Adult HIV Research Articles

The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis.

IntroductionThe prevalence of undiagnosed HIV is declining in Africa, and various HIV testing approaches are finding lower positivity rates. In this context, the epidemiological impact and cost‐effectiveness of community‐based HIV self‐testing (CB‐HIVST) is unclear. We aimed to assess this in different sub‐populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub‐Saharan Africa.MethodsThe synthesis model was used to address this aim. Three sub‐populations were considered for CB‐HIVST: (i) women having transactional sex (WTS); (ii) young people (15 to 24 years); and (iii) adult men (25 to 49 years).We assumed uptake of CB‐HIVST similar to that reported in epidemiological studies (base case), or assumed people use CB‐HIVST only if exposed to risk (condomless sex) since last HIV test. We also considered a five‐year time‐limited CB‐HIVST programme. Cost‐effectiveness was defined by an incremental cost‐effectiveness ratio (ICER; cost‐per‐disability‐adjusted life‐year (DALY) averted) below US$500 over a time horizon of 50 years. The efficiency of targeted CB‐HIVST was evaluated using the number of additional tests per infection or death averted.ResultsIn the base case, targeting adult men with CB‐HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision (VMMC). However, the approach was only cost‐effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB‐HIVST to WTS was the most cost‐effective. The main drivers of cost‐effectiveness were the cost of CB‐HIVST and the prevalence of undiagnosed HIV. All other CB‐HIVST scenarios had an ICER above US$500 per DALY averted.Conclusions CB‐HIVST showed an important epidemiological impact. To maximize population health within a fixed budget, CB‐HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub‐population and the overall costs of delivering this testing modality. Linkage to VMMC enhances its cost‐effectiveness.

Identifying gaps in adolescent HIV care and treatment delivery in Asia: results of a regional health provider survey

ABSTRACTAdolescents living with HIV (ALHIV) have substantial challenges accessing and adhering to HIV care and antiretroviral therapy (ART). We conducted a study to gather data on clinical service practices to support ALHIV-focused care in Asia using a 31-question survey for healthcare providers on care and treatment services, support for adherence and retention, and tracking of risk behaviors. It was generated in Google Forms, available in seven languages (Bahasa Indonesia, Chinese Mandarin, English, Malay, Khmer, Thai, Vietnamese), and hosted via Google Drive. Survey request emails were distributed to individual stakeholders (e.g. HIV clinicians, researchers, policymakers), and via sector listserves. Survey completion denoted consent to participate. Descriptive statistics with median values are provided. Between December 2015 and May 2016, 82 respondents from Cambodia (17%), China (6.1%), India (3.6%), Indonesia (20%), Malaysia (12%), Thailand (23%), and Vietnam (18%) participated. Most were physicians (73%) from tertiary-level hospitals (66%); 16% reported caring for >100 patients, 42% for 21–100, and 31% for <20; 95% of ALHIV in their care were on ART, 20% were on a second-line regimen. ALHIV-specific services were offered by less than half of the respondent clinics, and included 22% with designated adolescent care providers, and 19% with adolescent clinic times. Transition preparation included how to navigate adult care services (82%) and communicate with new health providers (67%), and some used a multidisciplinary team of pediatric and adult providers to coordinate transition (35%). Their most commonly reported challenges in ALHIV care included socio-economic limitations impacting care uptake (e.g. transportation, food insecurity; 44%), difficulty supporting self-disclosure by the adolescent (44%), and poor ART adherence (42%). These study results highlight the variable scope of HIV care offered by pediatric HIV centers to ALHIV in Asia, as well as challenges with service delivery, social support, and engaging adult HIV providers in the transition preparation process.

Impact of a Youth-Focused Care Model on Retention and Virologic Suppression Among Young Adults With HIV Cared for in an Adult HIV Clinic.

Young adults with HIV (YAHIV) are less likely to be retained in care or achieve viral suppression (VS) when seen in adult clinics. We assessed the outcomes of a youth-focused care model versus standard of care (SOC) within a large adult HIV clinic. The Accessing Care Early (ACE) program for YAHIV is embedded within an adult clinic. Eligibility for ACE includes age 18-30 years with ≥1 criteria: transfer from pediatric care, mental health diagnosis, substance use, or identified adherence barriers. Ineligible patients receive SOC. Retrospective analysis of patients entering ACE versus SOC from 2012 to 2014. Multivariable logistic regression assessed variables associated with retention and VS <200 copies per milliliter, and in separate analysis, clinical services utilization. One hundred thirty-seven YAHIV entered care (2012-2014), 61 ACE and 76 SOC. Despite higher risk factors, ACE YAHIV were less likely to be lost to follow-up compared with SOC (16% versus 37%, P < 0.01). At 24 months, 49% in ACE versus 26% in SOC met the retention measure (P < 0.01). In adjusted analysis, ACE was associated with retention in care [AOR 3.26 (1.23-8.63)]. Of those meeting the retention measure, 60% of ACE versus 89% of SOC had VS [AOR 0.63 (0.35-1.14)]. Retention was associated with more frequent social work visits, nurse phone calls, and peer navigator interactions. Higher risk ACE YAHIV had better retention than SOC YAHIV in an adult clinic. Improved retention did not lead to improved VS, underscoring the need for additional interventions to optimize VS for YAHIV.

Where are the positives? HIV testing in sub-Saharan Africa in the era of test and treat.

Where are the positives? HIV testing in sub-Saharan Africa in the era of test and treat.

Epidemiology and factors associated with peripheral neuropathy among HIV infected patients in Gondar, Ethiopia: A cross-sectional study.

BackgroundAntiretroviral therapy has surely increased the life expectancy of people living with HIV. However, long term complications like HIV associated sensory neuropathy has a negative impact on quality of life among people living with HIV (PLHIV). In Ethiopia, lack of data on magnitude of the burden and predictors of HIV associated sensory neuropathy in many resource limited setting has led to under diagnosis and eventually under management of HIV-SN. Hence, this study was set out to establish the burden of HIV-associated sensory neuropathy and, its association with demographic, health and clinical characteristics among people living with HIV in Ethiopia.MethodsCross-sectional study was conducted to assess the prevalence of HIV-associated sensory neuropathy and the associated factors among adult HIV patients at University of Gondar Teaching Hospital, Gondar, Ethiopia. Brief Peripheral Neuropathy Screening tool validated by AIDs Clinical trial group was used for screening HIV-associated sensory neuropathy. Data were analyzed descriptively and through uni- and multivariate logistic regression.ResultsIn total 359 adult PLHIV with a mean age of 36.5± 9.07 years participated, their median duration of HIV infection was 60 months (IQR 36–84) and their median CD4 count 143cells/μL (IQR 69.5–201.5). Age above 40 years, anti-tuberculosis regimen, tallness, and exposure to didanosine contained antiretroviral therapy were found to be associated with HIV-associated sensory neuropathy (AOR 1.82, 1.84, 1.98 and 4.33 respectively).ConclusionsMore than half of the HIV patients who attended HIV care clinic at University of Gondar hospital during the study period were found to present with peripheral sensory neuropathy. Higher age, tallness, TB medication, and didanosine in ART were significantly associated with HIV-SN as screened by effective diagnostic (BPNS) tool.

Tsogolo la Thanzi: A Longitudinal Study of Young Adults Living in Malawi's HIV Epidemic.

Tsogolo la Thanzi (TLT) was designed to study how young adults navigate sexual relationships and childbearing during a generalized HIV epidemic. TLT began in 2009 with a population‐representative sample of 1,505 women and 574 men between the ages of 15 and 25 living in Balaka, southern Malawi, where regional adult HIV prevalence then stood at 15 percent. The first phase (2009–11) included a series of eight interviews, spaced four months apart. During this time, women's romantic and sexual partners enrolled in the study on an ongoing basis. A refresher sample of 315 women was added in 2012. Seventy‐eight percent of respondents were re‐interviewed in the second phase of TLT (2015), which consisted of follow‐up interviews approximately 3.5 years after the previous interview (ages 21–31). At each wave, detailed information about fertility intentions and behaviors, relationships, sexual behavior, health, and a range of sociodemographic and economic traits was gathered by means of face‐to‐face surveys. Biomarkers for HIV and pregnancy were also collected. Distinguishing features include: a population‐representative sample, closely spaced data collection, dyadic data on couples over time, and an experimental approach to HIV testing and counseling. Data are available through restricted data‐user agreements managed by Data Sharing for Demographic Research (DSDR) at the University of Michigan.

Prognostic Factors of Mortality among Adult Patients on Antiretroviral Therapy in India: A Hospital Based Retrospective Cohort Study.

Introduction HIV related deaths still continue to occur in large numbers in spite of good quality drugs being freely available in India. This study was therefore done to assess the prognostic factors of mortality among people living with HIV (PLHIV) on antiretroviral therapy (ART). This would help in planning strategies for further improving their survival. Materials and Methods Record based data from baseline and follow-up visits of a cohort of patients aged above 14 years on ART was retrospectively reviewed over a seven-year period. The Kaplan-Meier models were used to estimate life time survival probability, and Cox proportional hazard regression model was used to determine independent prognostic factors of death, among patients, after initiation of ART. Results Mean age of the total 285 patients enrolled in this study was 45.8±9.7 years. Mean duration of treatment on ART was 1127±611.8 days. During the follow-up period, 44/285(15.4%) patients died, resulting in incidence density of death rate as 3.12 per 100 person years. Good adherence with treatment was reported by 267(93.7%) patients. Nearly half of the deaths, i.e., 21(47.7%), occurred within three months of them starting ART. The mean survival time after initiation of ART was 2084.0±55.3 days (95% CI is 1975.5-2192.5). The presence of opportunistic infections (OIs) and tuberculosis before and poor/average adherence to ART and alcohol usage after starting ART were independent prognostic factors of mortality among patients. Conclusion Several prognostic factors influencing mortality among adult HIV patients receiving treatment were identified in this study. Screening efforts is essential in early detection and management of OIs among PLHIV. Good counselling and monitoring is recommended to improve adherence and also to prevent alcohol usage after initiation of ART. Such measures would help in further reducing mortality among HIV patients in the settings.

Moderate-to-High Levels of Pretreatment HIV Drug Resistance in KwaZulu-Natal Province, South Africa.

There is evidence of increasing levels of pretreatment HIV drug resistance (PDR) in Southern Africa. We used data from two large population-based HIV surveillance studies to estimate prevalence of PDR in KwaZulu-Natal, the province with the highest HIV prevalence in South Africa. Sanger sequencing was performed on samples obtained from a longitudinal HIV surveillance program (study A, 2013-2014) and the HIV Incidence Provincial Surveillance System (study B, 2014-2015). Sequences were included for adult HIV positive participants (age ≥15 years for study A, age 15-49 years for study B) with no documented prior exposure to antiretroviral therapy (ART). Overall and drug class-specific PDR was estimated using the World Health Organization 2009 surveillance drug resistance mutation (SDRM) list, and phylogenetic analysis was performed to establish evidence of drug resistance transmission linkage. A total of 1,845 sequences were analyzed (611 study A; 1,234 study B). An overall PDR prevalence of 9.2% [95% confidence interval (CI) 7.0-11.7] was observed for study A and 11.0% (95% CI 8.9-13.2) for study B. In study B, the prevalence of non-nucleoside reverse-transcriptase inhibitor (NNRTI) PDR exceeded 10% for sequences collected in 2014 (10.2%, 95% CI 7.5-12.9). The most prevalent SDRMs were K103NS (7.5%), M184VI (2.4%), and V106AM (1.4%). There was no evidence of large transmission chains of drug-resistant virus. High level NNRTI PDR (>10%) suggests a need to modify the standard first-line ART regimen and to focus attention on improving the quality of HIV prevention, treatment, and care.

Understanding HIV-Related Pill Aversion as a Distinct Barrier to Medication Adherence

Pill aversion, defined as difficulty swallowing pills without identifiable medical cause, is a poorly characterized barrier to sustained viral suppression for many HIV-infected persons. We aimed to quantify the frequency of self-reported pill aversion, characterize its symptoms, and measure the association between self-reported pill aversion and missing antiretroviral doses. This is a prospective, observational, exploratory survey study of English-speaking persons living with HIV (PLHIV) at a single urban tertiary outpatient clinic. Participants completed anonymous questionnaires about their experiences of swallowing antiretroviral pills. The primary outcome was skipping pills due to pill aversion symptoms. Of 384 participants, a quarter (25.5%) skipped pills due to pill aversion symptoms. Younger age, being Non-Hispanic Black or Hispanic, not being married or partnered, having public insurance, not being employed, having less than a college education, and having a mental health diagnosis were associated with skipping pills due to pill aversion. On multivariable regression analyses, PLHIV who skipped pills were more likely to report symptoms of gagging, nausea at the time of swallowing, and heavy feeling in the stomach, as well as being bothered by the taste, smell, and size of the pills. PLHIV who skipped pills were also more likely to report negative and fear-based emotions about pill-taking than PLHIV who did not skip pills due to pill aversion. HIV-related pill aversion may represent a significant and frequent barrier to adherence in an adult HIV population.

Clinical burden of viral sexually transmitted infections in adolescents and young adults with HIV attending an urban clinic in sub-Saharan Africa

Viral sexually transmitted infections (STIs) are highly prevalent among people infected with HIV. Diagnosis of viral STIs in sub-Saharan Africa is still a challenge because of the high viral test costs involved and as a result, no published data exist on the burden of viral STIs among ALHIV and YALHIV in sub-Saharan Africa. This study aimed to provide data on the clinical burden of viral STI consultations among ALHIV and YALHIV in a resource-limited setting. Overall, 165 HIV positive adolescents and young adults accessed treatment from our transition STI program. Eightyone (49.1%) patients were diagnosed with viral STIs. Herpes simplex virus (HSV) infection was the predominant viral STI (70.4%) followed by Human Papilloma Virus (HPV) infection (Condylomata acuminata) (35.8%) and Molluscum contagiosum (MCV) (4.9%). Clinically diagnosed herpes simplex viral infections were the predominant sexually transmitted infection in our adolescent and young adult HIV cohort in a large urban HIV clinic in sub-Saharan Africa. Clinicians should maintain a high index of suspicion for the presence of genital HSV infections among symptomatic HIV positive adolescents and young adults. Opportunities directed at developing single, dual or multiple point-of-care viral STI testing in line with diagnosing asymptomatic viral STIs in this population should be explored.

Determinants of cervical cytological abnormalities among HIV-positive women receiving care in a tertiary health facility in Southeast Nigeria

Background: HIV infection is associated with increased risk of precancerous and cancerous lesions of the cervix. There is a need to identify the women mostly at risk to guide cervical cancer screening efforts. The objective of this study was to evaluate the determining factors for premalignant lesions of the cervix among HIV-positive women attending the adult HIV clinic in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria. Materials and Methods: The Pap smears of 110 HIV-positive women were selected through purposive sampling and evaluated for premalignant lesions of the cervix using the Bethesda system of classification. STATA software, version 12.0 SE (Stata Corporation, TX, USA; 1985), was used to analyze the data, and multiple logistic regression models were employed to determine the risk factors of premalignant lesions. P = 0.05 at 95% confidence interval was taken as statistically significant. Results: The prevalence of premalignant lesions of the cervix was 28.2%, and these constitute mainly of atypical squamous cells of undetermined significance (56.5%). Women with cervical cytological abnormalities have significantly lower mean age (35.39 vs. 38.89; P = 0.04), lower mean CD4 count (325.3 vs. 648; P

Incidence and determinants of mortality among adult HIV infected patients on second-line antiretroviral treatment in Amhara region, Ethiopia: a retrospective follow up study.

IntroductionMortality of adult patients who are on antiretroviral therapy (ART) is higher in low-income than in high-income countries. After the failure of standard first-line treatment, patients switch to second-line regimens. However, there are limited data about the outcome of patients after switching to a second-line regimen in the study area. This study aimed to measure the rate of mortality and its determinants among HIV patients on second-line ART regimens.MethodsMulticenter institution based retrospective follow up study was conducted among 1192 adult patients who started second-line ART between 2008 and 2016 in eight selected hospitals of Amhara region. Patients who started second-line treatment after the failure of first-line treatment were included. Patient medical records, registration books, and computer database were used to collect the data. Time to death after a switch to second-line ART was the primary outcome of interest. Cox proportional hazard model was fitted to identify determinant factors of mortality.ResultsAmong 1192 patients who were on second-line ART, 136 (11.4%) died with 3,157 person-years of follow up. Over the study period, the mortality rate was 4.33 per 100 person-years. Not taking isoniazid preventive therapy (IPT) (Adjusted Hazard Ratio (AHR): 6.6; 95% CI: 2.9, 15.0), did not make modification on second-line regimen (AHR: 4.4; 95% CI: 2.8, 6.8), poor clinical adherence (AHR: 2.5; 95% CI: 1.4, 4.5), functional status of bedridden (AHR: 2.7; 95% CI: 1.5, 4.8), and having attained a tertiary level of education (AHR: 0.4; 95% CI: 0.2, 0.8) were independent determinants of mortality.ConclusionThe incidence rate of mortality was high and most of the deaths occurred within 12 months after switching to second-line ART. Higher mortality among adult HIV-infected patients was associated with poor adherence, no formal education, not taking IPT, being bedridden at the time of the switch, and not modifying second-line treatment. Improving treatment adherence of patients by providing consistent adherence counseling, providing INH prophylaxis and monitoring patient's regimen more closely during the first twelve months after switch could decrease mortality of HIV patients on a second-line regimen.

Determinants of First Line Anti-Retroviral Treatment Failure Among Adult Human Immunodeficiency Virus Infected Patients in Western Oromia Public Hospitals, West Ethiopia

Back ground: First line antiretroviral treatment failure has led to increased HIV associated mortality especially in resource limited setting. A determinant of First line antiretroviral treatment failure is not well studied in Ethiopia. The objective of the study was to identify determinants of first line treatment failure among adults living with HIV in western Oromia public hospitals, West Ethiopia. Method: Unmatched case control study was conducted at public hospitals of West Oromia using medical record review. Cases were adult HIV patients on ART in selected hospitals who were switched to second line ART regimen because of first line treatment failure in the past ten years (2005-2015) and Controls were adult HIV patients on ART in selected hospitals who were on first line ART for greater or equal to six month in the same years (2005-2015).Data was collected by trained nurses (counselors) using checklists developed from Ministry of Health ART follow up form and entered to EPi data version 3.1 and transferred to SPSS version 20.0 for analysis. To identify determinants of first line anti-retroviral treatment failure, multivariate analysis with P-value <0.05 was done. Results: A total of 115 cases and 345 controls were included in the study. Baseline CD4 measure (AOR [95% CI] = 3.96 [1.84, 8.54]), regimen change due to drug stock out (AOR [95% CI] = 2.54 [1.38, 4.66]), treatment interruption (AOR [95% CI] = 5.09 [2.39, 10.82]), adverse effect of drug (AOR [95% CI] = 8.49 [1.87, 38.42]) and History of opportunistic infection (AOR [95% CI] = 2.15 [1.28, 3.64] were independently associated with first line antiretroviral treatment failure. Conclusion: Intervention for First line antiretroviral treatment failure needs to emphasize on regimen change due to drug stock out, treatment interruption, history of opportunistic infection, adverse effect of drug and base line CD4 <50cell/µ.

Knowledge, risk perception, and condom utilization pattern among female sex workers in Dire Dawa, Eastern Ethiopia 2016: a cross-sectional study.

IntroductionIn 2015, in Dire Dawa administration city, adult HIV prevalence was 3.26 with 9,523 HIV positive population, & 251 annual AIDS deaths. Female sex workers are one of the high-risk groups for contracting HIV. Therefore, this study has assessed the level of HIV/AIDS knowledge, risk perception and condom utilization pattern among female sex workers' in Diredawa city.MethodsA cross-sectional study was conducted from April 15-June 25, 2016, in Dire Dawa among 156 female sex workers using convenient sampling method. Respondents were interviewed face-to-face using a pretested questionnaire. Training was provided to the data collectors and supervisors. Close supervision was done and double data entry was performed. Then the data were checked for completeness, consistency and entered into Epi Info v3.1 and analyzed using SPSS v20. The descriptive statistical analysis was used to compute frequency, mean, mode and proportion of the findings of this study. The results were presented using tables, charts, graphs, and texts.ResultsAmong the 156 female sex workers (FSWs), 99 (63.5%) had been working on commercial sex for more than one year, 92 (59%) were usually street-based, and 80 (51.3%) had partners between 2-3 per night. Only, 17 (10.9%) respondents mentioned three and above ways of HIV/AIDS transmission and prevention methods. Less than two-thirds (64.1%) of FSWs used a condom with all partners. One hundred thirty-eight (88.5%) of participants were engaged in unsafe sexual practice at least once since their engagement in sex work. Majority of FSWs (85.3%)) believed that their occupation is hazardous and 145 (92.9%) reported that they were unhappy being a commercial sex worker. Regarding risk perception, 79 (50.64%) and 37 (23.7%) of respondents perceived their chances of contracting HIV/STIs to be high and moderate respectively.ConclusionKnowledge about HIV/STIs and magnitude of condom utilization were good. However, a high number of unsafe sex and unsatisfactory risk perception attitudes were observed. Thus, a collaborative effort is needed to create awareness regarding risk perception attitude and increase the level of their practice towards the prevention of unsafe sex.

High Abundance of genus Prevotella in the gut of perinatally HIV-infected children is associated with IP-10 levels despite therapy

Perinatal HIV infection is characterized by faster HIV disease progression and higher initial rate of HIV replication compared to adults. While antiretroviral therapy (ART) has greatly reduced HIV replication to undetectable levels, there is persistent elevated inflammation associated with HIV disease progression. Alteration of gut microbiota is associated with increased inflammation in chronic adult HIV infection. Here, we aim to study the gut microbiome and its role in inflammation in treated and untreated HIV-infected children. Examination of fecal microbiota revealed that perinatally infected children living with HIV had significantly higher levels of genus Prevotella that persisted despite ART. These children also had higher levels of soluble CD14 (sCD14), a marker of microbial translocation, and IP-10 despite therapy. The Prevotella positively correlated with IP-10 levels in both treated and untreated HIV-infected children, while genus Prevotella and species Prevotella copri was inversely associated with CD4 count. Relative abundance of genus Prevotella and species Prevotella copri showed positive correlation with sCD14 in ART-suppressed perinatally HIV-infected children. Our study suggests that gut microbiota may serve as one of the driving forces behind the persistent inflammation in children despite ART. Reshaping of microbiota using probiotics may be recommended as an adjunctive therapy along with ART.

Characteristics and Outcome of HIV-Associated Primary Effusion Lymphoma (PEL) As Observed in the German HIV-Related Lymphoma Cohort Study

Introduction: Human immunodeficiency virus (HIV)-associated primary effusion lymphoma (PEL) is a rare and aggressive subtype of B-cell Non-Hodgkin lymphomas (NHL). PEL usually arises in body cavities such as the peritoneum, the pleural space, and pericardium, but may also present as extracavitary lesions without effusion. Definitive diagnosis hinges on detection of viral infection by human herpes virus 8 (HHV-8) in the neoplastic cells. Optimal treatment for HIV-PEL has not been defined. The aim of the present study was to analyze clinical characteristics, treatment and outcome of pts with HIV-PEL who were included in the German HIV-related lymphoma cohort study.Methods: The German HIV-related lymphoma cohort study is a prospective multicenter study that includes adult HIV-1 infected pts with biopsy or cytologically proven HIV-related lymphoma. Patients were diagnosed at 32 participating centers in Germany and Austria since January 2005. Data on HIV-infection and lymphoma characteristics, treatments and outcomes were recorded. The present analysis focuses on pts with PEL.Results: Twelve out of 437 pts (2.7%) with HIV-NHL were diagnosed with PEL. All pts were male, and the median age at PEL diagnosis was 51.8 yrs (range, 35-64). 11 of 12 pts (92%) had stage IV disease and B-symptoms were present in 8 pts (67%). Five pts were diagnosed with a solid variant consisting of nodal and gastrointestinal (n=2), myocardial followed by gastrointestinal (n=1), pulmonary and lymph node (n=1), and lymph node followed by cutaneous involvement (n=1). The pleural space, pericardium, and peritoneum were affected in 6, 1, and 4 cases, respectively, with more than one body cavity involved in 4 pts. The median CD4-lymphocyte count at lymphoma diagnosis was 174/µl (range, 48-492), and 8 pts (67%) had an AIDS-defining illness prior to diagnosis of PEL. All but 3 pts (75%) were on combination antiretroviral treatment (cART) at time of PEL diagnosis, and HIV-RNA was below the limit of detection in 9 pts (67%). First line chemotherapy (CT) consisted of CHO(E)P-like regimens in 8 pts, liposomal doxorubicin for concurrent Kaposi sarcoma in 2 pts, and rituximab/bortezomib/liposomal doxorubcin in 1 case. One patient only received intrapleural mitoxantrone for pleural effusion. First salvage CT consisted of EPOCH (n=3) or DHAP with and without high dose chemotherapy (n=3). Further salvage treatments included the dose intensive GMALL B-ALL/B-NHL protocol, brentuximab vedotin, EPOCH, and lenalidomide, given to one patient each. After a median follow-up of 12 months for the entire study population, 2 pts (17%) were alive and in continuous complete remission. The 2-year-overall survival was 16.7%. Patients died of refractory lymphoma (n=5), neutropenic sepsis (n=1), pneumonia/non-neutropenic sepsis (n=2), hyperinflammatory syndrome (n=1), and in one case the cause of death remained unclear.Conclusions: The overall survival of patients with HIV-PEL remains poor, although long term survival may be achieved in selected cases. International collaborative studies may help to define the optimal treatment approach. DisclosuresNo relevant conflicts of interest to declare.

1282. Detection of HIV Transmitted Drug Resistance by Next-Generation Sequencing in a CRF01_AE Predominant Epidemic

BackgroundThe Philippines has the fastest growing HIV epidemic in the Asia-Pacific. Concurrent with this is a subtype shift from B to CRF01_AE. We have previously documented transmitted drug resistance (TDR) locally. However, the lack of drug pressure and the insensitivity of Sanger-based sequencing (SBS) may leave archived drug-resistance mutations (DRMs) undetected. To better detect TDR, we performed next-generation sequencing (NGS) on treatment-naïve patients and compared this with SBS.MethodsFollowing ethics approval, newly-diagnosed adult Filipino HIV patients were recruited from the Philippine General Hospital HIV treatment hub. Demographic data were collected, and blood samples underwent SBS with a WHO-approved protocol. Whole-genome NGS was performed using Illumina HiSeq through a commercial provider (Macrogen, Korea). Genotype and DRMs were analyzed and scored using the Stanford HIV Drug Resistance Database.Results113 patients were analyzed. Median age was 29 years (range 19–68), mean CD4 count was 147 cells/µL (range 0–556) and median viral load was 2.8 × 106 copies/mL. Genotype distribution was: CRF01_AE (93), B (13), possible CRF01_AE/B recombinants (5), CRF02_AG (1), possible URF (1). TDR prevalence by SBS and NGS at different minority variant cutoffs are shown in Table 1. All DRMs on SBS were found on NGS. Some samples had multiple DRMs. No factors were significantly associated with TDR, genotype, viral load or baseline CD4 count.ConclusionNGS is a more sensitive tool for detecting TDR compared with SBS. Nearly double the DRMs were found at an NGS cutoff of ≥5%, including INSTI DRMs. With increasing HIV drug resistance worldwide, switching to NGS may help decrease rates of initial treatment failure, especially in settings with limited repertoires of ARVs.Table 1. TDR Prevalence by SBS and NGS (N = 113).MethodAll (%)NRTI (%)NNRTI (%)PI (%)INSTI (%)SBS11 (9.7)2 (1.8)7 (6.2)3 (2.7)0 (0)*NGS≥1%59 (52.2)15 (13.3)29 (25.7)19 (16.8)17 (15.0)≥2%39 (34.5)7 (6.2)19 (16.8)9 (8.0)10 (8.8)≥5%22 (19.5)3 (2.7)15 (13.3)5 (4.4)2 (1.8)≥10%19 (16.8)1 (0.9)14 (12.4)4 (3.5)2 (1.8)≥15%15 (13.3)1 (0.9)12 (10.6)3 (2.7)1 (0.9)≥20%13 (11.5)1 (0.9)10(8.8)2 (1.8)1 (0.9)*SBS for INSTI only done for those with INSTI DRM on NGS ≥ 1% minority variantDisclosures All authors: No reported disclosures.

577. Barriers to Transitions of Care in the Detroit Young HIV Population

BackgroundOne of the issues faced by clinics which care for young adults infected with HIV is a disruption to treatment during the transition from pediatric to adult care. Adherence to routine treatment is essential for this population to ensure decreased rates of transmission and favorable health outcomes for the patients. The purpose of this study was to characterize the out of care transitioning patient population from pediatric to adult HIV care in an academic HIV clinic in Detroit, Michigan.MethodsWe assessed barriers to transition for youth with HIV who had not met the requirements for successful transition to the adult HIV clinic (three appointments). Patient barriers were assessed through telephone calls with three questions assessing their reasons for not coming to the adult clinic conducted by adult medical staff and by a pediatric social worker.ResultsOne hundred and four youth were identified as transitioning youth. Of those, 13 were excluded due to relocation. Thirty-two (30.7%) patients did not successfully transition and 19 (18%) were accessible through telephone/text for interview. Demographic data for the 32 patients was collected and the predictors of disengagement were identified which included transportation (22.2, n = 10) and work (8.9%, n = 4). There were no statistically significant differences in the measured variables of race, HIV mode of acquisition, housing status, or employment status between those who did and did not successfully transition. In regards to reasons for missed appointments, there were eight reasons given to the adult medical staff, but the pediatric social worker was able to elicit, a much broader range of answers, 13.ConclusionWe found that lack of phone access, transportation and work play a key role in patients transitioning to the adult clinic; however, we initially expected more socioeconomic factors to impair the transition process. In looking at the mismatched reasons for missed appointments given to the adult clinic and the pediatric social worker, it appears that the pediatric social worker could elicit a greater the variety of reasons for missed appointments. Moving forward, more pediatric social work support for the transitioning process may be beneficial.Figure 1. Reasons for Missed Appointments Given to Pediatric Social Worker. Disclosures J. Veltman, Jansen: Speaker’s Bureau, Speaker Bureau payment.

548. Antiretroviral Therapy Regimen Characteristics Within an Urban, Safety-Net Clinic in the United States

BackgroundContemporary antiretroviral-therapy (ART) regimens have simple dosing, low toxicity, minimal side-effects, and few drug interactions. We evaluated ART regimens in an urban, safety-net, adult HIV clinic in the United States to determine proportions of patients on contemporary ART and identify opportunities to optimize ART for patients on older regimens.MethodsData including current ART regimen, HIV-1 RNA level, and age were extracted from the electronic medical record (EMR) for all patients seen in the prior 13 months. Viral suppression was defined as HIV-1 RNA < 200 copies/mL. A patient was “off-ART” if there were no fills within 270 days or ART had a stop date >90 days prior to end of the study. Unclear regimens from the EMR (n = 179) were chart reviewed. ART regimens were assigned the following designations: contemporary first-line, contemporary non-first-line, older three-drug, two-drug, salvage, or off-ART. ART was also categorized as boosted (containing cobicistat/ritonavir) vs. unboosted, by single-tablet regimen (STR) vs. multi-tablet regimen (MTR), and frequency of dosing. Correlations between ART regimen, viral suppression, and age were analyzed.ResultsThe ART review included 1,215 individuals. Most patients (64%) were on contemporary first-line regimens; 20% were on contemporary non-first-line regimens (figure). Patients on salvage regimens had lower rates of viral suppression than those in other ART categories (80% vs. 90%, P <0.05). Most patients (90%) were prescribed once daily regimens, and of those, 39% were prescribed STRs. There were no significant associations between viral suppression and regimen complexity (P = 0.8). There were 447 (37%) patients on boosting agents with no difference in viral suppression rate (88% suppressed on boosted regimens vs. 90% on unboosted, P = 0.3). Patients on older regimens and greater than equal to twice daily MTRs were older than those on contemporary regimens and STRs. Individuals off ART were younger than those on ART (average age 41 vs. 46 years).ConclusionIn a US urban, safety-net clinic, most patients were on contemporary ART regimens and 90% were on once-daily therapy. Despite these encouraging findings, systematic review identified many patients that could be considered for modernization and simplification with intent to minimize toxicity, side-effects, drug interactions, and cost. Disclosures All authors: No reported disclosures.

Effectiveness of isoniazid preventive treatment among patients on antiretroviral treatment in Southeast Nigeria: A retrospective cohort study

Introduction: Isoniazid preventive treatment has been shown to reduce the risk of developing tuberculosis (TB) among HIV patients. It is, however, not clear if receiving a 6-month course of isoniazid preventive treatment (IPT) confers additional protection among HIV patients already on ART. We compared the incidence of TB among adult HIV patients on ART who had received IPT for 6 months with those who had not received IPT and identified factors associated with the development of TB to in our operational context.