Lower Odds Of Viral Suppression Research Articles

Associations Between Alcohol Use, Antiretroviral Therapy Use, and Viral Load Suppression Among People Living with HIV in Rural Central Uganda

Alcohol use among people living with HIV (PWH) is common and may negatively affect engagement in HIV care. We evaluated the relationships between alcohol use, ART use, and viral suppression among PWH in Uganda. PATH/Ekkubo was a trial evaluating a linkage to HIV care intervention in four Ugandan districts, Nov 2015-Sept 2021. Our analytical sample included: (1) baseline data from individuals not enrolled in the intervention trial (previously diagnosed HIV+); and 12-month follow-up data from the control group (newly diagnosed or previously diagnosed, but not in care). Level of alcohol use was categorized using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C): none (AUDIT-C = 0), low (women = 1–2, men = 1–3), medium (women = 3–5, men = 4–5), high/very high (6–12). Multivariable logistic regression models evaluated associations between alcohol use, ART use and viral suppression (a viral load of < 20); we also stratified by gender. Among 931 PWH, medium (OR: 0.43 [95% CI 0.25–0.72]) and high/very high (OR: 0.22 [95% CI 0.11–0.42]) levels of alcohol use were associated with lower odds of being on ART. In a sub-sample of 664, medium use (OR: 0.63 [95% CI 0.41–0.97]) was associated with lower odds of viral suppression. However, this association was not statistically significant when restricting to those on ART, suggesting the relationship between alcohol use and viral suppression is explained by ART use. Among men, high/very high, and among women, medium alcohol use levels were associated with lower odds of being on ART and being virally suppressed. Interventions for PWH who use higher levels of alcohol may be needed to optimize the benefits of Uganda’s Universal Test and Treat strategy.

Time spent at health facility is a key driver of patient satisfaction, but did not influence retention to HIV care: A serial cross-sectional study in Mozambique.

Patient satisfaction with clinical services can have an effect on retention in HIV care and adherence to antiretroviral therapy. This study assessed patient satisfaction and its association with retention and viral suppression in Zambézia Province, Mozambique. Monthly exit interviews with persons living with HIV were completed from August 2017-January 2019 in 20 health facilities; clinical data were extracted from medical records. Regression analyses assessed the effect of satisfaction scores on retention and viral suppression, adjusting for age, sex, education, civil status, time on treatment, and site. Satisfaction scores were correlated with time spent at health facilities using generalized linear regression models. Data from 4388 patients were analyzed. Overall median satisfaction score was 75% (IQR 53%-84%); median time spent at facilities (from arrival until completion of clinical services) was 2h54min (IQR 1h48min-4h). Overall satisfaction score was not associated with higher odds of retention or viral suppression, but association was seen between satisfaction regarding attention given to patient and respect and higher odds of viral suppression. Patient satisfaction was negatively associated with time spent in facility (Spearman's correlation -0.63). Increased time spent at facility (from 1 to 3 hours) was not associated with lower retention in care (OR 0.72 [95%CI:0.52-1.01] and 0.83 [95%CI: 0.63-1.09] at 6- and 12-months, respectively), nor with a lower odds of viral suppression (OR 0.96 [95%CI: 0.71-1.32]). Strategies to reduce patient wait times at the health facility warrant continued prioritization. Differentiated models of care have helped considerably, but novel approaches are still needed to further decongest crowded health facilities. In addition, a good client-provider communication and positive attitude can improve patient satisfaction with health services, with an overall improved retention.

HIV viral suppression at different thresholds and duration of treatment in the dolutegravir treatment era in Sierra Leone: a nationwide survey

IntroductionViral load assessment for people living with HIV is key for monitoring treatment and achieving the 95-95-95. In this study, we aimed to assess the degree of viral suppression at different thresholds and treatment duration after the introduction of dolutegravir-based therapy in ten public hospitals in Sierra Leone.MethodsWe used a cross-sectional study design to recruits patients aged 18 years or older between August 2022 and January 2023. Statistical analyses were performed using R-software. Logistic regression was used to assess factors independently associated with viral suppression. The level of significance was set at P < 0.05.ResultsOf the 2,253 patients recruited, 1,720 (76%) were women and 1,705 (76%) were receiving a fixed dose combination of tenofovir, lamivudine and dolutegravir. The median age and duration of anti-retroviral therapy (ART) was 36.0 (IQR, 28.0–45.0) years and 40.9 (IQR, 14.4–79.6) months, respectively. Using a threshold of HIV RNA < 1000 copies/mL, 1,715 (88.4%) patients on ART for more than 6 months were virally suppressed. Viral suppression rates were higher with dolutegravir-based (1,277, 89.5%) than efavirenz-based (418, 86.2%) ART. HIV RNA was < 200 copies/mL in 1,643 (84.6%) patients or < 50 copies/mL in 1,487 (76.6%) patients or between 50 and 999 copies/mL in 228 (11.7%) patients. Viral suppression rates at different ART durations (months) were as follows: 84.2% (≤ 3), 88.8% (4–6), 90.9% (6–12), and 88.1% (> 12). Viral suppression rates were higher for patients aged 40 or older (40–50 years: aOR 2.05, 95%CI 1.41–3.04, P < 0.01; 50–60 years: aOR 2.51, 95%CI 1.53–4.35, P < 0.01; >60 years: aOR 2.69, 95%CI 1.28–6.63, P = 0.02). Men had 49% lower odds of viral suppression than women (aOR 0.50, 95% CI 0.38–0.67, P < 0.01).ConclusionWe report a viral suppression rate of 88.4% among patients on treatment for at least 6 months, with higher rate of suppression with dolutegravir than efavirenz. Factors associated with virological suppression were age and gender, emphasizing the need for innovative differentiated ART delivery models to optimize viral suppression and achieve the 95% target.

Magnitude of Viral Load Suppression and Associated Factors among HIV-positive Patients Receiving Antiretroviral Therapy.

Viral load assessment is the preferred method for diagnosing and confirming virologic failure for patients on antiretroviral therapy. This study aimed to assess the proportion of viral load suppression and identify associated factors among HIV-positive patients receiving antiretroviral therapy at the Pokhara academy of health science in Nepal. This institution-based retrospective cohort study was conducted at Pokhara academy of health science in Pokhara, Nepal. The study included 567 HIV patients who were enrolled between January 2016 and December 2019 and had their viral load measured within a one-year period. Statistical analysis was performed using STATA version 13.0. The proportions of viral load suppression and non-suppression were determined. Bivariate and multivariate logistic regressions were performed to identify factors associated with viral load suppression. Statistical significance was determined at a 95% confidence interval and p < 0.05 Results: Out of the 567 HIV patients, 95.76 % (95% CI: 94.10-97.42) achieved viral suppression. In multivariate analysis, longer duration of antiretroviral therapy treatment (> 3 years) was independently associated with higher odds of achieving viral suppression compared to those on antiretroviral therapy for less than 6 months (adjusted odds ratio [aOR] = 11.98, 95% confidence interval: 1.32-108.81, p < 0.0027). Conversely, individuals in second-line treatment had significantly lower odds of viral suppression compared to those in first-line treatment (aOR = 0.19, 95% CI: 0.05-0.66, p < 0.009). Our study demonstrated a high rate of viral suppression among HIV patients receiving antiretroviral therapy, exceeding the UNAIDS 90-90-90 target. Longer duration of antiretroviral therapy and being in second-line treatment were identified as factors influencing viral load suppression. These findings emphasize the importance of early initiation and adherence to first-line treatment for optimal outcomes.

Intersection of alcohol use, HIV infection, and the HIV care continuum in Zambia: nationally representative survey

ABSTRACT Through a nationally-representative household survey, we measured the prevalence and correlates of unhealthy alcohol use (UAU) in Zambia and its association with the HIV care continuum. Adolescent and adult (ages 15–59 years) data, including the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), from the 2016 Zambia Population-based HIV Impact Assessment, were analyzed. UAU was defined as AUDIT-C of 3 + points for women and 4 + for men. Among 20,923 participants, 15.3% had UAU; this was 21.6% among people living with HIV (PLWH). Male sex, increasing age, being employed, urban residence, and having HIV were independent correlates of UAU (all P < 0.05). Among PLWH, UAU was associated with reduced HIV diagnosis (adjusted odds ratio [AOR]: 0.66, 95% CI 0.50–0.88) and non-significant trends toward reduced ART use if diagnosed (AOR: 0.73, 95% CI 0.73–1.10) and reduced viral suppression (VS) if on ART (AOR: 0.91, 95% CI 0.57–1.44). Overall, UAU was linked to 25% lower odds of VS compared to abstinence. UAU in Zambia disproportionately affects certain groups including PLWH. Achieving and sustaining HIV epidemic control in Zambia will require evidence-based approaches to screen and treat UAU.

Drug use stigma, antiretroviral therapy use, and HIV viral suppression in a community-based sample of people with HIV who inject drugs.

To examine the association of drug use stigma with antiretroviral therapy (ART) use and HIV viral suppression among people with HIV who inject drugs in India. Cross-sectional biobehavioral survey. Between August 2016 and May 2017, persons aged at least 18 years who reported injection drug use in the past 2 years were recruited via respondent-driven sampling (RDS) in 12 Indian cities (approximately 1000 per city). The analysis was restricted to participants with laboratory-confirmed HIV infection who self-reported a prior HIV diagnosis and were eligible for ART per concurrent national HIV treatment guidelines. Enacted and internalized drug use stigma were each measured by five to six-item subscales. The study outcomes were HIV viral suppression (<150 copies/ml) and self-reported past 30-day ART use. RDS-II weighted multivariable logistic regression with a city-level random-intercept was used to estimate adjusted odds ratios (aOR) and corresponding 95% confidence intervals (CIs). Among 971 ART-eligible participants previously diagnosed with HIV, 65.1% reported ART use and 56.1% were virally suppressed. Reporting any enacted stigma (vs. none) was associated with lower odds of ART use [aOR = 0.26 (95% CI = 0.15-0.44)] and viral suppression [aOR = 0.49 (95% CI = 0.31-0.78)]. High internalized stigma scores (>median vs. ≤median) were associated with lower odds of viral suppression among participants aged at least 35 years [aOR = 0.51 (95% CI = 0.27-0.97)] but not among participants aged less than 35 years [aOR = 1.22 (95% CI = 0.57-2.60)]. Similar associations were observed in analyses restricted to participants ever linked to HIV care. Drug use stigma may be a barrier to HIV viral suppression among people with HIV who inject drugs, thereby hindering efforts to achieve HIV control.

Development of a transition readiness score for adolescents living with perinatally-acquired HIV and transitioning to adult care

We created a transition readiness score for adolescents with perinatally-acquired HIV as they transition from pediatric to adult care. Of the 199 adolescents who transitioned to adult care, 84 (42%) had viral suppression (< 200 copies/ml) one year after transition. Adolescents on first-line ART, with documented HIV status disclosure, and higher rating on the HIV Adolescent Readiness to Transition Scale had significantly higher odds of viral suppression after transition. Conversely, females, those with older age at ART initiation, and those with prior alcohol use had significantly lower odds of viral suppression after transition. Using these data, we created a transition readiness score organized into low, intermediate, and high levels of transition readiness. This transition readiness score can be used to identify adolescents who are likely ready to transition to adult care and identify additional areas for intervention to improve the likelihood of successful transition for those with lower transition readiness scores.

Adopting a "Compound" Exposome Approach in Environmental Aging Biomarker Research: A Call to Action for Advancing Racial Health Equity.

Background:In June 2020, the National Academies of Sciences, Engineering, and Medicine hosted a virtual workshop focused on integrating the science of aging and environmental health research. The concurrent COVID-19 pandemic and national attention on racism exposed shortcomings in the environmental research field’s conceptualization and methodological use of race, which have subsequently hindered the ability of research to address racial health disparities. By the workshop’s conclusion, the authors deduced that the utility of environmental aging biomarkers—aging biomarkers shown to be specifically influenced by environmental exposures—would be greatly diminished if these biomarkers are developed absent of considerations of broader societal factors—like structural racism—that impinge on racial health equity.Objectives:The authors reached a post-workshop consensus recommendation: To advance racial health equity, a “compound” exposome approach should be widely adopted in environmental aging biomarker research. We present this recommendation here.Discussion:The authors believe that without explicit considerations of racial health equity, people in most need of the benefits afforded by a better understanding of the relationships between exposures and aging will be the least likely to receive them because biomarkers may not encompass cumulative impacts from their unique social and environmental stressors. Employing an exposome approach that allows for more comprehensive exposure–disease pathway characterization across broad domains, including the social exposome and neighborhood factors, is the first step. Exposome-centered study designs must then be supported with efforts aimed at increasing the recruitment and retention of racially diverse study populations and researchers and further “compounded” with strategies directed at improving the use and interpretation of race throughout the publication and dissemination process. This compound exposome approach maximizes the ability of our science to identify environmental aging biomarkers that explicate racial disparities in health and best positions the environmental research community to contribute to the elimination of racial health disparities. https://doi.org/10.1289/EHP8392

Virologic response of treatment experienced HIV-infected Ugandan children and adolescents on NNRTI based first-line regimen, previously monitored without viral load

BackgroundMany HIV-infected African children gained access to antiretroviral treatment (ART) through expansion of PEPFAR programs since 2004 and introduction of “Test and Treat” WHO guidelines in 2015. As ART access increases and children transition from adolescence to adulthood, treatment failure is inevitable. Viral load (VL) monitoring in Uganda was introduced in 2016 replacing clinical monitoring. However, there’s limited data on the comparative effectiveness of these two strategies among HIV-infected children in resource-limited settings (RLS).MethodsHIV-infected Ugandan children aged 1–12 years from HIV-care programs with > 1 year of first-line ART using only immunologic and clinical criteria to monitor response to treatment were screened in 2010. Eligible children were stratified by VL ≤ 400 and > 400 copies/ml randomized to clinical and immunological (control) versus clinical, immunological and VL monitoring to determine treatment failure with follow-up at 12, 24, 36, and 48 weeks. Plasma VL was analyzed retrospectively for controls. Mixed-effects logistic regression models were used to compare the prevalence of viral suppression between study arms and identify factors associated with viral suppression.ResultsAt baseline all children (n = 142) were on NNRTI based ART (75% Nevirapine, 25% efavirenz). One third of ART-experienced children had detectable VL at baseline despite high CD4%. Median age was 6 years (interquartile range [IQR]: 5–9) and 43% were female. Overall, the odds of viral suppression were not different between study arms: (arm by week interaction, p = 0.63), adjusted odds ratio [aOR]: 1.07; 95%CI: 0.53, 2.17, p = 0.57) and did not change over time (aOR: 0 vs 24 week: 1.15; 95% CI: 0.91, 1.46, p = 0.24 and 0 vs 48 weeks: 1.26; 95%CI: 0.92, 1.74, p = 0.15). Longer duration of a child’s ART exposure was associated with lower odds of viral suppression (aOR: 0.61; 95% CI: 0.42, 0.87, p < .01). Only 13% (9/71) of children with virologic failure were switched to second-line ART, in spite of access to real-time VL.ConclusionWith increasing ART exposure, viral load monitoring is critical for early detection of treatment failure in RLS. Clinicians need to make timely informed decisions to switch failing children to second-line ART.Trial registrationClinicalTrials.gov NCT04489953, 28 Jul 2020. Retrospectively registered. (https://register.clinicaltrials.gov).

Factors Associated With Peripartum Virologic Suppression in Eastern Cape Province, South Africa: A Retrospective Cross-Sectional Analysis.

BackgroundThis study describes the characteristics of pregnant women on antiretroviral therapy (ART) and the rate of peripartum virologic suppression in a large prevention of mother-to-child transmission cohort who delivered in some selected maternity centers in Eastern Cape Province, South Africa. In addition, the study examines the factors associated with virologic suppression in the cohort.MethodsThis multicenter, retrospective cross-sectional analysis included medical data of 1709 women with human immunodeficiency virus between September 2015 and May 2016 in Eastern Cape Province. The main outcome measure was the rate of peripartum virologic suppression, defined as viral load (VL) <1000 copies/mL and undetectable viremia (VL <20 copies/mL). Correlates of peripartum virologic suppression and undetectable viremia were examined by fitting logistic regression model analysis.ResultsOf 1463 women with available VL results, the overall rate of peripartum suppression was 82%, and undetectable viremia was 56.9%. Being aged 24 years or younger (adjusted odds ratio [AOR], 0.68 [95% confidence interval {CI}, .48–.94]), smoking during pregnancy (AOR, 0.50 [95% CI, .28–.90]), and starting ART in the first trimester were associated with lower odds of viral suppression (<1000 copies/mL). Women who had never defaulted ART had an increased odds of having an undetectable VL (AOR, 3.09 [95% CI, 2.12–4.49]) and virologic suppression (AOR, 3.88 [95% CI, 2.62–5.74]) compared to those who defaulted.ConclusionsMore than half of the women achieved undetectable VL, and 4 in 5 women achieved viral suppression at delivery in the region. Early antenatal booking, combined with enhanced adherence support for pregnant women on ART, would be crucial toward achieving the goal of elimination of mother-to-child transmission in the region.

Unintended pregnancy and viral suppression in pregnant women living with HIV

Approximately half of pregnancies in the United States are unintended; the likelihood of unintended pregnancy may be even higher for women living with HIV. Women with unintended pregnancies often have worse obstetrical outcomes than women who planned their pregnancies, although the relationship of unintended pregnancy to outcomes among women living with HIV in the United States is unknown. This study aimed to determine whether pregnancy intendedness among women living with HIV attending a specialty obstetrical clinic was associated with achievement of maternal viral suppression by delivery, a key component of preventing perinatal transmission of HIV. This is a retrospective cohort study of pregnant women living with HIV who received prenatal care and had a live-born infant at a single tertiary center (2007-2014). Women were asked as part of routine clinical care whether they intended their current pregnancy. Women who expressed at their initial obstetrician visit that their pregnancy was mistimed or undesired were determined to have an unintended pregnancy. Women were considered virally suppressed when the HIV RNA viral load was <20 copies/mL. We examined whether pregnancy intendedness was associated with whether the viral load was undetectable at the time of delivery. We also determined whether women with unintended pregnancies were less likely to be on antiretroviral therapy at the time of entry to prenatal care. Wilcoxon rank-sum tests and chi-square tests were used for bivariable analyses, and logistic and linear regression were used for multivariable analyses. Of the 215 women who met inclusion criteria, 201 (93.5%) had complete data on pregnancy intendedness. Of these 201 women, 137 (68.2%) had an unintended pregnancy. Unintended pregnancy was associated with lower odds of viral suppression at delivery (95.3% of women with planned pregnancies were virally suppressed at delivery compared with 76.6% of women with unplanned pregnancies; adjusted odds ratio, 0.22; 95% CI, 0.05-0.89, after adjusting for potential confounders). In this study, 48.9% of women with unintended pregnancies presented later in pregnancy for prenatal care (after the first trimester) compared with 21.9% of women with intended pregnancies (P<.001). Women with unintended pregnancies were also less likely to be on antiretroviral therapy before entry to prenatal care (20.4% of women with unintended pregnancies vs 50.0% of women with intended pregnancies; adjusted odds ratio, 0.35; 95% CI, 0.15-0.81; P<.001). Among pregnant women living with HIV, women with an unintended pregnancy were less likely to be on antiretroviral therapy before initiating prenatal care and were less likely to be virally suppressed at the time of delivery.

Clinic-level and individual-level factors that influence HIV viral suppression in adolescents and young adults: a national survey in Kenya.

To determine clinic-level and individual-level correlates of viral suppression among HIV-positive adolescents and young adult (AYA) aged 10-24 years receiving antiretroviral treatment (ART). Multilevel cross-sectional analysis using viral load data and facility surveys from HIV treatment programs throughout Kenya. We abstracted medical records of AYA in HIV care, analyzed the subset on ART for more than 6 months between January 2016 and December 2017, and collected information on services at each clinic. Multilevel logistic regression models were used to determine correlates of viral suppression at most recent assessment. In 99 HIV clinics, among 10 096 AYA on ART more than 6 months, 2683 (27%) had unsuppressed viral load at last test. Among 16% of clinics, more than 80% of AYA were virally suppressed. Clinic-level correlates of individual viral suppression included designated adolescent spaces [aOR: 1.32, 95% CI (1.07-1.63)] and faster viral load turnaround time [aOR: 1.06 (95% CI 1.03-1.09)]. Adjusting for clinic-level factors, AYA aged 10-14 and 15-19 years had lower odds of viral suppression compared with AYA aged 20-24 years [aOR: 0.61 (0.54-0.69) and 0.59 (0.52-0.67], respectively. Compared with female patients, male patients had lower odds of viral suppression [aOR: 0.69 (0.62-0.77)]. Compared with ART duration of 6-12 months, ART for 2-5, above 5-10 or more than 10 years was associated with poor viral suppression (P < 0.001). Dedicated adolescent space, rapid viral load turnaround time, and tailored approaches for male individuals and perinatally infected AYA may improve viral suppression. Routine summarization of viral load suppression in clinics could provide benchmarking to motivate innovations in clinic-AYA and individual-AYA care strategies.

A systematic review and meta-analyses on initiation, adherence and outcomes of antiretroviral therapy in incarcerated people.

Incarcerated people are at increased risk of human immunodeficiency virus (HIV) infection relative to the general population. Despite a high burden of infection, HIV care use among prison populations is often suboptimal and varies among settings, and little evidence exists explaining the discrepancy. Therefore, this review assessed barriers to optimal use of HIV care cascade in incarcerated people. Quantitative and qualitative studies investigating factors affecting linkage to care, ART (antiretroviral therapy) initiation, adherence and/or outcomes among inmates were systematically searched across seven databases. Studies published in English language and indexed up to 26 October 2018 were reviewed. We performed a narrative review for both quantitative and qualitative studies, and meta-analyses on selected quantitative studies. All retrieved quantitative studies were assessed for risk of bias. Meta-analyses were conducted using RevMan-5 software and pooled odds ratios were calculated using Mantel-Haenszel statistics with 95% confidence interval at a p<0.05. The review protocol has been published at the International Prospective Register of Systematic Reviews (PROSPERO; Number: CRD42019135502). Of forty-two studies included in the narrative review, eight were qualitative studies. Sixteen of the quantitative studies were eligible for meta-analyses. The narrative synthesis revealed structural factors such as: a lack of access to community standard of HIV care, particularly in resource limited countries; loss of privacy; and history of incarceration and re-incarceration as risk factors for poor HIV care use in prison populations. Among social and personal characteristics, lack of social support, stigma, discrimination, substance use, having limited knowledge about, and negative perception towards ART were the main determinants of suboptimal use of care in incarcerated people. In the meta-analyses, lower odds of ART initiation was noticed among inmates with higher baseline CD4 count (CD4 ≥500celss/mm3) (OR = 0.37, 95%CI: 0.14-0.97, I2 = 43%), new HIV diagnosis (OR = 0.07, 95%CI: 0.05-0.10, I2 = 68%), and in those who lacked belief in ART safety (OR = 0.32, 95%CI: 0.18-0.56, I2 = 0%) and efficacy (OR = 0.31, 95%CI: 0.17-0.57, I2 = 0%). Non-adherence was high among inmates who lacked social support (OR = 3.36, 95%CI: 2.03-5.56, I2 = 35%), had low self-efficiency score (OR = 2.50, 95%CI: 1.64,-3.80, I2 = 22%) and those with depressive symptoms (OR = 2.02, 95%CI: 1.34-3.02, I2 = 0%). Lower odds of viral suppression was associated with history of incarceration (OR = 0.40, 95%CI: 0.35-0.46, I2 = 0%), re-incarceration (OR = 0.09, 95%CI: 0.06-0.13, I2 = 64%) and male gender (OR = 0.55, 95%CI: 0.42-0.72, I2 = 0%). Higher odds of CD4 count <200cells/mm3 (OR = 2.01, 95%CI: 1.62, 2.50, I2 = 44%) and lower odds of viral suppression (OR = 0.20, 95%CI: 0.17-0.22, I2 = 0%) were observed during prison entry compared to those noticed during release. Given the high HIV risk in prison populations and rapid movements of these people between prison and community, correctional facilities have the potential to substantially contribute to the use of HIV treatment as a prevention strategy. Thus, there is an urgent need for reviewing context specific interventions and ensuring standard of HIV care in prisons, particularly in resource limited countries.

Patterns of Exposure to Socio-structural Stressors and HIV Care Engagement Among Transgender Women of Color.

Transgender women are disproportionately affected by HIV and experiences of social adversity that may interfere with engagement in care and viral suppression. We used latent class analysis to examine patterns of social adversity and their impact on HIV care continuum outcomes in an urban sample of transgender women of color. Participants (n = 224) were median age 29 and 86% non-Hispanic Black. Lack of resources, unemployment, and housing instability were reported by over 50%, and 41% reported history of incarceration. Latent class analysis identified 2 distinct classes representing higher and lower levels of social adversity. In latent class regression, membership in the higher social adversity class was associated with statistically significantly lower odds of viral suppression and HIV care engagement in univariate analysis; when adjusted for age, race, and recruitment site the association remained statistically significant for viral suppression (aOR 0.38, 95% CI 0.18-0.79; chi-square = 6.681, d.f. = 1, p = 0.010), though not for HIV care engagement. Our findings highlight the impact of socio-structural barriers on engagement in the HIV care continuum among transgender women.

Unintended pregnancy and viral suppression in pregnant women living with HIV

BACKGROUND Approximately half of pregnancies in the United States are unintended; the likelihood of unintended pregnancy may be even higher for women living with HIV. Women with unintended pregnancies often have worse obstetrical outcomes than women who planned their pregnancies, although the relationship of unintended pregnancy to outcomes among women living with HIV in the United States is unknown. OBJECTIVE This study aimed to determine whether pregnancy intendedness among women living with HIV attending a specialty obstetrical clinic was associated with achievement of maternal viral suppression by delivery, a key component of preventing perinatal transmission of HIV. STUDY DESIGN This is a retrospective cohort study of pregnant women living with HIV who received prenatal care and had a live-born infant at a single tertiary center (2007-2014). Women were asked as part of routine clinical care whether they intended their current pregnancy. Women who expressed at their initial obstetrician visit that their pregnancy was mistimed or undesired were determined to have an unintended pregnancy. Women were considered virally suppressed when the HIV RNA viral load was <20 copies/mL. We examined whether pregnancy intendedness was associated with whether the viral load was undetectable at the time of delivery. We also determined whether women with unintended pregnancies were less likely to be on antiretroviral therapy at the time of entry to prenatal care. Wilcoxon rank-sum tests and chi-square tests were used for bivariable analyses, and logistic and linear regression were used for multivariable analyses. RESULTS Of the 215 women who met inclusion criteria, 201 (93.5%) had complete data on pregnancy intendedness. Of these 201 women, 137 (68.2%) had an unintended pregnancy. Unintended pregnancy was associated with lower odds of viral suppression at delivery (95.3% of women with planned pregnancies were virally suppressed at delivery compared with 76.6% of women with unplanned pregnancies; adjusted odds ratio, 0.22; 95% CI, 0.05-0.89, after adjusting for potential confounders). In this study, 48.9% of women with unintended pregnancies presented later in pregnancy for prenatal care (after the first trimester) compared with 21.9% of women with intended pregnancies (P<.001). Women with unintended pregnancies were also less likely to be on antiretroviral therapy before entry to prenatal care (20.4% of women with unintended pregnancies vs 50.0% of women with intended pregnancies; adjusted odds ratio, 0.35; 95% CI, 0.15-0.81; P<.001). CONCLUSION Among pregnant women living with HIV, women with an unintended pregnancy were less likely to be on antiretroviral therapy before initiating prenatal care and were less likely to be virally suppressed at the time of delivery.

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S.

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24years (mean age=20.7years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

Non-Communicable Disease Preventive Screening by HIV Care Model.

ImportanceThe Human Immunodeficiency Virus (HIV) epidemic has evolved, with an increasing non-communicable disease (NCD) burden emerging and need for long-term management, yet there are limited data to help delineate the optimal care model to screen for NCDs for this patient population.ObjectiveThe primary aim was to compare rates of NCD preventive screening in persons living with HIV/AIDS (PLWHA) by type of HIV care model, focusing on metabolic/cardiovascular disease (CVD) and cancer screening. We hypothesized that primary care models that included generalists would have higher preventive screening rates.DesignProspective observational cohort study.SettingPartners HealthCare System (PHS) encompassing Brigham & Women’s Hospital, Massachusetts General Hospital, and affiliated community health centers.ParticipantsPLWHA age >18 engaged in active primary care at PHS.ExposureHIV care model categorized as infectious disease (ID) providers only, generalist providers only, or ID plus generalist providers.Main Outcome(s) and Measures(s)Odds of screening for metabolic/CVD outcomes including hypertension (HTN), obesity, hyperlipidemia (HL), and diabetes (DM) and cancer including colorectal cancer (CRC), cervical cancer, and breast cancer.ResultsIn a cohort of 1565 PLWHA, distribution by HIV care model was 875 ID (56%), 90 generalists (6%), and 600 ID plus generalists (38%). Patients in the generalist group had lower odds of viral suppression but similar CD4 counts and ART exposure as compared with ID and ID plus generalist groups. In analyses adjusting for sociodemographic and clinical covariates and clustering within provider, there were no significant differences in metabolic/CVD or cancer screening rates among the three HIV care models.ConclusionsThere were no notable differences in metabolic/CVD or cancer screening rates by HIV care model after adjusting for sociodemographic and clinical factors. These findings suggest that HIV patients receive similar preventive health care for NCDs independent of HIV care model.

HIV testing and the care continuum among transgender women: population estimates from Rio de Janeiro, Brazil.

Introduction: Evidence suggests that, of all affected populations, transgender women (transwomen) may have the heaviest HIV burden worldwide. Little is known about HIV linkage and care outcomes for transwomen. We aimed to estimate population-level indicators of the HIV cascade of care continuum, and to evaluate factors associated with viral suppression among transwomen in Rio de Janeiro, Brazil. Methods: We conducted a respondent-driven sampling (RDS) study of transwomen from August 2015 to January 2016 in Rio de Janeiro, Brazil and collected data on linkage and access to care, antiretroviral treatment and performed HIV viral load testing. We derived population-based estimates of cascade indicators using sampling weights and conducted RDS-weighted logistic regression analyses to evaluate correlates of viral suppression (viral load ≤50 copies/mL). Results: Of the 345 transwomen included in the study, 89.2% (95% CI 55–100%) had been previously tested for HIV, 77.5% (95% CI 48.7–100%) had been previously diagnosed with HIV, 67.2% (95% CI 39.2–95.2) reported linkage to care, 62.2% (95% CI 35.4–88.9) were currently on ART and 35.4% (95% CI 9.5–61.4%) had an undetectable viral load. The final adjusted RDS-weighted logistic regression model for viral suppression indicated that those who self-identified as black (adjusted odds ratio [aOR] 0.06, 95% CI 0.01–0.53, p < 0.01), reported earning ≤U$160/month (aOR 0.11, 95% CI 0.16–0.87, p = 0.04) or reported unstable housing (aOR 0.08, 95% CI 0.01–0.43, p < 0.01) had significantly lower odds of viral suppression. Conclusions: Our cascade indicators for transwomen showed modest ART use and low viral suppression rates. Multi-level efforts including gender affirming care provision are urgently needed to decrease disparities in HIV clinical outcomes among transwomen and reduce secondary HIV transmission to their partners.

Sa1309 Real-Life Experience in Chronic Hepatitis B Treatment With Tenofovir and Entecavir

Background: Viral suppression associated with entecavir varies depending on patients' resistance to lamivudine (LAM; BMS, label). The literature suggests that in aggregate, among a patient population with a history of LAM treatment, the majority will not have developed LAM resistance, with resistance rates ranging from approximately 22% to 39% (MargeridonThermet, 2013; Cooley, 2003). The impact of prior LAM on viral suppression rates with entecavir in a real-world patient population is unclear. Objective: To estimate viral suppression among entecavir-treated HBV patients previously treated with LAM versus with other antiviral medications. Methods: This retrospective study included medical and pharmacy claims, enrollment data, and laboratory results (1995-2013) from 2 large national health plan databases. Subjects were commercial and Medicare Advantage enrollees who newly initiated entecavir treatment between March 2005 and August 2012 and were previously treated with LAM or other antiviral medications. Index date was the first entecavir prescription fill. Patient cohorts were based on previous treatment: LAM and other antiviral medication (OTH). Viral suppression was identified using all HBV DNA laboratory results between 30 to 365 days after initiating and prior to discontinuing entecavir. Secondary analyses described viral suppression based on results within 1 year of initiating entecavir but that may have occurred after discontinuing entecavir. Logistic regressionmodeled viral suppression adjusted for patient characteristics (including age, gender, comorbid illnesses, and patient demographic characteristics). Results: Of 284 qualifying study subjects, 29.2% were LAM and 70.8% were OTH. Cohorts had similar mean age (LAM 45.8 vs. OTH 46.9 years, P=0.47) and a similar proportion of female patients (LAM 27.7% vs. 30.9%, P=0.60). Patients in the LAM cohort had lower pre-index comorbidity compared with OTH (Charlson score 1.9 vs. 2.5, P<0.001). Rates of viral suppression during entecavir treatment were 66.3% (LAM) vs. 73.1% (OTH), P=0.245). After adjustment for patient characteristics, the odds of viral suppression for LAM were not statistically different compared with the OTH cohort (odds ratio: 0.67; 95% CI: 0.37, 1.20). Compared with patients enrolled in commercial health plans, patients enrolled in Medicare Advantage plans had lower odds of viral suppression (OR=0.17; 95% CI: 0.05, 0.57). Intent-to-treat analyses found that 65.6% (LAM) and 75.6% (OTH) experienced viral suppression any time during the 1-year follow-up period (P=0.062).Conclusions: For patients treated with entecavir, HBV viral suppression among patients previously treated with LAM was not substantially different from viral suppression among patients previously treated with other HBV antiviral medications. Table 1: HBV viral suppression while on entecavir treatment

Sa1308 Hepatitis B (HBV) Viral Suppression Among Patients Treated With Entecavir and With Previous Treatment With Lamivudine or Other Antiviral Medications: Real-World Outcomes in a US Insured Population

Background: Viral suppression associated with entecavir varies depending on patients' resistance to lamivudine (LAM; BMS, label). The literature suggests that in aggregate, among a patient population with a history of LAM treatment, the majority will not have developed LAM resistance, with resistance rates ranging from approximately 22% to 39% (MargeridonThermet, 2013; Cooley, 2003). The impact of prior LAM on viral suppression rates with entecavir in a real-world patient population is unclear. Objective: To estimate viral suppression among entecavir-treated HBV patients previously treated with LAM versus with other antiviral medications. Methods: This retrospective study included medical and pharmacy claims, enrollment data, and laboratory results (1995-2013) from 2 large national health plan databases. Subjects were commercial and Medicare Advantage enrollees who newly initiated entecavir treatment between March 2005 and August 2012 and were previously treated with LAM or other antiviral medications. Index date was the first entecavir prescription fill. Patient cohorts were based on previous treatment: LAM and other antiviral medication (OTH). Viral suppression was identified using all HBV DNA laboratory results between 30 to 365 days after initiating and prior to discontinuing entecavir. Secondary analyses described viral suppression based on results within 1 year of initiating entecavir but that may have occurred after discontinuing entecavir. Logistic regressionmodeled viral suppression adjusted for patient characteristics (including age, gender, comorbid illnesses, and patient demographic characteristics). Results: Of 284 qualifying study subjects, 29.2% were LAM and 70.8% were OTH. Cohorts had similar mean age (LAM 45.8 vs. OTH 46.9 years, P=0.47) and a similar proportion of female patients (LAM 27.7% vs. 30.9%, P=0.60). Patients in the LAM cohort had lower pre-index comorbidity compared with OTH (Charlson score 1.9 vs. 2.5, P<0.001). Rates of viral suppression during entecavir treatment were 66.3% (LAM) vs. 73.1% (OTH), P=0.245). After adjustment for patient characteristics, the odds of viral suppression for LAM were not statistically different compared with the OTH cohort (odds ratio: 0.67; 95% CI: 0.37, 1.20). Compared with patients enrolled in commercial health plans, patients enrolled in Medicare Advantage plans had lower odds of viral suppression (OR=0.17; 95% CI: 0.05, 0.57). Intent-to-treat analyses found that 65.6% (LAM) and 75.6% (OTH) experienced viral suppression any time during the 1-year follow-up period (P=0.062).Conclusions: For patients treated with entecavir, HBV viral suppression among patients previously treated with LAM was not substantially different from viral suppression among patients previously treated with other HBV antiviral medications. Table 1: HBV viral suppression while on entecavir treatment