Commencement Of Antiretroviral Therapy Research Articles

Ocular and Adnexal Diseases in Human Immunodeficiency Virus-Infected Pregnant Women Attending HIV Clinics in Ibadan, Nigeria

Abstract Background: Human immunodeficiency virus (HIV) is a lentivirus. It is transmitted through sexual intercourse, shared intravenous drugs, contaminated needle use, blood transfusion, and mother-to-child transmission. Of the patients with HIV, 50%–75% have ocular manifestations and this may be the primary presentation. This study was carried out in two prevention of mother-to-child transmission (PMTCT)/HIV clinics. The aim was to determine the incidence, patterns of presentation, and determinants of ocular and adnexal diseases in HIV-positive pregnant women attending HIV clinics to develop an eye care protocol for them. Materials and Methods: The study was a cross-sectional study of HIV-positive pregnant women attending the PMTCT/HIV Clinics at University College Hospital and Adeoyo Maternity Teaching Hospital, Ibadan. Patients were interviewed using a structured questionnaire. Blood samples were taken for CD4+ count and viral load. The stage of the disease, type of antiretroviral therapy (ART), and the interval between HIV diagnosis and commencement of ART were recorded. Comprehensive ocular examination, which included visual acuity check unaided and with pinhole, lid, anterior segment examination with slit lamp and posterior segment examination with dilated binocular indirect ophthalmoscopy, was conducted. Statistical Package for Social Sciences version 23 was used to analyse the data. Results: A total of 153 pregnant women aged 23–42 years (mean, 33.5; standard deviation, ±5.6) were recruited. One hundred and fifteen (75.2%) of them were married in a monogamous setting. Multiple sexual partners (48.4%; n = 74—some women married in monogamous settings at the time of recruitment for this study had multiple sexual partners in the past) and the use of unsterilised objects (46.4%; n = 71) were major high-risk behaviours. Ocular and adnexal diseases were found in 81 (53%) participants. HIV-related ocular and adnexal diseases were found in 16 (10%) participants. Of the 16 HIV-related diseases, optic atrophy was found in seven (43.8%), presumed toxoplasmosis in three (18.7%), presumed cytomegalovirus retinitis in three (18.7%) lid warts in two (12.5%), and conjunctival microangiopathy in one (6.3%) participant. The association between HIV- related ocular and adnexal diseases and gestational age, CD4+ count, viral load and type of ART was not statistically significant. Conclusion: The few HIV-related findings in this study could be a result of the improved CD+ count/low viral load of most of the recruited participants. Ensuring that patients attending PMTCT/HIV clinic have at least one ocular examination during pregnancy by collaborating with eyecare professionals could ensure prompt detection and treatment of eye diseases, to improve the quality of life of HIV-positive pregnant women.

Predictors of tuberculosis treatment outcomes among people living with HIV in some States in Nigeria.

tuberculosis (TB) and Human Immunodeficiency Virus (HIV) remain major public health threats globally and worse when they co-exist in susceptible individuals. The study examined TB treatment outcomes and their predictive factors among people living with HIV (PLHIVs). a review of TB/HIV co-infected patients who had TB treatments across comprehensive antiretroviral therapy (ART) sites with ≥500 patients was conducted in seven United States of America President's Emergency Plan for AIDS Relief (PEPFAR)-supported States in Nigeria. Data on patient background, HIV and TB care, and TB treatment outcomes were collected using an Excel abstraction template. The data was analyzed using SPSS and an association was examined using a chi-square test while binary logistic regression was used to determine predictors of TB treatment outcomes (P< 0.05). two thousand six hundred and fifty-two co-infected patients participated in the study. The mean age of participants was 37 ± 14 years. A majority had TB treatment success (cured = 1059 (39.9%), completed = 1186 (44.7%)). Participants who had pulmonary TB, virally suppressed and commenced isoniazid (INH) before TB diagnosis were more likely to have a favorable TB treatment outcome compared to those who had extrapulmonary TB (AOR = 7.110, 95% CI = 1.506 - 33.565), virally unsuppressed (AOR = 1.677, 95% CI = 1.036 - 2.716) or did not commence INH before TB diagnosis (AOR = 1.486, 95% CI = 1.047 - 2.109). site of infection, immune status, exposure to ART, and INH prophylaxis were found to predict TB treatment outcomes among PLHIVs. Stakeholders should ensure early commencement of ART and INH prophylaxis for PLHIVs.

Demographic Distribution Pattern and Antiretroviral Therapy Status Among HIV Patients in Selected Tertiary Hospitals in Abeokuta, Ogun State

The occurrence of human immunodeficiency virus (HIV) in Nigeria is relatively high and compromised with low antiretroviral therapy (ART) coverage. The study aimed at investigating the effect of ART on the CD4 cell count among seropositive individuals. Blood samples of HIV patients visiting three referral hospitals in Abeokuta were collected and CD4 cell count determined via flow cytometry method. Socio-demographic data of patients were also collected and analyzed using STATA/IC. A total of 615 seropositive blood samples were collected from three hospitals. The female to male ratio was found to be 2:1 of which age bracket 20-40 years had the highest infective number (63.3%) among other age categories. There was higher HIV occurrence among the married (52%) than the single (26.8%), while those with primary or secondary education had the highest (42.4%) compared to tertiary education (36.7%) and no formal education (9.1%). The CD4 count of infected cases showed that 51.2% had CD4 count between 100-200 cells/µL with 5.2% above 200 cells/µL. Also only 47.3% of the total infected cases placed on ART had a mean CD4 cell count (132.1±4.23) higher than those not on ART (CD4 count = 98.67±3.56). As a way of effectively managing HIV in Ogun State and meeting the 2030 set goal of USAIDS there is need for more HIV screening for early commencement of ART towards suppressing viral load.

Assessment of the performance regarding confirmatory diagnosis and initiation of antiretroviral therapy under a modified national HIV testing algorithm and pay-for-performance program in Taiwan

BackgroundA pay-for-performance plan for rapid antiretroviral therapy (ART) commencement was initiated in 2018, while a modified testing algorithm offers immunochromatographic test (ICT) to replace Western blot (WB), and simultaneous testing with ICT and Nucleic Acid Amplification Test (NAAT) for HIV-positive sera was adopted in 2019 in Taiwan. MethodsSerum specimens collected from 1117 suspected or confirmed HIV infection cases in 2016–2019 were reassessed the performance of WB, ICT, and NAAT. We reviewed the medical records of 10,732 individuals diagnosed with HIV in 2015–2021 to determine the time from screening to confirmatory diagnosis, followed by ART commencement. ResultsAll 860 WB-positives were also positive by ICT and NAAT. The positive detection percentages were 37.0% by ICT and 51.4% by NAAT for 257 WB-indeterminate and -negative sera. The sensitivity for WB and ICT was 93.8% and 95.5%, respectively. In the people living with HIV (PLHIV) cohort, the median time from initial positive to confirmatory diagnosis decreased from 5 to 6 days before 2019 to 1 day in 2021. The median time from initial positive to ART initiation decreased from 37 days in 2015, 14 days in 2018, to 6 days in 2021. Compared to 2015–2017, the time to ART initiation was 91.48 days lower in 2018 (P < 0.001) and 100.66 days lower in 2019–2021 (P < 0.001) by the adjusted linear regression model. ConclusionA significant decrease in the time to ART initiation was observed after initiation of the pay-for-performance program and optimized testing algorithm in Taiwan.

Latency to initiation of antiretroviral therapy in people living with HIV in Japan

Rapid initiation of antiretroviral therapy (ART) in HIV infection is recommended because it increases care retention rate and reduces the time to viral suppression. In Japan, although ART initiation is delayed, there is little information on the latency to ART initiation (time from HIV diagnosis to ART initiation). The present study was designed to obtain information on the latency to ART initiation in individuals with 1) acute or recent HIV infection (ARH), and with 2) advanced HIV diseases. Questionnaires were sent to 379 regional AIDS facilities requesting information on the people living with HIV (PLWH) who visited their facilities during 2020. Among 1098 new PLWH visitors, 706 were treatment-naïve patients, including 111 (15.7%) with ARH and 304 (43.1%) with advanced HIV diseases. Among those with ARH, only 8.2% received rapid ART initiation (latency to ART <2 weeks) and the time from diagnosis to virological suppression was longer than 14 weeks in 40.4%. Among those with advanced HIV diseases, 36.2% received late ART initiation (latency to ART ≧6 weeks). Our data showed that only a small proportion of PLWH with ARH in Japan received rapid ART. Furthermore, in PLWH with advanced HIV diseases in Japan, current latency to ART seems too long, though the timing of ART commencement should be tailored according to the presence/lack of opportunistic infections and accessibility to medical care. Further investigation is required to identify barriers to rapid ART initiation in Japan.

Recent Updates in the Management of HIV Infection

Acquired immunodeficiency syndrome (AIDS) is a lethal disease caused by the dreaded pathogen, the human immunodeficiency virus (HIV). Fortunately, antiretroviral therapy (ART) distinctly reduces plasma viral load from the blood and thus mitigates HIV-associated morbidity and mortality. Further, ART also markedly reduces the risk of HIV transmission to sexual partners and infants. Consequently, antiretroviral therapy has converted HIV infection into a manageable chronic condition, with the expectation of life approaching that for people without HIV. However, lack of adherence to treatment results in the development of drug resistance as well as quickens disease development. Therefore, conditions that encourage adherence should be maximized before and after the commencement of antiretroviral therapy. Adverse effects, drug abuse, depression, socioeconomic status, low level of literacy, less social support, and interruptible access to medications are some of the reasons for poor adherence. Frequent monitoring, adequate counselling, and proper social protection help to improve treatment adherence.

Assessing renal impairment in treatment-naïve adolescents living with HIV commencing antiretroviral therapy in Zimbabwe.

People with HIV (PWH) are increasingly experiencing non-communicable complications, including renal impairment, which are associated with worse clinical outcomes. Limited information exists surrounding renal impairment in paediatric PWH, of which the majority live in sub-Saharan Africa, and further information is required to guide clinical practice. This study describes the prevalence of new or worsening renal impairment in adolescents commencing antiretroviral therapy (ART) in Zimbabwe and associated risk factors. Retrospective cohort study. Data were collected between January 2010 to January 2019 from the medical records of adolescents aged 12-17 years initiating ART at an outpatient HIV clinic in Zimbabwe. Renal function (estimated glomerular filtration rate, eGFR) was calculated using the Full Age Spectrum formula. Proteinuria was defined as a single urine dipstick score of ≥1+. Potential predictors of renal impairment at follow-up were assessed by logistical regression. Two hundred and sixty-six adolescents were included in analysis. Baseline renal impairment (eGFR < 90 ml/min/1.73 m 2 ) and proteinuria were present in 13% and 7% of the cohort, respectively. After a median of 4.1 years (interquartile range: 1.9-6.9) following ART commencement, mean eGFR increased by 10 ml/min/1.73 m 2 ( P < 0.01), and the prevalence of renal impairment decreased to 8% ( P < 0.01). Baseline renal impairment predicted renal impairment at follow-up (odds ratio [OR] 8.98; 95% confidence interval [CI] 2.81-28.68; P < 0.01). Proteinuria trended towards association with renal impairment at follow-up (OR 4.39; 95% CI 0.95-20.31; P = 0.06). Renal impairment is common in adolescent ART-naïve PWH, and baseline renal impairment is associated with longstanding renal impairment, whereas baseline proteinuria trended towards an association with longstanding renal impairment.

Evaluation of Apolipoprotein Profile in Hiv/Aids Subjects in Pre and Post 12 Months Antiretroviral Therapy Using 1.5 Mg/Ml Troponin Diagnostic Cut-Off for Myocardial Infarction in Nauth Nnewi, South Eastern Nigeria

Patients infected with HIV have an increased risk of developing heart disease. HIV causes Acquired Immune Deficiency Syndrome AIDS by invading the host cells and depleting the immune system. It has been reported that acute myocardial infarction might occur at 1.5 ng/ml troponin level. Information on cardiac status in HIV infected subjects in Nigeria is scanty. The aim is to evaluate the serum apolipoproteins in HIV subjects, in pre- and post- 12 months antiretroviral therapy (ART) using 1.5ng/ml troponin diagnostic cut-off for myocardial infarction. A total of 100 HIV subjects not on ART devoid of malaria co-infection were recruited in this study. Apolipoprotein parameters were re-classified based on 1.5 ng/ml troponin diagnostic cut-off for myocardial infection. 30 out of the 100 participants that were within 1.5 ng/ml troponin diagnostic cut-off for myocardial infection were followed up on commencement of ART for 12 months. Their blood samples were drawn at 3, 6, 9 and 12 months for some apolipoproteins and CD4 analyses using standard laboratory methods. The results showed that as months of antiretroviral therapy deepened or lengthened, the numbers of HIV positive subjects with values higher than the troponin diagnostic value reduces when compared with values before therapy (p&lt;0.05). Paired-wise comparison showed that there were significantly higher levels of CD4 counts, Apo A2, Apo C2, Apo E but lower levels ApoA1, Apo B and Apo C3 in symptomatic HIV individuals before ART when compared with values after therapy at p&lt;0.05 respectively. These lower levels ApoA1, Apo B and Apo C3 in symptomatic HIV individuals after therapy may indicate possible cardio- protective effect of the drug on the heart, which may connote immune recovery. The troponin values were significantly higher than the diagnostic cut off for acute myocardial infarction (AMI) studied amongst the group at p&lt;0.05 respectively. This may imply that AMI may occur at any group of study.

Bilateral symmetrical stress fractures of femoral neck in HIV patient: case report and brief review of literature

Osseous changes in HIV positive patients receiving ART are three times greater than in normal individuals. These changes include osteopaenia/osteoporosis, stress fractures, fragility fractures and osteonecrosis. On an average, bone mineral density reduces by 2-6% in the first 2 years after commencement of antiretroviral therapy. High risk for stress fractures is observed in these patients. In present article, we report a case of bilateral femoral neck stress fractures in a known HIV patient.

Predictors of renal impairment and proteinuria after commencement of antiretroviral therapy in a Zimbabwean HIV cohort.

Renal disease prevalence varies widely amongst reported cohorts of people living with HIV (PLWHIV) in sub-Saharan Africa. Renal function testing is not routine in those commencing antiretroviral therapy (ART) in the region, however. Further data on renal disease prevalence and the change associated with ART use are therefore needed. To explore changes in renal function and associated predictors after 1year of ART in an adult cohort of PLWHIV from Zimbabwe. A retrospective analysis of patients who attended the Newlands Clinic between January 2007 and September 2019. Eligible patients were aged ≥18years and had measures of serum creatinine at baseline and after 1year of ART. Predictors of renal function change were assessed by multiple linear regression. 1729 patients were eligible for inclusion. Median age was 36years (IQR 30-43) and 62.8% were female. After 1year of ART, the proportion of patients with an estimated glomerular filtration rate (eGFR) <60ml/min/1.732 did not significantly change (2.0% vs. 1.2%; p=0.094), but there was a decrease in the proportion of patients with proteinuria (11.0% vs. 5.6%; p<0.001). Hypertension (B=-6.43; 95% CI -8.97 to -3.89; p<0.001) and baseline proteinuria (B=-7.33; 95% CI -10.25 to -4.42; p<0.001) were negative predictors of change in eGFR from baseline, whereas diabetes status was not associated (p=0.476). Proteinuria was common, but its prevalence halved after 1year of ART. Screening for hypertension could be a simple way to identify patients at risk of renal function decline.

Frequency of CXCR3+ CD8+ T-Lymphocyte Subsets in Peripheral Blood Is Associated With the Risk of Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome Development in Advanced HIV Disease.

BackgroundTuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a clinical aggravation of TB symptoms observed among a fraction of HIV coinfected patients shortly after the start of antiretroviral therapy (ART). Of note, TB-IRIS is characterized by exacerbated inflammation and tissue damage that occurs in response to the elevated production of CD4+ T cell-derived IFN-γ. Nevertheless, the possible participation of CD8+ T cells in TB-IRIS development remains unclear.MethodsWe performed a comprehensive assessment of the composition of CD8+ T cell memory subsets and their association with circulating inflammation-related molecules in TB-HIV coinfected patients initiating ART.ResultsWe found that TB-IRIS individuals display higher frequencies of Antigen-experienced CD8+ T cells during the onset of IRIS and that the levels of these cells positively correlate with baseline mycobacterial smear grade. TB-IRIS individuals exhibited higher frequencies of effector memory and lower percentages of naïve CD8+ T cells than their Non-IRIS counterparts. In both TB-IRIS and Non-IRIS patients, ART commencement was associated with fewer significant correlations among memory CD8+ T cells and cells from other immune compartments. Networks analysis revealed distinct patterns of correlation between each memory subset with inflammatory cytokines suggesting different dynamics of CD8+ T cell memory subsets reconstitution. TB-IRIS patients displayed lower levels of memory cells positive for CXCR3 (a chemokine receptor that plays a role in trafficking activated CD8+ T cells to the tissues) than Non-IRIS individuals before and after ART. Furthermore, we found that CXCR3+ naïve CD8+ T cells were inversely associated with the risk of TB-IRIS development. On the other hand, we noticed that the frequencies of CXCR3+ effector CD8+ T cells were positively associated with the probability of TB-IRIS development.ConclusionOur data suggest that TB-IRIS individuals display a distinct profile of memory CD8+ T cell subsets reconstitution after ART initiation. Moreover, our data point to a differential association between the frequencies of CXCR3+ CD8+ T cells and the risk of TB-IRIS development. Collectively, our findings lend insights into the potential role of memory CD8+ T cells in TB-IRIS pathophysiology.

Duration on ART, Alcohol Use and HIV Stage May Predict Risky Sexual Behavior in a Resource-limited Environment: A Cross-sectional Study.

The intention of antiretroviral therapy (ART) and regular clinic visits are to engender safe sex attitudes among HIV-infected individuals. However, this may not be the case due to the perceived therapeutic benefits of ART and may result in exposure to drug-resistant HIV strains. We aimed to determine the prevalence and predict the factors associated with risky sexual behaviors among ART users in a resource-limited environment. Two hundred and ninety-one sexually active ART-users aged 18-50 years and seeking care at the HIV clinic in Dodoma, Tanzania, participated in this study. The outcome variables modeled in a logistic regression were condom use, multiple sex partners, casual sex partners, and payment for sex. The predictors included in the models were the patients' socio-demographic characteristics. In addition, a new variable, sexual risk scores, was generated by culminating all the outcome variables. Finally, a multiple Poisson regression with the socio-demographic variables of the participants was used to model the sexual risk scores. Patients reported inconsistent/no condom use (44%), payment for sex (4%), casual sex encounters (13%), multiple sex partners (21%), and STD symptoms (15%). While having a casual sexual partner was significantly associated with age group in a Pearson Chi-square (p=0.0147), participants ≤35 years old were less likely to have single-sex partners than older participants (AOR: 0.188, 95 C.I: 0.042-0.849). Meanwhile, the likelihood of condom use was higher among participants with no HIV-infected family members (AOR= 2.409, 95% C.I:1.236,4.697) and among participants who had single-sex partners (AOR= 2.721, 95% C.I.: 1.115,6.640); these participants were less likely to report STD symptoms (AOR=0.265, 95% C.I.: 0.081-0.865). Adjusted analysis showed that estimated mean sexual risk scores significantly increased (mean, λ=1.61, 95% C.I:1.0817-2.4063) for recent ART recipients (within 1-3 years vs. ≥8 years). However, sexual risk scores of participants with HIV stage 3 were 38.8% lower than participants at stage 4 (95% C.I.: 0.3910-0.9558), and non-alcohol drinkers had an adjusted mean sexual risk score of 29% lower than participants who were alcohol drinkers (95% C.I.: 0.5102-0.9879). Researchers should prioritize patients at HIV CTC for education concerning safe sexual practices for those characterized by alcohol consumption, younger age (less than 35 years old), HIV stage 4, or commencement of ART within three years.

Prevalence of Opportunistic Intestinal Parasitic Infections Among HIV/AIDS Patients Before and After Commencement of Antiretroviral Treatment at Felege Hiwot Referral Hospital: A Follow-up Study.

BackgroundCoccidian parasites are opportunistic intestinal parasites that cause diarrhea in immunocompromised individuals. Although the impacts of coccidian infection are significant among HIV/AIDS infected cases, proper diagnosis and management of coccidian infection is limited in sub-Saharan Africa including Ethiopia.ObjectiveThe aim of this study was to determine the prevalence of coccidian parasitic infections among HIV/AIDS cases before and after commencement of antiretroviral treatment.MethodsAn institution-based longitudinal study was conducted among 304 randomly selected HIV/AIDS cases from February to July 2018 before and after commencement of antiretroviral therapy. A structured questionnaire was used to collect sociodemographic and associated factors data. Stool and blood samples were collected before and three months after treatment. Coccidian detection and CD4+ count were conducted via modified acid fast stain technique and fluorescence-activated cell scanning, respectively. Data were entered and analyzed using SPSS version 20. Descriptive statistics were used to compute coccidian prevalence. Logistic regression was used to compute possible association between associated factors and coccidian parasitic infection. Variables with P<0.05 were considered to be statistically significant.ResultsAmong 304 HIV/AIDS cases, prevalence of coccidian parasitic infection before and after antiretroviral treatment was 23.4% and 8.9%, respectively. Prevalence of Cryptosporidium spp. (19.7%) and Isospora belli (4.3%) before antiretroviral treatment were higher than Cryptosporidium spp. (7.9%) and Isospora belli (1.0%) after treatment. Drinking unprotected water (AOR: 7.41; 95%CI: 1.64–33.45), poor knowledge of HIV/AIDS and coccidian parasite (AOR: 4.19; 95%CI: 1.69–10.40), and CD4+ count below 200 cells/mm3 (AOR: 62.49; 95%CI: 25.32–154.21) were significantly associated with coccidian infection.ConclusionPrevalence of coccidian parasites among HIV/AIDS cases decreases after antiretroviral treatment. Drinking unsafe water, limited knowledge of HIV/AIDS and coccidian parasite and low CD4+ cell count are factors associated with coccidian infection. Therefore, proper detection and treatment of coccidian parasites among HIV/AIDS cases should be prioritized.

Health care Providers' Perceptions About Overweight and Obesity Among People Living With Human Immunodeficiency Virus in Nigeria.

HIV infection was associated with significant weight loss before the advent of potent antiretroviral therapy (ART). Weight gain while on treatment was seen as a clinical indicator of treatment success. Perceptions of health care providers (HCPs) about obesity among people living with (PLHIV) were examined. We conducted 16 key informant interviews with HCPs in two states in southeastern Nigeria, which were then coded thematically. The respondents included seven physicians, four nurses, three adherence counselors, and two pharmacists. The analysis revealed three key themes: HCPs do not see excess weight gain as a problem; there are several challenges in managing obesity among PLHIV; and comorbidities play a role in the management of obesity among PLHIV. We conclude that obesity among PLHIV is an important clinical issue that HCPs need to address with the commencement of ART.

Treatment outcomes in HIV infected patients older than 50 years attending an HIV clinic in Harare, Zimbabwe: A cohort study.

There is a growing number of older people living with HIV (OPLHIV). While a significant proportion of this population are adults growing into old age with HIV, there are also new infections among OPLHIV. There is a lack of data describing the outcomes of OPLHIV who commenced antiretroviral therapy (ART) after the age of 50 years in sub-Saharan Africa. We conducted a cohort study of patients who enrolled in care at Newlands Clinic in Harare, Zimbabwe, at ages ≥50 years between February 2004 and March 2020. We examined demographic characteristics, attrition, viral suppression, immunological and clinical outcomes. Specifically, we described prevalent and incident HIV-related communicable and non-communicable comorbidities. We calculated frequencies, medians, interquartile ranges (IQR), and proportions; and used Cox proportional hazards models to identify risk factors associated with death. We included 420 (57% female) who commenced ART and were followed up for a median of 5.6 years (IQR 2.4-9.9). Most of the men were married (n = 152/179, 85%) whereas women were mostly widowed (n = 125/241, 51.9%). Forty per cent (n = 167) had WHO stage 3 or 4 conditions at ART baseline. Hypertension prevalence was 15% (n = 61) at baseline, and a further 27% (n = 112) had incident hypertension during follow-up. During follow-up, 300 (71%) were retained in care, 88 (21%) died, 17 (4%) were lost to follow-up, and 15 (4%) were transferred out. Of those in care, 283 (94%) had viral loads <50 copies/ml, and 10 had viral loads >1000 copies/ml. Seven patients (1.7%) were switched to second line ART during follow-up and none were switched to third-line. Higher baseline CD4 T-cell counts were protective against mortality (p = 0.001) while male sex (aHR: 2.29, 95%CI: 1.21-4.33), being unmarried (aHR: 2.06, 95%CI: 1.13-3.78), and being unemployed (aHR: 2.01, 95%CI: 1.2-3.37) were independent independent risk factors of mortality. There was high retention in care and virologic suppression in this cohort of OPLHIV. Hypertension was a common comorbidity. Being unmarried or unemployed were significant predictors of mortality highlighting the importance of sociologic factors among OPLHIV, while better immune competence at ART commencement was protective against mortality.

BK polyomavirus associated progressive multifocal leukoencephalopathy in a person living with HIV

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease of the white matter central nervous system occurring in immunocompromised patients particularly those with T cell deficiency such as in HIV, haematological and solid organ malignancies and those taking immunomodulatory medications. PML is caused by JC virus however in rare cases BK virus has been isolated in the cerebral spinal fluid of patients presenting with PML.In this case we describe a 49 year old man who presented to the emergency department with a 2 week history of progressive right sided weakness and dysarthria. His background history included HIV diagnosed in 2005, he had not engaged with care in the past 2 years and had not been taking anti-retroviral therapy (ART). Other past medical history included untreated hepatitis C. His CD4 count was 90 (11%) cells/mm3 on admission and his HIV viral load VL) was 141,000 copies/ml. Magnetic resonance imaging(MRI) showed a hypointense lesion on T1, hyperintense on T2 and FLAIR without diffusion restriction and without mass effect. A lumbar puncture was performed which confirmed JC virus was positive (PCR <50 copies/ml) and also revealed BK virus was positive (PCR 46,511 copies/ml). The patient was commenced on tenofovir alafenamide fumarate/emtricitabine/darunavir/cobicistat in combination with dolutegravir 50mg twice daily. On day 40 post commencement of ART the patient was readmitted with worsening of his right arm weakness and dysarthria. A repeat MRI was performed which showed the hyperdense lesion on T2 and FLAIR appeared slightly larger with some slight enhancement with gadolinium contrast but no other features suggesting PML immune reconstitution inflammatory syndrome (IRIS). The CD4 count had increased to 141(17%) and HIV VL had decreased to 85 copies/ml. A clinical diagnosis of PML IRIS was made and the patient was commenced on prednisolone 30mg BD which lead to an initial improvement in symptoms.Interestingly in this case, both JC virus and BK virus were detected in the CSF of this patient with the level of JC virus being too low to quantify. BK virus was not detectable on peripheral serum sampling suggesting that BK virus is replicating in the CNS independent of other body sites. There have been 5 case reports in the literature of BK virus as the cause of PML.Testing for BK virus should be considered in patients presenting with signs and symptoms of PML and encephalitis particularly when no other cause is found.

A nurse-led intervention to improve management of virological failure in public sector HIV clinics in Durban, South Africa: A pre- and post-implementation evaluation

Identification of patients on antiretroviral therapy (ART) with virological failure (VF) and the response in the public health sector remain significant challenges. We previously reported improvement in routine viral load (VL) monitoring after ART commencement through a health system-strengthening, nurse-led 'VL champion' programme as part of a multidisciplinary team in three public sector clinics in Durban, South Africa.To report on the impact of the VL champion model adapted to identify, support and co-ordinate the management of individuals with VF on first-line ART in a setting with limited electronic-based record capacity.We evaluated the VL champion model using a controlled before-after study design. A paper-based tool, the 'high VL register', was piloted under the supervision of the VL champion to improve data management, monitoring of counselling support, and enacting of clinical decisions. We abstracted chart and electronic data (TIER.net) for eligible individuals with VF in the year before and after implementation of the programme, and compared outcomes for individuals during these periods. Our primary outcome was successful completion of the VF pathway, defined as a repeat VL &lt;1 000 copies/mL or a change to second-line ART within 6 months of VF. In a secondary analysis, we assessed the completion of each step in the pathway.We identified 60 and 56 individuals in the pre-intervention and post-intervention periods, respectively, with VF who met the inclusion criteria. Sociodemographic and clinical characteristics were similar between the periods. Repeat VL testing was completed in 61.7% and 57.8% of individuals in these two groups, respectively. We found no difference in the proportion achieving our primary outcome in the pre- and post-intervention periods: 11/60 (18.3%; 95% confidence interval (CI) 9 - 28) and 15/56 (22.8%; 95% CI 15 - 38), respectively (p=0.28). In multivariable logistic regression models adjusted for potential confounding factors, individuals in the post-intervention period had a non-significant doubling of the odds of achieving the primary outcome (adjusted odds ratio 2.07; 95% CI 0.75 - 5.72). However, there was no difference in the rates of completion of each step along the first-line VF cascade of care.This enhanced intervention to improve VF in the public sector using a paper-based data management system failed to achieve significant improvements in first-line VF management over the standard of care. In addition to interventions that better address patient-centred factors that contribute to VF, we believe that there are substantial limitations to and staffing requirements involved in the ongoing utilisation of a paper-based tool. A prioritisation is needed to further expand and upgrade the electronic medical record system with capabilities for prompting staff regarding patients with missed visits and critical laboratory results demonstrating VF.

A Narrative Systematic Literature Review: A Focus on Qualitative Studies on HIV and Medication-Assisted Therapy in the United States.

Over the last two decades, the United States (U.S.) has experienced an opioid crisis that has had a significant negative societal and economic impact. Due to the high utilization of opioids in Persons Living with HIV and AIDS (PLWHA), there is a need for a qualitative literature review that presents opioid-use related problems in this population. This study aims to present and identify a thematic overview of the qualitative manuscripts on PLWHA who take opioid medications in the U.S., with a focus on perceptions surrounding medication assisted therapy. The systematic literature search was performed in December 2019. Four databases were searched: PubMed/MEDLINE, Scopus, Web of Science, and Cumulative Index to Nursing & Allied Health Literature (CINAHL). A total of 5348 results were exported from databases into EndNote x9, and duplicates were removed for a total of 3039 unique abstracts to screen. The records were imported into Rayyan, an online platform designed to expedite the screening process. Three authors screened titles and abstracts and determined 19 articles that would be screened in full text. On 9 April 2020, it was determined that eight articles would be included for review. The analysis of the eight manuscripts that fit the inclusion and exclusion criteria revealed barriers and facilitators to medication assisted therapy (MAT) in PLWHA. This review communicates or describes the story of PLWHA who might have delayed access to HIV healthcare providers and the commencement of antiretroviral therapy. In the literature, several studies have focused on the role of physicians in prescribing and addressing the medication regimens but none of the studies examined the role of pharmacists in access to care in this population. Therefore, further research is needed for a better understanding of the social aspects of taking opioid medications in PLWHA and the role of pharmacists within the continuum of care.

The evolution and adoption of World Health Organization policy guidelines on antiretroviral therapy initiation in sub-Saharan Africa: A scoping review.

BackgroundDespite past and present global interventions, the human immunodeficiency virus (HIV) pandemic remains a public health problem in low- and middle-income countries (LMICs). The World Health Organization (WHO) has assisted these countries by providing antiretroviral therapy (ART) policies for adoption and adaptation to local needs.ObjectivesThis article describes the response of countries in sub-Saharan Africa (SSA), to the WHO’s changing CD4-threshold ART-initiation recommendations of the past two decades.MethodsRelevant articles published in international peer-reviewed journals were accessed via the following search engines: PubMed, Google Scholar, Cochrane, Embase and EBSCOhost. The study’s inclusion criteria were articles published in the English language between 2000 and 2019 that highlighted changes to the CD4 ART-initiation threshold and that focused on the WHO’s ‘commencement of ART’ policy guidelines. Sixteen studies (n = 16) from SSA were identified and included in this review: four are cross-sectional, four deal with cost-effectiveness, four are retrospective, one is a randomised trial and three are observational studies. Only studies conducted in SSA were assessed.ResultsFour themes emerged: (1) adoption of the WHO CD4-ART-initiation policy by SSA countries, (2) timely implementation of the changing guideline initiation policy in the region, (3) barriers and facilitators encountered in the implementation of the changing guidelines and (4) description of similarities in policy implementation at country level from 2002 to 2019. Regional studies – cross-sectional, observational, retrospective, cost-effectiveness and randomised have described greater access to ART in SSA. However, barriers remain. The most common barriers to the timely implementation of ‘new’ ART-initiation guidelines were economic constraints, drug stock-outs, delays in obtaining baseline blood-test results and staff shortages.ConclusionAlthough countries in SSA have adopted the WHO-ART-CD4 initiation-threshold policy guidelines, implementation has seldom occurred in a timely manner. Barriers have been identified. Whilst a small number of countries have implemented recommendations promptly, for many, the barriers still require to be overcome.

Characteristics of Graves Disease in HIV-Infected Patients on Antiretroviral Therapy

Objective: To demonstrate clinical and laboratory characteristics of Graves disease in human immunodeficiency virus (HIV)-infected patients on antiretroviral therapy (ART). Methods: This is a single-institution study. All HIV-infected Thai patients who were diagnosed with Graves disease following the initiation of ART between January, 2007, and June, 2018, were retrospectively enrolled. Results: Of the 24 subjects, the mean age was 39.6 ± 10 years at the time of Graves disease diagnosis. The male to female ratio was 1:1.2. Palpitation and weight loss were the most common clinical manifestations. Of the 6 patients (25%) with evidence of Graves orbitopathy, 1 had sight-threatening orbitopathy. Two patients also had other autoimmune diseases (vitiligo and psoriatic arthritis). The median CD4 cell counts at HIV and Graves disease diagnosis were 73.5 (interquartile range [IQR], 15.5 to 189.5) and 525 (IQR, 402.3 to 725) cells/μL, respectively. The median time from ART commencement of the last effective ART regimen to the development of Graves disease was 29.5 (IQR, 13.8 to 48) months with a mean CD4 cell count increment of 328.7 ± 174.9 cells/μL. The median duration of antithyroid therapy was 34.5 (IQR, 23.8 to 51.0) months. Thirteen patients (54.2%) received radioactive iodine ablation. Conclusion: Graves disease should be suspected in HIV-infected patients who present with palpitations and weight loss despite good immunologic response to ART. Awareness of this condition can lead to diagnosis and appropriate management. Unlike immune reconstitution disease associated with infection, Graves disease may develop many years after ART initiation. Abbreviations: AIDS = acquired immunodeficiency syndrome; ART = antiretroviral therapy; HIV = human immunodeficiency virus; IQR = interquartile range; IRD = immune restoration disease; T3 = triiodothyronine; T4 = thyroxine; TgAb = thyroglobulin antibody; TPOAb = thyroid peroxidase antibody; TRAb = thyrotropin receptor antibody; TSH = thyroid-stimulating hormone.