partner who participated in population-based HIV impact assessment surveys in Eswatini, Lesotho, Namibia, Tanzania, Uganda, and Zambia.

METHODS

We evaluated the association between women's and their partner's mobility (being away from home for more than 1 month or staying elsewhere) and transactional sex (selling sex or receiving money or goods in exchange for sex). We examined associations for effect measure modification by food insecurity level in the household in the past month. We used survey-weighted logistic regression, pooled and by country, adjusting for individual, partner, and household-level variables.

RESULTS

Among women with a cohabitating male partner, 8.0% reported transactional sex, ranging from 2.7% in Lesotho to 13.4% in Uganda. Women's mobility [aOR 1.35 (95% CI: 1.08 to 1.68)], but not their partner's mobility [aOR 0.91 (0.74-1.12)], was associated with transactional sex. Food insecurity was associated with transactional sex independent of mobility [aOR 1.29 (1.10-1.52)]. Among those who were food insecure, mobility was not associated with increased odds of transactional sex.

CONCLUSION

Food insecurity and women's mobility each increased the odds of transactional sex. Because transactional sex is associated with HIV risk, prevention programs can address the needs of mobile and food-insecure women, including those in cohabitating relationships.

HIV suppression was maintained during the COVID-19 pandemic in Malawi: a program-level cohort study

Background and Objectives

Measures introduced to reduce the spread of SARS-CoV-2 by the Malawi government and the national HIV care program might have compromised treatment outcomes of patients living with HIV on antiretroviral therapy (ART). We studied viral load (VL) outcomes before and during the COVID-19 epidemic in Malawi.

Methods

In this population-based cohort study, we included all routine VL measurements collected from July 2019 to December 2020 in about 650 ART clinics in Malawi. We examined differences between pandemic periods (before/during COVID-19) for i) VL monitoring, and ii) VL suppression (VLS: <1,000 copies/ml). For i) we studied the number of VL measurements over time and assessed predictors of missed measurements before and during COVID-19 in logistic regression models. For ii) we estimated the odds of VLS before and during the COVID-19 epidemic stratified by treatment regimen using generalized estimation equations adjusted for age, sex, time on ART, and type of biological sample. We imputed missing treatment regimens by population-calibrated multiple imputation.

Results

We included 607,894 routine VL samples from 556,281 patients. VL testing declined during COVID-19 (243,729; 40%) compared to before COVID-19 (365,265; 60%), but predictors of missing tests were similar in the two periods. VLS rates increased slightly from 93% before to 94% during COVID-19. Compared to before COVID-19, the odds of VLS increased during COVID-19 for patients on protease inhibitor-based (PI) regimens (adjusted odds ratio [aOR] 1.22, 95% CI: 0.99-1.49) and for patients on integrase strand transfer inhibitor-based (INSTI) regimens (aOR 1.10, 95% CI: 1.03-1.17). There was no difference in VLS between the two periods among patients on nonnucleoside reverse transcriptase inhibitor-based (NNRTI) regimens. VLS varied by age, sex, regimen, and duration on ART, ranging from 45.1% (95% CI 40.3-50.0%) to 97.2% (95% CI 96.9-97.4%).

Conclusion

There was a significant decline in VL monitoring during COVID-19, but we did not find clear evidence that the pandemic reduced VL suppression rates. Routine scheduled VL monitoring, targeted adherence support, and timely regimen switches for patients with treatment failure remain critical to improving VLS.

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.

Current situation of fungal diseases in Eritrea

The epidemiology of fungal infections in Eritrea is unknown. Most cases are under‐reported due to a lack of diagnostics. This study estimates the burden of serious fungal infections and highlights treatment and diagnostic gaps in the country. All publications related to fungal infections were identified by searches using PubMed/Medline and Google Scholar. Where no data were available, data from neighbouring countries, then sub‐Saharan African countries, then other parts of the world were considered for deriving estimates. The Eritrea population was 3,546,427 in 2020. In 2020, HIV/AIDS patients numbered 1400 and TB incidence were 2875. The five‐year adult prevalence of asthma (2016–2020) was 41,390, and the total prevalence estimate of chronic obstructive pulmonary disease (COPD) was 308,328. The annual incidence of cryptococcal meningitis and Pneumocystis jirovecii pneumonia in AIDS patients was estimated at 96 and 205 cases. Oesophageal candidiasis incidence is 715 HIV‐infected patients. Chronic pulmonary aspergillosis prevalence, including post‐tuberculosis cases, was estimated at 1399 (39/100,000). Fungal asthma has a prevalence of 1035 and 1366 in adults. The estimated prevalence of recurrent vulvovaginal candidiasis and tinea capitis is 59,391 and 342,585, respectively. There are no data on candidaemia, but it is estimated at 5/100,000 (177 cases annually). Invasive aspergillosis in leukaemia, lung cancer, COPD and HIV is estimated at 540 cases and fungal keratitis in 514 cases annually. Serious fungal infections are prevalent in Eritrea with approximately 408,164 people (11.5%) affected annually. Studies on fungal diseases to improve diagnosis and treatment are required with the implementation of a national surveillance program.

Point-of-care viral load tests to detect high HIV viral load in people living with HIV/AIDS attending health facilities

BACKGROUND

Viral load (VL) testing in people living with HIV (PLHIV) helps to monitor antiretroviral therapy (ART). VL is still largely tested using central laboratory-based platforms, which have long test turnaround times and involve sophisticated equipment. VL tests with point-of-care (POC) platforms capable of being used near the patient are potentially easy to use, give quick results, are cost-effective, and could replace central or reference VL testing platforms.

OBJECTIVES

To estimate the diagnostic accuracy of POC tests to detect high viral load levels in PLHIV attending healthcare facilities.

SEARCH METHODS

We searched eight electronic databases using standard, extensive Cochrane search methods, and did not use any language, document type, or publication status limitations. We also searched the reference lists of included studies and relevant systematic reviews, and consulted an expert in the field from the World Health Organization (WHO) HIV Department for potentially relevant studies. The latest search was 23 November 2020.

SELECTION CRITERIA

We included any primary study that compared the results of a VL test with a POC platform to that of a central laboratory-based reference test to detect high viral load in PLHIV on HIV/AIDS care or follow-up. We included all forms of POC tests for VL as defined by study authors, regardless of the healthcare facility in which the test was conducted. We excluded diagnostic case-control studies with healthy controls and studies that did not provide sufficient data to create the 2 × 2 tables to calculate sensitivity and specificity. We did not limit our study inclusion to age, gender, or geographical setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles, abstracts, and full texts of the search results to identify eligible articles. They also independently extracted data using a standardized data extraction form and conducted risk of bias assessment using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Using participants as the unit of analysis, we fitted simplified univariable models for sensitivity and specificity separately, employing a random-effects model to estimate the summary sensitivity and specificity at the current and commonly reported World Health Organization (WHO) threshold (≥ 1000 copies/mL). The bivariate models did not converge to give a model estimate.

MAIN RESULTS

We identified 18 studies (24 evaluations, 10,034 participants) defining high viral loads at main thresholds ≥ 1000 copies/mL (n = 20), ≥ 5000 copies/mL (n = 1), and ≥ 40 copies/mL (n = 3). All evaluations were done on samples from PLHIV retrieved from routine HIV/AIDS care centres or health facilities. For clinical applicability, we included 14 studies (20 evaluations, 8659 participants) assessing high viral load at the clinical threshold of ≥ 1000 copies/mL in the meta-analyses. Of these, sub-Saharan Africa, Europe, and Asia contributed 16, three, and one evaluation respectively. All included participants were on ART in only nine evaluations; in the other 11 evaluations the proportion of participants on ART was either partial or not clearly stated. Thirteen evaluations included adults only (n = 13), five mixed populations of adults and children, whilst in the remaining two the age of included populations was not clearly stated. The majority of evaluations included commercially available tests (n = 18). Ten evaluations were POC VL tests conducted near the patient in a peripheral or onsite laboratory, whilst the other 10 were evaluations of POC VL tests in a central or reference laboratory setting. The test types evaluated as POC VL tests included Xpert HIV-1 Viral Load test (n = 8), SAMBA HIV-1 Semi-Q Test (n = 9), Alere Q NAT prototype assay for HIV-1 (n = 2) and m-PIMA HIV-1/2 Viral Load test (n = 1). The majority of evaluations (n = 17) used plasma samples, whilst the rest (n = 3) utilized whole blood samples. Pooled sensitivity (95% confidence interval (CI)) of POC VL at a threshold of ≥ 1000 copies/mL was 96.6% (94.8 to 97.8) (20 evaluations, 2522 participants), and pooled specificity (95% CI) was 95.7% (90.8 to 98.0) (20 evaluations, 6137 participants). Median prevalence for high viral load (≥ 1000 copies/mL) (n = 20) was 33.4% (range 6.9% to 88.5%). Limitations The risk of bias was mostly assessed as unclear across the four domains due to incomplete reporting.

AUTHORS' CONCLUSIONS

We found POC VL to have high sensitivity and high specificity for the diagnosis of high HIV viral load in PLHIV attending healthcare facilities at a clinical threshold of ≥ 1000 copies/mL.

Gender, working status, and access to HIV care among people who are HIV positive in Eswatini

This study investigated the relationship between gender, working status, and access to HIV care and explored whether working status mediates the relationship between gender and access to HIV care. Nationally representative data from the 2016 Swaziland HIV Incidence Measurement Survey used. Sample comprised of 2,826 adults positive for HIV. Both 30-day and 1-year employment records were used to define working status. Access to HIV care was defined using data on both HIV viral load suppression and current antiretroviral therapy (ART) enrollment. People who worked in the past 12 months had a significantly lower likelihood of current ART enrollment (odds ratio [OR] 0.75; 95% confidence interval [CI]: 0.62-0.91) and viral load suppression (OR 0.78; 95% CI: 0.67-0.92). Working in the past 30 days was also significantly associated with current ART enrollment (OR 0.71; 95% CI: 0.59-0.85) and viral load suppression (OR 0.78; 95% CI: 0.66-0.93). The negative influence of working status on access to HIV care (current ART enrollment and viral load suppression) was stronger in men than in women. Working status partially explained the relationship between gender (male) and access to HIV care. Time constraints are a likely explanation for this.

HIV care cascade and associated factors among men who have sex with men, transgender women, and genderqueer individuals in Zimbabwe: findings from a biobehavioural survey using respondent-driven sampling

BACKGROUND

Globally, men who have sex with men (MSM), transgender women, and genderqueer individuals are at greater risk for HIV than the general population although little data are available from these groups in Zimbabwe, a country with a national adult HIV prevalence of 12·9%. We aimed to examine progress towards the UNAIDS 90-90-90 treatment targets and factors associated with meeting the targets among a sample of MSM, transgender women, and genderqueer individuals in Zimbabwe.

METHODS

In this cross-sectional survey in 2019, we used respondent-driven sampling to identify MSM, transgender women, and genderqueer individuals aged at least 18 years to participate in a biobehavioural survey in Harare and Bulawayo, Zimbabwe. Participants were eligible to participate if they were assigned male at birth; had engaged in anal or oral sex with a man in the past 12 months; resided in Harare or Bulawayo for at least 1 month; spoke English, Shona, or Ndebele; provided written informed consent; and were in possession of a valid recruitment coupon if applicable. Enrolled participants completed a questionnaire and underwent HIV testing, and off-site viral load testing was done on all HIV-positive samples. Unweighted bivariate analyses and multivariable logistic regression models were used to evaluate the association of sociodemographic, behavioural, and other factors with HIV-positive status awareness among MSM, transgender women, and genderqueer individuals, and with viral load suppression among MSM. Analyses were done firstly using self-reported information and then by classifying those with a viral load of less than 200 copies per mL as being aware of their status and on treatment (viral load recategorisation).

FINDINGS

Among MSM, 248 (21%; 95% CI 19-24) of 1176 tested positive for HIV. Of those who tested positive, based on self-report, 119 (48%; 95% CI 42-54) reported knowing their HIV status, of whom 112 (94%; 88-98) reported using antiretroviral therapy (ART), of whom 89 (79%; 71-87) had viral load suppression. Based on viral load recategorisation, 180 (73%; 67-78) of 248 MSM testing HIV positive reported knowing their HIV status, of whom 174 (97%; 93-99) reported using ART, of whom 151 (87%; 81-91) had viral load suppression. 92 (28%; 23-33) of 335 transgender women and genderqueer individuals tested positive for HIV. Based on self-reports from these individuals 34 (37%; 27-48) of 92 participants reported knowing their HIV status, of whom 31 (91%; 76-98) reported using ART, of whom 27 (87%; 70-96%) had viral load suppression. Based on viral load recategorisation of data from transgender women and genderqueer participants, 53 (58%; 47-58) of 92 reported awareness of their HIV status, of whom 50 (94%; 84-99) reported using ART, of whom 46 (92%; 81-98) had viral load suppression. HIV-positive MSM aged 18-24 years had lower odds of being aware of their status than those aged at least 35 years (adjusted odds ratio [aOR] 0·34; 95% CI 0·13-0·92), as did HIV-positive MSM aged 25-34 years (aOR 0·26; 0·12-0·56). HIV-positive MSM aged 18-24 years also had a lower odds of having viral load suppression than those aged 35 years and older (aOR 0·35; 0·16-0·78), as did those aged 25-34 years (aOR 0·36; 0·19-0·67). No factors were significantly associated with awareness among transgender women and genderqueer individuals in multivariable models.

INTERPRETATION

Our survey showed that HIV prevalence was high and the largest difference between our results and the 90-90-90 treatment targets was in HIV status awareness, indicating the need for improvements in engaging MSM (especially young MSM), transgender women, and genderqueer individuals in HIV testing services.

FUNDING

US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

High Rates of Uncontrolled Blood Pressure in Malawian Adults Living with HIV and Hypertension

Background

Hypertension is among the most commonly diagnosed non-communicable diseases in Africa, and studies have demonstrated a high prevalence of hypertension among individuals with HIV. Despite high prevalence, there has been limited attention on the clinical outcomes of hypertension treatment in this population.

Objective

We sought to characterize rates of and factors associated with blood pressure control over one year among individuals on antiretroviral therapy (ART) and antihypertensive medications.

Methods

We performed a prospective observational cohort study at an HIV clinic in Malawi. We defined uncontrolled hypertension as a systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg at two or more follow-up visits during the year, while controlled hypertension was defined as <140 mm Hg systolic and <90 mm Hg diastolic at all visits, or at all but one visit. We calculated an antihypertensive non-adherence score based on self-report of missed doses at each visit (higher score = worse adherence) and used rank sum and chi-square tests to compare sociodemographic and clinical factors (including adherence) associated with blood pressure control over the year.

Results

At study entry, 158 participants (23.5%) were on antihypertensive medication; participants had a median age of 51.0 years, were 66.5% female, and had a median of 6.9 years on ART. 19.0% (n = 30) achieved blood pressure control over the year of follow-up. Self-reported non-adherence to hypertension medications was the only factor significantly associated with uncontrolled blood pressure. The average non-adherence score for those with controlled blood pressure was 0.22, and for those with uncontrolled blood pressure was 0.61 (p = 0.009).

Conclusions

Adults living with HIV and hypertension in our cohort had low rates of blood pressure control over one year associated with self-reported non-adherence to antihypertensive medications. Given the high prevalence and incidence of hypertension, interventions to improve blood pressure control are needed to prevent associated long-term cardio- and cerebrovascular morbidity and mortality.

Group counselling for adherence support among young people failing first-line antiretroviral therapy in Zimbabwe

Background

Sub-optimal adherence to antiretroviral therapy (ART) is reportedly worse amongst young people living with HIV (YPLHIV). Group adherence counselling can be useful to improve adherence.

Objectives

We evaluated an enhanced adherence counselling group intervention (EACGI) amongst YPLHIV failing a non-nucleoside reverse transcriptase (NNRTI)-based first-line ART regimen.

Method

This was a retrospective cohort study using routinely collected data of YPLHIV failing NNRTI-based first-line ART. Patients with confirmed virological failure were referred for EACGI, a 12-week curriculum of weekly, 1.5-h sessions accommodating 8–15 people per group. It aimed to facilitate readiness to switch to second-line ART and improve adherence through a mental health intervention. Viral loads of HIV were measured pre-EACGI; at baseline; 3, 6 and 12 months post switch.

Results

Fifty-seven patients aged 13–25 years were invited to EACGI and followed for up to 48 weeks. Thirty-three (58%) patients attended at least four sessions, whilst 24 (42%) attended none. Amongst those who attended none, two (8%) were transferred out, three (13%) were lost to follow-up and two (8%) had died by week 48 of follow-up, whilst all who attended were still in care. By week 48, amongst patients still in care, 29%, 44% and 67% of those who attended no sessions, 4–9 and 10–12 sessions, respectively, had viral loads of < 50 copies/mL.

Conclusion

An EACGI is a promising intervention for YPLHIV failing ART prior to treatment switch, leading to improved adherence. This study’s findings support the need for further enquiry into rigorous, evidence-based multilevel adherence interventions that are acceptable and effective for YPLHIV.

Naomi: a new modelling tool for estimating HIV epidemic indicators at the district level in sub-Saharan Africa

INTRODUCTION

HIV planning requires granular estimates for the number of people living with HIV (PLHIV), antiretroviral treatment (ART) coverage and unmet need, and new HIV infections by district, or equivalent subnational administrative level. We developed a Bayesian small-area estimation model, called Naomi, to estimate these quantities stratified by subnational administrative units, sex, and five-year age groups.

METHODS

Small-area regressions for HIV prevalence, ART coverage and HIV incidence were jointly calibrated using subnational household survey data on all three indicators, routine antenatal service delivery data on HIV prevalence and ART coverage among pregnant women, and service delivery data on the number of PLHIV receiving ART. Incidence was modelled by district-level HIV prevalence and ART coverage. Model outputs of counts and rates for each indicator were aggregated to multiple geographic and demographic stratifications of interest. The model was estimated in an empirical Bayes framework, furnishing probabilistic uncertainty ranges for all output indicators. Example results were presented using data from Malawi during 2016-2018.

RESULTS

Adult HIV prevalence in September 2018 ranged from 3.2% to 17.1% across Malawi's districts and was higher in southern districts and in metropolitan areas. ART coverage was more homogenous, ranging from 75% to 82%. The largest number of PLHIV was among ages 35 to 39 for both women and men, while the most untreated PLHIV were among ages 25 to 29 for women and 30 to 34 for men. Relative uncertainty was larger for the untreated PLHIV than the number on ART or total PLHIV. Among clients receiving ART at facilities in Lilongwe city, an estimated 71% (95% CI, 61% to 79%) resided in Lilongwe city, 20% (14% to 27%) in Lilongwe district outside the metropolis, and 9% (6% to 12%) in neighbouring Dowa district. Thirty-eight percent (26% to 50%) of Lilongwe rural residents and 39% (27% to 50%) of Dowa residents received treatment at facilities in Lilongwe city.

CONCLUSIONS

The Naomi model synthesizes multiple subnational data sources to furnish estimates of key indicators for HIV programme planning, resource allocation, and target setting. Further model development to meet evolving HIV policy priorities and programme need should be accompanied by continued strengthening and understanding of routine health system data.

Symptoms of common mental disorders and adherence to antiretroviral therapy among adults living with HIV in rural Zimbabwe: a cross-sectional study

OBJECTIVES

To examine the proportion of people living with HIV who screen positive for common mental disorders (CMD) and the associations between CMD and self-reported adherence to antiretroviral therapy (ART).

SETTING

Sixteen government-funded health facilities in the rural Bikita district of Zimbabwe.

DESIGN

Cross-sectional study.

PARTICIPANTS

HIV-positive non-pregnant adults, aged 18 years or older, who lived in Bikita district and had received ART for at least 6 months.

OUTCOME MEASURES

The primary outcome was the proportion of participants screening positive for CMD defined as a Shona Symptoms Questionnaire score of 9 or greater. Secondary outcomes were the proportion of participants reporting suicidal ideation, perceptual symptoms and suboptimal ART adherence and adjusted prevalence ratios (aPR) for factors associated with CMD, suicidal ideation, perceptual symptoms and suboptimal ART adherence.

RESULTS

Out of 3480 adults, 18.8% (95% CI 14.8% to 23.7%) screened positive for CMD, 2.7% (95% CI 1.5% to 4.7%) reported suicidal ideations, and 1.5% (95% CI 0.9% to 2.6%) reported perceptual symptoms. Positive CMD screens were more common in women (aPR 1.67, 95% CI 1.19 to 2.35) than in men and were more common in adults aged 40-49 years (aPR 1.47, 95% CI 1.16 to 1.85) or aged 50-59 years (aPR 1.51, 95% CI 1.05 to 2.17) than in those 60 years or older. Positive CMD screen was associated with suboptimal adherence (aPR 1.53; 95% CI 1.37 to 1.70).

CONCLUSIONS

A substantial proportion of people living with HIV in rural Zimbabwe are affected by CMD. There is a need to integrate mental health services and HIV programmes in rural Zimbabwe.

TRIAL REGISTRATION NUMBER

NCT03704805.

Serious fungal diseases in Democratic Republic of Congo - Incidence and prevalence estimates

A literature review was conducted to assess the burden of serious fungal infections in the Democratic Republic of the Congo (DRC) (population 95,326,000). English and French publications were listed and analysed using PubMed/Medline, Google Scholar and the African Journals database. Publication dates spanning 1943-2020 were included in the scope of the review. From the analysis of published articles, we estimate a total of about 5,177,000 people (5.4%) suffer from serious fungal infections in the DRC annually. The incidence of cryptococcal meningitis, Pneumocystis jirovecii pneumonia in adults and invasive aspergillosis in AIDS patients was estimated at 6168, 2800 and 380 cases per year. Oral and oesophageal candidiasis represent 50,470 and 28,800 HIV-infected patients respectively. Chronic pulmonary aspergillosis post-tuberculosis incidence and prevalence was estimated to be 54,700. Fungal asthma (allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitization) probably has a prevalence of 88,800 and 117,200. The estimated prevalence of recurrent vulvovaginal candidiasis and tinea capitis is 1,202,640 and 3,551,900 respectively.Further work is required to provide additional studies on opportunistic infections for improving diagnosis and the implementation of a national surveillance programme of fungal disease in the DRC.

Predictive factors of viral load high-risk events for virological failure in HIV/AIDS patients receiving long-term antiviral therapy

Background

In the era of anti-retroviral therapy (ART), the plasma HIV viral load (VL) is an important primary indicator for monitoring the HIV treatment response. To optimize the clinical management of HIV/AIDS patients, we investigated VL high-risk events related to virological failure (VF) and further explored the preventive factors of VL high-risk events.

Methods

The data were derived from China’s HIV/AIDS Comprehensive Response Information Management System. HIV infected patients who initiated or received ART in Guangxi between 2003 and 2019 were included. The contributions of VL after 6 months of ART to VF and AIDS-related death were analysed by Kaplan-Meier curves, log-rank tests and Cox regression analyses. Both descriptive analyses and bivariate logistic regression were employed to further explore the preventive factors related to VL high-risk events of VF.

Results

The cumulative rates of VF in the high low-level viremia group (high LLV) (χ² = 18.45; P <  0.001) and non-suppressed group (χ² = 82.99; P <  0.001) were significantly higher than those in the viral suppression (VS) group. Therefore, the VL high-risk events of VF was defined as highest VL > 200 copies/ml after 6 months of ART. Compared with the VS group, the adjusted hazard risk was 7.221 (95% CI: 2.668; 19.547) in the high LLV group and 8.351 (95% CI: 4.253; 16.398) in the non-suppressed group. Compared with single patients, married or cohabiting (AOR = 0.591; 95% CI: 0.408, 0.856) and divorced or separated (AOR = 0.425, 95% CI: 0.207, 0.873) patients were negatively associated with VL high-risk events. So were patients acquired HIV homosexually (AOR = 0.572; 95% CI: 0.335, 0.978). However, patients who had ART modification were 1.728 times (95% CI: 1.093, 2.732) more likely to have VL high-risk events, and patients who used cotrimoxazole during ART were 1.843 times (95% CI: 1.271, 2.672) more likely to have VL high-risk events.

Conclusions

A VL greater than 200 copies/ml is a VL high-risk event for VF. Intervention measurements should be adopted to optimize the surveillance of ART in patients who are single or widowed, who have ART modification, and who use cotrimoxazole during ART.

Feasibility and Acceptability of Smartphone-Based Cervical Cancer Screening Among HIV-Positive Women in Western Kenya

PURPOSE

Adjunct cervical cancer screening methods are under evaluation to improve the diagnostic accuracy of human papillomavirus (HPV)-based screening in low- and middle-income countries. We evaluated the feasibility and acceptability of smartphone-based cervicography among HPV-positive women living with HIV (WLWH) in Western Kenya.

METHODS

HPV-positive WLWH of 25-49 years of age enrolled in a clinical trial (ClinicalTrials.gov identifier: NCT04191967) had digital images of the cervix taken using a smartphone by a nonphysician provider following visual inspection with acetic acid. All participants had colposcopy-directed biopsy before treatment. Cervical images were evaluated by three off-site colposcopists for quality, diagnostic utility, and assigned a presumed diagnosis. We determined the proportion of images rates as low, medium, or high quality, interobserver agreement using Cohen's Kappa statistic, and the off-site colposcopist's sensitivity and specificity for diagnosis of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) compared with histopathology. Acceptability was evaluated using a questionnaire.

RESULTS

One hundred sixty-four HPV-positive WLWH underwent cervicography during the study period. Mean age was 37.3 years. Images from the first 94 participants were evaluated by off-site colposcopists, with a majority (70.9%) rated as high quality. Off-site colposcopists had a sensitivity ranging from 21.4% (95% CI, 0.06 to 0.43) to 35.7% (95% CI, 0.26 to 0.46) and a specificity between 85.5% (95% CI, 0.81 to 0.90) to 94.9% (95% CI, 0.92 to 0.98) for diagnosis of CIN2+ based compared with histopathology. The majority of women, 99.4%, were comfortable having an image of their cervix taken as part of screening.

CONCLUSION

Cervicography by a nonphysician provider as an adjunct to HPV-based screening among WLWH in a low- and middle-income country setting is feasible and acceptable. However, low sensitivity for diagnosis of CIN2+ by off-site expert colposcopists highlights the limitations of cervicography.

The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals

Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.