Effects of Gender and Baseline CD4 Count on Post-Treatment CD4 Count Recovery and Outcomes in Patients with Advanced HIV Disease: A Retrospective Cohort Study.

Presentation to care with advanced HIV disease (AHD) is a significant problem in sub-Saharan Africa. We evaluated factors associated with immune recovery among individuals presenting to care with AHD in Zimbabwe. We conducted a retrospective evaluation of outcomes among adult (>18 years old) individuals with AHD (CD4 count ≤200 cells/mm3) receiving care at 18 outpatient primary care clinics in Harare, Zimbabwe. Baseline and 12-month CD4 count data were extracted from medical records. CD4 count recovery (defined as CD4 count >200 cells/mm3) after 12 months on non-nucleotide reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy (ART) regimen was determined and factors associated with CD4 count recovery were established using logistic regression. All statistical analysis was performed on SPSS v23. A total of 1,338 participant records were included in the analysis. The median interquartile range (IQR) age was 37 (30-43) years and 52% were females. The baseline median (IQR) CD4 count was 50 (28-75) cells/mm3 and was significantly lower among patients with history of cryptococcal meningitis compared to those without [25 (10-52) vs. 52 (32-77), respectively; p = .0009]. The median (IQR) CD4 count at 12 months after ART initiation increased from 50 (28-75) at baseline to 180 (92-290) cells/mm3. Immune recovery with a CD4 count >200 cells/mm3 was observed in 181/417 (43%). Male gender and low baseline CD4 count were strong predictors of poor immunological recovery on ART. Immunological recovery following ART initiation was 43% among individuals with AHD. Male patients are most vulnerable to persistent immunological failure. Clinical Trial Registration number: NCT02434172.

Factors associated with CD4 + cell count recovery among males and females with advanced HIV disease.

OBJECTIVE: HIV/AIDS mortality remains significantly high in sub-Saharan Africa, mostly driven by opportunistic infections and advanced HIV disease (AHD). This study aimed to assess CD4 + cell count recovery following ART initiation and factors associated with immune reconstitution. METHODS: We conducted a prospective cohort study between 2015 and 2016. HIV-infected adults (≥18 years) with AHD (CD4 + cell count ≤100 cells/µl) receiving care at 20 outpatient HIV treatment facilities in Harare, Zimbabwe were enrolled. CD4 + cell count recovery (CD4 + cell count >200 cells/µl) was assessed following 12-month ART initiation and factors associated with immune reconstitution were investigated using logistic regression analysis. All statistical analyses were performed on Statistical Package for the Social Sciences (SPSS) version 23. RESULTS: 1320 participants were enrolled and 56.4% were males. The median (interquartile range, IQR) age was 37 (32-43) years. Tuberculosis was seen in 16.0%. Of the 739 participants that had CD4 + cell count at 12 months, CD4 + cell count recovery above 200 cells/µl was observed in 163 (22.1%) participants. Median (IQR) CD4 + cell count at 12-months increased to 127 (75-190) cells/µl from 31 (14-55) at baseline. Factors associated with CD4 + cell count recovery were younger age at baseline [odds ratio (OR) ≥40/<40  = 0.58, 95% confidence interval (CI): 0.40-0.85, P  = 0.005), sex (OR female/male  = 2.07, 95% CI: 1.44-2.99, P  < 0.0001) and baseline CD4 + cell count (OR ≥50/<50  = 1.60, 95% CI: 1.10-2.33, P  = 0.013). CONCLUSION: A significant proportion (77.9%) of patients seeking care with AHD in a resource limited setting failed to recover a CD4 + cell count >200 cells/µl. Male sex, older age and low CD4 + cell count at ART initiation were factors associated with poor immune reconstitution. Better differentiated care deliveries targeting this vulnerable population are critical for improving clinical outcomes and quality of life of the patients.

Investigating Attitudes, Motivations and Key Influencers for COVID-19 Vaccination Uptake among Late Adopters in Urban Zimbabwe.

The rapid development of vaccines in response to the COVID-19 pandemic has provided an effective tool for the management of COVID-19. However, in many African countries there has been a poor uptake of COVID-19 vaccines with only 32.5% first vaccine dose coverage compared to the WHO global target of 70%. As vaccine access improves, one of the important drivers of low uptake has been vaccine hesitancy, driven by levels of confidence, convenience, and complacency. Between 4 January-11 February 2022, we conducted a survey of vaccine late adopters to assess factors that influenced adults in Harare, Zimbabwe to present for their first COVID-19 vaccine dose almost 12 months after the vaccination program began. Of the 1016 adults enrolled, 50% were female and 12.4% had HIV co-infection. Binary logistic regression models were developed to understand factors associated with vaccine confidence. Women were more likely to have negative views about the COVID-19 vaccine compared to men (OR 1.51 (95%CI 1.16, 1.97, p = 0.002). Older adults (≥40 years) compared with youth (18-25 years) were more likely to have 'major concerns' about vaccines. When asked about their concerns, 602 (59.3%) considered immediate side effects as a major concern and 520 (52.1%) were concerned about long-term health effects. People living with HIV (PLWH) were more likely to perceive vaccines as safe (OR 1.71 (95%CI: 1.07, 2.74, p = 0.025) and effective (1.68 (95%CI: 1.07, 2.64, p = 0.026). Internet users were less likely to perceive vaccines as safe (OR 0.72 (95% CI: 0.55, 0.95, p = 0.021) compared to non-Internet users; and social media was a more likely source of information for youth and those with higher education. Family members were the primary key influencers for 560 (55.2%) participants. The most important reason for receiving the COVID-19 vaccine for 715 (70.4%) participants was the protection of individual health. Improving vaccine coverage will need targeted communication strategies that address negative perceptions of vaccines and associated safety and effectiveness concerns. Leveraging normative behavior as a social motivator for vaccination will be important, as close social networks are key influences of vaccination.

Vaccine Adverse Events Following COVID-19 Vaccination with Inactivated Vaccines in Zimbabwe.

Vaccination is one of the most effective methods for preventing morbidity and mortality from COVID-19. Vaccine hesitancy has led to a decrease in vaccine uptake; driven by misinformation, fear, and misperceptions of vaccine safety. Whole inactivated vaccines have been used in one-fifth of the vaccine recipients in Africa, however there are limited real-world data on their safety. We evaluated the reported adverse events and factors associated with reported adverse events following vaccination with whole inactivated COVID-19 vaccines-BBiBP-CorV (Sinopharm) and CoronaVac (Sinovac). A quantitative survey evaluating attitudes and adverse events from vaccination was administered to 1016 adults presenting at vaccination centers. Two follow-up telephone interviews were conducted to determine adverse events after the first and second vaccination dose. Overall, the vaccine was well tolerated; 26.0% and 14.4% reported adverse events after the first and second dose, respectively. The most frequent local and systemic adverse events were pain at the injection site and headaches, respectively. Most symptoms were mild, and no participants required hospitalization. Participants who perceived COVID-19 vaccines as safe or had a personal COVID-19 experience were significantly less likely to report adverse events. Our findings provide data on the safety and tolerability of whole inactivated COVID-19 vaccines in an African population, providing the necessary data to create effective strategies to increase vaccination and support vaccination campaigns.

Attitudes to Vaccine Mandates among Late Adopters of COVID-19 Vaccines in Zimbabwe.

Despite sufficient supply, <25% of the population in sub-Saharan Africa has received at least one dose of COVID-19 vaccine. Vaccine mandates have previously been effective in increasing vaccine uptake. Attitudes to COVID-19 vaccine mandates and vaccines for children in African populations are not well understood. We surveyed late-adopters presenting for COVID-19 vaccination one year after program initiation in Zimbabwe. Logistic regression models were developed to evaluate factors associated with attitudes to mandates. In total, 1016 adults were enrolled; 690 (67.9%) approved of mandating vaccination for use of public spaces, 686 (67.5%) approved of employer mandates, and 796 (78.3%) approved of mandating COVID-19 vaccines for schools. Individuals of lower economic status were twice as likely as high-income individuals to approve of mandates. Further, 743 (73.1%) participants indicated that they were extremely/very likely to accept vaccines for children. Approval of vaccine mandates was strongly associated with perceptions of vaccine safety, effectiveness, and trust in regulatory processes that approved vaccines. Vaccine hesitancy is an important driver of low vaccine coverage in Africa and can be mitigated by vaccine mandates. Overall, participants favored vaccine mandates; however, attitudes to mandates were strongly associated with level of education and socioeconomic status.

Evaluation of the FACSPresto, a New Point of Care Device for the Enumeration of CD4% and Absolute CD4+ T Cell Counts in HIV Infection.

INTRODUCTION: Enumeration of CD4+ T lymphocytes is important for pre-ART disease staging and screening for opportunistic infections, however access to CD4 testing in resource limited settings is poor. Point of care (POC) technologies can facilitate improved access to CD4 testing. We evaluated the analytical performance of a novel POC device the FACSPresto compared to the FACSCalibur as a reference standard and to the PIMA, a POC device in widespread use in sub-Saharan Africa. METHOD: Specimens were obtained from 253 HIV infected adults. Venous blood samples were analyzed on the FACSPresto and the FACSCalibur, in a subset of 41 samples additional analysis was done on the PIMA. RESULTS: The absolute CD4 count results obtained on the FACSPresto were comparable to those on the FACSCalibur with low absolute (9.5cells/µl) and relative bias (3.2%). Bias in CD4% values was also low (1.06%) with a relative bias of 4.9%. The sensitivity was lower at a CD4 count threshold of ≤350cells/µl compared with ≤500cells/µl (84.9% vs. 92.8%) resulting in a high upward misclassification rate at low CD4 counts. Specificity at thresholds of ≤350cells/µl and ≤500cells/µl were 96.6% and 96.8% respectively. The PIMA had a high absolute (-68.6cells/µl) and relative bias (-10.5%) when compared with the FACSCalibur. At thresholds of ≤350cells/µl and ≤500cells/µl the sensitivity was 100% and 95.5% respectively; specificity was 85.7% and 84.2% respectively. The coefficients of repeatability were 4.13%, 5.29% and 9.8% respectively. DISCUSSION: The analytic performance of the FACSPresto against the reference standard was very good with better agreement and precision than the PIMA. The FACSPresto had comparable sensitivity at a threshold of 500 cells/µl and better specificity than the PIMA. However the FACSPresto showed reduced sensitivity at low CD4 count thresholds. CONCLUSION: The FACSPresto can be reliably used as a POC device for enumerating absolute CD4 count and CD4% values.