Effect of immediate initiation of antiretroviral therapy on risk of severe bacterial infections in HIV-positive people with CD4 cell counts of more than 500 cells per μL: secondary outcome results from a randomised controlled trial

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

COPD in People with HIV: Epidemiology, Pathogenesis, Management, and Prevention Strategies

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by airflow limitation and persistent respiratory symptoms. People with HIV (PWH) are particularly vulnerable to COPD development; PWH have demonstrated both higher rates of COPD and an earlier and more rapid decline in lung function than their seronegative counterparts, even after accounting for differences in cigarette smoking. Factors contributing to this HIV-associated difference include chronic immune activation and inflammation, accelerated aging, a predilection for pulmonary infections, alterations in the lung microbiome, and the interplay between HIV and inhalational toxins. In this review, we discuss what is known about the epidemiology and pathobiology of COPD among PWH and outline screening, diagnostic, prevention, and treatment strategies.

HIV-1 treatment timing shapes the human intestinal memory B-cell repertoire to commensal bacteria

HIV-1 infection causes severe alterations of gut mucosa, microbiota and immune system, which can be curbed by early antiretroviral therapy. Here, we investigate how treatment timing affects intestinal memory B-cell and plasmablast repertoires of HIV-1-infected humans. We show that only class-switched memory B cells markedly differ between subjects treated during the acute and chronic phases of infection. Intestinal memory B-cell monoclonal antibodies show more prevalent polyreactive and commensal bacteria-reactive clones in late- compared to early-treated individuals. Mirroring this, serum IgA polyreactivity and commensal-reactivity are strongly increased in late-treated individuals and correlate with intestinal permeability and systemic inflammatory markers. Polyreactive blood IgA memory B cells, many of which egressed from the gut, are also substantially enriched in late-treated individuals. Our data establish gut and systemic B-cell polyreactivity to commensal bacteria as hallmarks of chronic HIV-1 infection and suggest that initiating treatment early may limit intestinal B-cell abnormalities compromising HIV-1 humoral response.

Instruments to assess adherence to medication in people living with HIV: a scoping review

OBJECTIVE

To compile the instruments validated in Brazil for assessing adherence of people living with HIV to antiretroviral therapy.

METHODS

Scoping review using the Web of Science, Scopus, Medline (via PubMed), Embase, BDENF, CINAHL and Lilacs databases. In addition, the Preprints bioRxiv, Google Scholar and OpenGrey servers were checked. There was no language restriction for the search, and it considered articles published from the year 1996 onwards.

RESULTS

Three publications were included in the qualitative synthesis. Following were the instruments identified "Questionário para Avaliação da Adesão ao Tratamento Antirretroviral" (Questionnaire for Assessment of Adherence to Antiretroviral Treatment) developed in Porto Alegre (RS) and published in 2007; the "Escala de autoeficácia para adesão ao tratamento antirretroviral em crianças e adolescentes com HIV/Aids" (Self-efficacy Scale for Adherence to Antiretroviral Treatment in Children and Adolescents with HIV/Aids) developed in São Paulo (SP) and published in 2008; and the "WebAd-Q, um instrumento de autorrelato para monitorar a adesão à terapia antirretroviral em serviços de HIV/Aids no Brasil" (WebAd-Q, a self-report instrument to monitor adherence to antiretroviral therapy in HIV/Aids services in Brazil) developed in São Bernardo do Campo (SP) and published in 2018. The instruments were validated in Brazil, and presented statistically acceptable values for psychometric qualities.

CONCLUSION

The instruments to assess adherence of people living with HIV to antiretroviral therapy are validated strategies for the Brazilian context. However, their (re)use in different settings and contexts of the nation should be expanded. The use of these instruments by health professionals can improve the understanding of factors that act negatively and positively on antiretroviral therapy adherence, and the proposition of strategies intended to consolidate good adherence and intervene in the treatment of people with low therapeutic engagement.

The contribution of late HIV diagnosis on the occurrence of HIV-associated tuberculosis

OBJECTIVES

To describe the timing of tuberculosis (TB) presentation in relation to diagnosis of HIV infection and antiretroviral therapy (ART) initiation and to evaluate whether the established impact from late presentation to care and late initiation of ART on the risk of TB is retained beyond the observation period of clinical trials.

DESIGN

We used marginal structural models to emulate a clinical trial with up to 5 years of follow-up to evaluate the impact of late initiation on TB risk.

METHODS

People with HIV (PWH) were enrolled from 2007 to 2016 in observational cohorts from Uganda, Peru, Mexico and Italy. The risk of TB was compared in LP (accessing care with CD4 + cell count ≤350 cells/μl) vs. nonlate presentation using survival curves and a weighted Cox regression. We emulated two strategies: initiating ART with CD4 + cell count less than 350 cells/μl vs. CD4 + cell count at least 350 cells/μl (late initiation). We estimated TB attributable risk and population attributable fraction up to 5 years from the emulated date of randomization.

RESULTS

Twenty thousand one hundred and twelve patients and 1936 TB cases were recorded. Over 50% of TB cases were diagnosed at presentation for HIV care. More than 50% of the incident cases of TB after ART initiation were attributable to late presentation; nearly 70% of TB cases during the first year of follow-up could be attributed to late presentation and more than 50%, 5 years after first attending HIV care.

CONCLUSION

Late presentation accounted for a large share of TB cases. Delaying ART initiation was detrimental for incident TB rates, and the impact of late presentation persisted up to 5 years from HIV care entry.

Improved induced innate immune response after cART initiation in people with HIV

Introduction

Impairment of the innate immune function may contribute to the increased risk of bacterial and viral infections in people with HIV (PWH). In this study we aimed to investigate the induced innate immune responses in PWH prior to and after initiation of combinational antiretroviral therapy (cART). Furthermore, we aimed to investigate if the induced innate immune responses before initiation of cART were associated with CD4+ T-cell recovery one year after initiating cART.

Material and method

The induced innate immune response was assessed by the TruCulture® whole blood technique in 32 PWH before cART initiation and after 1, 6 and 12 months. To mimic bacterial and viral infections we used a panel of three stimuli (lipopolysaccharide (LPS), resiquimod (R848), and polyinosinic:polycytidylic acid (Poly I:C)) to stimulate the extracellular Toll-like receptor (TLR) 4 and the intracellular TLR7/8 and TLR3, respectively. The following cytokine responses were analyzed by Luminex 200: Tumor Necrosis Factor (TNF)-α, Interleukin (IL)-1b, IL-6, IL-8, IL-10, IL-12p40, IL17A, Interferon (IFN)-α, and IFN-γ.

Results

At baseline PWH with nadir CD4+ T-cell count <350 cell/µL had lower levels of LPS-, R848-, and Poly I:C-induced IL-6 and IFN-γ, LPS- and R848-induced TNF-α and IL-12, LPS induced IL-1b, and R848-induced IL-10 than PWH with nadir CD4+ T-cell count >350 cells/µL. The majority (>50%) had induced cytokine concentrations below the reference intervals at baseline which was most pronounced for the LPS- and Poly I:C-induced responses. The induced responses in the whole population improved after 12 months of cART, and more PWH had induced cytokine concentrations within the reference intervals after 12 months. However, the majority of PWH still had LPS-induced INF-α, INF-γ and Poly I:C-induced TNF-α and IL-6 below the reference interval. The induced innate immune responses before cART initiation were not associated with the CD4+ T-cell recovery after 12 months of cART.

Conclusion

The innate immune response was impaired in PWH, with a more pronounced impairment in PWH with low nadir CD4+ T-cell count. Initiation of cART improved the innate immune response, but compared to the reference intervals, some impairment remained in PWH without viral replication.

Benefits and Risks of Rapid Initiation of Antiretroviral Therapy: A Systematic Review and Meta-Analysis

Objectives: To compare the benefits and risks between Rapid ART and standard/delayed treatment for HIV.

Methods: Databases of PubMed, Cochrane Library, Embase and Web of science were searched from the inception to 28 October 2021. Two investigators independently screened studies related to Rapid ART, extracted data, and evaluated the literature quality. The risk of bias was assessed by Cochrane Collaboration Risk of Bias Tool and the statistical software Stata15.0 was used for meta-analysis.

Results: Ten eligible studies were included in this meta-analysis, the results showed Rapid ART was superior to standard/delayed treatment in continuing care for at least 8 months (RR = 1.13, 95%CI: 1.03∼1.25, Z = 2.44, p = 0.015), and severe bacterial infection (RR = 0.42, 95%CI: 0.25∼0.70, Z = 3.33, p = 0.001). At 12 months following treatment, there was no statistically significant difference in viral load &lt;100 copies/mL (RR = 1.05, 95%CI: 0.80∼1.39, Z = 0.35, p = 0.726), mortality (RR = 0.77, 95%CI: 0.47∼1.24, Z = 1.09, p = 0.277), or the incidence of adverse events (RR = 0.52, 95%CI: 0.16∼1.76, Z = 1.05, p = 0.294) compared with standard/delayed treatment.

Conclusion: In comparison to standard/delayed treatment, rapid ART can reduce the incidence of TB and severe bacterial infections in HIV patients. Our findings suggest that rapid ART should be utilized when clinical conditions and the patient’s physical state allow.

Systematic Review Registration: [https://inplasy.com/?s=202210004], identifier [INPLASY202210004].

Exploring the application of immunotherapy against HIV infection in the setting of malignancy: A detailed review article

According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), as of 2019, approximately 42.2 million people have died from acquired immunodeficiency syndrome (AIDS)-related illnesses since the start of the epidemic. Antiretroviral therapy (ART) has significantly reduced mortality, morbidity, and incidence of the human immunodeficiency virus (HIV)/AIDS-defining cancers, taming once-dreaded disease into a benign chronic infection. Although the treatment has prolonged the patients' survival, general HIV prevalence has increased and this increase has dovetailed with an increasing incidence of Non-AIDS-defining cancers (NADCs) among people living with HIV (PLWH). This is happening when new promising approaches in both oncology and HIV infection are being developed. This review focuses on recent progress witnessed in immunotherapy approaches against HIV-related, Non-AIDS-defining cancers (NADCs), and HIV infection.

Size of HIV-1 reservoir is associated with telomere shortening and immunosenescence in early-treated European children with perinatally acquired HIV-1

Introduction

Persistence of HIV‐1, causing chronic immune activation, is a key determinant of premature senescence. Early antiretroviral therapy (ART) has been associated with a reduced HIV‐1 reservoir in children with perinatally acquired HIV‐1 (PHIV), but its impact on the senescence process is an open question. We investigated the association between HIV‐1 reservoir and biological and immune ageing profile in PHIV enrolled in the multicentre cross‐sectional study CARMA (Child and Adolescent Reservoir Measurements on early suppressive ART) conducted within the EPIICAL (Early treated Perinatally HIV Infected individuals: Improving Children's Actual Life) consortium.

Methods

Between September 2017 and June 2018, CARMA enrolled 40 PHIV who started ART before 2 years of age and had undetectable viremia for at least 5 years before sampling date. Samples from 37 children with a median age of 13.8 years were available for this study. HIV‐1 DNA copies on CD4 cells, relative telomere length (marker of cellular senescence) and levels of T‐cell receptor rearrangement excision circle (TREC, marker of thymic output) on CD4 and CD8 cells were quantified by qPCR. Immunological profile was assessed by flow cytometry. Associations between molecular and phenotypic markers, HIV‐1 reservoir and age at ART initiation were explored using a multivariable Poisson regression.

Results

Higher HIV‐1 reservoir was associated (p<0.001) with telomere shortening (incidence rate ratio [IRR] = 0.15 [0.13–0.17]), immunosenescence (CD28^–CD57⁺, IRR = 1.23 [1.21–1.26]) and immunoactivation (CD38⁺ HLADR⁺, IRR = 7.29 [6.58–8.09]) of CD4 cells. Late ART initiation (after 6 months of age) correlated with higher HIV‐1 reservoir levels (552 [303–1001] vs. 89 [56–365] copies/10⁶ CD4 cells, p = 0.003) and percentage of CD4 senescent cells (2.89 [1.95–6.31] vs. 1.02 [0.45–2.69, p = 0.047). TREC levels in CD8 cells were inversely associated with HIV‐1 reservoir (IRR = 0.77 [0.76–0.79]) and were significantly lower in late treated PHIV (1128 [486–1671] vs. 2278 [1425–3314], p = 0.042).

Conclusions

Later ART initiation is associated with higher HIV‐1 reservoir size, which correlates with increased telomere shortening and senescence of CD4 cells. Timing of ART initiation in infancy has long‐term consequences on the immune and biological ageing profile of children with perinatally acquired HIV‐1.

High Prevalence of Fecal Carriage of Extended Spectrum β-Lactamase-Producing Enterobacteriaceae Among Newly HIV-Diagnosed Adults in a Community Setting in Tanzania

Colonization in HIV-infected populations with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) is particularly worrisome in low-income settings. This study describes the prevalence of ESBL-PE carriage and associated risk factors among newly HIV-diagnosed adults in a community setting in Tanzania. A total of 595 newly diagnosed HIV adults with a median age of 35 years with interquartile range (IQR) 29–42 years and a median CD4 count of 492 cells/μL (IQR 390–666 cells/μL) were recruited. Among these, 194/595 (32.6%, 95% confidence interval [CI] 28.9–36.6) were ESBL-PE carriers. Participants with low CD4 count (<350 cells/μL) had significantly higher prevalence of ESBL-PE carriage compared with those with CD4 count ≥350 cells/μL (26/58, 44.8%, vs. 168/537, 31.3%, p = 0.04). Antibiotic use in last 4 weeks (odds ratio [OR] 1.55, 95% CI 1.08–2.22, p = 0.02) and CD4 count ≥350 cells/μL (OR 1.78, 95% CI 1.03–3.09, p = 0.04) were independent risk factors for fecal carriage of ESBL-PE. In total, 244 isolates of ESBL-PE were isolated from 194 participants. Of these, 238/244 (97.5%) harbored bla_CTX-M genes, with bla_CTX-M-15 being predominant (219/238 (92%), followed by bla_CTX-M-27 (9/238 (3.8%), bla_CTX-M-14 (8/238 (3.4%), bla_CTX-M-55 (1/238), and bla_{CTX-M 211/3} (1/238). bla_SHV-2a genes were detected in four isolates, whereas the bla_SHV-12 gene was detected in one isolate. Phenotypic carbapenemase-producing Enterobacteriaceae was detected in one HIV-positive person with CD4 count 132 cells/μL. In conclusion prevalence of ESBL-PE carriage is high among newly diagnosed HIV adults in Dar es Salaam, and is significantly associated antibiotic use and low CD4 count.

The development of an intervention to support uptake and adherence to antiretroviral therapy in people living with HIV: the SUPA intervention. A brief report

The effectiveness of antiretroviral therapy (ART) depends on prompt uptake of treatment and a high level of adherence over the long-term, yet these behaviors are suboptimal. Previous interventions have significantly improved adherence but effect sizes are generally small. The aim of this article is to describe the design and content of an intervention to support uptake and adherence to treatment in HIV positive patients (SUPA intervention), utilizing cognitive behavioral and motivational interviewing (MI) techniques. The intervention was developed in line with Medical Research Council (MRC) guidance for the development of complex interventions and informed by the NICE (National Institute for Health and Care Excellence) Guidelines for adherence, empirical evidence and focus groups. Behavior change techniques were mapped to perceptual and practical barriers to uptake and adherence to ART, identified in previous research. Intervention materials were designed and later discussed within focus groups, where feedback enabled an iterative process of development. We conclude it is possible to transparently report the design and content of a theory-based intervention to increase uptake and adherence to ART. The intervention has been evaluated within a randomized controlled trial (RCT) at 10 HIV clinics in England, the results of which will be reported elsewhere.

The Architecture of Circulating Immune Cells Is Dysregulated in People Living With HIV on Long Term Antiretroviral Treatment and Relates With Markers of the HIV-1 Reservoir, Cytomegalovirus, and Microbial Translocation

Long-term changes in the immune system of successfully treated people living with HIV (PLHIV) remain incompletely understood. In this study, we assessed 108 white blood cell (WBC) populations in a cohort of 211 PLHIV on stable antiretroviral therapy and in 56 HIV-uninfected controls using flow cytometry. We show that marked differences exist in T cell maturation and differentiation between PLHIV and HIV-uninfected controls: PLHIV had reduced percentages of CD4+ T cells and naïve T cells and increased percentages of CD8+ T cells, effector T cells, and T helper 17 (Th17) cells, together with increased Th17/regulatory T cell (Treg) ratios. PLHIV also exhibited altered B cell maturation with reduced percentages of memory B cells and increased numbers of plasmablasts. Determinants of the T and B cell composition in PLHIV included host factors (age, sex, and smoking), markers of the HIV reservoir, and CMV serostatus. Moreover, higher circulating Th17 percentages were associated with higher plasma concentrations of interleukin (IL) 6, soluble CD14, the gut homing chemokine CCL20, and intestinal fatty acid binding protein (IFABP). The changes in circulating lymphocytes translated into functional changes with reduced interferon (IFN)- γ responses of peripheral blood mononuclear cells to stimulation with Candida albicans and Mycobacterium tuberculosis. In conclusion, this comprehensive analysis confirms the importance of persistent abnormalities in the number and function of circulating immune cells in PLHIV on stable treatment.

Impact of immediate initiation of antiretroviral therapy among men who have sex with men infected with HIV in Chengdu, southwest China: trends analysis, 2008-2018

Background

Given the rampant HIV epidemic among men who have sex with men (MSM) in Chengdu, southwest China, Treat All policy, defined as immediate antiretroviral therapy (ART) initiation after HIV diagnosis, was implemented since 2014. Real-world research evaluating impacts of immediate ART on HIV epidemics is needed to optimize policy-making as national and international guidelines have been lowering ART eligibility threshold. The purpose of this study is to: assess temporal trends of the HIV epidemic and impacts of Treat All policy among MSM; and lay foundation for HIV-related policy evaluation using longitudinal routine data from health information systems.

Methods

Data used in this study were HIV sentinel seroprevalence, annual reported HIV cases and ART coverage rate among MSM in Chengdu from 2008 to 2018, derived from national HIV/AIDS information system. Temporal trends of the HIV epidemic were described using Joinpoint Regression Program. Interrupted time-series method was deployed to evaluate Treat All policy.

Results

HIV sentinel seroprevalence rose from 11.20% in 2008 to 17.67% in 2013 and Annual Percent Change (APC) was 8.25% (95% CI − 2.40%, 20.07%), then decreased to 5.17% in 2018 (APC = − 19.63%, 95% CI − 27.54%, − 10.86%). Newly reported HIV cases increased from 168 cases in 2008 to 1232 cases in 2015 (APC = 26.99%, 95% CI 21.32%, 32.93%), and reduced to 1014 cases in 2018 (APC = − 8.80%, 95% CI − 18.45%, 2.01%). ART coverage rate has been climbing from 11.11% in 2008 to 92.29% in 2018 and Average Annual Percent Change was 16.09% (95% CI 11.76%, 20.59%). Results of interrupted time-series models showed that compared to an annual increase of 0.87% during pre-policy period, there was a decline of 3.08% (95% CI − 0.0366%, − 0.0250%) per year of HIV sentinel seroprevalence since 2014; and compared to an annual increase of 116 cases before 2014, there was an annual drop of 158 newly reported HIV cases (95% CI − 194.87%, − 121.69%) during the post-policy period.

Conclusions

Immediate ART after HIV diagnosis could potentially curb HIV transmission at population level among MSM, along with other strategies. Future assessment of HIV prevention and control policy can be carried out using routinely collected longitudinal data from health information systems.

Risk of Severe Bacterial Infection in People Living Human Immunodeficiency Virus Infection in the Combined Antiretroviral Therapy Era

BACKGROUND

Severe bacterial infections are the first cause of morbidity in people with human immunodeficiency virus (PWH). We aimed to assess their incidence and to analyze their determinants.

METHODS

We studied human immunodeficiency virus (HIV)-1-infected individuals aged at least 15 years and prospectively followed between 2006 and 2015 in the French Hospital Database on HIV. The Andersen and Gill model was used to calculate the adjusted hazard ratios (HRs), focusing on heavy alcohol use and neutrophil function-altering comorbidities.

RESULTS

Of 25 795 participants, 1414 developed 1883 severe bacterial infections. Between 2006 and 2009 and 2013 and 2015, the incidence fell from 13.2 (95% confidence interval [CI], 12.3-14.1) to 7.1 (95% CI, 6.3-7.8) per 1000 person-years. Heavy alcohol use was associated with an increased risk of severe bacterial infection (HR = 1.3, 95% CI = 1.1-1.7 for 40-80 g/day and HR = 1.6, 95% CI = 1.2-2.1 for >80 g/day), as were diabetes, chronic kidney disease, and end-stage liver disease (HR = 1.2, 95% CI = 1.0-1.4 when 1 comorbidity; HR = 2.3, 95% CI = 1.6-3.4 when more than 1 comorbidity), and nonacquired immune deficiency syndrome-defining malignancy (HR = 2.0; 95% CI, 1.6-2.4).

CONCLUSIONS

Heavy alcohol use was associated with an increased risk of severe bacterial infection, as were neutrophil function-altering comorbidities. Controlled-drinking approaches should be promoted and comorbidity management should be strengthened in PWH.

Interstitial Lung Abnormalities in People With HIV Infection and Uninfected Controls

BACKGROUND

Chest computed tomography (CT) findings in well-treated people with HIV infection (PWH) remain poorly characterized.

METHODS

Cross-sectional analysis examining interstitial chest CT findings in PWH (n = 754) and uninfected controls (n = 470).

RESULTS

HIV infection was independently associated with 1.82 (95% CI, 1.18-2.88) and 5.15 (95% CI, 1.72-22.2) higher adjusted odds of any interstitial lung abnormality and findings suspicious for interstitial lung disease, respectively.

CONCLUSIONS

HIV infection was independently associated with interstitial lung abnormalities and findings suspicious for interstitial lung disease. Whether these abnormalities develop into more recognizable disease states over time is unknown but warrants further investigation.

U.S. Hospitalization rates and reasons stratified by age among persons with HIV 2014-15

Persons with HIV (PWH) are aging. The impact of aging on healthcare utilization is unknown. The objective of this study was to evaluate hospitalization rates and reasons stratified by age among PWH in longitudinal HIV care. Hospitalization data from 2014-2015 was obtained on all adults receiving HIV care at 14 diverse sites within the HIV Research Network in the United States. Modified clinical classification software from the Agency for Healthcare Research and Quality assigned primary ICD-9 codes into diagnostic categories. Analysis performed with multivariate negative binomial regression. Among 20,608 subjects during 2014-2015, all cause hospitalization rate was 201/1000PY. Non-AIDS defining infection (non-ADI) was the leading cause for admission (44.2/1000PY), followed by cardiovascular disease (CVD) (21.2/1000PY). In multivariate analysis of all-cause admissions, the incidence rate ratio (aIRR) increased with older age (age 18-29 reference): age 30-39 aIRR 1.09 (0.90,1.32), age 40-49 1.38 (1.16,1.63), age 50-59 1.58 (1.33,1.87), and age ≥ 60 2.14 (1.77,2.59). Hospitalization rates increased significantly with age for CVD, endocrine, renal, pulmonary, and oncology. All cause hospitalization rates increased with older age, especially among non-communicable diseases (NCDs), while non-ADIs remained the leading cause for hospitalization. HIV providers should be comfortable screening for and treating NCDs.

Whatman FTA cards versus plasma specimens for the quantitation of HIV-1 RNA using two real-time PCR assays

Background

Several studies have compared the use of dried blot spot (DBS) as an alternative to plasma specimens, mainly using Whatman 903 cards as filter paper. The aim of this study was to evaluate the use of Whatman FTA card (FTA card) specimens for HIV-1 viral load testing compared to plasma specimens using two real-time PCR assays manufactured by Roche and Abbott.

Methodology

A cross-sectional study was conducted between April 2017 and September 2017 on HIV-1 patients admitted to Yalgado Ouédraogo Teaching Hospital. Paired FTA cards and plasma specimens were collected and analysed using the Abbott Real-Time HIV-1 assay (Abbott) and COBAS AmpliPrep/COBAS TaqMan v2.0 (Roche).

Results

In total, 107 patients were included. No statistical differences (P>0.05) were observed between the mean viral loads obtained from the FTA cards and those of the plasma specimens using the Roche and Abbott assays. In total, 29 samples with Roche and 15 samples with Abbott assay showed discrepant results. At viral loads of ≤1000 copies ml⁻¹, the sensitivity and specificity of the FTA cards were 78.6 and 100% with Roche, and 92.3 and 95.9% with Abbott, respectively. Both the Roche and Abbott assays showed good correlation and agreement between the FTA cards and plasma values.

Conclusion

Our study demonstrates the feasibility of using FTA card filter paper for HIV-1 viral load testing. However, further studies will be required for the validation of the use of FTA card filter paper in HIV-1 treatment monitoring.

Addressing advanced HIV disease and mortality in global HIV programming

INTRODUCTION

The US President's Emergency Plan for AIDS Relief (PEPFAR) was launched to increase access to antiretroviral treatment (ART) among people living with HIV (PLHIV) and to prevent new HIV infections globally. As new infections have decreased in many PEPFAR-supported countries, PEPFAR is increasingly focusing on understanding and decreasing mortality among PLHIV, specifically by addressing advanced HIV disease (AHD) and its attendant opportunistic infections (OIs). Several developments in identifying AHD, in preventing, diagnosing, and treating selected OIs, and in PEPFAR's support for mortality surveillance make this an opportune moment for PEPFAR to address HIV-related mortality.

DISCUSSION

AHD upon diagnosis or re-engagement in HIV care is not uncommon, and it substantially increases risk of death from OIs. The World Health Organization provides evidence-based guidelines for a package of interventions for preventing, diagnosing, and treating common OIs, including tuberculosis (TB), cryptococcal meningitis, and severe bacterial infections. PEPFAR facilitates implementation of these guidelines. To identify PLHIV with low CD4, PEPFAR plans to support expanded access to CD4 testing, including a point-of-care assay that differentiates CD4 cell count as a binary of greater than or less than 200 cells/µL. To prevent AHD-related mortality, PEPFAR supports rapid ART initiation with integrase inhibitor-based regimens and implementation and documentation of TB preventive treatment. To diagnose selected OIs, PEPFAR is implementing urine lateral flow lipoarabinomannan use to identify TB among PLHIV who have a CD4 cell count < 200 cells/µL. To treat selected OIs, PEPFAR has focused on improving patient-centered care in TB/HIV co-infection services and scaling up implementation of new drug regimens for cryptococcal meningitis. To better understand mortality, PEPFAR has introduced an indicator, TX_ML, to routinely and systematically categorize outcomes, including deaths, among PLHIV on ART.

CONCLUSIONS

PEPFAR is increasing its efforts to identify AHD; to prevent, diagnose, and treat OIs; and to track mortality in its programs. These ongoing efforts, done in collaboration with other stakeholders, seek to decrease mortality among PLHIV.

Increased Risk of Anemia, Neutropenia, and Thrombocytopenia in People With Human Immunodeficiency Virus and Well-Controlled Viral Replication

BACKGROUND

Prior to the introduction of combination antiretroviral therapy (cART), cytopenias were common in people with human immunodeficiency virus (PWH), but it is unknown if well-controlled HIV infection is a risk factor for cytopenia. In this study we aimed to determine if HIV infection is an independent risk factor for anemia, neutropenia, lymphocytopenia, and thrombocytopenia.

METHODS

PWH with undetectable viral replication and absence of chronic hepatitis infection (n = 796) were recruited from the Copenhagen Comorbidity in HIV Infection (COCOMO) study and matched uninfected controls from the Copenhagen General Population Study (n = 2388). Hematology was analyzed in venous blood samples. Logistic regression analyses adjusted for age, sex, ethnicity, smoking status, alcohol, and high-sensitivity C-reactive protein were performed to determine possible associations between HIV and cytopenias.

RESULTS

PWH had a higher prevalence of anemia (6.9% vs 3.4%, P < .001), neutropenia (1.3% vs 0.2%, P < .001), and thrombocytopenia (5.5% vs 2.7%, P < .001) compared with uninfected controls. HIV was independently associated with anemia-adjusted odds ratio (aOR) of 2.0 (95% confidence interval [CI], 1.4-3.0); neutropenia aOR, 6.3 (95% CI, 2.0-19.6); and thrombocytopenia aOR, 2.7 (95% CI, 1.8-4.2). No association was found between HIV and lymphocytopenia.

CONCLUSIONS

Cytopenia is rare in people with well-controlled HIV, but HIV remains a risk factor for anemia, neutropenia, and thrombocytopenia and requires ongoing attention and monitoring.

Pathogenesis of HIV-Related Lung Disease: Immunity, Infection, and Inflammation

Despite anti-retroviral therapy (ART), human immunodeficiency virus-1 (HIV)-related pulmonary disease continues to be a major cause of morbidity and mortality for people living with HIV (PLWH). The spectrum of lung diseases has changed from acute opportunistic infections resulting in death to chronic lung diseases for those with access to ART. Chronic immune activation and suppression can result in impairment of innate immunity and progressive loss of T cell and B cell functionality with aberrant cytokine and chemokine responses systemically as well as in the lung. HIV can be detected in the lungs of PLWH and has profound effects on cellular immune functions. In addition, HIV-related lung injury and disease can occur secondary to a number of mechanisms including altered pulmonary and systemic inflammatory pathways, viral persistence in the lung, oxidative stress with additive effects of smoke exposure, microbial translocation, and alterations in the lung and gut microbiome. Although ART has had profound effects on systemic viral suppression in HIV, the impact of ART on lung immunology still needs to be fully elucidated. Understanding of the mechanisms by which HIV-related lung diseases continue to occur is critical to the development of new preventive and therapeutic strategies to improve lung health in PLWH.

Short-term outcomes of rapid initiation of antiretroviral therapy among HIV-positive patients: real-world experience from a single-centre retrospective cohort in Taiwan

OBJECTIVES

Rapid initiation of antiretroviral therapy (ART) engenders faster viral suppression but with suboptimal rates of durable viral suppression and engagement in care, as reported by clinical trials in resource-limited settings. Real-world experience with rapid ART initiation remains limited in resource-rich settings.

DESIGN

Retrospective cohort study.

SETTING

A tertiary hospital in metropolitan Taipei, Taiwan.

PARTICIPANTS

We included 631 patients newly diagnosed as having HIV infection between March 2014 and July 2018.

MAIN OUTCOME MEASURES

Rapid ART initiation was defined as starting ART within 7 days after HIV diagnosis confirmation. HIV diagnosis, ART initiation and viral suppression dates and clinical outcome data were collected by reviewing medical records. The rates of loss to follow-up (LTFU), engagement in care and virological rebound at 12 months were compared between patients with rapid ART initiation and those with standard initiation.

RESULTS

Rapid ART initiation increased from 33.8% in 2014 to 68.3% in 2017, and the median interval between HIV diagnosis and viral suppression (HIV RNA load <200 copies/mL) decreased from 138 to 47 days. Patients with rapid ART initiation had a significantly higher rate of engagement in care at 12 months than did those with standard initiation (88.3% vs 79.0%; p=0.002). Patients aged <30 years had a higher risk of LTFU (HR: 2.19; 95% CI 1.20 to 3.98); and rapid ART initiation was associated with a lower risk of LTFU (HR: 0.41; 95% CI 0.24 to 0.83). Patients aged <30 years were more likely to acquire incident sexually transmitted infections (STIs) before achieving viral suppression.

CONCLUSIONS

Rapid ART initiation was associated with a higher rate of engagement in care at 12 months and shortened interval from diagnosis to HIV suppression. Delayed ART initiation may increase onwards HIV transmission considering the high rates of STIs.

ETHICS APPROVAL

The study was approved by the Research Ethics Committee of National Taiwan University Hospital (Registration No. 201003112R).

Treating bacterial pneumonia in people living with HIV

Introduction: Bacterial pneumonia remains an important cause of morbidity and mortality in people living with HIV (PLWH) in the antiretroviral therapy (ART) era. In addition to being immunocompromised, as reflected by low CD4 cell counts and elevated HIV viral loads, PLWH often have other behaviors associated with an increased risk of pneumonia including smoking and injected drug use. As PLWH are aging, comorbid conditions such as chronic obstructive pulmonary disease (COPD), cancers, and cardiovascular, renal and liver diseases are emerging as additional risk factors for pneumonia. Pathogens are often similar to those in HIV-uninfected individuals; however, PLWH are at risk for unusual and/or multi-drug resistant organisms causing bacterial pneumonia based, in part, on their CD4 cell counts and other exposures. Areas covered: In this review, we focus on the recognition and management of bacterial community-acquired pneumonia (CAP) in PLWH. Along with antimicrobial treatment, we discuss prevention strategies such as vaccination and smoking cessation. Expert opinion: Early initiation of ART after HIV infection can decrease the risk of pneumonia. Improved efforts at vaccination, smoking cessation, and reduction of other substance use are urgently needed in PLWH to decrease the risk for bacterial pneumonia. As PLWH are aging, comorbidities are additional risk factors for bacterial CAP.

Screening for HIV Infection in Asymptomatic, Nonpregnant Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Untreated HIV infection can result in significant morbidity, mortality, and HIV transmission. A 2012 review for the US Preventive Services Task Force (USPSTF) found antiretroviral therapy (ART) associated with improved clinical outcomes and decreased transmission risk in persons with CD4 cell counts less than 500/mm3.

OBJECTIVE

To update the 2012 review on HIV screening to inform the USPSTF.

DATA SOURCES

Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from 2012 to June 2018, with surveillance through January 2019.

STUDY SELECTION

Nonpregnant individuals 12 years and older; randomized clinical trials (RCTs) and controlled observational studies of screening vs no screening, alternative screening strategies, earlier vs later initiation of ART, and long-term harms of ART.

DATA EXTRACTION AND SYNTHESIS

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality.

MAIN OUTCOMES AND MEASURES

Mortality, AIDS events, quality of life, function, and HIV transmission; harms of screening and long-term (≥2 years) harms of ART; screening yield.

RESULTS

Eighteen new studies (5 RCTs, 11 cohort studies, and 2 systematic reviews; N = 266 563) were included, and 11 studies (2 RCTs and 9 cohort studies; N = 218 542) were carried forward from the prior USPSTF report. No study directly evaluated effects of HIV screening vs no screening on clinical outcomes or harms, or the yield of alternative screening strategies. Two newly identified RCTs conducted completely or partially in low-resource settings found ART initiation at CD4 cell counts greater than 500/mm3 associated with lower risk of a composite outcome of mortality, AIDS-defining events, or serious non-AIDS events (relative risk [RR], 0.44 [95% CI, 0.31-0.63] and RR, 0.57 [95% CI, 0.35-0.95]); results were consistent with those from a large observational study. Early ART was not associated with increased risk of cardiovascular events. Early ART initiation was associated with sustained reduction in risk of HIV transmission at 5.5 years (RR, 0.07 [95% CI, 0.02-0.22] for linked transmission). New evidence regarding the association between abacavir use and risk of cardiovascular events was inconsistent. Certain antiretroviral regimens were associated with increased risk of long-term neuropsychiatric, renal, hepatic, and bone adverse events.

CONCLUSIONS AND RELEVANCE

In nonpregnant adolescents and adults there was no direct evidence on the clinical benefits and harms of screening for HIV infections vs no screening, or the yield of repeat or alternative screening strategies. New evidence extends effectiveness of ART to asymptomatic individuals with CD4 cell counts greater than 500/mm3 and shows sustained reduction in risk of HIV transmission at longer-term follow-up, although certain ART regimens may be associated with increased risk of long-term harms.

Serious Non-AIDS Conditions in HIV: Benefit of Early ART

PURPOSE OF REVIEW

Optimal control of HIV can be achieved by early diagnosis followed by the initiation of antiretroviral therapy (ART). Two large randomised trials (TEMPRANO and START) have recently been published documenting the clinical benefits to HIV-positive adults of early ART initiation. Main findings are reviewed with a focus on serious non-AIDS (SNA) conditions.

RECENT FINDINGS

Data from the two trials demonstrated that initiating ART early in the course of HIV infection resulted in marked reductions in the risk of opportunistic diseases and invasive bacterial infections. This indicates that HIV causes immune impairment in early infection that is remedied by controlling viral replication. Intriguingly, in START, a marked reduction in risk of cancers, both infection-related and unrelated types of cancers, was observed. Like the findings for opportunistic infections, this anti-cancer effect of early ART shows how the immune system influences important pro-oncogenic processes. In START, there was also some evidence suggesting that early ART initiation preserved kidney function, although the clinical consequence of this remains unclear. Conversely, while no adverse effects were evident, the trials did not demonstrate a clear effect on metabolic-related disease outcomes, pulmonary disease, or neurocognitive function. HIV causes immune impairment soon after acquisition of infection. ART reverses this harm at least partially. The biological nature of the immune impairment needs further elucidation, as well as mechanisms and clinical impact of innate immune activation. Based on the findings from TEMPRANO and START, and because ART lowers the risk of onward transmission, ART initiation should be offered to all persons following their diagnosis of HIV.

Uptake of peer-led venue-based HIV testing sites in Sweden aimed at men who have sex with men (MSM) and trans persons: a cross-sectional survey

Objectives

HIV testing among high-risk groups is a key intervention to diagnose persons living unknowingly with HIV to enable linkage to care and effective antiretroviral treatment. This study aimed to evaluate the uptake of Testpoint, the first large-scale HIV testing programme in Sweden where peer, non-healthcare personnel offered venue-based testing. Testing was performed by staff from the Swedish Foundation for Lesbian, Gay, Bisexual and Transgender Rights (RFSL Sweden) and testing was performed at the RFSL offices, gay clubs and gay cruising areas, as well as at various gay festivals. The test was a rapid test using capillary blood from a finger prick.

Methods

A cross-sectional survey of all persons aged >18 years who came for HIV testing at one of Testpoint’s locations in Sweden between 1 February and 31 December 2016.

Results

595 respondents (96% response rate) were included. Five persons were diagnosed with HIV and referred for treatment and care. A fifth of participants had never tested for HIV before. More than half of the participants were foreign born and the median age was 31 years. About one-fifth of participants stated they would not have tested through the healthcare system if Testpoint was not available.

Conclusions

Testpoint reached their target population of young, foreign-born men who have sex with men (MSM) as well as first time testers and persons who stated that they would not have tested within the healthcare system. Such peer HIV testing outside the healthcare setting is a possible way of increasing uptake of testing in high-risk groups.

Health outcomes of asymptomatic HIV-infected pregnant women initiating antiretroviral therapy at different baseline CD4 counts in Ethiopia

OBJECTIVE

To compare health outcomes following initiation of antiretroviral therapy (ART) for asymptomatic HIV-infected pregnant women at different CD4 levels.

METHODS

We analyzed data from 706 asymptomatic HIV-infected Ethiopian women initiating ART during pregnancy between February 2012 and October 2016. The outcomes evaluated were CD4 gain, CD4 normalization (CD4 count ≥750cells/mm3) and occurrence of HIV-related clinical events after twelve months of treatment.

RESULT

On average, CD4 count (cells/mm3) increased from 391 (95% CI: 372-409) at baseline to 523 (95% CI: 495-551) after twelve months of treatment. Rate of CD4 gain was higher among women with baseline CD4 between 350 and 499 compared to CD4 ≥500 (207 versus 6, p<0.001). But women with baseline CD4 between 350 and 499 could not catch up with women with CD4 ≥500. Women with baseline CD4 ≥500 had significantly higher likelihood of achieving CD4 normalization as compared to those with CD4 between 350 and 499 (AOR=0.32, 95% CI: 0.13-0.76). No strong evidence of differential risk in the occurrence of HIV-related clinical events.

CONCLUSION

Starting ART for asymptomatic HIV-infected women with CD4 count ≥500cells/mm3 was beneficial to preserve or recover immunity after 12 months of treatment in a resource limited setting.

Bloodstream infections in patients living with HIV in the modern cART era

Retrospective multicentre study aiming at analysing the etiology, characteristics and outcome of bloodstream infections (BSI) in people living with HIV (PLWHIV) in an era of modern antiretroviral therapy. Between 2008 and 2015, 79 PLWHIV had at least 1 BSI, for a total of 119 pathogens isolated. Patients were mainly male (72.1%), previous intravenous drug users (55.7%), co-infected with HCV or HBV (58.2%) and in CDC stage C (60.8%). Gram-positive (G+) pathogens caused 44.5% of BSI, followed by Gram-negative (G−), 40.3%, fungi, 10.9%, and mycobacteria, 4.2%. Candida spp. and coagulase-negative staphylococci were the most frequent pathogens found in nosocomial BSI (17% each), while E.coli was prevalent in community-acquired BSI (25%). At the last available follow-up, (mean 3.2 ± 2.7 years) the overall crude mortality was 40.5%. Factors associated with mortality in the final multivariate analysis were older age, (p = 0.02; HR 3.8, 95%CI 1.2–11.7) CDC stage C (p = 0.02; HR 3.3, 95%CI 1.2–9.1), malignancies, (p = 0.004; HR 3.2, 95%CI 1.4–7.0) and end stage liver disease (p = 0.006; HR 3.4, 95%CI 1.4–8.0). In conclusion, the study found high mortality following BSI in PLWHIV. Older age, neoplastic comorbidities, end stage liver disease and advanced HIV stage were the main factors correlated to mortality.

Interference of DNAJB6/MRJ Isoform Switch by Morpholino Inhibits Replication of HIV-1 and RSV

The molecular chaperon MRJ (DNAJB6) exhibits two splice isoforms that have different roles in human viral infection, but the regulatory mechanism of MRJ isoform expression is yet unclear. In this study, we show that reduction of the polyadenylation factor CstF64 was correlated with the increase of the MRJ large isoform (MRJ-L) in human macrophages and elucidate the mechanism underlying CstF64-modulated MRJ isoform expression. Moreover, we exploited an antisense strategy targeting MRJ-L for virus replication. A morpholino oligonucleotide complementary to the 5′ splice site of MRJ intron 8 downregulated MRJ-L expression and suppressed the replication of not only HIV-1 but also respiratory syncytial virus (RSV). We demonstrated that downregulation of the MRJ-L level reduced HIV-1 replication as well as the subgenomic mRNA and viral production of RSV. The present findings that two human health-threatening viruses take advantage of MRJ-L for infection suggest MRJ-L as a potential target for broad-spectrum antiviral strategy.

Early antiretroviral therapy and daily pre-exposure prophylaxis for HIV prevention among female sex workers in Cotonou, Benin: a prospective observational demonstration study

INTRODUCTION

In sub-Saharan Africa, HIV prevalence remains high, especially among key populations. In such situations, combination prevention including clinical, behavioural, structural and biological components, as well as adequate treatment are important. We conducted a demonstration project at the Dispensaire IST, a clinic dedicated to female sex workers (FSWs) in Cotonou, on early antiretroviral therapy (E-ART, or immediate "test-and-treat") and pre-exposure prophylaxis (PrEP). We present key indicators such as uptake, retention and adherence.

METHODS

In this prospective observational study, we recruited FSWs from October 4th 2014 to December 31st 2015 and followed them until December 31st 2016. FSWs were provided with daily tenofovir disoproxil fumarate/emtricitabine (Truvada® ) for PrEP or received a first-line antiretroviral regimen as per Benin guidelines. We used generalized estimating equations to assess trends in adherence and sexual behaviour.

RESULTS

Among FSWs in the catchment area, HIV testing coverage within the study framework was 95.5% (422/442). At baseline, HIV prevalence was 26.3% (111/422). Among eligible FSWs, 95.5% (105/110) were recruited for E-ART and 88.3% (256/290) for PrEP. Overall retention at the end of the study was 59.0% (62/105) for E-ART and 47.3% (121/256) for PrEP. Mean (±SD) duration of follow-up was 13.4 (±7.9) months for E-ART and 11.8 (±7.9) months for PrEP. Self-reported adherence was over 90% among most E-ART participants. For PrEP, adherence was lower and the proportion with 100% adherence decreased over time from 78.4% to 56.7% (p-trend < 0.0001). During the 250.1 person-years of follow-up among PrEP initiators, two seroconversions occurred (incidence 0.8/100 person-years (95% confidence interval: 0.3 to 1.9/100 person-years)). The two seroconverters had stopped using PrEP for at least six months before being found HIV-infected. In both groups, there was no evidence of reduced condom use.

CONCLUSIONS

This study provides data on key indicators for the integration of E-ART and PrEP into the HIV prevention combination package already offered to FSWs in Benin. PrEP may be more useful as an individual intervention for adherent FSWs rather than a specific public health intervention. E-ART was a more successful intervention in terms of retention and adherence and is now offered to all key populations in Benin.

STUDY REGISTRATION

ClinicalTrials.gov NCT02237.

Pulmonary Infections in Immunocompromised Hosts: Clinical

Pulmonary infections in immunocompromised patients remain a significant contributor to mortality, morbidity, and health care-associated costs in such a vulnerable patient population. Their epidemiology is changing, set forth by new trends in immunosuppressive regimens and also prophylaxis. The host characteristics, presenting clinical symptomatology, along with radiographic patterns, have also evolved. The microbiology diagnostics are now enriched with nonculture methods for better identification of the causative pathogens. Chest imaging remains the cornerstone of the initial workup. Our article will examine the new trends in epidemiology, clinical findings, and diagnostics for immunocompromised patients with pulmonary infections (transplant recipients, neutropenic hosts, HIV-infected patients, and patients with autoimmune conditions). We will also review the differential diagnosis that most of the times includes malignancies and drug or radiation-related toxicities.

HIV

The benefits of combination antiretroviral therapy (cART) for HIV replication and transmission control have led to its universal recommendation. Many people living with HIV are, however, still undiagnosed or diagnosed late, especially in sub-Saharan Africa, where the HIV disease burden is highest. Further expansion in HIV treatment options, incorporating women-centred approaches, is essential to make individualised care a reality. With a longer life expectancy than before, people living with HIV are at an increased risk of developing non-AIDS comorbidities, such as cardiovascular diseases and cancers. Antiretroviral strategies are evolving towards a decrease in drug burden, and some two-drug combinations have proven efficacy for maintenance therapy. Investigational immune checkpoint inhibitors and broadly neutralising antibodies with effector functions have energised the HIV cure research field as the search for an effective vaccine continues. In this Seminar, we review advances and challenges relating to the goal of an AIDS-free world.

Community-acquired bacterial pneumonia in adult HIV-infected patients

INTRODUCTION

Despite active antiretroviral therapy (ART), community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients and incurs high health costs. Areas covered: This article reviews the most recent publications on bacterial CAP in the HIV-infected population, focusing on epidemiology, prognostic factors, microbial etiology, therapy, and prevention. The data discussed here were mainly obtained from a non-systematic review using Medline, and references from relevant articles. Expert commentary: HIV-infected patients are more susceptible to bacterial CAP. Although ART improves their immune response and has reduced CAP incidence, these patients continue to present increased risk of pneumonia in part because they show altered immunity and because immune activation persists. The risk of CAP in HIV-infected patients and the probability of polymicrobial or atypical infections are inversely associated with the CD4 cell count. Mortality in HIV-infected patients with CAP ranges from 6% to 15% but in well-controlled HIV-infected patients on ART the mortality is low and similar to that seen in HIV-negative individuals. Vaccination and smoking cessation are the two most important preventive strategies for bacterial CAP in well-controlled HIV-infected patients on ART.

Evaluation of the Utility of Point-of-Care HIV Testing on a Canadian Internal Medicine Inpatient Unit

Point-of-care (POC) HIV testing has been shown to be an acceptable method for increasing HIV testing uptake. To date, no studies have examined the use of POC testing for routine HIV screening on the medicine inpatient unit. A prospective cross-sectional study was conducted over a three-month period in July, August, and October 2016 to evaluate the prevalence of undiagnosed HIV and the attitudes towards routine POC HIV testing. Patients admitted directly to medicine inpatient teaching units at a tertiary hospital in Winnipeg, Canada, were approached for participation. The POC HIV test was administered at the bedside. Reactive and indeterminate tests were confirmed with standard serological HIV testing. Participants were given a questionnaire regarding their attitudes towards POC testing on the unit. Although no cases of previously undiagnosed HIV were identified during the study period, only 35% of participants were found to have ever had HIV testing previously. The majority of participants were satisfied with the POC testing experience and would choose to have the POC testing again. Overall, the low rate of outpatient testing highlights the need for routine HIV testing on an inpatient basis.

The WHO public health approach to HIV treatment and care: looking back and looking ahead

In 2006, WHO set forth its vision for a public health approach to delivering antiretroviral therapy. This approach has been broadly adopted in resource-poor settings and has provided the foundation for scaling up treatment to over 19·5 million people. There is a global commitment to end the AIDS epidemic as a public health threat by 2030 and, to support this goal, there are opportunities to adapt the public health approach to meet the ensuing challenges. These challenges include the need to improve identification of people with HIV infection through expanded approaches to testing; further simplify and improve treatment and laboratory monitoring; adapt the public health approach to concentrated epidemics; and link HIV testing, treatment, and care to HIV prevention. Implementation of these key public health principles will bring countries closer to the goals of controlling the HIV epidemic and providing universal health coverage.

Immunological recovery in tuberculosis/HIV co-infected patients on antiretroviral therapy: implication for tuberculosis preventive therapy

BACKGROUND

Understanding the immune response to combination antiretroviral therapy (cART) is essential for a clear approach to tuberculosis (TB) preventive therapy. We investigated the immunological recovery in cART-treated HIV-infected patients developing TB compared to those who remained free of TB.

METHODS

We extracted data of HIV-infected patients from a multicenter cohort for the HIV clinical surveillance in Germany. No patients included in our study had TB at the beginning of the observation. Using a longitudinal mixed model, we assessed the differences in the mean change of biomarkers (CD4+ cell count, CD8+ cell count, CD4:CD8 ratio and viral load) since cART initiation in patients who remained free of TB vs. those developing TB. To detect the best-fit trajectories of the immunological biomarkers, we applied a multivariable fractional polynomials model.

RESULTS

We analyzed a total of 10,671 HIV-infected patients including 139 patients who developed TB during follow-up. The highest TB incidences were observed during the first two years since cART initiation (0.32 and 0.50 per 100 person-years). In an adjusted multivariable mixed model, we found that the average change in CD4+ cell count recovery was significantly greater by 33 cells/μl in patients who remained free of TB compared with those developing TB. After the initial three months of cART, 65.6% of patients who remaining free of TB achieved CD4+ count of ≥400 cells/μl, while only 11.3% of patients developing TB reached this immunological status after the three months of cART. We found no differences in the average change of CD8+ cell count, CD4:CD8 ratio or viral load between the two-patient groups.

CONCLUSION

All HIV-infected patients responded to cART. However, patients developing TB showed reduced recovery in CD4+ cell count and this might partly explain the incident TB in HIV-infected patients receiving cART. These findings reinforce the importance of adjunctive TB preventive therapy for patients with reduced recovery in CD4+ cell count.

Decades research and implementation science of HIV prevention, treatment and cure: highlights from Symposium 2017

The 19th Bangkok International Symposium on HIV Medicine, Bangkok, Thailand, 18–20 January 2017

This training is one of the most established and largest, with up-to-date information provided by well-renowned international speakers and hence considered one of the best in the Asia Pacific region. The Symposium is offered every third week of January for three full days. Celebrating HIV Netherlands Australia Thailand research collaboration's 20th anniversary, for the first time, the sessions were covered real-time through webcasts, streamed live via the internet. Speakers included community advocates voicing and addressing certain issues, and the entire third day was dedicated to symposiums. HIV Netherlands Australia Thailand research collaboration continues to strive to provide well-rounded trainings of quality to the region's professional healthcare workers, hoping to significantly impact the delivery of health services. Noteworthy sessions have been briefly summarized in this report.