A superiority of viral load over CD4 cell count when predicting mortality in HIV patients on therapy

Robustness of viral load over CD4 cell count in measuring the quality of life of people with HIV at second line regimen in Amhara region

Access to medication for people living with HIV in need is a global health priority. Monitoring the quality of life of people under treatment helps to optimize the resource allocated for the program. Therefore, the main objective of the current study was to assess the quality of life comparing viral load and CD4 cell count and factors affecting the variable of interest among HIV-positive people under the second-line regimens. A hospital-based retrospective secondary data were used for the current investigation. The study was conducted in governmental hospitals in Amhara region. ROC curve was used for comparing CD4 cell count and viral load in assessing the quality of life and its predictors. Among the participants in second-line regimen, about 18.3% of them had CD4 cell count < 200 cells/ml of blood and 49.4% of them had detectable/unsuppressed viral load. The result of ROC curve in the current study indicates that viral load was in favors of CD4 cell count in this regard. Among the predictors for quality of life, age of patients, level of CD4 cell count while transferring to second-line regimen, sex of patients, social discrimination, level of education of patients, functional status, adherence level, disclosure status of the disease, mental depression, existence of opportunistic infections and residence area had significant effect on the variable of interest (quality of life). Viral load was in favor of CD4 cell count in assessing the quality of people under treatment. Hence, a close follow ups of patients under treatment at second-line regimen using viral load assessment is highly recommended. Due attention should be given to patients with Unsuppressed HIV viral loads. Hence, awareness creation on how the quality of life be improved should be formulated for patients during visiting times. Knowledge of HIV transmission is also important to reduce the violence and discrimination against those HIV-positive adults to improve their health status. Experience sharing between medication adherent and non-adherent patients may encourage those non-adherent patients to get lessons from adherent patients.

Electrochemical microfluidic biosensor for the detection of CD4+ T cells

Since the onset of the HIV epidemic, assessing CD4+ T-cells has become a routine procedure for evaluating immune deficiency, with flow cytometry established as the gold standard. Over time, various strategies and platforms have been introduced to improve CD4+ cell enumeration, aiming to enhance the performance of diagnostic devices and bring the service closer to patients. These advancements are particularly critical for low-resource settings and point-of-care applications, where the excellent performance of flow cytometry is hindered by its unsuitability in such environments. This work presents an innovative electrochemical microfluidic device that, with further development, could be applied for HIV management in low resource settings. The setup integrates an electrochemical sensor within a PDMS microfluidic structure, allowing for on-chip electrode functionalization and cell detection. Using electrochemical impedance spectroscopy, the biosensor demonstrates a linear detection range from 1.25 × 105 to 2 × 106 cells/mL, with a detection limit of 1.41 × 105 cells/mL for CD4+ cells isolated from blood samples, aligning with clinical ranges for both healthy and HIV+ patients. The biosensor shows specificity towards CD4+ cells with negligible response to monocytes, neutrophils, and bovine serum albumin. Its integration with a microfluidic chip for sensor fabrication and cell detection, compact size, minimal manual handling, ease of fabrication, electrochemical detection capability, and potential for multiplexing together with the detection range make the device particularly advantageous for use in low-resource settings, standing out among other devices described in the literature. This study also investigates the integration of a microfluidic Dean Flow Fractionation (DFF) chip for cell separation.

Does climate change threaten delivery of HIV care in resource-limited settings?

PURPOSE OF REVIEW

Extreme weather events (EWEs) pose a challenge to achieving UNAIDS goal of eliminating HIV as a public health threat by 2030. This review summarizes recent findings describing the disruption of HIV services by EWEs and discusses strategies for a resilient HIV care programme in resource-limited settings.

RECENT FINDINGS

EWEs impact each component of the continuum of care - HIV testing, linkage to treatment, viral suppression and other HIV prevention services. EWEs disrupt healthcare provision either through impacting the ability of the healthcare system to deliver care because of infrastructure damage and increased workload or by limiting people's ability to seek healthcare because of access challenges and forced displacements. This culminates in disengagement from care, poor treatment adherence and increase in HIV disease progression with more vulnerable groups such as women and young people being more adversely impacted.

SUMMARY

Most people affected by or at risk of HIV reside in resource-poor settings which are the region with the least capacity to adapt to climate change. Few recent studies with very limited geographical coverage show that EWEs affect the delivery of HIV care in this setting. Climate adaptation and mitigation policies are required to protect health in resource-limited settings.

A likelihood approach to incorporating self-report data in HIV recency classification

Estimating new HIV infections is significant yet challenging due to the difficulty in distinguishing between recent and long-term infections. We demonstrate that HIV recency status (recent versus long-term) could be determined from self-report testing history and biomarkers, which are increasingly available in bio-behavioral surveys. HIV recency status is partially observed, given the self-report testing history. For example, people who tested positive for HIV over 1 year ago should have a long-term infection. Based on the nationally representative samples collected by the Population-based HIV Impact Assessment (PHIA) Project, we propose a likelihood-based probabilistic model for HIV recency classification. The model incorporates individuals with known recency status based on testing histories and individuals whose recency status could not be determined and integrates the mechanism of how HIV recency status depends on biomarkers and the mechanism of how HIV recency status, together with the self-report time of the most recent HIV test, impacts the test results. We compare our method to logistic regression and the binary classification tree (current practice) on Malawi PHIA data, as well as on simulated data. Our model obtains more efficient and less biased parameter estimates and is relatively robust to potential reporting error and model misspecification.

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.

Impact of Isoniazid Preventive Therapy on Tuberculosis Incidence and Predictors of Tuberculosis Among People Living With HIV/AIDS at Debre Tabor General Hospital, Northwest Ethiopia

Background: The World Health Organization (WHO) recommended isoniazid preventive therapy (IPT) to decrease the effects of tuberculosis (TB) on human immunodeficiency virus (HIV) patients. However, not enough research has been conducted to determine the impact of IPT on TB incidence and their predictors. Therefore, the goal of this study was to evaluate how IPT affects the incidence of TB and identify factors that are predictive of TB among HIV/AIDS patients. Methods: A total of 588 patients at Debre Tabor General Hospital (DTGH) who had taken IPT between December 2009 and January 2016 participated in the current study, which then followed them for 3 years and compared them to patients who did not receive IPT during the study period. The data were gathered from patient registries and charts. IPT users' and nonusers' TB-free survival curves were compared using log-rank testing. Predictors were identified using bivariate and multivariate Cox proportional hazards models. Results: In this study, 1656 person-years (PYs) follow-ups on 588 patients found 82 additional TB cases, with an overall incidence rate (IR) of 4.95/100 PY. When compared to individuals who were not on IPT, the TB IR among patients living with human immunodeficiency virus (PLHIV) on IPT was significantly lower (1.94/100 PY vs. 8.32/100 PY). A baseline CD4 cell count < 200 cells/uL, history of TB, Hgb level < 10 g/dL, BMI < 18.5 kg/m2, and not receiving IPT are independent predictors of TB among HIV/AIDS patients. Conclusion: The frequency of TB was high among PLHIV patients who did not receive IPT. It was discovered that a low CD4 cell count at baseline, a history of TB, IPT status, Hgb level, and BMI independently predicted the presence of TB. Therefore, addressing the independent predictors that are connected to a higher risk of TB in PLHIV as well as isoniazid (INH) prophylaxis has a significant impact on reducing the incidence of TB.

Selenium and zinc supplementation in HIV-infected patients

Background: The Human Immunodeficiency Virus (HIV) epidemic is still a public health concern. Micronutrient deficiencies can fasten the progression of this syndrome. Selenium and zinc are essential trace elements, which exert antioxidant and anti-inflammatory activities in HIV infection. The present overview aimed to evaluate the current knowledge from systematic reviews (SRs) of the effects of selenium and zinc supplementation in HIV patients to show the most updated and comprehensive summary of previous SRs. Methods: The current study was performed according to the guidelines of the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) statements. To assess the quality of articles we used the Measurement Tool to Checklist Assess Systematic Reviews (AMSTAR). PubMed/Medline, Web of Science, Scopus, and EMBASE databases and Google Scholar web search engine were searched up until March 2022, using relevant keywords. Results: Among 3731 articles assessed, five and four studies met the inclusion criteria for selenium and zinc supplementation, respectively. Four studies found that selenium supplementation can be effective in delaying CD4 decline in HIV-infected patients. In four SRs, the dosage of selenium supplementation was 200 μg/day. Three studies, however, reported no significant effect of zinc supplementation on CD4 cell counts, and HIV viral load. The dosage of zinc supplementation ranged from 12 to 100 mg/day. The intervention duration ranged from 2 weeks to 18 months. Conclusion: In the present study, we identified some clinical evidence of a potential beneficial effect of selenium supplementation in HIV-infected patients.

Virological Non-Suppression, Non-Adherence and the Associated Factors Among People Living with HIV on Dolutegravir-Based Regimens: A Retrospective Cohort Study

Background

HIV is one of the leading causes of morbidity and mortality, with 39.0 million people living with HIV worldwide, 25.6 million of whom reside in the African region. Highly active anti-retroviral therapy (HAART) has improved survival and quality of life, yet some patients develop viral non-suppression. Dolutegravir (DTG) has been recommended since 2018 as a first-line treatment option in low- and middle-income countries owing to its effectiveness, low cost, and tolerability, but some studies have reported virological non-suppression with its use. This study aims to explore the prevalence and factors associated with virological non-suppression in adults taking DTG-based regimens in Mbarara Regional Referral Hospital.

Methods

A retrospective cohort study was carried out among people living with HIV (PLWHIV) taking DTG-based HAART regimens by way of record review. SPSS was used for analysis, and both binary and multivariate logistic regression analyses were performed to test associated factors.

Results

Among the 422 participants' records reviewed, 62.8% were female (median age 40 years, IQR=13). The prevalence of virological non-suppression was 4.2%. Poor adherence to HAART was significantly associated with virological non-suppression, with 100.3 increased adjusted odds (95% CI: 28.90-348.12, p<0.001) compared to those with a record of good adherence. The reasons for poor adherence included alcohol use, stigma, forgetting to take medication, transport problems, and irregular timing of swallowing.

Conclusion

This study found poor adherence to be associated with a 4.2% prevalence of virological non-suppression among PLWHIV in a large public HIV care clinic. Despite the high suppression rates on DTG-based regimens, adherence counseling and viral load monitoring need to be emphasized at all HIV care centers to mark the trends of virological non-suppression.

Long-term non-progression and risk factors for disease progression among children living with HIV in Botswana and Uganda: A retrospective cohort study

OBJECTIVES

We utilize a large retrospective study cohort derived from electronic medical records to estimate the prevalence of long-term non-progression (LTNP) and determine the factors associated with progression among children infected with HIV in Botswana and Uganda.

METHODS

Electronic medical records from large tertiary HIV clinical centers in Botswana and Uganda were queried to identify LTNP children 0-18 years enrolled between June 2003 and May 2014 and extract demographic and nutritional parameters. Multivariate subdistribution hazard analyses were used to examine demographic factors and nutritional status in progression in the pre-antiretroviral therapy era.

RESULTS

Between the two countries, 14,246 antiretroviral therapy-naïve children infected with HIV were enrolled into clinical care. The overall proportion of LTNP was 6.3% (9.5% in Botswana vs 5.9% in Uganda). The median progression-free survival for the cohort was 6.3 years, although this was lower in Botswana than in Uganda (6.6 vs 8.8 years; P <0.001). At baseline, the adjusted subdistribution hazard ratio (aHRsd) of progression was increased among underweight children (aHRsd 1.42; 95% confidence interval [CI]: 1.32-1.53), enrolled after 2010 (aHRsd 1.32; 95% CI 1.22-1.42), and those from Botswana (aHRsd 2; 95% CI 1.91-2.10).

CONCLUSIONS

In our study, the prevalence of pediatric LTNP was lower than that observed among adult populations, but progression-free survival was higher than expected. Underweight, year of enrollment into care, and country of origin are independent predictors of progression among children.

Prevalence, severity and associated risk factors of anemia among human immunodeficiency virus-infected adults in Sawla General Hospital, Southern Ethiopia: A facility-based cross-sectional study

BACKGROUND

Anemia is a significant public health problem in HIV/AIDS patients worldwide. This study is aimed to determine the prevalence of anemia and its risk factors among HIV-infected adults in Sawla General Hospital, southern Ethiopia.

METHODS

A facility-based cross-sectional study involving HIV-infected adults was conducted in ART clinic of Sawla General Hospital from April 01 to May 31, 2019. A systematic random sampling technique was employed to recruit the study participants. Socio-demographic and clinical data were collected using a structured questionnaire and checklist. Hemoglobin concentration from venous blood was determined by HemoCue® 301 analyzer. Descriptive and inferential statistics, by Statistical Package for Social Science version 26.0, were applied; p-values ≤ 0.05 in the multivariable logistic regression analysis were considered statistically significant.

RESULTS

A total of 220 HIV-infected adults participated in this study. The prevalence of anemia was 38.6%, from which 90.6, 7.1, and 2.3% are mild, moderate, and severe anemia, respectively. Anemia among HIV-infected adults was significantly associated with CD4 cell count below 200 cells/mm3 (AOR: 4.32; 95% CI: 2.10-8.86), clinical stage III or above (AOR: 4.20; 95% CI: 1.06-16.62), five or more years duration of HIV infection (AOR: 2.32; 95% CI: 1.08-4.94) and BMI below 18.5 kg/m2 (AOR: 3.82; 95% CI: 1.83-8.00).

CONCLUSION

Anemia is a moderate public health problem among the study population. Longer duration of HIV infection, advanced clinical stage, lower CD4 cell count, and BMI are risk factors for anemia. Therefore, early ART enrolment for HIV-infected adults with nutritional support and rigorous monitoring of CD4 cell count are essential to lower the prevalence.

Role of CD4 count estimation in the era of HIV-1 viral load among PLHIV

BACKGROUND

ART has improved the life expectancy of people living with HIV (PLHIV) by suppressing the virus and increasing CD4 count. Some PLHIV shows immune-virological discordant responses i.e. suppressed viral load to the undetectable level but still with immunological failure or good immunological response with virological failure. Immuno-virological response plays a key role to address treatment outcome, regimen change and management for people living with HIV. It is reported that PLHIV with discordant responses were found to be at an increased risk to develop AIDS and non-AIDS events related death.

AIMS & OBJECTIVE

To determine immuno-virological discordance amongst PLHIV on ART and its effect on mortality.

MATERIAL & METHOD

After getting institutional Ethics committee approval, total 1921 patients were included in the study who were on ART for at least 6 month or more and have at least two CD4 count tests results and were tested from July 2019 to June 2020. Retrospective analysis was done.

RESULTS

Total 1921 patients were included in study of which 1383 (72%) showed immuno-virological concordance & 538 (28%) showed immuno-virological discordance. Overall mortality rate among PLHIV was 3.6%. Mortality rate in immuno-virological concordant group was 2.8%. Of immuno-virological discordant population, 505 (26.3%) were virological only responders (VO) with 5.35% mortality rate & 33 (1.7%) were immunological only responders (IO) with 9.09% mortality rate. High number of immunological discordant patients in the present study warrants the further evaluation of these patients with change in appropriate treatment strategy to decrease the mortality among this group.

CONCLUSION

This study emphasizes the role of immunological monitoring as well as virological monitoring to improve the life expectancy of PLHIV.

Population-level prevalence of detectable HIV viremia in people who inject drugs (PWID) in Ukraine: Implications for HIV treatment and case finding interventions

Achievement of viral load suppression among people living with HIV is one of the most important goals for effective HIV epidemic response. In Ukraine, people who inject drugs (PWID) experience the largest HIV burden. At the same time, this group disproportionally missed out in HIV treatment services. We performed a secondary data analysis of the national-wide cross-sectional bio-behavioral surveillance survey among PWID to assess the population-level prevalence of detectable HIV viremia and identify key characteristics that explain the outcome. Overall, 11.4% of PWID or 52.6% of HIV-positive PWID had a viral load level that exceeded the 1,000 copies/mL threshold. In the group of HIV-positive PWID, the detectable viremia was attributed to younger age, monthly income greater than minimum wage, lower education level, and non-usage of antiretroviral therapy (ART) and opioid agonistic therapy. Compared with HIV-negative PWID, the HIV-positive group with detectable viremia was more likely to be female, represented the middle age group (35-49 years old), had low education and monthly income levels, used opioid drugs, practiced risky injection behavior, and had previous incarceration history. Implementing the HIV case identification and ART linkage interventions focused on the most vulnerable PWID sub-groups might help closing the gaps in ART service coverage and increasing the proportion of HIV-positive PWID with viral load suppression.

Human immunodeficiency virus patients with low CD4 counts are more likely to have precancerous polyps identified during index colonoscopy

BACKGROUND

Antiretroviral treatment (ART) has improved the life expectancy of patients living with human immunodeficiency virus (HIV). As these patients age, they are at increased risk for developing non-acquired immunodeficiency syndrome defining malignancies (NADMs) such as colon cancers.

AIM

To determine which factors are associated with the development of precancerous polyps on screening colonoscopy in patients with HIV and to investigate whether HIV disease status, measured by viral load and CD4 count, might influence precancerous polyp development.

METHODS

A retrospective review of records at two urban academic medical centers was performed for HIV patients who had a screening colonoscopy between 2005-2015. Patients with a history of colorectal cancer or polyps, poor bowel preparation, or inflammatory bowel disease were excluded. Demographic data such as sex, age, race, and body mass index (BMI) as well as information regarding the HIV disease status such as CD4 count, viral load, and medication regimen were collected. Well-controlled patients were defined as those that had viral load < 50 copies, and poorly-controlled patients were those with viral load ≥ 50. Patients were also stratified based on their CD4 count, comparing those with a low CD4 count to those with a high CD4 count. Using colonoscopy reports in the medical record, the size, histology, and number of polyps were recorded for each patient. Precancerous polyps included adenomas and proximal serrated polyps. Data was analyzed using Fisher's exact tests and logistic regression through SAS 3.8 software.

RESULTS

Two hundred and seven patients met our inclusion criteria. The mean age was 56.13 years, and 58% were males. There were no significant differences in terms of age, race or ethnicity, insurance, and smoking status between patients with CD4 counts above or below 500. BMI was lower in patients with CD4 count < 500 as compared to those with count > 500 (P = 0.0276). In patients with CD4 > 500, 53.85% of patients were female, and 70.87% of patients with CD4 < 500 were male (P = 0.0004). Only 1.92% of patients with CD4 ≥ 500 had precancerous polyps vs 10.68% of patients with CD4 < 500 (P = 0.0102). When controlled for sex, BMI, and ART use, patients with CD4 < 500 were 9.01 times more likely to have precancerous polyps [95% confidence interval (CI): 1.69-47.97; P = 0.0100]. Patients taking non-nucleoside reverse transcriptase inhibitors were also found to be 10.23 times more likely to have precancerous polyps (95%CI: 1.08-97.15; P = 0.0428). There was not a significant difference noted in precancerous polyps between those that had viral loads greater or less than 50 copies.

CONCLUSION

Patients with low CD4 counts were more likely to have precancerous polyps on their screening colonoscopy although the etiology for this association is unclear. We also found an increased risk of precancerous polyps in patients taking non-nucleoside reverse transcriptase inhibitors, which is contradictory to prior literature showing ART has decreased the risk of development of NADMs. However, there have not been studies looking at colorectal cancer and ART by drug class, to our knowledge. Further prospective studies are needed to determine the effect of HIV control and therapies on polyp development.

Strategies of Managing Repeated Measures: Using Synthetic Random Forest to Predict HIV Viral Suppression Status Among Hospitalized Persons with HIV

The HIV/AIDS epidemic remains a major public health concern since the 1980s; untreated HIV infection has numerous consequences on quality of life. To optimize patients' health outcomes and to reduce HIV transmission, this study focused on vulnerable populations of people living with HIV (PLWH) and compared different predictive strategies for viral suppression using longitudinal or repeated measures. The four methods of predicting viral suppression are (1) including the repeated measures of each feature as predictors, (2) utilizing only the initial (baseline) value of the feature as predictor, (3) using the last observed value as the predictors and (4) using a growth curve estimated from the features to create individual-specific prediction of growth curves as features. This study suggested the individual-specific prediction of the growth curve performed the best in terms of lowest error rate on an independent set of test data.

Predictors of Viral Load and Medication Adherence Among HIV-Positive Adults Under Treatment at Felege-Hiwot Comprehensive Specialized Hospital, North-West, Ethiopia

Background

Maintaining good medication adherence and decreasing viral load in patients living with HIV/AIDS are critical to ensuring antiretroviral therapy's preventive and therapeutic benefits. The main objective of this study was to assess the predictors of viral load and medication adherence among HIV-positive adults under treatment at Felege Hiwot Comprehensive Specialized Hospital (FHCSH).

Methods

A retrospective cohort study design was conducted from a random sample of 281 adult HIV-infected patients under treatment at FHCSH in northwest Ethiopia from June 2017 to June 2021. Separate GLMM was used in analysis of viral load and medication adherence, and joint mode was applied to fit those two outcomes jointly. The potential correlation of those two outcomes was linked by random intercepts. Information criteria (AIC and BIC) were used for model comparison and covariance structure selection.

Results

The small standard error of significant predictors and significant correlation between viral load and medication adherence over time provide evidence for joint model selection. The correlation between viral load and medication adherence was -0.7688 (P-value=< 0.05), which indicates that the decrement of viral load tends to increase good medication adherence. Patient substance use, visit time, baseline CD4 cell, baseline hemoglobin, and the interaction of visit time by substance use were significantly associated with viral load and medication adherence jointly.

Conclusion

The study revealed that substance user adult patients, patients with low baseline CD4 cells, and patients with low baseline hemoglobin were with high viral loads and poor medication adherence. Therefore, health officials and other concerned bodies should give special attention and high intervention to patients with low baseline hemoglobin; poor adherence and low baseline CD4 cell count.

Virological Non-Suppression among Newly Diagnosed HIV-Positive Individuals on Dolutegravir-Based Antiretroviral Treatment in Eastern Ethiopia: Follow-Up Study

There have been limited studies linking baseline factors, including the viral load (VL) test, with virological non-suppression since the introduction of dolutegravir (DTG)-based regimens as first-line antiretroviral treatment (ART) in Ethiopia. This study aimed to identify baseline factors associated with virological non-suppression between October 2020 and July 2022. A follow-up study was conducted in eastern Ethiopia among newly diagnosed people living with HIV (PLHIV). A questionnaire and a checklist were used to collect the data. Five milliliters of venous blood were obtained at baseline and six months to determine the VL. A VL test was performed using the Abbott RealTime HIV-1 assay. To determine predictors of virological non-suppression, bivariate and multivariate logistic regression analyses were used. There were 235 PLHIV enrolled, 70.6% of whom were female, with a mean age of 33.9 years. Of the 161 retained on ART, virological non-suppression was 8.7% at six months. Baseline predictors of virological non-suppression were age ≤ 30 years, a history of substance use, and a VL greater than 4-log10 copies/mL. In this cohort, virological non-suppression was found to be optimal but still lagged slightly behind the third 95%-target. Thus, targeted interventions, the introduction of baseline VL testing to improve treatment outcomes, and fostering the attainment of UNAIDS 95-95-95 targets are recommended. Furthermore, broader research is recommended to explore the reasons for virological non-suppression in the study area.

Weight gain after antiretroviral therapy initiation in people living with HIV in the United States: analyses of electronic medical records and prescription claims

BACKGROUND

Treatment guidelines recommend integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) regimens for treatment naïve people living with HIV (PLWH) in the United States (US). This retrospective database study compared weight changes following initiation of INSTI-, non-nucleoside reverse transcriptase inhibitor (NNRTI)-, or protease inhibitor (PI)-based ART in treatment-naïve PLWH.

METHODS

Adult (≥18 years) PLWH initiated on INSTI, NNRTI, or PI plus ≥2 nucleoside reverse transcriptase inhibitors (NRTI) between 1 January 2014 to 31 August 2019 were identified in IQVIA's Ambulatory Electronic Medical Records (AEMR) linked to prescription drug claims (LRx). Weight changes over up to 36 months (M) of follow-up were compared among PLWH on INSTI- vs. NNRTI- and PI-based ART separately using non-linear mixed effect models, adjusting for demographics and baseline clinical characteristics.

RESULTS

The INSTI, NNRTI, and PI cohorts included 931, 245, and 124 PLWH, respectively. For all three cohorts, the majority were male (78.2-81.2%) and overweight/obese (53.6-61.6%) at baseline; 40.8-45.2% of the groups were African American. The INSTI vs. NNRTI/PI cohorts were younger (median age: 38 years vs. 44 years/46 years), had lower weight at ART initiation (mean: 80.9 kg vs. 85.7 kg/85.0 kg), and had higher TAF usage during follow-up (55.6% vs. 24.1%/25.8%; all p < .05). Multivariate models showed higher weight gain among PLWH in INSTI vs. NNRTI and PI cohorts during treated follow-up (estimated weight gain after 36 M: 7.1 kg vs. 3.8 kg and 3.8 kg, both p < .05).

CONCLUSION

Study findings highlight the need to monitor an increase in weight and potential metabolic complications among PLWH starting ART with INSTI.

Machine learning aided multiscale modelling of the HIV-1 infection in the presence of NRTI therapy

Human Immunodeficiency Virus (HIV) is one of the most common chronic infectious diseases in humans. Extending the expected lifetime of patients depends on the use of optimal antiretroviral therapies. Emergence of the drug-resistant strains can reduce the effectiveness of treatments and lead to Acquired Immunodeficiency Syndrome (AIDS), even with antiretroviral therapy. Investigating the genotype-phenotype relationship is a crucial process for optimizing the therapy protocols of the patients. Here, a mathematical modelling framework is proposed to address the impact of existing mutations, timing of initiation, and adherence levels of nucleotide reverse transcriptase inhibitors (NRTIs) on the evolutionary dynamics of the virus strains. For the first time, the existing Stanford HIV drug resistance data have been combined with a multi-strain within-host ordinary differential equation (ODE) model to track the dynamics of the most common NRTI-resistant strains. Overall, the D4T-3TC, D4T-AZT and TDF-D4T drug combinations have been shown to provide higher success rates in preventing treatment failure and further drug resistance. The results are in line with the genotype-phenotype data and pharmacokinetic parameters of the NRTI inhibitors. Moreover, we show that the undetectable mutant strains at the diagnosis have a significant effect on the success/failure rates of the NRTI treatments. Predictions on undetectable strains through our multi-strain within-host model yielded the possible role of viral evolution on the treatment outcomes. It has been recognized that the improvement of multi-scale models can contribute to the understanding of the evolutionary dynamics, and treatment options, and potentially increase the reliability of genotype-phenotype models.

Electronic Dose Monitoring Device Patterns in Youth Living With HIV Enrolled in an Adherence Intervention Clinical Trial

INTRODUCTION

Youth living with HIV in the US have low rates of viral suppression, in part because of challenges with antiretroviral therapy adherence.

METHODS

Daily dosing in the Adolescent Medicine Trials Network for HIV/AIDS Interventions 152 study, a randomized controlled trial of a 12-week adherence intervention (triggered escalating real-time adherence intervention) for viremic youth, compared with standard of care (SOC), was measured by electronic dose monitoring (EDM) throughout 48 weeks of follow-up. EDM data collected over the first 24 weeks were used to characterize patterns of antiretroviral therapy adherence with group-based trajectory models.

RESULTS

Four trajectory groups were identified among the 85 participants included in the analysis during the intervention phase of the study: (Worst) no interaction with EDM, (Declining) initially moderate EDM-based adherence followed by steep declines, (Good) initially high EDM-based adherence with modest declines, and (Best) consistently high EDM-based adherence. Being in the SOC arm, not being in school, higher evasiveness and panic decision-making scores, and lower adherence motivation were associated with higher odds of being in a worse trajectory group ( P < 0.05). A general decline in dosing was observed in the 12 weeks postintervention, when all participants were managed using SOC.

CONCLUSIONS

Use of group-based trajectory models allowed a more nuanced understanding of EDM-based adherence over time compared with collapsed summary measures. In addition to the study intervention, other factors influencing EDM-based adherence included being in school, decision-making styles, and adherence-related motivation. This information can be used to design better intervention services for youth living with HIV.

Artificial Intelligence and Machine Learning Based Prediction of Viral Load and CD4 Status of People Living with HIV (PLWH) on Anti-Retroviral Treatment in Gedeo Zone Public Hospitals

Background

Despite the success made in scaling up HIV treatment activities, there remains a tremendous unmet demand for the monitoring of the disease progression and treatment success, which threatens HIV/AIDS treatment and control. This research presented the assessments of viral load and CD4 classification of adults enrolled in ART care using machine learning algorithms.

Methods

We trained, validated, and tested eight machine learning (ML) classifier algorithms with historical data, including demographics, clinical, and laboratory data. Data were extracted from the ART registry database of Yirgacheffe Primary Hospital and Dilla University Referral Hospital. ML classifiers were trained to predict virological failure (viral load >1000 copies/mL) and poor CD4 (CD4 cell count <200 cells/mL). The model predictive performances were evaluated using accuracy, sensitivity, specificity, precision, f1-score, F-beta scores, and AUC.

Results

The mean age of the sample participants was 41.6 years (SD = 10.9). The experimental results showed that XGB classifier ranked as the best algorithm for viral load prediction in terms of sensitivity (97%), f1-score (96%), AUC (0.99), accuracy (96%), followed by RF. The GB classifier exhibited a better predictive capability in predicting participants with a CD4 cell count <200 cells/mL.

Conclusion

In this study, the XGB and RF models had the highest accuracy and outperformed on various evaluation metrics among the models examined for viral load classification. In the prediction of participants CD4, GB model had the highest accuracy.

Correlate of Left Ventricular Systolic Function in Children with Human Immunodeficiency Virus Infection on Combined Highly Active Antiretroviral Medications in Aminu Kano Teaching Hospital, Kano State

Background

Human immunodeficiency virus (HIV) affects many organ systems in the body including the cardiovascular system, often manifesting as a subclinical left ventricular (LV) systolic dysfunction that may progress to heart failure.

Aim

This study assessed the prevalence of LV systolic dysfunction in children on highly active antiretroviral therapy (HAART) with established clinical stage 1 HIV-disease.

Materials and Methods

The study was a cross-sectional comparative study conducted in Aminu Kano Teaching Hospital from April to August 2019 on 200. It involved study participants comprising 100 WHO clinical stage 1 HIV-infected children and 100 control subjects, aged between 1 and 18 years selected using systematic sampling method. Echocardiography was carried out on the study participants who had already completed a pretested questionnaire.

Results

Out of 100 HIV-infected children studied, 49 were males and 51 females (Male: Female ratio; 0.96:1.0). The mean age at diagnosis of HIV infection was 2.6 (±2.6 years) and the median viral load was 35 copies/ml. The mean ejection and shortening fractions in HIV-infected children were 59.0% and 31.0%, respectively, compared to 64.4% and 34.0% in control subjects, respectively, and were statistically significant (P = 0.000). The prevalence of LV systolic dysfunction was 8.0% (8 out of 100) in HIV-infected children while the control groups had zero prevalence (P = 0.002). The age at diagnosis correlated negatively with LV systolic dysfunction (r = 0.23, P = 0.02).

Conclusion

This study found a subclinical LV systolic dysfunction in an HAART-established clinical stage 1 HIV-infected children. The age at diagnosis was negatively correlated with the LV systolic function. This study, therefore, support the inclusion of routine echocardiography into the evaluation of HIV-infected children.

Seroprevalence and effect of HBV and HCV co-infections on the immuno-virologic responses of adult HIV-infected persons on anti-retroviral therapy

Chronic hepatitis negatively affects persons living with HIV. While varying in their transmission efficiency, HIV, HBV, and HCV have shared routes of transmission. Available data suggest widely variable rates of HBV and HCV infections in HIV-infected populations across sub-Saharan Africa. With prolonged survival rates due to increased accessibility to antiretroviral drugs, HBV and HCV have the potential to complicate the prognosis of HIV co-infected patients by contributing significantly to continued morbidity and mortality. The study sought to determine the seroprevalence of HIV/HBV and HIV/HCV co-infections among HIV patients on antiretroviral therapy and to evaluate the effect of HIV/HBV and HIV/HCV co-infections on the immunologic and virologic responses of patients. A cross-sectional study in which samples were taken from 500 people living with HIV and attending ART clinic at the Fevers unit of the Korle Bu Teaching Hospital and tested for Hepatitis B Surface Antigen (HBsAg) and Hepatitis C virus antibody (HCV). CD4 cell counts and HIV-1 RNA levels were estimated as well. Data generated were analysed using IBM SPSS version 22. The seroprevalence of HIV/HBV and HIV/HCV co-infections among people living with HIV was 8.4% and 0.2% respectively. HIV/HBV coinfection included 15/42 (35.7%) males and 27/42 (64.3%) females out of which the majority (97.6%) were in the 21-60 years old bracket. HIV/HBV and HIV/HCV co-infections have varied effects on the immunological and virological response of HIV patients on ART. The mean CD cell count was 361.0 ± 284.0 in HIV/HBV co-infected patients and 473.8 ± 326.7 in HIV mono-infected patients. The mean HIV-1 RNA level was not significantly different (X2 [df] = .057 [1]; P = .811) among HIV/HBV co-infected patients (Log102.9±2.0 copies/mL), compared to that of HIV mono-infected patients (Log102.8±2.1 copies/mL) although HIV mono-infected patients had lower viral load levels. One-third (14/42) of HIV/HBV co-infected patients had virologic failure and the only HIV/HCV co-infected patient showed viral suppression. 336/500 (67.2%) patients had HIV-1 viral suppression (females [66.1%]; males [33.9%]) while 164/500 (32.8%) had virologic failure (females [67.7%]; males [32.3%]). The mean CD4 count of patients with viral suppression and patients with virologic failure was 541.2 cells/μL (95% CI 508.5-573.8) and 309.9 cell/μL (95% CI 261.9-357.9) respectively.The study concludes that, HIV/HBV and HIV/HCV coinfections do not significantly affect the immunologic and virologic responses of patients who have initiated highly active antiretroviral therapy, and treatment outcomes were better in females than in males. There was no HBV/HCV co-infection among patients.

Is SARS-CoV-2 viral load a predictor of mortality in COVID-19 acute respiratory distress syndrome patients?

Objective

Viral load varies during infection and is higher during the initial stages of disease. Given the importance of the intensive care unit (ICU) in the late stages of COVID-19 infection, analyzing cycle threshold values to detect viral load upon ICU admission can be a clinically valuable tool for identifying patients with the highest mortality risk.

Methods

This was a retrospectively designed study. Patients older than 18 years who tested positive for SARS-CoV-2 PCR and had a PaO2/FiO2 ratio <200 were included in the study. The patient population was divided into two groups: survivors and non-survivors.

Results

Two hundred patients were included in the study. In non-survivors, age, relevant ICU admission scores, and procalcitonin levels were significantly higher whereas PaO2/FiO2 ratios and cycle threshold levels were significantly lower than in survivors.

Conclusion

Viral load at ICU admission has significant prognostic value. In combination with age, comorbidities, and severity scores, viral load may assist clinicians in identifying individuals who need more intensive monitoring. Increased awareness may improve outcomes by allowing the more effective monitoring and treatment of patients. More prospective studies are needed to determine how a high viral load worsens disease and how to avoid irreversible results.

Virological failure of first-line antiretroviral therapy in children living with HIV in Indonesia and associated factors

Background The World Health Organization (WHO) recommends viral load (VL) monitoring for HIV patients on antiretroviral therapy (ART). However, availability of VL monitoring in low-income countries remains limited. Objective To investigate factors associated with virological failure in HIV-infected children treated without routine VL monitoring. Methods This cohort study was done in children living with HIV (CLHIV) registered at Cipto Mangunkusumo General Hospital from 2004 to 2021. Viral load monitoring was not routinely done. Subjects with at least one VL result after 6 months on ART were included in the study. Virological failure was defined as a VL of >1,000 copies. Subjects’ data were obtained from medical records, laboratory reports, and dispensing pharmacies. Statistical analysis was done following survival analysis with hazard ratio. Results There were 384 children who had at least 1 VL result after ART was initiated. Median age at diagnosis was 30 months. Length of follow-up ranged from 6 to 216 months, with a mean frequency of VL monitoring of 0.7 times/person/year. Most subjects were already in clinical stages 3 and 4 (77.8%); 75% met severe immunodeficiency criteria. Virological failure was found in 45.8% of subjects after a median of 33 months on first-line ART, yielding an incidence of 3.3 per 1,000 person months. Independent associated factors were age at diagnosis of <60 months (HR 1.714; 95%CI 1.13 to 2.6), severe immunodeficiency (HR 1.71; 95%CI 1.15 to 2.54), referral cases (HR 1.70; 95%CI 1.23 to 2.36), and WHO clinical staging 3 (HR 1.987; 95%CI 0.995 to 3.969) and 4 (HR 2.084; 95%CI 1.034 to 4.201). Subjects with virological failure had lower weight-for-age z-scores [median 1.92; interquartile range (IQR) -3.003 to -0.81] and height-for-age z-scores [median -2.05; IQR -2.902 to -1.04] at the time of failure. Conclusions In HIV-infected children treated without routine VL monitoring, age at diagnosis <60 months, severe immunodeficiency, WHO clinical stage 3 and 4, and referral from other centers were associated with virological failure.

Lifestyle and adherence to antiretrovirals in people with HIV in the COVID-19 pandemic

OBJECTIVES

to assess the lifestyle and adherence to antiretrovirals in people living with HIV (PLHIV) in the COVID-19 pandemic.

METHODS

a cross-sectional study, through telephone interview to 150 patients, using a sociodemographic, epidemiological and clinical form, and questionnaires to assess lifestyle profile and adherence to antiretrovirals. Statistics analysis used Fisher's exact test, odds ratio and 95% confidence interval.

RESULTS

most patients had a satisfactory lifestyle (121; 80.7%) and adequate adherence to antiretrovirals (133; 88.7%). All were in social isolation, without follow-up appointments, with access to the health service only to receive antiretrovirals, and 16 (10.7%) had COVID-19 infection. Evangelicals (p=0.002), Spiritists (p=0.045), patients using atazanavir (p=0.0001) and ritonavir (p=0.002) had a more unsatisfactory lifestyle. Adherence to antiretrovirals was more inadequate in female patients (p=0.009), with two (p=0.004) and three or more children (p=0.006), retired (p=0.029), with serodiscordant partner (p=0.046) and diagnosis time of 5 to 10 years (p=0.027).

CONCLUSIONS

the most PLHIV had a satisfactory lifestyle and adequate adherence to antiretrovirals, but some groups needed intervention to improve medication adherence and lifestyle.

Can In-house HIV-2 Viral Load Assay be a Reliable Alternative to Commercial Assays for Clinical and Therapeutic Monitoring?

BACKGROUND

Currently, there is a global contemplation to end the AIDS epidemic by 2030. HIV-2 poses unique challenges to this end. The burden of HIV-2 is higher in resource-limited countries, and it is intrinsically resistant to NNRTI drugs. In addition, there is no FDA-approved plasma viral load assay to monitor disease progression and therapeutic efficacy. To overcome these challenges, we have developed and evaluated an in-house quantitative HIV-2 viral load assay.

METHODS

Blood samples were collected from 28 HIV-2 treatment-naïve monoinfected individuals and tested using an in-house qPCR HIV-2 viral load assay. The extracted RNA was amplified using Quantifast pathogen + IC kit.

RESULTS

The in-house qPCR has a limit of detection of 695 copies/ml. The intra- and inter-assay variation (% CV) of the assay was 0.61 and 0.95, respectively. The in-house assay quantified HIV-2 NIBSC accurately (1000 IU) with a mean of 1952 copies/mL. Among the 28 samples tested by in-house qPCR assay, 11 (39.2%) samples were quantified, whereas 17 (60.7%) samples were not detected. In comparison with Altona RealStar HIV-2 RT PCR and Exavir Load RT assay, the results were 96.4% and 69.6% concordant, respectively. No significant (p = 0.99 and p = 0.13) difference in quantifying viral load between the three assays. Based on clinical and immunological (CD4) staging, the performance characteristics were comparable.

CONCLUSION

To the best of our knowledge, this is the first in-house qPCR developed in India. The performance characteristics of the in-house assay are comparable to the commercial assays, and they can be used assertively to monitor HIV-2 patients.

Randomized Controlled Trial of a Remote Coaching mHealth Adherence Intervention in Youth Living with HIV

Youth living with HIV (YLWH) in the US have low rates of viral suppression (VS). In a prospective randomized clinical trial (ATN152) that enrolled 89 YLWH on antiretroviral therapy (ART) with detectable viral load, we evaluated a 12 week triggered escalating real-time adherence (TERA) intervention with remote coaching, electronic dose monitoring (EDM), and outreach for missed/delayed doses compared to standard of care (SOC). Median [Q1, Q3] percent days with EDM opening was higher in TERA (72% (47%, 89%)) versus SOC (41% (21%, 59%); p < 0.001) and incidence of numbers of 7 day gaps between openings were lower (TERA to SOC ratio: 0.40; 95% CI 0.30, 0.53; p < 0.001). There were no differences in VS at week 12 (TERA 35%; 95% CI 21%, 51% versus SOC 36%; 95% CI 22%, 51%; p > 0.99) or later time-points. The intervention improved adherence but not VS in heavily ART-experienced YLWH. Remote coaching more closely tailored to the unique dosing patterns and duration of need for youth struggling to reach VS warrants further investigation.

Evaluation of CCR5-Δ32 mutation and HIV-1 surveillance drug-resistance mutations in peripheral blood mononuclear cells of long-term non progressors of HIV-1-infected individuals

Aim: This study aimed to evaluate chemokine receptor 5 delta 32 (CCR5-Δ32) mutation and HIV-1 surveillance drug-resistance mutations (SDRMs) in peripheral blood mononuclear cells of long-term non progressors (LTNPs) of HIV-1-infected individuals. Materials and methods: This research was performed on 197 treatment-naive HIV-1-infected patients. After follow-up, it was determined that 15 (7.6%) of these people were LTNPs. The PCR assay was performed to identify the CCR5 genotype and HIV-1 SDRMs. Results: One (6.7%) of the LTNPs was heterozygous (wt/Δ32) for the CCR5 delta 32 (CCR5Δ32). However, none of the individuals was homozygous for this mutation (Δ32/Δ32). Moreover, none of the LTNPs showed HIV-1 SDRMs. The CRF35-AD subtype was the most dominant subtype, with a percentage of 93.3%. Conclusion: Iranian elite controllers are negative for CCR5-delta 32 homozygous genotype and drug resistance against antiretroviral drugs.

Impact of low-level viremia with drug resistance on CD4 cell counts among people living with HIV on antiretroviral treatment in China

Background

Maintaining plasma HIV RNA suppression below the limit of quantification is the goal of antiretroviral therapy (ART). When viral loads (VL) remain in low-level viremia (LLV), or between 201 and 999 copies/mL, the clinical consequences are still not clear. We investigated the occurrence of LLV with drug resistance and its effect on CD4 cell counts in a large Chinese cohort.

Methods

We analysed data of 6,530 ART-experienced patients (42.1 ± 10.9 years; 37.3% female) from the China’s national HIV drug resistance (HIVDR) surveillance database. Participants were followed up for 32.9 (IQR 16.7–50.5) months. LLV was defined as the occurrence of at least one viral load (VL) measurement of 50–200 copies/mL during ART. Outcomes were drug resistance associated mutations (DRAM) and CD4 cell counts levels.

Results

Among 6530 patients, 58.0% patients achieved VL less than 50 copies/mL, 27.8% with VL between 50 and 999 copies/mL (8.6% experienced LLV), and 14.2% had a VL ≥ 1000 copies/mL. Of 1818 patients with VL 50–999 copies/mL, 182 (10.0%) experienced HIVDR, the most common DRAM were M184I/V 28.6%, K103N 19.2%, and V181C/I/V 10.4% (multidrug resistance: 27.5%), and patients with HIVDR had a higher risk of CD4 cell counts < 200 cells/μL (AOR 3.8, 95% CI 2.6–5.5, p < 0.01) comparing with those without HIVDR. Of 925 patients with VL ≥ 1000 copies/mL, 495 (53.5%) acquired HIVDR, the most common DRAM were K103N 43.8%, M184I/V 43.2%, M41L 19.0%, D67N/G 16.4%, V181C/I/V 14.5%, G190A/S 13.9% and K101E 13.7% (multidrug resistance: 75.8%), and patients with HIVDR had a higher risk of CD4 cell counts < 200 cells/μL (AOR 5.8, 95% CI 4.6–7.4, p < 0.01) comparing with those without HIVDR.

Conclusion

Persistent with VL 50–999 copies/mL on ART is associated with emerging DRAM for all drug classes, and patients in this setting were at increased risk of CD4 cell counts < 200 cells/μL, which suggest resistance monitoring and ART optimization be earlier considered.

Retinal Microvasculature And Immune Restoration Among South Eastern Asian HIV/AIDS Patients Over A 9-Month Antiretroviral Therapy

BACKGROUND

Longitudinal evidence on retinal microvasculature and subsequent systemic inflammatory alteration is lacking. We investigated the association between retinal microvasculature and immune response among HIV/AIDS patients over a 9-month antiretroviral therapy (ART).

METHODS

We conducted a prospective cohort on HIV/AIDS patients at Singapore Communicable Disease Centre (CDC) since June 2011. We recruited all eligible patients and then reviewed them every three months over a 9-month follow-up, including performing blood tests (CD4+/CD8+ T-cell counts, HIV viral load), blood pressure, anthropometry measurements, and retinal photography at each visit. We assessed retinal vascular indexes via a semi-automated computer-based program. Lastly, we applied a linear mixed model to analyze associations between baseline retinal vascular indexes and 9-month changes of CD4+/CD8+ T-cell cell counts and HIV viral load throughout study observation, after adjusting for major confounders.

RESULTS

We found that narrower arteriolar caliber (per 10 μm decrease), wider venular caliber (per 10 μm increase), and larger arteriolar branching angle (per 10 degrees increase) in the retina assessed at baseline were significantly associated with 9-month reductions in CD4+ T-cell count by 52.97 cells/µl (p=0.006), 33.55 cells/µl (p=0.01), and 39.09 cells/ µl (p=0.008), accordingly.

CONCLUSION

HIV/AIDS Patients with a suboptimal retinal microvascular morphology tended to fail immune restoration undertaking a 9-month ART.

Higher Risk of Mortality and Virologic Failure in HIV-Infected Patients With High Viral Load at Antiretroviral Therapy Initiation: An Observational Cohort Study in Chongqing, China

Background

Viral load (VL) is a strong predictor of human immunodeficiency virus (HIV) disease progression. The aim of this study was to evaluate the effect of high baseline VL on antiretroviral therapy (ART) outcomes among HIV-infected patients.

Methods

This retrospective study observed HIV-infected patients who had baseline VL test at ART initiation between 2015 and 2019 in Chongqing, China. Cox proportional hazards regression and logistic regression models were used to evaluate the effects of baseline VL on Acquired immunodeficiency syndrome (AIDS)-related mortality and virologic failure, respectively.

Results

The cohort included 7,176 HIV-infected patients, of whom 38.7% had a baseline VL ≥ 100,000 copies/mL. Of the patients who died during follow-up, 58.9% had a baseline VL ≥ 100,000 copies/mL. Compared with a baseline VL < 10,000 copies/mL, ART initiation at VL ≥ 100,000 copies/mL was significantly associated with the AIDS-related death (adjusted hazard ratio, AHR = 1.4) and virologic failure (adjusted odds ratio, AOR = 2.4). Compared with patients with a baseline VL < 10,000 copies/mL, patients on the recommended first-line regimen with a VL ≥ 100,000 copies/mL at ART initiaition had higher mortality rate (5.1 vs. 1.7 per 100 person-years), but there was no significant difference in the mortality accoding to the initial VL level among patients on second-line ART (2.8 vs. 2.7 per 100 person-years). ART initiation ≤ 30 days after HIV diagnosis was associated with a lower risk of AIDS-related death (AHR = 0.6).

Conclusions

ART initiation with VL ≥ 100,000 copies/mL was associated with a significantly greater risk of mortality and virologic failure. Optimizing the ART regimen and initiating ART early may help to reduce mortality effectively among patients with a high baseline VL. VL testing for all HIV patients is recommended at HIV diagnosis or on ART initiation.

Cost-Utility Analysis of Dolutegravir- Versus Efavirenz-Based Regimens as a First-Line Treatment in Adult HIV/AIDS Patients in Ethiopia

BACKGROUND

In several countries, the dolutegravir (DTG)-based regimen is generally preferred as first-line antiretroviral therapy (ART) over the efavirenz (EFV)-based regimen, but the evidence in low-income countries is limited.

OBJECTIVE

Our study aimed to evaluate the cost effectiveness of DTG- versus EFV-based first-line human immunodeficiency virus (HIV) treatment in Ethiopia.

METHODS

We developed a microsimulation model for the progression of HIV/acquired immune deficiency syndrome (AIDS) to examine the cost effectiveness of DTG-based first-line ART compared with an EFV-based regimen from a healthcare payer perspective. We used a lifetime horizon with a 1-month cycle length and a 3% annual discount rate. The primary outcomes were a lifetime cost in US dollars ($), quality-adjusted life-months (QALMs) that converted to QALYs using the formula QALY = QALM/12, and incremental cost-effectiveness ratio (ICER). Deterministic sensitivity analysis was conducted to account for parameter uncertainty.

RESULTS

Compared with the EFV-based regimen, the DTG-based regimen was associated with an expected lifetime cost of $12,709 (vs. $12,701) and expected QALYs of 15.3 (vs. 14.7 QALYs) per patient, resulting in an ICER value of $13.33 per QALY. From an alternative analysis with a 5-year time horizon, DTG-based ART was found to be dominant, with expected gains of 0.17 QALYs at a lower cost of $1 per patient. The deterministic sensitivity analysis depicted that the maximum increase in ICER value was $72 per QALY, and all ICER values were below the estimated threshold value.

CONCLUSIONS

The DTG-based first-line regimen appears to be cost effective compared with the EFV-based regimen for the treatment of HIV/AIDS patients in an Ethiopian setting.

Association between BoLA-DRB3 polymorphism and bovine leukemia virus proviral load in Vietnamese Holstein Friesian cattle

Bovine leukemia virus (BLV) is the causative agent of enzootic bovine leukosis. Polymorphism in bovine leukocyte antigen (BoLA)-DRB3 allele can influence the host immune response to pathogens, including BLV. However, association between specific BoLA-DRB3 alleles and BLV proviral load (PVL), which is a useful index for estimating disease progression and transmission risk, in Vietnamese cattle are unknown. Here, association study of BoLA-DRB3 allele frequency between cattle with high or low PVL demonstrated BoLA-DRB3*12:01 associates with high PVL in Vietnamese Holstein-Friesian (HF) crossbred cattle. This is the first study to demonstrate that BoLA-DRB3 polymorphism confers susceptibility to BLV high PVL in HF crossbred kept in Vietnam. Our results may be useful in disease control and eradiation for BLV through genetic selection. This article is protected by copyright. All rights reserved.

Mortality, survival and prognostic factors of people with AIDS in intensive care unit

OBJECTIVE

To analyze mortality, survival and prognostic factors of patients with AIDS in Intensive Care Unit (ICU).

METHOD

Retrospective cohort study with a sample of 202 patients with AIDS in ICU, whose sociodemographic, epidemiological, and clinical characteristics were obtained from medical records and assessed.

RESULTS

Patients were mostly male (73.8%) and drug users (59.4%), with no regular health follow-up (61.4%) and no adherence to antiretrovirals (40.6%), presenting low CD4+ T lymphocyte count (94.0%) and high viral load (44.6%). The main causes of hospitalization were sepsis and respiratory and renal insufficiency. The mean duration of hospitalization was 11.9 days (p = 0.0001), with a 41.6% survival; 58.5% died in the ICU. Sepsis upon admission (p < 0.001), pressure injury (p = 0.038), sexual exposure (p = 0.002), high viral load (p = 0.00001) and prolonged hospitalization (p < 0.001) increased the risk of death.

CONCLUSION

Most patients had no regular health follow-up, were drug users and presented low CD4+ T lymphocyte count and high viral load. The high mortality indicated that antiretroviral adherence is essential to reduce viral resistance, opportunistic diseases, and mortality.

Virological failure and associated factors among children receiving anti-retroviral therapy, Northwest Ethiopia

BACKGROUND

Virological failure is under-recognized issue among children living with human immunodeficiency virus in developing countries. This partly may lead to failure to achieve the global goal of 90-90-90 targets in most developing countries including Ethiopia.

OBJECTIVES

This study aimed to assess the virological failure and its predictors among children receiving antiretroviral therapy at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia.

METHODS

An institutional based cross-sectional study was conducted among 253 study cohorts from January 2020-April 2021. Socio-demographic characteristics were collected using a structured questionnaire via a face-to-face interview, while detailed clinical data of the children were collected by reviewing the medical record. About 5 ml of blood were collected for the analysis of complete blood count and viral load quantification. Data were analyzed using SPSS version 20 and variables at p-value < 0.05 in the multivariable analysis were considered as statistically significant.

RESULTS

In this study, the viral load suppression rate among antiretroviral therapy experienced children was 68.8%. Meanwhile, the overall virological failure among study participants was 19.4%. Children living without family (AOR = 3.63; 95%CI: 1.27-10.24), children with unemployed family (AOR = 4.95; 95%CI: 1.74-14.12), being wasted (AOR = 3.02; 95%CI: 1.19-7.67) being stunted (AOR = 2.38;95%CI:1.03-5.46), anemia (AOR = 5.50:95%CI;1.37-22.04) and being lymphopenic (AOR = 2.69:95%CI;1.04-7.75) were significantly associated with virological failure among children under treatment.

CONCLUSION

Higher virological failure among children was noteworthy in the present study. Caretakers other than immediate family, unemployed family, wasted, stunted, anemia, and lymphopenia were significant independent predictors of virological failure. Hence, standard, and optimal management of children under treatment should be warranted.

Virologic outcomes of people living with human immunodeficiency virus who started antiretroviral treatment on the same-day of diagnosis in Ethiopia: A multicenter observational study

INTRODUCTION

There have been tremendous achievements in scaling-up antiretroviral therapy (ART) for treatment of human immunodeficiency virus (HIV), following universal "test and treat" policy implementation in low- and middle-income countries. However, its effects on virologic outcomes is not yet well investigated. We compared low viral load status in people living with HIV between those who were initiated on ART on the same-day and after 7 days of being diagnosed with HIV infection.

METHODS

We conducted a retrospective cohort study of persons age ≥15 years-old who were newly diagnosed and started on ART between October 2016 and July 2018 at 11 public health facilities in northwest Ethiopia. Exposure was initiation of ART on the same-day of HIV diagnosis. The outcome was low viral load at 12-months following ART initiation. We used double-robust estimator using inverse-probability-weighted regression adjustment to compare the groups.

RESULTS

A total of 398 people who started ART on the same-day of HIV diagnosis and 479 people who started 7 days after the initial diagnosis were included in this study. By 12-months following ART initiation, 73.4% (292) in the same-day group vs 83.7% (401) in the >7 days group achieved low viral load (absolute difference = 10.3% (95% CI: 4.9%, 15.8%)). After adjusting for baseline and follow-up covariates, there was statistically significant difference in low viral load status (adjusted difference = 8.3% (95% CI: 3.5%, 13.0%)) between the same-day group and the >7 days group.

CONCLUSIONS

Achievement of low viral load by 12-months post-initiation of ART was not optimal among participants who started ART on the same-day of HIV diagnosis. Efforts should be made to reinforce treatment adherence while initiating same-day ART.

Baseline CD4 count and the time interval between the initial HIV infection and diagnosis among PLHIV in Bhutan

INTRODUCTION

CD4 count is an important predictor of disease progression, opportunities infection, deaths, and to understand the time interval between initial HIV infection to the first diagnosis. However, baseline CD4 count and the time period between initial infection and the diagnosis amongst PLHIV in Bhutan never been evaluated.

METHODS

This is a retrospective study of the diagnosed PLHIV from the existing data system from January 10 to 30, 2021. Out of 512 reported HIV cases, 488 of those who were more than or equal to 18 years old and had their CD4 count testing within 6 months before initiating ART were considered for analysis. Descriptive statistical analysis was used to analyze the characteristics of the study population and relationship were established using the χ 2 Test. We have sought ethics approval and waiver for informed consent as it is the retrospective study of the client's record. The client's confidentiality was ensured by removing all the identifiers.

RESULTS

The mean CD4 was 345 cells/ml for males and females. Twenty-five percent of the clients had CD4 counts below 200, 30%, between 200 and 349, 25% between 350 and 499, and 20% above 500 cells/ml. A larger number of males showed a CD4 count below 200 cells/ml while more females showed a CD4 count more than 500 cells/ml. The mean time interval between initial infection to the first diagnosis was 4 years in males and females. However, about one-fourth were found to have been infected between 5 and 8 years before diagnosis and less than 10% were diagnosed within less than 1 year of infection.

CONCLUSIONS

The study revealed a late diagnosis of HIV infection in Bhutan thereby risking the transmission to the community and risk of severe disease and mortality. The upscaling of voluntary counseling and testing, medical screening, and alternative methods like community-based testing including HIV Self Testing for early detection needs to be implemented in the country.

Markov modelling of viral load adjusting for CD4 orthogonal variable and multivariate conditional autoregressive mapping of the HIV immunological outcomes among ART patients in Zimbabwe

BACKGROUND

This study aimed to jointly model HIV disease progression patterns based on viral load (VL) among adult ART patients adjusting for the time-varying "incremental transients states" variable, and the CD4 cell counts orthogonal variable in a single 5-stage time-homogenous multistate Markov model. We further jointly mapped the relative risks of HIV disease progression outcomes (detectable VL (VL ≥ 50copies/uL) and immune deterioration (CD4 < 350cells/uL) at the last observed visit) conditional not to have died or become loss to follow-up (LTFU).

METHODS

Secondary data analysis of individual-level patients on ART was performed. Adjusted transition intensities, hazard ratios (HR) and regression coefficients were estimated from the joint multistate model of VL and CD4 cell counts. The mortality and LTFU transition rates defined the extent of patients' retention in care. Joint mapping of HIV disease progression outcomes after ART initiation was done using the Bayesian intrinsic Multivariate Conditional Autoregressive prior model.

RESULTS

The viral rebound from the undetectable state was 1.78times more likely compared to viral suppression among patients with VL ranging from 50-1000copies/uL. Patients with CD4 cell counts lower than expected had a higher risk of viral increase above 1000copies/uL and death if their VL was above 1000copies/uL (state 2 to 3 (λ₂₃): HR = 1.83 and (λ₃₄): HR = 1.42 respectively). Regarding the time-varying effects of CD4 cell counts on the VL transition rates, as the VL increased, (λ₁₂ and λ₂₃) the transition rates increased with a decrease in the CD4 cell counts over time. Regardless of the individual's VL, the transition rates to become LTFU decreased with a decrease in CD4 cell counts. We observed a strong shared geographical pattern of 66% spatial correlation between the relative risks of detectable VL and immune deterioration after ART initiation, mainly in Matabeleland North.

CONCLUSION

With high rates of viral rebound, interventions which encourage ART adherence and continual educational support on the barriers to ART uptake are crucial to achieve and sustain viral suppression to undetectable levels. Area-specific interventions which focus on early ART screening through self-testing, behavioural change campaigns and social support strategies should be strengthened in heavily burdened regions to sustain the undetectable VL. Sustaining undetectable VL lowers HIV transmission in the general population and this is a step towards achieving zero HIV incidences by 2030.

Influence of HLA-B*5701 on 20 year survival rate among patients living with HIV

BACKGROUND

The life expectancy of people living with HIV (PLWH) remains shorter than that of the general population, despite significant improvement in the recent years. Mortality in HIV-infected individuals may be associated with a higher viral load at of diagnosis, a lower CD4 count, or clinical variables such as sex or route of transmission. This article investigated the role of the HLA-B*5701 varian on mortality among PLWH.

METHODS

Material for the analysis consist of the data of 2,393 patients for whom the HLA-B*57 variant was known. Those patients were followed under the care of the Infectious Diseases Hospital in Warsaw (n = 1555) and the Clinic of Acquired Immunodeficiency of the Pomeranian Medical University in Szczecin (n = 838). Factors such as age, gender, date of HIV diagnosis, route of transmission, date of death, baseline HIV viral load and baseline CD4 counts, were collected, and end-point cross-sectional analyses were marked at 60, 120, 180 and 240 month of observation.

RESULTS

HLA-B*5701 allele was found in 133 (5.5%) analyzed cases. Median age was notably higher for HLA-B*5701 positive patients [32.7 (28.3-41.3) vs. 31.6 (26.8-38.3)years p = 0.02]. HLA-B*5701 was associated with lower baseline viral load [4.21 (3.5-4.8) vs. 4.79 (4.2-5.3)log copies/ml p<0.001] and higher CD4count [448 (294.5-662) vs. 352 (176-514) cells/μl p<0.001]. There were no association between HLA-B*5701 and survival for any given end-point. Higher mortality was associated to male gender, intravenous drug users, lower CD4 count at baseline and higher baseline viral load.

CONCLUSIONS

In our study, the presence of HLA-B*5701 allel was not associated with mortality rate of HIV infected patients, irrespective of being associated with both higher baseline CD4 + cell count and lower baseline HIV viral load.

The efficacy and cost-effectiveness of a family-based economic empowerment intervention (Suubi + Adherence) on suppression of HIV viral loads among adolescents living with HIV: results from a Cluster Randomized Controlled Trial in southern Uganda

INTRODUCTION

Evidence from low-resource settings indicates that economic insecurity is a major barrier to HIV treatment adherence. Economic empowerment (EE) interventions have the potential to improve adherence outcomes among adolescents living with HIV (ALWHIV) by mitigating the effects of poverty. This study aims to assess the efficacy and cost-effectiveness of a savings-led family-based EE intervention, Suubi + Adherence, aimed at improving antiretroviral therapy (ART) adherence outcomes ALWHIV in Uganda.

METHODS

Adolescents (mean age 12 years at enrolment; 56% female) receiving ART for HIV at 39 health centres were randomized to Suubi + Adherence intervention (n = 358) or bolstered standard of care (BSOC; n = 344). A difference-in-differences analysis was employed to assess the change in the proportion of virally suppressed adolescents (HIV RNA viral load <40 copies/mL) over 24 months. The cost-effectiveness analysis examined how much the intervention cost to virally suppress one additional adolescent relative to BSOC from the healthcare provider perspective.

RESULTS

At 24 months, the intervention was associated with an 8.85-percentage point [95% confidence interval (CI) 0.80 to 16.90 percentage points] increase in the proportion of virally suppressed adolescents between the study arms (p = 0.032). Per-participant costs were US$177 and US$263 for the BSOC and intervention groups respectively. The incremental cost of virally suppressing one additional adolescent was estimated at US$970 [95% CI, US$508 to 10,725] over two years.

CONCLUSIONS

Our results support the integration of family-based EE interventions into adherence-support strategies as part of routine HIV care in low-resource settings to address the underlying economic drivers of poor ART adherence among ALWHIV. Moreover, per-participant costs to achieve viral suppression do not seem prohibitive compared to other community-based adherence interventions targeted at ALWHIV in low-resource settings. Further research on combination interventions at the nexus of economic security and HIV treatment and care is needed to inform the development of feasible and scalable HIV policies and programmes.

A review of multistate modelling approaches in monitoring disease progression: Bayesian estimation using the Kolmogorov-Chapman forward equations

There are numerous fields of science in which multistate models are used, including biomedical research and health economics. In biomedical studies, these stochastic continuous-time models are used to describe the time-to-event life history of an individual through a flexible framework for longitudinal data. The multistate framework can describe more than one possible time-to-event outcome for a single individual. The standard estimation quantities in multistate models are transition probabilities and transition rates which can be mapped through the Kolmogorov-Chapman forward equations from the Bayesian estimation perspective. Most multistate models assume the Markov property and time homogeneity; however, if these assumptions are violated, an extension to non-Markovian and time-varying transition rates is possible. This manuscript extends reviews in various types of multistate models, assumptions, methods of estimation and data features compatible with fitting multistate models. We highlight the contrast between the frequentist (maximum likelihood estimation) and the Bayesian estimation approaches in the multistate modeling framework and point out where the latter is advantageous. A partially observed and aggregated dataset from the Zimbabwe national ART program was used to illustrate the use of Kolmogorov-Chapman forward equations. The transition rates from a three-stage reversible multistate model based on viral load measurements in WinBUGS were reported.

Survival, CD4 T lymphocyte count recovery and immune reconstitution pattern during the first-line combination antiretroviral therapy in patients with HIV-1 infection in Mongolia

Mongolia has a low incidence of human immunodeficiency virus (HIV) infection, with 281 cases reported at the end of 2019 and an estimated incidence rate of <0.01 cases per 1000 population.

However, no study has analyzed the association between antiretroviral therapy (ART) outcomes and pretreatment characteristics of patients with HIV/acquired immunodeficiency syndrome (AIDS) in Mongolia. This retrospective study aimed to determine the survival, CD4 T cell recovery, and immune reconstitution pattern during ART in HIV patients and to determine baseline patient characteristics associated with ART outcomes. Based on three different World Health Organization (WHO) guidelines, we analyzed the 3-year observation data of 166 patients with HIV/AIDS who received treatment between 2010 and 2017. An increase of >50 cells/μL indicated CD4 T cell count recovery, and a cell count of ≥500 cells/μL in patients with a baseline cell count of <500 cells/μL indicated immune reconstitution. In this study, the 3- and 1-year mortality rates were 5.4% (survival rate: 94.6%) and 3.6%, respectively. A total of 83% of deaths that occurred in the observation time occurred within the first 3 months. The CD4 T cell count recovery rates at 3, 12, and 36 months were 62.7%, 80.7%, and 89.2%, respectively. The CD4 T cell count increased to >500 cells/μL in 95 of 145 (65.5%) patients with a baseline cell count of <500 cells/μL after 36 months of ART. The baseline CD4 T cell count was found to be a sensitive indicator for immune reconstitution. An advanced pretreatment clinical stage of HIV infection (as classified by the WHO classification), a low CD4 T cell count in the peripheral blood, and a high viral load before the initiation of the first-line ART accurately predicted survival, CD4 T cell count recovery, and immune reconstitution in Mongolian patients with HIV/AIDS.

A high prevalence of potential HIV elite controllers identified over 30 years in Democratic Republic of Congo

Background

In-depth analysis of the HIV pandemic at its epicenter in the Congo basin has been hampered by 40 years of political unrest and lack of functional public health infrastructure. In recent surveillance studies (2017-18), we found that the prevalence of HIV in Kinshasa, Democratic Republic of Congo (11%) far exceeded previous estimates.

Methods

10,457 participants were screened in Kinshasa with rapid tests from 2017-2019. Individuals confirmed as reactive by the Abbott ARCHITECT HIV Ag/Ab Combo assay (n=1968) were measured by the Abbott RealTime HIV-1 viral load assay. Follow up characterization of samples was performed with alternate manufacturer viral load assays, qPCR for additional blood borne viruses, unbiased next generation sequencing, and HIV Western blotting.

Findings

Our data suggested the existence of a significant cohort (n=429) of HIV antibody positive/viral load negative individuals. We systematically eliminated collection site bias, sample integrity, and viral genetic diversity as alternative explanations for undetectable viral loads. Mass spectroscopy unexpectedly detected the presence of 3TC antiviral medication in approximately 60% of those tested (209/354), and negative Western blot results indicated false positive serology in 12% (49/404). From the remaining Western blot positives (n=53) and indeterminates (n=31) with reactive Combo and rapid test results, we estimate 2.7-4.3% of infections in DRC to be potential elite controllers. We also analyzed samples from the DRC collected in 1987 and 2001-03, when antiretroviral drugs were not available, and found similarly elevated trends.

Interpretation

Viral suppression to undetectable viral loads without therapy occurs infrequently in HIV-1 infected patients around the world. Mining of global data suggests a unique ability to control HIV infection arose early in central Africa and occurs in <1% of founder populations. Identification of this group of elite controllers presents a unique opportunity to study potentially novel genetic mechanisms of viral suppression.

Funding

Abbott Laboratories funded surveillance in DRC and subsequent research efforts. Additional funding was received from a MIZZOU Award from the University of Missouri. Research was supported in part by the Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH.

Neurocognitive status and risk of mortality among people living with human immunodeficiency virus: an 18-year retrospective cohort study

HIV-related neurocognitive impairment (NCI) may increase the risk of death. However, a survival disadvantage for patients with NCI has not been well studied in the post-combination antiretroviral therapy (cART) era. Specifically, limited research has been conducted considering the reversible nature and variable progression of the impairment and this area demands further evaluation. We performed multivariable Cox proportional hazards modeling to assess the association between baseline NCI (global T scores) and mortality. A joint modeling approach was then used to model the trajectory of global neurocognitive functioning over time and the association between neurocognitive trajectory and mortality. Among the National NeuroAIDS Tissue Consortium's (NNTC) HIV-infected participants, we found a strong negative association between NCI and mortality in the older age groups (e.g., at age = 55, HR = 0.79; 95% CI 0.64-0.99). Three neurocognitive sub-domains (abstraction and executive functioning, speed of information processing, and motor) had the strongest negative association with mortality. Joint modelling indicated a 33% lower hazard for every 10-unit increase in global T scores (HR = 0.67; 95% CI 0.56-0.80). The study identified older HIV-infected individuals with NCI as a group needing special attention for the longevity of life. The study has considerable prognostic utility by not only predicting mortality hazard, but also future cognitive status.

A novel mathematical model of AIDS-associated Kaposi's sarcoma: Analysis and optimal control

Kaposi's sarcoma (KS) has been the most common HHV-8 virus-induced neoplasm associated with HIV-1 infection. Although the standard KS therapy has not changed in 20 years, not all cases of KS will respond to the same therapy. The goal of current AIDS-KS treatment modalities is to reconstitute the immune system and suppress HIV-1 replication, but newer treatment modalities are on horizon. There are very few mathematical models that have included HIV-1 viral load (VL) measures, despite VL being a key determinant of treatment outcome. Here we introduce a mathematical model that consolidates the effect of both HIV-1 and HHV-8 VL on KS tumor progression by incorporating low or high VLs into the proliferation terms of the immune cell populations. Regulation of HIV-1/HHV-8 VL and viral reservoir cells is crucial for restoring a patient to an asymptomatic stage. Therefore, an optimal control strategy given by a combined antiretroviral therapy (cART) is derived. The results indicate that the drug treatment strategies are capable of removing the viral reservoirs faster and consequently, the HIV-1 and KS tumor burden is reduced. The predictions of the mathematical model have the potential to offer more effective therapeutic interventions based on viral and virus-infected cell load and support new studies addressing the superiority of VL over CD4⁺ T-cell count in HIV-1 pathogenesis.

Validation of the BD FACSPresto system for the measurement of CD4 T-lymphocytes and hemoglobin concentration in HIV-negative and HIV-positive subjects

This study aimed to compare the performance of the BD FACSPresto system with the conventional standard-of-care technologies for the measurement of absolute CD4 count (AbsCD4), CD4 percentage (CD4%) and total hemoglobin concentration (Hb) in capillary and venous blood samples of HIV-negative and HIV-positive subjects. A total of 1304 participants were included in this prospective cohort study. Both venous and capillary blood samples were analyzed using the BD FACSPresto system and the results were compared against the BD FACSCalibur for enumerating AbsCD4 and CD4% and Sysmex XT-4000i hematology analyzer for determining Hb levels. Method comparison studies were performed using Deming regression and Bland-Altman plots. The Deming regression analyses comparing the accuracy of the BD FACSPresto system with the reference standard technologies demonstrated a significant linear correlation between the AbsCD4, CD4%, and Hb values generated by the two platforms. The 95% CI of the slopes for AbsCD4, CD4%, and Hb levels were 0.94-0.99, 0.99-1.01 and 0.86-0.93, respectively (P < 0.001). Bland-Altman plots for AbsCD4, CD4%, and Hb levels demonstrated close agreement between the BD FACSPresto system and the reference standards for all study participants. The performance and accuracy of BD FACSPresto system was comparable to the reference standard technologies. The BD FACSPresto system can be used interchangeably with BD FACSCalibur platform for CD4 and Sysmex XT-4000i hematology analyzer for Hb concentrations in resource-limited settings thus, improving accessibility to point-of-care testing services.

Admitted AIDS-associated Kaposi sarcoma patients: Indications for admission and predictors of mortality

Kaposi sarcoma (KS) is an AIDS-defining angioproliferative malignancy associated with high morbidity and mortality. Most KS patients in regions with high incidence such as sub-Saharan Africa present late with advanced stage disease. Admitted KS patients have high mortality rates. Factors associated with mortality of admitted KS patients are poorly defined.We conducted a retrospective file review to ascertain reasons for admission and identify factors associated with mortality of admitted HIV-associated (epidemic) KS patients in Zambia. Baseline study variables were collected, and patients were retrospectively followed from admission to time of discharge or death.Mortality rate for admitted epidemic KS patients was high at 20%. The most common reasons for admission included advanced KS disease, severe anemia, respiratory tract infections, and sepsis. The majority (48%) of admitted patients had advanced clinical stage with visceral involvement on admission. Clinical predictors of mortality on univariate analysis included visceral KS [odds ratio (OR) = 13.74; 95% confidence interval (95% CI) = 1.68-113; P = 0.02), fever (OR = 26; 95% CI = 4.85-139; P = .001), and sepsis (OR = 35.56; 95% CI = 6.05-209; P = .001). Baseline hemoglobin levels (5.6 vs 8.2 g/dL; P = .001) and baseline platelet counts (63 x 10^9/L vs 205 x 10^9/L; P = .01) were significantly lower in mortalities vs discharges. Baseline white cell counts were higher in mortalities vs discharges (13.78 x 10^9/L vs 5.58 x 10^9/L; P = .01), and HIV-1 viral loads at the time of admission were higher in mortalities vs discharges (47,607 vs 40 copies/μL; P = .02). However, only sepsis (or signs and symptoms of sepsis) were independently associated with mortality after controlling for confounders.In conclusion, common reasons for admission of epidemic KS patients include advanced disease, severe anemia, respiratory tract infections, and signs and symptoms of sepsis. Signs and symptoms of sepsis are independent predictors of mortality in these patients.

Does HIV infection affect the survival of dental implants? A systematic review and meta-analysis

STATEMENT OF PROBLEM

Immunosuppression and coinfections associated with human immunodeficiency virus (HIV) infection pose a relative contraindication for dental implant therapy. However, although implants have been placed in patients with HIV with reasonable success, how HIV infection affects their survival is unclear.

PURPOSE

The purpose of this systematic review of the literature and meta-analysis was to analyze the data on the survival of dental implants in patients with HIV.

MATERIAL AND METHODS

A search for relevant articles published up to November 2019 was performed in PubMed/Medline and Cochrane databases, Clinicaltrials.gov, and Google Scholar. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adopted for the conduct of the systematic review. The most pertinent data were extracted and pooled for qualitative and quantitative analyses with 95% confidence intervals. Heterogeneity was analyzed by using I-squared statistics.

RESULTS

A total of 8 studies involving 411 individuals with HIV and 1109 implants were included in the meta-analysis. The mean follow-up period was 2.8 years. A pooled estimate of 95% of implant survival rate with 95% confidence interval(92% to 96%) was noted. Heterogeneity across the 8 studies was found to be 41% with moderate true variability.

CONCLUSIONS

This systematic review demonstrated that HIV infection does not pose a serious threat to implant survival on short-term evaluation, but the evidence is of low quality.

Modeling Viral Suppression, Viral Rebound and State-Specific Duration of HIV Patients with CD4 Count Adjustment: Parametric Multistate Frailty Model Approach

INTRODUCTION

Combination antiretroviral therapy has become the standard care of human immunodeficiency virus (HIV)-infected patients and has further led to a dramatically decreased progression probability to acquired immune deficiency syndrome (AIDS) for patients under such a therapy. However, responses of the patients to this therapy have recorded heterogeneous complexity and high dynamism. In this paper, we simultaneously model long-term viral suppression, viral rebound, and state-specific duration of HIV-infected patients.

METHODS

Full-parametric and semi-parametric Markov multistate models were applied to assess the effects of covariates namely TB co-infection, educational status, marital status, age, quality of life (QoL) scores, white and red blood cell parameters, and liver enzyme abnormality on long-term viral suppression, viral rebound and state-specific duration for HIV-infected individuals before and after treatment. Furthermore, two models, one including and another excluding the effect of the frailty, were presented and compared in this study.

RESULTS

Results from the diagnostic plots, Akaike information criterion (AIC) and likelihood ratio test showed that the Weibull multistate frailty model fitted significantly better than the exponential and semi-parametric multistate models. Viral rebound was found to be significantly associated with many sex partners, higher eosinophils count, younger age, lower educational level, higher monocyte counts, having abnormal neutrophils count, and higher liver enzyme abnormality. Furthermore, viral suppression was also found to be significantly associated with higher QoL scores, and having a stable sex partner. The analysis result also showed that patients with a stable sex partner, higher educational levels, higher QoL scores, lower eosinophils count, lower monocyte counts, and higher RBC indices were more likely to spend more time in undetectable viral load state.

CONCLUSIONS

To achieve and maintain the UNAIDS 90% suppression targets, additional interventions are required to optimize antiretroviral therapy outcomes, specifically targeting those with poor clinical characteristics, lower education, younger age, and those with many sex partners. From a methodological perspective, the parametric multistate approach with frailty is a flexible approach for modeling time-varying variables, allowing for dealing with heterogeneity between the sequence of transitions, as well as allowing for a reasonable degree of flexibility with a few additional parameters, which then aids in gaining a better insight into how factors change over time.