The missed potential of CD4 and viral load testing to improve clinical outcomes for people living with HIV in lower-resource settings

"We have been so patient because we know where we are coming from" Exploring the acceptability and feasibility of a mobile electronic medical record system designed for community-based antiretroviral therapy in Lilongwe, Malawi

Background

Mobile health (mHealth) is reshaping healthcare delivery, especially in HIV management. The World Health Organization advocates for mHealth to provide healthcare workers (HCWs) with real-time data, enhancing patient care. However, in Malawi's Lighthouse Trust antiretroviral therapy (ART) clinic, the nurse-led community-based ART (NCAP) program faces hurdles with data management due to lack of access to electronic medical records systems (EMRS) in the community setting. EMRS is not typically available in differentiated service delivery settings where reliable power and internet are often unavailable. We used human-centered design (HCD) processes to create a mobile EMRS prototype, the Community-based ART Retention and Suppression (CARES) app. We explore progress to simplify workflow for HCWs and improve client care.

Methods

To evaluate the CARES app's feasibility and acceptability among NCAP HCWs, we conducted in-depth interviews among 15 NCAP HCWs. We used a rapid qualitative analysis approach guided by the extended Technology Acceptance Model. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results

As a likely result of HCD, HCWs demonstrated high expectations for the CARES app to improve healthcare delivery and data management. However, challenges such as app performance, data integration, and system navigation were significant barriers to acceptance or feasibility. Despite challenges, HCWs remained optimistic about the potential for CARES to enhance NCAP clinical decision-making and data flow. HCWs emphasized the need for continuous training and stakeholder engagement, improved infrastructure, data security protections, and establishing the CARES app and EMRS integration to facilitate CARES' longterm success at scale.

Conclusion

The study's findings underscore the importance of HCD for mHealth buy-in. As HCWs were invested in CARES success, they remained optimistic that the app could enhance NCAP services if user experience and app performance improved. Incorporation of HCW feedback would help deliver beyond the promise of CARES.

A Community-Based, Mobile Electronic Medical Record System App for High-Quality, Integrated Antiretroviral Therapy in Lilongwe, Malawi: Design Process and Pilot Implementation

BACKGROUND

Differentiated service delivery (DSD) increases antiretroviral therapy (ART) access in sub-Saharan Africa by moving clients out of congested ART clinics to communities for care. However, DSD settings challenge provider adherence to complex, chronic care treatment guidelines and have burdensome systems for client monitoring and evaluation (M&E), reducing data for decision-making. Electronic medical record systems (EMRS) improve client outcomes and reduce M&E workload. Traditional EMRS cannot operate in most DSD settings with unreliable power and poor connectivity.

OBJECTIVE

This study aims to detail the human-centered design (HCD) process of developing a mobile EMRS for community-based DSD services in Lilongwe, Malawi.

METHODS

Lighthouse Trust (LT) operates 2 Ministry of Health (MoH) clinics in Lilongwe, Malawi, with a combined total of >35,000 ART clients. LT's real-time, point-of-care EMRS collects complex client M&E data and provides decision-making support, ensuring adherence to integrated HIV and tuberculosis guidelines that optimize client and program outcomes. LT's EMRS scaled to all large MoH ART clinics. LT also implements a nurse-led community-based ART program (NCAP), a DSD model to provide ART and rapid assessment for 2400 stable LT clients in the community. LT, alongside collaborators, from the University of Washington's International Training and Education Center for Health and technology partner, Medic, used the open-source Community Health Toolkit (CHT) and HCD to develop an open-source, offline-first, mobile EMRS-like app, "community-based ART retention and suppression" (CARES). CARES aims to bring EMRS-like provider benefits to NCAP's DSD clients.

RESULTS

CARES design took approximately 12 months and used an iterative process of highly participatory feedback sessions with provider, data manager, and M&E team inputs to ensure CARES optimization for the NCAP and LT settings. The CARES mobile EMRS prototype supports NCAP providers with embedded prompts and alerts to ensure adherence to integrated MoH ART guidelines, aiming to improve the quality of client care. CARES facilitates improved data quality and flow for NCAP M&E, aiming to reduce data gaps between community and clinic settings. The CARES pilot demonstrates the potential of a mobile, point-of-care EMRS-like app that could benefit NCAP clients, providers, and program teams with integrated client care and complete M&E data for decision-making. CARES challenges include app speed, search features to align longitudinal records, and CARES to EMRS integration that supports timely care alerts.

CONCLUSIONS

Leveraging the CHT and HCD processes facilitated the design of a locally specified and optimized mobile app with the promise to bring EMRS-like benefits to DSD settings. Moving from the CARES prototype to routine NCAP implementation should result in improved client care and strengthened M&E while reducing workload. Our transparent and descriptive process shares the progress and pitfalls of the CARES design and development, helping others in this digital innovation area to learn from our experiences at this stage.

Risk indicators for oral ulcers among people living with HIV during the first wave of the pandemic: a cross sectional study

BACKGROUND

Little is currently known about HIV-related parameters that may increase the risk for oral ulcers during the COVID-19 pandemic. This study aimed to overcome this gap in research by assessing the associations between HIV viral load, antiretroviral adherence profile, co-morbidity status, SARS-CoV-2 infection and oral ulcers among people living with HIV (PLHIV).

METHODS

This was a secondary analysis of data generated from 21,206 to 18 years and above, recruited from 152 countries through an online survey between July and December 2020. Data were extracted for 874 people who reported living with HIV. The dependent variable was reporting having oral ulcer. The independent variables were the viral load, adherence to antiretroviral treatment and a history of SARS-CoV-2 infection. The confounding variables were age at last birthday and sex at birth. A multivariable logistic regression analysis was conducted to determine the associations between the dependent and independent variables after adjusting for the confounding variables.

RESULTS

Of the 874 participants, 99 (11.3%) reported having oral ulcers during the first wave of the COVID-19 pandemic. The odds of PLHIV having oral ulcers during the first wave of the COVID-19 pandemic was significantly higher for people who did not know their viral load than those who had undetectable viral load (AOR: 2.036; 95% CI: 1.204-3.443; p = 0.008); and people who did not adhere to the use of antiretroviral treatment than those who adhered (AOR: 4.113; 95% CI: 2.567-6.589; p < 0.001). Also, PLHIV who had SARS-CoV-2 infection had significantly higher odds of having oral ulcers than those who did not have the infection (AOR: 14.556; 95% CI: 4.500-47.078; p < 0.001). PLHIV who had co-morbidities had non-significantly higher odds of having oral ulcers than those without co-morbidities (AOR: 1.170; 95% CI: 0.656-2.085; p = 0.595).

CONCLUSION

Oral ulcers may be an indicator of poor adherence to antiretroviral therapy and unsuppressed viral load among PLHIV. It may also be an indicator of SARS-CoV-2 infection and a signal to take prompt and critical care of affected individuals because of the risk for severe COVID-19 for these individuals.

Point of Care CD4 Testing in National Household Surveys - Results and Quality Indicators from Eleven Population-Based HIV Impact Assessment (PHIA) Surveys

Population-based HIV Impact Assessments (PHIAs) are national household (HH) surveys that provide HIV diagnosis and CD4 testing with an immediate return of results. Accurate CD4 results improve HIV-positive participants' clinical care and inform the effectiveness of HIV programs. Here, we present CD4 results from the PHIA surveys that were conducted in 11 countries in sub-Saharan Africa between 2015 and 2018. All of the HIV-positive participants and 2 to 5% of the HIV-negative participants were offered Pima CD4 (Abbott, IL, USA) point-of-care (POC) tests. The quality of the CD4 test was ensured by conducting instrument verification, comprehensive training, quality control, a review of testing errors and an analysis of unweighted CD4 data by HIV status, age, gender, and antiretroviral (ARV) treatment status. Overall, CD4 testing was completed for 23,085 (99.5%) of the 23,209 HIV-positive and 7,329 (2.7%) of the 270,741 negative participants in 11 surveys. The instrument error rate was 11.3% (range, 4.4% to 15.7%). The median CD4 values among HIV-positive and HIV-negative participants (aged 15+) were 468 cells/mm3 (interquartile range [IQR], 307 to 654) and 811 cells/mm3 (IQR, 647 to 1,013), respectively. Among the HIV-positive participants (aged 15+), those with detectable ARVs had higher CD4 values (508 cells/mm3) than those with undetectable ARVs (385.5 cells/mm3). Among the HIV-positive participants (aged 15+), 11.4% (2,528/22,253) had a CD4 value of less than 200 cells/mm3, and approximately half of them (1,225/2,528 = 48.5%) had detectable ARVs, whereas 51.5% (1,303/2,528) had no detectable ARVs (P < 0.0001). We successfully implemented high quality POC CD4 testing using Pima instruments. Our data come from nationally representative surveys in 11 countries and provide unique insights regarding the CD4 distribution among HIV-positive individuals as well as the baseline CD4 values among HIV-negative individuals. IMPORTANCE The manuscript describes CD4 levels among HIV-positive individuals and baseline CD4 levels among HIV-negative individuals from 11 sub-Saharan countries, thereby highlighting the importance of CD4 markers in the context of the HIV epidemic. Despite increased ARV access in each country, advanced HIV disease (CD4 < 200 cells/mm3) persists among approximately 11% of HIV-positive individuals. Therefore, it is important that our findings are shared with the scientific community to assist with similar implementations of point-of-care testing and to conduct a review of HIV programmatic gaps.

Exosome and virus infection

Exosomes are messengers of intercellular communication in monolayer vesicles derived from cells. It affects the pathophysiological process of the body in various diseases, such as tumors, inflammation, and infection. It has been confirmed that exosomes are similar to viruses in biogenesis, and exosome cargo is widely involved in many viruses’ replication, transmission, and infection. Simultaneously, virus-associated exosomes can promote immune escape and activate the antiviral immune response of the body, which bidirectionally modulates the immune response. This review focuses on the role of exosomes in HIV, HBV, HCV, and SARS-CoV-2 infection and explores the prospects of exosome development. These insights may be translated into therapeutic measures for viral infections and reduce the disease burden.

Assessment of HIV viral load monitoring in remote settings in Vietnam - comparing people who inject drugs to the other patients

INTRODUCTION

Increasing access to viral load (VL) monitoring is essential to fight HIV epidemics. In remote settings in Vietnam, using dried blood spot (DBS) sampling for specimen collection could improve the situation. Here, people who inject drugs (PWID) represent many newly antiretroviral therapy (ART)-initiated patients. The goals of this evaluation were to evaluate if access to VL monitoring and the rate of virological failure differed between PWID and non-PWID.

METHODS

Prospective cohort study of patients newly initiated on ART in remote settings in Vietnam. DBS coverage at 6, 12 and 24 months of ART was investigated. Factors associated with DBS coverage were identified through logistic regression, as were factors associated with virological failure (VL ≥1,000 copies/mL) at 6, 12 and 24 months of ART.

RESULTS

Overall 578 patients were enrolled in the cohort, of whom 261 (45%) were PWID. DBS coverage improved from 74.7% to 82.9% between 6 and 24 months of ART (p = 0.001). PWID status was not associated with DBS coverage (p = 0.74), but DBS coverage was lower in patients who were late to clinical visits and in those in WHO stage 4 (p = 0.023 and p = 0.001, respectively). The virological failure rate decreased from 15.8% to 6.6% between 6 and 24 months of ART (p<0.001). In multivariate analysis, PWID were more at risk of failure (p = 0.001), as were patients who were late to clinical visits (p<0.001) and not fully adherent (p<0.001).

CONCLUSIONS

Despite training and simple procedures, DBS coverage was not perfect. DBS coverage was not associated with PWID status. Close management is required for effective routine HIV VL monitoring. PWID were more at risk of failure, as were patients who were not fully adherent and patients who were late to clinical visits. Specific interventions targeting these patients are needed to improve their outcomes. Overall, efforts in coordination and communication are essential to improve global HIV care.

TRIAL REGISTRATION

Clinical Trial Number: NCT03249493.

Better Predictive Value of Lymphocyte Count and Hemoglobin for CD4 Level of HIV Patients

OBJECTIVE

HIV patients are prone to infection and difficult to treat, which mainly manifests itself in decreased CD4+ T cells in the body. Therefore, the predictive value of lymphocyte count and hemoglobin for CD4+ levels in HIV patients was discussed in the prospective study.

METHODS

125 HIV patients (aged >18 or < 80 years) were recruited. Pearson chi-square test was used to explore the correlation between CD4+ content and blood-related parameters in HIV patients. Univariate and multivariate logistic regression analyses were used to calculate ORs for each variable. In addition, receiver ROC curves were constructed to assess each factor's accuracy and sensitivity in diagnosing CD4+.

RESULTS

Lymphocyte count and hemoglobin were significantly correlated with CD4+. In terms of multivariate logistic regression level, there was a significant correlation between lymphocyte count (OR = 3.170, 95% CI: 1.442-6.969, P = 0.004), hemoglobin (OR = 2.545, 95% CI: 1.148- 5.646, P = 0.022) and CD4+ content in HIV patients. Based on the neural network model, the level of lymphocyte and hemoglobin might be the predictive indexes of CD4+ level. We find the high-risk warning indicator of CD4+ level: 3 < lymphocyte (109/L) < 3.6, and 150 < hemoglobin (g/L) < 200.

CONCLUSION

Better predictive value of lymphocyte count and hemoglobin for CD4+ level of HIV patients.

Prevalence and factors associated with substance use among HIV positive youth attending HIV care and treatment centers in Dodoma, Tanzania

BACKGROUND

Substance use among people living with HIV is associated with poor health, social, and psychological outcomes. This study assessed the prevalence of substance use and associated factors among youth attending HIV care and treatment centers (CTCs) in Dodoma, Tanzania.

METHODS

This cross-sectional study was carried out in Dodoma, Tanzania, from February to April 2020 among youth aged 15-24 attending HIV CTCs. Data was collected using sociodemographic, WHO ASSIST Version 3.0, BDI II, and SERAD questionnaires. Data analysis was done using Stata 17. Descriptive statistics were used to summarize continuous and categorical variables. Univariable and multivariable logistic regression analyses were conducted to determine factors independently associated with substance use.

RESULTS

The prevalence of substance use was relatively low (6.6%). Older youth (20 to 24 years) were 2% less likely to use substances compared to the younger ones (15 to 19 years) (AOR: 0.07; 95% CI 0.01, 0.83). There were statistically significant decreasing odds of substance use with every year increase in age at HIV diagnosis (OR: 1.66; 95% CI 1.14, 2.41). Being unemployed was statistically significantly associated with decreased odds of substance use among this population (OR: 0.03; 95% CI 0.02, 0.33). Youth who had detectable viral loads were significantly more likely to use substances compared to those with undetectable viral loads (AOR: 12.9; 95% CI 1.07, 156.05).

CONCLUSIONS

Despite the low prevalence of substance use found in this study, it is important to note that late age of HIV diagnosis, employment, and detectable viral load negatively impacted HIV positive youth with regards to substance use. It is recommended that CTCs emphasize routine screening for substance use among youth who have detectable viral loads.

Correlation Between CD4 Cell Count, HIV Viral Load, and Chest CT Findings of AIDS-associated Pulmonary Cryptococcosis

Background: The computed tomography (CT) features of acquired immune deficiency syndrome (AIDS)-associated pulmonary cryptococcosis (PC) are correlated with the viral load of human immunodeficiency virus (HIV). An increase in CD4-positive T lymphocyte (CD4) cell count in peripheral blood after a highly active antiretroviral therapy (HAART) can reflect the morphological changes of lung lesions. Objectives: This study aimed to evaluate the correlation between CT features and HIV viral load and to determine a cut-off value for CD4 cell count increment to investigate the prognosis of PC. It also aimed to examine the morphology of PC lesions and their prognosis following HAART. Methods: Sixty-two patients with AIDS-associated PC, confirmed by pathology or follow-up, were enrolled in this study. The CT findings were recorded and classified as nodular, cavitary, and consolidation groups and their subtypes. Forty HIV patients who had undergone HAART were screened in this study, and the outcomes of lung lesions were recorded in a follow-up of 3 - 6 months. The participants were divided into improvement and progression groups. The correlation analysis and the receiver operator characteristic (ROC) curve analysis were used to examine the correlation between CT morphology and HIV viral load and to determine the cut-off value for CD4 cell count increment. The intraclass correlation coefficient (ICC) for inter-observer agreement was also calculated. Results: In the nodular group, patients with miliary nodules had the highest HIV viral load in peripheral blood (miliary nodules vs. solitary nodules, P = 0.009; miliary nodules vs. multiple nodules; P = 0.024). In the cavitary group, thick-walled cavity lesions had a higher HIV viral load than thin-walled cavity lesions (thin-walled vs. thick-walled cavity lesions, P = 0.036). Changes in the morphology of lesions, indicating the progression or improvement of PC, had a positive correlation with the CD4 cell count increment (F = 4.260, P = 0.045). The cut-off value for CD4 cell count increment to differentiate the two outcomes (progression and improvement) was 44/µL. The area under the curve (AUC) was 0.851, and sensitivity, specificity, and accuracy were estimated at 0.815, 0.714, and 0.764, respectively. Conclusion: In AIDS-associated PC, different types of lesions were related to the HIV viral load, and CD4 cell count increment following HAART was associated with the morphological changes of lesions. This finding can be helpful for clinicians and radiologists to make an accurate diagnosis and evaluate the treatment outcomes, as well as disease progression.

Diagnostic Accuracy of the Rapid Xpert HIV-1 Viral Load XC, Xpert HIV-1 Viral Load, & m-PIMA HIV-1/2 Viral Load in South African Clinics

BACKGROUND

We aimed to evaluate the analytic performance of 3 rapid HIV viral load assays: the novel Xpert HIV-1 VL XC (Xpert XC), Xpert HIV-1 VL (Xpert VL), and m-PIMA HIV-1/2 VL (m-PIMA).

SETTING

Two South African clinics.

METHODS

We conducted a prospective diagnostic accuracy study. Site-laboratory technicians and nurses used the Xpert XC, Xpert VL, and m-PIMA to test plasma samples from people with HIV receiving antiretroviral therapy. We compared results with the Roche cobas HIV-1 reference assay. We determined accuracy to detect viraemia at the World Health Organization (WHO) failure threshold of 1000 copies/mL on all 3 assays, and 50 and 200 copies/mL on the Xpert assays. We assessed the agreement using Bland-Altman plots.

RESULTS

We enrolled 140 participants (98 [70%] women, median age 37 years), who provided 189 paired samples at one or more timepoints. We tested 174 samples with the Xpert XC, 188 with the Xpert VL, and 128 with the m-PIMA. At 1000 copies/mL, sensitivity and specificity (95% confidence intervals) were 97% (82 to 100) and 98% (93 to 99) (Xpert XC), 100% (87 to 100) and 96% (91 to 98) (Xpert VL), and 92% (72 to 99) and 99% (93 to 100) (m-PIMA) respectively. At 50 copies/mL, sensitivity and specificity were 93% (81 to 98) and 96% (91 to 99) (Xpert XC), and 95% (84 to 99) and 95% (90 to 98) (Xpert VL) respectively. Mean bias was -0.10 (-0.54 to 0.34) log10 copies/mL (Xpert XC), 0.07 (-0.37 to 0.52) log10 copies/mL (Xpert VL), and -0.26 (-0.83 to 0.31) log10 copies/mL (m-PIMA).

CONCLUSIONS

In these South African clinics, the accuracy of all 3 assays was clinically acceptable to detect viraemia at the WHO failure threshold, whereas both Xpert assays were also accurate at detecting low-level viraemia.

Characteristics and clinical outcomes of patients presenting with advanced HIV disease in the "treat all" era: a retrospective cohort study from rural Rwanda

Background

In 2016 Rwanda adopted “treat all” where all patients with HIV are immediately eligible for ART regardless of disease progression. Despite widespread availability of treatment, it is unknown whether presentation with advanced HIV persists.

Methods

We conducted a retrospective cohort among patients aged ≥ 15 who enrolled in care between July 2016 and July 2018 in three rural Rwandan districts. We estimated the prevalence of advanced HIV, defined as presenting with CD4 count < 200 cells/mm³ or WHO stage 3 or 4, and compared baseline characteristics of patients with and without advanced HIV. We compared cumulative incidences and time to events using Chi squared tests and Cox proportional hazards models, respectively, for (a) viral load tests; (b) viral suppression; (c) death; and (d) treatment failure (a composite of death, lost to follow up, or virologic failure).

Results

Among 957 patients, 105 (11.0%) presented with advanced HIV. These patients were significantly more likely to have low body mass index, come from Burera district, be older, and be identified through inpatient settings rather than through voluntary or prenatal testing. Patients with advanced HIV had significantly higher risks of death at 12-months (9.5% vs 1.5%, p < 0.001) and 18-months (10.5% vs 1.9%, p < 0.001) and significantly higher risk of treatment failure at 12-months (21.9% vs. 14.2%, p = 0.037). After adjusting for confounders, patients with advanced HIV had still higher rates of death (adjusted Hazard ratio [aHR] = 4.4, 95% CI: 1.9, 10.2, p < 0.001) and treatment failure (aHR = 1.7, 95% CI: 1.1, 2.5, p = 0.017), but no difference in viral load testing (aHR = 1.1, 95% CI: 0.8, 1.5, p = 0.442) or viral suppression (aHR = 1.0, 95% CI: 0.8, 1.4, p = 0.949). When allowing for the hazard ratio to vary over time, patients with advanced HIV experienced elevated rates of treatment failure in the first six of enrollment, but not after nine months.

Conclusion

Presenting with advanced HIV remains common and is still associated with poor patient outcomes. Sensitization of the community to the benefits of early ART initiation, identification of patients with advanced HIV, and holistic support programs for the first 6 months of treatment may be needed to improve outcomes.

Viral load monitoring for people living with HIV in the era of test and treat: progress made and challenges ahead - a systematic review

Background

In 2016, we conducted a systematic review to assess the feasibility of treatment monitoring for people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in low and middle-income countries (LMICs), in line with the 90-90-90 treatment target. By 2020, global estimates suggest the 90-90-90 target, particularly the last 90, remains unattainable in many LMICs. This study aims to review the progress and identify needs for public health interventions to improve viral load monitoring and viral suppression for PLHIV in LMICs.

Methods

A literature search was conducted using an update of the initial search strategy developed for the 2016 review. Electronic databases (Medline and PubMed) were searched to identify relevant literature published in English between Dec 2015 and August 2021. The primary outcome was initial viral load (VL) monitoring (the proportion of PLHIV on ART and eligible for VL monitoring who received a VL test). Secondary outcomes included follow-up VL monitoring (the proportion of PLHIV who received a follow-up VL after an initial elevated VL test), confirmation of treatment failure (the proportion of PLHIV who had two consecutive elevated VL results) and switching treatment regimen rates (the proportion of PLHIV who switched treatment regimen after confirmation of treatment failure).

Results

The search strategy identified 1984 non-duplicate records, of which 34 studies were included in the review. Marked variations in initial VL monitoring coverage were reported across study settings/countries (range: 12–93% median: 74% IQR: 46–82%) and study populations (adults (range: 25–96%, median: 67% IQR: 50–84%), children, adolescents/young people (range: 2–94%, median: 72% IQR: 47–85%), and pregnant women (range: 32–82%, median: 57% IQR: 43–71%)). Community-based models reported higher VL monitoring (median: 85%, IQR: 82-88%) compared to decentralised care at primary health facility (median: 64%, IRQ: 48-82%). Suboptimal uptake of follow-up VL monitoring and low regimen switching rates were observed.

Conclusions

Substantial gaps in VL coverage across study settings and study populations were evident, with limited data availability outside of sub-Saharan Africa. Further research is needed to fill the data gaps. Development and implementation of innovative, community-based interventions are required to improve VL monitoring and address the “failure cascade” in PLHIV on ART who fail to achieve viral suppression.

Newly implemented community CD4 service in Tshwaragano, Northern Cape province, South Africa, positively impacts result turn-around time

Background

The Northern Cape is South Africa’s largest province with an HIV prevalence of 7.1% versus a 13.5% national prevalence. CD4 testing is provided at three of five National Health Laboratory Service district laboratories, each covering a 250 km precinct radius. Districts without a local service report prolonged CD4 turn-around times (TAT).

Objective

This study documented the impact of a new CD4 laboratory in Tshwaragano in the remote John Taolo Gaetsewe district of the Northern Cape, South Africa.

Methods

CD4 test volumes and TAT (total, pre-analytical, analytical, and post-analytical) data for the Northern Cape province were extracted for June 2018 to October 2019. The percentage of CD4 results within the stipulated 40-h TAT cut-off and the median and 75th percentiles of all TAT parameters were calculated. Pre-implementation, samples collected at Tshwaragano were referred to Kimberley or Upington, Northern Cape, South Africa.

Results

Pre-implementation, 95.4% of samples at Tshwaragano were referred to Kimberley for CD4 testing (36.3% of Kimberley’s test volumes). Only 7.5% of Tshwaragano’s total samples were referred post-implementation. The Tshwaragano laboratory’s CD4 median total TAT decreased from 24.7 h pre-implementation to 12 h post-implementation (p = 0.003), with > 95.0% of results reported within 40 h. The Kimberley laboratory workload decreased by 29.0%, and testing time significantly decreased from 10 h to 4.3 h.

Conclusion

The new Tshwaragano CD4 service significantly decreased local TAT. Upgrading existing community laboratories to include CD4 testing can alleviate provincial service load and improve local access, TAT and efficiency in the centralised reference laboratory.

A profile of the Visitect® CD4 and Visitect® CD4 advanced disease for management of people living with HIV

INTRODUCTION

CD4 testing plays an important role in clinical management and epidemiological surveillance of HIV disease. Rapid, point-of-care (POC) CD4 tests can improve patients' access to CD4 testing, enabling decentralization of HIV services.

AREAS COVERED

We conducted a profile review of the Visitect®CD4 and the Visitect®CD4 Advanced Disease (Omega Diagnostics, UK) - the two lateral flow, equipment-free POC CD4 tests, which can be used to identify people with HIV who have CD4 of less than 350 and 200 cells/μl, respectively. Using published data from independent studies, we discussed the performance and utility of these tests, highlighting the advantages as well as their limitations.

EXPERT OPINION

The tests are user-friendly, acceptable to health care workers, and feasible to implement in primary health care settings and can provide reliable results for clinical decision-making. Hands-on training with pictorial instructions for use is needed to enhance test's operator confidence in interpretation of test results. Quality assurance program should be in place to ensure the quality of testing. Development of a next-generation test with a cutoff of 100 cells/μl is recommended to identify patients with advanced immunosuppression for initiation of prophylaxis to reduce HIV-related death. Operational research is also needed to identify cost-effective implementation strategies in real-world settings.

Point-of-care CD4 testing: Differentiated care for the most vulnerable

Background

South Africa, with the highest burden of HIV infection globally, has made huge strides in its HIV/ART programme, but AIDS deaths have not decreased proportionally to ART uptake. Advanced HIV disease (CD4 < 200 cells/mm³) persists, and CD4 count testing is being overlooked since universal test-and-treat was implemented. Point-of-care CD4 testing could address this gap and assure differentiated care to these vulnerable patients with low CD4 counts.

Methods

A time randomised implementation trial was conducted, enrolling 603 HIV positive non-ART, not pregnant patients at a primary health care clinic in Durban, South Africa. Weeks were randomised to either point-of-care CD4 testing (n = 305 patients) or standard-of-care central laboratory CD4 testing (n = 298 patients) to assess the proportion initiating ART at 3 months. Cox regression, with robust standard errors adjusting for clustering by week, were used to assess the relationship between treatment initiation and arm.

Results

Among the 578 (299 point-of-care and 279 standard-of-care) patients eligible for analysis, there was no significant difference in the number of eligible patients initiating ART within 3 months in the point-of-care (73%) and the standard-of-care (68%) groups (P = 0.112). The time-to-treat analysis was not significantly different in patients with CD4 counts of 201-500 cells/mm³ which could have been due to appointment scheduling to cope with the large burden of cases. However, in patients with advanced HIV disease (CD4 < 200cells/mm³) 65% more patients started ART earlier in the point-of-care group (HR 1.65 (95% confidence interval (CI) = 0.99-2.75; P = 0.052) compared to the standard-of-care group.

Conclusions

Point-of-care testing decreased time-to-treatment in those with advanced HIV disease. With universal test and treat for HIV, rollout of simple point-of-care CD4 testing would ensure early diagnosis of advanced HIV disease and facilitate differentiated care for these vulnerable patients as per the World Health Organisation 2020 target product profile for point-of-care CD4 testing.

Trial registration

ISRCTN14220457.

An Android-Based Mobile App (ARVPredictor) for the Detection of HIV Drug-Resistance Mutations and Treatment at the Point of Care: Development Study

BACKGROUND

HIV/AIDS remains one of the major global human health challenges, especially in resource-limited environments. By 2017, over 77.3 million people were infected with the disease, and approximately 35.4 million individuals had already died from AIDS-related illnesses. Approximately 21.7 million people were accessing ART with significant clinical outcomes. However, numerous challenges are experienced in the delivery and accurate interpretation of data on patients with HIV data by various health care providers at different care levels. Mobile health (mHealth) technology is progressively making inroads into the health sector as well as medical research. Different mobile devices have become common in health care settings, leading to rapid growth in the development of downloadable software specifically designed to fulfill particular health-related purposes.

OBJECTIVE

We developed a mobile-based app called ARVPredictor and demonstrated that it can accurately define HIV-1 drug-resistance mutations in the HIV pol gene for use at the point of care.

METHODS

ARVPredictor was designed using Android Studio with Java as the programming language and is compatible with both Android and iOS. The app system is hosted on Nginx Server, and network calls are built on PHP's Laravel framework handled by the Retrofit Library. The DigitalOcean offers a high-performance and stable cloud computing platform for ARVPredictor. This mobile app is enlisted in the Google Play Store as an "ARVPredictor" and the source code is available under MIT permissive license at a GitHub repository. To test for agreement between the ARVPredictor and Stanford HIV Database in detecting HIV subtype and NNRT and NRTI mutations, a total of 100 known HIV sequences were evaluated.

RESULTS

The mobile-based app (ARVPredictor) takes in a set of sequences or known mutations (protease, reverse transcriptase and integrase). It then returns inferred levels of resistance to selected nucleoside, nonnucleoside protease, and integrase inhibitors for accurate HIV/AIDS management at the point of care. The ARVPredictor identified similar HIV subtypes in 98/100 sequences compared with the Stanford HIV Database (κ=0.98, indicating near perfect agreement). There were 89/100 major NNRTI and NRTI mutations identified by ARVPredictor, similar to the Stanford HIV Database (κ=0.89, indicating near perfect agreement). Eight mutations classified as major by the Stanford HIV Database were classified as others by ARVPredictor.

CONCLUSIONS

The ARVPredictor largely agrees with the Stanford HIV Database in identifying both major and minor proteases, reverse transcriptase, and integrase mutations. The app can be conveniently used robustly at the point of care by HIV/AIDS care providers to improve the management of HIV infection.

Managing laboratory waste from HIV-related molecular testing: Lessons learned from African countries

Waste generated from HIV viral load (VL) testing contains potentially hazardous guanidinium thiocyanate (GTC). GTC is toxic to humans and can pollute waters and harm aquatic life if not disposed of appropriately. We assessed gaps in waste management (WM) policies, regulations and practices through a self-assessment scorecard and an online survey questionnaire among 11 African countries participating in a laboratory systems strengthening community of practice and receiving technical assistance to scale-up VL testing. We identified solutions from national stakeholders, technical agencies, and manufacturers to inform interventions for improving WM. Nine of 11 countries did not have WM policies/guidelines in place. Most Countries reported disposing liquid chemical waste into the sewer. Nine countries prioritised the development of policies as a multi-sectoral approach in the short term. High-temperature incineration through cement factory kilns was identified as an effective, inexpensive and high-capacity disposal option for GTC-containing waste in the short term. A long-term consideration with funding from governments and donors were infrastructural investments for conventional high-temperature incineration where cement factory kilns are unavailable/inaccessible. Adequate WM of GTC-containing waste through available funding could provide the necessary impetus to establish comprehensive WM systems addressing all types of healthcare waste through a multisectoral approach.

Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis

BACKGROUND

The World Health Organization's Treat-All guidance recommends CD4 testing before initiating antiretroviral therapy (ART), and routine viral load (VL) monitoring (over CD4 monitoring) for patients on ART.

METHODS

We used regression discontinuity analyses to estimate changes in CD4 testing and VL monitoring among 547 837 ART-naive patients enrolling in human immunodeficiency virus (HIV) care during 2006-2018 at 225 clinics in 26 countries where Treat-All policies were adopted. We examined CD4 testing within 12 months before and VL monitoring 6 months after ART initiation among adults (≥20 years), adolescents (10-19 years), and children (0-9 years) in low/lower-middle-income countries (L/LMICs) and high/upper-middle-income countries (H/UMICs).

RESULTS

Treat-All adoption led to an immediate decrease in pre-ART CD4 testing among adults in L/LMICs, from 57.0% to 48.1% (-8.9 percentage points [pp]; 95% CI: -11.0, -6.8), and a small increase in H/UMICs, from 90.1% to 91.7% (+1.6pp; 95% CI: 0.2, 3.0), with no changes among adolescents or children; decreases in pre-ART CD4 testing accelerated after Treat-All adoption in L/LMICs. In L/LMICs, VL monitoring after ART initiation was low among all patients in L/LMICs before Treat-All; while there was no immediate change at Treat-All adoption, VL monitoring trends significantly increased afterwards. VL monitoring increased among adults immediately after Treat-All adoption, from 58.2% to 61.1% (+2.9pp; 95% CI: 0.5, 5.4), with no significant changes among adolescents/children.

CONCLUSIONS

While on-ART VL monitoring has improved in L/LMICs, Treat-All adoption has accelerated and disparately worsened suboptimal pre-ART CD4 monitoring, which may compromise care outcomes for individuals with advanced HIV.

High level of HIV drug resistance informs dolutegravir roll-out and optimized NRTI backbone strategy in Mozambique

Background

HIV drug resistance (HIV-DR) is rising in sub-Saharan Africa in both ART-naive and ART-experienced patients.

Objectives

To estimate the level of acquired DR (ADR) and pre-treatment DR (PDR) across selected urban and rural sites in Southern Africa, in Mozambique.

Methods

We conducted two cross-sectional surveys among adult HIV patients (October 2017–18) assessing ADR and PDR. In the (ADR) survey, those on NNRTI-based first-line ART for ≥6 months were recruited (three sites). In the PDR survey, those ART-naive or experienced with ≥3 months of treatment interruption prior were enrolled (eight sites).

Results

Among 1113 ADR survey participants 83% were receiving tenofovir (TDF)/lamivudine (3TC)/efavirenz (EFV). The median time on ART was 4.5 years (Maputo) and 3.2 years (Tete), 8.3% (95% CI 6.2%-10.6%, Maputo) and 15.5% (Tete) had a VL ≥ 1000 copies/mL, among whom 66% and 76.4% had NNRTI+NRTI resistance, and 52.8% and 66.7% had 3TC+TDF-DR. Among those on TDF regimens, 31.1% (Maputo) and 42.2% (Tete) were still TDF susceptible, whereas 24.4% and 11.5% had TDF+zidovudine (ZDV)-DR. Among those on ZDV regimens, 25% and 54.5% had TDF+ZDV-DR. The PDR survey included 735 participants: NNRTI-PDR was 16.8% (12.0–22.6) (Maputo) and 31.2% (26.2–36.6) (Tete), with a higher proportion (≥50%) among those previously on ART affected by PDR.

Conclusions

In Mozambique, viral failure was driven by NNRTI and NRTI resistance, with NRTI DR affecting backbone options. NNRTI-PDR levels surpassed the WHO 10% ‘alert’ threshold. Replacing NNRTI first-line drugs is urgent, as is frequent viral load monitoring and resistance surveillance. Changing NRTI backbones when switching to second-line regimens may need reconsideration.

Measuring and explaining inequality of continuous care for people living with HIV receiving antiretroviral therapy in Kunming, China

Background

In the context of scaling up free antiretroviral therapy (ART), healthcare equality is essential for people living with HIV. We aimed to assess socioeconomic-related inequalities in uptake of continuous care for people living with HIV receiving ART, including retention in care in the last six months, routine toxicity monitoring, adequate immunological and virological monitoring, and uptake of mental health assessment in the last 12 months. We also determined the contributions of socioeconomic factors to the degree of inequalities.

Methods

A hospital-based cross-sectional survey was conducted among consecutive clients visiting an HIV treatment center in Kunming, China in 2019. Participants were 702 people living with HIV aged ≥18 years (median age: 41.0 years, 69.4% male) who had been on ART for 1–5 years. Socioeconomic-related inequality and its contributing factors were assessed by a normalized concentration index (CI_n) with a decomposition approach.

Results

The uptake of mental health assessment was low (15%) but significantly higher among the rich (CI_n 0.1337, 95% CI: 0.0140, 0.2534). Retention in care, toxicity, and immunological monitoring were over 80% but non-significant in favor of the rich (CI_n: 0.0117, 0.0315, 0.0736, respectively). The uptake of adequate virological monitoring was 15% and higher among the poor (CI_n = -0.0308). Socioeconomic status positively contributed to inequalities of all care indicators, with the highest contribution for mental health assessment (124.9%) and lowest for virological monitoring (2.7%).

Conclusions

These findings suggest virological monitoring and mental health assessment be given more attention in long-term HIV care. Policies allocating need-oriented resources geared toward improving equality of continuous care should be developed.

Addressing Pediatric HIV Pretreatment Drug Resistance and Virologic Failure in Sub-Saharan Africa: A Cost-Effectiveness Analysis of Diagnostic-Based Strategies in Children ≥3 Years Old

Improvement of antiretroviral therapy (ART) regimen switching practices and implementation of pretreatment drug resistance (PDR) testing are two potential approaches to improve health outcomes for children living with HIV. We developed a microsimulation model of disease progression and treatment focused on children with perinatally acquired HIV in sub-Saharan Africa who initiate ART at 3 years of age. We evaluated the cost-effectiveness of diagnostic-based strategies (improved switching and PDR testing), over a 10-year time horizon, in settings without and with pediatric dolutegravir (DTG) availability as first-line ART. The improved switching strategy increases the probability of switching to second-line ART when virologic failure is diagnosed through viral load testing. The PDR testing strategy involves a one-time PDR test prior to ART initiation to guide choice of initial regimen. When DTG is not available, PDR testing is dominated by the improved switching strategy, which has an incremental cost-effectiveness ratio (ICER) of USD 579/life-year gained (LY), relative to the status quo. If DTG is available, improved switching has a similar ICER (USD 591/LY) relative to the DTGstatus quo. Even when substantial financial investment is needed to achieve improved regimen switching practices, the improved switching strategy still has the potential to be cost-effective in a wide range of sub-Saharan African countries. Our analysis highlights the importance of strengthening existing laboratory monitoring systems to improve the health of children living with HIV.

Provision of HIV viral load testing services in Zimbabwe: Secondary data analyses using data from health facilities using the electronic Patient Monitoring System

Introduction

Routine viral load (VL) testing among persons living with Human Immunodeficiency Virus (PLHIV) enables earlier detection of sub-optimal antiretroviral therapy (ART) adherence and for appropriate management of treatment failure. Since adoption of this policy by Zimbabwe in 2016, the extent of implementation is unclear. Therefore we set out to determine among PLHIV ever enrolled on ART from 2004–2017 and in ART care for ≥12 months at health facilities providing ART in Zimbabwe: numbers (proportions) with VL testing uptake, VL suppression and subsequently switched to 2^nd-line ART following confirmed virologic failure.

Materials and methods

We used retrospective data from the electronic Patient Monitoring System (ePMS) in which PLHIV on ART are registered at 525 public and 4 private health facilities.

Results

Among the 392,832 PLHIV in ART care for ≥12 months, 99,721 (25.4%) had an initial VL test done and results available of whom 81,932 (82%) were virally suppressed. Among those with a VL>1000 copies/mL; 6,689 (37.2%) had a follow-up VL test and 4,086 (61%) had unsuppressed VLs of whom only 1,749 (42.8%) were switched to 2^nd-line ART. Lower age particularly adolescents (10–19 years) were more likely (ARR 1.34; 95%CI: 1.25–1.44) to have virologic failure.

Conclusion

The study findings provide insights to implementation gaps including limitations in VL testing; low identification of high- risk PLHIV in care and lack of prompt utilization of test results. The use of electronic patient-level data has demonstrated its usefulness in assessing the performance of the national VL testing program. By end of 2017 implementation of VL testing was sub-optimal, and virological failure was relatively common, particularly among adolescents. Of concern is evidence of failure to act on VL test results that were received. A quality improvement initiative has been planned in response to these findings and its effect on patient management will be monitored.

Time to first viral load testing among pregnant women living with HIV initiated on option B+ at 5 government clinics in Kampala city, Uganda: Retrospective cohort study

BACKGROUND

Timely viral load (VL) testing is critical in the care of pregnant women living with HIV and receiving anti-retroviral therapy (ART). There is paucity of data regarding the Time to First Viral Load (TFVL) testing in resource-limited settings.

METHODS

We extracted clinical and VL test data from records of a cohort of ART-naïve pregnant women living with HIV who initiated Option B + and were retained in care between 01 Jan 2015 and 31 Dec 2015. The data were verified against laboratory VL registers. TFVL (in months) was calculated based on the time difference between the date of ART initiation and FVL test. Descriptive and Cox regression analyses of data up to 30 Sep 2017 (33 months later) were done.

RESULTS

Of the 622 records retrieved, 424 women were retained in care. Of 424 women retained in care, 182/424 (43%) had at least one VL result post ART initiation while 242/424 (57%) had no VL performed. Only 30/182 (16.5%) had a second VL. At six, nine, and twelve months, only 8/424 (1.9%), 47/424 (11.1%), and 94/424 (22.2%) had VL testing performed respectively post ART initiation. The median TFVL testing was 12.7 months (95 CI 11.6-13.7) post ART initiation. Across the five clinics, patient factors (age, gravidity, gestational age, marital status, and adherence at 12 months) were not significant predictors.

CONCLUSION

A dismal 1.9% rate of achieving WHO-recommended TFVL testing and a median TFVL testing of twelve months post ART initiation were observed. The non-association of patient factors to these observations may suggest a serious need to review health system factors likely associated with these observations and their effective interventions.

Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind

PURPOSE OF REVIEW

Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions.

RECENT FINDINGS

There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.

Point-of-care viral load testing among adolescents and youth living with HIV in Haiti: a protocol for a randomised trial to evaluate implementation and effect

INTRODUCTION

Adolescents living with HIV have poor antiretroviral therapy (ART) adherence and viral suppression outcomes. Viral load (VL) monitoring could reinforce adherence but standard VL testing requires strong laboratory capacity often only available in large central laboratories. Thus, coordinated transport of samples and results between the clinic and laboratory is required, presenting opportunities for delayed or misplaced results. Newly available point-of-care (POC) VL testing systems return test results the same day and could simplify VL monitoring so that adolescents receive test results faster which could strengthen adherence counselling and improve ART adherence and viral suppression.

METHODS AND ANALYSIS

This non-blinded randomised clinical trial is designed to evaluate the implementation and effectiveness of POC VL testing compared with standard laboratory-based VL testing among adolescents and youth living with HIV in Haiti. A total of 150 participants ages 10-24 who have been on ART for >6 months are randomised 1:1 to intervention or standard arms. Intervention arm participants receive a POC VL test (Cepheid Xpert HIV-1 Viral Load system) with same-day result and immediate ART adherence counselling. Standard care participants receive a laboratory-based VL test (Abbott m2000sp/m2000rt) with the result available 1 month later, at which time they receive ART adherence counselling. VL testing is repeated 6 months later for both arms. The primary objective is to describe the implementation of POC VL testing compared with standard laboratory-based VL testing. The secondary objective is to evaluate the effect of POC VL testing on VL suppression at 6 months and participant comprehension of the correlation between VL and ART adherence.

ETHICS AND DISSEMINATION

This study is approved by GHESKIO, Weill Cornell Medicine and Columbia University ethics committees. This trial will provide critical data to understand if and how POC VL testing may impact adolescent ART adherence and viral suppression. If effective, POC VL testing could routinely supplement standard laboratory-based VL testing among high-risk populations living with HIV.

TRIAL REGISTRATION NUMBER

NCT03288246.

Promoting Undetectable Equals Untransmittable in Sub-Saharan Africa: Implication for Clinical Practice and ART Adherence

In the last decade, reliable scientific evidence has emerged to support the concept that undetectable viral loads prevent human immunodeficiency virus (HIV). Undetectable equals untransmissible (U = U) is a simple message that everyone can understand. The success of this concept depends on strict adherence to antiretroviral therapy (ART) and the attainment of suppressed viral loads (VLs). To achieve U = U in sub-Saharan Africa (SSA), poor adherence to ART, persistent low-level viremia, and the emergence of drug-resistant mutants are challenges that cannot be overlooked. Short of a cure for HIV, U = U can substantially reduce the burden and change the landscape of HIV epidemiology on the continent. From a public health perspective, the U = U concept will reduce stigmatization in persons living with HIV (PLWHIV) in SSA and strengthen public opinion to accept that HIV infection is not a death sentence. This will also promote ART adherence because PLWHIV will aim to achieve U = U within the shortest possible time. This article highlights challenges and barriers to achieving U = U and suggests how to promote the concept to make it beneficial and applicable in SSA. This concept, if expertly packaged by policy-makers, clinicians, health service providers, and HIV control programs, will help to stem the tide of the epidemic in SSA.

Influence of evolving HIV treatment guidance on CD4 counts and viral load monitoring: A mixed-methods study in three African countries

Little is known about how CD4 and viral load testing have evolved following implementation of universal test and treat (UTT) in African settings. We reviewed World Health Organization (WHO) guidance from 2013 to 2018, and compared it against national HIV policies in Malawi, Tanzania and South Africa. Three surveys rounds were conducted in 2013, 2016 and 2017–2018 in 33 health facilities across the three settings to assess implementation of national policies on the use of biological markers. Qualitative interviews were conducted with 26 HIV policymakers or programme managers, 21 providers and 66 people living with HIV to explore understandings and experiences of these tests. Various factors influenced adoption and implementation of WHO guidance, including historical policies on CD4 counts, governance issues, supply chain challenges and funding mechanisms. Facility-level practices relating to the use of these tests often diverged from national policies. Patients and providers valued both tests, but did not always understand their roles. In addition to continued support for scaling-up viral load testing, renewed focus should be placed on the ongoing value of point-of-care CD4 tests in the UTT era, including its role in assessing disease progression and informing clinical management of cases to reduce HIV-related mortality.

Maternal viral load monitoring: Coverage and clinical action at 4 Kenyan hospitals

Background

Kenya’s guidelines for prevention of mother-to-child transmission of HIV (PMTCT) recommend routine viral load (VL) monitoring for pregnant and breastfeeding women.

Method

We assessed PMTCT VL monitoring and clinical action occurring between last menstrual period (LMP) and 6 months postpartum at 4 Kenyan government hospitals. Pregnant women enrolled in the HIV Infant Tracking System from May 2016-March 2018 were included. We computed proportions who received VL testing within recommended timeframes and who received clinical action after unsuppressed VL result.

Results

Of 424 participants, any VL testing was documented for 305 (72%) women and repeat VL testing was documented for 79 (19%). Only 115 women (27%) received a guideline-adherent baseline VL test and 27 (6%) received a guideline-adherent baseline and repeat VL test sequence. Return of baseline and repeat VL test results to the facility was high (average 96%), but patient notification of VL results was low (36% baseline and 49% repeat). Clinical action for unsuppressed VL results was even lower: 11 of 38 (29%) unsuppressed baseline results and 2 of 14 (14%) unsuppressed repeat results triggered clinical action.

Discussion

Guideline-adherent VL testing and clinical intervention during PMTCT must be prioritized to improve maternal care and reduce the risk of HIV transmission to infants.

Point-of-care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

Introduction

Routinely monitoring the HIV viral load (VL) of people living with HIV (PLHIV) on anti‐retroviral therapy (ART) facilitates intensive adherence counselling and faster ART regimen switch when treatment failure is indicated. Yet standard VL‐testing in centralized laboratories can be time‐intensive and logistically difficult in low‐resource settings. This paper evaluates the outcomes of the first four years of routine VL‐monitoring using Point‐of‐Care technology, implemented by Médecins Sans Frontières (MSF) in rural clinics in Malawi.

Methods

We conducted a retrospective cohort analysis of patients eligible for routine VL‐ testing between 2013 and 2017 in four decentralized ART‐clinics and the district hospital in Chiradzulu, Malawi. We assessed VL‐testing coverage and the treatment failure cascade (from suspected failure (first VL>1000 copies/mL) to VL suppression post regimen switch). We used descriptive statistics and multivariate logistic regression to assess factors associated with suspected failure.

Results and Discussion

Among 21,400 eligible patients, VL‐testing coverage was 85% and VL suppression was found in 89% of those tested. In the decentralized clinics, 88% of test results were reviewed on the same day as blood collection, whereas in the district hospital the median turnaround‐time for results was 85 days. Among first‐line ART patients with suspected failure (N = 1544), 30% suppressed (VL<1000 copies/mL), 35% were treatment failures (confirmed by subsequent VL‐testing) and 35% had incomplete VL follow‐up. Among treatment failures, 80% (N = 540) were switched to a second‐line regimen, with a higher switching rate in the decentralized clinics than in the district hospital (86% vs. 67%, p < 0.01) and a shorter median time‐to‐switch (6.8 months vs. 9.7 months, p < 0.01). Similarly, the post‐switch VL‐testing rate was markedly higher in the decentralized clinics (61% vs. 26%, p < 0.01). Overall, 79% of patients with a post‐switch VL‐test were suppressed.

Conclusions

Viral load testing at the point‐of‐care in Chiradzulu, Malawi achieved high coverage and good drug regimen switch rates among those identified as treatment failures. In decentralized clinics, same‐day test results and shorter time‐to‐switch illustrated the game‐changing potential of POC‐based VL‐testing. Nevertheless, gaps were identified along all steps of the failure cascade. Regular staff training, continuous monitoring and creating demand are essential to the success of routine VL‐testing.

How to Evolve the Response to the Global HIV Epidemic With New Metrics and Targets Based on Pre-Treatment CD4 Counts

PURPOSE OF THE REVIEW

Early diagnosis and treatment of HIV following seroconversion improves individual and population health. Using published data on pre-treatment CD4 cell counts, we benchmarked the level of immunodeficiency at HIV diagnosis and ART initiation in the "real world" against those of the treatment and control arms of landmark controlled trials that successfully reduced HIV-related deaths (INSIGHT/START) and onward HIV transmission (HPTN 052).

RECENT FINDINGS

The median CD4 count in the treatment vs. control arms of the INSIGHT/START trial and HPTN 052 were 650 vs. 408 cells/μL and 442 vs. 221 cells/μL, respectively. In the real world, recent global estimates of the median CD4 count at start of ART range from 234 to 350 cells/μL, and only 25% of those initiating ART do so early (i.e., with CD4 > 500 cells/μL). Recent global data on trends in the median CD4 count at diagnosis and ART initiation are not encouraging. We identify a critical need for new targets and metrics for persons newly diagnosed with HIV, newly enrolling in HIV care, and newly initiating ART, based on pre-treatment CD4 counts, to help increase the focus of implementation efforts on achieving earlier diagnosis, linkage to care, and ART initiation.