Frequency and reasons for delayed treatment initiation after HIV diagnosis: cross-sectional study in Lahore, Pakistan

Reduction in time to viral suppression among persons living with HIV in Jamaica between 2017-2019

INTRODUCTION

HIV viral suppression is important for effective treatment and for reducing new infections. In 2019, only 66% of persons on antiretroviral treatment (ART) in Jamaica were virally suppressed. We aim to compare time to viral suppression by ART initiation year and type of treatment site to understand the implications for programming.

METHODS

We assessed time to viral suppression among 4560 persons who received viral load testing either pre or post ART initiation from 2017-2019. We used descriptive statistics and Kaplan-Meier estimates to compare survival curves by ART year (2017, 2018, 2019), sex and type of treatment site (public and non-governmental organizations). Persons were censored if suppression was not achieved. Mixed effects Cox regression was used to determine the effect of covariates on the likelihood of viral suppression. We report hazard ratios and 95% confidence intervals.

RESULTS

Pre-ART viral load testing decreased from 36% in 2017 to 30% in 2019. For post-ART viral load tests, approximately 78% (n = 1589) of persons achieved suppression, 51% (n = 809) were female and 86% (n = 1341) used a public treatment site. The median time to suppression decreased by 3 months from 2017 to 2019. The likelihood of suppression was almost 2 times greater in 2018 (HR = 1.56, CI = 1.39-1.75) and 3 times greater in 2019 (HR = 3.17, CI = 2.76-3.64) compared to 2017. NGO treatment sites were also significantly associated with the likelihood of viral suppression compared to public sites.

CONCLUSION

Pre-ART viral load testing and the time to viral suppression decreased over three years. Initiating ART after 2017 and early use of NGO treatment sites were found to significantly increase the likelihood of achieving suppression. This demonstrates improvements in the national HIV response but there is need to increase the number of persons on ART and achieving viral suppression.

Factors associated with late initiation of antiretroviral therapy in Iran's HIV/AIDS surveillance data

Early initiation of Antiretroviral Treatment (ART) in HIV patients is essential for effectively suppressing the viral load and prognosis. This study utilized National HIV/AIDS Surveillance Data in Iran to identify factors associated factors with the duration to initiate ART. This hybrid cross-sectional historical cohort study was conducted on Iran's National HIV/AIDS Surveillance Data from 2001 to 2019. Sociodemographic characteristics, route of transmission, HIV diagnosis date, and ART initiation date were collected. Multivariable linear and quantile regression models were employed to analyze the duration to initiate ART by considering predictor variables. This study included 17,062 patients (mean age 34.14 ± 10.77 years, 69.49% males). Multivariate quantile regression coefficients varied across different distributions of the dependent variable (i.e., duration to initiate ART) for several independent variables. Generally, male gender, injecting drug use (IDU), and having an HIV-positive spouse were significantly associated with an increased duration to initiate ART (p < 0.05). However, a significant decrease was observed in older patients, those with a university level education, men who had sex with men (MSM), and patients diagnosed after 2016 (p < 0.05). Despite improvements in the duration to initiate ART after implementing the WHO's 2016 program in Iran, various sociodemographic groups were still vulnerable to delayed ART initiation in the region. Therefore, programs including early testing, early ART initiation, active care, educational and cultural interventions, and appropriate incentives are required for these groups.

Factors Associated With Delayed and Late Initiation of Antiretroviral Therapy Among Patients With HIV in Beijing, China, 2010-2020

Objectives: To determine factors associated with late and delayed antiretroviral therapy (ART) initiation in China and provide evidence for HIV prevention. Methods: Logistics regression model was used to determine factors associated with three outcomes: late (CD4 cell count <200 cells/µL or clinical AIDS diagnosis prior to ART initiation), delayed (more than 1 month between HIV diagnosis date and ART initiation) and either late or delayed ART initiation. Results: Multivariable analysis revealed that male, heterosexual, HIV diagnosis before 2014, HBV/HCV seropositive, and tuberculosis were associated with increased odds of all three outcomes. Conversely, married or cohabiting patients were less likely to have delayed ART initiation and either late or delayed ART initiation, while people who inject drugs were more likely to have these two outcomes. Additionally, older age was associated with an increased risk of having either late or delayed ART initiation, but a decreased risk of delayed ART initiation. Conclusion: The proportion of late and delayed ART initiation decreased significantly after the release of the 2016 guidelines in China. To further improve late diagnosis and early treatment, precise interventions for key populations are required.

Acceptability and feasibility of HIV self-testing among transgender people in Larkana, Pakistan: Results from a pilot project

Background

HIV self-testing (HIVST) is an innovative HIV testing approach that effectively reaches those who do not otherwise test, including key populations (KPs). Despite potential benefits, HIVST is not currently implemented in Pakistan. The high risk of HIV among transgender (TGs) persons is among the highest risk group for HIV in Pakistan, yet knowledge of HIV status remains low in this key population group. We conducted a pilot project to assess the acceptability and feasibility of distributing HIVST to TGs in Larkana.

Methods

Eligible participants were 18 years or above and self-identified as transgender (“hijra”). One oral fluid HIVST kit per person was distributed free of cost in the community by trained transgender peer outreach workers (ORW). Participants could request a demonstration of the HIVST procedure before performing self-testing which was provided by the trained ORW. Demographic characteristics of participants were collected. The ORW followed up with phone calls two days later to record if HIVST kits were used, the results, and whether assistance was required.

Results

Between November 2020 and February 2021, 150 HIVST kits were distributed to eligible TGs. The average age of participants was 25.5 years (standard deviation: 7.0). Over a third (52, 34.7%) had no formal education, while (16, 10.6%) had attended at least five years of schooling. Over one-third (58, 38.6%) of participants were first-time testers. One hundred and thirty-nine (92.7%) participants reported their results within two days. For the remaining 11 participants, ORWs had to contact them. All participants reported using HIVST kits within three days. A majority (141, 94%) used the kit in their homes, and the remaining nine (6%) used it at the community-based organization’s office. Overall, a small proportion (11, 7.3%) of participants requested a demonstration of the test procedure before performing HIVST. Four (2.7%) participants who had performed unsupervised self-tests reported reactive HIVST results; all were linked to treatment within five working days once their HIV result was confirmed. The majority (136, 90.6%) of participants felt that self-testing was easy to perform independently, and 143 (95%) reported that they would recommend HIVST to their peers.

Conclusion

HIVST is acceptable among TGs and identified by first-time testers as undiagnosed infections. Peer-led distribution appears to be a feasible approach for implementation in this setting. HIVST should be considered for routine implementation and scale up to reduce testing gaps among Pakistan’s key population, particularly TGs.

Late cART Initiation Consistently Driven by Late HIV Presentation: A Multicenter Retrospective Cohort Study in Taiwan from 2009 to 2019

INTRODUCTION

Late initiation (LI) of combination antiretroviral therapy (cART)-defined as having a CD4⁺ count of < 200 cells/μL or an AIDS-defining disease at cART initiation-has detrimental outcomes but remains prevalent worldwide, with LI trends and etiologies following the implementation of various HIV policies remaining underinvestigated. We assessed key concerns, characterized the determinants of various statuses at cART initiation, and evaluated the effects of those statuses on all-cause mortality after cART initiation.

METHODS

This multicenter retrospective cohort study enrolled 1198 patients with newly diagnosed HIV infection during 2009-2019 who were grouped by status at cART initiation: those without LI (non-LI group, 56.01%); those with LI but without late presentation (LP) of HIV (LP: a CD4 + count of < 200 cells/μL at HIV presentation or AIDS events ≤ 3 months of HIV diagnosis) [LILP(-) group, 4.51%]; and those with LI and with LP of HIV [LILP(+) group, 39.48%]. Joinpoint regression was used to identify changes in LI proportion.

RESULTS

The median CD4⁺ count at cART initiation increased significantly between 2009 (98 cells/μL) and 2015 (325 cells/μL) and stabilized thereafter (P for trend < 0.001). For LI, we identified one joinpoint in 2015: a substantial decrease from 77.14% in 2009 to 34.45% in 2015, followed by a nonsignificant increase to 39.1% in 2019. Overall, LILP(+) explained 89.8% of LI, without significant changes (92.59% in 2009 to 94.23% in 2019). In addition to HIV diagnosis during 2009-2012, multinomial logistic regression identified an age over 30 years and acute HIV infection as risk factors for LILP(+) and LILP(-), respectively. LILP(-) and LILP(+) were associated with a higher all-cause mortality risk.

CONCLUSION

Given the rise in LI from 2015 in the era of treat-all and rapid cART initiation, strategic interventions to increase earlier cART initiation must be intensified in Taiwan, especially among populations with delayed access to HIV testing services.

Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan

Background: With the increased availability of safe antiretroviral therapy (ART) in recent years, achieving optimal adherence and patient retention is becoming the biggest challenge for people living with HIV (PLWH). Care retention is influenced by several socioeconomic, socio-cultural, and government policies during the COVID-19 pandemic. Therefore, we aim to explore barriers and facilitators to adherence to ART among PLWH in Pakistan in general and COVID-19 pandemic related in particular.

Methods: Semi-structured interviews were conducted among 25 PLWH from December 2020 to April 2021 in the local language (Urdu) at the ART centre of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Interviews were audio-recorded in the local Urdu language, and bilingual expert (English, Urdu) transcribed verbatim, coded for themes and sub-themes, and analyzed using a phenomenological approach for thematic content analysis.

Results: Stigma and discrimination, fear of HIV disclosure, economic constraints, forgetfulness, religion (Ramadan, spiritual healing), adverse drug reactions, lack of social support, alternative therapies, and COVID-19-related lock-down and fear of lesser COVID-19 care due to HIV associated stigma were identified as barriers affecting the retention in HIV care. At the same time, positive social support, family responsibilities, use of reminders, the beneficial impact of ART, and initiation of telephone consultations, courier delivery, and long-term delivery of antiretrovirals during COVID-19 were identified as facilitators of HIV retention.

Conclusion: Improving adherence and retention is even more challenging due to COVID-19; therefore, it requires the integration of enhanced access to treatment with improved employment and social support. HIV care providers must understand these reported factors comprehensively and treat patients accordingly to ensure the continuum of HIV care. A coordinated approach including different stakeholders is required to facilitate patient retention in HIV care and consequently improve the clinical outcomes of PLWH.