Initiating patients on antiretroviral therapy at CD4 cell counts above 200 cells/microl is associated with improved treatment outcomes in South Africa

Epidemiological determinants and quality of life in PLHIV patients with tuberculosis in Bihar State, India

BACKGROUND

This study aimed to determine the prevalence of TB among patients living with HIV in Patna district, India. It also assessed the factors contributing to co-infection and evaluated patients' quality of life.

METHODS

This cross-sectional study was conducted at the Antiretroviral Therapy (ART) Centre in Patna, India, for a period of eight months. The socio-demographic information was collected through a pre-defined semi-structured questionnaire administered by the interviewer during face-to-face interviews at the time of enrolment. Clinical details were obtained from the hospital records. The statistical analysis was performed using SPSS software.

RESULTS

The study showed that out of 289 people living with HIV, 31% had TB as a co-infection. Male patients had a higher probability of contracting HIV-TB co-infection compared to female patients. The study indicated that advanced WHO staging, male gender, past history of TB, and opportunistic infections were strong predictors. Conversely, the odds of HIV-TB co-infection reduced with a CD4 count of over 300 cells/mm3. However, an increase in age, lower socio-economic status, BMI below the normal range, and presence of comorbidities might increase the odds of HIV-TB co-infection but were not statistically significant. The QoL of HIV-TB patients was significantly lower than that of HIV-only patients.

CONCLUSIONS

People with low CD4+ T cell count are at a higher risk of developing TB due to HIV/TB co-infection. The baseline clinical staging of HIV is significantly correlated with TB co-infection. Those in WHO Clinical Stage III and IV have a four times higher risk of developing TB.

PSGL-1, a Strategic Biomarker for Pathological Conditions in HIV Infection: A Hypothesis Review

P-selectin glycoprotein ligand-1 (PSGL-1) has been established to be a cell adhesion molecule that is involved in the cellular rolling mechanism and the extravasation cascade, enabling the recruitment of immune cells to sites of inflammation. In recent years, researchers have established that PSGL-1 also functions as an HIV restriction factor. PSGL-1 has been shown to inhibit the HIV reverse transcription process and inhibit the infectivity of HIV virions produced by cells expressing PSGL-1. Cumulative evidence gleaned from contemporary literature suggests that PSGL-1 expression negatively affects the functions of immune cells, particularly T-cells, which are critical participants in the defense against HIV infection. Indeed, some researchers have observed that PSGL-1 expression and signaling provokes T-cell exhaustion. Additionally, it has been established that PSGL-1 may also mediate virus capture and subsequent transfer to permissive cells. We therefore believe that, in addition to its beneficial roles, such as its function as a proinflammatory molecule and an HIV restriction factor, PSGL-1 expression during HIV infection may be disadvantageous and may potentially predict HIV disease progression. In this hypothesis review, we provide substantial discussions with respect to the possibility of using PSGL-1 to predict the potential development of particular pathological conditions commonly seen during HIV infection. Specifically, we speculate that PSGL-1 may possibly be a reliable biomarker for immunological status, inflammation/translocation, cell exhaustion, and the development of HIV-related cancers. Future investigations directed towards our hypotheses may help to evolve innovative strategies for the monitoring and/or treatment of HIV-infected individuals.

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.

ART uptake and adherence among female sex workers (FSW) globally: A scoping review

We conducted the first scoping literature review on ART uptake and adherence among Female Sex Workers (FSW), following PRISMA-ScR guidelines. Searches were conducted in PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting an ART uptake or adherence result among FSW aged 18 or older; peer-reviewed; published in English between 1996 and 2018. Our search identified 6,735 studies; 30 met eligibility requirements. ART uptake ranges from 0 to 100% and adherence ranges from 50-90%, depending on measurement methods. Uptake and adherence influencing factors are mapped onto a social ecological model (SEM). Knowledge and beliefs, substance use, food insecurity and sex-work engagement were negatively associated, while older age, relationships and social support were positively associated with ART uptake and adherence. Standardised methods to measure uptake and adherence prevalence must be established for data comparison. Evidence regarding ART uptake and adherence barriers and facilitators span multiple SEM levels, although more research is needed regarding structural and occupational level influencers. Results suggest that the multi-level ART uptake and adherence barriers faced by FSW require complex multi-level evidence-based interventions. Study findings can inform ART interventions, future research, and offer guidance to other support services with FSW, such as PrEP interventions.

Risk factors for loss to follow-up from antiretroviral therapy programmes in low-income and middle-income countries

INTRODUCTION

Loss to follow-up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, leading to poor treatment outcomes and onward transmission of HIV. Knowledge of risk factors is required to address LTFU. In this systematic review, risk factors for LTFU are identified and meta-analyses performed.

METHODS

PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults who initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95% CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed.

RESULTS

Eighty studies were included describing a total of 1 605 320 patients of which 87.4% from sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, nondisclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 cell count, tuberculosis at baseline, regimen, and geographical setting.

CONCLUSION

There are several sociodemographic, clinical, patient behaviour, treatment-related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients.

High IL-5 levels possibly contributing to HIV viremia in virologic non-responders at one year after initiation of anti-retroviral therapy

Lack of viral monitoring in HIV infected patients on anti-retroviral therapy in low income countries may result in missing virologic non-responders (VNR) who show immunologic recovery in spite of unsuppressed viral replication. Biomarkers and drug resistance patterns in these discordant patients in comparison to the concordant treatment failure group need to be studied to understand possible risk factors associated with this condition. HIV infected patients on anti-retroviral therapy for one year were enrolled under three categories namely VNRs (n = 25), treatment failures (n = 18) and treatment responders (n = 40). They were assessed for HIV drug resistance by sequencing, plasma cytokines by luminex assay, T cell activation status by flow cytometry and total IgE levels by ELISA. VNR and failure patients had significantly lower median baseline CD4 counts than the responders. VNRs had significantly higher CD4 counts but lower viral load than treatment failures at one year of ART. VNRs had the highest eosinophil counts and the highest IL-5 levels among all the groups. IL-5 levels in them correlated with their viral load values. Frequency of Treg cells was also highest among the VNR group participants. More than 60% of the viremic patients irrespective of their groups harboured multiple HIV drug resistance mutations and mutation pattern did not differ between the groups. Low baseline CD4 counts and presence of multiple drug resistance mutations in the viremic groups highlighted the importance of early ART initiation and viral load monitoring irrespective of presence of immunologic failure. High IL-5 levels in VNR group indicated a need for investigating causal relationship between IL-5 and viral replication to devise therapeutic strategies to control viremia.

An optimal BMI range associated with a lower risk of mortality among HIV-infected adults initiating antiretroviral therapy in Guangxi, China

Previous studies investigating HIV-infected patients suggested a direct link between underweight and the mortality rate of AIDS. However, there was a lack of evidence showing the optimal range of initial body mass index (BMI) patients maintain during antiretroviral therapy (ART). We aimed to evaluate associations of the BMI values pre-ART and during the entire ART duration with mortality among HIV-positive individuals. In total, 5101 HIV/AIDS patients, including 1439 (28.2%) underweight, 3047 (59.7%) normal-weight, 548 (10.7%) overweight and 67 (1.3%) obese patients, were included in this cohort. The cumulative mortality of underweight, normal-weight, and overweight were 2.4/100 person-years (95% CI 1.9–2.9), 1.1/100 person-years (95% CI 0.9–1.3), and 0.5/100 person-years (95% CI 0.1–0.9), respectively. Cumulative mortality was lower in both the normal-weight and overweight populations than in the underweight population, with an adjusted hazard ratio (AHR) of 0.5 (95% CI 0.4–0.7, p < 0.001) and 0.3 (95% CI 0.1–0.6, p = 0.002), respectively. Additionally, in the 1176 patients with available viral load data, there was significant difference between the underweight and normal-weight groups after adjustment for all factors, including viral load (p = 0.031). This result suggests that HIV-infected patients in Guangxi maintaining a BMI of 19–28 kg/m², especially 24–28 kg/m², have a reduced risk of death.

Impact of initiation of combination antiretroviral therapy according to the WHO recommendations on the survival of HIV-positive patients in Taiwan

BACKGROUND/PURPOSE

Early initiation of antiretroviral therapy (ART) reduces the risks for serious infections and mortality. We aimed to assess the outcomes of initiating ART among HIV-positive Taiwanese according to the CD4 cut-off values by the WHO recommendations.

METHODS

We reviewed medical records of patients with newly diagnosed HIV infection between 2004 and 2015 and 3 groups of patients were defined according to the timing of ART initiation based on CD4 count recommended by WHO: Group 1 between 2004 and 2009; Group 2 between 2010 and 2012; and Group 3 between 2013 and 2015. The primary outcome was all-cause mortality. All patients were followed until 2 years after the last patient was included in each group.

RESULTS

Of 2022 patients included, the mortality rate was 18.28, 14.01, and 9.10 deaths per 1000 person-years of follow-up (PYFU) in Groups 1, 2, and 3, respectively. In multivariable Cox regression analysis, factors associated with mortality were age (per 1-year increase, adjusted hazard ratio [AHR], 1.06; 95% CI, 1.05-1.08), presence of AIDS-defining disease at HIV diagnosis (AHR, 4.81; 95% CI, 2.99-7.74), solid-organ malignancy (AHR, 3.10; 95% CI, 1.86-5.18), and initiation of ART (AHR, 0.09; 95% CI, 0.05-0.16). By competing risk regression model for non-AIDS-related death, the AHR for Group 3 versus Group 1 was 0.27 (95% CI, 0.09-0.80).

CONCLUSIONS

While continued efforts are needed to improve early diagnosis and linkage to care, initiation of cART improved survival among HIV-positive patients in Taiwan according to the increasing CD4 cut-off values that were recommended by the WHO.

Comparison of anal cancer screening strategies including standard anoscopy, anal cytology, and HPV genotyping in HIV-positive men who have sex with men

BACKGROUND

There is no consensus on screening strategy of high-grade intraepithelial neoplasia (HGAIN). Guidelines range from clinical examination with digital anorectal examination followed by standard anoscopy (SA), to anal cytology (Pap)+/- HPV genotyping. We compared screening strategy yields based on Pap, SA, and HPV-16 genotyping alone or in combination in HIV-MSM.

METHODS

Pap, SA, and HPV-16 genotyping were performed in all HIV-MSM attending a first anal cancer screening consultation in Paris, France. High-resolution anoscopy, the gold standard to detect HGAIN, was performed in the case of HPV-16 positivity or abnormal cytology. Yield was defined as the number of patients with HGAIN relative to the total number of patients screened.

RESULTS

On 212 patients, the complete strategy (SA + Pap + HPV genotyping) yield (12.7%) was significantly higher than that of SA (3.3%, p < 0.001) and HPV-16 alone (6.6%, p < 0.05). Although none of the other strategies were significantly different from the complete strategy, Pap + HPV-16 and Pap + SA had closer yields (about 11%), with OR = 0.83 (95% CI [0.44;1.57]) and 0.87 (95% CI [0.46;1.64]), respectively.

CONCLUSIONS

Pap combined with HPV-16 genotyping or SA tended towards higher yields compared to Pap alone, and closer to that of the complete strategy.

High Proportions of Patients With Advanced HIV Are Antiretroviral Therapy Experienced: Hospitalization Outcomes From 2 Sub-Saharan African Sites

Background

Human immunodeficiency virus (HIV) remains an important cause of hospitalization and death in low- and middle- income countries. Yet morbidity and in-hospital mortality patterns remain poorly characterized, with prior antiretroviral therapy (ART) exposure and treatment failure status largely unknown.

Methods

We studied HIV-infected inpatients aged ≥13 years from cohorts in Kenya and the Democratic Republic of Congo (DRC), assessing clinical and demographic characteristics and hospitalization outcomes. Kenyan inpatients were prospectively enrolled during hospitalization; identical retrospective data were extracted for Congolese patients meeting the study criteria using routine medical information.

Results

Among 338 HIV-infected patients in Kenya and 411 in DRC, 83.7% (95% confidence interval [CI], 79.4%-87.3%) and 97.3% (95% CI, 95.2%-98.5%), were admitted with advanced disease (defined as CD4 <200 cells/µL or World Health Organization stage 3/4 illness). Among inpatients with advanced HIV, 35.4% and 21.7% were ART-naive at admission. Patients under care had a median time of 44.1 (interquartile range [IQR], 18.4-90.5) months and 55.9 (IQR, 28.1-99.6) months on treatment; 17.2% (95% CI, 13.5%-21.6%) and 29.6% (95% CI, 25.4%-34.3%) died, 25.9% (95% CI, 16.0%-39.0%) and 22.5% (95% CI, 15.8%-31.0%) of these within 48 hours.

Conclusions

Across 2 diverse clinical contexts in sub-Saharan Africa, advanced HIV inpatients were frequently admitted with low CD4 counts, often failing first-line ART. Earlier identification of treatment failure and rapid switching to second-line ART are needed.

Prognosis of HIV Patients Receiving Antiretroviral Therapy According to CD4 Counts: A Long-term Follow-up study in Yunnan, China

We aim to evaluate the overall survival and associated risk factors for HIV-infected Chinese patients on antiretroviral therapy (ART). 2517 patients receiving ART between 2006 and 2016 were prospectively enrolled in Yunnan province. Kaplan-Meier analyses and Cox proportional hazard regression analyses were performed. 216/2517 patients died during a median 17.5 (interquartile range [IQR] 6.8–33.2) months of follow-up. 82/216 occurred within 6 months of starting ART. Adjusted hazard ratios were10.69 (95%CI 2.38–48.02, p = 0.002) for old age, 1.94 (95%CI 1.40–2.69, p < 0.0001) for advanced WHO stage, and 0.42 (95%CI 0.27–0.63, p < 0.0001) for heterosexual transmission compared to injecting drug users. Surprisingly, adjusted hazard ratios comparing low CD4 counts group (<50 cells/µl) with high CD4 counts group (≥500 cells/µl) within six months after starting ART was 20.17 (95%CI 4.62–87.95, p < 0.0001) and it declined to 3.57 (95%CI 1.10–11.58, p = 0.034) afterwards. Age, WHO stage, transmission route are significantly independent risk factors for ART treated HIV patients. Importantly, baseline CD4 counts is strongly inversely associated with survival in the first six months; whereas it becomes a weak prognostic factor after six months of starting ART.

Comparative Evaluation of Subtyping Tools for Surveillance of Newly Emerging HIV-1 Strains

HIV-1 non-B subtypes/circulating recombinant forms (CRFs) are increasing worldwide. Since subtype identification can be clinically relevant, we assessed the added value in HIV-1 subtyping using updated molecular phylogeny (Mphy) and the performance of routinely used automated tools. Updated Mphy (2015 updated reference sequences), used as a gold standard, was performed to subtype 13,116 HIV-1 protease/reverse transcriptase sequences and then compared with previous Mphy (reference sequences until 2014) and with COMET, REGA, SCUEAL, and Stanford subtyping tools. Updated Mphy classified subtype B as the most prevalent (73.4%), followed by CRF02_AG (7.9%), C (4.6%), F1 (3.4%), A1 (2.2%), G (1.6%), CRF12_BF (1.2%), and other subtypes (5.7%). A 2.3% proportion of sequences were reassigned as different subtypes or CRFs because of misclassification by previous Mphy. Overall, the tool most concordant with updated Mphy was Stanford-v8.1 (95.4%), followed by COMET (93.8%), REGA-v3 (92.5%), Stanford-old (91.1%), and SCUEAL (85.9%). All the tools had a high sensitivity (≥98.0%) and specificity (≥95.7%) for subtype B. Regarding non-B subtypes, Stanford-v8.1 was the best tool for C, D, and F subtypes and for CRFs 01, 02, 06, 11, and 36 (sensitivity, ≥92.6%; specificity, ≥99.1%). A1 and G subtypes were better classified by COMET (92.3%) and REGA-v3 (98.6%), respectively. Our findings confirm Mphy as the gold standard for accurate HIV-1 subtyping, although Stanford-v8.1, occasionally combined with COMET or REGA-v3, represents an effective subtyping approach in clinical settings. Periodic updating of HIV-1 reference sequences is fundamental to improving subtype characterization in the context of an effective epidemiological surveillance of non-B strains.

Risk factors for mortality in TB patients: a 10-year electronic record review in a South African province

Background

Since 1990, reduction of tuberculosis (TB) mortality has been lower in South Africa than in other high-burden countries in Africa. This research investigated the influence of routinely captured demographic and clinical or programme variables on death in TB patients in the Free State Province.

Methods

A retrospective review of case information captured in the Electronic TB register (ETR.net) over the years 2003 to 2012 was conducted. Extracted data were subjected to descriptive and logistic regression analyses. The outcome variable was defined as all registered TB cases with ‘died’ as the recorded outcome. The variables associated with increased or decreased odds of dying in TB patients were established. The univariate and adjusted odds ratios (OR and AOR) together with their corresponding 95% confidence intervals (CI) were estimated, taking the clustering effect of the districts into account.

Results

Of the 190,472 TB cases included in the analysis, 30,991 (16.3%) had ‘died’ as the recorded treatment outcome. The proportion of TB patients that died increased from 15.1% in 2003 to 17.8% in 2009, before declining to 15.4% in 2012. The odds of dying was incrementally higher in the older age groups: 8–17 years (AOR: 2.0; CI: 1.5–2.7), 18–49 years (AOR: 5.8; CI: 4.0–8.4), 50–64 years (AOR: 7.7; CI: 4.6–12.7), and ≥65 years (AOR: 14.4; CI: 10.3–20.2). Other factors associated with increased odds of mortality included: HIV co-infection (males – AOR: 2.4; CI: 2.1–2.8; females – AOR: 1.9; CI: 1.7–2.1) or unknown HIV status (males – AOR: 2.8; CI: 2.5–3.1; females – AOR: 2.4; CI: 2.2–2.6), having a negative (AOR: 1.4; CI: 1.3–1.6) or a missing (AOR: 2.1; CI: 1.4–3.2) pre-treatment sputum smear result, and being a retreatment case (AOR: 1.3; CI: 1.2–1.4).

Conclusions

Although mortality in TB patients in the Free State has been falling since 2009, it remained high at more than 15% in 2012. Appropriately targeted treatment and care for the identified high-risk groups could be considered.

Long-term immune and virological response in HIV-infected patients receiving antiretroviral therapy

WHAT IS KNOWN AND OBJECTIVE

The trajectory of HIV viral load and CD4 count and the occurrence of clinical events are primary considerations in the evaluation of antiretroviral therapy (ART) success or failure, yet a large number of studies do not describe these events from the point of therapy initiation. This study aims to describe the virological and immune response to ART and factors associated with immune and virological success in outpatients from a HIV/AIDS clinic in southern Brazil from therapy initiation.

METHODS

Longitudinal observational with ambidirectional data collection study with adult patients followed for at least 12 months after enrolment. Outcomes include (i) favourable immune response, defined as CD4 count ≥200 cells/mm³; and (ii) virological success, defined as viral load below the limit of detection (50 copies/mL).

RESULTS

The study included 332 patients, mostly men (63%), whose mean age was 40 (±10) years and with median family income of BR$ 490·00 per month (IQR: 350-875). Before starting ART, 43% of patients had indications of stable immune status (CD4 count ≥200 cells/mm³); the median CD4 count was 179 cells/mm³ (IQR: 93·5, 267) and increased to 379·5 cells/mm³ (IQR: 236·5, 591·3). The proportion of patients with CD4 count ≥200 cells/mm³ increased from 76% to 83%, and with undetectable viral load (UVL) increased from 51·7% to 73%. Factors associated with immune success at the end of study follow-up were as follows: female gender, pretreatment CD4 count ≥200 cells/mm³, previous UVL (measured when started prospective follow-up) and treatment with three drugs compared with ≥4. Factors associated with virological success were as follows: UVL (measured when started prospective follow-up) and use of three drugs compared with ≥4.

WHAT IS NEW AND CONCLUSIONS

Results of this study show that a large proportion (73%) of patients have rapid and successful immune and virological responses to ART and that factors which predict this response include starting ART early, whereas viral load is low and CD4 count is high, with fewer drugs. These results further support the ongoing need for ongoing programmes to increase early HIV testing, early linkage to and treatment with ART, and increased viral suppression.

Intensive adherence counselling for HIV-infected individuals failing second-line antiretroviral therapy in Johannesburg, South Africa

OBJECTIVE

In resource-limited settings, where genotypic drug resistance testing is rarely performed and poor adherence is the most common reason for treatment failure, programmatic approaches to handling treatment failure are essential. This study was performed to describe one such approach to adherence optimisation.

METHODS

This was a single-arm study of patients on second-line protease inhibitor (PI)-based antiretroviral therapy (ART) with a HIV-1 RNA ≥400 copies/ml in Johannesburg, South Africa, between 1 March 2012 and 1 December 2013. Patients underwent enhanced adherence counselling. Those with improved adherence and a repeat viral load of >1000 copies/ml underwent HIV-1 drug resistance testing. We describe results using simple proportions and 95% confidence intervals.

RESULTS

Of the 400 patients who underwent targeted adherence counselling after an elevated viral load on second-line ART, 388 (97%) underwent repeat viral load testing. Most of these (n = 249; 64%, 95% CI 59-69) resuppressed (<400 copies/ml) on second line. By the end of follow-up (1 March 2014), among the 139 (36%, 95% CI: 31-41%), who did not initially resuppress after being targeted, 106 had a viral load >400 copies/ml, 11 switched to third line, 5 were awaiting third line, 4 had died and 13 were lost to follow-up. Among the unsuppressed, 48 successfully underwent resistance testing with some resistance detected in most (41/48).

CONCLUSIONS

Most (64%) second-line treatment failure in this clinic is related to adherence and can be overcome with careful adherence support. Controlled interventions are needed to determine what the optimal approach is to improving second-line outcomes and reducing the need for third-line ART.

Outcomes and factors associated with survival of patients with HIV/AIDS initiating antiretroviral treatment in Liangshan Prefecture, southwest of China: A retrospective cohort study from 2005 to 2013

Human immunodeficiency virus (HIV)-positive cases have been reported among people who injected drugs in Liangshan Prefecture in southwest of China since 1995 and Liangshan has become one of the most seriously affected epidemic areas in China. In 2004, several patients with HIV/acquired immunodeficiency syndrome (AIDS) initiated antiretroviral treatment (ART) at the Central Hospital of Liangshan Prefecture. From 2005 to 2013, the number of patients receiving ART dramatically increased.We conducted a retrospective cohort study to analyze the long-term survival time and associated factors among patients with HIV/AIDS who received ART in Liangshan Prefecture for the first time. Data were collected from the Chinese AIDS Antiretroviral Therapy DATAFax Information System. A life table and the Kaplan-Meier and Cox proportion hazard regression were used to calculate the survival time and its associated factors, respectively.Among 8310 ART-naïve patients with HIV/AIDS who initiated ART, 436 patients died of AIDS-related diseases, and their median time of receiving ART was 15.0 ± 12.3 months, whereas 28.7% of them died within the first 6 months after treatment. The cumulative survival rates of those receiving ART in 1, 2, 3, 4, and 5 years were 97.1%, 93.4%, 90.6%, 88.8%, and 86.0%, respectively. Multivariate Cox regression analysis showed that male patients on ART were at a higher risk of death from AIDS-related diseases (adjusted hazard ratio [AHR] = 1.5, 95% confidence interval [CI]: 1.1-2.1) than female patients. Patients infected with HIV through injection drug use (IDU) were at a higher risk of death (AHR = 1.6, 95% CI: 1.2-2.2) than those infected through heterosexual transmission. Patients with a baseline CD4 cell count <50/mm (AHR = 9.8, 95% CI: 6.0-15.9), 50-199/mm (AHR = 3.3, 95% CI: 2.3-4.6), and 200-349/mm (AHR = 1.7, 95% CI: 1.2-2.3) were at a higher risk of death than those with a CD4 cell count ≥350/mm.ART prolonged survival time of patients with HIV/AIDS and improved their survival probability. Patients with HIV/AIDS should be consistently followed up and the CD4 T-cell count regularly monitored, and timely and early antiretroviral therapy initiated in order to achieve a better survival rate.

Drug resistance mutations after the first 12 months on antiretroviral therapy and determinants of virological failure in Rwanda

OBJECTIVE

To evaluate HIV drug resistance (HIVDR) and determinants of virological failure in a large cohort of patients receiving first-line tenofovir-based antiretroviral therapy (ART) regimens.

METHODS

A nationwide retrospective cohort from 42 health facilities was assessed for virological failure and development of HIVDR mutations. Data were collected at ART initiation and at 12 months of ART on patients with available HIV-1 viral load (VL) and ART adherence measurements. HIV resistance genotyping was performed on patients with VL ≥1000 copies/ml. Multiple logistic regression was used to determine factors associated with treatment failure.

RESULTS

Of 828 patients, 66% were women, and the median age was 37 years. Of the 597 patients from whom blood samples were collected, 86.9% were virologically suppressed, while 11.9% were not. Virological failure was strongly associated with age <25 years (adjusted odds ratio [aOR]: 6.4; 95% confidence interval [CI]: 3.2-12.9), low adherence (aOR: 2.87; 95% CI: 1.5-5.0) and baseline CD4 counts <200 cells/μl (aOR 3.4; 95% CI: 1.9-6.2). Overall, 9.1% of all patients on ART had drug resistance mutations after 1 year of ART; 27% of the patients who failed treatment had no evidence of HIVDR mutations. HIVDR mutations were not observed in patients on the recommended second-line ART regimen in Rwanda.

CONCLUSIONS

The last step of the UNAIDS 90-90-90 target appears within grasp, with some viral failures still due to non-adherence. Nonetheless, youth and late initiators are at higher risk of virological failure. Youth-focused programmes could help prevent further drug HIVDR development.

Implementation and Operational Research: Cost-Effectiveness of Antiretroviral Therapy and Isoniazid Prophylaxis to Reduce Tuberculosis and Death in People Living With HIV in Botswana

OBJECTIVE

In Botswana, a 36-month course of isoniazid treatment of latent tuberculosis (TB) infection [isoniazid preventive therapy (IPT)] was superior to 6-month IPT in reducing TB and death in persons living with HIV (PLHIV), having positive tuberculin skin tests (TSTs) but not in those with negative TST. We examined the cost-effectiveness of IPT in Botswana, where antiretroviral therapy (ART) is widely available.

DESIGN

Using a decision-analytic model, we determined the incremental cost-effectiveness of strategies for reducing TB and death in 10,000 PLHIV over 36 months.

METHODS

IPT for 6 months and provision of ART if CD4 lymphocyte count <250 cells per microliter (2011 Botswana policy) was compared with 6 alternative strategies that varied the use of IPT, TST, and ART for CD4 count thresholds, including CD4 <350 and <500 cells per microliter.

RESULTS

Botswana policy, 2011 was dominated by most other strategies. IPT of 36 months for TST-positive PLHIV with ART for CD4 <250 cells per microliter resulted in 120 fewer TB cases for an additional cost of $1612 per case averted and resulted in 80 fewer deaths for an additional $2418 per death averted compared with provision of 6-month IPT to TST-positive PLHIV who received ART for CD4 <250 cells per microliter, the next most effective strategy. Alternative strategies offered lower incremental effectiveness at higher cost. These findings remained consistent in sensitivity analyses.

CONCLUSIONS

A strategy of treating PLHIV who have positive TST with 36-month IPT is more cost effective for reducing both TB and death compared with providing IPT without a TST, providing only 6-month IPT, or expanding ART eligibility without IPT.

Clinical progression of severely immunosuppressed HIV-infected patients depends on virological and immunological improvement irrespective of baseline status

OBJECTIVES

The aim of this study was to analyse factors associated with progression to AIDS/death in severely immunosuppressed HIV-infected patients receiving ART.

METHODS

This study included naive patients from the PISCIS Cohort with CD4 <200 cells/mm(3) at enrolment and who initiated ART consisting of two nucleoside analogues plus either a PI or an NNRTI between 1998 and 2011. The PISCIS Cohort is a multicentre, observational study of HIV-infected individuals aged >18 years followed at 14 participating hospitals in Catalonia and the Balearic Islands (Spain). Clinical and laboratory parameters were assessed every 3-4 months during follow-up. Cox regression models were used to assess the effect of CD4 and viral load on the risk of progression to AIDS/death, adjusting for baseline variables and confounders.

RESULTS

2295 patients were included and, after 5 years, 69.9% reached CD4 ≥200 cells/mm(3), 64.4% had an undetectable viral load and 482 (21%) progressed to AIDS/death. The lowest rate of disease progression was found in patients who reached both immunological and viral responses during follow-up, regardless of their baseline situation (1.9% in baseline CD4 >100 cells/mm(3) and viral load <5 log copies/mL; 2.3% in baseline CD4 ≤100 cells/mm(3) and/or viral load >5 log copies/mL). Achieving a CD4 count ≥200 cells/mm(3) was the main predictor of decreased progression to AIDS/death. In those not reaching this CD4 threshold, virological response reduced disease progression by half.

CONCLUSIONS

Even in the worse baseline scenario of CD4 ≤100 cells/mm(3) and high baseline viral loads, positive virological and immunological responses were associated with dramatic decreases in progression.

Treatment outcomes and their determinants in HIV patients on Anti-retroviral Treatment Program in selected health facilities of Kembata and Hadiya zones, Southern Nations, Nationalities and Peoples Region, Ethiopia

Background

Ethiopia has been providing free Antiretroviral Treatment (ART) since 2005 for HIV/AIDS patients. ART improves survival time and quality of life of HIV patients but ART treatment outcomes might be affected by several factors. However, factors affecting treatment outcomes are poorly understood in Ethiopia. Hence, this study assesses treatment outcomes and its determinants for HIV patients on ART in selected health facilities of Kembata and Hadiya zones.

Methods

A retrospective cohort study was conducted on 730 adult HIV/AIDS patients who enrolled antiretroviral therapy from 2007 to 2011 in four selected health facilities of Kembata and Hadiya zones of Southern Ethiopia. Study subjects were sampled from the health facilities based on population proportion to size. Data was abstracted using data extraction format from medical records. Kaplan-Meier survival function was used to estimate survival probability. Cox proportional hazards regression model was used to identify factors associated with time to death.

Result

Median age of patients was 32.4 years with Inter Quartile Range (IQR) [15, 65]. The female to male ratio of the study participants’ was 1.4:1. Median CD4 count significantly increased during the last four consecutive years of follow up. A total of 92 (12.6 %) patients died, 106(14.5 %) were lost to follow-up, and 109(15 %) were transferred out. Sixty three (68 %) deaths occurred in the first 6 months of treatment. The median survival time was 25 months with IQR [9, 43]. After adjustment for confounders, WHO clinical stage IV [HR 2.42; 95 % CI, 1.19, 5.86], baseline CD4 lymphocyte counts of 201 cell/mm³ and 350 cell/mm³ [HR 0.20; 95 % CI; 0.09−0.43], poor regimen adherence [HR 2.70 95 % CI: 1.4096, 5.20], baseline hemoglobin level of 10gm/dl and above [HR 0.23; 95 % CI: 0.14, 0.37] and baseline functional status of bedridden [HR 3.40; 95 % CI: 1.61, 7.21] were associated with five year survival of HIV patients on ART.

Conclusion

All people living with HIV/AIDS should initiate ART as early as possible. Initiation of ART at the early stages of the disease, before deterioration of the functional status of the patients and before the reduction of CD4 counts and hemoglobin levels with an intensified health education on adherence to ART regimen is recommended.

High Drop-off Along the HIV Care Continuum and ART Interruption Among Female Sex Workers in the Dominican Republic

BACKGROUND

Engagement in HIV care offers clear individual and societal benefits, but little evidence exists on the care experiences of key populations.

METHODS

A cross-sectional survey was conducted with 268 female sex workers (FSWs) living with HIV in Santo Domingo, Dominican Republic, to describe the HIV care continuum and to determine factors associated with antiretroviral therapy (ART) interruption.

RESULTS

FSWs disengaged throughout the care continuum with the highest drop-off after ART initiation. Most participants were linked to care (92%), retained in care (85%), and initiated onto ART (78%), but ART discontinuation and irregular adherence were frequent. Only 48% of participants had an undetectable HIV viral load. Overall, 36% of participants ever initiated onto ART reported lifetime experience with ART interruption. The odds of ART interruption were 3.24 times higher among women who experienced FSW-related discrimination [95% confidence interval (CI): 1.28 to 8.20], 2.41 times higher among women who used any drug (95% CI: 1.09 to 5.34), and 2.35 times higher among women who worked in an FSW establishment (95% CI: 1.20 to 4.60). Internalized stigma related to FSW was associated with higher odds of interruption (adjusted odds ratio: 1.09; 95% CI: 1.02 to 1.16), and positive perceptions of HIV providers were protective (adjusted odds ratio: 0.91; 95% CI: 0.85 to 0.98).

CONCLUSIONS

FSWs living with HIV confront multiple barriers throughout the HIV care continuum, many of which are related to the social context and stigmatization of sex work. Given the clear importance of maximizing the potential benefits of engagement in HIV care, there is an urgent need for interventions to support FSWs throughout the HIV care continuum.

Effect of baseline CD4 cell count at linkage to HIV care and at initiation of antiretroviral therapy on mortality in HIV-positive adult patients in Rwanda: a nationwide cohort study

BACKGROUND

Continued debate exists about whether initiation of antiretroviral therapy (ART) in symptom-free patients at higher baseline CD4 cell counts results in important clinical benefits. We aimed to examine to what extent baseline CD4 cell count at linkage to HIV care and at ART initiation predicts mortality in adults with HIV in Rwanda.

METHODS

We included data for patients with HIV in Rwanda who were aged 15 years or older and linked to care or initiated ART between Jan 1, 1997, and April 30, 2014, from nationally representative databases. We analysed the effect on mortality of baseline CD4 cell count at ART initiation and at linkage to care. Follow-up time was measured from time of ART initiation and from linkage to HIV care to study exit. To account for effect modification by time, we stratified by era of linkage (before 2008 vs 2008 or after) and for other indications for initiation of ART. We also stratified CD4 cell count by indication to initiate ART other than CD4 cell count status. We used Cox proportional hazard regressions to examine the effect of CD4 cell count at linkage and at ART initiation on mortality.

FINDINGS

Our analysis was based on data from 50,147 patients who initiated ART and 72,061 patients linked to care. In the late era (2008 and after), linkage to care at a CD4 cell count of 100-199 cells per μL without any further indication was associated with higher mortality than linkage at 200-349 cells per μL (hazard ratio [HR] 1·37, 95% CI 0·95-1·97); the effect was much the same for initiation of ART in this CD4 stratum (1·37, 0·92-2·04). For higher CD4 strata, linkage to care at 500 cells per μL or more was protective (0·53, 0·39-0·72), whereas the reported effect of initiation of ART on mortality was not distinguishable from chance alone (0·82, 0·21-3·20).

INTERPRETATION

Efforts are needed to link and retain patients early in pre-ART HIV care. In settings where ART is not yet available for immediate treatment, retention in a strong pre-ART programme is effective at improving survival.

FUNDING

The Bill & Melinda Gates Foundation.

Retention in HIV care among female sex workers in the Dominican Republic: implications for research, policy and programming

There are clear benefits of retention in HIV care, yet millions of people living with HIV are sub-optimally retained. This study described factors from Andersen's behavioral model that were associated with retention in HIV care among 268 female sex workers (FSWs) living with HIV in the Dominican Republic using two measures of retention: a 6-month measure of HIV clinic attendance and a measure that combined clinic attendance and missed visits. FSWs who ever attended HIV care reported high rates (92 %) of 6-month attendance, but 37 % reported missed visits. Using the combined retention measure, the odds of being retained in HIV care were higher among FSWs with more positive perceptions of HIV service providers [adjusted odds ratio (AOR) 1.17; 95 % confidence interval (CI) 01.09, 1.25] and lower among women who reported recent alcohol consumption (AOR 0.50; 95 % CI 0.28, 0.92) and self-stigmatizing beliefs related to sex work (AOR 0.93; 95 % CI 0.88, 0.98). These findings support the hypothesis that retention in HIV care may be best determined through a combined measure as missed visits are an important mechanism to identify in-care patients who require additional support.

Pattern of linkage and retention in HIV care continuum among patients attending referral HIV care clinic in private sector in India

Continued engagement throughout the HIV care continuum, from HIV diagnosis through retention on antiretroviral therapy (ART), is crucial for enhancing impact of HIV care programs. We assessed linkage and retention in HIV care among people living with HIV (PLHIV) enrolled at a private HIV care clinic in Pune, India. Of 1220 patients, 28% delayed linkage after HIV diagnosis with a median delay of 24 months (IQR = 8-43). Younger people, women, low socioeconomic status, and those diagnosed at facilities other than the study clinic were more likely to delay linkage. Those with advanced HIV disease at diagnosis and testing for HIV due to HIV-related illness were linked to care immediately. Of a total of 629 patients eligible for ART at first CD4 count, 68% initiated ART within 3 months. Among those not eligible for ART, only 46% of patients sought subsequent CD4 count in time. Multivariate logistic regression analysis revealed that patients with initial CD4 count of 350-500 cells/cu mm (OR: 2, 95% CI: 1.1-3.5) and >500 cells/cu mm (OR: 2.1, 95% CI: 1.2-3.7) were less likely to do subsequent CD4 test on time as compared to those with CD4 < 50 cells/cu mm. Among patients not eligible for ART, those having >12 years of education (OR: 0.4, 95% CI: 0.2-0.9) were more likely to have timely uptake of subsequent CD4 count. Among ART eligible patients, being an unskilled laborer (OR: 2.2, 95% CI: 1.1-4.2) predicted lower uptake. The study highlights a long delay from HIV diagnosis to linkage and further attrition during pre-ART and ART phases. It identifies need for newer approaches aimed at timely linkage and continued retention for patients with low education, unskilled laborers, and importantly, asymptomatic patients.

Attrition through multiple stages of pre-treatment and ART HIV care in South Africa

INTRODUCTION

While momentum for increasing treatment thresholds is growing, if patients cannot be retained in HIV care from the time of testing positive through long-term adherence to antiretroviral therapy (ART), such strategies may fall short of expected gains. While estimates of retention on ART exist, few cohorts have data on retention from testing positive through long-term ART care.

METHODS

We explored attrition (loss or death) at the Themba Lethu HIV clinic, Johannesburg, South Africa in 3 distinct cohorts enrolled at HIV testing, pre-ART initiation, and ART initiation.

RESULTS

Between March 2010 and August 2012 we enrolled 380 patients testing HIV+, 206 initiating pre-ART care, and 185 initiating ART. Of the 380 patients enrolled at testing HIV-positive, 38.7% (95%CI: 33.9-43.7%) returned for eligibility staging within ≤3 months of testing. Of the 206 enrolled at pre-ART care, 84.5% (95%CI: 79.0-88.9%) were ART eligible at their first CD4 count. Of those, 87.9% (95%CI: 82.4-92.2%) initiated ART within 6 months. Among patients not ART eligible at their first CD4 count, 50.0% (95%CI: 33.1-66.9%) repeated their CD4 count within one year of the first ineligible CD4. Among the 185 patients in the ART cohort, 22 transferred out and were excluded from further analysis. Of the remaining 163, 81.0% (95%CI: 74.4-86.5%) were retained in care through two years on treatment.

CONCLUSIONS

Our findings from a well-resourced clinic demonstrate continual loss from all stages of HIV care and strategies to reduce attrition from all stages of care are urgently needed.

Retention and risk factors for attrition in a large public health ART program in Myanmar: a retrospective cohort analysis

Background

The outcomes from an antiretroviral treatment (ART) program within the public sector in Myanmar have not been reported. This study documents retention and the risk factors for attrition in a large ART public health program in Myanmar.

Methods

A retrospective analysis of a cohort of adult patients enrolled in the Integrated HIV Care (IHC) Program between June 2005 and October 2011 and followed up until April 2012 is presented. The primary outcome was attrition (death or loss-follow up); a total of 10,223 patients were included in the 5-year cumulative survival analysis. Overall 5,718 patients were analyzed for the risk factors for attrition using both logistic regression and flexible parametric survival models.

Result

The mean age was 36 years, 61% of patients were male, and the median follow up was 13.7 months. Overall 8,564 (84%) patients were retained in ART program: 750 (7%) were lost to follow-up and 909 (9%) died. During the 3 years follow-up, 1,542 attritions occurred over 17,524 person years at risk, giving an incidence density of 8.8% per year. The retention rates of participants at 12, 24, 36, 48 and 60 months were 86, 82, 80, 77 and 74% respectively. In multivariate analysis, being male, having high WHO staging, a low CD4 count, being anaemic or having low BMI at baseline were independent risk factors for attrition; tuberculosis (TB) treatment at ART initiation, a prior ART course before program enrollment and literacy were predictors for retention in the program.

Conclusion

High retention rate of IHC program was documented within the public sector in Myanmar. Early diagnosis of HIV, nutritional support, proper investigation and treatment for patients with low CD4 counts and for those presenting with anaemia are crucial issues towards improvement of HIV program outcomes in resource-limited settings.

Regression discontinuity designs in epidemiology: causal inference without randomized trials

When patients receive an intervention based on whether they score below or above some threshold value on a continuously measured random variable, the intervention will be randomly assigned for patients close to the threshold. The regression discontinuity design exploits this fact to estimate causal treatment effects. In spite of its recent proliferation in economics, the regression discontinuity design has not been widely adopted in epidemiology. We describe regression discontinuity, its implementation, and the assumptions required for causal inference. We show that regression discontinuity is generalizable to the survival and nonlinear models that are mainstays of epidemiologic analysis. We then present an application of regression discontinuity to the much-debated epidemiologic question of when to start HIV patients on antiretroviral therapy. Using data from a large South African cohort (2007-2011), we estimate the causal effect of early versus deferred treatment eligibility on mortality. Patients whose first CD4 count was just below the 200 cells/μL CD4 count threshold had a 35% lower hazard of death (hazard ratio = 0.65 [95% confidence interval = 0.45-0.94]) than patients presenting with CD4 counts just above the threshold. We close by discussing the strengths and limitations of regression discontinuity designs for epidemiology.

Diagnostic accuracy of the WHO clinical staging system for defining eligibility for ART in sub-Saharan Africa: a systematic review and meta-analysis

INTRODUCTION

The World Health Organization (WHO) recommends that HIV-positive adults with CD4 count ≤500 cells/mm(3) initiate antiretroviral therapy (ART). In many countries of sub-Saharan Africa, CD4 count is not widely available or consistently used and instead the WHO clinical staging system is used to determine ART eligibility. However, concerns have been raised regarding its discriminatory ability to identify patients eligible to start ART. We therefore reviewed the accuracy of WHO stage 3 or 4 assessment in identifying ART eligibility according to CD4 count thresholds for ART initiation.

METHODS

We systematically searched PubMed and Global Health databases and conference abstracts using a comprehensive strategy for studies that compared the results of WHO clinical staging with CD4 count thresholds. Studies performed in sub-Saharan Africa and published in English between 1998 and 2013 were eligible for inclusion according to our predefined study protocol. Two authors independently extracted data and assessed methodological quality and risk of bias using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) tool. Summary estimates of sensitivity and specificity were derived for each CD4 count threshold and hierarchical summary receiver operator characteristic curves were plotted.

RESULTS

Fifteen studies met the inclusion criteria, including 25,032 participants from 14 countries. Most studies assessed individuals attending ART clinics prior to treatment initiation. WHO clinical stage 3 or 4 disease had a sensitivity of 60% (95% CI: 45-73%, Q=914.26, p<0.001) and specificity of 73% (95% CI: 60-83%, Q=1439.43, p<0.001) for a CD4 threshold of ≤200 cells/mm(3) (11 studies); sensitivity and specificity for a threshold of CD4 count ≤350 cells/mm(3) were 45% (95% CI: 26-66%, Q=1607.31, p<0.001) and 85% (95% CI: 69-93%, Q=896.70, p<0.001), respectively (six studies). For the threshold of CD4 count ≤500 cells/mm(3) sensitivity was 14% (95% CI: 13-15%) and specificity was 95% (95% CI: 94-96%) (one study).

CONCLUSIONS

When used for individual treatment decisions, WHO clinical staging misses a high proportion of individuals who are ART eligible by CD4 count, with sensitivity falling as CD4 count criteria rises. Access to accurate, accessible, robust and affordable CD4 count testing methods will be a pressing need for as long as ART initiation decisions are based on criteria other than seropositivity.

Short communication: Lower baseline CD4 count is associated with a greater propensity toward virological failure in a cohort of South African HIV patients

The antiretroviral (ARV) service at Edendale Hospital in Pietermaritzburg, KwaZulu-Natal, South Africa has initiated more than 9,000 adults on therapy since 2004; however, virological outcomes among this patient cohort have not been systematically assessed. We conducted a retrospective chart review of patients initiating ARVs in recent years of the antiretroviral roll-out to determine the efficacy of this program. Clinic records were randomly selected for patients who had initiated ARVs between January 2009 and December 2012. Demographic and virological data were collected. Virological failure was defined as failure to achieve a plasma viral load (VL) <25 copies/ml after 6-12 months of ARV initiation or ≥2 consecutive HIV-RNA VLs ≥400 copies/ml following suppression of <25 copies/ml. Records for 228 individuals were reviewed. Twenty-one (9%) individuals experienced virological failure necessitating a regimen change. The median (interquartile range, IQR) duration of antiretroviral exposure was 19 (11-31) months. Individuals experiencing virological failure did not differ from individuals experiencing success with regards to sex, age, baseline hemoglobin, creatinine, alanine aminotransferase level, or weight (p>0.05) except for having a lower baseline CD4 [median 74 (IQR 31-94) versus 142 (IQR 61-211) cells/μl; p=0.0036 (Mann-Whitney U test)]. No differences were observed between groups in type of ARV regimen, WHO stage at time of ARV initiation, or tuberculosis status. Therefore, using a relatively strict definition of virological failure, we observed that virological success was achievable in over 90% of individuals at the Edendale Hospital ARV clinic. Lower baseline CD4 was associated with greater propensity toward virological failure.

Predictors of mortality among patients enrolled on antiretroviral therapy in Aksum hospital, northern Ethiopia: a retrospective cohort study

BACKGROUND

Since launching of antiretroviral (ART) treatment, the numbers of patients enrolled in to ART are increasing in many developing countries. But many studies done across Africa including Ethiopia on antiretroviral therapy programs have shown higher mortality at the first six months of treatment initiation. But the factors associated with this high mortality are poorly characterized. So this study aims to determine mortality and identify predictors of it among patients on ART.

METHODS

Retrospective cohort study was employed among a total of 520 records of patients who were enrolled on antiretroviral therapy in Aksum hospital from September 2006 to August 2011. Baseline patient records were extracted from electronic and paper based medical records database and analysed using Kaplan Meier survival and Cox proportional hazard model to identify the independent predictors of mortality of patients on ART.

RESULTS

A total of 46 (8.85%) deaths was observed giving an overall mortality rate of 3.2 per 100 person-years. The independent predictor of mortality identified for this cohort were haemoglobin level <11 mg/dl (Hazard Ratio (HR) = 1.9, 95%-CI = 1.01, 3.52), CD4 cell counts lower than 50 cells/µl (HR = 2.1, 95%- CI = 1.13,3.89), Male gender (HR = 1.9, 95%-CI = 1.01,3.52), Weight <40 kg (HR = 2.3,95% CI = 1.24,4.55), primary level of education and lower (HR = 2.6, 95%- CI = 1.29,5.55).

CONCLUSIONS

The over all mortality of adults patients on ART was low but higher in the early months of ART initiation. low levels of haemoglobin <11 gm/dl, lower CD4 cell count, male gender, weight <40 Kg and individuals who have primary level of education and lower were identified as the independent predictors of mortality. For this reason, early initiation of ART despite the CD4 count and method of HIV diagnosis, nutritional support and close monitoring of patients in the early periods of ART treatment initiation is very crucial to improve patient survival.

Patient retention, clinical outcomes and attrition-associated factors of HIV-infected patients enrolled in Zimbabwe's National Antiretroviral Therapy Programme, 2007-2010

Background

Since establishment of Zimbabwe's National Antiretroviral Therapy (ART) Programme in 2004, ART provision has expanded from <5,000 to 369,431 adults by 2011. However, patient outcomes are unexplored.

Objective

To determine improvement in health status, retention and factors associated with attrition among HIV-infected patients on ART.

Methods

A retrospective review of abstracted patient records of adults ≥15 years who initiated ART from 2007 to 2009 was done. Frequencies and medians were calculated for rates of retention in care and changes in key health status outcomes at 6, 12, 24 and 36 months respectively. Cox proportional hazards models were used to determine factors associated with attrition.

Results

Of the 3,919 patients, 64% were female, 86% were either WHO clinical stage III or IV. Rates of patient retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. After ART initiation, median weight gains at 6, 12, and 24 months were 3, 4.5, and 5.0 kgs whilst median CD4+ cell count gains at 6, 12 and 24 months were 122, 157 and 279 cells/µL respectively. Factors associated with an increased risk of attrition included male gender (AHR 1.2; 95% CI, 1.1–1.4), baseline WHO stage IV (AHR 1.7; 95% CI, 1.1–2.6), lower baseline body weight (AHR 2.0; 95% CI, 1.4–2. 8) and accessing care from higher level healthcare facilities (AHR 3.5; 95% 1.1–11.2).

Conclusions

Our findings with regard to retention as well as clinical and immunological improvements following uptake of ART, are similar to what has been found in other settings. Factors influencing attrition also mirror those found in other parts of sub-Saharan Africa. These findings suggest the need to strengthen earlier diagnosis and treatment to further improve treatment outcomes. Whilst decentralisation improves ART coverage it should be coupled with strategies aimed at improving patient retention.

Trends in clinical characteristics of HIV-infected patients initiating antiretroviral therapy in Shanghai from 2006 to 2011

This study aimed to characterise the clinical characteristics of HIV-infected patients accessing antiretroviral therapy (ART) in Shanghai, China, from 2006 to 2011. We retrospectively reviewed the records of patients who initiated ART in Shanghai during the 6-year period of 2006 through 2011. The median age at ART initiation decreased from 41 years in 2008 to 38 years in 2011. The median CD4 counts at ART initiation rose from 65 cells/mm(3)in 2006 to 203 cells/mm(3)in 2011. The proportion of patients with CD4 counts <200 cells/mm(3)at ART initiation decreased from 88.5% in 2006 to 49.6% in 2011. The proportion of patients starting stavudine-based regimens of stavudine/lamivudine/efavirenz and stavudine/lamivudine/nevirapine fell from 49.2% in 2006 to 23.4% in 2011. The proportion of patients starting nevirapine-based regimens of zidovudine/lamivudine/nevirapine and stavudine/lamivudine/nevirapine fell from 44.3% in 2006 to 16.5% in 2011. The study reflects that the clinical characteristics of the patients initiating ART in Shanghai have changed over time; ART was increasingly provided in patients with higher CD4 counts; and the regimens containing stavudine were prescribed less frequently. Strategies to facilitate early access to ART and further reduction in stavudine use are needed.

A novel approach to accounting for loss to follow-up when estimating the relationship between CD4 Count at ART initiation and mortality

BACKGROUND

While CD4 strongly predicts mortality on antiretroviral therapy (ART), estimates from programmatic data suffer from incomplete patient outcomes.

METHODS

We conducted a pooled analysis of one-year mortality data on ART accounting for lost patients. We identified articles reporting one-year mortality by ART initiation CD4 count. We estimated the average mortality among those lost as the value that maximizes the fit of a regression of the natural log of mortality on the natural log of the imputed mean CD4 count in each band.

RESULTS

We found 20 studies representing 64,426 subjects and 51 CD4 observations. Without correcting for losses, one-year mortality was >4.8% for all CD4 counts <200 cells/mm(3). When searching over different values for mortality among those lost, the best fitting model occurs at 60% mortality. In this model, those with a CD4≤200 had a one-year mortality above 8.7, while those with a CD4>500 had a one-year mortality <6.8%. Comparing those starting ART at 500 vs. 50, one-year mortality risk was reduced by 54% (6.8 vs. 12.5%). Regardless of CD4 count, mortality was substantially higher than when assuming no mortality among those lost, ranging from a 23-94% increase.

CONCLUSIONS

Our best fitting regression estimates that every 10% increase in CD4 count at initiation is associated with a 2.8% decline in one-year mortality, including those lost. Our study supports the health benefits of higher thresholds for CD4 count initiation and suggests that reports of programmatic ART outcomes can and should adjust results for mortality among those lost.

Entry, Retention, and Virological Suppression in an HIV Cohort Study in India: Description of the Cascade of Care and Implications for Reducing HIV-Related Mortality in Low- and Middle-Income Countries

HIV treatment, care, and support programmes in low- and middle-income countries have traditionally focused more on patients remaining in care after the initiation of antiretroviral therapy (ART) than on earlier stages of care. This study describes the cumulative retention from HIV diagnosis to the achievement of virological suppression after ART initiation in an HIV cohort study in India. Of all patients diagnosed with HIV, 70% entered into care within three months. 65% of patients ineligible for ART at the first assessment were retained in pre-ART care. 67% of those eligible for ART initiated treatment within three months. 30% of patients who initiated ART died or were lost to followup, and 82% achieved virological suppression in the last viral load determination. Most attrition occurred the in pre-ART stages of care, and it was estimated that only 31% of patients diagnosed with HIV engaged in care and achieved virological suppression after ART initiation. The total mortality attributable to pre-ART attrition was considerably higher than the mortality for not achieving virological suppression. This study indicates that early entry into pre-ART care along with timely initiation of ART is more likely to reduce HIV-related mortality compared to achieving virological suppression.

Initiating antiretroviral therapy when presenting with higher CD4 cell counts results in reduced loss to follow-up in a resource-limited setting

OBJECTIVE

In August 2011, South Africa expanded its adult antiretroviral therapy (ART) guidelines to allow treatment initiation at CD4 cell values 350 cells/μl or less. Mortality and morbidity are known to be reduced when initiating at higher CD4 levels; we explored the impact on patient loss to follow-up.

DESIGN

An observational cohort study.

METHODS

We analyzed routine data of 1430 adult patients initiating ART from April to December 2010 from a Johannesburg primary healthcare clinic offering ART initiation at CD4 cell count 350 cells/μl or less since 2010. We compared loss to follow-up (≥3 months late for the last scheduled visit), death, and incident tuberculosis within 1 year of ART initiation for those initiating at CD4 cell values 200 or less versus 201-350 cells/μl.

RESULTS

: Half (52.0%) of patients presented in the lower CD4 cell group [≤200 cells/μl, median: 105 cells/μl, interquartile range (IQR): 55-154] and initiated ART, and 48.0% in the higher group (CD4 cell count 201-350 cells/μl, median: 268 cells/μl, IQR: 239-307). The proportion of women and pregnant women was greater in the high CD4 cell group; the lower CD4 cell group included more patients with prevalent tuberculosis. Among men and nonpregnant women, initiating at 201-350 cells/μl was associated with 26-42% reduced loss to follow-up compared to those initiating 200 cells/μl or less. We found no CD4 cell effect among pregnant women. Risk of mortality [adjusted hazard ratio (aHR) 0.34, 95% confidence interval (CI) 0.13-0.84] and incident tuberculosis (aHR 0.44, 95% CI 0.23-0.85) was lower among the higher CD4 cell group.

CONCLUSION

This is one of the first studies from a routine clinical setting to demonstrate South Africa's 2011 expansion of ART treatment guidelines can be enacted without increasing program attrition.

HIV non-B subtype distribution: emerging trends and risk factors for imported and local infections newly diagnosed in South Australia

Monitoring HIV subtype distribution is important for understanding transmission dynamics. Subtype B has historically been dominant in Australia, but in recent years new clades have appeared. Since 2000, clade data have been collected as part of HIV surveillance in South Australia. The aim of this study was to evaluate the prevalence of and risk factors for HIV-1 non-B subtypes. The study population was composed of newly diagnosed, genotyped HIV subjects in South Australia between 2000 and 2010. We analyzed time trends and subtype patterns in this cohort; notification data were aggregated into three time periods (2000-2003, 2004-2006, and 2007-2010). Main outcome measures were number of new non-B infections by year, exposure route, and other demographic characteristics. There were 513 new HIV diagnoses; 425 had information on subtype. The majority (262/425) were in men who have sex with men (MSM), predominantly subtype B and acquired in Australia. Infections acquired in Australia decreased from 77% (2000-2003) to 64% (2007-2010) (p=0.007) and correspondingly the proportion of subtype B declined from 85% to 68% (p=0.002). Non-B infections were predominantly (83%) heterosexual contacts, mostly acquired overseas (74%). The majority (68%) of non-B patients were born outside of Australia. There was a nonsignificant increase from 1.6% to 4.2% in the proportion of locally transmitted non-B cases (p=0.3). Three non-B subtypes and two circulating recombinant forms (CRFs) were identified: CRF_AE (n=41), C (n=36), CRF_AG (n=13), A (n=9), and D (n=2). There has been a substantial increase over the past decade in diagnosed non-B infections, primarily through cases acquired overseas.

Improved survival and antiretroviral treatment outcomes in adults receiving community-based adherence support: 5-year results from a multicentre cohort study in South Africa

INTRODUCTION

A large increase in lay health care workers has occurred in response to shortages of professional health care staff in sub-Saharan African antiretroviral treatment (ART) programs. However, little effectiveness data of the large-scale implementation of these programs is available. We evaluated the effect of a community-based adherence-support (CBAS) program on ART outcomes across 57 South African sites.

METHODS

CBAS workers provide adherence and psychosocial support for patients and undertake home visits to address household challenges affecting adherence. An observational multicohort study of adults enrolling for ART between 2004 and 2010 was performed. Mortality, loss to follow-up, and virological suppression were compared by intention to treat between patients who received and did not receive CBAS until 5 years of ART, using multiple imputation of missing covariate values.

RESULTS

Of the 66,953 patients who were included, 19,668 (29.4%) patients received CBAS and 47,285 (70.6%) patients did not. Complete-case covariate data were available for 54.3% patients. After 5 years, patient retention was 79.1% [95% confidence interval (CI): 77.7% to 80.4%] in CBAS patients versus 73.6% (95% CI: 72.6% to 74.5%) in non-CBAS patients; crude hazard ratio (HR) for attrition was 0.68 (95% CI: 0.65 to 0.72). Mortality and loss to follow-up were independently lower in CBAS patients, adjusted HR (aHR) was 0.65 (95% CI: 0.59 to 0.72) and 0.63 (95% CI: 0.59 to 0.68), respectively. After 6 months of ART, virological suppression was 76.6% (95% CI: 75.8% to 77.5%) in CBAS patients versus 72% (95% CI: 71.3% to 72.5%) in non-CBAS patients (P < 0.0001), adjusted odds ratio was 1.22 (95% CI: 1.14 to 1.30). Improvement in virological suppression occurred progressively for longer durations of ART [adjusted odds ratio was 2.66 (95% CI: 1.61 to 4.40) by 5 years].

CONCLUSIONS

Patients receiving CBAS had considerably better ART outcomes. Further scale-up of these programs should be considered in low-income settings.

HIV-1 subtype distribution and its demographic determinants in newly diagnosed patients in Europe suggest highly compartmentalized epidemics

Background

Understanding HIV-1 subtype distribution and epidemiology can assist preventive measures and clinical decisions. Sequence variation may affect antiviral drug resistance development, disease progression, evolutionary rates and transmission routes.

Results

We investigated the subtype distribution of HIV-1 in Europe and Israel in a representative sample of patients diagnosed between 2002 and 2005 and related it to the demographic data available. 2793 PRO-RT sequences were subtyped either with the REGA Subtyping tool or by a manual procedure that included phylogenetic tree and recombination analysis. The most prevalent subtypes/CRFs in our dataset were subtype B (66.1%), followed by sub-subtype A1 (6.9%), subtype C (6.8%) and CRF02_AG (4.7%). Substantial differences in the proportion of new diagnoses with distinct subtypes were found between European countries: the lowest proportion of subtype B was found in Israel (27.9%) and Portugal (39.2%), while the highest was observed in Poland (96.2%) and Slovenia (93.6%). Other subtypes were significantly more diagnosed in immigrant populations. Subtype B was significantly more diagnosed in men than in women and in MSM > IDUs > heterosexuals. Furthermore, the subtype distribution according to continent of origin of the patients suggests they acquired their infection there or in Europe from compatriots.

Conclusions

The association of subtype with demographic parameters suggests highly compartmentalized epidemics, determined by social and behavioural characteristics of the patients.

Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings

The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world's HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.

Rates of emergence of HIV drug resistance in resource-limited settings: a systematic review

BACKGROUND

The increasing availability of antiretroviral therapy (ART) has improved survival and quality of life for many infected with HIV, but can also engender drug resistance. This review summarizes the available information on drug resistance in adults in resource-limited settings.

METHODS

The online databases PubMed and Google Scholar, pertinent conference abstracts and references from relevant articles were searched for publications available before November 2011. Data collected after ART rollout were reviewed.

RESULTS

A total of 7 studies fulfilled the criteria for the analysis of acquired drug resistance and 22 fulfilled the criteria for the analysis of transmitted drug resistance (TDR). Acquired resistance was detected in 7.2% of patients on ART for 6-11 months, 11.1% at 12-23 months, 15.0% at 24-35 months, and 20.7% at ≥ 36 months. Multi-class drug resistance increased steadily with time on ART. The overall rate of TDR in all resource-limited countries studied was 6.6% (469/7,063). Patients in countries in which ART had been available for ≥ 5 years were 1.7 × more likely to have TDR than those living in a country where ART had been available for <5 years (P<0.001). The reported prevalence of TDR was 5.7% (233/4,069) in Africa, 7.6% (160/2,094) in Asia and 8.4% (76/900) in Brazil.

CONCLUSIONS

The emergence of drug resistance following access to ART in resource-limited settings resembles what was seen in resource-rich countries and highlights the need for virological monitoring for drug failure, drug resistance testing and alternative drug regimens that have proven beneficial in these resource-rich settings.

Viral load monitoring of antiretroviral therapy, cohort viral load and HIV transmission in Southern Africa: a mathematical modelling analysis

OBJECTIVES

In low-income settings, treatment failure is often identified using CD4 cell count monitoring. Consequently, patients remain on a failing regimen, resulting in a higher risk of transmission. We investigated the benefit of routine viral load monitoring for reducing HIV transmission.

DESIGN

Mathematical model.

METHODS

We developed a stochastic mathematical model representing the course of individual viral load, immunological response and survival in a cohort of 1000 HIV-infected patients receiving antiretroviral therapy (ART) in southern Africa. We calculated cohort viral load (CVL; sum of individual viral loads) and used a mathematical relationship between individual viral load values and transmission probability to estimate the number of new HIV infections. Our model was parameterized with data from the International epidemiologic Databases to Evaluate AIDS Southern African collaboration. Sensitivity analyses were performed to assess the validity of the results in a universal 'test and treat' scenario, wherein patients start ART earlier after HIV infection.

RESULTS

If CD4 cell count alone was regularly monitored, the CVL was 2.6 × 10 copies/ml and the treated patients transmitted on average 6.3 infections each year. With routine viral load monitoring, both CVL and transmissions were reduced by 31% to 1.7 × 10 copies/ml and 4.3 transmissions, respectively. The relative reduction of 31% between monitoring strategies remained similar for different scenarios.

CONCLUSION

Although routine viral load monitoring enhances the preventive effect of ART, the provision of ART to everyone in need should remain the highest priority.

Predictors of linkage to care following community-based HIV counseling and testing in rural Kenya

Despite innovations in HIV counseling and testing (HCT), important gaps remain in understanding linkage to care. We followed a cohort diagnosed with HIV through a community-based HCT campaign that trained persons living with HIV/AIDS (PLHA) as navigators. Individual, interpersonal, and institutional predictors of linkage were assessed using survival analysis of self-reported time to enrollment. Of 483 persons consenting to follow-up, 305 (63.2%) enrolled in HIV care within 3 months. Proportions linking to care were similar across sexes, barring a sub-sample of men aged 18-25 years who were highly unlikely to enroll. Men were more likely to enroll if they had disclosed to their spouse, and women if they had disclosed to family. Women who anticipated violence or relationship breakup were less likely to link to care. Enrollment rates were significantly higher among participants receiving a PLHA visit, suggesting that a navigator approach may improve linkage from community-based HCT campaigns.

Assessment at antiretroviral clinics during TB treatment reduces loss to follow-up among HIV-infected patients

SETTING

A South African township clinic where loss to follow-up during TB treatment may prevent HIV-infected TB patients from receiving life-saving ART.

OBJECTIVE

To determine factors associated with loss to follow-up during TB treatment.

DESIGN

Regression analyses of a cohort of ART-eligible TB patients who commenced TB treatment and were followed for 24 weeks.

RESULTS

Of 111 ART-eligible TB patients, 15 (14%) died in the ensuing 24 weeks. Of the remaining 96 TB patients, 11 (11%) were lost to follow-up. All TB patients lost to follow-up did not initiate ART. Of 85 TB patients in follow-up, 62 (73%) initiated ART 56 days after TB diagnosis (median, IQR 33-77 days) and 31 days after initial assessment at an ART clinic (median, IQR: 18-55 days). The median duration from TB diagnosis to initial assessment at an ART clinic was 19 days (IQR: 7-48 days). At 24 weeks, 6 of 85 (7%) TB patients who presented to an ART clinic for assessment were lost to follow-up, compared to 5 of 11 (45%) TB patients who did not present to an ART clinic for assessment. Logistic regression analysis (adjusted odds ratio = 0.1, 95% confidence interval [95% CI]: 0.03-0.66) and our Cox proportional hazards model (hazard ratio = 0.2, 95% CI: 0.04-0.68) confirmed that assessment at an ART clinic during TB treatment reduced loss to follow-up.

CONCLUSION

Assessment at antiretroviral clinics for HIV care by trained health-care providers reduces loss to follow-up among HIV-infected patients with TB.

Cohort profile: the Themba Lethu Clinical Cohort, Johannesburg, South Africa

The Themba Lethu Clinical Cohort was established in 2004 to allow large patient-level analyses from a single HIV treatment site to evaluate National Treatment Guidelines, answer questions of national and international policy relevance and to combine an economic and epidemiologic focus on HIV research. The current objectives of the Themba Lethu Clinical Cohort analyses are to: (i) provide cohort-level information on the outcomes of HIV treatment; (ii) evaluate aspects of HIV care and treatment that have policy relevance; (iii) evaluate the cost and cost-effectiveness of different approaches to HIV care and treatment; and (iv) provide a platform for studies on improving HIV care and treatment. Since 2004, Themba Lethu Clinic has enrolled approximately 30,000 HIV-positive patients into its HIV care and treatment programme, over 21,000 of whom have received anti-retroviral therapy since being enrolled. Patients on treatment are typically seen at least every 3 months with laboratory monitoring every 6 months to 1 year. The data collected include demographics, clinical visit data, laboratory data, medication history and clinical diagnoses. Requests for collaborations on analyses can be submitted to our data centre.

Treatment options for anal intraepithelial neoplasia and evidence for their effectiveness

There is a growing range of treatment options for anal intraepithelial neoplasia (AIN). In HIV-positive patients, sustained treatment is often required to achieve clearance. The treatments considered are topically applied fluorouracil, imiquimod, cidofovir and trichloroacetic acid, the potential treatments of topical lopinavir and photodynamic therapy with aminolevulenic acid, and the surgical methods of electrosurgery, infrared coagulation and laser. Destructive treatment methods, possibly including TCA, are more effective than self applied topical treatments. Combining or alternating different treatments should be considered.

Time to initiation of antiretroviral therapy among patients with HIV-associated tuberculosis in Cape Town, South Africa

We studied the time interval between starting tuberculosis treatment and commencing antiretroviral treatment (ART) in HIV-infected patients (n = 1433; median CD4 count 71 cells per microliter, interquartile range: 32-132) attending 3 South African township ART services between 2002 and 2008. The overall median delay was 2.66 months (interquartile range: 1.58-4.17). In adjusted analyses, delays varied between treatment sites but were shorter for patients with lower CD4 counts and those treated in more recent calendar years. During the most recent period (2007-2008), 4.7%, 19.7%, and 51.1% of patients started ART within 2, 4, and 8 weeks of tuberculosis treatment, respectively. Operational barriers must be tackled to permit further acceleration of ART initiation as recommended by 2010 WHO ART guidelines.

Current challenges to viral load testing in the context of emerging genetic diversity of HIV-1

INTRODUCTION

One of the major characteristics of HIV-1 is its extreme genetic diversity. A key factor in assessing the sensitivity of a molecular-based assay measuring HIV-1 RNA viral load (VL) in plasma is its ability to detect/quantify all (or most of) relevant HIV-1 genetic subtype/recombinant forms accurately.

AREAS COVERED

This review provides an overview of the current commercially available quantitative real-time assays (the Abbott RealTime HIV-1, Roche TaqMan HIV-1 versions 1.0 and 2.0, BioMérieux Nuclisens EasyQ HIV-1, Siemens VERSANT HIV-1 RNA 1.0 kinetic PCR, and Biocentric Generic HIV Viral Load assays). For each assay, studies from 2005 to 2010 assessing the impact of HIV-1 genetic diversity on the reliability of HIV-1 RNA quantification are described.

EXPERT OPINION

In light of HIV-1 genetic diversity, a general recommendation to favor one test over the other cannot categorically be made. Larger field evaluations of HIV-1 RNA assays should be conducted in areas where HIV-1 genetic diversity is the highest. The large-scale implementation of HIV-1 VL testing is urgently required in the developing world to change HIV infection from a likely death sentence into a manageable chronic infection, as done in Northern countries.