Viral suppression after 12 months of antiretroviral therapy in low- and middle-income countries: a systematic review

Prevalence of viral load suppression and acquired drug resistance among people living with HIV in Nepal: a nationally representative surveillance study

OBJECTIVES

This is the first nationally representative study to estimate the prevalence of viral load (VL) suppression and acquired HIV drug resistance (ADR) among people living with HIV (PLHIV) in Nepal.

METHODS

A cross-sectional study recruited 1418 PLHIV from 20 ART centres in Nepal, using a two-stage cluster design. Participants were eligible if they were HIV-positive individuals on ART for 9-15 months or at least 48 months. Plasma specimens were collected and tested for the quantification of HIV-1 RNA. Specimens with a VL ≥1000 copies/mL were further processed for sequencing of PR and RT genes of HIV-1. The sequences were then analysed to detect mutations causing HIV drug resistance.

RESULTS

The prevalence of ADR was 3.7% (95% confidence interval [CI]: 1.8-7.6) and 3.0% (95% CI: 1.8-5.2) among PLHIV who received ART for 9-15 months and 48 months or more, respectively. The prevalence of VL suppression was 95.3% (95% CI: 91.7-97.4) among those on ART for 9-15 months, and 96.5% (95% CI: 94.7-97.7) among those on ART for at least 48 months. The prevalence of any detectable acquired resistance to antiretroviral drugs was 80.7% (95% CI: 58.6-92.5) among those on ART for 9-15 months with VL ≥1000 copies/mL and 81.6% (95% CI: 55.4-94.0) among those on ART for at least 48 months with VL ≥1000 copies/mL.

CONCLUSION

This study suggests that improved accessibility to VL monitoring and timely assessment of drug resistance in routine HIV programs are crucial in Nepal to ensure access to HIV treatment for all in need.

Impact of the COVID-19 pandemic on routine HIV care and antiretroviral treatment outcomes in Kenya: A nationally representative analysis

BACKGROUND

The COVID-19 pandemic adversely disrupted global health service delivery. We aimed to assess impact of the pandemic on same-day HIV diagnosis/ART initiation, six-months non-retention and initial virologic non-suppression (VnS) among individuals starting antiretroviral therapy (ART) in Kenya.

METHODS

Individual-level longitudinal service delivery data were analysed. Random sampling of individuals aged >15 years starting ART between April 2018 -March 2021 was done. Date of ART initiation was stratified into pre-COVID-19 (April 2018 -March 2019 and April 2019 -March 2020) and COVID-19 (April 2020 -March 2021) periods. Mixed effects generalised linear, survival and logistic regression models were used to determine the effect of COVID-19 pandemic on same-day HIV diagnosis/ART initiation, six-months non-retention and VnS, respectively.

RESULTS

Of 7,046 individuals sampled, 35.5%, 36.0% and 28.4% started ART during April 2018 -March 2019, April 2019 -March 2020 and April 2020 -March 2021, respectively. Compared to the pre-COVID-19 period, the COVID-19 period had higher same-day HIV diagnosis/ART initiation (adjusted risk ratio [95% CI]: 1.09 [1.04-1.13], p<0.001) and lower six-months non-retention (adjusted hazard ratio [95% CI]: 0.66 [0.58-0.74], p<0.001). Of those sampled, 3,296 (46.8%) had a viral load test done at a median 6.2 (IQR, 5.3-7.3) months after ART initiation. Compared to the pre-COVID-19 period, there was no significant difference in VnS during the COVID-19 period (adjusted odds ratio [95% CI]: 0.79 [95%% CI: 0.52-1.20], p = 0.264).

CONCLUSIONS

In the short term, the COVID-19 pandemic did not have an adverse impact on HIV care and treatment outcomes in Kenya. Timely, strategic and sustained COVID-19 response may have played a critical role in mitigating adverse effects of the pandemic and point towards maturity, versatility and resilience of the HIV program in Kenya. Continued monitoring to assess long-term impact of the COVID-19 pandemic on HIV care and treatment program in Kenya is warranted.

Long-term outcomes of highly experienced people with HIV undergoing salvage therapy with raltegravir

Raltegravir and other third-line drugs have shown promise in improving outcomes in treatment-experienced patients. However, the efficacy and tolerability of these agents vary. This study assessed real-life virologic success, long-term survival, and adverse events in patients receiving raltegravir or other third-line drugs as salvage regimens. This retrospective cohort study included adults who experienced treatment failure (human immunodeficiency syndrome-1 RNA plasma viral load >1000 copies/mL) and subsequently initiated raltegravir or other third-line drugs (darunavir/ritonavir, maraviroc, or etravirine). Propensity score matching methods were employed to account for differences at the time of switching from failing antiretroviral therapy regimens. The matched subset was analyzed using the Kaplan-Meier method and Generalized Wilcoxon tests to evaluate the probability of achieving virologic suppression (plasma viral load <50 copies/mL). Mortality rates, toxicity, treatment interruption, virologic failure, and loss to follow-up were determined using Poisson regression. One hundred and sixty-eight patients initiating salvage regimens were included, with 123 receiving raltegravir and 45 other third-line drugs. Propensity score matching resulted in a subset of 90 patients, 45 in each group. During the follow-up period, there were no significant differences observed between the groups in terms of virologic suppression (77.8% vs 82.2%, P = .73), mortality rates (4.04 vs 6.18 persons per 100 person-years [p-y]; P = .67), drug toxicity (0.00 vs 2.06 persons per 100 p-y; P = .49), treatment interruption (8.07 vs 0.00 persons per 100 p-y; P = .06), virologic failure (2.02 vs 4.12 persons per 100 p-y; P = .61), and loss of follow-up (6.05 vs 4.12 persons per 100 p-y; P = .70). Our findings indicate comparable survival and virological success rates between raltegravir and other drugs used in salvage regimens. Similar rates of drug toxicity, treatment interruption, virologic failure, and loss of follow-up were also observed. These results suggest that raltegravir may be a viable option for salvage therapy, demonstrating outcomes comparable to other third-line drugs in real life.

Trends Analysis of HIV Infection and Antiretroviral Treatment Outcome in Amhara Regional from 2015 to 2021, Northeast Ethiopia

Background

The persistent efforts of HIV/AIDS epidemiology remain one of the world's most important community health threats. To avoid becoming an epidemic, UNAIDS has set three 90% fast-track targets for 2020, and Ethiopia has also changed its implementation since 2015. However, the achievement targets in the Amhara region have yet to be evaluated at the end of the programme period.

Objective

The aim of this study was to assess the Trends of HIV Infection and Antiretroviral Treatment outcome in Eastern Amhara Regional from 2015 to 2021, Northeast Ethiopia.

Methods

A retrospective study was conducted by reviewing the District Health Information System from 2015 to 2021. The collected data includes the trend of HIV testing services, the trend of HIV positivity, the yield of HIV testing approaches, the number of HIV positive patients linked to HIV care and treatment or access to lifelong antiretroviral therapy, viral load testing coverage, and viral suppression. A descriptive statistic and trend analysis were computed.

Results

A total of 145,639 people accessed antiretroviral therapy. The trend of HIV test positivity has been declining since 2015, peaking at 0.76% in 2015 and declining to 0.60% in 2020. A high level of positivity was reported in volunteer counselling and testing as compared with provider-initiated testing and counselling services. Following an HIV positive, there was an increase in linkage to HIV care and treatment. High suppression rates of viral load indicate testing coverage grew over time. The viral load monitoring coverage was 70% in 2021, with a viral suppression rate of 94%.

Conclusion and Recommendations

The trend in achievement in the first 90s was not consistent with predefined goals (90%). On the other hand, there was good achievement in the second and third goals. Hence, intensified case-finding approaches to HIV testing should be strengthened.

Machine learning to predict virological failure among HIV patients on antiretroviral therapy in the University of Gondar Comprehensive and Specialized Hospital, in Amhara Region, Ethiopia, 2022

BACKGROUND

Treatment with effective antiretroviral therapy (ART) reduces viral load as well as HIV-related morbidity and mortality in HIV-positive patients. Despite the expanded availability of antiretroviral therapy around the world, virological failure remains a serious problem for HIV-positive patients. Thus, Machine learning predictive algorithms have the potential to improve the quality of care and predict the needs of HIV patients by analyzing huge amounts of data, and enhancing prediction capabilities. This study used different machine learning classification algorithms to predict the features that cause virological failure in HIV-positive patients.

METHOD

An institution-based secondary data was used to conduct patients who were on antiretroviral therapy at the University of Gondar Comprehensive and Specialized Hospital from January 2020 to May 2022. Patients' data were extracted from the electronic database using a structured checklist and imported into Python version three software for data pre-processing and analysis. Then, seven supervised classification machine-learning algorithms for model development were trained. The performances of the predictive models were evaluated using accuracy, sensitivity, specificity, precision, f1-score, and AUC. Association rule mining was used to generate the best rule for the association between independent features and the target feature.

RESULT

Out of 5264 study participants, 1893 (35.06%) males and 3371 (64.04%) females were included. The random forest classifier (sensitivity = 1.00, precision = 0.987, f1-score = 0.993, AUC = 0.9989) outperformed in predicting virological failure among all selected classifiers. Random forest feature importance and association rules identified the top eight predictors (Male, younger age, longer duration on ART, not taking CPT, not taking TPT, secondary educational status, TDF-3TC-EFV, and low CD4 counts) of virological failure based on the importance ranking, and the CD-4 count was recognized as the most important predictor feature.

CONCLUSION

The random forest classifier outperformed in predicting and identifying the relevant predictors of virological failure. The results of this study could be very helpful to health professionals in determining the optimal virological outcome.

How Do People Living With HIV (PLHIV) and AIDS Feel About the Quality of Care They Received Amid the COVID-19 Pandemic in Lagos, Nigeria?

Background: This study aimed to assess the perception of quality of care among people living with HIV (PLHIV) in Lagos, Nigeria, and identify factors influencing their perceptions. Methodology: The study was a descriptive cross-sectional survey conducted between December 2020 and March 2021 among 578 PLHIVs drawn from various healthcare facilities in Lagos where HIV care and treatment services were provided. Data were collected through pretested questionnaires and analyzed using Stata SE 12. Results: About 83% of the respondents had a good attitude toward their HIV medication, and 95.5% had a good perception of the quality of care they received. PLHIVs with higher education, skilled or professional occupations and higher monthly income had a significantly higher perception of quality of care compared to others (P < .05). Conclusion: The PLHIV in Lagos had a positive attitude toward their medication and a good perception of the quality of care they received during the COVID-19 pandemic. All stakeholders' efforts should be sustained for continuous quality improvement in HIV care in Lagos.

Perinatal Depressive Symptoms and Viral Non-suppression Among a Prospective Cohort of Pregnant Women Living with HIV in Nigeria, Kenya, Uganda, and Tanzania

Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013-February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2-4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers.

Serum Interleukin-6 and Weight Loss in Antiretroviral-naïve and Antiretroviral-treated Patients with HIV/AIDS: Relationships and Predictors

BACKGROUND

Cachexia is usually associated with elevated serum interleukin-6 (IL.6) as it stimulates the breakdown of muscle proteins and promotes wasting.

OBJECTIVE

A case-control study to evaluate the relationship between weight loss, facial fat loss, and IL-6 in antiretroviral-naïve and treated participants living with HIV/AIDS.

METHODS

IL-6 was assayed by High performance liquid chromatography (HPLC) in 97 in consecutive newly diagnosed antiretroviral-naive (ART-naïve) people living with HIV/AIDS (age ≥18 years); and 118 consecutive, age-matched participants currently on Highly Active Antiretroviral Therapy (HAART), using age as a criterion. In the treated group, 78 (66.7%) subjects were on zidovudine, lamivudine with nevirapine (Z+L+N); 27(23.1%) on tenofovir, lamivudine with emtricitabine (T+L+E); 5(4.3%) on zidovudine, lamivudine with emtricitabine (Z+L+E); 4(3.4%) on zidovudine, lamivudine with tenofovir (Z+L+T); 2(1.7%) on lamivudine, tenofovir with nevirapine (L+T+N); 1(0.9%) on tenofovir, zidovudine, emtricitabine (Z+T+E).

RESULTS

A total of 215 participants: 97 ART-naive and 118 HAART-treated, age-matched subjects (40.3±9.6 versus 42.7±10.20years, p=0.08). The mean IL-6 was significantly higher in naïve than treated (0.69±0.04 versus 0.66±0.04 pg/ml, p =0.002). In all, 73 subjects experienced weight loss, 56(76.7%) naive, 17(23.3%) treated, p <0.0001, with significantly higher IL-6 in those with weight loss (0.69±0.05 versus 0.67±0.05pg/ml, p= 0.047). Fifty-eight (27.0%) subjects experienced facial fat loss, 49 (84.5%) naïve, and 9 (15.5%) treated, p <0.0001, with significantly higher IL-6 in those with facial fat loss (0.7 ± 0.05 versus 0.67±0.05pg/ml, p= 0.0001). Negative correlation exists between IL-6 and CD4+ count (r=-0.141, p=0.041). In logistic regression, independent predictors of weight loss include: IL-6 (Adjusted Odds Ratio, aOR 1.3, 95%CI 0·1-2·6, p=0.047); HIV duration (aOR 11.6, p <0.0001); AIDS-defining illness (aOR 3.5, p <0.0001); CD4+ count (aOR 3.2, p=0.004); HAART status (aOR 2.7, p<0.0001).

CONCLUSION

HIV infection is associated with elevation of serum interleukin-6, which likely contributes to weight and facial fat loss among the treatment-naïve participants; while HAART is associated with suppressed IL-6 levels, thereby ameliorating weight and facial fat loss. Inverse relationship exists between serum IL-6 and CD4+ count; serum IL-6 could differentiate between mild- to moderate and severe immunosuppressive states.

A Framework for Descriptive Epidemiology

In this paper, we propose a framework for thinking through the design and conduct of descriptive epidemiologic studies. A well-defined descriptive question aims to quantify and characterize some feature of the health of a population and must clearly state: 1) the target population, characterized by person and place, and anchored in time; 2) the outcome, event, or health state or characteristic; and 3) the measure of occurrence that will be used to summarize the outcome (e.g., incidence, prevalence, average time to event, etc.). Additionally, 4) any auxiliary variables will be prespecified and their roles as stratification factors (to characterize the outcome distribution) or nuisance variables (to be standardized over) will be stated. We illustrate application of this framework to describe the prevalence of viral suppression on December 31, 2019, among people living with human immunodeficiency virus (HIV) who had been linked to HIV care in the United States. Application of this framework highlights biases that may arise from missing data, especially 1) differences between the target population and the analytical sample; 2) measurement error; 3) competing events, late entries, loss to follow-up, and inappropriate interpretation of the chosen measure of outcome occurrence; and 4) inappropriate adjustment.

Comparative Clinical Outcomes With Scale-up of Dolutegravir as First-Line Antiretroviral Therapy in Ukraine

BACKGROUND

Achievement of the UNAIDS 95-95-95 targets requires ARV regimens that are easy to use, well-tolerated, and cost-effective. Dolutegravir (DTG)-based regimens are efficacious and less costly than other common first-line regimens. This study assessed real-world effectiveness of DTG regimens in treatment-naive people living with HIV in Ukraine.

METHODS

We extracted data from the national Medical Information System on all adult patients who initiated antiretroviral therapy (ART) with DTG, lopinavir/ritonavir, or efavirenz (EFV) between October 2017 and June 2018, at 23 large clinics in 12 regions of Ukraine. Viral suppression at 12 ± 3 months and retention at 12 months after treatment initiation were the outcomes of interest.

RESULTS

Of total 1057 patients, 721 had a viral load test within the window of interest, and 652 (90%) had viral load of ≤ 200 copies/mL. The proportion with suppression was lower in the EFV group [aOR = 0.4 (95% confidence interval: 0.2 to 0.8)] and not different in the LPV group [aOR = 1.6 (0.5 to 4.9)] compared with the DTG group. A 24-month or longer gap between diagnosis and treatment was associated with lower odds of suppression [aOR = 0.4 (0.2 to 0.8)]. Treatment retention was 90% (957/1057), with no significant difference by regimen group. History of injecting drug use was associated with decreased retention [aOR = 0.5 (0.3 to 0.8)].

CONCLUSIONS

DTG-based regimens were comparable with LPV and more effective than EFV in achieving viral suppression among ART-naive patients in a multisite cohort in Ukraine. Treatment retention was equally high in all 3 groups. This evidence from Ukraine supports the ART Optimization Initiative as a strategy to improve efficiency of the ART program without negatively affecting patient clinical outcomes.

Effect of Switching Antiretroviral Treatment Regimen in Patients With Drug-Resistant HIV-1 Infection: Retrospective Observational Cohort Study

BACKGROUND

Evidence on the efficacy of antiretroviral therapy (ART) regimen switches on the mortality of patients with HIV drug resistance (HIVDR) is limited.

OBJECTIVE

We aim to provide policy guidance for ART regimen selection and evaluate the effectiveness of ART regime switches for people living with HIV and HIV-1 drug resistance.

METHODS

This retrospective observational cohort study included 179 people living with HIV and HIV-1 drug resistance from 2011 to 2020. The time that participants switched treatment regimens either to protease inhibitor (PI)-based ART regimens (PIs) or nonnucleoside reverse transcriptase inhibitor (NNRTI)-based ART regimens (NNRTIs) was taken as an observation starting point and followed up every 12 months. The parametric g-formula was used to estimate the 5-year risk of mortality under the situations of (1) natural course, (2) immediate switch to NNRTIs, (3) immediate switch to PIs, and (4) if CD4(+) T cells<200 switched to PIs.

RESULTS

The follow-up time of the 179 patients ranged from 30 to 119 months. The median follow-up time was 90 months. During a follow-up of 15,606 person-months, 27 individuals died in the cohort. The estimated 5-year risk of mortality under natural course, immediate switch to NNRTIs, immediate switch to PIs, and if CD4(+), and switch to PIs if T cells<200 were 11.62% (95% CI 7.82-17.11), 31.88% (95% CI 20.79-44.94), 2.87% (95% CI 0.32-7.07), and 5.30% (95% CI 2.07-10.21), respectively. The risk ratios (RRs) of immediate switch to NNRTIs, immediate switch to PIs, and switch to PIs if CD4(+) T cells<200, compared with natural course mortality rate, were 2.74 (95% CI 2.01-3.47), 0.25 (95% CI: 0.04-0.54), and 0.46 (95% CI 0.22-0.71), respectively. The risk differences were 20.26% (95% CI 10.96-28.61), -8.76% (95% CI -13.34 to -5.09) and -6.32% (95% CI -9.75 to -3.11), respectively.

CONCLUSIONS

Our study found that a PI-based ART regimen was beneficial for reducing mortality in people living with HIV and HIV-1 drug resistance. More effort should be given to find HIV-1 drug resistance earlier to ensure a timely adjustment to PI-based ART, thereby maximizing the benefit of early switch treatment for people living with HIV and HIV-1 drug resistance.

Bidirectional Violence Is Associated with Poor Engagement in HIV Care and Treatment in Malawian Couples

Growing evidence suggests that intimate partner violence (IPV) is a barrier to engagement in HIV care. Bidirectional IPV-being both a perpetrator and victim-may be the most common pattern of IPV, yet no research has examined its effect on engagement in care, which could identify couples in most need of interventions. Married couples (N = 211) with at least one partner on antiretroviral therapy were recruited from HIV clinic waiting rooms in Zomba, Malawi. Partners completed separate surveys on physical, sexual, and emotional IPV, medication adherence, and appointment attendance. We created categorical variables indicating no violence, perpetrator-only, victim-only, and bidirectional violence. Generalized estimating equation regression models tested for associations between IPV and engagement in care. The bidirectional pattern represented 25.4%, 35.5%, and 34.0% of all physical, sexual, and emotional IPV. Physical IPV victimization-only (adjusted odds ratio [AOR]: 0.28, 95% confidence interval [CI]: 0.08, 0.92) was associated with lower adherence, but the association was stronger for bidirectional physical IPV (AOR: 0.10, 95% CI: 0.02, 0.51). Bidirectional sexual IPV was also associated with lower adherence (AOR: 0.14, 95% CI: 0.02, 0.80). Bidirectional physical IPV (AOR: 4.04, 94% CI: 1.35, 12.14) and emotional IPV (AOR: 3.78, 95% CI: 1.78, 8.05) were associated with missing 1+ appointment. Interventions to address the health effects of bidirectional IPV, which may be greater than victim-only or perpetrator-only IPV, should intervene with both partners to break cycles of violence. Couple-based interventions may be a viable option by intervening on both partners' trauma and aggression simultaneously.

The Impact of Timing of Antiretroviral Therapy Initiation on Retention in Care, Viral Load Suppression and Mortality in People Living with HIV: A Study in a University Hospital in Thailand

Studies investigating same-day antiretroviral therapy (ART) initiation demonstrate different clinical outcomes depending on settings. We retrospectively reviewed adults with newly positive human immunodeficiency virus (HIV) antibody testing. The proportion of individuals who were retained in care at 12 months was compared between early (≤2 weeks) and late (>2 weeks) ART initiation groups. Of all, the median (IQR) time from HIV diagnosis to ART initiation was 18 (9-30) days. This duration was 7 (7-13) days in the early ART initiation group (n = 116) and 28 (21-46) days in the late ART initiation group (n = 154). In the multivariate logistic regression, having pneumocystis pneumonia [odds ratio (OR) 9.30, 95% CI 2.56-33.75], tuberculosis (OR 2.21, 95% CI 1.03-4.73), and weight loss (OR 12.98, 95% CI 1.00-167.68) were associated with late ART initiation. The early ART initiation group had a slightly higher proportion of individuals retained in care at 12 months than those in the late ART initiation group (88.8% vs 80.5%, P = .066) and had a higher significant proportion of HIV viral load suppression (81.0% vs 70.1%, P = .041). No significant differences were observed in the proportion of individuals who died at 12 months (2.6% vs 3.2%, P = 1.000) between the two groups. Early ART initiation trends to retain individuals in care and higher HIV viral load suppression was determined. Nevertheless, ART initiation timing might not be a solely important factor in improving HIV care and minimizing mortality among HIV-infected individuals in a university hospital setting.

Clinical factors and outcomes associated with immune non-response among virally suppressed adults with HIV from Africa and the United States

A significant minority of people living with HIV (PLWH) achieve viral suppression (VS) on antiretroviral therapy (ART) but do not regain healthy CD4 counts. Clinical factors affecting this immune non-response (INR) and its effect on incident serious non-AIDS events (SNAEs) have been challenging to understand due to confounders that are difficult to control in many study settings. The U.S. Military HIV Natural History Study (NHS) and African Cohort Study (AFRICOS). PLWH with sustained VS (< 400 copies/ml for at least two years) were evaluated for INR (CD4 < 350 cells/µl at the time of sustained VS). Logistic regression estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for factors associated with INR. Cox proportional hazards regression produced adjusted hazard ratios (aHRs) for factors associated with incident SNAE after sustained VS. INR prevalence was 10.8% and 25.8% in NHS and AFRICOS, respectively. Higher CD4 nadir was associated with decreased odds of INR (aOR = 0.34 [95% CI 0.29, 0.40] and aOR = 0.48 [95% CI 0.40, 0.57] per 100 cells/µl in NHS and AFRICOS, respectively). After adjustment, INR was associated with a 61% increase in relative risk of SNAE [95% CI 1.12, 2.33]. Probability of "SNAE-free" survival at 15 years since sustained VS was approximately 20% lower comparing those with and without INR; nearly equal to the differences observed by 15-year age groups. CD4 monitoring before and after VS is achieved can help identify PLWH at risk for INR. INR may be a useful clinical indicator of future risk for SNAEs.

Global estimates of viral suppression in children and adolescents and adults on antiretroviral therapy adjusted for missing viral load measurements: a multiregional, retrospective cohort study in 31 countries

BACKGROUND

As countries move towards the UNAIDS's 95-95-95 targets and with strong evidence that undetectable equals untransmittable, it is increasingly important to assess whether those with HIV who are receiving antiretroviral therapy (ART) achieve viral suppression. We estimated the proportions of children and adolescents and adults with viral suppression at 1, 2, and 3 years after initiating ART.

METHODS

In this retrospective cohort study, seven regional cohorts from the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium contributed data from individuals initiating ART between Jan 1, 2010, and Dec 31, 2019, at 148 sites in 31 countries with annual viral load monitoring. Only people with HIV who started ART after the time a site started routine viral load monitoring were included. Data up to March 31, 2020, were analysed. We estimated the proportions of children and adolescents (aged <18 years at ART initiation) and adults (aged ≥18 years at ART initiation) with viral suppression (viral load <1000 copies per mL) at 1, 2, and 3 years after ART initiation using an intention-to-treat approach and an adjusted approach that accounted for missing viral load measurements.

FINDINGS

21 594 children and adolescents (11 812 [55%] female, 9782 [45%] male) from 106 sites in 22 countries and 255 662 adults (163 831 [64%] female, 91 831 [36%] male) from 143 sites in 30 countries were included. Using the intention-to-treat approach, the proportion of children and adolescents with viral suppression was 7303 (36%) of 20 478 at 1 year, 5709 (30%) of 19 135 at 2 years, and 4287 (24%) of 17 589 at 3 years after ART initiation; the proportion of adults with viral suppression was 106 541 (44%) of 240 600 at 1 year, 79 141 (36%) of 220 925 at 2 years, and 57 970 (29%) of 201 124 at 3 years after ART initiation. After adjusting for missing viral load measurements among those who transferred, were lost to follow-up, or who were in follow-up without viral load testing, the proportion of children and adolescents with viral suppression was 12 048 (64% [plausible range 43-81]) of 18 835 at 1 year, 10 796 (62% [41-77]) of 17 553 at 2 years, and 9177 (59% [38-91]) of 15 667 at 3 years after ART initiation; the proportion of adults with viral suppression was 176 964 (79% [53-80]) of 225 418 at 1 year, 145 552 (72% [48-79]) of 201 238 at 2 years, and 115 260 (65% [43-69]) of 178 458 at 3 years after ART initiation.

INTERPRETATION

Although adults with HIV are approaching the global target of 95% viral suppression, progress among children and adolescents is much slower. Substantial efforts are still needed to reach the viral suppression target for children and adolescents.

FUNDING

US National Institutes of Health.

Antiretroviral therapy adherence and viral suppression among HIV-infected adolescents and young adults at a tertiary hospital in Ghana

With the introduction of antiretroviral therapy (ART), many HIV-infected children are growing into adolescence and adulthood. A facility-based cross-sectional study was conducted at the Fevers Unit of one of the teaching hospitals in Ghana. The Morisky Medication Adherence Scale (MMAS-8) and pill count were used to assess adherence, while measured viral load levels of participants were used to assess viral suppression. The rate of viral suppression (<400 copies/ml) was 68.2%. Participants with high MMAS-8 scores were 8.4 times more likely to be virally suppressed compared to those with low MMAS-8 scores (OR = 8.4, p = 0.003, 95% CI: 2.11-33.48). The commonest reason for missing doses of their antiretroviral drugs (ARVs) was forgetfulness. Efforts must be made by all stakeholders involved in HIV care to engage adolescents and young adults living with HIV (AYALHIV) on personal and/or group levels to help identify and improve particular ART adherence issues so as to increase viral suppression rates.

Factors associated with immunological and virological discordant responses to highly active antiretroviral therapy among adult HIV positive individuals in Ethiopia: A cross-sectional study

In clinical practice, not all human immune deficiency virus (HIV) positive individuals who received highly active antiretroviral therapy (HAART) achieve the desired concordant response characterized by a sustained viral suppression or immune recovery. The expected success of HAART doesn't occur in all treated patients and a discordant response between CD4 count and the viral load (VL) has been a major concern in the treatment of HIV patients. Thus, this study is designed to describe the factors associated with immunological and virological discordant responses to HAART among adult HIV positive individuals.A hospital-based cross-sectional study with secondary data review was conducted on 423 HIV positive individuals on HAART from February 1 to April 30, 2017. Socio-demographic characteristics, clinical data and about 10 mL of blood specimen for HIV VL, and CD4 count measurement were collected. The data was entered into SPSS version 20 and descriptive, bivariate, and multivariate logistic regression analysis was employed.The mean age of the patients at study time was 39 (±9.8). The average follow-up duration of patients on antiretroviral therapy (ART) was 7 (±3) years. The prevalence of immunological discordance and virological discordance to HAART were 13.2% and 47%, respectively. With multivariate logistic regression analysis duration of follow-up on ART ≤ 6 years (adjusted odds ratio [AOR] = 3.29 (1.80-6.03), P ≤ .001) and VL ≥20 copies/mm3 (AOR = 3.08 [1.70-5.61], P ≤ .001) were significant factors for immunological discordance conversely the patients who switched drug as a result of TB (AOR = 3.33 [1.10-10.08], P = .03) was significant factors for virological discordance.The prevalence of immunological discordance and virological discordance to HAART among HIV patients is high. Patients with the duration of follow-up on ART ≤ 6 years, VL ≥ 20 copies/mm3 and patients who switched drugs as a result of TB were significant factors for discordance. Hence, intensive adherence support and counseling should be provided to achieve the UNAIDS 90 target. HIV positive individuals co-infected with TB, who have had VL ≥ 20 copies/mm3 and who are ≤6 years duration of follow-up on ART need to be carefully monitored. In addition, national based study of discordant groups is recommended.

Arterial stiffness is associated with oxidative stress and endothelial activation among persons with treated HIV in Zambia

BACKGROUND

Cardiovascular disease (CVD) prevalence is rising among persons with HIV (PLWH) in sub-Saharan Africa. Oxidative stress and endothelial activation, resulting in reduced vascular compliance, are contributors to CVD risk. However, there is a paucity of vascular health data in this population.

OBJECTIVES

To assess the relationships of oxidative stress and endothelial activation with vascular stiffness among PLWH.

METHOD

Fifty-four PLWH on antiretroviral therapy > 5 years and 57 HIV-negative controls, all aged 18-45 years, were enrolled from the University Teaching Hospital, Lusaka, Zambia. Oxidative stress was measured by nitrotyrosine, a peroxynitrite biomarker, and endothelial activation by soluble intercellular adhesion molecule-1 (sICAM-1) plasma levels. Vascular compliance was measured using carotid-radial pulse wave velocity (crPWV) and arterial stiffness index (crASI).

RESULTS

PLWH had higher sICAM-1 levels (median 345 ng/mL) compared to controls (275 ng/mL, p < 0.01), as well as higher nitrotyrosine levels (297 versus 182 nM; p = 0.02). Median crPWV was similar between the groups, but PLWH had higher crASI (2.4 versus 2.2 cm/ms; p < 0.05). After adjusting for age, fat mass, and blood pressure, the estimated effect of a one unit increase in nitrotyrosine on crPWV were twofold higher in the PLWH, but neither reached significance. In a model pooling all participants, there were significant differences in the relationship of nitrotyrosine with crPWV and crASI by HIV status.

CONCLUSION

PLWH in sub-Saharan Africa had significantly greater oxidative stress and endothelial activation compared to HIV-negative individuals. These factors may contribute to increased arterial stiffness and higher CVD prevalence in this population.

Interventions for improving treatment outcomes in adolescents on antiretroviral therapy with unsuppressed viral loads: a systematic review protocol

INTRODUCTION

Adolescents represent one of the most underserved population groups among people living with HIV. With successes in the elimination of mother to child transmission initiatives and advances in paediatric HIV treatment programmes, a large population of HIV-infected children are surviving into adolescence. Adolescence presents unique challenges that increase the risk of non-suppressed viral loads in adolescents living with HIV (ALHIV). There is a need to develop, implement and test interventions to improve viral suppression among ALHIV. Systematic reviews of recent studies present scarce and inconclusive evidence of effectiveness of current interventions, especially for adolescents. This protocol provides a description of a planned review of interventions to improve treatment outcomes among unsuppressed ALHIV.

METHODS AND ANALYSIS

A comprehensive search string will be used to search six bibliographic databases: PubMed/MEDLINE, Sabinet, EBSCOhost, CINAHL, Scopus and ScienceDirect, for relevant studies published between 2010 and 2020 globally, and grey literature. Identified articles will be exported into Mendeley Reference Management software and two independent reviewers will screen the titles, abstracts and full texts for eligibility. A third reviewer will resolve any discrepancies between the two initial reviewers. Studies reporting on interventions to improve viral suppression, retention and adherence for adolescents will be considered for inclusion. The systematic review will be performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Where feasible, a meta-analysis will be conducted using Stata Statistical Software: Release V.16. The quality of the studies and risk of bias will be assessed using the Critical Appraisal Skills Programme checklists and Risk of Bias in Non-randomised Studies of Interventions tool, respectively.

ETHICS AND DISSEMINATION

The systematic review entails abstracting and reviewing already publicly available data rather than any involvement of participants, therefore, no ethical clearance will be required. Results will be shared with relevant policy-makers, programme managers and service providers, and published and share through conferences and webinars.

PROSPERO REGISTRATION NUMBER

CRD42021232440.

HIV viral load suppression following intensive adherence counseling among people living with HIV on treatment at military-managed health facilities in Uganda

BACKGROUND

Uniformed service personnel have an increased risk of poor viral load suppression (VLS). This study was performed to evaluate the outcomes of interventions to improve VLS in the 28 military health facilities in Uganda.

METHODS

This operational research was conducted between October 2018 and September 2019, among people living with HIV (PLHIV) in the 28 health facilities managed by the military in Uganda. Patients with a viral load (VL) >1000 copies/ml received three sessions of intensive adherence counselling (IAC), 1 month apart, after which a repeat VL was done. The main outcome was the proportion with a suppressed VL following IAC.

RESULTS

Of the 965 participants included in this analysis, 592 (61.4%) were male and 367 (38.3%) were female. Average age was 35.5 ± 13.7 years, and 87.8% had at least one IAC session. At least 48.2% had a suppressed repeat VL. IAC increased the odds of VLS by 82% (P = 0.004), with adjusted OR of 1.56 (P = 0.054). An initial VL >10 000 copies/ml, being on antiretroviral therapy for at least 2 years, being male, and being <18 years of age were associated with repeat VL non-suppression.

CONCLUSIONS

IAC marginally improved VL suppression. There is a need to improve IAC in military health facilities.

Evaluation of Medication Therapy Issues, Resolutions, and Adherence Among Persons With HIV in the Pharmacist-Led Patient-Centered HIV Care Model

OBJECTIVE

To identify medication therapy issues and resolutions and assess their relationship to antiretroviral therapy (ART) adherence among participants of the Patient-Centered HIV Care Model demonstration project.

METHODS

Adult persons with HIV (PWH) in the United States were enrolled in the Patient-Centered HIV Care Model from August 2014 to September 2016. Pharmacists conducted regular medication therapy reviews and documented ART and non-ART issues and suggested resolutions. Adherence to ART was calculated using proportion of days covered (PDC), and the mean PDC by the number of ART issues was compared using a generalized linear model with linear trend estimation.

RESULTS

The most common ART issue was adherence (57%). Adherence ART issues were resolved by adherence management (48%) or patient education (36%). Participants had a mean of 4.2 ART issues and 6.4 non-ART issues. PDC was 89% for those with 0 ART issues and 73% for those with ≥3 ART issues. Persons with 0 ART issues had an increase in adherence (+8%) in the postperiod, whereas those with ≥3 ART issues had a decrease in adherence (-6%) (P = 0.02) in the postperiod.

CONCLUSIONS

Identifying therapy issues could help pharmacists improve care for PWH. Because PWH are an aging population with an increased risk of comorbidities and polypharmacy, pharmacists and providers should collaborate to provide holistic, primary care solutions to address both the number and nature of therapy issues.

Impact of pre-existing drug resistance on risk of virological failure in South Africa

OBJECTIVES

There is conflicting evidence on the impact of pre-existing HIV drug resistance mutations (DRMs) in patients infected with non-B subtype virus.

METHODS

We performed a case-cohort substudy of the AIDS Drug Resistance Surveillance Study, which enrolled South African patients initiating first-line efavirenz/emtricitabine/tenofovir. Pre-ART DRMs were detected by Illumina sequencing of HIV pol and DRMs present at <20% of the viral population were labelled as minority variants (MVs). Weighted Cox proportional hazards models estimated the association between pre-ART DRMs and risk of virological failure (VF), defined as confirmed HIV-1 RNA ≥1000 copies/mL after ≥5 months of ART.

RESULTS

The evaluable population included 178 participants from a randomly selected subcohort (16 with VF, 162 without VF) and 83 additional participants with VF. In the subcohort, 16% of participants harboured ≥1 majority DRM. The presence of any majority DRM was associated with a 3-fold greater risk of VF (P = 0.002), which increased to 9.2-fold (P < 0.001) in those with <2 active drugs. Thirteen percent of participants harboured MV DRMs in the absence of majority DRMs. Presence of MVs alone had no significant impact on the risk of VF. Inclusion of pre-ART MVs with majority DRMs improved the sensitivity but reduced the specificity of predicting VF.

CONCLUSIONS

In a South African cohort, the presence of majority DRMs increased the risk of VF, especially for participants receiving <2 active drugs. The detection of drug-resistant MVs alone did not predict an increased risk of VF, but their inclusion with majority DRMs affected the sensitivity/specificity of predicting VF.

Cerebrospinal fluid immune markers and HIV-associated neurocognitive impairments: A systematic review

HIV-1 is responsible for the development of a spectrum of cognitive impairments known as HIV-associated neurocognitive disorder (HAND). In the era of antiretroviral therapy (ART), HAND remains prevalent in people living with HIV (PLWH), despite low or undetectable viral loads. Persistent neuroinflammation likely plays an important role in the contributing biological mechanisms. Multiple cerebrospinal fluid (CSF) immune markers have been studied but it is unclear which markers most consistently correlate with neurocognitive impairment. We therefore conducted a systematic review of studies of the association of CSF immune markers with neurocognitive performance in ART-experienced PLWH. We aimed to synthesize the published data to determine consistent findings and to indicate the most noteworthy CSF markers of HAND. Twenty-nine studies were included, with 20 cross-sectional studies and 9 longitudinal studies. From the group of markers most often assayed, specific monocyte activation (higher levels of Neopterin, sCD163, sCD14) and neuroinflammatory markers (higher levels of IFN-γ, IL-1α, IL-7, IL-8, sTNFR-II and lower levels of IL-6) showed a consistent direction in association with HIV-associated neurocognitive impairment. Furthermore, significant differences exist in CSF immune markers between HIV-positive people with and without neurocognitive impairment, regardless of viral load and nadir/current CD4⁺ count. These markers may be useful in furthering our understanding of the neuropathology, diagnosis and prognosis of HAND. Studies using prospective designs (i.e. pre- and post-interventions), "multi-modal" methods (e.g. imaging, inflammation and neurocognitive evaluations) and utilizing a combination of the markers most commonly associated with HAND may help delineate the mechanisms of HAND.

Temporal Trends in the Epidemiology of HIV in Turkey

OBJECTIVE

The aim of this study was to analyze the temporal trends of HIV epidemiology in Turkey from 2011 to 2016.

METHODS

Thirty-four teams from 28 centers at 17 different cities participated in this retrospective study. Participating centers were asked to complete a structured form containing questions about epidemiologic, demographic and clinical characteristics of patients presented with new HIV diagnosis between 2011 and 2016. Demographic data from all centers (complete or partial) were included in the analyses. For the cascade of care analysis, 15 centers that provided full data from 2011 to 2016 were included. Overall and annual distributions of the data were calculated as percentages and the Chi square test was used to determine temporal changes.

RESULTS

A total of 2,953 patients between 2011 and 2016 were included. Overall male to female ratio was 5:1 with a significant increase in the number of male cases from 2011 to 2016 (p<0.001). The highest prevalence was among those aged 25-34 years followed by the 35-44 age bracket. The most common reason for HIV testing was illness (35%). While the frequency of sex among men who have sex with men increased from 16% to 30.6% (p<0.001) over the study period, heterosexual intercourse (53%) was found to be the most common transmission route. Overall, 29% of the cases presented with a CD4 count of >500 cells/mm3 while 46.7% presented with a CD4 T cell count of <350 cells/mm3. Among newly diagnosed cases, 79% were retained in care, and all such cases initiated ART with 73% achieving viral suppression after six months of antiretroviral therapy.

CONCLUSION

The epidemiologic profile of HIV infected individuals is changing rapidly in Turkey with an increasing trend in the number of newly diagnosed people disclosing themselves as MSM. New diagnoses were mostly at a young age. The late diagnosis was found to be a challenging issue. Despite the unavailability of data for the first 90, Turkey is close to the last two steps of 90-90-90 targets.

High HIV-1 Virological Failure and Drug Resistance among Adult Patients Receiving First-Line ART for At least 12 Months at a Decentralized Urban HIV Clinic Setting in Senegal before the Test-and-Treat

Background:

The feasibility of antiretroviral therapy (ART) monitoring remains problematic in decentralized HIV clinic settings of sub-Saharan Africa. We assessed the rates and correlates of HIV-1 virological failure (VF) and drug resistance (DR) in 2 pre-test-and-treat urban clinic settings of Senegal.

Methods:

Consenting HIV-1-infected adults (⩾18 years) receiving first-line ART for ⩾12 months were cross-sectionally enrolled between January and March 2015, at the referral outpatient treatment center of Dakar (n = 151) and decentralized regional hospital of Saint-Louis (n = 127). In the 12 months preceding plasma specimens’ collection patients at Saint-Louis had no viral load (VL) testing. Significant predictors of VF (VL ⩾ 1000 copies/ml) and DR (clinically relevant mutations) were determined using binomial logistic regression in R software.

Results:

Of the 278 adults on EFV-/NVP-based regimens, 32 (11.5% [95%CI: 8.0-15.9]) experienced VF. Failing and non-failing patients had comparable median time [interquartile] on ART (69.5 [23.0-89.5] vs 64.0 [34.0-99.0] months; P = .46, Mann–Whitney U-test). Of the 27 viraemic isolates successfully genotyped, 20 (74.1%) carried DR mutations; most frequent were M184VI (55.6%), K103N (37.1%), thymidine analog mutations (29.6%), Y181CY (22.2%). The pattern of mutations did not always correspond to the ongoing treatment. The adjusted odds of VF was significantly associated with the decentralized clinic site (P < .001) and CD4 < 350 cells/mm³ (P < .006). Strong correlates of DR also included Saint-Louis (P < .009), CD4 < 350 cells/mm³ (P <. 001), and nevirapine-based therapies (comparator: efavirenz-based therapies; P < .027). In stratification analyses by site, higher rate of VF at Saint-Louis (20.5% [95%CI: 13.8-28.5] vs 4.0% [95%CI: 1.5-8.5] in Dakar) was associated with nevirapine-based therapies (OR = 3.34 [1.07-11.75], P = .038), self-reported missing doses (OR = 3.30 [1.13-10.24], P = .029), and medical appointments (OR = 2.91 [1.05-8.47], P = .039) in the last 1 and 12 months(s), respectively. The higher rate of DR at Saint-Louis (12.9% [95%CI: 7.6-20.1] vs 2.7% [95%CI: 0.7-6.7] in Dakar) was associated with nevirapine-based therapies (OR = 5.13 [1.12-37.35], P = .035).

Conclusion:

At decentralized urban settings, there is need for enhanced virological monitoring and adherence support. HIV programs in Senegal should intensify early HIV diagnosis for effective test-and-treat. These interventions, in addition to the superiority of efavirenz-based therapies provide a favorable framework for transitioning to the recommended potent drug dolutegravir, thereby ensuring its long-term use.

A Single-Blind, Parallel Design RCT to Assess the Effectiveness of SMS Reminders in Improving ART Adherence Among Adolescents Living with HIV (STARTA Trial)

PURPOSE

The study evaluated the feasibility, acceptability, and efficacy of interactive and tailored short message reminders on antiretroviral therapy adherence among adolescents (15-19 years) living with HIV in southwest Nigeria.

METHODS

The study was a single-blind, parallel-design (ratio 1:1), and multicenter RCT of 209 medication-non-adherent adolescents living with HIV at HIV clinics in two states in southwest Nigeria. The research assessed ART adherence using the visual analog scale, viral suppression, pill count, and ACTG scores; the feasibility of the intervention by the SMS delivery and response (overall and individual) rates; and acceptability using self-report, willingness to continue receiving the intervention, and desire for its scale-up.

RESULTS

A total of 17,690 text messages were sent while 10,119 (57.2%) got delivered to the participants. Out of 9,216 responses that were received from the study participants, 8,781 (95.3%) indicated acceptability of the intervention. The end-of-study log₁₀ of viral load values between control and intervention groups had a mean difference of 0.66 (95% CI 0.26-1.06) and p-value of .001. Also, the unadjusted odds ratio of undetected viral load (≤20 copies/ml) was 1.356 (1.039-1.771) with a p-value of .002. However, the intervention had no effect on subjective measures of antiretroviral therapy adherence.

CONCLUSIONS

The use of interactive and tailored short message reminders to enhance antiretroviral therapy adherence among adolescents has good potential. It seems feasible, highly acceptable, and possibly leads to improved viral load count. It is likely that the associated antiretroviral therapy adherence enhances viral suppression and, therefore, improves outcomes in adolescent HIV.

Dental caries in association with viral load in children living with HIV in Phnom Penh, Cambodia: a cross-sectional study

Background

Oral health status is associated with the overall health among people living with human immunodeficiency virus (HIV) infection. However, it is unclear whether dental caries is associated with the viral load in this population. Particularly, dental caries among children living with HIV needs better understanding as this can affect their overall health and future well-being. This study assessed the association between dental caries and viral load among children living with HIV in Phnom Penh, Cambodia.

Methods

This cross-sectional study, conducted at the National Pediatric Hospital as a baseline survey of a randomized controlled trial, included 328, 3–15-year-old children living with HIV and their primary caregivers. Calibrated and trained examiners conducted oral examinations for dental caries (DMFT/dmft index) in the children and retrieved the latest HIV viral load data from the hospital’s patient information system. On the dental examination day, the children and their caregivers were invited to answer a questionnaire-based interview. Multiple logistic regression analysis was conducted to assess the association between dental caries and viral load. The cut-off point for undetectable viral load was set at < 40 copies/mL.

Results

Data from 328 children were included in the analysis; 68.3% had an undetectable viral load. The mean DMFT/dmft was 7.7 (standard deviation = 5.0). Adjusted regression analysis showed that dental caries in permanent or deciduous teeth was positively associated with detectable viral load (adjusted odds ratio [AOR]: 1.07, 95% confidence interval [CI]: 1.01–1.14). Conversely, antiretroviral therapy of ≥ 1 year and self-reported better adherence to antiretroviral drugs were negatively associated with detectable viral load. Among children with detectable viral load, dental caries in permanent or deciduous teeth was positively associated with non-suppression of viral load (> 1000 copies/mL) (AOR: 1.12, CI: 1.03–1.23).

Conclusions

Dental caries was associated with viral load status detection among children living with HIV. This finding suggests that dental caries may affect their immune status. The oral health of children living with HIV should be strengthened, and further research is needed to clarify the causal relationship between viral load and oral health status.

The initiation of human immunodeficiency virus treatment for children at different levels of care

Background: The human immunodeficiency virus (HIV) pandemic increased the demand for health care resources in South Africa. To decrease the burden on specialised facilities, the Department of Health decentralised antiretroviral (ARV) management. In the uMgungundlovu district, adult HIV primary care services reported lower rates of HIV viral load (VL) suppression after initiation of ARVs compared to other levels of care. The aim of the study was to evaluate paediatric HIV services in the same district. Methods: Four ARV clinics, at different levels of care, initiating and monitoring paediatric HIV infection treatment in uMgungundlovu district, KwaZulu Natal, were selected: primary healthcare services, general practitioner services, general paediatric services and subspecialist infectious diseases services were included. Paediatric patients newly diagnosed between January 2014 and June 2015 were included in the study. The rate of HIV VL suppression at one year after treatment initiation was the primary outcome measure. A total of 377 patients were included, 35 at the nurse-led primary care clinic, 25 at the general practitioner-led primary care clinic, 156 at the paediatrician-led secondary care clinic, and 161 at the HIV paediatric subspecialist-led tertiary care clinic. Of the 377 patients, 154 (59.9%) achieved VL suppression at one year, with 75% (18/24), 61.9% (13/21), 51.7% (60/116) and 66.7% (63/96) achieving HIV VL suppression at the four clinic types, respectively. Conclusion: HIV VL suppression rates were variable, but did not differ statistically across levels of health care. Outcomes were not improved by initiation in specialist or subspecialist-led clinics, which supports the strategy of increasing access by decentralising HIV care for paediatric patients.

The Comparison of Teen Clubs vs. Standard Care on Treatment Outcomes for Adolescents on Antiretroviral Therapy in Windhoek, Namibia

Background

Adolescents living with HIV (ALHIV) are challenged to adhere to antiretroviral therapy (ART) and achieve and maintain virologic suppression. Group-based adherence support interventions, such as adherence clubs, have been shown to improve long-term adherence in ART patients. The teen club intervention was introduced in 2010 in Namibia to improve treatment outcomes for ALHIV by providing adherence support in a peer-group environment. Adolescents who have completed the full HIV disclosure process can voluntarily join the teen clubs. The current study compared treatment outcomes of ALHIV receiving ART at a specialized paediatric HIV clinic between 1 July 2015 and 30 June 2017 in Windhoek, Namibia.

Methods

A retrospective cohort analysis was conducted on routine patient data extracted from the electronic Patient Monitoring System, individual Patient Care Booklets, and teen club attendance registers. A sample of 385 adolescents were analysed: 78 in teen clubs and 307 in standard care. Virologic suppression was determined at 6, 12, and 18 months from study start date, and compared by model of care, age, sex, disclosure status, and ART regimen. Comparisons between adolescents in teen clubs and those receiving standard care were performed using the chi-square test, and risk ratios were calculated to analyze differences in ART adherence and virologic suppression.

Results

The average clinician-measured ART adherence was 89% good, 6% fair, and 5% poor amongst all adolescents, with no difference between teen club members and adolescents in standard care (p = 0.277) at 3 months. Virologic suppression over the 2-year observation period was 87% (68% fully suppressed <40 copies/ml and 19% suppressed between 40–999 copies/ml), with no difference between teen club members and those in standard care. However, there were statistically significant differences in virologic suppression levels between the younger (10–14 years) adolescents and older (15–19 years) adolescents at 6 months (p = 0.015) and at 12 months (p = 0.021) and between adolescents on first-line and second-line ART regimen at 6 months (p = 0.012), 12 months (p = 0.004), and 18 months (p = 0.005).

Conclusion

The teen club model delivering psychosocial support only did not improve adherence and virologic suppression levels for adolescents in a specialized paediatric ART clinic, neither were they inferior to standard care. Considering the limitations of this study, teen clubs may still hold potential for improving adherence and virologic suppression levels for older adolescents, and more robust research on adherence interventions for adolescents with higher methodological quality is required.

Comparison of machine learning methods for predicting viral failure: a case study using electronic health record data

Background

Human immunodeficiency virus (HIV) viral failure occurs when antiretroviral therapy fails to suppress and sustain a person's viral load count below 1,000 copies of viral ribonucleic acid per milliliter. For those newly diagnosed with HIV and living in a setting where healthcare resources are limited, such as a low- and middle-income country, the World Health Organization recommends viral load monitoring six months after initiation of antiretroviral treatment and yearly thereafter. Deviations from this schedule are made in cases where viral failure occurs or at the discretion of the clinician. Failure to detect viral failure in a timely fashion can lead to delayed administration of essential interventions. Clinical prediction models based on information available in the patient medical record are increasingly being developed and deployed for decision support in clinical medicine and public health. This raises the possibility that prediction models can be used to detect potential for viral failure in advance of viral measurements, particularly when those measurements occur infrequently.

Objective

Our goal is to use electronic health record data from a large HIV care program in Kenya to characterize and compare the predictive accuracy of several statistical machine learning methods for predicting viral failure at the first and second measurements following initiation of antiretroviral therapy. Predictive accuracy is measured in terms of sensitivity, specificity and area under the receiver-operator characteristic curve.

Methods

We trained and cross-validated 10 statistical machine learning models and algorithms on data from over 10,000 patients in the Academic Model Providing Access to Healthcare care program in western Kenya. These included parametric, non-parametric, ensemble, and Bayesian methods. The input variables included 50 items from the clinical record, hand picked in consultation with clinician experts. Predictive accuracy measures were calculated using 10-fold cross validation.

Results

Viral load failure rate is about 20% in this patient cohort at both the first and second measurements. Ensemble techniques generally outperformed other methods. For predicting viral failure at the first follow up measure, specificity was over 90% for these methods, but sensitivity was typically in the 50-60% range. Predictive accuracy was greater for the second follow up measure, with sensitivities over 80%. Super Learner, gradient boosting and Bayesian additive regression trees consistently outperformed other methods. For a viral failure rate of 20%, the positive predictive value for the top-performing methods is between 75 and 85%, while the negative predictive value is over 95%.

Conclusion

Evidence from this study suggests that machine learning techniques have potential to identify patients at risk for viral failure prior to their scheduled measurements. Ultimately, prognostic virologic assessment can help guide the administration of earlier targeted intervention such as enhanced drug resistance monitoring, rigorous adherence counseling, or appropriate next-line therapy switching. External validation studies should be used to confirm the results found here.

Variation in estimated viral suppression associated with the definition of viral suppression used

OBJECTIVE

The proportion of people living with HIV with suppressed viral load is a key indicator of the HIV care continuum. We explored how this proportion varied depending on how it was calculated.

DESIGN

Observational cohort study.

METHODS

We calculated the proportion of the Johns Hopkins HIV Clinical Cohort who were virally suppressed each year, 2010-2018, based on different denominators; thresholds for suppression (≤20, ≤50, ≤200, or ≤400 copies/ml); and strategies for summarizing multiple viral load measurements (we classified persons as suppressed if they had any lab, ≥50% of labs, last lab, or all labs below the threshold). We also calculated 5-year risk of all-cause mortality associated with each classification of viral suppression.

RESULTS

Three thousand eleven persons contributed 60 858 viral load values to this analysis. Proportion classified as virally suppressed ranged from 51.8 to 92.5%, depending on the definition used and persons included in the calculation. Requiring more labs below the threshold; using a lower threshold; and assuming persons lost to follow-up were not suppressed (stricter definitions) resulted in a lower proportion estimated to be suppressed. Suppression by stricter definitions were associated with better 5-year survival.

DISCUSSION

The proportion suppressed varied greatly as a function of the subset of persons in whom it was calculated, the threshold used for suppression, and the way multiple viral loads per person per year were summarized. Measures of durable viral suppression, and low-level viremia (20-400 copies/ml), should be considered in describing the health of people with HIV, in addition to the standard estimates of suppression.

Polyethylene Glycol 40-Modified Peptide with High Therapeutic Efficacy in Simian-Human Immunodeficiency Virus-Acutely Infected Rhesus Monkeys

Anti-human immunodeficiency virus type 1 (anti-HIV-1) fusion peptides have been studied for nearly 2 decades, but few candidates have found useful clinical applications. One factor underlying the failure of such agents to reach the clinic is their poor pharmacokinetic properties, and many efforts have been made to overcome this problem. In this study, we modified C34, a peptide inhibitor of HIV-1 fusion, at its conserved glycosylation site using polyethylene glycols (PEGs) of different molecular weights. PEG40-NC, a conjugate of C34 and branched PEG 40 kDa (PEG40), which has been previously shown to improve the pharmacokinetic profiles of proteins, showed a significantly extended half-life (t _1/2; 10.39 h in rats), which compensated for decreased in vitro activity (50% effective concentration [EC₅₀] of 18.51 nM). PEG40-NC also showed a mechanism of action similar to that of C34. PEG40-NC monotherapy in acutely simian-human immunodeficiency virus (SHIV)-infected rhesus monkeys significantly suppressed viral load compared with a control treatment. Efficacy was linked to the extended half-life and lymphatic exposure conferred by attached PEG40. These results highlight the potential of further clinical investigations of PEG40-NC in combination with antiretroviral therapy or other anti-HIV agents.IMPORTANCE Poor pharmacokinetics have severely hindered the clinical use of anti-HIV peptides. Different small molecules, such as lipid, cholesterol, and small PEG, were designed to modify peptides to improve their pharmacokinetics. In this study, we incorporated large branched PEG to anti-HIV peptide and obtained a conjugate with extended half-life and improved in vivo efficacy. The strategy we developed in this study can also be applicable for the development of other peptide candidates.

Viral Suppression and Its Associated Factors in HIV Patients on Highly Active Antiretroviral Therapy (HAART): A Retrospective Study in the Ho Municipality, Ghana

Background. The WHO targets to end HIV/AIDS as a public health problem by 2030. The introduction of the ambitious “90-90-90” strategy to attain this target is expected to be achieved by the year 2020. However, there is lack of regional data, especially on the third “90.” This study sought to assess the rate and associated factors of viral suppression among people living with HIV (PLWH) on highly active antiretroviral therapy (HAART) at the Antiretroviral Therapy (ART) Clinic in a Ghanaian health facility. Method. The study design was a retrospective analysis of secondary data of 284 HIV registrants on HAART for at least 6 months at the ART Clinic from July 2016 to April 2019. Data on sociodemography including age, gender, marital status, education, and occupation as well as pharmacological (type of medication and duration on medication) and laboratory variable (current viral load results) were extracted from patients’ folders. Viral suppression and failure were determined using the WHO definitions (viral suppression as viral load <1000 copies/ml and virologic failure ≥1000 copies/ml). Regular clinic attendance (used as a proxy measure for medication adherence) was defined as consistent monthly clinic attendance for HAART medication and other clinical management within the past 12 months. Results. Out of the 284 HIV patients, 195 (69%) achieved viral suppression. Of the 195 who were virally suppressed, 77 (39.5%) had undetectable levels, with a similar proportion (39.5%) achieving viral load results ranging from 20 to 200 copies/ml. Moreover, 27 (13.8%) patients had viral load ranging from 201 to 500 copies/ml while 14 (7.2%) recorded viral load from 501 to 1000 copies/ml. No clear pattern in the viral suppression rate was associated with the age groups (p=0.1152). However, regular clinic attendance (used as proxy for medication adherence) (p<0.0001) and being on HAART for more than three (3) years (p=0.03) were associated with viral suppression. Conclusion. The rate of viral suppression among PLWH on HAART in the Ho municipality fell short of the WHO target. However, the study identified regular ART clinic attendance and treatment >3 years as factors associated with viral suppression.

HIV virological non-suppression and factors associated with non-suppression among adolescents and adults on antiretroviral therapy in northern Ethiopia: a retrospective study

Background

Despite the benefits of Antiretroviral Therapy (ART), there is a growing concern of treatment failure. This study aimed to assess viral non suppression rate and factors associated with HIV viral non suppression among adolescents and adults on ART in Northern Ethiopia.

Methods

A retrospective cross sectional study was done on 19,525 study subjects. All the data in the database of Tigray Health Research Institute was exported to Microsoft excel 2010 and then data verification and filtration were done before exporting to STATA 14.0 for analysis. Generalized Estimating Equation (GEE) logistic regression was used for statistical modeling of viral non suppression.

Results

A total of 5153 (26.39%; 95%CI (25.77%, 27.02)) patients had no viral suppression despite being on ART. Being male (AOR = 1.27, 95% CI: 1.18, 1.37), 15–19 years of age (AOR = 4.86, 95%CI: 3.86, 6.12), patients from primary hospital (AOR = 1.26, 95%CI: 1.05, 1.52), WHO staging II (AOR = 1.31, 95%CI: 1.10, 1.54), poor ART adherence level (AOR = 2.56, 95%CI: 1.97, 3.33), fair ART adherence level (AOR = 1.61, 95%CI: 1.36, 1.90), baseline CD-4 count of < 200 cells/micro liter (AOR = 1.33, 95%CI: 1.14, 1.54), recent CD-4 count of < 200 cells/micro liter (AOR = 3.78, 95%CI: 3.34, 4.27), regimen types: 1c (AZT-3TC-NVP) (AOR = 1.32, 95%CI: 1.22, 1.44), 2 h (TDF-3TC-ATV/R) (AOR = 1.79, 95%CI: 1.27, 2.52) and declined immunological responses after ART initiation (AOR = 1.45, 95%CI: 1.30, 1.61) were significantly associated with viral non-suppression.

Conclusions

The virological non suppression was high which makes it less likely to achieve the third 90 UNAIDS target. Being male, patients with WHO staging II and poor ART adherence level were significantly associated with viral non suppression. Therefore, intensive adherence support and counseling should be provided. It is also a high time to determine the antiretroviral drugs resistance pattern given the fact that a large number of patients had virological non suppression.

Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

BACKGROUND

Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories.

METHODS

We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections.

FINDINGS

Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets.

INTERPRETATION

Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.

FUNDING

Bill & Melinda Gates Foundation, National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

The Human Immunodeficiency Virus Care Continuum in China: 1985-2015

Background

Human immunodeficiency virus (HIV) care continuum attrition is a major global public health challenge. Few studies have examined this problem in resource-limited settings. We aimed to assess cumulative, current, and historical achievement along China's HIV continuum of care.

Methods

A nationwide, serial cross-sectional study of all individuals with HIV infection diagnosed in China between 1 January 1985 and 31 December 2015 was conducted using data from China's HIV/AIDS information systems. Biennial estimates of the number of persons living with HIV were also used. We defined 7 steps in HIV care continuum as infected (estimated), diagnosed, linked, retained, enrolled, receiving antiretroviral therapy (ART), and virally suppressed. Cumulative, 30-year performance, and biennial performance during the most recent 10 years were examined.

Results

A total of 573529 persons diagnosed with HIV infection were included. Cumulatively, 94% were linked, 88% were retained, 73% were enrolled, 67% were receiving ART, and 44% were suppressed. Greatest attrition was observed for adolescents, minorities, and those who reported injecting drug use as their route of infection. Improvement was observed from 2005 to 2015. As of the end of 2015, 68% among those infected were diagnosed, 67% among diagnosed were receiving ART, and 65% among those receiving ART were virally suppressed. After adjusting for those without viral load testing, the proportion suppressed increased to 89%.

Conclusions

Despite dramatic improvements, China faces serious challenges in achieving the Joint United Nations Programme on HIV/AIDS 90-90-90 targets, because of substantial attrition along its continuum of HIV care.

Antiretroviral Therapy-associated Adverse Drug Reactions and their Effects on Virologic Failure- A Retrospective Cohort Study in Nigeria

Background:

Adverse drug reactions (ADRs) associated with antiretroviral therapy (ART) can rapidly reverse the gains of ART resulting in poor health outcomes. We need an improved under-standing of specific ART-related ADRs that influence virologic outcomes.

Objective:

To investigate the frequency of clinical ADRs and assess their effect on virologic failure in patients on ART.

Method:

We described the prevalence of major clinical ADRs, and the association between specific ADRs and virologic failure in a clinic cohort of HIV-1 infected Nigerians aged ≥18 years, on first-line ART between June 2004 and February 2012. Multivariable logistic regression was run to identify predictors of virologic failure at 24 and 72 weeks of ART.

Results:

Data of 12,115 patients with a median age of 34 (interquartile range: 29-41) years, and pre-dominantly females (67%) were evaluated. Overall, 957 (7.9%) patients experienced at least one ADR during a median follow-up period of 4 years (interquartile range: 1-7). The three most prevalent ADRs were lipodystrophy (2.6%), anemia (1.9%), and skin rash (0.7%). Virologic failure rate was 36% and 34% at 24 and 72 weeks of ART, respectively. Anemia independently predicted the odds of virologic failure at 72 weeks of ART (adjusted odds ratio, 1.74; 95% CI: 1.2-2.51); adjusted for sex, age, pre-treatment CD4+ cell count, antiretroviral regimen, and medication refill adherence.

Conclusion:

Antiretroviral therapy-associated anemia increases the likelihood of late virologic failure. We recommend routine monitoring of hemoglobin levels and prompt management of anemia in all pa-tients on ART as a strategy to improve virologic success rates.

VIBRA trial - Effect of village-based refill of ART following home-based same-day ART initiation vs clinic-based ART refill on viral suppression among individuals living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho

BACKGROUND

There is a need for evaluating community-based antiretroviral therapy (ART) delivery models to improve overall performance of HIV programs, specifically in populations that may have difficulties to access continuous care. This cluster-randomized clinical trial aims to evaluate the effectiveness of a multicomponent differentiated ART delivery model (VIBRA model) after home-based same-day ART initiation in remote villages in Lesotho, southern Africa.

METHODS/DESIGN

The VIBRA trial (VIllage-Based Refill of ART) is a cluster-randomized parallel-group superiority clinical trial conducted in two districts in Lesotho, southern Africa. Clusters (i.e., villages) are randomly assigned to either the VIBRA model or standard care. The clusters are stratified by district, village size, and village access to the nearest health facility. Eligible individuals (HIV-positive, aged 10 years or older, and not taking ART) identified during community-based HIV testing campaigns are offered same-day home-based ART initiation. The intervention clusters offer a differentiated ART delivery package with two features: (1) drug refills and follow-ups by trained and supervised village health workers (VHWs) and (2) the option of receiving individually tailored adherence reminders and notifications of viral load results via SMS. The control clusters will continue to receive standard care, i.e., collecting ART refills from a clinic and no SMS notifications. The primary endpoint is viral suppression 12 months after enrolment. Secondary endpoints include linkage to and engagement in care. Furthermore, safety and cost-effectiveness analyses plus qualitative research are planned. The minimum target sample size is 262 participants. The statistical analyses will follow the CONSORT guidelines. The VIBRA trial is linked to another trial, the HOSENG (HOme-based SElf-testiNG) trial, both of which are within the GET ON (GETing tOwards Ninety) research project.

DISCUSSION

The VIBRA trial is among the first to evaluate the delivery of ART by VHWs immediately after ART initiation. It assesses the entire HIV care cascade from testing to viral suppression. As most countries in sub-Saharan Africa have cadres like the VHW program in Lesotho, this model-if shown to be effective-has the potential to be scaled up. The system impact evaluation will provide valuable cost estimations, and the qualitative research will suggest how the model could be further modified to optimize its impact.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03630549 . Registered on 15 August 2018.

Switching at Low HIV-1 RNA into Fixed Dose Combinations: TDF/FTC/RPV is non-inferior to TDF/FTC/EFV in first-line suppressed patients living with HIV

BACKGROUND

In low- and middle-income countries (LMICs), a substantial unmet need for affordable single-tablet regimen (STR) options remains. Rilpivirine (RPV, TMC278) is formulated in a low-cost STR with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC).

OBJECTIVES

Switching at Low HIV-1 RNA into Fixed Dose Combinations (SALIF) compared RPV with efavirenz (EFV), both as STRs with TDF and FTC, in maintaining virologic suppression.

METHODS

SALIF was a phase 3b, randomised, open-label, non-inferiority study in virologically suppressed adults (HIV-1 RNA < 50 copies/mL) on non-nucleoside reverse transcriptase inhibitor (NNRTI)-based first-line antiretroviral therapy (ART) in Cameroon, Kenya, Senegal, South Africa, Uganda and Thailand. Patients (N = 426), stratified by NNRTI use, were randomised 1:1 to receive TDF/FTC/RPV (300/200/25 mg qd) or TDF/FTC/EFV (300/200/600 mg qd). Primary endpoint was proportion of patients with virologic suppression (HIV-1 RNA < 400 copies/mL) at week 48 (intent-to-treat, modified Food and Drug Administration Snapshot, 10% non-inferiority margin).

RESULTS

Patients received TDF/FTC/RPV (n = 213) or TDF/FTC/EFV (n = 211). At week 48, virologic suppression was maintained in 200/213 (93.9%) patients in the RPV arm and 203/211 (96.2%) in the EFV arm (difference -2.3%; 95% confidence interval: -6.4, +1.8), demonstrating non-inferiority of TDF/FTC/RPV. One patient in each arm experienced virologic failure without treatment-emergent resistance. Twenty-seven patients discontinued prematurely (8.0% RPV vs. 4.7% EFV), the most frequent reasons being adverse events (3.3% vs. 0.5%, respectively), site closure (1.9% vs. 0.5%), loss to follow-up (0.9% vs. 1.4%) and consent withdrawal (0.9% vs. 1.4%).

CONCLUSION

In adults with suppressed viral load on first-line NNRTI-based ART in LMICs, switching to an STR of TDF/FTC/RPV was non-inferior to TDF/FTC/EFV in maintaining high rates of viral suppression with a comparable tolerability profile.

"I take my pills every day, but then it goes up, goes down. I don't know what's going on": Perceptions of HIV virological failure in a rural context in Mozambique. A qualitative research study

Background

HIV prevalence in Mozambique is estimated to be 13.2%. Routine viral load for HIV monitoring was first implemented in the rural area of Tete in 2014. Programmatic data showed an unexpected high proportion of high viral load results, with up to 40% of patients having a viral load above 1000 copies/ml.

Objectives

This qualitative study aimed to explore perceptions about virological failure and viral load monitoring from the perspective of HIV positive patients on first-line antiretroviral therapy (ART) and health-care workers.

Methods

The study was conducted in seven rural communities in Changara-Marara district, Tete province, Mozambique. A total of 91 participants took part in in-depth interviews (IDIs) and focus group discussions (FGDs), including health-care workers (n = 18), patients on ART in individual care or Community Adherence Groups (CAGs) who experienced virological failure and virological re-suppression (n = 39) and CAG focal points (n = 34). Purposive sampling was used to select participants. Interviews and FGDs were conducted in Nhuengue and Portuguese. IDIs and FGDs were translated and transcribed before being coded and thematically analysed.

Results

Emergent themes showed that patients and health-care workers attributed great importance to viral load monitoring. A supressed viral load was viewed by participants as a predictor of good health and good adherence. However, some patients were confused and appeared distressed when confronted with virological failure. Viral load results were often little understood, especially when virological failure was detected despite good adherence. Inadequate explanations of causes of virological failure, delayed follow-up viral load results, repeated blood tests and lack of access to second-line ART resulted in reduced confidence in the effectiveness of ART, challenged the patient-provider relationship and disempowered patients and providers.

Conclusion

In this rural context undetectable viral load is recognized as a predictor of good health by people living with HIV and health-care workers. However, a lack of knowledge and health system barriers caused different responses in patients and health-care workers. Adapted counselling strategies, accelerated viral load follow-up and second-line ART initiation in patients with virological failure need to be prioritized.

Prevalence and determinants of adherence to antiretroviral treatment among HIV patients on first-line regimen: a cross-sectional study in Dakar, Senegal

Introduction

Successful and long-term positive impact of antiretroviral treatment requires high rates of adherence (> 90%). In Senegal, there is a lack of data regarding adherence to antiretroviral treatment and only a few studies have looked at the determinants. The aim of this study is to assess the prevalence and determinants contributing to antiretroviral (ARV) adherence among Human Immunodeficiency Virus (HIV) infected outpatients receiving care at four public hospitals in Dakar, Senegal.

Methods

A cross-sectional based study was carried out among HIV-positive ART adults in Dakar, Senegal. Patients were systematically sampled during either their clinical visits or visit to collect ARV drugs from six public hospitals and data collected with a questionnaire. The study outcome was adherence to antiretroviral treatment assessed by a multiple approach method which combined three self-reported adherence tools: self-reporting, Visual Analog Scale (VAS), and the Simplified Medication Adherence Questionnaire (SMAQ). Data were entered with an Excel spreadsheet and transferred to STATA for descriptive, bivariate and multivariate analysis. All the statistical tests were done at the threshold level of 0.05.

Results

A total of 150 HIV-positive patients on first line ART regimen at six public health facilities were enrolled into the study. The mean age of patients was 43.1 years with a sex ratio of 0.3. Most of the patients were prescribed Tenofovir-based regimen. Of these patients, 26.67% were found to be highly adherent. After adjusting for health-related variables, demographic and socio-economic variables, better adherence was associated with participating actively within an association of persons living with HIV (AoR=2.89; 95% CI: 1.04 - 7.99; p value 0.041) while being widowed patient was associated with lower adherence (AoR=0.17; 95% CI: 0.03 - 0.94; p value 0.043).

Conclusion

Our study findings imply that adherence should be routinely assessed during medical visits. Ongoing strategies to improve adherence such as out-of-clinic group-based models or psychological support should be directed toward outpatients' clinics to assist in improving adherence and long term virologic suppression in Senegal.

Virologic and immunologic responses of patients on highly active antiretroviral therapy in a rural community health centre in Limpopo, South Africa: A retrospective study

Background

South Africa has a high HIV burden. Despite increased uptake of persons living with HIV into the South African national antiretroviral therapy programme, the incidence of HIV increased between 2013 and 2016. Studies suggest that increased community viral suppression results in reduced HIV incidence in that community ‘independent of unsafe sexual behaviours and sharing used syringes’.

Objective

The aim of this study was to investigate the viral and immunologic responses of patients, in a rural community health centre in South Africa, to combination antiretroviral therapy (cART) between January 2004 and July 2016.

Methods

This was a retrospective medical record review conducted in Thohoyandou Community Health Centre. Data analysis was done using SPSS 24.0 and Microsoft Excel. The estimates used were 95% confidence intervals, and a p-value < 0.05 was considered to be statistically significant.

Results

Analysis was done using 1247 individuals, with 76% of the cohort being female and 98% first-line cART. The proportion of patients with a suppressed viral load (VL) at 6 months post-treatment was 64%, and 72% at 60 months. Fifty-nine per cent had consistent viral suppression over a 6-month period and 14% over at least 54 months. The mean CD4+ cell count at baseline was 227 cells/µL, and 538 cells/µL at 60 months. Multivariate regression analysis revealed that males had poorer immunologic and virologic responses.

Conclusions

Viral suppression in the study population was inferior to the UNAIDS target of 90%. The sustainability of viral suppression, once attained, was also low. These may have a negative impact on HIV transmission.

Clinical predictor score to identify patients at risk of poor viral load suppression at six months on antiretroviral therapy: results from a prospective cohort study in Johannesburg, South Africa

Purpose: As countries work toward 90:90:90 targets, early identification of patients with inadequate response to antiretroviral therapy (ART) is critical for achieving optimal HIV treatment outcomes. We developed and evaluated a clinical prediction score (CPS) to identify HIV-positive patients at risk of poor viral load suppression at 6 months on ART. Patients and methods: We conducted a prospective cohort study of HIV-positive ART naïve adults (≥18 years) initiating standard first-line ART between February 2012 and April 2014 at Themba Lethu Clinic in Johannesburg, South Africa. We used Modified Poisson regression to estimate the association between patient characteristics and poor viral load suppression, defined as a viral load ≥400 copies/mL at 6 months on ART. We developed a CPS following the Spiegel Halter and Knill-Jones approach and determined the diagnostic accuracy compared to viral load as the "gold standard". We identified the optimal cutoff at which the CPS would identify those at risk of poor viral load suppression. Results: Among 353 patients, 67.7% had a viral load measurement at 6 months on ART and 30.1% of these were viremic (≥400 copies/mL). Male gender, platelet count <150 cells/mm3, ≥7 days late for ≥2 ARV visits, visual analog scale (VAS) <90% and <14.5 fL increase in mean cell volume from baseline to 6 months were included in the CPS. The optimal cutoff was 5 (≥5 vs <5; sensitivity [Se] 65.3%, specificity [Sp] 46.7%) and the CPS performed better than standard measures of adherence (eg, VAS Se 24.5%; Simplified Medication Adherence Questionnaire Se 26.5%). Conclusion: Our findings suggest a 6-month CPS may have the potential to identify patients at risk of poor viral load suppression. The CPS may be used to target patients who need intensive adherence support, with the caveat that there may be a three- to four-fold increase in the pool of patients identified for adherence counseling.

HIV viraemia during pregnancy in women receiving preconception antiretroviral therapy in KwaDukuza, KwaZulu-Natal

Background

Preconception antiretroviral therapy (PCART) followed by sustained viral suppression is effective in preventing mother-to-child transmission of HIV. The rates of persistent and transient viraemia in such patients have not been prospectively assessed in South Africa.

Objectives

We determined the prevalence of transient and persistent viraemia in HIV-positive women entering antenatal care on PCART and studied variables associated with viraemia.

Methods

We performed a prospective cross-sectional observational study of HIV-positive pregnant women presenting to a primary healthcare facility in KwaZulu-Natal. All had received at least 6 months of first-line PCART. Viral load (VL) was measured, patients were interviewed, adherence estimated using a visual analogue scale and adherence counselling provided. Viral load was repeated after 4 weeks where baseline VL exceeded 50 copies/mL.

Results

We enrolled 82 participants. Of them, 59 (72%) pregnancies were unplanned. Fifteen participants (18.3%) were viraemic at presentation with VL > 50 copies/mL. Of these, seven (8.5%) had viral suppression (VL < 50 copies/mL), and eight remained viraemic at the second visit. Adherence correlated significantly with viraemia at baseline. Level of knowledge correlated with adherence but not with lack of viral suppression at baseline. Socio-economic indicators did not correlate with viraemia. No instances of vertical transmission were observed at birth.

Conclusions

Approximately 20% of women receiving PCART may demonstrate viraemia. Half of these may be transient. Poor adherence is associated with viraemia, and efforts to encourage and monitor adherence are essential. The rate of unplanned pregnancies is high, and antiretroviral therapy programmes should focus on family planning needs of women in the reproductive age group to prevent viral non-suppression prior to pregnancy.

Keywords

Preconception Antiretroviral Therapy; HIV; Viraemia; Antenatal Care; Adherence.

HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria

INTRODUCTION

Global efforts to end HIV by 2030 focus on reducing and eventually eliminating new infections in priority populations. Identifying these populations and characterizing their vulnerability factors helps in guiding investment of scarce HIV prevention resources to achieve maximum impact. We sought to establish HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria.

METHODS

We conducted a cross-sectional survey of 2637 people from all the 308 fish-landing beaches on the Kenyan shore of Lake Victoria. The number of participants enrolled at each beach were weighted based on the size of the beach, determined by the number of functional registered boats. We used simple random sampling to select those to be approached for study participation. Consenting participants were privately interviewed about their socio-economic and demographic characteristics and sexual behavior, and were invited for HIV test using the Kenya rapid HIV testing protocol. We used descriptive statistics and multivariate logistic and linear regression for analysis.

RESULTS

We found high HIV prevalence of 32% with significant differences between men (29%) and women (38%). Among men, having an HIV negative sexual partner, being circumcised, increasing number of condom protected sex acts in the preceding month, being younger and being a resident of Homa Bay, Kisumu, Siaya and Busia counties compared to Migori County reduced the risk of HIV infection. For women, being married, having more children with the current spouse, having an HIV negative sexual partner and being a resident of Busia compared to Migori County reduced the risk of HIV infection. We also found that longer distance from the beaches to the nearest public health facilities was associated with increasing cumulative HIV prevalence at the beaches.

CONCLUSION

Fishing communities have high HIV prevalence and may greatly benefit from interventions such as wider ART coverage, couple HIV risk reduction counseling, PrEP use for HIV negative partner at substantial continuous risk, alongside other HIV prevention services that the Kenyan government is currently rolling out. This will additionally require adequate plans to synchronize the provision of these services with the population's routine schedules for all these options to be reasonably accessible to them.

The Treatment Cascade in Children With Unsuppressed Viral Load-A Reality Check in Rural Lesotho, Southern Africa

BACKGROUND

As per the guidelines of the World Health Organization, HIV-infected children who do not achieve viral suppression while under antiretroviral therapy (ART) receive enhanced adherence counseling (EAC) with follow-up viral load (VL). A persisting unsuppressed VL after EAC triggers switch to a second-line regimen. We describe the care cascade of children with unsuppressed VL while taking ART.

METHODS

Children, aged <16 years, on first-line ART for ≥6 months with unsuppressed VL (≥80 copies/mL) at first measurement were enrolled. As per guidelines, children/caregivers received EAC and a follow-up VL after 3 months, whereas those with persisting viremia despite good adherence were eligible for switching to second-line. Eighteen months after the first unsuppressed VL, outcomes were assessed.

RESULTS

Of 191 children receiving a first-time VL in May/June 2014, 53 (28%) had unsuppressed viremia. The care cascade of these 53 children was as follows: 49 (92%) received EAC and a follow-up VL in October 2014 (1 died, 3 lost to follow-up). 36/49 (73%) stayed unsuppressed, but only 24 were switched to second-line. At 18-months follow-up, 10 (19%) were retained in care with suppressed VL, 26 were retained with ongoing viremia (49%), 2 (4%) had died, and 15 (28%) had no VL documentation.

CONCLUSIONS

Only 1 of 5 children with unsuppressed initial VL under ART was retained in care and virally suppressed at 18 months of follow-up. ART programs must increase the focus onto the extremely vulnerable care cascade in children with unsuppressed VL.

HIV treatment outcomes following antiretroviral therapy initiation and monitoring: A workplace program in Papua, Indonesia

Background

Papua Province, Indonesia is experiencing an on-going epidemic of Human Immunodeficiency Virus (HIV) infection, with an estimated 9-fold greater prevalence than the overall national rate. This study reviewed the treatment outcomes of an HIV-infected cohort on Antiretroviral Therapy (ART) and the predictors in terms of immunological recovery and virological response.

Methods

ART-naïve individuals in a workplace HIV program in southern Papua were retrospectively analyzed. Patients were assessed at 6, 12 and 36 months after ART initiation for treatment outcomes, and risk factors for virological suppression (viral load (VL) <1,000 copies/ml), poor immune response (CD4 <200 cells/mm³) and immunological failure (CD4 <100 cells/ mm³) after at least 6 months on ART, using a longitudinal Generalized Estimating Equations multivariate model.

Results

Assessment of 105 patients were included in the final analysis with a median age of 34 years, 88% male, median baseline CD4 236 cells/ mm³, and VL 179,000 copies/ml. There were 74, 73, and 39 patients at 6, 12, and 36 months follow-up, respectively, with 5 deaths over the entire period. For the three observation periods, 68, 80, and 75% of patents achieved virological suppression, poor immune responders decreased from 15, 16 to 10%, whilst 15, 16, 10% met the immunological failure criteria, respectively. Using multivariate analysis, the independent predictor for viral suppression at 12 and 36 months was ≥1 log decrease in VL at 6 months (OR 19.25, p<0.001). Higher baseline CD4 was significantly correlated with better immunological outcomes, and lower likelihood of experiencing immunological failure (p <0.001).

Conclusion

Virological response at six months after beginning ART is the strongest predictor of viral suppression at 12 and 36 months, and may help in identifying patients needing additional adherence therapy support. Higher baseline CD4 positively affects the immunological outcomes of patients. The findings indicate HIV control programs should prioritize the availability of VL testing and begin ART regardless of CD4 counts in infected patients.

Behavioral changes following HIV seroconversion during the historical expansion of HIV treatment in the United States

OBJECTIVES

To identify the ways in which HIV seroconversion impacts subsequent health behaviors in the context of evolving HIV treatment technologies.

DESIGN

Prospective cohort study.

METHODS

We assessed changes in health and HIV risk behaviors following HIV seroconversion both before and after HIV treatment access (i.e. HAART) in the United States by drawing from the Multicenter AIDS Cohort Study, which collected data from men who have sex with men (MSM) (n = 4616) in four US cities from 1984 to 2008. Longitudinal regression analyses with individual fixed effects accounted for time-invariant, unobservable determinants of risk behaviors. Further analyses assessed the sensitivity of our results to controlling for indicators of physical and mental health (e.g. CD4 cell count, depression) and differential attrition by higher risk individuals.

RESULTS

Among those who seroconverted during observation (n = 558), HIV seroconversion was associated with reduced odds of subsequent engagement in sex with at least two partners [adjusted odds ratio [adjusted odds ratio (aOR): 0.371; confidence interval (CI): 0.263-0.523], insertive anal sex with at least two partners (aOR: 0.360; CI: 0.219-0.591), and heavy drinking (aOR: 0.704; CI: 0.508-0.977). Seroconversion after HAART availability and treatment initiation was associated with further reduced odds of engaging in these behaviors. CD4 cell count, depression, and attrition did not change these results.

CONCLUSION

Specific health and HIV risk behaviors declined following seroconversion, especially with treatment availability and utilization. These positive behavior changes following HIV seroconversion provide evidence for continued investment in the HIV care continuum, including support for HIV testing and engagement in clinical care and treatment.

Investigational drugs in HIV: Pros and cons of entry and fusion inhibitors (Review)

Despite the profound changes and improvements reached in the field of HIV treatment, tolerability and adherence to highly active antiretroviral therapy remains a challenge. Furthermore, multi-experienced patients could take advantage of drugs with different mechanisms of action to combat the spread of resistance to actual therapy. For these reasons identification of new HIV drugs is crucial. Among all the molecules that at present are under investigation, entry and fusion inhibitors pose an interesting class owing to their peculiar characteristics, including prevention of entry of the virus into the human cells. In this study, we reviewed articles, clinical trials, and conference communications about all the drugs under investigation belonging to the class of entry and fusion inhibitors that are at least in phase I clinical trials.