Trends and outcomes of late initiation of combination antiretroviral therapy driven by late presentation among HIV-positive Taiwanese patients in the era of treatment scale-up

Predictors of survival among older adults with HIV in Uganda's AIDS support organization centers of excellence (1987-2023): a retrospective longitudinal study

BACKGROUND

The growing number of older adults living with HIV, facilitated by wider access to antiretroviral therapy (ART), presents unique challenges. This study aims to identify predictors of survival among older persons living with HIV receiving ART in Uganda's AIDS Support Organization Centers of Excellence (1987-2023). Understanding these predictors can inform effective clinical interventions to improve outcomes for this population.

METHODS

This study conducted a retrospective analysis of medical records from 11 TASO centers of excellence in Uganda (1987-2023). Using Cox proportional hazards regression, we identified factors associated with survival among older adults living with HIV. TASO centers of excellence in Entebbe, Gulu, Jinja, Masaka, Masindi, Mbale, Mbarara, Mulago, Rukungiri, Soroti, and Tororo. Cox proportional hazards regression analysis identified factors influencing survival among older persons living with HIV (OPLHIV).

RESULTS

Of the 30,758 OPLHIV medical records analyzed (1987-2023), 72.5% were active on ART, 5.9% had died, 15.2% were lost to follow-up, and 5.6% transferred to other facilities. Survival was significantly associated with: gender (female, HR = 1.19, p < 0.001), marital status (married, HR = 0.99, p < 0.001; separated/divorced, HR = 0.85, p < 0.001), WHO clinical stage (II, HR = 1.66, p < 0.001), viral load (> 200 copies/ml, HR = 1.49, p < 0.001), and ART adherence (fair, HR = 0.94, p = 0.157).

CONCLUSION

Key predictors of survival among Older Adults Living with HIV (OPLHIV) include: female gender, age 50-59, weight 51-70 kg, married status, viral load > 200 copies/ml, WHO HIV clinical stage II, paid employment, and ART adherence. To improve survival outcomes, consistent clinical screenings of WHO clinical stages, viral load, and ART adherence are essential. These measures can guide healthcare providers in making informed treatment decisions to enhance survival and quality of life for OPLHIV in Uganda.

RECOMMENDATIONS

Strengthen routine monitoring of viral load, ART adherence, and WHO clinical staging. Provide targeted support to married and separated/divorced adults to improve their survival chances. Address gender disparities in care to enhance outcomes for females. Focus on maintaining ART adherence and viral suppression to reduce mortality risks.

Forty years of HIV infection and AIDS in Taiwan: Reflection on the past and looking toward the future

We review the epidemiology, policies, and control programs of HIV infection in Taiwan in the past 40 years since the first case of HIV infection was diagnosed in 1984. With the introduction of combination antiretroviral therapy (ART) in Taiwan in 1997, the incidences of HIV-related opportunistic illnesses and mortality have significantly declined. However, despite improved access to HIV testing and treatment, late presentation of HIV infection remains common. Unprotected sex, particularly among men who have sex with men, continues to be the leading risk for HIV transmission after implementation of harm reduction program to control an outbreak of HIV infection among people who inject drugs that occurred in 2003-2007. The sequential introduction of well-tolerated, effective, single-tablet antiretroviral regimens has facilitated the implementation of "treat-all" policy in 2016, rapid ART initiation within 7 days of diagnosis in 2018, and same-day ART initiation in 2021 when immunochromatography was used for rapid confirmation of HIV infection. Government-funded pilot program of pre-exposure prophylaxis for HIV infection, which was launched in 2016 followed by wider enrollment of people at high risk for HIV acquisition in 2018, have contributed to sustained declines of the incidence of HIV infection since 2018, along with high rates of linkage to HIV care, ART initiation, viral suppression, and retention in care in Taiwan. Challenges remain to achieve HIV elimination and long-term successful management of HIV infection, which include stigma and discrimination, late presentation of HIV infection, and accelerated ageing with increasing rates of co-morbidities among people with HIV.

Clinical benefits of rapid initiation of antiretroviral therapy within 14 days for newly diagnosed late-presentation people living with human immunodeficiency virus (PLWH)

This study evaluated the impact of initiating antiretroviral therapy (ART) within 14 days compared to starting after 14 days in newly diagnosed, late-presenting people living with human immunodeficiency virus (PLWH). A total of 1,538 PLWH with a baseline CD4+ T-cell count < 350 cells/μL who attended our outpatient clinic from January 2017 to June 2022 were included. Participants were divided into two groups based on ART initiation timing: rapid initiation (ART within 14 days) and delayed initiation (ART after 14 days). Rapid initiation led to significantly higher virologic suppression rates at 6 months (62.5% vs. 52.7%, P < 0.05) and 1 year (81.6% vs. 72.1%, P < 0.01) compared to delayed initiation. While overall treatment retention rates were comparable, rapid initiation improved retention at 6 months for those with baseline CD4+ < 200 cells/μL and at 1 year for those with baseline CD4+ between 200 and 350 cells/μL. No significant differences in CD4+ T-cell counts or CD4/CD8 ratio were observed. A positive correlation was found between baseline viral load and time to virologic suppression, with rapid initiation of ART leading to faster suppression, especially in those with higher baseline viral loads. Multivariate analysis confirmed that ART initiation timing and baseline viral load were key determinants of virologic suppression. In conclusion, rapid ART initiation within 14 days was associated with higher virologic suppression at 6 months and 1 year. Rapid initiation of ART and lower baseline viral load were critical for virologic suppression, with improved retention for specific subgroups.

Sociobehavioral Risk Factors and Clinical Implications of Late Presentation Among People Living with HIV in the Brazilian Amazon Region

This study aimed to analyze the prevalence, sociobehavioral factors and clinical-laboratory consequences of late presentation among people living with HIV (PLHIV) in the Brazilian Amazon region. In total, 402 HIV + individuals treated at reference units in Belém city (Pará, Brazil) between 2018 and 2019 were evaluated. Late presentation was defined as a first-collection LTCD4+ count below 350 cells/µL. Sociodemographic, behavioral and clinical data were obtained from questionnaires or medical records. Th1, Th2 and Th17 cytokine profiles were evaluated by flow cytometry. Longitudinal data on viral load, T lymphocytes, and antiretroviral therapy administration were obtained from control and logistic databases. Approximately 52.73% of the participants were late presenters and sought medical care 7-12 + months after their primary HIV diagnosis. Sociobehavioral factors associated with late presentation included illicit drug use for more than 5 years, polyamory, no alcohol consumption, homosexuality, and sexual inactiveness after HIV diagnosis. Clinically, late presentation was associated with coinfection rate; polysymptomatology; high IFN-ɣ, IL-6 and IL-10 levels; nonresponse to antiretroviral therapy; and virological failure- and tuberculosis coinfection-motivated changes to therapy. In summary, the prevalence of late presentation in Pará in the Brazilian Amazon region is high. Delays in seeking specialized care after a primary HIV diagnosis cause medium/long-term changes in the life expectancy and health of PLHIV.

The incidences and clinical outcomes of cryptococcosis in Taiwan: A nationwide, population-based study, 2002-2015

Large-scale epidemiological data on cryptococcosis other than cryptococcal meningitis (CM), human immunodeficiency virus (HIV)- or solid organ transplantation (SOT)-associated cryptococcosis are limited. This study investigated the disease burden of cryptococcosis in Taiwan over 14 years. Incident episodes of cryptococcosis, comorbidities, treatment, and outcomes were captured from Taiwan's National Health Insurance Research Database and National Death Registry between 2002 and 2015. Of 6647 episodes analyzed, the crude incidence rate per 100 000 population increased from 1.48 in 2002 to 2.76 in 2015, which was driven by the growing trend in the non-CM group (0.86-2.12) but not in the CM group (0.62-0.64). The leading three comorbidities were diabetes mellitus (23.62%), malignancy (22.81%), and liver disease (17.42%). HIV accounted for 6.14% of all episodes and was associated with the highest disease-specific incidence rate (269/100 000 population), but the value dropped 16.20% biennially. Within 90 days prior to cohort entry, 30.22% of episodes had systemic corticosteroid use. The in-hospital mortality of all episodes was 10.80%, which varied from 32.64% for cirrhosis and 13.22% for HIV to 6.90% for SOT. CM was associated with a higher in-hospital mortality rate than non-CM (19.15% vs. 6.33%). At diagnosis, only 48.53% of CM episodes were prescribed an amphotericin-based regimen. The incidence rate of cryptococcosis was increasing, especially that other than meningitis and in the non-HIV population. A high index of clinical suspicion is paramount to promptly diagnose, treat, and improve cryptococcosis-related mortality in populations other than those with HIV infection or SOT.

Factors associated with late initiation of antiretroviral therapy in Iran's HIV/AIDS surveillance data

Early initiation of Antiretroviral Treatment (ART) in HIV patients is essential for effectively suppressing the viral load and prognosis. This study utilized National HIV/AIDS Surveillance Data in Iran to identify factors associated factors with the duration to initiate ART. This hybrid cross-sectional historical cohort study was conducted on Iran's National HIV/AIDS Surveillance Data from 2001 to 2019. Sociodemographic characteristics, route of transmission, HIV diagnosis date, and ART initiation date were collected. Multivariable linear and quantile regression models were employed to analyze the duration to initiate ART by considering predictor variables. This study included 17,062 patients (mean age 34.14 ± 10.77 years, 69.49% males). Multivariate quantile regression coefficients varied across different distributions of the dependent variable (i.e., duration to initiate ART) for several independent variables. Generally, male gender, injecting drug use (IDU), and having an HIV-positive spouse were significantly associated with an increased duration to initiate ART (p < 0.05). However, a significant decrease was observed in older patients, those with a university level education, men who had sex with men (MSM), and patients diagnosed after 2016 (p < 0.05). Despite improvements in the duration to initiate ART after implementing the WHO's 2016 program in Iran, various sociodemographic groups were still vulnerable to delayed ART initiation in the region. Therefore, programs including early testing, early ART initiation, active care, educational and cultural interventions, and appropriate incentives are required for these groups.

Factors Associated With Delayed and Late Initiation of Antiretroviral Therapy Among Patients With HIV in Beijing, China, 2010-2020

Objectives: To determine factors associated with late and delayed antiretroviral therapy (ART) initiation in China and provide evidence for HIV prevention. Methods: Logistics regression model was used to determine factors associated with three outcomes: late (CD4 cell count <200 cells/µL or clinical AIDS diagnosis prior to ART initiation), delayed (more than 1 month between HIV diagnosis date and ART initiation) and either late or delayed ART initiation. Results: Multivariable analysis revealed that male, heterosexual, HIV diagnosis before 2014, HBV/HCV seropositive, and tuberculosis were associated with increased odds of all three outcomes. Conversely, married or cohabiting patients were less likely to have delayed ART initiation and either late or delayed ART initiation, while people who inject drugs were more likely to have these two outcomes. Additionally, older age was associated with an increased risk of having either late or delayed ART initiation, but a decreased risk of delayed ART initiation. Conclusion: The proportion of late and delayed ART initiation decreased significantly after the release of the 2016 guidelines in China. To further improve late diagnosis and early treatment, precise interventions for key populations are required.

Comparison of Virological Efficacy of DTG/ABC/3TG and B/F/TAF Regimens and Discontinuation Patterns in Persons Living with Advanced HIV in the Era of Rapid ART: A Retrospective Multicenter Cohort Study

INTRODUCTION

International treatment guidelines recommend the rapid initiation of antiretroviral therapy (ART) with bictegravir (B)/emtricitabine (F)/tenofovir alafenamide (TAF) and dolutegravir (DTG)-based regimens for treatment-naïve persons living with HIV (PLWH) irrespective of their disease stage. However, we lack evidence of the virological efficacy, virological failure, and tolerability of coformulated B/F/TAF and DTG/ABC/3TC regimens in persons living with advanced HIV (PLWAH; defined as persons with a CD4⁺ count of < 200 cells/μL or an AIDS-related opportunistic illness [AOI] at or before ART initiation) in the era of rapid ART.

METHODS

This retrospective multicenter study enrolled treatment-naïve PLWAH initiating ART with coformulated DTG/ABC/3TC or B/F/TAF in 2019-2020. Viral suppression at week 48 was analyzed using FDA snapshot analysis. Between-regimen differences in time to viral suppression (< 50 copies/mL), virological failure, and regimen discontinuation were examined using a Cox proportional hazards model. Analysis was also performed using time to regimen discontinuation due to adverse reactions (ARs) as the outcome.

RESULTS

We enrolled 162 patients, including 61.1% on DTG/ABC/3TC and 38.9% on B/F/TAF. At week 48 after ART initiation, 73.47% on DTG/ABC/3TC and 85.71% on B/F/TAF achieved viral suppression (P = 0.178). We identified no between-regimen differences in time to viral suppression or virological failure, regardless of pre-ART viral load. Compared with the DTG/ABC/3TC group, regimen discontinuation was less prevalent in the B/F/TAF group (adjusted hazard ratio = 0.23, 95% CI 0.06-0.85, P = 0.027). The main reason for discontinuation in both groups was ARs (61.9% in the DTG/ABC/3TC and 50% in the B/F/TAF, P = 0.877), of which skin manifestations were the most common in both groups (61.5% in the DTG/ABC/3TC and 50% in the B/F/TAF, P = 0.756). DTG/ABC/3TC, same-day ART prescription, and AOI were risk factors for AR or virological failure-related regimen discontinuation.

CONCLUSION

In the real world, the risk of regimen discontinuation was higher in PLWAH on coformulated DTG/ABC/3TC than in those on B/F/TAF, with no difference in viral suppression or virological failure. Given the findings concerning the effect of same-day ART prescription and AOIs on AR or virological failure-related regimen discontinuation, individualized approaches to PLWAH are necessary.

A retrospective clinical study of dolutegravir- versus efavirenz-based regimen in treatment-naïve patients with advanced HIV infection in Nanjing, China

Currently, there are limited data related to the efficacy and safety of ART regimens, as well as factors influencing immune recovery in antiretroviral therapy (ART)-naïve patients with advanced HIV infection, especially in China. We designed a single-center, retrospective cohort study from March 1, 2019, to May 31, 2022, at The Second Hospital of Nanjing, China. ART-naïve adults with advanced HIV infection (CD4+ T-cell count < 200 cells/μL) who met the study criteria were included. The plasma viral load (VL), CD4+ T-cell count, CD4/CD8 ratio, treatment discontinuation, and immune reconstitution inflammatory syndrome (IRIS) events were collected to compare the efficacy and safety of the dolutegravir (DTG) and the efavirenz (EFV) regimens. Factors of immune recovery were analyzed using the Cox regression model. Study enrolled 285 ART-naïve adults with advanced HIV-1 infection, of which 95 (33.3%) started regimens including DTG and 190 (66.7%) were treated with EFV. After ART initiation, the proportion of patients with HIV-1 RNA < 50 copies/mL was higher (22.5% versus 6.5%, P < 0.001) in those on DTG-based regimens at month 1, but no significant difference at other follow-up points. Compared to the baseline, the median CD4+ T-cell count and CD4/CD8 ratio increased significantly during follow-up both in the EFV and the DTG groups. However, the CD4+ T-cell count increased greater in patients on DTG-based regimens at months 6, 12, 24, and 36 (P < 0.05). A total of 52 (18.2%) patients discontinued treatment, with no significant difference between ART regimens in treatment discontinuation rates. Only 7 patients reported IRIS, without significant difference between ART regimens (P=0.224). Overall, 34.0% (97/285) achieved a CD4+ T-cell count ≥ 350 cells/μL during follow-up. Age (P < 0.001), baseline CD4+ T-cell count (P < 0.001), baseline VL (P < 0.001) and ART regimens (P = 0.019) were associated with the CD4+ T-cell count ≥ 350 cells/μL after adjusting for potential confounders. Among ART-naïve adults with advanced HIV infection, it appeared that DTG-based regimens were better options for initial therapy compared to regimens including EFV; in addition, ART regimens, age, baseline VL and CD4+ T-cell count were associated with immune recovery.

The prevalence of people who inject drugs among those with HIV late presentation: a meta-analysis

Background

One of the most important routes of HIV transmission is through injections of drugs, and this group, due to unawareness of their infection, causes the spread of HIV. The coexistence of other opportunistic infections and diseases with HIV among people who inject drugs (PWID) imposes healthcare costs and is associated with high morbidity/mortality rates. Early detection of HIV among PWID is essential to prevent and control the spread of the disease.

Objectives

This study aimed to determine the prevalence of PWID among those with late presentation (LP).

Methods

Three electronic databases of PubMed, Scopus, and Web of science were searched using appropriate keywords. Besides the prevalence data reported for PWID among LP, the other outcomes of interest were LP defined as having CD4 count < 350 cells/μL or HIV or advanced disease defined with CD4 count < 200 cells/μL or HIV at the time of diagnosis.

Results

Of the 160 studies found, only eight met the inclusion criteria. Among those presented late, 36.5% were PWID (95% CI = 24.88–48.17). Compared with men who have sex with men (MSM), HIV-infected PWID had a higher risk of LP [OR = 1.51; 95% CI = 0.96–2.06].

Conclusion

The results of this study show that HIV is diagnosed late in the majority of PWID when CD4 is less than 350 cells/μL. Targeted interventions/strategies are highly required to reduce LP among HIV-infected PWID.

Late cART Initiation Consistently Driven by Late HIV Presentation: A Multicenter Retrospective Cohort Study in Taiwan from 2009 to 2019

INTRODUCTION

Late initiation (LI) of combination antiretroviral therapy (cART)-defined as having a CD4⁺ count of < 200 cells/μL or an AIDS-defining disease at cART initiation-has detrimental outcomes but remains prevalent worldwide, with LI trends and etiologies following the implementation of various HIV policies remaining underinvestigated. We assessed key concerns, characterized the determinants of various statuses at cART initiation, and evaluated the effects of those statuses on all-cause mortality after cART initiation.

METHODS

This multicenter retrospective cohort study enrolled 1198 patients with newly diagnosed HIV infection during 2009-2019 who were grouped by status at cART initiation: those without LI (non-LI group, 56.01%); those with LI but without late presentation (LP) of HIV (LP: a CD4 + count of < 200 cells/μL at HIV presentation or AIDS events ≤ 3 months of HIV diagnosis) [LILP(-) group, 4.51%]; and those with LI and with LP of HIV [LILP(+) group, 39.48%]. Joinpoint regression was used to identify changes in LI proportion.

RESULTS

The median CD4⁺ count at cART initiation increased significantly between 2009 (98 cells/μL) and 2015 (325 cells/μL) and stabilized thereafter (P for trend < 0.001). For LI, we identified one joinpoint in 2015: a substantial decrease from 77.14% in 2009 to 34.45% in 2015, followed by a nonsignificant increase to 39.1% in 2019. Overall, LILP(+) explained 89.8% of LI, without significant changes (92.59% in 2009 to 94.23% in 2019). In addition to HIV diagnosis during 2009-2012, multinomial logistic regression identified an age over 30 years and acute HIV infection as risk factors for LILP(+) and LILP(-), respectively. LILP(-) and LILP(+) were associated with a higher all-cause mortality risk.

CONCLUSION

Given the rise in LI from 2015 in the era of treat-all and rapid cART initiation, strategic interventions to increase earlier cART initiation must be intensified in Taiwan, especially among populations with delayed access to HIV testing services.

Routine HIV Testing and Outcomes: A Population-Based Cohort Study in Taiwan

INTRODUCTION

Routine HIV testing is expected to facilitate early diagnosis and treatment. Nevertheless, to date, limited data are available on the presumed benefit of early detection with improved outcomes through routine HIV testing.

METHODS

This study was based on the Taiwan national HIV/AIDS registry, with follow-up data validated through December 31, 2014. Outcomes of people diagnosed with HIV infection through the routine (routinely offered in specific settings, opt-out) versus through nonroutine (individual risk-based) testing were compared. The main outcomes of the study were late diagnosis, HIV-related mortality, and all-cause mortality. Individuals were matched by year of HIV diagnosis and adjusted for age, sex, transmission routes, and SES. Analyses were conducted in 2019-2020.

RESULTS

This study included all 28,674 people diagnosed with HIV infection during 1986-2014 (8,431 [29%] by routine testing, 18,305 [64%] by individual risk-based testing) with a mean follow-up time of 6.2 years. Routine testing was associated with an 80% lower likelihood of late HIV diagnosis (AOR=0.20, 95% CI=0.18, 0.23, p<0.001), a 37% lower HIV-related mortality (adjusted hazard ratio=0.63, 95% CI=0.53, 0.75, p<0.001), and a 27% lower all-cause mortality (adjusted hazard ratio=0.73, 95% CI=0.67, 0.79, p<0.001).

CONCLUSIONS

Routine HIV testing was associated with highly favorable outcomes, including decreased late diagnosis, lower HIV-related mortality, and lower all-cause mortality, among people diagnosed with HIV infection. Under universal health coverage, expanding routine HIV testing in well-targeted settings may improve both HIV epidemic control for society and clinical outcomes for people living with HIV.

Different Trends of Distinct Time Points of AIDS Events Following HIV Diagnosis in Various At-risk Populations: A Retrospective Nationwide Cohort Study in Taiwan

Introduction

Acquired immune deficiency syndrome (AIDS) events at distinct time points after human immunodeficiency virus (HIV) diagnosis require various AIDS prevention strategies. However, no nationwide epidemiological surveillance studies have been conducted to explore the trends of distinct AIDS event time points in various at-risk populations. The aim of this study was to explore the issues and characterize the determinants of AIDS status after HIV diagnosis.

Methods

This nationwide cohort study enrolled HIV-positive Taiwanese during 1984–2016. AIDS events were classified into three time points (≤ 3, 4–12, > 12 months) by their occurrence time after HIV diagnosis. The periods of HIV/AIDS diagnosis were divided into six categories according to the calendar year of HIV/AIDS diagnosis: 1984–1991, 1992–1996, 1997–2001, 2002–2006, 2007–2011, and 2012–2016. HIV-positive Taiwanese during 1984–2011 were then selected to determine the factors associated with four AIDS statuses within 5 years after HIV diagnosis (no AIDS, AIDS ≤ 3 months, within 4–12 months, > 12 months) using multinomial logistic regression.

Results

Of 33,142 cases, we identified 15,254 (46%) AIDS events. The overall AIDS incidence (events/100 person-years) peaked during 1992–1996 (20.61), then declined, and finally stabilized from 2002 (8.96–9.82). The evolution of the proportion of distinct time points of AIDS events following HIV diagnosis changed significantly in heterosexuals and intravenous drug users (IDUs) during 1984–2016 (decline at ≤ 3 months in IDUs, decline at 4–12 months in IDUs, and increase at > 12 months in heterosexuals and IDUs) but not among men who have sex with men (MSM). Time points at ≤ 3 months remained at > 50% among MSM and at > 55% among heterosexuals. In multinomial logistic regression, IDUs (vs. men who have sex with men; MSM) had a lower risk of all AIDS statuses; heterosexuals (vs. MSM) had a higher risk of AIDS events ≤ 3 months after HIV diagnosis.

Conclusion

The magnitude of AIDS in Taiwan has been stable since 2002. Enhancing early diagnosis among people with sexual contact and optimizing the HIV care continuum among heterosexuals and IDUs should be priorities for further AIDS prevention strategies.

Late presentation for HIV impairs immunological but not virological response to antiretroviral treatment

OBJECTIVES

The aim of this study was to examine the impact of late presentation (CD4+ cell count <350 cells/μl or an AIDS-defining event) on effectiveness and safety of initial antiretroviral therapy (ART) and to evaluate whether treatment response depends on first-line ART regimen in late presenters.

DESIGN

ART-naive adults from the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) starting triple ART between 2010 and 2018.

METHODS

We used multivariable models to assess differences in viral suppression (viral load <50 copies/ml), immunological response (change in CD4+ cell count, CD4% (>29%) and CD4/CD8 normalization (>0.4 and >1) multiple T-cell marker recovery (MTMR): CD4+ cell count more than 500 cells/μl and CD4% >29% and CD4/CD8 >1), and treatment discontinuation due to adverse events (TDAE) at 48 weeks from ART initiation.

RESULTS

Out of 8002 participants, 48.7% were late presenters. Of them, 45.8% initiated ART with a NNRTI- (mostly TDF/FTC/EFV), 33.9% with a protease inhibitor (mostly TDF/FTC+boosted DRV) and 20.3% with an INI-based regimen (mostly ABC/3TC/DTG). At 48 weeks, late presenters had similar viral suppression, but worse immunological response, than non-late presenters with no difference on TDAE. Late presenters initiating with NNRTI-based regimens were more likely to achieve viral suppression than those starting with INI-based, due to the higher chance of achieving viral suppression observed with TDF/FTC/RPV compared to ABC/3TC/DTG. Initial treatment with NNRTI or protease inhibitor based showed similar immunological response than the INI-based regimens, which showed lower rates of TDAE than NNRTI- and protease inhibitor based regimens.

CONCLUSION

Despite safety and effectiveness of initial ART in terms of viral suppression, late presenters may not experience complete immunological response. In late presenters, effectiveness and safety depends on both the class and the specific first-line ART regimen.

Survival Time and Associated Factors Among Adults Living with HIV After Initiation of HAART in South Gondar, Northwest Ethiopia: A Retrospective Cohort

Background

Antiretroviral therapy consistently improves the survival of people living with HIV and contributes to preventing the development of new infections. Studies of antiretroviral therapy programs in Africa have shown a high mortality rate during the first 6 months after initiation of HAART in rural health facilities. This study looks at survival time and associated factors among adults with HIV in south Gondar, Northwest Ethiopia.

Methods

A 5-year retrospective cohort study design was conducted using patient records among 746 adults living with HIV/AIDS. A systematic random sampling technique was used to select respondents after proportional allocation was made for all health facilities included in the study. Epi-info version 7 and STATA 12 were used for data entry and analysis, respectively. Kaplan–Meier survival analysis was used to estimate mean survival time and a life table was used to estimate survival probability after initiation of HAART.

Results

A total of 746 respondents were followed for a median of 60 months. There were 102 (13.67%) deaths yielding an overall mortality rate of 2.59/1,000-person year observation (95% CI=0.02136–0.031736). Age of respondents >43 years (AHR=2.790; 95% CI=1.495–5.206), bedridden (AHR=9.57; 95% CI=3.87–23.64), past TB treatment (AHR=0.86; 95% CI=0.46–0.609), baseline WHO stage IV (AHR=3.02; 95% CI=1.77–5.18), pneumonia after ART start (AHR=3.6; 95% CI=1.4–9.2), INH prophylaxis (AHR=2.58; 95% CI=1.232–5.188), ambulatory functional status (AHR=5.86; 95% CI=2.67–12.86), and disclosure status (AHR=0.423; 95% CI=0.261–0.685) were significant predictors for survival time after initiation of HAART among adults living with HIV.

Conclusion

The mortality rate was highly (13.67%) observed in the early phase of antiretroviral treatment. Being ambulatory and bedridden, age of respondents >43 years, past TB treatment, baseline WHO stage IV, pneumonia after HAART, INH prophylaxis, and disclosure status were independent predictors of mortality.

Screening for Cryptococcal Antigenemia and Burden of Cryptococcosis at the Time of HIV Diagnosis: A Retrospective Multicenter Study

Introduction

Screening for cryptococcal antigen (CrAg) is recommended for people living with HIV (PLWH) who present with low CD4 lymphocyte counts. Real-world experience is important to identify gaps between the guidelines and clinical practice. We investigated the trends of CrAg testing and prevalence of cryptococcal antigenemia among PLWH at the time of HIV diagnosis and the related mortality in Taiwan from 2009 to 2018.

Methods

Medical records of newly diagnosed PLWH seeking care at six medical centers around Taiwan between 2009 and 2018 were reviewed. The annual trends of PLWH who had CrAg testing and cryptococcal antigenemia were examined by Cochran-Armitage test. Among PLWH with CD4 < 200 cells/µl, timing of CrAg testing was analyzed for association with 12-month all-cause mortality in Kaplan-Meier plots and in a Cox proportional hazards model after adjustments.

Results

Among 5372 included PLWH, 1150 (21.4%) presented with baseline CD4 < 100 cells/µl, and this proportion had decreased during the study period [from 108 (29.3%) in 2009 to 93 (22.3%) in 2018 (P = 0.039)]. The overall prevalence of cryptococcal antigenemia was 7.8% among PLWH with CD4 < 100 cells/µl, which remained stable during the 10-year study period (P = 0.356) and was 2.6% among PLWH with CD4 100–199 cells/µl. The uptake of CrAg testing had increased from 65.7% in 2009 to 78.0% in 2018 (P = 0.002) among PLWH with CD4 < 100 cells/µl. Late CrAg testing, defined by 14 days or later after HIV diagnosis, was associated with increased risk of 12-month mortality compared to early CrAg testing (adjusted hazard ratio 2.028, 95% CI 1.109–3.708).

Conclusions

Burden of cryptococcosis remained high among PLWH with low CD4 lymphocyte counts in Taiwan. Uptake of CrAg screening among late HIV presenters was still suboptimal and delayed. Late CrAg testing was associated with a higher mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00451-5.

High prevalence of sexually transmitted coinfections among at-risk people living with HIV

BACKGROUND/PURPOSE

Concurrent sexually transmitted infections (STIs) are not uncommon in at-risk populations, for which control requires integrated testing, treatment and prevention.

METHODS

From May, 2019 to February, 2020, multiplex real-time PCR assays were prospectively performed to detect Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) in the urine and rectal/vaginal swab specimens collected from HIV-positive patients with a history of STIs or symptoms suggestive of STIs. Patients confirmed to have acquired STIs were treated according to treatment guidelines.

RESULTS

During the study period, 430 participants (99.1% men who have sex with men and median age 37 years) were included. The overall prevalence of CT, NG, and/or TV infection was 30.0%, including 24.7%, 12.1%, and 0.2% for CT, NG, and TV infection, respectively. The factors associated with CT, NG, and/or TV infection were hepatitis B surface antigen (HBsAg) seropositivity (AOR, 2.76; 95% CI, 1.22-6.26), recently acquired hepatitis C virus (HCV) infection (AOR, 5.62; 95% CI, 1.99-15.88), using mobile dating application (AOR, 2.08; 95% CI, 1.13-3.83), and oral sex (AOR, 2.12; 95% CI, 1.04-4.32). The rates of CT, NG, and/or TV infection were 50.0% in participants with recent HCV infection, 44.2% in those with HBsAg positivity, and 35.9% in those with incident syphilis. Among participants completing test-of-cure visits, the microbiological cure rate was 91.7% and 90.0% for chlamydia and gonorrhea, respectively.

CONCLUSION

HIV-positive participants had a high prevalence of CT and/or NG, especially those coinfected with viral hepatitis and syphilis. Our results strongly support integrated STI services in the population.

Characteristics of suboptimal immune response after initiating antiretroviral therapy among people living with HIV with a pre-treatment CD4 T cell count <200 ​cells/mm3 in Thailand

Background

Complete recovery of the CD4 T cell count is uncommon among chronically HIV-infected individuals with very low pre-treatment CD4 count. We studied the prevalence of chronically immune recovery and its associated factors including immune characteristics chronic HIV-infected Thais.

Methods

Treatment-naïve participants (n ​= ​375) from the HIV-NAT 006 cohort with a pre-treatment CD4 T cell count after initiating antiretroviral therapy (ART) and having achieved a suppressed viremia (HIV-RNA level ​< ​400 copies/mL) were retrospectively followed at the Thai Red Cross AIDS Research Centre, Bangkok, Thailand. Suboptimal immune recovery (SIR) was defined as having a CD4⁺ T cell count <200 ​cells/mm³ for 3 years after ART initiation. A case-control sub-study matched for age, sex and pre-ART CD4 T cell count was conducted to compare immunological characteristics between SIR (n ​= ​17) and non-SIR (n ​= ​24) participants. Immunological biomarkers such as interleukin-7 (IL-7) and soluble CD14 (sCD14) and other covariates including cytomegalovirus (CMV) DNA level, baseline hemoglobin level, hepatitis B and C co-infections, and T cell subsets associated with immune activation and exhaustion were evaluated.

Results

Among 375 participants with pre-ART CD4 T cell counts < 200 ​cells/mm³, the prevalence of SIR was 39.7%, 19.7% and 7.7% at years 1, 2 and 3 after starting ART, respectively. In a multivariate analysis, a pre-ART CD4 T cell count ≤100 ​cells/mm³ (adjusted odds ratio [aOR] 9.45, 95% CI 2.92–30.61, p ​< ​0.001), older age (aOR 1.07, 95% CI 1.01–1.13, p ​= ​0.029) and baseline HIV-RNA level (aOR 0.36, 95% CI 0.21–0.59, p ​< ​0.001) were independently associated with SIR at year 3 after ART initiation. In the matched case-control sub-study (cases ​= ​17, controls ​= ​24), there was a higher prevalence of hepatitis C co-infection (18.8% vs. 0%, p ​= ​0.05), lower sCD14 levels (mean, 6.23 vs. 6.27 log₁₀ ​pg/mL, p ​= ​0.04), lower CD8 T cell counts (mean, 514 vs. 876, p ​= ​0.0003), lower CD4/CD8 T cell ratio (mean, 0.27 vs. 0.41, p ​= ​0.01) and higher expression of PD1 on CD8⁺ T cells (74.2% vs. 65.1%, p ​= ​0.02) observed in SIR participants compared to their non-SIR counterparts at year 3 after ART initiation.

Conclusions

Nearly 10% of the study participants who had achieved virological suppression failed to recover a CD4 T cell count > 200 cells/mm³ after 3 years of ART which was with a very low pre-ART CD4 T cell count and older age. The long-term clinical outcomes of SIR participants need to be further explored.

Early scale-up of antiretroviral therapy at diagnosis for reducing economic burden of cardiometabolic disease in HIV-infected population

OBJECTIVE

The current study aims to assess the effect of early scale-up of antiretroviral therapy (ART) at HIV diagnosis on the economic burden of cardiometabolic diseases (CMDs) in HIV-infected population.

DESIGN

Cohort study.

METHODS

The study cohort comprised 10 693 newly diagnosed HIV patients without CMDs before HIV diagnosis identified from a nationwide HIV cohort in Taiwan. The patients were stratified by ART use [medication possession ratio ≥0.8: (high) vs. <0.8: (low)] and AIDS-defining illnesses (ADI) status [present: (+) vs. absent: (-)] at the first year of HIV diagnosis into four groups: ART (low) and ADI (-), ART (low) and ADI (+), ART (high) and ADI (-), and ART (high) and ADI (+). The economic analysis of incident CMDs was from the perspective of Taiwan's single-payer healthcare system and estimated using generalized estimating equations.

RESULTS

CMDs significantly increased annual direct medical costs by 31% (hypertension) to 127% [cardiovascular diseases (CVDs)]. The annual cost burden of diabetes, dyslipidemia, and CVDs in the ART (high) and ADI (-) group significantly decreased by 42, 30, and 31%, respectively, compared with the ART (low) and ADI (+) group. Compared with the ART (low) and ADI (+) group, the annual cost burden of CVDs in the ART (high) and ADI (-) and ART (high) and ADI (+) groups decreased by 31 and 14%, respectively, suggesting increased cost-savings when ART is initiated at diagnosis before ADI occurrence.

CONCLUSION

The early scale-up of ART at diagnosis before ADI occurrence is important for minimizing the economic burden of incident CMDs among HIV-infected patients.

Weight gain and dyslipidemia among virally suppressed HIV-positive patients switching to co-formulated elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide

OBJECTIVE

To evaluate the evolution of weight and lipid profiles before and after switch to co-formulated elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) among virally suppressed HIV-positive patients.

METHODS

Patients switching to E/C/F/TAF between March and July 2018 were included. Weight, lipid profile (triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C)), and glycated hemoglobin (HbA1c) levels at 48 weeks before and after the switch were analyzed using generalized estimating equations in order to identify the associated factors.

RESULTS

A total of 693 patients were included, and a weight gain was noted after the switch at weeks 12 (mean +0.63 kg), 24 (+1.25), 36 (+1.58), and 48 (+1.75) (all p < 0.0001). The weight change after the switch was significantly greater than that observed within the preceding 48-week period before the switch (+1.75 kg vs +0.54, p < 0.0001) and was correlated with switch to E/C/F/TAF (coefficient 0.29), later clinic visit (0.15), baseline weight (0.99), diabetes mellitus (coefficient -0.96), and age (-0.02) (all p < 0.01). At week 48, significant increases were observed for TG (mean +62.93 mg/dl), TC (+22.30), LDL-C (+9.70), HDL-C (+3.65) (all p < 0.01), and HbA1c (+0.08%) (p < 0.05), but not TC/HDL-C ratio (+0.12, p = 0.38).

CONCLUSIONS

Virally suppressed HIV-positive patients gained a moderate amount of weight and had significant increases in lipid levels after switching to E/C/F/TAF.

Hepatitis E Virus Infections Among Human Immunodeficiency Virus-Positive Individuals During an Outbreak of Acute Hepatitis A in Taiwan

Hepatitis A virus (HAV) and hepatitis E virus (HEV) share the similar fecal-oral transmission route. During an outbreak of sexually transmitted acute hepatitis A among men who have sex with men (MSM) worldwide between 2015 and 2017, we investigated the possibility of sexual transmission and related morbidity of HEV infection among human immunodeficiency virus (HIV)-positive patients. From March 1, 2015 to August 31, 2017, anti-HEV immunoglobulin G was retrospectively determined among 3,293 HIV-positive patients, who were mainly MSM (87.6%) with a median CD4 count of 575 cells/μL. Prevalence and incidence of HEV infection were 3.7% (123 of 3,293) and 4.35 per 1,000 person-years of follow-up (PYFU), respectively, which were significantly lower compared with those of HAV infection (31.1% [996 of 3,204] and 12.61 per 1,000 PYFU, respectively). The number of patients with HEV infection did not increase with the hepatitis A epidemic. The factor associated with prevalent HEV infection was older age (per 1-year increase, adjusted odds ratio, 1.07; 95% confidence interval, 1.05-1.09), but neither sexual orientation nor acquisition of sexually transmitted infections was related to prevalent or incident HEV infection. Among 23 patients with incident HEV infection, 22 patients had viremia caused by HEV genotype 4. No patients had prolonged HEV viremia or clinical symptoms, and only a mild elevation of serum aminotransferase, ranging from 34 to 77 IU/L, was noted. Although 4 patients had hepatitis for a prolonged duration of between 8 and 17 months, no abdominal imaging revealed liver fibrosis or cirrhosis. Conclusion: HEV endemicity remained low among HIV-positive patients in Taiwan during the outbreak of acute hepatitis A. Our data suggest that sexual transmission of HEV with significant morbidity of HEV infection, if any, is rare in this population.

Reduced economic burden of AIDS-defining illnesses associated with adherence to antiretroviral therapy

OBJECTIVES

We assessed the economic burden of AIDS-defining illnesses (ADIs), which was further stratified by adherence to antiretroviral therapy (ART).

METHODS AND MATERIALS

A nationwide longitudinal cohort of 18,234 incident cases with HIV followed for 11years was utilized. Adherence to ART was measured by medication possession ratio (MPR). Generalized estimating equations modeling was used to estimate the cost impact of ADIs.

RESULTS

Having opportunistic infections increased the annual cost by 9% (varicella-zoster virus infection) to 98% (cytomegalovirus disease), while the annual costs increased by 26% (Kaposi's sarcoma) to 95% (non-Hodgkin's lymphoma) in the year when AIDS-related cancer occurred. ADIs occurred more frequently in the years with low adherence for ART compared to the high-adherence years (e.g., 0.1≤MPR<0.8 vs. MPR≥0.8, event rate of cytomegalovirus disease 4.03% vs. 0.51%). The annual baseline costs in the years with MPR<0.1, 0.1≤MPR<0.8, and MPR≥0.8 were $250, $4,752, and $8,990 (in 2018 USD), respectively. The economic impact of ADIs in the years with low adherence (MPR<0.1) was larger than that in the high-adherence years (MPR≥0.8) (e.g., MPR<0.1 vs. MPR≥0.8, annual cost increased by 244% vs. 9% when candidiasis occurred).

CONCLUSIONS

Adherence to ART may increase the baseline medical costs but mitigate the incidence and economic burden of ADIs.

A Simple Symptom Score for Acute Human Immunodeficiency Virus Infection in a San Diego Community-Based Screening Program

Background

Treatment of acute human immunodeficiency virus (HIV) infection (AHI) decreases transmission and preserves immune function, but AHI diagnosis remains resource intensive. Risk-based scores predictive for AHI have been described for high-risk groups; however, symptom-based scores could be more generalizable across populations.

Methods

Adults who tested either positive for AHI (antibody-negative, HIV nucleic acid test [NAT] positive) or HIV NAT negative with the community-based San Diego Early Test HIV screening program were retrospectively randomized 2:1 into a derivation and validation set. In the former, symptoms significant for AHI in a multivariate logistic regression model were assigned a score value (the odds ratio [OR] rounded to the nearest integer). The score was assessed in the validation set using receiver operating characteristics and areas under the curve (AUC). An optimal cutoff score was found using the Youden index.

Results

Of 998 participants (including 261 non-men who have sex with men [MSM]), 113 had AHI (including 4 non-MSM). Compared to HIV-negative cases, AHI cases reported more symptoms (median, 4 vs 0; P < .01). Fever, myalgia, and weight loss were significantly associated with AHI in the multivariate model and corresponded to 11, 8, and 4 score points, respectively. The summed score yielded an AUC of 0.85 (95% confidence interval [CI], .77-.93). A score of ≥11 was 72% sensitive and 96% specific (diagnostic OR, 70.27).

Conclusions

A 3-symptom score accurately predicted AHI in a community-based screening program and may inform allocation of resources in settings that do not routinely screen for AHI.

Fungal Diseases in Taiwan-National Insurance Data and Estimation

The burden of fungal diseases based on the real-world national data is limited. This study aimed to estimate the Taiwan incident cases with selected fungal diseases in 2013 using the National Health Insurance Research Database (NHIRD) which covered 99.6% of the 23.4 million population. Over 80,000 incident cases were found and the majority were superficial infections including vulvovaginal candidiasis (477 per 100,000 adult women) and oral candidiasis (90 cases per 100,000 population). Common potentially life-threating fungal diseases were Pneumocystis pneumonia (5.35 cases per 100,000 population), candidemia (3.68), aspergillosis (2.43) and cryptococcal meningitis (1.04). Of the aforementioned cases cancer patients contributed 30.2%, 42.9%, 38.6% and 22.2%, respectively. Of 22,270 HIV-infected persons in NHIRD in 2013, four common diseases were Pneumocystis pneumonia (28.3 cases per 1000 HIV-infected patients), oral candidiasis (17.6), esophageal candidiasis (6.06) and cryptococcal meningitis (2.29). Of pulmonary aspergillosis 32.9% occurred in patients with chronic pulmonary diseases and 26.3% had a prior diagnosis of tuberculosis. There are some notable gaps related to insurance claim data. Cutaneous, urinary tract and eye fungal infections were not captured.

Early Seroreversion After 2 Doses of Hepatitis A Vaccination in Human Immunodeficiency Virus-Positive Patients: Incidence and Associated Factors

Serological responses (Seroresponse) and durability of hepatitis A virus (HAV) vaccination are reduced among human immunodeficiency virus (HIV)-positive patients. Incidence of and associated factors with early seroreversion (loss of seroresponse) among HIV-positive patients who have achieved seroresponses after two doses of HAV vaccination remain unclear. In this multicenter study, we followed HIV-positive adults who had mounted seroresponses after completing two doses of HAV vaccination during a recent outbreak of acute hepatitis A between 2015 and 2017, a 1:4 case-control study was conducted to identify factors associated with seroreversion. Case patients were those with seroreversion, and controls were those with similar follow-up durations who were able to maintain seroresponses. During the study period, 49 of the 1,256 patients (3.9%) seroreverted after a median follow-up of 611 days. In a case-control study, seroreversion was more likely to occur in patients with a higher weight (adjusted odds ratio [aOR], 1.703; 95% confidence interval [CI], 1.292-2.323, per 10-kg increment) and HIV viremia at the time of vaccination (aOR, 2.922; 95% CI, 1.067-7.924), whereas positive seroresponse at 6 months of HAV vaccination and higher CD4 lymphocyte counts at vaccination were inversely associated with early seroreversion with an aOR of 0.059 (95% CI, 0.020-0.154) and 0.837 (95% CI, 0.704-0.979, per 100-cell/mm³ increment), respectively, in multivariable analyses. Conclusion: During an outbreak setting, early seroreversion following two-dose HAV vaccination occurred in 3.9% of HIV-positive patients. Lower and delayed seroresponses to HAV vaccination, a higher weight, and HIV viremia and lower CD4 lymphocyte counts at the time of HAV vaccination were associated with early seroreversion. Regular monitoring of seroresponse and booster vaccination might be warranted, especially in HIV-positive adults with predictors of early seroreversion.

Impact of antiretroviral therapy containing tenofovir disoproxil fumarate on the survival of patients with HBV and HIV coinfection

BACKGROUND

Tenofovir disoproxil fumarate (TDF) is active against both HBV and HIV. Whether the introduction of TDF-containing combination antiretroviral therapy (cART) has improved the outcome of HIV/HBV-coinfected patients remains unclear in areas of higher HBV endemicity.

METHODS

We retrospectively reviewed medical records of newly diagnosed antiretroviral-naïve HIV-infected patients between 2007 and 2015. Four groups of patients were defined, according to the HBV status and availability of TDF for HIV treatment in Taiwan in 2011. The primary outcome was all-cause mortality.

RESULTS

During the 9-year study period, 1,723 HIV-infected patients were included, with a median age of 31 years and baseline CD4 count of 273 cells per μL. The HBV seroprevalence had declined from 18.1% (125/692) in the pre-TDF era to 10.1% (104/1031) in the post-TDF era. The respective mortality rate for HIV/HBV-coinfected and HIV-monoinfected patients in the pre-TDF era was 23.2 (95% CI, 12.5-43.1) and 9.6 (95% CI, 6.1-15.0) deaths per 1000 person-years of follow-up [PYFU], and the respective mortality rate in the post-TDF era was 15.7 (95% CI, 7.0-34.8) and 8.0 (95% CI, 5.5-11.6) deaths per 1000 PYFU. The adjusted hazard ratio for mortality in multivariate Cox proportional-hazards regression analysis among HIV/HBV-coinfected patients compared to HIV-monoinfected patients was 2.79 (95% CI, 1.25-6.22) in pre-TDF era and 1.11 (95% CI, 0.45-2.72) in post-TDF era.

CONCLUSIONS

In this country of high HBV endemicity, the adverse impact of chronic HBV infection on the survival observed in the pre-TDF era has significantly diminished among HIV/HBV-coinfected patients compared to HIV-monoinfected patients in the era of TDF-containing cART.

Presentation to HIV care and antiretroviral therapy initiation and response in clinical practice from 2003 through 2013

Universal HIV screening and treatment initiation of HIV-positive persons are well-established standards. However, late presentation to care is a barrier to early antiretroviral therapy (ART) and prevention of HIV transmission. We sought to determine the immunodeficiency at presentation to care and characterize the initiation and response to ART among HIV-positive persons over 2003–2013 in our urban HIV clinical practice at the Cleveland Clinic. Using a retrospective cohort study design, we assessed the CD4 cell count of HIV-positive patients at entry into care for each year and evaluated the trend over time. For patients who initiated treatment, we assessed the pretreatment CD4 cell count, consistency of timing and regimen with US treatment guidelines, and HIV RNA level at one-year and last follow-up visits. Regression analyses were used to determine predictors of study outcomes. We found that the cohort (N = 452) median CD4 cell count at presentation to care was 297 cells/mm3 (inter-quartile range: 104–479 cells/mm3), without any significant change over time (P = 0.62), and with 37% and 21% of presentations being late and advanced, respectively. Guideline-consistency (85%–100%) and regimen-consistency (41%–100%) were moderate to high and improved over time. Virologic suppression (<400 copies/ml) at one year and last follow-up was high (79% and 92%) and associated with regimen selection and durability. We conclude that CD4 cell count at first presentation to HIV care remained less than 350 cells/mm3 for 11 years in our clinical practice, despite advances in HIV testing and treatment guidelines. Early diagnosis and linkage to care and treatment are critical for ending the HIV epidemic.

Socio-demographic and clinical determinants of late presentation among patients newly diagnosed with HIV in the Eastern Cape, South Africa

South Africa recently implemented the 'test and treat' strategy for all HIV-infected individuals receiving diagnosis at the health facility level. However, the impact of this programme in terms of the prevention of HIV transmission, morbidity and mortality associated with HIV can only be maximized if patients are diagnosed early. This study determines the prevalence of late presentation among newly diagnosed HIV-infected individuals and also examines the socio-demographic and clinical determinants for late presentation in health facilities in the Eastern Cape Province, South Africa.In this cross-sectional study, a total of 335 newly diagnosed patients were recruited consecutively between August 2016 and July 2017. Late presenter for HIV care was defined in accordance with the European Late Presenter Consensus working group as a patient who reports for care when the CD4 count is below 350 cells/μL and/or when there is an established AIDS-defining clinical condition, irrespective of CD4 count. Adjusted and unadjusted logistic regression analysis was used to examine the determinants of late HIV diagnosis.Participants' mean age was 33.6 (SD: 10.6). Almost 96% of the participants believed their route of HIV infection was heterosexual sex. Most newly diagnosed HIV-infected patients (60%) were late presenters (CD4+ count ≤350 cells/μL and/or having an AIDS-defining illness in World Health Organisation (WHO)-defined stage III/IV), with 35% presenting with Acquired Immune Deficiency Syndrome (AIDS)-related complications. In the adjusted model, only male sex (AOR: 2.81; CI: 1.51-5.23), no formal education (AOR: 5.63; CI: 1.68-18.85), and overweight body mass category (AOR: 2.45; CI: 1.04-5.75) were independently associated with late HIV diagnosis.The majority of newly diagnosed HIV-infected individuals were late presenters. To maximize the impact of the 'test and treat' policy aimed at reducing new HIV transmissions and preventing the morbidity and mortality associated with HIV, there is a need for programmes to improve early detection of HIV in the study settings. This programme should target males and individuals with no formal education for maximum impact.

Duration of Human Immunodef iciency Virus Infection at Diagnosis among New Human Immunodef iciency Virus Cases in Dehong, Yunnan, China, 2008-2015

Background:

On diagnosis of human immunodeficiency virus (HIV) infection, a person may have been infected already for many years. This study aimed to estimate the duration of HIV infection at the time of diagnosis.

Methods:

Newly diagnosed HIV cases in Dehong, China, from 2008 to 2015 were studied. Duration of infection at the time of diagnosis was calculated using the first CD4 cell count result after diagnosis and a CD4 depletion model of disease progression. Multiple linear regression analysis was used to investigate the associated risk factors.

Results:

A total of 5867 new HIV cases were enrolled. Overall, mean duration of infection was 6.3 years (95% confidence interval [CI]: 6.2, 6.5). After adjusting for confounding, significantly shorter durations of infection were observed among participants who were female (beta: −0.37, 95% CI: −0.64, −0.09), Dai ethnicity (beta: −0.28, 95% CI: −0.57, 0.01), and infected through injecting drug use (beta: −1.82, 95% CI: −2.25, −1.39). Compared to the hospital setting, durations were shorter for those diagnosed in any other settings, and compared to 2008, durations were shorter for those diagnosed all years after 2010.

Results:

A total of 5867 new HIV cases were enrolled. Overall, mean duration of infection was 6.3 years (95% confidence interval [CI]: 6.2, 6.5). After adjusting for confounding, significantly shorter durations of infection were observed among participants who were female (beta: −0.37, 95% CI: −0.64, −0.09), Dai ethnicity (beta: −0.28, 95% CI: −0.57, 0.01), and infected through injecting drug use (beta: −1.82, 95% CI: −2.25, −1.39). Compared to the hospital setting, durations were shorter for those diagnosed in any other settings, and compared to 2008, durations were shorter for those diagnosed all years after 2010.

Conclusion:

Although the reduction in duration of infection at the time of diagnosis observed in Dehong was significant, it may not have had a meaningful impact.

AIDS incidence trends at presentation and during follow-up among HIV-at-risk populations: a 15-year nationwide cohort study in Taiwan

BACKGROUND

Although Taiwan has implemented several important interventions for various HIV-at-risk populations to combat the HIV epidemic, little is known regarding AIDS incidence at presentation and during follow-up among the various HIV-at-risk populations in Taiwan. A better understanding of AIDS incidence trends would help improve patient care and optimize public health strategies aimed at further decreasing HIV-related morbidity and mortality.

METHODS

Data from Taiwan Centers for Disease Control-operated Notifiable Diseases Surveillance System and Taiwan National Health Insurance Research Database (1998-2012) was divided into five cohort periods (consecutive 3-year groups). Logistic regression was employed to identify factors associated with AIDS incidence at presentation. Time-dependent Cox regression was used to identify factors associated with AIDS incidence during the follow-up period.

RESULTS

Of 22,665 patients [mean age: 32 years; male (93.03%)], 6210 (27.4%) had AIDS incidence over 2 (1.16) [median (interquartile range)] years of follow-up. AIDS developed in ≤3 months of HIV diagnosis in 73.6% AIDS patients. AIDS incidence trends at presentation and during follow-up differed according to HIV transmission routes over the five periods: AIDS at presentation increased in the sexual contact groups (P < 0.001 for homosexuals/heterosexuals; 0.648 for bisexuals) but decreased to a nadir in period 3 and then increased slightly in period 5 (P < 0.001) in people who injected drugs (PWIDs). AIDS incidence during the follow-up period increased from period 1 to a peak in period 3 or 4, before declining slightly in period 5, in the sexual contact groups (P < 0.001 for homosexuals/heterosexuals; 0.549 for bisexuals). However, it increased throughout the five periods in PWIDs (P < 0.001). Older age, sexual contact group versus PWIDs, high versus low income level, cohort periods, and HIV diagnosis regions helped predict AIDS at presentation and during follow-up.

CONCLUSIONS

Disparities in AIDS incidence trends in various HIV-at-risk populations reflect different sociodemographic variables of HIV exposure and the adopted HIV prevention strategies. This study suggests the urgent need for tailored strategies aimed at specific populations at presentation and during follow-up.

Changing seroprevalence of hepatitis C virus infection among HIV-positive patients in Taiwan

Objective

The study aimed to describe the evolution of the seroprevalence of hepatitis C virus (HCV) among human immunodeficiency virus (HIV)-positive patients included in two cohorts in Taiwan.

Methods

We retrospectively collected the information on demographic and clinical characteristics of 4,025 and 3,856 HIV-positive Taiwanese, who were aged 18 years or older at designated hospitals around Taiwan in 2004–2007, when an outbreak of HIV infection was occurring, and 2012–2016, when the outbreak was controlled with the implementation of harm reduction program, respectively. Comparisons of HCV seropositivity were made among different age and risk groups for HIV transmission between these two cohorts.

Results

The overall HCV seroprevalence of the 2004–2007 cohort and 2012–2016 cohort was 43.4% (1,288/2,974) and 18.6% (707/3,793), respectively (P<0.001). The HCV seroprevalence among injecting drug users (IDUs), though decreasing, was constantly high across the two cohorts, 96.4% and 94.0% (P = 0.02), respectively, and all age groups. In contrast, the corresponding figures among men who have sex with men (MSM) and heterosexuals in the two cohorts were 5.9% vs. 3.5% (P = 0.002) and 9.4% vs. 10.9% (P = 0.59), respectively. Among sexually transmitted HIV-positive patients, HCV seropositivity was significantly correlated with age (adjusted odds ratio [aOR], per 1-year increase, 1.03; 95% confidence interval [CI], 1.02–1.05) and a rapid plasma reagin (RPR) titer ≥1:8 (aOR, 1.58; 95% CI, 1.03–2.43) in a multivariate analysis including age, gender, route for HIV transmission, baseline CD4 count and plasma HIV RNA load, the presence of hepatitis B surface antigen, and an RPR titer ≥1:8. Compared with heterosexuals, the aOR for HCV seropositivity among MSM was 0.47 (95% CI, 0.31–0.72).

Conclusions

HCV seroprevalence among HIV-positive patients in Taiwan decreased with time, probably related to the inclusion of younger adults and more non-IDUs, and remained high among IDUs. HCV seropositivity was associated with age and an RPR titer ≥1:8 among patients who acquired HIV through sexual contact.

Treatment of Pneumocystis jirovecii pneumonia in HIV-infected patients: a review

INTRODUCTION

Pneumocystis pneumonia is a potentially life-threatening pulmonary infection that occurs in immunocompromised individuals and HIV-infected patients with a low CD4 cell count. Trimethoprim-sulfamethoxazole has been used as the first-line agent for treatment, but mutations within dihydropteroate synthase gene render potential resistance to sulfamide. Despite advances of combination antiretroviral therapy (cART), Pneumocystis pneumonia continues to occur in HIV-infected patients with late presentation for cART or virological and immunological failure after receiving cART. Areas covered: This review summarizes the diagnosis and first-line and alternative treatment and prophylaxis for Pneumocystis pneumonia in HIV-infected patients. Articles for this review were identified through searching PubMed. Search terms included: 'Pneumocystis pneumonia', 'Pneumocystis jirovecii pneumonia', 'Pneumocystis carinii pneumonia', 'trimethoprim-sulfamethoxazole', 'primaquine', 'trimetrexate', 'dapsone', 'pentamidine', 'atovaquone', 'echinocandins', 'human immunodeficiency virus infection', 'acquired immunodeficiency syndrome', 'resistance to sulfamide' and combinations of these terms. We limited the search to English language papers that were published between 1981 and March 2017. We screened all identified articles and cross-referenced studies from retrieved articles. Expert commentary: Trimethoprim-sulfamethoxazole will continue to be the first-line agent for Pneumocystis pneumonia given its cost, availability of both oral and parenteral formulations, and effectiveness or efficacy in both treatment and prophylaxis. Whether resistance due to mutations within dihydropteroate synthase gene compromises treatment effectiveness remains controversial. Continued search for effective alternatives with better safety profiles for Pneumocystis pneumonia is warranted.