The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression

HIV Prevention and Treatment Interventions for Black Men Who Have Sex With Men in Canada: Scoping Systematic Review

BACKGROUND

Black men who have sex with men (MSM) experience disproportionately high HIV incidence globally. A comprehensive, intersectional approach (race, gender, and sexuality or sexual behavior) in understanding the experiences of Black MSM in Canada along the HIV prevention and care continuums has yet to be explored.

OBJECTIVE

This scoping review aims to examine the available evidence on the access, quality, gaps, facilitators, and barriers of engagement and identify interventions relevant to the HIV prevention and care continuum for Black MSM in Canada.

METHODS

We conducted a systematic database search, in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist, of the available studies on HIV health experience and epidemiology concerning Black MSM living with or without HIV in Canada and were published after 1983 in either English or French. Searched databases include MEDLINE, Excerpta, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, the NHUS Economic Development Database, Global Health, PsycInfo, PubMed, Scopus, and Web of Science. From the 3095 articles identified, 19 met the inclusion criteria and were analyzed.

RESULTS

Black MSM in Canada consistently report multiple forms of stigma and lack of community support contributing to an increased HIV burden. They experience discrimination based on their intersectional identities while accessing HIV preventative and treatment interventions. Available data demonstrate that Black MSM have higher HIV incidences than Black men who have sex with women (MSW) and White MSM, and low preexposure prophylaxis knowledge and HIV literacy. Black MSM experience significant disparities in HIV prevention and care knowledge, access, and use. Structural barriers, including anti-Black racism, homophobia, and xenophobia, are responsible for gaps in HIV prevention and care continuums, poor quality of care and linkage to HIV services, as well as a higher incidence of HIV.

CONCLUSIONS

Considering the lack of targeted interventions, there is a clear need for interventions that reduce HIV diagnoses among Black MSM, increase access and reduce structural barriers that significantly affect the ability of Black MSM to engage with HIV prevention and care, and address provider's capacity for care and the structural barriers. These findings can inform future interventions, programming, and tools that may alleviate this HIV inequity.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-043055.

Comparing Cancer Incidence in an Observational Cohort of Medicaid Beneficiaries With and Without HIV, 2001-2015

BACKGROUND

Life expectancy among people with HIV (PWH) is increasing, making chronic conditions-including cancer-increasingly relevant. Among PWH, cancer burden has shifted from AIDS-defining cancers (ADCs) toward non-AIDS-defining cancers (NADCs).

SETTING

We described incidence of cancer in a claims-based cohort of Medicaid beneficiaries. We included 43,426,043 Medicaid beneficiaries (180,058 with HIV) from 14 US states, aged 18-64, with >6 months of enrollment (with no dual enrollment in another insurance) and no evidence of a prveious cancer.

METHODS

We estimated cumulative incidence of site-specific cancers, NADCs, and ADCs, by baseline HIV status, using age as the time scale and accounting for death as a competing risk. We compared cumulative incidence across HIV status to estimate risk differences. We examined cancer incidence overall and by sex, race/ethnicity, and calendar period.

RESULTS

PWH had a higher incidence of ADCs, infection-related NADCs, and death. For NADCs such as breast, prostate, and colon cancer, incidence was similar or higher among PWH below age 50, but higher among those without HIV by age 65. Incidence of lung and head and neck cancer was always higher for female beneficiaries with HIV, whereas the curves crossed for male beneficiaries. We saw only small differences in incidence trends by race/ethnicity.

CONCLUSION

Our findings suggest an increased risk of certain NADCs at younger ages among PWH, even when compared against other Medicaid beneficiaries, and highlight the importance of monitoring PWH for ADCs and NADCs. Future work should explore possible mechanisms explaining the differences in incidence for specific cancer types.

Lower endoscopy, early-onset, and average-onset colon cancer among Medicaid beneficiaries with and without HIV

BACKGROUND

Studies suggest a lower colorectal cancer (CRC) risk and lower or similar CRC screening among people with HIV (PWH) compared with the general population. We evaluated the incidence of lower endoscopy and average-onset (diagnosed at ≥50) and early-onset (diagnosed at <50) colon cancer by HIV status among Medicaid beneficiares with comparable sociodemographic factors and access to care.

METHODS

We obtained Medicaid Analytic eXtract (MAX) data from 2001 to 2015 for 14 states. We included 41 727 243 and 42 062 552 unique individuals with at least 7 months of continuous eligibility for the endoscopy and colon cancer analysis, respectively. HIV and colon cancer diagnoses and endoscopy procedures were identified from inpatient and other nondrug claims. We used Cox proportional hazards regression models to assess endoscopy and colon cancer incidence, controlling for age, sex, race/ethnicity, calendar year and state of enrollment, and comorbidities conditions.

RESULTS

Endoscopy and colon cancer incidence increased with age in both groups. Compared with beneficiaries without HIV, PWH had an increased hazard of endoscopy; this association was strongest among those 18-39 years [hazard ratio: 1.85, 95% confidence interval (95% CI) 1.77-1.92] and attenuated with age. PWH 18-39 years also had increased hazard of early-onset colon cancer (hazard ratio: 1.66, 95% CI:1.05-2.62); this association was attenuated after comorbidity adjustment. Hazard ratios were null among all beneficiaries less than 50 years of age. PWH had a lower hazard of average-onset colon cancer compared with those without HIV (hazard ratio: 0.79, 95% CI: 0.66-0.94).

CONCLUSION

PWH had a higher hazard of endoscopy, particularly at younger ages. PWH had a lower hazard of average-onset colon cancer. Early-onset colon cancer was higher among the youngest PWH but not associated with HIV overall.

Predictors of Treatment Adherence and Virological Failure Among People Living with HIV Receiving Antiretroviral Therapy in a South African Rural Community: A Sub-study of the ITREMA Randomised Clinical Trial

A large proportion of people living with HIV (PLHIV) in sub-Saharan Africa reside in rural areas. Knowledge of enablers and barriers of adherence to antiretroviral treatment (ART) in these populations is limited. We conducted a cohort study of 501 adult PLHIV on ART at a rural South African treatment facility as a sub-study of a clinical trial (ClinicalTrials.gov NCT03357588). Socio-economic, psychosocial and behavioral characteristics were assessed as covariates of self-reported adherence difficulties, suboptimal pill count adherence and virological failure during 96 weeks of follow-up. Male gender was an independent risk factor for all outcomes. Food insecurity was associated with virological failure in males. Depressive symptoms were independently associated with virological failure in both males and females. Household income and task-oriented coping score were protective against suboptimal pill-count adherence. These results underscore the impact of low household income, food insecurity and depression on outcomes of ART in rural settings and confirm other previously described risk factors. Recognition of these factors and targeted adherence support strategies may improve patient health and treatment outcomes.

Mental Health Problems Across the HIV Care Continuum for Adolescents Living with HIV in Sub-Saharan Africa: A Scoping Review

Mental health problems (e.g., anxiety, depression) are frequently experienced by adolescents living with HIV (ALWH) and can worsen HIV-related outcomes. This scoping review synthesizes the existing research on ALWHs' mental health problems at multiple steps along the HIV care continuum in sub-Saharan Africa. Searching PubMed, CINAHL, EMBASE, and PsycINFO identified 34 peer-reviewed studies that met inclusion criteria. Most studies assessed ALWHs' mental health problems at the "Engaged or Retained in Care" continuum step, are cross-sectional, focus on depression and anxiety, and used measures developed in high-income countries. Studies identify mental health problems among ALWH as prevalent and barriers to care. Significant gaps remain in understanding how mental health problems and their relationships with HIV-related health outcomes shift across the continuum. Additional attention is needed, especially at the HIV testing and viral suppression steps, to generate a more comprehensive understanding of mental health needs and priority timepoints for intervention for ALWH.

Antiretroviral therapy uptake and predictors of virological failure in patients with HIV receiving first-line and second-line regimens in Johannesburg, South Africa: a retrospective cohort data analysis

OBJECTIVE

This study described the demographics, treatment information and identified characteristics associated with virological failure and being lost to follow-up (LTFU) for patients with HIV on first-line and second-line antiretroviral therapy (ART) regimens in a large South African cohort.

DESIGN

A quantitative retrospective cohort study using secondary data analysis.

SETTING

Seven Johannesburg inner city facilities.

PARTICIPANTS

Unique records of 123 002 people with HIV receiving ART at any point in the period 1 April 2004 to 29 February 2020 were included.

MEASURES

Demographic characteristics, ART status, CD4 count information and retention status were collected and analysed as covariates of outcomes (viral load (VL) and LTFU).

RESULTS

Of the total study patients, 95% (n=1 17 260) were on a first-line regimen and 5% (n=5742) were on a second-line regimen. Almost two-thirds were female (64%, n=79 226). Most patients (60%, n=72 430) were initiated on an efavirenz-based, tenofovir disoproxil fumarate-based and emtricitabine-based regimen (fixed-dose combination). 91% (n=76 737) achieved viral suppression at least once since initiating on ART and 60% (n=57 981) remained in care as at the end of February 2020. Patients from the community health centre and primary healthcare clinics were not only more likely to be virally suppressed but also more likely to be LTFU. Patients on second-line regimens were less likely to reach viral suppression (adjusted OR (aOR)=0.26, CI=0.23 to 0.28) and more likely to be LTFU (aOR=1.21, CI=1.09 to 1.35). Being older (≥25 years) and having a recent CD4 cell count≥100 cells/µL were predictors of viral suppression and retention in patients on ART.

CONCLUSION

Patients on first-line regimens had higher VL suppression rates and were more likely to remain in care than those on a second-line regimen. Being younger and having low CD4 cell counts were associated with poor outcomes, suggesting priority groups for ART adherence support.

Effectiveness of a "Suppression Bundle" to improve HIV virologic suppression in an outpatient infectious disease clinic: a pilot implementation study

Despite effectiveness and accessibility of combined anti-retroviral therapy (cART), only 85% of people living with HIV (PLHIV) in the United States are virologically suppressed. Improving suppression is complex. Our objective was to consider unique factors in PLHIV with non-suppressed viral loads in clinic and improve the percentage of suppressed patients by implementing a "Suppression Bundle" consisting of three to five bundled interventions with the goal of improved suppression. Prior to the study, there were 567 HIV-positive patients receiving care in clinic. Of those, 89 had a measurable viral load (>40 copies/mL). In this pilot pre-post implementation, we focused on the 89 non-suppressed patients to (1) determine feasibility of implementing bundles and (2) increase the number of patients with suppressed viral loads pre- to post-intervention. Of non-suppressed patients, 65 were active in care immediately pre-intervention and participated in the pilot. At the completion of the 9-month intervention, 46 had viral loads <40 copies/mL, demonstrating substantial improvement with 70.1% of the previously non-suppressed patients achieving suppression. By considering unique patient factors, an individualized Suppression Bundle is acceptable, feasible, and may increase virally suppressed patients in an outpatient clinic. Next steps include determining whether suppression bundles can be implemented in differing practices.

Unmasking legislative constraints: An institutional ethnography of linkage and engagement in HIV healthcare for African, Caribbean, and Black people in Ontario, Canada

The Human Immunodeficiency Virus (HIV) epidemic significantly impacts African, Caribbean, and Black (ACB) immigrants in Canada. Health scholarship has revealed striking injustices within Canada's public healthcare system that restrict access to healthcare and violate the human rights of ACB immigrants living with HIV who are marginalized. We conducted an institutional ethnography to comprehensively understand how HIV healthcare in Ontario is organized and experienced by ACB immigrants, focusing on unjust and discriminatory legislative frameworks and institutional practices regulating access to publicly funded healthcare resources and services. We interviewed 20 ACB immigrants and 15 healthcare workers, including specialists, primary care providers, immigration physicians, and social workers. We found a disjuncture between the organization of HIV healthcare in Ontario and how ACB immigrants experienced access to care. We uncovered how immigration, public health and healthcare laws and related institutional practices intersect to produce structural violence which create barriers and missed opportunities to timely linkage and engagement in HIV healthcare. Black immigrants' accounts revealed that they underwent mandatory HIV under the Immigration Medical Examination policy (IME) without providing informed consent and receiving pre and post-test counselling. Furthermore, Black immigrants did not receive referrals and were not adequately linked to care following HIV diagnosis. Troubling encounters with immigration and public health state agents and healthcare legislative barriers including difficulty finding a physician, the 3-month waiting period under the Ontario Health Insurance Plan (OHIP), long wait times, lack of drug coverage, and stigma, discrimination, and anti-Black racism shaped and affected Black people's linkage and engagement in HIV care. We elucidate how the legislative and structural organization of healthcare regulated and constrained health service access for ACB immigrants living with HIV, including their ability to "achieve" HIV undetectability.

The cascade of care of HIV after one year of follow-up in a cohort of HIV-positive adult patients in three health settings of Morrumbene in rural Mozambique

OBJECTIVE

To assess the state of the retention in care of HIV patients in three health settings in Morrumbene, a rural district of Inhambane Province, Mozambique. We evaluated potential factors associated with early loss to follow-up (LTFU), retention in care and ART adherence during the first year of follow-up.

MATERIAL AND METHODS

Retrospective, cross-sectional, observational study. We collected data on patients diagnosed with HIV infection in 2017 in two permanent clinics and one mobile clinic. Demographic, clinical, immunological and therapeutic data were retrieved up to December 31st, 2018. Data on follow-up were collected at 6 and 12 months for medical visits and for ART adherence and analysed for factors associated with LTFU, retention in care and adherence to ART by Stata Version 14 and univariate and stepwise multiple unconditional logistic regression models.

RESULTS

In 2017, 960 patients were diagnosed with HIV infection. At 6-month follow-up, 49% attended the medical visit and 157 (25%) adhered to ART. After one year, 34% of patients were available for follow-up, and only 72 patients adhered to ART. In multivariate analysis, factors associated with early LTFU were male sex (p = 0.036) and immediate prescription of ART (p = 0.064). Older age (p < 0.001) and being followed in the mobile clinic (p = 0.001) favoured retention in care. Advanced WHO status (p = 0.005) and being pregnant or breastfeeding showed a negative correlation with adherence to treatment (p = 0.068).

CONCLUSIONS

Only one-third of patients were available for follow-up after one year, and only 13% adhered to ART. Young individuals, men and pregnant/breastfeeding women seem to be particularly at risk for LTFU and non-adherence to treatment.

Measuring and explaining inequality of continuous care for people living with HIV receiving antiretroviral therapy in Kunming, China

Background

In the context of scaling up free antiretroviral therapy (ART), healthcare equality is essential for people living with HIV. We aimed to assess socioeconomic-related inequalities in uptake of continuous care for people living with HIV receiving ART, including retention in care in the last six months, routine toxicity monitoring, adequate immunological and virological monitoring, and uptake of mental health assessment in the last 12 months. We also determined the contributions of socioeconomic factors to the degree of inequalities.

Methods

A hospital-based cross-sectional survey was conducted among consecutive clients visiting an HIV treatment center in Kunming, China in 2019. Participants were 702 people living with HIV aged ≥18 years (median age: 41.0 years, 69.4% male) who had been on ART for 1–5 years. Socioeconomic-related inequality and its contributing factors were assessed by a normalized concentration index (CI_n) with a decomposition approach.

Results

The uptake of mental health assessment was low (15%) but significantly higher among the rich (CI_n 0.1337, 95% CI: 0.0140, 0.2534). Retention in care, toxicity, and immunological monitoring were over 80% but non-significant in favor of the rich (CI_n: 0.0117, 0.0315, 0.0736, respectively). The uptake of adequate virological monitoring was 15% and higher among the poor (CI_n = -0.0308). Socioeconomic status positively contributed to inequalities of all care indicators, with the highest contribution for mental health assessment (124.9%) and lowest for virological monitoring (2.7%).

Conclusions

These findings suggest virological monitoring and mental health assessment be given more attention in long-term HIV care. Policies allocating need-oriented resources geared toward improving equality of continuous care should be developed.

HIV prevention and treatment interventions for black men who have sex with men in Canada: a protocol for a scoping systematic review

INTRODUCTION

Globally, rates of HIV are disproportionately high among black men who have sex with men (MSM). In Canada, race, gender and sexuality have been investigated as separate factors that influence quality of care within and progression along the HIV care continuum. Traditional compartmental approaches to synthesising the HIV care continuum literature do not sufficiently account for intersectional experiences and marginalisation of Black MSM (BMSM). Moreover, there is limited research outlining access to and quality of care as specific barriers to progression along the care continuum among BMSM in Canada.

OBJECTIVES

The primary objective of this scoping review is to assess the state of the science regarding the influence of access to and quality of HIV care continuum outcomes for BMSM in Canada.

METHODS AND ANALYSIS

We will conduct a systematic search of published literature of quantitative and qualitative studies published on Canadian BMSM's healthcare and HIV status. The searches will be conducted through MEDLINE, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, the NHUS Economic Development Database, Global Health, APA PsychInfo, PubMed and Web of Science.

ELIGIBILITY CRITERIA

Eligible studies will include data on black MSM living with or without HIV in Canada and must be published after 1983 in either English or French. Screening and data extraction will be conducted in duplicate. Any discrepancies that arise will be resolved by consulting a third author. The findings will subsequently be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

ETHICS AND DISSEMINATION

Ethics approval is not required as secondary published data will be used. Our findings will be disseminated as peer-reviewed manuscripts, at conferences, student rounds and could be of interest to government health agencies and HIV/AIDS service organisations.

Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort

BACKGROUND

Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement.

METHODS

From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zambian health facilities, we prospectively followed disengaged HIV patients for return clinic visits. We estimated the cumulative incidence of return and the time to return using Kaplan-Meier methods. We used univariate and multivariable Cox proportional hazards regression to conduct a risk factor analysis identifying predictors of incident return across a social ecological framework.

RESULTS

Of the 556 disengaged patients, 73.0% [95% confidence interval (CI): 61.0 to 83.8] returned to HIV care. The median follow-up time from disengagement was 32.3 months (interquartile range: 23.6-38.9). The rate of return decreased with time postdisengagement. Independent predictors of incident return included a previous gap in care [adjusted Hazard Ratio (aHR): 1.95, 95% CI: 1.23 to 3.09] and confronting a stigmatizer once in the past year (aHR: 2.14, 95% CI: 1.25 to 3.65). Compared with a rural facility, patients were less likely to return if they sought care from an urban facility (aHR: 0.68, 95% CI: 0.48 to 0.96) or hospital (aHR: 0.52, 95% CI: 0.33 to 0.82).

CONCLUSIONS

Interventions are needed to hasten re-engagement in HIV care. Early and differential interventions by time since disengagement may improve intervention effectiveness. Patients in urban and tertiary care settings may need additional support. Improving patient resilience, outreach after a care gap, and community stigma reduction may facilitate return. Future re-engagement research should include causal evaluation of identified factors.

Annual and durable HIV retention in care and viral suppression among patients of Peter Ho Clinic, 2013-2017

Objectives

To determine rates of annual and durable retention in medical care and viral suppression among patients enrolled in the Peter Ho Clinic, from 2013–2017.

Methods

This is a retrospective review of medical record data in an urban clinic, located in Newark, New Jersey, a high prevalence area of persons living with HIV. Viral load data were electronically downloaded, in rolling 1-year intervals, in two-month increments, from January 1, 2013 to December 31, 2019. Three teams were established, and every two months, they were provided with an updated list of patients with virologic failure. Retention and viral suppression rates were first calculated for each calendar-year. After patients were determined to be retained/suppressed annually, the proportion of patients with durable retention and viral suppression were calculated in two, three, four, five and six-year periods. Descriptive statistics were used to summarize sample characteristics by retention in care, virologic failure and viral suppression with Pearson Chi-square; p-value <0.05 was statistically significant. Multiple logistic regression models identified patient characteristics associated with retention in medical care, virologic failure and suppression.

Results

As of December 31, 2017, 1000 (57%) patients were retained in medical care of whom 870 (87%) were suppressed. Between 2013 and 2016, decreases in annual (85% to 77%) and durable retention in care were noted: two-year (72% to 70%) and three-year (63% to 59%) periods. However, increases were noted for 2017, in annual (89%) and durable retention in the two-year period (79%). In the adjusted model, when compared to current patients, retention in care was less likely among patients reengaging in medical care (adjusted Odds Ratio (aOR): 0.77, 95% CI: 0.61–0.98) but more likely among those newly diagnosed from 2014–2017 (aOR: 1.57, 95% CI: 1.08–2.29), compared to those in care since 2013. A higher proportion of patients re-engaging in medical care had virologic failure than current patients (56% vs. 47%, p < 0.0001). As age decreased, virologic failure was more likely (p<0.0001). Between 2013 and 2017, increases in annual (74% to 87%) and durable viral suppression were noted: two-year (59% to 73%) and three-year (49% to 58%) periods. Viral suppression was more likely among patients retained in medical care up to 2017 versus those who were not (aOR: 5.52, 95% CI: 4.08–7.46). Those less likely to be suppressed were 20–29 vs. 60 years or older (aOR: 0.52, 95% CI: 0.28–0.97), had public vs. private insurance (aOR: 0.29, 95% CI: 0.15–0.55) and public vs. private housing (aOR: 0.59, 95% CI: 0.40–0.87).

Conclusions

Restructuring clinical services at this urban clinic was associated with improved viral suppression. However, concurrent interventions to ensure retention in medical care were not implemented. Both retention in care and viral suppression interventions should be implemented in tandem to achieve an end to the epidemic. Retention in care and viral suppression should be measured longitudinally, instead of cross-sectional yearly evaluations, to capture dynamic changes in these indicators.

Health insurance and AIDS Drug Assistance Program (ADAP) increases retention in care among women living with HIV in the United States

Our objective was to examine the association between healthcare payer type and missed HIV care visits among 1,366 US women living with HIV (WLWH) enrolled in the prospective Women's Interagency HIV Study (WIHS). We collected secondary patient-level data (October 1, 2017-September 30, 2018) from WLWH at nine WIHS sites. We used bivariate and multivariable binary logistic regression to examine the relationship between healthcare payer type (cross-classification of patients' ADAP and health insurance enrollment) and missed visits-based retention in care, defined as no-show appointments for which patients did not reschedule. Our sample included all WLWH who self-reported having received HIV care at least once during the two consecutive biannual WIHS visits a year prior to October 1, 2017-September 30, 2018. In the bivariate model, compared to uninsured WLWH without ADAP, WLWH with private insurance + ADAP were more likely to be retained in care, as were WLWH with Medicaid only and private insurance only. In the adjusted model, WLWH with private insurance only were more likely to be retained in care compared to uninsured WLWH without ADAP. Private health insurance and ADAP are associated with increased odds of retention in care among WLWH.

Does distance from a clinic and poverty impact visit adherence for noncommunicable diseases? A retrospective cohort study using electronic medical records in rural Haiti

BACKGROUND

Adherence to regular outpatient visits is vital to managing noncommunicable diseases (NCDs), a growing burden in low and middle-income countries. We characterized visit adherence among patients with NCDs in rural Haiti, hypothesizing higher poverty and distance from the clinic were associated with lower adherence.

METHODS

We analyzed electronic medical records from a cohort of adults in an NCD clinic in Mirebalais, Haiti (April 2013 to June 2016). Visit adherence was: 1) visit constancy (≥1 visit every 3 months), 2) no gaps in care (> 60 days between visits), 3) ≥1 visit in the last quarter, and 4) ≥6 visits per year. We incorporated an adapted measure of intensity of multidimensional poverty. We calculated distance from clinic as Euclidean distance or self-reported transit time. We used multivariable logistic regressions to assess the association between poverty, distance, and visit adherence.

RESULTS

We included 463 adult patients, mean age 57.8 years (SE 2.2), and 72.4% women. Over half of patients had at least one visit per quarter (58.1%), but a minority (19.6%) had no gaps between visits. Seventy percent of patients had a visit in the last quarter, and 73.9% made at least 6 visits per year. Only 9.9% of patients met all adherence criteria. In regression models, poverty was not associated with any adherence measures, and distance was only associated with visit in the last quarter (OR 0.87, 95% CI [0.78 to 0.98], p = 0.03) after adjusting for age, sex, and hardship financing.

CONCLUSIONS

Visit adherence was low in this sample of adult patients presenting to a NCD Clinic in Haiti. Multidimensional poverty and distance from clinic were not associated with visit adherence measures among patients seen in the clinic, except for visit in the last quarter. Future research should focus on identifying and addressing barriers to visit adherence.

HIV Pre-Exposure Prophylaxis for Conception Among HIV Serodiscordant Couples in the United States: A Cohort Study

Practice guidelines on pre-exposure prophylaxis (PrEP) for HIV serodiscordant couples recommend PrEP when the viral load of the partner living with HIV is either detectable or unknown. However, adherence to combination antiretroviral therapy is inconsistent, and research has found that individuals vulnerable to HIV place value on additional protective barriers. We conducted a prospective cohort study to assess the feasibility, perceptions, and adherence associated with periconceptional PrEP use among females without HIV and their male partners living with HIV across four academic medical centers in the United States. We performed descriptive statistics, McNemar's test of marginal homogeneity to assess discordance in female/male survey responses, and Spearman's correlation to determine associations between dried blood spot levels and female self-reported adherence to PrEP. We enrolled 25 women without HIV and 24 men living with HIV (one male partner did not consent to the study). Women took PrEP for a median of 10.9 months (interquartile range 3.8-12.0) and were generally adherent. In total, 87% of women (20/23) had a dried blood spot with >700 fmol/punch or ≥4 doses/week, 4% (1/23) at 350-699 fmol/punch or 2-3 doses/week, and 9% (2/23) at <350 fmol/punch or <2 doses/week (correlation between drug levels and adherence is based on prior data). Dried blood spot levels closely aligned with self-reported adherence (Spearman's rho = 0.64, p = 0.001). There were 10 pregnancies among 8 participants, 4 of which resulted in spontaneous abortions. There was one preterm delivery (36 5/7 weeks), no congenital abnormalities, and no HIV transmissions. Ten couples (40%) were either lost to follow-up or ended the study early. Overall, women attempting conception with male partners living with HIV in the United States are interested and able to adhere to PrEP as an additional tool for safer conception.

A Systematic Mixed Studies Review of the Intersections of Social-Ecological Factors and HIV Stigma in People Living With HIV in the U.S. South

The role of stigma on psychological wellness and treatment outcomes in people living with HIV (PLWH) has been well documented. However, within the context of the southern United States, the intersection between HIV-related stigma and social-ecological factors has been understudied. Thus, a results-based convergent, mixed synthesis design was used to examine the manifestations of HIV-related stigma in PLWH in the U.S. South. A literature search was conducted using PsycINFO, PubMed (includes MEDLINE), and CINAHL. The first level of screening by title and abstract was administered on 1,829 articles. A full-text screening of 169 studies was completed, and a total of 30 relevant articles were extracted. The mixed synthesis highlighted intervention strategies that can reduce HIV-related stigma while promoting positive health-behavior change. The findings of this review underscored the uniqueness of PLWH in the south and demonstrated the crucial role of intersectionality in investigating HIV-related stigma in treating and preventing HIV.

Partial Achievement of the 90-90-90 UNAIDS Target in a Cohort of HIV Infected Patients from Central Italy

Background

Despite progress in the prevention and treatment of HIV, persistent issues concerning the evaluation of continuum in care from the serological diagnosis to virologic success remains. Considering the 2020 UNAIDS target 90-90-90 for diagnosis, treatment, and viral suppression of people living with HIV (PLWH), our purpose was to verify if, starting from new diagnoses, the viral suppression rate of our cohort of new PLWH satisfied the second and the third steps.

Methods

This retrospective study regards all patients aged ≥15 undergoing HIV test at our clinic between January 2005 and December 2017. We evaluated the second and the third ‘90 UNAIDS targets and the unclaimed tests, linkage to care, retention in ART, and the viral suppression at 1 and 2 years. Logistic regression (odds ratio, 95% confidence interval) was performed.

Results

We observed 592 new diagnoses for HIV infection: 61.4% on Italians, 38.5% on foreigners. An antiretroviral treatment was started on 78.8% of the new diagnoses (467/592) (second UNAIDS target), and a viral suppression was obtained at 2 years on 82% of PLWH who had started ART (383/467) (third UNAIDS target), namely only 64.7% of the new diagnoses instead of the hoped-for 81% of the UNAIDS target. Logistic regressions demonstrated that second and third ‘90 UNAIDS targets were unrelated to sex, nationality, CD4 cells count, HIV-RNA and CDC stage (p>0.05). The age class 25–50 years (OR=2.24; 95% CI = 1.06–4.37; p=0.04) achieves more likely viral suppression when compared with patients <25 years. Considering the continuum of care, 88 (15%) PLWH were lost to engagement in care (55 unclaimed tests and 33 unlinked to care), 37 didn’t start ART, 51 were LFTU at 2 years.

Conclusions

UNAIDS goal was far to be reached. The main challenges were unreturned tests as well as the retention in ART. Rapid tests for a test-treat strategy and frequent phone communications in the first ART years could facilitate UNAIDS target achievement.

Social, Clinical, and Behavioral Determinants of HIV Infection and HIV Testing among Black Men in Toronto, Ontario: A Classification and Regression Tree Analysis

Black men bear a disproportionate burden of HIV infection. These HIV inequities are influenced by intersecting social, clinical, and behavioral factors. The purpose of this analysis was to determine the combinations of factors that were most predictive of HIV infection and HIV testing among black men in Toronto. Classification and regression tree analysis was applied to secondary data collected from black men (N = 460) in Toronto, 82% of whom only had sex with women and 18% whom had sex with men at least once. For HIV infection, 10 subgroups were identified and characterized by number of lifetime male partners, age, syphilis history, and perceived stigma. Number of lifetime male partners was the best single predictor of HIV infection. For HIV testing, the analysis identified 8 subgroups characterized by age, condom use, number of sex partners and Chlamydia history. Age (>24 years old) was the best single predictor of HIV testing.

Long-term retention on antiretroviral therapy among infants, children, adolescents and adults in Malawi: A cohort study

Objectives

We examine long-term retention of adults, adolescents and children on antiretroviral therapy under different HIV treatment guidelines in Malawi.

Design

Prospective cohort study.

Setting and participants

Adults and children starting ART between 2005 and 2015 in 21 health facilities in southern Malawi.

Methods

We used survival analysis to assess retention at clinic level, Cox regression to examine risk factors for loss to follow up, and competing risk analysis to assess long-term outcomes of people on antiretroviral therapy (ART).

Results

We included 132,274 individuals in our analysis, totalling 270,256 person years of follow up (PYFU; median per patient 1.3, interquartile range (IQR) 0.26–3.1), 62% were female and the median age was 32 years. Retention on ART was lower in the first year on ART compared to subsequent years for all guideline periods and age groups. Infants (0–3 years), adolescents and young adults (15–24 years) were at highest risk of LTFU. Comparing the different calendar periods of ART initiation we found that retention improved initially, but remained stable thereafter.

Conclusion

Even though the number of patients and the burden on health care system increased substantially during the study period of rapid ART expansion, retention on ART improved in the early years of ART provision, but gains in retention were not maintained over 5 years on ART. Reducing high attrition in the first year of ART should remain a priority for ART programs, and so should addressing poor retention among adolescents, young adults and men.

Cost-effectiveness of integrating buprenorphine-naloxone treatment for opioid use disorder into clinical care for persons with HIV/hepatitis C co-infection who inject opioids

BACKGROUND

Untreated opioid use disorder (OUD) affects the care of HIV/HCV co-infected people who inject opioids. Despite active injection opioid use, there is evidence of increasing engagement in HIV care and adherence to HIV medications among HIV/HCV co-infected persons. However, less than one-half of this population is offered HCV treatment onsite. Treatment for OUD is also rare and largely occurs offsite. Integrating buprenorphine-naloxone (BUP-NX) into onsite care for HIV/HCV co-infected persons may improve outcomes, but the clinical impact and costs are unknown. We evaluated the clinical impact, costs, and cost-effectiveness of integrating (BUP-NX) into onsite HIV/HCV treatment compared with the status quo of offsite referral for medications for OUD.

METHODS

We used a Monte Carlo microsimulation of HCV to compare two strategies for people who inject opioids: 1) standard HIV care with onsite HCV treatment and referral to offsite OUD care (status quo) and 2) standard HIV care with onsite HCV and BUP-NX treatment (integrated care). Both strategies assume that all individuals are already in HIV care. Data from national databases, clinical trials, and cohorts informed model inputs. Outcomes included mortality, HCV reinfection, quality-adjusted life years (QALYs), costs (2017 US dollars), and incremental cost-effectiveness ratios.

RESULTS

Integrated care reduced HCV reinfections by 7%, cases of cirrhosis by 1%, and liver-related deaths by 3%. Compared to the status quo, this strategy also resulted in an estimated 11/1,000 fewer non-liver attributable deaths at one year and 28/1,000 fewer of these deaths at five years, at a cost-effectiveness ratio of $57,100/QALY. Integrated care remained cost-effective in sensitivity analyses that varied the proportion of the population actively injecting opioids, availability of BUP-NX, and quality of life weights.

CONCLUSIONS

Integrating BUP-NX for OUD into treatment for HIV/HCV co-infected adults who inject opioids increases life expectancy and is cost-effective at a $100,000/QALY threshold.

Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study

Background

Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide.

Methods

We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death.

Results

We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00–1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79–1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35–0.99) decreased after adjustments for demographic variables.

Conclusion

This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.

Epidemiology of Perinatal HIV Transmission in the United States in the Era of Its Elimination

The number of infants born with HIV in the United States has decreased for years, approaching the Centers for Disease Control and Prevention's incidence goal for eliminating perinatal HIV transmission. We reviewed recent literature on perinatal HIV transmission in the United States. Among perinatally HIV-exposed infants (whose mothers have HIV, without regard to infants' HIV diagnosis), prenatal and natal antiretroviral use has increased, maternal HIV infection is more frequently diagnosed before pregnancy and breast-feeding is uncommon. In contrast, mothers of infants with HIV are tested at a lower rate for HIV, receive prenatal care less often, receive antiretrovirals (prenatal and natal) less often and breastfeed more often. The incidence of perinatal HIV remains 5 times as high among black than white infants. The annual number of births to women with HIV was estimated last for 2006 (8700) but has likely decreased. The numbers of women of childbearing age living with HIV and HIV diagnoses have decreased. The estimated time from HIV infection to diagnosis remains long among women and men who acquired HIV heterosexually. It is important to review the epidemiology and to continue monitoring outcomes and other health indicators for reproductive age adults living with HIV and their infants.

Do Symptoms of Depression Interact with Substance Use to Affect HIV Continuum of Care Outcomes?

Few studies examine how depression and substance use interact to affect HIV control. In 14,380 persons with HIV (PWH), we used logistic regression and generalized estimating equations to evaluate how symptoms of depression interact with alcohol, cocaine, opioid, and methamphetamine use to affect subsequent retention in care, maintaining an active prescription for ART, and consistent virologic suppression. Among PWH with no or mild depressive symptoms, heavy alcohol use had no association with virologic suppression (OR 1.00 [0.95-1.06]); among those with moderate or severe symptoms, it was associated with reduced viral suppression (OR 0.80 [0.74-0.87]). We found no interactions with heavy alcohol use on retention in care or maintaining ART prescription or with other substances for any outcome. These results highlight the importance of treating moderate or severe depression in PWH, especially with comorbid heavy alcohol use, and support multifaceted interventions targeting alcohol use and depression.

Barriers to HIV care among Francophone African, Caribbean and Black immigrant people living with HIV in Canada: a protocol for a scoping systematic review

INTRODUCTION

Language is a social determinant of health. Addressing social determinants of health is paramount to successful progression along the HIV-care continuum. Canada is a bilingual country with French and English as official languages. There are few studies to date that have focused on the impact of being a French-speaking linguistic minority on the HIV-care continuum. The primary objective of this scoping, systematic review of literature is to evaluate existing gaps in access to HIV- care among French-speaking people living with HIV in Canada. Our primary outcome is healthcare services availability and access for French- speaking people living with HIV.

METHODS AND ANALYSES

Our scoping, systematic review will draw on a systematic search of published literature, both quantitative and qualitative studies published on French-speaking individuals' healthcare and HIV status in Canada, with particular emphasis on the province of Ontario. We will conduct our search in MEDLINE, the Excerpta Medica Database, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, EBSCO and Google Scholar for work published between 1990 and 2018. Identified articles will be screened in duplicate and full-text articles of relevant studies will be retrieved. Data will also be extracted by two researchers working independently. Any discrepancies that arise will be resolved by consensus or by consulting a third author. Our findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

ETHICS AND DISSEMINATION

Our proposed research will not be conducted with human participants. We will only use secondary published data and therefore ethics approval is not required. Our findings will be disseminated as peer reviewed manuscripts at conferences and student rounds, and could be of interest to government health agencies and local HIV/AIDS service organisations.

Trends in HIV care cascade engagement among diagnosed people living with HIV in Ontario, Canada: A retrospective, population-based cohort study

Background

The HIV cascade is an important framework for assessing systems of care, but population-based assessment is lacking for most jurisdictions worldwide. We measured cascade indicators over time in a population-based cohort of diagnosed people living with HIV (PLWH) in Ontario, Canada.

Methods

We created a retrospective cohort of diagnosed PLWH using a centralized laboratory database with HIV diagnostic and viral load (VL) test records linked at the individual-level. Individuals enter the cohort with record of a nominal HIV-positive diagnostic test or VL test, and remain unless administratively lost to follow-up (LTFU, >2 consecutive years with no VL test and no VL test in later years). We calculated the annual percent of diagnosed PLWH (cohort individuals not LTFU) between 2000 and 2015 who were in care (≥1 VL test), on ART (as documented on VL test requisition) or virally suppressed (<200 copies/ml). We also calculated time from diagnosis to linkage to care and viral suppression among individuals newly diagnosed with HIV. Analyses were stratified by sex and age. Upper/lower bounds were calculated using alternative indicator definitions.

Results

The number of diagnosed PLWH increased from 8,859 (8,859–11,389) in 2000 to 16,110 (16,110–17,423) in 2015. Over this 16-year period, the percent of diagnosed PLWH who were: in care increased from 81% (63–81%) to 87% (81–87%), on ART increased from 55% (34–60%) to 81% (70–82%) and virally suppressed increased from 41% (23–46%) to 80% (67–81%). Between 2000 and 2014, the percent of newly diagnosed individuals who linked to care within three months of diagnosis or achieved viral suppression within six months of diagnosis increased from 67% to 82% and from 22% to 42%, respectively. Estimates were generally lower for females and younger individuals.

Discussion

HIV cascade indicators among diagnosed PLWH in Ontario improved between 2000 and 2015, but gaps still remain—particularly for younger individuals.

Cascade of care for people living with HIV infection in Southern Brazil: results from a public health network

The cascade of care for people living with HIV infection (PLHIV) describes steps in diagnosis, linkage and retention in care, as well as the provision and success of combination antiretroviral therapy (cART). The aim of this study was to evaluate the rates regarding the retention in care, on cART, and suppressed viral load for PLHIV attended at a Brazilian public health network. Data on PLHIV from 116 cities of Paraná, Southern Brazil, attended from 2012 to 2015, were retrospectively collected through the Laboratory Tests Control System (SISCEL). The number of PLHIV related to care increased about 22.5% from 2012 to 2015 (4,106 to 5,030 individuals). The proportion of PLHIV retained in care showed a trend toward stabilization around 81.7-86.9%. Every year, the use of cART increased up to 90.3% for PLHIV retained in care. Viral load suppression was achieved by 72.8% of patients on cART and 57.1% by those linked to care. Retention in care and HIV viral suppression were more likely to occur in older PLHIV than younger ones; similarly, patients living in medium-sized cities were more susceptible to these factors than in large- or small-sized cities. In conclusion, the study showed a high level of retention in care and HIV suppression on cART, as well as emphasized that current efforts for treating already-infected PLHIV remain a challenge for our health public institutions and may contribute to highlight steps for improvement of the HIV cascade of care in our population.

Impact of Alternative Encounter Types on HIV Viral Suppression Rates in an Integrated Health System

Kaiser Permanente Mid-Atlantic States (KPMAS) members are increasingly utilizing electronic encounter types, such as telephone appointments and secure messaging for healthcare purposes, although their impact on health outcomes is unknown. We evaluated whether use of alternative encounters by adult human immunodeficiency virus (HIV)-infected patients affected the likelihood of achieving viral suppression (VS). Our study population of 3114 patients contributed 6520 patient-years between 2014 and 2016. We compared VS (HIV RNA <200 copies/mL) by number of in-person visits (1 or ≥2), with further stratification for additional phone and/or e-mail encounters (none, phone only, e-mail only, and both phone and e-mail). Rate ratios (RRs) for VS by number of in-person visits and encounter types were obtained from Poisson modeling, adjusting for age, sex, race/ethnicity, and HIV risk. Compared to those with ≥2 visits, patients with one in-person visit alone were significantly less likely to achieve VS (RR = 0.93; 95% confidence interval, CI: [0.87-1.00]), as were those with one in-person visit plus a telephone encounter (0.93; [0.90-0.97]). We did not find significant differences in VS comparing patients with one in-person visit plus e-mail only (RR = 1.00; 95% CI: [0.97-1.02]) or plus e-mail and telephone (0.99; [0.97-1.01]) to those with ≥2 in-person visits. If supplemented by e-mail communications (with or without telephone contact), patients with one in-person visit per year had similar estimated rates of VS compared with ≥2 in-person visits. More research is needed to know if these findings apply to other care systems.

Time Spent with HIV Viral Load > 1500 Copies/mL Among Persons Engaged in Continuity HIV Care in an Urban Clinic in the United States, 2010-2015

Persons with HIV who have entered care but have viral load > 1500 copies/mL may be the source of the majority of new HIV infections in the United States. We followed patients engaged in continuity care in the Johns Hopkins HIV Clinical Cohort between January 2010 and August 2015. We estimated person-time spent with viral load > 1500 copies/mL while in care after antiretroviral therapy (ART) initiation, while in care, and while alive. Person-time was classified according to the most recent viral load measurement. Of 11,283.1 person-years in care on after ART initiation, 11,954.7 person-years in care and 13,990.0 total person-years of follow-up spent alive, 12.5, 14.8%, and between 12.6 and 27.2%, respectively (depending on assumptions about the viral load of persons lost to clinic) were spent with viral load > 1500 copies/mL. Patients with lower baseline CD4 cell count, younger age, black race, history of injection drug use, or baseline hazardous alcohol use spent more time with viral load > 1500 copies/mL after ART initiation.

Retention in HIV care during the 3 years following release from incarceration: A cohort study

BACKGROUND

Sustained retention in HIV care (RIC) and viral suppression (VS) are central to US national HIV prevention strategies, but have not been comprehensively assessed in criminal justice (CJ) populations with known health disparities. The purpose of this study is to identify predictors of RIC and VS following release from prison or jail.

METHODS AND FINDINGS

This is a retrospective cohort study of all adult people living with HIV (PLWH) incarcerated in Connecticut, US, during the period January 1, 2007, to December 31, 2011, and observed through December 31, 2014 (n = 1,094). Most cohort participants were unmarried (83.7%) men (77.0%) who were black or Hispanic (78.1%) and acquired HIV from injection drug use (72.6%). Prison-based pharmacy and custody databases were linked with community HIV surveillance monitoring and case management databases. Post-release RIC declined steadily over 3 years of follow-up (67.2% retained for year 1, 51.3% retained for years 1-2, and 42.5% retained for years 1-3). Compared with individuals who were not re-incarcerated, individuals who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p < 0.001) but less likely to have VS (72% versus 81%; p = 0.048). Using multivariable logistic regression models (individual-level analysis for 1,001 individuals after excluding 93 deaths), both sustained RIC and VS at 3 years post-release were independently associated with older age (RIC: adjusted odds ratio [AOR] = 1.61, 95% CI = 1.22-2.12; VS: AOR = 1.37, 95% CI = 1.06-1.78), having health insurance (RIC: AOR = 2.15, 95% CI = 1.60-2.89; VS: AOR = 2.01, 95% CI = 1.53-2.64), and receiving an increased number of transitional case management visits. The same factors were significant when we assessed RIC and VS outcomes in each 6-month period using generalized estimating equations (for 1,094 individuals contributing 6,227 6-month periods prior to death or censoring). Additionally, receipt of antiretroviral therapy during incarceration (RIC: AOR = 1.33, 95% CI 1.07-1.65; VS: AOR = 1.91, 95% CI = 1.56-2.34), early linkage to care post-release (RIC: AOR = 2.64, 95% CI = 2.03-3.43; VS: AOR = 1.79; 95% CI = 1.45-2.21), and absolute time and proportion of follow-up time spent re-incarcerated were highly correlated with better treatment outcomes. Limited data were available on changes over time in injection drug use or other substance use disorders, psychiatric disorders, or housing status.

CONCLUSIONS

In a large cohort of CJ-involved PLWH with a 3-year post-release evaluation, RIC diminished significantly over time, but was associated with HIV care during incarceration, health insurance, case management services, and early linkage to care post-release. While re-incarceration and conditional release provide opportunities to engage in care, reducing recidivism and supporting community-based RIC efforts are key to improving longitudinal treatment outcomes among CJ-involved PLWH.

Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.

The impact of drug coverage on viral suppression among people living with HIV in Ontario, Canada

OBJECTIVES

We investigated the effect of drug coverage on viral suppression (sVL) in Ontario, Canada, where there is no universal coverage of prescription drugs, including antiretroviral therapy (ART).

METHODS

Ontarians without employment coverage may be eligible for varying degrees of coverage through government-sponsored programs. Remaining individuals pay all expenses entirely out of pocket. Among participants on ART enrolled in the Ontario HIV Treatment Network Cohort Study (OCS) who were interviewed in 2008-2013 with known or imputable drug coverage, we estimated the prevalence with sVL (< 200 copies/mL) as of their last viral load each year. We calculated prevalence ratios (PR) according to time-updated socio-economic and behavioural factors using multivariable generalized estimating equations with a log-link function. Multiple imputation was used to assess the sensitivity of these findings to different assumed missing data models.

RESULTS

One thousand two hundred forty-seven participants were included (3463 person-years). Compared to study participants with employer coverage, individuals covered through the Ontario Drug Benefit (ODB) were less likely to be suppressed (PR, 95% confidence interval (CI) 0.96, 0.93-0.98). After multivariable adjustment, ODB remained independently associated with less success in achieving sVL (adjusted PR, 95% CI 0.98, 0.95-0.99). These findings were robust to different assumptions about the missing data.

CONCLUSION

Our findings suggest that drug coverage can affect viral suppression in our setting. Further research is needed to identify the mechanisms by which coverage interacts with individual patient factors to affect viral suppression. Mechanisms to improve access and coverage for ART are needed.

Healthcare Empowerment and HIV Viral Control: Mediating Roles of Adherence and Retention in Care

INTRODUCTION

This study assessed longitudinal relationships between patient healthcare empowerment, engagement in care, and viral control in the Women's Interagency HIV Study, a prospective cohort study of U.S. women living with HIV.

METHODS

From April 2014 to March 2016, four consecutive 6-month visits were analyzed among 973 women to assess the impact of Time 1 healthcare empowerment variables (Tolerance for Uncertainty and the state of Informed Collaboration Committed Engagement) on Time 2 reports of ≥95% HIV medication adherence and not missing an HIV primary care appointment since last visit; and on HIV RNA viral control across Times 3 and 4, controlling for illicit drug use, heavy drinking, depression symptoms, age, and income. Data were analyzed in 2017.

RESULTS

Adherence of ≥95% was reported by 83% of women, 90% reported not missing an appointment since the last study visit, and 80% were categorized as having viral control. Logistic regression analyses revealed a significant association between the Informed Collaboration Committed Engagement subscale and viral control, controlling for model covariates (AOR=1.08, p=0.04), but not for the Tolerance for Uncertainty subscale and viral control (AOR=0.99, p=0.68). In separate mediation analyses, the indirect effect of Informed Collaboration Committed Engagement on viral control through adherence (β=0.04, SE=0.02, 95% CI=0.02, 0.08), and the indirect effect of Informed Collaboration Committed Engagement on viral control through retention (β=0.01, SE=0.008, 95% CI=0.001, 0.030) were significant. Mediation analyses with Tolerance for Uncertainty as the predictor did not yield significant indirect effects.

CONCLUSIONS

The Informed Collaboration Committed Engagement healthcare empowerment component is a promising pathway through which to promote engagement in care among women living with HIV.

Informing Targeted Interventions to Optimize the Cascade of HIV Care Using Cluster Analyses of Health Resource Use Among People Living with HIV/AIDS

Increased awareness of the secondary preventive benefits of antiretroviral treatment (ART) has strengthened the desire to optimize health care systems' response to HIV/AIDS. We identified clusters of health resource utilization (HRU) among people living with HIV (PLHIV) to inform targeted interventions aimed to optimize the cascade of HIV care. Using linked population-level health databases in British Columbia, Canada, we selected two analytic samples of PLHIV with 3 years of follow-up between 2006-2011 that were classified as intermittently retained in care or intermittently engaged in ART, and executed a probabilistic model-based clustering analysis for each sample with 5 and 9 quarterly HRU variables, respectively. We found clear HRU profile differences among both samples with similar HIV-related care: one featured active involvement in non-HIV care, the other little or no health care interaction following linkage to care. Differential reengagement intervention strategies capitalizing on missed opportunities in non-HIV care and further engaging physicians delivering HIV care are needed to optimize the response to the HIV epidemic.

Implementing a Pre-Exposure Prophylaxis Intervention for Safer Conception among HIV Serodiscordant Couples: Recommendations for Health Care Providers

Couples in HIV serodiscordant relationships frequently desire children. Although partners who are virally suppressed pose almost no risk of transmitting HIV to their partners, partners who are inconsistently on therapy may transmit HIV to their partners when attempting to conceive. Pre-exposure prophylaxis (PrEP) is an available safer conception strategy for these couples but is not consistently offered. We sought to better understand barriers to PrEP implementation for couples seeking conception and patient perceptions on what providers could do to encourage use. We conducted in-depth, qualitative interviews with 11 participants representing six couples taking PrEP for safer conception in a safety-net hospital in New England. Semi-structured qualitative interviews assessed the following: Relationship nature and contextual factors; attitudes and perceptions regarding PrEP for safer conception; experience within health care systems related to HIV and PrEP; and facilitators, barriers, and other experiences using PrEP for safer conception. Four key themes have important implications for implementation of PrEP for safer conception: Knowledge and understanding gaps regarding HIV and PrEP among both members of the couple, role of insurance and financing in decision-making, learning to manage and adhere to a treatment plan, and the need for providers to enhance knowledge and offer further support. Addressing barriers to safer conception strategies at multiple levels is needed to prevent HIV transmission within serodiscordant couples who desire children. Providers can play an important role in lowering these barriers through the use of multiple strategies.

The City of Johannesburg can end AIDS by 2030: modelling the impact of achieving the Fast-Track targets and what it will take to get there

INTRODUCTION

In 2014, city leaders from around the world endorsed the Paris Declaration on Fast-Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The City of Johannesburg - one of South Africa's metropolitan municipalities and also a health district - has over 600,000 people living with HIV (PLHIV), more than any other city worldwide. We estimate what it would take in terms of programmatic targets and costs for the City of Johannesburg to meet the Fast-Track targets, and demonstrate the impact that this would have.

METHODS

We applied the Optima HIV epidemic and resource allocation model to demographic, epidemiological and behavioural data on 26 sub-populations in Johannesburg. We used data on programme costs and coverage to produce baseline projections. We calculated how many people must be diagnosed, put onto treatment and maintained with viral suppression to achieve the 2020 and 2030 targets. We also estimated how treatment needs - and therefore fiscal commitments - could be reduced if the treatment targets are combined with primary HIV prevention interventions (voluntary medical male circumcision (VMMC), an expanded condom programme, and comprehensive packages for female sex workers (FSW) and young females).

RESULTS

If current programmatic coverage were maintained, Johannesburg could expect 303,000 new infections and 96,000 AIDS-related deaths between 2017 and 2030 and 769,000 PLHIV by 2030. Achieving the Fast-Track targets would require an additional 135,000 diagnoses and 232,000 people on treatment by 2020 (an increase in around 80% over 2016 treatment numbers), but would avert 176,000 infections and 56,500 deaths by 2030. Assuming stable ART unit costs, this would require ZAR 29 billion (USD 2.15 billion) in cumulative treatment investments over the 14 years to 2030. Plausible scale-ups of other proven interventions (VMMC, condom distribution and FSW strategies) could yield additional reductions in new infections (between 4 and 15%), and in overall treatment investment needs. Scaling up VMMC in line with national targets is found to be cost-effective in the medium term.

CONCLUSIONS

The scale-up in testing and treatment programmes over this decade has been rapid, but these efforts must be doubled to reach 2020 targets. Strategic investments in proven interventions will help Johannesburg achieve the treatment targets and be on track to end AIDS by 2030.

Sexual risk taking and the HIV care continuum in an online sample of men who have sex with men

Antiretroviral Therapy (ART) suppresses HIV replication, reducing the risk of transmission. However, many people living with HIV in the US are not virally suppressed even after diagnosis and initiating ART, and may become disengaged from care at each stage of the HIV care continuum (HCC). In the current study we assessed the sexual risk behaviors of MSM by HCC stage. US MSM who completed an online survey (N = 12,995) in 2015 were categorized into 6 HCC groups. Mean age was 39.2 and a majority identified as White (49.6%). At every stage of the HCC, we found higher proportions of individuals engaged in care compared to CDC estimates. A majority of the sample was HIV-positive and engaged in care, with 67.2% of HIV-positive participants reporting viral suppression with ART. Across HCC groups, participants reported high rates of past 6-month condomless anal sex (CAS) (79.2%-84.8%) and CAS with serodiscordant or unknown status partners (38.0%-84.1%). Notably, MSM with unknown HIV serostatus reported the highest proportion of CAS and serodiscordant CAS. HIV-positive MSM not on ART were more likely to report an STI diagnosis (p < .002) compared to those unaware of their HIV status or HIV negative. Moreover, young Black MSM were less likely to be on ART (p < .002) or virally suppressed (p < .002) compared to older White MSM. Our findings highlight potentially problematic sexual risk behaviors among MSM by level of HCC engagement, which can impede the preventive impact of ART. Online platforms provide an avenue to assess the progress of MSM along the HCC, as well as other subpopulations in need of appropriate behavioral interventions to decrease HIV incidence.

A state transition framework for patient-level modeling of engagement and retention in HIV care using longitudinal cohort data

The human immunodeficiency virus (HIV) care cascade is a conceptual model used to outline the benchmarks that reflects effectiveness of HIV care in the whole HIV care continuum. The models can be used to identify barriers contributing to poor outcomes along each benchmark in the cascade such as disengagement from care or death. Recently, the HIV care cascade has been widely applied to monitor progress towards HIV prevention and care goals in an attempt to develop strategies to improve health outcomes along the care continuum. Yet, there are challenges in quantifying successes and gaps in HIV care using the cascade models that are partly due to the lack of analytic approaches. The availability of large cohort data presents an opportunity to develop a coherent statistical framework for analysis of the HIV care cascade. Motivated by data from the Academic Model Providing Access to Healthcare, which has provided HIV care to nearly 200,000 individuals in Western Kenya since 2001, we developed a state transition framework that can characterize patient-level movements through the multiple stages of the HIV care cascade. We describe how to transform large observational data into an analyzable format. We then illustrate the state transition framework via multistate modeling to quantify dynamics in retention aspects of care. The proposed modeling approach identifies the transition probabilities of moving through each stage in the care cascade. In addition, this approach allows regression-based estimation to characterize effects of (time-varying) predictors of within and between state transitions such as retention, disengagement, re-entry into care, transfer-out, and mortality. Copyright © 2017 John Wiley & Sons, Ltd.

Assessing Antiretroviral Use During Gaps in HIV Primary Care Using Multisite Medicaid Claims and Clinical Data

BACKGROUND

Some individuals who appear poorly retained by clinic visit-based retention measures are using antiretroviral therapy (ART) and maintaining viral suppression. We examined whether individuals with a gap in HIV primary care (≥180 days between HIV outpatient clinic visits) obtained ART during that gap after 180 days.

SETTING

HIV Research Network data from 5 sites and Medicaid Analytic Extract eligibility and pharmacy data were combined.

METHODS

Factors associated with having both an HIV primary care gap and a new (ie, nonrefill) ART prescription during a gap were evaluated with multinomial logistic regression.

RESULTS

Of 6892 HIV Research Network patients, 6196 (90%) were linked to Medicaid data, and 4275 had any Medicaid ART prescription. Over half (54%) had occasional gaps in HIV primary care. Women, older people, and those with suppressed viral load were less likely to have a gap. Among those with occasional gaps (n = 2282), 51% received a new ART prescription in a gap. Viral load suppression before gap was associated with receiving a new ART prescription in a gap (odds ratio = 1.91, 95% confidence interval: 1.57 to 2.32), as was number of days in a gap (odds ratio = 1.04, 95% confidence interval: 1.02 to 1.05), and the proportion of months in the gap enrolled in Medicaid.

CONCLUSIONS

Medicaid-insured individuals commonly receive ART during gaps in HIV primary care, but almost half do not. Retention measures based on visit frequency data that do not incorporate receipt of ART and/or viral suppression may misclassify individuals who remain suppressed on ART as not retained.

Use of national standards to monitor HIV care and treatment in a high prevalence city-Washington, DC

We sought to benchmark the quality of HIV care being received by persons living with HIV in care in Washington, DC and identify individual-level and structural-level differences. Data from the DC Cohort, an observational HIV cohort of persons receiving outpatient care in DC, were used to estimate the Institute of Medicine (IOM) and Department of Health and Human Services (HHS) quality of care measures. Differences in care by demographics and clinic type were assessed using χ2 tests and multivariable regression models. Among 8,047 participants, by HHS standards, 69% of participants were retained in care (RIC), 95% were prescribed antiretroviral therapy (ART), and 84% were virally suppressed (VS). By IOM standards, 84% were in continuous care; and 78% and 80% underwent regular CD4 and VL monitoring, respectively. Screening for syphilis, chlamydia, and gonorrhea was 51%, 31%, and 26%, respectively. Older participants were 1.5 times more likely to be RIC compared to younger participants (OR: 1.5; 95% CI: 1.3, 1.8). Participants enrolled in community-based clinics were more likely to be RIC (OR: 1.7; 95% CI: 1.4, 2.0) versus those enrolled at hospital-based clinics. Older participants were more likely to achieve VS than younger participants (OR: 1.8; 95% CI: 1.5, 2.2) while Black participants were less likely compared to white participants (OR: 0.4; 95% CI: 0.3, 0.5). Despite high measures of quality of care, disparities remain. Continued monitoring of the quality of HIV care and treatment can inform the development of public health programs and interventions to optimize care delivery.

Trends in HIV Continuum of Care Outcomes over Ten Years of Follow-Up at a Large HIV Primary Medical Home in the Southeastern United States

Longitudinal studies of retention in care (RIC) and viral suppression (VS) in the southeastern United States (US), a region disproportionately affected by HIV infection, are lacking. HIV-infected adults with ≥1 medical visit at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2004 to 2013 were included. RIC was ≥2 (a) laboratory dates [CD4+ counts or HIV-1 viral loads (VLs)] or (b) provider encounters and/or laboratory dates in the year of interest, ≥90 days apart. VS was a VL of <200 copies/ml at last measurement in the year of interest. Modified Poisson regression estimated relative risk (RR) of RIC and VS, adjusting for age, race, sex, HIV transmission risk, and socioeconomic status (SES). Among 4,641 persons, 76.8% achieved RIC and 70.2% achieved VS. RIC and VS increased from 2004 to 2013 (p < .001 each). For lack of RIC, younger patients (RR = 1.2 and RR = 1.1, 18-24 and 25-34 vs. 35-44 year-olds, respectively), Blacks (RR = 1.3 vs. Whites), and injection drug users (IDUs) (RR = 1.2 vs. heterosexual contact [Hetero]) fared worse (p < .05 each); those with male-to-male sexual contact fared better (RR = 0.8 vs. Hetero, p < .05). For lack of VS, younger patients (RR = 1.3 and RR = 1.2, 18-24 and 25-34 vs. 35-44 year olds, respectively), Blacks (RR 1.3 vs. Whites), Females (RR = 1.1 vs. Males), IDUs (RR 1.3 vs. Hetero), and those with low SES (RR = 1.1 vs. not low SES) fared worse (p < .05, each). RIC and VS increased over time, suggesting that efforts to improve outcomes have been effective. However, disparities persist and resources should focus on groups most at risk.

HIV-Positive Individuals on Antiretroviral Therapy and with Viral Load Suppressed in 12 Infectious Diseases Clinics in Italy: Successes and Disparities in the HIV Continuum of Care

The HIV care continuum is a tool that describes the quality of HIV care for people living with HIV and assesses the extent to which the goal of viral suppression has been achieved. In 2014, we conducted a retrospective cross-sectional study to assess the characteristics associated with three steps of the HIV continuum of care in Italy [i.e., most recent diagnoses, people diagnosed and in care who are on therapy, and people with viral load (VL) suppressed among those on therapy]. Among the 10,262 individuals diagnosed and linked to care, 9,810 (95.6%) were on therapy and among these 8,383 (85.7%) had VL suppressed. The comparison between people diagnosed in 2013 to those diagnosed before 2013 shows that they were more likely to be male [adjusted odds ratios (AOR) = 1.46; 95% confidence interval (95% CI): 1.18-1.79], <25 years of age (AOR = 7.59; 95% CI: 4.17-13.79), and born in Italy (AOR = 1.33; 95% CI: 1.09-1.62). Factors significantly associated with not being in therapy were as follows: age <35 years (AOR = 4.03; 95% CI: 2.50-6.51), age 35-55 years (AOR = 1.85; 95% CI: 1.19-2.87), being migrants (AOR = 1.25; 95% CI: 1.13-1.39), being men who have sex with men (MSM) (AOR = 1.54; 95% CI: 1.22-1.95), have been diagnosed in 2010-2012 (AOR = 4.51; 95% CI: 3.03-6.73), or before 2010 (AOR = 3.18; 95% CI: 2.41-4.21), and not had previous clinical AIDS (AOR = 8.24; 95% CI: 3.33-20.23), whereas factors significantly associated with not having VL suppressed were as follows: age <35 years (AOR = 1.56; 95% CI: 1.13-2.13) and age 35-55 years (AOR = 1.23; 95% CI: 1.10-1.38), being migrants (AOR = 1.38; 95% CI: 1.11-1.70), have been diagnosed in 2010-2012 (AOR = 1.34; 95% CI: 1.14-1.57), in 2013 (AOR = 4.35; 95% CI: 2.47-7.68), and not having had previous clinical AIDS (AOR = 0.74; 95% CI: 0.63-0.86). Despite this we observed significant disparities for young people, MSM, and migrants, overall in Italy the vast majority of people diagnosed with HIV and in care in 2013 received therapy and the percentage of people who are VL suppressed is near the Joint United Nations Programme on HIV/AIDS goal.

Mobile Text Messaging to Improve Medication Adherence and Viral Load in a Vulnerable Canadian Population Living With Human Immunodeficiency Virus: A Repeated Measures Study

Background

Combination antiretroviral therapy (cART) as treatment for human immunodeficiency virus (HIV) infection is effective and available, but poor medication adherence limits benefits, particularly in vulnerable populations. In a Kenyan randomized controlled trial, a weekly text-messaging intervention (WelTel) improved cART adherence and HIV viral load (VL). Despite growing evidence for short message service (SMS) text-message interventions in HIV care, there is a paucity of data utilizing these interventions in marginalized or female cohorts.

Objective

This study was undertaken to assess whether the standardized WelTel SMS text-message intervention applied to a vulnerable, predominantly female, population improved cART adherence and VL.

Methods

We conducted a repeated measures study of the WelTel intervention in high-risk HIV-positive persons by measuring change in VL, CD4 count, and self-reported adherence 12 months before and 12 months after the WelTel intervention was introduced. Inclusion criteria included VL ≥200 copies/mL, indication for treatment, and meeting vulnerability criteria. Participants were given a mobile phone with unlimited texting (where required), and weekly check-in text messages were sent for one year from the WelTel computer platform. Clinical data were collected for control and intervention years. Participants were followed by a multidisciplinary team in a clinical setting. Outcomes were assessed using Wilcoxon signed ranks tests for change in CD4 and VL from control year to study end and mixed-effects logistic regressions for change in cART adherence and appointment attendance. A secondary analysis was conducted to assess the effect of response rate on the outcome by modeling final log₁₀ VL by number of responses while controlling for mean log₁₀ VL in the control year.

Results

Eighty-five participants enrolled in the study, but 5 withdrew (final N=80). Participants were predominantly female (90%, 72/80) with a variety of vulnerabilities. Mean VL decreased from 1098 copies/mL in the control year to 439 copies/mL at study end (P=.004). Adherence to cART significantly improved (OR 1.14, IQR 1.10-1.18; P<.001), whereas appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). A response was received for 46.57% (1753/3764) of messages sent and 9.62% (362/3764) of text messages sent were replied to with a problem. An outcome analysis examining relationship between reply rate and VL did not meet statistical significance (P=.07), but may be worthy of investigating further in a larger study.

Conclusions

WelTel may be an effective tool for improving cART adherence and reducing VLs among high-risk, vulnerable HIV-positive persons.

Trial Registration

Clinicaltrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/6qK57zCwv)

Predictors of loss to follow-up among patients on ART at a rural hospital in KwaZulu-Natal, South Africa

INTRODUCTION

Improved HIV outcomes as a result of expanded antiretroviral therapy (ART) access is threatened by increasing rates of loss to follow up (LTFU) among those on ART, largely reported in urban populations. Some reports suggest that LTFU rates are overestimated due to patient movement to other facilities and inadequate medical records.

STUDY OBJECTIVE

To define the proportion disengaging from HIV care as well as the characteristics of those LTFU in order to design and implement appropriate interventions to increase retention.

METHODS

We performed a retrospective review of patients who discontinued ART at a central hospital ART clinic in rural South Africa and compared with patients receiving care at the 15 primary health clinics (PHCs) to determine the true proportion of those who were LTFU. We also compared those who discontinued ART with those who did not at the central hospital ART clinic to determine predictors of loss to follow up.

RESULTS

Among 3242 patients on ART, 820 were originally marked as LTFU. Among all patients, 272 (8.4%) were found at a clinic on treatment, 56 (1.7%) were found at a clinic from which they had since discontinued treatment, and 10 (0.3%) returned to care between June and July 2016, leaving 475 (14.7%) unaccounted for and thus categorized as 'true' LTFU. Factors found to be associated with discontinuation include being male, age 18-35, having a CD4 count under 200 cells/μL, and being on ART for under six months.

CONCLUSIONS

Young men with low CD4 counts early after ART initiation are at highest risk of ART disengagement in this rural South African HIV clinic. Novel interventions targeting this group are needed to improve retention in care.

An Exploratory Study to Assess Individual and Structural Level Barriers Associated With Poor Retention and Re-engagement in Care Among Persons Living With HIV/AIDS

BACKGROUND

Retention in care is the most challenging step along the HIV care continuum. Many patients who engage in care and achieve viral suppression have care interruptions, characterized by moving in and out of care ("churn"). Poor retention has clinical consequences and contributes to new HIV transmissions, but how to predict or prevent it remains elusive. This study sought to understand the relationship between individual- and structural-level barriers, and poor retention for persons living with HIV/AIDS in Atlanta, GA.

METHODS

We administered a survey, through interviews, with HIV-infected patients continuously retained in care for 6 years ("continuously retained," n = 32) and patients with recent gaps in care ("unretained" n = 27). We assessed individual-level protective factors for successful engagement (self-efficacy, resilience, perceived social support, and disclosure), risk factors for poor engagement (substance use, mental illness, and stigma), and structural/systemic-level barriers (financial and housing instability, transportation, food insecurity, communication barriers, and incarceration history). Chi-square and Mann-Whitney U tests were used to compare the 2 populations.

RESULTS

Both continuously retained and unretained populations had high rates of prior viral suppression but few unretained patients were virologically suppressed upon return to care (11%). Younger age, crack cocaine use, food insecurity, financial instability, housing instability, and phone number changes in the past year were significantly more likely to be present in the unretained population.

CONCLUSIONS

Our findings suggest the need for targeted risk assessment tools to predict the highest-risk patients for poor retention whereby public health interventions can be directed to those individuals.

The HIV Care Cascade and sub-analysis of those linked to but not retained in care: the experience from a tertiary HIV referral service in Dublin Ireland

BACKGROUND

The HIV Care Cascade model can be used to measure how clinical services align with United Nations' (UN) HIV treatment targets. Previous models have highlighted sequential losses at each step of the Cascade with a significant proportion being not retained in care (NRIC).

OBJECTIVE

We aimed to assess the feasibility of meeting the UN targets and assess factors associated with, and calculate the true proportion of those, NRIC.

METHODS

All people living with HIV who were linked to our service, one of three specialist HIV care providers in Dublin Ireland, from its establishment in 1993 to 1 December 2014, were included in the cohort and were categorized as linked to care, retained in care (RIC), on antiretroviral therapy (on ART), virally suppressed (HIV RNA <40copies/ml), and NRIC. An analysis of those NRIC was performed to categorize their current status through direct/indirect contact.

RESULTS

Of 1000 patients linked to care, 78.7% (n = 787) were RIC, of whom 91.5% (n = 720) were on ART, with 89.9% (n = 644) virally suppressed. Those RIC were more likely older (p = 0.006) and non-IVDU (p < 0.001). Of 213 (21.3%) NRIC, 56 (26.3%) emigrated, 27 (12.7%) transferred care, 15 (7.0%) stopped attending but were contactable, 38 (17.8%) died, and 77 (36.1%) were lost to follow-up. After revision, 10.5% of the cohort was confirmed as NRIC, with 6 of 15 defined as "stopped attending" re-linked to care following direct contact.

CONCLUSIONS

Our HIV Care Cascade model demonstrates that the true numbers of patients NRIC may be significantly lower than previously estimated and once RIC, treatment goals approaching the United Nations Programme on HIV and AIDS targets are possible with 91.5% on treatment and almost 90% of those on treatment virally suppressed. That 40% reengaged following direct contact suggests benefit through regular monitoring and direct contact based on the HIV Care Cascade model.

The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future

The HIV care continuum is a framework that models the dynamic stages of HIV care. The continuum consists of five main steps, which, at the population level, are depicted cross-sectionally as the HIV treatment cascade. These steps include diagnosis, linkage to care (LTC), retention in care (RiC), adherence to antiretroviral therapy (ART), and viral suppression. Although the HIV treatment cascade is represented as a linear, unidirectional framework, persons living with HIV (PLWH) often experience the care continuum in a less streamlined fashion, skip steps altogether, or even exit the continuum for a period of time and regress to an earlier stage. The proportion of PLWH decreases at each successive step of the cascade, beginning with an estimated 86% who are diagnosed and dropping dramatically to approximately 30% of PLWH who are virally suppressed in the United States (US). In this current issues review, we describe each step in the cascade, discuss targeted interventions that address weak points in the continuum, review domestic and international policies that help shape and direct HIV care strategies, and conclude with recommendations and future directions for HIV providers and policymakers. While we primarily examine issues related to domestic HIV care in the US, we also discuss international applications of the continuum in order to provide broader context.

Positive affect and its association with viral control among women with HIV infection

OBJECTIVE

We assessed the relationship between positive affect and viral suppression among women with HIV infection.

METHOD

Three waves of 6-month data were analyzed from 995 women on HIV antiretroviral therapy participating in the Women's Interagency HIV Study (10/11-3/13). The predictor variable was self-reported positive affect over 2 waves of data collection, and the outcome was suppressed viral load, defined as plasma HIV-1 RNA <200 copies/mL, measured at a third wave.

RESULTS

Women with higher positive affect (36%) were more likely to have viral suppression at a subsequent wave (OR 1.92, 95% CI [1.34, 2.74]). Adjusting for covariates and their interactions, including negative affect, Wave 1 viral suppression, adherence, study site, recruitment cohort, substance use, heavy drinking, relationship status, interpersonal difficulties, and demographics, a statistically significant interaction was detected between negative affect, positive affect and viral suppression, t(965) = -2.7, p = .008. The association of positive affect and viral suppression differed at negative affect quartile values. For those reporting no negative affect, the AOR for positive affect and viral suppression was 2.41 (95% CI [1.35, 4.31]); at a negative affect score of 2, the AOR was 1.44 (95% CI [0.87, 2.36]); and at a score of 5.5, the AOR was 0.58 (95% CI [0.24, 1.42]).

CONCLUSION

Our central finding related to the interaction effect, that positive affect is associated with viral control under conditions of lower negative affect, is consistent with previous theory and research with other health outcomes, and can help guide efforts to further delineate mechanisms linking affect and health. (PsycINFO Database Record

Increased antiretroviral therapy prescription and HIV viral suppression among persons receiving clinical care for HIV infection

OBJECTIVE

To assess trends during 2009-2013 in antiretroviral therapy (ART) prescription and viral suppression among adults receiving HIV clinical care in the United States.

DESIGN

We used data from the Medical Monitoring Project, a surveillance system producing national estimates of characteristics of HIV-infected adults receiving clinical care in the United States.

METHODS

We estimated weighted proportions of persons receiving HIV medical care who were prescribed ART and achieved HIV viral suppression (<200 copies/ml) at both last test and at all tests in the previous 12 months during 2009-2013. We assessed trends overall and by gender, age, race/ethnicity, and sexual behavior/orientation.

RESULTS

ART prescription and viral suppression increased significantly during 2009-2013, overall and in subgroups. ART prescription increased from 89 to 94% (P for trend <0.01). Viral suppression at last measurement increased from 72 to 80% (P for trend <0.01). The largest increases were among 18-29 year olds (56-68%), 30-39 year olds (62-75%), and non-Hispanic blacks (64-76%). Sustained viral suppression increased from 58 to 68% (P for trend <0.01). The largest increases were among 18-29 year olds (32-51%), 30-39 year olds (47-63%), and non-Hispanic blacks (49-61%).

CONCLUSION

Adults receiving HIV medical care are increasingly likely to be prescribed ART and achieve viral suppression. Recent efforts to promote early antiretroviral therapy use may have contributed to these increases, bringing us closer to realizing key goals of the National HIV/AIDS Strategy.