Loss to Follow-up Trends in HIV-Positive Patients Receiving Antiretroviral Treatment in Asia From 2003 to 2013

Mortality of cytomegalovirus infection among people living with HIV: A retrospective study from a tertiary hospital in Indonesia

BACKGROUND

There are still many patients newly diagnosed with HIV at an advanced stage in Indonesia. We aimed to identify factors associated with 1-year mortality among cytomegalovirus (CMV)-infected people living with HIV (PLHIV).

METHODS

This retrospective cohort study was carried out at a tertiary-care hospital in Jakarta, Indonesia (January 2017 to December 2022). We included PLHIV with CMV end-organ disease (EOD) and CMV syndrome. The presence of CMV infection was confirmed by fulfilling one of the following criteria: (1) positive PCR from plasma, urine, cerebrospinal fluid, or other body fluids, or associated tissue for CMV EOD; (2) positive immunoglobulin M (IgM); or (3) consistent symptoms and signs of CMV retinitis.

RESULTS

Out of 1737 PLHIV, 147 (8.5%, 95% CI: 7.2 to 9.9%) were diagnosed with CMV infection. Forty (27.2%, 95% CI: 20.6 to 35.1%) patients died within 1 year of being diagnosed. Only anti-retroviral therapy (ART) defaulting (aHR 3.31, 95% CI: 1.12 to 9.73) was found to be significantly associated with 1-year mortality in multivariate analysis.

CONCLUSION

Defaulted ART status is significantly associated with reduced 1-year survival after CMV infection diagnosis. Patients with low CD4 counts, especially those with <50 cells/μL, should be assessed for CMV infection, monitored, and treated accordingly.

Evaluation of an HIV homecare program for lost-to-follow-up populations: a mixed methods study in Detroit, Michigan

BACKGROUND

Maintaining people living with HIV (PLWHIV) in clinical care is a global priority. In the Metro Detroit area of Michigan, approximately 30% of PLWHIV are out of care. To re-engage lost-to-follow-up patients, Wayne Health Infectious Disease clinic launched an innovative Homecare program in 2017. In addition to home healthcare delivery, the program included links to community resources and quarterly community meetings. We aimed to evaluate Homecare's impact on participants' ability to stay engaged in HIV care and reach viral suppression. We included data from PLWHIV and their healthcare workers.

METHODS

We used a convergent mixed-methods design, including first year program record review, semi-structured interviews, and a validated Likert scale questionnaire rating illness perception before and after Homecare. Interview data were collected from 15 PLWHIV in Metro Detroit and two healthcare workers responsible for program delivery. Semi-structured interviews focused on obstacles to clinic-based care, support networks, and illness perceptions. Interview data were transcribed and analyzed using a thematic approach. A fully coded analysis was used to create a conceptual framework of factors contributing to Homecare's success. Means in eight categories of the Brief Illness Perception (IPQ) were compared using paired T-tests.

RESULTS

In the first year of Homecare, 28 of 34 participants (82%) became virally suppressed at least once. The program offered (1) social support and stigma reduction through strong relationships with healthcare workers, (2) removal of physical and resource barriers such as transportation, and (3) positive changes in illness perceptions. PLWHIV worked towards functional coping strategies, including improvements in emotional regulation, acceptance of their diagnosis, and more positive perspectives of control. Brief-IPQ showed significant changes in six domains before and after Homecare.

CONCLUSION

Homecare offers an innovative system for successfully re-engaging and maintaining lost-to-follow-up PLWHIV in care. These findings have implications for HIV control efforts and could inform the development of future programs for difficult to reach populations.

Survival probability and factors associated with time to loss to follow-up and mortality among patients on antiretroviral treatment in central Kenya

BACKGROUND

Retention of patients who are receiving antiretroviral therapy (ART) remains a challenge especially in the setting of rapid expansion of HIV services. Retention in care remains vital to the HIV care continuum, and has been associated with viral suppression and improved survival. This study aimed to ascertain survival rates, time to loss to follow-up (LTFU) or mortality events and factors associated with time to LTFU or mortality among patients enrolled on antiretroviral therapy at health facilities in central Kenya.

METHODS

This was a retrospective cohort study among patients initiated on ART between 2004 and 2012 in central Kenya. Demographic characteristics, clinical characteristics and outcomes data were analyzed using Stata version 15.1. Competing risks regression analysis and cummulative incidence functions were used to estimate survival.

RESULTS

A total of 31,346 patients were included, of whom 65.6% were female, 76.0% were aged between 20 and 50 years old, and 38.9% were diagnosed at WHO stage III. At 36 months, overall retention was 68.8%, LTFU was 27.1%, and mortality was 4.1%. The total person-years of follow up was 74,986. The incidence rate of LTFU was 9.99 per 100 person years for a total of 9383.25 person-years of follow up. The mortality rate was 1.25 per 100 person years for a total of 875.5 person-years among those who died. The median time to LTFU was 11 months (IQR 3-22) while median time to death was 3 months (IQR 0-13). Men, unmarried patients, patients presenting with advanced HIV, not on TB treatment, and enrolled into the HIV program in later cohorts, had a shorter time to mortality and LTFU.

CONCLUSION

Our study demonstrated evidence of scale-up of HIV treatment programs in central Kenya. While most patients were enrolled at an advanced WHO clinical stage, overall 36-month mortality remained low, but occurred earlier during follow-up. Cohort LTFU at 36-months reduced in later years with the losses occurring within the 1st year of follow-up. Predictors of early mortality and LTFU included being male, single, separated or divorced, advanced WHO clinical stage, and among patients not on TB treatment.

Cascade of care among hepatitis B patients in Maastricht, the Netherlands, 1996 to 2018

Background & aims

Methods

Results

Conclusions

Baseline and Process Factors of Anti-Retroviral Therapy That Predict Loss to Follow-up Among People Living with HIV/AIDS in China: A Retrospective Cohort Study

We explored the predictors and predictive models of loss to follow-up (LTFU) during the first year of anti-retroviral therapy (ART). LTFU was defined as the failure to visit the clinic for antiretroviral drugs for ≥ 90 days after the last missed scheduled visit. Based on the electronic medical records of 5953 patients who were HIV positive and began ART between 2016 and 2019 in China, the LTFU rate was 7.24 (95% confidence interval 6.49-7.97) per 100 person-years during the first year of ART. ART baseline factors were associated with LTFU, but were non-optimal predictors. A model including ART process-related factors such as follow-up behaviors and physical health status had an area under the receiver operating characteristic curve of 73.4% for predicting LTFU. Therefore, the medical records of follow-up visits can be used to identify patients with a high risk of LTFU and allow interventions to be implemented proactively.

Time to lost to follow-up and its predictors among adult patients receiving antiretroviral therapy retrospective follow-up study Amhara Northwest Ethiopia

Antiretroviral therapy lowers viral load only when people living with HIV maintain their treatment retention. Lost to follow-up is the persistent major challenge to the success of ART program in low-resource settings including Ethiopia. The purpose of this study is to estimate time to lost to follow-up and its predictors in antiretroviral therapies amongst adult patients. Among registered HIV patients, 542 samples were included. Data cleaning and analysis were done using Stata/SE version 14 software. In multivariable Cox regression, a p-value < 0.05 at 95% confidence interval with corresponding adjusted hazards ratio (AHR) were statistically significant predictors. In this study, the median time to lost to follow-up is 77 months. The incidence density of lost to follow-up was 13.45 (95% CI: 11.78, 15.34) per 100 person-years. Antiretroviral therapy drug adherence [AHR: 3.04 (95% CI: 2.18, 4.24)], last functional status [AHR: 2.74 (95% CI: 2.04, 3.67)], and INH prophylaxis [AHR: 1.65 (95% CI: 1.07, 2.56) were significant predictors for time to lost to follow-up. The median time to lost was 77 months and incidence of lost to follow-up was high. Health care providers should be focused on HIV counseling and proper case management focused on identified risks.

Predictors of lost to follow up from antiretroviral therapy among adults in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

It is known that 'drop out' from human immunodeficiency virus (HIV) treatment, the so called lost-to-follow-up (LTFU) occurs to persons enrolled in HIV care services. However, in sub-Saharan Africa (SSA), the risk factors for the LTFU are not well understood.

METHODS

We performed a systematic review and meta-analysis of risk factors for LTFU among adults living with HIV in SSA. A systematic search of literature using identified keywords and index terms was conducted across five databases: MEDLINE, PubMed, CINAHL, Scopus, and Web of Science. We included quantitative studies published in English from 2002 to 2019. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for methodological validity assessment and data extraction. Mantel Haenszel method using Revman-5 software was used for meta-analysis. We demonstrated the meta-analytic measure of association using pooled odds ratio (OR), 95% confidence interval (CI) and heterogeneity using I2 tests.

RESULTS

Thirty studies met the search criteria and were included in the meta-analysis. Predictors of LTFU were: demographic factors including being: (i) a male (OR = 1.2, 95% CI 1.1-1.3, I2 = 59%), (ii) between 15 and 35 years old (OR = 1.3, 95% CI 1.1-1.3, I2 = 0%), (iii) unmarried (OR = 1.2, 95% CI 1.2-1.3, I2 = 21%), (iv) a rural dweller (OR = 2.01, 95% CI 1.5-2.7, I2 = 40%), (v) unemployed (OR = 1.2, 95% CI 1.04-1.4, I2 = 58%); (vi) diagnosed with behavioral factors including illegal drug use(OR = 13.5, 95% CI 7.2-25.5, I2 = 60%), alcohol drinking (OR = 2.9, 95% CI 1.9-4.4, I2 = 39%), and tobacco smoking (OR = 2.6, 95% CI 1.6-4.3, I2 = 74%); and clinical diagnosis of mental illness (OR = 3.4, 95% CI 2.2-5.2, I2 = 1%), bed ridden or ambulatory functional status (OR = 2.2, 95% CI 1.5-3.1, I2 = 74%), low CD4 count in the last visit (OR = 1.4, 95% CI 1.1-1.9, I2 = 75%), tuberculosis co-infection (OR = 1.2, 95% CI 1.02-1.4, I2 = 66%) and a history of opportunistic infections (OR = 2.5, 95% CI 1.7-2.8, I2 = 75%).

CONCLUSIONS

The current review identifies demographic, behavioral and clinical factors to be determinants of LTFU. We recommend strengthening of HIV care services in SSA targeting the aforementioned group of patients. Trial registration Protocol: the PROSPERO Registration Number is CRD42018114418.

Risk factors for loss to follow-up from antiretroviral therapy programmes in low-income and middle-income countries

INTRODUCTION

Loss to follow-up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, leading to poor treatment outcomes and onward transmission of HIV. Knowledge of risk factors is required to address LTFU. In this systematic review, risk factors for LTFU are identified and meta-analyses performed.

METHODS

PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults who initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95% CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed.

RESULTS

Eighty studies were included describing a total of 1 605 320 patients of which 87.4% from sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, nondisclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 cell count, tuberculosis at baseline, regimen, and geographical setting.

CONCLUSION

There are several sociodemographic, clinical, patient behaviour, treatment-related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients.

Determinants of loss to follow-up among HIV positive patients receiving antiretroviral therapy in a test and treat setting: A retrospective cohort study in Masaka, Uganda

Background

Retaining patients starting antiretroviral therapy (ART) and ensuring good adherence remain cornerstone of long-term viral suppression. In this era of test and treat (T&T) policy, ensuring that patients starting ART remain connected to HIV clinics is key to achieve the UNAIDS 90-90-90 targets. Currently, limited studies have evaluated the effect of early ART initiation on loss to follow up in a routine health care delivery setting. We studied the cumulative incidence, incidence rate of loss to follow up (LTFU), and factors associated with LTFU in a primary healthcare clinic that has practiced T&T since 2012.

Methods

We retrospectively analyzed extracted routine program data on patients who started ART from January 2012 to 4^th July 2016. We defined LTFU as failure of a patient to return to the HIV clinic for at least 90 days from the date of their last appointment. We calculated cumulative incidence, incidence rate and fitted a multivariable Cox proportion hazards regression model to determine factors associated with LTFU.

Results

Of the 7,553 patients included in our sample, 3,231 (42.8%) started ART within seven days following HIV diagnosis. There were 1,180 cases of LTFU observed over 15,807.7 person years at risk. The overall incidence rate (IR) of LTFU was 7.5 (95% CI, 7.1–7.9) per 100 person years of observation (pyo). Cumulative incidence of LTFU increased with duration of follow up from 8.9% (95% CI, 8.2–9.6%) at 6 months to 20.2% (95% CI, 19.0–21.4%) at 48 months. Predictors of elevated risk of LTFU were: starting ART within 7 days following HIV diagnosis ((aHR) = 1.69, 95% CI, 1.50–1.91), lack of a telephone set (aHR = 1.52, 95% CI, 1.35–1.71), CD4 cell count of 200–350μ/ml (aHR = 1.21, 95% CI, 1.01–1.45) and baseline WHO clinical stage 3 or 4 (aHR = 1.35, 95% CI, 1.10–1.65). Factors associated with a reduced risk of LTFU were: baseline age ≥25 years (aHR ranging from 0.62, 95% CI, 0.47–0.81 for age group 25–29 years to 0.24, 95% CI, 0.13–0.44 for age group ≥50 years), at least primary education level (aHR ranging from aHR = 0.77, 95% CI, 0.62–0.94 for primary education level to 0.50, 95% CI, 0.34–0.75 for post-secondary education level), and having a BMI ≥ 30 (aHR = 0.28, 95% CI, 0.15–0.51).

Conclusion

The risk of loss to follow up increased with time and was higher among patients who started ART within seven days following HIV diagnosis, higher among patients without a telephone set, lower among patients aged ≥ 25 years, lower among patients with at least primary education and lower among patients with BMI of ≥ 30. In this era of T&T, it will be important for HIV programs to initiate and continue enhanced therapeutic education programs that target high risk groups, as well as leveraging on mHealth to improve patients’ retention on ART throughout the cascade of care.

Conceptual framework for strengthening nurse-initiated management of antiretroviral therapy training and implementation in North West province

BACKGROUND

The implementation of nurse-initiated management of antiretroviral therapy (NIMART) management training is a challenge in the primary health care (PHC). It is evident from the literature reviewed and the data obtained from the North West province that gaps still exist. There is no conceptual framework providing guidance to NIMART training and implementation.

AIM

Therefore, the aim of this study was to develop a conceptual framework to strengthen NIMART training and implementation in the North West province to improve patients and human immunodeficiency virus (HIV) programme outcomes.

SETTING

The study was conducted in the North West Province, South Africa.

METHODS

A pragmatic, explanatory, sequential, mixed-methods research design was followed. A descriptive and explorative programme evaluation design was used. Data were collected from two sources: antiretroviral therapy (ART) statistics from District Health Information System (DHIS) & Tier.net of 10 PHC facilities to evaluate and determine the impact of NIMART on the HIV programme and five focus group discussions conducted amongst 28 NIMART nurses and three HIV programme managers to describe challenges influencing NIMART training and implementation.

RESULTS

The study revealed that there was low ART initiation compared to the number of clients who tested HIV-positive. There was poor monitoring of patients on ART, which was evident in the low viral load collection and suppression, high loss to follow-up and deaths related to HIV. Challenges exist and this was confirmed by the qualitative findings, including human resource ratios, training and mentoring and the entire absence of a conceptual framework or model that guides training and implementation.

CONCLUSION

The study findings were conceptualised to describe and develop a framework needed to facilitate and influence NIMART training and implementation to improve the HIV programme and patient outcomes. Dickoff, James and Wiedenbach's practice-oriented theory and Donabedian's structure process outcomes model provided a starting point in the ultimate development of the framework. Although the study was limited to the North West province's PHC clinics and community health centres and did not include hospitals, it is of high significance as there is no such conceptual framework in the province or in even South Africa.

Global variations in mortality in adults after initiating antiretroviral treatment: an updated analysis of the International epidemiology Databases to Evaluate AIDS cohort collaboration

BACKGROUND

UNAIDS models use data from the International epidemiology Databases to Evaluate AIDS (IeDEA) collaboration in setting assumptions about mortality rates after antiretroviral treatment (ART) initiation. This study aims to update these assumptions with new data, to quantify the extent of regional variation in ART mortality and to assess trends in ART mortality.

METHODS

Adult ART patients from Africa, Asia and the Americas were included if they had a known date of ART initiation during 2001-2017 and a baseline CD4 cell count. In cohorts that relied only on passive follow-up (no patient tracing or linkage to vital registration systems), mortality outcomes were imputed in patients lost to follow-up based on a meta-analysis of tracing study data. Poisson regression models were fitted to the mortality data.

RESULTS

464 048 ART patients were included. In multivariable analysis, mortality rates were lowest in Asia and highest in Africa, with no significant differences between African regions. Adjusted mortality rates varied significantly between programmes within regions. Mortality rates in the first 12 months after ART initiation were significantly higher during 2001-2006 than during 2010-2014, although the difference was more substantial in Asia and the Americas [adjusted incidence rate ratio (aIRR) 1.43, 95% CI: 1.22-1.66] than in Africa (aIRR 1.07, 95% CI: 1.04-1.11).

CONCLUSION

There is substantial variation in ART mortality between and within regions, even after controlling for differences in mortality by age, sex, baseline CD4 category and calendar period. ART mortality rates have declined substantially over time, although declines have been slower in Africa.

Loss to follow-up and associated factors among adult people living with HIV at public health facilities in Wakiso district, Uganda: a retrospective cohort study

BACKGROUND

Loss to follow-up (LTFU) from care among people living with HIV (PLHIV) is thought to be more common in the public setting compared to the private health care. It is anticipated that the problem may become worse with the current "test and treat" policy in Uganda due to the likely increases in patient loads and its attendant pressure on health care providers to support patient counseling. This study determined the incidence and factors associated with LTFU from HIV care among adult PLHIV in public health facilities in Wakiso district, Uganda.

METHODS

This was a retrospective cohort study that involved the review of 646 records of patients initiated on antiretroviral therapy (ART) between January 1st, 2015 and December 31st, 2017 at 13 randomly selected public health facilities in Wakiso district. The cox proportional hazards regression was used to determine the factors associated with LTFU. The results were supported by sequential in-depth and key informant interviews to explore reasons for LTFU.

RESULTS

Of the 646 patients enrolled, 391 were female (60.5%), 282 were below 30 years (43.6%) and 207 were married (50.1%). A total of 216 patients (33.4%) had no documented outcomes and were considered LTFU. The incidence of LTFU was 21 per 1000 person months (95% confidence interval (CI): 18-25 per 1000 person months). Factors associated with LTFU included having normal weight compared to underweight (adjusted hazard ratio (aHR) 0.64, 95% CI: 0.45-0.90, p = 0.011), receiving HIV care from hospitals compared to lower level facilities (aHR 0.22, 95% CI: 0.12-0.41, p < 0.001), and no telephone contact compared to those with a telephone contact (aHR 2.16, 95% CI: 1.33-3.51, p = 0.002). Stigmatization and long waiting times were the prominent reasons for LTFU reported from the in-depth and key informant interviews.

CONCLUSIONS

The incidence of LTFU in public health facilities in Uganda is quite high and is associated with being underweight, not having a telephone contact to receive reminders and receiving care at lower level facilities. Early diagnosis, routine use of patient address locator forms and improved quality of HIV care at lower level health facilities may reduce LTFU among PLHIV.

Using a HIV registry to develop accurate estimates for the HIV care cascade - the Singapore experience

INTRODUCTION

Achieving UNAIDS 90-90-90 targets is a crucial step towards ending the AIDS epidemic. Many countries have published estimates of care cascades, although often with methodological limitations. We describe an approach that used the national HIV registry as a starting-point to determine the HIV care cascade and resulting UNAIDS 90-90-90 estimates for Singapore in 2014.

METHODS

HIV is a legally notifiable disease in Singapore. The anonymized HIV registry data provided for a back-calculation model from the European Centre for Disease Prevention and Control to obtain 2014 estimates for the total number of persons living with HIV (PLHIV), and the count in the registry for proportions diagnosed with HIV and linked to care. Using additional data collected for a simple random sample from the registry, outcomes in 2015 and 2016 were ascertained retrospectively to derive proportions for those retained in care, on antiretroviral therapy, and achieved viral suppression. Findings were extrapolated to derive national estimates and UN90-90-90 estimates. Bootstrapped samples from the model and sample were used to derive 95% confidence intervals.

RESULTS

An estimated 6900 (95% CI 6650, 7050) persons were living with HIV and AIDS in 2014. Of these, 4948 were diagnosed with HIV, and 4820 had been linked to care. The random sample of 500 persons was further analysed, and of these, 87.2% were retained in care, 84.6% on antiretroviral therapy, and 79.6% had suppressed viral loads. The proportions of HIV-infected individuals on antiretroviral therapy and achieving viral suppression were 60.7% (95% CI 58.4, 63.6) and 57.1% (95% CI 55.0, 60.5) respectively. The corresponding UNAIDS 90-90-90 estimates were 71.7% (95% CI 70.0, 74.2) of all persons diagnosed; 84.6% (95% CI 81.6, 87.4) of diagnosed persons being on antiretroviral therapy, and 94.1% (95% CI 91.6, 96.2) of persons on therapy having achieved viral suppression.

CONCLUSIONS

A national HIV registry, alongside back-calculation and additional data from a sample, can be used to estimate attainment of UNAIDS 90-90-90 targets and identify system gaps. The registry had advantages of providing a well-established, comprehensive capture of diagnosed persons and easily accessible data. The same approach can be used elsewhere if similar data are available.

Long-term loss to follow-up in the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES

With earlier antiretroviral therapy (ART) initiation, time spent in HIV care is expected to increase. We aimed to investigate loss to follow-up (LTFU) in Asian patients who remained in care 5 years after ART initiation.

METHODS

Long-term LTFU was defined as LTFU occurring after 5 years on ART. LTFU was defined as (1) patients not seen in the previous 12 months; and (2) patients not seen in the previous 6 months. Factors associated with LTFU were analysed using competing risk regression.

RESULTS

Under the 12-month definition, the LTFU rate was 2.0 per 100 person-years (PY) [95% confidence interval (CI) 1.8-2.2 among 4889 patients included in the study. LTFU was associated with age > 50 years [sub-hazard ratio (SHR) 1.64; 95% CI 1.17-2.31] compared with 31-40 years, viral load ≥ 1000 copies/mL (SHR 1.86; 95% CI 1.16-2.97) compared with viral load < 1000 copies/mL, and hepatitis C coinfection (SHR 1.48; 95% CI 1.06-2.05). LTFU was less likely to occur in females, in individuals with higher CD4 counts, in those with self-reported adherence ≥ 95%, and in those living in high-income countries. The 6-month LTFU definition produced an incidence rate of 3.2 per 100 PY (95% CI 2.9-3.4 and had similar associations but with greater risks of LTFU for ART initiation in later years (2006-2009: SHR 2.38; 95% CI 1.93-2.94; and 2010-2011: SHR 4.26; 95% CI 3.17-5.73) compared with 2003-2005.

CONCLUSIONS

The long-term LTFU rate in our cohort was low, with older age being associated with LTFU. The increased risk of LTFU with later years of ART initiation in the 6-month analysis, but not the 12-month analysis, implies that there was a possible move towards longer HIV clinic scheduling in Asia.

Trends in mortality among ART-treated HIV-infected adults in the Asia-Pacific region between 1999 and 2017: results from the TREAT Asia HIV Observational Database (TAHOD) and Australian HIV Observational Database (AHOD) of IeDEA Asia-Pacific

INTRODUCTION

AIDS-related deaths in people living with HIV/AIDS have been decreasing in number since the introduction of combination antiretroviral treatment (cART). However, data on recent causes of death in the Asia-Pacific region are limited. Hence, we analysed and compared AIDS-related and non-AIDS-related mortality in high- and low-income settings in the region.

METHODS

Patients from the TREAT Asia HIV Observational Database (TAHOD) and Australian HIV Observational Database (AHOD) receiving cART between 1999 and 2017 were included. Causes of death verification were based on review of the standardized Cause of Death (CoDe) form designed by the D:A:D group. Cohorts were grouped as AHOD (all high-income sites), TAHOD-high (high/upper-middle income countries) and TAHOD-low (lower-middle income countries). TAHOD sites were split into high/upper-middle income and lower-middle income country settings based on World Bank classifications. Competing risk regression was used to analyse factors associated with AIDS and non-AIDS-related mortality.

RESULTS

Of 10,386 patients, 522 died; 187 from AIDS-related and 335 from non-AIDS-related causes. The overall incidence rate of deaths during follow-up was 0.28 per 100 person-years (/100 PYS) for AIDS and 0.51/100 PYS for non-AIDS. Analysis indicated that the incidence rate of non-AIDS mortality decreased from 0.78/100 PYS to 0.37/100 PYS from year groups 2003 to 2007 to 2013 to 2017 (p < 0.001). Similarly, incidence rates of AIDS-related deaths decreased from 0.51/100 PYS to 0.09/100 PYS from year groups 2003 to 2007 to 2013 to 2017 (p < 0.001). More recent years of follow-up were associated with reduced hazard for non-AIDS mortality (2008 to 2012: aSHR (adjusted sub-hazard ratio) 0.72, 95% confidence interval (CI) 0.54 to 0.96, p = 0.027; 2013 to 2017: aSHR 0.64, 95% CI 0.47 to 0.87, p = 0.004) compared to years 2003 to 2007. The AHOD cohort had almost twice the hazard of non-AIDS mortality compared to TAHOD-low (lower-middle income sites) (aSHR 1.72, 95% CI, 1.20 to 2.46, p = 0.003); there were no differences between cohorts for AIDS-related mortality (p = 0.834).

CONCLUSION

AIDS and non-AIDS-related mortality rates have decreased over the past years in the Asia-Pacific region. There is a greater risk for non-AIDS-associated deaths in the AHOD cohort compared to lower-middle income settings in TAHOD.

The cascade of HIV care among key populations in Indonesia: a prospective cohort study

BACKGROUND

Indonesia has had low uptake of HIV testing and treatment. We did a study to estimate the cascade of HIV care in key populations and identify predictors of outcomes at key cascade steps.

METHODS

We used an observational cohort study design to recruit and follow up men who have sex with men (MSM), female sex workers, transgender women (known as waria in Indonesia), and people who inject drugs (PWID) diagnosed with HIV in four locations in Indonesia: Bali, Bandung, Jakarta, and Yogyakarta. Recruitment, baseline, and follow-up visits were done at collaborating clinical services, including both primary care sites and hospitals. Inclusion criteria for participants included identifying as a member of a key population, age 16 years or older, not previously tested positive for HIV, and HIV positivity at baseline. All participants were offered treatment as per national guidelines, with the addition of viral load testing and completion of study-specific forms. Estimates were calculated of proportions of participants linked to care, commencing treatment, adherent to treatment, and who achieved virological suppression. We used logistic regression to investigate characteristics associated with antiretroviral therapy (ART) initiation and viral suppression and Cox regression to identify factors associated with loss to follow-up. This study is registered with ClinicalTrials.gov, NCT03429842.

FINDINGS

Between Sept 15, 2015, and Sept 30, 2016, 831 individuals were enrolled in the study, comprising 637 (77%) MSM, 116 (14%) female sex workers, 27 (3%) waria, and 51 (6%) PWID. Of those enrolled, 703 (84·6%, 95% CI 82·1-87·1) were linked to HIV care and 606 (86·2%, 83·7-88·8) who were linked with care started ART. Among participants who started treatment, 457 (75·4%, 71·8-78·9) were retained in care, of whom 325 (71·1%, 66·7-75·2) had a viral load test about 6 months after enrolment, with 294 (90·5%, 86·7-93·4) of those tested (294 [35%, 32·1-38·7] of the original cohort) virally suppressed. 146 (24%) of 606 who started treatment were lost to follow-up. People who enrolled at sites that offered both testing and treatment had a higher likelihood of treatment initiation than those who enrolled at sites offering testing only (p<0·0001 by multivariate analysis), and participants who had been linked to care and had a high school or university education were significantly more likely to achieve viral suppression than those with a primary school or lower level of education (p≤0·029 by mulivariate analysis).

INTERPRETATION

HIV cascade data among key populations in Indonesia show very poor rates of retention in treatment and viral suppression. Site and individual characteristics associated with initiating and continuing treatment suggest an urgent need to develop and implement effective interventions to support patients in achieving viral suppression among all people with HIV.

FUNDING

Australian Government Department of Foreign Affairs and Trade, WHO, and Indonesian Government.

Is substance use associated with HIV cascade outcomes in Latin America?

BACKGROUND

The HIV care cascade has improved in Latin America over the last decade. However, the influence of alcohol and noninjected drug use (NIDU) on cascade outcomes is mostly unknown. This study estimated the association of alcohol and NIDU with retention in care, loss to follow up (LTFU), and virologic failure (VF).

METHODS

Individuals ≥18 years attending routine HIV clinic visits and completing the Rapid Screening Tool (RST; evaluating NIDU and ART adherence in 7-day recall period) during 2012-13 were followed up to 2015 in the Caribbean, Central and South America network for HIV epidemiology. Adjusted odds ratios (aOR) were calculated for the association of alcohol consumption and NIDU with retention in care by logistic regression; adjusted hazard ratios (aHR) were estimated for the associations with LTFU and VF by Cox regression.

RESULTS

Among 3604 individuals, the proportions retained in care for one year were 84%, 79%, 72%, and 69% for patients reporting non-use, alcohol use, NIDU, and both alcohol and NIDU, respectively. For the same patient groups, the proportions LTFU over 18 months were 6%, 8%, 12%, and 13%, respectively. There were 1901 patients (53%) with HIV RNA results; VF proportions were similar between users and nonusers (ranging from 14-16%). After controlling for age, sex, study site, HIV transmission mode, time on ART, AIDS status, and CD4 count, neither alcohol use (aOR = 1.1, CI = 0.9-1.4; aHR = 1.0, CI = 0.8-1.3) nor NIDU (aOR = 1.3, CI = 0.9-1.8; aHR = 1.4, CI = 0.9-2.1) were significantly associated with retention or VF, respectively. However, both alcohol use (aHR = 1.2, CI = 1.02-1.4) and NIDU (aHR = 1.3, CI = 1.00-1.8) were associated with increased LTFU.

CONCLUSION

Alcohol use and NIDU in a 7-day recall period increased the risk of being LTFU during the next 18 months, highlighting the need for routine screening and targeted interventions to keep these individuals in care and on ART.