Antiretroviral Program Research Articles

Feasibility of Implementing a Low-Barrier Long-Acting Injectable Antiretroviral Program for HIV Treatment and Prevention for People Experiencing Homelessness.

Long-acting (LA) antiretrovirals may provide meaningful benefit to people who use drugs and people experiencing homelessness (PEH) who face disproportionate structural and psychosocial barriers in adhering to daily oral HIV antiretroviral therapy or pre-exposure prophylaxis (PrEP), but their use in these populations has not been studied. The Maria X. Martinez Health Resource Center is a low-barrier (eg, no appointment) community-based clinic serving San Francisco PEH. A multidisciplinary care model with robust monitoring and outreach support was developed to provide LA antiretroviral therapy (ART) and LA-PrEP to eligible patients experiencing difficulties adhering to oral antiretrovirals. Feasibility was assessed by evaluating the rates of HIV viremia and on-time injections among patients receiving LA antiretrovirals over the first 24 months of program implementation. Between November 2021 and November 2023, 33 patients initiated LA-ART or LA-PrEP (median age, 37 years; 27% transgender/nonbinary; 73% non-White; 27% street homeless; 52% sheltered homeless; 30% with opioid use disorder; 82% with methamphetamine use disorder). Among 18 patients with HIV, 14 initiated LA-ART injections with detectable viremia (median CD4 count, 340 cells/mm 3 ; mean log 10 viral load, 3.53; SD, 1.62), 8 had never previously been virally suppressed, and all but 1 achieved or maintained virologic suppression (mean, 9.67 months; SD, 8.30). Among 15 LA-PrEP patients, all remained HIV negative (mean, 4.73 months; SD, 2.89). Of 224 total injections administered, 8% were delayed >7 days. The implementation of LA antiretrovirals is feasible in low-barrier, highly supportive clinical settings serving vulnerable PEH. Expansion of such programs will be critical in ending the HIV epidemic.

Lessons learned from U.S. rapid antiretroviral therapy initiation programs.

Rapid antiretroviral therapy initiation (R-ART) for treatment of HIV has been recommended since 2017, however it has not been adopted widely across the US. The study purpose was to understand facilitators and barriers to R-ART implementation in the U.S. This was a qualitative design involving semi-structured interviews. The study sample was comprised of the medical leadership of nine US HIV clinics that were early implementers of R-ART. In-depth, semi-structured interviews were performed. The Consolidated Framework for Implementation Research (CFIR) was used to guide thematic analysis. We identified three main content areas: strong scientific rationale for R-ART, buy-in from multiple key stakeholders, and the condensed timeline of R-ART. The CFIR construct of Evidence Strength and Quality was cited as an important factor in R-ART implementation. Buy-in from key stakeholders and immediate access to medications ensured the success of R-ART implementation. Patient acceptance of the condensed timeline for ART initiation was facilitated when presented in a patient-centered manner, including empathetic communication and addressing other patient needs concurrently. The condensed timeline of R-ART presented logistical challenges and opportunities for the development of intense patient-provider relationships. Results from the analysis showed that R-ART implementation should address the following: 1) logistical planning to implement HIV treatment with a condensed timeline 2) patients' mixed reactions to a new HIV diagnosis and 3) the high cost of HIV medications.

Long‐term usage patterns and clinical outcomes in a community‐based differentiated antiretroviral therapy delivery programme in South Africa

AbstractIntroductionThere is little data on long‐term implementation and outcomes for people living with HIV (PLHIV) in differentiated antiretroviral therapy (ART) delivery programmes. We aimed to analyse usage patterns of and associated treatment outcomes in a community ART programme, within the Centralized Chronic Medicines Dispensing and Distribution programme, in South Africa over 3.5 years.MethodsWe performed a retrospective cohort study among PLHIV on first‐line ART who were eligible for community ART delivery between October 2016 and March 2019, from 56 urban clinics in KwaZulu‐Natal, South Africa. Follow‐up ended in March 2020. We measured referral rates and, among those referred, we characterized patterns of community ART usage using group‐based trajectory modelling following referral. We used survival analysis to measure the association between community ART usage and loss‐to‐care (no visit for ≥365 days) and logistic regression to measure the association between community ART usage and viraemia (≥50 copies/ml).ResultsAmong the 80,801 patients eligible for community ART, the median age was 36 years, 69.8% were female and the median (interquartile range [IQR]) follow‐up time was 22 (13–31) months. In total, 49,961 (61.8%) were referred after a median of 6 (IQR 2–13) months from first eligibility. After referral, time spent in community ART varied; 42% remained consistently in community ART, 15% returned to consistent clinic‐based care and the remaining 43% oscillated between community ART and clinic‐based care. Following referral, the incidence of loss‐to‐care was 3.93 (95% confidence interval [CI]: 3.71–4.15) per 100 person‐years during periods of community ART usage compared to 5.75 (95% CI: 5.28–6.25) during clinic‐based care. In multivariable models, community ART usage was associated with a 36% reduction in the hazards of loss‐to‐care (adjusted hazard ratio: 0.64 [95% CI: 0.57–0.72]). The proportion of patients who became viraemic after first community ART referral was 5.2% and a 10% increase in time in community ART was associated with a 3% reduction in odds of viraemia (adjusted odds ratio: 0.97 [95% CI: 0.95–0.99]).ConclusionsCommunity ART usage patterns vary considerably, while clinical outcomes were good. Promoting consistent community ART usage may reduce clinic burden and the likelihood of patients being lost to care, while sustaining viral suppression.

Pharmacist-Involved Antiretroviral Stewardship Programs in People Living with HIV/AIDS: A Systematic Review.

People living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS; PLWHA) frequently encounter antiretroviral (ARV) therapy-related problems. Clinical pharmacists with specialized training in ARV stewardship play an important role in managing these problems. However, there is a paucity of evidence to clarify the impact of clinical pharmacists' interventions on managing ARV therapy-related problems in PLWHA. Therefore, we aim to systematically review the literature to determine the nature and impact of pharmacists' interventions on managing medication-related problems in PLWHA. The review protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO; CRD42020173078). Relevant records were identified from six electronic bibliographic databases (PubMed, Embase, EBSCOhost, ProQuest, Scopus, and the Cochrane Central Register) from their inception until September 2022. We included all randomized and nonrandomized interventional studies that were published in English. After the abstract and full-text screening, data were extracted from the selected studies, and the quality of the studies was assessed. The electronic database search and citation tracking identified two thousand and three citations. The review included 21 of these studies, involving 2998 PLWHA, published between 2014 and 2022. Pharmacists' interventions, working alone or in a multi-disciplinary team, comprised ARV medication review, management of adverse drug reactions (ADRs), therapeutic drug monitoring, prevention of drug interactions, and provision of drug information to PLWHA or the health care team. The pharmacist-involved interventions significantly reduced incorrect/incomplete ARV regimens, drug interactions, incorrect dosages, duplicate therapy, polypharmacy, administration errors, missing medication, wrong formulation, ADRs, and prescribing errors. Most studies reported that physicians usually accept more than 90% of the pharmacists' recommendations. ARV medication-related problems remain highly prevalent in PLWHA. Pharmacist-led interventions and stewardship significantly reduce ARV therapy-related problems in PLWHA and are widely accepted by physicians. Dedicated pharmacists with specialized training and credentialing in infectious diseases or HIV/AIDS have a great potential to improve health outcomes in PLWHA.

The LEAP Process: Streamlining the Development of Long-Acting Products and Formulations for Infectious Diseases.

Developing long-acting products and formulations for infectious diseases is a nontrivial undertaking that is frequently classified as high risk and low reward by the pharmaceutical industry. The Long-Acting/Extended Release Antiretroviral Research Resource Program (LEAP) was founded in 2015 with the support of the National Institutes of Health to encourage, promote, and accelerate the development of such products. Assessment methodology for any new proposal brought to this group is part of a framework-the LEAP Process-that includes a landscape analysis of what is currently available in the public domain. This is followed by in silico modeling and simulation offered as a service to the relevant scientific community. A variety of preclinical and clinical outcome metrics are applied to each new agent as part of a continuous feedback loop to improve product characteristics. This allows us to catalog knowledge gaps and barriers that can be addressed by engaged stakeholders. Results are communicated in scientific articles, reviews, and position papers. This undertaking serves to de-risk discovery, development, and implementation by bridging the gaps between academic, regulatory, and industrial investigators, and by engaging those in the community who will be the eventual users of these medicines. The LEAP Process has supported formulations now approved for human immunodeficiency virus, as well as products in clinical and preclinical development for tuberculosis and hepatitis viruses B and C.

INTERNAL FACTORS AFFECTING THE ADHERENCE OF ANTIRETROVIRAL (ARV) THERAPY OF PATIENTS WITH HIV/AIDS IN RSUD KOTA BOGOR

Antiretroviral (ARV), as the primary therapy, plays an essential role in preventing the risk of opportunistic infections and increasing the quality of life patients with HIV. The main purpose of the ARV program treatment affected the patient’s health behavior, namely the adherence to consuming ARV daily. This study tries to elaborate on some internal factors that can affect patient compliances to finishing ARV. The study was conducted at RSUD Kota Bogor on 94 patients. The variables were classifiedased on age group, gender, level of education, work history, and compliance status Furthermore, an analysis was carried out to determine the factors affecting ARV compliance. The study showed that there were 84.2% (16) males, 68.4% (13) aged > 25 y.o, 73.7% (14) with low education, and 57.9% (11) jobless patients with a low level of adherence. In summary, this study showed that internal factors, such as age, gender, education, and occupation, are descriptively related to the level of compliance as advice analytical study with other factors was needed.

"Some believe those who say they can cure it" perceived barriers to antiretroviral therapy for children living with HIV/AIDS: Qualitative exploration of caregivers experiences in tamale metropolis.

HIV/AIDS is now a chronic disease, as adherence to anti-retrovirals impacts positively on the quality as well as expectancy of life. However, there exist multifaceted barriers to treatments for which children are most disadvantaged. Since Ghana subscribed to the "treat all" policy less percentage (25.5%) of children (2-14 years) living with HIV/AIDS have been enrolled on the antiretroviral program compared to other categories of the population by 2019. At present no study has explored these barriers to children living with HIV/AIDS enrollment and adherence. This study aims to explore the perceived barriers of caregivers of children living with HIV/AIDS in the Tamale Metropolis. We used descriptive phenomenology to explore the phenomena. Caregivers were purposively selected and interviewed till information became repetitive at the ninth (9th) caregiver. A semi-structured interview guide was used to collect data through face-to-face in-depth interviews which were audio recorded. The interviews lasted an average of 47 minutes. Audio interviews were transcribed verbatim (English) and translated back-to-back (Daghani) before analysis was done manually according to Collaizi's seven-step approach. We used the Guba and Lincoln guidelines to ensure the rigour of the study and its findings. Results are presented in themes and supported with quotes. Six themes emerged from the analysis of the caregivers' transcripts; (1) denial of HIV/AID diagnosis, (2) stock-outs and privacy at the clinic, (3) busy schedule and poor support, (4) ignorance and alternative herbal cure, (5) stigma and discrimination, (6) transportation and distance. Perceived barriers are multi-dimensional and encountered by all PLWHA, especially children. These barriers could derail the gains of HIV/AIDS interventions among children. Adherence counselling among caregivers alongside campaigns among faith and herbal healers are of grave concern to reduce myths of cure.

Risk Factors of Syphilis and HIV/AIDS Coinfection

Background: Syphilis infection and HIV are major health problems worldwide. Both of these diseases can be transmitted through sexual contact, so often a person suffers from both diseases at the same time. Purpose: To describe the risk factors of syphilis and HIV/AIDS coinfection in the Infectious Disease Intermediate Treatment Unit (UPIPI) inpatient and outpatient ward of Dr. Soetomo General Academic Hospital in 2019. Methods: The study design used in this study is a retrospective descriptive study aimed at evaluating sexual and non-sexual factors that cause syphilis and HIV coinfection. The research population was patients in the inpatient and outpatient rooms of UPIPI RSUD Dr. Soetomo Surabaya for the January-December 2019 period. The sampling technique was sourced from secondary data, namely medical record data from the inpatient and outpatient rooms of UPIPI RSUD Dr. Soetomo Surabaya for the period January-December 2019. The data in this study were obtained from medical records and patient biodata. Result: Based on the calculation results, it is known that age group (P=0.022>0.05), and gender (P=0.024>0.05) had no effect on the risk of syphilis and HIV coinfection, while marital status (P=0.048<0.05), sexual orientation (P=0.048<0.05), transmission model (P=0.044<0.05), and type of work (P=0.046<0.05fected the risk of syphilis and HIV coinfection. Conclusion: People with HIV/AIDS are expected to be active in participating in programs that are needed by patients, such as antiretroviral (ARV) therapy assistance programs and counseling that will prolong the quality of life in various aspects of life, both physical, psychological and social aspects.

Individual and healthcare supply-related HIV transmission factors in HIV-positive patients enrolled in the antiretroviral treatment access program in the Centre and Littoral regions in Cameroon (ANRS-12288 EVOLCam survey).

Despite great progress in antiretroviral treatment (ART) access in recent decades, HIV incidence remains high in sub-Saharan Africa. We investigated the role of individual and healthcare supply-related factors in HIV transmission risk in HIV-positive adults enrolled in 19 HIV services in the Centre and Littoral regions of Cameroon. Factors associated with HIV transmission risk (defined as both unstable aviremia and inconsistent condom use with HIV-negative or unknown status partners) were identified using a multi-level logistic regression model. Besides socio-demographic and behavioral individual variables, the following four HIV-service profiles, identified using cluster analysis, were used in regression analyses as healthcare supply-related variables: 1) district services with large numbers of patients, almost all practicing task-shifting and not experiencing antiretroviral drugs (ARV) stock-outs (n = 4); 2) experienced and well-equipped national reference services, most practicing task-shifting and not experiencing ARV stock-outs (n = 5); 3) small district services with limited resources and activities, almost all experiencing ARV stock-outs (n = 6); 4) small district services with a wide range of activities and half not experiencing ARV stock-outs (n = 4). Of the 1372 patients (women 67%, median age [Interquartile]: 39 [33-44] years) reporting sexual activity in the previous 12 months, 39% [min-max across HIV services: 25%-63%] were at risk of transmitting HIV. The final model showed that being a woman (adjusted Odd Ratio [95% Confidence Interval], p-value: 2.13 [1.60-2.82], p<0.001), not having an economic activity (1.34 [1.05-1.72], p = 0.019), having at least two sexual partners (2.45 [1.83-3.29], p<0.001), reporting disease symptoms at HIV diagnosis (1.38 [1.08-1.75], p = 0.011), delayed ART initiation (1.32 [1.02-1.71], p = 0.034) and not being ART treated (2.28 [1.48-3.49], p<0.001) were all associated with HIV transmission risk. Conversely, longer time since HIV diagnosis was associated with a lower risk of transmitting HIV (0.96 [0.92-0.99] per one-year increase, p = 0.024). Patients followed in the third profile had a higher risk of transmitting HIV (1.71 [1.05-2.79], p = 0.031) than those in the first profile. Healthcare supply constraints, including limited resources and ARV supply chain deficiency may impact HIV transmission risk. To reduce HIV incidence, HIV services need adequate resources to relieve healthcare supply-related barriers and provide suitable support activities throughout the continuum of care.

Prevalence and the associated factors of hepatitis B and hepatitis C viral infections among HIV-positive individuals in same-day antiretroviral therapy initiation program in Bangkok, Thailand

BackgroundViral hepatitis is highly prevalent among people with HIV (PWH) and can lead to chronic liver complications. Thailand started universal hepatitis B vaccination at birth in 1992 and achieved over 95% coverage in 1999. We explored the prevalence of hepatitis B and C viral infections and the associated factors among PWH from same-day antiretroviral therapy (SDART) service at the Thai Red Cross Anonymous Clinic, Bangkok, Thailand.MethodsWe collected baseline characteristics from PWH enrolled in the SDART service between July 2017 and November 2019. Multivariable logistic regression was performed to determine factors associated with positive hepatitis B surface antigen (HBsAg) and hepatitis C antibody (anti-HCV).ResultsA total of 4011 newly diagnosed PWH who had HBsAg or anti-HCV results at baseline: 2941 men who have sex with men (MSM; 73.3%), 851 heterosexuals (21.2%), 215 transgender women (TGW; 5.4%), and 4 transgender men (0.1%). Median age was 27 years. Overall seroprevalence of HBsAg and anti-HCV were 6.0 and 4.1%, respectively. Subgroup prevalence were 6.2 and 4.7% among MSM, 4.6 and 2.4% among heterosexuals, and 9.3 and 3.7% among TGW, respectively. Factors associated with HBsAg positivity were being MSM, TGW, born before 1992, CD4 count < 200 cells/mm3, and alanine aminotransferase ≥ 62.5 U/L. Factors associated with anti-HCV positivity were being MSM, age > 30 years, alanine aminotransferase ≥ 62.5 U/L, creatinine clearance < 60 ml/min, and syphilis infection.ConclusionsAround 5–10% of newly diagnosed PWH in Bangkok had hepatitis B viral infection after 25 years of universal vaccination. Anti-HCV positivity was found in 4–5% of PWH who were MSM and TGW. As World Health Organization and Thailand national guidelines already support routine screening of hepatitis B and C viral infections in PWH and populations at increased risk of HIV including MSM and TGW, healthcare providers should reinforce this strategy and provide linkage to appropriate prevention and treatment interventions. Catch-up hepatitis B vaccination should be made available under national health coverage.

Analysis of Antiretroviral Drugs (ARV) Logistic Management in the Province of Sumatera Utara (Case Study: Regional Public Hospital Dr. Pirngadi Medan And Public Hospital HKBP Balige)

Good drug management including planning, procurement, storage, distribution, destruction, recording and reporting is one of the tasks of the North Sumatra Provincial Health Office and HIV Services in the Regency/City. The purpose of this study was to analyze the drug management of the Antiretroviral program drugs in 2019 and 2020 at the Pharmacy Warehouse of the Health Office of North Sumatra Province, the Pharmacy Installation of Pirngadi Hospital Medan, and Pharmacy Installation at HKBP Balige Hospital. The research was conducted in January-April 2021. This research is descriptive with quantitative data obtained retrospectively and concurrently, qualitative data obtained through observation and interviews with informants. The data obtained were analyzed using indicators and compared to standard research results. The results showed in the North Sumatra Provincial Health Office 5 indicators have not met the standards and 9 indicators have met the standards, in Pirngadi Hospital Medan 4 indicators have not met the standards and 8 indicators have met the standards, but have not done the process of planning drug needs, and in HKBP Balige Hospital there are no indicators that meet the standards and do not do the planning of drug needs. The conclusion of this study is drug planning at the North Sumatra Provincial Health Office using the consumption method of the previous period. Pirngadi Hospital Medan and HKBP Balige Hospital did not plan for drug needs. Drug distribution at the North Sumatra Provincial Health Office uses a decentralized system starting in 2020 from the previous centralized system. In Pirngadi Hospital Medan the system is decentralized, while at HKBP Balige Hospital the distribution system is centralized.

‘A Song is Not Just a Song’: Community Mobilisation and Psychosocial Healing in South Africa’s AIDS Crisis

ABSTRACT South Africa has the highest number of HIV infections in the world, with more than five million people receiving anti-retroviral (ARV) therapies (UNAIDS 2019). However, during the early stages of the epidemic, there was no provision for ARVs through the state-run public health system, effectively limiting access to life-saving drugs. In response, the AIDS activist group the Treatment Action Campaign (TAC) and their HIV positive choir, The Generics, were established to mobilise South African civil society towards pressuring the government into deploying a national ARV programme. This article analyses and compares three culturally significant songs that were appropriated by The Generics. The analyses are socially and historically contextualised by interview data with current and former TAC members. The article suggests that songs facilitated collective mourning and psychosocial healing at a time when HIV treatments were largely unavailable. They further provided a catalyst for mobilisation that was steeped in the recent history of racial oppression against a virus that affected a disproportionate number of black South Africans. By appropriating struggle songs for their cause, The Generics tapped into emotional reservoirs of resistance culture to propel their agenda of government accountability and access to HIV medication.

Does antiretroviral therapy alter the course of Parkinson's disease in people living with HIV?

South Africa has the world's largest antiretroviral programme which has resulted in an increase in life expectancy in persons living with HIV. Parkinson's disease (PD) is an age-related neurodegenerative disorder. No data has been published in this setting with regards to the interaction between PD and people infected with HIV. This was a retrospective study which matched two HIV non-infected PD patients to one HIV-infected patient with PD. Patients with secondary causes of Parkinsonism were excluded. Demographic, clinical and laboratory data were extracted from the charts. Hoehn and Yahr scale was used to assess PD severity. Twenty PD patients were recruited from 1 January 2008 to 31 October 2020 and were diagnosed with HIV for a median of 72 months. The median age at onset of PD was 52 years. All patients were on antiretroviral therapy. There were no statistically significant differences in the levodopa equivalent daily dose, clinical phenotype, impulse control disorders (ICDs) and frequency of a positive family history between the two groups. HIV-infected patients had a higher frequency of dopamine dysregulation syndrome. At the end of follow-up, 3 (15%) PLH-PD had moderate to severe PD compared to 16 (40%) of PD controls. The OR of having moderate to severe PD in HIV non-infected PD patients was 4. Persons living with HIV and Parkinson's disease present with PD symptoms at a younger age, progress slower to a severe stage and respond well to dopaminergic replacement therapy.

Individual and healthcare supply-related barriers to treatment initiation in HIV-positive patients enrolled in the Cameroonian antiretroviral treatment access programme.

Increasing demand for antiretroviral treatment (ART) together with a reduction in international funding during the last decade may jeopardize access to ART. Using data from a cross-sectional survey conducted in 2014 in 19 HIV services in the Centre and Littoral regions in Cameroon, we investigated the role of healthcare supply-related factors in time to ART initiation in HIV-positive patients eligible for ART at HIV diagnosis. HIV service profiles were built using cluster analysis. Factors associated with time to ART initiation were identified using a multilevel Cox model. The study population included 847 HIV-positive patients (women 72%, median age: 39 years). Median (interquartile range) time to ART initiation was 1.6 (0.5-4.3) months. Four HIV service profiles were identified: (1) small services with a limited staff practising partial task-shifting (n = 4); (2) experienced and well-equipped services practising task-shifting and involving HIV community-based organizations (n = 5); (3) small services with limited resources and activities (n = 6); (4) small services providing a large range of activities using task-shifting and involving HIV community-based organizations (n = 4). The multivariable model showed that HIV-positive patients over 39 years old [hazard ratio: 1.26 (95% confidence interval) (1.09-1.45), P = 0.002], those with disease symptoms [1.21 (1.04-1.41), P = 0.015] and those with hepatitis B co-infection [2.31 (1.15-4.66), P = 0.019] were all more likely to initiate ART early. However, patients in the first profile were less likely to initiate ART early [0.80 (0.65-0.99), P = 0.049] than those in the second profile, as were patients in the third profile [association only significant at the 10% level; 0.86 (0.72-1.02), P = 0.090]. Our findings provide a better understanding of the role played by healthcare supply-related factors in ART initiation. In HIV services with limited capacity, task-shifting and support from community-based organizations may improve treatment access. Additional funding is required to relieve healthcare supply-related barriers and achieve the goal of universal ART access.

The impact of the South African antiretroviral treatment programme on the age-standardised incidence rate of Kaposi sarcoma, 1999–2016: An interrupted time series analysis

ObjectiveThe objective of this study was to quantify the impact of the South African antiretroviral treatment programme on the age-standardised incidence rate of Kaposi sarcoma among black South African residents of all ages. MethodsWe performed an interrupted time series analysis using routinely collected, histologically confirmed surveillance data from the South African National Cancer Registry for the years 1999 to 2016. The analysis was performed using R statistical software. The total number of cases was 29,623 (12,475 females and 17,166 males). The background antiretroviral treatment coverage was less than 1% at the time that the antiretroviral programme was introduced and increased to over 50% in 2016. ResultsIn 1999, the age-standardised rates were 1.48 and 2.82 cases per 100,000 per year for black females and males, respectively. These rates increased to 5.52 and 7.46 in 2008 before declining. The antiretroviral treatment programme was started in 2004. Five years after 2008 (nine years after the antiretroviral programme was introduced), the predicted standardised rates were 58.3% and 50.3% lower for females and males, respectively, than what they would have been without the treatment programme. ConclusionIntroduction of the antiretroviral treatment programme was associated with a decrease of over 50% in the predicted age-standardised incidence rates of Kaposi sarcoma.

HIV-1 viral load testing in resource-limited settings: Challenges and solutions for specimen integrity.

HIV-1 viral load (VL) testing is a crucial element in providing an antiretroviral treatment monitoring program. The success of these programs depends on the availability and quality of the VL testing services. There are several pre-analytic factors which can affect the quality of VL testing. Many of the challenges faced by resource-limited countries result in a compromise of specimen integrity, thus limiting widespread access to VL monitoring. The various logistic and financial challenges that exist are not insurmountable and several innovative solutions currently exist to overcome these barriers to providing widespread VL testing. This review summarizes the VL testing challenges in resource-limited settings and provides an overview of potential solutions including testing dried blood spots, dried plasma spots, plasma separation cards and the use of point of care tests.

Antiretroviral Stewardship: A Review of Published Outcomes with Recommendations for Program Implementation.

Persons living with HIV (PLWHs) are at high risk for medication errors when hospitalized, but antiretroviral medications are not often evaluated by antimicrobial stewardship programs (ASPs) because they are not specifically discussed in the standards of practice. However, antiretroviral (ARV) stewardship programs (ARVSPs) have been shown to decrease medication error rates and improve other outcomes. The goal of this article is to review published literature on ARVSPs and provide guidance on key aspects of ARVSPs. A MEDLINE search using the term “antiretroviral stewardship” was conducted. Original research articles evaluating ARVSPs in hospitalized, adult PLWHs were included. Six original research articles evaluating unique inpatient ARVSPs met inclusion criteria. All 6 studies evaluating medication errors as the primary outcome found a significant reduction in errors in the postimplementation phase. Based on current standards for ASPs, we propose core elements for ARVSPs. Future organizational guidelines for antimicrobial stewardship should include official recommendations for ARV medications.

Evaluation of human immunodeficiency virus medication errors in a community hospital following the implementation of a pharmacist‐led antiretroviral stewardship program

AbstractIntroductionCombination antiretroviral therapy has greatly improved survivability in people living with human immunodeficiency virus (PLWH); however, medication‐related problems can attenuate virologic suppression and lead to therapeutic failure and drug resistance. The prevalence of antiretroviral (ARV) medication errors in hospitalized PLWH is highly variable, but it is clear that the potential for errors increases with the transition to inpatient care. Pharmacist‐led ARV stewardship programs in large, academic institutions have demonstrated reductions in ARV errors during hospitalizations, but the feasibility of such programs in smaller, community hospitals in the Deep South remains unclear.MethodsWe conducted a retrospective quasi‐experimental study of non‐pregnant, adult PLWH admitted to a community hospital between 2014 and 2018. The primary objective was to compare the percentage of admissions associated with a composite of ARV medication errors (inappropriate regimens, inaccurate dosing, delayed dosing, and major drug‐drug interactions [DDIs]) before and after implementation of an ARV stewardship program.ResultsThe percentage of admissions associated with the primary composite of ARV medication errors decreased by 70% between the pre‐intervention (56 [70%] of 80 admissions) and post‐intervention period (13 [21.3%] of 61 admissions). The percentage of admissions associated with inappropriate ART regimens, major DDIs, and multiple ARV errors all decreased by more than 80%. There was no significant difference in the percentage of admissions associated with renal, non‐renal, or delayed dosing errors despite an overall decrease in error frequency.DiscussionA significant reduction in ARV medication error rates comparable to those reported in similar studies conducted at large, academic institutions was observed. The impact of this innovative pharmacist‐led ARV stewardship program provides additional evidence of the effectiveness of such programs in community hospitals with modest personnel resources.

Lessons for test and treat in an antiretroviral programme after decentralisation in Uganda: a retrospective analysis of outcomes in public healthcare facilities within the Lablite project.

We describe the decentralisation of antiretroviral therapy (ART) alongside Option B+ roll-out in public healthcare facilities in the Lablite project in Uganda. Lessons learned will inform programmes now implementing universal test and treat (UTT). Routine data were retrospectively extracted from ART registers between October 2012 and March 2015 for all adults and children initiating ART at two primary care facilities (spokes) and their corresponding district hospitals (hubs) in northern and central Uganda. We describe ART initiation over time and retention and use of Cox models to explore risk factors for attrition due to mortality and loss to follow-up. Results from tracing of patients lost to follow-up were used to correct retention estimates. Of 2100 ART initiations, 1125 were in the north, including 944 (84%) at the hub and 181 (16%) at the spokes; children comprised 95 (10%) initiations at the hubs and 14 (8%) at the spokes. Corresponding numbers were 642 (66%) at the hub and 333 (34%) at the spokes in the central region (77 [12%] and 22 [7%], respectively, in children). Children <3y of age comprised the minority of initiations in children at all sites. Twenty-three percent of adult ART initiations at the north hub were Option B+ compared with 45% at the spokes (25% and 65%, respectively, in the central region). Proportions retained in care in the north hub at 6 and 12mo were 92% (95% CI 90 to 93) and 89% (895% CI 7 to 91), respectively. Corresponding corrected estimates in the north spokes were 87% (95% CI 78 to 93) and 82% (95% CI 72 to 89), respectively. In the central hub, corrected estimates were 84% (95% CI 80 to 87) and 78% (95% CI 74 to 82), and were 89% (95% CI 77.9 to 95.1) and 83% (95% CI 64.1 to 92.9) at the spokes, respectively. Among adults newly initiating ART, being older was independently associated with a lower risk of attrition (adjusted hazard ratio [aHR] 0.93 per 5y [95% CI 0.88 to 0.97]). Other independent risk factors included initiating with a tenofovir-based regimen vs zidovudine (aHR 0.60 [95% CI 0.46 to 0.77]), year of ART initiation (2013 aHR 1.55 [95% CI 1.21 to 1.97], ≥2014 aHR 1.41 [95% CI 1.06 to 1.87]) vs 2012, hub vs spoke (aHR 0.35 [95% CI 0.29 to 0.43]) and central vs north (aHR 2.28 [95% CI 1.86 to 2.81]). Independently, patient type was associated with retention. After ART decentralisation, people living with human immunodeficiency virus (HIV) were willing to initiate ART in rural primary care facilities. Retention on ART was variable across facilities and attrition was higher among some groups, including younger adults and women initiating ART during pregnancy/breastfeeding. Interventions to support these groups are required to optimise benefits of expanded access to HIV services under UTT.

Implications of the human immunodeficiency virus test and treat strategy on antiretroviral treatment uptake and retention outcomes in Cameroon

Background: Success of the human immunodeficiency virus (HIV) test-and-treat (T&amp;T) strategy requires high antiretroviral (ART) uptake and retention. However, low ART uptake and retention continue to be reported in ART programs. This study assessed ART uptake and retention outcomes of the HIV T&amp;T strategy in three HIV clinics in Cameroon.Methods: A retrospective chart review was done for 423 patients who initiated HIV care within a period of three months prior to the implementation of the HIV T&amp;T strategy, and for another 423 patients who initiated HIV care within a three-month period following the HIV T&amp;T strategy implementation. For each group, sociodemographic, ART uptake and retention data were collected. Chi square and Student T tests were used to test for differences proportions and means between the two groups at p &lt;0.05 and 95% confidence interval.Results: The mean ages (years) in the pre-T&amp;T and the T&amp;T groups were 39.73 and 39.72, and the proportion of female were 65.85% and 65.08% respectively. ART uptake proportion was higher amongst those enrolled under the T&amp;T strategy (98.08% vs 95.39%, p=0.02). A greater proportion of the patients in the T&amp;T group initiated ART within 2 weeks following HIV diagnosis (55.84% vs 48.17%, p=0.03). However, ART retention at 24th month was lower in the T&amp;T group (78.83% vs. 85.79%, p=0.01).Conclusions: The findings suggest that the T&amp;T strategy is associated with higher ART uptake, earlier ART initiation, and lower ART retention. This underscores a need for strategies to improve ART retention under the HIV T&amp;T guidelines.