British HIV Association guidelines for the routine investigation and monitoring of adult HIV-1-infected individuals 2011

CRISPR Cas12a-Powered Silicon Surface-Enhanced Raman Spectroscopy Ratiometric Chip for Sensitive and Reliable Quantification

Sensitive and reliable clustered regularly interspaced short palindromic repeats (CRISPR) quantification without preamplification of the sample remains a challenge. Herein, we report a CRISPR Cas12a-powered silicon surface-enhanced Raman spectroscopy (SERS) ratiometric chip for sensitive and reliable quantification. As a proof-of-concept application, we select the platelet-derived growth factor-BB (PDGF-BB) as the target. We first develop a microfluidic synthetic strategy to prepare homogeneous silicon SERS substrates, in which uniform silver nanoparticles (AgNPs) are in situ grown on a silicon wafer (AgNPs@Si) by microfluidic galvanic deposition reactions. Next, one 5'-SH-3'-ROX-labeled single-stranded DNA (ssDNA) is modified on AgNPs via Ag-S bonds. In our design, such ssDNA has two fragments: one fragment hybridizes to its complementary DNA (5'-Cy3-labeled ssDNA) to form double-stranded DNA (dsDNA) and the other fragment labeled with 6'-carboxy-X-rhodmine (ROX) extends out as a substrate for Cas12a. The cleavage of the ROX-tagged fragment by Cas12a is controlled by the presence or not of PDGF-BB. Meanwhile, Cy3 molecules serving as internal standard molecules still stay at the end of the rigid dsDNA, and their signals remain constant. Thereby, the ratio of ROX signal intensity to Cy3 intensity can be employed for the reliable quantification of PDGF-BB concentration. The developed chip features an ultrahigh sensitivity (e.g., the limit of detection is as low as 3.2 pM, approximately 50 times more sensitive than the fluorescence counterpart) and good reproducibility (e.g., the relative standard deviation is less than 5%) in the detection of PDGF-BB.

Identifying Longitudinal CD4:CD8 Ratio Trajectories Indicative of Chronic Renal Disease Risk among People Living with HIV: An Application of Growth Mixture Models

The incidence of chronic kidney disease (CKD) is increasing among people living with HIV (PLWH). Routine monitoring of indicators such as CD4:CD8 ratio might improve the early detection of CKD. Our objective was to identify clinically relevant CD4:CD8 ratio trajectories indicative of CKD risk. Participants were ≥ 18 years old, initiated antiretroviral therapy between 2000 and 2016, and were followed for ≥6 months until 31 March 2017 or last contact date. Outcome was incidence of CKD. Growth mixture models (GMMs) and decay models were used to compare CD4:CD8 ratio trajectories. Following GMM, 4547 (93.5%) participants were classified in Class 1 with 5.4% developing CKD, and 316 (6.5%) participants were classified in Class 2 with 20.9% developing CKD. The final model suggested that participants in Class 2 had 8.72 times the incidence rate of developing CKD than those in Class 1. Exponential decay models indicated a significant CD4:CD8 ratio decline among Class 2 participants who developed CKD. Among those who developed CKD in Class 2, starting at 5.5 years of follow-up, the slope of their ratio trajectory curve changed significantly, and the rate of decline increased dramatically. Routine monitored CD4:CD8 ratios can be an effective strategy to identify early CKD risk among PLWH.

Analysis of virologic outcome in low-level HIV-1 viremia patients in a small cohort

Aim: It is unclear whether a low-level viremia (LLV) status is maintained in HIV-infected patients. Materials & methods: HIV-infected patients with LLV were enrolled and followed up for 5 years. Factors associated with virological outcomes were assessed via regression analyses. Results: A total of 39 patients maintained an LLV status, whereas 19 had disease progression with a viral load of ≥1000 copies/ml. LLV duration and drug resistance (DR) were associated with virological failure. Among the DR cases, the most frequent mutations were M184V/I (70.4%) and K103N (40.7%). Protease inhibitor (PI) mutations were rare. Conclusion: There is an increased risk for virologic failure in HIV-1-infected patients maintaining LLV for a long time. DR was not a rare phenomenon in LLV patients.

Associations with sub-optimal clinic attendance and reasons for missed appointments among heterosexual women and men living with HIV in London

Poor engagement in HIV care is associated with poorer health outcomes and increased mortality. Our survey examined experiential and circumstantial factors associated with clinic attendance among women (n = 250) and men (n = 106) in London with heterosexually-acquired HIV. While no associations were found for women, among men, sub-optimal attendance was associated with insecure immigration status (25.6% vs. 1.8%), unstable housing (32.6% vs. 10.2%) and reported effect of HIV on daily activities (58.7% vs. 40.0%). Among women and men on ART, it was associated with missing doses of ART (OR = 2.96, 95% CI:1.74-5.02), less belief in the necessity of ART (OR = 0.56, 95% CI:0.35-0.90) and more concern about ART (OR = 3.63, 95% CI:1.45-9.09). Not wanting to think about being HIV positive was the top reason for ever missing clinic appointments. It is important to tackle stigma and the underlying social determinants of health to improve HIV prevention, and the health and well-being of people living with HIV.

Integrative literature review of evidence-based guidelines on antiretroviral therapy adherence among adult persons living with HIV

AIM

To summarize recommendations from available evidence-based guidelines that enhance, address or guide antiretroviral therapy adherence among adult persons living with human immunodeficiency virus.

DESIGN

An integrative literature review approach.

DATA SOURCE

Guidelines were accessed through Google from the databases of the Canadian Medical Association InfoBase clinical practice database, National Guidelines Clearinghouse, Writer's Guidelines database, the National Institute for Health and Clinical Excellence, UNICEF and WHO. Databases such as PubMed, Google Scholar, EBSCOhost (CINAHL, ERIC, Academic search complete, E-journals, Psych Info and MEDLINE), EMERALD INSIGHT, JSTOR, SCIENCE DIRECT and FINDPLUS were also searched, followed by a citation search. Data sources were searched between 1996 and January 2022.

REVIEW METHODS

The five steps of the integrative literature review process, as described by Whittemore and Knafl, were used. These steps are as follows: step one; problem identification, step two; literature search, step three; data evaluation; step four: data analysis and the final step was data presentation.

RESULTS

Sixteen guidelines related to antiretroviral therapy adherence were included for data extraction and synthesis. The findings revealed two themes as follows: theme 1: monitoring antiretroviral therapy adherence and theme 2: interventions to promote antiretroviral therapy adherence related to education and counselling, adherence tools, health service delivery and antiretroviral strategies.

CONCLUSION

Antiretroviral therapy adherence in adult persons requires both interventions as well as monitoring. The various contributing factors relating to antiretroviral therapy adherence should be further explored.

IMPACT

Evidence from the included guidelines can assist nurses in promoting a person's adherence to antiretroviral treatment, which could improve their health and well-being.

Unmasking legislative constraints: An institutional ethnography of linkage and engagement in HIV healthcare for African, Caribbean, and Black people in Ontario, Canada

The Human Immunodeficiency Virus (HIV) epidemic significantly impacts African, Caribbean, and Black (ACB) immigrants in Canada. Health scholarship has revealed striking injustices within Canada's public healthcare system that restrict access to healthcare and violate the human rights of ACB immigrants living with HIV who are marginalized. We conducted an institutional ethnography to comprehensively understand how HIV healthcare in Ontario is organized and experienced by ACB immigrants, focusing on unjust and discriminatory legislative frameworks and institutional practices regulating access to publicly funded healthcare resources and services. We interviewed 20 ACB immigrants and 15 healthcare workers, including specialists, primary care providers, immigration physicians, and social workers. We found a disjuncture between the organization of HIV healthcare in Ontario and how ACB immigrants experienced access to care. We uncovered how immigration, public health and healthcare laws and related institutional practices intersect to produce structural violence which create barriers and missed opportunities to timely linkage and engagement in HIV healthcare. Black immigrants' accounts revealed that they underwent mandatory HIV under the Immigration Medical Examination policy (IME) without providing informed consent and receiving pre and post-test counselling. Furthermore, Black immigrants did not receive referrals and were not adequately linked to care following HIV diagnosis. Troubling encounters with immigration and public health state agents and healthcare legislative barriers including difficulty finding a physician, the 3-month waiting period under the Ontario Health Insurance Plan (OHIP), long wait times, lack of drug coverage, and stigma, discrimination, and anti-Black racism shaped and affected Black people's linkage and engagement in HIV care. We elucidate how the legislative and structural organization of healthcare regulated and constrained health service access for ACB immigrants living with HIV, including their ability to "achieve" HIV undetectability.

CRISPR-based diagnostics

The accurate and timely diagnosis of disease is a prerequisite for efficient therapeutic intervention and epidemiological surveillance. Diagnostics based on the detection of nucleic acids are among the most sensitive and specific, yet most such assays require costly equipment and trained personnel. Recent developments in diagnostic technologies, in particular those leveraging clustered regularly interspaced short palindromic repeats (CRISPR), aim to enable accurate testing at home, at the point of care and in the field. In this Review, we provide a rundown of the rapidly expanding toolbox for CRISPR-based diagnostics, in particular the various assays, preamplification strategies and readouts, and highlight their main applications in the sensing of a wide range of molecular targets relevant to human health.

Use of Coronary Artery Calcium Scoring to Improve Cardiovascular Risk Stratification and Guide Decisions to Start Statin Therapy in People Living With HIV

BACKGROUND

Cardiovascular disease (CVD) risk assessment remains a critical step in guiding decisions to initiate primary prevention interventions in people living with HIV (PLWH).

SETTING

We investigated whether coronary artery calcium (CAC) scoring allowed a more accurate selection of patients who may benefit from statin therapy, compared with current risk assessment tools alone.

METHODS

Cross-sectional analysis of PLWH over 50 years old who underwent CAC scoring between 2009 and 2019. Framingham Risk score (FRS), QRISK2 and D:A:D scores were calculated for each participant at the time of CAC scoring and statin eligibility determined based on current European guidelines on the prevention of CVD in PLWH.

RESULTS

A total of 739 patients were included (mean age 56 ± 5, 92.8% male, 84% white). Among 417 (56.4%) candidates for statin therapy based on FRS ≥10%, 174 (23.5%) had no detectable calcification (CAC = 0). Conversely, 145 (19.6%) patients with detectable calcification (CAC > 0) were identified as low-risk (FRS < 10%). When compared with FRS, CAC scoring reclassified CVD risk in 43.1% of patients, 145 (19.6%) to a higher risk group that could benefit from statin therapy and 174 (23.5%) statin candidates to a lower risk group. QRISK2 and D:A:D scores performed similarly to FRS, underestimating the presence of significant coronary calcification in 21.1% and 24.9% respectively and overestimating risk in 16.9% and 18.8% patients with CAC = 0.

CONCLUSIONS

Establishing a decision-model based on the combination of conventional risk tools and CAC scoring improves risk assessment and the selection of PLWH who would benefit from statin therapy.

Scaling-up PrEP Delivery in Sub-Saharan Africa: What Can We Learn from the Scale-up of ART?

Purpose of Review

Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020.

Recent Findings

Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced lessons-learned relevant for scaling-up PrEP delivery, including the importance of streamlining laboratory tests, expanding prescription and management authority, differentiating medication access points, and reducing stigma and barriers of parental consent for PrEP uptake. Further research is especially needed in areas differentiating PrEP from ART delivery, including repeat HIV testing to ensure HIV negative status and defining and measuring prevention-effective adherence.

Summary

Evidence from 15 years of ART scale-up could immediately inform a public health approach to PrEP delivery.

Is Screening for Chlamydia and Gonorrhea in Men Who Have Sex With Men Associated With Reduction of the Prevalence of these Infections? A Systematic Review of Observational Studies

BACKGROUND

Neisseria gonorrhoeae (gonorrhea) could become untreatable in the near future. Indeed, while the treatment of symptomatic gonorrhea in core groups, such men who have sex with men (MSM), is crucial for gonorrhea control programs, screening for and treating asymptomatic gonorrhea/Chlamydia trachomatis(chlamydia) in MSM may contribute to antibiotic resistance in gonorrhea. In this systematic review, we aim to assess if there is evidence that screening MSM for gonorrhea/chlamydia is associated with a decline in the prevalence of these infections.

METHODS

We conducted a systematic review in PubMed and Web of Science for relevant studies including uncontrolled observational studies and reported the results following the PRISMA guidelines. The change in estimated prevalences for chlamydia and gonorrhea across the different time points for 3 anatomical sites (oral, urethral and anal) were collected and examined.

RESULTS

Twelve studies met our entry criteria. We were able to statistically assess the change in prevalence in 10 of 12 studies. In 3 studies, there was a significant increase in chlamydia prevalence, whereas for gonorrhea, 2 studies reported a significant increase and 2 others a decrease. Our review provides little evidence that screening for gonorrhea and chlamydia in MSM has an effect on the prevalence of these infections. No evidence was found that more frequent screening reduces prevalence more effectively than annual screening.

CONCLUSIONS

Our study was not able to provide evidence that screening for chlamydia and gonorrhea lowers the prevalence of these infections in MSM. Randomized controlled trials are required to assess the risks and benefits of gonorrhea/chlamydia screening in high- and low-risk MSM.

Veterans Aging Cohort Study Index as a Marker of Bone Disease in HIV-Infected Patients

People living with human immunodeficiency virus (HIV) infection have higher risk of low bone mineral density (BMD) and fragility fracture than general population. The aim of our retrospective study was to explore if HIV-specific Veterans Aging Cohort Study (VACS) Index and its specific components could help identify patients at risk for low BMD. A total of 195 HIV-infected patients with dual-energy X-ray absorptiometry (DXA) scan between 2007 and 2014 were included and DXA scan results were used to classify patients with osteopenia. VACS Index was calculated for all patients using laboratory values closest to the date of DXA scan. Logistic regression was used to assess the association between VACS Index score or individual components of VACS Index with the presence of low BMD after adjusting for confounding variables. A total of 109 (56%) patients were diagnosed with low BMD. VACS Index score was significantly associated with low BMD, with the odds of low BMD increasing 1.21 times for each 10 unit increase in VACS Index score [confidence interval (95% CI) 1.03-1.42; p = .02]. The two groups differed significantly on patient weights, proportion of white patients, and hepatitis C-coinfected patients. After adjusting for white race and weight, hepatitis C coinfection was significantly associated with increased risk of low BMD (odds ratio 24.4; 95% CI 7.45-80.16). VACS Index score, previously demonstrated to be a marker of frailty in HIV-infected patients, is significantly associated with risk of low BMD and could be used to develop a prediction tool to screen for low BMD in resource-limited setting where DXA scans are not easily available.

Emulating a trial of joint dynamic strategies: An application to monitoring and treatment of HIV-positive individuals

Decisions about when to start or switch a therapy often depend on the frequency with which individuals are monitored or tested. For example, the optimal time to switch antiretroviral therapy depends on the frequency with which HIV-positive individuals have HIV RNA measured. This paper describes an approach to use observational data for the comparison of joint monitoring and treatment strategies and applies the method to a clinically relevant question in HIV research: when can monitoring frequency be decreased and when should individuals switch from a first-line treatment regimen to a new regimen? We outline the target trial that would compare the dynamic strategies of interest and then describe how to emulate it using data from HIV-positive individuals included in the HIV-CAUSAL Collaboration and the Centers for AIDS Research Network of Integrated Clinical Systems. When, as in our example, few individuals follow the dynamic strategies of interest over long periods of follow-up, we describe how to leverage an additional assumption: no direct effect of monitoring on the outcome of interest. We compare our results with and without the "no direct effect" assumption. We found little differences on survival and AIDS-free survival between strategies where monitoring frequency was decreased at a CD4 threshold of 350 cells/μl compared with 500 cells/μl and where treatment was switched at an HIV-RNA threshold of 1000 copies/ml compared with 200 copies/ml. The "no direct effect" assumption resulted in efficiency improvements for the risk difference estimates ranging from an 7- to 53-fold increase in the effective sample size.

A continuum of HIV care describing mortality and loss to follow-up: a longitudinal cohort study

Background

The cross-sectional HIV care continuum is widely used to assess the success of HIV care programmes among populations of people with HIV and the potential for ongoing transmission. We aimed to investigate whether a longitudinal continuum, which incorporates loss to follow-up and mortality, might provide further insights about the performance of care programmes.

Methods

In this longitudinal cohort study, we included individuals who entered the UK Collaborative HIV Cohort (CHIC) study between Jan 1, 2000, and Dec 31, 2004, and were linked to the national HIV cohort database (HIV and AIDS Reporting System). For each month during a 10 year follow up period, we classified individuals into one of ten distinct categories according to engagement in care, antiretroviral therapy (ART) use, viral suppression, loss to cohort follow-up and loss to care, and mortality, and assessed the proportion of person-months of follow-up spent in each stage of the continuum. 5 year longitudinal continuums were also constructed for three separate cohorts (baseline years of entry 2000–03, 2004–07, and 2008–09) to compare changes over time.

Findings

We included 12 811 people contributing 1 537 320 person-months in our analysis. During 10 years of follow-up, individuals spent 811 057 (52·8%) of 1 537 320 person-months on ART. Of the 811 057 person-months spent on ART, individuals had a viral load of 200 copies per mL or less for 607 185 (74·9%) person-months. 10 years after cohort entry, 3612 (28·1%) of 12 811 individuals were lost to follow-up, 954 (26·4%) of whom had transferred to a non-CHIC UK clinic for care. By 10 years, 759 (5·9%) of 12 811 participants who entered the cohort had died. Loss to follow-up decreased and the proportion of person-months that individuals spent virally suppressed increased over calendar time.

Interpretation

Loss to follow-up in HIV care programmes was high and rates of viral suppression were lower than previously reported. Complementary information provided by a longitudinal continuum might highlight areas for intervention along the HIV care pathway, however, transfers outside the cohort must be accounted for.

Funding

Medical Research Council, UK.

HIV virologic failure and its predictors among HIV-infected adults on antiretroviral therapy in the African Cohort Study

INTRODUCTION

The 2016 WHO consolidated guidelines on the use of antiretroviral drugs defines HIV virologic failure for low and middle income countries (LMIC) as plasma HIV-RNA ≥ 1000 copies/mL. We evaluated virologic failure and predictors in four African countries.

MATERIALS AND METHODS

We included HIV-infected participants on a WHO recommended antiretroviral therapy (ART) regimen and enrolled in the African Cohort Study between January 2013 and October 2017. Studied outcomes were virologic failure (plasma HIV-RNA ≥ 1000 copies/mL at the most recent visit), viraemia (plasma HIV-RNA ≥ 50 copies/mL at the most recent visit); and persistent viraemia (plasma HIV-RNA ≥ 50 copies/mL at two consecutive visits). Generalized linear models were used to estimate relative risks with their 95% confidence intervals.

RESULTS

2054 participants were included in this analysis. Viraemia, persistent viraemia and virologic failure were observed in 396 (19.3%), 160 (7.8%) and 184 (9%) participants respectively. Of the participants with persistent viraemia, only 57.5% (92/160) had confirmed virologic failure. In the multivariate analysis, attending clinical care site other than the Uganda sitebeing on 2nd line ART (aRR 1.8, 95% CI 1·28-2·66); other ART combinations not first line and not second line (aRR 3.8, 95% CI 1.18-11.9), a history of fever in the past week (aRR 3.7, 95% CI 1.69-8.05), low CD4 count (aRR 6.9, 95% CI 4.7-10.2) and missing any day of ART (aRR 1·8, 95% CI 1·27-2.57) increased the risk of virologic failure. Being on 2nd line therapy, the site where one receives care and CD4 count < 500 predicted viraemia, persistent viraemia and virologic failure.

CONCLUSION

In conclusion, these findings demonstrate that HIV-infected patients established on ART for more than six months in the African setting frequently experienced viraemia while continuing to be on ART. The findings also show that being on second line, low CD4 count, missing any day of ART and history of fever in the past week remain important predictors of virologic failure that should trigger intensified adherence counselling especially in the absence of reliable or readily available viral load monitoring. Finally, clinical care sites are different calling for further analyses to elucidate on the unique features of these sites.

Prevalence of HIV-1 transmitted drug resistance and viral suppression among recently diagnosed adults in São Paulo, Brazil

HIV-1 transmitted drug resistance (TDR) mutations may reduce the efficacy of antiretroviral therapy (ART), but pre-treatment testing to determine the virus genotype can improve the efficacy of ART. Unfortunately, issues related to cost and logistics of pre-treatment testing limit its use in resource-limited settings. We studied 596 ART-naive individuals who were newly diagnosed from 2014 to 2016 in São Paulo, Brazil, to evaluate TDR and virological outcome after 48 weeks of genotype-guided therapy. One or more TDR (based on the WHO surveillance list) was observed in 10.9% (CI 95%, 8.6-13.6) of the sequences, the most common of which was the K103 N mutation, which confers resistance to first-generation drugs of the non-nucleoside reverse transcriptase inhibitor (NNRTI) antiretroviral drug class. Dual-class (1%, 6/596) and triple-class (0.34%, 2/596) resistance were uncommon. After 48 weeks of treatment with ART, infection was suppressed to below 200 copies/mL in most patients (95%), with full suppression (RNA target not detected) in 65%. The following characteristics at patient enrollment were independently associated with a lack of full suppression: CD4 T cell counts below 500 cells/µL, viremia above 100,000 copies/mL, older age, and TDR to NNRTI. The rates of resistance were intermediate, but genotype-guided therapy resulted in high rates of viral suppression. The observed resistance profile should not be an obstacle to the use of the dolutegravir-based regimen now recommended in Brazil, but genotype testing may be warranted before initiating first-generation NNRTI-based regimens.

Development of an mHealth platform for HIV Care: Gathering User Perspectives Through Co-Design Workshops and Interviews

Background

Despite advances in testing and treatment, HIV incidence rates within European countries are at best stable or else increasing. mHealth technology has been advocated to increase quality and cost-effectiveness of health services while dealing with growing patient numbers. However, studies suggested that mHealth apps are rarely adopted and often considered to be of low quality by users. Only a few studies (conducted in the United States) have involved people living with HIV (PLWH) in the design of mHealth.

Objective

The goal of this study was to facilitate a co-design process among PLWH and clinicians across 5 clinical sites in the European Union to inform the development of an mHealth platform to be integrated into clinical care pathways. We aimed to (1) elicit experiences of living with HIV and of working in HIV care, (2) identify mHealth functionalities that are considered useful for HIV care, and (3) identify potential benefits as well as concerns about mHealth.

Methods

Between January and June 2016, 14 co-design workshops and 22 semistructured interviews were conducted, involving 97 PLWH and 63 clinicians. Data were analyzed thematically and iteratively, drawing on grounded theory techniques.

Results

Findings were established into 3 thematic clusters: (1) approaching the mHealth platform, (2) imagining the mHealth platform, and (3) anticipating the mHealth platform’s implications. Co-design participants approached the mHealth platform with pre-existing concerns arising from their experiences of receiving or providing care. PLWH particularly addressed issues of stigma and questioned how mHealth could enable them to manage their HIV. Clinicians problematized the compatibility of mHealth with existing information technology systems and questioned which patients should be targeted by mHealth. Imagining the potential of mHealth for HIV care, co-design participants suggested medical functionalities (accessing test results, managing medicines and appointments, and digital communication channels), social functionalities (peer support network, international travel, etc), and general features (security and privacy, credibility, language, etc). Co-design participants also anticipated potential implications of mHealth for self-management and the provision of care.

Conclusions

Our approach to co-design enabled us to facilitate early engagement in the mHealth platform, enabling patient and clinician feedback to become embedded in the development process at a preprototype phase. Although the technologies in question were not yet present, understanding how users approach, imagine, and anticipate technology formed an important source of knowledge and proved highly significant within the technology design and development process.

Chronic Kidney Disease in Persons Living with HIV: A Systematic Review

The purpose of our systematic review of research on chronic kidney disease (CKD) in persons living with HIV (PLWH) was to (a) compare and contrast diagnostic criteria for CKD, (b) identify risk factors of CKD in PLWH, and (c) elucidate the prevalence of CKD in PLWH. Keyword searches of PubMed and PsycInfo databases were followed by manual searches of references from 2000 through 2016; 21 studies met inclusion criteria. Sample sizes ranged from 8 to 15,140, with a mean age of 50 years, and represented diverse ethnicities/races and countries of origin. Fourteen studies were cross-sectional, six were cohort studies, and one was a case study. Major risk factors were related to hypertension, diabetes, and age. Prevalence ranged from 2.3% to 53.3% across a variety of countries and patient populations. The wide range in prevalence may have been due to differences in risk factors for the sample populations.

Differentiated Human Immunodeficiency Virus RNA Monitoring in Resource-Limited Settings: An Economic Analysis

Background.

Viral load (VL) monitoring for patients receiving antiretroviral therapy (ART) is recommended worldwide. However, the costs of frequent monitoring are a barrier to implementation in resource-limited settings. The extent to which personalized monitoring frequencies may be cost-effective is unknown.

Methods.

We created a simulation model parameterized using person-level longitudinal data to assess the benefits of flexible monitoring frequencies. Our data-driven model tracked human immunodeficiency virus (HIV)–infected individuals for 10 years following ART initiation. We optimized the interval between viral load tests as a function of patients’ age, gender, education, duration since ART initiation, adherence behavior, and the cost-effectiveness threshold. We compared the cost-effectiveness of the personalized monitoring strategies to fixed monitoring intervals every 1, 3, 6, 12, and 24 months.

Results.

Shorter fixed VL monitoring intervals yielded increasing benefits (6.034 to 6.221 discounted quality-adjusted life-years [QALYs] per patient with monitoring every 24 to 1 month over 10 years, respectively, standard error = 0.005 QALY), at increasing average costs: US$3445 (annual monitoring) to US$5393 (monthly monitoring) per patient, respectively (standard error = US$3.7). The adaptive policy optimized for low-income contexts achieved 6.142 average QALYs at a cost of US$3524, similar to the fixed 12-month policy (6.135 QALYs, US$3518). The adaptive policy optimized for middle-income resource settings yields 0.008 fewer QALYs per person, but saves US$204 compared to monitoring every 3 months.

Conclusions.

The benefits from implementing adaptive vs fixed VL monitoring policies increase with the availability of resources. In low- and middle-income countries, adaptive policies achieve similar outcomes to simpler, fixed-interval policies.

Therapeutic drug monitoring in treatment-experienced HIV-infected patients receiving darunavir-based salvage regimens: A case series

Therapeutic drug monitoring (TDM) constitutes a compelling approach for the optimization of antiretroviral therapy in treatment-experienced HIV-1 patients. While various inhibitory indices have been proposed to predict virologic outcome, there is a lack of consensus on the clinical value of TDM. Here, we report the comparative results of TDM in 14 HIV-1-infected patients who had previously received at least two different PI-based regimens and who initiated darunavir (DRV)-based salvage therapy. Pharmacokinetic/pharmacodynamics (PK/PD) parameters were calculated for each subject. Seventy-nine percent of subjects had a viral load <50 copies/mL at 48 weeks. The only subject with two consecutive viral loads >50 copies/mL at the end of the study period was the patient with the lowest instantaneous inhibitory potential (IIP). The sample size was insufficient to show an association between any of the PK/PD parameters and virologic response. Based on our observations, we suggest that the utility of IIP for antiretroviral combinations for the prediction of virologic outcome in HIV-1 drug-experienced patients should be studied further.

Current levels of gonorrhoea screening in MSM in Belgium may have little effect on prevalence: a modelling study

There is considerable uncertainty as to the effectiveness of Neisseria gonorrhoeae (NG) screening in men who have sex with men. It is important to ensure that screening has benefits that outweigh the risks of increased antibiotics resistance. We develop a mathematical model to estimate the effectiveness of screening on prevalence. Separable Temporal Exponential family Random Graph Models are used to model the sexual relationships network, both with main and casual partners. Next, the transmission of Gonorrhoea is simulated on this network. The models are implemented using the R package 'statnet', which we adapted among other things to incorporate infection status at the pharynx, urethra and rectum separately and to distinguish between anal sex, oral sex and rimming. The different screening programmes compared are no screening, 3.5% of the population screened, 32% screened and 50% screened. The model simulates day-by-day evolution for 10 years of a population of 10 000. If half of the population would be screened, the prevalence in the pharynx decreases from 11.9% to 10.2%. We conclude that the limited impact of screening on NG prevalence may not outweigh the increased risk of antibiotic resistance.

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

This guideline is intended for use in UK Genitourinary medicine clinics and sexual health services but is likely to be of relevance in all sexual health settings, including general practice and Contraception and Sexual Health (CASH) services, where men who have sex with men (MSM) seek sexual health care or where addressing the sexual health needs of MSM may have public health benefits. For the purposes of this document, MSM includes all gay, bisexual and all other males who have sex with other males and both cis and trans men. This document does not provide guidance on the treatment of particular conditions where this is covered in other British Association for Sexual Health and HIV (BASHH) Guidelines but outlines best practice in multiple aspects of the sexual health care of MSM. Where prevention of sexually transmitted infections including HIV can be addressed as an integral part of clinical care, this is consistent with the concept of combination prevention and is included. The document is designed primarily to provide guidance on the direct clinical care of MSM but also makes reference to the design and delivery of services with the aim of supporting clinicians and commissioners in providing effective services. Methodology This document was produced in accordance with the guidance set out in the BASHH CEG's document 'Framework for guideline development and assessment' published in 2010 at http://www.bashh.org/guidelines and with reference to the Agree II instrument. Following the production of the updated framework in April 2015, the GRADE system for assessing evidence was adopted and the draft recommendations were regraded. Search strategy (see also Appendix 1) Ovid Medline 1946 to December 2014, Medline daily update, Embase 1974 to December 2014, Pubmed NeLH Guidelines Database, Cochrane library from 2000 to December 2014. Search language English only. The search for Section 3 was conducted on PubMed to December 2014. Priority was given to peer-reviewed papers published in scientific journals, although for many issues evidence includes conference abstracts listed on the Embase database. In addition, for 'Identification of problematic recreational drug and alcohol use' section and 'Sexual problems and dysfunctions in MSM' section, searches included PsycINFO. Methods Article titles and abstracts were reviewed and if relevant the full text article was obtained. Priority was given to randomised controlled trial and systematic review evidence, and recommendations made and graded on the basis of best available evidence. Piloting and feedback The first draft of the guideline was circulated to the writing group and to a small group of relevant experts, third sector partners and patient representatives who were invited to comment on the whole document and specifically on particular sections. The revised draft was reviewed by the CEG and then reviewed by the BASHH patient/public panel and posted on the BASHH website for public consultation. The final draft was piloted before publication. Guideline update The guidelines will be reviewed and revised in five years' time, 2022.

Management of precancerous anal intraepithelial lesions in human immunodeficiency virus-positive men who have sex with men: Clinical effectiveness and cost-effectiveness

BACKGROUND

Human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) are at disproportionately high risk for anal cancer. There is no definitive approach to the management of high-grade squamous intraepithelial lesions (HSIL), which are precursors of anal cancer, and evidence suggests that posttreatment adjuvant quadrivalent human papillomavirus (qHPV) vaccination improves HSIL treatment effectiveness. The objectives of this study were to evaluate the optimal HSIL management strategy with respect to clinical effectiveness and cost-effectiveness and to identify the optimal age for initiating HSIL management.

METHODS

A decision analytic model of the natural history of anal carcinoma and HSIL management strategies was constructed for HIV-positive MSM who were 27 years old or older. The model was informed by the Surveillance, Epidemiology, and End Results-Medicare database and published studies. Outcomes included the lifetime cost, life expectancy, quality-adjusted life expectancy, cumulative risk of cancer and cancer-related deaths, and cost-effectiveness from a societal perspective.

RESULTS

Active monitoring was the most effective approach in patients 29 years or younger; thereafter, HSIL treatment plus adjuvant qHPV vaccination became most effective. When cost-effectiveness was considered (ie, an incremental cost-effectiveness ratio [ICER] < $100,000/quality-adjusted life-year), do nothing was cost-effective until the age of 38 years, and HSIL treatment plus adjuvant qHPV vaccination was cost-effective beyond the age of 38 years (95% confidence interval, 34-43 years). The ICER decreased as the age at HSIL management increased. Outcomes were sensitive to the rate of HSIL regression or progression and the cost of high-resolution anoscopy and biopsy.

CONCLUSIONS

The management of HSIL in HIV-positive MSM who are 38 years old or older with treatment plus adjuvant qHPV vaccination is likely to be cost-effective. The conservative approach of no treatment is likely to be cost-effective in younger patients. Cancer 2017;123:4709-4719. © 2017 American Cancer Society.

Routine monitoring and assessment of adults living with HIV: results of the British HIV Association (BHIVA) national audit 2015

Background

The clinical care of people living with HIV changed fundamentally as a result of the development of effective antiretroviral therapy (ART). HIV infection is now a long-term treatable condition. We report a national audit to assess adherence to British HIV Association guidelines for the routine investigation and monitoring of adult HIV-1-infected individuals.

Methods

All UK sites known as providers of adult HIV outpatient services were invited to complete a case-note review and a brief survey of local clinic practices. Participating sites were asked to randomly select 50–100 adults, who attended for specialist HIV care during 2014 and/or 2015. Each site collected data electronically using a self-audit spreadsheet tool. This included demographic details (gender, ethnicity, HIV exposure, and age) and whether 22 standardised and pre-defined clinical audited outcomes had been recorded.

Results

Data were collected on 8258 adults from 123 sites, representing approximately 10% of people living with HIV reported in public health surveillance as attending UK HIV services. Sexual health screening was provided within 96.4% of HIV services, cervical cytology and influenza vaccination within 71.4% of HIV services. There was wide variation in resistance testing across sites. Only 44.9% of patients on ART had a documented 10-year CVD risk within the past three years and fracture risk had been assessed within the past three years for only 16.7% patients aged over 50 years.

Conclusions

There was high participation in the national audit and good practice was identified in some areas. However improvements can be made in monitoring of cardiovascular risk, bone and sexual health.

Benchmarked performance charts using principal components analysis to improve the effectiveness of feedback for audit data in HIV care

BACKGROUND

Feedback tools for clinical audit data that compare site-specific results to average performance over all sites can be useful for quality improvement. Proposed tools should be simple and clearly benchmark the site's performance, so that a relevant action plan can be directly implemented to improve patient care services. We aimed to develop such a tool in order to feedback data to UK HIV clinics participating in the 2015 British HIV Association (BHIVA) audit assessing compliance with the 2011 guidelines for routine investigation and monitoring of adult HIV-1- infected individuals.

METHODS

HIV clinic sites were asked to provide data on a random sample of 50-100 adult patients attending for HIV care during 2014 and/or 2015 by completing a self-audit spreadsheet. Outcomes audited included the proportion of patients with recorded resistance testing, viral load monitoring, adherence assessment, medications, hepatitis testing, vaccination management, risk assessments, and sexual health screening. For each outcome we benchmarked the proportion for a specific site against the average performance. We produced performance charts for each site using boxplots for the outcomes. We also used the mean and differences from the mean performance to produce a dashboard for each site. We used principal components analysis to group correlated outcomes and simplify the dashboard.

RESULTS

The 106 sites included in the study provided information on a total of 7768 patients. Outcomes capturing monitoring of treatment of HIV-infection showed high performance across the sites, whereas testing for hepatitis, and risk assessment for cardiovascular disease and smoking, management of flu vaccination, sexual health screening, and cervical cytology for women were very variable across sites. The principal components analysis reduced the original 12 outcomes to four factors that represented HIV care, hepatitis testing, other screening tests, and resistance testing. These provided simplified measures of adherence to guidelines which were presented as a 4 bar dashboard of performance.

CONCLUSION

Our dashboard performance charts provide easily digestible visual summaries of locally relevant audit data that are benchmarked against the overall mean and can be used to improve feedback to HIV services. Feedback from clinicians indicated that they found these charts acceptable and useful.

Yield of yearly routine physical examination in HIV-1 infected patients is limited: A retrospective cohort study in the Netherlands

Background

Routine physical examinations might be of value in HIV-infected patients, but the yield is unknown. We determined the diagnoses that would have been missed without performing annual routine physical examinations in HIV-infected patients with stable disease.

Methods

Data were collected from the medical records of 299 HIV-1-infected patients with CD4 count >350 cells/mm³ if not using combination antiretroviral therapy (cART), or CD4 count >100 cells/mm3 and undetectable viral load if using cART. We defined the diagnoses that would have been missed without performing routine physical examinations on annual check-ups in 2010. Exclusion criteria were hepatitis B/C co-infection, start/ switch of cART < 24 weeks, pregnancy, and transgenderism.

Results

215 patients (72%) had positive findings: lipodystrophy (30%), lymphadenopathy (16%) and hypertension (8.4%) were the most common. Two-thirds of all findings were not new or were based on complaints indicating a physical examination even if not routinely scheduled. For 24 patients (8.0%) the routine physical examination led to the finding of a new diagnosis: six—all men who have sex with men (MSM)—had a concurrent sexually transmitted infection, eight had hypertension, and ten others had a large variety of diagnoses. A total atrioventricular block with bradycardia was the most clinically relevant finding.

Conclusions

Annual physical examinations of HIV-infected patients with stable disease brought few new diagnoses that would have been missed without performing a routine examination. Our results suggest that standard assessments could be restricted to six-monthly measuring blood pressure in all patients and annually performing anogenital and digital rectal examination on MSM.

Comparison of dynamic monitoring strategies based on CD4 cell counts in virally suppressed, HIV-positive individuals on combination antiretroviral therapy in high-income countries: a prospective, observational study

BACKGROUND

Clinical guidelines vary with respect to the optimal monitoring frequency of HIV-positive individuals. We compared dynamic monitoring strategies based on time-varying CD4 cell counts in virologically suppressed HIV-positive individuals.

METHODS

In this observational study, we used data from prospective studies of HIV-positive individuals in Europe (France, Greece, the Netherlands, Spain, Switzerland, and the UK) and North and South America (Brazil, Canada, and the USA) in The HIV-CAUSAL Collaboration and The Centers for AIDS Research Network of Integrated Clinical Systems. We compared three monitoring strategies that differ in the threshold used to measure CD4 cell count and HIV RNA viral load every 3-6 months (when below the threshold) or every 9-12 months (when above the threshold). The strategies were defined by the threshold CD4 counts of 200 cells per μL, 350 cells per μL, and 500 cells per μL. Using inverse probability weighting to adjust for baseline and time-varying confounders, we estimated hazard ratios (HRs) of death and of AIDS-defining illness or death, risk ratios of virological failure, and mean differences in CD4 cell count.

FINDINGS

47 635 individuals initiated an antiretroviral therapy regimen between Jan 1, 2000, and Jan 9, 2015, and met the eligibility criteria for inclusion in our study. During follow-up, CD4 cell count was measured on average every 4·0 months and viral load every 3·8 months. 464 individuals died (107 in threshold 200 strategy, 157 in threshold 350, and 200 in threshold 500) and 1091 had AIDS-defining illnesses or died (267 in threshold 200 strategy, 365 in threshold 350, and 459 in threshold 500). Compared with threshold 500, the mortality HR was 1·05 (95% CI 0·86-1·29) for threshold 200 and 1·02 (0·91·1·14) for threshold 350. Corresponding estimates for death or AIDS-defining illness were 1·08 (0·95-1·22) for threshold 200 and 1·03 (0·96-1·12) for threshold 350. Compared with threshold 500, the 24 month risk ratios of virological failure (viral load more than 200 copies per mL) were 2·01 (1·17-3·43) for threshold 200 and 1·24 (0·89-1·73) for threshold 350, and 24 month mean CD4 cell count differences were 0·4 (-25·5 to 26·3) cells per μL for threshold 200 and -3·5 (-16·0 to 8·9) cells per μL for threshold 350.

INTERPRETATION

Decreasing monitoring to annually when CD4 count is higher than 200 cells per μL compared with higher than 500 cells per μL does not worsen the short-term clinical and immunological outcomes of virally suppressed HIV-positive individuals. However, more frequent virological monitoring might be necessary to reduce the risk of virological failure. Further follow-up studies are needed to establish the long-term safety of these strategies.

FUNDING

National Institutes of Health.

Hepatitis B serological markers and plasma DNA concentrations

OBJECTIVES

To examine hepatitis B (HBV) serological markers and plasma DNA concentrations in a large group of untreated HBV/HIV-coinfected individuals in two sub-Saharan settings.

DESIGN

Baseline analysis of a randomized controlled trial.

METHODS

DART was a large trial of treatment monitoring practices in HIV-infected adults with advanced disease starting antiretroviral therapy at centres in Kampala or Entebbe, Uganda (n = 2317) and Harare, Zimbabwe (n = 999). HBV serological markers [antibody to HBV core antigen, HBV surface antigen (HBsAg), antibody to HBV surface antigen, HBV 'e' antigen (HBeAg), and antibody to hepatitis B 'e' antigen] and plasma HBV DNA viral load were measured retrospectively on stored baseline samples. Logistic regression was used to examine associations with baseline demographic and clinical factors.

RESULTS

The rate of HBsAg positivity was significantly higher in Zimbabwe than Uganda (12.2 vs. 7.7%, adjusted odds ratio = 1.54, P < 0.001) despite a similar prevalence of antibody to HBV core antigen (56.3 vs. 52.4%) in the two settings. Overall, HBsAg positivity was associated with male sex (adjusted odds ratio = 1.54, P < 0.001) but not with age, WHO disease stage, or CD4 cell count. HBeAg was detected among 37% of HBsAg-positive patients, with higher rates among those with advanced WHO stage (P = 0.02). Also in HBsAg-positive patients, HBV DNA was undetectable in 21%, detectable but below the level of quantification in 14%, and quantifiable in 65%. A total of 96% of HBeAg-positive and 70% of HBeAg-negative patients had detectable HBV DNA; 92 and 28% of patients, respectively, had HBV DNA viral load more than 2000 IU/ml.

CONCLUSION

High rates of HBV coinfection were observed, highlighting the importance of ensuring that coinfected patients receive an antiretroviral regimen, whether first-line or not, that is active against both viruses.

Development and application of a new measure of engagement in out-patient HIV care

OBJECTIVES

Commonly used measures of engagement in HIV care do not take into account that the frequency of attendance is related to changes in treatment and health status. This study developed a new measure of engagement in care (EIC) incorporating clinical factors.

METHODS

We conducted semi-structured interviews with eight HIV physicians to identify factors associated with the timing of patients' next scheduled appointments. These factors informed the development of an algorithm to classify each month of follow-up as "in care" (on or before the time of the next expected attendance) or "out of care" (after the time of the next expected attendance). The EIC algorithm was applied to data from the UK Collaborative HIV Cohort (UK CHIC) study, a large clinical cohort study.

RESULTS

The interviews indicated that time to next appointment varied depending on psychosocial and physical comorbidities, and clinical factors (time since diagnosis, AIDS diagnosis, treatment status, CD4 count and viral load). The resulting EIC algorithm was applied to 44 432 patients; 83.9% of the 3 021 224 person-months were "in care". Greater EIC was independently associated with older age, white ethnicity, HIV acquisition through sex between men, current use of antiretroviral therapy (ART), a higher nadir CD4 count, later calendar year and being seen at the clinic for the first time within the last year.

CONCLUSIONS

This algorithm describing engagement in HIV care incorporates a time-updated measure of patients' treatment and health status. It adds to the options available for measuring this key performance indicator.

Simple screening for neurocognitive impairment in routine HIV outpatient care: is it deliverable?

Routine screening for psychological and cognitive difficulties is recommended in BHIVA guidelines but screening questions are not specified and studies give varied recommendations. Our aim was to see if simple screening in the routine clinic could help better direct our referrals to psychology and highlight those patients requiring, and likely to benefit from, further assessment. We introduced brief questions to assess neurocognitive impairment (NCI) and mood into routine HIV visits, with an onward referral pathway for further investigation for those screening positive. Routine attendees to HIV outpatient care over 12 weeks completed brief screening for depression (PHQ-2) and anxiety (GAD-2) and answered three short questions to screen for possible neurocognitive impairment (NCI-3Q). Patients screening positive underwent further screening via our psychologists and/or referral for neuropsychometric testing. Patient demographics, HIV markers and treatment history were recorded. 97 HIV outpatients were screened; 44 (45%) initially screened positive for NCI and/or mood. 29/44 (66%) were referred for further screening and/or psychological assessment and 21/29 (72%) of those engaged. The Montreal Cognitive Assessment (MoCA) and International HIV Dementia Scale (IHDS) were conducted on seven patients; four of these received full neuropsychometric testing. A detectable viral load was associated with positive neurocognitive screening. Rates of NCI and mood disorder among those who were tested were consistent with previous studies. The PHQ-2 and GAD-2 did detect mood problems; however, our results suggest the NCI-3Q questions alone are not good at detecting those with possible NCI. Screening for NCI remains practically difficult in the routine outpatient setting and this pilot supports the need for clearer guidelines on detecting HIV related NCI.

Association between engagement in-care and mortality in HIV-positive persons

Objective:

To assess associations between engagement in-care and future mortality.

Design:

UK-based observational cohort study.

Methods:

HIV-positive participants with more than one visit after 1 January 2000 were identified. Each person-month was classified as being in or out-of-care based on the dates of the expected and observed next care visits. Cox models investigated associations between mortality and the cumulative proportion of months spent in-care (% IC, lagged by 1 year), and cumulative %IC prior to antiretroviral therapy (ART) in those attending clinic for more than 1 year, with adjustment for age, CD4⁺/viral load, year, sex, infection mode, ethnicity, and receipt/type of ART.

Results:

The 44 432 individuals (27.8% women; 50.5% homosexual, 28.9% black African; median age 36 years) were followed for a median of 5.5 years, over which time 2279 (5.1%) people died. Higher %IC was associated with lower mortality both before [relative hazard 0.91 (95% confidence interval 0.88–0.95)/10% higher, P = 0.0001] and after [0.90 (0.87–0.93), P = 0.0001] adjustment. Adjustment for future CD4⁺ changes revealed that the association was explained by poorer CD4⁺ cell counts in those with lower %IC. In total 8730 participants under follow-up for more than 1 year initiated ART of whom 237 (2.7%) died. Higher values of %IC prior to ART initiation were associated with a reduced risk of mortality before [0.29 (0.17–0.47)/10%, P = 0.0001] and after [0.36 (0.21–0.61)/10%, P = 0.0002] adjustment; the association was again explained by poorer post-ART CD4⁺/ viral load in those with lower pre-ART %IC.

Conclusions:

Higher levels of engagement in-care are associated with reduced mortality at all stages of infection, including in those who initiate ART.

Recent trends and patterns in HIV-1 transmitted drug resistance in the United Kingdom

OBJECTIVES

Transmission of drug-resistant HIV-1 has decreased in the UK since the early 2000s. This analysis reports recent trends and characteristics of transmitted drug resistance (TDR) in the UK from 2010 to 2013.

METHODS

Resistance tests conducted in antiretroviral treatment (ART)-naïve individuals between 2010 and 2013 were analysed for the presence of transmitted drug resistance mutations (TDRMs), defined as any mutations from a modified 2009 World Health Organization surveillance list, or a modified 2013 International Antiviral Society-USA list for integrase tests. Logistic regression was used to examine associations between demographics and the prevalence of TDRMs.

RESULTS

TDRMs were observed in 1223 (7.5%) of 16 425 individuals; prevalence declined from 8.1% in 2010 to 6.6% in 2013 (P = 0.02). The prevalence of TDRMs was higher among men who have sex with men (MSM) compared with heterosexual men and women (8.7% versus 6.4%, respectively) with a trend for decreasing TDRMs among MSM (P = 0.008) driven by a reduction in nucleoside reverse transcriptase inhibitor (NRTI)-related mutations. The most frequently detected TDRMs were K103N (2.2%), T215 revertants (1.6%), M41L (0.9%) and L90M (0.7%). Predicted phenotypic resistance to first-line ART was highest to the nonnucleoside reverse transcriptase inhibitors (NNRTIs) rilpivirine and efavirenz (6.2% and 3.4%, respectively) but minimal to NRTIs, including tenofovir, and protease inhibitors (PIs). No major integrase TDRMs were detected among 101 individuals tested while ART-naïve.

CONCLUSIONS

We observed a decrease in TDRMs in recent years. However, this was confined to the MSM population and rates remained stable in those with heterosexually acquired HIV infection. Resistance to currently recommended first-line ART, including integrase inhibitors, remained reassuringly low.

REACH: a mixed-methods study to investigate the measurement, prediction and improvement of retention and engagement in outpatient HIV care

Background

Antiretroviral therapy (ART) benefits individuals living with human immunodeficiency virus (HIV) through reduced morbidity and mortality, and brings public health gains through a reduction in HIV transmission. People living with human immunodeficiency virus (PLWH) need to know their HIV status and engage in HIV care in order for these individual and public health benefits to be realised.

Objective

To explore, describe and understand HIV outpatient attendance in PLWH, in order to develop cost-effective interventions to optimise engagement in care.

Design

A mixed-methods study incorporating secondary analysis of data from the UK Collaborative HIV Cohort (UK CHIC) study and primary data collection.

Methods

Phase 1 – an engagement-in-care (EIC) algorithm was developed to categorise patients as in care or out of care for each month of follow-up. The algorithm was used in group-based trajectory analysis to examine patterns of attendance over time and of the association between the proportion of months in care before ART initiation and post-ART mortality and laboratory test costs. Phase 2 – a cross-sectional survey was conducted among patients attending seven London HIV clinics. Regular attenders (all appointments attended in past year), irregular attenders (one or more appointments missed in past year) and non-attenders (recent absence of ≥ 1 year) were recruited. A ‘retention risk tool’ was developed to identify those at risk of disengaging from care. Individual in-depth interviews and focus groups were conducted with PLWH. Phase 3 – key informant interviews were conducted with HIV service providers. Interventions were developed from the findings of phases 2 and 3.

Results

Plots from group-based trajectory analysis indicated that four trajectories best fitted the data. Higher EIC is associated with reduced mortality but the association between EIC before starting ART, and post-ART mortality [relative hazard (RH) per 10% increase in EIC 0.29, 95% confidence interval (CI) 0.18 to 0.47] was attenuated after adjustment for fixed covariates and post-ART cluster of differentiation 4 counts and viral loads (RH 0.74, 95% CI 0.42 to 1.30). Small differences were found in pre-ART EIC and the costs of post-ART lab tests. The final model for the retention risk tool included age at diagnosis, having children, recreational drug use, drug/alcohol dependency, insufficient money for basic needs and use of public transport to get to the clinic. Quantitative and qualitative data showed that a range of psychological, social and economic issues were associated with disengagement from care. The negative impact of stigma on attendance was highlighted. Interventions were proposed that support a holistic approach to care including peer support, address stigma by holding clinics in alternative locations and involve training staff to encourage attendance.

Conclusions

The study shows the adverse health impacts of disengaging from HIV care and demonstrates the importance of the wider health and social context in managing HIV effectively. Although phase 1 analysis was based on UK data, phases 2 and 3 were limited to London. The interventions proposed are supported by the data but their cost-effectiveness requires testing. Future research is needed to evaluate the interventions, to validate our retention risk tool across populations and settings, and to fully analyse the economic costs of disengaging from HIV care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme. The UK CHIC study is funded by the Medical Research Council UK (grant numbers G0000199, G0600337, G0900274 and M004236).

Hypogonadism in the HIV-Infected Man

Low testosterone levels are frequently observed among men with treated and untreated HIV infection. However, the interpretations of biochemical measurements of testicular function are challenging and need to be considered in the context of the clinical presentation and scenario. The distinction between primary and secondary hypogonadism and determination of the underlying clinical pathophysiology are not always straightforward. Early recognition of clinical hypogonadism and appropriate treatment may improve clinical outcomes and quality of life for affected individuals. A principal aim of testosterone replacement is to maintain serum testosterone concentrations in the normal physiological range and should be considered in clinically symptomatic patients.

Recreational drug use and chemsex among HIV-infected in-patients: a unique screening opportunity

OBJECTIVES

While a high rate of recreational drug use (RDU) has been documented among HIV-infected out-patients, particularly in men who have sex with men (MSM), there is a distinct lack of data for HIV-infected in-patients. Hospital admission offers a unique opportunity to engage drug users. We aimed to establish and characterize RDU among new admissions to a large dedicated London HIV in-patient unit and compare it to RDU among general medical admissions to inform clinical pathways.

METHODS

A prospective opt-out survey was administered to all new HIV-positive admissions over a 10-week period (cases) and all medical Acute Assessment Unit admissions over two 24-h periods (controls). All provided consent for urine toxicology upon admission.

RESULTS

Data were collected in 59 of 65 (91%) newly admitted HIV-positive individuals and in 48 of 54 (89%) non-HIV-positive medical admissions. HIV-infected in-patients were more likely than non-HIV-positive medical admissions to be male (P < 0.0001) (71% MSM), to be younger (P < 0.0001), to report current RDU (41 vs. 10%, respectively; P = 0.0001), to have a positive urine toxicology screen (19 vs. 2%, respectively; P = 0.0091) and to be a drug-related admission (15% vs. none; P = 0.004). Thirteen of 26 HIV-infected current recreational drug users admitted to sexualized drug taking and nine to injecting drugs. Twenty-seven per cent (seven of 26) were known to drug services. Crystal methamphetamine, mephedrone, gamma butyrolactone/gamma hydroxybutyrate and ketamine were exclusively taken by MSM. In total, 13 of 59 HIV-infected in-patients had current or past infection with hepatitis C virus, of whom 92% reported lifetime drug use.

CONCLUSIONS

These data strongly support the use of formal screening and drug service referral pathways at the time of admission to hospital to engage HIV-positive drug users.

Specialist care of older adults with HIV infection in the UK: a service evaluation

OBJECTIVES

There is a clear trajectory towards cohort ageing in the UK. HIV infection is associated with an increased prevalence of traditionally age-related comorbidities and geriatric syndromes. Some HIV services have been proactive in innovating models that cater for adapting needs. We aimed to describe how widespread this practice is and what form such services take.

METHODS

We conducted an evaluation of the perceived need for and current provision of specialist ageing services, and the need for formal guidance on monitoring or treatment of older adults with HIV infection. A web-based questionnaire was sent to the audit lead at every British HIV Association (BHIVA)-registered HIV clinic.

RESULTS

A total of 102 clinics responded, with a broad geographical spread. Five of the 102 clinics have a clinician with an interest in ageing. Two dedicated HIV ageing services exist, practising different models. A quarter (23 of 98; 23%) of clinics reported a need for an ageing service, with three in development. The majority (65 of 95; 68%) supported dedicated guidance for monitoring in older adults, but fewer (39 of 94; 41%) felt that dedicated guidance on treatment was necessary.

CONCLUSIONS

We identified two existing and three proposed HIV ageing services. Another 20 clinics (20%) reported an unmet need for a specialist ageing service, suggesting that complex older adults may pose a management challenge. This is the first survey of its kind to attempt to describe the current landscape and opinion around such services. HIV-infected cohorts will continue to age and current models of care may be insufficient, which should prompt services, their users and commissioners to consider what models may best fit current and future demand.

Deep sequencing for HIV-1 clinical management

The emerging HIV-1 resistance epidemic is threatening the impressive global advances in HIV-1 infection treatment and prevention achieved in the last decade. Next-generation sequencing is improving our ability to understand, diagnose and prevent HIV-1 resistance, being increasingly cost-effective and more accessible. However, NGS still faces a number of limitations that need to be addressed to enable its widespread use. Here, we will review the main NGS platforms available for HIV-1 diagnosis, the factors affecting the clinical utility of NGS testing and the evidence supporting -or not- ultrasensitive genotyping over Sanger sequencing for routine HIV-1 diagnosis. Now that global HIV-1 eradication might be within our reach, making NGS accessible also to LMICs has become a priority. Reductions in sequencing costs, particularly in library preparation, and accessibility to low-cost, robust but simplified automated bioinformatic analyses of NGS data will remain essential to end the HIV-1 pandemic.

Pre-treatment minority HIV-1 drug resistance mutations and long term virological outcomes: is prediction possible?

Background

Although the use of highly active antiretroviral therapy in HIV positive individuals has proved to be effective in suppressing the virus to below detection limits of commonly used assays, virological failure associated with drug resistance is still a major challenge in some settings. The prevalence and effect of pre-treatment resistance associated variants on virological outcomes may also be underestimated because of reliance on conventional population sequencing data which excludes minority species. We investigated long term virological outcomes and the prevalence and pattern of pre-treatment minority drug resistance mutations in individuals initiating HAART at a local HIV clinic.

Methods

Patient’s records of viral load results and CD4 cell counts from routine treatment monitoring were used and additional pre-treatment blood samples for Sanger sequencing were obtained. A selection of pre-treatment samples from individuals who experienced virological failure were evaluated for minority resistance associated mutations to 1 % prevalence and compared to individuals who achieved viral suppression.

Results

At least one viral load result after 6 months or more of treatment was available for 65 out of 78 individuals followed for up to 33 months. Twenty (30.8 %) of the 65 individuals had detectable viremia and eight (12.3 %) of them had virological failure (viral load > 1000 RNA copies/ml) after at least 6 months of HAART. Viral suppression, achieved by month 8 to month 13, was followed by low level viremia in 10.8 % of patients and virological failure in one patient after month 20. There was potentially reduced activity to Emtricitabine or Tenofovir in three out of the eight cases in which minority drug resistance associated variants were investigated but detectable viremia occurred in one of these cases while the activity of Efavirenz was generally reduced in all the eight cases.

Conclusions

Early viral suppression was followed by low level viremia for some patients which may be an indication of failure to sustain viral suppression over time. The low level viremia may also be representing early stages of resistance development. The mutation patterns detected in the minority variants showed potential reduced drug sensitivity which highlights their potential to dominate after treatment initiation.

Trial registration

Not applicable.

Electronic supplementary material

The online version of this article (doi:10.1186/s12985-016-0628-x) contains supplementary material, which is available to authorized users.

Detection and quantification of HIV-1 RNA with a fully automated transcription-mediated-amplification assay

BACKGROUND

Nucleic acid testing is the major method used to monitor HIV viral load. Commercial systems based on real-time PCR assays are available for high-volume centralized laboratory testing, but they are not fully automated.

OBJECTIVES AND STUDY DESIGN

We have compared the diagnostic performance of the Hologic Aptima HIV-1 Quant Dx assay (Aptima) (based on real-time TMA) on the Panther instrument, a fully-automated random access platform, to that of, the Roche Cobas Ampliprep Cobas TaqMan (CAP/CTM) HIV-1 version 2.0 (based on real-time PCR).

RESULTS

Probit analysis of replicate dilutions of NIBSC WHO International HIV-1 Standard, gave LODs of 8.6 c/ml for Aptima and 15.2 c/ml for CAP/CTM. The agreement between the assays was excellent when measuring HIV RNA in a calibrated reference (κ=0.90, p<0.001) and good when measuring clinical samples (κ=0.62, p<0.001). The correlation among the samples quantified by the two methods was very good (r=0.95, p<0.001) and the mean difference between the values obtained with the two assays was 0.02 log c/ml for B and non-B subtypes. The vast majority of results showed <0.5 log variance between the two assays (89%); only one sample showed results that differed by over 1.0 log c/ml.

CONCLUSION

The performance of the new fully automated Aptima assay is adequate for clinical monitoring of HIV-1 RNA during infections and treatment. The Aptima assay is well suited for routine laboratory use.

Guidelines for Evaluation and Management of Cognitive Disorders in HIV-Positive Individuals

Antiretroviral therapy has revolutionised the treatment for people living with HIV (PLWH). Where antiretroviral coverage is high, the treatment paradigm for HIV-disease is now one of managing the long-term consequences of the virus and its treatment rather than the consequences of untreated HIV-disease such as immunosuppression and opportunistic infections. One such long-term consequence is HIV-associated cognitive impairment which is reported to occur in up to 50 % of treated PLWH and has been associated with poorer outcomes. Given the ageing cohort and increased frequency of comorbidities, the prevalence of symptomatic cognitive impairment may increase with time. High quality evidence for management strategies including screening, diagnosis and treatment of HIV-associated cognitive impairment are lacking and in general guidelines are based on best clinical practice. In this article, we assessed recent guidelines concerning the management of HIV-associated cognitive impairment by performing a systematic review of the MEDLINE database using PubMed. We report that, in general, guidelines from around the world regarding the management of HIV-associated cognitive impairment are converging. Screening is generally not recommended in asymptomatic PLWH. Diagnosis of HIV-associated cognitive impairment should be made only after a comprehensive assessment and exclusion of other potential causes. Antiretroviral therapy forms the cornerstone of management of HIV-associated cognitive impairment and should be guided by plasma and cerebrospinal fluid (CSF) genotype(s).

Obesity in the HIV-infected population in Northeast England: a particular issue in Black-African women

People living with HIV are surviving longer on successful antiretroviral therapy and obesity rates are increasing. We sought to determine the prevalence of being overweight or obese in a regional population of people living with HIV and to explore the demographic and clinical characteristics associated with obesity or being overweight. Data on patients attending three Northeast England clinics were collected including body mass index and demographics. The prevalence of being overweight (body mass index ≥ 25 kg/m²) or obese (body mass index ≥ 30 kg/m²) was determined and compared with regional population data. Associations between being overweight or obese and demographic and other data were further explored using logistic regression models. In 560 patients studied (median age 45 years, 26% Black-African and 69% male), 65% were overweight/obese and 26% obese, which is similar to the local population. However, 83% and 48% of Black-African women were overweight/obese or obese, respectively, with 11% being morbidly obese (body mass index > 40 kg/m²). In the multivariate analyses, the only factors significantly associated with obesity were Black-African race (adjusted odds ratio 2.78, 95% confidence interval 1.60-4.85) and type 2 diabetes (adjusted odds ratio 4.23, 95% confidence interval 1.81-9.91). Levels of obesity and overweight in people living with HIV are now comparable to the levels in the local population of Northeast England; however, the prevalence is significantly higher in Black-African women. Given the additional risk factors for cardiovascular disease inherent in people living with HIV, better strategies to prevent, identify and manage obesity in this population are needed.

Determinants of virological response to antiretroviral therapy: socio-economic status still plays a role in the era of cART. Results from the ANRS-VESPA 2 study, France

BACKGROUND

Disparities in combined antiretroviral therapy (cART) outcomes have been consistently reported among people living with HIV (PLWHIV). The present study aims at investigating the mechanisms underlying those disparities among PLWHIV in France.

METHODS

We used data from the Vespa2 survey, a large national cross-sectional survey, representative of HIV-infected people followed at hospitals in 2011. Among participants diagnosed ≥1996, HIV treatment-naive at the time of cART initiation and on cART for at least 12 months, the frequency of sustained virological suppression (SVS; undetectable viral load [<50 copies/ml] for at least 6 months) at the time of the survey, was assessed and its social determinants were measured through logistic regression, accounting for clinical and biological determinants of response to cART.

RESULTS

Among 1,246 participants, 77.7% had achieved SVS. SVS was less frequent among those unemployed (0.6 [range 0.3-1.0]) and those with the lowest level of education (0.4 [range 0.2-0.9]). The late presenters, diagnosed at a CD4⁺ T-cell count <200/mm³ (0.5 [range 0.3-0.9]) and the late starters, diagnosed at a CD4⁺ T-cell count >200 but initiating cART at CD4⁺ T-cell count <200 (0.3 [range 0.1-0.8]) were less likely than the ideal starters (≥350 CD4⁺ T-cells/mm³ at cART initiation) to achieve SVS, as were those who reported suboptimal adherence versus those reporting optimal adherence (0.4 [range 0.2-0.7]). In bivariate analyses, material deprivation, discrimination and a weak social network were also associated with a poorer treatment response.

CONCLUSIONS

Structural social factors remain strong determinants of treatment response and should be addressed in a broad approach of care, but wider political issues should also be investigated.

When to Monitor CD4 Cell Count and HIV RNA to Reduce Mortality and AIDS-Defining Illness in Virologically Suppressed HIV-Positive Persons on Antiretroviral Therapy in High-Income Countries: A Prospective Observational Study

OBJECTIVE

To illustrate an approach to compare CD4 cell count and HIV-RNA monitoring strategies in HIV-positive individuals on antiretroviral therapy (ART).

DESIGN

Prospective studies of HIV-positive individuals in Europe and the USA in the HIV-CAUSAL Collaboration and The Center for AIDS Research Network of Integrated Clinical Systems.

METHODS

Antiretroviral-naive individuals who initiated ART and became virologically suppressed within 12 months were followed from the date of suppression. We compared 3 CD4 cell count and HIV-RNA monitoring strategies: once every (1) 3 ± 1 months, (2) 6 ± 1 months, and (3) 9-12 ± 1 months. We used inverse-probability weighted models to compare these strategies with respect to clinical, immunologic, and virologic outcomes.

RESULTS

In 39,029 eligible individuals, there were 265 deaths and 690 AIDS-defining illnesses or deaths. Compared with the 3-month strategy, the mortality hazard ratios (95% CIs) were 0.86 (0.42 to 1.78) for the 6 months and 0.82 (0.46 to 1.47) for the 9-12 month strategy. The respective 18-month risk ratios (95% CIs) of virologic failure (RNA >200) were 0.74 (0.46 to 1.19) and 2.35 (1.56 to 3.54) and 18-month mean CD4 differences (95% CIs) were -5.3 (-18.6 to 7.9) and -31.7 (-52.0 to -11.3). The estimates for the 2-year risk of AIDS-defining illness or death were similar across strategies.

CONCLUSIONS

Our findings suggest that monitoring frequency of virologically suppressed individuals can be decreased from every 3 months to every 6, 9, or 12 months with respect to clinical outcomes. Because effects of different monitoring strategies could take years to materialize, longer follow-up is needed to fully evaluate this question.

Chronic obstructive pulmonary disease and HIV: are we appropriately screening?

Individuals with human immunodeficiency virus (HIV) represent a population that is at a higher risk of developing chronic obstructive pulmonary disease (COPD). In this study, we sought to determine the effects of smoking on respiratory symptoms and diseases among HIV-positive patients and to determine if symptomatic patients are being appropriately screened for COPD. HIV-positive individuals completed a self-administered questionnaire. The effects of smoking on respiratory symptoms and diseases were reported as odds ratios (ORs). The COPD screening criteria were adapted from the Canadian Thoracic Society (CTS) guidelines. Two hundred and forty-seven participants were recruited. The median age was 49 years; 75% were male and 92% were on highly active antiretroviral therapy. Smokers represented 66% of the population. Smoking had a statistically significant effect on respiratory symptoms including wheeze (OR 4.8 [95% confidence interval (CI) 1.6-14.2]), phlegm production (OR 4.9 [95% CI: 2.2-10.5]), cough (OR 7.0 [95% CI: 3.0-16.2]), and dyspnea (OR 7.2 [95% CI: 1.7-31.2]). Smoking had a higher odds of respiratory diseases including COPD (OR 4.9 [95% CI: 1.1-21.9]) and bronchitis (OR 3.8 [95% CI: 1.9-7.7]). Among HIV-positive smokers, 40% met the CTS screening criteria, while only 12% self-reported a diagnosis of COPD. The burden of smoking in the HIV population is significant. HIV-positive smokers are more likely to report both respiratory symptoms and diseases than HIV-positive non-smokers. A discrepancy exists between patients who met the CTS screening criteria and those who were diagnosed with COPD, raising the concern for under-recognition and under-diagnosis of COPD in this population.

Atazanavir exposure in utero and neurodevelopment in infants: a comparative safety study

OBJECTIVE

To evaluate the safety of in-utero exposure to atazanavir and neurodevelopment in perinatally HIV-exposed but uninfected (PHEU) infants.

DESIGN

Prospective cohort study of mother-PHEU infant pairs in the Surveillance Monitoring for ART Toxicities protocol of the Pediatric HIV/AIDS Cohort Study.

METHODS

Pregnant women living with HIV who initiated an antiretroviral regimen during pregnancy were followed from the date of antiretroviral initiation. Women were classified according to whether the antiretroviral regimen contained atazanavir and the trimester of antiretroviral initiation. Neurodevelopment at 9-15 months was evaluated using the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III). We estimated mean differences for the five Bayley-III domains for atazanavir-containing regimens versus all other regimens. Models included baseline covariates and adjustment for failure to complete the Bayley-III using inverse probability weighting.

RESULTS

PHEU infants were exposed in utero to atazanavir-containing (n = 167) and nonatazanavir-containing (n = 750) antiretroviral regimens. The adjusted mean differences (95% confidence interval) in Bayley-III domain scores for initiating an atazanavir-containing regimen in the first trimester were: cognitive, -1.5 (-6.2, 3.2); language, -3.3 (-7.6, 1.0); motor, -2.9 (-7.7, 1.9); social-emotional, 0.1 (-6.2, 6.4); and adaptive behavior, -0.1 (-4.3, 4.0). The mean differences for the second or third trimester were: cognitive, 0.4 (-3.2, 4.0); language, -3.4 (-6.2, -0.5); motor, 0.3 (-2.9, 3.4); social-emotional, -5.9 (-9.4, -2.3); and adaptive behavior, -2.5 (-5.9, 0.8).

CONCLUSION

In-utero exposure to atazanavir-containing regimens compared with non-atazanavir-containing regimens may adversely affect language and social-emotional development in PHEU infants during the first year of life, but the absolute difference is small.

Dose Optimization of Efavirenz Based on Individual CYP2B6 Polymorphisms in Chinese Patients Positive for HIV

The purpose of this study was to investigate the impact of CYP2B6‐G516T polymorphisms on the pharmacokinetics (PKs) of efavirenz among the Chinese population and to propose doses for different genotypic populations that optimize therapeutic outcomes. Nonlinear mixed‐effect modeling was applied to describe PKs of efavirenz in Chinese patients with human immunodeficiency virus (HIV). Probabilities of successful treatment at different doses were obtained by simulations using the developed model to identify the optimal doses. The model was based on data from 163 individuals. Efavirenz clearance was found to be significantly influenced by CYP2B6‐G516T polymorphisms and body weight. The typical values of oral clearance were 10.2 L/h, 7.33 L/h, and 2.38 L/h and simulation results suggested that the optimal daily oral doses are 550 mg, 350 mg, and 100 mg for the GG, GT, and TT populations, respectively. The effect of CYP2B6‐G516T polymorphisms on efavirenz clearance was successfully quantified. Pharmacogenetics‐based dose individualization of efavirenz may optimize patient outcomes by promoting efficacy while minimizing central nervous system (CNS) side effects.