Large HIV Clinic Research Articles

Using national laboratory data to assess cumulative frequency of linkage after transfer to community-based HIV clinics in South Africa.

IntroductionChanges to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding have led to closures of non‐governmental HIV clinics with patient transfers to government‐funded clinics. We sought to determine the success of transfers in South Africa using a national data source.MethodsAll adults (≥18 years) on antiretroviral therapy (ART) who visited a single PEPFAR‐funded hospital‐based HIV clinic in Durban, South Africa from March to June 2012 were transferred to community‐based clinics. Previously, we matched patient records from the hospital‐based HIV clinic with National Health Laboratory Services (NHLS) Corporate Data Warehouse (CDW) data to estimate the proportion of patients with a CD4 count or viral load (VL) in the CDW during the year before transfer. As a proxy for retention in care, in this study we evaluated whether patients had a CD4 count or VL at another facility within approximately three years of transfer. Patients referred to a private doctor at transfer were excluded from the analysis. We assessed predictors (age, sex, CD4 count, VL status, ART duration and location of future care) of not having post‐transfer laboratory data using Cox proportional hazards models.ResultsOf the 3893 patients referred to a government facility at transfer, 41% were male and median age was 39 years (IQR 34 to 46). There was a post‐transfer CD4 count or VL from another facility for 23% of these individuals within six months, 44% within one year, 57% within two years and 61% within approximately three years. Male sex (aHR 1.20, 95% CI 1.10 to 1.31) and shorter duration on ART (<3 months, aHR 3.80, 95% CI 2.77 to 5.21; three months to one year, aHR 1.32, 95% CI 1.15 to 1.51, each compared with >1 year) were associated with not having a post‐transfer record.ConclusionsUsing data from the NHLS CDW, 61% of patients had evidence of a post‐transfer laboratory record at another facility within approximately three years after closure of a large South African HIV clinic. Males and those with shorter time on ART prior to transfer were at highest risk for lacking follow‐up laboratory data. As patients transfer care, national data sources can be used to evaluate long‐term patient care trajectories.

Acceptability of Cell and Gene Therapy for Curing HIV Infection Among People Living with HIV in the Northwestern United States: A Qualitative Study.

Multiple strategies to cure HIV infection are under investigation, including cell and gene therapy (C&GT) approaches. Research, and ultimately treatment, with these novel strategies will require patients' willingness to participate. To elicit the perspectives of people living with HIV specific to these novel approaches, we conducted 4 focus group discussions with a diverse group of 19 English-speaking men and women living with HIV in care at a large academic HIV clinic in the northwestern United States. Thematic analysis indicated participants expressed initial fear about C&GT research. They articulated specific concerns about risks, including analytical treatment interruptions, and thought only a person in desperate straits would participate. They voiced significant mistrust of research in general and believed there was already a cure from HIV that was being withheld from the poor. Overall, they were satisfied with their health and quality of life on antiretroviral therapy. These findings suggest the importance of community engagement and educational efforts about C&GT for HIV cure to ensure optimal collaborative partnerships.

190. Patterns of Retention In HIV Care And Factors Associated With Viral Suppression In Youth And Young Adults Age 18-30 With HIV In An Urban Practice

The burden of HIV-1 infection in the United States is disproportionately seen in youth and young adults. Retention in care and viral suppression are often used to measure outcomes and can be described in a stepwise manner, the care cascade. There may be a complex relationship between retention parameters and viral suppression. This study explored the risk factors for viral suppression based on retention status and characterized patterns and changes in retention status over time in youth and young adults. This study is a secondary analysis of data collected from a cohort of 137 youth and young adults age 18-30 years living with HIV who entered care between 2012-2014 at a large HIV clinic within an urban academic medical center in Baltimore, Maryland. Based on the outcome measures of viral suppression and retention in care over a two-year period, each individual was classified as Retained/Suppressed, Retained/Not Suppressed, Not Retained/Suppressed, Not Retained/Not Suppressed. Viral suppression was defined as HIV-1 RNA viral load of less than 200 copies/mL. We performed logistic regression to identify independent risk factors for not being virally suppressed in each of the retention groups. Retention status was also calculated after each year and the changes in status were assessed. Of the 118 individuals included in the analysis, 41 individuals were retained in care and 77 did not meet the retention measure. Among those retained in care, female gender was independently associated with not being virally suppressed (AOR, 13.3 [95% CI, 1.56-114.15]. In the group not retained in care, females (AOR=4.49, 95% CI, 1.14-17.86), individuals with CD4 count 200-349 cells/mm3 at entry (AOR=7.6, 95% CI, 1.30-45.41) and viral load at entry of ≥200 copies/mL (AOR=5.5, 95% CI, 1.13-26.47) had higher odds of not being virally suppressed. Overall, 35% (41/118) of individuals switched from retained to not retained after the first year and 6.7% (8/118) of individuals were not retained in the first year, but were in the second year. The relationship between retention in care and viral suppression is not linear and characteristics of those who are virally suppressed are different based on retention status. Understanding the characteristics of individuals with different patterns of engagement and suppression may help future programs in the design, implementation, and assessment of youth-targeted programs.

Low provider and staff self-care in a large safety-net HIV clinic in the Southern United States: Implications for the adoption of trauma-informed care

Objective:This mixed-methods needs assessment study examined self-care practices among providers, staff, and administrators at an HIV clinic and identified barriers and facilitators to strengthening self-care services in this setting.Methods:Surveys (n = 31) and qualitative interviews (n = 23) were conducted with staff, providers, and administrators at a large, safety-net HIV clinic.Results:Surveys indicated an overall absence of formal self-care services including resources to manage stress, opportunities to debrief, and formal mechanisms to voice concerns. Based on interviews with staff and providers, deficiencies in self-care services included support for dealing with complex patients, formal mechanisms for feedback, and time for self-care. Administrators recognized the need for more support, acknowledged that opportunities for employees to voice concerns were lacking, and felt that implementing multi-disciplinary team meetings could improve morale and reduce stress and burnout.Conclusion:This assessment revealed a need to enhance self-care in safety-net HIV services. Adoption of trauma-informed care, which includes activities to strengthen self-care, could reduce workplace burnout.

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

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

1493. Effect of HIV Status on Early Syphilis Treatment Response in the Era of Combination Antiretroviral Therapy

BackgroundRates of incident early syphilis are increasing and HIV-coinfection is common. Syphilis treatment for HIV-positive individuals does not differ from that of the general population, although data published prior to combination antiretroviral therapy (cART) suggest that HIV-infected persons may be less likely to achieve expected serologic responses to treatment (SRT).MethodsWe conducted a cohort study of early syphilis diagnosed in a large HIV clinic and a public sexually transmitted diseases (STD) clinic in San Diego. SRT was defined as a fourfold or greater decline in rapid plasma reagin (RPR) titer following syphilis treatment. We compared SRT at 6 and 12 months post-treatment between HIV-infected and HIV-uninfected persons.ResultsOf 1,239 early syphilis cases reviewed, 742 (61%) were included in the analysis. Reasons for exclusion included lack of follow-up RPR (n = 454), nonreactive RPR at syphilis diagnosis (n = 33), and incomplete data (n = 10). Of those analyzed, 533 (72%) were HIV-positive; 168 (23%) HIV-negative; HIV status was unknown for 41 (5%). Overall, 449 (60%) and 657 (89%) of analyzed cases achieved SRT 6 and 12 months after treatment, respectively. HIV-positive cases were less likely to achieve SRT at 12 months than HIV-negative cases (464/533 [87%] vs. 160/168 [95%], P = 0.003, Figure 1), as were early latent syphilis cases (285/348 [82%]) vs. primary (102/117 [92%]) and secondary syphilis (264/277 [94%]) (Table 1).Table 1.Serologic Response to Treatment by Syphilis Clinical StageSyphilis StageRPR Titer ResponsePrimary N = 117Secondary N = 277Early Latent N = 348 P-Value6 months post-treatment ≥4-fold decline70 (60%)177 (64%)202 (58%) <4-fold decline47 (40%)100 (36%)146 (42%)0.32312 months post-treatment ≥4-fold decline108 (92%)264 (95%)285 (82%) <4-fold decline9 (8%)13 (5%)63 (18%)<0.001 ConclusionIn this cohort of early syphilis cases, most achieved SRT within 12 months of treatment, but only 60% achieved SRT within 6 months. Significantly lower 12-month SRT responses were seen in HIV-positive compared with HIV-negative persons and in early latent compared with primary and secondary syphilis. The impact of cART use, viral suppression, and treatment choice on outcomes is being analyzed.Disclosures All authors: No reported disclosures.

538. Integrase Inhibitor-Based HAART Is Associated with Greater BMI Gains in Blacks, Hispanics, and Women

BackgroundWhile older protease inhibitors (PI) were more likely to lead to isolated central fat accumulation, progressive increases in generalized obesity in HIV-infected patients following HAART initiation have been observed with most modern regimens, with greater increases in body mass index (BMI) reported in women and with integrase inhibitors (INSTI) use. We sought to analyze changes in BMI following initiation of HAART in a large urban HIV clinic and identify predictors of BMI changes.MethodsAll patients initiating HAART at the clinic from 2009 to 2017 were included in the analysis. Exposure to HAART was defined as concurrent receipt of at least two nucleoside reverse transcriptase inhibitors (NRTI) plus at least one PI, non-nucleoside reverse transcriptase inhibitor (NNRTI) or INSTI. The effects of sex, race, and ethnicity on changes in BMI (kg/m2) per year on HAART were examined using mixed-effects random regression.ResultsAmong the 4,048 patients initiating HAART, 69% were male, 53% Black (B), 28% Hispanic (H), and 16% non-Hispanic Whites (NHW). Mean age was 46.3 years (SD 11.9) and mean BMI was 27.0 (6.4). Median follow-up time on HAART was 6.7 years. Cumulative exposure to NNRTI, PI, and INSTI-based HAART were 3,546, 6,184, and 3,090 person-years respectively. The BMI slope per year of HAART exposure by regimen type, sex, race, and ethnicity are presented in Table 1 and Figure 1. There was no significant interaction between sex and race/ethnicity on BMI. Proportion of overweight/obese (BMI ≥ 25) increased from 51% at HAART initiation to 65% at year 3 (P < 0.001) (Figure 2).Table 1: BMI Slopes by Year on HAARTAll PatientsBy Race/EthnicityBy SexNSlopeBHNHWP valueMenWomenP valueAll40480.260.280.260.190.030.230.300.008NNRTI13640.220.210.260.120.150.240.150.07PI20870.240.270.200.200.230.190.330.0004INSTI22640.320.390.320.150.0080.250.430.005ConclusionINSTI-based HAART is associated with greater increases in BMI in Blacks and Hispanics. Women had greater BMI gains than men on both PI- and INSTI-based HAART. The mechanisms of these differential effects by sex and race/ethnicity should be examined in prospective studies. Disclosures R. Bedimo, ViiV Healthcare: Consultant and Grant Investigator, Consulting fee and Research grant. Merck & Co.: Consultant and Grant Investigator, Consulting fee and Research grant. Bristol Myers Squibb: Grant Investigator, Research grant. Gilead Sciences: Consultant, Consulting fee. J. Lake, Gilead Sciences: Consultant and Grant Investigator, Consulting fee and Research grant. Merck & Co.: Consultant, Consulting fee.

Low prevalence of depressive symptoms among stable patients on antiretroviral therapy in Johannesburg, South Africa.

BackgroundDepression is a leading cause of disability and may be associated with decreased adherence to ART. We sought to describe the prevalence of depressive symptoms and outcomes one year after screening among patients receiving ART at a large HIV Clinic in Johannesburg, South Africa.MethodsAdult (≥18) patients who had been on first-line ART between 6–18 months who could communicate in English were eligible. Depressive symptoms were evaluated using the Patient Health Questionnaire (PHQ)-9 and a score ≥10 indicated depression.Results97 patients enrolled. Patients had been on ART for a median (IQR) of 8 (7–10) months, 61% were female, the median (IQR) age at enrollment was 38 (33–42) years, and the median (IQR) CD4 count at ART initiation was 154.5 (65–263) cells/mm3. 7 (7%) patients were found to have symptoms of depression; 4 (4%) had symptoms of moderate depression (PHQ score of 10–14) and 3 (3%) had symptoms of moderate/severe depression (PHQ score of 15–19). Women (10%) were more likely to have symptoms of depression than men (3%; prevalence difference [PD]: 7.5%; 95% confidence interval [CI]:-1.7%-16.8%); as were patients under the age of 30 (14%) compared to those 30–39 (4%; PD: -10.2; 95% CI: -29.4–9.0%) or ≥40 (9%; PD: -5.5%; -26.1%-15.2%), those with lower CD4 counts at ART initiation (<200 cells/mm3 vs ≥200 cells/mm3: 8% vs 3%; PD: 4.8%; 95% CI: -4.5%-14.0%), and those with high viral loads (>1000 copies/mL vs. <400 copies/mL: 40% vs. 5%; PD: 34.6%; 95% CI: -8.6%-77.6%). No relationship between depressive symptoms and retention in HIV care one year after screening was observed.ConclusionsWe found a lower prevalence of depressive symptoms compared to findings from other HIV-positive populations in South Africa but more than one-third of patients with an elevated viral load had evidence of depression. Further research on the relationship between depression, adherence, and viral failure is warranted as this may present an opportunity for early interventions to improve treatment outcomes and reduce the need for second-line treatment.

Suboptimal Retention in Care Among Recently Released Prisoners: Implications for Social Workers in HIV Primary Care.

Certain populations of people living with HIV (PLWH) are at greater risk for falling out of care, including PLWH with a history of incarceration. This is associated with increased risk of morbidity and mortality. In the current retrospective cohort study, we examined patient-level information for 340 PLWH who had transferred HIV care services from prison or from other community-based or private HIV primary care providers to a large urban HIV clinic in the southeastern United States. Results indicated that, compared to those transferring care from another community-based or private medical provider, PLWH transferring care from prison were significantly less likely to be retained in care than PLWH transferring care from other providers, even after controlling for other factors. HIV primary care social workers, who are trained to provide case management services, can help provide PLWH with a coordinated continuum of care that addresses the complex issues faced post-release.

Effect of age at initiation of antiretroviral therapy on treatment outcomes; A retrospective cohort study at a large HIV clinic in southwestern Uganda.

BackgroundThe prevalence of HIV infection among older persons is increasing yet older age at initiation of antiretroviral therapy (ART) may be associated with poorer treatment outcomes including mortality. However, majority of these studies have been done in the western world and there is limited data in resource limited settings. Our study used routinely collected health facility data to assess trends in age at initiation of ART, the effect of age at ART initiation on mortality and immunological response at a large urban hospital in south western Uganda.MethodsWe conducted a retrospective records review of patients attending the HIV clinic at Mbarara Regional Referral Hospital in western Uganda. We retrieved records for 8,533 patients who started ART between January 2006 and December 2012. Their data had been collected and stored as part of the larger International Epidemiological Database for the Evaluation of AIDS (IeDEA). Age was stratified into three categories namely; 18–34 (young adults), 35–49 (mid-age) and 50 years or older (older adults). Survival analysis procedures with Kaplan-Meier’s plots were used to calculate the survival probability with mortality as the endpoint and Poisson regression analysis used to determine the adjusted relative risks (RR) of mortality.ResultsThe proportion of young adults and patients at WHO stage I initiating ART increased steadily over the 7-year period. Older age at ART initiation (> = 50 years) was associated with a higher risk of mortality with adjusted relative risk (RR) at 1.63, (95% CI 1.26–2.11) compared to younger age. Male gender, WHO stages III and IV, lower CD4 count and lower body mass index were also all independently and significantly associated with higher risk for mortality. Older adults also had a poorer immunological response RR = 1.79 (95% CI 0.89–3.58) but was not statistically significant.ConclusionsFollowing ART initiation, older adults compared to the young, have a higher risk of mortality. This age group should be targeted first for ‘screen and treat’ approach. Optimization of ART treatment regimens for this age group is also required to reduce mortality and improve immunological response.

High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa.

Outcomes of HIV-infected children have improved dramatically over the past decade, but are undermined by patient loss to follow-up (LTFU). We assessed patterns of LTFU among HIV-infected children receiving antiretroviral treatment (ART) at a large inner-city HIV clinic in Johannesburg, South Africa between 2005 and 2014.Demographic and clinical data were extracted from clinic records of children under 12 years. Differences between characteristics of children retained in care and LTFU were assessed using Wilcoxon rank sum tests or Pearson χ2 tests. Cox proportional hazard models then identified characteristics associated with LTFU.Of 135 children, the median age at ART initiation was 21.5 months (IQR: 6.3–47.7) with a median follow-up time of 3.3 years (IQR: 1.4–5.0). The incidence rate of LTFU was 10.8 per 100 person-years (95% CI: 8.2–14.4); cumulatively 36% of children were LTFU. Almost a third (n = 39) of children missed a clinic visit, but then returned to care; 77% of these were eventually LTFU. In total, 18% of children had elevated viral loads after 6 or more months of ART. Older age at ART initiation (18–59 months: aHR 1.6, 95% CI: 3.9–14.2) and ever missing a clinic visit (aHR 7.4 95% CI: 3.9–14.2) were independent predictors of LTFU.High rates of LTFU were observed in this primary care clinic. Risks for LTFU included older age (>18 months old) and missed clinic visits. Identifying children who miss scheduled visits and developing strategies directed at retaining them in care is critical to improving long-term pediatric HIV outcomes.

Factors associated with desired fertility among HIV-positive women and men attending two urban clinics in Lilongwe, Malawi.

As access to antiretroviral therapy increases, more HIV-infected patients in sub-Saharan Africa may desire fertility. We conducted a cross-sectional study of reproductive health knowledge, attitudes and practices to identify factors associated with desired fertility among women and men receiving care at two large public HIV clinics in Lilongwe, Malawi. Research assistants administered questionnaires to participants. We performed descriptive, bivariable and multivariable analysis of factors related to desired fertility and of factors related to contraceptive non-use among participants who did not desire fertility. One-third of participants desired future children. Having a partner who desired fertility and having lower parity were associated with desiring children among both genders. For women, believing that pregnancy was unhealthy was associated with decreased fertility desire. Fifty-five percent of women and 69% of men who did not want children in the future reported using contraception at last intercourse. Increasing age, lower parity, and making the decision to use contraception herself were associated with contraceptive non-use among women who did not desire fertility. Having discussed family planning with his partner was associated with contraceptive use among men who did not desire fertility. Knowledge of these factors can guide reproductive health counseling and service provision.

Implementation of a Rapid Entry Program Decreases Time to Viral Suppression Among Vulnerable Persons Living With HIV in the Southern United States.

BackgroundRapid entry programs (REPs) improve time to antiretroviral therapy (ART) initiation (TAI) and time to viral suppression (TVS). We assessed the feasibility and effectiveness of a REP in a large HIV clinic in Atlanta, Georgia, serving a predominately un- or underinsured population.MethodsThe Rapid Entry and ART in Clinic for HIV (REACH) program was implemented on May 16, 2016. We performed a retrospective cohort study with the main independent variable being period of enrollment: January 1, 2016, through May 15, 2016 (pre-REACH); May 16, 2016, through July 31, 2016 (post-REACH). Included individuals were HIV-infected and new to the clinic with detectable HIV-1 RNA. Six-month follow-up data were collected for each participant. Survival analyses were conducted for TVS. Logistic and linear regression analyses were used to evaluate secondary outcomes: attendance at first clinic visit, viral suppression, TAI, and time to first attended provider visit.ResultsThere were 117 pre-REACH and 90 post-REACH individuals. Median age (interquartile range [IQR]) was 35 (25–45) years, 80% were male, 91% black, 60% men who have sex with men, 57% uninsured, and 44% active substance users. TVS decreased from 77 (62–96) to 57 (41–70) days (P < .0022). Time to first attended provider visit decreased from 17 to 5 days, and TAI from 21 to 7 days (P < .0001), each remaining significant in adjusted models.ConclusionsThis is the largest rapid entry cohort described in the United States and suggests that rapid entry is feasible and could have a positive impact on HIV transmission at the population level.

Trends, treatment outcomes, and determinants for attrition among adult patients in care at a large tertiary HIV clinic in Nairobi, Kenya: a 2004-2015 retrospective cohort study.

BackgroundUnderstanding trends in patient profiles and identifying predictors for adverse outcomes are key to improving the effectiveness of HIV care and treatment programs. Previous work in Kenya has documented findings from a rural setting. This paper describes trends in demographic and clinical characteristics of antiretroviral therapy (ART) treatment cohorts at a large urban, referral HIV clinic and explores treatment outcomes and factors associated with attrition during 12 years of follow-up.MethodsThis was a retrospective cohort analysis of HIV-infected adults who started ART between January 1, 2004, and September 30, 2015. ART-experienced patients and those with missing data were excluded. The Cochran–Armitage test was used to determine trends in baseline characteristics over time. Cox proportional hazards models were used to determine the effect of baseline characteristics on attrition.ResultsART uptake among older adolescents (15–19 years), youth, and young adults increased over time (p=0.0001). Independent predictors for attrition included (adjusted hazard ratio [95% CI]) male sex: 1.30 (1.16–1.45), p=0.0001; age: 15–19 years: 1.83 (1.26–2.66), p=0.0014; 20–24 years: 1.93 (1.52–2.44), p=0.0001; and 25–29 years: 1.31 (1.11–1.54), p=0.0012; marital status – single: 1.27 (1.11–1.44), p=0.0005; and divorced/separated: 1.56 (1.30–1.87), p=0.0001; urban residence: 1.40 (1.20–1.64), p=0.0001; entry into HIV care following hospitalization: 1.31 (1.10–1.57), p=0.0026, or transfer from another facility: 1.60 (1.26–2.04), p=0.0001; initiation of ART more than 12 months after the date of HIV diagnosis: 1.36 (1.19–1.55), p=0.0001, and history of a current or past opportunistic infection (OI): 1.15 (1.02–1.30), p=0.0284.ConclusionAlthough ART uptake among adolescents and young people increased over time, this group was at increased risk for attrition. Single marital status, urban residence, history of hospitalization or OI, and delayed initiation of ART also predicted attrition. This calls for focused evidence-informed strategies to address attrition and improve outcomes.

Predictors of switch to and early outcomes on third-line antiretroviral therapy at a large public-sector clinic in Johannesburg, South Africa

BackgroundWhile efficacy data exist, there are limited data on the outcomes of patients on third-line antiretroviral therapy (ART) in sub-Saharan Africa in actual practice. Being able to identify predictors of switch to third-line ART will be essential for planning for future need. We identify predictors of switch to third-line ART among patients with significant viraemia on a protease inhibitor (PI)-based second-line ART regimen. Additionally, we describe characteristics of all patients on third-line at a large public sector HIV clinic and present their early outcomes.MethodsRetrospective analysis of adults (≥ 18 years) on a PI-based second-line ART regimen at Themba Lethu Clinic, Johannesburg, South Africa as of 01 August 2012, when third-line treatment became available in South Africa, with significant viraemia on second-line ART (defined as at least one viral load ≥ 1000 copies/mL on second-line ART after 01 August 2012) to identify predictors of switch to third-line (determined by genotype resistance testing). Third-line ART was defined as a regimen containing etravirine, raltegravir or ritonavir boosted darunavir, between August 2012 and January 2016. To assess predictors of switch to third-line ART we used Cox proportional hazards regression among those with significant viraemia on second-line ART after 01 August 2012. Then among all patients on third-line ART we describe viral load suppression, defined as a viral load < 400 copies/mL, after starting third-line ART.ResultsAmong 719 patients in care and on second-line ART as of August 2012 (with at least one viral load ≥ 1000 copies/mL after 01 August 2012), 36 (5.0% over a median time of 54 months) switched to third-line. Time on second-line therapy (≥ 96 vs. < 96 weeks) (adjusted Hazard Ratio (aHR): 2.53 95% CI 1.03–6.22) and never reaching virologic suppression while on second-line ART (aHR: 3.37 95% CI 1.47–7.73) were identified as predictors of switch. In a separate cohort of patients on third-line ART, 78.3% (47/60) and 83.3% (35/42) of those in care and with a viral load suppressed their viral load at 6 and 12 months, respectively.ConclusionsOur results show that the need for third-line is low (5%), but that patients’ who switch to third-line ART have good early treatment outcomes and are able to suppress their viral load. Adherence counselling and resistance testing should be prioritized for patients that are at risk of failure, in particular those who never suppress on second-line and those who have been on PI-based regimen for extended periods.

Association of Substance Use With Hospitalization and Virologic Suppression in a Southern Academic HIV Clinic

BackgroundPersons with HIV infection who do not achieve virologic suppression contribute significantly to the ongoing HIV epidemic and have an increased risk of clinical sequelae related to immunosuppression. The extent to which substance use and mental health diagnoses affect HIV outcomes and the care continuum has not been previously assessed at the Medical University of South Carolina (MUSC), a large academic HIV clinic. MethodsTo address this knowledge gap and identify targets for intervention, we performed a retrospective chart review to examine associations of substance use and mental health diagnoses with hospitalization and virologic suppression. ResultsPatients with substance use or mental health diagnoses had increased rates of hospitalization and lower rates of sustained longitudinal HIV suppression. Prevalence of distinct substance-related disorders differed by race and sex. Although cocaine, alcohol and cannabis use were common, documented opiate use disorder was surprisingly infrequent given the ongoing opioid epidemic in South Carolina. ConclusionsThese data suggest effective assessment and treatment of substance use disorders will help improve the HIV care continuum in South Carolina.

Middle-aged man with symmetrical lesions in his throat

A 51-year-old man infected with HIV for more than 10 years visited our HIV clinic due to lesions in his throat. He had a CD4 T-cell count of >500 cells per μl and a HIV-RNA viral load of <20 copies per mm3. Nearly 3 months before this presentation, the patient participated in oral sex. At the clinic, he presented with a milky and (Fig. 1A ). He did not have any other symptoms on his skin. What is the diagnosis? Answer: Butterfly sign of pharyngeal syphilis. The patient had a history of syphilis 4 years prior to this visit. Although he was treated with amoxicillin 4 years prior, his serological tests for syphilis (STS) titer had remained positive at a low level. Laboratory testing revealed that his rapid plasma reagin (RPR) test result increased from 1:4 to 1:512 (normal value, <1), and his Treponema pallidum hemagglutination (TPHA) level had increased from 1280 to >40,960 (normal value, <1). Co-infections of HIV and syphilis are common [[1]Imahashi M. Izumi T. Watanabe D. Imamura J. Matsuoka K. Ode H. et al.Lack of association between intact/deletion polymorphisms of the APOBEC3B gene and HIV-1 risk.PLoS One. 2014; 9e92861Crossref PubMed Scopus (22) Google Scholar]. Notably, HIV patients often demonstrate prolonged STS positivity even after appropriate treatment. Thus, it is hazardous to diagnose syphilis solely based on a serological test. Pharyngeal syphilis accounts for 7% of syphilis cases [[2]Nishijima T. Teruya K. Shibata S. Yanagawa Y. Kobayashi T. Mizushima D. et al.Incidence and risk factors for incident syphilis among HIV-1-infected men who have sex with men in a large urban HIV Clinic in Tokyo, 2008–2015.PLoS One. 2016; 11e0168642Crossref PubMed Scopus (17) Google Scholar]. Due to the diversification of patients' sexual behaviors, healthcare providers should be aware of the oral manifestation of syphilis [[3]Dybeck Udd S. Lund B. Oral syphilis: a reemerging infection prompting Clinicians' alertness.Case Rep Dent. 2016; 20166295920PubMed Google Scholar]. The patient was treated with amoxicillin for a month, and the symptoms of pharyngeal lesions resolved rapidly. The picture shows the patient's soft palate after 2 months of follow-up (Fig. 1B). The authors disclose no financial or proprietary conflicts of interest with this publication. Consent was obtained and no patient identifiers are evident on the clinical image.

A time-motion study of cardiovascular disease risk factor screening integrated into HIV clinic visits in Swaziland.

IntroductionScreening of modifiable cardiovascular disease (CVD) risk factors is recommended but not routinely provided for HIV‐infected patients, especially in low‐resource settings. Potential concerns include limited staff time and low patient acceptability, but little empirical data exists. As part of a pilot study of screening in a large urban HIV clinic in Swaziland, we conducted a time‐motion study to assess the impact of screening on patient flow and HIV service delivery and exit interviews to assess patient acceptability.MethodsA convenience sample of patients ≥40 years of age attending routine HIV clinic visits was screened for hypertension, diabetes, hyperlipidemia and tobacco smoking. We observed HIV visits with and without screening and measured time spent on HIV and CVD risk factor screening activities. We compared screened and unscreened patients on total visit time and time spent receiving HIV services using Wilcoxon rank‐sum tests. A separate convenience sample of screened patients participated in exit interviews to assess their satisfaction with screening.ResultsWe observed 172 patient visits (122 with CVD risk factor screening and 50 without). Screening increased total visit time from a median (range) of 4 minutes (2 to 11) to 15 minutes (9 to 30) (p < 0.01). Time spent on HIV care was not affected: 4 (2 to 10) versus 4 (2 to 11) (p = 0.57). We recruited 126 patients for exit interviews, all of whom indicated that they would recommend screening to others.ConclusionProvision of CVD risk factor screening more than tripled the length of routine HIV clinic visits but did not reduce the time spent on HIV services. Programme managers need to take longer visit duration into account in order to effectively integrate CVD risk factor screening and counselling into HIV programmes.

Social Support as a Key Protective Factor against Depression in HIV-Infected Patients: Report from large HIV clinics in Hanoi, Vietnam

Depression is the most common mental health issue among people living with HIV/AIDS (PLWHA). This study explored how different types and sources of social support are associated with depression among HIV-infected patients in Vietnam. We carried out a cross-sectional survey on 1,503 HIV-infected patients receiving antiretroviral therapy at two HIV clinics in Hanoi in 2016. Depression was prevalent in 26.2% of participants. Higher score of social support, especially emotional/informational support and positive social interaction, showed significant association with lower depression rate. Although family was primary source of all types of social support, receiving emotional/informational support not only from family but also from outside of family correlated with a lower proportion of depression. In countries with constrained social resources and/or with family-oriented social structures, as in Vietnam, expanding social networks between HIV populations and society is a potentially important option for reducing depression.

Prevalence and factors associated with chronic kidney disease and end-stage renal disease in HIV-1-infected Asian patients in Tokyo

This single-center cross-sectional study determined the prevalence and factors associated with chronic kidney disease (CKD) and end-stage renal disease (ESRD) in HIV-1-infected Asian patients at the largest HIV clinic in Japan. HIV-1-infected patients who visited the clinic between September and December 2016 were analyzed. CKD was defined as estimated glomerular filtration rate of <60 ml/min/1.73 m2 or proteinuria ≥1+, observed at least over three months. A logistic regression model was used to estimate the effects of various variables on CKD. The study included 1,990 patients; with 97% Asians, 34% aged of ≥50 years, and 94% had HIV-1 load <50 copies/ml. The median time from HIV-1 diagnosis to study enrollment and duration of ART were 9.1 years (IQR4.8–14.2) and 7.35 years (IQR3.28–12), respectively. CKD and ESRD were diagnosed in 256 (13%) and 9 (0.5%) patients, respectively. The prevalence of CKD was 18.6% for age 50–59, 28.5% for 60–69, and 47% for over 70. Older age, heavier body weight, diabetes mellitus, hypertension, and longer duration of ART, but not duration of TDF exposure, were associated with CKD. The traditional risk factors, rather than HIV-1-related variables, were associated with CKD, suggesting the importance of management of such comorbidities in maintenance of renal function.