HIV Disease Management Research Articles

A prospective evaluation of the diagnostic accuracy of the point-of-care VISITECT CD4 Advanced Disease test in seven countries.

CD4 measurement is pivotal in the management of advanced HIV disease. VISITECT® CD4 Advanced Disease (AccuBio Limited, Alva, UK; VISITECT) is an instrument-free, point-of-care, semi-quantitative test allowing visual identification of a CD4 ≤200 cells/µl, or >200 cells/µl from finger-prick or venous blood. As part of a diagnostic accuracy study of FUJIFILM SILVAMP TB LAM (clinicaltrials.gov: NCT04089423), people living with HIV of ≥18 years old were prospectively recruited in seven countries from outpatient departments if a tuberculosis symptom was present, and from inpatient departments. Participants provided venous blood for CD4 measurement using flow cytometry (reference standard) and finger-prick blood for VISITECT (index text), performed at point-of-care. Sensitivity, specificity, and positive and negative predictive values of VISITECT to determine a CD4 ≤200 cells/µl were evaluated. Among 1604 participants, the median flow cytometry CD4 was 367 (IQR 128-626) cells/µl and 521 (32.5%) had a CD4 ≤200 cells/µl. VISITECT sensitivity was 92.7% (483/521, 95% CI 90.1-94.7%) and specificity was 61.4% (665/1083, 95% CI 58.4-64.3%). For participants with a CD4 between 0-100, 101-200, 201-300, 301-500, and >500 cells/µl, VISITECT misclassified 4.5% (95% CI 2.5-7.2%), 12.5 (95% CI 8.0-18.2%), 74.1% (95% CI 67.0-80.5%), 48.0% (95% CI 42.5-53.6%), and 22.6% (95% CI 19.3-26.3%), respectively. VISITECT's sensitivity, but not specificity, met the World Health Organization's minimal sensitivity and specificity threshold of 80% for point-of-care CD4 tests. VISITECT's quality needs to be assessed and its accuracy optimized. VISITECT´s utility as CD4 triage test should be investigated.

Loss to Follow Up and Missing Clinical Information, a Challenge of Hiv Management Care In A Developing Country; a 14-Year Retrospective Analysis

Background: HIV/AIDS, a transmissible and deadly disease is now a chronic manageable disease. However, loss to follow-up (LTFU) is threatening its manageability by increasing the risk of drug resistance and transmission of resistant strains. Missing critical client information may not be random but predictive of LTFU. The study aims to determine the period prevalence, incidence rates, patterns, predictors and the predictive relationship of missing clinical information with LTFU in an HIV Treatment Program in a developing country. Methods: A 14-year retrospective analysis was conducted on routinely collected data validated using the Retention and Audit Determination Tool (RADET) from adult HIV clients who initiated treatment from 2008 to 2021 in the HIV treatment centre of Imo State University Teaching Hospital, Nigeria. LTFU was established when a client had not been seen at the clinic for at least 90 days after the last missed scheduled clinic appointment. Kaplan Meier (KM) curves, log-rank test and Cox proportional hazards regression analyses were used to determine the distributions of LTFU and predictors with the level of significance set at p≤ 0.05. Results: The 14-year period prevalence was 39.4% with an incidence rate of 13 new cases of loss to follow-up per 100 HIV clients per year. The majority of the HIV clients (59.3%) had at least one critical missing file information. LTFU were significantly more likely to occur in those aged less than 45 years old (aHR:1.38, p<0.001) who are males (aHR: 1.19, p=0.006), suspected or diagnosed with TB (aHR: 7.78, p<0.001) and weighing 70kg or less (aHR:1.79, p<0.001). Missing viral load information (aHR: 51.37 p<0.001) and missing HAART regimen line information (aHR: 8.44, p<0.001) were the most predictive of LTFU in the model. Conclusion: Though LTFU in HIV patients linked to treatment, appears to be reducing, it is still a significant threat in the management of HIV disease. Further reduction in LTFU could be achieved by institutionalizing biometric capture, improving HIV/TB services and training staff in HIV-enhanced adherence counselling services.

Management of advanced HIV disease in Africa

Management of advanced HIV disease in Africa

Psychometric Properties of the Korean Version of Self-Efficacy for HIV Disease Management Skills

This study evaluated the validity and reliability of Shively and colleagues' self-efficacy for HIV disease management skills (HIV-SE) among Korean participants. The original HIV-SE questionnaire, comprising 34 items, was translated into Korean using a translation and back-translation process. To enhance clarity and eliminate redundancy, the author and expert committee engaged in multiple discussions and integrated two items with similar meanings into a single item. Further, four HIV nurse experts tested content validity. Survey data were collected from 227 individuals diagnosed with HIV from five Korean hospitals. Construct validity was verified through confirmatory factor analysis. Criterion validity was evaluated using Pearson's correlation coefficients with the new general self-efficacy scale. Internal consistency reliability and test-retest were examined for reliability. The Korean version of HIV-SE (K-HIV-SE) comprises 33 items across six domains: "managing depression/mood," "managing medications," "managing symptoms," "communicating with a healthcare provider," "getting support/help," and "managing fatigue." The fitness of the modified model was acceptable (minimum value of the discrepancy function/degree of freedom = 2.49, root mean square error of approximation = .08, goodness-of-fit index = .76, adjusted goodness-of-fit index = .71, Tucker-Lewis index = .84, and comparative fit index = .86). The internal consistency reliability (Cronbach's α = .91) and test-retest reliability (intraclass correlation coefficient = .73) were good. The criterion validity of the K-HIV-SE was .59 (p < .001). This study suggests that the K-HIV-SE is useful for efficiently assessing self-efficacy for HIV disease management.

Twelve-year neurocognitive decline in HIV is associated with comorbidities, not age: a CHARTER study.

Modern antiretroviral therapy (ART) has increased longevity of people with HIV and shifted the age distribution of the HIV pandemic upward toward that of the general population. This positive development has also led to concerns about premature and/or accelerated neurocognitive and physical ageing due to the combined effects of chronic HIV, accumulating comorbidities, adverse effects or possible toxicities of ART and biological ageing. Here we present results of comprehensive assessments over 12 years of 402 people with HIV in the CNS HIV ART Effects Research (CHARTER) programme, who at follow-up were composed of younger (<60 years) and older (≥60 years) subgroups. Over the 12 years, ART use and viral suppression increased in both subgroups as did systemic and psychiatric comorbidities; participants in both subgroups also evidenced neurocognitive decline beyond what is expected in typical ageing. Contrary to expectations, all these adverse effects were comparable in the younger and older CHARTER subgroups, and unrelated to chronological age. Neurocognitive decline was unrelated to HIV disease or treatment characteristics but was significantly predicted by the presence of comorbid conditions, specifically diabetes, hypertension, chronic pulmonary disease, frailty, neuropathic pain, depression and lifetime history of cannabis use disorder. These results are not consistent with premature or accelerated neurocognitive ageing due to HIV itself but suggest important indirect effects of multiple, potentially treatable comorbidities that are more common among people with HIV than in the general population. Good medical management of HIV disease did not prevent these adverse outcomes, and increased attention to a range of comorbid conditions in people with HIV may be warranted in their care.

An Integrated Reporting Tool for Management of Hiv And Non-communicable Diseases for Primary Health Care Facilities in Limpopo Province, South Africa

Introduction:Reporting of a health programme such as integrated management of the Human Immunodeficiency Virus (HIV) and Non-communicable Diseases (NCDs) is essential for programme evaluation to improve patient clinical outcomes. It is a criterion that all services that are provided in primary health care facilities and hospitals are monitored, evaluated and reported according to the approved reporting tools and approved health indicators.Aim:This study aimed to develop a reporting tool to report the implementation of integrated management of HIV and NCDs in Limpopo Province, South Africa.Methodology:The South African National Indicators Data Sets (NIDS) were adopted and used to develop the integrated management of HIV and NCDs reporting tool. A Delphi technique was used to validate the developed reporting tool. Eight (8) HIV and NCDs programme experts participated in the review process to establish the validity of the developed tool.Results:Eight integrated HIV and NCDs data elements reporting tool were developed and reviewed by eight (8) programme experts. The tool was found to be relevant and useful and likely to be adopted by Limpopo province for implementation.Conclusion:This was the first integrated HIV and NCDs reporting tool to be developed for Nurse Initiated Management of Antiretroviral Therapy (NIMART) Nurses in Limpopo Province to serve as a basic reporting tool to improve the integrated management of HIV and NCDs including patient outcomes.

Chronic pain and substance use disorders among older sexual minority men living with HIV: Implications for HIV disease management across the HIV care continuum

ABSTRACT HIV continues to be a critical health issue for sexual minority men (SMM) in the USA. Chronic pain is common in individuals with HIV, including older SMM, and is associated with substance use behaviors. This cross-sectional study sought to address a gap in the literature by characterizing interrelationships among chronic pain, substance use disorders (SUDs), medication adherence, and engagement in HIV care among older (≥50) SMM living with HIV and chronic pain (N = 63). The unadjusted relationship between an opioid use disorder and pain indicated that participants with an opioid use disorder reported higher pain ratings than those without. Presence of alcohol use disorder was significantly associated with missed HIV-care appointments due to chronic pain or substance use, showing that individuals with an alcohol use disorder reported more missed appointments in the past year. Higher pain was significantly associated with the same missed appointments variable, such that those reporting higher pain ratings also reported more missed appointments in the past year. These findings provide preliminary evidence of the interrelationships among chronic pain, SUDs, and engagement in HIV care among older SMM living with HIV and suggest that pain management in this population might support fuller engagement in HIV care.

Implementation of WHO guidelines on management of advanced HIV disease and its impact among TB co-infected patients in Tanzania: a retrospective follow-up study

BackgroundThe commonest causes of mortality in people living with HIV (PLHIV) are preventable and the majority can be attributed to undiagnosed tuberculosis (TB). National HIV/AIDS control programs are encouraged to implement the WHO package of interventions to improve survival among PLHIV. We assessed the implementation of the WHO TB-related package of care for Advanced HIV Disease (AHD) and its impact on treatment outcomes among HIV/TB patients in Tanzania.MethodsA retrospective cohort study was employed among HIV/AIDS patients on antiretroviral therapy from 21 public health facilities in three regions (Dar es Salaam, Coastal, and Morogoro) of Tanzania. Patients enrolled in care between January 2013- June 2017 (before the introduction of the WHO guidelines) and July 2017-Sept 2018 (during the implementation of the guidelines) were recruited. Data abstraction was done from patient hospital files using a structured questionnaire uploaded on a tablet.ResultsData from 2624 patients records were collected. Overall, 50% of patients with HIV had AHD with 7.8% of these co-infected with TB. Among AHD participants, 58.3% were female, 80.7% were from urban areas and 40.0% visited care and treatment centres as self-referrals. Implementation of the WHO AHD package of care was very low, ranging from 0% for Urine LF-LAM test done among patients with symptoms and signs of TB to 39.7% AHD concurrent with TB patients whose ART initiation was deferred for 2 weeks. Overall, the Proportion of AHD patients diagnosed with TB was 4.8%, Of which sputum Xpert as the first test for TB diagnosis was 4.4%. Five patients (0.6%) were documented to have received IPT at enrolment. Tailored counselling to ensure optimal adherence to ART for viral suppression was given to 12.1%.AHD patients co-infected with TB were retained in care more before the introduction of WHO AHD guideline (82.1%) compared to the period after the introduction of the guideline (53.9%) (p = 0.008). Clinical failure at 6 months among AHD patients was 10.6% before the guideline and 11.4% after the guideline. Immunological failure was observed in 1 patient (9.1%) before the guideline and 1 patient (7.1%) after the guideline. After the introduction of the guideline, mortality was 5.9% and no mortality was observed before the guideline. All the differences were not statistically significant.ConclusionsImplementation of the TB related WHO packages of care for AHD is very low. Except for TB diagnosis, other parameters did not improve with the introduction of the guidelines. More research is recommended to ascertain the effectiveness of guidelines as well as an understanding of the mechanisms involved.

A profile of the Visitect® CD4 and Visitect® CD4 Advanced Disease for Management of People Living with HIV

ABSTRACT Introduction CD4 testing plays an important role in clinical management and epidemiological surveillance of HIV disease. Rapid, point-of-care (POC) CD4 tests can improve patients’ access to CD4 testing, enabling decentralisation of HIV services. Areas covered We conducted a profile review of the Visitect®CD4 and the Visitect®CD4 Advanced Disease (Omega Diagnostics, UK) – the two lateral flow, equipment-free POC CD4 tests which can be used to identify people with HIV who have CD4 of less than 350 and 200 cells/μl, respectively. Using published data from independent studies, we discussed the performance and utility of these tests, highlighting the advantages as well as their limitations. Expert opinion The tests are user-friendly, acceptable to healthcare workers, feasible to implement in primary healthcare settings and can provide reliable results for clinical decision-making. Hand-on training with pictorial instructions for use are needed to enhance test’s operator confidence in interpretation of test results. Quality assurance program should be in place to ensure the quality of testing. Development of a next generation test with a cut-off of 100-cells/μl is recommended to identify patients with advanced immunosuppression for initiation of prophylaxis to reduce HIV-related death. Operational research is also needed to identify cost-effective implementation strategies in real-world settings.

Advanced HIV disease management practices within inpatient medicine units at a referral hospital in Zambia: a retrospective chart review

BackgroundZambia recently achieved UNAIDS 90-90-90 treatment targets for HIV epidemic control; however, inpatient facilities continue to face a large burden of patients with advanced HIV disease and HIV-related mortality. Management of advanced HIV disease, following guidelines from outpatient settings, may be more difficult within complex inpatient settings. We evaluated adherence to HIV guidelines during hospitalization, including opportunistic infection (OI) screening, treatment, and prophylaxis.MethodsWe reviewed inpatient medical records of people living with HIV (PLHIV) admitted to the University Teaching Hospital in Lusaka, Zambia between December 1, 2018 and April 30, 2019. We collected data on patient demographics, antiretroviral therapy (ART), HIV biomarkers, and OI screening and treatment—including tuberculosis (TB), Cryptococcus, and OI prophylaxis with co-trimoxazole (CTX). Screening and treatment cascades were constructed based on the 2017 WHO Advanced HIV Guidelines.ResultsWe reviewed files from 200 charts of patients with advanced HIV disease; of these 92% (184/200) had been on ART previously; 58.1% (107/184) for more than 12 months. HIV viral load (VL) testing was uncommon but half of VL results were high. 39% (77/200) of patients had a documented CD4 count result. Of the 172 patients not on anti-TB treatment (ATT) on admission, TB diagnostic tests (either sputum Xpert MTB/RIF MTB/RIF or urine TB-LAM) were requested for 105 (61%) and resulted for 60 of the 105 (57%). Nine of the 14 patients (64%) with a positive lab result for TB died before results were available. Testing for Cryptococcosis was performed predominantly in patients with symptoms of meningitis. Urine TB-LAM testing was rarely performed.ConclusionsAt a referral hospital in Zambia, CD4 testing was inconsistent due to laboratory challenges and this reduced recognition of AHD and implementation of AHD guidelines. HIV programs can potentially reduce mortality and identify PLHIV with retention and adherence issues through strengthening inpatient activities, including reflex VL testing, TB-LAM and serum CrAg during hospitalization.

A public health value-based healthcare paradigm for HIV

BackgroundHIV patients face considerable acute and chronic healthcare needs and battling the HIV epidemic remains of the utmost importance. By focusing on health outcomes in relation to the cost of care, value-based healthcare (VBHC) proposes a strategy to optimize quality of care and cost-efficiency. Its implementation may provide an answer to the increasing pressure to optimize spending in healthcare while improving patient outcomes. This paper describes a pragmatic value-based healthcare framework for HIV care.MethodsA value-based HIV healthcare framework was developed during a series of roundtable discussions bringing together 16 clinical stakeholder representatives from the Belgian HIV reference centers and 2 VBHC specialists. Each round of discussions was focused on a central question translating a concept or idea to the next level of practical implementation: 1) how can VBHC principles be translated into value-based HIV care drivers; 2) how can these value-based HIV care divers be translated into value-based care objectives and activities; and 3) how can value-based HIV care objectives and activities be translated into value-based care indicators. Value drivers were linked to concrete objectives and activities using a logical framework approach. Finally, specific, measurable, and acceptable structure, process and outcomes indicators were defined to complement the framework.ResultsOur framework identifies 4 core value areas where HIV care would benefit most from improvements: Prevention, improvement of the cascade of care, providing patient-centered HIV care and sustaining a state-of-the-art HIV disease management context. These 4 core value areas were translated into 12 actionable core value objectives. For each objective, example activities were proposed. Indicators are suggested for each level of the framework (outcome indicators for value areas and objectives, process indicators for suggested activities).ConclusionsThis framework approach outlines how to define a patient- and public health centered value-based HIV care paradigm. It proposes how to translate core value drivers to practical objectives and activities and suggests defining indicators that can be used to track and improve the framework’s implementation in practice.

Nursing Recommendations for the Management of HIV and Hypertension in a rural Primary Health Care Setting, Eastern Cape, South Africa

South Africa has an increased number of people living with the human immunodeficiency virus (PLWH). In addition, older PLWH are prone to developing non-communicable diseases (NCDs) as co-morbid illnesses, in particular hypertension. South Africa is experiencing a dual burden of care, that being the co-morbidity of HIV and hypertension. The integration of HIV and non-communicable disease management is needed towards a synergised and comprehensive approach within primary health care (PHC) settings. This article presents nursing recommendations yielded by a descriptive phenomenological study on the management of HIV and hypertension in a rural PHC context. A qualitative research approach, using Husserl’s descriptive phenomenology, was employed, and data were gathered using semi-structured interviews. The interviews were conducted by the first author at Sakhisizwe sub-district clinics, Eastern Cape. Purposive sampling was used to select nine participants. Giorgi’s phenomenological steps underpinned data analysis. Six nursing recommendations were developed to support professional nurses in the management of the co-morbidity of HIV and hypertension: 1) disease-specific health education as opposed to generic health education; 2) utilisation of existing programmes on the integration and management of chronic illnesses; 3) creating social support platforms or spaces; 4) referral pathways; 5) surveillance and monitoring; and 6) management of disease-related stigma. Professional nurses working in PHC clinics have several guidelines to manage chronic illnesses. However, there are limited nursing recommendations on how to manage the co-morbidity of HIV and hypertension. This study focused on a smaller sample of nine participants, in one sub-district and in one district.

Exploring the Impacts of Alcohol and Other Drug Use on HIV Care Among Older African American Adults in Kentucky: A Constructivist Grounded Theory Study.

This grounded theory study examined the use of alcohol and other drugs (AOD) on the management of HIV disease among 27 older African Americans (≥50 years). Interview transcripts were analyzed using constructivist grounded theory analytic techniques. Participants reported facing (a) environmental impacts of AOD use and (b) discrimination from the health care system. The analysis revealed six phases of AOD use, occurring at various stages of the HIV care continuum: (a) linking AOD use as the cause of HIV diagnosis, (b) having AOD use facilitate denial of HIV, (c) experiencing problematic use as a barrier to care engagement, (d) "testing the waters," (e) relying on AIDS service organizations and medical providers, and (f) changing or maintaining patterns of AOD use to maintain engagement with care. Recommendations include assessing a patient's AOD use in relationship to the care continuum to evaluate patients' experiences and barriers within systems of care.

Disability, a priority area for health research in South Africa: an analysis of the burden of disease study 2017

Purpose Disabilities are increasing globally, which is attributed to the overall ageing of populations in affluent countries. This trend may differ in low and middle-income countries. This paper assesses the change over time in Years Lived with Disability (YLD) for South Africa and how this compares to regional and global trends. Materials and methods This secondary analysis of the Global Burden of Disease Study 2017 dataset describes the observed contribution of YLD to Disability-Adjusted Life Years (DALYs) per 100 000 people over the period 1990–2016, and forecast to 2030 using simple linear prediction. South African trends are compared to global and sub-Saharan African (SSA) trends to highlight the effect of HIV and policy implications. Results Globally, the contribution of YLD to DALYs has increased from ±21.7% in 1990 to ±34% by 2016, with high socio-demographic index countries having a higher contribution (49%). HIV, mental health, musculoskeletal, neurological, and sense organ disorders are the five main contributors to YLD in South Africa (54%). Removing the effects of HIV/AIDS and sexually transmitted infections on YLD, South Africa’s trend appears similar to the global trend, yet opposite to the SSA trend. Conclusion Our analysis shows there is a growing burden of disability in South Africa. Differences in trends with the regional and global patterns can be attributed to the high burden of HIV and non-communicable diseases in South Africa. Therefore, strategies are urgently needed to increase integration of disability and rehabilitation services into chronic HIV and non-communicable disease management. This calls for disability screening to identify functional limitations in routine data collection and case management. IMPLICATIONS FOR REHABILITATION South Africa has experienced an increase in disability prevalence over time. This requires strengthening of services such as mental health interventions, physiotherapy, optometry, and audiology, and linking major disease clusters, such as HIV and the NCDs, to rehabilitation services. The greatest contributors towards disability adjusted life years in South Africa are currently mental disorders (13.8%), HIV and sexually transmitted infections (11.8%), musculoskeletal disorders (10.4%), neurological disorders (8.2%), and sense organ diseases (7.5%). Routine data collection and case management needs to include disability screening to identify developing functional limitations.

Cd4 T-Lynphocyte count associated with patient infected with Typei &amp;Typeii HIV attending Malali clinic and maternity, Kaduna Kaduna - Nigeria

Background: More than 25 million people in developing countries are living with HIV infection. An enormous global effort is now underway to bring antiretroviral treatment to at least 2.5 million of those infected. While drug prices have dropped considerably, the cost and technical complexity of laboratory tests essential for the management of HIV disease, such as CD4 cell counts, remain prohibitive. New, simple, and affordable methods for measuring CD4 cells that can be implemented in resource-scarce settings are urgently needed [5, 6]. Methods and Findings: Here we describe the development of a prototype for a simple, rapid, and affordable method for counting CD4 lymphocytes. Microliter volumes of blood without further sample preparation are stained with fluorescent antibodies, captured on a membrane within a minimized flow cell and imaged through microscope optics with the type of charge-coupled device developed for digital camera technology [10]. An associated computer algorithm converts the raw digital image into absolute CD4 counts and CD4 percentages in real time. The accuracy of this prototype system was validated through testing in the United States and Botswana, and showed close agreement with standard flow cytometry (r = 0.95) over a range of absolute CD4 counts, and the ability to discriminate clinically relevant CD4 count thresholds with high sensitivity and specificity [1,4]

Correlates and Effects of Alcohol Use Expectancies Among Persons Living with HIV in Uganda.

Unhealthy alcohol use fuels difficulties with HIV disease management and potentiates secondary transmission of HIV but less is known about how these alcohol use expectancies may shape alcohol use behaviors, particularly in the presence of depressive symptomatology. In this paper, we utilize data from a prospective study of 208 people living with HIV in Southwest Uganda, to examine the correlates of alcohol use expectancies and their association with unhealthy alcohol use. Affective depressive symptoms were positively associated with alcohol use expectancies. Gender moderation was observed such that depression was more strongly associated with alcohol use expectancies among women. In unadjusted analyses, alcohol use expectancies were marginally associated with unhealthy alcohol use and this association was not significant in adjusted analyses. Findings underscore the need to strengthen screening for depression and alcohol use within HIV care services, particularly among women.

Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries

ObjectiveTo determine whether Treat-All policy impacted laboratory testing practices of antiretroviral therapy (ART) programs in Southern Africa. Study Design and SettingWe used HIV cohort data from Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in a regression discontinuity design to estimate changes in pre-ART CD4 testing and viral load monitoring following national Treat-all adoption that occurred during 2016 to 2017. This study included more than 230,000 ART-naïve people living with HIV (PLHIV) aged five years or older who started ART within two years of national Treat-All adoption. ResultsWe found pre-ART CD4 testing decreased following adoption of Treat-All recommendations in Malawi (-21.4 percentage points (pp), 95% confidence interval, CI: -26.8, -16.0) and in Mozambique (-8.8pp, 95% CI: -14.9, -2.8), but increased in Zambia (+2.7pp, 95% CI: +0.4, +5.1). Treat-All policy had no effect on viral load monitoring, except among females in South Africa (+7.1pp, 95% CI: +1.1, +13.0). ConclusionTreat-All policy expanded ART eligibility, but led to reductions in pre-ART CD4 testing in some countries that may weaken advanced HIV disease management. Continued and expanded support of CD4 and viral load laboratory capacity is needed to further improve treatment successes and allow for uniform evaluation of ART implementation across Southern Africa.

Prevalence of Advanced HIV Disease, Cryptococcal Antigenemia, and Suboptimal Clinical Outcomes Among Those Enrolled in Care in Vietnam.

Background:People living with advanced HIV disease are at high risk of morbidity and mortality. We assessed the prevalence of cryptococcal antigenemia (CrAg) and clinical outcomes among patients newly presenting with CD4 ≤100 cells/μL in Vietnam.Setting:Twenty-two public HIV clinics in Vietnam.Methods:During August 2015–March 2017, antiretroviral therapy (ART)-naïve adults presenting for care with CD4 ≤100 cells/μL were screened for CrAg. Those who consented to study enrollment were followed up for up to 12 months and assessed for clinical outcomes.Results:Of 3504 patients with CD4 results, 1354 (38.6%) had CD4 ≤100 cells/μL, of whom 1177 (86.9%) enrolled in the study. The median age was 35 years (interquartile range 30–40); 872 (74.1%) of them were men, and 892 (75.8%) had CD4 <50 cells/μL. Thirty-six patients (3.1%) were CrAg-positive. Overall, 1151 (97.8%) including all who were CrAg-positive initiated ART. Of 881 patients (76.5%) followed up for ≥12 months, 623 (70.7%) were still alive and on ART at 12 months, 54 (6.1%) had transferred to nonstudy clinics, 86 (9.8%) were lost to follow-up, and 104 (11.8%) had died. Among all 1177 study participants, 143 (12.1%) died, most of them (123, 86.0%) before or within 6 months of enrollment. Twenty-seven patients (18.9%) died of pulmonary tuberculosis, 23 (16.1%) died of extrapulmonary tuberculosis, 8 (5.6%) died of Talaromyces marneffei infection, and 6 (4.2%) died of opioid overdose. Eight deaths (5.8%) occurred among the 36 CrAg-positive individuals.Conclusions:Late presentation for HIV care was common. The high mortality after entry in care calls for strengthening of the management of advanced HIV disease.

Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique.

IntroductionAIDS‐mortality remains unacceptably high in sub‐Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact‐tracing intervention (Xpatial‐TB). The aim was to assess the burden of AHD among high‐risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO‐recommended package of care to this population.MethodsAll PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial‐TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB‐lipoarabinomannan (TB‐LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow‐up visits carried out under routine programmatic conditions for six months.ResultsA total of 2881 adults were identified in the Xpatial TB‐contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB‐contacts) consented to the study and were screened for AHD. Seventy percent of TB index‐patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum‐CrAg was positive in 4.6% (4/87) of TB‐index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six‐month mortality was 21% among TB‐index cases and zero in TB contacts.ConclusionsA TB contact‐tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO‐recommended package of care in this rural Mozambican population. Same‐day and accelerated ART initiation was feasible and safe in this population including among those with AHD.

#3029 HIV-associated neurocognitive disorder: an investigation using structural neuroimaging in a c-ART treated tanzanian cohort

BackgroundThere is a newly emergent ageing population of people living with HIV (PLWH) in Africa. However, there is little research into HIV-associated neurocognitive disorder (HAND) in this population. Existing research suggests HAND is prevalent however the aetiology remains unclear. This study aims to determine whether HAND is truly prevalent and explore potential causes in PLWH on c-ART using objective structural measures.AimsExplore whether substantial atrophy and/or white matter hyperintensities (WMH) is present on the clinical magnetic resonance imaging (MRI) reports and quantitative analysis of people with optimally managed HIV in Northern Tanzania.Explore the aetiology of HAND by assessing whether cerebral atrophy and/or WMH is associated with demographic risk factors, HIV–related factors and/or comorbidities.Investigate whether structural damage is related to objectively measured cognitive impairment, and whether this is a subcortical or cortical impairment.Explore which neurocognitive test is the best predictor of structural damage and therefore most valid diagnostic test for HAND.MethodsA systematic sample of PLWH aged ≥ 50 were recruited from a HIV clinic in Kilimanjaro, Tanzania. Demographic data and comorbidities were self-reported. HIV-disease management data were obtained. Viral load and CD4 count were measured. A neurocognitive battery and informant history of functional impairment identified HAND. Cerebral atrophy (brain and ventricle volume) and WMH were measured using quantitative analysis of 1.5T MRI.Preliminary resultsThis cohort (n=91) had well-managed HIV (75.9% suppressed viral load, median CD4 507 cells/ul). The significant independent predictor (IP) of decreased brain volume was older age at HIV diagnosis (p=.001), and of increased ventricle volume was increased age (p&lt;.0001), male gender (p&lt;.0001) and increased frailty (p&lt;.0001). The significant IPs of increased WMH volume were increased age (p&lt;.0001) and smoking (p=.021). Only memory impairment independently predicted all structural measures.ConclusionsThis is the first MRI study of older c-ART treated PLWH in Africa. Despite c-ART and good disease management, HAND was objectively prevalent and unrelated to measures of HIV. Cerebral atrophy and WMH were associated with factors of neurodegeneration. Cerebral atrophy was associated with male gender and age at diagnosis (legacy effect).