Factors associated with viral suppression among adults living with HIV on antiretroviral therapy in Nigeria: Analysis of a population-based survey, 2018.

OBJECTIVE: Viral load suppression (VLS) is critical in reducing morbidity and mortality associated with HIV as well as minimizing the likelihood of HIV transmission to uninfected persons. The objective of this study was to identify factors associated with VLS among people living with HIV (PLWH) on antiretroviral (ARV) therapy to inform HIV programme strategies in Nigeria. METHODS: Adult participants, aged 15-64 years, from the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), who self-reported to be a PLWH or had detectable ARVs, were analysed to examine factors associated with VLS defined as HIV RNA <1000 copies/mL. NAIIS measured HIV prevalence, viral load, ARV and hepatitis B in PLWH. Logistic regression models were used and reported weighted prevalence. RESULTS: Of 1322 participants, 949 (68.25%) were women and 1287 (96.82%) had detectable ARVs. The median age was 39.31 [interquartile range (IQR): 31.47-47.63] years. Prevalence of VLS was 80.88%. Compared with participants with detectable ARVs, those with undetectable ARVs in their blood specimens had lower odds of VLS [adjusted odds ratio (aOR) = 0.24, 95% confidence interval (CI): 0.08-0.64). Coinfection with hepatitis B and nonnucleoside reverse transcriptase inhibitor metabolites were also associated with lower odds of VLS. Older people (45-54 vs 15-24 years) had increased odds of VLS (aOR = 2.81, 95% CI: 1.14-6.90). CONCLUSION: Young people and those with undetectable ARVs had lower odds of virological suppression. Targeted interventions focusing on young people and adherence to medication are needed to achieve the UNAIDS 95-95-95 goals for HIV epidemic control.

Determinants of Preexposure Prophylaxis Cascade Among Sexual and Gender Minorities in Nigeria.

BACKGROUND: Preexposure prophylaxis (PrEP) is effective in preventing human immunodeficiency virus (HIV) infection among sexual and gender minorities (SGMs). We evaluated the characteristics associated with engagement in 7 steps of the PrEP cascade among SGMs in Nigeria. METHODS: Sexual and gender minorities without HIV from the Abuja site of TRUST/RV368 cohort who were surveyed on awareness of and willingness to use PrEP were approached for PrEP initiation upon availability of oral daily PrEP. To understand gaps in the uptake of oral daily PrEP, we categorized the HIV PrEP cascade as (i) education about PrEP, (ii) interest in PrEP, (iii) successful contact, (iv) appointment scheduled, (v) appointment attendance, (vi) PrEP initiation, and (vii) plasma protective levels of tenofovir disoproxil fumarate. Multivariable logistic regression models were used to determine factors associated with each of the 7 steps in the HIV PrEP cascade. RESULTS: Of 788 participants, 718 (91.1%) showed interest in taking oral daily PrEP every day and/or after a sexual act, 542 (68.8%) were successfully contacted, 433 (54.9%) scheduled an appointment, 409 (51.9%) attended a scheduled appointment, 400 (50.8%) initiated oral daily PrEP, and 59 (7.4%) had protective levels of tenofovir disoproxil fumarate. Of initiators of PrEP, 23 (5.8%) seroconverted at a rate of 13.9 cases/100 person-years. Better social support, larger network density, and higher education were associated with engagement in 4 to 5 components of the cascade. CONCLUSIONS: Our data highlight a gap between willingness and actual PrEP use. Despite PrEP's effectiveness in preventing HIV, the optimal impact of PrEP for SGMs in sub-Saharan Africa will require multifaceted approaches that combine social support, education, and destigmatization.

The quality of life among men who have sex with men (MSM) living with and those not living with HIV in Abuja Nigeria.

Our objective was to assess factors associated with health-related quality of life (HRQoL) among men who have sex with men (MSM) living with or those not living with HIV in Nigeria. A cross-sectional subset of adult MSM in the ongoing TRUST/RV368 HIV prevention and treatment study were recruited and completed the World Health Organization quality of life in HIV infection (WHOQOL-BREF) questionnaire. The tool comprises physical health, psychological health, social relationships and environmental health domains from which scores were extracted. T-tests were used to compare mean HRQoL scores between participants living with or those not living with HIV and among persons living with HIV who had been on antiretroviral therapy for ≥1 year or <1 year. Of 322 study participants, 186 (57.8%) were living with HIV. The mean scores were significantly lower for participants living with HIV as compared to those not living with HIV in physical health, psychological health and social relationship domains. Among persons living with HIV and taking ART, scores were significantly lower for those whose duration was <1 year as compared to ≥1 year regarding physical health and psychological health. Strategies to improve HIV prevention and early detection and linkage to HIV care may improve HRQoL.

Combined cART including Tenofovir Disoproxil, Emtricitabine, and Dolutegravir has potent therapeutic effects in HIV-1 infected humanized mice.

HIV-1 reservoirs persist in the presence of combined antiretroviral therapy (cART). However, cART has transformed HIV-1 infection into a chronic disease marked by control of HIV-1 viral load and mortality reduction. Major challenges remain, including viral resistance upon termination of cART and persistence and identification of tissue distribution of HIV-1 reservoirs. Thus, appropriate animal models that best mimic HIV-1 pathogenesis are important, and the current study complements our previously published validation of the CD34+ hematopoietic humanized mouse model for this purpose. Here we analyze viral suppression using the recently developed combination of antiretrovirals that include Tenofovir Disoproxil (TDF), Emtricitabine (FTC), and Dolutegravir (DTG), a choice based on recent clinical outcomes showing its improved antiretroviral potency, CD4+ T cell preservation, tolerability, and prevention of viral drug resistance compared to that of previous regimens. We used quantitative Airyscan-based super resolution confocal microscopy of selected mouse tissues. Our data allowed us to identify specific solid tissue reservoirs of human T cells expressing the HIV-1 core protein p24. In particular, lymph node, brain, spleen, and liver were visualized as reservoirs for residual infected cells. Marked reduction of viral replication was evident. Considering that detection and visualization of cryptic sites of HIV-1 infection in tissues are clearly crucial steps towards HIV-1 eradication, appropriate animal models with pseudo-human immune systems are needed. In fact, current studies with humans and non-human primates have limited sample availability at multiple stages of infection and cannot easily analyze the effects of differently administered combined antiretroviral treatments on multiple tissues. That is easier to manage when working with humanized mouse models, although we realize the limitations due to low human cell recovery and thus the number of cells available for thorough and comprehensive analyses. Nonetheless, our data further confirm that the CD34+ humanized mouse model is a potentially useful pre-clinical model to study and improve current anti-HIV-1 therapies.

Hepatitis B virus infection among men who have sex with men and transgender women living with or at risk for HIV: a cross sectional study in Abuja and Lagos, Nigeria.

BACKGROUND: Despite the development of a safe and efficacious hepatitis B vaccine in 1982, the hepatitis B virus (HBV) remains a public health burden in sub-Saharan Africa. Due to shared risk factors for virus acquisition, men who have sex with men (MSM) and transgender women (TGW) living with HIV are at increased risk of HBV. We estimated the prevalence of HBV and associated factors for MSM and TGW living with or without HIV in Nigeria. METHODS: Since March 2013, TRUST/RV368 has recruited MSM and TGW in Abuja and Lagos, Nigeria using respondent driven sampling. Participants with HIV diagnosis, enrollment as of June 2015, and available plasma were selected for a cross-sectional study and retrospectively tested for hepatitis B surface antigen and HBV DNA. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with prevalent HBV infection. RESULTS: A total of 717 MSM and TGW had a median age of 25 years (interquartile range [IQR]: 21-27), 5% self-reported HBV vaccination, 61% were living with HIV, 10% had prevalent HBV infection and 6% were HIV-HBV co-infected. HIV mono-infected as compared to HIV-HBV co-infected had a higher median CD4 T cell count [425 (IQR: 284-541) vs. 345 (IQR: 164-363) cells/mm3, p = 0.03] and a lower median HIV RNA viral load [4.2 (IQR: 2.3-4.9) vs. 4.7 (IQR: 3.9-5.4) log10copies/mL, p < 0.01]. The only factor independently associated with HBV was self-report of condomless sex at last anal intercourse (OR: 2.2, 95% CI: 1.3, 3.6). HIV infection was not independently associated with HBV (OR: 1.0, 95% CI: 0.7-1.6). CONCLUSION: HBV prevalence was moderately high but did not differ by HIV in this cohort of MSM and TGW. Recent condomless sex was associated with elevated HBV risk, reinforcing the need to increase communication and education on condom use among key populations in Nigeria. Evaluating use of concurrent HIV antiretroviral therapy with anti-HBV activity may confirm the attenuated HBV prevalence for those living with HIV.

Individual and partnership characteristics associated with consistent condom use in a cohort of cisgender men who have sex with men and transgender women in Nigeria.

BACKGROUND: This study reports on the individual and partnership characteristics that influence consistent condom use in cisgender men who have sex with men (MSM) and transgender women (TGW) attending trusted community centers that provide HIV prevention and treatment services in Nigeria. METHODS: Adults assigned male at birth who reported anal sex with male partners who enrolled between March 2013-2019 and had information about at least one male sexual partner were included in these analyses. At enrollment and follow-up visits every 3 months for up to 18 months, participants were administered detailed questionnaires that collected information about demographics, sexual practices, HIV risk behaviors, and characteristics and behaviors of their partners in the previous year (at enrollment) or the preceding 3 to 6-months (at follow-up visits). Logistic regression models with generalized estimating equations were used to assess the odds ratio (OR) and 95% confidence intervals (CI) of individual, partner, and partnership characteristics associated with consistent condom use (CCU). A participant was defined as consistently using condom if they reported always using condoms all the time they had insertive, receptive or both types of anal sex with a male partner. RESULTS: At the individual level, CCU was positively associated with higher education, disclosure of key population status to a healthcare worker and negatively associated with poor access to condoms. At the partner and partnership level, CCU was associated with partners with higher education (aOR: 1.36; 95% CI: 1.07-1.72), casual relationships (aOR: 1.22; 95% CI: 1.11-1.34) and relationships in which partners encouraged the participant to use condoms with other partners (aOR: 1.14; 95% CI: 1.02-1.28). Relationships in which the partner was married to a woman and/or the partner's HIV status positive or unknown were negatively associated with CCU. CONCLUSIONS: These findings suggest that individuals in relationships where partners were more open and encouraged safer sex were more likely to consistently use condoms. HIV prevention programs should consider leveraging communication to sexual partners to encourage condom use as this may support condom use with other sexual partners. Given sustained and growing HIV and STI epidemics among MSM and TGW, even with pre-exposure prophylaxis scale-up, it is crucial to continue to study optimal implementation strategies to increase condom use.

Correlates of reported modern contraceptive use among postpartum HIV-positive women in rural Nigeria: an analysis from the MoMent prospective cohort study.

BACKGROUND: Nigeria has an annual population of ~ 200,000 women who are both pregnant and HIV-positive. High unmet need for family planning in this population could lead to unintended pregnancies, along with the increased risk of mother-to-child transmission of HIV (MTCT). To identify modifiable barriers and facilitators in effective family planning, we examined correlates of modern contraceptive use among HIV-positive women enrolled in the MoMent prevention of MTCT (PMTCT) implementation research study in rural North-Central Nigeria. METHODS: In this prospective cohort study, HIV-positive pregnant women were enrolled at 20 Primary Healthcare Centers and followed up to 12 months postpartum. Baseline socio-demographic, clinical and obstetric data were collected at enrollment. Participants were to receive routine family planning counselling from healthcare workers during postnatal visits. Analysis utilized baseline data linked to available family planning information collected from each woman at the first postpartum visit. Multivariate logistic regression was performed to determine factors associated with modern contraceptive use. RESULTS: Out of 497 women enrolled, family planning data was available for 399 (80.3%) women, of whom 349 (87.5%) received family planning counselling, and 321 (80.5%) were 30 years old or less. Two-thirds (268, 67.2%) of the cohort analyzed had 1-2 children at baseline; 24.8% (n = 99) had 3-4 children, and 8.0% (n = 32) had > 4 children. Approximately half (199, 49.9%) of the women reported no modern contraceptive use in the postpartum period. Male condoms (116, 29.1%) were the most reported method of contraception; other methods reported included oral hormones (71, 17.8%) and intrauterine devices (13, 3.2%). Only disclosure of HIV status to male partner or relative (aOR = 2.0, 95% CI: 1.2-3.3; p = 0.01) and receipt of family planning counselling (aOR = 2.3, 95% CI: 1.1-4.8; p = 0.03) were positively associated with reported modern contraceptive use. Age, marital or educational status, religious affiliation, employment status, gravidity and parity were non-correlates. CONCLUSIONS: Family planning counselling and disclosure of HIV status are modifiable positive predictors of contraceptive use among our cohort of postpartum HIV-positive women in rural Nigeria. Rates of unintended pregnancy and concomitant risk of MTCT could be significantly reduced through strategies that facilitate these correlates. CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov registration number: NCT 01936753; registered September 3, 2013.

Patient-Initiated Repackaging of Antiretroviral Therapy, Viral Suppression and Drug Resistance.

Patient-initiated repackaging of antiretroviral therapy (ART) refers to removal of ART medications from their original manufacturer's containers, and putting them into alternative containers. This behavior may be triggered by stigma associated with HIV infection, and may impact patient outcomes. We assessed association between patient initiated repackaging of ART and failure to achieve viral suppression (FVS) in a sample of 450 HIV-infected adults (≥8 years) on first line ART for ≥6 months. FVS was defined as a plasma HIV RNA level ≥400 copies/mL. A total of 197 (43.7%) patients reported repackaging their ART medications. One hundred ninety-one patients (42.4%) failed to suppress and FVS was associated with medication repackaging [adjusted odds ratio (aOR), 2.2; 95% CI 1.4-3.3.] Adherence to ART was also associated with FVS (aOR; 0.4; 95% CI 0.2-0.6.). Benefits of retaining drugs in their original packaging along with adherence to ART should be emphasized to reduce the risk of FVS.

HIV status disclosure to male partners among rural Nigerian women along the prevention of mother-to-child transmission of HIV cascade: a mixed methods study.

BACKGROUND: HIV status disclosure to male partners is important for optimal outcomes in the prevention of mother-to-child transmission of HIV (PMTCT). Depending on timing of HIV diagnosis or pregnancy status, readiness to disclose and disclosure rates may differ among HIV-positive women. We sought to determine rates, patterns, and experiences of disclosure among Nigerian women along the PMTCT cascade. METHODS: HIV-positive women in rural North-Central Nigeria were purposively recruited according to their PMTCT cascade status: pregnant-newly HIV-diagnosed, pregnant-in care, postpartum, and lost-to-follow-up (LTFU). Participants were surveyed to determine rates of disclosure to male partners and others; in-depth interviews evaluated disclosure patterns and experiences. Tests of association were applied to quantitative data. Qualitative data were manually analysed by theme and content using the constant comparative method in a Grounded Theory approach. RESULTS: We interviewed 100 women; 69% were 21-30 years old, and 86% were married. There were 25, 26, 28 and 21 women in the newly-diagnosed, in-care, postpartum, and LTFU groups, respectively. Approximately 81% of all participants reported disclosing to anyone; however, family members were typically disclosed to first. Ultimately, more women had disclosed to male partners (85%) than to family members (55%). Rates of disclosure to anyone varied between groups: newly-diagnosed and LTFU women had the lowest (56%) and highest (100%) rates, respectively (p = 0.001). However, family (p = 0.402) and male partner (p = 0.218) disclosure rates were similar between cascade groups. Across all cascade groups, fear of divorce and intimate partner violence deterred women from disclosing to male partners. However, participants reported that with assistance from healthcare workers, disclosure and post-disclosure experiences were mostly positive. CONCLUSION: In our study cohort, although disclosure to male partners was overall higher, family members appeared more approachable for initial disclosure. Across cascade groups, male partners were ultimately disclosed to at rates > 75%, with no significant inter-group differences. Fear appears to be a major reason for non-disclosure or delayed disclosure by women to male partners. Augmentation of healthcare workers' skills and involvement can mediate gender power differentials, minimize fear and shorten time to male partner disclosure among women living with HIV, regardless of their PMTCT cascade status. TRIAL REGISTRATION: Clinicaltrials.gov registration number NCT 01936753 , September 3, 2013 (retrospectively registered).

Sexual partner characteristics and incident rectal Neisseria gonorrhoeae and Chlamydia trachomatis infections among gay men and other men who have sex with men (MSM): a prospective cohort in Abuja and Lagos, Nigeria.

BACKGROUND: STIs including Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) potentiate HIV acquisition and transmission especially among gay men and other men who have sex with men (MSM). We investigated the influence of sexual network composition on incident rectal NG and/or CT infections among Nigerian MSM. METHODS: TRUST/RV368 is a cohort of MSM recruited using respondent-driven sampling at trusted community centres in Abuja and Lagos, Nigeria. MSM respondents (egos) provided STI risk factors and demographic information for up to five of their most recent sexual partners (alters) within their sexual networks. Egos were tested for HIV, NG and CT every 3 months. Log-binomial regression was used to assess associations between alter characteristics and incident NG and/or CT. RESULTS: Between March 2013 and October 2015, 492 MSM were longitudinally screened for STIs, of which 28.0% (n=138) were positive for incident rectal STI (61 NG only, 42 CT only and 35 NG and CT). Among egos, condom use was associated with STIs (half of the time vs never (adjusted risk ratio (aRR) 0.5; 95% CI 0.3 to 0.8), always/almost always vs never (aRR 0.7; 95% CI 0.5 to 1.0)). Incident STIs were associated with having a younger alter ≤19 versus 30 years (aRR 0.6; 95% CI 0.4 to 1.0), HIV infection (aRR 1.5; 95% CI 1.1 to 2.0) and engaging in sex under the influence of alcohol (aRR 1.4 95% CI 1.1 to 1.7) among regular alters and age ≤19 versus 30 years (aRR 0.3; 95% CI 0.2 to 0.6), HIV infection (aRR 1.4; 95% CI 1.1 to 1.8) and engaging in sex under the influence of alcohol (aRR 1.2 95% CI 1.0 to 1.4) among casual alters. CONCLUSIONS: Given the centrality of sexual partner characteristics as risks for incident STIs among Nigerian MSM, there is a need to move beyond individual interventions and syndromic surveillance and get 'out there' in the STI management.

Correlates of facility delivery for rural HIV-positive pregnant women enrolled in the MoMent Nigeria prospective cohort study.

BACKGROUND: Low rates of maternal healthcare service utilization, including facility delivery, may impede progress in the prevention of mother-to-child transmission of HIV (PMTCT) and in reducing maternal and infant mortality. The MoMent (Mother Mentor) study investigated the impact of structured peer support on early infant diagnosis presentation and postpartum maternal retention in PMTCT care in rural Nigeria. This paper describes baseline characteristics and correlates of facility delivery among MoMent study participants. METHODS: HIV-positive pregnant women were recruited at 20 rural Primary Healthcare Centers matched by antenatal care clinic volume, client HIV prevalence, and PMTCT service staffing. Baseline and delivery data were collected by participant interviews and medical record abstraction. Multivariate logistic regression with generalized estimating equation analysis was used to evaluate for correlates of facility delivery including exposure to structured (closely supervised Mentor Mother, intervention) vs unstructured (routine, control) peer support. RESULTS: Of 497 women enrolled, 352 (71%) were between 21 and 30 years old, 319 (64%) were Christian, 245 (49%) had received secondary or higher education, 402 (81%) were multigravidae and 299 (60%) newly HIV-diagnosed. Delivery data was available for 445 (90%) participants, and 276 (62%) of these women delivered at a health facility. Facility delivery did not differ by type of peer support; however, it was positively associated with secondary or greater education (aOR 1.9, CI 1.1-3.2) and Christian affiliation (OR 1.4, CI 1.0-2.0) and negatively associated with primigravidity (OR 0.5; 0.3-0.9) and new HIV diagnosis (OR 0.6, CI 0.4-0.9). CONCLUSIONS: Primary-level or lesser-educated HIV-infected pregnant women and those newly-diagnosed and primigravid should be prioritized for interventions to improve facility delivery rates and ultimately, healthy outcomes. Incremental gains in facility delivery from structured peer support appear limited, however the impact of duration of pre-delivery support needs further investigation. Religious influences on facility delivery and on general maternal healthcare service utilization need to be further explored. TRIAL REGISTRATION: ClinicalTrials.gov number NCT01936753 , registered September 2013.

Association of knowledge on ART line of treatment, scarcity of treatment options and adherence.

BACKGROUND: Adherence to Antiretroviral Therapy (ART) is critical piece in the management of HIV infected patients. Despite the benefits of ART, non-adherence to ART persists. This study explores association between patient's knowledge of the ART line of treatment, availability of future treatment options and adherence. METHODS: A cross sectional survey of HIV infected adolescent and adults was conducted. Cumulative optimal and sub-optimal adherence was defined as percentage adherence of ≥ 95 % and < 95 %, respectively. Binomial regression models were used to assess the association of patient's knowledge of the ART line of treatment, availability of future treatment options and adherence. RESULTS: Of the 402 patients reviewed, 101 (25.1 %) patients knew their ART line of treatment and were aware that future treatment options are limited. Compared to those who were not aware of the ART line of treatment and/or scarcity of future treatment options, those who were aware were more likely to be adherent (adjusted prevalence ratio [APR], 1.1; 95 % CI, 1.0-1.3). CONCLUSION: The study reports knowledge of patient's ART line of treatment and future treatment options is important indicator of adherence to ART. Although majority of the patients did not have the knowledge, those who had the knowledge demonstrated to be more adherent. It is critical for the physicians/health care providers in these settings to clearly educate patients about ART line of treatment and limited availability of future treatment options as such information is likely to influence individual behavior and improve patient's adherence to ART.

Interferon-free hepatitis C treatment increases a surrogate of atherosclerotic cardiovascular disease risk in Black veterans living with HIV.

Veterans living with HIV (VLWH) and hepatitis C virus (HCV) co-infection have an exacerbated risk of cardiovascular disease (CVD). It is unknown if HCV cure reduces CVD risk in this population. We evaluated changes in low-density lipoprotein (LDL), as a surrogate of CVD risk, 18 months after HCV cure in VLWH. We found significant increases in LDL in VLWH with advanced fibrosis, potentially increasing CVD risk. Lower LDL thresholds to initiate lipid-lowering therapies in VLWH after HCV cure may be warranted.

Impact of enhanced adherence counselling on viral re-suppression among adolescents and young persons with persistent viremia.

OBJECTIVE: Kenya ART guidelines recommend three sessions of enhanced adherence counselling (EAC) following detectable viral load. The objective of this study was to assess completion of EAC sessions and factors associated with viral re-suppression amongst adolescents and young persons (AYPs) with persistent viremia in Western Kenya. METHODS: A retrospective analysis of routinely collected data abstracted from viral load registers was done. AYP with persistent viremia (consecutive viral load ≥1000 copies/ml) between October 2017 to September 2019 were followed for 12 months; those with more than one follow-up viral load results were analyzed. EAC was satisfactory if at least three sessions attended, barriers identified and addressed. Morisky scores 0 and at least 1 indicated optimal and sub-optimal adherence, respectively. Logistic regression models were used to assess predictors of viral load suppression (VLS). RESULTS: Of 124 AYPs with persistent viremia, 118 (95.2%) had documented follow-up viral load results and 119 (96%) completed three EAC sessions. Overall, 55 (47%) clients re-suppressed during the study period. AYPs who had satisfactory EAC sessions had higher odds of achieving VLS [odds ratio (OR) = 3.7, 95% confidence interval (CI): 1.6-8.1]. Similarly, AYPs with an optimal adherence had eight times (OR = 8.1, 95% CI: 3.5-18.5) higher odds of achieving VLS, and those who were suppressed at 6 months post-ART initiation had higher odds of achieving VLS at 12-months (OR = 2.5, 95% CI: 1.1-5.8). CONCLUSION: Satisfactory EAC sessions and optimal ART adherence was strongly associated with viral re-suppression among AYPs with persistent viremia. Continued support to EAC intervention is critical to improve treatment outcome among AYP living with HIV.

Factors associated with adherence and viral suppression among patients on second-line antiretroviral therapy in an urban HIV program in Kenya.

Objective: The aim of this study is to estimate the proportion of virologically suppressed People living with HIV on second-line ART and to identify factors associated with virologic suppression. With an increasing population of patients on complex second-line anti retroviral therapy (ART), understanding the factors associated with viral suppression and adherence is critical for ensured longevity of ART. Methods: A retrospective study was conducted of patients on second-line ART in 17 facilities supported by University of Maryland, Baltimore, in Nairobi, Kenya, covering the period beginning October 2016 up to August 2019. Viral suppression was defined as viral load <1000 copies/mL in a test conducted in the last 12 months. Adherence was assessed through self-reports and classified as optimal (good) or suboptimal (inadequate/poor). Associations were presented as adjusted risk ratios with 95% confidence intervals. Statistical significance was considered when p value ⩽0.05. Results: Of 1100 study participants with viral load data, 974 (88.5%) reported optimal adherence while on first-line ART and 1029 (93.5%) reported optimal adherence to second-line ART. Overall, viral load suppression on second-line ART was 90%. Optimal adherence ((adjusted risk ratio) 1.26; 95% confidence interval 1.09-1.46)) and age 35-44 versus 15-24 years ((adjusted risk ratio) 1.06; 95% confidence interval 1.01-1.13)) were associated with viral suppression . Adherence to first-line ART ((adjusted risk ratio) 1.19; 95% confidence interval 1.02-1.40)) was associated with adherence to second-line ART. Conclusion: Viral suppression remains high and adherence was strongly associated with viral suppression, underscoring the need to adequately address the barriers to adherence before switching regimens.

Same-day ART initiation, loss to follow-up and viral load suppression among people living with HIV in low- and middle-income countries: systematic review and meta-analysis.

Introduction: in 2015, the World Health Organization recommended early antiretroviral therapy (ART) initiation after HIV diagnosis. Mixed results on the effect of same-day ART initiation (SDI) over non-same-day ART initiation (NSDI) on loss to follow-up (LTFU) and viral load suppression (VLS) necessitate further evaluation. Methods: this was a systematic review and meta-analysis of people living with HIV in low- and middle-income countries (LMICs). Multiple databases were searched from January 2016 to December 2022. VLS was defined as HIV RNA <1,000 or <400 cells/ml, depending on the study. Forest plots were used to present the pooled prevalence and 95% confidence intervals (CIs). Heterogeneity was tested by an I2 statistic and a p-value of <0.05 indicated its presence. Analyses were performed in STATA. Results: sixteen studies (5 clinical trials, 10 cohorts, and 1 cross-sectional) were included in the final analysis. Nine studies with 157,633 people living with HIV were analyzed for LTFU and the pooled prevalence of LTFU was 22.0% (95%CI; 18.5-25.7). The pooled prevalence of VLS was 72.7% (95%CI; 65.4-79.5%). The I2 statistic had a Q value of 200.62 (p<0.001) and 44.63 (p<0.001) for pooled prevalence of LTFU and VLS, respectively. Overall, compared to those who received NSDI, SDI had a significantly increased risk of LTFU (risk difference (RD)=0.04; 95%CI: 0.01-0.07). Although observational studies showed an increased risk of LTFU among SDI compared to NSDI (RD=0.05, 95%CI: 0.02-0.08), clinical trials did not. There was no statistically significant difference in VLS comparing those who received SDI vs NSDI (RD= 0.02, 95%CI: -0.03 - 0.07). Conclusion: nearly two in ten people living with HIV in LMICs who initiated ART were LTFU. SDI was associated with increased risk of LTFU. Efforts to prevent LTFU among those who receive SDI are critical to maximize its potential benefits.

Bacteremic disseminated tuberculosis in sub-saharan Africa: a prospective cohort study.

BACKGROUND: Disseminated tuberculosis is a major health problem in countries where generalized human immunodeficiency virus (HIV) infection epidemics coincide with high tuberculosis incidence rates; data are limited on patient outcomes beyond the inpatient period. METHODS: We enrolled consecutive eligible febrile inpatients in Moshi, Tanzania, from 10 March 2006 through 28 August 2010; those with Mycobacterium tuberculosis bacteremia were followed up monthly for 12 months. Survival, predictors of bacteremic disseminated tuberculosis, and predictors of death were assessed. Antiretroviral therapy (ART) and tuberculosis treatment were provided. RESULTS: A total of 508 participants were enrolled; 29 (5.7%) had M. tuberculosis isolated by blood culture. The median age of all study participants was 37.4 years (range, 13.6-104.8 years). Cough lasting >1 month (odds ratio [OR], 13.5; P< .001), fever lasting >1 month (OR, 7.8; P = .001), weight loss of >10% (OR, 10.0; P = .001), lymphadenopathy (OR 6.8; P = .002), HIV infection (OR, undefined; P < .001), and lower CD4 cell count and total lymphocyte count were associated with bacteremic disseminated tuberculosis. Fifty percent of participants with M. tuberculosis bacteremia died within 36 days of enrollment. Lower CD4 cell count (OR, 0.88; P = .049) and lower total lymphocyte count (OR, 0.76; P = .050) were associated with death. Magnitude of mycobacteremia tended to be higher among those with lower CD4 cell counts, but did not predict death. CONCLUSIONS: In the era of free ART and access to tuberculosis treatment, almost one half of patients with M. tuberculosis bacteremia may die within a month of hospitalization. Simple clinical assessments can help to identify those with the condition. Advanced immunosuppression predicts death. Efforts should focus on early diagnosis and treatment of HIV infection, tuberculosis, and disseminated disease.

Performance of nucleic acid amplification following extraction of 5 milliliters of whole blood for diagnosis of Mycobacterium tuberculosis bacteremia.

To investigate the performance of a nucleic acid amplification test (NAAT) for the diagnosis of Mycobacterium tuberculosis bacteremia, 5-ml aliquots of blood were inoculated into bioMérieux mycobacterial (MB) bottles and incubated, and 5-ml aliquots of blood were extracted and tested by real-time PCR. Of 25 samples from patients with M. tuberculosis bacteremia, 9 (36.0%) were positive and 1 (1.5%) of 66 control samples was positive by NAAT. The NAAT shows promise, but modifications should focus on improving sensitivity.

Prevalence and factors associated with anogenital warts among sexual and gender minorities attending a trusted community health center in Lagos, Nigeria.

Anogenital warts caused by human papillomavirus are common in sexual and gender minorities (SGM). The prevalence of, and factors associated with warts were described for SGM with a high burden of HIV in Nigeria. Individuals who reported anal sex with men were enrolled in the TRUST/RV368 cohort. Participants completed an interviewer-led survey, provided biological samples, and had a physical examination. Specific to the Lagos site, clinic staff offered standardized warts treatment services. RDS-weighted multivariable logistic regression was used to estimate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors potentially associated with anogenital warts. Of 672 enrolled SGM, 478 (71%) engaged in warts services and had complete data. The median age (interquartile range) was 22 (20-26) years, 272 (52%) initiated sex before age 18, and 347 (79%) were cisgender men. Multiple male sexual partners in the previous year were reported by 448 (90%) of the participants, and 342 (66%) were living with HIV. Warts were diagnosed in 252 (54%), including anal warts in 234 (43%) and penile warts in 44 (8%); 26 (5%) had both anal and penile warts. Factors independently associated with warts included HIV (AOR:2.97; CI:1.44-6.14), engaging in receptive anal sex (AOR:3.49; CI:1.25-9.75), having multiple male sexual partners (AOR:7.26; CI:2.11-24.87), age at sexual debut (AOR:0.53; CI:0.28-0.98), and non-binary gender identity (AOR:0.20; CI:0.05-0.71). Warts were common among SGM in Nigeria, particularly those living with HIV. Administration of HPV vaccination before sexual debut or as a catch-up vaccination may prevent HPV-associated complications.

Predictors of Self-repackaging of Antiretroviral Therapy in Northern Tanzania.

Objectives: In this study, we explored determinants of "researcher-observed" patient-initiated antiretroviral therapy (ART) repackaging practices among people living with HIV (PLHIV) in Northern Tanzania. Methods: We used a quasi-experimental design to describe the prevalence of ART self- repackaging; we conducted face-to-face surveys to determine factors associated with ART self- repackaging practices. Data collection sites included the Kilimanjaro Christian Medical Centre and the Mawenzi Referral Hospital. We used study-specific numerical identifiers assigned to ARTs packaging to determine self-repackaging behavior. Self-repackaging was defined as a binary variable where participants who discarded antiretroviral drugs packaging in at least 2 clinic visits were classified as self- repackagers. We used multivariable logistic regression to assess the determinants of patient-initiated repackaging practices. Results: Among 590 study participants, 57.6% self-repackaged based on researcher observation and 55.6% self-repackaged based on patient report. Researcher-observed self- repackaging was associated with gender (AOR = 1.590; 95% CI: 1.011, 2.502), employment status (AOR = 0.475: 95% CI; 0.239, 0.942), and study site (AOR = 0.218; 95% CI: 0.134, 0.355). Conclusions: A substantial proportion of patients self-repackage their ARTs for various reasons. Health system interventions should focus on addressing the attributes of repackaging among men and unemployed patients.