Gender Differences in Adherence and Response to Antiretroviral Treatment in the Stratall Trial in Rural District Hospitals in Cameroon

Factors associated with viral load non-suppression in people living with HIV on ART in Nigeria: cross-sectional analysis from 2017 to 2021

OBJECTIVES

Identify factors (demographic and clinical) associated with a non-suppressed viral load (VL) of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Nigeria.

DESIGN

Cross-sectional study.

SETTING

Sixteen US Agency for International Development supported states in Nigeria.

PARTICIPANTS

585 632 PLHIV on ART.

PRIMARY OUTCOME MEASURES

VL non-suppression (defined as having a VL of at least 1000 HIV RNA copies per mL of plasma). χ² testing and multivariable modified Poisson regression with robust variance estimates were conducted on routinely collected ART programme data.

RESULTS

Sixty-six per cent of the study population were females. The largest age groups were 25-34 and 35-44, accounting for 32.1% and 31.1%, respectively. Males had a 9% greater likelihood (adjusted prevalence ratio, APR=1.09) of being non-suppressed. The age groups below 60+ (APR=0.67) had a higher likelihood of a non-suppressed VL, with the highest in the 0-14 age group (APR=2.38). Clients enrolled at tertiary and secondary level facilities had the greatest likelihood of a non-suppressed VL. Clients who started ART between 2010 and 2015 had the greatest likelihood of viral non-suppression (APR=6.19). A shorter time on ART (<1 year (APR=3.92)) was associated with a higher likelihood of a non-suppressed VL. Clients receiving care at private facilities had a lower likelihood of viral non-suppression in the adjusted model. Clients in the Edo (APR=2.66) and Niger (APR=2.54) states had the greatest likelihood of viral non-suppression.

CONCLUSIONS

Targeting males, clients of younger age, those on treatment for less than 3 years, clients at tertiary and secondary health facilities, small and medium facilities, and clients in the Edo, Niger and Borno states for interventions could lead to improvements in VL suppression in Nigeria. The independent factors associated with a non-suppressed VL can guide improvements in ART programme development and VL suppression of PLHIV on ART in Nigeria.

Testing a social network approach to promote HIV self-testing and linkage to care among fishermen at Lake Victoria: study protocol for the Owete cluster randomized controlled trial

BACKGROUND

Nearly 50% of men living with HIV in many countries are unaware of their HIV status; men also have lower uptake of HIV treatment and pre-exposure prophylaxis (PrEP). In SSA, highly mobile men such as those working in fishing communities alongside Lake Victoria have low uptake of HIV testing and low rates of linkage to HIV treatment and PrEP, despite increasing availability of these services. HIV self-testing (HIVST) kits hold promise for overcoming barriers to HIV testing and linkage to services for HIV-positive and HIV-negative men. We describe here a protocol for an HIV status-neutral, social network-based approach to promote HIV testing, linkage to care and prevention, and better health outcomes, including adherence, in fishermen around Lake Victoria.

METHODS

Utilizing beach management unit (BMU) registries of fishermen operating in three Lake Victoria fishing communities in Siaya County, Kenya, we completed a census and social network mapping to identify close social networks of men. Network clusters identified by a socially-central lead ("promotor") and selected to ensure maximal separation between treatment and control will be randomized. Promotors in both arms will receive basic HIV training; intervention promotors are further trained in HIVST to distribute kits to their cluster, while control promotors will distribute to their cluster vouchers for free HIVST at nearby clinics. We will test whether these promoters can enhance linkage to ART and PrEP after self-testing, thereby addressing a key limitation of HIVST. We will also measure 6- and 12-month viral load in those living with HIV and PrEP adherence among those without HIV via urine tenofovir levels as objective markers of adherence.

DISCUSSION

This study has the potential to improve HIV health and promote HIV prevention among a hard to reach, at-risk, and highly mobile population of men in Western Kenya-a critical population in Kenya's HIV prevention and treatment program. Further, if successful, this innovative social networks-based model could be scaled at the regional level to address HIV prevention and care among similarly at-risk populations of men in eastern Africa and inland fisheries settings across the continent.

TRIAL REGISTRATION

Self-Test Strategies and Linkage Incentives to Improve ART and PrEP Uptake in Men, registered on February 26, 2021, registration # NCT04772469 .

Barriers and facilitators of male engagement in Community Client-Led Antiretroviral therapy Delivery groups (CCLADS) for HIV care and treatment in Southwestern Uganda: a qualitative study

Background

Male engagement in HIV programs is a persistent challenge that results in poor utilization of HIV care services. Differentiated service delivery models, such as Community Client-Led Antiretroviral Delivery Groups (CCLADs), provide an opportunity for male engagement in HIV care. In southwestern Uganda. In southwestern Uganda few men living with HIV (MLWHIV) are involved in CCLADS. We aimed to identify facilitators, barriers and perceptions to CCLADs enrollment by MLWHIV at ART Clinics in southwestern Uganda.

Methods

A qualitative study was conducted among MLWHIV who were registered and receiving ART at two ART Clinics/health facilities in southwestern Uganda, irrespective of their enrollment status into CCLADs. In-depth interviews (IDI) were conducted among recruited HIV positive men, and Key informant interviews (KIIs) among clinic in-charges and counselors, women enrolled in CCLADS using a semi-structured interview guide. We used thematic analysis to analyze the data from the interviews.

Results

We conducted 16 interviews, 7 KII and 8 IDI were conducted. MLWHIV and key informants shared the facilitators and barriers. Men who were not involved in CCLADs shared the barriers to joining the CCLADs. The themes identified included 1. Motivations to join CCLADS 2. Challenges related to CCLADS initiation 3. Perceived facilitators for male participation in CCLADS, 4. Perceived barriers for male participation in CCLADS and 5. Proposed strategies for best implementation of CCLADs for better male engagement. Overall men liked the idea of CCLADs but they had preferences on how they should be implemented.

Conclusion

Men’s enrollment into CCLADs is still low despite the benefits. Addressing the barriers to men’s engagement and adopting proposed strategies may improve men’s enrollment in CCLADS and thus improve their access to ART, Adherence and quality of life.

Determinants of viral load non-suppression among adolescents in Mbale District, Eastern Rural Uganda

BACKGROUND

Adolescents are lagging behind in the "third 95" objective of the Joint United Nations Program on HIV/AIDS requiring 95% of individuals on antiretroviral therapy (ART) to have viral load (VL) suppression. This study aimed to describe factors associated with viral non-suppression among adolescents in Mbale district, Uganda.

METHODS

We conducted a retrospective review of routinely collected HIV programme records. Data such as age, education, ART Regimen, ART duration, WHO Clinical stage, comorbidities, etc., were extracted from medical records for the period January 2018 to December 2018. Descriptive analysis was done for continuous variables using means and frequencies to describe study sample characteristics, and to determine the prevalence of outcome variables. We used logistic regression to assess factors associated with VL non-suppression among adolescents.

RESULTS

The analysis included 567 HIV-infected adolescents, with 300 (52.9%) aged between 13 to 15 years, 335 (59.1%) female, and mean age of 15.6 years (interquartile range [IQR] 13.5-17.8. VL non-suppression was 31.4% (178/567). Male sex (AOR = 1.78, 95% CI 1.06, 2.99; p < 0.01), age 16-19 years (AOR = 1.78, 95% CI 1.06, 2.99; p < 0.05), No formal education (AOR = 3.67, 95% CI 1.48-9.09; p < 0.01), primary education (AOR = 2.23, 95% CI 1.05-2.32; p < 0.01), ART duration of > 12 months to 5 years (AOR = 3.20, 95% CI 1.31-7.82; p < 0.05), ART duration > 5 years (AOR = 3.47, 95% CI 1.39- 8.66; p < 0.01), WHO Clinical Stage II (AOR = 0.48, 95% CI: 0.28, 0.82; p < 0.01), second-line ART regimen (AOR = 2.38, 95% CI 1.53-3.72; p < 0.001) and comorbidities (AOR = 3.28, 95% CI 1.20-9.00; p < 0.05) were significantly associated with viral non-suppression.

CONCLUSIONS

VL non-suppression among adolescents was almost comparable to the national average. VL non-suppression was associated with being male, age 16-19 years, education level, duration on ART therapy, WHO Clinical Staging II, second-line ART regimen, and presence of comorbidities. Adolescent-friendly strategies to improve VL suppression e.g. peer involvement, VL focal persons to identify and actively follow-up non-suppressed adolescents, patient education on VL suppression and demand creation for ART are needed, especially for newly-initiated adolescents and adolescents on ART for protracted periods, to foster attainment of the UNAIDS 95-95-95 targets.

HIV Viremia Is Associated With APOL1 Variants and Reduced JC-Viruria

Variants in the Apolipoprotein L1 (APOL1) gene (G1-rs60910145, rs73885319, G2-rs71785313) are common in Africans and in individuals of recent African ancestry and are associated with an increased risk of non-diabetic chronic kidney disease (CKD) and in particular of HIV associated nephropathy (HIVAN). In light of the significantly increased risk of HIVAN in carriers of two APOL1 risk alleles, a role in HIV infectivity has been postulated in the mechanism of APOL1 associated kidney disease. Herein, we aim to explore the association between HIV viremia and APOL1 genotype. In addition, we investigated interaction between BK and JC viruria, CKD and HIV viremia. A total of 199 persons living with HIV/AIDS (comprising 82 CKD cases and 117 controls) from among the participants in the ongoing Human Heredity and Health in Africa (H3Africa) Kidney Disease Research Network case control study have been recruited. The two APOL1 renal risk alleles (RRA) genotypes were associated with a higher risk of CKD (OR 12.6, 95% CI 3.89-40.8, p < 0.0001). Even a single APOL1 RRA was associated with CKD risk (OR 4.42, 95% CI 1.49-13.15, p = 0.007). The 2 APOL1 RRA genotypes were associated with an increased probability of having HIV viremia (OR 2.37 95% CI 1.0-5.63, p = 0.05). HIV viremia was associated with increased CKD risk (OR 7.45, 95% CI 1.66-33.35, P = 0.009) and with a significant reduction of JC virus urine shedding (OR 0.35, 95% CI 0.12-0.98, p = 0.046). In contrast to prior studies, JC viruria was not associated with CKD but was restricted in patients with HIV viremia, regardless of CKD status. These findings suggest a role of APOL1 variants in HIV infectivity and emphasize that JC viruria can serve as biomarker for innate immune system activation.

Risk factors for HIV virological non-suppression among adolescents with common mental disorder symptoms in Zimbabwe: a cross-sectional study

INTRODUCTION

Adolescents are at increased risk of HIV virological non-suppression compared to adults and younger children. Common mental disorders such as anxiety and depression are a barrier to adherence and virological suppression. The aim of this study was to identify factors associated with virological non-suppression among adolescents living with HIV (ALWH) in Zimbabwe who had symptoms of common mental disorders.

METHODS

We utilized baseline data from a cluster-randomized controlled trial of a problem-solving therapy intervention to improve mental health and HIV viral suppression of ALWH. Sixty clinics within 10 districts were randomized 1:1 to either the intervention or control arm, with the aim to recruit 14 adolescents aged 10 to 19 per clinic. Adolescents were eligible if they scored ≥7 on the Shona Symptom Questionnaire measuring symptoms of common mental disorders. Multivariable mixed-effects logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for factors associated with non-suppression, defined as viral load ≥1000 copies/mL.

RESULTS

Between 2 January and 21 March 2019 the trial enrolled 842 participants aged 10 to 19 years (55.5% female, 58.8% aged <16). Most participants (N = 613) were taking an NNRTI-based ART regimen (13 PI-based, 216 unknown) and median duration on ART was six years (IQR three to nine years, 240 unknown). Of the 833 with viral load data 292 (35.1%) were non-suppressed. Virological non-suppression was independently associated with male sex (adjusted OR (aOR) = 1.43, 95% CI 1.04 to 1.97), and with not knowing one's own HIV status (aOR = 1.77, 95% CI 1.08 to 2.88), or knowing one's status but not disclosing it to anyone (aOR = 1.99, 95% CI 1.36 to 2.93), compared to adolescents who knew their status and had disclosed it to someone.

CONCLUSIONS

ALWH with symptoms of common mental disorders have high prevalence of virological non-suppression in Zimbabwe, especially if they do not know their status or have not disclosed it. In general adolescents should be informed of their HIV status, with encouragement on the beneficial health and social effects of viral suppression, to incentivise adherence. Efforts to strengthen the operationalization of disclosure guidelines for adolescents should now be prioritized.

Gender disparities operate in opposite directions for hospitalizations and mortality among individuals receiving long-term ART in rural Uganda

OBJECTIVES

We conducted an analysis to determine if differences in health-seeking behaviour can explain gender disparities in mortality among long-term survivors receiving antiretroviral therapy (ART) in rural Uganda.

METHODS

From June 2012 to January 2014, we enrolled patients receiving a first-line ART regimen for at least 4 years without previous viral load (VL) testing in Jinja, Uganda. We measured HIV VL at study entry. We switched participants to second-line therapy, if VL was ≥ 1000 copies/mL on two measurements, and followed participants for 3 years. We collected clinical and behavioural data at enrolment and every 6 months after that. We used Poisson regression to examine factors associated with hospitalizations and Cox proportional hazards modelling to assess mortality to September 2016.

RESULTS

We enrolled 616 participants (75.3% female), with a median age of 44 years and a median duration of ART use of 6 years. Of these, 113 (18.3%) had VLs ≥ 1000 copies/mL. Hospitalizations occurred in 101 participants (7% of men vs. 20% of women; P < 0.001). A total of 22 (3.6%) deaths occurred, 9% of men vs. 2% of women (P < 0.001). Multivariate modelling revealed that mortality was associated with age [adjusted hazard ratio (AHR) = 1.07 per year increase; 95% confidence interval (CI): 1.01-1.13], male gender (AHR = 2.57; 95% CI 1.06-6.23) and time-updated CD4 counts (AHR = 0.67 per 100 cell increment; 95% CI: 0.52-0.88). Virological failure was not associated with mortality (P = 0.762).

CONCLUSION

Female patients receiving ART in rural Uganda were three times more likely to be hospitalized than men, but male mortality was nearly four times higher. Facilitating care for acute medical problems may help to improve survival among male ART patients.

Clinic-level and individual-level factors that influence HIV viral suppression in adolescents and young adults: a national survey in Kenya

OBJECTIVES

To determine clinic-level and individual-level correlates of viral suppression among HIV-positive adolescents and young adult (AYA) aged 10-24 years receiving antiretroviral treatment (ART).

DESIGN

Multilevel cross-sectional analysis using viral load data and facility surveys from HIV treatment programs throughout Kenya.

METHODS

We abstracted medical records of AYA in HIV care, analyzed the subset on ART for more than 6 months between January 2016 and December 2017, and collected information on services at each clinic. Multilevel logistic regression models were used to determine correlates of viral suppression at most recent assessment.

RESULTS

In 99 HIV clinics, among 10 096 AYA on ART more than 6 months, 2683 (27%) had unsuppressed viral load at last test. Among 16% of clinics, more than 80% of AYA were virally suppressed. Clinic-level correlates of individual viral suppression included designated adolescent spaces [aOR: 1.32, 95% CI (1.07-1.63)] and faster viral load turnaround time [aOR: 1.06 (95% CI 1.03-1.09)]. Adjusting for clinic-level factors, AYA aged 10-14 and 15-19 years had lower odds of viral suppression compared with AYA aged 20-24 years [aOR: 0.61 (0.54-0.69) and 0.59 (0.52-0.67], respectively. Compared with female patients, male patients had lower odds of viral suppression [aOR: 0.69 (0.62-0.77)]. Compared with ART duration of 6-12 months, ART for 2-5, above 5-10 or more than 10 years was associated with poor viral suppression (P < 0.001).

CONCLUSION

Dedicated adolescent space, rapid viral load turnaround time, and tailored approaches for male individuals and perinatally infected AYA may improve viral suppression. Routine summarization of viral load suppression in clinics could provide benchmarking to motivate innovations in clinic-AYA and individual-AYA care strategies.

Effects of undernutrition on mortality and morbidity among adults living with HIV in sub-Saharan Africa: a systematic review and meta-analysis

Background

Undernutrition is one of the most common problems among people living with HIV, contributing to premature death and the development of comorbidities within this population. In Sub-Saharan Africa (SSA), the impacts of these often inter-related conditions appear in a series of fragmented and inconclusive studies. Thus, this review examines the pooled effects of undernutrition on mortality and morbidities among adults living with HIV in SSA.

Methods

A systematic literature search was conducted from PubMed, EMBASE, CINAHL, and Scopus databases. All observational studies reporting the effects of undernutrition on mortality and morbidity among adults living with HIV in SSA were included. Heterogeneity between the included studies was assessed using the Cochrane Q-test and I² statistics. Publication bias was assessed using Egger’s and Begg’s tests at a 5% significance level. Finally, a random-effects meta-analysis model was employed to estimate the overall adjusted hazard ratio.

Results

Of 4309 identified studies, 53 articles met the inclusion criteria and were included in this review. Of these, 40 studies were available for the meta-analysis. A meta-analysis of 23 cohort studies indicated that undernutrition significantly (AHR: 2.1, 95% CI: 1.8, 2.4) increased the risk of mortality among adults living with HIV, while severely undernourished adults living with HIV were at higher risk of death (AHR: 2.3, 95% CI: 1.9, 2.8) as compared to mildly undernourished adults living with HIV. Furthermore, the pooled estimates of ten cohort studies revealed that undernutrition significantly increased the risk of developing tuberculosis (AHR: 2.1, 95% CI: 1.6, 2.7) among adults living with HIV.

Conclusion

This review found that undernutrition has significant effects on mortality and morbidity among adults living with HIV. As the degree of undernutrition became more severe, mortality rate also increased. Therefore, findings from this review may be used to update the nutritional guidelines used for the management of PLHIV by different stakeholders, especially in limited-resource settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05706-z.

Development and Acceptability of a Tablet-Based App to Support Men to Link to HIV Care: Mixed Methods Approach

Background

The poor engagement of men with HIV care is attributed to a number of factors: fear of stigma, masculine representations, concerns related to confidentiality, and the time commitment needed to visit public health clinics. Digital technologies are emerging as an approach to support the engagement of men with care.

Objective

This study aims to deliver a usable and engaging tablet-based app, called EPIC-HIV 2 (Empowering People through Informed Choices for HIV 2), to support men in making informed decisions about engaging with HIV care in rural KwaZulu Natal, South Africa.

Methods

We employed a mixed methods, iterative, and three-phased design that was guided by self-determination theory (SDT), a person-based approach, and human-computer interaction techniques. We reviewed related literature and conducted secondary analyses of existing data to identify barriers and facilitators to linkage to care and inform content development and design principles and used focus group discussions with members of the community advisory board and general community to evaluate a PowerPoint prototype of the app; used observations and guided questions with a convenience sample of potential users from the intervention community to iteratively test and refine a functioning interactive app; and conducted qualitative interviews and satisfaction surveys with actual users to evaluate acceptability.

Results

Phase 1 identified supply- and demand-side barriers to linkage to care. Specifically, clinics were feminized spaces unattractive to men with high social costs of attendance. Men did not feel vulnerable to HIV, preferred traditional medicine, and were afraid of the consequences of being HIV positive. Thus, the app needed to allow men to identify the long-term health benefits to themselves and their families of starting antiretroviral therapy early and remaining on it, and these benefits typically outweigh the social costs of attending and being seen at a clinic. SDT led to content design that emphasized long-term benefits but at the same time supported the need for autonomy, competence, and relatedness and informed decision making. Phase 2 indicated that we needed to use simpler text and more images to help users understand and navigate the app. Phase 3 indicated that the app was acceptable and likely to encourage men to link to care.

Conclusions

We found that iteratively developing the app with potential users using local narratives ensured that EPIC-HIV 2 is usable, engaging, and acceptable. Although the app encouraged men to link to HIV care, it was insufficient as a stand-alone intervention for men in our sample to exercise their full autonomy to link to HIV care without other factors such as it being convenient to initiate treatment, individual experiences of HIV, and support. Combining tailored digital interventions with other interventions to address a range of barriers to HIV care, especially supply-side barriers, should be considered in the future to close the present linkage gap in the HIV treatment cascade.

Gender difference in all-cause mortality of people living with HIV in Iran: findings from a 20-year cohort study

OBJECTIVES

Gender differences in the efficacy of treatment and the mortality of HIV-infected patients have not yet been fully elucidated. For the first time, we used data from a 20-year cohort of people living with HIV (PLWH) in four provinces (Fars, Bushehr, Bandar Abbas, and Kohgiluyeh and Boyer-Ahmad) in the southern part of Iran to assess the gender difference in all-cause mortality in PLWH in Iran.

METHODS

We analysed data for 1216 patients aged ≥ 15 years who were diagnosed with HIV/AIDS between 1997 and 2017. Three hundred and fourteen (25.8%) were women.

RESULTS

The death rate from all causes among women was 13.7% vs. 43.8% among men (P < 0.001). All-cause mortality was significantly associated with gender [the adjusted hazard ratio (aHR) for men compared with women was 3.20], not being on antiretroviral therapy (ART) compared with being on ART at the last visit (aHR 5.42), older age (aHR 1.03), delayed HIV diagnosis compared with early diagnosis (aHR 1.72), history of incarceration (aHR 1.57), higher log CD4 count at diagnosis (aHR 0.54), and prophylaxis for Pneumocystis pneumonia (aHR 0.09).

CONCLUSIONS

The results of this 20-year cohort study suggest that gender is an important predictor of survival among HIV-infected patients. Improving early HIV diagnosis and early ART initiation in men, as well as increased access to hepatitis C virus treatment are needed to increase the survival rate of HIV-infected patients in Iran.

Ten-year survival with analysis of gender difference, risk factors, and causes of death during 13 years of public antiretroviral therapy in rural Kenya

Evidence for why antiretroviral therapy (ART) outcomes differ by gender in developing countries has been inconclusive. In this first study to assess 10-year survival on ART in Kenya, our objective was to compare gender differences in survival for those who began ART as adults and as children. Kakamega County Referral Hospital (KCRH) is a tertiary rural hospital that has provided public ART to Kenyans since 2004. All patients enrolled in ART at KCRH who died between July 2004 and March 2017 and a sample of living patients were included in a survival analysis that bootstrapped sampled data. Case-cohort regressions identified adjusted hazard ratios. In total, 1360 patients were included in the study. Ten-year survival was 77% (95% confidence band [CB] 73-81%), significantly different for men (65%; 95% CB: 45-74%) and women (83%; 95% CB: 78-86%) who began therapy as adults. Ten-year survival was intermediate with no significant gender difference (76%; 95% CB: 69-81%) for patients who began therapy as children. Hazard of death was increased for men (hazard ratio [HR] 1.56; 95% confidence interval [CI] 1.13-2.17), infants (HR 2.87; 95% CI 1.44-5.74), patients with consistently poor clinic attendance (HR 3.94; 95% CI 3.19-4.86), and divorced patients (HR 2.25; 95% CI 1.19-4.25). Tuberculosis, diarrheal illnesses, human immunodeficiency virus (HIV) wasting syndrome, and malaria were leading causes of death. Survival was significantly lower for men than for women in all time periods, but only for patients who began therapy as adults, indicating against biological etiologies for the gender mortality difference.

Engaging men in HIV programmes: a qualitative study of male engagement in community-based antiretroviral refill groups in Zimbabwe

INTRODUCTION

Suboptimal male engagement in HIV programmes is a persistent challenge, leading to lower coverage of HIV testing, prevention and treatment services, and to worse outcomes for men. Differentiated service delivery models, such as peer-led community antiretroviral refill groups (CARGs), offer the opportunity to enhance patient satisfaction, retention and treatment outcomes. We conducted an exploratory qualitative study to identify facilitators and barriers to CARG participation by HIV-positive men, with inputs from recipients of HIV care, community members, healthcare workers (HCWs), donors and policymakers.

METHODS

Between July and October 2017, we conducted 20 focus group discussions (FGDs) with 147 adults living with HIV, including men and women enrolled in CARGs and men not enrolled in CARGs, and 46 key informant interviews (KIIs) with policymakers, donors, HCWs and community members. FGDs and KIIs were recorded, transcribed and translated. A constant comparison approach was used to triangulate findings and identify themes related to male engagement in CARGs in rural Zimbabwe.

RESULTS

CARG participants, policymakers, donors, HCWs, and community members noted many advantages to CARG participation, including convenience, efficiency, solidarity and mutual psychosocial support. Although those familiar with CARGs reported that these groups decreased HIV-related stigma, concerns about stigma and privacy were perceived to be the primary reason for men's non-participation. Other important barriers to male enrolment included lack of awareness of CARGs, misunderstanding of how CARGs operate, few perceived benefits and lack of flexibility in CARG implementation.

CONCLUSIONS

More effective educational and awareness campaigns, community-based anti-stigma campaigns, more flexible CARG designs, and provision of financial and/or in-kind support to CARG members could mitigate many of the barriers to male enrolment in CARGs. Men may also prefer alternative differentiated service delivery models that are facility-based and/or do not require group participation.

Sociodemographic, lifestyle and metabolic predictors of all-cause mortality in a cohort of community-dwelling population: an 18-year follow-up of the North West Adelaide Health Study

INTRODUCTION

Studies examining potential factors of all-cause mortality comprehensively at community level are rare. Using long-term community-based follow-up study, we examined the association of sociodemographic and behavioural characteristics, metabolic and chronic conditions, and medication and health service utilisation with all-cause mortality.

METHODS

We followed 4056 participants, aged 18-90 years, for 18 years in the North West Adelaide Health Study (NWAHS). Mortality data were obtained from South Australian (SA) public hospitals and registries including SA births, deaths and marriages, the National Death Index and the NWAHS follow-up. Predictors of all-cause mortality were explored using Cox proportional hazard model, adjusting for potential confounders. We performed subgroup analyses by sex and age.

RESULTS

Mean (SD) age at baseline was 50.4 (16.4) years. Less than half (47.8%) of the participants were men. A total of 64 689.7 person-years from 4033 participants with 18.7 years of follow-up were generated. The median follow-up time was 17.7 years; 614 deaths were recorded. The overall crude death rate was 9.6 (95% CI 8.9 to 10.4) per 1000 person-years. After adjusting for potential confounders, a reduced risk of mortality was significantly associated with being separated or divorced, being in the highest Socioeconomic Indexes for Areas quintile, engaging in moderate exercise, being overweight (body mass index: 25.0-29.9 kg/m²) and per 10% increase in per cent predicted forced expiratory volume in 1 s. We found that the most important predictors of all-cause mortality were sociodemographic and behavioural characteristics. Sociodemographic factors were more important predictors of all-cause mortality in young age bracket compared with older people.

CONCLUSIONS

Socioeconomic factors were found to be the most important predictors of all-cause mortality. The study highlights the need to address the social inequalities and strengthen behavioural interventions for different subgroups of population to prevent premature deaths.

A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV

A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.

Delayed disease progression in HIV-2: the importance of TRIM5α and the retroviral capsid

HIV-2 is thought to have entered the human population in the 1930s through cross-species transmission of SIV from sooty mangabeys in West Africa. Unlike HIV-1, HIV-2 has not led to a global pandemic, and recent data suggest that HIV-2 prevalence is declining in some West African states where it was formerly endemic. Although many early isolates of HIV-2 were derived from patients presenting with AIDS-defining illnesses, it was noted that a much larger proportion of HIV-2-infected subjects behaved as long-term non-progressors (LTNP) than their HIV-1-infected counterparts. Many HIV-2-infected adults are asymptomatic, maintaining an undetectable viral load for over a decade. However, despite lower viral loads, HIV-2 progresses to clinical AIDS without therapeutic intervention in most patients. In addition, successful treatment with anti-retroviral therapy (ART) is more challenging than for HIV-1. HIV-2 is significantly more sensitive to restriction by host restriction factor tripartite motif TRIM5α than HIV-1, and this difference in sensitivity is linked to differences in capsid structure. In this review we discuss the determinants of HIV-2 disease progression and focus on the important interactions between TRIM5α and HIV-2 capsid in long-term viral control.

Treatment of HIV among tuberculosis patients: A replication study of timing of antiretroviral therapy for HIV-1-associated tuberculosis

Co-diagnosis of HIV and tuberculosis presents a treatment dilemma. Starting both treatments at the same time can cause a flood of immune response called immune reconstitution inflammatory syndrome (IRIS) which can be lethal. But, how long to delay HIV treatment is less understood. In 2011, based on the conclusions of three separate studies, WHO recommended starting HIV treatment earlier for those with later HIV disease progression. This paper conducts a replication study of one of the three studies, by Havlir and colleagues. Using their publicly available data, we were able to replicate most of the results presented in the original paper. In our measurement and estimation analyses we use different estimation techniques to assess the robustness of the results. We find that adjusting for loss to follow-up does not affect the main results of the paper. However, an ANCOVA estimation and an instrumental variable model weaken the main result of the paper of better outcomes with early HIV treatment only for those who are sicker, reducing significance from the 5% to the 10% level. A change-point analysis also detects no changes in effect by timing of HIV treatment initiation or different thresholds of CD4 count for the primary outcome. This result suggests that the choice of start time for HIV treatment initiation should be based on other factors including potential drug interactions, overlapping side effects, a high pill burden and severity of illness rather than CD4 threshold and preset timeframes. While we caution against overgeneralizing, the result of this replication is aligned with more recent studies that show no evidence that early initiation of HIV treatment reduces mortality for any patients.

The Role of Gender in Patient-Provider Relationships: A Qualitative Analysis of HIV Care Providers in Western Kenya with Implications for Retention in Care

The disproportionate burden of HIV among women in sub-Saharan Africa reflects underlying gender inequities, which also impact patient-provider relationships, a key component to retention in HIV care. This study explored how gender shaped the patient-provider relationship and consequently, retention in HIV care in western Kenya. We recruited and consented 60 HIV care providers from three facilities in western Kenya affiliated with the Academic Model Providing Access to Healthcare (AMPATH). Trained research assistants conducted and audio recorded 1-h interviews in English or Swahili. Data were transcribed and analyzed in NVivo using inductive thematic analysis. Gender constructs, as culturally defined, emerged as an important barrier negatively impacting the patient-provider relationship through three main domains: (1) challenges establishing clear roles and sharing power due to conflicting gender versus patient/provider identities, (2) provider frustration over suboptimal patient adherence resulting from gender-influenced contextual barriers, and (3) negative provider perceptions shaped by differing male and female approaches to communication. Programmatic components addressing gender inequities in the health care setting are urgently needed to effectively leverage the patient-provider relationship and fully promote long-term adherence and retention in HIV care.

Factors predictive of successful retention in care among HIV-infected men in a universal test-and-treat setting in Uganda and Kenya: A mixed methods analysis

Background

Previous research indicates clinical outcomes among HIV-infected men in sub-Saharan Africa are sub-optimal. The SEARCH test and treat trial (NCT01864603) intervention included antiretroviral care delivery designed to address known barriers to HIV-care among men by decreasing clinic visit frequency and providing flexible, patient-centered care with retention support. We sought to understand facilitators and barriers to retention in care in this universal treatment setting through quantitative and qualitative data analysis.

Methods

We used a convergent mixed methods study design to evaluate retention in HIV care among adults (age > = 15) during the first year of the SEARCH (NCT01864603) test and treat trial. Cox proportional hazards regression was used to evaluate predictors of retention in care. Longitudinal qualitative data from n = 190 in-depth interviews with HIV-positive individuals and health care providers were analyzed to identify facilitators and barriers to HIV care engagement.

Results

There were 1,863 men and 3,820 women who linked to care following baseline testing. Retention in care was 89.7% (95% CI 87.0–91.8%) among men and 89.0% (86.8–90.9%) among women at one year. In both men and women older age was associated with higher rates of retention in care at one year. Additionally, among men higher CD4+ at ART initiation and decreased time between testing and ART initiation was associated with higher rates of retention. Maintaining physical health, a patient-centered treatment environment, supportive partnerships, few negative consequences to disclosure, and the ability to seek care in facilities outside of their community of residence were found to promote retention in care.

Conclusions

Features of the ART delivery system in the SEARCH intervention and social and structural advantages emerged as facilitators to retention in HIV care among men. Messaging around the health benefits of early ART start, decreasing logistical barriers to HIV care, support of flexible treatment environments, and accelerated linkage to care, are important to men’s success in ART treatment programs. Men already benefit from increased social support following disclosure of their HIV-status. Future efforts to shift gender norms towards greater equity are a potential strategy to support high levels of engagement in care for both men and women.

The association between gender and HIV viral suppression on third-line therapy in Zambia: a retrospective cohort study

Patient's gender may impact pharmacokinetics and play a role in viral suppression. Existing literature has focused on treatment-naïve patients and produced inconclusive results, often implicating differences in adherence as the driver of gender-based outcome differences. The present analysis assessed whether viral suppression on third-line HIV treatment among a closely followed population differs by gender. A retrospective cohort study of patients on third-line HIV treatment was initiated at the HIV Advanced Treatment Centre in Lusaka, Zambia between January 2012 and December 2015. The association between gender and viral suppression was assessed using log binomial regression adjusted for core drug, number of drug mutations, and baseline viral load. Of the 80 included patients (56% female; median age: 40 years), 50 (62%) were virally suppressed at six months. After adjustment, females were less likely to be virologically suppressed at six months on third-line treatment compared to male HIV patients (relative risk 0.82, 95% confidence interval: 0.56, 1.20). Our data suggest that women were less likely to be suppressed following six months of third-line therapy compared to men; however, the difference was not statistically significant. Larger studies are needed to determine whether women are at increased risk of viral failure on third-line therapy compared to men.

Heterogeneity of virological suppression in the national antiretroviral programme of Cameroon (ANRS 12288 EVOLCAM)

OBJECTIVES

In terms of HIV infection, western and central Africa is the second most affected region world-wide, and the gap between the regional figures for the testing and treatment cascade and the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets is particularly worrying. We assessed the prevalence of virological suppression in patients routinely treated in 19 hospitals in Cameroon.

METHODS

A cross-sectional survey was performed in adult patients receiving antiretroviral therapy (ART) in the Centre and Littoral regions. The prevalences of virological suppression (<1000 HIV-1 RNA copies/mL) were compared among all 19 hospitals using the χ² test. Potential individual and health care-related determinants of virological suppression were assessed using multivariate logistic regression models.

RESULTS

A total of 1700 patients (74% women; median age 41 years; median time on ART 3.7 years) were included in the study. The prevalence of virological suppression was 82.4% overall (95% confidence interval 80.5-84.2%). It ranged from 57.1 to 97.4% according to the individual hospital (P < 0.001). After adjustment, virological suppression was associated with age, CD4 cell count at ART initiation, disclosure of HIV status to family members, interruption of ART for more than two consecutive days, and location of patient's residence and hospital (rural/urban). These factors did not explain the heterogeneity of virological suppression between the study hospitals (P < 0.001).

CONCLUSIONS

The overall prevalence of virological suppression was reassuring. Nevertheless, the heterogeneity of virological suppression among hospitals highlights that, in addition to programme-level data, health facility-level data are crucial in order to tailor the national AIDS programme's interventions with a view to achieving the third UNAIDS 90 target.

Parental obligations, care and HIV treatment: How care for others motivates self-care in Zimbabwe

This article examines how parental obligations of care intersect with HIV treatment-seeking behaviours and retention. It draws on qualitative data from eastern Zimbabwe, produced from 65 interviews. Drawing on theories of practice and care ethics, our analysis revealed that norms of parental obligation and care acted as key motivators for ongoing engagement with HIV services and treatment. Parents' attentiveness to the future needs of their children (caring about), and sense of obligation (taking care of) and improved ability to care (caregiving) following treatment initiation, emerged as central to understanding their drive for self-care and engagement with HIV services.

Attrition From Human Immunodeficiency Virus Treatment Programs in Africa: A Longitudinal Ecological Analysis Using Data From 307 144 Patients Initiating Antiretroviral Therapy Between 2005 and 2010

Background

As access to antiretroviral therapy (ART) in Africa has increased dramatically, concerns have been raised regarding patient attrition, an important measure of program quality.

Methods

We examined aggregate data from 307144 patients initiating ART in 5638 successive cohorts at 638 facilities in 9 African countries from 2005 to 2010, a period characterized by massive treatment expansion. Poisson regression assessed trends in 6- and 12-month cohort attrition (ie, the proportion of patients in each cohort no longer receiving ART at their initiating facility) over calendar time and as ART services matured, and identified factors associated with attrition.

Results

Across all 9 countries, 6- and 12-month cohort attrition was 21% and 29%, respectively, with no decrease over calendar time (6-month P = .8735; 12-month P = .5717) or as ART services matured (6-month P = .3005; 12-month P = .2277). Additionally, attrition remained stable or decreased across both measures in nearly all countries. Initiating ART in facilities with more documented transfers and fewer women on ART, and in cohorts with poor CD4 count documentation and lower median CD4 count at ART initiation was associated with increased 6-month attrition. Increased 12-month attrition was observed in semiurban facilities and those with more documented transfers, and in cohorts with poor CD4 count documentation, whereas higher patient load was associated with decreased attrition.

Conclusions

Stable or decreasing trends in attrition for ART patients were observed in most countries, suggesting programs can be expanded without compromising quality. However, further reductions in attrition are needed to maximize individual and population benefits of ART.

Incidence of Tuberculosis Among HIV-Positive Individuals Initiating Antiretroviral Treatment at Higher CD4 Counts in the HPTN 071 (PopART) Trial in South Africa

INTRODUCTION

Antiretroviral treatment (ART) guidelines recommend life-long ART for all HIV-positive individuals. This study evaluated tuberculosis (TB) incidence on ART in a cohort of HIV-positive individuals starting ART regardless of CD4 count in a programmatic setting at 3 clinics included in the HPTN 071 (PopART) trial in South Africa.

METHODS

A retrospective cohort analysis of HIV-positive individuals aged ≥18 years starting ART, between January 2014 and November 2015, was conducted. Follow-up was continued until 30 May 2016 or censored on the date of (1) incident TB, (2) loss to follow-up from HIV care or death, or (3) elective transfer out; whichever occurred first.

RESULTS

The study included 2423 individuals. Median baseline CD4 count was 328 cells/μL (interquartile range 195-468); TB incidence rate was 4.41/100 person-years (95% confidence interval [CI]: 3.62 to 5.39). The adjusted hazard ratio of incident TB was 0.27 (95% CI: 0.12 to 0.62) when comparing individuals with baseline CD4 >500 and ≤500 cells/μL. Among individuals with baseline CD4 count >500 cells/μL, there were no incident TB cases in the first 3 months of follow-up. Adjusted hazard of incident TB was also higher among men (adjusted hazard ratio 2.16; 95% CI: 1.41 to 3.30).

CONCLUSIONS

TB incidence after ART initiation was significantly lower among individuals starting ART at CD4 counts above 500 cells/μL. Scale-up of ART, regardless of CD4 count, has the potential to significantly reduce TB incidence among HIV-positive individuals. However, this needs to be combined with strengthening of other TB prevention strategies that target both HIV-positive and HIV-negative individuals.

Community outreach programs and major adherence lapses with antiretroviral therapy in rural Kakamega, Kenya

We investigated features of major adherence lapses in antiretroviral therapy (ART) at public Emusanda Health Centre in rural Kakamega County, Kenya using medical records from 2008 to 2015 for all 306 eligible patients receiving ART. Data were modelled using survival analysis. Patients were more likely to lapse if they received stavudine (hazard ratio (HR) 2.54, 95% confidence interval (95%CI):1.44-4.47) or zidovudine (HR 1.64, 95%CI:1.02-2.63) relative to tenofovir. Each day a patient slept hungry per month increased risk of major adherence lapse by 3% (95%CI:0-7%). Isolated home visits by community health workers (CHWs) were more effective to assist patients to return to the health centre than isolated phone calls (HR 2.52, 95%CI:1.02-6.20).

Gender Differences in Outcomes of Antiretroviral Treatment Among HIV-Infected Patients in China: A Retrospective Cohort Study, 2010-2015

BACKGROUD

Women now account for about half of all people living with HIV worldwide, but researchers lack clear information and large population-based study about gender differences in treatment outcomes.

METHODS

A nationwide retrospective observational cohort study with data from the China National Free Antiretroviral Treatment Program was performed. Antiretroviral-naive patients older than 18 years initiating standard antiretroviral therapy between January 1, 2010, and December 31, 2011, were included and followed up to December 31, 2015. We used modified Poisson regression models to estimate the impact of gender on virological suppression and retention in treatment, and Kaplan-Meier analysis and Cox proportional hazard models to evaluate gender difference in mortality.

RESULTS

Sixty-eight thousand six hundred forty-six patients [46,083 (67.1%) men and 22,563 (32.9%) women] with HIV met eligibility criteria. Women were significantly more likely to achieve virological suppression than men both at 12 months [adjusted relative risk (aRR) 1.02, 95% confidence interval (CI): 1.01 to 1.03, P < 0.001] and 48 months (aRR 1.01, 95% CI: 1.00 to 1.02, P = 0.005) after initiating antiretroviral treatment. Women were also more likely to remain in treatment at 12 months (aRR 1.02, 95% CI: 1.01 to 1.02, P < 0.001) and 48 months (aRR 1.04, 95% CI: 1.03 to 1.05, P < 0.001), although the difference became insignificant in alive patients. All-cause mortality was lower in women than in men (2.34 vs. 4.03 deaths/100PY, adjusted hazard ratio 0.72, 95% CI: 0.67 to 0.77, P < 0.001).

CONCLUSIONS

In China, women are more likely to achieve virological suppression, remain in treatment, and have a significantly lower risk of death than men. Future studies could take both biological and sociobehavioral factors into analysis to clarify the influence factors.

High mortality rates in men initiated on anti-retroviral treatment in KwaZulu-Natal, South Africa

In attaining UNAIDS targets of 90-90-90 to achieve epidemic control, understanding who the current utilizers of HIV treatment services are will inform efforts aimed at reaching those not being reached. A retrospective chart review of CAPRISA AIDS Treatment Program (CAT) patients between 2004 and 2013 was undertaken. Of the 4043 HIV-infected patients initiated on ART, 2586 (64.0%) were women. At ART initiation, men, compared to women, had significantly lower median CD4+ cell counts (113 vs 131 cells/mm3, p <0.001), lower median body mass index (BMI) (21.0 vs 24.2 kg/m2, p<0.001), higher mean log viral load (5.0 vs 4.9 copies/ml, p<0.001) and were significantly older (median age: 35 vs. 32 years, p<0.001). Men had higher mortality rates compared to women, 6.7 per 100 person-years (p-y), (95% CI: 5.8-7.8) vs. 4.4 per 100 p-y, (95% CI: 3.8-5.0); mortality rate ratio: 1.54, (95% CI: 1.27-1.87), p <0.001. Age-standardised mortality rate was 7.9 per 100 p-y (95% CI: 4.1-11.7) for men and 5.7 per 100 p-y (95% CI: 2.7 to 8.6) for women (standardised mortality ratio: 1.38 (1.15 to 1.70)). Mean CD4+ cell count increases post-ART initiation were lower in men at all follow-up time points. Men presented later in the course of their HIV disease for ART initiation with more advanced disease and experienced a higher mortality rate compared to women.

A cross-sectional study to evaluate second line virological failure and elevated bilirubin as a surrogate for adherence to atazanavir/ritonavir in two urban HIV clinics in Lilongwe, Malawi

Background

Malawi’s national antiretroviral therapy program provides atazanavir/ritonavir–based second line regimens which cause concentration-dependent rise in indirect bilirubin. We sought to determine if elevated bilirubin, as a surrogate of atazanavir/ritonavir adherence, can aid in the evaluation of second line virological failure in Malawi.

Methods

We conducted a cross-sectional study of HIV-infected patients ≥15 years who were on boosted protease inhibitor-based second line antiretroviral therapy for at least 6 months in two urban HIV clinics in Lilongwe, Malawi. Antiretroviral therapy history and adherence data were extracted from the electronic medical records and blood was drawn for viral load, complete blood count, total bilirubin, and CD4 cell count at a clinic visit. Factors associated with virological failure were assessed using multivariate logistic regression model.

Results

Out of 376 patients on second line antiretroviral therapy evaluated, 372 (98.9%) were on atazanavir/ritonavir-based therapy and 142 (37.8%) were male. Mean age was 40.9 years (SD ± 10.1), mean duration on second line antiretroviral therapy was 41.9 months (SD ± 27.6) and 256 patients (68.1%) had elevated bilirubin >1.3 mg/dL. Overall, 35 (9.3%) patients had viral load >1000 copies/ml (virological failure). Among the virologically failing vs. non-failing patients, bilirubin was elevated in 34.3% vs. 72.0% respectively (p < 0.001), although adherence by pill count was similar (62.9% vs. 60.7%, p = 0.804). The odds of virological failure were higher for adults aged 25–40 years (adjusted odds ratio (aOR) 2.5, p = 0.048), those with CD4 cell count <100 (aOR 17.5, p < 0.001), and those with normal bilirubin levels (aOR 5.4, p < 0.001); but were lower for the overweight/obese patients (aOR 0.3, p = 0.026). Poor pill count adherence (aOR 0.7, p = 0.4) and male gender (aOR 1.2, p = 0.698) were not associated with second line virological failure.

Conclusions

Among patients receiving atazanavir/ritonavir-based second line antiretroviral therapy, bilirubin levels better predicted virological failure than pill count adherence. Therefore, strategic use of bilirubin and viral load testing to target adherence counseling and support may be cost-effective in monitoring second line antiretroviral therapy adherence and virological failure. Drug resistance testing targeted for patients with virological failure despite elevated bilirubin levels would facilitate timely switch to third line antiretroviral regimens whenever available.

Adherence to Antiretroviral Therapy (ART) in Yaoundé-Cameroon: Association with Opportunistic Infections, Depression, ART Regimen and Side Effects

Following global efforts to increase antiretroviral therapy (ART) access in Sub-Saharan Africa, ART coverage among HIV-infected Cameroonians increased from 0% in 2003 to 22% in 2014. However, the success of current HIV treatment programs depends not only on access to ART, but also on retention in care and good treatment adherence. This is necessary to achieve viral suppression, prevent virologic failure, and reduce viral transmission and HIV/AIDS-related deaths. Previous studies in Cameroon showed poor adherence, treatment interruption, and loss to follow-up among HIV+ subjects on ART, but the factors that influence ART adherence are not well known. In the current cross-sectional study, patient/self-reported questionnaires and pharmacy medication refill data were used to quantify ART adherence and determine the factors associated with increased risk of non-adherence among HIV-infected Cameroonians. We demonstrated that drug side-effects, low CD4 cell counts and higher viral loads are associated with increased risk of non-adherence, and compared to females, males were more likely to forego ART because of side effects (p<0.05). Univariate logistic regression analysis demonstrated that subjects with opportunistic infections (on antibiotics) had 2.42-times higher odds of having been non-adherent (p<0.001). Multivariable analysis controlling for ART regimen, age, gender, and education showed that subjects with opportunistic infections had 3.1-times higher odds of having been non-adherent (p<0.0003), with significantly longer periods of non-adherence, compared to subjects without opportunistic infections (p = 0.02). We further showed that compared to younger subjects (≤40 years), older subjects (>40 years) were less likely to be non-adherent (p<0.01) and had shorter non-adherent periods (p<0.0001). The presence of depression symptoms correlated with non-adherence to ART during antibiotic treatment (r = 0.53, p = 0.04), and was associated with lower CD4 cell counts (p = 0.04) and longer non-adherent periods (p = 0.04). Change in ART regimen was significantly associated with increased likelihood of non-adherence and increased duration of the non-adherence period. Addressing these underlying risk factors could improve ART adherence, retention in care and treatment outcomes for HIV/AIDS patients in Cameroon.

Virologic Failure and Human Immunodeficiency Virus Drug Resistance in Rural Cameroon With Regard to the UNAIDS 90-90-90 Treatment Targets

Background.

In rural Africa, data on virologic effectiveness of antiretroviral treatment (ART) are not sufficient to assess the gap with the UNAIDS 90-90-90 treatment targets. We investigated the prevalences of unsuppressed viral load and antiretroviral drug resistance and the profile of genotypic resistance mutations among patients routinely treated in rural Cameroon.

Methods.

A cross-sectional study was performed in 2013–2014 among patients ≥15 years and on first-line ART for ≥6 months in a district hospital. Patients were offered free access to human immunodeficiency virus viral load testing. Genotypic drug resistance testing was done when the viral load was >1000 copies/mL. Multivariate logistic regression models were used to assess the relationship of unsuppressed viral load or antiretroviral drug resistance with sociodemographic and medical characteristics.

Results.

Of 407 patients (women 74.9%, median age 41.8 years, median time on ART 29.2 months), 96 (23.6%; 95% confidence interval [CI], 19.5–28.0) had unsuppressed viral load and 74 (18.2%; 95% CI, 14.6–22.3) had antiretroviral drug resistance. The prevalences of unsuppressed viral load and resistance increased with time on ART, from 12.0% and 8.0% in the 6- to 12-month group to 31.3% and 27.1% in the >72-month group, respectively. All 74 patients with antiretroviral drug resistance were resistant to nonnucleoside reverse-transcriptase inhibitors, and 57 of them were also resistant to nucleoside reverse-transcriptase inhibitors.

Conclusions.

Our estimations were among the highest observed in the west and central African region. The proportion of patients with virologic failure should be divided at least by 2 to reach the UNAIDS 90-90-90 treatment targets.

Predictors of poor retention on antiretroviral therapy as a major HIV drug resistance early warning indicator in Cameroon: results from a nationwide systematic random sampling

Background

Retention on lifelong antiretroviral therapy (ART) is essential in sustaining treatment success while preventing HIV drug resistance (HIVDR), especially in resource-limited settings (RLS). In an era of rising numbers of patients on ART, mastering patients in care is becoming more strategic for programmatic interventions. Due to lapses and uncertainty with the current WHO sampling approach in Cameroon, we thus aimed to ascertain the national performance of, and determinants in, retention on ART at 12 months.

Methods

Using a systematic random sampling, a survey was conducted in the ten regions (56 sites) of Cameroon, within the “reporting period” of October 2013–November 2014, enrolling 5005 eligible adults and children. Performance in retention on ART at 12 months was interpreted following the definition of HIVDR early warning indicator: excellent (>85%), fair (85–75%), poor (<75); and factors with p-value < 0.01 were considered statistically significant.

Results

Majority (74.4%) of patients were in urban settings, and 50.9% were managed in reference treatment centres. Nationwide, retention on ART at 12 months was 60.4% (2023/3349); only six sites and one region achieved acceptable performances. Retention performance varied in reference treatment centres (54.2%) vs. management units (66.8%), p < 0.0001; male (57.1%) vs. women (62.0%), p = 0.007; and with WHO clinical stage I (63.3%) vs. other stages (55.6%), p = 0.007; but neither for age (adults [60.3%] vs. children [58.8%], p = 0.730) nor for immune status (CD4_351–500 [65.9%] vs. other CD4-staging [59.86%], p = 0.077).

Conclusions

Poor retention in care, within 12 months of ART initiation, urges active search for lost-to-follow-up targeting preferentially male and symptomatic patients, especially within reference ART clinics. Such sampling strategy could be further strengthened for informed ART monitoring and HIVDR prevention perspectives.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1991-3) contains supplementary material, which is available to authorized users.

Long-Term Outcomes on Antiretroviral Therapy in a Large Scale-Up Program in Nigeria

Background

While there has been a rapid global scale-up of antiretroviral therapy programs over the past decade, there are limited data on long-term outcomes from large cohorts in resource-constrained settings. Our objective in this evaluation was to measure multiple outcomes during first-line antiretroviral therapy in a large treatment program in Nigeria.

Methods

We conducted a retrospective multi-site program evaluation of adult patients (age ≥15 years) initiating antiretroviral therapy between June 2004 and February 2012 in Nigeria. The baseline characteristics of patients were described and longitudinal analyses using primary endpoints of immunologic recovery, virologic rebound, treatment failure and long-term adherence patterns were conducted.

Results

Of 70,002 patients, 65.2% were female and median age was 35 (IQR: 29–41) years; 54.7% were started on a zidovudine-containing and 40% on a tenofovir-containing first-line regimen. Median CD4+ cell counts for the cohort started at 149 cells/mm³ (IQR: 78–220) and increased over duration of ART. Of the 70,002 patients, 1.8% were reported as having died, 30.1% were lost to follow-up, and 0.1% withdrew from treatment. Overall, of those patients retained and with viral load data, 85.4% achieved viral suppression, with 69.3% achieving suppression by month 6. Of 30,792 patients evaluated for virologic failure, 24.4% met criteria for failure and of 45,130 evaluated for immunologic failure, 34.0% met criteria for immunologic failure, with immunologic criteria poorly predicting virologic failure. In adjusted analyses, older age, ART regimen, lower CD4+ cell count, higher viral load, and inadequate adherence were all predictors of virologic failure. Predictors of immunologic failure differed slightly, with age no longer predictive, but female sex as protective; additionally, higher baseline CD4+ cell count was also predictive of failure. Evaluation of long-term adherence patterns revealed that the majority of patients retained through 84 months maintained ≥95% adherence.

Conclusion

While improved access to HIV care and treatment remains a challenge in Nigeria, our study shows that a high quality of care was achieved as evidenced by strong long-term clinical, immunologic and virologic outcomes.

Determinants of time to antiretroviral treatment initiation and subsequent mortality on treatment in a cohort in rural northern Malawi

BACKGROUND

To optimise care HIV patients need to be promptly initiated on antiretroviral therapy (ART) and subsequently retained on treatment. In this study we report on the interval between enrolment and treatment initiation, and investigate subsequent attrition and mortality of patients on ART at a rural clinic in Malawi.

METHODS

HIV-positive individuals were recruited to a cohort study between January 2008 and August 2011 at Chilumba Rural Hospital (CRH). Outcomes were ascertained, up to 7 years after enrolment, through follow-up and by linkage to ART registers and the Karonga Health and Demographic Surveillance System (KHDSS). Kaplan-Meier methods and Cox regression were used to examine ART initiation after enrolment, mortality after ART initiation, and attrition after ART initiation.

RESULTS

Of the 617 individuals recruited, 523 initiated ART between January 2008 and January 2015. Median time from HIV testing to commencement of ART was 59 days (IQR: 10-330). By a year after enrolment 74.2 % (95 % CI 70.6-77.7 %) had initiated ART. Baseline clinical data at ART initiation and data on attrition was only available for the 438 individuals who initiated ART during active follow-up, between January 2008 and August 2011. Of these individuals, 6 were missing Ministry of Health numbers, leaving 432 included in analyses of attrition and mortality. At 4 years after ART initiation 71.3 % (95 % CI 65.7-76.2 %) of these patients were retained on treatment at the CRH and 17.2 % (95 % CI 13.8-21.4 %) had died. Participants who had a lower CD4 count at enrolment (≤350 cells/μl), enrolled in 2008, or tested for HIV at the CRH rather than through serosurveys, initiated treatment faster. Once on treatment, mortality rates were higher in patients who were HIV tested at the CRH, male, older (≥35 years), missing a CD4 count, or underweight (BMI < 18.5) at ART initiation.

CONCLUSIONS

Through linkage to the KHDSS and ART registers it was possible to continue follow-up beyond the end of the initial cohort study. Annual mortality after ART initiation remained considerable over a period of 4 years. Greater access to HIV and CD4 testing alongside initiation at higher CD4 counts, as planned in the test and treat strategy, could reduce this mortality.