HIV and the Millennium Development Goals

Disease burden of AIDS in last 30-year period and its predicted level in next 25-years based on the global burden disease 2019

BACKGROUND

This study examines global trends in acquired immune deficiency syndrome (AIDS) incidence, mortality, and disability-adjusted life years (DALYs) from 1990 to 2019, focusing on regional disparities in AIDS incidence, mortality, and DALYs across various levels of socio-demographic index (SDI). It also investigates variations in AIDS incidence, mortality, and DALYs across different age groups, and projects specific trends for the next 25 years.

METHODS

Comprehensive data on AIDS from 1990 to 2019 in 204 countries and territories was obtained from a GBD study. This included information on AIDS incidence, mortality, DALYs, and age-standardized rates (ASRs). Projections for AIDS incidence and mortality over the next 25 years were generated using the Bayesian age-period-cohort model.

RESULTS

From 1990 to 2019, the global incidence of HIV cases increased from 1,989,282 to 2,057,710, while the age-standardized incidence rate (ASIR) decreased from 37.59 to 25.24 with an estimated annual percentage change (EAPC) of -2.38. The ASIR exhibited an upward trend in high SDI and high-middle SDI regions, a stable trend in middle SDI regions, and a downward trend in low-middle SDI and low SDI regions. In regions with higher SDI, the ASIR was higher in males than in females, while the opposite was observed in lower SDI regions. Throughout 1990 to 2019, the age-standardized death rate (ASDR) and age-standardized DALY rate remained stable, with EAPCs of 0.24 and 0.08 respectively. Countries with the highest HIV burden affecting women and children under five years of age are primarily situated in lower SDI regions, particularly in sub-Saharan Africa. Projections indicate a significant continued decline in the age-standardized incidence and mortality rates of AIDS over the next 25 years, for both overall and by gender.

CONCLUSIONS

The global ASIR decreased from 1990 to 2019. Higher incidence and death rates were observed in the lower SDI region, indicating a greater susceptibility to AIDS among women and < 15 years old. This underscores the urgent need for increased resources to combat AIDS in this region, with focused attention on protecting women and < 15 years old as priority groups. The AIDS epidemic remained severe in sub-Saharan Africa. Projections for the next 25 years indicate a substantial and ongoing decline in both age-standardized incidence and mortality rates.

Anti-HIV activity in traditional Chinese medicine: clinical implications of monomeric herbal remedies and compound decoctions

With the global spread of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS), the pursuit of potent treatments has ascended as a paramount concern in global healthcare. Traditional Chinese medicine (TCM) has been used for thousands of years in China and other East Asian countries and it offers remedies for an extensive array of ailments, including HIV and AIDS. This review focuses on the clinical significance of single herbs and composite tonics in TCM with antiviral activity against HIV. Initially, the anti-HIV activity of single herbs was analyzed in detail. Many herbs have been shown to have significant anti-HIV activity. The active ingredients of these herbs exhibit their anti-HIV effects through various mechanisms, such as inhibiting viral replication, preventing viral binding to host cells, and interfering with the viral lifecycle. Furthermore, we delved into the clinical significance of HIV-associated formulations provided as a result of Chinese compound prescription. These combinations of herbal ingredients are designed to amplify therapeutic efficacy and minimize adverse effects. Clinical trials have demonstrated the therapeutic benefits of these prescriptions for individuals infected with HIV. The intricate composition of these prescriptions potentially augments their anti-HIV activity through synergistic effects. Additionally, this review underscores the clinical importance of TCM in the context of HIV treatment. While numerous herbs and prescriptions exhibit anti-HIV activity, their safety and efficacy in clinical applications warrant further investigation. When combined with contemporary antiretroviral drugs, TCM may serve as an adjunctive therapy, assisting in reducing side effects, and enhancing patients' quality of life. To optimally harness these natural resources, further exploration is imperative to ascertain their efficacy, safety, and optimal utilization, thereby offering a broader spectrum of therapeutic options for HIV-afflicted individuals.

Trend and principal components of HIV/AIDS among adults in SSA

This study aimed to identify the most important principal components (PCs) that contribute to the prevalence and change of HIV/AIDS in 44 SSA and data from different national and international datasets. The study estimated HIV prevalence, trend, and principal component analysis (PCA). Using the elbow method, the number of important PCs and contributions was identified. The quality of representation was checked, and more contributing variables for most important PCs were identified. Finally, the status by prevalence, the progress by trend, the more influenced component by PCA, and the more influenced variable with quality of representation by PCs were reported. The study found that HIV prevalence varied significantly, with 30 of the countries showed good progress/decline. Four PCs accounted for 51% of the total variance. Literacy, cohabitation, media exposure, and HIV status awareness are highly contributing factors. Based on these findings, a gap-based response will help reduce the burden of HIV.

Nationwide Longitudinal Annual Survey of HIV/AIDS Referral Hospitals in Japan From 1999 to 2021: Trend in Non-AIDS-defining Cancers Among Individuals Infected With HIV-1

BACKGROUND

Non-AIDS-defining cancers (NADCs) in patients infected with HIV have recently attracted attention because of the improved survival of this patient population. To obtain accurate data, a longitudinal study is warranted for the nationwide surveillance of the current status and national trend of NADCs in patients infected with HIV in Japan.

SETTING

An annual nationwide surveillance of NADCs in patients infected with HIV-1 in Japan from 1999 to 2021.

METHODS

An annual questionnaire was sent to 378 HIV/AIDS referral hospitals across Japan to collect data (clusters of differentiation 4-positive lymphocytes, time of onset, outcomes, and antiretroviral therapy status) of patients diagnosed with any of the NADCs between 1999 and 2021.

RESULTS

The response and case-capture rates for the questionnaires in 2021 were 37.8% and 81.2%, respectively. The number of reported NADC cases subsequently increased since the beginning of this study. Evaluation of the case counts of NADCs demonstrated a high incidence of lung, colorectal, gastric, and liver cancers as the top 4 cancers. Pancreatic cancer (0.63), lung cancer (0.49), and leukemia (0.49) had the highest mortality rates among the NADCs. Trends of NADCs regarding transmission routes were maintained over the years in male individuals who have sex with male individuals compared with heterosexual male individuals and female individuals.

CONCLUSIONS

We demonstrated an increasing trend in the incidence of NADCs over a period of 23 years in Japan. The current data highlighted the importance of raising awareness regarding cancer management for patients infected with HIV in Japan.

Temporal trends in inequalities of the burden of HIV/AIDS across 186 countries and territories

BACKGROUND

The Global Burden of Disease, Injuries, and Risk Factors Study (GBD) has reported that HIV/AIDS continues to take a disproportionate toll on global health. However, the trends in global inequality of HIV/AIDS burden have remained ambiguous over the past two decades. The objectives of our study were to assess the socioeconomic inequalities, and temporal trends of HIV/AIDS across 186 countries and territories from 2000 to 2019.

METHODS

We extracted data from the GBD 2019, and conducted a cross-national time-series analysis. Age-standardized disability-adjusted life-year (DALY) rates were used to measure the global burden of HIV/AIDS. Gross national income (GNI) per capita was used to approximate the national socioeconomic status. Linear regression analysis was conducted to investigate the relationship between age-standardized DALY rates due to HIV/AIDS and GNI per capita. The concentration curve and concentration index (CI) were generated to evaluate the cross-national socioeconomic inequality of HIV/AIDS burden. A joinpoint regression analysis was used to quantify the changes in trends in socioeconomic inequality of HIV/AIDS burden from 2000 to 2019.

RESULTS

A decrease in age-standardized DALY rates for HIV/AIDS occurred in 132 (71%) of 186 countries/territories from 2000 to 2019, of which 52 (39%) countries/territories achieved a decrease in DALYs of more than 50%, and 27 (52%) of the 52 were from sub-Saharan Africa. The concentration curves of the age-standardized DALY rates of HIV/AIDS were above the equality line from 2000 to 2019. The CI rose from - 0.4625 (95% confidence interval - 0.6220 to -0.2629) in 2000 to -0.4122 (95% confidence interval - 0.6008 to -0.2235) in 2019. A four-phase trend of changes in the CIs of age-standardized DALY rates for HIV/AIDS was observed across 2000 to 2019, with an average increase of 0.6% (95% confidence interval 0.4 to 0.8, P < 0.001).

CONCLUSIONS

Globally, the burden of HIV/AIDS has decreased over the past two decades, accompanied by a trend of narrowing cross-country inequalities of HIV/AIDS burden. Moreover, the burden of HIV/AIDS continues to fall primarily in low-income countries.

Evolution of prevention of mother to child transmission of HIV policy in Zambia: Application of the policy triangle to understand the roles of actors, process and power

The Prevention of Mother-to-child Transmission (PMTCT) of HIV program in Zambia has undergone several policy iterations over the past 10 years. This qualitative study aimed to contribute towards addressing this knowledge gap by analysing the evolution and actors' influence during the policy process using the Walt and Gilson policy triangle as our evaluation framework. Document review and key informant interviews with policy makers were undertaken to identify the contextual factors that had shaped the PMTCT policy evolution in Zambia. Overall, the study revealed that over the past decade, at least five PMTCT policy changes have occurred, averaging three years per policy with extensive overlap between policies. This resulted in more than two policies being implemented at a given time. Pressure from the international community and scientific evidence were the main drivers of policy change in Zambia, with local actors being mainly reactive. Among international agencies, UNICEF and WHO were the key actors who had driven the policy changes as they had the power and resources. The rapid changes, negatively impacted the health system, disrupted service delivery, which was unprepared to effectively and efficiently shift from one policy to another.

Costing and cost-effectiveness of Cepheid Xpert HIV -1 Qual Assay using whole blood protocol versus PCR by Abbott Systems in Malawi

Background

Timely diagnosis of HIV in infants and children is an urgent priority. In Malawi, 40,000 infants annually are HIV exposed. However, gold standard polymerase-chain-reaction (PCR) based testing requires centralised laboratories, causing turn-around times (TAT) of 2 to 3 months and significant loss to follow-up. If feasible and acceptable, minimising diagnostic delays through HIV Point-of-care-testing (POCT) may be cost-effective. We assessed whether POCT Cepheid Xpert HIV-1 Qual assay whole blood (XpertHIV) was more cost-effective than PCR.

Methods

From July-August 2018, 700 PCR Abbott tests using dried blood spots (DBS) were performed on 680 participants who enrolled on the feasibility, acceptability and performance of the XpertHIV study. Newly identified HIV-positive We conducted a cost-minimisation and cost-effectiveness analysis of XpertHIV against PCR, as the standard of care. A random sample of 200 caregivers from the 680 participants had semi-structured interviews to explore costs from a societal perspective of XpertHIV at Mulanje District Hospital, Malawi. Analysis used TAT as the primary outcome measure. Results were extrapolated from the study period (29 days) to a year (240 working days). Sensitivity analyses characterised individual and joint parameter uncertainty and estimated patient cost per test.

Results

During the study period, XpertHIV was cost-minimising at $42.34 per test compared to $66.66 for PCR. Over a year, XpertHIV remained cost-minimising at $16.12 compared to PCR at $27.06. From the patient perspective (travel, food, lost productivity), the cost per test of XpertHIV was $2.45. XpertHIV had a mean TAT of 7.10 hours compared to 153.15 hours for PCR. Extrapolates accounting for equipment costs, lab consumables and losses to follow up estimated annual savings of $2,193,538.88 if XpertHIV is used nationally, as opposed to PCR.

Conclusions

This preliminary evidence suggests that adopting POCT XpertHIV will save time, allowing HIV-exposed infants to receive prompt care and may improve outcomes. The Malawi government will pay less due to XpertHIV's cost savings and associated benefits.

Spatial and Temporal Trends in HIV/AIDS Burden Among Worldwide Regions From 1990 to 2019: A Secondary Analysis of the Global Burden of Disease Study 2019

Purpose

HIV/AIDS is a critical public health concern worldwide. This article investigated the spatial and temporal trends in HIV/AIDS burden from 1990 to 2019.

Methods

Data were extracted from the Global Burden of Disease (GBD) Study 2019. The estimated annual percentage change (EAPC) and the age-standardized rate (ASR) were used to quantify the change in trends at the global, regional, and national levels.

Results

In terms of temporal trends, during the period 1990–2004, increasing trends in prevalence (EAPC = 7.47, 95% confidence interval [CI] 5.84, 9.12), death (EAPC = 10.85, 95% CI 8.90–12.84), and disability-adjusted life years (DALYs) (EAPC = 10.40, 95% CI 8.47–12.36) of HIV/AIDS were observed. During the period 2005–2019, the global trends in HIV/AIDS incidence, death, and DALYs of HIV/AIDS decreased, with the EAPCs of −2.68 (95% CI−2.82–−2.53), −6.73 (95% CI −6.98–−6.47), and −6.75 (95% CI −6.95–−6.54), respectively. However, the disease prevalence showed a slight increasing trend (EAPC = 0.71, 95% CI 0.54–0.87). In terms of spatial trends, over the past 15 years, trends in HIV/AIDS incidence of HIV/AIDS appeared upward in High-middle and High sociodemographic index (SDI) areas (EAPC = 6.51, 95% CI 5.50–7.53; EAPC = 2.31, 95% CI 2.02–2.60, respectively).

Conclusion

Decreasing trends in HIV/AIDS incidence, death, and DALYs have been observed worldwide over the past 15 years, especially in death and DALYs rates. However, the global population living with HIV/AIDS is still increasing. It is worth noting that an unfavorable trend emerged in High-middle and High SDI areas. Prevention and control of HIV/AIDS still need to be strengthened to counteract these concerning trends.

The changing profile of paediatric HIV infection: An experience from the Middle East

OBJECTIVE

To describe the clinical and epidemiological profiles of HIV-infected Omani children before and after the implementation of the prevention of mother-to-child transmission of HIV (PMTCT) programme.

METHODS

A retrospective review of HIV-infected children seen at a national paediatric HIV unit between 1992 and 2015 was performed.

RESULTS

Ninety-one HIV-infected children were identified; 59 (65%) were ≤5 years of age at diagnosis, with 28 (47.5%) of these being <1 year old. The average annual incidence of infection per million children (≤14 years old) was 5.7, and the highest (11.6) was in 2010. At diagnosis, 48 (60%) patients had a CD4 count of ˂200cells/mm³. The median HIV viral load was 81600copies/ml at diagnosis and 5911copies/ml at 12 months after HIV treatment (p=0.015). The median CD4 count was 586cells/mm³ at diagnosis and 800cells/mm³ at 12 months after therapy (p=0.004). Compared to those diagnosed before 2009 (n=68), HIV-infected children diagnosed after 2009 (n=22) were more likely to be asymptomatic at the time of HIV diagnosis (23.5% (16/68) vs. 59.1% (13/22); p=0.002) and to have a favourable clinical outcome (42.6% (29/68) vs. 86.4% (19/22); p<0001).

CONCLUSIONS

The number of HIV-infected children in Oman has decreased substantially since the introduction of the PMTCT programme. Furthermore, the HIV-infected children diagnosed after 2009 had higher proportions of asymptomatic HIV infections at diagnosis and favourable clinical outcomes, in comparison to those diagnosed before 2009.

Attributes of HIV infection over decades (1982-2018): A systematic review and meta-analysis

Understanding the risk factors for HIV infection is the foundation of successful preventive strategies, which must bundle sociocultural, behavioural and biomedical interventions to halt disease transmission. We aimed in this study to provide a pooled estimation of HIV risk factors and trace changes across decades in order to drive consensus and accurate assessment of disease transmission risk. We comprehensively searched PubMed, ISI Web of Knowledge, Medline, EMBASE, ScienceDirect, Ovid, EBSCO, Google Scholar and the Egyptian Universities Library Consortium from October to December 2018. Two independent reviewers extracted data from eligible studies. Funnel plots were inspected to identify publication bias. Heterogeneity across studies was checked using the Q and I² statistics. The results were reported based on the pooled odds ratio (pOR) with 95% CI using a random-effects model. Meta-analysis of HIV risk factors revealed a superior role for risky sexual practices (unprotected vaginal/anal sex), injecting drug use (IDU), sharing needles, sexually transmitted infections (STIs), child sexual abuse and vertical transmissions. Trends across decades (1982-1999 and 2000-2018, respectively) showed rising evidence for prostitution [pOR (95% CI)= 2.3 (1.12-4.68) versus 2.69 (1.67-4.32)] and men who have sex with men (MSM) [pOR (95% CI)= 2.28 (1.64-3.17) versus 3.67 (1.88-7.17)], while transmission through IDU [pOR (95% CI)= 3.42 (2.28-5.12) versus 2.16 (1.74-2.70)], alcoholism [pOR (95% CI)= 2.35 (0.73-7.59) versus 1.71(1.08-2.72)], and sharing syringes [pOR (95% CI)= 6.10 (2.57-14.5) versus 2.70 (2.01-6.35)] showed notable decline. Harm reduction programs and condom use have been recognized as chief HIV prevention strategies, while male circumcision contributed a partial role. Collectively, sexual risk factors continue to be a key driver of the global HIV epidemic. Persistent and emerging risk factors identified in our analysis should constitute the forefront targets of HIV prevention programmes to accelerate efforts towards HIV elimination.

'If nurses were in our shoes would they breastfeed their own babies?' A qualitative inquiry on challenges faced by breastfeeding mothers on the PMTCT programme in a rural community in Zimbabwe

BACKGROUND

The Prevention of Mother to Child Transmission (PMTCT) of HIV programme in Zimbabwe has had remarkable success despite the country's economic challenges. The aim of this study was to explore the challenges faced by breastfeeding mothers on the PMTCT programme.

METHOD

Narratives from 15 women (age range 19-35 years) were collected at two rural health facilities in Zimbabwe through in-depth interviews over a period of 6 months. Thematic analysis was used to describe breastfeeding mothers' experiences and challenges of being on the PMTCT programme.

RESULTS

The findings suggest that breastfeeding women on the PMTCT programme face challenges that include internal, external and institutional stigma and discrimination. Women reported a sense of powerlessness in decision making on following through with the PMTCT programme and were ambivalent regarding disclosure of their HIV status to their partners and significant others.

CONCLUSION

HIV and AIDS programmes should pay attention to women's readiness for interventions. There is need to understand women's life experiences to ensure informed and targeted programming for PMTCT.

Effectiveness of the prevention of HIV mother -to-child transmission (PMTCT) program via early infant diagnosis (EID) data in Senegal

BACKGROUND

To improve the care and treatment of HIV-exposed children, early infant diagnosis (EID) using dried blood spot (DBS) sampling has been performed in Senegal since 2007, making molecular diagnosis accessible for patients living in decentralized settings. This study aimed to determine the evolution of the HIV transmission rate in children from 2008 to 2015 and to analyze associated factors, particularly the mother's treatment status and/or child's prophylaxis status and the feeding mode.

METHODS

The data were analyzed using EID reports from the reference laboratory. Information related to sociodemographic characteristics, HIV profiles, the mother's treatment status, the child's prophylaxis status, and the feeding mode was included. Descriptive statistics were calculated, and bivariate and multivariate logistic regression analyses were performed.

RESULTS

During the study period, a total of 5418 samples (5020 DBS and 398 buffy coat) from 168 primary prevention of HIV mother-to-child transmission (PMTCT) intervention sites in Senegal were tested. The samples were collected from 4443 children with a median age of 8 weeks (1-140 weeks) and a sex ratio (M/F) of 1.1 (2309/2095). One-third (35.2%; N = 1564) of the children were tested before 6 weeks of age. Twenty percent (N = 885) underwent molecular diagnostic testing more than once. An increased number of mothers receiving treatment (57.4%; N = 2550) and children receiving prophylaxis (52.1%; N = 2315) for protection against HIV infection during breastfeeding was found over the study period. The transmission rate decreased from 14.8% (95% confidence interval (CI): 11.4-18.3) in 2008 to 4.1% (95% CI: 2.5-7.5) in 2015 (p < 0.001). However, multivariate logistic regression analysis revealed that independent predictors of HIV mother-to-child transmission included lack of mother's treatment (adjusted odd ratio (aOR) = 3.8, 95% CI: 1.9-7.7; p˂0.001), lack of child's prophylaxis (aOR = 7.8, 95% CI: 1.7-35.7; p = 0.009), infant age at diagnosis (aOR = 2.2, 95% CI: 1.1-4.3 for ≤6 weeks versus 12-24 weeks; p = 0.025) and protective effect of breastfeeding on ART against formula feeding (aOR = 0.4, 95% CI: 0.2, 0.7; p = 0.005).

CONCLUSION

This study demonstrates the effectiveness of PMTCT interventions in Senegal but indicates also that increased efforts should be continued to reduce the MTCT rate to less than 2%.

A realist review of infant feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa: what works for whom and in what contexts

BACKGROUND

The most recent World Health Organization (WHO) guidelines on Human Immunodeficiency Virus (HIV) and infant feeding promotes exclusive breastfeeding (EBF) in resource limited settings for the prevention of mother to child transmission (PMTCT) of HIV. Literature reveals poor uptake of WHO feeding guidelines, with mixed feeding being a regular practice. In light of the limited success in EBF promotion, a realist review was conducted, analysing the use of feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa, where the majority of HIV childhood infections occur. We considered what mechanisms were at play, for whom and in what circumstances they led to exclusive breastfeeding.

METHODS

Because infant feeding counselling is a complex social intervention with a non-linear causal pathway for preventing mother to child HIV transmission, a realist methodology was chosen for this study. Using Pawson's five stage sequence for conducting realist reviews, the results are presented as a set of identified and refined context-mechanism-outcome (CMO) configurations. These CMO configurations were used to show how particular outcomes occurred in specific contexts due to a generative mechanism and were developed through identifying a review question and program theory, searching for primary studies, quality appraisal, data extraction and data synthesis.

RESULTS

From an initial 1010 papers, 27 papers met the inclusion criteria and were used to refine the program theory. Exclusive breastfeeding occurred when a woman was motivated regarding motherhood, had correct learning and understanding about infant feeding practices through counselling, no fear of breastfeeding or the impact of opposing feeding related cultural beliefs, and the support from others to be assertive about their feeding choices when faced with pressure to mix-feed. An additional CMO configuration was added during the refinement of the program theory identifying that mothers needed to not just understand but also prioritize EBF advice over cultural beliefs and stigma.

CONCLUSION

The intended audience for this review are researchers and health care workers in PMTCT, particularly sub-Saharan Africa, who may benefit from the work that has been done to identify contexts for the success and failures of EBF.

Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa

BACKGROUND

Under Option B+ guidelines for prevention of mother-to-child transmission of HIV, pregnant and breastfeeding women initiate antiretroviral therapy for lifelong use. The objectives of this study were: (1) to synthesize data on retention in care over time in option B+ programs in Africa, and (2) to identify factors associated with retention in care.

METHODS

PubMed, EMBASE, and African Index Medicus were systematically searched from January 2012 to June 2017. Pooled estimates of the proportion of women retained were generated and factors associated with retention were analyzed thematically.

RESULTS

Thirty-five articles were included in the final review; 22 reported retention rates (n = 60,890) and 25 reported factors associated with retention. Pooled estimates of retention were 72.9% (95% confidence interval: 66.4% to 78.9%) at 6 months for studies reporting <12 months of follow-up and 76.4% (95% confidence interval: 69.0% to 83.1%) at 12 months for studies reporting ≥12 months of follow-up. Data on undocumented clinic transfers were largely absent. Risk factors for poor retention included younger age, initiating antiretroviral therapy on the same day as diagnosis, initiating during pregnancy versus breastfeeding, and initiating late in the pregnancy. Retention was compromised by stigma, fear of disclosure, and lack of social support.

CONCLUSIONS

Retention rates in prevention of mother-to-child transmission under option B+ were below those of the general adult population, necessitating interventions targeting the complex circumstances of women initiating care under option B+. Improved and standardized procedures to track and report retention are needed to accurately represent care engagement and capture undocumented transfers within the health system.

p24 revisited: a landscape review of antigen detection for early HIV diagnosis

: Despite major advances in HIV testing, early detection of infection at the point of care (PoC) remains a key challenge. Although rapid antibody PoC and laboratory-based nucleic acid amplification tests dominate the diagnostics market, the viral capsid protein p24 is recognized as an alternative early virological biomarker of infection. However, the detection of ultra-low levels of p24 at the PoC has proven challenging. Here we review the landscape of p24 diagnostics to identify knowledge gaps and barriers and help shape future research agendas. Five hundred and seventy-four research articles to May 2018 that propose or evaluate diagnostic assays for p24 were identified and reviewed. We give a brief history of diagnostic development, and the utility of p24 as a biomarker in different populations such as infants, the newly infected, those on preexposure prophylaxis and self-testers. We review the performance of commercial p24 assays and consider elements such as immune complex disruption, resource-poor settings, prevalence, and assay antibodies. Emerging and ultrasensitive assays are reviewed and show a number of promising approaches but further translation has been limited. We summarize studies on the health economic benefits of using antigen testing. Finally, we speculate on the future uses of high-performance p24 assays, particularly, if available in self-test format.

Unmet needs of high-risk mothers reduce success of antiretroviral treatment in HIV-infected infants

In the era of effective prevention of mother-to-child transmission of HIV, the same psychosocioeconomic factors that predispose to mother-to-child transmission also substantially increase the likelihood of antiretroviral therapy failure in infected infants. For HIV-infected infants to benefit from early infant diagnosis and treatment initiation, into which much funding and effort is now invested, it is vital that these unmet needs of high-risk mothers are urgently attended to. From an ongoing study of early infant diagnosis and treatment following in utero transmission in KwaZulu-Natal, South Africa, we describe four cases to highlight these challenges facing transmitting mothers that contribute to treatment failure in their infants.

Global Trends in CD4 Cell Count at the Start of Antiretroviral Therapy: Collaborative Study of Treatment Programs

Background

Early initiation of combination antiretroviral therapy (cART), at higher CD4 cell counts, prevents disease progression and reduces sexual transmission of human immunodeficiency virus (HIV). We describe the temporal trends in CD4 cell counts at the start of cART in adults from low-income, lower-middle-income, upper-middle-income, and high-income countries (LICs, LMICs, UMICs, and HICs, respectively).

Methods

We included HIV-infected individuals aged ≥16 years who started cART between 2002 and 2015 in a clinic participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) or the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). Missing CD4 cell counts at the start of cART were estimated through multiple imputation. Weighted mixed-effect models were used to smooth trends in median CD4 cell counts.

Results

A total of 951855 adults from 16 LICs, 11 LMICs, 9 UMICs, and 19 HICs were included. Overall, the modeled median CD4 cell count at the start of cART increased from 2002 to 2015, from 78/µL (95% confidence interval, 58-104/µL) to 287/µL (250-328/µL) in LICs, from 99/µL (71-140/µL) to 234/µL (192-285/µL) in LMICs, from 71/µL (49-104/µL) to 311/µL (255-379/µL) in UMICs, and from 161/µL (143-181/µL) to 327/µL (286-372/µL) in HICs. In LICs, LMICs, and UMICs, the increase was more pronounced in women; in HICs, the opposite was observed.

Conclusions

Median CD4 cell counts at the start of cART increased in all income groups, but generally remained below 350/μL in 2015. Substantial additional efforts and resources are required to achieve earlier diagnosis, linkage to care, and initiation of cART.

Predictors of Infant Age at Enrollment in Early Infant Diagnosis Services in Kenya

Despite the importance of early detection to signal lifesaving treatment initiation for HIV+ infants, early infant diagnosis (EID) services have received considerably less attention than other aspects of prevention of mother to child transmission care. This study draws on baseline data from an on-going cluster randomized study of an intervention to improve EID services at six government hospitals across Kenya. Two logistic regressions examined potential predictors of “on time” (infant ≤6 weeks of age) vs. “late” (≥7 weeks) and “on time” versus “very late” (≥12 weeks) EID engagement among 756 mother-infant pairs. A quarter of the infants failed to get “on time” testing. Predictors of “on time” testing included being informed about EID by providers when pregnant, perceiving less HIV stigma, and mother’s level of education. Predictors of “very late” testing (≥12 weeks of age) included not being informed about EID by providers when pregnant and living farther from services. Findings highlight the importance of ensuring that health care providers actively and repeatedly inform HIV+ mothers of the availability of EID services, reduce stigma by frequently communicating judgment free support, and assisting mothers in early planning for accessing EID services. Extra care should be focused on engaging mothers with less formal education who are at increased risk for seeking “late” EID testing. This study offers clear targets for improving services so that all HIV-exposed infants can be properly engaged in EID services, thus increasing the potential for the best possible outcomes for this vulnerable population.

Sensitivity of HIV rapid tests compared with fourth-generation enzyme immunoassays or HIV RNA tests

OBJECTIVE

Determine the sensitivity of HIV rapid tests compared with fourth-generation enzyme immunoassays (EIA) or nucleic acid amplification tests (NAAT) in clinical settings.

DESIGN

Systematic review and meta-analysis.

METHODS

Medline, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane reviews and Cumulative Index to Nursing and Allied Health Literature were searched until 14 July 2015 for studies of adults comparing point-of-care HIV rapid tests to fourth-generation HIV EIA antibody/p24 antigen or HIV NAAT.

RESULTS

From 953 titles, 18 studies were included, involving 110 122 HIV rapid test results. Compared with EIA, the estimated sensitivity (random effects) of HIV rapid tests was 94.5% [95% confidence interval (CI): 87.4-97.7]. Compared with NAAT, the sensitivity of HIV rapid tests was 93.7% (95% CI: 88.7-96.5). The sensitivity of HIV rapid tests in high-income countries was 85.7% (95% CI: 81.9-88.9) and in low-income countries was 97.7% (95% CI: 95.2-98.9) compared with either EIA or NAAT (P < 0.01 for difference between settings). Proportions of antibody negative acute infections were 13.6 (95% CI: 10.1-18.0) and 4.7% (95% CI: 2.8-7.7) in studies from high-income and low-income countries, respectively (P < 0.01).

CONCLUSION

In clinical settings, HIV rapid tests were less sensitive in high-income countries compared with low-income countries, missing about one in seven infections, possibly because of the larger proportion of acute infections in targeted populations. This suggests that in high-income countries, HIV rapid tests should be used in combination with fourth-generation EIA or NAAT tests, except in special circumstances. Prospective Registration of Systematic Reviews registration number CRD42015020154.Supplementary video link: http://links.lww.com/QAD/A924.

Nevirapine- Versus Lopinavir/Ritonavir-Based Antiretroviral Therapy in HIV-Infected Infants and Young Children: Long-term Follow-up of the IMPAACT P1060 Randomized Trial

BACKGROUND

The International Maternal Pediatric Adolescent AIDS Clinical Trials Network (IMPAACT) P1060 study demonstrated short-term superiority of lopinavir/ritonavir (LPV/r) over nevirapine (NVP) in antiretroviral therapy (ART), regardless of prior NVP exposure. However, NVP-based ART had a marginal benefit in CD4 percentage (CD4%) and growth. We compared 5-year outcomes from this clinical trial.

METHODS

Human immunodeficiency virus (HIV)-infected, ART-eligible children were enrolled into 2 cohorts based on prior NVP exposure and randomized to NVP- or LPV/r-based ART. The data safety monitoring board recommended unblinding results in both cohorts due to superiority of LPV/r for the primary endpoint: stopping randomized treatment, virologic failure (VF), or death by 6 months. Participants were offered a switch in regimens (if on NVP) and continued observational follow-up. We compared time to VF or death, death, and CD4% and growth changes using intention-to-treat analyses. Additionally, inverse probability weights were used to account for treatment switching and censoring.

RESULTS

As of September 2014, 329 of the 451 (73%) enrolled participants were still in follow-up (median, 5.3 years; interquartile range [IQR], 4.3-6.4), with 52% on NVP and 88% on LPV/r as originally randomized. NVP arm participants had significantly higher risk of VF or death (adjusted hazard ratio [aHR], 1.90; 95% confidence interval [CI], 1.37-2.65) but not death alone (aHR, 1.65; 95% CI, .72-3.76) compared with participants randomized to LPV/r. Mean CD4% was significantly higher in the NVP arm up to 1 year after ART initiation, but not beyond. Mean weight-for-age z scores were marginally higher in the NVP arm, but height-for-age z scores did not differ. Similar trends were observed in sensitivity analyses.

CONCLUSIONS

These findings support the current World Health Organization recommendation of LPV/r in first-line ART regimens for HIV-infected children.

CLINICAL TRIALS REGISTRATION

NCT00307151.

Outcomes of prevention of mother to child transmission of the human immunodeficiency virus-1 in rural Kenya--a cohort study

BACKGROUND

Success in prevention of mother-to-child transmission (PMTCT) raises the prospect of eliminating pediatric HIV infection. To achieve global elimination, however, strategies are needed to strengthen PMTCT interventions. This study aimed to determine PMTCT outcomes and identify challenges facing its successful implementation in a rural setting in Kenya.

METHODS

A retrospective cohort design was used. Routine demographic and clinical data for infants and mothers enrolling for PMTCT care at a rural hospital in Kenya were analysed. Cox and logistic regression were used to determine factors associated with retention and vertical transmission respectively.

RESULTS

Between 2006 and 2012, 1338 infants were enrolled and followed up for PMTCT care with earlier age of enrollment and improved retention observed over time. Mother to child transmission of HIV declined from 19.4 % in 2006 to 8.9 % in 2012 (non-parametric test for trend p = 0.024). From 2009 to 2012, enrolling for care after 6 months of age, adjusted Odds Ratio [aOR]: 23.3 [95 % confidence interval (CI): 8.3-65.4], presence of malnutrition ([aOR]: 2.3 [95 % CI: 1.1-5.2]) and lack of maternal use of highly active antiretroviral therapy (HAART) (aOR: 6.5 [95 % CI: 1.4-29.4]) was associated with increased risk of HIV infection. Infant's older age at enrollment, malnutrition and maternal HAART status, were also associated with drop out from care. Infants who were not actively followed up were more likely to drop out from care (adjusted Hazard Ratio: 6.6 [95 % CI: 2.9-14.6]).

DISCUSSION

We report a temporal increase in the proportion of infants enrolling for PMTCT care before 3 months of age, improved retention in PMTCT and a significant reduction in the proportion of infants enrolled who became HIV-infected, emphasizing the benefits of PMTCT.

CONCLUSION

A simple set of risk factors at enrollment can identify mother-infant pairs most at risk of infection or drop out for targeted intervention.

Acceptability and preferences for safer conception HIV prevention strategies: a qualitative study

Safer conception strategies to reduce the HIV transmission risk include antiretroviral therapy for HIV-positive partners, pre-exposure prophylaxis for HIV-negative partners, condomless sex limited to fertile periods, and home-based self-insemination. Resistance to taking treatment or cultural concerns may limit uptake of strategies and intervention success. Understanding the acceptability and preferences between different approaches is important to optimise service delivery. Between February and July 2013, 42 adults (21 HIV-positive and 21 HIV-negative) receiving primary care at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, participated in focus group discussions or in-depth interviews. Themes were analysed using a grounded theory approach. Acceptability of antiretroviral-based strategies varied. Concerns over side effects, antiretroviral treatment duration and beliefs that treatment is only for the sick were common barriers; however, desperation for a child was noted as a facilitator for uptake. HIV-negative men and HIV-positive women had favourable attitudes towards self-insemination, though paternity and safety concerns were raised. Self-insemination was generally preferred over pre-exposure prophylaxis by HIV-negative men, and antiretroviral-based strategies were preferred by couples with HIV-negative female partners, despite concerns raised about condomless sex while virally suppressed. Knowledge about the fertile window was low. A strong counselling component will be required for effective uptake and adherence to safer conception services.

Eliminating mother-to-child transmission of the human immunodeficiency virus in sub-Saharan Africa: The journey so far and what remains to be done

This review was carried out to provide a comprehensive overview of efforts toward elimination of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) with respect to progress, challenges, and recommendations in 21 sub-Saharan African priority countries. We reviewed literature published from 2011 to April 2015 using 3 databases; PubMed, Scopus, and Web of Science, as well as the 2014 Global Plan Progress Report. A total of 39 studies were included. Between 2009 and 2013, there was a 43% reduction in new HIV infections, the final MTCT rate was reduced from 28% to 18%, and antiretroviral therapy (ART) coverage increased from 11% to 24%. Challenges included poor adherence to antiretroviral therapy, poor linkage between mother-child pairs and post-natal healthcare services low early infant diagnosis coverage, low pediatric ART coverage, and high unmet needs for contraceptive services. Future recommendations include identification of key barriers, health system strengthening, strengthening community involvement, and international collaboration. There has been significant progress toward eliminating MTCT of HIV, but more effort is still needed.