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Ugarte A, De La Mora L, De Lazzari E, Chivite I, Fernández E, Inciarte A, Laguno M, Ambrosioni J, Solbes E, Berrocal L, González-Cordón A, Martínez-Rebollar M, Foncillas A, Calvo J, Blanco JL, Martínez E, Mallolas J, Torres B. Rapid initiation of bictegravir/emtricitabine/tenofovir alafenamide as first-line therapy in HIV infection. A prospective study. J Antimicrob Chemother 2024; 79:2343-2353. [PMID: 39045754 DOI: 10.1093/jac/dkae235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/22/2024] [Indexed: 07/25/2024] Open
Abstract
INTRODUCTION Rapid initiation of ART after HIV diagnosis is recommended for individual and public health benefits. However, certain clinical and ART-related considerations hinder immediate initiation of therapy. METHODS An open-label, single-arm, single-centre 48-week prospective clinical trial involving ART-naïve HIV-diagnosed adults who started bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) within a week from the first hospital visit, before the availability of baseline laboratory and genotype results. The primary aim was to determine the proportion of people with at least one condition that would hinder immediate initiation of any recommended ART regimen other than BIC/FTC/TAF. Clinicaltrials.gov: NCT04416906. RESULTS We included 100 participants: 79% men, 64% from Latin America, median age 32 years. According to European AIDS Clinical Society (EACS) and US Department of Health and Human Services 2023 guidelines, 11% (95%CI 6; 19) of participants had at least one condition that made any ART different from BIC/FTC/TAF less appropriate for a rapid ART strategy. Seventy-nine percent of the people started BIC/FTC/TAF within the first 48 hours of their first hospital visit. There were 16 early discontinuations (11 lost to follow-up). By week 48, 92% (95%CI 86; 98) of the participants of the ITT population with observed data achieved viral suppression. Eight grade 3-4 adverse events (AEs), five serious AEs and six ART-related AEs were identified. Adherence remained high. CONCLUSIONS BIC/FTC/TAF is an optimal treatment for rapid initiation of ART. However, additional strategies to improve retention in care must be implemented.
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Affiliation(s)
- Ainoa Ugarte
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
| | - Lorena De La Mora
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
| | - Elisa De Lazzari
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Carlos III, Madrid, Spain
| | - Iván Chivite
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
| | - Emma Fernández
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
| | - Alexy Inciarte
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
| | - Montserrat Laguno
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Carlos III, Madrid, Spain
| | - Juan Ambrosioni
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Carlos III, Madrid, Spain
| | - Estela Solbes
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
| | - Leire Berrocal
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
| | - Ana González-Cordón
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
| | - María Martínez-Rebollar
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
| | - Alberto Foncillas
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
| | - Júlia Calvo
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
| | - José Luis Blanco
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Carlos III, Madrid, Spain
| | - Esteban Martínez
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Carlos III, Madrid, Spain
| | - Josep Mallolas
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Carlos III, Madrid, Spain
| | - Berta Torres
- HIV Unit, Infectious Diseases Service, Hospital Clinic of Barcelona, Villarroel Street 170, Barcelona 08036, Spain
- University of Barcelona, Barcelona, Spain
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Campbell CK, Koester KA, Erguera XA, Moran L, LeTourneau N, Broussard J, Crouch PC, Lynch E, Camp C, Torres S, Schneider J, VanderZanden L, Coffey S, Christopoulos KA. Effective Messages to Reduce Stigma among People Newly Diagnosed with HIV during Rapid ART Initiation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:1133. [PMID: 39338016 PMCID: PMC11431257 DOI: 10.3390/ijerph21091133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/23/2024] [Accepted: 08/23/2024] [Indexed: 09/30/2024]
Abstract
HIV stigma has a negative influence on antiretroviral therapy (ART) initiation and persistence and viral suppression. Immediate access to ART (RAPID ART) has been shown to accelerate viral suppression (VS) that is sustained up to one year after HIV diagnosis. Little is known about the role of RAPID ART in reducing individual-level stigma. We explored how stigma manifests in RAPID ART encounters and whether RAPID ART interventions influence individual-level HIV stigma during and in the time immediately after the diagnosis experience. We conducted in-depth interviews with 58 RAPID ART patients from three health clinics in San Francisco, CA, and Chicago, IL. Interviews were transcribed, coded, and thematically analyzed. In the results, we discuss three main themes. First, Pre-Diagnosis HIV Beliefs, which included three sub-themes: HIV is "gross" and only happens to other people; HIV (Mis)education; and People are "living long and strong" with HIV. Second, Positive and Reassuring Messages During the RAPID Experience, which included two sub-themes: Correcting Misinformation and Early Interactions with People Living with HIV. Third, The RAPID ART Process Can Disrupt Stigma. RAPID ART encounters served as a potent mechanism to disrupt internalized stigma by providing accurate information and dispelling unhelpful myths through verbal and nonverbal messages. Reducing internalized stigma and misinformation about HIV at this early stage has the potential to reduce the effect of HIV stigma on ART initiation and adherence over time.
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Affiliation(s)
- Chadwick K Campbell
- Herbert Wertheim School of Public Health and Human Longevity, University of California San Diego, La Jolla, CA 92093, USA
| | - Kimberly A Koester
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Xavier A Erguera
- Division of HIV, ID & Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94110, USA
| | - Lissa Moran
- Division of HIV, ID & Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94110, USA
| | - Noelle LeTourneau
- Division of HIV, ID & Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94110, USA
| | - Janessa Broussard
- School of Nursing, University of California San Francisco, San Francisco, CA 94143, USA
| | | | - Elizabeth Lynch
- Division of HIV, ID & Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94110, USA
| | - Christy Camp
- Division of HIV, ID & Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94110, USA
| | - Sandra Torres
- Division of HIV, ID & Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94110, USA
| | | | | | - Susa Coffey
- Division of HIV, ID & Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94110, USA
| | - Katerina A Christopoulos
- Division of HIV, ID & Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA 94110, USA
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Trevisan S, Gasparro G, Kiros ST, Pozzi M, Malcontenti C, Campolmi I, Paggi R, Cavallo A, Farese A, Ducci F, Meli M, Pittorru M, Bartoloni A, Sterrantino G, Lagi F. Impact of rapid-antiretroviral therapy in a cohort of treatment-naïve migrants living with HIV in a high income setting. Int J STD AIDS 2024:9564624241270970. [PMID: 39106048 DOI: 10.1177/09564624241270970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
BACKGROUND We evaluated the effect of rapid ART (RA) compared to delayed ART (DA) on viral load suppression (viral load <50 cp/mL) and loss to follow-up (LTFU) in a cohort of migrants living with HIV (MLWHs) in Italy. METHODS Data were retrospectively gathered from MLWHs who began care at the Infectious and Tropical Diseases Unit of the Careggi University Hospital from January 2014 to December 2022. RA was defined as antiretrovirals prescribed within 7 days of HIV diagnosis. The study ended on April 30, 2023, or upon patient LTFU. Chi-square and non-parametric tests assessed differences in categorical and continuous variables, respectively. Kaplan-Meyer survival analysis was performed to estimate the probability of loss to follow-up. Cox regression analysis was performed to evaluate factors associated with a loss to follow-up. RESULTS 87 MLWHs were enrolled: 20 (23%) on RA and 67 (77%) on DA. In the RA group there were more PLWH with a previous AIDS event (p < .001) however, there was no significant difference in the LTFU rates between the groups (aHR 0.6, 95%CI 0.1-3.1; p = .560; Logrank = 0.2823). Being an out-of-status MLWH was the only predictor of LTFU. By 6 months, virological suppression was achieved in 61.2% (n = 41) in DA and 70.0% in the RA group (n = 14) (Logrank p = .6747). CONCLUSIONS RA did not significantly affect LTFU rates or the achievement of viral load suppression. The study suggests that further research is needed to assess the impact of RA in high income settings.
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Affiliation(s)
- Sasha Trevisan
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giuseppe Gasparro
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Seble Tekle Kiros
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Pozzi
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Costanza Malcontenti
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Irene Campolmi
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Riccardo Paggi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Annalisa Cavallo
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Farese
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Filippo Ducci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Massimo Meli
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Mario Pittorru
- Hospital Pharmacy, Careggi University Hospital, Florence, Italy
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Gaetana Sterrantino
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Filippo Lagi
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
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Juta PM, Jansen van Vuuren JM, Mbaya KJ. A multidisciplinary approach for people with HIV failing antiretroviral therapy in South Africa. South Afr J HIV Med 2024; 25:1579. [PMID: 39113780 PMCID: PMC11304356 DOI: 10.4102/sajhivmed.v25i1.1579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/11/2024] [Indexed: 08/10/2024] Open
Abstract
Background South Africa (SA) has the largest antiretroviral therapy (ART) programme worldwide. Multiple factors contribute to virological failure (VF), including poor adherence and viral resistance mutations. A multidisciplinary team (MDT) clinic dedicated to those with VF may be of benefit; however, very little data from SA exist. Objectives To assess whether an MDT approach achieved virological suppression (VS) in patients failing second-line-ART (2LART); assess the number of MDT sessions required to achieve VS; assess local resistance mutation patterns and whether the MDT reduced the number of genotypic resistance testing (GRT) required. Method An observational, retrospective, cross-sectional chart review study was conducted between January 2018 and December 2019 at a Target High Viral Load (VL) MDT clinic in KwaZulu-Natal, SA. Results Ninety-seven medical records were eligible. Women accounted for 63% of patients, with a mean age of 37 years. A significant reduction in the first VL measurement following the MDT was seen (median reduction 2374 c/mL; P < 0.001). This was maintained at the second VL measurement post-MDT (median reduction 2957 c/mL; P < 0.001). Patients attended a mean of 2.71 MDT sessions and 73.2% achieved VS, resulting in 61.86% fewer GRTs required. Of the GRTs performed, nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitor-related mutations were noted most frequently. Conclusion The MDT approach resulted in a significant reduction in VL, with most participants achieving VS. The MDT was successful in reducing the need for GRT. Resistance mutations were similar to those found in other studies conducted across SA.
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Affiliation(s)
- Parisha M Juta
- Department of Internal Medicine, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Juan M Jansen van Vuuren
- Department of Internal Medicine, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Internal Medicine, Joint Royal Colleges of Physicians Training Board, National Health Service (NHS) England, Chelmsford, United Kingdom
| | - Kabamba J Mbaya
- KwaZulu-Natal Department of Health, Northdale Hospital, Pietermaritzburg, South Africa
- Department of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Valenti W, Scutaru J, Mancenido M, Zuppelli A, Danforth A, Corales R, Hilliard S. Real world community-based HIV Rapid Start Antiretroviral with B/F/TAF versus prior models of antiretroviral therapy start - the RoCHaCHa study, a pilot study. AIDS Res Ther 2024; 21:45. [PMID: 38987825 PMCID: PMC11238360 DOI: 10.1186/s12981-024-00631-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/05/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND The rapid start of antiretroviral therapy (RSA) model initiates antiretroviral therapy (ART) as soon as possible after a new or preliminary diagnosis of HIV, in advance of HIV-1 RNA and other baseline laboratory testing. This observational study aims to determine if RSA with a single tablet regimen of bictegravir, emtricitabine, and tenofovir alafenamide (B/F/TAF) is an effective regimen for achieving viral suppression and accepted by patients at the time of diagnosis. METHODS Adults newly or preliminarily diagnosed with HIV were enrolled from October 2018 through September 2021. Real world advantage, measured in days between clinical milestones and time to virologic suppression, associated with B/F/TAF RSA was compared to historical controls. RESULTS All Study RSA participants (n = 45) accepted treatment at their first visit and 43(95.6%) achieved virologic suppression by week 48. Study RSA participants had a significantly shorter time (median 32 days) from diagnosis to ART initiation and virologic suppression, in comparison to historical controls (median 181 days) (n = 42). Qualitative feedback from study RSA participants showed high acceptance positive response to RSA. CONCLUSIONS RSA is feasible and well accepted by patients in a real-world community-based clinic setting. Promoting RSA in community-based clinics is an important tool in ending the HIV epidemic.
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Affiliation(s)
- William Valenti
- Trillium Health, 259 Monroe Ave Suite 100, Rochester, NY, 14607, USA
| | - Jacob Scutaru
- Trillium Health, 259 Monroe Ave Suite 100, Rochester, NY, 14607, USA
| | - Michael Mancenido
- Trillium Health, 259 Monroe Ave Suite 100, Rochester, NY, 14607, USA
| | - Ashley Zuppelli
- Trillium Health, 259 Monroe Ave Suite 100, Rochester, NY, 14607, USA
| | | | - Roberto Corales
- Gilead Sciences, 333 Lakeside Drive, Foster City, CA, 94404, USA
| | - Shealynn Hilliard
- Trillium Health, 259 Monroe Ave Suite 100, Rochester, NY, 14607, USA.
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Dupnik K, Rivera VR, Dorvil N, Duffus Y, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumont E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification Among Patients With Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-income Countries. Open Forum Infect Dis 2024; 11:ofae356. [PMID: 39022393 PMCID: PMC11252845 DOI: 10.1093/ofid/ofae356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024] Open
Abstract
Background The World Health Organization recommends initiating same-day antiretroviral therapy (ART) while tuberculosis (TB) testing is under way for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve TB risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with TB symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP as a continuous variable using generalized linear models. Results Eighty-seven (17.5%) participants were diagnosed with baseline TB. The median CRP was 33.0 mg/L (interquartile range: 5.1, 85.5) in those with TB, and 2.6 mg/L (interquartile range: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4% and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3- to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Affiliation(s)
- Kathryn Dupnik
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Nancy Dorvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Yanique Duffus
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Yipeng Gao
- The Analysis Group, Boston, Massachusetts, USA
| | - Jingyi Liu
- The Analysis Group, Boston, Massachusetts, USA
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumont
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Cynthia Riviere
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Samuel Pierre
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rouzier
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Kathleen F Walsh
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Anthony L Byrne
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean William Pape
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Serena P Koenig
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Hickey MD, Grochowski J, Mayorga-Munoz F, Oskarsson J, Imbert E, Spinelli M, Szumowski JD, Appa A, Koester K, Dauria EF, McNulty M, Colasanti J, Havlir DV, Gandhi M, Christopoulos KA. Identifying Implementation Determinants and Strategies for Long-Acting Injectable Cabotegravir-Rilpivirine in People With HIV Who Are Virally Unsuppressed. J Acquir Immune Defic Syndr 2024; 96:280-289. [PMID: 38534179 PMCID: PMC11192618 DOI: 10.1097/qai.0000000000003421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/13/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Early evidence suggests long-acting injectable cabotegravir and rilpivirine (LA-CAB/RPV) may be beneficial for people with HIV (PWH) who are unable to attain viral suppression (VS) on oral therapy. Limited guidance exists on implementation strategies for this population. SETTING Ward 86, a clinic serving publicly insured PWH in San Francisco. METHODS We describe multilevel determinants of and strategies for LA-CAB/RPV implementation for PWH without VS, using the Consolidated Framework for Implementation Research. To assess patient and provider-level determinants, we drew on pre-implementation qualitative data. To assess inner and outer context determinants, we undertook a structured mapping process. RESULTS Key patient-level determinants included perceived ability to adhere to injections despite oral adherence difficulties and care engagement challenges posed by unmet subsistence needs; strategies to address these determinants included a direct-to-inject approach, small financial incentives, and designated drop-in days. Provider-level determinants included lack of time to obtain LA-CAB/RPV, assess injection response, and follow-up late injections; strategies included centralizing eligibility review with the clinic pharmacist, a pharmacy technician to handle procurement and monitoring, regular multidisciplinary review of patients, and development of a clinic protocol. Ward 86 did not experience many outer context barriers because of rapid and unconstrained inclusion of LA-CAB/RPV on local formularies and ability of its affiliated hospital pharmacy to stock the medication. CONCLUSIONS Multilevel strategies to support LA-CAB/RPV implementation for PWH without VS are required, which may necessitate additional resources in some settings to implement safely and effectively. Advocacy to eliminate outer-context barriers, including prior authorizations and specialty pharmacy restrictions, is needed.
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Affiliation(s)
- Matthew D. Hickey
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Janet Grochowski
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Francis Mayorga-Munoz
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Jon Oskarsson
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Elizabeth Imbert
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Matthew Spinelli
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - John D. Szumowski
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Ayesha Appa
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Kimberly Koester
- Division of Prevention Science, University of California, San Francisco
| | - Emily F. Dauria
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh
| | - Moira McNulty
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago
| | | | - Diane V Havlir
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Katerina A. Christopoulos
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
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Zhou Y, Meng J, Zhang X, Ma J, Fan S, Zuo H, Shi J, Wang W, Wang H. Nurse-led sequential multiple assignment randomized trial of nudging intervention for early antiretroviral therapy initiation among patients with HIV/AIDS: Implementation study protocol. J Adv Nurs 2024. [PMID: 38923586 DOI: 10.1111/jan.16259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/18/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024]
Abstract
AIMS In China, more than 30% of patients have not initiated treatment within 30 days of HIV diagnosis. Delayed initiation has a detrimental influence on disease outcomes and increases HIV transmission. The study aims to evaluate the effectiveness of a nurse-led antiretroviral therapy initiation nudging intervention for people newly diagnosed with HIV in China to find the optimal intervention implementation strategy. METHODS A Hybrid Type II sequential multiple assignment randomized trial will be conducted at four Centers for Disease Control and Prevention in Hunan, China. This study will recruit 447 people newly diagnosed with HIV aged ≥18 years and randomly assign them into two intervention groups and one control group. On top of the regular counselling services and referrals, intervention groups will receive a 4-week, 2-phase intervention based on the dual-system theory and the nudge theory. The control group will follow the currently recommended referral procedures. The primary outcomes are whether treatment is initiated, as well as the length of time it takes. The study outcomes will be measured at the baseline, day 15, day 30, week 12, week 24 and week 48. Generalized estimating equations and survival analysis will be used to compare effectiveness and explore factors associated with antiretroviral therapy initiation. Both qualitative and quantitative information will be collected to assess implementation outcomes. DISCUSSION Existing strategies mostly target institutional-level factors, with little consideration given to patients' decision-making. To close this gap, we aim to develop an effective theory-driven nudging strategy to improve early ART initiation. IMPACT This nurse-led study will help to prevent delayed initiation by employing implementation science strategies for people newly diagnosed with HIV. This study contributes to the United Nations' objective of ending the AIDS pandemic by 2030. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR2300070140. The trial was prospectively registered before the first participant was recruited. PATIENT AND PUBLIC INVOLVEMENT The nudging intervention was finalized through the Nominal Group Technique where we invited five experts in the related field and five people living with HIV to participate.
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Affiliation(s)
- Yaqin Zhou
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Jingjing Meng
- School of Nursing, Anhui Medical University, Hefei, China
| | - Xiangjun Zhang
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jun Ma
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Sisi Fan
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Hong Zuo
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Jingzheng Shi
- Xiangya School of Public Health, Central South University, Changsha, China
| | - Wenru Wang
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Honghong Wang
- Xiangya School of Nursing, Central South University, Changsha, China
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9
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Hidalgo-Tenorio C, Sequera S, Vivancos MJ, Vinuesa D, Collado A, Santos IDL, Sorni P, Cabello-Clotet N, Montero M, Font CR, Terron A, Galindo MJ, Martinez O, Ryan P, Omar-Mohamed M, Albendín-Iglesias H, Javier R, Ruz MÁL, Romero A, Garcia-Vallecillos C. Bictegravir/emtricitabine/tenofovir alafenamide as first-line treatment in naïve HIV patients in a rapid-initiation model of care: BIC-NOW clinical trial. Int J Antimicrob Agents 2024; 63:107164. [PMID: 38574873 DOI: 10.1016/j.ijantimicag.2024.107164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/29/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE Multiple strategies have been utilised to reduce the incidence of HIV, including PrEP and rapid antiretroviral therapy initiation. The study objectives were to evaluate the efficacy, safety, satisfaction, treatment adherence, and system retention obtained with rapid initiation of bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) in naïve patients. METHODS This phase IV, multicenter, open-label, single-arm, 48-week clinical trial enrolled patients between January 2020 and June 2022. Adherence to treatment was evaluated with the SMAQ questionnaire and patient satisfaction with the EQ-5D. RESULTS Two hundred eight participants were enrolled with mean age of 35.6 years; 87.6% were males; mean CD4 count was 393.5 cells/uL (<200 cells/uL in 22.1%); viral load log was 5.6 (VL>100 000 cop/mL in 43.3%); 22.6% had AIDS, and 4.3% were coinfected with HBV. BIC/FTC/TAF was initiated on the day of their first visit to the HIV specialist in 98.6% of participants, and 9.6% were lost to follow-up. The efficacy at week 48 was 84.1 % by intention-to- treat (ITT), 94.6% by modified ITT, and 98.3% by per protocol analysis. The regimen was discontinued in two subjects (0.9%) during week 1 for grade 3 adverse events. Treatment adherence (weeks 4 [90%, IQR: 80-99%] vs. 48 [90%, IQR: 80-95%; P = 0.49]) and patient satisfaction (weeks 4 [90%, IQR: 80-99%] vs. 48 [90%, IQR: 80-95 P = 0.49]) rates were very high over the 48- week study period. CONCLUSIONS BIC/FTC/TAF is an appropriate option for rapid ART initiation in naïve HIV patients, offering high efficacy, safety, durability, treatment adherence, retention in the healthcare system, and patient satisfaction. Number Clinical Trial registration: NCT06177574.
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Affiliation(s)
- Carmen Hidalgo-Tenorio
- Unit of Infectious Diseases, Hospital Universitario Virgen de las Nieves, Granada, Spain.
| | - Sergio Sequera
- Unit of Infectious Diseases, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - David Vinuesa
- Unit of Infectious Diseases, Hospital Universitario San Cecilio, Granada, Spain
| | - Antonio Collado
- Unit of Infectious Diseases, Hospital Universitario Torrecardenas, Almería, Spain
| | | | - Patricia Sorni
- Unit of Infectious Diseases, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | - Noemi Cabello-Clotet
- Infectious Diseases Unit, Hospital Clínico San Carlos, Complutense University, Madrid, Spain
| | - Marta Montero
- Infectious Diseases Service, Hospital Universitario La Fe, Valencia, Spain
| | - Carlos Ramos Font
- Nuclear Medicine Service, Hospital Universitario Virgen de las Nieves Granada, Granada, Spain
| | - Alberto Terron
- Unit of Infectious Diseases, Hospital Universitario de Jerez, Cádiz, Spain
| | - Maria José Galindo
- Infectious Diseases Service, Hospital Universitario Clínico de Valencia, Spain
| | - Onofre Martinez
- Unit of Infectious Diseases, Hospital Universitario Santa Lucía, Cartagena, Spain
| | - Pablo Ryan
- Internal Medicine Service, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - Helena Albendín-Iglesias
- Department of Internal Medicine, HIV and STI Unit, Hospital Universitario Virgen de la Arrixaca, IMIB, Murcia, Spain
| | - Rosario Javier
- Unit of Infectious Diseases, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Alberto Romero
- Unit of Infectious Diseases, Facultad de Medicina, Hospital Universitario Puerto Real, INIBICA, Universidad de Cadiz, Cádiz, Spain
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10
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Brotherton AL, Coroniti AM, Ayuninjam DK, Sanchez MC, Benitez G, Garland JM. Pharmacist-Driven Rapid Initiation of Antiretroviral Therapy Decreases Time to Viral Suppression in People With HIV. Open Forum Infect Dis 2024; 11:ofae237. [PMID: 38737433 PMCID: PMC11088354 DOI: 10.1093/ofid/ofae237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024] Open
Abstract
Background Rapid initiation of antiretroviral therapy (rapid ART) improves clinical outcomes in people with HIV and is endorsed by clinical guidelines. However, logistical challenges limit widespread implementation. We describe an innovative rapid ART model led by pharmacists and its impact on clinical outcomes, including time to viral suppression (TVS). Methods On 1 January 2019, we implemented Pharmacist-Driven Rapid ART (PHARM-D RAPID ART), including rapid ART initiation by pharmacists. Our retrospective cohort study compared TVS, using a Cox proportional hazards model, and clinical outcomes among individuals with a new HIV diagnosis before (1 January 2017 to 31 December 2017) and after (1 January 2019 to 31 December 2019) implementation. Results A total of 108 individuals were included. TVS was significantly shorter (P < .001) for the PHARM-D RAPID ART group (n = 51) compared with the preimplementation group (n = 57) (median: 30 days and 66 days, respectively). Those in the PHARM-D RAPID ART group were significantly more likely to achieve VS at any given time during the study period (adjusted hazard ratio: 3.47 [95% confidence interval, 2.25-5.33]). A total of 94.1% (48/51) of patients in the PHARM-D RAPID ART group were retained in care at 1 year. With a median follow-up of 2.4 years in the PHARM-D RAPID ART group, 98% remained suppressed at last recorded viral load. Conclusions A pharmacist-driven model for rapid ART delivery decreases TVS with high rates of retention in care and durable VS. This model could improve clinical outcomes and increase program feasibility and sustainability.
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Affiliation(s)
- Amy L Brotherton
- Department of Pharmacy, The Miriam Hospital Infectious Diseases and Immunology Center, Providence, Rhode Island, USA
- Division of Infectious Diseases, Department of Medicine, The Miriam Hospital Infectious Diseases and Immunology Center, Providence, Rhode Island, USA
- Division of Infectious Diseases, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Ann-Marie Coroniti
- Department of Pharmacy, Healthcare Associates, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Diane K Ayuninjam
- Department of Pharmacy, The Miriam Hospital Infectious Diseases and Immunology Center, Providence, Rhode Island, USA
- Division of Infectious Diseases, Department of Medicine, The Miriam Hospital Infectious Diseases and Immunology Center, Providence, Rhode Island, USA
| | - Martha C Sanchez
- Division of Infectious Diseases, Department of Medicine, The Miriam Hospital Infectious Diseases and Immunology Center, Providence, Rhode Island, USA
- Division of Infectious Diseases, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Gregorio Benitez
- Division of Infectious Diseases, Department of Medicine, The Miriam Hospital Infectious Diseases and Immunology Center, Providence, Rhode Island, USA
- Division of Infectious Diseases, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Joseph M Garland
- Division of Infectious Diseases, Department of Medicine, The Miriam Hospital Infectious Diseases and Immunology Center, Providence, Rhode Island, USA
- Division of Infectious Diseases, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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11
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Thornhill JP, Fox J, Martin GE, Hall R, Lwanga J, Lewis H, Brown H, Robinson N, Kuldanek K, Kinloch S, Nwokolo N, Whitlock G, Fidler S, Frater J. Rapid antiretroviral therapy in primary HIV-1 infection enhances immune recovery. AIDS 2024; 38:679-688. [PMID: 38133660 DOI: 10.1097/qad.0000000000003825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE We present findings from a large cohort of individuals treated during primary HIV infection (PHI) and examine the impact of time from HIV-1 acquisition to antiretroviral therapy (ART) initiation on clinical outcomes. We also examine the temporal changes in the demographics of individuals presenting with PHI to inform HIV-1 prevention strategies. METHODS Individuals who fulfilled the criteria of PHI and started ART within 3 months of confirmed HIV-1 diagnosis were enrolled between 2009 and 2020. Baseline demographics of those diagnosed between 2009 and 2015 (before preexposure prophylaxis (PrEP) and universal ART availability) and 2015-2020 (post-PrEP and universal ART availability) were compared. We examined the factors associated with immune recovery and time to viral suppression. RESULTS Two hundred four individuals enrolled, 144 from 2009 to 2015 and 90 from 2015 to 2020; median follow-up was 33 months. At PHI, the median age was 33 years; 4% were women, 39% were UK-born, and 84% were MSM. The proportion of UK-born individuals was 47% in 2009-2015, compared with 29% in 2015-2020. There was an association between earlier ART initiation after PHI diagnosis and increased immune recovery; each day that ART was delayed was associated with a lower likelihood of achieving a CD4 + cell count more than 900 cells/μl [hazard ratio 0.99 (95% confidence interval, 95% CI 0.98-0.99), P = 0.02) and CD4/CD8 more than 1.0 (hazard ratio 0.98 (95% CI 0.97-0.99). CONCLUSION Early initiation of ART at PHI diagnosis is associated with enhanced immune recovery, providing further evidence to support immediate ART in the context of PHI. Non-UK-born MSM accounts for an increasing proportion of those with primary infection; UK HIV-1 prevention strategies should better target this group.
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Affiliation(s)
- John Patrick Thornhill
- Department of Infectious Diseases, Imperial College
- Imperial College National Institute of Health Research Biomedical Research Centre
- Imperial College NHS Trust
| | - Julie Fox
- Department of Genitourinary Medicine and Infectious Disease, Guys and St Thomas' NHS Trust and Kings College London, London
| | | | - Rebecca Hall
- Department of Infectious Diseases, Imperial College
- Imperial College National Institute of Health Research Biomedical Research Centre
- Imperial College NHS Trust
| | - Julianne Lwanga
- Department of Genitourinary Medicine and Infectious Disease, Guys and St Thomas' NHS Trust and Kings College London, London
| | - Heather Lewis
- Department of Infectious Diseases, Imperial College
- Imperial College National Institute of Health Research Biomedical Research Centre
| | - Helen Brown
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford
- Oxford National Institute of Health Research Biomedical Research Centre, Oxford
| | - Nicola Robinson
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford
- Oxford National Institute of Health Research Biomedical Research Centre, Oxford
| | - Kristen Kuldanek
- Department of Infectious Diseases, Imperial College
- Imperial College National Institute of Health Research Biomedical Research Centre
| | | | - Nneka Nwokolo
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Gary Whitlock
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah Fidler
- Department of Infectious Diseases, Imperial College
- Imperial College National Institute of Health Research Biomedical Research Centre
- Imperial College NHS Trust
| | - John Frater
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford
- Oxford National Institute of Health Research Biomedical Research Centre, Oxford
- Royal Free Hospital
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12
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Chen C, Chen H, Wu L, Gong Q, He J. Factors influencing rapid antiretroviral therapy initiation in Jiulongpo, Chongqing, China: a retrospective cohort from 2018 to 2022. AIDS Res Ther 2024; 21:15. [PMID: 38494484 PMCID: PMC10944594 DOI: 10.1186/s12981-024-00601-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/03/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Antiretroviral Therapy (ART) is pivotal in extending the lives of people living with HIV (PLWH) and minimizing transmission. Rapid ART initiation, defined as commencing ART within seven days of HIV diagnosis, is recommended for all PLWH. METHOD A retrospective cohort study was conducted using data from the China Information System for Disease Control and Prevention. This study included PLWH diagnosed between January 2018 and December 2021 and treated by December 2022. Factors influencing rapid ART initiation were examined using univariate and multivariate Cox regression analyses. RESULTS The study analyzed 1310 cases. The majority were male (77.4%), over 50 years old (46.7%), and contracted HIV through heterosexual transmission (70.0%). Rapid ART initiation was observed in 36.6% (n = 479) of cases, with a cumulative treatment rate of 72.9% within 30 days post-diagnosis. Heterosexual contact was associated with longer intervals from diagnosis to treatment initiation compared to homosexual contact (Adjusted Hazard Ratio (HR) = 0.813, 95% Confidence Interval (CI): 0.668-0.988). Individuals older than 50 years (Adjusted HR = 1.852, 95%CI: 1.149-2.985) were more likely to initiate ART rapidly. Conversely, treatment at the Second Public Hospital (Adjusted HR = 0.483, 95% CI: 0.330-0.708) and a CD4 cell counts above 500 (Adjusted HR = 0.553, 95% CI: 0.332-0.921) were associated with a lower likelihood of initiating treatment within seven days. CONCLUSIONS A higher CD4 cell counts and receiving care in local public hospitals may deter rapid ART initiation. Providing CD4 counts results at diagnosis and offering testing and treatment in the same facility could enhance the rate of rapid ART initiation.
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Affiliation(s)
- Cheng Chen
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China
| | - Hao Chen
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China
| | - Lingli Wu
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China
| | - Qin Gong
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China
| | - Jingchun He
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China.
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13
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Clemenzi-Allen AA, Hebert J, Reid MA, Mains T, Hammer H, Gandhi M, Pratt L, Wesson P. Interruptions in HIV and Behavioral Health Care for Criminal-Legal Involved People Living with HIV Following Implementation of Decarceration and Shelter in Place in San Francisco, California. AIDS Behav 2024; 28:1093-1103. [PMID: 38060113 PMCID: PMC10896806 DOI: 10.1007/s10461-023-04221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/08/2023]
Abstract
Decarceration policies, enacted for SARS-CoV-2 mitigation in carceral settings, potentially exacerbated barriers to care for people living with HIV (PWH) with criminal legal involvement (CLI) during Shelter-in-Place (SIP) by limiting opportunities for engagement in provisions of HIV and behavioral health care. We compared health care engagement for PWH with CLI in San Francisco, California before and after decarceration and SIP using interrupted time series analyses. Administrative data identified PWH booked at the San Francisco County Jail with at least one clinic encounter from 01/01/2018-03/31/2020 within the municipal health care network. Monthly proportions of HIV, substance use, psychiatric and acute care encounters before (05/01/2019-02/29/2020) and after (03/01/2020-12/31/2020) SIP and decarceration were compared using Generalized Estimating Equation (GEE) log-binomial and logistic regression models, clustering on the patient-level. Of 436 patients, mean age was 43 years (standard-deviation 11); 88% cisgender-male; 39% white, 66% homeless; 67% had trimorbidity by Elixhauser score (medical comorbidity, psychotic disorder or depression, and substance use disorder). Clinical encounters immediately dropped following SIP for HIV (aOR = 0.77; 95% CI: 0.67, 0.90) and substance use visits (aRR = 0.83; 95% CI: 0.70, 0.99) and declined in subsequent months. Differential reductions in clinical encounters were seen among Black/African Americans (aRR = 0.93; 95% CI: 0.88, 0.99) and people experiencing homelessness (aRR = 0.92; 95% CI: 0.87, 0.98). Significant reductions in care were observed for PWH with CLI during the COVID-19 pandemic, particularly among Black/African Americans and people experiencing homelessness. Strategies to End the HIV Epidemic must improve engagement across diverse care settings to improve outcomes for this key population.
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Affiliation(s)
- A Asa Clemenzi-Allen
- San Francisco Department of Public Health, San Francisco, CA, USA.
- Division of HIV, Infection Diseases and Global Medicine, University of California, San Francisco, USA.
- , 798 Brannan St, San Francisco, CA, 94103, USA.
| | - Jillian Hebert
- Department of Family and Community Medicine, University of California, San Francisco, USA
| | - Michael Alistair Reid
- Division of HIV, Infection Diseases and Global Medicine, University of California, San Francisco, USA
| | - Tyler Mains
- San Francisco Department of Public Health, San Francisco, CA, USA
| | - Hali Hammer
- San Francisco Department of Public Health, San Francisco, CA, USA
| | - Monica Gandhi
- Division of HIV, Infection Diseases and Global Medicine, University of California, San Francisco, USA
| | - Lisa Pratt
- San Francisco Department of Public Health, San Francisco, CA, USA
| | - Paul Wesson
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
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14
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Uhrig Castonguay BJ, Mancuso N, Hatcher S, Watson S, Okumu E, Abbott R, Golin CE, Mobley V, Samoff E, Swygard H, McNeil CJ, Gay CL. Provider Perspectives on Rapid Treatment Initiation Among People Newly Diagnosed With HIV: A New Message of "Urgency"? J Int Assoc Provid AIDS Care 2024; 23:23259582241269919. [PMID: 39234631 PMCID: PMC11378170 DOI: 10.1177/23259582241269919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Early initiation of antiretroviral therapy improves human immunodeficiency virus (HIV) outcomes. However, achieving earlier treatment initiation is challenging for many reasons including provider awareness and clinic barriers; this study sought to understand perceptions of an early initiation program. METHODS We interviewed 10 providers from 3 HIV clinics in North Carolina (October-November 2020). We asked providers about overall perceptions of early initiation and the pilot program. We developed narrative summaries to understand individual contexts and conducted thematic analysis using NVivo. RESULTS Providers believed earlier initiation would signal an "extra sense of urgency" about the importance of antiretroviral therapy-a message not currently reflected in standard of care. Safety was a consistent concern. Cited implementation barriers included transportation assistance, medication sustainability, and guidance to address increased staff time and appointment availability. CONCLUSION Our qualitative findings highlight the need for training on the safety of early initiation and addressing staffing needs to accommodate quicker appointments.
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Affiliation(s)
- Breana J Uhrig Castonguay
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Noah Mancuso
- Research Triangle Institute (RTI) International, Research Triangle Park, NC, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Queer Health Collaborative (QHC), Atlanta, GA, USA
| | - Sarah Hatcher
- Department of Medicine, Section on Infectious Diseases, Wake Forest University School of Medicine, Wake Forest, NC, USA
| | - Sable Watson
- Center for AIDS Research (CFAR), University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eunice Okumu
- Center for AIDS Research (CFAR), University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rica Abbott
- Department of Medicine, Section on Infectious Diseases, Wake Forest University School of Medicine, Wake Forest, NC, USA
| | - Carol E Golin
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for AIDS Research (CFAR), University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Victoria Mobley
- Division of Public Health, Communicable Disease Branch, North Carolina Department of Health and Human Services, Chapel Hill, NC, USA
| | - Erika Samoff
- Division of Public Health, Communicable Disease Branch, North Carolina Department of Health and Human Services, Chapel Hill, NC, USA
| | - Heidi Swygard
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Candice J McNeil
- Department of Medicine, Section on Infectious Diseases, Wake Forest University School of Medicine, Wake Forest, NC, USA
| | - Cynthia L Gay
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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15
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Chow JY, Gao A, Ahn C, Nijhawan AE. Rapid Start of Antiretroviral Therapy in a Large Urban Clinic in the US South: Impact on HIV Care Continuum Outcomes and Medication Adherence. J Int Assoc Provid AIDS Care 2024; 23:23259582241228164. [PMID: 38297512 PMCID: PMC10832401 DOI: 10.1177/23259582241228164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 02/02/2024] Open
Abstract
Rapid start of antiretroviral therapy (ART) has been associated with improvement in several HIV-related outcomes in clinical trials as well as demonstration projects, but how regional and contextual differences may affect the effectiveness of this intervention necessitates further study. In this study of a large, urban, Southern US clinic-based retrospective cohort, we identified 544 patients with a new diagnosis of HIV during 2016 to 2019 and compared HIV care continuum outcomes for the first 12 months of care before and after rapid start implementation. Kaplan-Meier time-to-event curves were used to summarize time to virologic suppression, and stepwise Cox, linear, and logistic regression models were used to create multivariate models to evaluate the association between rapid start and time to virologic suppression, medication adherence, and retention in care and sustained virologic suppression, respectively. We found that rapid start was significantly associated with improved medication adherence scores (+15.37 points, 95% confidence interval [CI] 9.36-21.39, P < .01) and retention in care (adjusted odds ratio = 1.51, 95% CI 1.05-2.19, P = .03). Time to virologic suppression (median 2.46 months before, 2.56 months after rapid start) and sustained virologic suppression were not associated with rapid start in our setting. Though rapid start was associated with improved medication adherence and retention in care, more support may be needed to achieve the same outcomes seen in other studies and sustained over the entire HIV care continuum, especially in settings with significant patient and systemic barriers to care such as unstable housing, lack of Medicaid expansion, and frequent coverage interruptions.
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Affiliation(s)
- Jeremy Y. Chow
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ang Gao
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Chul Ahn
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ank E. Nijhawan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Dupnik K, Rivera VR, Dorvil N, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumond E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification among Patients with Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-Income Countries. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.19.23300232. [PMID: 38196598 PMCID: PMC10775334 DOI: 10.1101/2023.12.19.23300232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Article Summary We assessed the association between C-reactive protein (CRP) and Mycobacterium tuberculosis (TB) diagnosis in symptomatic patients at HIV diagnosis. We found that CRP concentrations can improve tuberculosis risk stratification, facilitating decision making about whether (specific) tuberculosis testing is indicated before antiretroviral therapy initiation. Background The World Health Organization recommends initiating same-day ART while tuberculosis testing is underway for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve tuberculosis risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with tuberculosis symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP (≥3 mg/dL) using generalized linear models. Results Eighty-seven (17.5%) patients were diagnosed with baseline TB. The median CRP was 33.0 mg/L (IQR: 5.1, 85.5) in those with TB, and 2.6 mg/L (IQR: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4%, and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART, and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3-fold to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Gregori N, Renzetti S, Izzo I, Faletti G, Fumarola B, Degli Antoni M, Arsuffi S, Storti S, Tiecco G, Calza S, Caruso A, Castelli F, Quiros-Roldan E, Focà E. Does the rapid initiation of antiretroviral therapy at HIV diagnosis impact virological response in a real-life setting? A single-centre experience in Northern Italy. AIDS Care 2023; 35:1938-1947. [PMID: 36795128 DOI: 10.1080/09540121.2023.2176425] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/22/2023] [Indexed: 02/17/2023]
Abstract
Rapid initiation of antiretroviral therapy (ART) has been proven efficacious and safe, but more investigations are needed to define feasibility of rapid ART approach in real-life settings.We conducted a retrospective, observational study on newly HIVdiagnosed patients referred to our Infectious Diseases Department from September 1st, 2015, to July 31st, 2019. According to the timing of ART initiation, we distinguished 3 groups of patients (rapid, intermediate and late group) and represented the trend of virological response during a 400-days-period. The hazard ratios of each predictor on viral suppression were estimated through the Cox proportional hazard model.The median time from HIV diagnosis to the first medical referral was 15 days and the median time from the first care access to therapy start was 24 days. Among patients, 37.6% started ART within 7 days, 20.6% between 8 and 30 days, and 41.8% after 30 days. Longer time to ART start and higher baseline viral load were associated with a lower probability of viral suppression. After one year, all groups showed a high viral suppression rate (99%). In a high-income setting the rapid ART approach seems useful to accelerate viral suppression which is great over time regardless of ART initiation timing.
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Affiliation(s)
- Natalia Gregori
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Stefano Renzetti
- Unit of Biostatistics and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Ilaria Izzo
- Department of Infectious and Tropical Diseases, ASST Spedali Civili, Brescia, Italy
| | - Giulio Faletti
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Benedetta Fumarola
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Melania Degli Antoni
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Stefania Arsuffi
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Samuele Storti
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Giorgio Tiecco
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Stefano Calza
- Unit of Biostatistics and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Arnaldo Caruso
- Section of Microbiology, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Francesco Castelli
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Eugenia Quiros-Roldan
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Emanuele Focà
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
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Kimanga DO, Makory VNB, Hassan AS, Ngari F, Ndisha MM, Muthoka KJ, Odero L, Omoro GO, Aoko A, Ng’ang’a L. Impact of the COVID-19 pandemic on routine HIV care and antiretroviral treatment outcomes in Kenya: A nationally representative analysis. PLoS One 2023; 18:e0291479. [PMID: 38011132 PMCID: PMC10681195 DOI: 10.1371/journal.pone.0291479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 11/03/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic adversely disrupted global health service delivery. We aimed to assess impact of the pandemic on same-day HIV diagnosis/ART initiation, six-months non-retention and initial virologic non-suppression (VnS) among individuals starting antiretroviral therapy (ART) in Kenya. METHODS Individual-level longitudinal service delivery data were analysed. Random sampling of individuals aged >15 years starting ART between April 2018 -March 2021 was done. Date of ART initiation was stratified into pre-COVID-19 (April 2018 -March 2019 and April 2019 -March 2020) and COVID-19 (April 2020 -March 2021) periods. Mixed effects generalised linear, survival and logistic regression models were used to determine the effect of COVID-19 pandemic on same-day HIV diagnosis/ART initiation, six-months non-retention and VnS, respectively. RESULTS Of 7,046 individuals sampled, 35.5%, 36.0% and 28.4% started ART during April 2018 -March 2019, April 2019 -March 2020 and April 2020 -March 2021, respectively. Compared to the pre-COVID-19 period, the COVID-19 period had higher same-day HIV diagnosis/ART initiation (adjusted risk ratio [95% CI]: 1.09 [1.04-1.13], p<0.001) and lower six-months non-retention (adjusted hazard ratio [95% CI]: 0.66 [0.58-0.74], p<0.001). Of those sampled, 3,296 (46.8%) had a viral load test done at a median 6.2 (IQR, 5.3-7.3) months after ART initiation. Compared to the pre-COVID-19 period, there was no significant difference in VnS during the COVID-19 period (adjusted odds ratio [95% CI]: 0.79 [95%% CI: 0.52-1.20], p = 0.264). CONCLUSIONS In the short term, the COVID-19 pandemic did not have an adverse impact on HIV care and treatment outcomes in Kenya. Timely, strategic and sustained COVID-19 response may have played a critical role in mitigating adverse effects of the pandemic and point towards maturity, versatility and resilience of the HIV program in Kenya. Continued monitoring to assess long-term impact of the COVID-19 pandemic on HIV care and treatment program in Kenya is warranted.
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Affiliation(s)
- Davies O. Kimanga
- Division for Global HIV & TB (DGHT), Center for Global Health, US Centres for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Valeria N. B. Makory
- National AIDS and STI Control Program (NASCOP), Ministry of Health, Nairobi, Kenya
| | - Amin S. Hassan
- Department of HIV/STI, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Faith Ngari
- National AIDS and STI Control Program (NASCOP), Ministry of Health, Nairobi, Kenya
| | - Margaret M. Ndisha
- Division for Global HIV & TB (DGHT), Center for Global Health, US Centres for Disease Control and Prevention (CDC), Nairobi, Kenya
| | | | - Lydia Odero
- Health Population and Nutrition, United States Agency for International Development (USAID), Nairobi, Kenya
| | - Gonza O. Omoro
- Strategic Information, Military HIV Research Program/Walter Reed Army Institute of Research (MHRP/WRAIR), Nairobi, Kenya
| | - Appolonia Aoko
- Division for Global HIV & TB (DGHT), Center for Global Health, US Centres for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Lucy Ng’ang’a
- Division for Global HIV & TB (DGHT), Center for Global Health, US Centres for Disease Control and Prevention (CDC), Nairobi, Kenya
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Doshi RK, Hull S, Broun A, Boyani S, Moch D, Visconti AJ, Castel AD, Baral S, Colasanti J, Rodriguez AE, Jones J, Coffey S, Monroe AK. Lessons learned from U.S. rapid antiretroviral therapy initiation programs. Int J STD AIDS 2023; 34:945-955. [PMID: 37461333 PMCID: PMC11000141 DOI: 10.1177/09564624231185622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
BACKGROUND Rapid antiretroviral therapy initiation (R-ART) for treatment of HIV has been recommended since 2017, however it has not been adopted widely across the US. PURPOSE The study purpose was to understand facilitators and barriers to R-ART implementation in the U.S. RESEARCH DESIGN This was a qualitative design involving semi-structured interviews. STUDY SAMPLE The study sample was comprised of the medical leadership of nine US HIV clinics that were early implementers of R-ART. DATA COLLECTION AND ANALYSIS In-depth, semi-structured interviews were performed. The Consolidated Framework for Implementation Research (CFIR) was used to guide thematic analysis. RESULTS We identified three main content areas: strong scientific rationale for R-ART, buy-in from multiple key stakeholders, and the condensed timeline of R-ART. The CFIR construct of Evidence Strength and Quality was cited as an important factor in R-ART implementation. Buy-in from key stakeholders and immediate access to medications ensured the success of R-ART implementation. Patient acceptance of the condensed timeline for ART initiation was facilitated when presented in a patient-centered manner, including empathetic communication and addressing other patient needs concurrently. The condensed timeline of R-ART presented logistical challenges and opportunities for the development of intense patient-provider relationships. CONCLUSIONS Results from the analysis showed that R-ART implementation should address the following: 1) logistical planning to implement HIV treatment with a condensed timeline 2) patients' mixed reactions to a new HIV diagnosis and 3) the high cost of HIV medications.
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Affiliation(s)
- Rupali K Doshi
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
- The HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA), District of Columbia Department of Health, Washington, DC, USA
| | - Shawnika Hull
- Rutgers University School of Communication and Information, New Brunswick, NJ, USA
| | - Aaron Broun
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Saanjh Boyani
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Darryl Moch
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Adam J Visconti
- The HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA), District of Columbia Department of Health, Washington, DC, USA
| | - Amanda D Castel
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Joyce Jones
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susa Coffey
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Anne K Monroe
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
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20
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Dalal A, Clark E, Samiezade-Yazd Z, Lee-Rodriguez C, Lam JO, Luu MN. Outcomes and Predictors of Rapid Antiretroviral Therapy Initiation for People With Newly Diagnosed HIV in an Integrated Health Care System. Open Forum Infect Dis 2023; 10:ofad531. [PMID: 37965643 PMCID: PMC10642730 DOI: 10.1093/ofid/ofad531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Background Rapid antiretroviral therapy (ART) is the recommended treatment strategy for patients newly diagnosed with HIV, but the literature supporting this strategy has focused on short-term outcomes. We examined both long-term outcomes and predictors of rapid ART among patients newly diagnosed with HIV within an integrated health care system in Northern California. Methods This observational cohort study included adults newly diagnosed with HIV between January 2015 and December 2020 at Kaiser Permanente Northern California. Rapid ART was defined as ART initiation within 7 days of HIV diagnosis. We collected demographic and clinical data to determine short-term and long-term outcomes, including viral suppression, care retention, medication adherence, and cumulative viral burden. Logistic regression models were used to identify predictors of rapid ART initiation. Results We enrolled 1409 adults; 34.1% initiated rapid ART. The rapid ART group achieved viral suppression faster (48 vs 77 days; P < .001) and experienced lower cumulative viral burden (log10 viremia copy-years, 3.63 vs 3.82; P < .01) but had slightly reduced medication adherence (74.8% vs 75.2%; P < .01). There was no improvement in long-term viral suppression and care retention in the rapid group during follow-up. Patients were more likely to initiate rapid ART after 2017 and were less likely if they required an interpreter. Conclusions Patients who received rapid ART had an improved cumulative HIV burden but no long-term improvement in care retention and viral suppression. Our findings suggest that rapid ART should be offered but additional interventions may be needed for patients newly diagnosed with HIV.
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Affiliation(s)
- Avani Dalal
- Graduate Medical Education, Kaiser Permanente Northern California, Oakland, California, USA
| | - Earl Clark
- Graduate Medical Education, Kaiser Permanente Northern California, Oakland, California, USA
| | - Zahra Samiezade-Yazd
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | | | - Jennifer O Lam
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mitchell N Luu
- Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
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Hughes AJ, Nimbal V, Hsu L, Schwarcz S, Scheer S. Trends in Time Spent Viremic Among Persons Newly Diagnosed With HIV in San Francisco. J Acquir Immune Defic Syndr 2023; 94:107-115. [PMID: 37707298 PMCID: PMC10497196 DOI: 10.1097/qai.0000000000003237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/18/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE To examine trends in time spent viremic and initiation into antiretroviral treatment (ART) among persons newly diagnosed with HIV in San Francisco. METHODS Using HIV surveillance data, we included persons diagnosed with HIV during 2012-2020, a San Francisco resident at HIV diagnosis, alive 12 months after HIV diagnosis, and had ≥2 viral load tests within 12 months after diagnosis. Percent person-time spent (pPT) >200, pPT >1500, and pPT >10,000 copies per milliliter was calculated during the 12 months after HIV diagnosis. Multivariate regression models assessed the year of diagnosis and time spent above each viral threshold and year of diagnosis and ART initiation within 0-7 days (rapid), 8-365 days (delayed), or no ART initiation. RESULTS Of 2471 new HIV diagnoses in San Francisco from 2012 to 2020, 1921 (72%) were included. Newly diagnosed persons spent a mean of 40.4% pPT >200, 32.4% pPT >1,500%, and 23.4% pPT >10,000 copies per milliliter; 33.8% had rapid ART initiation, 57.3% delayed, and 9% had no ART initiation. After adjustment, persons diagnosed in years 2014-2015, 2016-2017, 2018-2019, and 2020 were associated with less time spent above all viral thresholds and lower risk of delayed or no ART initiation compared with those diagnosed in 2012-2013. Greater time above thresholds correlated with injection drug use, ages 25-29 and 30-39 years, and homelessness. CONCLUSIONS Percent time spent above each viremic level decreased significantly, whereas rapid ART initiation increased among newly diagnosed persons from 2014 through 2020 compared with 2012-2013. Population differences in time spent unsuppressed highlight the need for targeted interventions to reduce new HIV infections and improve health.
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Affiliation(s)
| | - Vani Nimbal
- San Francisco Department of Public Health, San Francisco, CA
| | - Ling Hsu
- San Francisco Department of Public Health, San Francisco, CA
| | - Sandra Schwarcz
- San Francisco Department of Public Health, San Francisco, CA
| | - Susan Scheer
- San Francisco Department of Public Health, San Francisco, CA
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Moran L, Koester KA, Le Tourneau N, Coffey S, Moore K, Broussard J, Crouch PC, VanderZanden L, Schneider J, Lynch E, Roman J, Christopoulos KA. The Rapid interaction: a qualitative study of provider approaches to implementing Rapid ART. Implement Sci Commun 2023; 4:78. [PMID: 37452427 PMCID: PMC10349523 DOI: 10.1186/s43058-023-00464-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Offering antiretroviral therapy (ART) to patients directly following an HIV diagnosis ("Rapid ART") improves clinical outcomes and is feasible and acceptable for patients and providers. Despite this, implementation of Rapid ART is not yet standard practice in the USA. Structural-level implementation guidance is available, but research at the individual provider level that explores the patient-provider interaction itself remains scarce. The Consolidated Framework for Implementation Research (CFIR) provides a nuanced guide to investigating the less visible, more social elements of implementation like the knowledge and feelings of people, and the influences of culture and resources on individual approaches. METHODS We conducted a multi-site qualitative study, exploring intervention commonalities across three HIV clinic environments: an HIV primary care clinic; an HIV/STI testing, treatment, and prevention clinic; and a large federally qualified health center (FQHC). Qualitative data were gathered from 27 provider informants-Rapid ART program staff and clinicians-using an interview guide developed using the CFIR. An experienced qualitative team conducted a comprehensive thematic analysis and identified cross-cutting themes in how providers approach and engage in the Rapid interaction, as well as longer-form narratives from providers that describe more fully what this interaction looks like for them. RESULTS Three main themes represent the range and content of individual provider approaches to the Rapid interaction: (1) patient-centeredness; (2) emotional support and partnership; and (3) correcting misperceptions about HIV. Each theme encompassed both conceptual approaches to offering Rapid ART and concrete examples of messaging to the patient that providers used in the Rapid interaction. We describe and show examples of these themes, offer key take-aways for implementation, and provide expanded narratives of providers' personal approaches to the Rapid interaction. CONCLUSIONS Exploration of provider-level approaches to Rapid ART implementation, as carried out in the patient-provider Rapid interaction, contributes a critical layer of evidence for wider implementation. It is our hope that, together with existing research showing positive outcomes and core components of systems-level implementation, these findings add to an instructive body of findings that facilitates the implementation of Rapid ART as an enhanced model of HIV care.
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Affiliation(s)
- Lissa Moran
- Department of Medicine, University of California, 550 16Th Street, San Francisco, CA, USA.
| | - Kimberly A Koester
- Department of Medicine, University of California, 550 16Th Street, San Francisco, CA, USA
| | - Noelle Le Tourneau
- Department of Medicine, University of California, 550 16Th Street, San Francisco, CA, USA
| | - Susa Coffey
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kelvin Moore
- Department of Medicine, University of California, 550 16Th Street, San Francisco, CA, USA
| | - Janessa Broussard
- Department of Community Health Systems, School of Nursing, University of California, 2 Koret Way, San Francisco, CA, USA
| | - Pierre-Cedric Crouch
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | | | - John Schneider
- Department of Medicine, University of Chicago, 5841 South Maryland Street, Chicago, IL, USA
| | - Elizabeth Lynch
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Jorge Roman
- San Francisco AIDS Foundation, 470 Castro Street, San Francisco, CA, USA
| | - Katerina A Christopoulos
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
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23
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Derigubah CA, Nkansah C, Mensah K, Appiah SK, Osei‐Boakye F, Odame E, Owusu M, Serwaa D, Hubert MA, Bani SB, Kuugbee E, Issahaku RG, Debrah AY, Addai‐Mensah O. Plasma levels of fibrinolytic and coagulation biomarkers in HIV-infected individuals on highly active antiretroviral therapy: A case-control study in a Northern Ghanaian population. Health Sci Rep 2023; 6:e1436. [PMID: 37484058 PMCID: PMC10360046 DOI: 10.1002/hsr2.1436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/27/2023] [Accepted: 07/07/2023] [Indexed: 07/25/2023] Open
Abstract
Background and Aim Impaired coagulation and fibrinolysis have been implicated in thromboembolism in human immunodeficiency virus (HIV)-infected individuals. This study evaluated the plasma levels of plasminogen activator inhibitor-1 (PAI-1) and coagulation biomarkers in HIV-infected individuals on highly active antiretroviral therapy (HAART). Methods This matched case-control study from March to December, 2020 comprised 76 participants: 38 HIV-positive individuals on HAART and 38 apparently healthy HIV-negative individuals as controls. Blood samples were collected for prothrombin time (PT), activated partial thromboplastin time (aPTT), D-dimers, PAI-1, and soluble fibrin monomer complex (SFMC) estimations. The data were analysed using SPSS version 22.0 and statistical significance was set at p < 0.05. Results Activated partial thromboplastin time was significantly lower in HIV seropositive individuals on HAART compared with HIV seronegative controls (25.90 s vs. 29.0 s, p = 0.030); however, PT, SFMC, D-dimers, and PAI-1 were significantly higher among the HIV-seropositive individuals compared with the controls: PT: (16.29 s ± 2.16 vs. 15.15 s ± 2.60, p = 0.010), SFMC: [8.53 ng/mL (8.03-9.12) vs. 7.84 ng/mL (7.32-8.58), p = 0.005]), D-Dimer: [463.37 ng/mL (402.70-526.33) vs. 421.11 ng/mL (341.11-462.52), p = 0.015], and PAI-1: [12.77 ng/mL (10.63-14.65) vs. 11.27 ng/mL (10.08-12.95), p = 0.039]. PAI-1 showed a moderate positive correlation with D-Dimer (r = 0.659, p < 0.001) and SFMC (r = 0.463, p = 0.003) among HIV-positive individuals on HAART. There was a strong positive correlation between the plasma PAI-1 concentration and the HIV viral load (r = 0.955, p < 0.001). Conclusion HIV-seropositive individuals on HAART have deranged coagulation and fibrinolytic markers. Higher HIV viral load correlates strongly with elevated plasma levels of PAI-1 antigens. Periodic assessment of markers of coagulation and fibrinolysis be included in the management of HIV/AIDS in Ghana.
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Affiliation(s)
- Charles A. Derigubah
- Department of Medical Laboratory TechnologySchool of Applied Science and Arts, Bolgatanga Technical UniversityBolgatangaGhana
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Charles Nkansah
- Department of HaematologySchool of Allied Health Sciences, University for Development StudiesTamaleGhana
- Department of Medical Laboratory SciencesFaculty of Health Science and Technology, Ebonyi State UniversityAbakalikiNigeria
| | - Kofi Mensah
- Department of HaematologySchool of Allied Health Sciences, University for Development StudiesTamaleGhana
- Department of Medical Laboratory SciencesFaculty of Health Science and Technology, Ebonyi State UniversityAbakalikiNigeria
| | - Samuel K. Appiah
- Department of HaematologySchool of Allied Health Sciences, University for Development StudiesTamaleGhana
- Department of Medical Laboratory SciencesFaculty of Health Science and Technology, Ebonyi State UniversityAbakalikiNigeria
| | - Felix Osei‐Boakye
- Department of Medical Laboratory TechnologyFaculty of Applied Science and Technology, Sunyani Technical UniversitySunyaniGhana
| | - Enoch Odame
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Michael Owusu
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
- Department of Molecular BiologyKumasi Centre for Collaborative Research (KCCR)KumasiGhana
| | - Dorcas Serwaa
- Department of Obstetrics and GynaecologyUniversity of MelbourneMelbourneAustralia
| | - Maxwell A. Hubert
- Department of Medical Laboratory ScienceKoforidua Technical UniversityKoforiduaGhana
| | - Simon Bannison Bani
- Department of Biomedical Laboratory SciencesSchool of Allied Health Sciences, University for Development StudiesTamaleGhana
| | - Eugene Kuugbee
- Department of Clinical Microbiology, School of Medicine and Health SciencesUniversity for Development StudiesTamaleGhana
| | | | - Alexander Y. Debrah
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Otchere Addai‐Mensah
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
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Bourdeau B, Shade SB, Koester KA, Rebchook GM, Steward WT, Agins BM, Myers JJ, Phan SH, Matosky M. Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol. BMC Health Serv Res 2023; 23:503. [PMID: 37198586 DOI: 10.1186/s12913-023-09500-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND In 2020, the Health Resources and Services Administration's HIV/AIDS Bureau funded an initiative to promote implementation of rapid antiretroviral therapy initiation in 14 HIV treatment settings across the U.S. The goal of this initiative is to accelerate uptake of this evidence-based strategy and provide an implementation blueprint for other HIV care settings to reduce the time from HIV diagnosis to entry into care, for re-engagement in care for those out of care, initiation of treatment, and viral suppression. As part of the effort, an evaluation and technical assistance provider (ETAP) was funded to study implementation of the model in the 14 implementation sites. METHOD The ETAP has used implementation science methods framed by the Dynamic Capabilities Model integrated with the Conceptual Model of Implementation Research to develop a Hybrid Type II, multi-site mixed-methods evaluation, described in this paper. The results of the evaluation will describe strategies associated with uptake, implementation outcomes, and HIV-related health outcomes for patients. DISCUSSION This approach will allow us to understand in detail the processes that sites to implement and integrate rapid initiation of antiretroviral therapy as standard of care as a means of achieving equity in HIV care.
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Affiliation(s)
- Beth Bourdeau
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA.
| | - Starley B Shade
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Kimberly A Koester
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Greg M Rebchook
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Wayne T Steward
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Bruce M Agins
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Janet J Myers
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Son H Phan
- Division of Policy and Data, Health Resources and Services Administration HIV/AIDS Bureau, Rockville, MD, USA
| | - Marlene Matosky
- Division of Policy and Data, Health Resources and Services Administration HIV/AIDS Bureau, Rockville, MD, USA
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Khazanchi R, Powers S, Killelea A, Strumpf A, Horn T, Hamp A, McManus KA. Access to a novel first-line single-tablet HIV antiretroviral regimen in Affordable Care Act Marketplace plans, 2018-2020. J Pharm Policy Pract 2023; 16:57. [PMID: 37081570 PMCID: PMC10116786 DOI: 10.1186/s40545-023-00559-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/04/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND A pillar of the United States' Ending the HIV Epidemic (EHE) initiative is to rapidly provide antiretroviral therapy (ART) in order to achieve HIV viral suppression. However, insurance benefit design can impede ART access. The primary objective of this study is to understand how Affordable Care Act (ACA) Marketplace qualified health plan (QHP) formularies responded to two new ART single tablet regimens (STRs): dolutegravir/abacavir/lamivudine (DTG/ABC/3TC; approved in 2014) and bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF; approved in 2018). METHODS We conducted a descriptive study of individual and small group QHPs to assess coverage, cost sharing (coinsurance vs. copay), specialty tiering, prior authorization, and out-of-pocket (OOP) costs for DTG/ABC/3TC and BIC/FTC/TAF. All individual and small group QHPs offered in state ACA Marketplaces from 2018-2020 were identified using plan-level formulary data from Ideon linked to end-of-year data from Robert Wood Johnson Foundation's Individual Market Health Insurance Exchange (HIX). RESULTS For 2018, 2019, and 2020, respectively, we identified 19,533, 17,007, and 21,547 QHPs. While DTG/ABC/3TC coverage was above 91% from 2018-2020, BIC/FTC/TAF coverage improved from 60 to 86%. Coverage of BIC/FTC/TAF improved in EHE priority jurisdictions from 73 to 90% driven by increased coverage with coinsurance. Although BIC/FTC/TAF had a higher wholesale acquisition cost than DTG/ABC/3TC, monthly OOP cost trends differed regionally in the Midwest but did not differ by EHE priority jurisdiction status. CONCLUSIONS QHP coverage of STRs is heterogeneous across the US. While coverage of BIC/FTC/TAF increased over time, many QHPs in EHE priority jurisdictions required coinsurance. Access to new ART regimens may be slowed by delayed QHP coverage and benefit design.
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Affiliation(s)
- Rohan Khazanchi
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Harvard Internal Medicine-Pediatrics Residency Program, Brigham & Women's Hospital, Boston Children's Hospital, and Boston Medical Center, Boston, MA, USA
- Departments of Internal Medicine and Pediatrics, Harvard Medical School, Boston, MA, USA
- FXB Center for Health and Human Rights, Harvard University, Boston, MA, USA
| | - Samuel Powers
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, P.O. Box 801379, Charlottesville, VA, 22908, USA
| | - Amy Killelea
- Health Systems and Policy, National Alliance of State and Territorial AIDS Directors (NASTAD), Washington, DC, USA
- Killelea Consulting, Arlington, VA, USA
| | - Andrew Strumpf
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, P.O. Box 801379, Charlottesville, VA, 22908, USA
| | - Tim Horn
- Health Systems and Policy, National Alliance of State and Territorial AIDS Directors (NASTAD), Washington, DC, USA
| | - Auntré Hamp
- Health Systems and Policy, National Alliance of State and Territorial AIDS Directors (NASTAD), Washington, DC, USA
| | - Kathleen A McManus
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, P.O. Box 801379, Charlottesville, VA, 22908, USA.
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26
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Sarıgül Yıldırım F, Candevir A, Akhan S, Kaya S, Çabalak M, Ersöz G, İnan D, Ceren N, Karaoğlan İ, Damar Çakırca T, Özer Balin Ş, Alkan S, Kandemir Ö, Üser Ü, Karabay O, Çelen MK. Comparison of Immunological and Virological Recovery with Rapid, Early, and Late Start of Antiretroviral Treatment in Naive Plwh: Real-World Data. Int J Gen Med 2023; 16:1867-1877. [PMID: 37213471 PMCID: PMC10195690 DOI: 10.2147/ijgm.s393370] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/01/2023] [Indexed: 05/23/2023] Open
Abstract
Background Rapid initiation of antiretroviral therapy (ART) reduces the transmission of HIV infection in the community. This study aimed to determine whether rapid ART initiation is effective compared to standard ART treatment in our country. Methods Patients were grouped based on time to treatment initiation. HIV RNA levels, CD+4 T cell count, CD4/CD8 ratio, and ART regimens were recorded at baseline and follow-up visits for 12 months. Results There were 368-ART naive adults (treatment initiated at the time of HIV diagnosis; 143 on the first day, 48 on the second-seventh day, and 177 after the seventh day). Although virological suppression rates at 12th months were higher in all groups, over 90% on average, there were no statistically significant differences in HIV-1 RNA suppression rates, CD+4 T cell count, and CD4/CD8 ratio normalization in the studied months but in multivariate logistic regression analysis; showed a significant correlation between both virological and immunological response and those with CD4+ T <350 cells/mL at 12th month in total patients. Conclusion Our findings support the broader application of recommendations for rapid ART initiation in HIV patients.
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Affiliation(s)
- Figen Sarıgül Yıldırım
- Antalya Life Hospital, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey
- Correspondence: Figen Sarıgül Yıldırım, Antalya Life Hospital, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey, Tel +90 532 473 44 46, Email
| | - Aslıhan Candevir
- Cukurova University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Adana, Turkey
| | - Sıla Akhan
- Kocaeli Üniversity, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Kocaeli, Turkey
| | - Selçuk Kaya
- Karadeniz Teknik University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Trabzon, Turkey
| | - Mehmet Çabalak
- Mustafa Kemal University Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Hatay, Turkey
| | - Gülden Ersöz
- Mersin University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Mersin, Turkey
| | - Dilara İnan
- Akdeniz University Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey
| | - Nurgül Ceren
- Health Science University, Haydarpaşa Numune Education and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, İstanbul, Turkey
| | - İlkay Karaoğlan
- Gaziantep University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Gaziantep, Turkey
| | - Tuba Damar Çakırca
- Health Science University, Şanlıurfa Numune Education and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Şanlıurfa, Turkey
| | - Şafak Özer Balin
- Fırat University Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Elazığ, Turkey
| | - Sevil Alkan
- Çanakkale 18 Mart University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Çanakkale, Turkey
| | - Özlem Kandemir
- Mersin University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Mersin, Turkey
| | - Ülkü Üser
- Health Science University, Antalya Education and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey
| | - Oğuz Karabay
- Sakarya University Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Hatay, Turkey
| | - Mustafa Kemal Çelen
- Dicle University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Diyarbakır, Turkey
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Mohr KB, Lee-Rodriguez C, Samiezade-Yazd Z, Lam JO, Imp BM, Luu MN. Impact of the Coronavirus Disease 2019 Pandemic on Antiretroviral Therapy Initiation and Care Delivery for People With Newly Diagnosed HIV in an Integrated Healthcare System. Open Forum Infect Dis 2022; 9:ofac639. [PMID: 36519122 PMCID: PMC9745762 DOI: 10.1093/ofid/ofac639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/22/2022] [Indexed: 11/16/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic disrupted health systems. For patients newly diagnosed with human immunodeficiency virus, starting immediate antiretroviral therapy (ART) is recommended. For periods before and during the COVID-19 pandemic, Kaiser Permanente Northern California found similar rates of rapid ART initiation and time to viral suppression, concurrent with an increase in telemedicine.
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Affiliation(s)
- Kurtis B Mohr
- Graduate Medical Education, Kaiser Permanente Northern California, Oakland, California, USA
| | | | - Zahra Samiezade-Yazd
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jennifer O Lam
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Brandon M Imp
- Graduate Medical Education, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mitchell N Luu
- Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
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Goldbach JT, Kipke MD. What affects timely linkage to HIV Care for Young Men of Color who have sex with Men? Young Men's Experiences Accessing HIV Care after Seroconverting. AIDS Behav 2022; 26:4012-4025. [PMID: 35672551 DOI: 10.1007/s10461-022-03727-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/26/2022]
Abstract
The HIV care continuum provides intervention points that should be addressed to optimally identify, engage, and retain populations in HIV care. This study addressed the lack of research into barriers and facilitators of linkage to care for HIV-positive young men who have sex with men (YMSM) of color. Data were collected using a qualitative timeline follow-back interview approach with YMSM who had seroconverted in the last 6 months. Interviews were conducted with 15 YMSM from April 2017 to April 2018. This study provides important information about what can delay linkage to care for YMSM of color. These delays include fractured referrals to care providers via mobile HIV testing vans, adapting to an HIV diagnosis and integrating it into their lives, and finding caring and competent providers that offer wraparound services, specifically mental health services, as soon as possible after an HIV diagnosis. Addressing these issues is imperative to optimize YMSM's engagement in the HIV care continuum and work toward ending the epidemic.
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Affiliation(s)
- Jeremy T Goldbach
- The Brown School, Washington University in St. Louis, 1 Brookings Dr, 63130, St. Louis, MO, United States.
| | - Michele D Kipke
- Division of Research on Children, Youth, and Families, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, United States
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, United States
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Antiretroviral therapy initiation within 7 and 8-30 days post-HIV diagnosis demonstrates similar benefits in resource-limited settings. AIDS 2022; 36:1741-1743. [PMID: 35866529 PMCID: PMC9451863 DOI: 10.1097/qad.0000000000003327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We estimated the optimum time to initiate antiretroviral therapy (ART) in a retrospective observational cohort. We observed that ART initiation 7 days or less ( n = 817) and 8-30 days ( n = 1009) were the most important factors with viral suppression, and had similar viral suppression rate, CD4 + T-cell count increase and fractions of individuals with links at least 4 and individuals linked to recent HIV infection in HIV molecular networks. This study provides real-world evidence on the benefits of rapid ART initiation in resource-limited setting.
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Same‐day
and rapid initiation of antiretroviral therapy in people living with
HIV
in Asia. How far have we come? HIV Med 2022; 23 Suppl 4:3-14. [DOI: 10.1111/hiv.13410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 09/01/2022] [Indexed: 11/04/2022]
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Edwards JK, Cole SR, Breger TL, Filiatreau LM, Zalla L, Mulholland GE, Horberg MA, Silverberg MJ, John Gill M, Rebeiro PF, Thorne JE, Kasaie P, Marconi VC, Sterling TR, Althoff KN, Moore RD, Eron JJ. Five-Year Mortality for Adults Entering Human Immunodeficiency Virus Care Under Universal Early Treatment Compared With the General US Population. Clin Infect Dis 2022; 75:867-874. [PMID: 34983066 PMCID: PMC9477443 DOI: 10.1093/cid/ciab1030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Mortality among adults with human immunodeficiency virus (HIV) remains elevated over those in the US general population, even in the years after entry into HIV care. We explore whether the elevation in 5-year mortality would have persisted if all adults with HIV had initiated antiretroviral therapy within 3 months of entering care. METHODS Among 82 766 adults entering HIV care at North American AIDS Cohort Collaboration clinical sites in the United States, we computed mortality over 5 years since entry into HIV care under observed treatment patterns. We then used inverse probability weights to estimate mortality under universal early treatment. To compare mortality with those for similar individuals in the general population, we used National Center for Health Statistics data to construct a cohort representing the subset of the US population matched to study participants on key characteristics. RESULTS For the entire study period (1999-2017), the 5-year mortality among adults with HIV was 7.9% (95% confidence interval [CI]: 7.6%-8.2%) higher than expected based on the US general population. Under universal early treatment, the elevation in mortality for people with HIV would have been 7.2% (95% CI: 5.8%-8.6%). In the most recent calendar period examined (2011-2017), the elevation in mortality for people with HIV was 2.6% (95% CI: 2.0%-3.3%) under observed treatment patterns and 2.1% (.0%-4.2%) under universal early treatment. CONCLUSIONS Expanding early treatment may modestly reduce, but not eliminate, the elevation in mortality for people with HIV.
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Affiliation(s)
- Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Stephen R Cole
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Tiffany L Breger
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lindsey M Filiatreau
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Lauren Zalla
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Grace E Mulholland
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Michael A Horberg
- Kaiser Permanent Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | | | - M John Gill
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Peter F Rebeiro
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jennifer E Thorne
- School of Medicine, Johns Hopkins University, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Parastu Kasaie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Vincent C Marconi
- School of Medicine, and Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Timothy R Sterling
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USAand
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Richard D Moore
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joseph J Eron
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Arora AK, Engler K, Lessard D, Kronfli N, Rodriguez-Cruz A, Huerta E, Lemire B, Routy JP, Wittmer R, Cox J, de Pokomandy A, Del Balso L, Klein M, Sebastiani G, Vedel I, Quesnel-Vallée A, Lebouché B. Experiences of Migrant People Living with HIV in a Multidisciplinary HIV Care Setting with Rapid B/F/TAF Initiation and Cost-Covered Treatment: The 'ASAP' Study. J Pers Med 2022; 12:1497. [PMID: 36143282 PMCID: PMC9503330 DOI: 10.3390/jpm12091497] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/02/2022] [Accepted: 09/09/2022] [Indexed: 11/21/2022] Open
Abstract
This study aimed to explore the experiences of migrant people living with HIV (MLWH) enrolled in a Montreal-based multidisciplinary HIV care clinic with rapid antiretroviral treatment (ART) initiation and cost-covered ART. Between February 2020 and March 2022, 32 interviews were conducted with 16 MLWH at three time-points (16 after 1 week of ART initiation, 8 after 24 weeks, 8 after 48 weeks). Interviews were analyzed via the Framework Method. Thirty categories were identified, capturing experiences across the HIV care cascade. At diagnosis, most MLWH described "initially experiencing distress". At linkage, almost all MLWH discussed "navigating the health system with difficulty". At treatment initiation, almost all MLWH expressed "being satisfied with treatment", particularly due to a lack of side effects. Regarding care retention, all MLWH noted "facing psychosocial or health-related challenges beyond HIV". Regarding ART adherence, most MLWH expressed "being satisfied with treatment" with emphasis on their taking control of HIV. At viral suppression, MLWH mentioned "finding more peace of mind since becoming undetectable". Regarding their perceived health-related quality of life, most MLWH indicated "being helped by a supportive social network". Efficient, humanizing, and holistic approaches to care in a multidisciplinary setting, coupled with rapid and free ART initiation, seemed to help alleviate patients' concerns, address their bio-psycho-social challenges, encourage their initial and sustained engagement with HIV care and treatment, and ultimately contribute to positive experiences.
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Affiliation(s)
- Anish K. Arora
- Department of Family Medicine, Faculty of Medicine & Health Sciences, McGill University, Montréal, QC H3S 1Z1, Canada
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR/SPOR) Mentorship Chair in Innovative Clinical Trials in HIV Care, Montréal, QC H4A 3S5, Canada
| | - Kim Engler
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR/SPOR) Mentorship Chair in Innovative Clinical Trials in HIV Care, Montréal, QC H4A 3S5, Canada
| | - David Lessard
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR/SPOR) Mentorship Chair in Innovative Clinical Trials in HIV Care, Montréal, QC H4A 3S5, Canada
| | - Nadine Kronfli
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
| | - Adriana Rodriguez-Cruz
- Department of Family Medicine, Faculty of Medicine & Health Sciences, McGill University, Montréal, QC H3S 1Z1, Canada
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR/SPOR) Mentorship Chair in Innovative Clinical Trials in HIV Care, Montréal, QC H4A 3S5, Canada
| | - Edmundo Huerta
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR/SPOR) Mentorship Chair in Innovative Clinical Trials in HIV Care, Montréal, QC H4A 3S5, Canada
| | - Benoit Lemire
- Pharmacy Department, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
| | - Jean-Pierre Routy
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
| | - René Wittmer
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC H3C 3J7, Canada
| | - Joseph Cox
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine & Health Sciences, McGill University, Montréal, QC H3A 1A2, Canada
| | - Alexandra de Pokomandy
- Department of Family Medicine, Faculty of Medicine & Health Sciences, McGill University, Montréal, QC H3S 1Z1, Canada
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
| | - Lina Del Balso
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
| | - Marina Klein
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
| | - Giada Sebastiani
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
| | - Isabelle Vedel
- Department of Family Medicine, Faculty of Medicine & Health Sciences, McGill University, Montréal, QC H3S 1Z1, Canada
| | - Amélie Quesnel-Vallée
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine & Health Sciences, McGill University, Montréal, QC H3A 1A2, Canada
- Department of Sociology, Faculty of Arts, McGill University, Montréal, QC H3A 0G5, Canada
| | - ASAP Migrant Advisory Committee
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
| | - Bertrand Lebouché
- Department of Family Medicine, Faculty of Medicine & Health Sciences, McGill University, Montréal, QC H3S 1Z1, Canada
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC H4A 3S5, Canada
- Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR/SPOR) Mentorship Chair in Innovative Clinical Trials in HIV Care, Montréal, QC H4A 3S5, Canada
- Department of Medicine, Chronic Viral Illness Service, Division of Infectious Diseases, McGill University Health Centre, Montréal, QC H4A 3J1, Canada
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Gopalsamy SN, Shah NS, Marconi VC, Armstrong WS, del Rio C, Pennisi E, Wortley P, Colasanti JA. The Impact of Churn on HIV Outcomes in a Southern United States Clinical Cohort. Open Forum Infect Dis 2022; 9:ofac338. [PMID: 35899283 PMCID: PMC9314921 DOI: 10.1093/ofid/ofac338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Persons with human immunodeficiency virus (PWH) may experience a cycle of engaging and disengaging in care referred to as “churn.” While human immunodeficiency virus (HIV) churn is predicted to be more prevalent in the southern United States (US), it has not been well characterized in this region. Methods We conducted a retrospective cohort study involving PWH newly establishing care at a large urban clinic in Atlanta, Georgia, from 2012 to 2017, with follow-up data collected through 2019. The primary exposure was churn, defined as a ≥12-month gap between routine clinic visits or viral load (VL) measurements. We compared HIV metrics before and after churn and assessed the risk of future churn or loss to follow-up. Results Of 1303 PWH newly establishing care, 81.7% were male and 84.9% were Black; 200 (15.3%) experienced churn in 3.3 years of median follow-up time. The transmissible viremia (TV) rate increased from 28.6% prechurn to 66.2% postchurn (P < .0001). The 122 PWH having TV on reengagement had delayed time to subsequent viral suppression (adjusted hazard ratio, 0.59 [95% confidence interval {CI}, .48–.73]), and PWH returning to care contributed disproportionately to the community viral load (CVL) (proportion of CVL/proportion of patients, 1.96). Churn was not associated with an increased risk of subsequent churn (adjusted odds ratio [aOR], 1.53 [95% CI, .79–2.97]) or loss to follow-up (aOR, 1.04 [95% CI, .60–1.79]). Conclusions The rate of churn in a southern US clinic was high, and those who experienced churn had increased TV at reentry and disproportionately contributed to the CVL and likely contributing to ongoing HIV transmission.
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Affiliation(s)
| | - N Sarita Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta, GA , USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Department of Medicine and Department of Global Health, Rollins School of Public Health, Emory University , Atlanta, GA , USA
- Atlanta VA Medical Center , Decatur, GA , USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
| | - Eugene Pennisi
- HIV/AIDS Epidemiology Section, Georgia Department of Public Health , Atlanta, GA , USA
| | - Pascale Wortley
- HIV/AIDS Epidemiology Section, Georgia Department of Public Health , Atlanta, GA , USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
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Pettit AC, Pichon LC, Ahonkhai AA, Robinson C, Randolph B, Gaur A, Stubbs A, Summers NA, Truss K, Brantley M, Devasia R, Teti M, Gimbel S, Dombrowski JC. Comprehensive Process Mapping and Qualitative Interviews to Inform Implementation of Rapid Linkage to HIV Care Programs in a Mid-Sized Urban Setting in the Southern United States. J Acquir Immune Defic Syndr 2022; 90:S56-S64. [PMID: 35703756 PMCID: PMC9204789 DOI: 10.1097/qai.0000000000002986] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 02/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rapid antiretroviral therapy (ART) initiation, in which people living with HIV start ART within days of diagnosis, is a key component of the US Ending the HIV Epidemic initiative. SETTING The Memphis Metropolitan Statistical Area ranked fourth in the United States for the highest HIV incidence per 100,000 population in 2018. Rapid ART programs are limited in the Memphis Metropolitan Statistical Area, and our objective was to identify local implementation barriers. METHODS We conducted participatory process mapping and in-depth interviews to detail steps between HIV testing at the municipal health department's Sexually Transmitted Infections Clinic and ART prescription from a nearby high-volume Ryan White-funded HIV Clinic. RESULTS Process mapping identified 4 modifiable, rate-limiting rapid ART barriers: (1) requiring laboratory-based confirmatory HIV results, (2) eligibility documentation requirements for Ryan White-funded services, (3) insufficient HIV Clinic medical provider availability, and (4) variability in ART initiation timing among HIV Clinic providers. Staff at both sites highlighted suboptimal communication and sense of shared management between facilities, limited resources to address important social determinants of health, and lack of Medicaid expansion in Tennessee as key barriers. In-depth interview themes negatively affecting rapid ART initiation included clinic burden; provider knowledge, attitudes, and beliefs; and client psychosocial needs. CONCLUSIONS Our preimplementation work identified modifiable and systemic barriers to systems flow and patient-level outcomes. This work will inform the design and implementation of a locally relevant rapid ART program in Memphis, a community disproportionately affected by the HIV epidemic.
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Affiliation(s)
| | | | | | | | | | - Aditya Gaur
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Andrea Stubbs
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Nathan A. Summers
- University of Tennessee Health Science Center and Regional One Health, Adult Special Care Clinic, Memphis, Tennessee
| | | | | | - Rose Devasia
- Tennessee Department of Health, Nashville, Tennessee
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O'Shea JG, Gallini JW, Cui X, Moanna A, Marconi VC. Rapid Antiretroviral Therapy Program: Development and Evaluation at a Veterans Affairs Medical Center in the Southern United States. AIDS Patient Care STDS 2022; 36:219-225. [PMID: 35587641 PMCID: PMC9353996 DOI: 10.1089/apc.2022.0039] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Early HIV viral suppression (VS) improves individual health outcomes and decreases onward transmission. We designed an outpatient clinic protocol to rapidly initiate antiretroviral therapy (ART) in a large Veterans Health Administration (VA) HIV clinic. A pre-post evaluation was performed using a retrospective cohort study design for new diagnoses of HIV infection from January 2012 to February 2020. Time-to-event analyses were performed using the Cox proportional hazards model with the intervention group as the main exposure adjusted for integrase inhibitor usage, baseline viral load, age, gender, and race. Most of the patients were men (historical control: 94.8%, n = 55; Rapid Start: 94.8%, n = 55) and Black or African American persons (historical control: 87.9%, n = 51; Rapid Start: 82.8%, n = 48). More patients initiated treatment with an integrase inhibitor-based regimen in the Rapid Start group (98.3%, n = 57) compared with the historical control group (39.7%, n = 23). Compared with controls, the Rapid Start patients were significantly more likely to achieve VS at any given time during the study period (hazard ratio 2.65; p < 0.001). Median days (interquartile range) from diagnosis to VS decreased from 180.5 (102.5-338.5) to 62 (40-105) (p < 0.001), first appointment to VS decreased from 123 (68.5-237.5) to 45 (28-82) (p < 0.001), referral to first visit decreased from 20 (10-43) to 1 (0-3) (p < 0.001), and from first visit to ART dispense date decreased from 27.5 (3-50) to 0 (0-0) (p = 0.01). Prioritizing immediate ART initiation can compress the HIV care continuum from diagnosis to linkage to VS. Implementation of the Rapid Start Protocol should be considered at all VA facilities providing HIV care.
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Affiliation(s)
- Jesse G. O'Shea
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Julia W. Gallini
- Infectious Diseases, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
| | - Xiangqin Cui
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Abeer Moanna
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Infectious Diseases, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
| | - Vincent C. Marconi
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Infectious Diseases, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Zhao A, Rizk C, Zhao X, Esu A, Deng Y, Barakat L, Villanueva M. Longitudinal Improvements in Viral Suppression for Persons With New HIV Diagnosis Receiving Care in the Ryan White Program: A 10-Year Experience in New Haven, CT (2009-2018). Open Forum Infect Dis 2022; 9:ofac196. [PMID: 35794946 PMCID: PMC9251657 DOI: 10.1093/ofid/ofac196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 04/11/2022] [Indexed: 11/14/2022] Open
Abstract
Background The Ryan White (RW) program funds medical and other support services for low-income persons with HIV, significantly improving progress along the HIV care continuum. Although the program has shown overall improvements in achievement of viral suppression, the relative contributions of changes in clinical practice and RW service components to the optimization of the HIV care continuum, particularly for those with new HIV diagnoses, remain unknown. Methods The target population was patients with recent HIV diagnoses who received care at RW-funded clinics in the greater New Haven area between 2009 and 2018. Client data were extracted from the RW-funded database, CAREWare, and the electronic medical record. Primary outcomes included time between HIV diagnosis and first HIV primary care (PC) visit, antiretroviral therapy (ART) initiation, and viral suppression (VS). Results There were 386 eligible patients. Between 2009 and 2018, the median number of days from HIV diagnosis to first PC visit decreased from 58.5 to 8.5 days, and ART initiation decreased from 155 to 9 days. In 2018, 86% of participants achieved viral suppression within 1 year, compared with 2.5% in 2009. Patients who initiated single-tablet ART and integrase inhibitor-containing regimens were more likely to reach viral suppression within 1 year (P < .001). Receipt of medical case management services was also associated with achieving viral suppression (P < .001). Conclusions Longitudinal improvements over 10 years in ART initiation and viral suppression were observed due to clinical advances and their effective implementation through the RW comprehensive care model. Further study of the essential components promoting these outcomes is needed.
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Affiliation(s)
- Alice Zhao
- Correspondence: Alice Zhao, MPH, 135 College Street, New Haven, CT 06510 ()
| | - Christina Rizk
- Section of Infectious Diseases, Department of Internal Medicine, HIV/AIDS Program, Yale School of Medicine, New Haven, Connecticut, USA
| | - Xiwen Zhao
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Arit Esu
- Waterbury Hospital, Waterbury, Connecticut, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Lydia Barakat
- Section of Infectious Diseases, Department of Internal Medicine, HIV/AIDS Program, Yale School of Medicine, New Haven, Connecticut, USA
| | - Merceditas Villanueva
- Section of Infectious Diseases, Department of Internal Medicine, HIV/AIDS Program, Yale School of Medicine, New Haven, Connecticut, USA
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Koester KA, Moran L, LeTourneau N, VanderZanden L, Coffey S, Crouch PC, Broussard J, Schneider J, Christopoulos KA. Essential elements of and challenges to rapid ART implementation: a qualitative study of three programs in the United States. BMC Infect Dis 2022; 22:316. [PMID: 35361148 PMCID: PMC8968260 DOI: 10.1186/s12879-022-07297-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) initiation on the day of an HIV diagnosis or as soon as possible after diagnosis, known as rapid ART (henceforth "RAPID"), is considered to be a safe and effective intervention to quickly reduce viral load and potentially improve engagement in care over time. However, implementation of RAPID programming is not yet widespread. To facilitate broader dissemination of RAPID, we sought to understand health care worker experiences with RAPID implementation and to identify essential programmatic elements. METHODS We conducted 27 key informant interviews with medical providers and staff involved in RAPID service delivery in three distinct clinical settings: an HIV clinic, a Federally Qualified Health Center and a sexual health and wellness clinic. Interviews were structured around domains associated with the Consolidated Framework for Implementation Research and were audio-recorded, transcribed, and thematically analyzed. FINDINGS We identified seven (7) essential elements across settings associated with successful RAPID program implementation. These high-impact elements represent essential components without which a RAPID program could not function. There was no one requisite formation. Instead, we observed a constellation of essential elements that could be operationalized in various formations and by various people in various roles. The essential elements included: (1) presence of an implementation champion; (2) comfort and competence prescribing RAPID ART; (3) expedited access to ART medications; (4) expertise in benefits, linkage, and care navigation; (5) RAPID team member flexibility and organizations' adaptive capacity; (6) patient-centered approach; and (7) strong communication methods and culture. CONCLUSIONS The RAPID model can be applied to a diverse range of clinical contexts. The operational structure of RAPID programs is shaped by the clinical setting in which they function, and therefore the essential elements identified may not apply equally to all programs. Based on the seven essential elements described above we recommend future implementers identify where these elements currently exist within a practice; leverage them when possible; strengthen them when necessary or develop them if they do not yet exist; and look to these elements when challenges arise for potential solutions.
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Affiliation(s)
- Kimberly A Koester
- Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA, USA.
| | - Lissa Moran
- Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA, USA
| | - Noelle LeTourneau
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | | | - Susa Coffey
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | | | - Janessa Broussard
- San Francisco AIDS Foundation, 470 Castro Street, San Francisco, CA, USA
| | - John Schneider
- Howard Brown Health Center, 4025 N. Sheridan Rd, Chicago, IL, USA
| | - Katerina A Christopoulos
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
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Virological and Immunological Outcomes of an Intensified Four-Drug versus a Standard Three-Drug Antiretroviral Regimen, Both Integrase Strand Transfer Inhibitor-Based, in Primary HIV Infection. Pharmaceuticals (Basel) 2022; 15:ph15040403. [PMID: 35455400 PMCID: PMC9024471 DOI: 10.3390/ph15040403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 12/04/2022] Open
Abstract
The optimal therapeutic approach for primary HIV infection (PHI) is still debated. We aimed to compare the viroimmunological response to a four- versus a three-drug regimen, both INSTI-based, in patients with PHI. This was a monocentric, prospective, observational study including all patients diagnosed with PHI from December 2014 to April 2018. Antiretroviral therapy (ART) was started, before genotype resistance test results, with tenofovir/emtricitabine and either raltegravir plus boosted darunavir or dolutegravir. Cumulative probability of virological suppression [VS] (HIV-1 RNA< 40 cp/mL), low-level HIV-1 DNA [LL-HIVDNA] (HIV-1 DNA < 200 copies/106PBMC), and CD4/CD8 ratio ≥1 were estimated using Kaplan−Meier curves. Factors associated with the achievement of VS, LL-HIVDNA, and CD4/CD8 ≥ 1 were assessed by a Cox regression model. We enrolled 144 patients (95.8% male, median age 34 years): 110 (76%) started a four-drug-based therapy, and 34 (24%) a three-drug regimen. Both treatment groups showed a comparable high probability of achieving VS and a similar probability of reaching LL-HIVDNA and a CD4/CD8 ratio ≥1 after 48 weeks from ART initiation. Higher baseline HIV-1 RNA and HIV-1 DNA levels lowered the chance of VS, whereas a better preserved immunocompetence increased that chance. Not statistically significant factors associated with LL-HIVDNA achievement were found, whereas a higher baseline CD4/CD8 ratio predicted the achievement of immune recovery. In PHI patients, the rapid initiation of either an intensified four-drug or a standard three-drug INSTI-based regimen showed comparable responses in terms of VS, viral reservoir size, and immunological recovery.
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Hidalgo-Tenorio C, Pasquau J, Vinuesa D, Ferra S, Terrón A, SanJoaquín I, Payeras A, Martínez OJ, López-Ruz MÁ, Omar M, de la Torre-Lima J, López-Lirola A, Palomares J, Blanco JR, Montero M, García-Vallecillos C. DOLAVI Real-Life Study of Dolutegravir Plus Lamivudine in Naive HIV-1 Patients (48 Weeks). Viruses 2022; 14:524. [PMID: 35336931 PMCID: PMC8951045 DOI: 10.3390/v14030524] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 12/28/2022] Open
Abstract
Brief: Real-world data in naïve HIV-1 patients demonstrate that dolutegravir plus lamivudine in a multiple tablet regimen is effective, safe, and satisfactory; it causes moderately increasing weight and abdominal circumference and is administrable on a test-and-treat strategy. Background: Our objectives were to determine the real-life effectiveness and safety of DT with dolutegravir (50 mg/QD) plus lamivudine (300 mg/QD) in a multiple-tablet regimen (MTR) in naïve PLHIV followed up for 48 weeks and to evaluate the compliance and satisfaction of patients. Material and methods: An open, single-arm, multicenter, non-randomized clinical trial from May 2019 through September 2020 with a 48-week follow-up. Results: The study included 88 PLHIV patients (87.5% male) with a mean age of 35.9 years; 76.1% were MSM patients. The mean baseline CD4 was 516.4 cells/uL, with a viral load (VL) of 4.49 log10, and 11.4% were in the AIDS stage. DT started within 7 days of first specialist consultation in all patients and the same day in 84.1%; 3.4% had baseline resistance mutations (K103N, V106I + E138A, and V108I); 12.5% were lost to follow-up. At week 48, 86.3% had VL < 50 cop/uL by intention-to-treat analysis and 98.7% by per-protocol (PP) analysis. Virological failure (VF) was recorded in 1.1%, with no resistance mutation. One blip was detected in 5.2% without VF. Three reported anxiety, dizziness, and cephalgia, respectively, at week 4 and one reported insomnia at week 24; none reported adverse events at week 48. The mean weight was 4 kg higher at 48 weeks (p = 0.0001) and abdominal circumference 3 cm larger at 24 weeks (p = 0.022). No forgetfulness occurred in 98.7% of patients. Patient satisfaction was 90/100 at 4, 24, and 48 weeks. Conclusion: Real-world data demonstrate that dolutegravir plus lamivudine in MTR is effective, safe, and satisfactory, moderately increasing weight and abdominal circumference and administrable on a test-and-treat strategy.
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Affiliation(s)
- Carmen Hidalgo-Tenorio
- Unit of Infectious Diseases, Virgen de las Nieves University Hospital, 18014 Granada, Spain; (J.P.); (M.Á.L.-R.); (C.G.-V.)
| | - Juan Pasquau
- Unit of Infectious Diseases, Virgen de las Nieves University Hospital, 18014 Granada, Spain; (J.P.); (M.Á.L.-R.); (C.G.-V.)
| | - David Vinuesa
- Unit of Infectious Diseases, University Hospital San Cecilio, 18016 Granada, Spain;
| | - Sergio Ferra
- Unit of Infectious Diseases, Torrecárdenas University Hospital, 04009 Almería, Spain;
| | - Alberto Terrón
- Unit of Infectious Diseases, Hospital de Jerez, 11407 Jerez de la Frontera, Spain;
| | - Isabel SanJoaquín
- Unit of Infectious Diseases, Hospital Lozano Blesa, 50009 Zaragoza, Spain;
| | - Antoni Payeras
- Internal Medicine Service, Hospital Son Llatzer, 07198 Palma, Spain;
| | | | - Miguel Ángel López-Ruz
- Unit of Infectious Diseases, Virgen de las Nieves University Hospital, 18014 Granada, Spain; (J.P.); (M.Á.L.-R.); (C.G.-V.)
| | - Mohamed Omar
- Unit of Infectious Diseases, Hospital Complex of Jaén, 23007 Jaén, Spain;
| | | | - Ana López-Lirola
- Unit of Infectious Diseases, University Hospital Canarias, 38320 San Cristóbal de La Laguna, Spain;
| | - Jesús Palomares
- Internal Medicine Service, Hospital Santa Ana, 18600 Motril, Spain;
| | - José Ramón Blanco
- Unit of Infectious Diseases, Hospital San Pedro, 26006 Logroño, Spain;
| | - Marta Montero
- Service of Infectious Diseases, Hospital de La Fe, 46026 València, Spain;
| | - Coral García-Vallecillos
- Unit of Infectious Diseases, Virgen de las Nieves University Hospital, 18014 Granada, Spain; (J.P.); (M.Á.L.-R.); (C.G.-V.)
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Burke RM, Rickman HM, Singh V, Kalua T, Labhardt ND, Hosseinipour M, Wilkinson RJ, MacPherson P. Same-day antiretroviral therapy initiation for people living with HIV who have tuberculosis symptoms: a systematic review. HIV Med 2022; 23:4-15. [PMID: 34528368 DOI: 10.1111/hiv.13169] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Tuberculosis symptoms are very common among people living with HIV (PLHIV) initiating antiretroviral therapy (ART), are not specific for tuberculosis disease and may result in delayed ART start. The risks and benefits of same-day ART initiation in PLHIV with tuberculosis symptoms are unknown. METHODS We systematically reviewed nine databases on 12 March 2020 to identify studies that investigated same-day ART initiation among PLHIV with tuberculosis symptoms and reported both their approach to TB screening and clinical outcomes. We extracted and summarized data about TB screening, numbers of people starting same-day ART and outcomes. RESULTS We included four studies. Two studies deferred ART for everyone with any tuberculosis symptoms (one or more of cough, fever, night sweats or weight loss) and substantial numbers of people had deferred ART start (28% and 39% did not start same-day ART). Two studies permitted some people with tuberculosis symptoms to start same-day ART, and fewer people deferred ART (2% and 16% did not start same-day). Two of the four studies were conducted sequentially; proven viral load suppression at 8 months was 31% when everyone with tuberculosis symptoms had ART deferred, and 44% when the algorithm was changed so that some people with tuberculosis symptoms could start same-day ART. CONCLUSIONS Although tuberculosis symptoms are very common in people starting ART, there is insufficient evidence about whether presence of tuberculosis symptoms should lead to ART start being deferred or not. Research to inform clear guidelines would help to maximise the benefits of same-day ART.
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Affiliation(s)
- Rachael M Burke
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Hannah M Rickman
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Vindi Singh
- WHO Global HIV, Hepatitis and STI Programme, Geneva, Switzerland
- Global Fund to fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Thokozani Kalua
- Department of HIV and AIDS, Ministry of Health, Government of Malawi, Basel, Switzerland
| | - Niklaus D Labhardt
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | | | - Robert J Wilkinson
- Department of Infectious Disease, Imperial College London, UK
- Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, South Africa
- Francis Crick Institute, London, UK
| | - Peter MacPherson
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
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Christopoulos KA, Erguera XA, VanderZanden L, Campbell C, Green M, Tsuzuki MD, Schneider J, Coffey S, Bacon O, Gandhi M, Koester KA. A Qualitative Study of the Experience of Immediate Antiretroviral Therapy Among Urban Persons With Newly Diagnosed Human Immunodeficiency Virus. Open Forum Infect Dis 2021; 8:ofab469. [PMID: 34877362 PMCID: PMC8643677 DOI: 10.1093/ofid/ofab469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background Guidelines recommend immediate antiretroviral therapy (ART) at or shortly after human immunodeficiency virus (HIV) diagnosis, yet little is known about how people living with HIV (PLWH) experience this treatment strategy, including racial/ethnic minorities, cisgender/transgender women, and those with housing instability. Methods To assess the acceptability of immediate ART offer among urban PLWH, understand how this approach affects the lived experience of HIV diagnosis, and explore reasons for declining immediate ART, we conducted a cross-sectional qualitative study using semi-structured interviews with individuals who had been offered immediate ART after HIV diagnosis at a safety-net HIV clinic in San Francisco and a federally qualified health center in Chicago. Interviews were analyzed using thematic analysis. Results Among 40 participants with age range 19-52 years, 27% of whom were cisgender/transgender women or gender-queer, 85% racial/ethnic minority, and 45% homeless/unstably housed, we identified 3 major themes: (1) Individuals experienced immediate ART encounters as supportive; (2) individuals viewed immediate ART as sensible; and (3) immediate ART offered emotional relief by offsetting fears of death and providing agency over one's health. Reasons for declining immediate ART ranged from simply needing a few more days to complex interactions of logistical and psychosocial barriers. Conclusions Immediate ART was highly acceptable to urban persons with newly diagnosed HIV infection. Immediate ART was viewed as a natural next step after HIV diagnosis and provided a sense of control over one's health, mitigating anxiety over a decline in physical health. As such, immediate ART somewhat eased but in no way obviated the psychosocial challenges of HIV diagnosis.
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Affiliation(s)
| | - Xavier A Erguera
- University of California, San Francisco, San Francisco, California, USA
| | | | - Chadwick Campbell
- University of California, San Francisco, San Francisco, California, USA
| | - Maya Green
- Howard Brown Health, Chicago, Illinois, USA
| | | | - John Schneider
- Howard Brown Health, Chicago, Illinois, USA.,University of Chicago, Chicago, Illinois, USA
| | - Susa Coffey
- University of California, San Francisco, San Francisco, California, USA
| | - Oliver Bacon
- University of California, San Francisco, San Francisco, California, USA.,San Francisco Department of Public Health, San Francisco, California, USA
| | - Monica Gandhi
- University of California, San Francisco, San Francisco, California, USA
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Thompson MA, Horberg MA, Agwu AL, Colasanti JA, Jain MK, Short WR, Singh T, Aberg JA. Erratum to: Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2021; 74:1893-1898. [PMID: 34878522 DOI: 10.1093/cid/ciab801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | - Allison L Agwu
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Mamta K Jain
- Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William R Short
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tulika Singh
- Internal Medicine, HIV and Infectious Disease, Desert AIDS Project, Palm Springs, California, USA
| | - Judith A Aberg
- Division of Infectious Diseases, Mount Sinai Health System, New York, New York, USA
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Llata E, Cuffe KM, Picchetti V, Braxton JR, Torrone EA. Demographic, Behavioral, and Clinical Characteristics of Persons Seeking Care at Sexually Transmitted Disease Clinics - 14 Sites, STD Surveillance Network, United States, 2010-2018. MMWR. SURVEILLANCE SUMMARIES : MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES 2021; 70:1-20. [PMID: 34735419 PMCID: PMC8575410 DOI: 10.15585/mmwr.ss7007a1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PROBLEM Sexually transmitted diseases (STDs) are a major cause of morbidity in the United States, with an estimated $15.9 billion in lifetime direct medical costs. Although the majority of STDs are diagnosed in the private sector, publicly funded STD clinics have an important role in providing comprehensive sexual health care services, including STD and HIV screening, for a broad range of patients. In certain cases, STD clinics often are the only source of sexual health care for patients, particularly among gay, bisexual, and other men who have sex with men (MSM). PERIOD COVERED 2010-2018. DESCRIPTION OF THE SYSTEM The STD Surveillance Network (SSuN) is an ongoing sentinel surveillance system for monitoring clinical information among patients attending STD clinics. SSuN is a collaboration of competitively selected state and city health departments that conduct facility-based sentinel surveillance in STD clinics. Information routinely collected through the course of patient encounters is obtained for all patients seeking care in the participating STD clinics. This information includes demographic, behavioral, and clinical characteristics (e.g., STD and HIV tests performed and STD and HIV diagnoses). This report presents 2010-2018 SSuN data from 14 STD clinics in five cities (Baltimore, Maryland; New York City, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington) to describe the patient populations seeking care in these STD clinics. Estimated numbers and percentages of patients receiving selected STD-related health services were calculated for each year by using an inverse variance weighted random-effects model, adjusting for heterogeneity among SSuN jurisdictions. Trends in receipt of selected STD-related health services were examined and included HIV screening after an acute STD diagnosis among persons not previously known to have HIV infection, annual chlamydia screening among adolescent and young females, and extragenital chlamydia and gonorrhea screening among MSM. RESULTS During 2010-2018, the total number of annual visits made in the 14 participating STD clinics decreased 29.8% (from 145,728 to 102,275 visits), and the total number of unique patients examined in the clinics decreased 35.1% (from 94,281 to 61,172 patients). Decreases in the number of unique patients occurred both among men who have sex with women only (42.4%; from 37,842 in 2010 to 21,781 in 2018) and among females (51.4%; from 36,485 in 2010 to 17,721 in 2018). The decreases in the number of female patients were observed across all age groups, although they were more pronounced among females aged ≤24 years (66.4%; from 17,721 in 2010 to 5,962 in 2018). In contrast, the number of patients identified as MSM increased 44.0% (from 12,859 in 2010 to 18,512 in 2018), with the greatest increase among MSM aged ≥25 years (58.6%; from 9,918 in 2010 to 15,733 in 2018). Among visits during which an acute STD (defined as chlamydia, gonorrhea, or primary or secondary syphilis) was diagnosed, the percentage of visits during which an HIV test was performed within approximately 14 days of the STD diagnosis increased from 58.2% in 2010 to 70.2% in 2018. Among those patients tested, 1,672 HIV infections were identified, of which 84.0% were among MSM. Among females aged 15-24 years, the percentage screened for chlamydia in any calendar year increased from 88.6% in 2010 to 90.6% in 2018. However, because fewer females aged 15-24 years attended these clinics during the study period, the crude number of adolescent and young females tested for chlamydia decreased from 14,249 in 2010 to 4,507 in 2018. During 2010-2018, the percentage of females retested after their first positive chlamydia diagnosis during the same year ranged from 11.4% to 13.3%. During 2010-2018, the percentage of MSM tested for rectal chlamydia and rectal gonorrhea increased (from 54.7% to 57.8% and from 55.0% to 58.4%, respectively). During the same period, increases were noted in the percentage of MSM with diagnosed rectal chlamydia (from 15.5% in 2010 to 17.7% in 2018) and rectal gonorrhea (from 13.3% in 2010 to 17.1% in 2018). In contrast with pharyngeal chlamydia, pharyngeal gonorrhea screening was more common (from 69.5% in 2010 to 74.6% in 2018), and the percentage positive doubled during the study period (from 7.3% in 2010 to 14.8% in 2018). Pharyngeal chlamydia testing also increased (from 50.3% in 2010 to 72.9% in 2018), with concurrent decreases in positivity (from 4.2% in 2010 to 2.6% in 2018). INTERPRETATION During 2010-2018, changes occurred in the demographic composition of patients attending STD clinics participating in SSuN. Understanding trends in the demographic profile of STD patients and services provided can help identify addressable gaps in STD control efforts and direct public health action. Overall, fewer females, especially those aged 15-24 years, accessed care in these STD clinics during the study period. Untreated STDs among adolescent and young females can have serious consequences, including pelvic inflammatory disease and infertility. Additional efforts to monitor where adolescent and young females seek care and to ensure they are receiving quality STD-related health services are needed, especially considering increases in reported cases of STDs among females. Increases in the number of MSM attending STD clinics present a unique opportunity to reach this population with STD and HIV prevention services. Although a large percentage of STD cases are diagnosed outside of STD clinics, publicly funded STD clinics are an important safety-net provider of STD-related health services and provide vital STD-related health services for patient populations at risk for the consequences of STDs and HIV infection. PUBLIC HEALTH ACTIONS STD-related health services represent effective strategies for preventing STD and HIV transmission and acquisition or STD-related sequelae. Ensuring that all persons receive quality HIV and STD prevention and treatment services is vital for an effective public health approach to reducing STDs. STD clinics provide crucial safety-net services for preventing STD-related morbidity, including timely identification and treatment of curable STDs such as chlamydia, gonorrhea, and syphilis. Increases in the numbers of MSM attending STD clinics participating in SSuN provide additional opportunities for linking patients to high-impact HIV preventive services (e.g., pre-exposure prophylaxis), and the clinics are positioned to facilitate initiation or resumption of treatment among persons living with HIV.
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Affiliation(s)
- Eloisa Llata
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Kendra M Cuffe
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Viani Picchetti
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Jimmy R Braxton
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Elizabeth A Torrone
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC
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Bacon OML, Coffey SC, Hsu LC, Chin JCS, Havlir DV, Buchbinder SP. Development of a Citywide Rapid Antiretroviral Therapy Initiative in San Francisco. Am J Prev Med 2021; 61:S47-S54. [PMID: 34686290 DOI: 10.1016/j.amepre.2021.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Ending the HIV epidemic in the U.S. holds rapid antiretroviral therapy as a key strategy to improve the health of those with HIV and to decrease transmission. In 2015, Getting to Zero San Francisco, a multisector consortium, expanded rapid antiretroviral therapy citywide. METHODS A Getting to Zero San Francisco Rapid ART Program Initiative for HIV Diagnoses Committee (academic, community, service delivery, health department partners) designed the program, protocol, dissemination plan, and monitoring strategy. Newly diagnosed patients were linked to an HIV medical home or Rapid ART Program Initiative for HIV Diagnoses initiation hub to best deliver rapid antiretroviral therapy across a diverse patient mix, with a goal of ≤5 working days from diagnosis to care and ≤1 day from care to antiretroviral therapy. Stakeholders were trained on rapid antiretroviral therapy via Getting to Zero San Francisco meetings, in-services, public health detailing, and peer-to-peer recruiting, prioritizing HIV clinics serving patients of color, Latinx ethnicity, youth, and the uninsured or publicly insured. Rapid ART Program Initiative for HIV Diagnoses-specific metrics were derived from surveillance data; stratified by sex/gender, age, race/ethnicity, and housing status; and presented at public meetings. Data were analyzed between January and April 2021. RESULTS From 2014 to 2018, median time from diagnosis to care decreased 71% (7 to 2 days), care to antiretroviral therapy decreased from 19 to 0 days, and diagnosis to virologic suppression decreased 51% (94 to 46 days). Improvements occurred regardless of age, race/ethnicity, sex/gender, exposure, or housing status. CONCLUSIONS During a citywide initiative to optimize antiretroviral therapy initiation, time from HIV diagnosis to care, antiretroviral therapy, and virologic suppression decreased across all affected groups to varying degrees. The Rapid ART Program Initiative for HIV Diagnoses Committee continues to address challenges to retention and expand implementation.
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Affiliation(s)
- Oliver M L Bacon
- San Francisco City Clinic, Disease Prevention & Control, Population Health Division, San Francisco Department of Public Health, San Francisco, California; UCSF Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, UCSF School of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California.
| | - Susa C Coffey
- UCSF Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, UCSF School of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Ling C Hsu
- HIV Surveillance Unit, Applied Research, Community Health, Epidemiology and Surveillance (ARCHES), San Francisco Department of Public Health, San Francisco, California
| | - Jennie C S Chin
- HIV Surveillance Unit, Applied Research, Community Health, Epidemiology and Surveillance (ARCHES), San Francisco Department of Public Health, San Francisco, California
| | - Diane V Havlir
- UCSF Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, UCSF School of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Susan P Buchbinder
- Bridge HIV, San Francisco Department of Public Health, San Francisco, California
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Benbow ND, Mokotoff ED, Dombrowski JC, Wohl AR, Scheer S. The HIV Treat Pillar: An Update and Summary of Promising Approaches. Am J Prev Med 2021; 61:S39-S46. [PMID: 34686289 PMCID: PMC11107265 DOI: 10.1016/j.amepre.2021.05.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 01/22/2023]
Abstract
The Treat pillar of the Ending the HIV Epidemic in the U.S. plan calls for comprehensive strategies to enhance linkage to, and engagement in, HIV medical care to improve viral suppression among people with HIV and achieve the goal of 95% viral suppression by 2025. The U.S. has seen large increases in the proportion of people with HIV who have a suppressed viral load. Viral suppression has increased 41%, from 46% in 2010 to 65% in 2018. An additional increase of 46% is needed to meet the Ending the HIV Epidemic in the U.S. goal. The rate of viral suppression among those in care increased to 85% in 2018, highlighting the need to ensure sustained care for people with HIV. Greater increases in all steps along the HIV care continuum are needed for those disproportionately impacted by HIV, especially the young, sexual and racial/ethnic minorities, people experiencing homelessness, and people who inject drugs. Informed by systematic reviews and current research findings, this paper describes more recent promising practices that suggest an impact on HIV care outcomes. It highlights rapid linkage and treatment interventions; interventions that identify and re-engage people in HIV care through new collaborations among health departments, providers, and hospital systems; coordinated care and low-barrier clinic models; and telemedicine-delivered HIV care approaches. The interventions presented in this paper provide additional approaches that state and local jurisdictions can use to reach their local HIV elimination plans' goals and the ambitious Ending the HIV Epidemic in the U.S. Treat pillar targets by 2030.
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Affiliation(s)
- Nanette D Benbow
- Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | | | - Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington; Public Health - Seattle & King County, Seattle, Washington
| | - Amy R Wohl
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - Susan Scheer
- HIV Epidemiology Section, San Francisco Department of Public Health, San Francisco, California
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Jacobs P, Feaster DJ, Pan Y, Gooden LK, Daar ES, Lucas GM, Jain MK, Marsh EL, Armstrong WS, Rodriguez A, del Rio C, Metsch LR. Initiation of Antiretroviral Therapy in the Hospital Is Associated With Linkage to Human Immunodeficiency Virus (HIV) Care for Persons Living With HIV and Substance Use Disorder. Clin Infect Dis 2021; 73:e1982-e1990. [PMID: 32569355 PMCID: PMC8492224 DOI: 10.1093/cid/ciaa838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 06/18/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies have demonstrated benefits of antiretroviral therapy (ART) initiation on the day of human immunodeficiency virus (HIV) testing or at first clinical visit. The hospital setting is understudied for immediate ART initiation. METHODS CTN0049, a linkage-to-care randomized clinical trial, enrolled 801 persons living with HIV (PLWH) and substance use disorder (SUD) from 11 hospitals across the United States. This secondary analysis examined factors related to initiating (including reinitiating) ART in the hospital and its association with linkage to HIV care, frequency of outpatient care visits, retention, and viral suppression. RESULTS Of 801 participants, 124 (15%) initiated ART in the hospital, with more than two-thirds of these participants (80/124) initiating ART for the first time. Time to first HIV care visit among those who initiated ART in the hospital and those who did not was 29 and 54 days, respectively (P = .0145). Hospital initiation of ART was associated with increased frequency of HIV outpatient care visits at 6 and 12 months. There was no association with ART initiation in the hospital and retention and viral suppression over a 12-month period. Participants recruited in Southern hospitals were less likely to initiate ART in the hospital (P < .001). CONCLUSIONS Previous research demonstrated benefits of immediate ART initiation, yet this approach is not widely implemented. Research findings suggest that starting ART in the hospital is beneficial for increasing linkage to HIV care and frequency of visits for PLWH and SUD. Implementation research should address barriers to early ART initiation in the hospital.
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Affiliation(s)
- Petra Jacobs
- National Institute on Drug Abuse, Bethesda, Maryland, USA
| | | | - Yue Pan
- University of Miami, Miami, Florida, USA
| | | | - Eric S Daar
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | | | - Mamta K Jain
- UT Southwestern Medical Center, Dallas, Texas, USA
| | | | | | | | - Carlos del Rio
- Emory University School of Medicine, Atlanta, Georgia, USA
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Antela A, Rivero A, Llibre JM, Moreno S. Redefining therapeutic success in HIV patients: an expert view. J Antimicrob Chemother 2021; 76:2501-2518. [PMID: 34077524 PMCID: PMC8446931 DOI: 10.1093/jac/dkab168] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Thanks to advances in the field over the years, HIV/AIDS has now become a manageable chronic condition. Nevertheless, a new set of HIV-associated complications has emerged, related in part to the accelerated ageing observed in people living with HIV/AIDS, the cumulative toxicities from exposure to antiretroviral drugs over decades and emerging comorbidities. As a result, HIV/AIDS can still have a negative impact on patients' quality of life (QoL). In this scenario, it is reasonable to believe that the concept of therapeutic success, traditionally associated with CD4 cell count restoration and HIV RNA plasma viral load suppression and the absence of drug resistances, needs to be redefined to include other factors that reach beyond antiretroviral efficacy. With this in mind, a group of experts initiated and coordinated the RET Project, and this group, using the available evidence and their clinical experience in the field, has proposed new criteria to redefine treatment success in HIV, arranged into five main concepts: rapid initiation, efficacy, simplicity, safety, and QoL. An extensive review of the literature was performed for each category, and results were discussed by a total of 32 clinicians with experience in HIV/AIDS (4 coordinators + 28 additional experts). This article summarizes the conclusions of these experts and presents the most updated overview on the five topics, along with a discussion of the experts' main concerns, conclusions and/or recommendations on the most controversial issues.
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Affiliation(s)
- Antonio Antela
- Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Antonio Rivero
- Hospital Universitario Reina Sofía, Cordoba, Spain
- Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, Spain
| | - Josep M Llibre
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Santiago Moreno
- Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
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48
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Pathela P, Jamison K, Braunstein SL, Borges CM, Lazar R, Mikati T, Daskalakis D, Blank S. Initiating antiretroviral treatment for newly diagnosed HIV patients in sexual health clinics greatly improves timeliness of viral suppression. AIDS 2021; 35:1805-1812. [PMID: 33973874 DOI: 10.1097/qad.0000000000002937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The 'JumpstART' program in New York City (NYC) public Sexual Health Clinics (SHC) provides patients newly diagnosed with human immunodeficiency virus (HIV) with antiretroviral medication (ART) (1-month supply) on day of diagnosis and active linkage to HIV care (LTC). We examined viral suppression (VS) among patients who did and did not receive JumpstART services. DESIGN Retrospective cohort. METHODS Among newly diagnosed SHC patients (23 November 2016-30 September 2018) who were matched to the NYC HIV surveillance registry to obtain HIV laboratory test results through 30 June 2019, we compared 230 JumpstART and 73 non-JumpstART patients regarding timely LTC (≤30 days), probability of VS (viral load < 200 copies/ml) by 3 months post-diagnosis, and time to and factors associated with achieving VS within the follow-up period. RESULTS Of 303 patients, 76% (230/303) were JumpstART and the remaining were non-JumpstART patients; 36 (11%) had acute HIV infections. LTC ≤30 days was observed for 63% of JumpstART and 73% of non-JumpstART patients. By 3 months post-diagnosis, 83% of JumpstART versus 45% of non-JumpstART patients achieved VS (log-rank, P < .0001). Median times to VS among virally suppressed JumpstART and non-JumpstART patients were 31 (interquartile range [IQR]: 24-51) and 95 days (IQR: 52-153), respectively. For groups with and without timely LTC, JumpstART was associated with viral suppression within 3 months post-diagnosis, after adjusting for age and baseline viral load. CONCLUSIONS Prompt ART initiation among SHC patients, some with acute HIV infections, resulted in markedly shortened intervals to VS. Immediate ART provision and active LTC can be key contributors to improved HIV treatment outcomes and the treatment-as-prevention paradigm, with potential for downstream, population-level benefit.
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Affiliation(s)
- Preeti Pathela
- New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Infections, New York, NY
| | - Kelly Jamison
- New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Infections, New York, NY
| | - Sarah L Braunstein
- New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Infections, New York, NY
| | - Christine M Borges
- New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Infections, New York, NY
| | - Rachael Lazar
- New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Infections, New York, NY
| | - Tarek Mikati
- New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Infections, New York, NY
| | - Demetre Daskalakis
- New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Infections, New York, NY
| | - Susan Blank
- Retired (formerly with New York City Department of Health and Mental Hygiene and Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, GA, USA)
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Doshi RK, Greenberg AE. Test, treat, and maintain: rapid initiation of antiretroviral therapy. AIDS 2021; 35:1867-1869. [PMID: 34397486 PMCID: PMC8459936 DOI: 10.1097/qad.0000000000002994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Rupali K Doshi
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
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Summary of 2021 Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS in HIV-infected Koreans. Infect Chemother 2021; 53:592-616. [PMID: 34405598 PMCID: PMC8511382 DOI: 10.3947/ic.2021.0305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Indexed: 12/15/2022] Open
Abstract
Since the establishment of the Committee for Clinical Guidelines for the Diagnosis and Treatment of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) by the Korean Society for AIDS in 2010, clinical guidelines have been prepared in 2011, 2013, 2015, and 2018. As new research findings on the epidemiology, diagnosis, and treatment of AIDS have been published in and outside of Korea along with the development and introduction of new antiretroviral medications, a need has arisen to revise the clinical guidelines by analyzing such new data. The clinical guidelines address the initial evaluation of patients diagnosed with HIV/AIDS, follow-up tests, appropriate timing of medication, appropriate antiretroviral medications, treatment strategies for patients who have concurrent infections with hepatitis B or C virus, recommendations for resistance testing, treatment for patients with HIV and tuberculosis coinfections, and treatment in pregnant women. Through these clinical guidelines, the Korean Society for AIDS and the Committee for Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS contributes to overcoming AIDS by delivering latest data and treatment strategies to healthcare professionals who treat AIDS in the clinic.
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