Lower Viral Suppression Research Articles

HIV viral load suppression rates among adults and children living with HIV in the North West Region of Cameroon: A call for action!

HIV continues to be a major public health problem in Cameroon where 2.7% of the population aged 15 to 49 are living with HIV. The prevalence remains higher in females, 3.4% versus 1.9% in males. The North West region of Cameroon has a higher prevalence than the national average; 4% in the general population, 5.8% in females and 1.6% in males. Despite the availability of pediatric HIV treatment, gaps in outcomes of children living with HIV (CLHIV) persists. This study aimed to compare the HIV viral suppression rates among adults and children living with HIV receiving antiretroviral therapy (ART) in the North West Region of Cameroon. In this study we hypothesized that the virologic outcome of children living with HIV is unfavorable compared to adults. This study was a comparative cross-sectional analytical study with secondary analysis of Viral load laboratory database. Data was collected in June 2023. We systematically collected deidentified data on viral load test of all PLHIV with HIV viral load results in the Bamenda TB reference laboratory database for the period January 1, 2022 to December 31, 2022. Data was analyzed using Stata SE 14.2. Categorical variables were described using absolute and relative frequencies. These were compared using Pearson's chi-squared test. Quantitative variables were described using mean as a characteristic of central tendency and standard deviation (SD) as a characteristic of dispersion. Analysis revealed that of the 23,814 PLHIV whose viral load test was done at the Bamenda TB reference laboratory during the year 2022, 17,364(73%) were female and 1436 (6%) were children. The level of HIV viral suppression (viral load<1000 copies/ml) in children was lower compared to that of adults (80% vs. 95%; p<0.001). Females had lower viral suppression than males (94% vs. 91%; p<0.001). The results revealed a significant lower HIV viral suppression rate in children than in adults. Women also had a significantly higher HIV viral suppression than males. Findings indicated that HIV viral suppression rate is significantly higher for routine viral load testing than for targeted testing after enhanced adherence counselling, thus the need to systematically offer enhanced adherence counselling and other evidence-based support interventions in routine care to all PLHIV to avoid persistent high viral non-suppression. Action is needed to tackle all known factors contributing to high viral non-suppression in children living with HIV and to help achieve 95% viral suppression rate in CLHIV in the North West region of Cameron.

Healthcare practitioners' experiences in managing HIV among young people in Namibia.

Low viral load suppression rates among older adolescents and young adults with HIV are a global challenge, including in Namibia. Healthcare providers struggle with managing these age groups due to their unique demographic characteristics. Monitoring viral load suppression is vital for evaluating antiretroviral treatment effectiveness, making it essential to identify and address existing gaps. This study aimed to explore and describe healthcare practitioners' understanding and experiences in managing older adolescents and younger adults living with HIV in seven high-burden districts of Namibia. Qualitative descriptive phenomenological research was followed in this study. Healthcare practitioners directly managing older adolescents and younger adults living with HIV were purposively recruited. Telephonic individual interviews were conducted, and data saturation was achieved with the 29th participant. Colaizzi's seven-step analysis was used to analyse the data. Two themes emerged from the study: (1) healthcare practitioners' knowledge of viral load management and (2) the strategies employed to manage high viral load in these age groups. These strategies included implementing differentiated service delivery, adopting interprofessional and Ubuntu approaches, psychosocial support, community engagement, enhancing adherence counselling, and support from implementing partners. The findings revealed inadequate knowledge among healthcare practitioners regarding viral load management, which negatively impacts the provision of quality care and an effective HIV response within the spirit of Ubuntu.Contribution:This study enhances healthcare practitioners' capacity in viral load management and guides policy makers in supporting this unique population, thus improving their health outcomes.

Pathways between adverse childhood experiences and viral suppression among male HIV-infected adolescents in South Africa

ABSTRACT Fewer adolescents achieve viral suppression compared to adults. One impediment may be a history of adverse childhood experiences (ACEs). To better develop targets and timeframes for intervention, this study created more robust estimates of the impact of cumulative adversity on viral suppression, tested whether the association is sensitive to the timing of adversity, and simultaneously tested several potential mechanisms. We focus on males, who have lower viral suppression than females and who may contribute to disproportionate incidence among young women. We recruited 251 male perinatally HIV-infected adolescents aged 15–19 from HIV clinics in Soweto, South Africa. Adversity was captured using the Adverse Childhood Experience – International Questionnaire (ACE-IQ). Viral load was measured using blood samples; viral suppression was defined as <20 copies/mL. Indicators of medication adherence, depression, post-traumatic stress disorder (, and substance misuse were captured. A series of pathway analysis were performed. Our sample experienced a median of 7 lifetime and 4 past-year adversities. Less than half (44%) exhibited viral suppression. Adversity demonstrated a significant association with suppression; depression mediated the association. Primary prevention of adversity among children living with HIV is paramount, as is addressing the subsequent mental and behavioral health challenges that impede viral suppression among adolescents.

Targeted solutions to increase dolutegravir coverage, viral load testing coverage, and viral suppression among children living with HIV in Togo: An analysis of routine facility data.

According to UNAIDS, Togo halved AIDS-related deaths among children ages 0-14 from 2010 to 2020. However, available data show low dolutegravir (DTG)-containing antiretroviral therapy (ART) coverage and low viral load suppression (VLS) among children living with HIV (CLHIV). We analyzed routine facility data before and after implementation of root-cause-based solutions for improving DTG coverage, viral load (VL) testing coverage, and VLS among CLHIV. We analyzed routine data for CLHIV ≤14 years from October 2019 through September 2022. We assessed proportion of CLHIV on ART receiving DTG, VL testing coverage (CLHIV on ART with documented VL test result), and VLS (CLHIV with documented VL test result of <1,000 copies among those with test result). From October 2019 to September 2020, 52% were on a DTG-containing regimen, 48% had documented VL test results, and 64% had VLS. Site-level teams conducted a root-cause analysis and designed corresponding solutions implemented beginning October 2020: line listing and contacting eligible CLHIV to start/transition to DTG-containing regimen and collect VL samples; ART adherence support; monthly DTG stock monitoring; tracking pending VL test results through laboratory focal persons; documenting VL test results; and informing caregivers within one week if CLHIV not virally suppressed. Granular data were used to prioritize technical assistance to sites with lowest DTG coverage, VL testing coverage, and VLS. From baseline (October 2019-September 2020) to endline (October 2021-September 2022), increases were observed for DTG coverage (52% to 71%), VL testing coverage (48% to 90%), and VLS (64% to 82%). Age-disaggregated data showed positive trends. Root-cause-based solutions and granular data use increased DTG coverage, resulting in increased VL testing and VLS among CLHIV. These interventions should be scaled and become the national standard of care.

Examining the Association Between a Modified Quan-Charlson Comorbidity Index and HIV Viral Suppression: A Cross-Sectional Analysis of DC Cohort Participants.

With the advancement of effective antiretroviral therapy, people with HIV live longer, and many are developing non-AIDS comorbidities. It is important to assess how comorbidities are associated with HIV-related health outcomes, such as viral suppression (VS). The aim of this study was to analyze the association between comorbidity burden, measured using a modified Quan-Charlson Comorbidity Index (QCCI), and VS (viral load result of <200 copies/mL). We hypothesized that an increase in QCCI score, indicating a higher risk for mortality, would correlate with lower likelihood of VS because of the burden of comorbidity treatment, possibly leading to worse antiretroviral adherence. Our analysis included participants from the DC Cohort Longitudinal HIV Study in Washington, DC. Eligible participants were aged ≥18 years and enrolled in the cohort as of January 1, 2018 (n = 2,471). A modified QCCI score, which weighs selected comorbidities (not including HIV/AIDS) and predicts mortality, was calculated using International Classification of Disease-9/10 codes from electronic health records. Multivariable logistic regressions were used to characterize the association between QCCI composite scores and VS. Participants were predominantly virally suppressed (89.6%), male (73.9%), non-Hispanic Black (74.7%), and between 18 and 55 years (59.3%). The median QCCI score was 1 (range = 1-12, interquartile range = 0-2), demonstrating predominately low mortality risk. We did not establish a statistically significant association between QCCI score and VS (adjusted odds ratio = 1.06, 95% confidence interval 0.96-1.17). Our findings suggest that a higher QCCI score was not associated with lower VS in this population, which may be partly due to the high retention in care among cohort participants.

Effectiveness of a community-based intervention (Konga model) to address factors contributing to low viral load suppression among children living with HIV in Tanzania: a preliminary, cluster, randomized clinical trial report

BackgroundDespite effective antiretroviral therapy (ART) coverage in other groups living with human immunodeficiency virus (HIV) in Tanzania, virologic suppression among HIV-positive children receiving ART remains unacceptably low. This study evaluated the effectiveness of a community-based intervention (Konga model) in addressing the factor contributing to low viral load suppression among children living with HIV in the Simiyu region, Tanzania.MethodsThis study used a parallel cluster randomized trial. The cluster was only eligible if the health facility provided HIV care and treatment. All eligible resident children aged 2‒14 years who attended the cluster with a viral load > 1,000 cells/mm were enrolled. The intervention included three distinct activities: adherence counseling, psychosocial support, and co-morbidity screening such as tuberculosis. The evaluation was based on patient-centered viral load outcomes measured at baseline and 6 months later. Using a pre- and post-test design, we compared the means of participants in the intervention and control groups. We performed an analysis of covariance. The effect of a Konga was calculated using omega-squared. We used F-tests, with their corresponding p-values, as measures of improvement.ResultsWe randomly assigned 45 clusters to the treatment (15) and control (30) groups. We enrolled 82 children with amedian age of 8.8 years(interquartile range(IQR);5.5–11.2), and a baseline median viral load of 13,150 cells/mm (interquartile range (IQR);3600–59,200). After the study, both children in each group had good adherence, with children in the treatment group scoring slightly higher than those in the control group, 40 (97.56%) versus 31(75%61), respectively. At the end of the study, the difference in viral load suppression between the two groups was significant. The median viral load suppression at the end of the study was 50 cells/mm [IQR, (20–125)]. After adjusting for the viral load before the intervention, the effect size of the Konga intervention explained 4% (95% confidence interval [0%, 14.1%]) of the viral load variation at the end of the intervention.ConclusionThe Konga model demonstrated significant positive effects that improved viral load suppression. We recommend implementing the Konga model trial in other regions to improve the consistency of results.

Moderation effect of community health on the relationship between racial/ethnic residential segregation and HIV viral suppression in South Carolina: A county-level longitudinal study from 2013 to 2018.

Viral suppression is the ultimate goal of the HIV treatment cascade and a primary endpoint of antiretroviral therapy. Empirical evidence found racial/ethnic disparities in viral suppression among people living with HIV (PWH), but the evidence of the relationship between racial/ethnic residential segregation and place-based viral suppression is scarce. Further exploring potential structural moderators in this relationship has substantial implications for healthcare policymaking and resource allocation. The current study aimed to investigate the spatial-temporal disparities in the HIV viral suppression rate across 46 counties in South Carolina from 2013 to 2018. We also examined the impact of racial/ethnic residential segregation and the moderation effect of community health, one measurement of community engagement and volunteerism. The proportion of PWH who achieved viral suppression for each county and calendar year was calculated using de-identified electronic medical records. The isolation index was calculated and used to measure racial/ethnic residential segregation. The community health index and other county-level factors were directly extracted from multiple publicly available datasets. We used geospatial mapping to explore the spatial-temporal variations of HIV viral suppression rates. Hierarchical quasi-binominal regression models were used to examine the impacts of racial/ethnic residential segregation on county-level viral suppression rate by the extent of community health. From 2013 to 2018, the average viral suppression rate across 46 counties in SC increased from 64.3% to 65.4%. Regression results revealed that counties with high racial/ethnic residential segregation were more likely to have a low viral suppression rate (β = -0.56, 95% CI: -0.75 to -0.37). In counties with high levels of community health, the impact of racial/ethnic residential segregation on viral suppression rate decreased as compared with those with low levels of community health (β = 5.50, 95% CI: 0.95-10.05). Racial/ethnic residential segregation acts as a structural barrier to placed-based viral suppression rates and compromises the goal of the HIV treatment cascade. Concentrated and sustained county-level interventions aiming to improve community health can be practical approaches to promote health equity in HIV treatment and care.

Progress towards the UNAIDS 95-95-95 targets among pregnant women in South Africa: Results from the 2017 and 2019 national Antenatal HIV Sentinel Surveys.

ObjectivesThe UNAIDS 95-95-95 global targets for epidemic control aim to ensure by 2030 that 95% of HIV-positive people know their HIV status, 95% of people diagnosed with HIV receive sustained antiretroviral therapy (ART), and 95% of people on ART have viral suppression. While data on the first and second 95 targets are routinely reported nationally, data on the third 95 target are not available for pregnant women in South Africa. The lack of data on the third 95 target limits the inclusion of low viral suppression as one of the contributing factors in MTCT root cause analyses. This study assessed progress towards the 95-95-95 targets among pregnant women between the ages of 15–49 years attending public health facilities in South Africa.MethodData were obtained from two consecutive national cross-sectional antenatal HIV sentinel surveys conducted between 1 October and 15 November in both 2017 and 2019. In each survey, data on age, knowledge of HIV status, ART initiation, and geographical location (province) were extracted from medical records. A blood specimen was collected from each woman and tested for HIV. Viral load tests were performed on HIV-positive specimens. Descriptive and multiple logistic regression analyses were performed to examine association between province and viral suppression (defined as viral load <50 copies/mL) using the combined dataset (i.e., both 2017 and 2019 data combined). All analyses considered the survey design.ResultsOf 10 065 and 11 321 HIV-positive women included in the 2017 and 2019 surveys, respectively, 96.0% (95% confidence interval (CI): 95.6–96.4%) and 97.6% (95% CI: 97.3–97.8%) knew their HIV-positive status; 86.6% (95% CI: 85.9–87.3%) and 96.0% (95% CI: 95.6–96.4%) of those who knew their HIV status were receiving ART; while 64.2% (95% CI: 63.2–65.2%) and 66.0% (95% CI: 65.1–66.8%) of those receiving ART were virally suppressed. Achievement of the third 95 target significantly varied by province ranging from 33.9–72.6% in 2017 and 43.4–77.3% in 2019. Knowledge of HIV-positive status, ART initiation, and viral suppression increased in both 15–24 and 25–49 year age groups between 2017 and 2019. In a multivariable analysis adjusting for survey year, gravidity, and education, the odds of viral suppression significantly varied by province (except KwaZulu-Natal and Western Cape, other provinces were less likely to attain viral suppression compared to Gauteng), age (adjusted odds ratio (AOR) for 15–24 years vs 25–49 years: 0.7, 95% CI: 0.6–0.8), and timing of ART initiation (AOR for ART initiation during pregnancy vs before pregnancy: 0.4, 95% CI: 0.5–0.6).ConclusionAlthough in 2019 the first and second 95 targets were achieved among pregnant women, meeting the third 95 target remains a challenge. This study highlighted the importance of promoting early ART initiation and the need to target young women in efforts to improve progress towards the third 95 target. Additionally, the provincial variation in viral suppression could be further investigated in future studies to identify and address the root causes underlying these differences.

An Exploratory Study to Describe Transgender People with HIV Who Accessed Medicaid and Their Viral Suppression Over Time in New York City, 2013-2017.

Although HIV surveillance contains information on HIV outcomes among transgender persons with HIV (TPWH), it does not include other important data, for example, gender-affirming health care, which may influence viral suppression (VS). We describe TPWH accessing Medicaid and the association of gender-affirming surgery with VS. Through matching Medicaid claims with HIV registry data, a cohort of previously identified TPWH in Medicaid was compared to cisgender women and men in terms of VS in 2013-2017 in New York City. Medicaid claims were used to identify TPWH who obtained gender-affirming surgery (e.g., chest, genital surgeries). We described the VS of those who had surgery and examined temporal trends in VS pre- and postsurgery and by surgery type. 1730 TPWH were enrolled in Medicaid and in HIV care in 2013-2017. Overall for VS at last laboratory, TPWH in Medicaid had lower VS (76.0%) than cisgender women (80.4%) and men (83.3%). The exception was the 185 TPWH who obtained gender-affirming surgery (86.5%). Among 160 TPWH in Medicaid who obtained gender-affirming surgery and achieved VS, VS increased presurgery (66.3% 2 years prior, 76.9% 1 year prior) and remained high 1 year after (86.3%) and 2 years after (87.7%) (the last percentage is only among those who had surgery before 2017, N=81). Gender-affirming surgery may be an important motivator to becoming virally suppressed and was associated with sustained high VS, which can lead to improved survival and quality of life. Medicaid and other insurers should consider improving access to gender-affirming surgery among TPWH.

Moving forward with dolutegravir in children weighing less than 20 kg

Dolutegravir was recommended as first line antiretroviral therapy (ART) across all ages by WHO in 2018. At that time, no dosing data was available for children living with HIV weighing less than 15 kg and appropriate formulations were not available in high burden settings.1 There was also no evidence of superior outcomes in children living with HIV.1 With approximately 800 000 children living with HIV not receiving ART and low viral suppression rates,2 robust child friendly dolutegravir-based regimens will allow for once daily dosing, align with adult guidelines, and improve outcomes.

Improving Viral Load Suppression Among Men and Children Active in Care Through Community-Designed and Led Solutions: Protocol for Retrospective Closed Cohort Study in Eastern Uganda.

BackgroundIn collaboration with facilities, communities, district local government, and the United States Agency for International Development (USAID) implementing partners, the iDARE methodology was implemented at the community level to address root causes of low HIV antiretroviral therapy adherence among men and children actively enrolled in care, resulting in low viral load suppression (VLS) in two districts in the eastern region of Uganda. The methodology encourages the use of cocreated sustainable solutions addressing gender, youth, and social inclusion issues to reduce barriers to care and reach the 95-95-95 Joint United Nations Programme on HIV/AIDS target for HIV epidemic control. We aim to measure the impact of iDARE on VLS for men and children active in care and investigate the practical scale up of the solutions designed using the iDARE methodology.ObjectiveThe primary objective of this study will be to measure the implementation impact of the iDARE methodology at the facility and community levels on VLS for people living with HIV. The secondary objective is to investigate the practical scale up of the iDARE methodology using evidence-based gender, youth, and social inclusion social behavior change packages to rapidly meet the Ugandan Ministry of Health targets for VLS.MethodsA retrospective cohort study design will be used to analyze program data that aims to increase the rates of VLS in men and children who are classified as active in care using community engagement and quality improvement techniques. We will examine 3 pilot health centers’ data from a USAID-funded program aimed at social behavior change to increase health-seeking behavior in Uganda. Based on the iDARE process and results, change packages were developed to highlight lessons learned and best practices in order to share with subsequent implementation sites.ResultsThe USAID-funded Social and Behavior Change Activity began implementation of iDARE in September 2020, with baseline data collected in August 2020.ConclusionsData on viral load suppression was collected from facilities on a monthly basis to record progress toward the 95-95-95 goal. The expected primary outcome is an increase in actively enrolled men and children reaching VLS in order to meet the Ugandan Ministry of Health target of 95% VLS among those active in care.International Registered Report Identifier (IRRID)DERR1-10.2196/32784

A Technology-Based Intervention Among Young Men Who Have Sex With Men and Nonbinary People (The Conectad@s Project): Protocol for A Vanguard Mixed Methods Study.

BackgroundIn many parts of the world, including Brazil, uptake for biomedical interventions has been insufficient to reverse the HIV epidemic among key populations at high risk for HIV, including men who have sex with men. Young MSM (YMSM), particularly Black YMSM, have high HIV incidence, low viral suppression, and low preexposure prophylaxis (PrEP) uptake and adherence. Therefore, novel approaches to increase the HIV biomedical interventions uptake by YMSM are urgently needed.ObjectiveWe describe the Conectad@s Project, which aims to: (1) estimate the prevalence and incidence of HIV and other sexually transmitted infections, the onset of sexual risk behavior, and barriers to biomedical interventions among YMSM aged 18 to 24 years in Rio de Janeiro, Brazil; and (2) conduct a technology-based adherence intervention study to promote a rapid linkage of YMSM to HIV care or prevention, and support and sustain adherence.MethodsA cross-sectional survey will be conducted with 400 YMSM recruited using respondent-driven sampling (RDS) adapted for social media-based sampling, preceded by a formative phase. HIV and sexually transmitted infections testing will be conducted, including early HIV infection biomarker detection. Behavioral, partnership, network, and structural measures will be collected through structured questionnaires. All individuals recruited for the survey will have access to HIV risk assessment, antiretroviral therapy (ART), PrEP, prevention counseling, and a technology-based adherence intervention. Those who accept the adherence intervention will receive weekly text messages via a social networking app (WhatsApp) for 24 weeks, with follow-up data collected over 48 weeks.ResultsThe Conectad@s project has been approved by our local institutional review board (#CAAE 26086719.0.0000.4262) in accordance with all applicable regulations. Questionnaires for the RDS survey and intervention were developed and tested in 2020, formative interviews were conducted in January and February 2021 to guide the development of the RDS, and enrollment is planned to begin in early 2022.ConclusionsThe Conectad@s Project is a vanguard study that, for the first time, will apply digital RDS to sample and recruit YMSM in Brazil and rapidly connect them to ART, PrEP, or prevention counseling through a technology-based adherence intervention. RDS will allow us to estimate HIV prevalence among YMSM and measure HIV infection biomarkers in the context of the onset of risky behavior. The data will lay the groundwork to adapt and implement HIV prevention strategies, identify barriers to the earliest HIV infection diagnosis, immediate ART or PrEP initiation, and detect new clusters of HIV transmission.International Registered Report Identifier (IRRID)DERR1-10.2196/34885

Transmitted HIV-1 Drug-resistance Mutations among Newly Diagnosed Patients of the North Western Region of Cameroon

Background: First line antiretroviral treatment (ART) regimens in Cameroon comprises of reverse transcriptase inhibitors (RTIs). As ART continues to expand, the emergence of HIV drug resistance mutations (DRMs) is a challenging problem. The ongoing scale up of ART in Cameroon has prompted the interest in surveillance of transmitted drug resistance (TDR). The aim of this study was to evaluate the prevalence of TDR among drug naïve individuals residing in the North West Region (NWR) of Cameroon.&#x0D; Methods: Ethics approval was obtained from the National Ethics Committee of Cameroon and patients informed consents were obtained. A total of 81 HIV-1 infected and drug naïve patients were recruited from randomly selected clinics located in the NWR of Cameroon from February 2016 and April 2016. HIV-1 protease-reverse transcriptase region was sequenced using an in-house protocol. HIV drug resistance mutations were identified and analyzed using Stanford HIVDR database and the Calibrated Population Resistance (CPR) tools. Data was analyzed using SPSS version 23.&#x0D; Results: Of the 81 samples analyzed, the prevalence of TDR was 11.1% (9/81). Of these 9.9% (8/81) had drug resistance mutations to nucleoside and non-nucleoside reverse transcriptase inhibitors (NRTIs and NNRTIs) and a single individual (1.2%) with protease inhibitors. A total of 8.6 % (7/81), 4.9(4/81), and 3.7 % (3/81) individuals had a major mutation to NRTIs, NNRTIs, and both NRTIs and NNRTIs respectively. Thymidine analogue mutations [TAM] (M41ML, D67N, K70T/R, T215TA/F, and K219Q) were detected in five individuals. The most frequent NRTI and NNRTI DRMs were K219Q (n=2) and E138A (n=2) respectively. Mutations associated with NRTIs were TAM and M184MV; NNRTIs were A98G, K103N, V108I, V179E, and Y181C and I54IFV for PI. CPR tool revealed a 4.9% (4/81) prevalence with the following single mutations K103N D67N, K70R, M184V, T215F, K219Q.The difference between two methods was statistically significant p=0.0001. These mutations confer resistance to all NRTIs and NNRTIs drugs.&#x0D; Conclusions: Although moderate transmitted drug resistance (11.1%) levels were detected in this study, this calls for routine drug resistance surveillance among patients on ART. This will ensure relative maintenance of low viral suppression amongst HIV patients.

912. Expansion of Hepatitis C Treatment with New Medicaid Subscription Model in Louisiana

BackgroundIt is estimated that nearly 80,000 people with hepatitis C are living in Louisiana, many with Medicaid coverage. Previously, only Medicaid patients free from drugs and alcohol with a fibrosis score of F3 or F4 were eligible for treatment, resulting in few patients receiving treatment. Beginning in July 2019, generic sofosbuvir/velpatasvir was made available through the Medicaid program in a subscription model, allowing unlimited hepatitis C treatment in Louisiana’s Medicaid program for 5 years at a set price to the program. This has dramatically expanded access to Hepatitis C treatment for people with Medicaid in Louisiana. MethodsPatients with Hepatitis C seen in the Infectious Diseases Center at University Medical Center in New Orleans, in 2020 by the 5 main hepatitis C providers were included. Demographics and laboratory data were collected to determine outcomes. ResultsMost patients with a hepatitis C (HCV) viral load and insurance data had Medicaid (80%, N=275). Twenty-two (8%) were HIV co-infected. Most were men (75%) and African-American (77%). Among the mono-infected patients with Medicaid and an HCV viral load, 216 (85%) had an undetectable viral load by the beginning of June 2021. Of the remaining 37 patients, 30 patients were prescribed treatment; but did not take it (n=4), didn’t follow-up (n=23), or followed-up but never got labs (n=3). One was treated but had a treatment failure (n=1). Six of the 37 were not prescribed medications due to a short life expectancy or significant drug interactions. The percentage of patients with an undetectable viral load was similar by gender and race, however younger age groups had lower viral suppression. In those aged less than 35, only 47% had an undetectable viral load and among those aged 36 to 44, it was 66%. Using the previous criteria of requiring a fibrosis score of F3 or F4, only 20% (n=44) would have been eligible for medicine to treat hepatitis C. ConclusionThe new hepatitis C treatment subscription model with resultant removal of previous barriers has dramatically expanded treatment for people with Medicaid in Louisiana. More than five times the number of Medicaid patients received treatment in 2020 in our academic medical clinic.Disclosures Yussef Bennani, MD, MPH, Gilead Sciences (Scientific Research Study Investigator)ViiV Healthcare (Scientific Research Study Investigator)

Retention in Care, Mortality, Loss-to-Follow-Up, and Viral Suppression among Antiretroviral Treatment-Naïve and Experienced Persons Participating in a Nationally Representative HIV Pre-Treatment Drug Resistance Survey in Mexico

We describe associations of pretreatment drug resistance (PDR) with clinical outcomes such as remaining in care, loss to follow-up (LTFU), viral suppression, and death in Mexico, in real-life clinical settings. We analyzed clinical outcomes after a two-year follow up period in participants of a large 2017–2018 nationally representative PDR survey cross-referenced with information of the national ministry of health HIV database. Participants were stratified according to prior ART exposure and presence of efavirenz/nevirapine PDR. Using a Fine-Gray model, we evaluated virological suppression among resistant patients, in a context of competing risk with lost to follow-up and death. A total of 1823 participants were followed-up by a median of 1.88 years (Interquartile Range (IQR): 1.59–2.02): 20 (1%) were classified as experienced + resistant; 165 (9%) naïve + resistant; 211 (11%) experienced + non-resistant; and 1427 (78%) as naïve + non-resistant. Being ART-experienced was associated with a lower probability of remaining in care (adjusted Hazard Ratio(aHR) = 0.68, 0.53–0.86, for the non-resistant group and aHR = 0.37, 0.17–0.84, for the resistant group, compared to the naïve + non-resistant group). Heterosexual cisgender women compared to men who have sex with men [MSM], had a lower viral suppression (aHR = 0.84, 0.70–1.01, p = 0.06) ART-experienced persons with NNRTI-PDR showed the worst clinical outcomes. This group was enriched with women and persons with lower education and unemployed, which suggests higher levels of social vulnerability.

Coverage of maternal viral load monitoring during pregnancy in South Africa: Results from the 2019 national Antenatal HIV Sentinel Survey.

Objectives:South Africa has made remarkable progress in increasing the coverage of antiretroviral therapy (ART) among pregnant women; however, viral suppression among pregnant women receiving ART is reported to be low. Access to routine viral load testing is crucial to identify women with unsuppressed viral load early in pregnancy and to provide timely intervention to improve viral suppression. This study aimed to determine the coverage of maternal viral load monitoring nationally, focusing on viral load testing, documentation of viral load test results, and viral suppression (viral load < 50 copies/mL). At the time of this study, the first-line regimen for women initiating ART during pregnancy was non-nucleoside reverse transcriptase (NNRTI)-based regimen.Methods:Between 1 October and 15 November 2019, a cross-sectional survey was conducted among 15- to 49-year-old pregnant women attending antenatal care in 1589 nationally representative public health facilities. Data on ART status, viral load testing and viral load test results were extracted from medical records. Logistic regression was used to examine factors associated with coverage of viral load testing.Results:Of 8112 participants eligible for viral load testing, 81.7% received viral load testing, and 94.1% of the viral load test results were documented in the medical records. Of those who had viral load test results documented, 74.1% were virally suppressed. Women initiated on ART during pregnancy and who received ART for three months had lower coverage of viral load testing (73%) and viral suppression (56.8%) compared with women initiated on ART before pregnancy (82.8% and 76.1%, respectively). Initiating ART during pregnancy rather than before pregnancy was associated with a lower likelihood of receiving a viral load test during pregnancy (adjusted odds ratio = 1.6, 95% confidence interval: 1.4–1.8).Conclusions:Viral load result documentation was high; viral load testing could be improved especially among women initiating ART during pregnancy. The low viral suppression among women who initiated ART during pregnancy despite receiving ART for three months highlights the importance of enhanced adherence counselling during pregnancy. Our finding supports the WHO recommendation that a Dolutegravir-containing regimen be the preferred regimen for women who are newly initiating ART during pregnancy for more rapid viral suppression.

Barriers for Antiretroviral Therapy Adherence and Viral Suppression in Members of the Key Population in Mumbai, India: Implications for Interventions.

Background:Poor adherence to antiretroviral therapy (ART) is associated with poor virologic control and drug resistance in people living with HIV/AIDS. Some barriers to ART adherence are cost, lack of information, stigma, or dissatisfaction with health services.Aims and Objectives:To study the association between barriers for ART adherence and viral suppression, and explore the role of "missing ART dose" as a potential mediator in high-risk groups.Materials and Methods:Demographic, clinical, and behavioral data from 50 "virally suppressed" (viral load [VL] <1000 copies/ml) and 48 "not suppressed" (VL > 1000 copies/ml) individuals belonging to the key population in Mumbai were collected. Sociodemographic, behavioral, and other characteristics were compared, and mediation analysis was used to identify the mediator in the pathway to viral suppression.Results:Those who had missed their ART at least once in the past three months (37% versus 60%, P = 0.03) and stayed alone were less likely to be virally suppressed (31% versus 69%, P = 0.002). Individuals who had negative perception about ART (adjusted odds ratio [aOR]: 0.11, 95% confidence interval [CI]: 0.02, 0.47; P = 0.002), poor ART-related knowledge/behaviors (aOR: 0.14, 95% CI: 0.03, 0.60; P = 0.007), and poor pill taking practices (aOR: 0.10, 95% CI: 0.02, 0.61; P = 0.01) were significantly less likely to be virally suppressed. The mediation pathway "adherence theme > missed ART in the past three months > viral suppression" was significant in these themes.Conclusions:The factors associated with low viral suppression were knowledge/behaviors, perceptions about ART, and poor pill taking practices. Thus, it is important to provide correct information about ART, its effects, side effects, and potential limitations to marginalized population. Involving brothel keepers and Gurus (head of male-to-female transgendered people/Hijras clans), and technology enabled customized counseling sessions will be helpful.

Law, Criminalization and HIV in the World: Have Countries That Criminalize Achieved More or Less Successful Pandemic Response?

How do choices in criminal law and rights protections affect disease-fighting efforts? This long-standing question facing governments around the world is acute in the context of pandemics like HIV and COVID-19. The Global AIDS Strategy of the last 5 years sought to prevent mortality and HIV transmission in part through ensuring people living with HIV (PLHIV) knew their HIV status and could suppress the HIV virus through antiretroviral treatment. This article presents a cross-national ecological analysis of the relative success of national AIDS responses under this strategy, where laws were characterised by more or less criminalisation and with varying rights protections. In countries where same-sex sexual acts were criminalised, the portion of PLHIV who knew their HIV status was 11% lower and viral suppression levels 8% lower. Sex work criminalisation was associated with 10% lower knowledge of status and 6% lower viral suppression. Drug use criminalisation was associated with 14% lower levels of both. Criminalising all three of these areas was associated with approximately 18%–24% worse outcomes. Meanwhile, national laws on non-discrimination, independent human rights institutions and genderbased violence were associated with significantly higher knowledge of HIV status and higher viral suppression among PLHIV. Since most countries did not achieve 2020 HIV goals, this ecological evidence suggests that law reform may be an important tool in speeding momentum to halt the pandemic.

1030. Medicaid Expansion: How Does it Impact HIV Outcomes in One Non-urban Southeastern Ryan White HIV/AIDS Program Clinic?

BackgroundPeople living with HIV (PLWH) with Medicaid historically have lower viral suppression (VS) rates than those with other insurance. VS rates with Medicaid expansion (ME) are unknown. We examined HIV outcomes (engagement in care, VS) by insurance status for a non-urban Southeastern Ryan White HIV/AIDS Program (RWHAP) Clinic cohort for year after ME.MethodsParticipants were PLWH ages 18-63 who attended > 1 HIV medical visit/year in 2018 and 2019. Log-binomial models were used to estimate the association of characteristics with Medicaid enrollment prevalence and one-year risks of engagement in care and VS in 2019.ResultsAmong 577 patients, 241 (42%) were newly eligible for Medicaid due to ME and 79 (33%) enrolled (Figure 1a). For those without Medicare, Medicaid enrollment was higher for those with incomes < 100% FPL (adjusted prevalence ratio [aPR] 1.67; 95% confidence interval [CI] 1.00-1.86) compared to those with incomes > 101% FPL. Those enrolled in Medicaid due to ME had 87% engagement in care compared to 80-92% for other insurance plans (Figure 1b). Controlling for 2018 engagement, older age (adjusted risk ratio [aRR] for 10 years 1.03, 95% CI 1.00-1.05; Table 1) was associated with being engaged in 2019. Engagement was lower for those with employment-based insurance (aRR 0.91, 95% CI 0.83-0.99) and Medicare (aRR 0.87, 95% CI 0.78-0.96). Of those with viral loads in 2018 and 2019 (n=549), those who newly enrolled in Medicaid due to ME had 85% VS compared to 87-99% for other insurance plans (Figure 1c). In univariate analysis, age, income, and baseline viral load status were associated with viral suppression (Table 2), and those with Medicaid due to ME (aRR 0.90, 95% CI 0.81-1.00) were less likely to achieve VS compared with others.Figure 1 Table 1 Table 2 ConclusionThe low uptake of ME was likely influenced by many PLWH already having Medicare. While the RWHAP supports high quality HIV care, Medicaid enrollment improves access to non-HIV care and should be supported by RWHAP. Given that engagement in care was high for PLWH who newly enrolled in Medicaid, the finding of lower VS is surprising. The discordance may be due to medication access gaps associated with changes in pharmacy logistics. Future studies with larger cohorts will need to examine how ME contributes to PLWH’s overall health and to ending the HIV epidemic.DisclosuresKathleen A. McManus, MD, MSCR, Gilead Sciences, Inc (Research Grant or Support, Shareholder) Rebecca Dillingham, MD, MPH, Gilead Sciences, Inc (Research Grant or Support)Warm Health Technologies, Inc (Consultant)

Medicaid Expansion's Impact on Human Immunodeficiency Virus Outcomes in a Nonurban Southeastern Ryan White HIV/AIDS Program Clinic.

BackgroundAlthough the Ryan White HIV/AIDS Program supports high-quality human immunodeficiency virus (HIV) care, Medicaid enrollment provides access to non-HIV care. People with HIV (PWH) with Medicaid historically have low viral suppression (VS) rates. In a state with previously high Qualified Health Plan coverage of PWH, we examined HIV outcomes by insurance status during the first year of Medicaid expansion (ME).MethodsParticipants were PWH ages 18–63 who attended ≥1 HIV medical visit/year in 2018 and 2019. We estimated associations of sociodemographic characteristics with ME enrollment prevalence and associations between insurance status and engagement in care and VS.ResultsAmong 577 patients, 151 (33%) were newly eligible for Medicaid, and 77 (51%) enrolled. Medicaid enrollment was higher for those with incomes <100% federal poverty level (adjusted prevalence ratio, 1.67; 95% confidence interval [CI], 1.00–1.86) compared with others. Controlling for age, income, and 2018 engagement, those with employment-based private insurance (adjusted risk difference [aRD], −8.5%; 95% CI, −16.9 to 0.1) and Medicare (aRD, −12.5%; 95% CI, −21.2 to −3.0) had lower 2019 engagement than others. For those with VS data (n = 548), after controlling for age and baseline VS, those with Medicaid (aRD, −4.0%; 95% CI, −10.3 to 0.3) and with Medicaid due to ME (aRD, −6.2%; 95% CI, −14.1 to −0.8) were less likely to achieve VS compared with others.ConclusionsGiven that PWH who newly enrolled in Medicaid had high engagement in care, the finding of lower VS is notable. The discordance may be due to medication access gaps associated with changes in medication procurement logistics.