Viral Non-suppression Research Articles

Factors associated with viral load non-suppression in people living with HIV on ART in Nigeria: cross-sectional analysis from 2017 to 2021

ObjectivesIdentify factors (demographic and clinical) associated with a non-suppressed viral load (VL) of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Nigeria.DesignCross-sectional study.SettingSixteen US Agency for International Development...

Assessing community barriers exacerbating viral non-suppression in children living with HIV (CLHIV) in Mangochi, Malawi

Assessing community barriers exacerbating viral non-suppression in children living with HIV (CLHIV) in Mangochi, Malawi

Factors Associated with HIV Virological Non-Suppression Among Adults Receiving Anti-Retroviral Therapy at Lira Regional Referral Hospital, Northern Uganda

Background: By 2030, all Adults with HIV will have been diagnosed, will be receiving antiretroviral therapy (ART), and will have achieved viral load suppression. These goals form the global effort to stop new HIV infections, increase treatment coverage, and end AIDS-related deaths. This study investigated the variables that affect HIV RNA viral non-suppression among Adults living with HIV at Lira Regional Referral Hospital in Uganda. Methods: For this mixed-methods study, data was collected using a data extraction form, a semi-structured questionnaire, and a key informant interview guide. STATA 17 was used to analyze the quantitative data, and the thematic method was used to analyze the qualitative data. The results were presented in charts, tables, and themes for quantitative data and qualitative data, respectively. Results: Of the 425 respondents, 235 (55.3%) were female and 190 (44.7%) were male. The majority, 208 (48.9%), were between the ages of 31 and 40. Of those, 238 (56%) had at least a primary education, and 264 (62.1%) were married. The prevalence of HIV RNA viral non-suppression was at 8.5% among Adults living with HIV and 91.5% were HIV RNA virologically suppressed. Recent CD4 counts, Baseline viral load, and WHO clinical stage were significantly associated with HIV RNA virological suppression. In addition to that, adherence (aOR =1.00, 95%CI: 0.004-0.07, p=0.001) was associated with HIV RNA virological non-suppression. Qualitatively, results revealed that Status disclosure is always done by close relatives of the victims, stigma, and discrimination were not common in the community. There is a need for strategies on how to promote drug adherence among Adults living with HIV rather than just providing the treatment, as viral load suppression is related to baseline viral load, CD4, marital status, and drug adherence. In this study, monitoring the immunological response through scheduled CD4 and viral load tests is critical for maintaining patients' immunity and preventing disease progression. Intensive adherence support and counseling should conclusively be provided through the effective implementation of ART programs by providers to enhance viral suppression and ensure the quality of care and treatment.

The association between low-level viraemia and subsequent viral non-suppression among people living with HIV/AIDS on antiretroviral therapy in Uganda.

Uganda's efforts to end the HIV epidemic by 2030 are threatened by the increasing number of PLHIV with low-level viraemia (LLV). We conducted a study to determine the prevalence of LLV and the association between LLV and subsequent viral non-suppression from 2016 to 2020 among PLHIV on ART in Uganda. This was a retrospective cohort study, using the national viral load (VL) program data from 2016 to 2020. LLV was defined as a VL result of at least 50 copies/ml, but less than 1,000 copies/ml. Multivariable logistic regression was used to determine the factors associated with LLV, and cox proportional hazards regression model was used to determine the association between LLV and viral non-suppression. A cohort of 17,783 PLHIV, of which 1,466 PLHIV (8.2%) had LLV and 16,317 (91.8%) had a non-detectable VL was retrospectively followed from 2016 to 2020. There were increasing numbers of PLHIV with LLV from 2.0% in 2016 to 8.6% in 2020; and LLV was associated with male sex, second line ART regimen and being of lower age. 32.5% of the PLHIV with LLV (476 out of 1,466 PLHIV) became non-suppressed, as compared to 7.7% of the PLHIV (1,254 out of 16,317 PLHIV) with a non-detectable viral load who became non-suppressed during the follow-up period. PLHIV with LLV had 4.1 times the hazard rate of developing viral non-suppression, as compared to PLHIV with a non-detectable VL (adjusted hazard ratio was 4.1, 95% CI: 3.7 to 4.7, p < 0.001). Our study indicated that PLHIV with LLV increased from 2.0% in 2016 to 8.6% in 2020, and PLHIV with LLV had 4.1 times the hazard rate of developing viral non-suppression, as compared to PLHIV with a non-detectable VL. Hence the need to review the VL testing algorithm and also manage LLV in Uganda.

Mental Health, ART Adherence, and Viral Suppression Among Adolescents and Adults Living with HIV in South Africa: A Cohort Study

We followed adolescents and adults living with HIV aged older than 15 years who enrolled in a South African private-sector HIV programme to examine adherence and viral non-suppression (viral load > 400 copies/mL) of participants with (20,743, 38%) and without (33,635, 62%) mental health diagnoses. Mental health diagnoses were associated with unfavourable adherence patterns. The risk of viral non-suppression was higher among patients with organic mental disorders [adjusted risk ratio (aRR) 1.55, 95% confidence interval (CI) 1.22–1.96], substance use disorders (aRR 1.53, 95% CI 1.19–1.97), serious mental disorders (aRR 1.30, 95% CI 1.09–1.54), and depression (aRR 1.19, 95% CI 1.10–1.28) when compared with patients without mental health diagnoses. The risk of viral non-suppression was also higher among males, adolescents (15–19 years), and young adults (20–24 years). Our study highlights the need for psychosocial interventions to improve HIV treatment outcomes—particularly of adolescents and young adults—and supports strengthening mental health services in HIV treatment programmes.

Prevalence and predictors of viral load suppression in adults living with HIV in the western region of Ghana: A cross-sectional study.

Although antiretroviral therapy is beneficial and available free of cost to patients, several roadblocks still prevent patients from reaching viral suppression. This research aimed to determine the prevalence rate of viral suppression among people living with HIV in the western region of Ghana and identify the factors contributing to viral non-suppression. A cross-sectional study was conducted on 7199 HIV-positive adults. All data from the Sekondi Public Health Laboratory database was exported to Microsoft Excel and then verified and filtered before being exported to STATA 16.1. Viral non-suppression was modeled statistically using logistic regression. Viral load suppression was achieved in 5465 (75.91%) study participants who received antiretroviral treatment. However, 1734 participants (24.0%) did not achieve viral suppression. Patients with poor adherence to ARV (AOR 0.30; 95% CI 0.16, 0.58) and fair adherence to ARV (AOR 0.23; 95% CI 0.12, 0.45) were associated with a lower odd of viral non-suppression. Patients with six (6) months to two (2) years of treatment before viral load testing (AOR 0.67; 95% CI 0.46, 0.98) were also associated with a lower likelihood of viral non-suppression. The rate of non-suppression was high, and the suppression rate fell short of the UNAIDS target. Poor ARV adherence, fair ARV adherence, and a treatment duration of six (6) months to two (2) years before viral load testing appear to be obstacles to viral load suppression. The research findings seem to suggest that viral load testing supports viral non-suppression. Therefore, using viral load tests to monitor medication's effects on health can motivate patients to adhere to their prescribed medication regimen. More research is needed to determine whether viral load testing can improve adherence. Given the high rate of virologic failure, the study highlights the importance of identifying antiretroviral resistance patterns.

2353. Distance and Time to Clinic Are Associated with Increased Risk of Detectable HIV-1 Viral Load at a Peripheral Health Center in Rural Western Uganda

Abstract Background Antiretroviral therapy (ART) improves the health of people living with HIV (PLHIV) and reduces HIV transmission. While availability and efficacy of ART have improved in sub-Saharan Africa (SSA), access remains a challenge. Travel burden, measured as travel time, distance, and cost, has been posited as a potential barrier to ART. For example, a previous study at a large, urban referral center in Uganda showed GPS-measured distance was associated with clinic absenteeism. However, others suggest that PLHIV are willing to travel farther for HIV care because of stigma or for higher quality care. Less is known about the effect of travel burden in rural settings where transportation infrastructure is sparse, and there are few transportation options. Therefore, the objective of this study funded by the IDSA GERM Program was to explore potential associations between distance- and time-to-clinic in a highland area of rural western Uganda with HIV outcomes including viral suppression. Methods We enrolled 129 adult participants receiving care at the Bugoye ART clinic. Using a handheld GPS device, we mapped routes between participants’ home and clinic recording trip distance, time, and mode of transportation. We abstracted clinical outcomes from participant medical records. Modified Poisson regression with robust error variance was used to estimate risk ratios of associations between main exposures (e.g., distance to clinic, time to clinic) and primary outcomes (e.g., detectable viral load, missed an ART dose, and history of opportunistic infection [OI]). Results Distance and time to clinic were significantly and positively associated with probability of detectable viral load. In adjusted analyses, for every 10-km increase in distance, participants were almost twice as likely to have detectable viral loads (PR: 1.95 [95% CI 1.12, 3.41]). For every 10 additional minutes spent traveling, risk of viral non-suppression increased by almost 40% (PR=1.39 [95% CI 1.08, 1.78]). Neither distance nor time to clinic was associated with increased risk having missed an ART dose or history of OI. Conclusion These results suggest travel burden may adversely affect achievement of 90/90/90 goals, and novel, decentralized ART distribution mechanisms may be required. Disclosures All Authors: No reported disclosures.

Task-sharing with lay counsellors to deliver a stepped care intervention to improve depression, antiretroviral therapy adherence and viral suppression in people living with HIV: a study protocol for the TENDAI randomised controlled trial

IntroductionNon-adherence to antiretroviral therapy (ART) is the main cause of viral non-suppression and its risk is increased by depression. In countries with high burden of HIV, there is a lack...

Determinants of viral load non-suppression among HIV-positive children and adolescents attending care and treatment clinics in Tabora region, Tanzania

BackgroundIn Africa, data on viral suppression among human immunodeficiency virus (HIV)-positive children and adolescents on antiretroviral (ART) are scarce. This study aimed to determine determinants of HIV viral load (VL) non-suppression among HIV-positive children and adolescents (< 20 years old) who attend care and treatment clinics (CTCs) in Tabora region from January 2018 to April 2022. Data were abstracted from CTCs’ database and patient records including socio-demographic, ART drug regimen, clinical, virological and immunological features, for a maximum of 52 months. Viral non-suppression was defined as plasma VL ≥ 1000 copies/mil after 6 months on ART, during the follow-up period. Cox proportional hazards regression model and hazard ratios (HRs) were used in estimating the determinants of viral non-suppression.ResultsA total of 378 HIV-positive children (0–9 years) and adolescents (10–19 years) were enrolled, of whom 124 (32.8%) had virological non-suppression. The overall rate of VL non-suppression was 1.38 (95% CI 1.15, 1.64) per 100 person-months of observation. After adjusting for other factors, determinants of viral non-suppression were poor ART adherence level at initiation of ART (HR = 3.3; 95% CI 2.16, 4.91), low CD4 count at ART initiation (HR = 1.66; 95% CI 1.20, 2.30), nevirapine (NVP)-based regimen (HR = 2.64; 95% CI 1.32, 5.26), efavirenz (EFV)-based regime (HR = 2.08; 95% CI 1.03, 4.18), lopinavir/ritonavir (LPV/r)-based regimen (HR = 2.21; 95% CI 1.13, 4.32) and being on second-line regimen (HR = 6.11; 95% CI 2.50, 14.96).ConclusionsHIV viral non-suppression among children and adolescents on ART in central Tanzania in the Tabora region is high (32.8%) and is associated with poor ART adherence level, low CD4 count, NVP-, EFV-, and LPV/r-based regimen. Early initiation of ART and intensified monitoring are required to improve viral suppression rates of HIV-infected children to attain the third goal of the UNAIDS 95-95-95.

Transition Interventions for Adolescents on Antiretroviral Therapy on Transfer from Pediatric to Adult Healthcare: A Systematic Review.

Globally, adolescents living with HIV (ALHIV) experience poor health outcomes such as low retention in care, ART non-adherence and viral non-suppression. These outcomes coincide with the period during and after their transition from pediatric to adult healthcare. This study aimed to systematically describe the compendium of transition interventions and synthesize the effects of such transition interventions on adherence to ART, retention in care and viral load suppression. Seven databases and Google Scholar were searched and the review findings were reported according to the Preferred Reporting Items Stipulated for Systematic Reviews and Meta-Analyses. The risk of bias and the strength of evidence were assessed using the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. Seven studies (two cross-sectional, two retrospective cohort and three prospective cohort studies), with sample sizes ranging from 13 to 192, were included in the narrative synthesis. There was high-quality evidence that these interventions-Individualized care plans, communication, psychological support, and health and sexual education and mHealth-improved adherence, retention in care and viral load suppression at post-transition over the short and long term. In contrast, group transition intervention produced weak quality evidence. Hence, transition interventions including a combination of the high-quality evidenced interventions mentioned above can improve treatment outcomes for adolescents on ART.

Closing the HIV Treatment Gap for Adolescents in Windhoek, Namibia: A Retrospective Analysis of Predictors of Viral Non-Suppression.

Windhoek joined the Fast-Track Cities Initiative in 2017 to optimize HIV service delivery for adolescents, promoting adherence and sustaining viral suppression. Recent surveys and programmatic data show that the treatment gap remains greatest among children and adolescents living with HIV. A retrospective cohort analysis of adolescents living with HIV (ALHIV) receiving antiretroviral therapy (ART) at Windhoek healthcare facilities was conducted. Routine clinical data were extracted from the electronic Patient Monitoring System (ePMS). The SPSS statistical package was used to determine viral non-suppression and perform inferential statistics. 695 ALHIV were analysed with median age of 16 years (IQR = 13-18). Viral non-suppression at 1000 copies/mL threshold was 12%. Viral non-suppression was associated with age at ART initiation, duration on ART, current ART regimen and WHO Clinical Stage. In multivariate analysis, longer duration on ART was a protective factor for viral non-suppression (13-24 months vs. >24 months: aOR = 8.92, 95% CI 2.60-30.61), while being on third line regimen (vs. first line) was protective against viral non-suppression (aOR = 0.11, 95% CI 0.03-0.49). A significant treatment gap is evident for ALHIV with high viral non-suppression levels. Interventions are required to counter treatment fatigue to keep adolescents engaged in ART, and timely switching to rescue regimens for failing adolescents.

Low-level viraemia: An emerging concern among people living with HIV in Uganda and across sub-Saharan Africa.

Attaining viral load (VL) suppression for over 95% of the people living with HIV on antiretroviral therapy is a fundamental step in enabling Uganda and other sub-Saharan African countries to achieve global Sustainable Development Goal targets to end the HIV/AIDS epidemic by 2030. In line with the 2013 World Health Organization recommendations, several sub-Saharan African countries, including Uganda, use a threshold of 1000 HIV viral RNA copies/mL to determine HIV viral non-suppression. The United States Centers for Disease Control and Prevention and the International Association of Providers of AIDS Care deem this threshold very high, and hence recommend using 200 copies/mL to determine viral non-suppression. Using 1000 copies/mL as a threshold ignores people living with HIV who have low-level viraemia (LLV; HIV VL of at least 50 copies/mL but less than 1000 copies/mL). Despite the 2021 World Health Organization recommendations of using intensive adherence counselling for people living with HIV with LLV, several sub-Saharan African countries have no interventions to address LLV. However, recent studies have associated LLV with increased risks of HIV drug resistance, virologic failure and transmission. The purpose of this narrative review is to provide insights on the emerging concern of LLV among people living with HIV receiving antiretroviral therapy in sub-Saharan Africa. The review also provides guidance for Uganda and other sub-Saharan African countries to implement immediate appropriate interventions like intensive adherence counselling, reducing VL thresholds for non-suppression and conducting more research to manage LLV which threatens progress towards ending HIV by 2030.

Incidence, survival time and associated factors of virological failure among adult HIV/AIDS patients on first line antiretroviral therapy in St. Paul's Hospital Millennium Medical College-A retrospective cohort study.

Human Immune deficiency Virus or Acquired Immune deficiency Syndrome (HIV/AIDS) is a pandemic affecting millions around the world. The 2020 the Joint United Nations Programme on HIV/AIDS report stated that the estimated number of people living with HIV (PLHIV) is 38 million globally by 2019. Ethiopia is among HIV high burden countries in Africa. By 2021, PLHIV in Ethiopia is estimated to be 754, 256. Globally out of 25.4 million PLHIV on ART, 41% reported virally non-suppressed. According to UNAIDS, the estimated viral non-suppression in Ethiopia is about 27%. A hospital based retrospective cohort study was conducted among 323 patients who were enrolled to ART from July 2016 to December 2020. The medical records of study participants were selected using simple random sampling technique & data was collected using data extraction checklist. The collected data was entered and cleaned using SPSS V.25. Kaplan-Meier is used to estimate the cumulative hazard of virological failure at different time points. During bivariate analysis variables with p<0.25 were taken for Multivariate Cox regression analysis to assess predictors of virological failure & statistically significant association was declared at p<0.05 with 95% confidence interval. The overall incidence rate of virological failure was 1.75 per 1000 months of observations. The mean survival time of virological failure was 14.80 months. Disclosure of sero-status (AHR = 0.038, 95% CI: 0.008-018), poor adherence (AHR = 4.24, 95% CI: 1.04-16), having OIs (Opportunistic infections) (AHR = 4.59, 95% CI: 1.17-18) and use of cotrimoxazole (CPT) prophylaxis (AHR = 0.13, 95% CI: 0.026-0.68) have shown statistically significant association with virological failure. The incidence of virological failure among patients on first line ART in St. Paul's hospital is low. Disclosure of sero-status, poor adherence, having OIs and use of CPT prophylaxis were associated with virological failure. Therefore, a due attention needs to be given to these factors in order to minimize virological failure in patients on ART.

Perinatal Depressive Symptoms and Viral Non-suppression Among a Prospective Cohort of Pregnant Women Living with HIV in Nigeria, Kenya, Uganda, and Tanzania

Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013–February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2–4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers.

Routine Antiretroviral Pharmacy Refill Information Can Predict Failure Postpartum in Previously Suppressed South African Women With HIV.

Detection of antiretrovirals (ARVs) in biological specimens is a reliable, objective way to measure adherence. However, routine ARV testing is not feasible in many high-burden settings. This study explored if pharmacy data could accurately predict HIV viremia postpartum in previously virally suppressed women. South African women with HIV who initiated antiretroviral therapy (ART) during pregnancy and achieved viral suppression (VS; viral load [VL]≤50 copies/mL) were followed postpartum; during follow-up, plasma VL was measured and ARV adherence self-reported. A portion of samples were tested for the presence of ARV using mass spectrometry. Patient-level routine pharmacy data were used to classify if women should have the drug in hand for the past 7 days before the visit date. Logistic regressions were used to calculate associations between adherence and viral nonsuppression (VNS; VL > 50) or failure (VF; VL > 1000) at the first study visit of women who had ARV measured. Data for all women were examined for associations of self-reported adherence and drug in hand with VS and VF at 2, 6, and 12 months postpartum. Women with no ARV detected were significantly more likely to have VNS (odds ratio [OR], 26.4). Having no drug in hand for 7 days was also predictive of VNS in these same women (OR, 7.0) and the full cohort (n = 572) at 3 (OR, 2.9), 6 (OR, 8.7), and 12 months (OR, 14.5). Similar results were seen for VF. These data show that routine pharmacy data can act as a highly predictive mechanism for identifying patients at risk of VNS and VF due to nonadherence.

Supporting Treatment for Anti-Retroviral Therapy (START) Together: Protocol for a pilot, randomized, couple-based intervention to promote women's ART adherence and men's engagement in HIV care in KwaZulu-Natal, South Africa

BackgroundSouth Africa currently has the greatest number of people with HIV globally. The country has not yet met its 95-95-95 goals, with different gaps in the HIV care cascade for women and men. This paper reports on a protocol to pilot test a couple-based intervention designed to improve women's antiretroviral therapy (ART) adherence and men's engagement in care in heterosexual couples living in the Vulindlela area of KwaZulu-Natal, South Africa. Study goals are two-fold: (1) assess the acceptability, feasibility, and fidelity of the experimental intervention, START Together, and (2) collect efficacy data on START Together for women's ART adherence, men's engagement in HIV care, and the couple's relationship functioning. MethodsWomen (N = 20) who were not engaged with ART adherence (defined via self-reported ART difficulties, record of missed clinic visits, or viral non-suppression) are the target patients; male partners are not required to know or disclose their HIV status to be part of the study. Couples are randomized 1:1 to the experimental treatment (START Together) or treatment as usual (referrals to the local clinic to support ART adherence or any other HIV-related care). START Together is a 5-session intervention based in cognitive-behavioral couple therapy, which is a skill-based intervention focusing on communication and problem-solving skills, and Life Steps, a problem-solving intervention identifying barriers and solutions to medication adherence. Couples are assessed at baseline, post-treatment (8 weeks post-randomization), and follow-up (12 weeks post-randomization). ConclusionThis study will provide preliminary implementation and efficacy data on whether this novel approach has potential to improve women and men's HIV and healthcare-related needs.

Virological outcomes and risk factors for non-suppression for routine and repeat viral load testing after enhanced adherence counselling during viral load testing scale-up in Zimbabwe: analytic cross-sectional study using laboratory data from 2014 to 2018

BackgroundSince the scale-up of routine viral load (VL) testing started in 2016, there is limited evidence on VL suppression rates under programmatic settings and groups at risk of non-suppression. We conducted a study to estimate VL non-suppression (> 1000 copies/ml) and its risk factors using "routine" and "repeat after enhanced adherence counselling (EAC)" VL results.MethodsWe conducted an analytic cross-sectional study using secondary VL testing data collected between 2014 and 2018 from a centrally located laboratory. We analysed data from routine tests and repeat tests after an individual received EAC. Our outcome was viral load non-suppression. Bivariable and multivariable logistic regression was performed to identify factors associated with having VL non-suppression for routine and repeat VL.ResultsWe analysed 103,609 VL test results (101,725 routine and 1884 repeat test results) collected from the country’s ten provinces. Of the 101,725 routine and 1884 repeat VL tests, 13.8% and 52.9% were non-suppressed, respectively. Only one in seven (1:7) of the non-suppressed routine VL tests had a repeat test after EAC. For routine VL tests; males (vs females, adjusted odds ratio (aOR) = 1.19, [95% CI 1.14–1.24]) and adolescents (10–19 years) (vs adults (25–49 years), aOR = 3.11, [95% CI 2.9–3.31]) were more at risk of VL non-suppression. The patients who received care at the secondary level (vs primary, aOR = 1.21, [95% CI 1.17–1.26]) and tertiary level (vs primary, aOR = 1.63, [95% CI 1.44–1.85]) had a higher risk of VL non-suppression compared to the primary level. Those that started ART in 2014–2015 (vs < 2010, aOR = 0.83, [95% CI 0.79–0.88]) and from 2016 onwards (vs < 2010, aOR = 0.84, [95% CI 0.79–0.89]) had a lower risk of VL non-suppression. For repeat VL tests; young adults (20–24 years) (vs adults (25–49 years), (aOR) = 3.48, [95% CI 2.16 -5.83]), adolescents (10–19 years) (vs adults (25–49 years), aOR = 2.76, [95% CI 2.11–3.72]) and children (0–9 years) (vs adults (25–49 years), aOR = 1.51, [95% CI 1.03–2.22]) were at risk of VL non-suppression.ConclusionClose to 90% suppression in routine VL shows that Zimbabwe is on track to reach the third UNAIDS target. Strategies to improve the identification of clients with high routine VL results for repeating testing after EAC and ART adherence in subpopulations (men, adolescents and young adolescents) at risk of viral non-suppression should be prioritised.

HIV Treatment Outcomes in POP-UP: Drop-in HIV Primary Care Model for People Experiencing Homelessness.

People with HIV experiencing homelessness have low rates of viral suppression, driven by sociostructural barriers and traditional care system limitations. Informed by the capability-opportunity-motivation-behavior (COM-B) model and patient preference research, we developed POP-UP, an integrated drop-in (nonappointment-based) HIV clinic with wrap-around services for persons with housing instability and viral nonsuppression in San Francisco. We report HIV viral suppression (VS; <200 copies/mL), care engagement, and mortality at 12 months postenrollment. We used logistic regression to determine participant characteristics associated with VS. We enrolled 112 patients with viral nonsuppression and housing instability: 52% experiencing street-homelessness, 100% with a substance use disorder, and 70% with mental health diagnoses. At 12 months postenrollment, 70% had ≥1 visit each 4-month period, although 59% had a 90-day care gap; 44% had VS, 24% had viral nonsuppression, 23% missing, and 9% died (6 overdose, 2 AIDS-associated, 2 other). No baseline characteristics were associated with VS. The POP-UP low-barrier HIV care model successfully reached and retained some of our clinic's highest-risk patients. It was associated with VS improvement from 0% at baseline to 44% at 12 months among people with housing instability. Care gaps and high mortality from overdose remain major challenges to achieving optimal HIV treatment outcomes in this population.

Exploring definitions of retention in care for people living with HIV in the United States in the modern treatment era.

To describe retention in HIV care based on various definitions of retention in the modern treatment era. A cohort study of people enrolled in care at seven mostly urban HIV clinics across the United States, 2010-2018. We estimated retention based on missed visits, kept visits, kept encounters (clinical visits, CD4 counts, and viral loads), and HIV labs. We contrasted risk factors for retention by different definitions and estimated odds ratios for of viral suppression and hazard ratios for mortality in 2 years immediately following the year in which retention was defined (the study year). Across 108 171 person-years (N = 21 481 people), in 71% of years people kept ≥75% of scheduled visits; in 78%, people kept ≥2 visits >90 days apart; in 74%, people had ≥2 HIV labs >90 days apart; and in 47%, people had no gaps >6 months in clinic visits. Missing >25% of scheduled visits despite attending ≥2 visits >90 days apart was associated with nonwhite non-Hispanic race/ethnicity, history of injection drug use, and prior AIDS diagnosis. In contrast, attending ≥75% of scheduled visits while not attending ≥2 visits >90 days apart was associated with male sex, white race, no injection drug use history, and no prior AIDS diagnosis. Subsequent viral nonsuppression was more strongly associated with missed- than kept-visit measures of retention; 2-year mortality was only associated with failure to be retained by missed-visit measures. Missed and kept-visit definitions of retention capture different constructs. Missed-visit measures are more strongly associated with poor HIV outcomes.

Body mass index, proteinuria and total lymphocyte counts in predicting treatment responses among ART naïve individuals with HIV initiated on antiretroviral treatment in Dar es Salaam, Tanzania, 2019: a cohort study

ObjectivesTo explore the potential use of body mass index (BMI), proteinuria and total lymphocyte count changes in predicting immunological and virological response in individuals with HIV initiated on antiretroviral treatment...