Implementation of a rapid diagnostic assay package for cryptococcosis, histoplasmosis and tuberculosis in people living with HIV in Paraguay

BACKGROUND

Opportunistic infections (OIs) are common causes of mortality among people living with HIV (PLHIV). We determined prevalence and 30-day mortality due to histoplasmosis, cryptococcosis, and TB in PLHIV with advanced HIV disease (AHD).

METHODS

PLHIV 18 years and older, with a CD4 + T-cell count of less than 350 cells/mm3 newly diagnosed with HIV infection or re-engaged in care after being without ART for more than 90 days (Group A). The second group included symptomatic PLHIV regardless of ART status or CD4 + T-cell count (Group B); all followed for 30 days. Detection of Histoplasma Ag (HisAg) in urine was done by enzyme immunoassay (EIA), Cryptococcus antigen (CrAg) was detected in serum and cerebrospinal fluid (CSF) specimens by lateral flow assay (LFA), and lipoarabinomannan (LAM) detection in urine was by LFA (TB LAM) and in sputum by GeneXpert for diagnosis of Mycobacterium infections.

RESULTS

From August 2021 to June 2022, 491 PLHIV were enrolled; 482 (98%) had a CD4 + T-cell result, and 381 patients (79%) were classified with AHD according to CD4 + T-cell count (< 200 CD4/mm3). Frequency of an OI was 38% (n = 145/381). Antigen test positivity rate was 16% (72/467) for TB-LAM, 9% (43/464) for HisAg, and 11% (51/484) for CrAg. Twenty-one of 34 (62%) patients receiving CSF CrAg tests were positive, confirming meningitis. Significant differences in 30-day mortality were observed in patients with an OI (16%) vs. no OI (7%) (p = 0.002). Mortality was highest in patients with histoplasmosis (25%), co-infection (22%), cryptococcosis (18% overall; 19% for cryptococcal meningitis), and TB (10%).

CONCLUSIONS

TB and fungal OIs, including co-infection, were common in PLHIV in Paraguay and had high associated mortality. Laboratories and health facilities need access to CD4 + T-cell testing and rapid diagnostic assays.

Intergenerational sex and early sexual debut are associated with HIV infection among transgender women in Paraguay

INTRODUCTION

HIV prevalence among transgender women is high worldwide. The objectives of the present study were to estimate the current prevalence of HIV and identify factors associated with high HIV burden among transgender women in Paraguay.

METHODS

Transgender women aged ≥15 years in four regions of Paraguay were recruited by Starfish sampling between February and March 2021.

RESULTS

In total, 322 transgender women were included. Mean age was 31 years (range 15-67), and 102 had positive HIV test results (31.7%, 95% confidence interval [CI] 26.6-37.1). In multivariable analysis, factors associated with HIV infection were age at first intercourse ≤17 years (adjusted odds ratio [aOR] 5.47; 95% CI 1.05-28.42), >10 years difference in age with the last sexual partner (aOR 1.60; 95% CI 1.04-2.46), substance use (mostly cocaine) (aOR 3.00; 95% CI 1.47-6.12), higher risk perception (aOR 3.08; 95% CI 1.53-6.17), not testing for HIV (aOR 1.23; 95% CI 1.09-1.39), and accessed by a peer educator (aOR 3.86; 95% CI 1.77-8.38).

CONCLUSIONS

Sexual debut as a minor and a large age difference with sexual partners are associated with high burden of HIV among transgender women in Paraguay. Our study corroborates the finding of cocaine use during sex as a risk factor for HIV. Prevention programmes must address structural and social vulnerabilities to stem the tragically high burden of HIV among transgender women.

HIV prevalence and associated risk factors among men who have sex with men in three regions of Paraguay, 2020

BACKGROUND

Our study aimed to measure HIV prevalence and associated risk factors among men who have sex with men (MSM) in three regions of Paraguay in 2020.

METHODS

MSM were recruited for cross-sectional surveys in three regions of Paraguay using respondent-driven sampling. Interview were conducted face-to-face to collect demographic characteristics and risk and preventive behaviors. The analysis assessed HIV prevalence and associated risk factors in the three samples of MSM within each region.

RESULTS

A total of 1,207 MSM were recruited, including 559 in Asunción-Central, 245 in Alto Paraná, and 403 in Caaguazú. HIV prevalence was 24.2% (95% CI 20.6-27.9) in Asunción-Central, 10.2% (95% CI 6.7-14.6) in Alto Paraná, and 3.2% (95% CI 1.7-5.4) in Caaguazú. In Asunción-Central, associations with HIV were age ≥25 years (1.86, 95% CI 1.15-3.00), being employed (1.82, 95% CI 1.07-3.11), self-reporting as homosexual (1.90, 95% CI 1.06-3.43), having sex with a known HIV-positive partner acquisition (4.19, 95% CI 2.37-7.43), self-perceived as being at higher risk for HIV acquisition (4.15, 95% CI 2.54-6.77), and able to access condoms and lubricants (1.82, 95% CI 1.08-3.05). In Alto Paraná, associations with HIV were self-reporting as homosexual (4.33, 95% CI 1.19-15.65) and having higher HIV knowledge (2.53, 95% CI 0.97-6.61). In Caaguazú, associations with HIV were self-reporting as homosexual (7.06, 95% CI 1.53-32.46) and being diagnosed with depression (4.68, 95% CI 0.89-24.43).

CONCLUSIONS

HIV prevalence among MSM in Paraguay varied by region, being highest in the capital and major metropolitan area of Asunción-Central, followed by the border area of Alto Paraná. While being self-identified as homosexual was associated with HIV in all three regions, other associations differed, indicating prevention programs need to be tailored to the locale.

P258 Incidence of Histoplasmosis, Cryptococcosis, and TB Among People Living with HIV in Paraguay-Preliminary Report

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Objectives

Endemic fungal infections such as Histoplasmosis and Cryptococcosis as well as tuberculosis (TB) are important causes of mortality among people living with HIV (PLHIV) in Latin America. Rapid diagnostic assays (RDAs) could decrease the time to diagnosis and treatment of these infections, resulting in a reduction in mortality. The objectives of this study were to determine the incidence of Histoplasmosis, Cryptococcosis, and TB using RDAs in PLHIV with advanced HIV disease (AHD) and calculate 30-day mortality.

Methods

PLHIV 18 years and older, treated at the Institute of Tropical Medicine hospital in Asuncion, Paraguay, not receiving ART and presenting CD4 count ≤ 200 cells/μL or clinical symptoms suggestive of WHO stage 3 or 4 diseases were enrolled and followed for 30 days. Detection of Histoplasma Ag (HisAg) in urine was performed by enzyme immunoassay (EIA), Cryptococcus Ag (CrAg) detection in serum and cerebrospinal fluid specimens by lateral flow assay (LFA), and liparabinomannan (LAM) detection in urine by LFA (TB LAM) (limited to those patients with CD4 counts ≤ 100 cells/μL) and by GeneXpert (limited to patients with respiratory symptoms).

Results

From August 2021 to 25 March 2022, a total of 335 PLHIV were enrolled. Patient median age was 37 years [Interquartile Range (IQR) 16 years], median CD4 count at enrollment was 91 cells/μL (IQR 147 cell/μL). A total of 80% (n = 269) of patients were symptomatic for one or more of the three diseases being screened for. Ag positivity rate was 20% (40/196) for TB-LAM, 10% (32/314) for HisAg, and 11% (35/329) for CrAg (15 diagnosed with cryptococcal meningitis). GeneXpert testing showed a positivity of 14% (15/108), and six of these patients with positive GeneXpert also tested positive for TB-LAM.

In total, 100/335 (30%) of patients tested had a positive result and coinfections were observed among 14/335 (4.2%) patients (Table 1). Histoplasmosis + TB was the most frequent co-infection observed 12/335 (3.6%).

Mortality among those who completed 30-day follow-up was 12.6% (32/254) and 11% among those with an OI (11/102)

Conclusions

Preliminary results show that TB and fungal opportunistic infections, including co-infection were common in people with advanced HIV. Longitudinal follow-up will help to evaluate the feasibility and cost of implementing RDAs for the early detection of opportunistic infections in PLHIV with AHD in Paraguay. Early diagnosis could impact mortality reduction.

HIV drug resistance in persons initiating or reinitiating first-line antiretroviral therapy in Paraguay: Results of a National Patient Survey

Human immunodeficiency virus (HIV) drug resistance increases mortality and morbidity and antiretroviral therapy (ART) costs. We describe Paraguay's first nationally representative survey on pretreatment drug resistance (PDR) conducted among persons who initiated or reinitiated ART in 2019. ​​​​We conducted a cross-sectional survey of antiretroviral (ARV) drug resistance in Paraguay in 2019. Participants were sampled at four comprehensive care clinics where 90% of patients with HIV in Paraguay initiate ART. Patients included were adults ≥18 years old who initiated first-line ART or reinitiated the same first-line ART regimen after ≥3 months of discontinuation. Of 208 patients, 93.8% had no prior ART exposure, 3.8% reinitiated the same regimen, 2.4% had unknown prior ART exposure; and 31.3% had a CD4 count <200 cells/µl. Mutations associated with resistance were present in 15.4% of patients. Mutations associated with resistance to nonnucleoside reverse transcriptase inhibitors (NNRTI) were present in 13.0% of patients, nucleoside reverse transcriptase inhibitors in 4.3%, and integrase inhibitors in 3.4%. Mutations associated with resistance to tenofovir were present in 1.0% of patients and emtricitabine/lamivudine in 1.4%. ​​Nearly one in six patients had PDR in Paraguay's first nationally representative sample. High NNRTI PDR prevalence underscores the need to accelerate the transition to dolutegravir-based first-line ART. The low PDR prevalence of tenofovir and emtricitabine is reassuring as these ARVs are part of the World Health Organization (WHO)-recommended oral pre-exposure prophylaxis regimen. The high proportion of individuals initiating ART at a late disease stage highlights the need to improve treatment linkage strategies and implement WHO rapid ART initiation recommendations.

WHO method for estimating congenital syphilis to inform surveillance and service provision, Paraguay

Problem

In Paraguay, incomplete surveillance data resulted in the burden of congenital syphilis being underestimated, which, in turn, led to missed opportunities for infant diagnosis and treatment.

Approach

The prevalence of congenital syphilis, as defined by the World Health Organization (WHO), was estimated for Paraguay using the WHO congenital syphilis estimation tool. This tool was also used to monitor progress towards the elimination of mother-to-child transmission of syphilis.

Local setting

The burden of syphilis in Paraguay has historically been high: its prevalence in pregnant women was estimated to be 3% in 2018.

Relevant changes

The incidence rate of congenital syphilis estimated using the WHO tool was around nine times the reported prevalence. Subsequently, Paraguay: (i) provided training to improve diagnosis and case reporting; (ii) strengthened information systems for case monitoring and reporting; and (iii) procured additional rapid dual HIV–syphilis and rapid plasma reagin tests to increase syphilis testing capacity. In addition, the Ministry of Health prepared a new national plan for eliminating mother-to-child transmission of syphilis, with clear monitoring milestones.

Lessons learnt

Health-care providers’ reporting and surveillance procedures for congenital syphilis may not adequately reflect national and international case definitions. Use of the WHO congenital syphilis estimation tool in Paraguay drew attention to congenital syphilis as a national public health problem and highlighted the importance of comprehensive national surveillance systems and accurate data. Ongoing use of the WHO tool can track progress towards the elimination of mother-to-child transmission of syphilis by helping improve syphilis service coverage and national surveillance.

High HIV prevalence among transgender women in Paraguay

Transgender women have been understudied and underserved in Paraguay; data are urgently needed to understand their HIV prevention and care needs. To estimate HIV prevalence and related risk and preventive behaviors among trans women in Paraguay, we conducted a cross-sectional survey in 2017. We employed starfish sampling - a hybrid venue-based and peer-referral method combining recruitment at randomly sampled venues and randomly selected clients from program lists, followed by short-chain referrals of eligible peers. Among 304 trans women enrolled, HIV prevalence was 24.8% (95% confidence interval [CI] 18.5-31.2%), with risk increasing with age (adjusted odds ratio [AOR] 1.06 per year, 95% CI 1.03-1.10), residence in Asunción department (AOR 4.75, 95% CI 1.57-14.36), and cocaine use (AOR 2.09, 95% CI 1.11-3.95). Trans women in Paraguay need to be prioritized for interventions with high HIV prevention efficacy. Substance use interventions to address cocaine use may also yield prevention benefits for trans women in our context.

Mortality Rate and Predictors in Children Under 15 Years Old Who Acquired HIV from Mother to Child Transmission in Paraguay

We estimated mortality rate and predictors of death in children and adolescents who acquired HIV through mother-to-child transmission in Paraguay. In 2000-2014, we conducted a cohort study among children and adolescents aged < 15 years. We abstracted data from medical records and death certificates. We used the Cox proportional hazards model for the multivariable analysis of mortality predictors. A total of 302 subjects were included in the survey; 216 (71.5%) were younger than 5 years, 148 (51.0%) were male, and 214 (70.9%) resided in the Asunción metropolitan area. There were 52 (17.2%) deaths, resulting in an overall mortality rate of 2.06 deaths per 100 person-years. The children and adolescents with hemoglobin levels ≤ 9 g/dL at baseline had a 2-times higher hazard of death compared with those who had levels > 9 g/dL (HR 2.27, 95% CI 1.01-5.10). The mortality of HIV-infected children and adolescents in Paraguay is high, and anemia is associated with mortality. Improving prenatal screening to find cases earlier and improving pediatric follow-up are needed.

[Epidemiological characteristics of HIV infection in Paraguay during 2015]

To characterize the epidemiology of HIV in Paraguay, from january to december, in 2015. The epidemic remains focused in those groups under risk, predominantly male. The characteristics of the study population shows that most of the affected were from the central area and from the capital city, and sexual transmission remains the most common pathway, with delayed diagnosis, which is reflected by the percentage of people presenting a low CD4 cell count.