HIV in Lebanon: Reasons for Testing, Engagement in Care, and Outcomes in Patients with Newly Diagnosed HIV Infections

Retention in care among people living with human immunodeficiency virus (HIV) in a low-resource setting

BACKGROUND

This study aimed to evaluate the retention in care among a cohort of Egyptian people living with HIV (PLWHIV).

METHOD

The study was conducted on PLWHIV attending Kasr Alainy HIV and Viral Hepatitis Centre, Cairo, Egypt, from January 1, 2019, to March 31, 2023. PLWHIV were considered not retained in care if there was no documented clinical visit or HIV viral load (VL) or CD4 count test for more than 6 months from their last recorded visit or test. Multivariable logistic regression analysis was used to test factors associated with retention in care.

RESULTS

After excluding those who died and were referred, 369 PLWHIV were included in the analysis, and retention in care was observed in 325 (88%). The majority were males (81.8%) with a median age of 34 [29-41] years. Undetectable VL (OR: 3.555; 95% CI: 1.49-8.47), hepatitis B vaccination (OR: 2.835; 95% CI: 1.07-7.48), CD4 test availability (OR: 2.604; 95% CI: 1.02-6.64), receiving dolutegravir based antiretroviral therapy (OR: 2.429; 95% CI: 1.06-5.537), and longer duration of know HIV infection (OR: 1.025; 95% CI: 1.01- 1.04) were correlated with retention in care. Surprisingly, higher education levels were negatively correlated with retention in care (OR: 0.195, 95%: CI: 0.071-0.533), suggesting the need for further research to explore this relationship.

CONCLUSION

These results are invaluable for developing targeted interventions and informing health policies to improve retention in HIV care in Egypt. Enhancing access to VL and CD4 testing, promoting VL suppression, and focusing on specific groups at risk of dropping out of care are essential strategies.

Trends in HIV testing and HIV stage at diagnosis among people newly diagnosed with HIV

OBJECTIVE

To identify groups more likely to be referred for HIV testing because of symptomatic presentation rather than as part of asymptomatic screening.

DESIGN

A retrospective analysis of Australian National HIV Registry (NHR) surveillance data including sociodemographic and clinical data, as well as reasons for HIV test.

METHODS

Using notification records from 2017 to 2022, we summarised reasons for testing leading to an HIV diagnosis. Reasons for testing were combined with clinical status at diagnosis to derive HIV testing categories: testing while symptomatic; asymptomatic HIV screening; seroconversion; and other test reason. We stratified these categories by stage of HIV at diagnosis with late-stage HIV defined as a CD4 + cell count <350 cells/μl at time of diagnosis.

RESULTS

Among 4134 HIV notifications with at least one reason for testing recorded, STI screening was the predominant reason for test referral (38%), followed by HIV indicative symptoms (31%), and risk behaviour (13%). By testing category, people aged 50 years or older (24%), people with HIV attributed to heterosexual sex (21%), people born in sub-Saharan Africa (19%), and women (17%) had lower levels of asymptomatic screening. More late-stage HIV diagnoses resulted from testing while symptomatic (58%) compared with asymptomatic screening (25%).

CONCLUSIONS

Older people and heterosexuals may not access HIV focused healthcare where HIV screening is routinely offered. Instead, HIV testing opportunities may arise in other settings. By normalising HIV testing and offering low-cost HIV screening in a range of settings, it may be possible to facilitate earlier HIV diagnoses, better health outcomes, and reduced onward transmission.

Advanced HIV disease and its predictors among newly diagnosed PLHIV in the Gedeo zone, southern Ethiopia

BACKGROUND

Globally, HIV infection remains a leading cause of morbidity and mortality. Despite reducing new infections, the global response to advanced HIV disease (AHD) remains ineffective, leaving HIV epidemics a significant public health threat worldwide. In Ethiopia, evidence regarding AHD is scarce. Therefore, this study aimed to assess the prevalence and predictors of AHD among newly diagnosed people living with HIV (PLHIV) initiating antiretroviral therapy in the Gedeo zone, southern Ethiopia.

METHODS

A facility-based cross-sectional study was conducted from May 29, 2023, to February 06, 2024, at health facilities providing HIV care in the Gedeo zone, southern Ethiopia. A total of 427 PLHIV-initiating antiretroviral therapy (ART) were recruited for the study. The data were collected through face-to-face interviews and record reviews using KoboCollect version 2.4 and analyzed using R version 4.3.3. The Akaike information criterion (AIC) model selection was used to evaluate and choose the best-fitting model to describe the relationship between AHD and predictors. Finally, variables with a p-value less than 0.05 were considered independent predictors in the multivariable regression analysis.

RESULTS

The study participants' mean (±SD) age was 31.3 (±8.7) years. The overall prevalence of AHD among newly diagnosed PLHIV-initiating ART was 34.4% (95% CI: 29.8%, 39.1%). Rural residence (AOR = 3.48, 95% CI: 2.24, 5.47), alcohol consumption (AOR = 2.48, 95% CI: 1.59, 3.90), and being identified through community-based index case testing (ICT) (AOR = 0.26, 95% CI: 0.13, 0.51) were found to be independent predictors of AHD.

CONCLUSIONS

The prevalence of AHD among newly diagnosed individuals initiating ART was high. PLHIV who consume alcohol should receive detailed counseling on how it can negatively impact their progress with antiretroviral treatment. HIV testing should be enhanced in rural communities by strengthening community health campaigns. Furthermore, community-based index case testing should be strengthened for early identification of PLHIV.

Breaking barriers: Assessing pre-exposure prophylaxis awareness and willingness to use in the Lebanese community

BACKGROUND

In the evolving HIV landscape, the Middle East and Northern Africa (MENA) grapples with data gaps, hindering the 95-95-95 targets. Lebanon, despite progress, falls short. Our study addresses Pre-exposure Prophylaxis (PrEP) gaps for effective HIV prevention.

METHODS

Surveying 410 participants via snowball sampling and an online questionnaire, we analyzed data with chi-square and regression over 5 months for insights into PrEP awareness and readiness.

RESULTS

Summarizing the pivotal statistical outcomes of the study, 22.2% reported awareness of PrEP, showcasing diverse knowledge levels about its purpose and usage. Out of them, 57.1% expressed a willingness to use it; while a mere 5.5% have utilized it. The study reveals diverse demographic profiles, with age influencing PrEP awareness and willingness to use. Positive correlations exist between PrEP discussions within social circles, increased information availability, and elevated willingness. Financial considerations and accessibility at pharmacies emerge as critical determinants, guiding the development of targeted interventions.

CONCLUSIONS

This analysis emphasizes tailored education, community initiatives, and policy enhancements to address PrEP challenges in Lebanon. Guiding public health initiatives, our study considers age, social dynamics, education, and accessibility in HIV prevention.

Late presentations and missed opportunities among newly diagnosed HIV patients presenting to a specialty clinic in Lebanon

Late presentation to medical care of individuals infected with the human immunodeficiency virus (HIV) is linked to poor outcomes and increased morbidity and mortality. Missed opportunities for a prompt diagnosis are frequently reported among late presenters. We aimed to estimate the proportion of late presenters and missed opportunities in diagnosis among newly diagnosed HIV-positive subjects presenting to a specialty clinic in Lebanon. This is a retrospective chart review of all newly diagnosed adult HIV-positive subjects presenting to clinic from 2012 to 2022. Demographic, laboratory, and clinical data were collected at initial HIV diagnosis or presentation to medical care. We defined late presentation as having a CD4 count < 350 or AIDS-defining event regardless of CD4 count. Advanced disease is defined as having a CD4 count below 200 cells/μL or the presence of an AIDS-defining illness, regardless of the CD4 count. A missed opportunity was defined as the presence of an indicator condition (IC) that suggests infection with HIV/AIDS during 3 years preceding the actual HIV diagnosis and not followed by a recommendation for HIV testing. The proportions for demographic, epidemiological, and clinical characteristics are calculated by excluding cases with missing information from the denominator. Our cohort included 150 subjects (92.7% males; 63.6% men who have sex with men (MSM); 33.3% heterosexuals; median age 30.5 years at diagnosis). 77 (51.3%) were late presenters and 53 (35.3% of all subjects, 68.8% of late presenters) had advanced HIV on presentation. Up to 76.5% of late presenters had a presentation with an HIV-related condition at a healthcare provider without getting HIV test within the previous 3 years. The most frequent ICs were weight loss, generalized lymphadenopathy, constitutional symptoms, and chronic idiopathic diarrhea. Overall mortality rate was 4% (6/150 individuals). All-cause mortality among those who presented with AIDS was 15.4% (6/39 subjects). In our setting, late presentations and missed opportunities for HIV diagnosis are common. In the Middle East, AIDS mortality remains high with a large gap in HIV testing. To effectively influence policies, comprehensive analyses should focus on estimating the preventable health and financial burdens of late HIV presentations. Another concern pertains to healthcare providers' attitudes and competencies.

Treatment outcomes 12 months after antiretroviral therapy initiation in Oman: a nationwide study from the Middle East

ABSTRACTWe used routinely collected programme data on people living with HIV in Oman who started ART in 2014-2018 to assess retention on ART, viral suppression, attrition (mortality or loss to follow-up [LTFU]) and treatment failure (attrition or HIV viral load of > 1000 copies/mL) 12 months after antiretroviral therapy (ART) initiation. We identified 726 patients; 72% were male. Overall, 12 months retention on ART and viral suppression (intention-to-treat [ITT] analysis) were 85.7% and 74.5%, respectively. Attrition occurred in 14.3% (mortality of 7% and LTFU of 7.3%). Retention increased from 78.8% (93/118) to 90.6% (144/159) among patients who started ART in 2014 and 2018, respectively. Similarly, ITT and on-treatment analyses revealed that viral suppression 12 months after ART initiation increased from 57.6% (68/118) and 73.1% (68/93) among patients who initiated therapy in 2014-80.5% (128/159) and 88.8% (128/144) among patients started treatment in 2018, respectively. On multivariate analysis, older age, having "Other" as an HIV risk factor (compared to heterosexual) and receiving HIV care outside the capital Muscat independently predicted both attrition and treatment failure. Our findings have been useful in identifying factors at the individual and programme level that influenced the risk of attrition and treatment failure.

HIV epidemiology in the WHO Eastern Mediterranean region: a multicountry programme review

BACKGROUND

Worldwide, HIV incidence, and mortality has decreased since 2010; however, in the WHO Eastern Mediterranean region, trends continue to increase. We reviewed the regional progress to understand determinants of this situation and inform strategies to accelerate the response.

METHODS

We conducted a multicountry programme review of 22 countries in the WHO Eastern Mediterranean region from Jan 1, 2010 to Dec 31, 2020. We extracted data from WHO's global AIDS monitoring system, UNAIDS estimates, and country reports regarding incident cases, policy uptake, and antiretrovirals used. We analysed data to describe incidence, testing practices, treatment coverage, and mortality to identify bottlenecks leading to persisting incidence and mortality.

FINDINGS

Due to COVID-19 disruptions, the volume of HIV testing in 2020 halved to 3·0 million tests compared with 2019 with 8017 people living with HIV identified (0·27% positivity yield). In comparison with a 0·18% positivity yield from the 6·5 million tests in 2019. HIV tests were done in migrants (59·6%), groups at low risk (38·9%), and key populations (1·5%). Diagnoses with advanced disease increased from 27·3% in 2017 to 37·0% in 2019. In 2019, among 52 318 people on treatment, only 2888 (6%) received optimised regimens as per WHO recommendations. The number of people on treatment increased from 19 000 in 2010 with a coverage of 8% to 110 000 in 2020 with a coverage of 25%. Late diagnoses and suboptimal regimens could explain the increase in mortality from 9600 in 2010 to 17 000 in 2020.

INTERPRETATION

In the Eastern Mediterranean region, inefficient testing and suboptimal treatment lead to underdiagnosis, persisting transmission, late treatment, and rising mortality. The HIV epidemic is growing faster than the response. A change in thinking is needed to test groups at high risk, transition to optimised treatment, and deliver patient-centred services that maximise retention.

FUNDING

World Health Organization.