Randomized Controlled Pilot Study of Antiretrovirals and a Behavioral Intervention for Persons With Acute HIV Infection: Opportunity for Interrupting Transmission

Implementing HIV Prevention in Sub-Saharan Africa: A Systematic Review of Interventions Targeting Systems, Communities, and Individuals

HIV remains a threat to global public health, disproportionately affecting countries across Sub-Saharan Africa. Although treatment and access to care have improved, prevention remains critical to ending new HIV infections by 2030. A variety of prevention strategies exist, yet their effectiveness is difficult to measure and variable due to the nature of the interventions and vulnerability of the intervention during implementation. This systematic review of 51 studies synthesizes data on the implementation and evaluation of evidence-based HIV prevention interventions across Sub-Saharan Africa. Studies were included if they occurred between January 1, 2008, and December 31, 2019, inclusive in Sub-Saharan Africa, were written in English, implemented an HIV prevention intervention in the field, and had reportable results. Using a modified social-ecological model for HIV prevention, we divided studies into three categories: interventions targeting health systems (n = 16), communities (n = 8), and individuals (n = 27). Across all categories, the data emphasized preventing mother-to-child transmission (PMTCT), medical interventions, and psychosocial interventions. The most successful programs bundled several interventions that were integrated into the health system. There is a notable lack of interventions targeting key populations and there are significant rates of loss to follow up (LTFU) across many studies. This review provides insight into the prioritization of evidence-based HIV prevention interventions across Sub-Saharan Africa.

Brief Report: Blood and Genital Fluid Viral Load Trajectories Among Treated and Untreated Persons With Acute HIV Infection in Malawi

BACKGROUND

Persons with acute HIV infection (AHI) are highly infectious and responsible for a disproportionate share of incident infections. Immediate antiretroviral therapy (ART) rapidly reduces blood viral loads (VLs), but genital VLs after ART initiation during AHI are less well described.

SETTING

Lilongwe, Malawi, 2012-2014.

METHODS

HIV-seronegative and HIV-serodiscordant persons aged ≥18 years were screened for AHI (RNA positive) and randomized to standard of care, behavioral intervention, or behavioral intervention plus short-term ART (raltegravir/emtricitabine/tenofovir) (1:2:2). Persons who were ART eligible under Malawi guidelines could receive first-line therapy. Blood and genital VLs were assessed at weeks 1, 4, 8, and 12. Fisher's Exact test was used to compare viral suppression by ART status.

RESULTS

Overall, 46 persons with AHI were enrolled; of whom, 17 started ART within 12 weeks. Median blood VL at AHI diagnosis was 836,115 copies/mL. At week 12, 7% (1/14) of those who initiated ART had a blood VL of ≥400 copies/mL, compared with 100% (23/23; P < 0.0001) of those who did not initiate ART (median VL: 61,605 copies/mL). Median genital VL at week 1 was 772 copies/mL, with 13 of 22 (59%) having VL of ≥400 copies/mL. At week 12, 0 of 10 (0%) of those who initiated ART had genital VL of ≥400 copies/mL, compared with 7 of 15 (47%) of those who did not initiate ART (P = 0.02).

CONCLUSION

Although highly correlated, VLs in blood and genital fluids occupy discrete biological compartments with distinct virologic dynamics. Our results corroborate the dramatic reduction in both compartments after ART initiation. Increasing AHI screening and rapidly initiating treatment is key to interrupting transmission.

Evaluation of the integration of telehealth into the same-day antiretroviral therapy initiation service in Bangkok, Thailand in response to COVID-19: a mixed-method analysis of real-world data

Introduction

Same‐day antiretroviral therapy (SDART) initiation has been implemented at the Thai Red Cross Anonymous Clinic (TRCAC) in Bangkok, Thailand, since 2017. HIV‐positive, antiretroviral therapy (ART)‐naïve clients who are willing and clinically eligible start ART on the day of HIV diagnosis. In response to the first wave of the coronavirus disease 2019 (COVID‐19) outbreak in March 2020, telehealth follow‐up was established to comply with COVID‐19 preventive measures and allow service continuation. Here, we evaluate its implementation.

Methods

Pre‐COVID‐19 (until February 2020) clients who initiated SDART received a 2‐week ART supply and returned to the clinic for evaluation before being referred to long‐term ART maintenance facilities. If no adverse events (AEs) occurred, another 8‐week ART supply was provided while referral was arranged. During the first wave of COVID‐19 (March–May 2020), clients received a 4‐week ART supply and the option of conducting follow‐up consultation and physical examination via video call. Clients with severe AEs were required to return to TRCAC; those without received another 6‐week ART supply by courier to bridge transition to long‐term facilities. This adaptation continued post‐first wave (May–August 2020). Routine service data were analysed using data from March to August 2019 for the pre‐COVID‐19 period. Interviews and thematic analysis were conducted to understand experiences of clients and providers, and gain feedback for service improvement.

Results

Of 922, 183 and 321 eligible clients from the three periods, SDART reach [89.9%, 96.2% and 92.2% (p = 0.018)] and ART initiation rates [88.1%, 90.9% and 94.9% (p<0.001)] were high. ART uptake, time to ART initiation and rates of follow‐up completion improved over time. After the integration, 35.3% received the telehealth follow‐up. The rates of successful referral to a long‐term facility (91.8% vs. 95.3%, p = 0.535) and retention in care at months 3 (97.5% vs. 98.0%, p = 0.963) and 6 (94.1% vs. 98.4%, p = 0.148) were comparable for those receiving in‐person and telehealth follow‐up. Six clients and nine providers were interviewed; six themes on service experience and feedback were identified.

Conclusions

Telehealth follow‐up with ART delivery for SDART clients is a feasible option to differentiate ART initiation services at TRCAC, which led to its incorporation into routine service.

High rates of transmitted NNRTI resistance among persons with acute HIV infection in Malawi: implications for first-line dolutegravir scale-up

High rates of non-nucleoside reverse transcriptase inhibitors (NNRTI) resistance was a key consideration in the WHO policies transitioning first-line regimens to include integrase inhibitors (dolutegravir [DTG]). However, recent data suggests a relationship between DTG and neural tube defects among women exposed during conception, giving providers and policymakers pause regarding the planned regimen changes. We examined HIV drug resistance among a cohort of 46 acutely infected persons in Malawi. Our data demonstrates high levels of transmitted resistance, 11% using standard resistance surveillance mutations and 20% when additional NNRTI polymorphisms that may affect treatment response are included. High resistance rates in this treatment-naïve patient population reinforces the critical nature of DTG-based options in the context of public-health driven treatment programs.

Randomized Controlled Pilot Study of Antiretrovirals and a Behavioral Intervention for Persons With Acute HIV Infection: Opportunity for Interrupting Transmission

Background

Persons with acute HIV infection (AHI) have heightened transmission risk. We evaluated potential transmission reduction using behavioral and biomedical interventions in a randomized controlled pilot study in Malawi.

Methods

Persons were randomized 1:2:2 to standard counseling (SC), 5-session behavioral intervention (BI), or behavioral intervention plus 12 weeks of antiretrovirals (ARVs; BIA). All were followed for 26–52 weeks and, regardless of arm, referred for treatment according to Malawi-ARV guidelines. Participants were asked to refer partners for testing.

Results

Among 46 persons (9 SC, 18 BI, 19 BIA), the average age was 28; 61% were male. The median viral load (VL) was 5.9 log copies/mL at enrollment. 67% (10/15) of BIA participants were suppressed (<1000 copies/mL) at week 12 vs 25% BI and 50% SC (P = .07). Although the mean number of reported condomless sexual acts in the past week decreased from baseline across all arms (1.5 vs 0.3 acts), 36% experienced incident sexually transmitted infection by 52 weeks (12% SC, 28% BI, 18% BIA). Forty-one percent (19/46) of participants referred partners (44% SC, 44% BI, 37% BIA); 15 of the partners were HIV-infected.

Conclusions

Diagnosis of AHI facilitates behavioral and biomedical risk reduction strategies during a high-transmission period that begins years before people are typically identified and started on ARVs. Sexually transmitted infection incidence in this cohort suggests ongoing risk behaviors, reinforcing the importance of early intervention with ARVs to reduce transmission. Early diagnosis coupled with standard AHI counseling and early ARV referral quickly suppresses viremia, may effectively change behavior, and could have tremendous public health benefit in reducing onward transmission.