Analysis of antiretroviral therapy interruption in people living with HIV during the 2010-2021 period

INTRODUCTION

In the context of the advancement of antiretroviral therapy and as the characteristics of people living with HIV progress toward an ageing population, understanding the causes of treatment interruption becomes crucial. The aim of the study was to determine the change in reasons for antiretroviral treatment discontinuation for 12 years. Secondarily, compare annual antiretroviral regimen discontinuation rate and factors associated.

METHODS

We conducted an analysis using data from people living with HIV who were receiving antiretroviral therapy and discontinued it for any reason. The study included people with HIV infection who visited an outpatient hospital pharmacy clinic from January 2010 to December 2021. Two periods were differentiated for the analysis: 2010-2015 and 2016-2021. The reasons for antiretroviral treatment discontinuation followed classification described by Swiss cohort. In the context of this study, it is pertinent to note that the term "discontinuation" is employed synonymously with "interruption". The term "discontinuation" will be consistently used in this article to refer to the act of switching or stopping antiretroviral treatment. To examine factors associated with antiretroviral therapy discontinuation, we utilised Kaplan-Meier methods and Cox proportional models.

RESULTS

We included 789 people living with HIV, predominantly male (81.5%). The main reason for discontinuation was clinical decision (50.2%) followed by adverse effects (37.9%). Focusing on clinical decision, we observed a trend change that went from antiretroviral treatment simplification regimen (56.1%) in the first part of the period analysed to the therapeutic optimisation (53.6%) in the second half. Furthermore, factors that were statistically significantly associated with antiretroviral treatment discontinuation were people with HIV≥50 years (HR 1.60; 95%CI 1.25-2.04), post-discontinuation single-tablet regimen (HR 1.49; 95%CI 1.06-2.11) and antiretroviral drug classes.

CONCLUSION

Over the 12 years, there has been a change in the main cause of antiretroviral treatment discontinuation, currently therapeutic optimisation being the main reason. Integrase inhibitors-based regimens and single-tablet regimen strategies were less likely to be discontinued than others antiretroviral drug classes, allowing for better clinical management due to the efficacy profile, especially in people living with HIV≥50 years with comorbidities.

Sagittal Abdominal Diameter as the Best Predictor of Metabolic Syndrome in HIV-Infected Men on Antiretroviral Therapy

BACKGROUND

The interaction of human immunodeficiency virus (HIV), host and antiretroviral therapy causes a range of metabolic disorders that can be characterized as a metabolic syndrome (MetS) that increases the cardiovascular risk. MetS involves central obesity, which can be detected using different anthropometric parameters.

OBJECTIVE

To assess the abilities of different anthropometric parameters in the prediction of MetS in HIV-infected men on ART.

METHOD

The study involved 92 male participants (mean age 44.46±10.38 years), divided into two groups: with and without MetS. All subjects underwent biochemical evaluation (triglycerides, HDL-cholesterol, fasting glucose), blood pressure measurement and anthropometric assessment: body mass, body height, body mass index (BMI), body fat mass, body circumferences (chest, upper arm, forearm, waist, hip, proximal and middle thigh and calf), sagittal abdominal diameter (SAD), skinfold thicknesses (subscapular, anterior and posterior upper arm, anterior and lateral forearm, abdominal, supraspinal, thigh and calf), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), waist-to-thigh ratio (WTR), sagittal abdominal diameter-to-body height ratio (SADH), body adiposity index (BAI) and conicity index. MetS was specified according to IDF criteria.

RESULTS

Subjects with MetS had statistically significant higher values of all anthropometric parameters except middle thigh circumference, calf skinfold and body height. According to ROC analysis and Binary Logistic Regression, SAD has been shown as the best predictor of MetS with a predictive value of 21.40 cm (AUC:0.91), followed by WHR with a predictive value of 0.93.

CONCLUSION

Sagittal abdominal diameter is the strongest anthropometric indicator of MetS in HIV-infected patients on ART.

Medicinal chemistry perspectives on the development of piperazine-containing HIV-1 inhibitors

The Human immunodeficiency virus (HIV) is the causative agent of acquired immunodeficiency syndrome (AIDS), one of the most perilous diseases known to humankind. A 2023 estimate put the number of people living with HIV around 40 million worldwide, with the majority benefiting from various antiretroviral therapies. Consequently, the urgent need for the development of effective drugs to combat this virus cannot be overstated. In the realm of medicinal and organic chemistry, the synthesis and identification of novel compounds capable of inhibiting HIV enzymes at different stages of their life cycle are of paramount importance. Notably, the spotlight is on the progress made in enhancing the potency of HIV inhibitors through the use of piperazine-based compounds. Multiple studies have revealed that the incorporation of a piperazine moiety results in a noteworthy enhancement of anti-HIV activity. The piperazine ring assumes a pivotal role in shaping the pharmacophore responsible for inhibiting HIV-1 at critical stage, including attachment, reverse transcription, integration, and protease activity. This review also sheds light on the various opportunities that can be exploited to develop effective antiretroviral targets and eliminate latent HIV reservoirs. The advancement of highly potent analogues in HIV inhibitor research has been greatly facilitated by contemporary medicinal strategies, including molecular/fragment hybridization, structure-based drug design, and bioisosterism. These techniques have opened up new avenues for the development of compounds with enhanced efficacy in combating the virus.

Salivary biochemical parameters in people living with HIV on ART and dental caries: a cross-sectional study in Monastir, Tunisia

BACKGROUND

Studies regarding salivary biochemical parameters and dental caries in adult people living with HIV/AIDS (PLWHA) are scanty.

AIM

To investigate salivary biochemical parameters and dental caries in adult PLWHA who are on antiretroviral therapy (ART) and compare the findings with people negative for HIV infection.

METHODS

The study included 50 HIV positive individuals as a test group (TG) and 50 HIV negative individuals as a control group (CG). Dental examination was performed according to WHO guidelines to assess DMFT. Digital panoramic radiographs were taken to detect additional infectious foci. Non-stimulated saliva was collected between 9 and 12 a. m for 5 min to evaluate 18 biochemical parameters and salivary flow rate (SFR). Parametric and non parametric tests were used according to data distribution. The level of significance was set at p < 0.05%.

RESULTS

Patients' mean ages and M/F sex ratios for TG and CG were 38.80 ± 9.69 y/o. vs. 37.98 ± 13.47 y/o. and 3.54 vs. 2.33, respectively. Higher means of decayed teeth were recorded in TG, 4.47 ± 3.00 vs. 3.88 ± 2.81 in CG with no significant difference (p = 0.41). Means of filled teeth were significantly lower in TG 2.38 ± 2.16 vs. 4.16 ± 3.35 in CG (p = 0.01), respectively. No statistical significant difference was noted in DMFT indices between the 2 groups (8.04 ± 6.90 vs. 8.52 ± 6.24, p = 0.71). The following salivary parameters were significantly lower in TG compared to CG, respectively: mean SFR 0.44 ± 0.18 ml/min vs. 0.61 ± 0.26 ml/min; median levels of sodium and chlorides, 4 mmol/L and 13.5 mmol/L vs. 9 mmol/L and 19 mmol/L (p < 0.001) and uric acid, 103.50 mmol/L vs. 163 (p = 0.009). However, higher median levels were recorded with calcium, 1.09 mmol/L vs. 0.54 (p < 0.001) and sIgA 23 mg/dl vs. 5 mg/dl (p < 0.001). In TG, a positive correlation was found between DC, potassium, urea, and chlorides (p < 0.05). Salivary renal and hepatic biomarkers were comparable between the two groups.

CONCLUSIONS

PLWHA have shown an alteration in some salivary parameters, more decayed teeth and less filled teeth. Preventive measures should be implemented to lower dental caries and enhance accessibility to oral care services. In addition, saliva can be utilized to monitor oral and general health status among PLWHA on ART.

Human Immunodeficiency Virus as a Risk Factor for Cardiovascular Disease

The developments in HIV treatments have increased the life expectancy of people living with HIV (PLWH), a situation that makes cardiovascular disease (CVD) in that population as relevant as ever. PLWH are at increased risk of CVD, and our understanding of the underlying mechanisms is continually increasing. HIV infection is associated with elevated levels of multiple proinflammatory molecules, including IL-6, IL-1β, VCAM-1, ICAM-1, TNF-α, TGF-β, osteopontin, sCD14, hs-CRP, and D-dimer. Other currently examined mechanisms include CD4 + lymphocyte depletion, increased intestinal permeability, microbial translocation, and altered cholesterol metabolism. Antiretroviral therapy (ART) leads to decreases in the concentrations of the majority of proinflammatory molecules, although most remain higher than in the general population. Moreover, adverse effects of ART also play an important role in increased CVD risk, especially in the era of rapid advancement of new therapeutical options. Nevertheless, it is currently believed that HIV plays a more significant role in the development of metabolic syndromes than treatment-associated factors. PLWH being more prone to develop CVD is also due to the higher prevalence of smoking and chronic coinfections with viruses such as HCV and HBV. For these reasons, it is crucial to consider HIV a possible causal factor in CVD occurrence, especially among young patients or individuals without common CVD risk factors.

Psychosocial experiences of pregnant women living with HIV in Ibadan, Oyo State

Introduction

Pregnancy often intensifies psychological vulnerabilities in women living with HIV (WLHIV) due to increased stressors such as health concerns, infant infection risks, and the management of special neonatal needs like prophylactic antiretroviral care.

Methodology

The study was conducted in four HIV treatment centres with participant selection based on the following criteria: an Edinburgh Postnatal Depression Scale (EPDS) score of 13 or above, gestational age between 14 to 40 weeks, less than five years of antiretroviral therapy (ART) usage, and history of partner conflict. This research forms a more extensive study of stress and depression amongst pregnant and postpartum WLWH. In-depth interviews, ranging from 20 to 40 minutes, were conducted with 26 HIV-positive pregnant women in private rooms within selected antiretroviral clinics from October and December 2022.

Results and Discussion

The study discovered that the support received from healthcare providers concerning ART and Prevention of Mother-To-Child Transmission (PMTCT) practices alleviated women's fear of death and perinatal transmission which bolstered their involvement in HIV care and fostered the birth of children not infected with HIV. Women perceived monogamy as a protective measure against HIV contraction. Participants who reported having partners engaging in unsafe sexual practices expressed anger and blame. The observation of other women with similar experiences aided in coping mechanisms, reaffirming previous findings that knowing someone living with HIV helps to accept their status due to the comfort derived from shared experiences.

Conclusion

Healthcare providers attending to pregnant WLWH can alleviate psychological distress by reinforcing positive coping strategies. These include consistent psychological distress screenings in HIV clinics and relevant mental health evaluations with appropriate care referrals.

Survival of patients living with HIV and cancer in Cali, Colombia

Background

People living with HIV have an increased risk of cancer compared to the general population. However, with the increase in life expectancy and advances in antiretroviral therapy, the survival of patients with cancer and HIV has changed.

Objective

To determine the survival of patients living with HIV and cancer in Cali, Colombia.

Methods

A retrospective cohort study was conducted at the Fundación Valle del Lili, Cali, Colombia. Data from the HIV database was crossed with data from the hospital and population-based cancer registries between 2011-2019. Patients <18 years, limited available clinical information on the diagnosis and treatment of HIV and cancer, and non-oncological tumor diagnosis were excluded.

Results

A total of 173 patients were included. The frequencies of AIDS-defining neoplasms were: Non-Hodgkin lymphoma (42.8%), Kaposi sarcoma (27.8%), and cervical cancer (4.6%). Overall survival was 76.4% (95% CI 68.9-82.3) at five years. Poorer survival was found in patients with AIDS-defining infections (56.9% vs. 77.8%, p=0.027) and non-AIDS-defining infections (57.8% vs. 84.2%, p=0.013), while there was better survival in patients who received antiretroviral therapy (65.9% vs. 17.9%, p=0.021) and oncological treatment (66.7% vs. 35.4%, p<0.001). The presence of non-AIDS-defining infections increases the risk of dying (HR = 2.39, 95% CI 1.05-5.46, p=0.038), while oncological treatment decreases it (HR = 0.33, 95% CI 0.14-0.80, p=0.014).

Conclusions

In people living with HIV, Non-Hodgkin lymphoma and Kaposi sarcoma are the most common neoplasms. Factors such as AIDS-associated and non-AIDS-associated infections have been identified as determinants of survival. Cancer treatment seems to improve survival.

Unexpected effects of COVID-19 outbreak: adaption of Anti-Retroviral Therapy (ART) delivery policies improved adherence in a population of People Living With HIV (PLWH)

Background

Adherence to Anti-Retroviral Therapy (ART) is crucial for People Living With HIV (PLWH). In Italy, ART is delivered by Hospital Pharmacies, on a renewable prescription from the hospital physician. The measurement of package-refill (the rate of ART packages actually collected out of those to be collected in order to comply with therapy) is an effective tool to evaluate the adherence.During COVID-19 outbreak, at "D. Cotugno" hospital in Naples, Italy, the ART delivery policies have been adapted, in order to reduce the number of patients' access. We analysed the impact of these changes on the pill-refill of ART in January-August 2020, compared with 2018-2019.

Methods

"D. Cotugno" hospital is a mono-specialistic Infectious Diseases hospital, caring for about 2500 PLWH. Since February 2020, the hospital was almost entirely dedicated to COVID-19 patients. All out-patient activities were interrupted, except for those dedicated to HIV/AIDS patients.In this preliminary study we included all patients assigned to one of the three Medical Divisions dedicated to HIV, who were already under treatment since at least 2017. Rate of package-refill was obtained by the Hospital Pharmacy registry, demographic and clinical data were derived from clinical database.During COVID-19, many measures were adopted in order to increase safety of PLWH attending to hospital. Among these, medical prescription validity increased from 4 to 6 months, and number of packages to be collected increased from 2 to 4, adopting a multi-month dispensing strategy.Package-refill is adequate if at least 95% of ART have been actually collected; partial and inadequate if 75%-94% or less than 75% of ART, respectively, have been collected. Package-refill was measured during the first year of COVID-19 (March 2020 - February 2021), compared to the same period in the two years before.

Results

A total of 594 PLWH were included. PLWH with optimal pill-refill significantly increased in 2020-21 compared to 2018-2020 (62% vs 55%, p 0.013).

Discussion

Due to COVID-19, we would have expected a reduction in ART deliveries. Surprisingly, the opposite occurred. The increase of pill-refill rates may be due to different reasons, but we hypothesized that the adaption of delivery policies, with a higher number of packages allowed to be collected, strongly contributed to this result. This study suggests that multi-month dispensing policies may contribute to the improvement of adherence among PLWH.

Should we expect weight changes in people with HIV and a reported weight gain only by switching antiretroviral therapy?

Weight gain following the initiation or the switch of antiretroviral therapy (ART) is well documented and mainly associated with some of the most recent drugs, such as integrase strand transfer inhibitors and tenofovir alafenamide. However, limited data have been published on weight trends in ART-experienced people living with HIV (PLWH) with a long exposure to HIV infection and antiretroviral drugs. In our study, we assessed changes in weight after switching ART among PLWH who reported weight gain under a previous regimen.

Predictors of migration in an HIV hyper-endemic rural South African community: evidence from a population-based cohort (2005-2017)

Globally, South Africa hosts the highest number of people living with HIV (PLHIV) and the unique legacy of internal labour migration continues to be a major driver of the regional epidemic, interrupting treatment-as-prevention efforts. The study examined levels, trends, and predictors of migration in rural KwaZulu-Natal Province, South Africa, using population-based surveillance data from 2005 through 2017. We followed 69 604 adult participants aged 15-49 years and recorded their migration events (i.e., out-migration from the surveillance area) in 423 038 person-years over 525 397 observations. Multiple failure Cox-regression models were used to measure the risk of migration by socio-demographic factors: age, sex, educational status, marital status, HIV, and community antiretroviral therapy (ART) coverage. Overall, 69% of the population cohort experienced at least one migration event during the follow-up period. The average incidence rate of migration was 9.96 events and 13.23 events per 100 person-years in women and men, respectively. Migration rates declined from 2005 to 2008 then peaked in 2012 for both women and men. Adjusting for other covariates, the risk of migration was 3.4-times higher among young women aged 20-24 years compared to those aged ≥ 40 years (adjusted Hazard Ratio [aHR] = 3.37, 95% Confidence Interval [CI]: 3:19-3.57), and 2.9-times higher among young men aged 20-24 years compared to those aged ≥ 40 years (aHR = 2.86, 95% CI:2.69-3.04). There was a 9% and 27% decrease in risk of migration among both women (aHR = 0.91, 95% CI: 0.83 - 0.99) and men (aHR = 0.73, 95% CI 0.66 - 0.82) respectively per every 1% increase in community ART coverage. Young unmarried women including those living with HIV, migrated at a magnitude similar to that of their male counterparts, and lowered as ART coverage increased over time, reflecting the role of improved HIV services across space in reducing out-migration. A deeper understanding of the characteristics of a migrating population provides critical information towards identifying and addressing gaps in the HIV prevention and care continuum in an era of high mobility.

Drug-drug interactions of Integrase Strand Transfer Inhibitors among older people living with HIV: Interazioni farmacologiche degli inibitori delle integrase tra le persone anziane che vivono con HIV

The advancement of Human Immunodeficiency Virus (HIV) treatment improves the life expectancy of HIV-positive individuals. People living with HIV have more polypharmacy and drug-drug interactions than those without HIV. Integrase strand transfer inhibitors (INSTIs) are the newest class commonly used for HIV treatment. There are five INSTIs currently approved by the Food and Drug Administration, including raltegravir, elvitegravir, dolutegravir, bictegravir, and cabotegravir. INSTIs class contributes to better safety and efficacy profile, making them the preferred or recommended antiretroviral regimens in HIV treatment guidelines worldwide. Despite the shared mechanism of action, INSTIs differ in pharmacokinetics, contributing to different drug-drug interactions. This review summarized the potential drug interactions of INSTIs and the management of the drug interactions in clinical practice.

HIV-associated dysbiosis and immune recovery during antiretroviral therapy

The microbiomes of people living with HIV (PLWH) are significantly dysregulated with a loss of bacteria diversity and shifts in composition, including increases in pathogenic and decreases in beneficial species. Because of the microbiome's role in modulating health, the effect of this dysbiosis on immune response in PLWH has been a significant concern, mainly because these shifts can persist even after viral suppression during combination antiretroviral therapy (cART). However, due to limitations on sample availability, few studies have been able to provide insights into these microbiome-immune interactions. Recently, Olivas-Martínez, et al. characterized ileum and caecum mucosa-associated microbiomes of PLWH based on their level of peripheral CD4+ T-cell reconstitution following long-term cART. Their analysis revealed distinct microbiome signatures predictive of recovery. Additionally, differences in markers of gut inflammation and damage between response groups were described, further implicating mucosal disruptions with immune reconstitution. These new data demonstrate an interdependence of microbiome and therapy response, and additional studies were urgently required to fully elucidate this crosstalk and microbiome dynamics from before/after infection and finally, long-term viral suppression with cART.

Virologic failure in people living with HIV in 1st line ART: A 10-year Mexican population-based study

Background

In Mexico, the number of people living with HIV (PLWH) receiving antiretroviral therapy (ART) has increased in the last 20 years. The elimination of a CD4 threshold to initiate publicly funded ART was a major policy implemented in 2014. The study objective was to assess the determinants of Virologic Failure (VF) in Mexican PLWH on first-line ART between 2008 and 2017 and to evaluate the effects of changes following the 2014 policy.

Methods

A 10-year patient-level data analysis was conducted using the Mexican SALVAR database. The main outcome was the proportion of PLWH with VF. A multivariable logistic regression was conducted to identify the association between covariates and VF before and after the 2014 policy implementation.

Results

We found a lower proportion of people with VF in 2014–2017 compared with 2008–2013 (50% vs 33%, p<0.001). The multivariable analysis showed a reduction in the odds of virologic failure after 2014 (Odds ratio: 0.50 [95% CI: 0.48–0.51]). Place of treatment and level of deprivation were significant predictors of VF in during 2014–2017, but not before.

Conclusion

This study indicates that, by lowering threshold levels of CD4 required for treatment initiation in Mexico, a higher number of PLWH initiated treatment during 2014–2017, compared to 2008–2013 and the odds of VF were reduced.

The Effect of Antiretroviral Therapy for the Treatment of HIV-1 in Pregnancy on Gestational Weight Gain

BACKGROUND

Gestational weight gain above the Institute of Medicine recommendations is associated with increased risk of pregnancy complications. The goal was to analyze the association between newer HIV antiretroviral regimens (ART) on gestational weight gain.

METHODS

This is a retrospective cohort study of pregnant women with HIV-1 on ART. The primary outcome was incidence of excess gestational weight gain. Treatment effects were estimated by ART regimen type using log-linear models for relative risk, adjusting for pre-pregnancy BMI and presence of detectable viral load at baseline.

RESULTS

303 pregnant women were included in the analysis. Baseline characteristics including pre-pregnancy BMI, viral load at prenatal care entry, and gestational age at delivery were similar by ART, including 53% of the entire cohort initiated ART before pregnancy ( p = NS). Excess gestational weight gain occurred in 29% of the cohort. Compared to non-INSTI or TAF exposed persons, receipt of INSTI+TAF had a 1.7-fold increased relative risk of excess gestational weight gain, (95%CI 1.18, 2.68, p< 0.01), while women who received TDF had a 0.64-fold decreased relative risk (95% CI 0.41, 0.99, p=0.047) of excess gestational weight gain. INSTI alone was not significantly associated with excess weight gain in this population. The effect of TAF without INSTI could not be inferred from our data. There was no difference in neonatal, obstetric, or maternal outcomes between the groups.

CONCLUSIONS

Pregnant women receiving ART with a combined regimen of INSTI and TAF have increased risk of excess gestational weight gain.

Viral suppression among HIV-positive patients on antiretroviral therapy in northwestern Nigeria: an eleven-year review of tertiary care centre records, January 2009-December 2019

BACKGROUND

Human Immuno-Deficiency Virus (HIV) remains one of the world's significant public health challenges. Viral suppression is the key indicator for treatment success in People living with HIV (PLHIV). We determined the level of viral suppression, and its associated factors among PLHIV attending Federal Medical Centre Katsina (FMC Katsina), Nigeria.

METHODS

This retrospective descriptive cross-sectional study was conducted on 913 HIV positive adults enrolled in care between January 2009 and December 2019. Information on socio-demographics, clinical, immunological, Viral load (VL), and other relevant parameters were extracted from the patients' care records. The primary outcome was the proportion of patients that achieved viral suppression. We also analyzed variables that were associated with VL suppression.

RESULTS

Of 913, records of 831 (91.0%) registered patients were analyzed. During the period, 751 (90.4%) achieved viral suppression, 427 (51.4%) had CD4 counts  ≥ 500 and 477 (57.4%) were on HAART for ≥ 5 years. Majority, 793 (95.4%) were on first-line HAART regimen (Tenofovir-Lamivudine-Dolutegravir or Abacavir-Lamivudine-Dolutegravir), and 809 (97.4%) in the non-advanced stage (WHO stages 1 and 2). The median (interquartile range) of viral load was 20 (20-40) vs 19,989 (3311-110,340) cp/ml in virally suppressed, and unsuppressed  respectively. Factors associated with viral suppression included being unemployed (Adjusted OR [AOR] 4.9, 95% CI 2.771, 8.539), educated (AOR 4.2, 95% CI 1.098, 16.223), having a baseline CD4 count ≥ 500 cells/µl (AOR 2.7, 95% CI 1.588, 4.625), and being on first line HAART regimen [AOR 7.0, 95% CI 3.220, 15.648].

CONCLUSIONS

Our study demonstrated a good viral suppression among PLHIV on HAART. Variables associated with viral suppression included unemployment, formal education, high baseline CD4 count, and first line HAART regimen.

Pharmacist Intervention Lowers HgbA1c in Diabetic Patients Regardless of HIV Status

Aim

Compare glycemic control in human immunodeficiency (HIV)-positive patients on antiretroviral therapy to HIV-negative patients following pharmacist interventions.

Methods/Results

This retrospective observational cohort study conducted at a Federally Qualified Health Center included adults with type II diabetes mellitus who attended at least two clinical pharmacy appointments between January 1, 2018 and July 31, 2019. Exclusion criteria included missing pre- or post-hemoglobin A1c (HgbA1c) values, type 1 diabetes, pregnancy, breastfeeding, deceased, or untreated HIV. The primary endpoint was change in HgbA1c from baseline to month 3. Secondary endpoints were change in HgbA1c at 6, 9, and 12 months, and time to goal. Additional endpoints included changes in number of anti-diabetic agents, blood pressure, body mass index, hypoglycemic events, percent of patients on a sodium-glucose co-transporter-2 (SGLT-2) inhibitor or glucagon-like peptide (GLP-1) agonist. This study was exempt from the University of California, Davis Institutional Review Board as a continuous quality improvement study.Seventy-eight patients were included, 17 of whom were HIV-positive. At 3 months, HgbA1c was reduced by -1.7% and -1.2% (p =0.31) for HIV-positive and -negative patients, respectively. In the pooled cohort, HgbA1c was reduced from baseline at all time points, and 24% of patients achieved HgbA1c below 7.0%. The number of antidiabetic medications remained unchanged or was decreased in 60% of patients.

Conclusion

The study demonstrated clinically important HgbA1c reductions without increasing the medication burden in most patients. There was no significant difference in glycemic management between HIV-positive and HIV-negative patients.

Guillain-Barré syndrome as the first presentation of human immunodeficiency virus infection

AIM

Antiretroviral therapy (ART) development has reduced the severity of neurological complications of the human immunodeficiency virus (HIV), but they remain prevalent and need prompt recognition. Acute inflammatory demyelinating polyneuropathy (AIDP) is a rare complication of human immunodeficiency virus (HIV) infection that may appear at any stage of the disease. In this case, AIDP represents a late presentation of HIV infection.

METHODS

Descriptive study. Patient data were collected from their medical records and by health assessment interviews.

RESULTS

We report a case of a 52-year-old male with acute lower limb weakness. Given the suggestive clinical presentation of AIDP and a positive HIV test, intravenous immunoglobulin (IVIG) was administered along with antiretroviral therapy. Progressive weakness to the upper limbs, autonomic dysfunction, and pain was observed. The second regimen of IVIG plus corticosteroids was administered. Muscle strength improved after three weeks.

CONCLUSIONS

Screening for HIV in a patient with AIDP may provide a better outcome because of the early start of ART with good central nervous system penetration in HIV-infected patients.

Natural Bioactives as a potential Therapeutic Modality against NeuroAIDS

With the introduction of antiretroviral therapy, the worldwide AIDS-related deaths have decreased, and life expectancy has increased, so has the prevalence of AIDS-related neurological disorders or neuroAIDS. HIV associated neurocognitive disorder such as mild neurocognitive disorder and asymptomatic neurocognitive impairment have largely remained stable or increased among the HIV infected individuals in the combination antiretroviral therapy era and with the emerging evidence that antiretrovirals with high CNS penetration effectiveness score contribute to the neurotoxicity and HIV associated neurocognitive disorder. have ushered the search for natural, nontoxic bioactive constituents having pre-established neuroprotective, anti-inflammatory and restorative neurocognitive activity. In this review, we have highlighted the probable mechanism of neuroAIDS infection, the problem with the existing antiretroviral therapy, along with various bioactive constituents with in vivo, in vitro, or ex vivo evidence of their neuroprotective activity that can be used as an adjuvant with the current combination antiretroviral therapy regimen or can even serve as an alternate to the antiretrovirals for treatment of HIV associated neurocognitive disorder.

Sexual Health in HIV-Positive Men Under Stable Antiretroviral Therapy During a 12-Month Period

BACKGROUND

Sexual health is becoming increasingly important for many HIV-positive men undergoing highly effective antiretroviral therapy (ART) but remains frequently unaddressed in routine clinical consultation.

AIM

To comprehensively evaluate sexual health in male patients with HIV on stable ART over a 12-month period.

METHODS

The prospectively registered cohort study comprising 87 HIV-positive men on stable ART (median age: 43 years) was conducted between 2011 and 2015 at a university hospital. Patients were enrolled from the outpatient infectious disease unit and underwent an extensive andrological workup to assess parameters of sexual health (questionnaires, sex hormones, ultrasound, 2-glass urine test including semen analysis with microbiological and viral diagnostics). The study period per patient lasted 12 months.

OUTCOME

The primary endpoint was the impact of chronic HIV infection on sexual health.

RESULTS

Although, on average, sexual health was fine at baseline, 56% of the patients reported erectile dysfunction, 28% experienced reduced libido, 5% had hypogonadism, 36% showed at least 1 atrophic testicle with a volume of <10 ml, 8% suffered bacterial sexually transmitted infections, 35% had seminal inflammation, and up to 47% showed reduced sperm quality. Sexual satisfaction was linked to mental health (12-Item Short Form Health Survey questionnaire) and International Index of Erectile Function scores. During the study period, the collected parameters on sexual health were generally stable. However, 35% of patients had new sex partners (median: 5 partners), 7% had fathered a child or were planning procreation, 47% reported changed libido, 17% suffered bacterial sexually transmitted infections in the urogenital tract, 16% revealed a positive HIV viral load in blood, 11% had a positive HIV viral load in semen, and 28% were treated for andrological disorders.

CLINICAL IMPLICATIONS

Sexual ill-health exists in about one third of patients. This manifests itself in sexual dysfunction, sexually transmitted infections, urogenital tract inflammation, and abnormal sperm parameters, all of which require adequate counseling and therapy.

STRENGTH AND LIMITATIONS

The strength of this study is its comprehensive analysis of male sexual health over a 12-month period of stable ART treatment. Limitations are a heterogeneous patient cohort and a rather small percentage of patients with a positive HIV viral load in blood or semen, which prevented multivariate risk analysis.

CONCLUSION

Our study provides evidence that sexual health should be actively taken into account in the routine consultation by infectious disease specialists, and an interdisciplinary approach is desirable in the case of symptoms or signs of sexual ill-health. Pilatz A, Maresch CC, Discher T, et al. Sexual Health in HIV-Positive Men Under Stable Antiretroviral Therapy During a 12-Month Period. J Sex Med 2021;18:284-294.

The Effect of Successful Antiretroviral Therapy on Immune Activation and Reconstitution in HIV Infected Adults: A Systematic Review and Meta-Analysis

We performed a systematic review and meta-analysis to investigate the impact of antiretroviral therapy (ART) on immune activation and reconstitution in people living with human immunodeficiency virus (PLWH). The PubMed electronic database and gray literature were searched from inception until March 2020. Studies were included if they reported the levels of immune activation and reconstitution at baseline and post-treatment. The random-effect model was used to calculate effect sizes. We included a total of ten studies comprising of 1 553 PLWH with an average age of 38.02 ± 10.10 years and a male/female ratio of 3.76. Pooled estimates showed a modest increase in the level of immune activation post-treatment (SMD: 0.64 [95% CI: -1.34, 2.63]; I2 = 98%, pH < 0.00001). In addition, treatment with ART significantly reconstituted the immune system (SMD: 0.70 [95% CI: 0.27, 1.44]; I2 = 68%, pH = 0.009). Notably, the level of immune reconstitution was independent of viral load or the treatment duration but dependent on the class of ARV drugs. Consequently, protease inhibitors were associated with the highest degree of immune restoration, followed by chemokine antagonists and lastly integrase inhibitors. In conclusion, immune activation persists in PLWH despite viral suppression and the degree of immune reconstitution is dependent on the drug class. Therefore, inclusion of protease inhibitors in ART may be of great benefit in immune restoration in patients with very low CD4 count.

Twenty Years Of Antiretroviral Therapy For People Living With HIV: Global Costs, Health Achievements, Economic Benefits

Since the introduction of azidothymidine in 1987, significant improvements in treatment for people living with HIV have yielded substantial improvements in global health as a result of the unique benefits of antiretroviral therapy (ART). ART averted 9.5 million deaths worldwide in 1995-2015, with global economic benefits of $1.05 trillion. For every $1 spent on ART, $3.50 in benefits accrued globally. If treatment scale-up achieves the global 90-90-90 targets of the Joint United Nations Programme on HIV/AIDS, a total of 34.9 million deaths are projected to be averted between 1995 and 2030. Approximately 40.2 million new HIV infections could also be averted by ART, and economic gains could reach $4.02 trillion in 2030. Having provided ART to 19.5 million people represents a major human achievement. However, 15.2 million infected people are currently not receiving treatment, which represents a significant lost opportunity. Further treatment scale-up could yield even greater health and economic benefits.

The Unaddressed Needs of Alcohol-Using Couples on Antiretroviral Therapy in Malawi: Formative Research on Multilevel Interventions

Alcohol use among HIV-positive individuals in sub-Saharan Africa directly impacts adherence to antiretroviral therapy and HIV outcomes. Few studies have examined approaches to reduce alcohol use among HIV-affected couples, despite evidence that alcohol use is a couple-level concern. We conducted a qualitative study with 23 alcohol-using couples to identify multilevel barriers and facilitators of alcohol use, and potential intervention options with couples. Data were analyzed at individual and dyadic levels using framework analysis. All couples were married and had at least one partner on ART. Men were the primary alcohol drinkers with few women reporting alcohol use. Most women tried to persuade their partners to reduce their alcohol intake and when unsuccessful, enlisted help from relatives and HIV care providers. Effective couple negotiation around men's alcohol use was constrained by negative peer influence and men's desire for friendship to cope with life stressors. Women were primarily concerned about the expense of alcohol and described how alcohol prevented the family from meeting basic needs and investing in the future. Alcohol use was described as a major barrier to ART adherence, but was also viewed as the cause of couple and family violence, extramarital partnerships, food insecurity, and poverty. We conclude that multilevel interventions based on couples' needs and preferences are urgently needed. Couple-based intervention approaches could include provider-led alcohol counseling with couples, alcohol reduction support groups for couples, couples' counseling to bolster couple communication and problem-solving around alcohol, and economic-strengthening interventions for couples.

[Helicobacter pylori infection in the HIV + population: a comorbidity to think about]

Introducción

. Las alteraciones gastrointestinales, son frecuentes en VIH+. Helicobacter pylori puede ser una causa infradiagnosticada.

Material y métodos

Se realizó una búsqueda retrospectiva de pacientes VIH+ con infección por H. pylori entre enero de 1998 hasta diciembre de 2017.

Resultados

Se incluyeron 132 pacientes. La dispepsia fue la sintomatología más frecuente. Un 88,5% tuvo gastritis crónica atrófica. Se consiguió la erradicación en 102 (77,3%). La curación fue más frecuente con pauta cuádruple (p=0,004) y en los más jóvenes (p=0,041).

Conclusión

La infección por H. pylori podría ser responsable de manifestaciones digestivas inespecíficas en los pacientes VIH+.

Perinatal HIV Transmission Prevention: Challenges among Women Living with HIV in sub-Saharan Africa

About 86 percent of the estimated 160,000 children newly-infected with the human immunodeficiency virus (HIV) live in sub-Saharan Africa. Despite global efforts to reduce perinatal HIV transmission, this phenomenon continues to be a public health problem in sub-Saharan Africa. This paper discusses challenges associated with perinatal HIV transmission prevention in sub-Saharan Africa and offers strategies for the way forward. These strategies include safe sex education and behavioral change, increased access to integrated antenatal care, training of unskilled traditional birth attendants into formal delivery systems, access to antiretroviral therapy, and investing in virologic testing.

Factors Associated with HIV Antiretroviral Therapy among Men Who Have Sex with Men in 20 US Cities, 2014

Reducing HIV among men who have sex with men (MSM) is a national goal, and early diagnosis, timely linkage to HIV medical care, and ongoing care and treatment are critical for improving health outcomes for MSM with HIV and preventing transmission to others. We assessed demographic, social, and economic factors associated with HIV antiretroviral treatment among HIV-infected MSM. Data are from the National HIV Behavioral Surveillance (NHBS) collected in 2014 among MSM. We estimated prevalence ratios and 95% confidence intervals using average marginal predictions from logistic regression. Overall, 89% of HIV-positive MSM reported currently taking antiretroviral therapy (ART). After controlling for other variables, we found that higher perceived community stigma and not having health insurance were significant risk factors for not taking ART. We also found that high socioeconomic status (SES) was associated with taking ART. Race/ethnicity was not significantly associated with taking ART in either the unadjusted or adjusted analyses. Findings suggest that to increase ART use for MSM with HIV, we need to move beyond individual-level approaches and move towards the development, dissemination, and evaluation of structural and policy interventions that respond to these important social and economic factors.

Significance of Increased Rapid Treatment from HIV Diagnosis to the First Antiretroviral Therapy in the Recent 20 Years and Its Implications: the Korea HIV/AIDS Cohort Study

From December 2006 to December 2016, 1,429 patients enrolled in the Korea human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) Cohort Study were investigated. Based on the year of diagnosis, the time interval between HIV diagnosis and initiation of antiretroviral therapy (ART) was analyzed by dividing it into 2 years. The more recent the diagnosis, the more likely rapid treatment was initiated (P < 0.001) and the proportion of patients starting ART on the same day of HIV diagnosis was increased in 2016 (6.5%) compared to that in 2006 (1.7%). No significant difference in the median values of CD4+ cell counts according to the diagnosis year was observed. In the past 20 years, the time from the HIV diagnosis to the initiation of ART was significantly reduced. Rapid treatment was being implemented at the HIV diagnosis, regardless of CD4+ cell count. Considering the perspective "treatment is prevention," access to more rapid treatment is necessary at the time of HIV diagnosis.

Baseline CD4 and mortality trends in the South African human immunodeficiency virus programme: Analysis of routine data

Background

Despite widespread availability of antiretroviral therapy (ART) in South Africa, there remains a considerable burden of human immunodeficiency virus (HIV)-related morbidity and mortality.

Objectives

To describe ART initiation and outcome trends over time, with a focus on clients presenting with advanced HIV-infection, so as to identify interventions to reduce morbidity and mortality.

Methods

Routine TIER.Net data from HIV-infected adults who had a documented baseline CD4 count and were newly initiating ART in Johannesburg or Mopani districts from 2004 to 2017 were analysed. Trends in baseline CD4 count and 5-year mortality were investigated and the population initiating ART with CD4 < 200 cells/mm³ was described.

Results

The Johannesburg and Mopani data sets comprised 203 131 and 101 814 records, respectively. Although median CD4 count increased over time, the proportion of initiations at CD4 < 200 cells/mm³ in 2017 remained high (Johannesburg 39%, Mopani 35%). Mortality was significantly increased among clients with CD4 < 200 compared to those with higher baseline counts (p < 0.001). Even though mortality among clients with low CD4 declined over time, likely because of improved drug regimens, in 2016-2017 mortality was still significantly increased among these clients (p < 0.001). Delivery of cotrimoxazole prophylaxis to clients with low CD4 declined over time to < 30% in 2017 and was associated with clinical stage. Presentation with CD4 < 200 cells/mm³ was associated with older age, male gender and hospitalisation.

Conclusion

A concerningly large proportion of South Africans still initiate ART at low CD4 counts. This is associated with increased mortality and requires targeted interventions to improve delivery of prophylactic regimens and early engagement in care.

Changes health-related quality of life in HIV-infected patients following initiation of antiretroviral therapy: a longitudinal study

BACKGROUND

Several tools have been developed to evaluate HIV health-related quality of life (HRQoL) during and after antiretroviral therapy (ART). Few longitudinal studies evaluated the effect of ART on the quality of life of HIV patients.

OBJECTIVE

To evaluate changes in HRQoL in HIV-infected individuals one year after initiating ART.

METHODS

A prospective study was conducted from May 2016 to July 2018. Data on clinical and sociodemographic characteristics of 91 HIV-infected patients were collected prior to initiation of ART and one year thereafter. Demographic and clinical data were collected and the questionnaires 36-item Short Form Health Survey (SF-36) and HIV/AIDS-targeted quality of life (HAT-QoL) were administered in both periods. Asymptomatic individuals, aged ≥18 years, were included in the study. Patients who discontinued treatment were excluded. The association between predictors of physical and mental HRQoL was analyzed by multiple linear regression analysis.

RESULTS

Patients were predominantly male (78.0%), mean age 35.3 ± 10.7 years, with no stable relationship (80.2%), and no comorbidities (73.6%). Most of the SF-36 domains improved after one year, particularly Physical Function (p = 0.0001), General Health (p = 0.0001), Social Functioning (p = 0.0001), Mental Health (p = 0.001), and Mental Component Summary (p = 0.004). HAT-QoL domains improved in the Overall Function (p = 0.0001), Life Satisfaction (p = 0.0001), Provider Trust (p = 0.001), and Sexual Function (p = 0.0001) domains. Sex (p = 0.032), age (p = 0.001), income (p = 0.007), and stable relationship (p = 0.004) were good predictors of the Physical Component Summary. Sex (p = 0.002) and stable relationship (p = 0.038) were good predictors of the Mental Component Summary. SF-36 and HAT-QoL scales presented strong correlations, except for Medication Concerns (0.15-0.37), HIV Mastery (0.18-0.38), Disclosure Worries (-0.15 to 0.07), and Provider Trust (-0.07 to 0.15).

CONCLUSIONS

ART improved HRQoL after one year of use. The HAT-QoL and SF-36 correlated well and are good tools to evaluate HRQoL in HIV-infected patients on ART.

Prevalence of depression in people living with HIV and AIDS at the Kalafong Provincial Tertiary Hospital Antiretroviral Clinic

BACKGROUND

Compared to the general population, there is an increased prevalence of depression in people living with HIV and AIDS (PLWHA). The combination of these two common illnesses has profound consequences on the patient and on the healthcare system.

OBJECTIVE

This study determined the prevalence of depressive symptomatology in PLWHA attending the Kalafong Hospital ARV Clinic. The study also established if the patients received definitive treatment for unipolar depression.

METHODS

A cross-sectional, descriptive study was carried out on 622 adult patients, aged 18 years or older. A brief rating scale for depression, the Centre for Epidemiological Study Depression Scale (CES-D) was administered to participants. The CES-D is a 20-item self-rating scale that assesses current levels of depression as per DSM-IV criteria. The traditional score of 16 and above was used to define a case of depression.

RESULTS

The prevalence of depression according to CES-D scale was 53.8%. The study found that none of the 622 patients ever received definitive treatment for depression. A lower CD4 count is associated with more depressive symptomatology, most significantly in patients with a CD4 count of 50 or less.

CONCLUSIONS

Depressive symptomatology was highly prevalent in the study patients. Despite the high prevalence, none of the study sample patients were treated for clinical depression. The findings reflect the importance of evaluating for depression in PLWHA, especially in high-risk groups such as patients presenting for their initiation visit or patients with a CD4 count of 50 or less. Depression remains under-recognised and under-treated in PLWHA.

HIV Treatment Adherence - A Shared Burden for Patients, Health-Care Providers, and Other Stakeholders

Successful HIV treatment is contingent on sustained high levels of treatment adherence. Several barriers to optimal adherence have been documented. In this article, we first review the global burden of non-adherence among HIV/AIDS positive individuals on a public health scale. Second, we synthesized available evidence from different study designs and stratified across the European, African, and Asian literature to determine the factors influencing adherence to scheduled clinic appointments and medication non-adherence. Third, we discuss common measurement techniques that quantify the magnitude of non-adherence, their relative advantages and limitations in current practice. From January to May 2018, we reviewed guidelines, standard operating procedures, journal articles, and book chapters on treatment adherence among HIV patients receiving adherence to antiretroviral therapy (ART) globally. We searched PubMed, Medline, Google Scholar, and Cochrane Database of Systematic Reviews with the search terms "adherence," "adherence behavior," "medication adherence," and "HIV patients," or "HIV/AIDS," and "Antiretroviral Therapy" or "ART" or "ARVs" or "highly active ART " from 2000 to 2017. We also identified articles through searches of authors' files and previous research on HIV. We included only papers published in English in this review. We then generated a final list of reference on the basis of originality and the broad scope of this review. We found rich literature evidence of research findings and best practice recommendations on the importance of adherence in HIV/AIDS management, a general understanding of factors associated with non-adherence and approaches to investigating non-adherence behavior among different populations. We observed significant contextual differences exist with regard to barriers and burden of non-adherence among these populations.

Progress towards the United Nations 90-90-90 and 95-95-95 targets: the experience in British Columbia, Canada

Introduction

Antiretroviral therapy (ART) scale‐up is central to the global strategy to control the HIV/AIDS pandemic. To accelerate efforts towards ending the AIDS epidemic, the Joint United Nations Programme on HIV/AIDS released the 90‐90‐90 and 95‐95‐95 targets, which have recently been approved by the United Nations (UN). This study characterizes the province of British Columbia (BC)'s progress towards achieving the UN targets, predicts a trajectory up to 2030 according to each of the individual steps (i.e. %Diagnosed, %On ART and %Virologically Suppressed), and identifies the population sub‐groups at higher risk of not achieving these targets.

Methods

The analyses were based on linked individual‐level datasets of people living with HIV (PLWH) in BC, aged ≥18 months, from 2000 to 2013. Using past trends in HIV prevalence and of each individual UN targets, we forecasted these outcomes until 2030 via generalized additive models. We ran a second set of analyses to assess the associations between individual demographic and behavioural factors and each of the individual steps of the UN targets. Lastly, we performed sensitivity analyses to account for uncertainty associated with prevalence estimates and suppression definitions.

Results

Among the estimated 10666 PLWH in BC in 2013, 82% were diagnosed, 76% of those diagnosed were on ART and 83% of those on ART were virologically suppressed. We identified that females, PLWH aged <30 years and those with unknown risk or who self‐identify as having a history of injection drug use were the population subgroups that experienced the most challenge in engaging on ART and achieving viral suppression. Our model projections suggest that BC will achieve 90%‐91%‐90% and 97%‐99%‐97% by 2020 and 2030 respectively.

Conclusions

As we approach 2020, BC is rapidly moving towards achieving the UN targets. However, region‐specific challenges persist. Identification of remaining regional challenges will be essential to achieving the proposed UN targets and therefore fulfilling the promise to end AIDS as a pandemic by 2030.

ASSESSING THE RELATIONSHIP BETWEEN PHYSICIAN AVAILABILITY AND VIRAL LOAD SUPPRESSION IN BRITISH COLUMBIA

OBJECTIVES

In 2014, the Joint United Nations Programme HIV/AIDS (UNAIDS) set the target of dramatically reducing the burden of HIV through expansion of access to timely HIV treatment. In order to achieve this target it is necessary to expand access to care along the HIV cascade of care. This study examines the relationship between viral suppression and the availability of physicians providing HIV treatment in British Columbia, Canada.

METHODS

Data from the Drug Treatment Program of the British Columbia (BC) Centre for Excellence in HIV/AIDS was used for this analysis. The floating catchment method was used to assess physician availability. Multivariable Logistic Regression was used to implement a confounder selection technique to independently assess the relationship between physician availability and viral load suppression.

RESULTS

Individuals with more than 25 physicians within a one-hour catchment were more likely to reside in urban areas and almost twice as likely to have a suppressed viral load (adjusted odd ratio: 1.97; 95% CI 1.50 - 2.58).

CONCLUSIONS

This study highlights the impact of physicians' availability on viral load levels. Mapping technology was used to identify the locations in which patients were most impacted by the lack of physicians.

Scientific Production about the Adherence to Antiretroviral Therapy

OBJECTIVE

To identify the elite of authors about the subject adherence to antiretroviral therapy; to identify the journals turned to publishing articles about adherence to antiretroviral therapy; and to identify and analyze the most commonly used words in abstracts of articles about adherence to antiretroviral therapy.

METHOD

A bibliometric study conducted through the Scopus base. We used articles published between 1996 and 2014, after application of the eligibility criteria, there were composed the sample with 24 articles. The data were analyzed descriptively. Were used the laws of bibliometric (Lotka, Bradford and Zipf) and the conceptual cloud map of words, through the program Cmap tools.

RESULTS

Lotka's Law identified the 5 authors more productive (46% of the total published). Bradford is impaired in this study. Concerning Zipf, 3 zones were determined, 31.47% of the words with in the first zone, 26.46% in the second and 42.06% in the third. In the conceptual map, the words/factors that positively and negatively influence adherence were emphasized, among them the need for more research in the health services.

CONCLUSION

There are few publications about the accession to antiretroviral therapy, and the scientific production is in the process of maturation. One can infer that the theme researched is not yet an obsolete topic. It should be noted that the Bibliometric was a relevant statistic tool to generate information about the publications about the antiretroviral therapy.

Trends in Malignancies among Korean Patients Infected with Human Immunodeficiency Virus in the Highly Active Antiretroviral Therapy Era

Since the introduction of highly active antiretroviral therapy, the life span of people with human immunodeficiency virus (HIV) or AIDS (PWHA) has been extended significantly. Therefore, the importance of non-AIDS-defining cancers (NADCs), as well as AIDS-defining cancers (ADCs) has increased. There is little information concerning the epidemiology of malignancies in PWHA in Korea. A descriptive epidemiologic study was conducted at a tertiary care hospital in Korea. PWHA who visited Pusan National University Hospital from January 2000 to October 2014 were included. Demographics and clinical data were obtained from the medical records and analyzed. A total of 950 PWHA were observed for 4,439.71 person-years. Forty-eight episodes (5.05%) of cancers were diagnosed in 47 patients. Mean age of the enrolled patients was 40.66 ± 12.15 years and 88% were male. Among the 48 cancer episodes, 20 (42%) were ADCs and 28 were NADCs. The most common ADCs was non-Hodgkin's lymphoma (53.6%), followed by Kaposi's sarcoma (17.9%). The most common NADCs were lung cancer (25%) and hepatocellular carcinoma (25%). The overall incidence of total cancers, ADCs, and NADCs was 10.8 (95% confidence interval [CI], 8.0-14.3), 4.5 (95% CI, 2.8-7.0), and 6.3 (95% CI, 4.2-9.1)/1,000 person-years, respectively. NADCs accounted for 12/15 (80%) of cancers among PWHA with good adherence to care. The 5-year survival rate of PWHA and NADC was 26.3%. NADCs have become the main type of malignancy among Korean PWHA with good adherence to care. Effective strategies to improve screening of NADCs among PWHA are required in Korea.

At-Risk Alcohol Use is Associated with Antiretroviral Treatment Nonadherence Among Adults Living with HIV/AIDS

BACKGROUND

Alcohol use is a risk factor for nonadherence to antiretroviral therapy (ART) among people living with HIV/AIDS (PLWHA); however, differences in ART adherence across levels of alcohol use are unclear. This study examined whether "at-risk" alcohol use, defined by National Institute of Alcohol Abuse and Alcoholism guidelines, was associated with ART nonadherence among PLWHA.

METHODS

Participants were 535 HIV-infected adults enrolled in studies at the HIV Neurobehavioral Research Program. ART nonadherence was identified by either self-reported missed dose or plasma viral load detectability (≥50 copies/ml). Potential covariates for multivariable logistic regression included demographics, depression, and substance use disorders.

RESULTS

Using a stepwise model selection procedure, we found that at-risk alcohol use (OR = 0.64; p = 0.032) and low education (OR = 1.09 per 1 year increase in education; p = 0.009) significantly predict lower ART adherence.

CONCLUSIONS

A greater focus on the treatment of at-risk alcohol use may improve ART adherence among HIV-infected persons.

Economic impact of optimising antiretroviral treatment in human immunodeficiency virus-infected adults with suppressed viral load in Spain, by implementing the grade A-1 evidence recommendations of the 2015 GESIDA/National AIDS Plan

INTRODUCTION

The objective of this study is to estimate the economic impact associated with the optimisation of triple antiretroviral treatment (ART) in patients with undetectable viral load according to the recommendations from the GeSIDA/PNS (2015) Consensus and their applicability in the Spanish clinical practice.

METHODS

A pharmacoeconomic model was developed based on data from a National Hospital Prescription Survey on ART (2014) and the A-I evidence recommendations for the optimisation of ART from the GeSIDA/PNS (2015) consensus. The optimisation model took into account the willingness to optimise a particular regimen and other assumptions, and the results were validated by an expert panel in HIV infection (Infectious Disease Specialists and Hospital Pharmacists). The analysis was conducted from the NHS perspective, considering the annual wholesale price and accounting for deductions stated in the RD-Law 8/2010 and the VAT.

RESULTS

The expert panel selected six optimisation strategies, and estimated that 10,863 (13.4%) of the 80,859 patients in Spain currently on triple ART, would be candidates to optimise their ART, leading to savings of €15.9M/year (2.4% of total triple ART drug cost). The most feasible strategies (>40% of patients candidates for optimisation, n=4,556) would be optimisations to ATV/r+3TC therapy. These would produce savings between €653 and €4,797 per patient per year depending on baseline triple ART.

CONCLUSION

Implementation of the main optimisation strategies recommended in the GeSIDA/PNS (2015) Consensus into Spanish clinical practice would lead to considerable savings, especially those based in dual therapy with ATV/r+3TC, thus contributing to the control of pharmaceutical expenditure and NHS sustainability.

Pregnancy Outcomes in HIV-Infected Women: Experience from a Tertiary Care Center in India

BACKGROUND AND OBJECTIVES

There is conflicting data on the effect of HIV infection as well as antiretroviral therapy (ART) on pregnancy outcome. The objectives of this study were to compare pregnancy outcomes in women with and without HIV infection, and to evaluate the effect of HAART on pregnancy in HIV-infected women.

METHODS

This is a prospective case record analysis of 212 HIV-infected women delivering between 2002 and 2015, in a tertiary health care center in India. The pregnancy outcome in HIV-infected women was compared to 238 HIV-uninfected controls. Women received ART for prevention of mother to child transmission as per protocol which varied during the period of study. Effect of use of ART on preterm birth (PTB) and intrauterine growth restriction (IUGR) was analyzed.

RESULTS

HIV-infected women were more likely to have PTB, IUGR, and anemia (9.4%, 9.9%, 5.2%) compared to uninfected women (7.6%, 5%, 3.8%), this did not reach statistical significance (P-value = >0.05). The incidence of PIH, diabetes mellitus and intrahepatic cholestasis of pregnancy was similar in both groups. Mean birth weight was significantly lower in neonates of HIV-infected women (2593.60±499g) than HIV-uninfected women (2919±459g) [P-value=0.001]. neonatal intensive care unit admissions were also significantly higher in infants born to HIV-infected women (P-value=0.002). HIV-infected women on ART had decreased incidence of PTB and IUGR.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Good antenatal care and multidisciplinary team approach can optimize pregnancy outcomes in HIV-infected women.

A Novel Combined Mother-Infant Clinic to Optimize Post-Partum Maternal Retention, Service Utilization, and Linkage to Services in HIV Care in Rural Rwanda

BACKGROUND AND OBJECTIVES

Despite recent improvements in accessibility of services to prevent mother-to-child transmission of HIV, maternal retention in HIV care remains a challenge in the post-partum period. This study assessed service utilization, program retention, and linkage to routine services, as well as clinical outcomes for mothers and infants, following implementation of an integrated mother-infant clinic in rural Rwanda.

METHODS

We conducted a retrospective cohort study of all HIV-positive mothers and their infants enrolled in the integrated clinics in two rural districts between July 1, 2012, and June 30, 2013. At 18 months post-partum, data on mother-infant service utilization and program outcomes were reported.

RESULTS

Of the 185 mother-infant pairs in the clinics, 98.4% of mothers were on antiretroviral therapy (ART) and 30.3% used modern contraception at enrollment. At 18 months post-partum, 98.4% of mothers were retained and linked back to adult HIV program. All mothers were on ART and 72.0% on modern contraception. For infants, 93.0% completed follow-up. Two (1.1%) infants tested HIV positive.

CONCLUSION AND GLOBAL HEALTH IMPLICATION

An integrated clinic was successfully implemented in rural Rwanda with high mother retention in care and low mother to child HIV transmission rates. This model of integration of services may contribute to improved mother-infant retention in care during post-partum period and should be considered as one approach to addressing this challenge in similar settings.

HIV-Positive Women Taking Lifelong Antiretroviral Therapy Report Better Adherence Than Women Taking Short-Course Prophylaxis During and After Pregnancy Under PMTCT Program Option A in Lusaka, Zambia

BACKGROUND AND OBJECTIVES

HIV-positive women's adherence to antiretrovirals is critical for prevention of mother-to-child transmission. We aimed to establish if mothers taking triple lifelong antiretroviral therapy report higher adherence compared to mothers taking short-course prophylaxis under Option A in Lusaka, Zambia.

METHODS

In this clinic-based cross-sectional study, we interviewed 320 HIV-positive mothers at a large public health facility in Lusaka in 2014. Participants reported adherence using a visual analog scale. Multiple logistic regression models were used to determine the adjusted odds of adherence by mother's prescribed regimen.

RESULTS

Women taking lifelong triple antiretroviral therapy report higher adjusted odds of adherence during pregnancy, postpartum, and to giving the infant prophylaxis compared to women to women taking short-course prophylaxis.

DISCUSSION

Women on lifelong therapy may have better adherence compared to women on short course prophylaxis because they knew their positive status for longer or were symptomatic with HIV-related disease. The lifelong therapy regimen may be easier for women to follow, particularly because they are required to give the infant prophylaxis for a shorter duration of time.

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

Our results indicate that lifelong triple antiretroviral therapy has the potential to promote better drug adherence during and after pregnancy among women living with HIV in sub-Saharan Africa, compared to short-course antiretroviral regimens.

Simplification of HAART therapy on ambulatory HIV patients in Malaysia:a randomized controlled trial

Objective:

Evaluate the impact of fixed-dose combination (FDC) containing emtricitabine (FTC), tenofovir (TDF), and efavirenz (EFV) versus a free-dose combination (FRC) of the same three drugs on clinical outcomes, adherence and quality of life in Malaysian outpatients with HIV.

Methods:

HIV patients (n=120) on highly active antiretroviral therapy (HAART) in the infectious disease clinic of Hospital Sungai Buloh were randomized to either FDC (n=60) or FRC (n=60). Morisky scores, health-related quality of life scores and clinical outcomes such as CD4 count and viral load were assessed in both groups at baseline and six months.

Result:

Patients on FDC (108 SD=1.1) had a significantly higher CD4 count increase compared to the FRC group (746.1 SD=36.3 vs 799.8 SD=33.8) (p <0.001). The viral load profile was unchanged and remained undetectable in both groups. The quality of life EQ-5D scores showed a positive correlation with CD4 counts in the FDC group (ρ=0.301, p=0.019) at six months. On the other hand, quality of life EQ-VAS scores was significantly associated with medication adherence in the FDC group at six months (ρ=0.749, p=0.05). However, no significant changes or associations were observed in the FRC group.

Conclusion:

Management of HAART using an FDC demonstrated a positive clinical outcome, adherence and quality of life within six months in local HIV patients.

Application of Radial Basis Function Network Tool for Correlation of CD4+ Count with Plasma Viral Load in HIV-Seropositive Individuals

INTRODUCTION

Human Immunodeficiency Virus (HIV) infects and cripples the immune system of the body. The two important marker CD4+T cells and Plasma viral load are crucial not only in understanding the disease progression but also in starting the antiretroviral therapy. A lot of research is going on in understanding the dynamic nature of HIV.

AIM

To find the correlation between CD4+ count and Plasma Viral Load (PVL) measured by two different technologies; with the help of correlation technique in conjunction with the three dimensional HIV model with a purpose of establishing a mathematical model between the CD4+ cells and PVL using a sinusoidal function as well as Radial Basis Function (RBF) neural network.

MATERIALS AND METHODS

Plasma Viral Load were determined by two different methods viz Exavir Cavidi(TM) and Abbott Real time HIV-1 assay and then they were correlated with the CD4+ count with the help of computational intelligence in predicting viral load.

RESULTS

It was found that there exists a positive correlation between the CD4+ cells and viral loads. A correlation value of 0.4082 and 0.3652 was observed between CD4+ cells and viral measured using Exavir Cavidi(TM) and Abbott Real time HIV-1 assay respectively.

CONCLUSION

The existence of positive correlation had helped us to understand the nature and dynamic of the existence of HIV and how the CD4 + and PVL act.

Poor CD4 count is a predictor of untreated depression in human immunodeficiency virus-positive African-Americans

AIM: To determine if efforts to improve antiretroviral therapy (ART) adherence minimizes the negative impact of depression on human immunodeficiency virus (HIV) outcomes.

METHODS: A cross-sectional study of a clinic-based cohort of 158 HIV seropositive (HIV+) African Americans screened for major depressive disorder (MDD) in 2012. CD4 T lymphocyte (CD4+) counts were obtained from these individuals. Self-report on adherence to ART was determined from questionnaire administered during clinic visits. The primary outcome measure was conditional odds of having a poorer CD4+ count (< 350 cells/mm³). Association between CD4+ count and antidepressant-treated or untreated MDD subjects was examined controlling for self-reported adherence and other potential confounders.

RESULTS: Out of 147 individuals with available CD4+ T lymphocyte data, 31% hadCD4+ count < 350 cells/mm³ and 28% reported poor ART adherence. As expected the group with > 350 cells/mm³ CD4+ T lymphocyte endorsed significantly greater ART adherence compared to the group with < 350 cells/mm³ CD4+ T lymphocyte count (P < 0.004). Prevalence of MDD was 39.5% and 66% of individuals with MDD took antidepressants. Poor CD4+ T lymphocyte count was associated with poor ART adherence and MDD. Adjusting for ART adherence, age, sex and education, which were potential confounders, the association between MDD and poor CD4+ T lymphocyte remained significant only in the untreated MDD group.

CONCLUSION: Therefore, CD4+ count could be a clinical marker of untreated depression in HIV+. Also, mental health care may be relevant to primary care of HIV+ patients.

Adherence to antiretroviral therapy and its determinants among persons living with HIV/AIDS in Bayelsa state, Nigeria

Background:

A high level of adherence is required to achieve the desired outcomes of antiretroviral therapy. There is paucity of information about adherence to combined antiretroviral therapy in Bayelsa State of southern Nigeria.

Objectives:

The objectives of the study were to determine the level of adherence to combined antiretroviral therapy among the patients, evaluate the improvement in their immune status and identify reasons for sub-optimal adherence to therapy.

Methods:

The cross-sectional study involved administration of an adapted and pretested questionnaire to 601 consented patients attending the two tertiary health institutions in Bayesla State,

Nigeria:

The Federal Medical Centre, Yenagoa and the Niger-Delta University Teaching Hospital Okolobiri. The tool was divided into various sections such as socio-demographic data, HIV knowledge and adherence to combined antiretroviral therapy. Information on the patient’s CD4+ T cells count was retrieved from their medical records. Adherence was assessed by asking patients to recall their intake of prescribed doses in the last fourteen days and subjects who had 95-100% of the prescribed antiretroviral drugs were considered adherent.

Results:

Three hundred and forty eight (57.9%) of the subjects were females and 253 (42.1%) were males. The majority of them, 557 (92.7%) have good knowledge of HIV and combined anti-retroviral therapy with a score of 70.0% and above. A larger proportion of the respondents, 441 (73.4%), had ≥95% adherence. Some of the most important reasons giving for missing doses include, “simply forgot” 147 (24.5%), and “wanted to avoid the side-effects of drugs” 33(5.5%). There were remarkable improvements in the immune status of the subjects with an increment in the proportion of the subjects with CD4+ T cells count of greater than 350 cells/mm3 from 33 (5.5%) at therapy initiation to 338 (56.3%) at study period (p<0.0001).

Conclusion:

The adherence level of 73.4% was low which calls for intervention and improvement. The combined antiretroviral therapy has significantly improved the immune status of the majority of patients which must be sustained. “Simply forgot” was the most important reason for missing doses.

Predictors of Poor Retention in Care of HIV-infected Patients Receiving Antiretroviral Therapy in Korea: Five-Year Hospital-based Retrospective Cohort Study

Poor retention in care (RIC) is associated with higher antiretroviral therapy (ART) failure and worse survival. Identifying high risk patients for poor RIC is important for targeted intervention. A retrospective cohort study was conducted at a tertiary care hospital in Korea. HIV-infected patients initiating ART during 2002-2008 were included. 5 year-RIC was measured by hospital visit constancy (HVC) at 5 years after initiating ART. Among 247 enrolled patients, 179 (72.5%) remained in care, 20 (8.1%) were transferred to other hospitals, 9 (3.6%) died and 39 (15.8%) were lost to follow-up. We compared the demographic, psychosocial, and clinical characteristics between the groups with 100% HVC (n = 166, 67.2%) and ≤ 50% HVC (n = 33, 13.4%). In multivariable analysis, ART-starting age ≤ 30 years (odds ratio [OR] 4.08 vs. > 50; 95% confidence interval [CI] 1.10-15.15, P = 0.036), no non-HIV related comorbidity (OR 2.94 vs. comorbidity ≥ 1; 95% CI 1.02-8.49, P = 0.046), baseline CD4 cell count > 300 cells/μL (OR 3.58 vs. ≤ 200; 95% CI 1.33-9.65, P = 0.012) were significant predictable factors of poor RIC. HIV/AIDS care-givers should pay attention to young patients with higher baseline CD4 cell counts and no non-HIV related comorbidity.

Fatal Tenofovir-Associateacd Lactic Acidosis: A Case Report

Introduction:

The introduction of highly active antiretroviral therapy (HAART), in 1996, has resulted in marked reductions in the rate of illness and death, due to HIV infection. The HAART has transformed HIV infection into a manageable chronic disease. However, although many regimens lower plasma viral load, to below the limit of detection, in most patients, maintaining viral load suppression remains challenging, because of adverse effects and toxicity in the long term, which can lead to non-adherence, virologic failure and drug resistance. Although rare, lactic acidosis often develops fatal complications, as reported in several human immunodeficiency virus infected patients treated with nucleoside reverse transcriptase inhibitors (NRTIs). The purpose of this paper is to report a case of tenofovir induced lactic acidosis and review the literature.

Case Presentation:

A 52-year-old Malay gentleman, with hepatitis C virus and HIV infection was admitted to the intensive care unit for severe lactic acidosis, with concurrent Escherichia coli bacteremia with multiorgan dysfunction. The patient was started on highly active antiretroviral therapy, which included tenofovir, 5 weeks before presentation. Antimicrobial therapy, continuous veno-venous hemofiltration, and other supportive treatments were instituted. However, the patient eventually succumbed to his illness.

Conclusions:

It is essential for clinicians to be able to recognize the signs and symptoms of lactic acidosis in NRTIs treated HIV patients, as an early diagnosis is important to institute treatment.

Intrahepatic Cholestasis of Pregnancy and Serum Bile Acids in HIV-Infected Pregnant Women

OBJECTIVES

Intra-hepatic cholestasis of pregnancy (ICP) is uncommon, but has severe effects on pregnancy outcomes. ICP is characterized by elevated serum bile acids and liver enzymes and preferentially affects women with liver disorders. We compared bile acids and pregnancy outcomes of HIV-infected pregnant women, who commonly have elevated live enzymes, with uninfected controls.

METHODS

Twenty-four HIV-infected, including 2 co-infected with hepatitis C virus (HCV), and 25 uninfected women were tested during early and late pregnancy and postpartum.

RESULTS

After exclusion of the HCV-infected women, serum bile acids were similar in HIV-infected and uninfected participants. -glutamyl transpeptidase was elevated in HIV-infected compared with uninfected women during pregnancy and postpartum. Bilirubin and aspartate transaminase were higher in uninfected compared with HIV-infected women in early pregnancy, but subsequently similar. Bile acids in late pregnancy correlated with bile acids in the baby at birth. An HIV- and HCV-co-infected pregnant woman with active hepatitis developed ICP complicated by fetal distress. Another co-infected participant without active hepatitis had an uneventful pregnancy and delivery.

CONCLUSION

In the absence of HCV co-infection, bile acid metabolism appeared to be similar in HIV-infected and uninfected pregnant women. Both HIV-infected and uninfected pregnant women had mild liver enzyme elevations.

Renal safety of coformulated tenofovir/emtricitabine vs other nucleoside analogues in combination therapy in antiretroviral-naive patients aged 50 years or older in Spain: The TRIP study

OBJECTIVES

Our aim is to describe the impact of emtricitabine (FTC)/tenofovir (TDF) versus other nucleoside reverse transcriptase inhibitor (NRTIs)-based regimens on renal function of human immunodeficiency virus (HIV) naïve patients >50 years old who started combination antiretroviral therapy (cART).

DESIGN

National, retrospective cohort analysis of patients >50 years old when they started cART (January 1, 2006-December 31, 2009).

METHODS

We compared renal safety (changes in estimated glomerular filtration rate [eGFR] during the first year, and time to renal events during 4 years of follow-up) in FTC/TDF versus non-FTC/TDF users. Among FTC/TDF users, we compared protease inhibitors vs non-nucleoside reverse transcriptase inhibitors and Lopinavir/ritonavir vs Efavirenz.

RESULTS

We included 103 patients: median age: 54.9 years, 84% males, median CD4 count 247 cells/μl, median viral load 4.7 log; median follow up 18 months (max: 48 months); 73 started with FTC/TDF and 30 with other NRTIs. Change in eGFR was significantly worse for ritonavir-boosted lopinavir (LPV/r) vs efavirenz (EFV) users in the FTC/TDF group (71.2 vs 98.9 ml/min/1.73 m(2) at month 12, P < 0.05). The risk of renal events (progression to an Chronic Kidney Disease Epidemiology Collaboration value < 60 ml/min/1.73 m(2) in subjects with baseline values >60) was comparable for FTC/TDF users and non users, but was higher and almost significant for LPV/r as compared to EFV users in the FTC/TDF group (adjusted hazard ratio 6.1, 95% CI 0.8-45.5).

CONCLUSIONS

In our study with a population of HIV infected subjects ≥ 50 years old, renal safety was similar for FTC/TDF and other NRTI-based regimens, but worse for LPV/r as compared to other regimens.

Antiretroviral Therapy and Pregnancy Outcomes in Developing Countries: A Systematic Review

BACKGROUND

Despite significant efforts to understand adverse pregnancy outcome in women receiving Antiretroviral Therapy (ART), ART-related adverse birth outcomes are still poorly understood. We systematically review ART-related adverse birth outcomes among HIV-infected pregnant women; we also review the covariates associated with adverse birth outcomes in the aforementioned group.

METHODS

The main source for our systematic review was electronic bibliographic databases. Databases such as MEDLINE, PubMed, EMBASE and AIDSLINE were searched. Furthermore, search engines such as Google and Google Scholar were specifically searched for gray literature. Methodological quality of available literature was assessed using the Newcastle - Ottawa Quality Assessment Scale & M. Hewitt guideline. We examined a total of 1,124 papers and reviewed the studies using the PICOT criteria which stands for Patient (population), Intervention (or "Exposure"), Comparison, Outcome and Type of study. Finally, 32 methodologically fit studies were retained and included in our review.

RESULTS

Frequently observed adverse birth outcomes included low birth weight (LBW), Preterm Birth (PB), Small for Gestational Age (SGA), while still birth and congenital anomalies were infrequent. Type of regimen such as Protease Inhibitor (PI) based regimens and timing of initiation of ART are some of the factors associated with adverse pregnancy outcomes. Covariates principally included malnutrition and other co-morbidities such as malaria and HIV.

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

There is growing evidence in published literature suggesting that ART might be causing adverse birth outcomes among pregnant women in developing countries. There is a need to consider regimen types for HIV-infected pregnant women. There is need to design large cohort studies.

Severe manifestations of extrapulmonary tuberculosis in HIV-infected children initiating antiretroviral therapy before 2 years of age

BACKGROUND

Early initiation of antiretroviral therapy (ART) in HIV-infected infants reduces mortality and opportunistic infections including tuberculosis (TB). However, young HIV-infected children remain at high risk of TB disease following mycobacterial infection. We document the spectrum of TB disease in HIV-infected children <2 years of age on ART.

METHODS

Retrospective cohort study; records of children <2 years of age initiating routine ART at Tygerberg Children's Hospital, Cape Town, January 2003-December 2010 were reviewed. Clinical data at ART initiation (baseline) and TB episodes after ART initiation, to June 2012, were recorded. TB immune reconstitution syndrome (TB-IRIS) and incident TB were defined as TB diagnosed within 3 months, and >3 months after, ART initiation respectively. Baseline characteristics were compared in children with TB-IRIS and those with incident TB.

RESULTS

In 494 children, median follow-up time on ART was 10.7 months. Fifty-five TB treatment episodes occurred after ART initiation: 23 (42%) TB-IRIS (incidence 21.9/100 person years (py)) and 32 (58%) incident TB (incidence 3.9/100 py). Children with TB-IRIS and those with incident TB had similar baseline characteristics. Eight of 10 cases of extrapulmonary TB were severe: 4 IRIS (2 meningitis, 1 disseminated, 1 pericarditis) and 4 incident cases (1 each miliary, meningitis, pericarditis and spinal). Fifty-one children (10%) died (mortality rate 5.96/100 py). Starting ART at <1 year of age approached significance as a risk factor for TB-IRIS (adjusted OR (AOR) 8.64, p=0.06); weight-for-age Z score <-2 predicted death (AOR 6.37, p<0.001).

CONCLUSIONS

Severe TB manifestations were observed among young HIV-infected children on ART.