Frequency and correlates of late presentation for HIV infection in France: older adults are a risk group - results from the ANRS-VESPA2 Study, France

Sociobehavioral Risk Factors and Clinical Implications of Late Presentation Among People Living with HIV in the Brazilian Amazon Region

This study aimed to analyze the prevalence, sociobehavioral factors and clinical-laboratory consequences of late presentation among people living with HIV (PLHIV) in the Brazilian Amazon region. In total, 402 HIV + individuals treated at reference units in Belém city (Pará, Brazil) between 2018 and 2019 were evaluated. Late presentation was defined as a first-collection LTCD4+ count below 350 cells/µL. Sociodemographic, behavioral and clinical data were obtained from questionnaires or medical records. Th1, Th2 and Th17 cytokine profiles were evaluated by flow cytometry. Longitudinal data on viral load, T lymphocytes, and antiretroviral therapy administration were obtained from control and logistic databases. Approximately 52.73% of the participants were late presenters and sought medical care 7-12 + months after their primary HIV diagnosis. Sociobehavioral factors associated with late presentation included illicit drug use for more than 5 years, polyamory, no alcohol consumption, homosexuality, and sexual inactiveness after HIV diagnosis. Clinically, late presentation was associated with coinfection rate; polysymptomatology; high IFN-ɣ, IL-6 and IL-10 levels; nonresponse to antiretroviral therapy; and virological failure- and tuberculosis coinfection-motivated changes to therapy. In summary, the prevalence of late presentation in Pará in the Brazilian Amazon region is high. Delays in seeking specialized care after a primary HIV diagnosis cause medium/long-term changes in the life expectancy and health of PLHIV.

Time to Treatment Initiation and HIV Viral Suppression in People Diagnosed With HIV-1 During COVID-19 Pandemic in Ex-Aquitaine, France (ANRS CO3 AQUIVIH-NA Cohort-QuAliCOV Study)

OBJECTIVES

The COVID-19 pandemic's impact on initiation and effectiveness of antiretroviral therapy (ART) in people diagnosed with HIV remains unclear. We evaluated critical delays in HIV care in people diagnosed before and during the pandemic in ex-Aquitaine, France.

METHODS

We considered adults diagnosed with HIV-1 in 2018-2021 and enrolled in the ANRS CO3 AQUIVIH-NA and followed them until October 10, 2022 for those diagnosed during the pandemic (April 01, 2020-December 31, 2021) and until March 31, 2020 for historical controls. We compared their characteristics at inclusion and the median time between diagnosis and ART initiation, ART initiation and viral suppression, and diagnosis and virologic, suppression (effective management).

RESULTS

Eighty-three individuals were diagnosed during the pandemic versus 188 during the prepandemic period. Median follow-up was 549 (interquartile range: 329-713) days. Populations were similar in sex, age, HIV acquisition mode, hospital type, and clinical characteristics at diagnosis; however, fewer were foreign-born during the pandemic (15.7% versus 33.5%, P = 0.003). The probability of ART initiation, therapeutic success, and effective management was higher in people living with HIV (PLWH) diagnosed during the pandemic in adjusted analyses (hazard ratio [HR]: 2.0; 95% CI: 1.5 to 2.7; HR: 1.7; 95% CI: 1.2 to 2.3; HR: 1.8; 95% CI: 1.3 to 2.6, respectively). Those diagnosed during the pandemic were 2.3 (95% CI: 1.2 to 4.1) times more likely to be virologically suppressed within six months of diagnosis compared with historical controls.

CONCLUSIONS

Pandemic-related reorganizations may have resulted in newly diagnosed PLWH being prioritized; however, the lower proportion of foreign-born PLWH diagnosed during the pandemic period, likely because of reduced migration and potential delays in diagnosis, may contribute to these preliminary findings.

HIV Late Presenters in Asia: Management and Public Health Challenges

Many individuals are diagnosed with human immunodeficiency virus (HIV) infection at an advanced stage of illness and are considered late presenters. We define late presentation as a CD4 cell count below 350 cells/mm³ at the time of HIV diagnosis, or presenting with an AIDS-defining illness regardless of CD4 count. Across Asia, an estimated 34-72% of people diagnosed with HIV are late presenters. HIV late presenters generally have a higher disease burden and higher comorbidity such as opportunistic infections than those who are diagnosed earlier. They also have a higher mortality rate and generally exhibit poorer immune recovery following combined antiretroviral therapy (cART). As such, late HIV presentation leads to increased resource burden and costs to healthcare systems. HIV late presentation also poses an increased risk of community transmission since the transmission rate from people unaware of their HIV status is approximately 3.5 times higher than that of early presenters. There are several factors which contribute to HIV late presentation. Fear of stigmatisation and discrimination are significant barriers to both testing and accessing treatment. A lack of perceived risk and a lack of knowledge by individuals also contribute to late presentation. Lack of referral for testing by healthcare providers is another identified barrier in China and may extend to other regions across Asia. Effective strategies are still needed to reduce the incidence of late presentation across Asia. Key areas of focus should be increasing community awareness of the risk of HIV, reducing stigma and discrimination in testing, and educating healthcare professionals on the need for early testing and on the most effective ways to engage with people living with HIV. Recent initiatives such as intensified patient adherence support programs and HIV self-testing also have the potential to improve access to testing and reduce late diagnosis.

Trends of late HIV presentation and advance HIV disease among newly diagnosed HIV cases in Jiangsu, China: A serial cross-sectional study from 2008 to 2020

Background

This study aimed to assess the trends and determine the factors associated with late presentation (LP) and advanced HIV disease (AHD) among newly diagnosed people living with HIV (PLWH) from 2008 to 2020 in Jiangsu, China.

Methods

Newly diagnosed PLWH registered in the HIV surveillance system from 2008 to 2020 were included. Multivariable logistic regression models were used to analyze the factors associated with LP and AHD. The LP and AHD trends were assessed using Joint-point analysis.

Results

Of 37,251 newly diagnosed PLWH identified, 30,251(81.2%) patients met the inclusion criteria. Among those, 16,672 (55.1%) were considered LP, and 8,691 (28.7%) had AHD. LP trends steadily increased from 2008 (39.0%) to 2020 (59.4%), but AHD trends decreased visibly from 2016 (32.3%) to 2020 (23.4%). The overall median CD4 trends decreased slowly from 389 to 305 cells/mm³ between 2008 and 2020. Married patients and those older than 35 years were more likely to be LP and have AHD. Patients infected via heterosexual transmission had a higher risk of being classified as AHD (aOR: 1.13, 95%CI: 1.06-1.21) than patients infected via homosexual transmission. Patients that were diagnosed at sexually transmitted infections (STIs) clinics (aOR: 1.10, 95%CI: 1.01-1.20) and in hospitals (aOR: 1.69, 95%CI: 1.59-1.79) were more likely to be classified as LP compared with patients diagnosed at voluntary counseling and testing (VCT) centers. Similar, patients diagnosed at STIs clinics (aOR: 1.23, 95%CI: 1.11-1.36) and hospitals (aOR: 2.27, 95%CI: 2.12-2.43) were more likely to have AHD than patients diagnosed in VCT.

Conclusion

Our findings indicate an alarming burden of LP in Jiangsu, suggesting the need for more attention toward HIV diagnosis at early CD4 stages. National HIV control programs must strengthen comprehensive interventions for HIV prevention and promote HIV services. Also, strategies for HIV prevention (PrEP and PEP), testing, and treatment must be extended, especially among the general population.

Estimation of the determinants for HIV late presentation using the traditional definition and molecular clock-inferred dates: Evidence that older age, heterosexual risk group and more recent diagnosis are prognostic factors

OBJECTIVES

HIV late presentation (LP) has been increasing in recent years in Europe. Our aim was to investigate the characteristics of LP in Greece using in addition to the traditional definition for LP, the time interval between HIV infection and diagnosis.

METHODS

Our nationwide sample included HIV-1 sequences generated from 6166 people living with HIV (PLWH) in Greece during the period 1999-2015. Our analysis was based on the molecularly inferred HIV-1 infection dates for PLWH infected within local molecular transmission clusters of subtypes A1 and B.

RESULTS

Analysis of the determinants of LP was conducted using either CD4 counts or AIDS-defining condition at diagnosis or the time from infection to diagnosis. Older age, heterosexual transmission risk group and more recent diagnosis were associated with increased risk for LP. In contrast to previous studies, people who inject drugs (PWID) had a shorter median time to diagnosis (0.63 years) compared to men who have sex with men (MSM) (1.72 years) and heterosexuals (2.43 years). Using HIV infection dates that provide an unbiased marker for LP compared to CD4 counts at diagnosis, which are age-dependent, we estimated that the time to diagnosis increased gradually with age. Migrants infected regionally do not differ with respect to LP status compared to native Greeks.

CONCLUSIONS

We demonstrate that older people and heterosexuals are among those at higher risk for LP; and given the growing number of older people among newly diagnosed cases, tailored interventions are needed in these populations.

Frequency and reasons for delayed treatment initiation after HIV diagnosis: cross-sectional study in Lahore, Pakistan

Background

Well-timed initiation of HIV therapy enhances life expectancy, decreases mortality and morbidity, and inhibits the transmission of HIV and complications related to it. The purpose of the present survey is to investigate the frequency and reasons for delayed initiation of anti-retroviral therapy (ART) and to determine its relationship with various socio-demographic variables and HIV-related characteristics.

Methods

The analysis is based on a cross-sectional study involving 355 people living with HIV (diagnosed by PCR) who were more than 18 years of age and not receiving HIV therapy before enrolment at the HIV clinics of two selected tertiary-care teaching hospitals in Lahore, Pakistan. In this study, delayed initiation of ART was defined as not attending the HIV management centre or a clinic for ART within 3 months of a confirmed diagnosis. The participants were selected using a systematic probability sampling technique. Bivariate logistic regression was performed using a backward stepwise technique to establish the variables related to delayed onset of HIV therapy. Factors significant at p ≤ 0.20 were considered for multivariate analysis, which was used to describe the association between independent factors and delayed initiation of treatment.

Results

Delayed onset of ART was observed in 28.5% of individuals. Factors such as no schooling (AOR = 5.92; 95% CI: 1.38–25.41; p = 0.017) and occasional household income (AOR = 3.88; 95% CI: 1.01–14.89; p = 0.048) were significantly associated with late onset of ART. Our research findings also indicated that the main reasons for late beginning of HIV therapy were: feeling healthy (45.5%), did not have time to go to the HIV treatment centre (42.6%), did not want to discuss HIV test result (37.6%), and fear of stigma and discrimination within their community (35.6%).

Conclusions

Late commencement of HIV therapy in Pakistan is common, and an improved connection is needed between identification of HIV and beginning of therapy. HIV management centres should counsel and monitor patients from the time of a positive HIV test result until they initiate therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11031-0.

Promoting HIV, Hepatitis B Virus, and Hepatitis C Virus Screening Among Migrants With a Language Barrier: Protocol for the Development and Evaluation of an Electronic App (Apidé)

Background

Late diagnoses of HIV, hepatitis B, and hepatitis C are important public health problems that affect the population at large and migrants in particular. Missed opportunities of HIV and hepatitis screening are numerous, with language differences being a significant barrier to testing. Several studies have shown that migrants who do not speak the language of the health provider are less likely to get tested, due to health providers’ reluctance to offer a test and to migrants’ reluctance to accept testing.

Objective

The aim of our study is to develop a multilingual electronic tool (app) that assists health providers in offering and explaining HIV and hepatitis screenings to migrants with a language barrier and to evaluate its acceptability and impact in terms of public health.

Methods

The study will go through 3 stages: (1) concept development, (2) app development, and (3) app evaluation. A qualitative study has been undertaken to explore language barriers during health care encounters and their effect on communication, specifically when a screening test is offered. In parallel, a systematic review of the literature was conducted to have a comprehensive overlook of electronic tools designed to help health care providers communicate with migrants with a language barrier. To generate a list of items to be translated for inclusion in the app, we will conduct a focus group and Delphi survey. The development of the app will include translation and voice recording of items. The electronic development will also include 3 steps of user testing. The acceptability of the app will be evaluated using the System Usability Scale. Evaluation of the app’s efficacy will consist of a stepped wedge randomized controlled trial. The study will be carried out in 16 centers that treat migrants and offer them screening tests for infectious diseases. The primary outcome is the percentage of screening tests realized. The secondary outcomes are the rate of screening proposal by health professionals, acceptance rate by migrants, number of positive cases using this app, and frequency of use of the app.

Results

The app evaluation study received a 3-year grant from the Agence Nationale de la Recherche contre le SIDA et les hépatites virales (ANRS) and from the Office Français de l’Immigration et Intégration (OFII). At the time of publication of this protocol, the initial qualitative study and systematic literature review were completed.

Conclusions

This study will develop an app that assists health providers in offering and explaining HIV and hepatitis screenings to migrants with a language barrier and measure its acceptability and effectiveness in terms of public health. When completed, this app could be distributed to numerous professionals carrying out screening with migrant populations in various health care settings.

International Registered Report Identifier (IRRID)

PRR1-10.2196/22239

Late presentation for HIV remains a major health issue in Spain: Results from a multicenter cohort study, 2004-2018

OBJECTIVES

With the purpose of reducing the well-known negative impact of late presentation (LP) on people living with HIV (PLWH), guidelines on early HIV diagnosis were published in 2014 in Spain, but since then no data on LP prevalence have been published. To estimate prevalence and risk factors of LP and to evaluate their impact on the development of clinical outcomes in the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) during 2004-2018.

METHODS

CoRIS is an open prospective multicenter cohort of PLWH, adults, naive to ART at entry. LP was defined as HIV diagnosis with CD4 count ≤350 cells/μL or an AIDS defining event (ADE). Multivariable Poisson regression models were used to estimate both prevalence ratios (PR) for the association of potential risk factors with LP and Incidence rate ratios (IRRs) for its impact on the development of the composite endpoint (first ADE, first serious non-AIDS event [SNAE] or overall mortality).

RESULTS

14,876 individuals were included. Overall, LP prevalence in 2004-2018 was 44.6%. Risk factors for LP included older age, having been infected through injection drug use or heterosexual intercourse, low educational level and originating from non-European countries. LP was associated with an increased risk of the composite endpoint (IRR: 1.34; 95%CI 1.20, 1.50), ADE (1.39; 1.18, 1.64), SNAE (1.22; 1.01, 1.47) and mortality (1.71; 1.41, 2.08).

CONCLUSIONS

LP remains a health problem in Spain, mainly among certain populations, and is associated with greater morbidity and mortality. Public policies should be implemented to expand screening and early diagnosis of HIV infection, for a focus on those at greatest risk of LP.

Association of County-Level Social Vulnerability with Elective Versus Non-elective Colorectal Surgery

INTRODUCTION

A person's community, or lived environment, may play an important role in achieving optimal health outcomes. The objective of the current study was to assess the association of county-level vulnerability with the probability of having a non-elective colon resection. We hypothesized that individuals from areas with a high social vulnerability would be at greater risk of non-elective colon resection compared with patients from low social vulnerability areas.

METHODS

Patients aged 65-99 who underwent a colon resection for a primary diagnosis of either diverticulitis (n = 11,812) or colon cancer (n = 33,312) were identified in Medicare Part A and Part B for years 2016-2017. Logistic regression analysis was used to evaluate differences in probability of undergoing an elective versus non-elective operation from counties relative to county-level social vulnerability index (SVI). Secondary outcomes included postoperative complications, mortality, readmission, and index hospitalization expenditure.

RESULTS

Among 45,124 patients, 11,812 (26.2%) underwent a colon resection for diverticulitis, while 33,312 (73.8%) had a resection for colon cancer; 31,012 (68.7%) patients had an elective procedure (diverticulitis n = 7291 (61.7%) vs. cancer n = 23,721 (71.2%)), while 14,112 (31.3%) had an emergent operation (diverticulitis n = 4521 (38.3%) vs. cancer n = 9591 (28.8%)). Patients with a high SVI were more likely to undergo an emergent colon operation compared with low SVI patients (43.7% vs. 40.4%) (p < 0.001). The association of high SVI with increased risk of an emergent colon operation was similar among patients with diverticulitis (emergent: low SVI 37.2% vs. high SVI 40.4%) or colon cancer (emergent: low SVI 26.0% vs. high SVI 29.9%) (both p < 0.05). On multivariable analyses, risk-adjusted probability of undergoing an urgent/emergent operation remained associated with SVI (p < 0.05).

CONCLUSION

Patients residing in vulnerable communities characterized by a high SVI were more likely to undergo a non-elective colon resection for either diverticulitis or colon cancer. Patients from high SVI areas had a higher risk of postoperative complications, as well as index hospitalization expenditures; however, there were no differences in mortality or readmission rates.

Immune profile at HIV infection diagnosis: Evolution in the French Alps area over the last 20 years

OBJECTIVES

Health of HIV-infected people relies on early antiretroviral therapy, i.e. early diagnosis. We aimed to determine whether the characteristics at HIV diagnosis in two French medical centres changed over the last 20 years.

PATIENTS AND METHODS

All individuals diagnosed with HIV infection in Grenoble University Hospital (N=814) and Annecy Hospital (N=246) between 1997 and 2015 were included. We collected age, country of birth, mode of transmission, CD4T cell count, CD4/CD8 ratio, and HIV viral load.

RESULTS

Among the 1060 patients (mean age 37.4±11 years, 70.2% of men), 42.5% were men having sex with men (MSM); 65.2% were born in France, and 24.4% were born in Africa. Mean CD4T cell count at diagnosis was 396±288/mm³ and was stable over the study period when considering all patients; when considering the MSM group, a significant increase over time was observed, with a mean increase of 7.3 CD4/mm³ per year (P<0.001). A higher CD4 count at diagnosis was observed after 2005 (400±289 vs 468±271/mm³, P=0.005). The proportion of MSM patients with a CD4 count<200/mm³ at diagnosis was lower after 2005 (14.7% after 2005 and 25.6% before, P=0.028) This was not observed in heterosexual patients (born in Africa or not).

CONCLUSION

In the MSM population, CD4 count at diagnosis is higher after 2005, suggesting that screening campaigns have become more efficient. This was not observed in other populations, who should be better targeted in future strategies.

Elderly HIV-positive women: A gender-based analysis from the Multicenter Italian "GEPPO" Cohort

Background

HIV-positive patients are facing age-and disease-related comorbidities. Since gender differences in viro-immunological, clinical and therapeutic features have been described, aim of this analysis was to explore such differences in elderly HIV-positive females compared to males coming from the same cohort.

Design

Cross-sectional study.

Setting

Ten Infectious Diseases Center participating to a new multicenter Italian geriatric Cohort aiming at describing health transition over time in HIV-positive individuals.

Participants

HIV-positive patients aged ≥65 years old.

Measurements

We recorded clinical, viro-immunological and therapeutical data.

Results

We included 210 women (17%) out of 1237 patients. Compared to males, elderly females were less likely to present a HIV-RNA <50 copies/mL (74.3% vs. 81.8%, OR 0.64, 95%CI 0.44–0.93); they showed higher CD4+/CD8+ ratio (p = 0.016). Combined antiretroviral therapy (cART) strategies were similar between genders (p>0.05), although women were less likely to be treated with protease Inhibitors (PIs) (p = 0.05); specifically, in triple-drug regimens females received less PIs (28% vs 38% p = 0.022) and more integrase inhibitors (30% vs. 20% p = 0.012). Bone disease was more common in females (p<0.001) while males presented more frequently cardiovascular disease (CVD) (p<0.001). In females with bone disease, PIs and boosted regimens (38% vs. 53.7% p = 0.026 and 30.4 vs 44.0% p = 0.048 respectively) were prescribed less frequently. Polypharmacy was common and similar in both genders (20% vs. 22.8%, p = >0.05). A higher use of lipid-lowering drugs (20.5% vs. 14.8%, p = 0.04) was observed in females and yet they were less likely to receive anti-thrombotic agents (18.6% vs. 26.3%, p = 0.019) even when CVD was recorded (57.1% vs. 83.1%, p = 0.018). In multivariate analysis, we found that female gender was independently associated with a higher CD4+/CD8+ ratio but not with virological suppression

Conclusions

Elderly HIV-positive women display a worse virologic response despite a better immune reconstitution compared to males. The burden of comorbidities as well as the medications received (including cART) may slightly differ according to gender. Our data suggest that more efforts and focused interventions are needed in this population.

Long-term trends in HIV care entry: over 15 years of clinical experience from Poland

INTRODUCTION

Delay in HIV diagnosis and consequently late care entry with low CD4 counts remain a major challenge for the control of the HIV/AIDS epidemic. The aim of this study was to analyse the evolution of characteristics of the HIV epidemic in Poland.

METHODS

Cross-sectional data were collected for 3972 HIV-infected patients followed up in 14 of 17 Polish HIV treatment centres in the years 2000-2015. Clinical data were analysed and factors associated with late presentation (baseline CD4 count < 350 cells/μL or history of AIDS-defining illness) and advanced HIV disease (baseline CD4 count < 200 cells/μL or history of AIDS) were identified.

RESULTS

The majority (57.6%) of patients entered care late, while 35.6% presented with advanced HIV disease. The odds of being linked to care late or with advanced HIV disease increased consistently across age categories, increasing from 2.55 [95% confidence interval (CI) 1.46-4.47] for late presentation and 3.13 (95% CI 1.49-6.58) for advanced disease for the 21-30-year-old category to 5.2 (95% CI 1.94-14.04) and 8.15 (95% CI 2.88-23.01), respectively, for individuals > 60 years of age. Increased risks of late entry and advanced HIV disease were also observed for injecting drug users [adjusted odds ratio (aOR) 1.74 (95% CI 1.16-2.60) and 1.55 (95% CI 1.05-2.30), respectively], with lower aOR associated with the men who have sex with men transmission route [aOR 0.3 (95% CI 0.31-0.59) and 0.39 (95% CI 0.29-0.53), respectively]. The frequencies of cases in which patients were linked to care late and with advanced HIV disease decreased over time from 67.6% (2000) to 53.5% (2015) (P < 0.0001) and from 43.5% (2000) to 28.4% (2015) (P = 0.001), respectively.

CONCLUSIONS

Despite improvements over time, most patients diagnosed with HIV infection entered care late, with a third presenting with advanced HIV disease. Late care entry remains common among people who inject drugs and heterosexual groups.

Late presentation of HIV positive adults and its predictors to HIV/AIDS care in Ethiopia: a systematic review and meta-analysis

Introduction

Late presentation to HIV/AIDS care which is attended by problems like, poor treatment outcomes, early development of opportunistic infections, increased healthcare costs, and mortality is a major problem in Ethiopia. Although evidences are available on the prevalence and associated factors of late presentation to HIV/AIDS care, discrepancies among findings are appreciated. Thus, the country has faced difficulties of having a single estimated data.

Objective

This study aimed to estimate the pooled prevalence of late presentation of HIV positive adults to HIV/AIDS care and its predictors in Ethiopia.

Method

We searched all available articles through Google Scholar, PubMed, Web of Sciences, and EMBASE databases. Additionally, we accessed articles from the Ethiopian institutional online research repositories and reference lists of included studies. We included cohort, case- control, and cross-sectional studies in our review. Besides, we utilized the weighted inverse variance random-effects model. The total percentage of variation among studies due to heterogeneity was determined by I² statistic. Searching was limited to studies conducted in Ethiopia and published in the English language. Publication bias was checked by Egger’s regression test.

Results

A total of 8 studies with 7, 568 participants were included. The pooled prevalence of late presentation to HIV/AIDS care was 52.89% (95%CI: 35.37, 70.40). The odds of late presentation to HIV/AIDS care of frequent alcohol users [3.67(95% CI = 1.52–5.83)], high fear of stigma [3.90 (95% CI = 1.51–6.28)], chronic illness [3.34(95% CI = 1.52–5.16)], and the presence of symptoms at the time of HIV diagnosis [3.06 (95% CL = 1.18–4.94)] were higher compared to participants who did not experience the preceding.

Conclusion

The prevalence of late presentation of HIV positive adults to HIV/AIDS care was high in Ethiopia. Frequent alcohol use, high fear of stigma, chronic illness, and the presence of symptoms at the time of HIV diagnosis were associated with high odds of late presentation to HIV/AIDS care.

Trial registration

Registered in PROSPERO databases with the registration number of CRD42018081840.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4156-3) contains supplementary material, which is available to authorized users.

HIV late presentation and advanced HIV disease among patients with newly diagnosed HIV/AIDS in Southwestern China: a large-scale cross-sectional study

OBJECTIVE

This study aimed to investigate the prevalence of HIV late presentation and advanced HIV disease and to identify the factors associated with HIV late presentation and advanced HIV disease among patients with newly diagnosed HIV/AIDS in the Guangxi Zhuang Autonomous Region, in Southwestern China.

METHODS

Patients with newly diagnosed HIV registered in the HIV surveillance system of Guangxi Centers for Disease Control between January 2012 and December 2016 were included in this study.

RESULTS

Of 45,118 newly diagnosed patients, 70.2% had late presentation, and 45.1% had advanced HIV disease. A higher prevalence of late presentation and advanced HIV disease was found in male heterosexuals and female people who use drugs (PWID). Heterosexuals (OR 2.11 [95% CI 1.90-2.34]) and PWID (OR 1.55 [95% CI 1.30-1.84]) had a higher risk of late presentation than men who have sex with men (MSM). Blood testing of the blood receivers (OR 1.75 [95% CI 1.36-2.26]) and diagnosed in hospital (OR 1.74 [95% CI 1.65-1.84]) had an increased risk of late presentation compared to those who diagnosis in voluntary counseling and testing (VCT). Heterosexuals (OR 2.86 [95% CI 2.51-3.27]), PWID (OR 2.23 [95% CI 1.83-2.71]), blood testing of the blood receivers (OR 1.58 [95% CI 1.29-1.94]) and diagnosed in hospital (OR 1.85 [95% CI 1.76-1.94]) were also independent risk factors associated with advanced HIV disease. Older age, lower level of education and being divorced or widowed were also associated with late presentation and advanced HIV disease.

CONCLUSIONS

Late presentation and advanced HIV disease were very common among patients with newly diagnosed HIV in Guangxi, China during 2012-2016. Targeted programs are urgently required to reduce HIV late diagnosis in Guangxi, especially for male heterosexuals, PWID, and patients with characteristics such as older age, lower level of education, divorced or widowed.

Perceived HIV-related physical fatigue, sociodemographic characteristics and physical activity: A cross-sectional study

AIMS AND OBJECTIVES

To get a deeper understanding of correlates of perceived HIV-related fatigue by exploring its associations with sociodemographic characteristics and physical activity level of HIV-infected people.

BACKGROUND

Previous studies on HIV-related fatigue have mainly focused on physiological and psychological characteristics, but few have considered its associations with sociodemographic variables. In addition, while physical activity has been found to reduce acute fatigue among HIV-infected people, its links with chronic HIV-related fatigue remain to be explored.

DESIGN

The study employed an observational and cross-sectional survey design. The manuscript was organised according to STROBE guidelines.

METHOD

A total of 560 people living with HIV in France completed a measure of perceived physical fatigue using the Fatigue Intensity Scale. The predictors targeted sociodemographic characteristics and two measures of individuals' reported level of physical activity. Data were analysed by a stepwise multiple regression model.

RESULTS

The results showed that lower age, higher physical activity level and socio-economic status were significantly associated with reduced perceived physical fatigue, explaining 25% of the variance.

CONCLUSIONS

The results highlighted the importance of considering sociodemographic and lifestyle characteristics to better characterise HIV-related fatigue, in particular in an era where HIV as a chronic illness challenges questions of quality of life throughout increasingly longer lifespans.

RELEVANCE TO CLINICAL PRACTICE

The results of this study have implications for HIV care professionals in terms of improving strategies for managing chronic fatigue or promoting physical activity according to more specific profiles of HIV-infected people.

Socio-demographic and clinical determinants of late presentation among patients newly diagnosed with HIV in the Eastern Cape, South Africa

South Africa recently implemented the 'test and treat' strategy for all HIV-infected individuals receiving diagnosis at the health facility level. However, the impact of this programme in terms of the prevention of HIV transmission, morbidity and mortality associated with HIV can only be maximized if patients are diagnosed early. This study determines the prevalence of late presentation among newly diagnosed HIV-infected individuals and also examines the socio-demographic and clinical determinants for late presentation in health facilities in the Eastern Cape Province, South Africa.In this cross-sectional study, a total of 335 newly diagnosed patients were recruited consecutively between August 2016 and July 2017. Late presenter for HIV care was defined in accordance with the European Late Presenter Consensus working group as a patient who reports for care when the CD4 count is below 350 cells/μL and/or when there is an established AIDS-defining clinical condition, irrespective of CD4 count. Adjusted and unadjusted logistic regression analysis was used to examine the determinants of late HIV diagnosis.Participants' mean age was 33.6 (SD: 10.6). Almost 96% of the participants believed their route of HIV infection was heterosexual sex. Most newly diagnosed HIV-infected patients (60%) were late presenters (CD4+ count ≤350 cells/μL and/or having an AIDS-defining illness in World Health Organisation (WHO)-defined stage III/IV), with 35% presenting with Acquired Immune Deficiency Syndrome (AIDS)-related complications. In the adjusted model, only male sex (AOR: 2.81; CI: 1.51-5.23), no formal education (AOR: 5.63; CI: 1.68-18.85), and overweight body mass category (AOR: 2.45; CI: 1.04-5.75) were independently associated with late HIV diagnosis.The majority of newly diagnosed HIV-infected individuals were late presenters. To maximize the impact of the 'test and treat' policy aimed at reducing new HIV transmissions and preventing the morbidity and mortality associated with HIV, there is a need for programmes to improve early detection of HIV in the study settings. This programme should target males and individuals with no formal education for maximum impact.

HIV prevention strategies and risk of infection: a model-based analysis

Risk populations for HIV infections tend to neglect condom use, making alternative preventive approaches necessary. Accordingly, we modelled the risk of sexual HIV transmission for condom use vs. use of rapid diagnostic test (RDT) systems with subsequent exclusion of potential sexual partners with a correctly or falsely positive test from unprotected sex with and without the use of HIV pre-exposure prophylaxis (PrEP) in a bio-statistical approach. We combined a previously described model of transmission risk for HIV-exposed individuals with a newly suggested model of risk of HIV exposure for sexually active HIV-negative individuals. The model was adapted for several stages of infection and different strategies of HIV infection prevention.HIV prevention with RDTs can reduce the transmission risk by up to 97% compared with having sex without any prevention and up to 80% compared with condom use. Nevertheless, RDT-based prevention strategies demonstrate a lack of protection in several stages of infection; in particular, RNA-based RDT systems may fail under treatment. RDT-based pre-screening of potential sex partners prior to unprotected sexual contacts substantially reduces HIV transmission risk. Combination of different prevention strategies is advisable for high-risk groups.

New HIV diagnoses among adults aged 50 years or older in 31 European countries, 2004-15: an analysis of surveillance data

BACKGROUND

The HIV burden is increasing in older adults in the European Union (EU) and European Economic Area (EEA). We investigated factors associated with HIV diagnosis in older adults in the 31 EU/EEA countries during a 12 year period.

METHODS

In this analysis of surveillance data, we compared data from older people (aged ≥50 years) with those from younger people (aged 15-49 years). We extracted new HIV diagnoses reported to the European Surveillance System between Jan 1, 2004, and Dec 31, 2015, and stratified them by age, sex, migration status, transmission route, and CD4 cell count. We defined late diagnosis as CD4 count of less than 350 cells per μL at diagnosis and diagnosis with advanced HIV disease as less than 200 cells per μL. We compared the two age groups with the χ² test for difference, and used linear regression analysis to assess temporal trends.

FINDINGS

During the study period 54 102 new HIV diagnoses were reported in older adults. The average notification rate of new diagnoses was 2·6 per 100 000 population across the whole 12 year period, which significantly increased over time (annual average change [AAC] 2·1%, 95% CI 1·1-3·1; p=0·0009). Notification rates for new HIV diagnoses in older adults increased significantly in 16 countries in 2004-15, clustering in central and eastern EU/EEA countries. In 2015, compared with younger adults, older individuals were more likely to originate from the reporting country, to have acquired HIV via heterosexual contact, and to present late (p<0·0001 for all comparisons). HIV diagnoses increased significantly over time among older men (AAC 2·2%, 95% CI 1·2-3·3; p=0·0006), women (1·3%, 0·2-2·4; p=0·025), men who have sex with men (5·8%, 4·3-7·5; p<0·0001), and injecting drug users (7·4%, 4·8-10·2; p<0·0001).

INTERPRETATION

Our findings suggest that there is a compelling need to deliver more targeted testing interventions for older adults and the general adult population, such as by increasing awareness among health-care workers and expanding opportunities for provider-initiated and indicator-condition-guided testing programmes.

FUNDING

European Centre for Disease Prevention and Control.

Late Presentation of HIV Infection: Prevalence, Trends, and the Role of HIV Testing Strategies in Guangzhou, China, 2008-2013

Background. The prevalence, trends, and the role of different HIV testing strategies in late presentation of HIV infection in China were unknown. Methods. Data of newly reported HIV cases in Guangzhou between 2008 and 2013 was analyzed to examine the prevalence, trends, and characteristics of late presentation of HIV infection by three types of HIV testing strategies. Results. Overall, 53.2% (1412/2653) and 27.3% (724/2653) met the criteria of late presentation and presentation with advanced HIV disease. The overall trend of late presentation of HIV infection within the study period was declining. Late presentation was 62.9% in 2008 and dropped to 43.3% in 2013 (P < 0.001); presentation with advanced HIV disease was 40.3% in 2008 and dropped to 15.2% in 2013 (P < 0.001). Of the three testing strategies, PITC presented higher odds of both late presentation [AOR (95% CI): PITC versus VCT: 1.37 (1.09, 1.73); PITC versus MHT: 3.09 (2.16, 4.42)] and presentation with advanced HIV disease [AOR (95% CI): PITC versus VCT: 1.65 (1.29, 2.11); PITC versus MHT: 13.14 (8.47, 20.39)]. Conclusions. Although the late presentation of HIV infection was declining, it was still high in Guangzhou. The worse situation among PITC cases urges the policy adjustment in medical settings to increase early HIV diagnosis.

The late-presenting HIV-infected patient 30 years after the introduction of HIV testing: spectrum of opportunistic diseases and missed opportunities for early diagnosis

OBJECTIVES

The aim of the study was to describe the characteristics of HIV-infected late presenters, opportunistic diseases at diagnosis and missed opportunities to diagnose HIV infection earlier.

METHODS

In a retrospective cohort study, we reviewed the medical records of all adults with newly diagnosed HIV infection admitted to the Department of Infectious Diseases of the Vivantes Auguste-Viktoria Hospital, Berlin, Germany.

RESULTS

In the 5-year period from 2009 to 2013, 270 late presenters were identified. The most common AIDS-defining conditions were oesophageal candidiasis (n = 136; 51%), wasting syndrome (n = 106; 40%) and pneumocystis pneumonia (n = 91; 34%). Fifty-five patients (21%) had presented with at least one HIV indicator condition on prior contact with health care services without being offered testing for HIV. Female patients and heterosexual men [not men who have sex with men ('non-MSM')] had a significantly higher chance of being among patients previously presenting with indicator conditions and not being tested [odds ratio (OR) 4.7; 95% confidence interval (CI) 2.2-10.0; P < 0.001; and OR 2.4; 95% CI 1.2-5.1; P < 0.01, respectively]. The most commonly missed indicator conditions were leucocytopenia (n = 13; 24%), thrombocytopenia (n = 12; 22%), oral candidiasis (n = 9; 16%), unexplained weight loss (n = 7; 13%), herpes zoster (n = 5; 9%) and cervical dysplasia/cancer (n = 4; 20% of women). The median time between presentation with an indicator condition and the diagnosis of HIV infection was 158.5 days [interquartile range (IQR) 40-572 days]. Patients with oral candidiasis and unexplained weight loss had the shortest time between the "missed opportunity" and the diagnosis of HIV infection. Fifty-five hospital admissions with a total cost of over EUR 500 000 and - most importantly - six in-hospital deaths might have been prevented if HIV testing had been performed in patients with documented indicator conditions.

CONCLUSIONS

Indicator conditions are still missed by clinicians. Women and 'non-MSM' are at highest risk of presenting with an indicator condition but not being tested for HIV infection.

Factors associated with the level of CD4 cell counts at HIV diagnosis in a French cohort: a quantile regression approach

The consensus definition of late presentation for human immunodeficiency virus patient based on a CD4 threshold of 350 cells/mm³ has limitations concerning risk factors identification since there is growing biomedical justification for earlier initiation of treatment. The objective was to overcome this problem by simultaneously determining factors associated with different levels of CD4 counts at the time of diagnosis. Between January 2000 and July 2014, 1179 patients with a first human immunodeficiency virus diagnosis and entering care in a French human immunodeficiency virus reference center were enrolled. Factors associated with each 5 percentile from 5th to 95th quantile of CD4 counts at diagnosis were simultaneously studied in a multivariable quantile regression model. At each of the quantiles, the factors identified as negatively associated with CD4 count at diagnosis were older age, male sex , foreign patients, hepatitis B virus or hepatitis C virus co-infection, employment status, non-MSM transmission, heterosexual transmission, suburban and rural's place of residence and earlier period of diagnosis. Association with CD4 count was not uniformly significant, most factors being significant for some quantiles. The only significant determinant for all quantiles was being born in a foreign country. These results are particularly helpful in the context of human immunodeficiency virus clinical care, management and prevention.

Treatment and disease outcomes of migrants from low- and middle-income countries in the Australian HIV Observational Database cohort

People from culturally and linguistically diverse backgrounds, including low- and middle-income countries, account for a third of new HIV diagnoses in Australia and are a priority for HIV prevention and treatment programs. We describe the demographic and clinical characteristics of participants in the Australian HIV Observational Database (AHOD) and compare disease outcomes, progression to AIDS and treatment outcomes of those born in low- and middle-income countries, with those born in high-income countries and Australia. All participants enrolled in AHOD sites where country of birth is routinely collected were included in the study. Age, CD4 count, HIV viral load, antiretroviral therapy, hepatitis co-infection, all-cause mortality and AIDS illness were analysed. Of 2403 eligible participants, 77.3% were Australian born, 13.7% born in high-income countries and 9.0% born in middle- or low-income countries. Those born in Australia or high-income countries were more likely to be male (96%) than those from middle- or low-income countries (76%), p < .0001 and more likely to have acquired HIV via male to male sexual contact (77%; 79%) compared with those from middle- or low-income countries (50%), p < .0001. At enrolment, mean CD4 cell count was higher in Australian born (528 cells/µL) than both those born in high-income countries (468 cells/µL) and those born in middle- and low-income countries (451 cells/µL), p < .0001; whereas the mean HIV RNA level (log10 copies/mL) was similar in all three groups (4.44, 4.76 and 4.26, respectively), p = .19.There was no difference in adjusted incidence risk ratios for all-cause mortality and AIDS incidence in all three groups, p = .39. These findings reflect successful outcomes of people born in low- and middle-income countries once engaged in HIV care.

Predictors of opportunistic illnesses incidence in post combination antiretroviral therapy era in an urban cohort from Rio de Janeiro, Brazil

Background

Opportunistic illnesses still account for a huge proportion of hospitalizations and deaths among HIV-infected patients in the post combination antiretroviral therapy (cART) era, particularly in middle- and low-income countries. The aim of this study was to assess predictors of the top four most incident opportunistic illnesses (tuberculosis, esophageal candidiasis, cerebral toxoplasmosis and Pneumocystis jiroveci pneumonia) in an HIV clinical cohort from a middle-income country in the post cART era.

Methods

A total of 2835 HIV infected participants aged ≥ 18 years at enrollment were followed from January 2000 to December 2012 until the occurrence of their first opportunistic illness, death or end of study, whichever occurred first. Extended Cox proportional hazards regression models, stratified by use of cART, were fitted to assess predictors of opportunistic illness incidence during follow-up.

Results

The incidence rates of tuberculosis, esophageal candidiasis, cerebral toxoplasmosis and Pneumocystis jiroveci pneumonia were 15.3, 8.6, 6.0, 4.8 per 1000 persons-year, respectively. Disease specific adjusted Cox models showed that presence of an opportunistic illness at enrollment significantly increased disease incidence while higher nadir CD4+ T lymphocyte count had a significant protective effect in patients not in use of cART. Duration of cART use also significantly reduced disease incidence.

Conclusions

Our findings show that, still in the post-cART era, prevention of opportunistic infections can be achieved by preventing immune deterioration by instituting early use of cART. Interventions focusing on early diagnosis and linkage to care in addition to the prompt initiation of cART are essential to reduce the incidence of opportunistic illnesses among HIV infected patients in post-cART era.

Brief Report: Consequences of Presentation With Advanced HIV Disease in Pregnancy: Data From a National Study in Italy

Among 469 women with a diagnosis of HIV in pregnancy, 74 (15.8%) presented with less than 200 CD4 cells per cubic millimeter. The only variable significantly associated with this occurrence was African origin (odds ratio: 2.22, 95% confidence intervals: 1.32 to 3.75, P = 0.003). Four women with low CD4 (5.6%), compared with none with higher CD4 counts, had severe AIDS-defining conditions (P < 0.001) during pregnancy or soon after delivery, and one transmitted HIV to the newborn. Early preterm delivery (<32 weeks) was significantly more frequent with low CD4 (6.2% vs. 1.4%, P = 0.015). An earlier access to HIV testing, particularly among immigrants of African origin, can prevent severe HIV-related morbidity.

Discordant responses to cART in HIV-1 patients in the era of high potency antiretroviral drugs: clinical evaluation, classification, management prospects

The goal of antiretroviral treatment (ART) in HIV-1 patients is immune reconstitution following control of viral replication. CD4+ cell number/proportions are a crude but essential correlate of immune reconstitution. Despite suppression of HIV replication, a fraction of ART-treated patients still fails to fully reconstitute CD4+ T cell numbers (immunological nonresponders, INRs). New drugs, regimens and treatment strategies led to increased efficacy, lower side effects and higher virological success rates in clinical practice. The multitude of described immune defects and clinical events accompanying INR opposed to the marginal effect of antiretroviral intensification or immunotherapy trials underline the need for continuing efforts at understanding the mechanisms that underlie INR. Here, we reassess INR definition, frequency, and the achievements of active clinical and translational research suggesting a shared definition for insufficient, partial and complete CD4+ cell number recovery thus improving homogeneity in patient selection and mechanism identification.

Profile of an HIV Testing and Counseling Unit in Bangladesh: Majority of New Diagnoses among Returning Migrant Workers and Spouses

Introduction

Analysis of data from HIV testing and counseling (HTC) services provides an opportunity to identify important populations for targeting of HIV prevention efforts. Our primary aim was to describe the demographics of clients presenting to HTC in Bangladesh, a low HIV prevalence country. Our secondary aim was to determine the risk factors for HIV positivity among returning migrant workers who were tested.

Methods

We performed a cross-sectional study of data collected between 2002 and 2010 from the first HTC service established in Bangladesh, located in three large cities.

Results

8973 individuals attended HTC services, with 558 (6.2%) of clients testing positive for HIV, including 33 children. The majority of those who tested positive were aged 25–44 (71%), male (70%), and married (68%). Key populations considered at increased risk of HIV, such as female sex workers, people who inject drugs, and males who have sex with males accounted for only 11% of adults who tested positive. Notably, 75% of adults testing positive had a history of migrant work or was the spouse of a migrant worker. In multivariable logistic regression of those with a migrant work history presenting for HTC, we found rural residence, working in the Middle East, and longer duration of migrant work to be independently associated with testing positive, and female gender and higher level of education to be negatively associated.

Conclusions

These data suggest that in Bangladesh, in addition to targeting traditional key populations, HIV prevention efforts should also focus on migrant workers and their spouses.

Risk of Severe Non AIDS Events Is Increased among Patients Unable to Increase their CD4+ T-Cell Counts >200+/μl Despite Effective HAART

Background

Immunological non-response (INR) despite virological suppression is associated with AIDS-defining events/death (ADE). Little is known about its association with serious non-AIDS-defining events (nADE).

Methods

Patients highly-active antiretroviral therapy (HAART) with <200 CD4+/μl and achieving HIV-RNA <50 copies/ml within 12 (±3) months were categorized as INR if CD4+ T-cell count at year 1 was <200/μl. Predictors of nADE (malignancies, severe infections, renal failure—ie, estimated glomerular filtration rate <30 ml/min, cardiovascular events and liver decompensation) were assessed using multivariable Cox models. Follow-up was right-censored in case of HAART discontinuation or confirmed HIV-RNA>50.

Results

1221 patients were observed for a median of 3 (IQR: 1.3-6.1) years. Pre-HAART CD4+ were 77/μl (IQR: 28-142) and 56% of patients had experienced an ADE. After 1 year, CD4+ increased to 286 (IQR: 197-387), but 26.1% of patients were INR. Thereafter, 86 nADE (30.2% malignancies, 27.9% infectious, 17.4% renal, 17.4% cardiovascular, 7% hepatic) were observed, accounting for an incidence of 1.83 events (95%CI: 1.73-2.61) per 100 PYFU. After adjusting for measurable confounders, INR had a significantly greater risk of nADE (HR 1.65; 95%CI: 1.06-2.56). Older age (per year, HR 1.03; 95%CI: 1.01-1.05), hepatitis C co-infection (HR 2.09; 95%CI: 1.19-3.7), a history of previous nADE (HR 2.16; 95%CI: 1.06-4.4) and the occurrence of ADE during the follow-up (HR 2.2; 95%CI: 1.15-4.21) were other independent predictors of newly diagnosed nADE.

Conclusions

Patients failing to restore CD4+ to >200 cells/μl run a greater risk of serious nADE, which is intertwined or predicted by AIDS progression. Improved management of this fragile population and innovative therapy able to induce immune-reconstitution are urgently needed. Also, our results strengthen the importance of earlier diagnosis and HAART introduction.