The role of point-of-care viral load monitoring in achieving the target of 90% suppression in HIV-infected patients in Nigeria: study protocol for a randomized controlled trial

m-PIMA™ HIV1/2 VL: A suitable tool for HIV-1 and HIV-2 viral load quantification in West Africa

Point-of-Care for HIV viral RNA quantification seems to be a complementary strategy to the existing conventional systems. This study evaluated the performance of the m-PIMA™ HIV1/2 Viral Load for the quantification of both HIV-1 and HIV-2 RNA viral load. A total of 555 HIV-1 and 90 HIV-2 samples previously tested by Abbott RealTime HIV-1 (Abbott, Chicago, USA) and Generic HIV-2® Charge virale (Biocentric, France) were tested using the m-PIMA™ HIV1/2 Viral Load at the HIV National Reference lab in Senegal. For HIV-1, Pearson correlation and Bland-Altman plots showed a coefficient r = 0.97 and a bias of -0.11 log10 copies/ml (95% confidence interval [CI]: -0.086 to -0.133 log10 copies/ml) for the m-PIMA™ HIV1/2 Viral Load, respectively. Sensitivity and specificity at 3 log10 copies/ml (threshold of virological failure) were 93.6% (95%[CI]: 91.5% to 95.6%) and 99.1% (95%[CI]: 98.3% to 99.9%), respectively. For HIV-2, a correlation of r = 0.95 was also noted with a bias of - 0.229 log10 copies/ml (95%[CI]: -0.161 to -0.297 log10 copies/ml). Sensitivity and specificity at 3 log10 copies/ml were 97.6% (95%[CI]: 94.3% to 100%) and 93.9% (95%[CI]: 88.9% to 98.8%), respectively. These results confirmed that m-PIMA™ HIV1/2 VL could be a good alternative for HIV-1 and HIV-2 viral load testing in decentralized settings in Senegal.

Clinical and Immunological Profiles of HIV/AIDS Patients With First-Line Antiretroviral Treatment Failure Attending a Tertiary Care Hospital

Objectives Highly active antiretroviral therapy (HAART) has decreased morbidity and mortality among HIV/AIDS-infected patients; however, many patients experience treatment failure. The present study aims to evaluate HIV-infected patients' clinical and immunological profiles with first-line antiretroviral treatment (ART) failure (immunological and clinical) at tertiary care hospitals in Northeast India and explore related treatment failure factors. Methods The hospital-based observational study was conducted among HIV-infected patients with first-line ART failure attending a tertiary care hospital from July 1, 2019, to June 30, 2020. The type of first-line ART failure was defined as a clinical, immunological, or virological failure as decided by the State AIDS Clinical Expert Panel (SACEP) meeting. Data were analyzed with Windows MS Excel (Microsoft Corporation, Redmond, Washington) and Statistical Package for the Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY). Results Among the 90 HIV-infected patients experiencing first-line ART treatment failure, the majority, 38 (42.2%), were in the age group of 30-40 years, 64 (71.1%) were males, and 70 (77.8%) were of average weight. Tuberculosis was the most typical opportunistic infection, affecting 11 (12.2%) patients. Most patients (38.9%) were initially presented at clinical stage 3. Maximum failures were experienced by patients with baseline CD4 ranging from 100-200 cells/mm3, with 38 (42.2%) patients, and by patients on efavirenz (64.5%) and tenofovir-based regimens (56.6%). Failures occurred more for 24-30 months and were common among patients with adherence below 90%. Conclusion Treatment failure was more common among young male patients and those with normal body mass index (BMI). Low baseline CD4 count and poor adherence were influential in the occurrence of treatment failure. First-line ART failure was higher in tenofovir- and efavirenz-based regimens.

Assessing the acceptability of technological health innovations in sub-Saharan Africa: a scoping review and a best fit framework synthesis

Acceptability is a key concept used to analyze the introduction of a health innovation in a specific setting. However, there seems to be a lack of clarity in this notion, both conceptually and practically. In low and middle-income countries, programs to support the diffusion of new technological tools are multiplying. They face challenges and difficulties that need to be understood with an in-depth analysis of the acceptability of these innovations. We performed a scoping review to explore the theories, methods and conceptual frameworks that have been used to measure and understand the acceptability of technological health innovations in sub-Saharan Africa. The review confirmed the lack of common definitions, conceptualizations and practical tools addressing the acceptability of health innovations. To synthesize and combine evidence, both theoretically and empirically, we then used the "best fit framework synthesis" method. Based on five conceptual and theoretical frameworks from scientific literature and evidence from 33 empirical studies, we built a conceptual framework in order to understand the acceptability of technological health innovations. This framework comprises 6 determinants (compatibility, social influence, personal emotions, perceived disadvantages, perceived advantages and perceived complexity) and two moderating factors (intervention and context). This knowledge synthesis work has also enabled us to propose a chronology of the different stages of acceptability.

Clinic-based SAMBA-II vs centralized laboratory viral load assays among HIV-1 infected children, adolescents and young adults in rural Zimbabwe: A randomized controlled trial

BACKGROUND

In Zimbabwe, children, adolescents and young adults living with HIV (CALWH) who are on public health antiretroviral therapy (ART) have inadequate viral load (VL) suppression. We assessed whether a clinic-based VL monitoring could decrease 12-month virologic failure rates among these CALWH.

METHODS

The study was registered on ClinicalTrials.gov: NCT03986099. CALWH in care at Chidamoyo Christian Hospital (CCH) and 8 rural outreach sites (ROS) on long-term community-based ART were randomized (1:1) to 6 monthly VL monitoring by COBAS®Ampliprep®/Taqman48® HIV-1 at the provincial referral laboratory (PRL) as per standard of care (SOC) or by the clinic-based SAMBA II assay, Diagnostics for the Real World, at CCH. VL suppression, turn-around-time (TAT) for VL results, drug switching and drug resistance in second-line failure were assessed at 12 months.

RESULTS

Of 390 CALWH enrolled 347 (89%) completed 12 months follow-up. Median (IQR) age and ART duration were 14.1 (9.7-18.2) and 6.4 (3.7-7.9) years, respectively. Over half (57%) of the participants were female. At enrolment, 78 (20%) had VL ≥1,000 copies/ml and VL suppression of 80% was unchanged after 12 months, with no significant difference between the SOC (81%) and the clinic-based (80%) arms (p = 0.528). Median (IQR) months to confirmatory VL result at CCH vs PRL was 4.0 (2.1-4.4) vs 4.5 (3.5-6.3) respectively; p = 0.027 at 12 months. Drug switching was documented among 26/347 (7%) participants with no difference between the median (IQR) time to switch in SOC vs clinic-based arms (5.1 (3.9-10.0) months vs 4.4 (2.5-8.4) respectively; p = 0.569). Out of 24 confirmed second-line failures, only 4/19 (21%) had protease inhibitor resistance.

CONCLUSION

In rural Zimbabwe, the clinic-based SAMBA II assay was able to provide confirmatory VL results faster than the SOC VL assay at the PRL. However, this rapid TAT did not allow for a more efficient drug switch among these CALWH.

Timeliness of Point-of-Care Viral Load Results Improves Human Immunodeficiency Virus Monitoring in Nigeria

BACKGROUND

Human immunodeficiency virus (HIV) viral load (VL) monitoring is critical for antiretroviral therapy (ART) management. Point-of-care (POC) VL testing has been reported to be feasible and preferred over standard-of-care (SOC) testing in many low- and middle-income country settings where rapid results could improve patient outcomes.

METHODS

The timeliness of receipt of VL results was evaluated in an open-label, randomized, controlled trial among patients newly initiating ART. Clinical outcomes with POC VL monitoring using Cepheid Xpert vs SOC VL at Jos University Teaching Hospital and Comprehensive Health Centre Zamko in Nigeria were assessed. We determined time between specimen collection and recording of VL in patient charts, receipt of results, and ART switch for those who met virologic failure criteria.

RESULTS

Between April 2018 and October 2019, we screened 696 ART-naive individuals; 273 were randomized to POC and 268 to SOC HIV-1 VL testing. Participants in the POC arm received VL results significantly faster than those in the SOC arm (0.1 median days, interquartile range [IQR], 0.1-0.2 vs 143.1 days, IQR, 56.0-177.1, respectively; P < .0001). Participants in the POC arm with confirmed virologic failure vs those in the SOC arm were switched more rapidly to a second-line regimen (0 median days, IQR, 0-28 vs 66 days, IQR, 63-123, respectively; P = .03).

CONCLUSIONS

POC VL testing resulted in significant improvement in the timeliness of VL result receipt by patients and use for effective HIV clinical management. In patients experiencing VL failure, POC monitoring enabled prompt switching to second-line ART regimens.

CLINICAL TRIALS REGISTRATION

NCT03533868.

Clinical Outcomes in a Randomized Controlled Trial Comparing Point-of-Care With Standard Human Immunodeficiency Virus (HIV) Viral Load Monitoring in Nigeria

BACKGROUND

Point-of-care (POC) viral load (VL) tests provide results within hours, enabling same-day treatment interventions. We assessed treatment outcomes with POC vs standard-of-care (SOC) VL monitoring.

METHODS

We implemented a randomized controlled trial at an urban and rural hospital in Nigeria. Participants initiating antiretroviral therapy (ART) were randomized 1:1 for monitoring via the POC Cepheid Xpert or SOC Roche COBAS (v2.0) HIV-1 VL assays. Viral suppression (VS) and retention in care at 12 months were compared via intention-to-treat (ITT) and per-protocol (PP) analyses. Post-trial surveys for POC patients and healthcare workers (HCWs) evaluated acceptability.

RESULTS

During April 2018-October 2019, 268 SOC and 273 POC patients enrolled in the trial. Viral suppression at <1000 copies/mL at 12 months was 59.3% (162/273) for POC and 52.2% (140/268) for SOC (P = .096) in ITT analysis and 77.1% (158/205) for POC and 65.9% (137/208) for SOC (P = .012) in PP analysis. Retention was not significantly different in ITT analysis but was 85.9% for POC and 76.9% for SOC (P = .02) in PP analysis. The increased VS in the POC arm was attributable to improved retention and documentation of VL results. POC monitoring was preferred over SOC by 90.2% (147/163) of patients and 100% (15/15) of HCWs thought it facilitated patient care.

CONCLUSIONS

POC VL monitoring did not improve 12-month VS among those with results but did improve retention and VS documentation and was preferred by most patients and HCWs. Further research can inform best POC implementation conditions and approaches to optimize patient care.

CLINICAL TRIALS REGISTRATION

NCT03533868.

Impact of the Implementation of Laboratory Information System (WWDISA) on Timely Provision of HIV-1 Viral Load Results in a Rural Area, Inhambane, Mozambique

WWDISA is an optional module of the DISA Laboratory Information system (LIS) that offers a web portal that allows access to test results over the internet for patient clinical management. This study aims to assess the applicability of using the WWDISA web application, and the lessons learned from its implementation in six health facilities in Mabote district, Inhambane province. Data from 2463 and 665 samples for HIV-viral load (HIVVL) tests, extracted from paper-based and WWDISA systems, respectively, were included, from January to December 2020. Data were simultaneously collected on a quarterly basis from both systems to allow comparison. The WWDISA turnaround time (TAT) from sample collection to results becoming available was found to be 10 (IQR: 8−12) days and significantly lower than the health unit manual logbook (p value < 0.001). Regarding the system efficiency, it was found that among 1978 search results, only 642 (32.5%) were found, and the main challenges according to the users were lack of connectivity (77%) and the website going down (62%). The WWDISA module has been shown to be effective in reducing the TAT, although a stable internet connection and accurate data entry are essential to make the system functional.

The practice of pilot/feasibility studies in informing the conduct of HIV related clinical trials in sub-Saharan Africa: A scoping review

Introduction

Pilot/feasibility studies represent a fundamental phase of the research process and play a vital role in the preliminary planning of a full size HIV clinical trial. Published HIV clinical trial protocols were reviewed to establish the extent to which the proposed HIV clinical trials are informed by a prior pilot/feasibility study.

Methods

The JBI methodology for scoping reviews was followed. Six databases were systematically searched to identify articles for inclusion.

Results

Thirty two (32) published HIV study protocols were included. Articles were in the English language and were published in the past 10 years (2011-2020). The review results showed that the majority of HIV-related clinical trials in sub-Saharan Africa were not informed by pilot/feasibility studies. The results further indicated that the number of HIV clinical trials informed by a pilot/feasibility study have been on the increase in the 8 years' period since 2012, a trend that indicates positive uptake of pilot studies in HIV related studies. A few select countries (South Africa, Uganda, Zimbabwe, Malawi and Kenya) comprised more than 70% of all clinical trials that were informed by a pilot/feasibility study, conducted in sub Saharan Africa.

Conclusions

Although there is an increasing interest among researchers to integrate pilot/feasibility studies in HIV related research, limited countries in sub-Saharan Africa appear to have embraced this trend. Strategies that can motivate researchers to engage in a culture of incorporating pilot/feasibility studies in HIV related research should be implemented.

HIV supply chains in low- and middle-income countries: overview and research opportunities

Purpose

Despite HIV being reported as one of the major global health issues, availability and accessibility of HIV services and supplies remain limited, especially in low- and middle-income countries. The effective and efficient operation of HIV supply chains is critical to tackle this problem. The purpose of this paper is to give an introduction to HIV supply chains in low- and middle-income countries and identify research opportunities for the operations research/operations management (OR/OM) community.

Design/methodology/approach

First, the authors review a combination of the scientific and grey literature, including both qualitative and quantitative papers, to give an overview of HIV supply chain operations in low- and middle-income countries and the challenges that are faced by organizing such supply chains. The authors then classify and discuss the relevant OR/OM literature based on seven classification criteria: decision level, methodology, type of HIV service modeled, challenges, performance measures, real-life applicability and countries covered. Because research on HIV supply chains in low- and middle-income countries is limited in the OR/OM field, this part also includes papers focusing on HIV supply chain modeling in high-income countries.

Findings

The authors conclude this study by identifying several tendencies and gaps and by proposing future research directions for OR/OM research.

Originality/value

To the best of the authors’ knowledge, this paper is the first literature review addressing this specific topic from an OR/OM perspective.

Protocol for a randomised feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression in South Africa: the POwER study

INTRODUCTION

Access to HIV viral load testing remains difficult for many people on antiretroviral therapy (ART) in low-income and middle-income countries. Weak laboratory and clinic systems often delay the detection and management of viraemia, which can lead to morbidity, drug resistance and HIV transmission. Point-of-care testing could overcome these challenges. We aim to assess whether it is feasible to conduct a randomised trial of point-of-care viral load testing to manage viraemia.

METHODS AND ANALYSIS

We will conduct an open-label, single-site, individually randomised, feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression, in Durban, South Africa. We will enrol approximately 100 people living with HIV who are aged ≥18 years, receiving first-line ART but with recent viraemia ≥1000 copies/mL, and randomise them 1:1 to receive point-of-care viral load or standard laboratory viral load monitoring, after 12 weeks. All participants will continue to receive care from public sector healthcare workers following South African HIV management guidelines. Participants with persistent viraemia ≥1000 copies/mL will be considered for switching to second-line ART. We will compare the proportion in each study arm who achieve the primary outcome of viral suppression <50 copies/mL at 24 weeks after enrolment. Additional outcomes include proportions retained in the study, proportions with HIV drug resistance, time to viral load results and time to switching to second-line ART. We will assess implementation of point-of-care viral load testing using process evaluation data, and through interviews and focus groups with healthcare workers.

ETHICS AND DISSEMINATION

University of Oxford Tropical Research Ethics Committee and the Biomedical Research Ethics Committee of the University of KwaZulu-Natal have approved the study. We will present results to stakeholders, and through conferences and open-access, peer-reviewed journals.

TRIAL REGISTRATION NUMBER

PACTR202001785886049.

Monitoring HIV infection in Minas Gerais state: 15-year assessment of adults living with HIV initiating Antiretroviral Therapy

INTRODUCTION

The first Brazilian HIV treatment recommendation was put forward in 1996, resulting in 12 subsequent guidelines. Several changes were made regarding "when" and "how" to begin treatment. The latest guideline recommends immediate initiation of antiretroviral therapy (ART). This study aimed to describe the evolution of HIV treatment among people living with HIV (PLHIV) who initiated ART between 2004 and 2018 based on the national guideline recommendations concerning T-CD4+ and VL measurements.

METHODS

A cross-sectional analysis of data of PLHIV aged >18 years, in Minas Gerais who received ART between 2004 and 2018 was conducted. Clinical, therapeutic, and demographic information were obtained from national healthcare databases. The study was divided into four periods: 2004-2007, 2008-2012, 2013-2016, and 2017-2018. Descriptive analyses were performed.

RESULTS

A total of 60,618 PLHIV initiated ART (67% male and 48% aged 25-39 years), 36% of whom had CD4 counts at ART initiation and 51% documented VL after ART initiation. The median CD4 count ranged from 288 to 373 cells/µL. The median time to ART initiation decreased from 604 to 28 days and was lower among males (p <0.01). The median time from ART initiation to the first VL result decreased from 101 to 62 days over the study period, while the median VL after ART initiation ranged from 2.3 to 1.7 log10 copies/ml.

CONCLUSIONS

Although our results demonstrated that most recommendations were followed, there seemed to be little impact on CD4 counts and VL testing. This may result in an inadequate evaluation of ART effectiveness.

Time to Treatment Initiation and Retrospective Analysis of Antiretroviral Therapy Outcomes among HIV-positive Methadone Maintenance Therapy Clients in Primary Health-care Centers, Kuantan, Pahang

Introduction:

Methadone maintenance therapy (MMT) program helped to improve access to antiretroviral therapy (ART) among people who inject drugs (PWID) with human immunodeficiency virus (HIV). However, the time to treatment initiation (TTI) and outcomes of ART intervention in this population have scarcely been analyzed.

Objectives:

The aim of this study was to analyze the TTI and outcomes of ART among MMT clients in primary health-care centers in Kuantan, Pahang.

Materials and Methods:

This was a retrospective evaluation of MMT clients from 2006 to 2019. The TTI was calculated from the day of MMT enrolment to ART initiation. The trends of CD4 counts and viral loads were descriptively evaluated. Cox proportional hazard model was used to analyze the survival and treatment retention rate.

Results:

A total of 67 MMT clients from six primary health-care centers were HIV-positive, of which 37 clients were started on ART. The mean TTI of ART was 27 months. The clients who were given ART had a mean CD4 count of 119 cells/mm³ at baseline and increased to 219 cells/mm³ after 6 months of ART. Only two patients (5.4%) in the ART subgroup had an unsuppressed viral load. The initiation of ART had reduced the risk of death by 72.8% (hazard ratio = 0.27, P = 0.024), and they are 13.1 times more likely to remain in treatment (P < 0.01).

Conclusion:

The TTI of ART was delayed in this population. MMT clients who were given ART have better CD4 and viral load outcomes, helped reduced death risk and showed higher retention rates in MMT program.

Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials

PURPOSE OF REVIEW

In 2018-2019, studies were published assessing the effectiveness of reducing HIV incidence by expanding HIV testing, linkage to HIV treatment, and assistance to persons living with HIV to adhere to their medications (the "90-90-90" strategy). These tests of "treatment as prevention" (TasP) had complex results.

RECENT FINDINGS

The TasP/ANRS 12249 study in South Africa, the SEARCH study in Kenya and Uganda, and one comparison (arms A to C) of the HPTN 071 (PopART) study in South Africa and Zambia did not demonstrate a community impact on HIV incidence. In contrast, the Botswana Ya Tsie study and the second comparison (arms B to C) of PopART indicated significant ≈ 30% reductions in HIV incidence in the intervention communities where TasP was expanded. We discuss the results of these trials and outline future research and challenges. These include the efficient expansion of widespread HIV testing, better linkage to care, and viral suppression among all persons living with HIV. A top implementation science priority for the next decade is to determine what strategies to use in specific local contexts.