People Living With HIV In Care Research Articles

Evaluation of an HIV homecare program for lost-to-follow-up populations: a mixed methods study in Detroit, Michigan

BackgroundMaintaining people living with HIV (PLWHIV) in clinical care is a global priority. In the Metro Detroit area of Michigan, approximately 30% of PLWHIV are out of care. To re-engage lost-to-follow-up patients, Wayne Health Infectious Disease clinic launched an innovative Homecare program in 2017. In addition to home healthcare delivery, the program included links to community resources and quarterly community meetings. We aimed to evaluate Homecare’s impact on participants’ ability to stay engaged in HIV care and reach viral suppression. We included data from PLWHIV and their healthcare workers.MethodsWe used a convergent mixed-methods design, including first year program record review, semi-structured interviews, and a validated Likert scale questionnaire rating illness perception before and after Homecare. Interview data were collected from 15 PLWHIV in Metro Detroit and two healthcare workers responsible for program delivery. Semi-structured interviews focused on obstacles to clinic-based care, support networks, and illness perceptions. Interview data were transcribed and analyzed using a thematic approach. A fully coded analysis was used to create a conceptual framework of factors contributing to Homecare’s success. Means in eight categories of the Brief Illness Perception (IPQ) were compared using paired T-tests.ResultsIn the first year of Homecare, 28 of 34 participants (82%) became virally suppressed at least once. The program offered (1) social support and stigma reduction through strong relationships with healthcare workers, (2) removal of physical and resource barriers such as transportation, and (3) positive changes in illness perceptions. PLWHIV worked towards functional coping strategies, including improvements in emotional regulation, acceptance of their diagnosis, and more positive perspectives of control. Brief-IPQ showed significant changes in six domains before and after Homecare.ConclusionHomecare offers an innovative system for successfully re-engaging and maintaining lost-to-follow-up PLWHIV in care. These findings have implications for HIV control efforts and could inform the development of future programs for difficult to reach populations.

Cross-sectional HIV and HCV cascades of care across the regions of Ukraine between 2019 and 2020: findings from the CARE cohort.

Eastern Europe is facing major HIV and hepatitis C (HCV) epidemics, with many people living with HIV (PLHIV) and HIV/HCV coinfection living in Ukraine. Despite the previous progress towards care quality improvement, the ongoing war in Ukraine is disrupting HIV and HCV care. We described an HIV cascade of care (CoC) in PLHIV from two clinical sites and an HCV CoC for anti-HCV-positive PLHIV from six sites in Ukraine, enrolled in the CARE cohort between 1 January 2019 and 1 June 2020. The cross-sectional HIV CoC and HCV CoC are described at study enrolment. Of 1028 PLHIV, 1014 (98.6%, 95% confidence interval [CI] 97.7-99.3) were on antiretroviral therapy (ART), and 876 (86.4% of those on ART, 95% CI 84.1-88.4) were virologically suppressed. Of 894 participants on ART >6 months, 90.8% (95% CI 88.7-92.6) were virologically suppressed (HIV-RNA <200 copies/ml). Of 2040 anti-HCV-positive PLHIV, 417 (20.4%, 95% CI 18.7-22.3) were ever tested for HCV-RNA prior to enrolment, ranging from 4.9% to 54.4% across sites, and 13.5% were currently HCV-RNA positive. One hundred and eighteen persons (7.3% of ever chronically infected) had received HCV treatment, and 25 persons (1.6% of ever chronically infected) were cured, with variations across sites (0%-7.5%). The site diagnosing 54.4% of people with chronic HCV was the only one providing free RNA testing for all anti-HCV-positive persons, while the intra-country differences in treatment coverage were driven by the number of available direct-acting antiviral (DAA) courses. Over 98% of PLHIV in care in both CARE sites in Ukraine were receiving ART, and the target of 90% virally suppressed was achieved in persons >6 months on ART. Only one of six HIV/HCV study sites tested over 50% anti-HCV-positive PLHIV for HCV-RNA and treated over 25% of eligible persons. While free HCV-RNA testing and DAA treatment are paramount to achieving HCV elimination targets, they remained a challenge in Ukraine in 2019-2020. The extent of the HIV and HCV care disruption during the war will be further assessed in the CARE cohort and compared with the pre-war findings.

Heavily treatment-experienced people living with HIV in the OPERA® cohort: population characteristics and clinical outcomes

BackgroundMulti-class resistance, intolerance, and drug–drug interactions can result in unique antiretroviral (ART) combinations for heavily treatment-experienced (HTE) people living with HIV (PLWH). We aimed to compare clinical outcomes between HTE and non-HTE PLWH.MethodsEligible ART-experienced PLWH in care in the OPERA® Cohort were identified in a cross-sectional manner on December 31, 2016 and observed from the date of initiation of the ART regimen taken on December 31, 2016 until loss to follow up, death, study end (December 31, 2018), or becoming HTE (non-HTE group only). In the absence of resistance data, HTE was defined based on the ART regimens used (i.e., exposed to ≥ 3 core agent classes or regimen suggestive of HTE). Time to virologic undetectability, failure, and immunologic preservation were assessed using Kaplan–Meier methods; cumulative probabilities were compared between the two groups. Regimen changes, incident morbidities, and death were described.ResultsA total of 24,183 PLWH (2277 HTE PLWH, 21,906 non-HTE) were followed for a median of 28 months (IQR 21, 38). Viremic HTE PLWH (viral load [VL] ≥ 50 copies/mL) were less likely to achieve undetectability (VL < 50 copies/mL; 24-month cumulative probability: 80% [95% Confidence Interval 77–82]) than their non-HTE counterparts (85% [84–86]). No difference was observed in the probability of maintaining VLs < 200 copies/mL over the first 48 months after achieving suppression (< 50 copies/mL). HTE PLWH were less likely than non-HTE PLWH to maintain CD4 cell counts ≥ 200 cells/µL (24-month cumulative probability: 95% HTE [91–93]; 97% non-HTE [97–97]), and more likely to change regimens (45% HTE; 41% non-HTE). Incident non-AIDS defining event (ADE) morbidities were common in both populations, though more likely among HTE PLWH (45%) than non-HTE PLWH (35%). Incident ADE morbidities and deaths were uncommon among HTE (ADEs 5%; deaths 2%) and non-HTE (ADEs 2%; deaths 1%) PLWH.ConclusionsHTE PLWH were at greater risk of unfavorable treatment outcomes than non-HTE PLWH, suggesting additional therapeutic options are needed for this vulnerable population.

Cross sectional analysis of the effect of alcohol on pulmonary function in a cohort of men and women living with HIV.

People living with HIV (PLWH) are at increased risk for noncommunicable diseases such as lung disease in part due to opportunistic infections including pneumonia. HIV infection is associated with increased prevalence of impaired lung function and abnormal gas exchange. Alcohol use disorder (AUD) is exceedingly common in PLWH and is associated with higher risk of pneumonia in PLWH. Alcohol use may lead to lung damage through several mechanisms. Data on the long-term effect of AUD on pulmonary function in PLWH are sparse and conflicting. To evaluate this relationship, we conducted a cross-sectional analysis of adult PLWH in care in Louisiana. We hypothesized that chronic alcohol use would be associated with subsequent pulmonary dysfunction in a dose-dependent fashion. All participants performed standardized spirometry on study entry. In total, 350 participants with acceptable spirometry were included in this analysis. Thirty-one percent of participants were female. Women reported less lifetime alcohol use and less smoking; however, they reported more chronic respiratory symptoms. In adjusted models, total lifetime alcohol use was not associated with spirometry measures of pulmonary function. HIV-related variables (CD4 count and viral load) were also not associated with measures of pulmonary function. We then conducted sex-stratified analyses to eliminate residual confounding of sex and similarly found no association of total lifetime alcohol use and pulmonary function. We found no association of AUDIT score or early life alcohol use and pulmonary function. In latent class factor analysis, current heavy alcohol use was associated with lower measures of pulmonary function as compared to former heavy alcohol use. In summary, in this cohort of New Orleanian men and women living with HIV with robust measures of alcohol use, though total lifetime alcohol use and early life alcohol use were not associated with pulmonary function, current heavy alcohol use was associated with impaired pulmonary function.

“The one who doesn’t take ART medication has no wealth at all and no purpose on Earth” – a qualitative assessment of how HIV-positive adults in Uganda understand the health and wealth-related benefits of ART

BackgroundIncreases in life expectancy from antiretroviral therapy (ART) may influence future health and wealth among people living with HIV (PLWH). What remains unknown is how PLWH in care perceive the benefits of ART adherence, particularly in terms of improving health and wealth in the short and long-term at the individual, household, and structural levels. Understanding future-oriented attitudes towards ART may help policymakers tailor care and treatment programs with both short and long-term-term health benefits in mind, to improve HIV-related outcomes for PLWH.MethodsIn this qualitative study, we conducted semi-structured interviews among a subsample of 40 PLWH in care at a clinic in Uganda participating in a randomized clinical trial for treatment adherence in Uganda (clinicaltrials.gov: NCT03494777). Interviews were transcribed verbatim and translated from Luganda into English. Two co-authors independently reviewed transcripts, developed a detailed codebook, achieved 93% agreement on double-coded interviews, and analyzed data using inductive and deductive content analysis. Applying the social-ecological framework at the individual, household, and structural levels, we examined how PLWH perceived health and wealth-related benefits to ART.ResultsOur findings revealed several benefits of ART expressed by PLWH, going beyond the short-term health benefits to also include long-term economic benefits. Such benefits largely focused on the ability of PLWH to live longer and be physically and mentally healthy, while also fulfilling responsibilities at the individual level pertaining to themselves (especially in terms of positive long-term habits and motivation to work harder), at the household level pertaining to others (such as improved relations with family and friends), and at the structural level pertaining to society (in terms of reduced stigma, increased comfort in disclosure, and higher levels of civic responsibility).ConclusionsPLWH consider short and long-term health benefits of ART. Programming designed to shape ART uptake and increase adherence should emphasize the broader benefits of ART at various levels. Having such benefits directly integrated into the design of clinic-based HIV interventions can be useful especially for PLWH who face competing interests to increase medication adherence. These benefits can ultimately help providers and policymakers better understand PLWH’s decision-making as it relates to improving ART-related outcomes.

Disengagement From HIV Care and Failure of Second-Line Therapy in Nigeria: A Retrospective Cohort Study, 2005-2017.

Understanding the correlates of disengagement from HIV care and treatment failure during second-line antiretroviral therapy (ART) could inform interventions to improve clinical outcomes among people living with HIV (PLHIV). We conducted a retrospective cohort study of PLHIV aged >15 years who started second-line ART at a tertiary center in Nigeria between 2005 and 2017. Participants were considered to have disengaged from care if they had not returned within a year after each clinic visit. Cox proportional hazard models were used to investigate factors associated with: (1) viral failure (HIV-1 RNA >1000 copies/mL), (2) immunologic failure (CD4 count decrease or <100 cells/mm3), and (3) severe weight loss (>10% of bodyweight), after >6 months of second-line ART. Among 1031 participants, 33% (341) disengaged from care during a median follow-up of 6.9 years (interquartile range 3.7-8.5). Of these, 26% (89/341) subsequently reentered care. Disengagement was associated with male gender, age <30 years, lower education level, and low CD4 count at second-line ART initiation. Among participants with endpoint assessments available, 20% (112/565) experienced viral failure, 32% (257/809) experienced immunologic failure, and 23% (190/831) experienced weight loss. A lower risk of viral failure was associated with professional occupations compared with elementary: adjusted hazard ratio 0.17 (95% confidence interval 0.04 to 0.70). Adverse outcomes were common during second-line ART. However, reengagement is possible and resources should be allocated to focus on retaining PLHIV in care and providing services to trace and reengage those who have disengaged from care.

Factors Associated with Severe COVID-19 and Post-Acute COVID-19 Syndrome in a Cohort of People Living with HIV on Antiretroviral Treatment and with Undetectable HIV RNA.

SARS-CoV-2 can produce both severe clinical conditions and long-term sequelae, but data describing post-acute COVID-19 syndrome (PACS) are lacking for people living with HIV (PLWH). We aimed at assessing the prevalence and factors associated with severe COVID-19 and PACS in our cohort. We included all unvaccinated adult PLWH on antiretroviral treatment and plasma HIV-RNA < 40 cp/mL since at least six months before SARS-CoV-2 infection at the Infectious and Tropical Diseases Unit of Padua (Italy), from 20 February 2020 to 31 March 2021. COVID-19 severity was defined by WHO criteria; PACS was defined as the persistence of symptoms or development of sequelae beyond four weeks from SARS-CoV-2 infection. Demographic and clinical variables were collected, and data were analyzed by non-parametric tests. 123 subjects meeting the inclusion criteria among 1800 (6.8%) PLWH in care at the Infectious and Tropical diseases Unit in Padua were diagnosed with SARS-CoV-2 infection/COVID-19 during the study period. The median age was 51 years (40–58), 79.7% were males, and 77.2% of Caucasian ethnicity. The median CD4+ T-cell count and length of HIV infection were 560 cells/mmc (444–780) and 11 years, respectively. Of the patients, 35.0% had asymptomatic SARS-CoV-2 infection, 48% developed mild COVID-19, 17.1% presented moderate or severe COVID-19 requiring hospitalization and 4.1% died. Polypharmacy was the single independent factor associated with severe COVID-19. As for PACS, among 75 patients who survived SARS-CoV-2 symptomatic infection, 20 (26.7%) reported PACS at a median follow-up of six months: asthenia (80.0%), shortness of breath (50.0%) and recurrent headache (25.0%) were the three most common complaints. Only the severity of the COVID-19 episode predicted PACS after adjusting for relevant demographic and clinical variables. In our study, PLWH with sustained viral suppression and good immunological response showed that the risk of hospital admission for COVID-19 was low, even though the severity of the disease was associated with high mortality. In addition, the likelihood of developing severe COVID-19 and PACS was mainly driven by similar risk factors to those faced by the general population, such as polypharmacy and the severity of SARS-CoV-2 infection.

The challenge of minimizing tuberculosis burden in people living with HIV in the Asia Pacific.

The challenge of minimizing tuberculosis burden in people living with HIV in the Asia Pacific.

Hepatitis B screening practices and viral control among persons living with HIV in urban Senegal.

Chronic hepatitis B virus (HBV) infection affects >10% of the general population and is the leading cause of liver cirrhosis and cancer in West Africa. Despite current recommendations, HBV is often not tested for in clinical routine in the region. We included all people living with HIV (PLWH) in care between March and July 2019 at Fann University Hospital in Dakar (Senegal) and proposed hepatitis B surface antigen (HBsAg) test to those never tested. All HBsAg‐positive underwent HIV and HBV viral load (VL) and liver stiffness measurement. We evaluated, using logistic regression, potential associations between patient characteristics and (a) HBV testing uptake; (b) HIV/HBV co‐infection among individual HBsAg tested. We determined the proportion of co‐infected who had HBV DNA >20 IU/ml on ART and sequenced HBV polymerase in those with HBV replication.of 1076 PLWH in care, 689 (64.0%) had never had an HBsAg test prior to our HBV testing intervention. Women and individuals >40 years old were less likely to have been previously tested. After HBV testing intervention,107/884 (12.1%) PLWH were HBsAg‐positive. Seven of 58 (12.1%) individuals newly diagnosed with HIV/HBV co‐infection had a detectable HBV VL, of whom five were HIV‐suppressed. Two patients on ART including 3TC and AZT as backbone showed the presence of the triple resistance mutation 180M/204I/80V. In this Senegalese urban HIV clinic, the majority of patients on ART had never been tested for HBV infection. One in ten co‐infected individuals had a detectable HBV VL despite HIV suppression, and 8% were not receiving a TDF‐containing regimen.

Role of Self-Stigma in Pathways from HIV-Related Stigma to Quality of Life Among People Living with HIV.

This study examined the relationships between perceived public stigma, experienced stigma, and quality of life in people living with HIV (PLHIV), and whether self-stigma mediates these relationships. Cross-sectional data were analyzed from 1704 PLHIV in care at OLVG hospital in the Netherlands. We measured different types of stigma (perceived public stigma, experienced stigma, and self-stigma), and various quality-of-life outcomes (disclosure concerns, depression, anxiety, sexual problems, sleeping difficulties, self-esteem, general health, and social support). Structural equation modeling was used to test the paths from different types of stigma to quality-of-life outcomes. All direct effects of self-stigma on quality-of-life outcomes were significant. The final mediation model showed that the effects of both perceived public and experienced stigma on quality-of-life outcomes were mediated by self-stigma. These findings highlight the importance of addressing self-stigma in PLHIV, and call for (psychosocial) interventions that reduce the harmful effects of HIV-related stigma.

Jail-Based Data-to-Care to Improve Continuity of HIV Care: Perspectives and Experiences from Previously Incarcerated Individuals.

Incarceration can disrupt retention in HIV care and viral suppression, yet it can also present an opportunity to reengage people living with HIV (PLWH) in care. Data-to-care (D2C) is a promising new public health strategy that uses HIV surveillance data to improve continuity of care for PLWH. The goal of this study was to examine perspectives on and experiences with D2C among PLWH who had recently been incarcerated in jail. Semistructured, qualitative interviews were conducted with 24 PLWH in community and prison settings about (1) knowledge of and experiences with D2C and (2) attitudes about implementing D2C in the jail setting. Participants who had been contacted for D2C described their interactions with state public health workers favorably, although almost half were not aware that the state performs HIV surveillance and D2C. While most participants indicated they would welcome assistance from the state for reengaging in care, they also framed retention in care as an individual responsibility. Most participants supported the idea of jail-based D2C. A vocal minority expressed adamant opposition, citing concerns about the violation of privacy and the threat of violence in the jail setting. Findings from this study suggest that D2C interventions in jails could be beneficial to reengaging PLWH in care, and acceptable to PLWH if done in a way that is sensitive to the needs and concerns of incarcerated individuals. If implemented, jail-based D2C programs must be designed with care to preserve privacy, confidentiality, and the autonomy of incarcerated individuals.

Types of Stroke Among People Living With HIV in the United States.

Most studies of stroke in people living with HIV (PLWH) do not use verified stroke diagnoses, are small, and/or do not differentiate stroke types and subtypes. CNICS, a U.S. multisite clinical cohort of PLWH in care. We implemented a centralized adjudication stroke protocol to identify stroke type, subtype, and precipitating conditions identified as direct causes including infection and illicit drug use in a large diverse HIV cohort. Among 26,514 PLWH, there were 401 strokes, 75% of which were ischemic. Precipitating factors such as sepsis or same-day cocaine use were identified in 40% of ischemic strokes. Those with precipitating factors were younger, had more severe HIV disease, and fewer traditional stroke risk factors such as diabetes and hypertension. Ischemic stroke subtypes included cardioembolic (20%), large vessel atherosclerosis (13%), and small vessel (24%) ischemic strokes. Individuals with small vessel strokes were older, were more likely to have a higher current CD4 cell count than those with cardioembolic strokes and had the highest mean blood pressure of the ischemic stroke subtypes. Ischemic stroke, particularly small vessel and cardioembolic subtypes, were the most common strokes among PLWH. Traditional and HIV-related risk factors differed by stroke type/subtype. Precipitating factors including infections and drug use were common. These results suggest that there may be different biological phenomena occurring among PLWH and that understanding HIV-related and traditional risk factors and in particular precipitating factors for each type/subtype may be key to understanding, and therefore preventing, strokes among PLWH.

606. HIV Homecare: Understanding its Impact for Lost-to-Follow-Up Populations

BackgroundMaintaining people living with HIV (PLWH) in clinical care is a global priority. In the metro-Detroit area of Michigan, approximately 30% of PLWH are out of care. To re-engage lost-to-follow-up patients, the Wayne State University Physician Group – Infectious Disease clinic launched an innovative Homecare program in 2017. In addition to home healthcare delivery, the program included links to community resources and quarterly community meetings. In the first year of Homecare, 28 of 34 participants became virally suppressed at least once. We aimed to understand reasons why people who left clinic-based treatment were able to become virally suppressed in this program. We included data from PLWH and their healthcare workers.MethodsWe used a mixed-methods design, including (1) semi-structured interviews with PLWH and healthcare workers, and (2) a validated Likert scale questionnaire rating illness perception before and after Homecare. Data were collected from 15 PLWH in metro-Detroit and two healthcare workers responsible for program delivery. Semi-structured interviews focused on obstacles to clinic-based care, support networks, and illness perceptions. Interview data were transcribed and analyzed using a grounded theory approach. A fully coded analysis was used to create a conceptual framework of factors contributing to Homecare’s success. Means in eight categories of the brief illness perception questionnaire (BIPQ) were compared using paired T-tests.ResultsThe Homecare program offered (1) social support and stigma reduction through strong relationships with healthcare workers; (2) removal of physical and resource barriers such as transportation; and (3) positive changes in illness perceptions. PLWH worked towards functional coping strategies, including improvements in emotional regulation, acceptance of their diagnosis, and more positive perspectives of control. BIPQ showed significant changes in six domains before and after Homecare.Homecare Conceptual Framework General Joint Display: Brief Illness Perception Questionnaire ConclusionHomecare offers an innovative system for successfully re-engaging and maintaining lost-to-follow-up PLWH in care. These findings have implications for HIV control efforts and could inform the development of future programs for difficult to reach populations.Disclosures All Authors: No reported disclosures

Predictors of vaccination rates in people living with HIV followed at a specialty care clinic

ABSTRACT People Living with HIV (PLWH) remain disproportionately susceptible to vaccine-preventable illnesses due to increased morbidity and mortality from common pathogens, increased transmission related to epidemiologic factors, and decreased vaccination rates. We aimed to describe patient-specific predictive factors that may impact adherence to the CDC’s recommended vaccination schedules in PLWH. We retrospectively evaluated adult PLWH in care at the University of Nebraska Medical Center’s HIV clinic and collected information related to demographics, clinic visits, vaccination status, and measures of HIV disease control. Patients were categorized as “Adherent” if they had received all vaccinations for which they were eligible and were categorized as “Non-Adherent” if they were deficient or delayed in receiving one or more vaccinations. Participant characteristics were compared between groups by multivariable logistic regression to identify predictors associated with vaccine schedule non-adherence. We evaluated 502 PLWH who met our inclusion criteria; 206 of these (41%) had received all eligible vaccinations, while 296 (59%) were missing one or more vaccinations. The mean age of participants was 48 years old, 76% were male, and 53% were white. Our participants had a median of 2.83 clinic visits per year and missed 8.3% of scheduled clinic visits. Factors associated with non-adherence to vaccination schedules included a high frequency of missed clinic appointments (>10%), men who have sex with men, and a CD4 count <200 cells/mm3. Knowledge of variables associated with vaccination rates may be beneficial in identifying patients at-risk for under-vaccination and designing targeted education programs for providers and patients.

PIN89 REGIMEN DURABILITY AMONG HEAVILY TREATMENT-EXPERIENCED (HTE) COMPARED TO NON-HTE TREATMENT-EXPERIENCED HIV PATIENTS IN THE OPERA COHORT

To compare durability of antiretroviral therapy (ART) regimens among heavily treatment-experienced (HTE) people living with HIV (PLWH) and non-HTE treatment-experienced PLWH in care in the United States. ART-experienced PLWH in care in the OPERA Cohort on 12/31/2016 were identified as HTE (defined as being on a regimen indicative of HTE or experienced ≥3 core agent classes prior to current regimen) or non-HTE treatment experienced (not meeting the definition of HTE and on a three-drug regimen of 1 core agent and 2 nucleoside reverse transcriptase inhibitors (NRTIs)). Core agents were ART medications in classes other than NRTI. Regimens indicative of HTE included: twice-daily dolutegravir, twice-daily darunavir, etravirine, maraviroc, enfuvirtide, or integrase inhibitor+ protease inhibitor. Baseline was the start of the regimen taken on 12/31/2016; study end was 12/31/2018. Differences in time to regimen modification (defined as switching, discontinuing, or adding core agents) were compared using Kaplan-Meier methods. HTE PLWH (n=2,277) were more likely to experience regimen modifications than non-HTE PLWH (n=21,906) (HTE: 45.3%, non-HTE: 41.3%; p=0.0002), but HTE had longer times to first modification [median 27.2 months (IQR: 16.6, 46.4)] than non-HTE [23.0 months (IQR: 14.4, 33.8); log-rank p<0.0001]. Among HTE PLWH, modifications to regimens containing ≥2 core agents occurred most frequently (58.4%). Modifications were more likely single core agent switches among non-HTE, including switches within the same ART class (non-HTE: 22.7%, HTE: 4.8%; p<0.0001) or between different classes (non-HTE: 35.8%, HTE: 7.8%; p<0.0001). HTE PLWH were less likely to experience treatment gaps of >45 days (HTE: 20.7%, non-HTE: 33.4%; p<0.0001). HTE PLWH often require complex, highly-tailored ART regimens due to decreased effectiveness and tolerability of multiple ART classes developed over long-term ART exposure. In this analysis, baseline regimens were less durable among HTE PLWH, with more frequent and complex regimen modifications needed compared to non-HTE PLWH.

Barriers influencing task-shifting for the management of depression in people living with HIV: a study from West Africa IeDEA cohort collaboration

ABSTRACT Depression is highly prevalent in people living with HIV (PLHIV) worldwide. As mental health specialists are scarce in sub-Saharan Africa (SSA), the World Health Organization (WHO) encourages task-shifting. We aimed to evaluate the barriers that could compromise task-shifting in front-line health care workers (HCWs) who provide HIV integrated care in West Africa. We collected knowledge, attitudes and practices (KAP) information on symptoms, causes and management of depression in PLHIV in care in four clinics in Senegal and Côte d'Ivoire (N = 168). The main barriers that could compromise task-shifting came from poor knowledge, particularly on symptoms and causes. Knowledge was more limited in HCWs other than medical doctors (good answers < 70%). The access to a depression training was limited (32.7%) and was the main factor associated to poor knowledge on depression. Even when social distance and barriers to practice were low (70.8% and 69.6%, respectively), some barriers persisted. More than half of respondents considered that diagnosis and management needed to be performed by a specialist. To guarantee the success of task-shifting, in the perspective of integrated care, efforts are needed to improve the access to specific training on depression considering screening, management, but also perceptions and attitudes, as some barriers subsist.

Mortality and causes of death in people living with HIV in the era of combination antiretroviral therapy compared with the general population in Japan.

Objectives:To determine the mortality and causes of death in people living with HIV (PLHIV) in Japan.Design:A prospective cohort study at AIDS Clinical Center, Tokyo, which treats approximately 10% of PLHIV in care in Japan.Methods:Either PLHIV who visited our center for the first time between January 2005 and December 2014 or PLHIV who started their regular visit before January 2005 and visited us between January and March 2005 were included and followed by the end of 2016. Causes of death were defined according to the CoDe protocol.Results:Two thousand, seven hundred and ninety-seven PLHIV were analysed with total of 18 858 person-years of follow-up, which constitutes 14% of the estimated number of PLHIV in care in Japan. One hundred and sixty-five (5.9%) PLHIV died with all-cause mortality rate of 8.75 per 1000 person-years. All-cause mortality rate for PLHIV in care in Japan was estimated to be 8.75 per 1000 person-years (95% CI 5.53–12.0). Among causes of death, AIDS-defining illnesses accounted for 39% and malignancy contributed to 47%. Standardized mortality ratio (SMR) for all-cause mortality, malignancy-related mortality, and suicide were 5.96 (95% CI 5.05–6.87), 7.76 (95% CI 6.02–9.51), and 3.24 (95% CI 1.54–4.94), respectively. Even among the patients who were diagnosed early or without history of AIDS, SMR was four times higher than the general population.Conclusion:Mortality of PLHIV, even among those with early diagnosis, is substantially higher than that of the general population in Japan, highlighting the importance of further efforts towards prevention, early diagnosis and prompt treatment initiation.

Opioid misuse among persons with HIV engaged in care in the Southeastern US

ABSTRACT The prevalence of opioid misuse by people living with HIV (PLWH) during the current US opioid epidemic has not been fully described. Among a cohort of persons engaged in HIV care in North Carolina, we examined the prevalence of and risk factors for opioid misuse, defined as self-reported “street” opioid use (e.g., heroin) or nonmedical prescription opioid use on a patient reported outcomes survey. Recent (past three-month) opioid misuse among 1,440 PLWH in care 2012–2017 was 2% (95% CI 2-3%) and lifetime misuse 15% (13-16%). Persons reporting lifetime or recent misuse more commonly had hepatitis C and reported injecting drugs. In multivariable logistic regression models, male-to-male sexual contact was inversely associated with recent or lifetime misuse. White/non-Hispanic race/ethnicity was associated with lifetime misuse and CD4 count and viral load were not associated with opioid misuse. Among 32 persons reporting recent misuse, 81% had a contemporaneous viral load <50 copies/mL. In this cohort of PLWH engaged in care, recent opioid misuse prevalence was similar to general population estimates. Assessments of opioid misuse among PLWH not in care are urgently needed to fully characterize the impact of opioids on all PLWH.

Potential lung cancer screening outcomes using different age and smoking thresholds in the ANRS-CO4 French Hospital Database on HIV cohort.

In most lung screening programmes, only subjects ≥55years old and smoking ≥30 pack-years are eligible to undergo chest low-dose computed tomography. Whether the same criteria should apply to people living with HIV (PLHIV) is uncertain, given the increased lung cancer risks associated with immunodeficiency and high rates of smoking. We assessed different outcomes obtained from simulating one round of lung cancer screening in PLHIV using different age and smoking thresholds for eligibility. Data from the French Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS)-CO4 French Hospital Database on HIV (FHDH) cohort of PLHIV and a national representative survey of PLHIV in care in 2011 (the ANRS-VESPA2 [enquête sur les personnes atteintes] study) were used to estimate the maximum proportion of incident lung cancers occurring between 2012 and 2016 that would have potentially been detected by screening in 2011. Secondary outcomes were numbers of eligible subjects in the cohort and numbers of subjects needed to screen (NNS) to detect one lung cancer. Among 77819 PLHIV in 2011 (median age 46years; 66% men), 285 subjects subsequently developed lung cancer. Adoption of the US Preventive Services Task Force (USPSTF) recommendations (55-80years; ≥30 pack-years) would have detected 31% of lung cancers at most. Lowering the minimum age to 50 and 45years would have detected 49% and 60% of cancers, respectively, but would have greatly increased the number of eligible subjects and the NNS to detect one case of lung cancer. Use of the USPSTF criteria would have detected only a minority of lung cancers in a large French cohort of PLHIV in 2011. Screening PLHIV at younger ages (45 or 50years) and/or the use of lower smoking thresholds (20 pack-years) may be beneficial, despite the consequently higher numbers of eligible subjects and NNS to detect one case of lung cancer, and should be evaluated in future studies.

Virologic Outcomes Among ART-Naïve Individuals Initiating Dolutegravir, Elvitegravir, Raltegravir or Darunavir: An Observational Study.

IntroductionDolutegravir (DTG), Elvitegravir (EVG), Raltegravir (RAL) and Darunavir (DRV) are commonly prescribed core agents for antiretroviral therapy (ART), and a need exists to compare their clinical effectiveness, as defined by virologic failure risks in real-world settings.MethodsThis observational analysis of a US clinical cohort consisted of ART-naïve people living with HIV (PLWH) in the OPERA database initiating DTG-, EVG-, RAL- or DRV-based regimens between August 2013 and July 2016, with follow-up to July 2017. PLWH were observed from first core agent initiation until core agent discontinuation, clinical activity cessation, death, or study end. Key outcomes included viral suppression (HIV RNA < 50 copies/mL) and confirmed virologic failure (two consecutive viral loads > 200 copies/mL or a viral load > 200 copies/mL followed by discontinuation). Association between core agent and time to virologic failure was assessed with multivariate Cox proportional hazards models.ResultsOverall, 4049 ART-naïve PLWH initiated EVG (47.4%), DTG (34.7%), DRV (14.6%), or RAL (3.2%). DTG and EVG initiators had generally similar baseline demographics and clinical characteristics, including race, risk of infection, baseline viral load, and baseline CD4 levels. RAL and DRV initiators were older and generally sicker than DTG initiators. During follow-up, more DTG initiators achieved virologic suppression (78.7%) compared with EVG (73.6%; p < 0.05), RAL (51.9%; p < 0.0001) and DRV (48.6%; p < 0.0001) initiators. Compared to DTG, both RAL and DRV were associated with higher rates of virologic failure, with adjusted hazard ratios (95% confidence interval) of 4.70 (3.03, 7.30) and 2.38 (1.72, 3.29), respectively. No difference was observed between EVG and DTG with an adjusted hazard ratio of 1.24 (0.94, 1.64).ConclusionIn this large cohort representative of PLWH in care in the US, ART-naïve PLWH prescribed DTG had better virologic outcomes than RAL and DRV, but had virologic failure risks comparable to EVG, although RAL and DRV were preferentially prescribed to sicker individuals.FundingViiV Healthcare.