Lower Rates Of Viral Suppression Research Articles

Improving Estimation of HIV Viral Suppression in the United States: A Method to Adjust HIV Surveillance Estimates From the Medical Monitoring Project Using Cohort Data.

The US Centers for Disease Control and Prevention has estimated human immunodeficiency virus (HIV) viral suppression (VS) using 2 data sources. The National HIV Surveillance System estimate (50% of HIV-diagnosed persons in 2012) is derived from viral load reporting from a subset of jurisdictions that vary yearly. The Medical Monitoring Project (MMP) estimate (42% of HIV-diagnosed persons in 2012) is based on a sample of persons receiving HIV care during the first 4 months of each year. We developed the cohort-adjustment method to reconstruct VS estimates, accounting for persons receiving care later in the year. Using the HIV Outpatient Study cohort, we assessed timing of care receipt, demographics, and VS at last test (<200 vs. ≥200 copies/mL), standardizing MMP to HIV Outpatient Study data using multivariable regression models and yielding adjusted VS estimates. We estimated that 52% (95% CI: 48, 56) of HIV-diagnosed persons achieved VS in 2012. Differences from previously published estimates were due to: 1) 23% underestimation of persons receiving HIV care, and 2) lower VS rates among persons receiving care outside versus inside the 4-month MMP sampling period (79% vs. 88%). This methodology yielded VS estimates closer to the National HIV Surveillance System estimate than previously published. Use of more, geographically diverse cohort data may enable assessment of temporal trends.

Psychiatric Illness, Substance Use, and Viral Suppression Among HIV-Positive Men of Color Who Have Sex with Men in Los Angeles.

For individuals living with human immunodeficiency virus (HIV), viral suppression positively affects quality and length of life and reduces risks for HIV transmission. Men of color who have sex with men (MoCSM) who have been diagnosed with HIV have disproportionately low rates of viral suppression, with concomitant increases in incidence. We identified specific social, structural, and psychiatric factors associated with viral suppression among a sample of 155 HIV-positive MoCSM. Cigarette smoking and biological markers of recent drug use were significantly associated with detectable viral load. In contrast, individuals reporting a history of psychiatric illness during medical examination were more likely to be virally suppressed. Further analyses demonstrated that psychiatric illness may affect virologic outcomes through increased probability of being prescribed HIV medications. Alternatively, cigarette smoking and drug use appear to negatively affect subsequent HIV Care Continuum milestones such as medication adherence. Findings provide support for comprehensive intervention programs that emphasize prevention and treatment of cigarette, methamphetamine, and other drug use, and promote improved connection to psychiatric care. Continual achievement of this goal may be a crucial step to increase rates of viral suppression and slow HIV incidence in communities of MoCSM in Los Angeles and other urban areas.

Perinatally HIV-Infected Youths After Transition from Pediatric to Adult Care, a Single-Center Experience from Northern Italy.

With the development of combination antiretroviral therapy (cART), the first generation of perinatally HIV-infected children has reached young adulthood. A retrospective study was conducted on perinatally HIV-infected young adults after transition to adult care in Brescia (Northern Italy). Twenty-four patients were transferred to Infectious Disease outpatient Clinic from Pediatric Clinic between 2004 and 2016. Median age at transition was 18 years. 37.5% were male, and 75% were Italian. Median CD4+ T-cell count was 534 cell/μL, and 9/24 presented detectable HIV-RNA at the time of transition. At month 12 after transition, median CD4+ T-cell count was 626 cell/μL, and HIV-RNA was still detectable in 25% of patients. Nineteen patients were still in care at the end of follow-up (median of 52 months); 100% on cART, with undetectable HIV-RNA and a median CD4+ T-cell count of 716 cell/μL. After transition, cART regimen was modified in 14/19 patients (in 13 of them it was modified at least twice). Resistance testing is available for 13 patients showing resistance-associated mutations to at least one class of drugs in 9 patients. Transition to adult care is a critical point and youths present lower rates of viral suppression compared to adults. We observed 80% of viral suppression (5 young patients were lost to follow-up and considered as failures), notwithstanding social problems and resistance mutations. With the availability of more potent and better-tolerated drugs, optimization of cART is possible also in this previously difficult-to-treat group of patients. Novel tools to address adherence to cART in young adults and teenagers will also be needed.

Healthcare Engagement among Persons with HIV: More Than Just Viral Load and Clinic Attendance

BackgroundThe traditional definition of engagement in HIV care in terms of only clinic attendance and viral suppression provides a limited understanding of how persons with HIV interact with the healthcare system.MethodsWe conducted a retrospective analysis of patients with ≥ 1 HIV clinic visit at the Duke Adult Infectious Diseases Clinic between 2008 and 2013. Healthcare utilization was characterized by four indicators: clinic attendance in each half of the calendar year (yes/no), number of emergency department (ED) visits (0, 1 or 2+), inpatient admissions per year (0, 1, 2+), and viral suppression (never, intermittent, always). Healthcare engagement patterns were modeled using latent class/latent transition analysis, with model fit assessed using the Bayesian Information Criterion.ResultsThe cohort included 2686 patients (median age 42.9 years, 72% male, 56% black). A three-class model best fit the data: “Adherent” “Non-adherent” and “Sick”. “Adherent” patients had high rates of clinic attendance in each half of the year (84%), rarely visited the ED (3.6% with ≥1 ED visit per year), and moderate rates of (54%) viral suppression. “Non-adherent” patients rarely attended clinic visits in both halves of the year (1.5%), used the ED more than “adherent” patients (10.3% with ≥1 ED visit per year), and had low rates of viral suppression (19%). “Sick” patients also had high rates of clinic attendance (75%), were frequent users of the ED (53% with ≥1 ED visit per year), and comparable rates of viral suppression to the “adherent” group (55%) viral suppression. Non-white race (OR 1.9) and age ≤ 40 (OR 3.76) were associated with membership in the “non-adherent” class. Movement between classes was dynamic, especially in the “sick” group (30–40% of whom moved to a different class the following year). Across all years, persons in the “non-adherent” class were more likely to completely disengage from care the following year than “adherent” persons (23.6% v. 0.2%, P <0.001).ConclusionA broader definition of healthcare engagement revealed distinct and dynamic patterns among persons with HIV that would have been hidden had only clinic attendance and viral suppression been considered. These patterns may be useful for designing engagement-targeted interventions.Disclosures All authors: No reported disclosures.

WeCARE: A Social Media-Based Intervention Designed to Increase HIV Care Linkage, Retention, and Health Outcomes for Racially and Ethnically Diverse Young MSM.

Estimates suggest that only about 30% of all individuals living with HIV in the U.S. have achieved viral suppression. Men who have sex with men (MSM), particularly racial/ethnic minority young MSM, are at increased risk for HIV infection and may have even lower viral suppression rates. HIV testing rates among MSM are low, and when tested, racial/ethnic minority young MSM have disproportionately lower rates of retention in care and viral suppression compared to other subgroups. This article describes the design and development of weCare, our social media-based intervention to improve care linkage and retention and health outcomes among racially and ethnically diverse MSM, ages 13-34, living with HIV that will be implemented and evaluated beginning in late 2016. The intervention harnesses established social media that MSM between these ages commonly use, including Facebook, text messaging, and established GPS-based mobile applications (apps). We are using community-based participatory research (CBPR) to enhance the quality and validity of weCare, equitably involving community members, organization representatives, healthcare providers, clinic staff, and academic researchers.

Strategic information is everyone's business: perspectives from an international stakeholder meeting to enhance strategic information data along the HIV Cascade for people who inject drugs.

People who inject drugs (PWID) are at increased HIV transmission risk because of unsafe injecting practices and a host of other individual, network, and structural factors. Thus, PWID have a great need for services within the Cascade of HIV prevention, diagnosis, care, and treatment (HIV Cascade). Yet the systems that monitor their progress through the Cascade are often lacking. Subsequently, fewer reliable data are available to guide programs targeting this key population (KP). Programmatic data, which are helpful in tracking PWID through the Cascade, also are limited because not all countries have harm reduction programming from which to estimate Cascade indicators. Also, due to stigma and the illegal nature of drug use, PWID may not disclose their drug use behavior or HIV status when accessing services. Consequently, PWID appear to have low HIV testing rates and, for those living with HIV, lower access to health services and lower viral suppression rates than do other KP groups. This commentary, based on outcomes from an international stakeholder meeting, identifies data gaps and proposes solutions to strengthen strategic information (SI), the systematic collection, analysis, and dissemination of information, to optimize HIV prevention, care, and treatment programming for PWID.

P136 Service evaluation of care needs of young people aged under 25 living with HIV: are they consistent?

<h3>Background/introduction</h3> CHIVA standards recommend all adolescents and young people living with HIV have an individualised care plan to transition them to adult services over time, as is appropriate to their age, developmental stage and social circumstances. Within the UK, adolescents living with HIV acquire the infection either via vertical transmission or sexual acquisition. These 2 groups differ in terms of medical, social and psychological needs, with the former group historically doing less well in terms of adherence and prognosis compared to the latter group. <h3>Aim(s)/objectives</h3> To understand and characterise patients under the age of 25 attending for HIV care in a provincial UK adult HIV clinic, and identify care needs. <h3>Methods</h3> Case note review of all HIV positive patients attending care under the age of 25. <h3>Results</h3> Of 39 patients (29 male, 10 female), mode of transmission was 27(69%) sexual, 11(28%) vertical, and 1 unknown. The vertically-acquired cohort have lower CD4 counts (64% vs 93% CD4 &gt;350), more resistance mutations (including triple class resistance) and lower rates of viral suppression (45% vs 90%) compared to the sexually-acquired cohort. Retention in care is also lower, (72% vs 92% attending in the last year). STI rates are high overall but higher in the sexual transmission cohort, 75% vs 55%. <h3>Discussion/conclusion</h3> The under 25 HIV clinic cohort comprises 2 distinct groups: a vertically -acquired cohort with poorer outcomes, who consistently require more support and motivation to remain engaged in care; and a sexually-acquired cohort who adhere to HAART, but have higher rates of STIs and would benefit from support involving motivational interviewing and health promotion.

HIV and reincarceration: time for a comprehensive approach

Individuals who are released from prison have complex health needs that are too often unmet by health-care systems.1,2 In The Lancet HIV, Jaimie Meyer and colleagues3 describe longitudinal treatment outcomes for a cohort of people living with HIV/AIDS who repeatedly interact with the criminal justice system. Their analysis showed very low rates of viral suppression for individuals incarcerated more than once. Although national surveillance data suggest that more than 70% of people who are prescribed antiretroviral therapy (ART) achieve viral suppression, only 31% of patients incarcerated more than once, all of whom previously received ART, had viral suppression at the time of reincarceration.

Efficacy and Safety of Lersivirine Versus Etravirine for the Treatment of HIV-1 Infection in Patients with Prior Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) Use and Evidence of NNRTI Resistance: A Randomized Phase 2B Trial

Objective: To assess the efficacy and safety of lersivirine versus etravirine in patients with HIV-1 and prior non-nucleoside reverse transcriptase inhibitor (NNRTI) use and evidence of NNRTI resistance. Methods: In this 96-week, phase 2b study, 97 patients were randomized and treated with lersivirine 750 mg qd (n = 31), lersivirine 1,000 mg qd (n = 32), and etravirine 200 mg bid (n = 34), plus one optimized nucleoside reverse transcriptase inhibitor and darunavir/ritonavir 600/100 mg bid. The primary endpoint was the percentage of patients with HIV-1 RNA <50 copies/mL at week 24. Results: At week 24, HIV-1 RNA <50 copies/mL was achieved by fewer patients receiving lersivirine 750 mg (48.4%) and 1,000 mg (43.8%) qd compared with etravirine 200 mg qd (67.7%) (intention to treat [ITT], missing/switch/discontinuation equals failure [MSDF]). At week 48, HIV-1 RNA <50 copies/mL and <400 copies/mL were also achieved by fewer patients receiving lersivirine 750 mg (41.9% and 41.9%, respectively) and 1,000 mg (31.3% and 34.4%, respectively) qd compared with etravirine 200 mg bid (61.8% and 70.6%, respectively) (ITT, MSDF). Least squares means (SE) change from baseline in log transformed HIV-1 RNA at week 48 was -1.42 (0.27) and -0.95 (0.28) copies/mL for lersivirine 750 mg and 1,000 mg qd, respectively, versus -2.02 (0.26) copies/mL for etravirine 200 mg bid (ITT). Lersivirine and etravirine were generally safe and well-tolerated. Conclusions: Lersivirine 750 mg and 1,000 mg qd was associated with lower rates of viral suppression at week 24 and week 48 versus etravirine in patients with prior NNRTI use and evidence of NNRTI resistance. No new safety signals were detected.

Earlier Diagnosis of HIV Infection Linked to Lower Rates of Viral Suppression

The HIV continuum-of-care analysis is becoming a standard tool to monitor care objectives. Researchers recently evaluated HIV care outcomes among

Impact of tuberculosis cotreatment on viral suppression rates among HIV-positive children initiating HAART

To evaluate the association between treatment of HIV-tuberculosis (TB) coinfection and primary virologic failure among children initiating antiretroviral therapy in South Africa. We performed a retrospective cohort study of 1029 children initiating antiretroviral therapy at two medical centers in KwaZulu Natal, South Africa, a region of very high TB incidence. Data were extracted from electronic medical records and charts and the impact of TB cotreatment on viral suppression at 6 and 12 months was assessed using logistic regression. The overall rate of virologic suppression (<400 HIV RNA copies/ml) was 85% at 6 months and 87% at 12 months. Children who received concurrent treatment for TB had a significantly lower rate of virologic suppression at 6 months (79 vs. 88%; P = 0.003). Those who received nonnucleoside reverse transcriptase inhibitor-based HAART had similar rates of viral suppression regardless of whether they received concurrent TB therapy. In contrast, children who received protease inhibitor-based HAART had significantly lower viral suppression rates at both 6 and 12 months if treated concurrently for TB (P = 0.02 and 0.03). Multivariate logistic regression revealed that age at initiation, protease inhibitor therapy, and TB coinfection were each independently associated with primary virologic failure. Concurrent treatment for TB is associated with lower rates of viral suppression among children receiving protease inhibitor-based HAART, but not among those receiving nonnucleoside reverse transcriptase inhibitor-based HAART. Guidelines for the care of young HIV-TB coinfected infants should be continually evaluated, as protease inhibitor-based antiviral therapy may not provide optimal viral suppression in this population.

HIV care and treatment for children in resource-limited settings

Although efforts to combat the HIV epidemic have focused on the perinatal reduction of HIV transmission, many children are still being infected with HIV in resource-limited settings. Access to HIV care, cotrimoxazole and antiretroviral therapy (ART) for HIV-infected children has greatly improved in recent years, and has proven to be very effective in reducing mortality in all age categories. Many challenges remain to be resolved, such as the retention in care of children born to HIV-infected mothers, the lack of pharmacokinetic data on ART in malnourished children, optimum timing of ART, treatment and diagnosis of concomitant tuberculosis, and the effects of ART and HIV on the child’s development. In the long term, treatment success might be negated due to lower rates of viral suppression in children and the accumulation of resistance mutations. Evidenced-based comprehensive care models should allow for decentralizing care up to the level of the community, allowing larger numbers of children to receive HIV care.

The Schönlein-Henoch syndrome (anaphylactoid purpura) compared with certain features of nephritis and rheumatism.

<h3>Abstract</h3> <h3>Introduction</h3> Same-day initiation (SDI) of antiretroviral therapy (ART) for HIV consistently increases ART uptake, but concerns remain about higher attrition from care after initiation. We analysed twelve-month retention in the SLATE SDI trials. <h3>Methods</h3> SLATE I and SLATE II were individually randomized trials at public outpatient clinics in Johannesburg that enrolled patients not yet on ART and administered the SLATE I or II algorithm, which included a symptom self-report, medical history, brief physical examination, and readiness questionnaire, to assess eligibility for SDI. ART uptake and early retention have been reported. Using routine clinic records, we conducted a pooled analysis of retention in care and HIV viral suppression 14 months after study enrolment. <h3>Results and discussion</h3> We enrolled 1,193 study participants (standard arms, n=599, 50%; intervention arms, n=594, 50%) and analysed by originally assigned groups. By 14 months after study enrolment (equivalent to 12-month retention in care), 50% of intervention arm patients and 46% of standard arm patients remained in care at the initiating site (crude risk difference 4% (95% confidence interval −1% to 10%; crude relative risk 1.10 (0.97-1.23), with similar viral suppression between arms. Observed attrition from care at site by 14 months was high in both study arms, but we found no evidence that the offer of SDI led to greater overall attrition or lower rates of viral suppression one year after starting ART and may have led to small improvements. Same-day initiation may have shifted some attrition from before to after dispensing of the first dose of medication. <h3>Conclusions</h3> An offer of same-day initiation of ART, following a carefully designed protocol to identify patients who are eligible and ready to start treatment, is not inherently associated with an overall increase in patient attrition from care. <h3>Trial registration</h3> Clinicaltrials.govNCT02891135, registered September 1, 2016. First participant enrolled March 6, 2017 in South Africa. Clinicaltrials.govNCT03315013, registered October 19, 2017. First participant enrolled 14 March 2018.