1328. Post-War and Post-Ebola HIV Care Continuum in a Liberian Academic Center: Fresh Insights and Trends Over 5-Year Period

Background

Two-thirds of people living with HIV (PLWH) reside in sub-Saharan Africa. The UNAIDS 90-90-90 target to end the HIV epidemic is an aspirational but achievable goal. The Continuum of Care model allows evaluating the progress toward this goal as well as identifying gaps in diagnosis, linkage to care, HIV treatment. In Liberia, the estimated number of PLWH is 40,000 with only 26,000 (65%) diagnosed, 14,000 (53%) on combination ART (cART), and of those, 53% virally suppressed. After a devastating war and Ebola epidemic, the country has only one academic medical center, John F. Kennedy (JFK) Hospital in Monrovia, with the largest HIV clinic caring for a cohort of 3,000 PLWH. This study was designed to evaluate the HIV care continuum at this center over a 5-year period.

Methods

Data from 2014 to 2018 were collected from a database at JFK hospital HIV clinic. Data were extracted for all patients tested for HIV. The proportion of those tested positive, who were linked to care, retained in care, and subsequently initiated on cART was analyzed. Only a sample of PLWH received HIV viral load monitoring test. Utilizing the HIV care continuum model, data on each step of the care cascade were reported as simple percentages or proportions.

Results

Over the 5-year study period, a total of 41,343 individuals were screened for HIV and 4,066 tested positive (10%), much higher than the national rate of 3–5%. Linkage to care was inconsistent; 87% (592/678) in 2014, 98% (622/636) in 2015, 61% (644/1057) in 2016, 73% (570/786) in 2017, and 64% (584/909) in 2018 were enrolled in the clinic. ART initiation improved over time; of the PLWH enrolled in the clinic, 75%, 64%, 76%, 86%, and 84% for the years 2014, 2015, 2016, 2017, and 2018, respectively, were initiated on cART, also higher than the national rate estimated at 53%. Only a sample of 100 patients had HIV VL performed and of those 53% had viral suppression. From the total clinic cohort of 5,280 PLWH, 19–28% of HIV patients were lost to care with a 2–4% death rate annually.

Conclusion

Although the HIV Care Continuum rates at the largest academic center in Monrovia, Liberia were above national rates, they were suboptimal and fell below the 90-90-90 UNAIDS target. Current efforts are focused on understanding gaps in care and investigating opportunities to improve linkage to, and retention in care.

Disclosures

All authors: No reported disclosures.

1261. Alarming High Rate of HIV Detected by Testing and Prevention Opportunities: Observations From the Largest HIV Program in Liberia

Background

HIV/AIDS remains one of the world’s most significant public health challenges. Sub-Saharan Africa is home to only 12% of the world’s population, yet accounts for 71% of the global burden of HIV infection. While the HIV prevalence among reproductive aged Liberians (age 15–49 years) is estimated at 1.9%. As the critical first step in HIV disease management is detection of cases, it is important to optimize HIV testing particularly among high-risk groups. Identifying these high-risk groups for HIV infection also provides information on prevention opportunities. We report on 5 year HIV testing data at a tertiary hospital in Monrovia, Liberia stratified by age and gender.

Methods

A single-center academic hospital-based retrospective analysis of HIV testing data over a period of 5 years (January 2014 to December 2018) obtained from the Infectious Disease Center (IDC) of John F. Kennedy Medical Center in Monrovia, Liberia. The IDC has a peer-led counseling program on site and offers HIV testing daily. Data on the study population (all individuals screened for HIV disease at the center) was extracted from ledgers and registries within the IDC. The following information was collected on all participants: age, sex, and pregnancy status. Positive test results are reported as simple proportions of either all patients or all individuals tested within the category reported.

Results

Over the 5-year study period, 41,343 individuals were screened for HIV disease including 2 key demographics - 7875 individuals aged 15–24 years and 24,913 pregnant women. 4,066 individuals were diagnosed with HIV (a case detection rate of 10%), and ranged from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15–24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018, respectively. From 2014–2018, 2–3% of all pregnant women tested were diagnosed with HIV infection. Almost three-quarters (74%) of diagnosed cases were subsequently enrolled in an HIV clinic.

Conclusion

A peer-led HIV testing program is effective in HIV case detection, with young individuals (aged 15–24 years) and pregnant women having higher case detection rates than expected. These findings highlight opportunities for HIV prevention targeting these high-risk groups.

Disclosures

All authors: No reported disclosures.

Prevalence of HIV-1 drug resistance among patients failing first-line ART in Monrovia, Liberia: a cross-sectional study

OBJECTIVES

To assess the prevalence of acquired drug resistance in HIV-1-infected patients living in Monrovia, Liberia, who had clinical and/or immunological failure of first-line ART according to WHO criteria.

PATIENTS AND METHODS

Patients receiving ART for >1 year with clinical and/or immunological failure were included. Sequencing of protease and reverse transcriptase regions was performed using Agence Nationale de Recherche sur le SIDA et les hépatites virales (ANRS) procedures and sequences were interpreted using the ANRS resistance algorithm.

RESULTS

Ninety patients were enrolled. They had been receiving ART for a median time of 42 months and half were receiving zidovudine/lamivudine/nevirapine. Seventy-five per cent of patients were infected with CRF02_AG. Twenty-seven per cent of patients displayed a plasma viral load <50 copies/mL. Among the 66 patients with detectable viraemia, the median viral load was 4.7 log10 copies/mL (IQR = 3.0-5.6). The prevalence of NRTI and NNRTI resistance-associated mutations (RAMs) was 63% and 71%, respectively; and the median number of NRTI and NNRTI RAMs was 2 and 3, respectively. Two patients (4%) displayed viruses with PI RAMs. Regarding NRTI drug resistance, 29%, 38%, 63%, 29% and 25% of patients had viruses resistant to zidovudine, stavudine, lamivudine/emtricitabine, abacavir and tenofovir, respectively. Regarding the NNRTI drug class, 56%, 65%, 33% and 42% of patients had viruses resistant to efavirenz, nevirapine, etravirine and rilpivirine, respectively.

CONCLUSIONS

The high prevalence of acquired drug resistance in patients followed in two centres of the Liberian capital city, documented after a median of 3 years on a first-line ART regimen, jeopardizes the activity of second-line regimens and highlights the need for virological monitoring in these settings.

Short communication: Prevalence of HIV-1 transmitted drug resistance in Liberia

No data on HIV-transmitted drug resistance (TDR) are available in Liberia in which the HIV prevalence in the general population is estimated at 1.5%. The aim of the study was to assess the prevalence of TDR in HIV-1 from recently diagnosed and untreated patients living in Monrovia, Liberia. The study was performed in the John F. Kennedy Medical Center and in the Redemption Hospital, both located in Monrovia. All newly HIV-1 diagnosed patients attending voluntary counseling testing centers and antiretroviral therapy naive were consecutively included. Protease and reverse transcriptase (RT) regions sequencing was performed using the ANRS procedures (www.hivfrenchresistance.org). Drug resistance mutations (DRM) were identified according to the 2009 updated WHO surveillance DRM list. Among the 116 HIV-1-infected patients enrolled in the study, 85 (73%) were women. Protease and RT sequencing was successful in 109 (94%) and 102 (88%) samples, respectively. Seventy-five (66%) patients were infected with CRF02_AG. One DRM was observed in six samples, leading to a TDR prevalence of 5.9% (CI 95%=1.7-10.1). DRM were observed in two patients (2.0%; CI 95%=0.0-4.7), four patients (3.9%; CI 95%=0.1-7.7), and one patient (0.9%; CI 95%=0.0-2.7) for nucleoside RT inhibitors (NRTI), non-NRTI (NNRTI), and protease inhibitors, respectively. Overall, one patient exhibited dual class-resistant viruses, harboring NRTI and NNRTI resistance mutations (1.0%; CI 95%=0.0-2.9). This first survey study in Liberia reported a TDR prevalence of 5.9%, classified as moderate according to the WHO criteria, indicating that further surveillance is warranted to follow the level and evolution of TDR prevalence in recently HIV-1 diagnosed patients.