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Alvis-Estrada JP, Azmitia-Rugg A, Sobalvarro-Stolz X, Romo-Dueñas D, Díaz F, Martínez A, Morales RE, Chang LR, Vega N, Araúz AB, Ávila-Montes G. Evaluation of rapid antiretroviral initiation strategy in a cohort of newly diagnosed people living with HIV in Panama, 2018-2019. AIDS Care 2024:1-8. [PMID: 38991109 DOI: 10.1080/09540121.2024.2373397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 06/21/2024] [Indexed: 07/13/2024]
Abstract
Antiretroviral therapy (ART) has been adopted as a form of HIV treatment and prevention. This study assesses rapid ART initiation using clinical outcomes such as viral load (VL) and CD4+ T lymphocytes count. Over the course of one year, the progress of newly diagnosed people living with HIV who started ART early in a hospital in Panama City was followed. The evaluation of early initiation of ART in achieving viral suppression (VL <200 copies/ml) was analyzed using descriptive statistics. Additionally, the cost difference between early (first 7 days) and late initiation of ART was evaluated from the perspective of the service provider. In total, 209 people were followed up during the study; 85% were male, 70% started ART on same day from hospital arrival, 80% had suppressed viral load at 6 months, and the median count of CD4 increased from 285 (IQR: 166-429) to 509 (IQR: 373-696) over 12 months. Starting ART early led to a 42% increase for the provider in terms of staffing costs; however, the clients had the opportunity to decrease absenteeism in daily activities. The results reveal that early initiation of ART generates clinical and economic benefits for the person in treatment.
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Affiliation(s)
- Juan Pablo Alvis-Estrada
- Juan Pablo Alvis-Estrada, Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Andrés Azmitia-Rugg
- Andrés Azmitia-Rugg, Center for Disease Control and Prevention (CDC) Central America Region, Guatemala City, Guatemala
| | - Ximena Sobalvarro-Stolz
- Ximena Soblavarro-Stolz, Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Daniela Romo-Dueñas
- Daniela Romo-Dueñas, Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Félix Díaz
- Félix Diaz, Hospital Santo Tomás, Panama City, Panama
| | - Alexander Martínez
- Alexander Martinez, Instituto Conmemorativo Gorgas de Estudios en Salud, Panama City, Panama
| | - Rosa Elena Morales
- Rosa Elena Morales, Center for Disease Control and Prevention (CDC) Central America Region, Guatemala City, Guatemala
| | - Lissette Raquel Chang
- Lissette Raquel Chang, Center for Disease Control and Prevention (CDC) Central America Region, Panama City, Panama
| | - Natalia Vega
- Natalia Vega, Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Ana Belén Araúz
- Ana Belén Araúz, Instituto Conmemorativo Gorgas de Estudios en Salud, Panama City, Panama
| | - Gustavo Ávila-Montes
- Gustavo Ávila-Montes, Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
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2
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Dupnik K, Rivera VR, Dorvil N, Duffus Y, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumont E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification Among Patients With Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-income Countries. Open Forum Infect Dis 2024; 11:ofae356. [PMID: 39022393 PMCID: PMC11252845 DOI: 10.1093/ofid/ofae356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024] Open
Abstract
Background The World Health Organization recommends initiating same-day antiretroviral therapy (ART) while tuberculosis (TB) testing is under way for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve TB risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with TB symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP as a continuous variable using generalized linear models. Results Eighty-seven (17.5%) participants were diagnosed with baseline TB. The median CRP was 33.0 mg/L (interquartile range: 5.1, 85.5) in those with TB, and 2.6 mg/L (interquartile range: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4% and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3- to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Affiliation(s)
- Kathryn Dupnik
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Nancy Dorvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Yanique Duffus
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Yipeng Gao
- The Analysis Group, Boston, Massachusetts, USA
| | - Jingyi Liu
- The Analysis Group, Boston, Massachusetts, USA
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumont
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Cynthia Riviere
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Samuel Pierre
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rouzier
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Kathleen F Walsh
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Anthony L Byrne
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean William Pape
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Serena P Koenig
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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3
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Richterman A, Dorvil N, Rivera V, Bang H, Severe P, Lavoile K, Pierre S, Apollon A, Dumond E, Pierre Louis Forestal G, Rouzier V, Joseph P, Cremieux PY, Pape JW, Koenig SP. Predictors of Clinical Outcomes among People with HIV and Tuberculosis Symptoms after Rapid Treatment Initiation in Haiti. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.19.24309189. [PMID: 38946994 PMCID: PMC11213038 DOI: 10.1101/2024.06.19.24309189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Introduction Few studies have evaluated baseline predictors of clinical outcomes among people with HIV starting antiretroviral therapy (ART) in the modern era of rapid ART initiation. Methods We conducted a secondary analysis of a randomized controlled trial of two rapid treatment initiation strategies for people with treatment-naïve HIV and tuberculosis symptoms at an urban clinic in Haiti. We used logistic regression models to assess associations between baseline characteristics and (1) retention in care at 48 weeks, (2) HIV viral load suppression at 48 weeks (among participants who underwent viral load testing), and (3) all-cause mortality. Results 500 participants were enrolled in the study 11/2017-1/2020. Eighty-eight (18%) participants were diagnosed with tuberculosis, and ART was started in 494 (99%). After adjustment, less than secondary education (adjusted odds ratio [AOR] 0.21, 95% CI 0.10-0.46), dolutegravir initiation (AOR 2.57, 95% CI 1.22-5.43), age (AOR 1.42 per 10-year increase, 95% CI 1.01-1.99), and tuberculosis diagnosis (AOR 3.92, 95% CI 1.36-11.28) were significantly associated with retention. Age (AOR 1.36, 95% CI 1.05-1.75), dolutegravir initiation (AOR 1.75, 95% CI 1.07-2.85), and tuberculosis diagnosis (AOR 0.50, 95% CI 0.28-0.89) were associated with viral suppression. Higher CD4 cell count at enrollment (unadjusted odds ratio [OR] 0.69, 95% CI 0.55-0.87) and anemia (OR 4.86, 95% CI 1.71-13.81) were associated with mortality. Conclusions We identified sociodemographic, treatment-related, clinical, and laboratory-based predictors of clinical outcomes. These characteristics may serve as markers of sub-populations that could benefit from additional interventions to support treatment success after rapid treatment initiation.
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Affiliation(s)
- Aaron Richterman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Nancy Dorvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Heejung Bang
- University of California, Davis School of Medicine, Davis, California, United States of America
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerylyne Lavoile
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Samuel Pierre
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumond
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Vanessa Rouzier
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Weill Cornell Medical College, New York, New York, United States of America
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean W Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Weill Cornell Medical College, New York, New York, United States of America
| | - Serena P Koenig
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Xia H, Li L, Wu Y, Gao L, Zhang D, Ma P. Rapid Initiation of Antiretroviral Therapy Under the Treat-All Policy Reduces Loss to Follow-Up and Virological Failure in Routine Human Immunodeficiency Virus Care Settings in China: A Retrospective Cohort Study (2016-2022). AIDS Patient Care STDS 2024; 38:168-176. [PMID: 38656215 DOI: 10.1089/apc.2024.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Following the World Health Organization's guidelines for rapid antiretroviral therapy (ART) initiation [≤7 days after human immunodeficiency virus (HIV) diagnosis], China implemented Treat-All in 2016 and has made significant efforts to provide timely ART since 2017. This study included newly diagnosed HIV adults from Tianjin, China, between 2016 and 2022. Our primary outcome was loss to follow-up (LTFU) at 12 months after enrollment. The secondary outcome was 12-month virological failure. The association between rapid ART and LTFU, as well as virological failure, was assessed via Cox regression and logistic regression. A total of 896 (19.1%) of 4688 participants received ART ≤7 days postdiagnosis. The rate of rapid ART has increased from 7.5% in 2016 to 33.3% by 2022. The rapid ART group had an LTFU rate of 3.3%, as opposed to 5.0% in the delayed group. The rapid ART group had a much reduced virological failure rate (0.6% vs. 1.8%). Rapid ART individuals had a reduced likelihood of LTFU [adjusted hazard ratio: 0.65, 95% confidence intervals (CI): 0.44-0.96] and virological failure (adjusted odds ratio: 0.35, 95% CI: 0.12-0.80). The real-world data indicated that rapid ART is practicable and beneficial for Chinese people with HIV, providing evidence for its widespread implementation and scaling up.
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Affiliation(s)
- Huan Xia
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, China
| | - Lei Li
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, China
| | - Yue Wu
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, China
| | - Liying Gao
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, China
| | - Defa Zhang
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, China
| | - Ping Ma
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, China
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Nabukalu D, Yiannoutsos CT, Semeere A, Musick BS, Murungi T, Namulindwa JV, Waswa F, Nakigozi G, Sewankambo NK, Reynolds SJ, Lutalo T, Makumbi F, Kigozi G, Nalugoda F, Wools-Kaloustian K. Mortality Among HIV-Infected Adults on Antiretroviral Therapy in Southern Uganda. J Acquir Immune Defic Syndr 2024; 95:268-274. [PMID: 38408217 PMCID: PMC10898547 DOI: 10.1097/qai.0000000000003330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/24/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Monitoring and evaluation of clinical programs requires assessing patient outcomes. Numerous challenges complicate these efforts, the most insidious of which is loss to follow-up (LTFU). LTFU is a composite outcome, including individuals out of care, undocumented transfers, and unreported deaths. Incorporation of vital status information from routine patient outreach may improve the mortality estimates for those LTFU. SETTINGS We analyzed routinely collected clinical and patient tracing data for individuals (15 years or older) initiating antiretroviral treatment between January 2014 and December 2018 at 2 public HIV care clinics in greater Rakai, Uganda. METHODS We derived unadjusted mortality estimates using Kaplan-Meier methods. Estimates, adjusted for unreported deaths, applied weighting through the Frangakis and Rubin method to represent outcomes among LTFU patients who were successfully traced and for whom vital status was ascertained. Confidence intervals were determined through bootstrap methods. RESULTS Of 1969 patients with median age at antiretroviral treatment initiation of 31 years (interquartile range: 25-38), 1126 (57.2%) were female patients and 808 (41%) were lost. Of the lost patients, 640 patient files (79.2%) were found and reviewed, of which 204 (31.8%) had a tracing attempt. Within the electronic health records of the program, 28 deaths were identified with an estimated unadjusted mortality 1 year after antiretroviral treatment initiation of 2.5% (95% CI: 1.8% to 3.3%). Using chart review and patient tracing data, an additional 24 deaths (total 52) were discovered with an adjusted 1-year mortality of 3.8% (95% CI: 2.6% to 5.0%). CONCLUSIONS Data from routine outreach efforts by HIV care and treatment programs can be used to support plausible adjustments to estimates of client mortality. Mortality estimates without active ascertainment of vital status of LTFU patients may significantly underestimate program mortality.
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Affiliation(s)
| | | | - Aggrey Semeere
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | | | | | - Nelson K. Sewankambo
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Steven J. Reynolds
- Division of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
- Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Tom Lutalo
- Rakai Health Sciences Program, Rakai, Uganda
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6
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Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Yaylali E, Erdogan ZM, Calisir F, Pullukcu H, Yildirim F, Inan A, Aydin OA, Tekin S, Sonmezer MC, Sahin T, Ozcagli TG, Ozelgun B. Rapid initiation of antiretroviral therapy in Turkey: a modeling study. Front Public Health 2024; 12:1224449. [PMID: 38344235 PMCID: PMC10853345 DOI: 10.3389/fpubh.2024.1224449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 01/02/2024] [Indexed: 02/15/2024] Open
Abstract
Background To effectively control the HIV epidemic and meet global targets, policymakers recommend the rapid initiation of antiretroviral therapy (ART). Our study aims to investigate the effect of rapid ART programs on individuals diagnosed with HIV, considering varying coverage and initiation days after diagnosis, and compare it to standard-of-care ART treatment in Turkey. Methods We used a dynamic compartmental model to simulate the dynamics of HIV infection in Turkey. Rapid treatment, defined as initiation of ART within 7 days of diagnosis, was contrasted with standard-of-care treatment, which starts within 30 days of diagnosis. This study considered three coverage levels (10%, 50%, and 90%) and two rapid periods (7 and 14 days after diagnosis), comparing them to standard-of-care treatment in evaluating the number of HIV infections between 2020 and 2030. Results Annual HIV incidence and prevalence for a 10-year period were obtained from model projections. In the absence of a rapid ART program, the model projected approximately 444,000 new HIV cases while the number of cases were reduced to 345,000 (22% reduction) with 90% of diagnosed cases included in the rapid ART program. Similarly, 10% and 50% rapid ART coverage has resulted in 3% and 13% reduction in HIV prevalence over a 10-year period. Conclusion Rapid ART demonstrates the potential to mitigate the increasing HIV incidence in Turkey by reducing the number of infections. The benefit of the rapid ART program could be substantial when the coverage of the program reaches above a certain percentage of diagnosed population.
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Affiliation(s)
- Emine Yaylali
- Department of Industrial Engineering, Istanbul Technical University, Istanbul, Türkiye
| | | | - Fethi Calisir
- Department of Industrial Engineering, Istanbul Technical University, Istanbul, Türkiye
| | | | - Figen Yildirim
- Infectious Diseases and Clinical Microbiology, Akdeniz Yasam Hospital, Antalya, Türkiye
| | - Asuman Inan
- Infectious Diseases and Clinical Microbiology, Haydarpasa-Numune Training and Research Hospital, Istanbul, Türkiye
| | - Ozlem Altuntas Aydin
- Infectious Diseases and Clinical Microbiology, University of Health Sciences, Istanbul, Türkiye
| | - Suda Tekin
- Infectious Diseases and Clinical Microbiology, Koc University, Istanbul, Türkiye
| | - Meliha Cagla Sonmezer
- Infectious Diseases and Clinical Microbiology, Hacettepe University, Ankara, Türkiye
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8
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Camici M, Gagliardini R, Lanini S, Del Duca G, Mondi A, Ottou S, Plazzi MM, De Zottis F, Pinnetti C, Vergori A, Grilli E, Mastrorosa I, Mazzotta V, Paulicelli J, Bellagamba R, Cimini E, Tartaglia E, Notari S, Tempestilli M, Cicalini S, Amendola A, Abbate I, Forbici F, Fabeni L, Girardi E, Vaia F, Maggi F, Antinori A. Rapid ART initiation with bictegravir/emtricitabine/tenofovir alafenamide in individuals presenting with advanced HIV disease (Rainbow study). Int J Antimicrob Agents 2024; 63:107049. [PMID: 38056572 DOI: 10.1016/j.ijantimicag.2023.107049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/10/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND A rapid ART initiation approach can be beneficial in people with advanced HIV disease, in consideration of their high morbidity and mortality. The aim of our study was to evaluate the feasibility, efficacy and safety of rapid ART start with BIC/FTC/TAF in this setting. METHODS Pilot, single-centre, single-arm, prospective, phase IV clinical trial conducted in a tertiary Italian hospital. Thirty ART-naïve people presenting with advanced HIV-1 diagnosis (defined as the presence of an AIDS-defining event and/or CD4 cell count <200 µL), were enrolled. Main exclusion criteria were active tuberculosis, cryptococcosis and pregnant/breastfeeding women. BIC/FTC/TAF was started within 7 days from HIV diagnosis. The primary endpoint was clinical or virologic failure (VF). Immunological parameters, safety, feasibility, neurocognitive performances and patient-reported outcomes were assessed as well. RESULTS Over the study period, 40 (34%) of 116 patients diagnosed with HIV infection at INMI Spallanzani had advanced disease, of whom 30 (26%) were enrolled. The proportion of participants with HIV-RNA <50 cp/mL was 9/30 (30%) at week (w) 4, 19/30 (63%) at w12, 24/30 (80%) at w24, 23/30 (77%) at w36 and 27/30 (90%) at w48. Two unconfirmed VF occurred. No ART discontinuation due to toxicity or VF was observed. No ART modification was performed based on the review of genotype and no mutations for the study drugs were detected. Mean CD4 cells count changed by 133 cells/μL at BL to 309 cells/μL at w 48 and 83% of participants had a CD4 > 200 cells/µL at w 48. Two participants developed IRIS and one was diagnosed with disseminated TB and needed an ART switch. INTERPRETATIONS Our results support the feasibility, efficacy and safety of BIC/FTC/TAF as a rapid ART strategy in patients with advanced HIV disease.
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Affiliation(s)
- Marta Camici
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy.
| | - Roberta Gagliardini
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Simone Lanini
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Giulia Del Duca
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Annalisa Mondi
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Sandrine Ottou
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Maria M Plazzi
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Federico De Zottis
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Carmela Pinnetti
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Alessandra Vergori
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Elisabetta Grilli
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Ilaria Mastrorosa
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Valentina Mazzotta
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Jessica Paulicelli
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Rita Bellagamba
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Eleonora Cimini
- Laboratory of Cellular Immunology and Pharmacology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Eleonora Tartaglia
- Laboratory of Cellular Immunology and Pharmacology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Stefania Notari
- Laboratory of Cellular Immunology and Pharmacology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Massimo Tempestilli
- Laboratory of Cellular Immunology and Pharmacology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Stefania Cicalini
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Alessandra Amendola
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Isabella Abbate
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Federica Forbici
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Lavinia Fabeni
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Enrico Girardi
- Scientific Direction, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Francesco Vaia
- General Direction, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Fabrizio Maggi
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Andrea Antinori
- Clinical and Research Infectious Diseases Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
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9
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Dupnik K, Rivera VR, Dorvil N, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumond E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification among Patients with Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-Income Countries. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.19.23300232. [PMID: 38196598 PMCID: PMC10775334 DOI: 10.1101/2023.12.19.23300232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Article Summary We assessed the association between C-reactive protein (CRP) and Mycobacterium tuberculosis (TB) diagnosis in symptomatic patients at HIV diagnosis. We found that CRP concentrations can improve tuberculosis risk stratification, facilitating decision making about whether (specific) tuberculosis testing is indicated before antiretroviral therapy initiation. Background The World Health Organization recommends initiating same-day ART while tuberculosis testing is underway for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve tuberculosis risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with tuberculosis symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP (≥3 mg/dL) using generalized linear models. Results Eighty-seven (17.5%) patients were diagnosed with baseline TB. The median CRP was 33.0 mg/L (IQR: 5.1, 85.5) in those with TB, and 2.6 mg/L (IQR: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4%, and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART, and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3-fold to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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10
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Laur C, Ladak Z, Hall A, Solbak NM, Nathan N, Buzuayne S, Curran JA, Shelton RC, Ivers N. Sustainability, spread, and scale in trials using audit and feedback: a theory-informed, secondary analysis of a systematic review. Implement Sci 2023; 18:54. [PMID: 37885018 PMCID: PMC10604689 DOI: 10.1186/s13012-023-01312-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/05/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Audit and feedback (A&F) is a widely used implementation strategy to influence health professionals' behavior that is often tested in implementation trials. This study examines how A&F trials describe sustainability, spread, and scale. METHODS This is a theory-informed, descriptive, secondary analysis of an update of the Cochrane systematic review of A&F trials, including all trials published since 2011. Keyword searches related to sustainability, spread, and scale were conducted. Trials with at least one keyword, and those identified from a forward citation search, were extracted to examine how they described sustainability, spread, and scale. Results were qualitatively analyzed using the Integrated Sustainability Framework (ISF) and the Framework for Going to Full Scale (FGFS). RESULTS From the larger review, n = 161 studies met eligibility criteria. Seventy-eight percent (n = 126) of trials included at least one keyword on sustainability, and 49% (n = 62) of those studies (39% overall) frequently mentioned sustainability based on inclusion of relevant text in multiple sections of the paper. For spread/scale, 62% (n = 100) of trials included at least one relevant keyword and 51% (n = 51) of those studies (31% overall) frequently mentioned spread/scale. A total of n = 38 studies from the forward citation search were included in the qualitative analysis. Although many studies mentioned the need to consider sustainability, there was limited detail on how this was planned, implemented, or assessed. The most frequent sustainability period duration was 12 months. Qualitative results mapped to the ISF, but not all determinants were represented. Strong alignment was found with the FGFS for phases of scale-up and support systems (infrastructure), but not for adoption mechanisms. New spread/scale themes included (1) aligning affordability and scalability; (2) balancing fidelity and scalability; and (3) balancing effect size and scalability. CONCLUSION A&F trials should plan for sustainability, spread, and scale so that if the trial is effective, the benefits can continue. A deeper empirical understanding of the factors impacting A&F sustainability is needed. Scalability planning should go beyond cost and infrastructure to consider other adoption mechanisms, such as leadership, policy, and communication, that may support further scalability. TRIAL REGISTRATION Registered with Prospero in May 2022. CRD42022332606.
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Affiliation(s)
- Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - Zeenat Ladak
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
- Ontario Institute for Studies in Education, University of Toronto, 252 Bloor Street West, Toronto, ON, M5S 1V6, Canada
| | - Alix Hall
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- National Centre of Implementation Science, The University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Nathan M Solbak
- Physician Learning Program, Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
- Health Quality Programs, Queen's University, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada
| | - Nicole Nathan
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- National Centre of Implementation Science, The University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Shewit Buzuayne
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Noah Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, M5G 1V7, Canada
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11
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Tao Y, Xiao X, Zhang C, Xie Y, Wang H. Prevalence of delayed antiretroviral therapy initiation among people living with HIV: A systematic review and meta-analysis. PLoS One 2023; 18:e0286476. [PMID: 37874794 PMCID: PMC10597480 DOI: 10.1371/journal.pone.0286476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 05/16/2023] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE HIV continues to be a global challenge. Key recommendations for HIV prevention and treatment are presented on rapid antiretroviral therapy (ART) initiation. However, several studies showed a high prevalence of delayed ART initiation. The aim of this systematic review and meta-analysis was to assess the prevalence of delayed ART initiation among HIV-infected patients globally. METHODS This review summarised eligible studies conducted between January 2015 and August 2022 on the prevalence of delayed ART initiation in HIV-infected adults (age ≥ 15). Relevant studies were systematic searched through PubMed/Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and Chongqing VIP databases. Random-effects models were used to calculate pooled prevalence estimates. The heterogeneity was evaluated using Cochran's Q test and I2 statistics. Moreover, potential sources of heterogeneity were explored using univariate subgroup analysis. RESULTS Data on the prevalence of delayed ART initiation was pooled across 29 studies involving 34,937 participants from 15 countries. The overall pooled prevalence of delayed ART initiation was 36.1% [95% confidence interval (CI), 29.7-42.5%]. In subgroup analysis, the estimated pooled prevalence decreased with age. By sex, the prevalence was higher among male patients (39.3%, 95% CI: 32.2-46.4%) than female (36.5%, 95% CI: 26.9-50.7%). Patients with high CD4 cell count were more likely to delay ART initiation than those with low CD4 cell count (>500cells/mm3: 40.3%; 201-500cells/mm3: 33.4%; and ≤200cells/mm3: 25.3%). CONCLUSIONS Our systematic review and meta-analysis identified a high prevalence of delayed ART initiation. The prolonged time interval between diagnosis and treatment is a prevalent and unaddressed problem that should spur initiatives from countries globally. Further research is urgently needed to identify effective strategies for promoting the early ART initiation.
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Affiliation(s)
- Yan Tao
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Xueling Xiao
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Ci Zhang
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Ying Xie
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Honghong Wang
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
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12
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Labhardt ND, Brown JA, Sass N, Ford N, Rosen S. Treatment Outcomes After Offering Same-Day Initiation of Human Immunodeficiency Virus Treatment-How to Interpret Discrepancies Between Different Studies. Clin Infect Dis 2023; 77:1176-1184. [PMID: 37229594 PMCID: PMC10573746 DOI: 10.1093/cid/ciad317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 05/27/2023] Open
Abstract
The World Health Organization recommends same-day initiation of antiretroviral therapy (ART) for all persons diagnosed with HIV and ready to start treatment. Evidence, mainly from randomized trials, indicates offering same-day ART increases engagement in care and viral suppression during the first year. In contrast, most observational studies using routine data find same-day ART to be associated with lower engagement in care. We argue that this discrepancy is mainly driven by different time points of enrollment, leading to different denominators. While randomized trials enroll individuals when tested positive, most observational studies start at the time point when ART is initiated. Thus, most observational studies omit those who are lost between diagnosis and treatment, thereby introducing a selection bias in the group with delayed ART. This viewpoint article summarizes the available evidence and argues that the benefits of same-day ART outweigh a potential higher risk of attrition from care after ART initiation.
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Affiliation(s)
- Niklaus Daniel Labhardt
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Jennifer Anne Brown
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nikita Sass
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nathan Ford
- Department of HIV, Hepatitis, and Sexually Transmitted Infections, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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13
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Mgbako O, Loughran C, Mathu R, Castor D, McLean J, Sobieszczyk ME, Olender S, Gordon P, Lopez-Rios J, Remien RH. Rapid or Immediate ART, HIV Stigma, Medical Mistrust, and Retention in Care: An Exploratory Mixed Methods Pilot Study. AIDS Behav 2023; 27:3430-3446. [PMID: 37071333 PMCID: PMC10111080 DOI: 10.1007/s10461-023-04058-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 04/19/2023]
Abstract
Rapid or immediate antiretroviral therapy (iART) after HIV diagnosis improves linkage to care and time to viral suppression. However, iART may affect or be affected by HIV-related stigma and medical mistrust. In this mixed-methods pilot study, we examined the bi-directional role of HIV stigma, medical mistrust, and visit adherence (VA) in the context of iART in a diverse, newly diagnosed patient population. Participants were recruited from an HIV clinic in New York City and we utilized a convergent parallel design integrating quantitative data from demographic surveys, the HIV Stigma Survey (HIVSS), the Medical Mistrust Index (MMI) and electronic medical records, and qualitative data from in-depth interviews. Among the sample (N = 30), 26% (N = 8) initiated ART same-day or within 3 days, while the majority (N = 17) initiated between 4 and 30 days, and 17% (N = 5) initiated ART > 30 days. The median (range) age was 35, and most were English-speaking, Black or Hispanic men and identified as gay. Time to ART initiation was associated with time to linkage to care and time to viral suppression. Day 0-3 group's major theme was iART as stigma prevention, and they had the highest mean HIVSS, lowest MMI score, and a visit adherence of 0.86. Day 4-30 group's major theme was alleviation of internalized stigma, and they had the lowest mean HIVSS score, and highest visit adherence of 0.91. Day > 30 group's major theme was exacerbation of perceived or anticipated stigma, had the highest MMI score and a visit adherence of 0.85. iART implementation requires equitable strategies that address HIV-stigma and mistrust.
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Affiliation(s)
- Ofole Mgbako
- Division of Infectious Diseases and Immunology, Department of Internal Medicine, NYU Langone Health, New York, NY, USA.
- NYU Langone Institute for Excellence in Health Equity, New York, NY, USA.
- NYC Health + Hospitals/Bellevue, 462 1st Ave. H building, Office 16s10, New York, NY, 10016, USA.
| | - Claire Loughran
- NewYork Presbyterian, Columbia University Irving Medical Center, New York, NY, USA
| | - Rachel Mathu
- ICAP, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Delivette Castor
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Jacob McLean
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Magdalena E Sobieszczyk
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Susan Olender
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter Gordon
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Javier Lopez-Rios
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY, USA
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14
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Dorvil N, Rivera VR, Riviere C, Berman R, Severe P, Bang H, Lavoile K, Devieux JG, Faustin M, Saintyl G, Mendicuti MD, Pierre S, Apollon A, Dumond E, Forestal GPL, Rouzier V, Marcelin A, McNairy ML, Walsh KF, Dupnik K, Reif LK, Byrne AL, Bousleiman S, Orvis E, Joseph P, Cremieux PY, Pape JW, Koenig SP. Same-day testing with initiation of antiretroviral therapy or tuberculosis treatment versus standard care for persons presenting with tuberculosis symptoms at HIV diagnosis: A randomized open-label trial from Haiti. PLoS Med 2023; 20:e1004246. [PMID: 37294843 PMCID: PMC10292694 DOI: 10.1371/journal.pmed.1004246] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/26/2023] [Accepted: 05/25/2023] [Indexed: 06/11/2023] Open
Abstract
BACKGROUND Same-day HIV testing and antiretroviral therapy (ART) initiation is being widely implemented. However, the optimal timing of ART among patients with tuberculosis (TB) symptoms is unknown. We hypothesized that same-day treatment (TB treatment for those diagnosed with TB; ART for those not diagnosed with TB) would be superior to standard care in this population. METHODS AND FINDINGS We conducted an open-label trial among adults with TB symptoms at initial HIV diagnosis at GHESKIO in Haiti; participants were recruited and randomized on the same day. Participants were randomized in a 1:1 ratio to same-day treatment (same-day TB testing with same-day TB treatment if TB diagnosed; same-day ART if TB not diagnosed) versus standard care (initiating TB treatment within 7 days and delaying ART to day 7 if TB not diagnosed). In both groups, ART was initiated 2 weeks after TB treatment. The primary outcome was retention in care with 48-week HIV-1 RNA <200 copies/mL, with intention to treat (ITT) analysis. From November 6, 2017 to January 16, 2020, 500 participants were randomized (250/group); the final study visit occurred on March 1, 2021. Baseline TB was diagnosed in 40 (16.0%) in the standard and 48 (19.2%) in the same-day group; all initiated TB treatment. In the standard group, 245 (98.0%) initiated ART at median of 9 days; 6 (2.4%) died, 15 (6.0%) missed the 48-week visit, and 229 (91.6%) attended the 48-week visit. Among all who were randomized, 220 (88.0%) received 48-week HIV-1 RNA testing; 168 had <200 copies/mL (among randomized: 67.2%; among tested: 76.4%). In the same-day group, 249 (99.6%) initiated ART at median of 0 days; 9 (3.6%) died, 23 (9.2%) missed the 48-week visit, and 218 (87.2%) attended the 48-week visit. Among all who were randomized, 211 (84.4%) received 48-week HIV-1 RNA; 152 had <200 copies/mL (among randomized: 60.8%; among tested: 72.0%). There was no difference between groups in the primary outcome (60.8% versus 67.2%; risk difference: -0.06; 95% CI [-0.15, 0.02]; p = 0.14). Two new grade 3 or 4 events were reported per group; none were judged to be related to the intervention. The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain. CONCLUSIONS In patients with TB symptoms at HIV diagnosis, we found that same-day treatment was not associated with superior retention and viral suppression. In this study, a short delay in ART initiation did not appear to compromise outcomes. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov NCT03154320.
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Affiliation(s)
- Nancy Dorvil
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa R. Rivera
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Cynthia Riviere
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Richard Berman
- The Analysis Group, Boston, Massachusetts, United States of America
| | - Patrice Severe
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Heejung Bang
- University of California, Davis School of Medicine, Davis, California, United States of America
| | - Kerlyne Lavoile
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Devieux
- Florida International University, Miami, Florida, United States of America
| | - Mikerlyne Faustin
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Giovanni Saintyl
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Maria Duran Mendicuti
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Samuel Pierre
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumond
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Vanessa Rouzier
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Weill Cornell Medicine, New York, New York, United States of America
| | - Adias Marcelin
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Kathleen F. Walsh
- Weill Cornell Medicine, New York, New York, United States of America
| | - Kathryn Dupnik
- Weill Cornell Medicine, New York, New York, United States of America
| | - Lindsey K. Reif
- Weill Cornell Medicine, New York, New York, United States of America
| | - Anthony L. Byrne
- St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | | | - Eli Orvis
- The Analysis Group, Boston, Massachusetts, United States of America
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean William Pape
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Weill Cornell Medicine, New York, New York, United States of America
| | - Serena P. Koenig
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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15
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Mgbako O, Mathu R, Davila MG, Mehta M, Cabrera J, Carnevale C, Zucker J, Gordon P, Olender S. Immediate ART and clinical outcomes in New York City among patients newly diagnosed with HIV. AIDS Care 2023; 35:545-554. [PMID: 35895602 PMCID: PMC9880246 DOI: 10.1080/09540121.2022.2104799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 07/18/2022] [Indexed: 01/31/2023]
Abstract
Immediate antiretroviral therapy (iART) has been shown to decrease time to viral suppression. Our center underwent significant practice transformation to support iART, including a same-day Open Access (OA) model and enhanced care coordination. We examined whether same-day ART at linkage was associated with favorable proximate and long-term HIV care outcomes. From 2018 to 2019, patients newly diagnosed with HIV, linked to care at our institution, and iART eligible were included. We evaluated the association between iART and time to viral suppression, and between iART and initial/sustained viral suppression and retention in care. We also evaluated the association between use of OA and frequency of care coordination with the same outcomes. Of the 107 patients included, 72 initiated same-day ART at linkage and 35 did not. There was no statistically significant differences in whether patients were ever suppressed, had sustained viral suppression, or were retained in care between those who received same-day ART and those who did not. More care coordination was associated with retention in care (RR 1.21 [1.01-1.5]; p = 0.05). Organizing vital services and ensuring implementation strategies that facilitate iART, while tailoring the approach to the patient's comfort level, is likely optimal for longitudinal HIV care engagement.
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Affiliation(s)
- Ofole Mgbako
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia, University, New York, NY, USA
| | - Rachel Mathu
- NewYork-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY, USA
| | - Mila Gonzalez Davila
- NewYork-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY, USA
| | - Monica Mehta
- NewYork-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY, USA
| | - Joselyn Cabrera
- NewYork-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY, USA
| | - Caroline Carnevale
- NewYork-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY, USA
| | - Jason Zucker
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center
| | - Peter Gordon
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center
| | - Susan Olender
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center
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16
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Ross J, Brazier E, Fatti G, Jaquet A, Tanon A, Haas AD, Diero L, Castelnuovo B, Yiannoutsos CT, Nash D, Anastos KM, Yotebieng M. Same-Day Antiretroviral Therapy Initiation as a Predictor of Loss to Follow-up and Viral Suppression Among People With Human Immunodeficiency Virus in Sub-Saharan Africa. Clin Infect Dis 2023; 76:39-47. [PMID: 36097726 PMCID: PMC10202422 DOI: 10.1093/cid/ciac759] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/31/2022] [Accepted: 09/08/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Treat-All guidelines recommend initiation of antiretroviral therapy (ART) for all people with HIV (PWH) on the day of diagnosis when possible, yet uncertainty exists about the impact of same-day ART initiation on subsequent care engagement. We examined the association of same-day ART initiation with loss to follow-up and viral suppression among patients in 11 sub-Saharan African countries. METHODS We included ART-naive adult PWH from sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium who enrolled in care after Treat-All implementation and prior to January 2019. We used multivariable Cox regression to estimate the association between same-day ART initiation and loss to follow-up and Poisson regression to estimate the association between same-day ART initiation and 6-month viral suppression. RESULTS Among 29 017 patients from 63 sites, 18 584 (64.0%) initiated ART on the day of enrollment. Same-day ART initiation was less likely among those with advanced HIV disease versus early-stage disease. Loss to follow-up was significantly lower among those initiating ART ≥1 day of enrollment, compared with same-day ART initiators (20.6% vs 27.7%; adjusted hazard ratio: .66; 95% CI .57-.76). No difference in viral suppression was observed by time to ART initiation (adjusted rate ratio: 1.00; 95% CI: .98-1.02). CONCLUSIONS Patients initiating ART on the day of enrollment were more frequently lost to follow-up than those initiating later but were equally likely to be virally suppressed. Our findings support recent World Health Organization recommendations for providing tailored counseling and support to patients who accept an offer of same-day ART.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Health System, Bronx, New York, USA
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Geoffrey Fatti
- Kheth’Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Antoine Jaquet
- University of Bordeaux, National Institute for Health and Medical Research (INSERM), UMR 1219, Research Institute for Sustainable Development (IRD), EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Aristophane Tanon
- Service de Maladies Infectieuses et Tropicales (SMIT), Treichville Teaching Hospital, Abidjan, Côte d’Ivoire
| | - Andreas D Haas
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Lameck Diero
- Department of Medicine, Moi University School of Medicine and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Barbara Castelnuovo
- Department of Medicine, Moi University School of Medicine and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Kathryn M Anastos
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Health System, Bronx, New York, USA
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Health System, Bronx, New York, USA
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17
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Sarıgül Yıldırım F, Candevir A, Akhan S, Kaya S, Çabalak M, Ersöz G, İnan D, Ceren N, Karaoğlan İ, Damar Çakırca T, Özer Balin Ş, Alkan S, Kandemir Ö, Üser Ü, Karabay O, Çelen MK. Comparison of Immunological and Virological Recovery with Rapid, Early, and Late Start of Antiretroviral Treatment in Naive Plwh: Real-World Data. Int J Gen Med 2023; 16:1867-1877. [PMID: 37213471 PMCID: PMC10195690 DOI: 10.2147/ijgm.s393370] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/01/2023] [Indexed: 05/23/2023] Open
Abstract
Background Rapid initiation of antiretroviral therapy (ART) reduces the transmission of HIV infection in the community. This study aimed to determine whether rapid ART initiation is effective compared to standard ART treatment in our country. Methods Patients were grouped based on time to treatment initiation. HIV RNA levels, CD+4 T cell count, CD4/CD8 ratio, and ART regimens were recorded at baseline and follow-up visits for 12 months. Results There were 368-ART naive adults (treatment initiated at the time of HIV diagnosis; 143 on the first day, 48 on the second-seventh day, and 177 after the seventh day). Although virological suppression rates at 12th months were higher in all groups, over 90% on average, there were no statistically significant differences in HIV-1 RNA suppression rates, CD+4 T cell count, and CD4/CD8 ratio normalization in the studied months but in multivariate logistic regression analysis; showed a significant correlation between both virological and immunological response and those with CD4+ T <350 cells/mL at 12th month in total patients. Conclusion Our findings support the broader application of recommendations for rapid ART initiation in HIV patients.
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Affiliation(s)
- Figen Sarıgül Yıldırım
- Antalya Life Hospital, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey
- Correspondence: Figen Sarıgül Yıldırım, Antalya Life Hospital, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey, Tel +90 532 473 44 46, Email
| | - Aslıhan Candevir
- Cukurova University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Adana, Turkey
| | - Sıla Akhan
- Kocaeli Üniversity, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Kocaeli, Turkey
| | - Selçuk Kaya
- Karadeniz Teknik University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Trabzon, Turkey
| | - Mehmet Çabalak
- Mustafa Kemal University Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Hatay, Turkey
| | - Gülden Ersöz
- Mersin University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Mersin, Turkey
| | - Dilara İnan
- Akdeniz University Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey
| | - Nurgül Ceren
- Health Science University, Haydarpaşa Numune Education and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, İstanbul, Turkey
| | - İlkay Karaoğlan
- Gaziantep University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Gaziantep, Turkey
| | - Tuba Damar Çakırca
- Health Science University, Şanlıurfa Numune Education and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Şanlıurfa, Turkey
| | - Şafak Özer Balin
- Fırat University Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Elazığ, Turkey
| | - Sevil Alkan
- Çanakkale 18 Mart University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Çanakkale, Turkey
| | - Özlem Kandemir
- Mersin University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Mersin, Turkey
| | - Ülkü Üser
- Health Science University, Antalya Education and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey
| | - Oğuz Karabay
- Sakarya University Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Hatay, Turkey
| | - Mustafa Kemal Çelen
- Dicle University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Diyarbakır, Turkey
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18
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Yin H, Ye R, Yang Y, Wang J, Tang R, Yao S, Duan S, Ding Y, He N. Longitudinal impact of compliance with routine CD4 monitoring on all cause deaths among treated people with HIV in China. Biosci Trends 2022; 16:434-443. [PMID: 36504071 DOI: 10.5582/bst.2022.01479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Keeping adherence to the continuous and standardized CD4 follow-up monitoring service is of great significance to the control of disease progression and the reduction of avoidable mortality for HIV-infected patients. As non-communicable diseases (NCDs) have become main causes of deaths for people with HIV (PWH) in the era of combination antiretroviral therapy (cART), how and to what extent does adherence to routine CD4 monitoring differentially impact on AIDS-related versus NCDs-related deaths in low- and middle-income countries (LMIC) remains elucidated. A CD4 test index was developed by dividing the actual number of received CD4 tests by the theoretical number of CD4 tests that should have been performed according to national treatment guidelines during the study period, with an index value of 0.8-1.2 reflecting compliance. From 1989 to 2020, 14,571 adults were diagnosed with HIV infection in Dehong Prefecture of Yunnan province in Southwestern China, 6,683 (45.9%) PWH had died with the all-cause mortality of 550.13 per 10,000 person-years, including 3,250 (48.6%) AIDS-related deaths (267.53 per 10,000 person-years). Among patients on cART, the median CD4 test index was 1.0 (IQR 0.6-1.3), and 35.2% had a CD4 test index less than 0.8. Cox proportional hazards regression analysis indicated that PWH with CD4 test index at 0.8-1.2 were at the lowest risk of both AIDS-related (aHR = 0.06; 95%CI: 0.05-0.07) and NCDs-related (aHR = 0.13; 95%CI: 0.11-0.16)deaths. Adherence to routine CD4 monitoring is critical for reducing both AIDS-related and NCDs-related mortality of PWH. An appropriate (once or twice a year) rather than an unnecessarily higher frequency of routine CD4 testing could be most cost-effective in reducing mortality in LMIC.
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Affiliation(s)
- Hao Yin
- Department of Epidemiology, School of Public Health, and Shanghai Institute of Infectious Diseases and Biosecurity, Fudan University, Shanghai, China.,Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China.,Yi-Wu Research Institute, Fudan University, Shanghai, China
| | - Runhua Ye
- Dehong Prefecture Center for Disease Control and Prevention, Dehong, Yunnan, China
| | - Yuecheng Yang
- Dehong Prefecture Center for Disease Control and Prevention, Dehong, Yunnan, China
| | - Jibao Wang
- Dehong Prefecture Center for Disease Control and Prevention, Dehong, Yunnan, China
| | - Renhai Tang
- Dehong Prefecture Center for Disease Control and Prevention, Dehong, Yunnan, China
| | - Shitang Yao
- Dehong Prefecture Center for Disease Control and Prevention, Dehong, Yunnan, China
| | - Song Duan
- Dehong Prefecture Center for Disease Control and Prevention, Dehong, Yunnan, China
| | - Yingying Ding
- Department of Epidemiology, School of Public Health, and Shanghai Institute of Infectious Diseases and Biosecurity, Fudan University, Shanghai, China.,Yi-Wu Research Institute, Fudan University, Shanghai, China
| | - Na He
- Department of Epidemiology, School of Public Health, and Shanghai Institute of Infectious Diseases and Biosecurity, Fudan University, Shanghai, China.,Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China.,Yi-Wu Research Institute, Fudan University, Shanghai, China
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19
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Uptake and effect of universal test-and-treat on twelve months retention and initial virologic suppression in routine HIV program in Kenya. PLoS One 2022; 17:e0277675. [PMID: 36413522 PMCID: PMC9681077 DOI: 10.1371/journal.pone.0277675] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 11/01/2022] [Indexed: 11/23/2022] Open
Abstract
Early combination antiretroviral therapy (cART), as recommended in WHO's universal test-and-treat (UTT) policy, is associated with improved linkage to care, retention, and virologic suppression in controlled studies. We aimed to describe UTT uptake and effect on twelve-month non-retention and initial virologic non-suppression (VnS) among HIV infected adults starting cART in routine HIV program in Kenya. Individual-level HIV service delivery data from 38 health facilities, each representing 38 of the 47 counties in Kenya were analysed. Adults (>15 years) initiating cART between the second-half of 2015 (2015HY2) and the first-half of 2018 (2018HY1) were followed up for twelve months. UTT was defined based on time from an HIV diagnosis to cART initiation and was categorized as same-day, 1-14 days, 15-90 days, and 91+ days. Non-retention was defined as individuals lost-to-follow-up or reported dead by the end of the follow up period. Initial VnS was defined based on the first available viral load test with >400 copies/ml. Hierarchical mixed-effects survival and generalised linear regression models were used to assess the effect of UTT on non-retention and VnS, respectively. Of 8592 individuals analysed, majority (n = 5864 [68.2%]) were female. Same-day HIV diagnosis and cART initiation increased from 15.3% (2015HY2) to 52.2% (2018HY1). The overall non-retention rate was 2.8 (95% CI: 2.6-2.9) per 100 person-months. When compared to individuals initiated cART 91+ days after a HIV diagnosis, those initiated cART on the same day of a HIV diagnosis had the highest rate of non-retention (same-day vs. 91+ days; aHR, 1.7 [95% CI: 1.5-2.0], p<0.001). Of those included in the analysis, 5986 (69.6%) had a first viral load test done at a median of 6.3 (IQR, 5.6-7.6) months after cART initiation. Of these, 835 (13.9%) had VnS. There was no association between UTT and VnS (same-day vs. 91+ days; aRR, 1.0 [95% CI: 0.9-1.2], p = 0.664). Our findings demonstrate substantial uptake of the UTT policy but poor twelve-month retention and lack of an association with initial VnS from routine HIV settings in Kenya. These findings warrant consideration for multi-pronged program interventions alongside UTT policy for maximum intended benefits in Kenya.
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20
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Ayakaka I, Armstrong-Hough M, Hannaford A, Ggita JM, Turimumahoro P, Katamba A, Katahoire A, Cattamanchi A, Shenoi SV, Davis JL. Perceptions, preferences, and experiences of tuberculosis education and counselling among patients and providers in Kampala, Uganda: A qualitative study. Glob Public Health 2022; 17:2911-2928. [PMID: 35442147 PMCID: PMC11005908 DOI: 10.1080/17441692.2021.2000629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/21/2021] [Indexed: 12/15/2022]
Abstract
Tuberculosis (TB) education seeks to increase patient knowledge about TB, while TB counselling seeks to offer tailored advice and support for medication adherence. While universally recommended, little is known about how to provide effective, efficient, patient-centred TB education and counselling (TEC) in low-income, high HIV-TB burden settings. We sought to characterise stakeholder perceptions of TEC in a public, primary care facility in Kampala, Uganda, by conducting focus group discussions with health workers and TB patients in the TB and HIV clinics. Participants valued TEC but reported that high-quality TEC is rarely provided, because of a lack of time, space, staff, planning, and prioritisation given to TEC. To improve TEC, they recommended adopting practices that have proven effective in the HIV clinic, including better specifying educational content, and employing peer educators focused on TEC. Patients and health workers suggested that TEC should not only improve TB patient knowledge and adherence, but should also empower and assist all those undergoing evaluation for TB, whether confirmed or not, to educate their households and communities about TB. Community-engaged research with patients and front-line providers identified opportunities to streamline and standardise the delivery of TEC using a patient-centred, peer-educator model.
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Affiliation(s)
- Irene Ayakaka
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Liverpool School of Tropical Medicine, LSTM IMPALA Program, Liverpool, UK
| | - Mari Armstrong-Hough
- Department of Social and Behavioural Sciences and Department of Epidemiology, School of Global Public Health, New York University, New York, New York, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alisse Hannaford
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M. Ggita
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | | | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Clinical Epidemiology Unit, Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Anne Katahoire
- Child Health and Development Centre, School of Medicine; College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Sheela V. Shenoi
- Center for Interdisciplinary Research on AIDS, Yale School of Medicine, New Haven, Connecticut, USA
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - J. L. Davis
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Center for Interdisciplinary Research on AIDS, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Epidemiology of Microbial Diseases and Centre for Methods in Implementation and Prevention Science, Yale School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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21
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Same‐day
and rapid initiation of antiretroviral therapy in people living with
HIV
in Asia. How far have we come? HIV Med 2022; 23 Suppl 4:3-14. [DOI: 10.1111/hiv.13410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 09/01/2022] [Indexed: 11/04/2022]
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22
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Katende A, Nakiyingi L, Andia-Biraro I, Katairo T, Muhumuza R, Ssemata AS, Nsereko C, Semitala FC, Meya DB. Antiretroviral therapy initiation and outcomes of hospitalized HIV-infected patients in Uganda—An evaluation of the HIV test and treat strategy. PLoS One 2022; 17:e0268122. [PMID: 35984779 PMCID: PMC9390910 DOI: 10.1371/journal.pone.0268122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 04/25/2022] [Indexed: 11/29/2022] Open
Abstract
Background Uganda adopted the HIV Test and Treat in 2016. There is paucity of data about its implementation among hospitalized patients. We aimed to determine the proportion of patients initiating anti-retroviral therapy (ART) during hospitalization, barriers and mortality outcome. Methods In this mixed methods cohort study, we enrolled hospitalized patients with a recent HIV diagnosis from three public hospitals in Uganda. We collected data on clinical characteristics, ART initiation and reasons for failure to initiate ART, as well as 30 day outcomes. Healthcare workers in-depth interviews were also conducted and data analyzed by sub-themes. Results We enrolled 234 patients; females 140/234 (59.8%), median age 34.5 years (IQR 29–42), 195/234 (83.7%) had WHO HIV stage 3 or 4, and 74/116 (63.8%) had CD4 ≤ 200 cell/μL. The proportion who initiated ART during hospitalization was 123/234 (52.6%) (95% CI 46.0–59.1), of these 35/123 (28.5%) initiated ART on the same day of hospitalization, while 99/123 (80.5%) within a week of hospitalization. By 30 days 34/234 (14.5%) (95% CI 10.3–19.7) died. Patients residing ≥ 35 kilometers from the hospital were more likely not to initiate ART during hospitalization, [aRR = 1.39, (95% CI 1.22–1.59). Inadequate patient preparation for ART initiation and advanced HIV disease were highlighted as barriers of ART initiation during hospitalization. Conclusion In this high HIV prevalence setting, only half of newly diagnosed HIV patients are initiated on ART during hospitalization. Inadequate pre-ART patient preparation and advanced HIV are barriers to rapid ART initiation among hospitalized patients in public hospitals.
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Affiliation(s)
- Andrew Katende
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Ifakara Health Institute, Ifakara, Tanzania
- * E-mail:
| | - Lydia Nakiyingi
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Andia-Biraro
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thomas Katairo
- Infectious Disease Research Collaboration, Kampala, Uganda
| | - Richard Muhumuza
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Andrew S. Ssemata
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Fred C. Semitala
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Disease Research Collaboration, Kampala, Uganda
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - David B. Meya
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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23
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Loveday M, Furin J, Hlangu S, Naidoo T. "I am alive because of her": factors affecting adherence to combination antiretroviral therapy among people living with HIV in KwaZulu-Natal, South Africa. BMC Infect Dis 2022; 22:680. [PMID: 35941552 PMCID: PMC9361592 DOI: 10.1186/s12879-022-07667-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People living with HIV need to take lifelong, combination antiretroviral therapy (cART), but there have been only limited explorations of how factors affecting adherence can change over the course of an individual's lifetime. METHODS We carried out a qualitative study of men and women living with HIV in KwaZulu, Natal, South Africa who were prescribed cART and who had periods of higher and lower adherence. RESULTS 18 individuals participated in open-ended interviews. Using a dynamic theory of adherence, we identified factual, relational, and experiential factors that were associated with adherence and non-adherence to cART. Periods of non-adherence were commonly reported. Participants described relationships and experiences as being important influences on their ability to adhere to cART throughout their treatment journeys. CONCLUSIONS Periods of non-adherence to cART are common. While many cART counseling models are based on conveying facts to people prescribed cART, providing opportunities for supportive relationship where people can process their varied experiences is likely important to maintaining health for people living with HIV.
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Affiliation(s)
- Marian Loveday
- HIV Prevention Research Unit, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa.,CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, 02115, USA.
| | - Sindisiwe Hlangu
- HIV Prevention Research Unit, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa
| | - Tasneem Naidoo
- R. K. Khan Hospital HAST Unit, Department of Health, Durban, KwaZulu-Natal, South Africa
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24
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Shao C, Wang H, Sang F, Xu L. Study on the Mechanism of Improving HIV/AIDS Immune Function with Jian Aikang Concentrated Pill Based on Network Pharmacology Combined with Experimental Validation. Drug Des Devel Ther 2022; 16:2731-2753. [PMID: 36003311 PMCID: PMC9394786 DOI: 10.2147/dddt.s369832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose This study was the first to screen the active compounds of Jian Aikang Concentrated Pill (JAKCP) with network pharmacology, predict its potential targets, screen the signaling pathways, and combine with cellular experimental validation to explore the potential mechanism of JAKCP for the treatment of acquired immunodeficiency syndrome (AIDS). Methods The main compounds and targets of Chinese herbs in JAKCP were identified by TCMSP; the targets of AIDS were collected from Genecards, Online Mendelian Inheritance in Man (OMIM), Disgenet, Therapeutic Target Database (TTD) and Drugbank; the network of “Chinese herbs-active compounds-targets” for JAKCP was constructed by Cytoscape, and protein–protein interaction (PPI) network was constructed using STRING to generate the intersection targets, Metascape was conducted to analyze the Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG), and the network of “main active compounds-core targets-pathways” was constructed by Cytoscape. Finally, the effect of JAKCP on the survival rate of HIV pseudovirus-infected MT-4 cells was investigated by CCK-8 assay, and the predicted targets were verified by ELISA, qPCR and Western blot. Results A total of 147 active compounds of JAKCP were screened covering 351 targets and 416 AIDS disease targets were obtained, besides 140 intersection targets and 321 KEGG pathways were collected. Ultimately, quercetin, kaempferol, stigmasterol, beta-sitosterol, epigallocatechin gallate were identified as the important compounds, the core targets are HSP90AA1, IL-10, IL-6, TNF, IL-1β, TP53, and IL-1ɑ, and the biological pathways and processes mainly include T cell activation, regulation of DNA-binding transcription factor activity and apoptotic signaling pathway. Experiments on the targets of “T cell activation” demonstrated that JAKCP promotes the survival of HIV pseudovirus-infected MT-4 cells. Also, JAKCP down-regulated mRNA and protein levels of IL-1ɑ, IL-1β, and IL-6 while up-regulated mRNA and protein levels of IL-2, IL-6ST, and IL-10 in vitro. Conclusion JAKCP exerted regulatory immune functions through multi-component, multi-target and multi-pathway, thereby providing novel ideas and clues for the treatment of AIDS.
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Affiliation(s)
- Cancan Shao
- Department of First Clinical School of Medicine of Henan University of Chinese Medicine, Zhengzhou, Henan, 450000, People’s Republic of China
| | - Haojie Wang
- Department of Tuberculosis of Henan Provincial Chest Hospital, Zhengzhou, Henan, 450000, People’s Republic of China
| | - Feng Sang
- Key Laboratory of Viral Diseases Prevention and Treatment with TCM of Henan Province, Zhengzhou, Henan, 450000, People’s Republic of China
- Department of Acquired Immune Deficiency Syndrome Treatment and Research Center, The First Affiliated Hospital of Henan University of CM, Zhengzhou, Henan, 450000, People’s Republic of China
| | - Liran Xu
- Department of First Clinical School of Medicine of Henan University of Chinese Medicine, Zhengzhou, Henan, 450000, People’s Republic of China
- Key Laboratory of Viral Diseases Prevention and Treatment with TCM of Henan Province, Zhengzhou, Henan, 450000, People’s Republic of China
- Department of Acquired Immune Deficiency Syndrome Treatment and Research Center, The First Affiliated Hospital of Henan University of CM, Zhengzhou, Henan, 450000, People’s Republic of China
- Correspondence: Liran Xu, Department of Acquired Immune Deficiency Syndrome Treatment and Research Center, The First Affiliated Hospital of Henan University of CM, No. 19 Renmin Road, Zhengzhou, Henan, 450000, People’s Republic of China, Tel +86-371-13633818030, Email
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25
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Harkness A, Wawrzyniak AJ, Kolber MA, Villamizar K, Botero V, Rodriguez JE, Orr JL, Zukerberg J, Rodríguez AE. Multilevel Determinants of Rapid Antiretroviral Treatment Implementation and Demand in Miami-Dade County. J Acquir Immune Defic Syndr 2022; 90:S177-S189. [PMID: 35703770 PMCID: PMC9204784 DOI: 10.1097/qai.0000000000002978] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rapidly linking newly diagnosed HIV patients to antiretroviral treatment (ART) is the best practice for achieving optimal treatment outcomes, including viral suppression. However, rapid ART implementation varies throughout the United States, highlighting the importance of identifying rapid ART implementation determinants in US HIV epicenters, such as Miami-Dade County (MDC). METHODS Clinic focus groups (N = 4 clinics) and patient interviews (N = 31 recently diagnosed patients) systematically and qualitatively assessed rapid ART implementation determinants in MDC. Independent coders analyzed focus groups and interviews using a directed content analysis approach guided by the Consolidated Framework for Implementation Research. RESULTS For clinic stakeholders, key rapid ART implementation determinants included the following: complexity and adaptability (innovation characteristics); networks between clinics and patient needs rooted in structural inequities (outer setting); leadership and available resources (inner setting); staff/provider flexibility (characteristics of individuals); and appointing patient navigators and champions (process). For patients, key determinants included complexity and relative advantage of rapid treatment (innovation characteristics); patient needs and clinic networks (outer setting); provider knowledge and skills (inner setting); provider warmth and affirmation (characteristics of individuals); and need for improved outreach (process). CONCLUSIONS Multilevel factors impact clinic implementation and patient demand for rapid ART in MDC. Informed by these factors, we identified potential implementation strategies to enhance rapid ART implementation throughout MDC. These implementation strategies can be tested in an implementation trial, enhancing the toolkit of strategies to ensure that evidence-based tools, particularly rapid ART, are readily available to the most impacted communities.
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Affiliation(s)
- Audrey Harkness
- Division of Prevention Science and Community Health, Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, FL
| | - Andrew J Wawrzyniak
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Michael A Kolber
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Kira Villamizar
- Florida Department of Health in Miami-Dade County, Miami, FL; and
| | - Valeria Botero
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Jacqueline E Rodriguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Jessica L Orr
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | | | - Allan E Rodríguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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Geng EH, Nash D, Phanuphak N, Green K, Solomon S, Grimsrud A, Sohn AH, Mayer KH, Bärnighausen T, Bekker LG. The question of the question: impactful implementation science to address the HIV epidemic. J Int AIDS Soc 2022; 25:e25898. [PMID: 35384312 PMCID: PMC8982316 DOI: 10.1002/jia2.25898] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 02/18/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Questions about the implementation of evidence-based intervention to treat and prevent HIV have risen to the top of the field's scientific priorities. Despite the availability of highly efficacious treatment and prevention interventions, impact has fallen short of targets because these interventions are used with insufficient reach, consistency, sustainability and equity in diverse real-world settings. At present, substantial excitement for implementation science - defined as research methods and strategies to improve use of evidence-based interventions - has focused on developing and disseminating methods to conduct rigorous research. Yet, impactful answers depend on a sometimes less visible, but even more important, step: asking good questions about implementation. DISCUSSION In this commentary, we offer several considerations for researchers formulating implementation research questions based on several distinctive features of the field. First, as findings are used not only by other researchers but by implementers, scientific questions must incorporate a range of stakeholder and community perspectives to be most relevant. Second, real-world settings are contextually diverse, and the most relevant scientific questions must position answers to make sense within these contexts (whether geographical, organizational and sociological), rather than apart from them. Third, implementation is complex and dynamic; consequently, research questions must make use of emerging standards in describing implementation strategies and their effects whenever possible. Finally, the field of implementation science continues to evolve, so framing problems with a diverse disciplinary lens will enable researchers to pose insightful and impactful questions. CONCLUSIONS We are now at a juncture marked by both rich evidence-based interventions and a persistent global pandemic. To achieve continued scientific progress against the HIV epidemic, asking the right questions might be part of the answer itself.
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Affiliation(s)
- Elvin H Geng
- Center for Dissemination and Implementation, Institute of Public Health, Division of Infectious Diseases, Department of Medicine, School of Medicine at Washington University in St. Louis, St. Louis, Missouri, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, USA.,Department of Epidemiology and Biostatistics, Graduate School of Public Health, City University of New York, New York, USA
| | | | | | - Sunil Solomon
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Kenneth H Mayer
- The Fenway Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg, Germany
| | - Linda-Gail Bekker
- Institute of Infectious Disease and Molecular Medicine, Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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Montebatsi M, Lavoie MCC, Blanco N, Marima R, Sebina K, Mangope J, Ntwayagae O, Whittington A, Letebele M, Lekone P, Hess KL, Thomas V, Ramaabya D, Ramotsababa M, Stafford KA, Ndwapi N. Improving same-day antiretroviral therapy in Botswana: effects of a multifaceted national intervention. AIDS 2022; 36:533-538. [PMID: 34873088 DOI: 10.1097/qad.0000000000003139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2019, the Botswana Ministry of Health and Wellness (MOHW) implemented an HIV national Reboot program, which was needed for refocusing and intensifying efforts for achieving epidemic control. The strategies deployed as part of Reboot were reviewed and evaluated for their effect on same-day and within-seven-days (fast-track initiation) antiretroviral therapy (ART) initiation among adults newly identified with HIV. METHODS We conducted a retrospective cohort analysis of patients aged 18 years or older who were newly diagnosed with HIV from October 2018 to September 2019 across 41 health facilities. We used generalized linear mixed models, adjusting for clustering by facility, to assess the association of the Reboot with same-day or within-seven-days ART initiation (fast-track initiation). RESULTS From October 2018 to January 2019, 28% (636/2269) of newly diagnosed HIV patients were initiated the same day of diagnosis, and 56% (1260/2269) were initiated within seven days. Following the launch of Reboot (February to September 2019), 59% (2092/3553) were initiated the same day of diagnosis, and 77% (2752/3553) were initiated within seven days. Clients were 2.08 (adjusted risk ratio 95% confidence interval 1.79-2.43) times more likely to be initiated the same day of diagnosis and 1.39 (adjusted risk ratio 95% confidence interval 1.28-1.52) times more likely to be initiated within seven days than before Reboot after adjusting for sex and age. CONCLUSION In Botswana, a multifaceted national intervention improved timely ART initiation. Identifying and implementing different client-centered strategies to facilitate ART initiation is critical to preventing AIDS-related complications and prevent ongoing transmission.
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Affiliation(s)
- Milton Montebatsi
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Marie-Claude C Lavoie
- Center for International Health, Education, and Biosecurity, Institute of Human Virology-University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Natalia Blanco
- Center for International Health, Education, and Biosecurity, Institute of Human Virology-University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Reson Marima
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Kagiso Sebina
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Justin Mangope
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Ookeditse Ntwayagae
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Anna Whittington
- Center for International Health, Education, and Biosecurity, Institute of Human Virology-University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mpho Letebele
- US Centers for Disease Control and Prevention, (CDC), CDC- Botswana
| | - Phenyo Lekone
- US Centers for Disease Control and Prevention, (CDC), CDC- Botswana
| | - Kristen L Hess
- US Centers for Disease Control and Prevention, (CDC), CDC- Botswana
| | - Vasavi Thomas
- US Centers for Disease Control and Prevention, (CDC), CDC- Botswana
| | - Dinah Ramaabya
- Botswana Ministry of Health and Wellness, (MOHW), Gaborone, Botswana
| | | | - Kristen A Stafford
- Center for International Health, Education, and Biosecurity, Institute of Human Virology-University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ndwapi Ndwapi
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
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Le Tourneau N, Germann A, Thompson RR, Ford N, Schwartz S, Beres L, Mody A, Baral S, Geng EH, Eshun-Wilson I. Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis. PLoS Med 2022; 19:e1003959. [PMID: 35316272 PMCID: PMC8982898 DOI: 10.1371/journal.pmed.1003959] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/05/2022] [Accepted: 03/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Global HIV treatment programs have sought to lengthen the interval between clinical encounters for people living with HIV (PLWH) who are established on antiretroviral treatment (ART) to reduce the burden of seeking care and to decongest health facilities. The overall effect of reduced visit frequency on HIV treatment outcomes is however unknown. We conducted a systematic review and meta-analysis to evaluate the effect of implementation strategies that reduce the frequency of clinical appointments and ART refills for PLWH established on ART. METHODS AND FINDINGS We searched databases between 1 January 2010 and 9 November 2021 to identify randomized controlled trials (RCTs) and observational studies that compared reduced (6- to 12-monthly) clinical consultation or ART refill appointment frequency to 3- to 6-monthly appointments for patients established on ART. We assessed methodological quality and real-world relevance, and used Mantel-Haenszel methods to generate pooled risk ratios (RRs) with 95% confidence intervals for retention, viral suppression, and mortality. We evaluated heterogeneity quantitatively and qualitatively, and overall evidence certainty using GRADE. Searches yielded 3,955 records, resulting in 10 studies (6 RCTs, 3 observational studies, and 1 study contributing observational and RCT data) representing 15 intervention arms with 33,599 adults (≥16 years) in 8 sub-Saharan African countries. Reduced frequency clinical consultations occurred at health facilities, while reduced frequency ART refills were delivered through facility or community pharmacies and adherence groups. Studies were highly pragmatic, except for some study settings and resources used in RCTs. Among studies comparing reduced clinical consultation frequency (6- or 12-monthly) to 3-monthly consultations, there appeared to be no difference in retention (RR 1.01, 95% CI 0.97-1.04, p = 0.682, 8 studies, low certainty), and this finding was consistent across 6- and 12-monthly consultation intervals and delivery strategies. Viral suppression effect estimates were markedly influenced by under-ascertainment of viral load outcomes in intervention arms, resulting in inconclusive evidence. There was similarly insufficient evidence to draw conclusions on mortality (RR 1.12, 95% CI 0.75-1.66, p = 0.592, 6 studies, very low certainty). For ART refill frequency, there appeared to be little to no difference in retention (RR 1.01, 95% CI 0.98-1.06, p = 0.473, 4 RCTs, moderate certainty) or mortality (RR 1.45, 95% CI 0.63-3.35, p = 0.382, 4 RCTs, low certainty) between 6-monthly and 3-monthly visits. Similar to the analysis for clinical consultations, although viral suppression appeared to be better in 3-monthly arms, effect estimates were markedly influence by under-ascertainment of viral load outcomes in intervention arms, resulting in overall inclusive evidence. This systematic review was limited by the small number of studies available to compare 12- versus 6-monthly clinical consultations, insufficient data to compare implementation strategies, and lack of evidence for children, key populations, and low- and middle-income countries outside of sub-Saharan Africa. CONCLUSIONS Based on this synthesis, extending clinical consultation intervals to 6 or 12 months and ART dispensing intervals to 6 months appears to result in similar retention to 3-month intervals, with less robust conclusions for viral suppression and mortality. Future research should ensure complete viral load outcome ascertainment, as well as explore mechanisms of effect, outcomes in other populations, and optimum delivery and monitoring strategies to ensure widespread applicability of reduced frequency visits across settings.
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Affiliation(s)
- Noelle Le Tourneau
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
- * E-mail:
| | - Ashley Germann
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ryan R. Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nathan Ford
- Department of Global HIV, Hepatitis and Sexually Transmitted Diseases, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Laura Beres
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Aaloke Mody
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, Saint Louis, Missouri, United States of America
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
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Eamsakulrat P, Kiertiburanakul S. The Impact of Timing of Antiretroviral Therapy Initiation on Retention in Care, Viral Load Suppression and Mortality in People Living with HIV: A Study in a University Hospital in Thailand. J Int Assoc Provid AIDS Care 2022; 21:23259582221082607. [PMID: 35229678 PMCID: PMC8891835 DOI: 10.1177/23259582221082607] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Studies investigating same-day antiretroviral therapy (ART) initiation demonstrate different clinical outcomes depending on settings. We retrospectively reviewed adults with newly positive human immunodeficiency virus (HIV) antibody testing. The proportion of individuals who were retained in care at 12 months was compared between early (≤2 weeks) and late (>2 weeks) ART initiation groups. Of all, the median (IQR) time from HIV diagnosis to ART initiation was 18 (9-30) days. This duration was 7 (7-13) days in the early ART initiation group (n = 116) and 28 (21-46) days in the late ART initiation group (n = 154). In the multivariate logistic regression, having pneumocystis pneumonia [odds ratio (OR) 9.30, 95% CI 2.56-33.75], tuberculosis (OR 2.21, 95% CI 1.03-4.73), and weight loss (OR 12.98, 95% CI 1.00-167.68) were associated with late ART initiation. The early ART initiation group had a slightly higher proportion of individuals retained in care at 12 months than those in the late ART initiation group (88.8% vs 80.5%, P = .066) and had a higher significant proportion of HIV viral load suppression (81.0% vs 70.1%, P = .041). No significant differences were observed in the proportion of individuals who died at 12 months (2.6% vs 3.2%, P = 1.000) between the two groups. Early ART initiation trends to retain individuals in care and higher HIV viral load suppression was determined. Nevertheless, ART initiation timing might not be a solely important factor in improving HIV care and minimizing mortality among HIV-infected individuals in a university hospital setting.
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Affiliation(s)
- Pruke Eamsakulrat
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasisopin Kiertiburanakul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Spooner E, Reddy T, Mchunu N, Reddy S, Daniels B, Ngomane N, Luthuli N, Kiepiela P, Coutsoudis A. Point-of-care CD4 testing: Differentiated care for the most vulnerable. J Glob Health 2022; 12:04004. [PMID: 35136596 PMCID: PMC8818294 DOI: 10.7189/jogh.12.04004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background South Africa, with the highest burden of HIV infection globally, has made huge strides in its HIV/ART programme, but AIDS deaths have not decreased proportionally to ART uptake. Advanced HIV disease (CD4 < 200 cells/mm3) persists, and CD4 count testing is being overlooked since universal test-and-treat was implemented. Point-of-care CD4 testing could address this gap and assure differentiated care to these vulnerable patients with low CD4 counts. Methods A time randomised implementation trial was conducted, enrolling 603 HIV positive non-ART, not pregnant patients at a primary health care clinic in Durban, South Africa. Weeks were randomised to either point-of-care CD4 testing (n = 305 patients) or standard-of-care central laboratory CD4 testing (n = 298 patients) to assess the proportion initiating ART at 3 months. Cox regression, with robust standard errors adjusting for clustering by week, were used to assess the relationship between treatment initiation and arm. Results Among the 578 (299 point-of-care and 279 standard-of-care) patients eligible for analysis, there was no significant difference in the number of eligible patients initiating ART within 3 months in the point-of-care (73%) and the standard-of-care (68%) groups (P = 0.112). The time-to-treat analysis was not significantly different in patients with CD4 counts of 201-500 cells/mm3 which could have been due to appointment scheduling to cope with the large burden of cases. However, in patients with advanced HIV disease (CD4 < 200cells/mm3) 65% more patients started ART earlier in the point-of-care group (HR 1.65 (95% confidence interval (CI) = 0.99-2.75; P = 0.052) compared to the standard-of-care group. Conclusions Point-of-care testing decreased time-to-treatment in those with advanced HIV disease. With universal test and treat for HIV, rollout of simple point-of-care CD4 testing would ensure early diagnosis of advanced HIV disease and facilitate differentiated care for these vulnerable patients as per the World Health Organisation 2020 target product profile for point-of-care CD4 testing. Trial registration ISRCTN14220457.
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Affiliation(s)
- Elizabeth Spooner
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Tarylee Reddy
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
| | - Nobuhle Mchunu
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | | | - Brodie Daniels
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | | | | | | | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
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OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1741-1747. [DOI: 10.1093/jac/dkac079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/06/2022] [Indexed: 11/13/2022] Open
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Seekaew P, Phanuphak N, Teeratakulpisarn N, Amatavete S, Lujintanon S, Teeratakulpisarn S, Pankam T, Nampaisan O, Jomja P, Prabjunteuk C, Plodgratoke P, Ramautarsing R, Phanuphak P. Same-day antiretroviral therapy initiation hub model at the Thai Red Cross Anonymous Clinic in Bangkok, Thailand: an observational cohort study. J Int AIDS Soc 2021; 24:e25869. [PMID: 34967504 PMCID: PMC8717692 DOI: 10.1002/jia2.25869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/14/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction WHO has recommended rapid antiretroviral therapy (ART) initiation, including same‐day ART (SDART). However, data on the feasibility in real‐world settings are limited. We implemented a cohort study at a stand‐alone HIV testing centre to examine its applicability and effectiveness. Methods Data were collected from the Thai Red Cross Anonymous Clinic in Bangkok, Thailand, between July 2017 and July 2018 from clients who were ART‐naïve and could return for follow‐up visits. Baseline laboratory tests and chest X‐ray were performed according to national guidelines, and clinical eligibility was determined based on physical examination and chest X‐ray findings. Primary outcomes were retention in care and viral load suppression at 3, 6 and 12 months. Results During the study period, 2427 people tested HIV positive. Of these, 2107 (2207/2427, 86.8%) met logistical criteria, and 1904 (1904/2427, 78.5%) agreed to SDART. One thousand seven hundred and twenty‐nine (1729/2427, 71.2%) were placed on ART, with 1257 received same‐day initiation and 1576 initiated ART within 7 days; 1198 clients were successfully referred to free, sustained ART sites. Retention among eligible clients who accepted SDART service at months 3, 6 and 12 was 79.8%, 75.2% and 75.3%, respectively. Conclusions Same‐day ART initiation hub model at a stand‐alone HIV testing centre in an urban setting in Bangkok, Thailand, is highly feasible and has a potential for scaling up. Clinical Trial Number NCT04032028
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Affiliation(s)
- Pich Seekaew
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA.,Institute of HIV Research and Innovation, Bangkok, Thailand
| | | | | | | | | | | | | | | | - Pintip Jomja
- Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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Christopoulos KA, Erguera XA, VanderZanden L, Campbell C, Green M, Tsuzuki MD, Schneider J, Coffey S, Bacon O, Gandhi M, Koester KA. A Qualitative Study of the Experience of Immediate Antiretroviral Therapy Among Urban Persons With Newly Diagnosed Human Immunodeficiency Virus. Open Forum Infect Dis 2021; 8:ofab469. [PMID: 34877362 PMCID: PMC8643677 DOI: 10.1093/ofid/ofab469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background Guidelines recommend immediate antiretroviral therapy (ART) at or shortly after human immunodeficiency virus (HIV) diagnosis, yet little is known about how people living with HIV (PLWH) experience this treatment strategy, including racial/ethnic minorities, cisgender/transgender women, and those with housing instability. Methods To assess the acceptability of immediate ART offer among urban PLWH, understand how this approach affects the lived experience of HIV diagnosis, and explore reasons for declining immediate ART, we conducted a cross-sectional qualitative study using semi-structured interviews with individuals who had been offered immediate ART after HIV diagnosis at a safety-net HIV clinic in San Francisco and a federally qualified health center in Chicago. Interviews were analyzed using thematic analysis. Results Among 40 participants with age range 19-52 years, 27% of whom were cisgender/transgender women or gender-queer, 85% racial/ethnic minority, and 45% homeless/unstably housed, we identified 3 major themes: (1) Individuals experienced immediate ART encounters as supportive; (2) individuals viewed immediate ART as sensible; and (3) immediate ART offered emotional relief by offsetting fears of death and providing agency over one's health. Reasons for declining immediate ART ranged from simply needing a few more days to complex interactions of logistical and psychosocial barriers. Conclusions Immediate ART was highly acceptable to urban persons with newly diagnosed HIV infection. Immediate ART was viewed as a natural next step after HIV diagnosis and provided a sense of control over one's health, mitigating anxiety over a decline in physical health. As such, immediate ART somewhat eased but in no way obviated the psychosocial challenges of HIV diagnosis.
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Affiliation(s)
| | - Xavier A Erguera
- University of California, San Francisco, San Francisco, California, USA
| | | | - Chadwick Campbell
- University of California, San Francisco, San Francisco, California, USA
| | - Maya Green
- Howard Brown Health, Chicago, Illinois, USA
| | | | - John Schneider
- Howard Brown Health, Chicago, Illinois, USA.,University of Chicago, Chicago, Illinois, USA
| | - Susa Coffey
- University of California, San Francisco, San Francisco, California, USA
| | - Oliver Bacon
- University of California, San Francisco, San Francisco, California, USA.,San Francisco Department of Public Health, San Francisco, California, USA
| | - Monica Gandhi
- University of California, San Francisco, San Francisco, California, USA
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Longitudinal analysis of sociodemographic, clinical and therapeutic factors of HIV-infected individuals in Kinshasa at antiretroviral therapy initiation during 2006-2017. PLoS One 2021; 16:e0259073. [PMID: 34739506 PMCID: PMC8570501 DOI: 10.1371/journal.pone.0259073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/12/2021] [Indexed: 11/22/2022] Open
Abstract
Background The benefits of antiretroviral therapy (ART) underpin the recommendations for the early detection of HIV infection and ART initiation. Late initiation (LI) of antiretroviral therapy compromises the benefits of ART both individually and in the community. Indeed, it promotes the transmission of infection and higher HIV-related morbidity and mortality with complicated and costly clinical management. This study aims to analyze the evolutionary trends in the median CD4 count, the median time to initiation of ART, the proportion of patients with advanced HIV disease at the initiation of ART between 2006 and 2017 and their factors. Methods and findings HIV-positive adults (≥ 16 years old) who initiated ART between January 1, 2006 and December 31, 2017 in 25 HIV care facilities in Kinshasa, the capital of DRC, were eligible. The data were processed anonymously. LI is defined as CD4≤350 cells/μl and/or WHO clinical stage III or IV and advanced HIV disease (AHD), as CD4≤200 cells/μl and/or stage WHO clinic IV. Factors associated with advanced HIV disease at ART initiation were analyzed, irrespective of year of enrollment in HIV care, using logistic regression models. A total of 7278 patients (55% admitted after 2013) with an average age of 40.9 years were included. The majority were composed of women (71%), highly educated women (68%) and married or widowed women (61%). The median CD4 was 213 cells/μl, 76.7% of patients had CD4≤350 cells/μl, 46.1% had CD4≤200 cells/μl, and 59% of patients were at WHO clinical stages 3 or 4. Men had a more advanced clinical stage (p <0.046) and immunosuppression (p<0.0007) than women. Overall, 70% of patients started ART late, and 25% had AHD. Between 2006 and 2017, the median CD4 count increased from 190 cells/μl to 331 cells/μl (p<0.0001), and the proportions of patients with LI and AHD decreased from 76% to 47% (p< 0.0001) and from 18.7% to 8.9% (p<0.0001), respectively. The median time to initiation of ART after screening for HIV infection decreased from 40 to zero months (p<0.0001), and the proportion of time to initiation of ART in the month increased from 39 to 93.3% (p<0.0001) in the same period. The probability of LI of ART was higher in married couples (OR: 1.7; 95% CI: 1.3–2.3) (p<0.0007) and lower in patients with higher education (OR: 0.74; 95% CI: 0.64–0.86) (p<0.0001). Conclusion Despite increasingly rapid treatment, the proportions of LI and AHD remain high. New approaches to early detection, the first condition for early ART and a key to ending the HIV epidemic, such as home and work HIV testing, HIV self-testing and screening at the point of service, must be implemented.
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Dah TTE, Yaya I, Mensah E, Coulibaly A, Kouamé JBM, Traoré I, Mora M, Palvadeau P, Anoma C, Keita BD, Spire B, Laurent C. Rapid antiretroviral therapy initiation and its effect on treatment response in MSM in West Africa. AIDS 2021; 35:2201-2210. [PMID: 34352834 PMCID: PMC8505135 DOI: 10.1097/qad.0000000000003046] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/07/2021] [Accepted: 07/17/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess the time from HIV diagnosis to ART initiation and the effect of rapid ART initiation (i.e. within 7 days of HIV diagnosis) on attrition and virologic and immunologic responses among MSM in Burkina Faso, Côte d'Ivoire, Mali, and Togo. DESIGN Prospective cohort study between 2015 and 2019. METHODS MSM aged 18 years or older newly diagnosed with HIV infection were eligible to participate. ART was proposed to participants upon HIV diagnosis, irrespective of clinical stage and CD4+ cell count, and was initiated as soon as possible, with no specific time frame. Determinants of rapid ART initiation and its effect on treatment outcomes were assessed using multivariate analyses. RESULTS Of 350 MSM, 335 (95.7%) initiated ART after a median time of 5 days. Of the latter, 216 (64.5%) had rapid ART initiation. The 335 participants were followed up for a median time of 24.1 months. One hundred and eleven (33.1%) were not retained in care. Rapid ART initiation was less likely in participants with a CD4+ cell count at least 200 cells/μl [adjusted odds ratio (aOR) 0.37, 95% confidence interval (CI) 0.15-0.88]. It improved viral load suppression (aOR 6.96, 95% CI 1.98-24.46) but had no effect on attrition (aOR 0.87, 95% CI 0.57-1.33) or CD4+ cell count increase (adjusted coefficient 28.23, 95% CI -17.00 to 73.45). CONCLUSION These results in MSM in West Africa support the WHO recommendation for rapid ART initiation. Clinics need to develop context-specific strategies for rapid ART initiation and for retaining MSM in HIV care.ClinicalTrials.gov, number NCT02626286.
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Affiliation(s)
- Ter Tiero Elias Dah
- Association African Solidarité, Ouagadougou, Burkina Faso
- TransVIHMI, Univ Montpellier, Inserm, IRD, Montpellier, France
- Institut National de Santé Publique, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Issifou Yaya
- TransVIHMI, Univ Montpellier, Inserm, IRD, Montpellier, France
| | | | | | | | - Issa Traoré
- Association African Solidarité, Ouagadougou, Burkina Faso
| | - Marion Mora
- SESSTIM, Aix Marseille Univ, Inserm, IRD, Marseille
| | | | | | | | - Bruno Spire
- SESSTIM, Aix Marseille Univ, Inserm, IRD, Marseille
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Effects of implementing universal and rapid HIV treatment on initiation of antiretroviral therapy and retention in care in Zambia: a natural experiment using regression discontinuity. Lancet HIV 2021; 8:e755-e765. [PMID: 34656208 DOI: 10.1016/s2352-3018(21)00186-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Universal testing and treatment (UTT) for all people living with HIV has only been assessed under experimental conditions in cluster-randomised trials. The public health effectiveness of UTT policies on the HIV care cascade under real-world conditions is not known. We assessed the real-world effectiveness of universal HIV treatment policies that were implemented in Zambia on Jan 1, 2017. METHODS We used data from Zambia's routine electronic health record system to analyse antiretroviral therapy (ART)-naive adults who newly enrolled in HIV care up to 1 year before and after the implementation of universal treatment (ie, Jan 1, 2016, to Jan 1, 2018) at 117 clinics supported by the Centre for Infectious Disease Research in Zambia. We used a regression discontinuity design to estimate the effects of implementing UTT on same-day ART initiation, ART initiation within 1 month, and retention on ART at 12 months (defined as clinic attendance 9-15 months after enrolment and at least 6 months on ART), under the assumption that patients presenting immediately before and after UTT implementation were balanced on both measured and unmeasured characteristics. We did an instrumental variable analysis to estimate the effect of same-day ART initiation under routine conditions on 12-month retention on ART. FINDINGS 65 673 newly enrolled patients with HIV (40 858 [62·2%] female, median age 32 years [IQR 26-39], median CD4 count 287 cells per μL [IQR 147-466]) were eligible for inclusion in the analyses; 31 145 enrolled before implementation of UTT, and 34 528 enrolled after UTT. Implementation of universal treatment increased same-day ART initiation from 41·7% to 74·8% (risk difference [RD] 33·1%, 95% CI 30·5-35·7), ART initiation by 1 month from 69·6% to 87·0% (RD 17·4%, 15·5-19·3), and 12-month retention on ART from 56·2% to 63·3% (RD 7·1%, 4·3-9·9). ART initiation rates became more uniform across patient subgroups after implementation of universal treatment, but heterogeneity in 12-month retention on ART between subgroups was unchanged. Instrumental variable analyses indicated that same-day ART initiation in routine settings led to a 15·8% increase (95% CI 12·1-19·5) in 12-month retention on ART. INTERPRETATION UTT policies implemented in Zambia increased the rapidity and uptake of ART, as well as retention on ART at 12 months, although overall retention on ART remained suboptimal. UTT policies reduced disparities in treatment initiation, but not 12-month retention on ART. Natural experiments reveal both the anticipated and unanticipated effects of real-world implementation and indicate the need for new strategies leveraging the short-term effects of UTT to cultivate long-term treatment success. FUNDING National Institutes of Health.
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Zitko P, Hojman M, Sabato S, Parenti P, Cuini R, Calanni L, Contarelli J, Teran R, Araujo V, Bakolis I, Chaverri J, Morales M, Arauz AB, Moncada W, Thormann M, Beltrán C. Antiretroviral therapy use in selected countries in Latin America during 2013-2017: results from the Latin American Workshop in HIV Study Group. Int J Infect Dis 2021; 113:288-296. [PMID: 34563708 DOI: 10.1016/j.ijid.2021.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To document antiretroviral use in Latin America during the last decade. METHODS We collected indicators from 79 HIV health care centres in 14 Latin American Spanish-speaking countries for 2013-2017. Indicators were analysed by age, sex and other characteristics and weighted by the estimated people under care (PUC) population in each country. RESULTS We gathered information on 116 299 PUC. One-third belonged to centres reporting a shortage of at least one antiretroviral therapy (ART) drug for >30 days during 2017. At end 2017, 95.1% of PUC were receiving ART. During 2013-2017, 45 329 people living with HIV were admitted to 39 centres. ART initiated during the first year after admission increased from 76.7% in 2013 to 83.8% in 2017. In 35 centres across the study period, 71.7% of PUC started ART with tenofovir disoproxil fumarate and lamivudine, and zidovudine use decreased. The third most common ART drug, EFV, reached 64.8%. Raltegravir and other alternatives increased annually to almost 10% of total use in 2017. CONCLUSIONS Initial ART in Latin America is not based on the most recent scientific evidence and recommendations; use of drugs with higher efficacy and safety profiles and guarantee of ART availability continues to be a public health challenge.
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Affiliation(s)
- Pedro Zitko
- Hospital Barros Luco Trudeau, Santiago Chile; Department of Health Services and Population Research, IoPPN, King's College London
| | - Martin Hojman
- Hospital General de Agudos "Bernardino Rivadavia", Ciudad de Buenos Aires, Argentina.
| | - Sofía Sabato
- Fundación del Centro de Estudios Infectológicos (FUNCEI), Ciudad de Buenos Aires, Argentina
| | - Pablo Parenti
- Hospital Provincial del Centenario, Rosario, Santa Fe, Argentina
| | - Rosana Cuini
- Hospital Teodoro Alvarez- Ciudad de Buenos Aires, Argentina
| | | | - Jorge Contarelli
- Centro de Estudio y Tratamiento Infectológico, La Plata, Provincia de Buenos Aires, Argentina
| | | | | | - Ioannis Bakolis
- Departments of Biostatistics and Health Informatics & Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London
| | - Jorge Chaverri
- Hospital Dr. Rafaél Ángel Calderón Guardia, San José de Costa Rica, Costa Rica
| | | | | | - Wendy Moncada
- Instituto Nacional Cardiopulmonar, Tegucigalpa, Honduras
| | - Mónica Thormann
- Hospital Salvador Bienvenido Gautier, Santo Domingo, Dominican Republic
| | - Carlos Beltrán
- Hospital Barros Luco Trudeau, Santiago Chile; Department of Health Services and Population Research, IoPPN, King's College London
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Doshi RK, Greenberg AE. Test, treat, and maintain: rapid initiation of antiretroviral therapy. AIDS 2021; 35:1867-1869. [PMID: 34397486 PMCID: PMC8459936 DOI: 10.1097/qad.0000000000002994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Rupali K Doshi
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
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Bacon O, Chin J, Cohen SE, Hessol NA, Sachdev D, Coffey S, Scheer S, Buchbinder S, Havlir DV, Hsu L. Decreased Time From Human Immunodeficiency Virus Diagnosis to Care, Antiretroviral Therapy Initiation, and Virologic Suppression during the Citywide RAPID Initiative in San Francisco. Clin Infect Dis 2021; 73:e122-e128. [PMID: 32449916 PMCID: PMC8561247 DOI: 10.1093/cid/ciaa620] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/19/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Early virologic suppression (VS) after human immunodeficiency virus (HIV) infection improves individual health outcomes and decreases onward transmission. In San Francisco, immediate antiretroviral therapy (ART) at HIV diagnosis was piloted in 2013-2014 and expanded citywide in 2015 in a rapid start initiative to link all new diagnoses to care within 5 days and start ART at the first care visit. METHODS HIV providers and linkage navigators were trained on a rapid start protocol with sites caring for vulnerable populations prioritized. Dates of HIV diagnosis, first care visit, ART initiation, and VS were abstracted from the San Francisco Department of Public Health HIV surveillance registry. RESULTS During 2013-2017, among 1354 new HIV diagnoses in San Francisco, median days from diagnosis to first VS decreased from 145 to 76 (48%; P < .0001) and from first care visit to ART initiation decreased from 28 to 1 (96%; P < .0001). By 2017, 28% of new diagnoses had a rapid start, which was independently associated with Latinx ethnicity (AOR, 1.73; 95% CI, 1.15-2.60) and recent year of diagnosis (2017; AOR, 16.84; 95% CI, 8.03-35.33). Persons with a rapid ART start were more likely to be virologically suppressed within 12 months of diagnosis than those with a non-rapid start (RR, 1.17; 95% CI, 1.10-1.24). CONCLUSIONS During a multisector initiative to optimize ART initiation, median time from diagnosis to VS decreased by nearly half. Immediate ART at care initiation was achieved across many, but not all, populations, and was associated with improved suppression rates.
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Affiliation(s)
- Oliver Bacon
- San Francisco City Clinic, Disease Prevention and Control Branch, San Francisco Department of Public Health, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Jennie Chin
- HIV Surveillance Unit, Applied Research, Community Health Epidemiology and Surveillance (ARCHES), San Francisco Department of Public Health, San Francisco, California, USA
| | - Stephanie E Cohen
- San Francisco City Clinic, Disease Prevention and Control Branch, San Francisco Department of Public Health, San Francisco, California, USA
| | - Nancy A Hessol
- School of Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Darpun Sachdev
- San Francisco City Clinic, Disease Prevention and Control Branch, San Francisco Department of Public Health, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Susa Coffey
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Susan Scheer
- HIV Surveillance Unit, Applied Research, Community Health Epidemiology and Surveillance (ARCHES), San Francisco Department of Public Health, San Francisco, California, USA
| | - Susan Buchbinder
- BridgeHIV, San Francisco Department of Public Health, San Francisco, California, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ling Hsu
- HIV Surveillance Unit, Applied Research, Community Health Epidemiology and Surveillance (ARCHES), San Francisco Department of Public Health, San Francisco, California, USA
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d'Arminio Monforte A, Tavelli A, Cozzi-Lepri A, Castagna A, Passerini S, Francisci D, Saracino A, Maggiolo F, Lapadula G, Girardi E, Perno CF, Antinori A. Virological response and retention in care according to time of starting ART in Italy: data from the Icona Foundation Study cohort. J Antimicrob Chemother 2021; 75:681-689. [PMID: 31865395 DOI: 10.1093/jac/dkz512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To describe: (i) factors associated with rapid and delayed ART initiation; (ii) rates of 12 week virological response; and (iii) virologically controlled retention in care by 1 year from ART initiation according to timing of start in a real-life setting. METHODS All individuals in the Icona cohort diagnosed with HIV in 2016-17 who initiated ART were grouped according to the time between HIV diagnosis and ART initiation: Group 1, ≤7 days; Group 2, 8-14 days; Group 3, 15-30 days; Group 4, 31-120 days; and Group 5, >120 days. Multivariable logistic regression models were used to identify factors associated with: (i) the probability of rapid (Group 1) and very delayed (Group 5) ART initiation; (ii) the 12 week virological response (by a modified snapshot algorithm); and (iii) the probability of retention in care at 1 year (on ART with HIV-RNA <50 copies/mL). RESULTS A total of 1247 individuals were included [82 (6.6%) in Group 1, 115 (9.2%) in Group 2, 267 (21.4%) in Group 3, 641 (51.4%) in Group 4 and 142 (11.4%) in Group 5]. Main predictors of rapid ART start (Group 1) were low CD4 cell count and high HIV-RNA at first contact with the infectious diseases centre. There was no association between probability of virological response and timing of ART initiation. Overall, 90% of individuals remained on ART after 1 year, 91% with undetectable HIV-RNA. Participants of Italian nationality, those with higher CD4 cell count and lower HIV-RNA at ART initiation were more likely to be retained in care after 1 year. CONCLUSIONS In our high-income observational setting, we did not observe differences in the 1 year rate of virological response and retention in care according to timing of ART initiation.
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Affiliation(s)
- Antonella d'Arminio Monforte
- ASST Santi Paolo e Carlo, University of Milan, Clinic of Infectious and Tropical Diseases, Department of Health Sciences, Milan, Italy
| | | | - Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, UCL, London, UK
| | - Antonella Castagna
- Division of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Simone Passerini
- III Division of Infectious Diseases, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | - Annalisa Saracino
- Department of Infectious Diseases, Policlinic Hospital, University of Bari 'Aldo Moro', Bari, Italy
| | - Franco Maggiolo
- Division of Infectious Diseases, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Lapadula
- Clinic of Infectious Diseases, ASST Monza San Gerardo Hospital, University Milano-Bicocca, Monza, Italy
| | - Enrico Girardi
- Clinical Epidemiology Unit, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | | | - Andrea Antinori
- HIV/AIDS Clinical Unit, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
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Bogdanić N, Bendig L, Lukas D, Zekan Š, Begovac J. Timeliness of antiretroviral therapy initiation in the era before universal treatment. Sci Rep 2021; 11:10508. [PMID: 34006927 PMCID: PMC8131373 DOI: 10.1038/s41598-021-90043-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 05/06/2021] [Indexed: 11/08/2022] Open
Abstract
We assessed the prevalence and factors related to the time to antiretroviral (ART) initiation among persons who entered HIV care and subsequently started ART in Croatia from 2005 to 2014. Included were patients ≥ 18 years, the follow-up ended on Dec/31/2017. 628 patients were included into the study 91.9% were men; median age was 36.1 (Q1-Q3: 29.6-43.8) years. Rapid (within 7 days of diagnosis) ART initiation was observed in 21.8% patients, 49.8% initiated ART within 30 days, 21.7% and 28.5% had intermediate (31 days-1 year) and late initiation (> 1 year), respectively. Of 608 patients that achieved an undetectable viral load, 94% had a plasma HIV-1 RNA < 50 copies/ml at last measurement after a median follow-up of 5.2 years. On quantile regression analysis, calendar year of entry into care, and markers of more advanced HIV disease (higher viral load, lower CD4 cell count and clinical AIDS) were significantly associated with earlier ART initiation. Early ART was not related to a gap in care afterwards at all quantiles. In conclusion, a significant proportion of patients started ART early in Croatia in 2005-2014. Early ART initiation led to durable viral load suppression and was not associated with a subsequent gap in care.
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Affiliation(s)
- Nikolina Bogdanić
- University Hospital for Infectious Diseases, Mirogojska 8, Zagreb, Croatia
| | - Liam Bendig
- Medical Scholars Program, AU/UGA Medical Partnership, Athens, GA, USA
| | - Davorka Lukas
- University Hospital for Infectious Diseases, Mirogojska 8, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Šime Zekan
- University Hospital for Infectious Diseases, Mirogojska 8, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Josip Begovac
- University Hospital for Infectious Diseases, Mirogojska 8, Zagreb, Croatia.
- University of Zagreb School of Medicine, Zagreb, Croatia.
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Dolutegravir Plus Lamivudine Two-Drug Regimen: Safety, Efficacy and Diagnostic Considerations for Its Use in Real-Life Clinical Practice-A Refined Approach in the COVID-19 Era. Diagnostics (Basel) 2021; 11:diagnostics11050809. [PMID: 33947009 PMCID: PMC8145545 DOI: 10.3390/diagnostics11050809] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/17/2022] Open
Abstract
The diagnostic and therapeutic management of the Coronavirus Disease 2019 (COVID-19) pandemic in the HIV population brought some known criticalities (and opportunities) to the forefront, for both those who are facing their first therapeutic line today, and for those already well viro-suppressed. The clinical, socioeconomic, and psychological impact of the COVID-19 pandemic should not affect the long-term care of people living with HIV, which creates an urgent need to optimize the diagnostic and treatment approach to the first-line or switch regimens. The use of dolutegravir plus a lamivudine two-drug regimen is one of the most promising solutions to ease the management of HIV treatment in this difficult period. In this review, we report the most salient features related to the use of this regimen from real-life cohorts, meta-analyses, randomized clinical trials, and studies presented at international conferences up to March 2021. We focused on the diagnostic and clinical-management implications of its use in real life, and how these comply with the contingent historical situation. The issue of the timing and type of diagnostic procedures and the relevance of classical diagnostic tests (such as genotype for resistance detection) is also discussed. According to the currently available results, dolutegravir plus a lamivudine two-drug regimen represents an outstanding tool, whose expected advantages fulfill the current requirements for optimal daily care of our HIV patients.
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Amstutz A, Brown JA, Ringera I, Muhairwe J, Lejone TI, Klimkait T, Glass TR, Labhardt ND. Engagement in Care, Viral Suppression, Drug Resistance, and Reasons for Nonengagement After Home-Based Same-Day Antiretroviral Therapy Initiation in Lesotho: A Two-Year Follow-up of the CASCADE Trial. Clin Infect Dis 2021; 71:2608-2614. [PMID: 31781759 PMCID: PMC7745003 DOI: 10.1093/cid/ciz1126] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/13/2019] [Indexed: 12/02/2022] Open
Abstract
Background The CASCADE trial showed that compared with usual care (UC), offering same-day (SD) antiretroviral therapy (ART) during home-based human immunodeficiency virus testing improved engagement in care and viral suppression 12 months after diagnosis. However, questions remain regarding long-term outcomes and the risk of propagating drug resistance. Methods After completion of the primary endpoint at 12 months, participants not in care in both arms were traced and encouraged to access care. At 24 months, the following outcomes were assessed in both arms: engagement in care, viral suppression, and reasons for nonengagement. Furthermore, we explored the acquisition of drug resistance mutations (DRMs) among SD arm nonlinkers. Results At 24 months, 64% (88/137) in the SD arm vs 59% (81/137) in the UC arm were in care (absolute difference [AD], 5%; 95% confidence interval [CI], −6 to16; P = .38) and 57% (78/137) vs 54% (74/137) had documented viral suppression (AD, 3%; 95% CI, −9 to 15; P = .28). Among 36 participants alive and not in care at 24 months with ascertained status, the majority rejected contact with the health system or were unwilling to take ART. Among 8 interviewed SD arm nonlinkers, 6 had not initiated ART upon enrollment, and no acquired DRMs were detected. Two had taken the initial 30-day ART supply and acquired DRMs. Conclusions SD ART resulted in higher rates of engagement in care and viral suppression at 12 months but not at 24 months. Leveling off between both arms was driven by linkage beyond 12 months in the UC arm. We did not observe compensatory long-term disengagement in the SD arm. These long-term results endorse SD ART initiation policies. Clinical Trials Registration NCT02692027.
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Affiliation(s)
- Alain Amstutz
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Jennifer Anne Brown
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | | | | | | | - Thomas Klimkait
- University of Basel, Basel, Switzerland.,Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Tracy Renée Glass
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Tarigan YN, Woodman RJ, Miller ER, Wisaksana R, Ward PR. Impact of strategic use of antiretroviral therapy intervention to the HIV continuum of care in 13 cities in Indonesia: an interrupted time series analysis. AIDS Res Ther 2021; 18:22. [PMID: 33902631 PMCID: PMC8074419 DOI: 10.1186/s12981-021-00340-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/08/2021] [Indexed: 12/01/2022] Open
Abstract
Background In 2013 the Indonesian government introduced the strategic use of antiretroviral therapy (SUFA) initiative of expanding access to HIV test and treatment, to help achieve the UNAIDS 90–90–90 targets. However, there has been no comprehensive evaluation of the impact of this intervention in Indonesia. We conducted an interrupted time series (ITS) analysis across 6-years to assess its immediate and medium-term impact. Methods Monthly aggregated HIV data from all HIV care clinics for persons aged ≥ 15 years were collected from 13 pilot cities. The data period encompassed 3-years prior to SUFA (26 Dec 2010–25 Dec 2013) and 3-years post-SUFA (26 Dec 2013–25 Dec 2016). The ITS was performed using a multilevel negative binomial regression model to assess the immediate and trend changes in each stage of the HIV continuum of care. Results In the pre-SUFA period, the overall coverage in the respective risk populations for HIV tests, cases, enrolments, eligible cases and ARV initiation were 1.0%, 8.6%, 98.9%, 76.9% and 75.8% respectively. In the post-SUFA period coverage was 3%, 3.8%, 98.6%, 90.3% and 81.2% respectively—with a significant increase in the median number of HIV tests, HIV cases, those eligible for ARV treatment and treatment initiation (p < 0.05 for each). The ITS analysis demonstrated immediate increases in HIV tests (IRR = 1.41, 95% CI 1.25, 1.59; p < 0.001) and an immediate decrease in detected HIV cases per person tested (IRR = 0.77, 95% CI 0.69–0.86; p < 0.001) in the month following commencement of SUFA. There was also a 3% decline in the monthly trend for HIV tests performed (IRR = 0.97; 95% CI 0.97–0.98, p < 0.001), a 1% increase for detected cases (IRR = 1.01, 95% CI 1.0–1.02, p < 0.001), and a 1% decline for treatment initiation (IRR = 0.99,95% CI 0.99–1.0 p < 0.05). Conclusions SUFA was associated with an immediate and sustained increase in the absolute number of HIV tests performed, detected HIV cases, and close to complete coverage of detected cases that were enrolled to care and defined as eligible for treatment. However, treatment initiation remained sub-optimal. The findings of this study provide valuable information on the real-world effect of accelerating ARV utilizing Treatment as Prevention for the full HIV continuum of care in limited resource countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00340-4.
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Bachanas P, Alwano MG, Lebelonyane R, Block L, Behel S, Raizes E, Ussery G, Wang H, Ussery F, Pretorius Holme M, Sexton C, Pals S, Lasry A, Del Castillo L, Hader S, Lockman S, Bock N, Moore J. Finding, treating and retaining persons with HIV in a high HIV prevalence and high treatment coverage country: Results from the Botswana Combination Prevention Project. PLoS One 2021; 16:e0250211. [PMID: 33882092 PMCID: PMC8059857 DOI: 10.1371/journal.pone.0250211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/02/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION The scale-up of Universal Test and Treat has resulted in reductions in HIV morbidity, mortality and incidence. However, healthcare system and personal challenges have impacted the levels of treatment coverage achieved. We implemented interventions to improve linkage to care, retention, viral load (VL) coverage and service delivery, and describe the HIV care cascade over the course of the Botswana Combination Prevention Project (BCPP) study. METHODS BCPP was designed to evaluate the impact of prevention interventions on HIV incidence in 30 communities in Botswana. We followed a longitudinal cohort of newly identified and known HIV-positive persons not on antiretroviral therapy (ART) identified through community-based testing activities through BCPP and referred with appointments to local HIV clinics in 15 intervention communities. Those who did not keep the first or follow-up appointments were tracked and traced through phone and home contacts. Improvements to service delivery models in the intervention clinics were also implemented. RESULTS A total of 3,657 newly identified or HIV-positive persons not on ART were identified and referred to their local HIV clinic; 90% (3,282/3,657) linked to care and of those, 93% (3,066/3,282) initiated treatment. Near the end of the study, 221 persons remained >90 days late for appointments or missing. Tracing efforts identified 54/3,066 (2%) persons who initiated treatment but died, and 106/3,066 (3%) persons were located and returned to treatment. At study end, 61/3,066 (2%) persons remained missing and were never reached. Overall, 2,951 (98%) persons living with HIV (PLHIV) who initiated treatment were still alive, retained in care and still receiving ART out of the 3,001 persons alive at the end of the study. Of those on ART, 2,854 (97%) had current VL results and 2,784 (98%) of those were virally suppressed at study end. CONCLUSIONS This study achieved high rates of linkage, treatment initiation, retention and VL coverage and suppression in a cohort of newly identified and known PLHIV not on ART. Tracking and tracing interventions effectively identified those persons who needed more resource intensive follow-up. The interventions implemented to improve service delivery and data quality may have also contributed to high linkage and retention rates. Clinical trial number: NCT01965470.
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Affiliation(s)
- Pamela Bachanas
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Mary Grace Alwano
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Gaborone, Botswana
| | | | - Lisa Block
- Northrup Grumman, Atlanta, Georgia, United States of America
| | - Stephanie Behel
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Elliot Raizes
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Gene Ussery
- Northrup Grumman, Atlanta, Georgia, United States of America
| | - Huisheng Wang
- Northrup Grumman, Atlanta, Georgia, United States of America
| | - Faith Ussery
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Molly Pretorius Holme
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Connie Sexton
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Sherri Pals
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Arielle Lasry
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Lisetta Del Castillo
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Gaborone, Botswana
| | | | - Shahin Lockman
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Naomi Bock
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Janet Moore
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Boeke CE, Joseph J, Wang M, Abate ZM, Atem C, Coulibaly KD, Kebede A, Kiernan B, Kingwara L, Mangwendeza P, Maparo T, Mbaye RN, Mukungunugwa S, Ngugi C, Nzuobontane D, Okomo Assoumou MC, Reta Y, Wambugu B, Rioja MR, Peter T, Doi N, Vojnov L, Khan S, Sacks JA. Point-of-care testing can achieve same-day diagnosis for infants and rapid ART initiation: results from government programmes across six African countries. J Int AIDS Soc 2021; 24:e25677. [PMID: 33745234 PMCID: PMC7981587 DOI: 10.1002/jia2.25677] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/15/2021] [Accepted: 01/27/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Point-of-care (POC) early infant diagnosis (EID) testing has been shown to dramatically decrease turnaround times from sample collection to caregiver result receipt and time to ART initiation for HIV-positive infants compared to centralized laboratory testing. As governments in sub-Saharan Africa implement POC EID technologies, we report on the feasibility and effectiveness of POC EID testing and the impact of same-day result delivery on rapid ART initiation within national programmes across six countries. METHODS This pre-/post-evaluation compared centralized laboratory-based (pre) with POC (post) EID testing in 52 facilities across Cameroon, Democratic Republic of Congo, Ethiopia, Kenya, Senegal and Zimbabwe between April 2017 and October 2019 (country-dependent). Data were collected retrospectively from routine records at health facilities for all infants tested under two years of age. Hazard ratios and 95% confidence intervals were calculated to compare time-to-event outcomes, visualized with Kaplan-Meier curves, and the Somers' D test was used to compare continuous outcomes. RESULTS Data were collected for 2892 EID tests conducted on centralized laboratory-based platforms and 4610 EID tests on POC devices with 127 (4%) and 192 (4%) HIV-positive infants identified, respectively. POC EID significantly reduced the time from sample collection to caregiver result receipt (POC median: 0 days, IQR: 0 to 0 vs. centralized: 35 days, IQR: 26 to 56) and time from sample collection to ART initiation for HIV-positive infants (POC median: 1 day, IQR: 0 to 7 vs. centralized: 39 days, IQR: 26 to 57). With POC testing, 72% of infants received results on the same day as sample collection; HIV-positive infants with a same-day diagnosis had six times the rate of ART initiation compared to those diagnosed one or more days after sample collection (HR: 6.39; 95% CI: 3.44 to 11.85). CONCLUSIONS Same-day diagnosis and treatment initiation for infants is possible with POC EID within routine government-led and -supported public sector healthcare facilities in resource-limited settings. Given that POC EID allows for rapid ART initiation, aligning to the World Health Organization's recommendation of ART initiation within seven days, its use in public sector programmes has the potential to reduce overall mortality for infants with HIV through early treatment initiation.
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Affiliation(s)
| | | | | | | | | | - Khady Diatou Coulibaly
- Division de la Lutte Contre le SIDA et les ISTMinistère de la Santé et de l’Action SocialeDakarSenegal
| | - Adisu Kebede
- Ethiopian Public Health InstituteAddis AbabaEthiopia
| | | | - Leonard Kingwara
- National HIV Reference LabNairobiKenya
- National AIDS and STI Control Programme (NASCOP)NairobiKenya
| | | | | | | | | | - Catherine Ngugi
- National AIDS and STI Control Programme (NASCOP)NairobiKenya
| | | | | | | | - Barbara Wambugu
- National AIDS and STI Control Programme (NASCOP)NairobiKenya
| | | | | | - Naoko Doi
- Clinton Health Access InitiativeBostonMAUSA
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Jopling R, Nyamayaro P, Andersen LS, Kagee A, Haberer JE, Abas MA. A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries. Curr HIV/AIDS Rep 2021; 17:529-546. [PMID: 32776179 PMCID: PMC7497365 DOI: 10.1007/s11904-020-00511-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review We reviewed interventions to improve uptake and adherence to antiretroviral therapy (ART) in African countries in the Treat All era. Recent Findings ART initiation can be improved by facilitated rapid receipt of first prescription, including community-based linkage and point-of-care strategies, integration of HIV care into antenatal care and peer support for adolescents. For people living with HIV (PLHIV) on ART, scheduled SMS reminders, ongoing intensive counselling for those with viral non-suppression and economic incentives for the most deprived show promise. Adherence clubs should be promoted, being no less effective than facility-based care for stable patients. Tracing those lost to follow-up should be targeted to those who can be seen face-to-face by a peer worker. Summary Investment is needed to promote linkage to initiating ART and for differentiated approaches to counselling for youth and for those with identified suboptimal adherence. More evidence from within Africa is needed on cost-effective strategies to identify and support PLHIV at an increased risk of non-adherence across the treatment cascade. Electronic supplementary material The online version of this article (10.1007/s11904-020-00511-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca Jopling
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Primrose Nyamayaro
- Department of Psychiatry, University of Zimbabwe College of Health Sciences, Mazowe Street, Avondale, Harare, Zimbabwe
| | - Lena S Andersen
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital Anzio Road, Observatory, Cape Town, South Africa
| | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Stellenbosch, 7602, South Africa
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Melanie Amna Abas
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
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Mody A, Glidden DV, Eshun-Wilson I, Sikombe K, Simbeza S, Mukamba N, Somwe P, Beres LK, Pry J, Bolton-Moore C, Padian N, Holmes CB, Sikazwe I, Geng EH. Longitudinal Care Cascade Outcomes Among People Eligible for Antiretroviral Therapy Who Are Newly Linking to Care in Zambia: A Multistate Analysis. Clin Infect Dis 2020; 71:e561-e570. [PMID: 32173743 PMCID: PMC7744998 DOI: 10.1093/cid/ciaa268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/13/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Retention in human immunodeficiency virus (HIV) care is dynamic, with patients frequently transitioning in and out of care. Analytical approaches (eg, survival analyses) commonly used to assess HIV care cascade outcomes fail to capture such transitions and therefore incompletely represent care outcomes over time. METHODS We analyzed antiretroviral therapy (ART)-eligible adults newly linking to care at 64 clinics in Zambia between 1 April 2014 and 31 July 2015. We used electronic medical record data and supplemented these with updated care outcomes ascertained by tracing a multistage random sample of patients lost to follow-up (LTFU, >90 days late for last appointment). We performed multistate analyses, incorporating weights from sampling, to estimate the prevalence of 9 care states over time since linkage with respect to ART initiation, retention in care, transfers, and mortality. RESULTS In sum, 23 227 patients (58% female; median age 34 years [interquartile range 28-41]) were ART-eligible at enrollment. At 1 year, 75.2% had initiated ART and were in care: 61.8% were continuously retained, 6.1% had reengaged after LTFU, and 7.3% had transferred. Also, 10.1% were LTFU within 7 days of enrollment, and 15.2% were LTFU at 1 year (6.7% prior to ART). One year after LTFU, 51.6% of those LTFU prior to ART remained out of care compared to 30.2% of those LTFU after initiating ART. Overall, 6.9% of patients had died by 1 year with 3.0% dying prior to ART. CONCLUSION Multistate analyses provide more complete assessments of longitudinal HIV cascade outcomes and reveal treatment gaps at distinct timepoints in care that will still need to be addressed even with universal treatment.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Sandra Simbeza
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Laura K Beres
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Jake Pry
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, USA
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, California, USA
| | - Charles B Holmes
- Department of Medicine, Georgetown University, Washington, D.C., USA
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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49
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Mgbako O, E. Sobieszczyk M, Olender S, Gordon P, Zucker J, Tross S, Castor D, H. Remien R. Immediate Antiretroviral Therapy: The Need for a Health Equity Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197345. [PMID: 33050039 PMCID: PMC7579579 DOI: 10.3390/ijerph17197345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 12/27/2022]
Abstract
Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as possible after diagnosis, has recently been recommended by global and national clinical care guidelines for patients newly diagnosed with human immunodeficiency virus (HIV). Based on San Francisco’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) model, most iART programs in the US condense ART initiation, insurance acquisition, housing assessment, and mental health and substance use evaluation into an initial visit. However, the RAPID model does not explicitly address structural racism and homophobia, HIV-related stigma, medical mistrust, and other important factors at the time of diagnosis experienced more poignantly by African American, Latinx, men who have sex with men (MSM), and transgender patient populations. These factors negatively impact initial and subsequent HIV care engagement and exacerbate significant health disparities along the HIV care continuum. While iART has improved time to viral suppression and linkage to care rates, its association with retention in care and viral suppression, particularly in vulnerable populations, remains controversial. Considering that in the US the HIV epidemic is sharply defined by healthcare disparities, we argue that incorporating an explicit health equity approach into the RAPID model is vital to ensure those who disproportionately bear the burden of HIV are not left behind.
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Affiliation(s)
- Ofole Mgbako
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
- Correspondence:
| | - Magdalena E. Sobieszczyk
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Susan Olender
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Peter Gordon
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Jason Zucker
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Susan Tross
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
| | - Delivette Castor
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
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50
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Nel J, Dlamini S, Meintjes G, Burton R, Black JM, Davies NECG, Hefer E, Maartens G, Mangena PM, Mathe MT, Moosa MY, Mulaudzi MB, Moorhouse M, Nash J, Nkonyane TC, Preiser W, Rassool MS, Stead D, van der Plas H, van Vuuren C, Venter WDF, Woods JF. Southern African HIV Clinicians Society guidelines for antiretroviral therapy in adults: 2020 update. South Afr J HIV Med 2020; 21:1115. [PMID: 33101723 PMCID: PMC7564911 DOI: 10.4102/sajhivmed.v21i1.1115] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jeremy Nel
- Helen Joseph Hospital, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Sipho Dlamini
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Rosie Burton
- Southern African Medical Unit, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - John M Black
- Department of Medicine, Division of Infectious Diseases, Livingstone Tertiary Hospital, Port Elizabeth, South Africa
| | | | - Eric Hefer
- Private Practice Medical Adviser, Johannesburg, South Africa
| | - Gary Maartens
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Phetho M Mangena
- Department of Internal Medicine, School of Medicine, Pietersburg Hospital, Polokwane, South Africa.,Department of Medicine, School of Medicine, University of Limpopo, Turfloop, South Africa
| | | | - Mahomed-Yunus Moosa
- Department of Infectious Diseases, Division of Internal Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Michelle Moorhouse
- Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Nash
- Specialist Family Physician, Amathole District Clinical Specialist Team, East London, South Africa
| | - Thandeka C Nkonyane
- Department of Infectious Diseases, Faculty of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Department of Medicine, Dr George Mokhari Hospital, Pretoria, South Africa
| | - Wolfgang Preiser
- Department of Medical Virology, National Health Laboratory Service, Tygerberg, South Africa.,Department of Pathology, Faculty of Medicine and Health, Stellenbosch University, Cape Town, South Africa
| | - Mohammed S Rassool
- Clinical HIV Research Unit, Wits Health Consortium, Johannesburg, South Africa
| | - David Stead
- Department of Medicine, Faculty of Infectious Diseases, Frere and Cecilia Makiwane Hospitals, East London, South Africa.,Department of Medicine, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
| | - Helen van der Plas
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Cloete van Vuuren
- Department of Internal Medicine, Military Hospital, Bloemfontein, South Africa.,Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joana F Woods
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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