The HIV care cascade: models, measures and moving forward

Immuno-Diagnostic Interest in Monitoring CD16+CD56+ (Natural Killer) Cells and CD19+CD45+ (B Lymphocytes) in Individuals Newly Diagnosed with HIV in a Tertiary Care Center

BACKGROUND/OBJECTIVE

Monitoring multiple cellular markers of immune cells may provide a more accurate evaluation of the immune status of people living with human immunodeficiency virus (PLHIV). This study assessed the value of CD16+CD56+ cells (NK cells) and CD19+ lymphocytes (B cells) phenotyping in indicating viral load, AIDS status, and treatment efficacy.

METHOD

A retrospective, laboratory-based study was conducted at the Diagnostic immunology division of a referral tertiary hospital. It involved 82 newly diagnosed HIV patients treated between 2009-2016. We explored three objectives: (1) the paired change in CD16+CD56+ and CD19+CD45+ cells counts and percentages from baseline to 2-to-6 months after treatment; (2) the association of these phenotypes with 5 gradual categories of viral load; and (3) the accuracy of CD16+CD56+ and CD19+CD45+ cells counts in indicating AIDS stage defined as CD4+ < 200 cells/mm3. The second and third objectives were tested using a pooled analysis (N = 300-373).

RESULT

The median CD19+CD45+ and CD16+CD56+ counts increased by 1.9-fold and 1.3-fold after treatment respectively (p < 0.001). A negative correlation of viral load with both CD16+CD56+ (ρ = -0.29, p < 0.001) and CD19+CD45+ (ρ = -0.34, p < 0.001) counts was observed. CD16+CD56+ count < 73 cells/mm3 and CD19+CD45+ count < 166.5 were indicative for AIDS with 95.5% and 63.6% sensitivity respectively.

CONCLUSIONS

Findings advocate for the usefulness of CD16+CD56+ and CD19+CD45+ phenotyping in characterizing the severity of HIV infection and its impact on both the humoral and cellular immunity, as well as monitoring the effectiveness of treatment.

Programme science: a route to effective coverage and population-level impact for HIV and sexually transmitted infection prevention

Improvements in context-specific programming are essential to address HIV and other sexually transmitted and blood-borne infection epidemics globally. A programme science approach emphasises the need for context-specific evidence and knowledge, generated on an ongoing basis, to inform timely and appropriate programmatic decisions. We aim to accelerate and improve the use of embedded research, inquiry, and learning to optimise population-level impact of public health programmes and to introduce an effective programme coverage framework as one tool to facilitate this goal. The framework was developed in partnership with public health experts in HIV and sexually transmitted and blood-borne infections through several workshops and meetings. The framework is a practice-based tool that centres on the use of data from iterative cycles of programme-embedded research and learning, as well as routine programme monitoring, to refine the strategy and implementation of a programme. This programme science approach aims to reduce programme coverage gaps, to optimise impact at the population level, and to achieve effective coverage. This framework should facilitate the generation of programme-embedded research and learning agendas to inform resource allocation, optimise population-level impact, and achieve equitable and effective programme coverage.

Racial/ethnic disparities in HIV care outcomes among insured patients at a large urban sexual health clinic

Prior studies demonstrate that non-White patients are less likely to achieve human immunodeficiency virus (HIV) suppression compared to White patients due to lack of health insurance. This study aims to determine whether racial disparities in the HIV care cascade persist among a cohort of privately and publicly insured patients. This retrospective analysis evaluated HIV care outcomes during the first year of care. Eligible patients were aged 18-65 years, treatment-naïve, and seen between 2016 and 2019. Demographic and clinical variables were extracted from the medical record. Differences in the proportion of patients achieving each HIV care cascade stage by race were evaluated using unadjusted chi-square testing. Risk factors for viral non-suppression at 52 weeks were analyzed using multivariate logistic regression. We included 285 patients; ninety-nine were White, 101 were Black, and 85 identified as Hispanic/LatinX ethnicity. Significant differences in retention in care for Hispanic/LatinX patients (odds ratio (OR): 0.214, 95% confidence interval (CI): 0.067-0.676) and viral suppression for both Black (OR: 0.348, 95% CI: 0.178, 0.682) and Hispanic/LatinX patients (OR: 0.392, 95% CI: 0.195, 0.791) compared to White patients were observed. In multivariate analyses, Black patients were less likely to achieve viral suppression compared to White patients (OR: 0.464, 95% CI: 0.236, 0.902). This study showed that non-White patients were less likely to achieve viral suppression after 1 year despite insurance and suggests that other unmeasured factors may disproportionately affect viral suppression in these patients. Interventions to identify and address these factors are needed to improve HIV care outcomes for non-White populations.

Health systems performance for hypertension control using a cascade of care approach in South Africa, 2011-2017

Hypertension is a major contributor to global morbidity and mortality. In South Africa, the government has employed a whole systems approach to address the growing burden of non-communicable diseases. We used a novel incident care cascade approach to measure changes in the South African health system's ability to manage hypertension between 2011 and 2017. We used data from Waves 1-5 of the National Income Dynamics Study (NIDS) to estimate trends in the hypertension care cascade and unmet treatment need across four successive cohorts with incident hypertension. We used a negative binomial regression to identify factors that may predict higher rates of hypertension control, controlling for socio-demographic and healthcare factors. In 2011, 19.6% (95%CI 14.2, 26.2) of individuals with incident hypertension were diagnosed, 15.4% (95%CI 10.8, 21.4) were on treatment and 7.1% had controlled blood pressure. By 2017, the proportion of individuals with diagnosed incident hypertension had increased to 24.4% (95%CI 15.9, 35.4). Increases in treatment (23.3%, 95%CI 15.0, 34.3) and control (22.1%, 95%CI 14.1, 33.0) were also observed, translating to a decrease in unmet need for hypertension care from 92.9% in 2011 to 77.9% in 2017. Multivariable regression showed that participants with incident hypertension in 2017 were 3.01 (95%CI 1.77, 5.13) times more likely to have a controlled blood pressure compared to those in 2011. Our data show that while substantial improvements in the hypertension care cascade occurred between 2011 and 2017, a large burden of unmet need remains. The greatest losses in the incident hypertension care cascades came before diagnosis. Nevertheless, whole system programming will be needed to sufficiently address significant morbidity and mortality related to having an elevated blood pressure.

Racial and ethnic differences in the association of social cohesion and social capital with HIV testing

HIV testing rates vary by race and ethnicity. Whether social capital indicators are related to HIV testing and whether these associations differ by race or ethnicity is unknown. Multivariable analysis was used to examine whether social capital (collective engagement and civic and social participation), including social cohesion (trust in neighbors, neighbors willing to help, feelings of belongingness) were associated with testing for HIV in the past 12 months. Participants were white, Black or African American, and Hispanic/Latino adults ages 18 to 44 (N = 2823) from the general population, in Philadelphia, PA who participated in the Southeastern Pennsylvania Household Health Surveys 2010 and 2012. Overall HIV testing in this sample was 42%, and was higher among women, and Black compared to white people. Mean social capital scores were significantly highest among whites. Greater trust in neighbors was associated with lower odds of testing for HIV (adjusted Odds Ratio[aOR]:0.61, 95% CI = 0.49-0.74), and this relationship varied by race/ethnicity, with stronger inverse associations among Hispanic/Latino (aOR = 0.43, p < 0.001) and white adults (aOR = 0.50, p < -0.001) than among Black adults (aOR = 0.75, p < 0.05). Greater neighborhood belongingness (aOR = 1.31, 95% CI = 1.11-1.54) and working together to improve the neighborhood (aOR = 1.33, 95%CI = 1.03-1.73) were associated with higher odds of testing for HIV. Different indicators of social capital were associated with higher as well as lower odds of testing for HIV. These patterns did not vary statistically by race or ethnicity. HIV testing prevention interventions will need to address social capital in design and implementation strategies.

A descriptive retrospective study on HIV care cascade in a tertiary hospital in the Philippines

INTRODUCTION

The HIV care cascade is a model used to examine the engagement of people living with HIV (PLHIV) in medical care from the time of diagnosis to sustained viral suppression. This study describes the stages of the cascade from linkage to care, antiretroviral therapy (ART) initiation, retention in care, and virologic suppression- at the University of the Philippines-Philippine General Hospital (UP-PGH) STD/AIDS Guidance and Intervention Prevention (SAGIP) treatment hub in the context of existing cascades with similar demographics.

METHODS

We retrospectively reviewed the medical records of patients enrolled at the UP-PGH SAGIP treatment hub from June 2015 to December 2017. Baseline demographic and clinical data were collected, relevant to each stage of the cascade. Descriptive statistics using Microsoft Excel version 16.0 was used to characterize data and cumulative and conditional proportions were reported.

RESULTS

Of the 584 patients included in the cohort, majority were male (91.1%), with a median age of 29 years (range, 0.17 to 68 years). Male-to-male sex was the most common mode of transmission (325/584, 55.6%). Among all patients enrolled at the UP PGH SAGIP treatment hub, 99.5% were linked to care, 95.0% initiated ART, 78.8% were retained in care and maintained on ART, 47.9% were tested for HIV viral load, and 45.5% achieved viral suppression.

CONCLUSION

A high proportion of patients enrolled at the UP-PGH SAGIP treatment hub are linked to care and initiate ART, exceeding the set goal of 90%, which is higher than reported nationwide. However, there is a substantial decrease in the number of patients who are subsequently retained in care, tested for HIV viral load, and achieve viral suppression. Gaps in the cascade related to healthcare delivery need to be investigated further and addressed by future studies. We recommend implementation of a community-based, patient-centered approach in order to reach the goals of the HIV cascade, with particular focus on young, MSM-PLHIV.

HIV treatment cascade in regions of Peru with the highest HIV prevalence

OBJECTIVES

To describe the HIV treatment cascade and care continuum in regions of highest HIV prevalence in Peru.

METHODS

An observational longitudinal study was carried out in 14 tertiary hospitals in Peru. These are the main hospitals that administer antiretroviral treatment (ART) in the regions that represent approximately 95% of reports of HIV/AIDS cases in Peru in 2013. We included individuals older than 18 years newly diagnosed with HIV from 1 January 2011 to 31 December 2012. Medical records were reviewed until 2015.

RESULTS

A total of 2119 people living with HIV (PLHIV) were identified in the selected health facilities (mean age = 35.26 years, 78% male). 97.25% [1845/1897; 95% confidence interval (CI): 96.4-97.9%] of the patients attended the consultation at least once during the follow-up, but only 64.84% (885/1365; 95% CI: 62.2-67.4%) attended within a month after the diagnosis. After starting ART, 74.63% (95% CI: 71.9-77.2%) of PLHIV remained in healthcare. Regardless of the time after diagnosis, 88.40% (1837/2078; 95% CI: 86.9-89.7%) of PLHIV started ART during the observation time. However, 78.68% (95% CI: 76.8-80.4%) did so during the first post-treatment year and only 28.88% (95% CI: 27.9-31.9%) after 1 month. After starting treatment, it was observed that 51.60% (95% CI: 49.2-54%) of PLHIV reached viral suppression during the follow-up period.

CONCLUSIONS

Further analysis and improvements in the definition of indicators are required to achieve conclusive results; however, these data will give us a general understanding of the progress of Peruvian health policies in achieving the goal established by the WHO.

Addressing Health Inequities in Digital Clinical Trials: A Review of Challenges and Solutions From the Field of HIV Research

Clinical trials are considered the gold standard for establishing efficacy of health interventions, thus determining which interventions are brought to scale in health care and public health programs. Digital clinical trials, broadly defined as trials that have partial to full integration of technology across implementation, interventions, and/or data collection, are valued for increased efficiencies as well as testing of digitally delivered interventions. Although recent reviews have described the advantages and disadvantages of and provided recommendations for improving scientific rigor in the conduct of digital clinical trials, few to none have investigated how digital clinical trials address the digital divide, whether they are equitably accessible, and if trial outcomes are potentially beneficial only to those with optimal and consistent access to technology. Human immunodeficiency virus (HIV), among other health conditions, disproportionately affects socially and economically marginalized populations, raising questions of whether interventions found to be efficacious in digital clinical trials and subsequently brought to scale will sufficiently and consistently reach and provide benefit to these populations. We reviewed examples from HIV research from across geographic settings to describe how digital clinical trials can either reproduce or mitigate health inequities via the design and implementation of the digital clinical trials and, ultimately, the programs that result. We discuss how digital clinical trials can be intentionally designed to prevent inequities, monitor ongoing access and utilization, and assess for differential impacts among subgroups with diverse technology access and use. These findings can be generalized to many other health fields and are practical considerations for donors, investigators, reviewers, and ethics committees engaged in digital clinical trials.

The comparative effectiveness of Core versus Core+Enhanced implementation strategies in a randomized controlled trial to improve substance use treatment receipt among justice-involved youth

BACKGROUND

Most justice-involved youth are supervised in community settings, where assessment and linkage to substance use (SU) treatment services are inconsistent and fragmented. Only 1/3 of youth with an identified SU need receive a treatment referral and even fewer initiate services. Thus, improving identification and linkage to treatment requires coordination across juvenile justice (JJ) and behavioral health (BH) agencies. The current study examines the comparative effectiveness of two bundled implementation intervention strategies for improving SU treatment initiation, engagement, and continuing care among justice-involved youth supervised in community settings. Exploration, Preparation, Implementation, Sustainment (EPIS) served as the conceptual framework for study design and selection/timing of implementation intervention components, and the BH Services Cascade served as the conceptual and measurement framework for identifying and addressing gaps in service receipt.

METHODS

Part of a larger Juvenile-Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) Cooperative, this study involved a multisite, cluster-randomized control trial where sites were paired then randomly assigned to receive Core (training teams on the BH Services Cascade and data-driven decision making; supporting goal selection) or Core+Enhanced (external facilitation of implementation teams) intervention components. Youth service records were collected from 20 JJ community supervision agencies (in five states) across five study phases (baseline, pre-randomization, early experiment, late experiment, maintenance). Implementation teams comprised of JJ and BH staff collaboratively identified goals along the BH Cascade and used data-driven decision-making to implement change.

RESULTS

Results suggest that Core intervention components were effective at increasing service receipt over time relative to baseline, but differences between Core and Core+Enhanced conditions were non-significant. Time to service initiation was shorter among Core+Enhanced sites, and deeper Cascade penetration occurred when external facilitation (of implementation teams) was provided. Wide variation existed in the degree and nature of change across service systems.

CONCLUSIONS

Findings demonstrate the criticality of early EPIS phases, demonstrating that strategies provided during the formative exploration and preparation phases produced some improvement in service receipt, whereas implementation-focused activities produced incremental improvement in moving youth farther along the Cascade.

Understanding the Reasons for Deferring ART Among Patients Diagnosed Under the Same-Day-ART Policy in Johannesburg, South Africa

We aimed to examine the correlates of antiretroviral therapy (ART) deferral to inform ART demand creation and retention interventions for patients diagnosed with HIV during the Universal Test and Treat (UTT) policy in South Africa. We conducted a cohort study enrolling newly diagnosed HIV-positive adults (≥ 18 years), at four primary healthcare clinics in Johannesburg between October 2017 and August 2018. Patients were interviewed immediately after HIV diagnosis, and ART initiation was determined through medical record review up to six-months post-test. ART deferral was defined as not starting ART six months after HIV diagnosis. Participants who were not on ART six-months post-test were traced and interviewed telephonically to determine reasons for ART deferral. Modified Poisson regression was used to evaluate correlates of six-months ART deferral. We adjusted for baseline demographic and clinical factors. We present crude and adjusted risk ratios (aRR) associated with ART deferral. Overall, 99/652 (15.2%) had deferred ART by six months, 20.5% men and 12.2% women. Baseline predictors of ART deferral were older age at diagnosis (adjusted risk ratio (aRR) 1.5 for 30-39.9 vs 18-29.9 years, 95% confidence intervals (CI): 1.0-2.2), disclosure of intentions to test for HIV (aRR 2.2 non-disclosure vs disclosure to a partner/spouse, 95% CI: 1.4-3.6) and HIV testing history (aRR 1.7 for  > 12 months vs < 12 months/no prior test, 95% CI: 1.0-2.8). Additionally, having a primary house in another country (aRR 2.1 vs current house, 95% CI: 1.4-3.1) and testing alone (RR 4.6 vs partner/spouse support, 95% CI: 1.2-18.3) predicted ART deferral among men. Among the 43/99 six-months interviews, women (71.4%) were more likely to self-report ART initiation than men (RR 0.4, 95% CI: 0.2-0.8) and participants who relocated within SA (RR 2.1 vs not relocated, 95% CI: 1.2-3.5) were more likely to still not be on ART. Under the treat-all ART policy, nearly 15.2% of study participants deferred ART initiation up to six months after the HIV diagnosis. Our analysis highlighted the need to pay particular attention to patients who show little social preparation for HIV testing and mobile populations.

The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions

INTRODUCTION

The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade.

METHODS

We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero.

RESULTS AND DISCUSSION

Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care.

CONCLUSIONS

The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.

HIV/AIDS epidemic in a western border municipality of Rio Grande do Sul, Brazil: evolution, HIV cascade of care and lethality

OBJECTIVE

To analyze the characteristics and trends of HIV/AIDS epidemic in Uruguaiana, Rio Grande do Sul, between 2005 and 2015 through indicators related to infection and the cascade of care of people living with HIV/AIDS (PLWHA).

METHODS

Descriptive study performed with data from the Health Information Systems of the Ministry of Health. Historical sets of indicators related to detection of HIV/AIDS cases and deaths were developed, comparing with national and state data from 2005 to 2015. Also, the cascades of care for PLWHA were elaborated for the municipality between 2013 and 2015.

RESULTS

AIDS detection rates of Uruguaiana were higher in comparison to the country and state, the same happened with the mortality and lethality indicators, which varied between 35.1 and 17.7 deaths/100,000 inhabitants and 6.5 and 2.7 deaths/100 inhabitants, respectively. The cascades of care for PLWHA showed an increase in individuals diagnosed with HIV in the period (from 1,125 to 1,527). The main gap occurred between the "diagnosed" and "connected" categories, expanding over time (78, 48 and 43.4%, respectively). There was a low proportion of individuals in the "undetectable viral load" category in the three years, ranging from 32 to 22.9%.

CONCLUSION

Indicators of detection, mortality, and lethality due to HIV/AIDS are high in Uruguaiana, with an increase in the number of people diagnosed with HIV and decrease in their link with health services, suggesting the need for advances in strategies to attract and link PLWHA to the health care network.

Hepatitis C Virus (HCV) Care Continuum Outcomes and HCV Community Viral Loads Among Patients in an Opioid Treatment Program

BACKGROUND

Hepatitis C virus (HCV) remains endemic among people who use drugs (PWUD). Measures of HCV community viral load (CVL) and HCV care continuum outcomes may be valuable for ascertaining unmet treatment need and for HCV surveillance and control.

METHODS

Data from patients in an opioid treatment program during 2013-2016 were used to (1) identify proportions of antibody and viral load (VL) tested, linked-to-care, and treated, in 2013-2014 and 2015-2016, and pre- and postimplementation of qualitative reflex VL testing; (2) calculate engaged-in-care HCV CVL and "documented" and "estimated" unmet treatment need; and (3) examine factors associated with linkage-to-HCV-care.

RESULTS

Among 11 267 patients, proportions of HCV antibody tested (52.5% in 2013-2014 vs 73.3% in 2015-2016), linked-to-HCV-care (15.7% vs 51.8%), and treated (12.0% vs 44.7%) all increased significantly. Hispanic ethnicity was associated with less linkage-to-care, and Manhattan residence was associated with improved linkage-to-care. The overall engaged-in-care HCV CVL was 4 351 079 copies/mL (standard deviation = 7 149 888); local HCV CVLs varied by subgroup and geography. Documented and estimated unmet treatment need decreased but remained high.

CONCLUSIONS

After qualitative reflex VL testing was implemented, care continuum outcomes improved, but gaps remained. High rates of unmet treatment need suggest that control of the HCV epidemic among PWUD will require expansion of HCV treatment coverage.

Low engagement in HIV services and progress through the treatment cascade among key populations living with HIV in Mozambique: alarming gaps in knowledge of status

Background

Mozambique has a generalized HIV epidemic of 13.5% among the general population. Early modeling exercises in Mozambique estimate that key populations (KP), defined as men who have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID), along with their partners account for about one third of all new infections. There is limited data describing the engagement of KP living with HIV in testing, care and treatment services.

Methods

We conducted a secondary data analysis of HIV-positive participants in the first Bio-behavioral Surveillance (BBS) surveys in Mozambique conducted 2011–2014 in order to assess service uptake and progress though the HIV treatment cascade among MSM, FSW, and PWID. Unweighted pooled estimates were calculated for each key population group.

Results

Among HIV-positive MSM, 63.2% of participants had ever received an HIV test, 8.8% were aware of their status, 6.1% reported having been linked to care, while 3.5% initiated ART and were currently on treatment. Of the HIV-infected FSW participants, 76.5% reported a previous HIV test and 22.4% were previously aware of their status. Linkage to care was reported by 20.1%, while 12.7% reported having initiated ART and 11.8% reported being on treatment at the time of the survey. Among HIV-infected PWID participants, 79.9% had previously received an HIV test, 63.2% were aware of their HIV status, and 49.0% reported being linked to care for their HIV infection. ART initiation was reported by 42.7% of participants, while 29.4% were on ART at the time of the survey.

Conclusion

Among the three high risk populations in Mozambique, losses occurred throughout critical areas of service uptake with the most alarming breakpoint occurring at knowledge of HIV status. Special attention should be given to increasing HIV testing and linkage to ART treatment. Future surveys will provide the opportunity to monitor improvements across the cascade in line with global targets and should include viral load testing to guarantee a more complete picture of the treatment cascade.

The HIV care cascade for adolescents initiated on antiretroviral therapy in a health district of South Africa: a retrospective cohort study

BACKGROUND

Little evidence exists to comprehensively estimate adolescent viral suppression after initiation on antiretroviral therapy in sub-Saharan Africa. This study examines adolescent progression along the HIV care cascade to viral suppression for adolescents initiated on antiretroviral therapy in South Africa.

METHODS

All adolescents ever initiated on antiretroviral therapy (n=1080) by 2015 in a health district of the Eastern Cape, South Africa, were interviewed in 2014-2015. Clinical records were extracted from 52 healthcare facilities through January 2018 (including records in multiple facilities). Mortality and loss to follow-up rates were corrected for transfers. Predictors of progression through the HIV care cascade were tested using sequential multivariable logistic regressions. Predicted probabilities for the effects of significant predictors were estimated by sex and mode of infection.

RESULTS

Corrected mortality and loss to follow-up rates were 3.3 and 16.9%, respectively. Among adolescents with clinical records, 92.3% had ≥1 viral load, but only 51.1% of viral loads were from the past 12 months. Adolescents on ART for ≥2 years (AOR 3.42 [95%CI 2.14-5.47], p< 0.001) and who experienced decentralised care (AOR 1.39 [95%CI 1.06-1.83], p=0.018) were more likely to have a recent viral load. The average effect of decentralised care on recent viral load was greater for female (AOR 2.39 [95%CI 1.29-4.43], p=0.006) and sexually infected adolescents (AOR 3.48 [95%CI 1.04-11.65], p=0.043). Of the total cohort, 47.5% were recorded as fully virally suppressed at most recent test. Only 23.2% were recorded as fully virally suppressed within the past 12 months. Younger adolescents (AOR 1.39 [95%CI 1.06-1.82], p=0.017) and those on ART for ≥2 years (AOR 1.70 [95%CI 1.12-2.58], p=0.013) were more likely to be fully viral suppressed.

CONCLUSIONS

Viral load recording and viral suppression rates remain low for ART-initiated adolescents in South Africa. Improved outcomes for this population require stronger engagement in care and viral load monitoring.

Autonomy-Supportive Healthcare Climate and HIV-Related Stigma Predict Linkage to HIV Care in Men Who Have Sex With Men in Ghana, West Africa

In Ghana, the HIV prevalence among MSM is more than 10 times greater than the general population of adults, and rates of engagement in HIV medical care are low among MSM diagnosed with HIV. Using structured surveys, we investigated the impact of HIV-related stigma, same-sex behavior stigma, and gender nonconformity stigma on linkage to HIV care (LTC) in MSM (N = 225) living with HIV in Ghana. Autonomy-supportive healthcare climate (OR = 1.63, p < .01), vicarious HIV stigma (OR = 2.73, p < .01), and age (OR = 1.06, p < .004) predicted LTC. Conversely, felt normative HIV stigma negatively predicted LTC (OR = 0.65, p < .05). Finally, we identified regional disparities, with MSM from Takoradi being 4 times and 5 times more likely to be LTC compared to Kumasi and Accra, respectively. Our findings highlight the nuanced roles of stigmas in shaping the HIV care continuum among MSM living with HIV, while revealing potential gaps in current measures of HIV-related stigma.

The HIV care cascade in Manitoba, Canada: Methods, measures, and estimates to meet local needs

BACKGROUND AND OBJECTIVE

We describe the development of the first HIV care cascade for Manitoba, Canada, detailing steps taken to establish indicator definitions for each cascade step, and derive a full complement of local estimates.

METHODS

Manitoba is a Canadian Prairie Province with disproportionately high annual HIV incidence. In 2013, a clinical cohort of people living with HIV was established within the primary HIV care program in Manitoba. Using cohort data from 2017, we describe the creation of a set of indicator definitions and calculate estimates for each cascade step to create the first Manitoban cascade model.

RESULTS

Of the 703 cohort participants categorized as alive and diagnosed, 638 (90.8%) were in care, 606 (86.2%) retained in care, 573 (81.5%) on treatment, and 523 (74.4%) virologically suppressed. The greatest point of leakage occurred between the first and second steps; 9.3% of those alive and diagnosed in 2017 were not in care in the same calendar year.

CONCLUSION

This is the first comprehensive examination of HIV clinical epidemiology in Manitoba using a cascade framework, with the potential inform programming to improve service coverage within Manitoba and significantly contribute to evidence informing provincial policies to support these efforts.

The Benefits of Immediate ART

The benefits of “early” antiretroviral therapy (ART; ie, initiation when CD4 ≥500 cells/mm³) are now well accepted as reflected in the removal of the CD4-based eligibility from new ART guidelines by the World Health Organization (WHO). However, neither the “treat-all” strategy recommendations presented in the guidelines nor the HIV care cascade goals in the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets adequately address the issue of ART timing. Our recent study on “immediate” ART (ie, ≤30 days after HIV diagnosis) adds important evidence demonstrating the real and meaningful benefits of rapid ART initiation even among those who have CD4 ≥500 cells/mm³. We call on WHO and UNAIDS to consider this research and encourage a shift from the treat-all strategy to an “immediately-treat-all” strategy, and from a slow, fragmented, complicated, multistep HIV care cascade to a fast, easy, and simple cascade with effectiveness measures that incorporate the important aspect of time.

Limitations of the UNAIDS 90-90-90 metrics: a simulation-based comparison of cross-sectional and longitudinal metrics for the HIV care continuum

The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 and other cross-sectional metrics can lead to potentially counterintuitive conclusions when used to evaluate health systems’ performance. This study demonstrates how time and population dynamics impact UNAIDS 90–90–90 metrics in comparison with a longitudinal analogue.

America's opioid crisis: the need for an integrated public health approach

Continued increases in overdose deaths and recent declines in life expectancy call for need to adopt comprehensive public health approaches to the United States opioid crisis and to establish an infrastructure to avert future crises. Successfully addressing the challenges posed by the crisis requires a translational, integrated approach that combines the contribution of neuroscience, pharmacology, epidemiology, treatment services and prevention. It also is critical to integrate interventions across settings, including healthcare, justice, education and social service systems. This review highlights four interconnected themes: (1) social determinants of health and disease; (2) person-centered approaches for prevention and treatment; (3) bridging the gap between implementation science and practice; and (4) using data to build learning systems of care, relevant to public health approaches to address the opioid crisis. We discuss how across these four themes taking into account the influence of developmental factors on brain function and sensitivity to environmental stimuli including drugs, addressing the complex interactions between biological and social factors, and promoting an ongoing dialogue across disciplines and settings will help accelerate public health advances that are evidenced based and sustainable to address the current opioid crisis and avert future ones.

The effect of "universal test and treat" program on HIV treatment outcomes and patient survival among a cohort of adults taking antiretroviral treatment (ART) in low income settings of Gurage zone, South Ethiopia

BACKGROUND

Through universal "test and treat approach" (UTT) it is believed that HIV new infection and AIDS related death will be reduced at community level and through time HIV can be eliminated. With this assumption the UTT program was implemented since 2016. However, the effect of this program in terms of individual patient survival and treatment outcome was not assessed in relation to the pre-existing defer treatment approach.

OBJECTIVE

To assess the effects of UTT program on HIV treatment outcomes and patient survival among a cohort of adult HIV infected patients taking antiretroviral treatment in Gurage zone health facilities.

METHODS

Institution based retrospective cohort study was conducted in facilities providing HIV care and treatment. Eight years (2012-2019) HIV/AIDS treatment records were included in the study. Five hundred HIV/AIDS treatment records were randomly selected and reviewed. Data were abstracted using standardized checklist by trained health professionals; then it was cleaned, edited and entered by Epi info version 7 and analyzed by STATA. Cox model was built to estimate survival differences across different study variables.

RESULTS

A total of 500 patients were followed for 1632.6 person-year (PY) of observation. The overall incidence density rate (IDR) of death in the cohort was 3 per-100-PY. It was significantly higher for differed treatment program, which is 3.8 per-100-PY compared to 2.4 per-100-PY in UTT program with a p value of 0.001. The relative risk of death among differed cases was 1.58 times higher than the UTT cases. The cumulative probability of survival at the end of 1st, 2nd, 3rd, and 4th years was 98%, 90.2%, 89.2% and 88% respectively with difference between groups. The log rank test and Kaplan-Meier survival curve indicated patients enrolled in the UTT program survived longer than patients enrolled in the differed treatment program (log rank X2 test = 4.1, p value = 0.04). Age, residence, base line CD4 count, program of enrolment, development of new OIS and treatment failure were predicted mortality from HIV infection.

CONCLUSION

Mortality was significantly reduced after UTT. Therefore, intervention to further reduce deaths has to focus on early initiation of treatment and strengthening UTT programs.

Which delivery model innovations can support sustainable HIV treatment?

The rapid scale-up of antiretroviral treatment (ART) for HIV since the mid-2000s, mostly through disease-specific or "vertical" programmes, has been a highly successful undertaking, which averted millions of deaths and prevented many new infections. However, the dynamics of the HIV epidemic and changing political and financial commitment to fight the disease will likely require new models for the delivery of ART over the coming decades if the promises of universal treatment are to be met. Delivery model innovations for ART are intended to improve both the effectiveness and efficiency of the HIV treatment cascade, reaching new people who require ART and providing ART to more people without an increase in resources. We describe twelve models for ART delivery, which could be achieved through five categories of delivery innovations: integrating ART ("vertical ART plus", "partially-integrated ART" and "fully-integrated ART"); modifying steps in the ART value chain ("professional task-shifted ART", "people task-shifted ART" and "technology-supported ART"); eliminating steps in the ART value chain ("immediate ART" and "less frequent ART pick-up"); changing ART locations ("private-sector ART", "traditional-sector ART" and "ART outside the health sector"); and keeping the status quo ("vertical ART"). The different delivery model innovations are not mutually exclusive and several could be combined, such as "vertical ART plus" with "task-shifted ART". Suitability of the models will highly depend on local and national contexts, including existing health systems resources, available funding, and type of HIV epidemic. Future implementation research needs to identify which models are the best fit for different contexts.

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.

Estimating HIV-1 incidence in Japan from the proportion of recent infections

The first step of the UNAIDS/WHO 90-90-90 targets to encourage early diagnosis with treatment for the control of HIV-1 epidemic is to achieve 90% HIV-1 diagnosis in infected individuals. In Japan, approximately 30% of newly reported cases have been annually identified by AIDS onset, implying that substantial numbers of HIV-1-infected individuals remain undiagnosed. However, the proportion of undiagnosed cases has not yet been determined. In the present study, the proportion of recent HIV-1 infections to newly-diagnosed cases was determined from 2006 to 2015 using a recent infection assay for three metropolitan areas in Japan: Tokyo, Osaka, and Fukuoka. Estimated median periods between infection and diagnosis were 1.0, 1.8, and 2.9 years for Tokyo, Osaka, and Fukuoka, respectively. Estimation of annual HIV-1 incidence by a back-calculation method using these data as well as HIV/AIDS national surveillance data indicated proportions of undiagnosed to new HIV-1 infections from 2006 to 2015 to be 18% in Tokyo, 22% in Osaka, 38% in Fukuoka, and 28% in Japan. This is the first report estimating HIV-1 incidence in Japan using a serological biomarker in combination with national HIV/AIDS surveillance data.

Juvenile justice staff endorsement of HIV/STI prevention, testing, and treatment linkage

BACKGROUND

While involvement in the legal system offers an opportunity to educate, screen, and treat high-risk youth, research shows that staff attitudes toward these practices can serve as barriers to implementation. The current study investigates the degree to which JJ staff endorse HIV prevention, testing, and treatment linkage practices with youth under community supervision and examines differences between individuals who supervise youth (e.g., juvenile probation officer) and those working in non-supervisory roles (e.g., case manager, assessment specialist).

METHODS

Juvenile justice staff consenting to participation in JJ-TRIALS completed an initial staff survey (N = 501). Survey items measured perceived importance of HIV/STI prevention (4 items); perceived importance of HIV/STI testing (7 items); and perceived importance of HIV/STI treatment linkage (8 items).

RESULTS

Confirmatory Factor Analysis (CFA) was computed (SAS CALIS procedure) for each of the three domains. Findings suggest that while staff recognize that youth are at risk for HIV/STIs and require provision of HIV/STI prevention and treatment linkage, attitudes concerning the importance of procuring or providing testing services for youth is substantially lower. Furthermore, analytic models comparing staff with and without supervision responsibilities (computed using SAS PROC MIXED) indicated that attitudes differed by site and staff responsible for supervision rated HIV treatment linkage practices as less important compared to non-supervising staff.

CONCLUSIONS

Establishing partnerships with health agencies equipped with resources and skillsets to provide HIV/STI testing and related services may be an effective model to promote greater awareness and use of best practices among JJ staff and more effectively address the unmet needs of this high-risk population of youth.

Re-thinking Linkage to Care in the Era of Universal Test and Treat: Insights from Implementation and Behavioral Science for Achieving the Second 90

To successfully link to care, persons living with HIV must negotiate a complex series of processes from HIV diagnosis through initial engagement with HIV care systems and providers. Despite the complexity involved, linkage to care is often oversimplified and portrayed as a single referral step. In this article, we offer a new conceptual framework for linkage to care, tailored to the current universal test and treat era that presents linkage to care as its own nuanced pathway within the larger HIV care cascade. Conceptualizing linkage to care in this way may help better identify and specify processes posing a barrier to linkage, and allow for the development of targeted implementation and behavioral science-based approaches to address them. Such approaches are likely to be most relevant to programmatic and clinical settings with limited resources and high HIV burden.

Benchmarking HIV Quality Measures Across US Payer Types

Despite advances in antiretroviral therapy (ART), human immunodeficiency virus (HIV) remains a significant issue in the United States. Early diagnosis, continuous treatment access/adherence, and long-term care engagement help patients benefit fully from ART; however, a shortfall in care engagement remains, potentially leading to poorer health outcomes. This analysis benchmarks rates of health care quality and process measures to identify areas for improvement. This retrospective, claims-based, real-world cohort study assessed the percentage of prevalent (existing) and incident (newly diagnosed) patients with HIV with commercial or public health insurance meeting 4 National Quality Forum (NQF)-endorsed, 1 Pharmacy Quality Alliance (PQA), and 3 Centers for Disease Control and Prevention (CDC) measures over a 4-year period. Most prevalent patients consistently met the NQF-endorsed prescribed ART and gaps in visits measures. Longer-term visit frequency measure rates were well below the 90% Joint United Nations Programme on HIV/AIDS target. Proportion of prevalent patients meeting each NQF-endorsed measure was maintained/increased with increasing age in 2015–2016. Substantially fewer incident patients than prevalent patients met NQF-endorsed measures across all measurement periods, particularly for visit frequency (32%–51%). PQA ART adherence was low (36%–73%). CDC receipt of care rates were high (83%–92%), whereas retention in care rates were low (67%–72%) among prevalent patients. For incident patients, linkage to care rates were consistently low (21%–44%). This study benchmarks current US HIV care engagement and highlights the need for improvement in early care engagement, ART adherence and long-term retention of care among patients with HIV.

Rapid initiation of antiretroviral therapy for people living with HIV

BACKGROUND

Despite antiretroviral therapy (ART) being widely available, HIV continues to cause substantial illness and premature death in low-and-middle-income countries. High rates of loss to follow-up after HIV diagnosis can delay people starting ART. Starting ART within seven days of HIV diagnosis (rapid ART initiation) could reduce loss to follow-up, improve virological suppression rates, and reduce mortality.

OBJECTIVES

To assess the effects of interventions for rapid initiation of ART (defined as offering ART within seven days of HIV diagnosis) on treatment outcomes and mortality in people living with HIV. We also aimed to describe the characteristics of rapid ART interventions used in the included studies.

SEARCH METHODS

We searched CENTRAL, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, and four other databases up to 14 August 2018. There was no restriction on date, language, or publication status. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and websites for unpublished literature, including conference abstracts.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared rapid ART versus standard care in people living with HIV. Children, adults, and adolescents from any setting were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of the studies identified in the search, assessed the risk of bias and extracted data. The primary outcomes were mortality and virological suppression at 12 months. We have presented all outcomes using risk ratios (RR), with 95% confidence intervals (CIs). Where appropriate, we pooled the results in meta-analysis. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included seven studies with 18,011 participants in the review. All studies were carried out in low- and middle-income countries in adults aged 18 years old or older. Only one study included pregnant women.In all the studies, the rapid ART intervention was offered as part of a package that included several cointerventions targeting individuals, health workers and health system processes delivered alongside rapid ART that aimed to facilitate uptake and adherence to ART.Comparing rapid ART with standard initiation probably results in greater viral suppression at 12 months (RR 1.18, 95% CI 1.10 to 1.27; 2719 participants, 4 studies; moderate-certainty evidence) and better ART uptake at 12 months (RR 1.09, 95% CI 1.06 to 1.12; 3713 participants, 4 studies; moderate-certainty evidence), and may improve retention in care at 12 months (RR 1.22, 95% CI 1.11 to 1.35; 5001 participants, 6 studies; low-certainty evidence). Rapid ART initiation was associated with a lower mortality estimate, however the CIs included no effect when compared to standard of care (RR 0.72, 95% CI 0.51 to 1.01; 5451 participants, 7 studies; very low-certainty evidence). It is uncertain whether rapid ART has an effect on modification of ART treatment regimens as data are lacking (RR 7.89, 95% CI 0.76 to 81.74; 977 participants, 2 studies; very low-certainty evidence). There was insufficient evidence to draw conclusions on the occurrence of adverse events.

AUTHORS' CONCLUSIONS

RCTs that include initiation of ART within one week of diagnosis appear to improve outcomes across the HIV treatment cascade in low- and middle-income settings. The studies demonstrating these effects delivered rapid ART combined with several setting-specific cointerventions. This highlights the need for pragmatic research to identify feasible packages that assure the effects seen in the trials when delivered through complex health systems.

Comparative efficacy and safety of dolutegravir relative to common core agents in treatment-naïve patients infected with HIV-1: a systematic review and network meta-analysis

Background

Network meta-analyses (NMAs) provide comparative treatment effects estimates in the absence of head-to-head randomized controlled trials (RCTs). This NMA compared the efficacy and safety of dolutegravir (DTG) with other recommended or commonly used core antiretroviral agents.

Methods

A systematic review identified phase 3/4 RCTs in treatment-naïve patients with HIV-1 receiving core agents: ritonavir-boosted protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), or integrase strand inhibitors (INSTIs). Efficacy (virologic suppression [VS], CD4⁺ cell count change from baseline) and safety (adverse events [AEs], discontinuations, discontinuation due to AEs, lipid changes) were analyzed at Week 48 using Bayesian NMA methodology, which allowed calculation of probabilistic results. Subgroup analyses were conducted for VS (baseline viral load [VL] ≤/> 100,000copies/mL, ≤/> 500,000copies/mL; baseline CD4⁺ ≤/>200cells/μL). Results were adjusted for the nucleoside/nucleotide reverse transcriptase inhibitors (NRTI) combined with the core agent (except subgroup analyses).

Results

The NMA included 36 studies; 2 additional studies were included in subgroup analyses only. Odds of achieving VS with DTG were statistically superior to PIs (odds ratios [ORs] 1.78–2.59) and NNRTIs (ORs 1.51–1.86), and similar but numerically higher than other INSTIs. CD4⁺ count increase was significantly greater with DTG than PIs (difference: 23.63–31.47 cells/μL) and efavirenz (difference: 34.54 cells/μL), and similar to other core agents. INSTIs were more likely to result in patients achieving VS versus PIs (probability: 76–100%) and NNRTIs (probability: 50–100%), and a greater CD4⁺ count increase versus PIs (probability: 72–100%) and NNRTIs (probability: 60–100%). DTG was more likely to result in patients achieving VS (probability: 94–100%), and a greater CD4⁺ count increase (probability: 53–100%) versus other core agents, including INSTIs (probability: 94–97% and 53–93%, respectively). Safety outcomes with DTG were generally similar to other core agents. In patients with baseline VL > 100,000copies/mL or ≤ 200 CD4⁺cells/μL (18 studies), odds of achieving VS with DTG were superior or similar to other core agents.

Conclusion

INSTI core agents had superior efficacy and similar safety to PIs and NNRTIs at Week 48 in treatment-naïve patients with HIV-1, with DTG being among the most efficacious, including in patients with baseline VL > 100,000copies/mL or ≤ 200 CD4⁺cells/μL, who can be difficult to treat.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3975-6) contains supplementary material, which is available to authorized users.

Cohort profile: Development and profile of a population-based, retrospective cohort of diagnosed people living with HIV in Ontario, Canada (Ontario HIV Laboratory Cohort)

PURPOSE

Population-based cohorts of diagnosed people living with HIV (PLWH) are limited worldwide. In Ontario, linked HIV diagnostic and viral load (VL) test databases are centralised and contain laboratory data commonly used to measure engagement in HIV care. We used these linked databases to create a population-based, retrospective cohort of diagnosed PLWH in Ontario, Canada.

PARTICIPANTS

A datamart was created by integrating diagnostic and VL databases and linking records at the individual level. These databases contain information on laboratory test results and sociodemographic/clinical information collected on requisition/surveillance forms. Datamart individuals enter our cohort with the first record of a nominal HIV-positive diagnostic test (1985-2015) or VL test (1996-2015), and remain unless administratively lost to follow-up (LTFU; no VL test for >2 years and no VL test in later years). Non-nominal diagnostic tests are excluded as they lack identifying information to permit linkage to other tests. However, individuals diagnosed non-nominally are included in the cohort with record of a VL test. The LTFU rule is applied to indirectly censor for death/out-migration.

FINDINGS TO DATE

As of the end of 2015, the datamart contained 40 372 HIV-positive diagnostic tests and 23 851 individuals with ≥1 VL test. Almost half (46.3%) of the diagnostic tests were non-nominal and excluded, although this was lower (~15%) in recent years. Overall, 29 587 individuals have entered the cohort-contributing 229 302 person-years of follow-up since 1996. Between 2000 and 2015, the number of diagnosed PLWH (cohort individuals not LTFU) increased from 8859 to 16 110, and the percent who were aged ≥45 years increased from 29.1% to 62.6%. The percent of diagnosed PLWH who were virally suppressed (<200 copies/mL) increased from 40.7% in 2000 to 79.5% in 2015.

FUTURE PLANS

We plan to conduct further analyses of HIV care engagement and link to administrative databases with information on death, migration, physician billing claims and prescriptions. Linkage to other data sources will address cohort limitations and expand research opportunities.

How to "Live a Good Life": Aging and HIV Testing in Rural South Africa

OBJECTIVE

The African HIV epidemic is aging, yet HIV testing behavior studies either exclude older persons or include too few to say much about age differences.

METHOD

Strategically combining focus group interviews (participants in 40s/50s/60s-plus age groups) and survey data from rural South Africa (where HIV prevalence peaks in the late 30s, but continues to be over 10% into the late 60s), we examine gender and life course variation, motivations, and barriers in HIV testing.

RESULTS

We find significant gender differences-Women test at higher rates at younger ages, men at older ages. Our qualitative data not only highlight recognition of testing importance but also suggest gendered motivations and perceptions of testing. Men and women report similar barriers, however, including fear of finding out their (positive) HIV status, limited confidentiality, and partner nondisclosure.

DISCUSSION

We conclude with recommendations to increase HIV testing uptake among older adults including home testing, couples testing, and HIV testing concurrently with noncommunicable diseases.

Understanding the Time Needed to Link to Care and Start ART in Seven HPTN 071 (PopART) Study Communities in Zambia and South Africa

To achieve UNAIDS 90:90:90 targets at population-level, knowledge of HIV status must be followed by timely linkage to care, initiation and maintenance of antiretroviral therapy (ART) for all people living with HIV (PLHIV). Interpreting quantitative patterns using qualitative data, we investigate time taken to link to care and initiate ART amongst individuals aware of their HIV-status in high HIV-prevalence urban communities in the HPTN 071 (PopART) study, a community-randomised trial of a combination HIV prevention package, including universal testing and treatment, in 21 communities in Zambia and South Africa. Data are drawn from the seven intervention communities where immediate ART irrespective if CD4 count was offered from the trial-start in 2014. Median time from HIV-diagnosis to ART initiation reduced after 2 years of delivering the intervention from 10 to 6 months in both countries but varied by gender and community of residence. Social and health system realities impact decisions made by PLHIV about ART initiation.

Acceptability, perceived reliability and challenges associated with distributing HIV self-test kits to young MSM in Uganda: a qualitative study

INTRODUCTION

HIV self-testing is a flexible, accessible and acceptable emerging technology with a particular potential to identify people living with HIV who are reluctant to interact with conventional HIV testing approaches. We assessed the acceptability, perceived reliability and challenges associated with distributing HIV self-test (HIVST) to young men who have sex with men (MSM) in Uganda.

METHODS

Between February and May, 2018, we enrolled 74 MSM aged ≥18 years purposively sampled and verbally consented to participate in six focus group discussions (FGDs) in The AIDS Support Organization (TASO Masaka and Entebbe). We also conducted two FGDs of 18 health workers. MSM FGD groups included individuals who had; (1) tested greater than one year previously; (2) tested between six months and one year previously; (3) tested three to six months previously; (4) never tested. FGDs examined: (i) the acceptability of HIVST distribution; (iii) preferences for various HIVST distribution channels; (iv) perceptions about the accuracy of HIVST; (v) challenges associated with HIVST distribution. We identified major themes, developed and refined a codebook. We used Nvivo version 11 for data management.

RESULTS

MSM participants age ranged between 19 and 30 years. Participants described HIVST as a mechanism that would facilitate HIV testing uptake in a rapid, efficient, confidential, non-painful; and non-stigmatizing manner. Overall, MSM preferred HIVST to the conventional HIV testing approaches. Health workers were in support of distributing HIVST kits through MSM peers. MSM participants were willing to distribute the kits and recommended HIVST to their peers and sexual partners. They suggested HIVST kit distribution model work similarly to the current condom and lubricant peer model being implemented by TASO. Preferred channels were peers, hot spots, drop-in centres, private pharmacies and MSM friendly health facilities. Key concerns regarding use of HIVST were; unreliable HIVST results, social harm due to a positive result, need for a confirmatory test and linking both HIV positive and negative participants for additional HIV services.

CONCLUSIONS

Distribution of HIVST kits by MSM peers is an acceptable strategy that can promote access to testing. HIVST was perceived by participants as beneficial because it would address many barriers that affect their acceptance of testing. However, a combined approach that includes follow-up, linkage to HIV care and prevention services are needed for effective results.

Trends in HIV care cascade engagement among diagnosed people living with HIV in Ontario, Canada: A retrospective, population-based cohort study

BACKGROUND

The HIV cascade is an important framework for assessing systems of care, but population-based assessment is lacking for most jurisdictions worldwide. We measured cascade indicators over time in a population-based cohort of diagnosed people living with HIV (PLWH) in Ontario, Canada.

METHODS

We created a retrospective cohort of diagnosed PLWH using a centralized laboratory database with HIV diagnostic and viral load (VL) test records linked at the individual-level. Individuals enter the cohort with record of a nominal HIV-positive diagnostic test or VL test, and remain unless administratively lost to follow-up (LTFU, >2 consecutive years with no VL test and no VL test in later years). We calculated the annual percent of diagnosed PLWH (cohort individuals not LTFU) between 2000 and 2015 who were in care (≥1 VL test), on ART (as documented on VL test requisition) or virally suppressed (<200 copies/ml). We also calculated time from diagnosis to linkage to care and viral suppression among individuals newly diagnosed with HIV. Analyses were stratified by sex and age. Upper/lower bounds were calculated using alternative indicator definitions.

RESULTS

The number of diagnosed PLWH increased from 8,859 (8,859-11,389) in 2000 to 16,110 (16,110-17,423) in 2015. Over this 16-year period, the percent of diagnosed PLWH who were: in care increased from 81% (63-81%) to 87% (81-87%), on ART increased from 55% (34-60%) to 81% (70-82%) and virally suppressed increased from 41% (23-46%) to 80% (67-81%). Between 2000 and 2014, the percent of newly diagnosed individuals who linked to care within three months of diagnosis or achieved viral suppression within six months of diagnosis increased from 67% to 82% and from 22% to 42%, respectively. Estimates were generally lower for females and younger individuals.

DISCUSSION

HIV cascade indicators among diagnosed PLWH in Ontario improved between 2000 and 2015, but gaps still remain-particularly for younger individuals.

Mentoring the next generation of behavioral health scientists to promote health equity

Health inequities and disparities among various racial/ethnic minority, sexual minority, and rural populations are the focus of increasing national efforts. Three health problems disproportionately affecting these populations-HIV/AIDS, substance abuse, and trauma-deserve particular attention because of their harmful effects on health across the life span. To address these problems, our training program, the UCLA HIV/AIDS, Substance Abuse, and Trauma Training Program (HA-STTP), mentors and trains early career behavioral health scientists to conduct research using scientifically sound, culturally collaborative, and population-centered approaches. HA-STTP has been highly successful in training a diverse, productive, nationwide group of scholars. The program provides 2 years of training and mentorship to 20 (5 per year over 4 years) scholars. It is unique in its attention to traumatic stress as a form of dysregulation, particularly as experienced by underserved populations. Furthermore, our training program embraces a uniquely comprehensive, culturally grounded understanding of traumatic stress and its implications for substance abuse and HIV. HA-STTP advances scholars' knowledge of the interconnections among substance abuse, HIV/AIDS, traumatic stress, and health disparities, particularly in underrepresented populations; provides intensive mentorship to support scholars' research interests and career trajectories; capitalizes on a multidisciplinary, multiracial/ethnic network of expert faculty; and evaluates the program's impact on scholars' knowledge and productivity. By fostering the growth of scholars committed to conducting research with underrepresented populations that are disproportionately affected by HIV/AIDS, substance abuse, and traumatic stress, this program enhances nationwide efforts to diminish the prevalence of these problems and improve health and quality of life. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cascade of care for people living with HIV infection in Southern Brazil: results from a public health network

The cascade of care for people living with HIV infection (PLHIV) describes steps in diagnosis, linkage and retention in care, as well as the provision and success of combination antiretroviral therapy (cART). The aim of this study was to evaluate the rates regarding the retention in care, on cART, and suppressed viral load for PLHIV attended at a Brazilian public health network. Data on PLHIV from 116 cities of Paraná, Southern Brazil, attended from 2012 to 2015, were retrospectively collected through the Laboratory Tests Control System (SISCEL). The number of PLHIV related to care increased about 22.5% from 2012 to 2015 (4,106 to 5,030 individuals). The proportion of PLHIV retained in care showed a trend toward stabilization around 81.7-86.9%. Every year, the use of cART increased up to 90.3% for PLHIV retained in care. Viral load suppression was achieved by 72.8% of patients on cART and 57.1% by those linked to care. Retention in care and HIV viral suppression were more likely to occur in older PLHIV than younger ones; similarly, patients living in medium-sized cities were more susceptible to these factors than in large- or small-sized cities. In conclusion, the study showed a high level of retention in care and HIV suppression on cART, as well as emphasized that current efforts for treating already-infected PLHIV remain a challenge for our health public institutions and may contribute to highlight steps for improvement of the HIV cascade of care in our population.

Associations between health systems capacity and mother-to-child HIV prevention program outcomes in Zambia

Introduction

Zambia has made substantial investments in health systems capacity, yet it remains unclear whether improved service quality improves outcomes. We investigated the association between health system capacity and use of prevention of mother-to-child HIV transmission (PMTCT) services in Zambia.

Materials and methods

We analyzed data from two studies conducted in rural and semi-urban Lusaka Province in 2014–2015. Health system capacity, our primary exposure, was measured with a validated balanced scorecard approach. Based on WHO building blocks for health systems strengthening, we derived overall and domain-specific facility scores (range: 0–100), with higher scores indicating greater capacity. Our outcome, community-level maternal antiretroviral drug use at 12 months postpartum, was measured via self-report in a large cohort study evaluating PMTCT program impact. Associations between health systems capacity and our outcome were analyzed via linear regression.

Results

Among 29 facilities, median overall facility score was 72 (IQR:67–74). Median domain scores were: patient satisfaction 75 (IQR 71–78); human resources 85 (IQR:63–87); finance 50 (IQR:50–67); governance 82 (IQR:74–91); service capacity 77 (IQR:68–79); service provision 60 (IQR:52–76). Our programmatic outcome was measured from 804 HIV-infected mothers. Median community-level antiretroviral use at 12 months was 81% (IQR:69–89%). Patient satisfaction was the only domain score significantly associated with 12-month maternal antiretroviral use (β:0.22; p = 0.02). When we excluded the human resources and finance domains, we found a positive association between composite 4-domain facility score and 12-month maternal antiretroviral use in peri-urban but not rural facilities.

Conclusions

In these Zambian health facilities, patient satisfaction was positively associated with maternal antiretroviral 12 months postpartum. The association between overall health system capacity and maternal antiretroviral drug use was stronger in peri-urban versus rural facilities. Additional work is needed to guide strategic investments for improved outcomes in HIV and broader maternal-child health region-wide.

The cascade of HIV care among key populations in Indonesia: a prospective cohort study

BACKGROUND

Indonesia has had low uptake of HIV testing and treatment. We did a study to estimate the cascade of HIV care in key populations and identify predictors of outcomes at key cascade steps.

METHODS

We used an observational cohort study design to recruit and follow up men who have sex with men (MSM), female sex workers, transgender women (known as waria in Indonesia), and people who inject drugs (PWID) diagnosed with HIV in four locations in Indonesia: Bali, Bandung, Jakarta, and Yogyakarta. Recruitment, baseline, and follow-up visits were done at collaborating clinical services, including both primary care sites and hospitals. Inclusion criteria for participants included identifying as a member of a key population, age 16 years or older, not previously tested positive for HIV, and HIV positivity at baseline. All participants were offered treatment as per national guidelines, with the addition of viral load testing and completion of study-specific forms. Estimates were calculated of proportions of participants linked to care, commencing treatment, adherent to treatment, and who achieved virological suppression. We used logistic regression to investigate characteristics associated with antiretroviral therapy (ART) initiation and viral suppression and Cox regression to identify factors associated with loss to follow-up. This study is registered with ClinicalTrials.gov, NCT03429842.

FINDINGS

Between Sept 15, 2015, and Sept 30, 2016, 831 individuals were enrolled in the study, comprising 637 (77%) MSM, 116 (14%) female sex workers, 27 (3%) waria, and 51 (6%) PWID. Of those enrolled, 703 (84·6%, 95% CI 82·1-87·1) were linked to HIV care and 606 (86·2%, 83·7-88·8) who were linked with care started ART. Among participants who started treatment, 457 (75·4%, 71·8-78·9) were retained in care, of whom 325 (71·1%, 66·7-75·2) had a viral load test about 6 months after enrolment, with 294 (90·5%, 86·7-93·4) of those tested (294 [35%, 32·1-38·7] of the original cohort) virally suppressed. 146 (24%) of 606 who started treatment were lost to follow-up. People who enrolled at sites that offered both testing and treatment had a higher likelihood of treatment initiation than those who enrolled at sites offering testing only (p<0·0001 by multivariate analysis), and participants who had been linked to care and had a high school or university education were significantly more likely to achieve viral suppression than those with a primary school or lower level of education (p≤0·029 by mulivariate analysis).

INTERPRETATION

HIV cascade data among key populations in Indonesia show very poor rates of retention in treatment and viral suppression. Site and individual characteristics associated with initiating and continuing treatment suggest an urgent need to develop and implement effective interventions to support patients in achieving viral suppression among all people with HIV.

FUNDING

Australian Government Department of Foreign Affairs and Trade, WHO, and Indonesian Government.

The impact of a therapeutic exercise intervention on depression and body self-image in HIV-positive women in sub-Saharan Africa

INTRODUCTION

Attitudes, responses, and reactions of HIV-positive women in three sub-Saharan African regions toward a therapeutic exercise intervention, aimed to determine the presence of depression and low body self-image, were captured. This provided insight into body satisfaction and desire to exercise (Stage 1, n=60), body self-image and depression (Stage 2, n=60), and overall concerns around the often adverse side effects of antiretroviral treatment (ART). A program of therapeutic (specialty) exercise was developed for the experimental design (Stage 2), to quantify the psychological side effects of these variables.

METHODOLOGY

Stage 1 constituted a qualitative exploration into attitudes and perceptions around ART, toxicity, health concerns, metabolic irregularities (lipodystrophy), body shape and size dissatisfaction, and cultural attitudes toward exercise. This stage deployed brief informal face-to-face interviews, based on the World Health Organization (WHO)/United Nations Fund for Population Activities (UNFPA) AIDS Inventory, in three sub-Saharan African regions (including provincial and district hospitals, nongovernmental organizations, voluntary counseling and testing/HIV and testing centers, and primary care outpatient clinics). Stage 2 of the study comprised a quantitative experimental design, conducted on a sample of HIV-positive women (mean age=39.0 years; mean years on ART=5.5; 86% black) in three selected HIV outpatient clinics in Johannesburg, South Africa.

DATA ANALYSIS

The collated data sets from both stages of the research were presented, analyzed, and interpreted (thematic analyses [Stage 1] and statistical analyses [Stage 2]) using the body self-image questionnaire and Beck's depression inventory.

RESULTS

Stage 1 outlined participants' concerns and reports around 1) body shape and size, including long-term effects of ART and 2) attitudes toward exercise, as a function of HIV status. Stage 2 represented pre- and posttest statistics, showing low statistical means for both the experiment and the control groups, with statistical significance for four out of nine items of subscales of body self-image questionnaire.

Towards 90-90-90 Target: Factors Influencing Availability, Access, and Utilization of HIV Services-A Qualitative Study in 19 Ugandan Districts

Background

UNAIDS has set a new target 90-90-90 by 2020. To achieve this target, current programs need to address challenges that limit access, availability, and utilization of HIV testing and treatment services. Therefore, the aim of this study was to identify the barriers that influence access, availability, and utilization of HIV services in rural Uganda within the setting of a large donor funded program.

Methods

We conducted key informant interviews with stakeholders at the district level, staff of existing HIV/AIDS projects, and health facilities in 19 districts. Data were also collected from focus group discussions comprised of clients presenting for HIV care and treatment. Data were transcribed and analyzed using content analysis. Results. Barriers identified were as follows: (1) drug shortages including antiretroviral drugs at health facilities. Some patients were afraid to start ART because of worrying about shortages; (2) distance and (3) staffing shortages; (4) stigma persistence; (5) lack of social and economic support initiatives that enhance retention in treatment.

Conclusions

In conclusion, our study has identified several factors that influence access, availability, and utilization of HIV services. Programs need to address drug and staff shortages, HIV stigma, and long distances to health facilities to broaden access and utilization in order to realize the UNAIDS target.

Barriers, Motivators, and Facilitators to Engagement in HIV Care Among HIV-Infected Ghanaian Men Who have Sex with Men (MSM)

In Ghana, men who have sex with men (MSM) bear a high burden of HIV. Identifying factors that influence engagement in HIV care among HIV-infected Ghanaian MSM is critical to devising novel interventions and strengthening existing programs aimed at improving outcomes across the HIV care continuum. Consequently, we conducted an exploratory qualitative research study with 30 HIV-infected Ghanaian MSM between May 2015 and July 2015. Common barriers were fear of being seen in HIV-related health facility, financial difficulties, and health system challenges. Major motivators for engagement in care included social support, fear of mortality from HIV, and knowledge of effectiveness of HIV treatment. Key facilitators were enrollment in health insurance, prior relationship and familiarity with hospital personnel, and positive experience in healthcare setting. Our findings highlight the need for new and innovative care delivery mediums, affirming and competent healthcare providers, and increased access to health insurance.

The City of Johannesburg can end AIDS by 2030: modelling the impact of achieving the Fast-Track targets and what it will take to get there

INTRODUCTION

In 2014, city leaders from around the world endorsed the Paris Declaration on Fast-Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The City of Johannesburg - one of South Africa's metropolitan municipalities and also a health district - has over 600,000 people living with HIV (PLHIV), more than any other city worldwide. We estimate what it would take in terms of programmatic targets and costs for the City of Johannesburg to meet the Fast-Track targets, and demonstrate the impact that this would have.

METHODS

We applied the Optima HIV epidemic and resource allocation model to demographic, epidemiological and behavioural data on 26 sub-populations in Johannesburg. We used data on programme costs and coverage to produce baseline projections. We calculated how many people must be diagnosed, put onto treatment and maintained with viral suppression to achieve the 2020 and 2030 targets. We also estimated how treatment needs - and therefore fiscal commitments - could be reduced if the treatment targets are combined with primary HIV prevention interventions (voluntary medical male circumcision (VMMC), an expanded condom programme, and comprehensive packages for female sex workers (FSW) and young females).

RESULTS

If current programmatic coverage were maintained, Johannesburg could expect 303,000 new infections and 96,000 AIDS-related deaths between 2017 and 2030 and 769,000 PLHIV by 2030. Achieving the Fast-Track targets would require an additional 135,000 diagnoses and 232,000 people on treatment by 2020 (an increase in around 80% over 2016 treatment numbers), but would avert 176,000 infections and 56,500 deaths by 2030. Assuming stable ART unit costs, this would require ZAR 29 billion (USD 2.15 billion) in cumulative treatment investments over the 14 years to 2030. Plausible scale-ups of other proven interventions (VMMC, condom distribution and FSW strategies) could yield additional reductions in new infections (between 4 and 15%), and in overall treatment investment needs. Scaling up VMMC in line with national targets is found to be cost-effective in the medium term.

CONCLUSIONS

The scale-up in testing and treatment programmes over this decade has been rapid, but these efforts must be doubled to reach 2020 targets. Strategic investments in proven interventions will help Johannesburg achieve the treatment targets and be on track to end AIDS by 2030.

When patients fail UNAIDS' last 90 - the "failure cascade" beyond 90-90-90 in rural Lesotho, Southern Africa: a prospective cohort study

Introduction: HIV-infected individuals on first-line antiretroviral therapy (ART) in resource-limited settings who do not achieve the last “90” (viral suppression) enter a complex care cascade: enhanced adherence counselling (EAC), repetition of viral load (VL) and switch to second-line ART aiming to achieve resuppression. This study describes the “failure cascade” in patients in Lesotho.

Methods: Patients aged ≥16 years on first-line ART at 10 facilities in rural Lesotho received a first-time VL in June 2014. Those with VL ≥80 copies/mL were included in a cohort. The care cascade was assessed at four points: attendance of EAC, result of follow-up VL after EAC, switch to second-line in case of sustained unsuppressed VL and outcome 18 months after the initial unsuppressed VL. Multivariate logistic regression was used to assess predictors of being retained in care with viral resuppression at follow-up.

Results: Out of 1563 patients who underwent first-time VL, 138 (8.8%) had unsuppressed VL in June 2014. Out of these, 124 (90%) attended EAC and 116 (84%) had follow-up VL (4 died, 2 transferred out, 11 lost, 5 switched to second-line before follow-up VL). Among the 116 with follow-up VL, 36 (31%) achieved resuppression. Out of the 80 with sustained unsuppressed VL, 58 were switched to second-line, the remaining continued first line. At 18 months’ follow-up in December 2015, out of the initially 138 with unsuppressed VL, 56 (41%) were in care and virally suppressed, 37 (27%) were in care with unsuppressed VL and the remaining 45 (33%) were lost, dead, transferred to another clinic or without documented VL. Achieving viral resuppression after EAC (adjusted odds ratio (aOR): 5.02; 95% confidence interval: 1.14–22.09; p = 0.033) and being switched to second-line in case of sustained viremia after EAC (aOR: 7.17; 1.90–27.04; p = 0.004) were associated with being retained in care and virally suppressed at 18 months of follow-up. Age, gender, education, time on ART and level of VL were not associated.

Conclusions: In this study in rural Lesotho, outcomes along the “failure cascade” were poor. To improve outcomes in this vulnerable patient group who fails the last “90”, programmes need to focus on timely EAC and switch to second line for cases with continuous viremia despite EAC.