The changing landscape of both causes and locations of death in a regional HIV population 2010-2021.

BACKGROUND: Although HIV-related deaths among people with HIV have dramatically decreased, deaths from other medical conditions and non-medical events have increased. The location of death among people with HIV remains underreported. OBJECTIVES: We reviewed the deaths, causes of death, and reported location of death (i.e. within or outside of medical settings) of all people with HIV with the Southern Alberta Cohort, Calgary, Canada, between 1 January 2010 and 1 January 2022. METHODS: This was a retrospective longitudinal cohort study reviewing all deaths within a comprehensive geographically defined HIV cohort over 11 years. RESULTS: Deaths from HIV-related causes decreased from 52% of all deaths in 2010 to 14% in 2021. In 2021, non-HIV medical deaths increased from 38% to 44%, and non-medical deaths (e.g. violence, suicide, drug overdose) increased from 0.5% to 39%. Of non-medical deaths, 67% resulted from substance use/overdose. Overall, deaths in any medical setting decreased from 91% in 2010 to 39% in 2021; 61% of all deaths occurred in a medical setting (e.g. hospital/emergency department or supported/long-term/hospice care), 27% in a residence, and 9% in the community. CONCLUSION: The shifting causes of death (i.e. fewer HIV-related deaths, more overdose deaths) and location of death (i.e. fewer in medical settings, more at home/in the community) requires close monitoring so future resources can be matched to predicted patient needs.

COVID-19 vaccine uptake among people with HIV: identifying characteristics associated with vaccine hesitancy.

People with HIV (PWH) are at increased risk of COVID-19 infection. Both Canadian (NACI) and US (CDC) guidelines recommend that all PWH receive at least 2 doses of COVID-19 vaccine, and a booster. We examined vaccination uptake among PWH in Southern Alberta, Canada. Among adult PWH, we evaluated COVID-19 vaccination uptake between December 2020 and August 2022. Poisson regression models with robust variance (approximating log binomial models) estimated crude and adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for receiving (1) any vs. no vaccine, and (2) primary series with booster (≥ 3 vaccines) versus primary series without booster. Among 1885 PWH, 10% received no COVID-19 vaccinations, 37% < 3 vaccines and 54% received ≥ 3 vaccines. Females (vs. males) were less likely to receive a vaccine booster. Receiving no COVID-19 vaccines was associated with White ethnicity, unsuppressed HIV viral load (> 200 copies/mL), and using illegal substances. Factors associated with decreased booster uptake included being younger, Black (vs. White) ethnicity, substance use, lower educational attainment, and having an unsuppressed HIV viral load. COVID-19 booster uptake among PWH does not meet vaccine guidelines, and receipt of vaccines is unevenly distributed. Booster uptake is lowest among young females and marginalized individuals. Focused outreach is necessary to close this gap.

The changing use and program costs of HIV-related laboratory testing over 20 years in an HIV cohort.

PURPOSE OF REVIEW: The improved health of persons with HIV (PWH) resulting from antiretroviral therapy (ART) has led to recommendations for reduced laboratory monitoring. We studied, for all PWH in care over 20 years at the Southern Alberta Clinic (SAC), Canada, the changing use and results of HIV-specific laboratory testing [i.e., CD4+ testing, plasma HIV viral load (PVL), and genotypic antiretroviral resistance testing (GART)].In this descriptive retrospective longitudinal cohort observational study, we examined HIV-specific laboratory testing for all PWH from 2000 to 2020 within the context of HIV-related health outcomes, program costs, and mortality. RECENT FINDINGS: The number of PWH in care increased from 755 in 2000 to 2050 in 2020. Annual CD4+ testing per PWH increased from 2.7 per person in 2000 peaking to 3.5 in 2005 but decreasing to 1.4 by 2020. Annual PVL tests per PWH gradually decreased from 3.2 in 2000 to 2.0 in 2020. GART increased from 93 tests in 2000 to 315 in 2008 decreasing to 127 in 2020. Patients received GART at baseline, and after a viral breakthrough when indicated. Viral suppression rates for the population increased from 66 to 96%; median CD4+ cell count increased from 443 to 470 cells/µl, and overall morbidity decreased from 9.2 to 2.0% by 2020, respectively. Annual per patient laboratory costs decreased from a high of $302 in 2008 to $161 by 2020. SUMMARY: The reduced annual laboratory surveillance per PWH associated with modern ART resulted in modest cost savings and no apparent loss in quality of HIV care.

Viral Breakthrough Episodes Among Persons with HIV in Care in Alberta, Canada: Clinical and Public Health Implications.

Unsuppressed HIV viremia damages immunity and increases the risk for secondary HIV transmission. Successful engagement of persons with HIV (PWH) into care resulting in viral suppression is vital. PWH already engaged in care, who, after achieving viral suppression, experience viral breakthrough episodes (VBEs) with a sequence of suppressed/unsuppressed/suppressed viral loads remain problematic. We examined the frequency and outcomes of PWH experiencing VBE. HIV care is provided at no cost to all patients under Alberta's universal health program. All PWH followed at Southern Alberta Clinic, Canada, with two or more viral load tests between January 1, 2010, and January 1, 2020, were evaluated. Sociodemographic, clinical, and lifestyle variables were determined along with health outcomes (CD4 levels, HIV-related hospitalizations, and HIV/AIDS-related mortality). Descriptive and multi-variable analyses were performed comparing PWH with and without VBEs. Of 2096 PWH, 386 (18%) experienced one or more VBEs. A higher risk of VBEs was seen in adjusted analyses in those diagnosed age ≤40 years. Increased risk of VBE was seen with injection drug use (46%) and in heterosexuals (56%) compared with MSM. Experience of intimate partner violence, unstable housing, homelessness, and past incarceration also increased risks by 36%, 44% 79%, and 51%, respectively. PWH with VBEs experienced lower CD4 counts (median -417/mm3 vs. 576/mm3), higher rates of HIV-related hospitalizations (16% vs. 5%), and a 67% increased risk of death (95% confidence interval 1.17-2.39) over the study period. Nearly 20% of all PWH, after achieving viral suppression, experienced VBEs. Distinct clinical, lifestyle, and life experiences predict PWH at greatest risk for more than one VBEs. Serious negative health outcomes of VBEs were identified, suggesting that novel customized care programming is required for PWH at greatest risk.

Longitudinal analysis of HIV outcomes for persons living with HIV in non-urban areas in southern Alberta, Canada.

BACKGROUND: Many challenges remain in successfully engaging people with HIV (PWH) into lifelong HIV care. Living in non-urban or rural areas has been associated with worse outcomes. Uncertainties remain regarding how to provide optimal HIV care in non-urban areas. METHODS: Using a retrospective descriptive analysis framework, we compared multiple measurable HIV care metrics over time on the basis of urban versus non-urban residency, under a centralized HIV care model. We examined rates of HIV diagnosis, access to and retention in HIV care, and longitudinal outcomes for all newly diagnosed PWH between January 1, 2008, and January 1, 2020, categorized by their home location at the time of HIV diagnosis in southern Alberta. RESULTS: Of 719 newly diagnosed PWH, 619 (86%) lived in urban areas and 100 (14%) lived in non-urban areas. At HIV diagnosis, the groups had no significant differences in initial CD4 count or clinical characteristics (p = 0.73). Non-urban PWH, however, had slightly longer times to accessing HIV care and initiating antiretroviral therapy (ART) (p < 0.01). Non-urban PWH showed trends toward slightly lower retention in care and lower sustained ART use, with higher rates of unsuppressed viral loads at 12, 24, and 36 months after diagnosis (p < 0.01). However, by 2020 both cohorts had suppression rates above 90%. CONCLUSIONS: Sustained retention in care was more challenging for non-urban PWH; however, adherence to ART and viral suppression rates were more than 90%. Although encouraging, challenges remain in identifying and reducing unique barriers for optimal care of PWH living in non-urban areas.

HISTORIQUE: Il reste de nombreux défis à relever pour mobiliser les personnes atteintes du VIH (PAV) à adhérer aux soins du VIH jusqu'à la fin de leurs jours. La résidence en région non urbaine ou rurale est associée à des résultats cliniques plus négatifs. Il reste des incertitudes quant aux moyens d'offrir des soins optimaux du VIH hors des régions urbaines. MÉTHODOLOGIE: Au moyen d'une analyse descriptive rétrospective, les chercheurs ont comparé de multiples mesures des soins du VIH au fil du temps d'après le lieu de résidence en milieu urbain ou non urbain, en fonction d'un modèle de soins du VIH centralisé. Ils ont examiné les taux de diagnostic du VIH, l'accès aux soins du VIH et la rétention de ces soins, ainsi que les résultats cliniques longitudinaux de toutes les PAV nouvellement diagnostiquées entre le 1er janvier 2008 et le 1er janvier 2020, classées d'après leur lieu de résidence au moment du diagnostic de VIH dans le sud de l'Alberta. RÉSULTATS: Sur les 719 PAV nouvellement diagnostiquées, 619 (86 %) vivaient en région urbaine et 100 (14 %), en région non urbaine. Au diagnostic du VIH, les groupes ne présentaient pas de différence significative pour ce qui est de la numération initiale des CD4 ou des caractéristiques cliniques (p = 0,73). Cependant, il fallait légèrement plus de temps aux PAV de milieu non urbain pour accéder aux soins du VIH et entreprendre une thérapie antirétrovirale (TAR) (p < 0,01). Ainsi, 12, 24 et 36 mois après le diagnostic, les PAV des milieux non urbains affichaient des tendances vers une rétention légèrement plus faible des soins et une utilisation soutenue légèrement plus faible du traitement antirétroviral (TAR), de même que des charges virales non supprimées plus élevées (p < 0,01). Cependant, en 2020, les deux cohortes présentaient des taux de suppression supérieurs à 90 %. CONCLUSIONS: Il était plus difficile de maintenir une rétention soutenue des soins pour les PAV hors des milieux urbains, mais l'adhésion au TAR et les taux de suppression virale étaient supérieurs à 90 %. C'était encourageant, mais il reste des défis pour déterminer et réduire les obstacles à des soins optimaux chez les PAV qui habitent hors des milieux urbains.

Seropositivity, Risks, and Morbidity From Varicella-Zoster Virus Infections in an Adult PWH Cohort From 2000-2020.

Background: Varicella-zoster virus (VZV) infection disproportionately affects people with HIV (PWH), primarily presenting as herpes zoster. However, VZV seroprevalence, its association with zoster, and clinical outcomes remain understudied in era of modern antiretroviral therapy (ART). We assessed VZV seroprevalence, rates of VZV illness, and associated health care costs in a large cohort of PWH over 20 years. Methods: We performed retrospective chart reviews of patients followed at a regional HIV clinic from January 1, 2000, to December 31, 2020. Serological, immunization, clinical, and costing data were extracted from in-house databases. VZV-related inpatient admissions, emergency department (ED), and urgent care (UC) visits were identified using relevant International Classification of Disease (ICD-10) codes and validated where possible by 2 physicians. Health care utilization costs were adjusted to 2020 Canadian dollars. Results: Of 3006 PWH, VZV serology was available for 2628; of these, 2503 (95.2%) were seropositive. Only 39% of known seronegative patients were subsequently immunized for varicella. During 29 768 years of patient follow-up, 38 hospitalizations and 138 ED/UC visits due to VZV infection were identified. Most occurred in VZV-seropositive PWH <50 years of age (82%) who were unimmunized (99.2%) and not on ART (64.8%). Nearly 25% of hospitalizations were due to laboratory-confirmed VZV meningitis/encephalitis. The average admission cost was CDN$33 001; the total measured cost of VZV illness was CDN$1 258 718. Conclusions: Despite ART and vaccines for chickenpox and shingles, VZV still caused significant costs and morbidity for PWH, occurring at younger ages and often as encephalitis/meningitis. Supporting ART adherence may reduce VZV illness and hospitalization costs in PWH, and the cost-effectiveness of expanding shingles vaccine use warrants further study.

Uptake Success and Cost Savings from Switching to a Two-Drug Antiretroviral Regimen.

The emergence of dual therapy for antiretroviral (ARV)-experienced persons living with HIV (PWH) offers the opportunity to reduce lifetime exposure to unnecessary ARV drugs while maintaining viral suppression and reducing the cost of care. Our objective, using retrospective analysis of a quality care initiative, was to examine in routine clinical practice the clinical impact of switching PWH stable on a three-drug to a two-drug single-tablet formulation (STF) ARV regimen. We also examined the cost implications of this STF adjustment. Between January 1, 2020 and January 1, 2021 eligible patients (i.e., virally suppressed, no active hepatitis B infection, no documented nucleoside reverse transcriptase inhibitors/integrase strand transfer inhibitor resistance) were offered, on a convenience basis and as part of routine care, the opportunity to adjust their current three-drug STF to a two-drug STF (dolutegarvair/lamivudine). The acceptance, clinical efficacy, safety, tolerability, and cost of treatment were measured for patients who switched in 2020. Of 989 eligible PWH, 408 were approached and 391 (39.5%) switched to two-drug regimen; 99% remained on the two-drug STF at year's end (median 240 days follow-up). Only 2/391 patients who switched lost viral control. The total ARV drug cost for all 989 patients decreased by 10.3% generating an actual savings of $1,596,666 among patients approached and switched in 2020. Patient interest and uptake in switching to two-drug STF was substantial and resulted in few discontinuations for any reason. It provided significant and immediate cost savings within the first year. Our results bring clarity to discussions on whether using two-drug regimens would be practical and acceptable in nonclinical trial settings.

What are the drivers of high-cost HIV patients?

We aimed to identify "high-cost" patients with HIV (PWH) and determine drivers behind higher costs. All PWH at the Southern Alberta HIV Clinic, Canada, and active in 2017 were included. Sociodemographic, clinical, and healthcare utilization data were collected. The direct care costs from the payers' perspective including antiretroviral drugs (ARV), outpatient visits, and hospital admissions were determined for 2017. Patients' annual total costs were grouped into top 5% (i.e., high-cost), top 20%, middle 60%, and bottom 20%. High-cost patients were older, Caucasian or indigenous Canadian, and more likely acquired HIV from intravenous drug use (all p < 0.05). High-cost patients had lower nadir CD4, more comorbidities, missed more clinic appointments, had more ARV interruptions, and developed more ARV resistance (p < 0.01). The overall median cost of HIV care was US$14,064 [IQR US$13,121-US$17,883] (2017 Cdn$). High-cost patients had a median cost of US$29,902 [IQR US$27,229-US$37,891] and accounted for 14% of total costs and 84% of all inpatient costs. Hospitalizations constituted 58% of costs for high-cost patients. Although heterogeneous, high-cost patients have distinct sociodemographic and clinical characteristics driving their healthcare utilization. Addressing these social determinants of health and using novel ARV administration approaches may preserve health and save costs.

Reporting on patients living with HIV "disengaging from care". Who is actually "lost to follow-up"?

Retention in care remains an important concern for health care providers. However, accurately identifying who is or is not retained in care can be problematic. Not all patients believed to be engaged in care are actually in care, and not all patients believed to be disengaged are truly disengaged. Identifying the status of individuals within populations is important for clinical, administrative and surveillance concerns. As part of the Linkage and Retention in Care Project at St Michael's Hospital in Toronto, Canada, we investigated the status of patients diagnosed with HIV. Detailed investigation determined who was actually Lost-to-Follow-Up (i.e., disengaged from care >12 months) and who had disengaged for known reasons. This approach determined more precisely who was currently followed in care and who was not, and to target efforts to contact and reengage patients more effectively. This study illustrates the importance of accurately monitoring populations enhancing disease management.

Long-term consequences of interpersonal violence experiences on treatment engagement and health status in people living with HIV.

OBJECTIVE: To examine the impact of previous interpersonal violence (IPersV) experiences on long-term healthcare engagement and health outcomes in a large Canadian HIV-cohort. DESIGN: People living with HIV (PLHIV) were screened for IPersV, and their healthcare outcomes over the nine subsequent years were analyzed. METHODS: A total of 1064 PLHIV were screened for past and present IPersV experiences through semistructured interviews. Follow-up included core treatment engagement (e.g. clinic visits) and health-status variables (HIV viral load, CD4+ T-cell count, mortality, comorbidities), analyzed descriptively and with longitudinal Cox regressions. RESULTS: At intake, 385 (36%) PLHIV reported past or present IPersV including childhood (n = 224, 21%) or adulthood experiences (n = 161, 15%) and were offered conventional social work support. Over 9 years, individuals with any IPersV experiences were 36% more likely to discontinue care, 81% more likely to experience viremia, 47% more likely to experience a drop in CD4+ cell counts below 200/µl, and 65% more likely to die compared with patients not reporting IPersV (P < 0.05). Outcomes were similar when adjusted for sociodemographic factors. Childhood IPersV in particular was linked to several of the outcomes, with higher rates of discontinuation of care, viremia, and mortality related to mental health/addiction or HIV-related complications. CONCLUSION: IPersV is associated with an increased risk over time of healthcare discontinuation, poorer long-term HIV-related health outcomes, and increased mortality, especially for patients victimized in childhood. Apart from targeted IPersV screening to initiate conventional supports (e.g. through social work), increased efforts to engage vulnerable populations in their long-term care seems warranted.

Missed opportunities within healthcare for an earlier diagnosis of HIV.

Despite guidelines, many individuals are not routinely tested for HIV within healthcare settings. Our objective was to quantify and characterize preceding clinical encounters by newly-diagnosed persons living with HIV in southern Alberta, Canada. We discuss the clinical impact of missed HIV testing, and options for remediation. Clinical encounters prior to HIV diagnosis including the discharge diagnosis were collected between 1 April 2011 and 1 April 2016. We followed the HIV Indicator Diseases across Europe Study criteria to identify HIV Clinical Indicator Conditions (HCICs) present at clinical encounters. Patients accessing prior care were compared to those who had not previously accessed care. Of 393 individuals, 231 (58.7%) had ≥1 encounter prior to diagnosis; 224 (57%) of encounters occurred in outpatient clinics, 130 (33.1%) in emergency departments, and 39 (9.9%) in urgent care clinics. Approximately 25% (n = 57) of patients who engaged healthcare had ≥ 1 recognized HCIC but did not receive HIV testing. The most frequent HCICs were infection (n = 34; 60%) and hematological disorders (n = 12; 21%). The median CD4 cell count at HIV diagnosis for patients with an HCIC was 127 cells/mm3. In this population, three of five patients had accessed healthcare prior to diagnosis with one of four presenting with HCICs but were not offered HIV testing. Protocols beyond the current recommendations are urgently required to address missed HIV diagnostic opportunities who engaged healthcare.

An Emerging Concern-High Rates of Frailty among Middle-aged and Older Individuals Living with HIV.

BACKGROUND: The aim of the present study was to calculate a frailty index (FI) in older adults (≥50) living with HIV, search for cross-sectional associations with the FI, and investigate the association between the FI score and two-year mortality. METHODS: Cross-sectional study with a short-term prospective component for the determination of two-year mortality was performed. The study took place in an HIV outpatient clinic in Calgary, Canada between November 1, 2016 and December 31, 2018. Over 700 patients 50 years of age or older took part. We calculated a FI for each patient, examined associations between FI and select patient characteristics, and evaluated the association between FI value and two-year mortality. RESULTS: The mean FI was 0.303 (± 0.128). Mean FI did not differ between males and females, nor was it associated with either nadir or current CD4 cell count. It did increase with age, duration of ART, and duration of diagnosed HIV infection. Mean FI was higher among those who died compared to survivors (0.351 vs. 0.301; p=.033). CONCLUSIONS: Frailty is highly prevalent in persons living with HIV and associated with a higher mortality rate. Health-care providers should be aware of the earlier occurrence of frailty in adults living with HIV.

The Impact of "Churn" on Plasma HIV Burden Within a Population Under Care.

BACKGROUND: Cross-sectional reporting of viral suppression rates within a population underestimates the community viral load (VL) burden. Longitudinal approaches, while addressing cumulative effects, may still underestimate viral burden if "churn" (movement in and out of care) is not incorporated. We examined the impact of churn on the cumulative community HIV viral burden. METHODS: All HIV+ patients followed in 2016-2017 at the Southern Alberta Clinic (Calgary, Canada) were categorized as follows: (1) in continuous care, (2) newly diagnosed, (3) diagnosed elsewhere transferring care, (4) returning to care, (5) lost-to-follow-up, (6) moved care elsewhere, or (7) died. Patient days were classified by VL as suppressed (≤200copies/ml), unsuppressed (>200 copies/ml), and transmittable (>1500 copies/ml). RESULTS: Of 1934 patients, 78.4% had suppressed VL; 21.4% had ≥1 unsuppressed VL, and 18.7% ≥1 transmittable VL. Of 1 276 507 total patient days in care, 92.1% were spent suppressed, 7.9% unsuppressed (101 459 days), and 6.4% (81 847 days) transmittable. 88.7% of category 1 patients had suppressed VL, 11.3% ≥1 unsuppressed VL, and 8.9% ever a transmittable VL. Of category 2 patients, 90% became suppressed on treatment (mean - 62 days). 38.5% of category 3 patients presented with a transmittable VL. Category 4 and 5 patients combined had high rates of unsuppressed (54.5%) and transmittable (51.2%) VL and, while representing only 6.2% of all patients, they accounted for 37.1% of unsuppressed and 41.5% of all transmittable days. CONCLUSION: Focus on VL of patients continuously in care misses those with unsuppressed and transmittable VL in a community. Patients moving in and out of care pose an underappreciated risk for HIV transmissions.

A retrospective study of the clinical features of new syphilis infections in an HIV-positive cohort in Alberta, Canada.

OBJECTIVES: Syphilis is a global health concern with an estimated 12 million infections occurring annually. Due to the increasing rates of new syphilis infections being reported in patients infected with HIV, and their higher risk for atypical and severe presentations, periodic screening has been recommended as a routine component of HIV care. We aimed to characterise incident syphilis presentation, serological features and treatment response in a well-defined, HIV-infected population over 11 years. METHODS: Since 2006, as routine practice of both the Southern Alberta Clinic and Calgary STI programmes, syphilis screening has accompanied HIV viral load measures every 4 months. All records of patients who, while in HIV care, either converted from being syphilis seronegative to a confirmed seropositive or were reinfected as evidenced by a fourfold increase in rapid plasma reagin (RPR) after past successful treatment, were reviewed. RESULTS: We identified 249 incident syphilis infections in 194 different individuals infected with HIV; 72% were initial infections whereas 28% were reinfections. Half (50.8%) of the infections were asymptomatic and identified only by routine screening. Symptomatic syphilis was more common when RPR titres were higher (p=0.03). In patients with recurrent syphilis infection, a trend was noted favouring symptomatic presentation (62%, p=0.07). All 10 patients with central nervous system (CNS) syphilis involvement presented with an RPR titre ≥1:32. Following syphilis infection, a decline of 42 cells/mm3 in CD4 (p=0.004) was found, but no significant changes in viral load occurred. No association was found with the stage of syphilis or symptoms at presentation and antiretroviral therapy use, CD4 count or virological suppression. CONCLUSION: Routine screening of our HIV-infected population identified many asymptomatic syphilis infections. The interaction of HIV and syphilis infection appears to be bidirectional with effects noted on both HIV and syphilis clinical and serological markers.

Long-term HIV/AIDS survivors: Patients living with HIV infection retained in care for over 20 years. What have we learned?

Individuals diagnosed with HIV before 1996 had poor prognoses. Few HIV care centers can track patients continuously from the 1980s to present. We determined the sociodemographic, clinical, and health care utilization characteristics of patients diagnosed and followed for >20 years (i.e. long-term HIV/AIDS survivors) to understand what factors contributed to survival. All HIV-positive patients diagnosed before 1996 were categorized as active, moved/lost, or died as of 1 January 2016. Baseline sociodemographic, clinical characteristics, antiretroviral therapy (ART) usage, retention, HIV care costs, and health status were analyzed. Of 876 patients, 49.5% died, 30.3% moved or left, 20.3% remained active in care for a median of 23.4 years. At diagnosis, continuously-followed patients were younger with a higher CD4 cell count, attended regular clinic visits at higher frequencies, and had received more ART than patients who moved or died. As of 1 January 2016, their median age was 57 years (interquartile range 53-62), 15% were aged >65 years, median CD4 cell count was 591 cells/mm3 (475-863) with 68% >500 cells/mm3. Sixty-two percent remained employed. The total cost of HIV care was $32,251,030 (Cdn$); median cost per patient per year $15,418 ($13,697-$18,392). Individuals diagnosed prior to 1996 benefited from early diagnosis and engagement to care, regular follow-ups, and timely initiation of ART, strongly supporting the modern guidelines of care.

Increasing incidence of syphilis among patients engaged in HIV care in Alberta, Canada: a retrospective clinic-based cohort study.

BACKGROUND: Syphilis is a global health concern disproportionately affecting HIV-infected populations. In Alberta, Canada, the incidence of syphilis in the general population has recently doubled with 25% of these infections occurring in HIV-infected patients. The Southern Alberta HIV Clinic (SAC) and Calgary STI Program (CSTI) analyzed the epidemiologic characteristics of incident syphilis infections in our well-defined, HIV-infected population over 11 years. METHODS: Since 2006, as routine practice of both the Southern Alberta Clinic (SAC) and Calgary STI Programs (CSTI), syphilis screening has accompanied HIV viral load measures every four months. All records of patients who, while in HIV care, either converted from being syphilis seronegative to a confirmed seropositive or were re-infected as evidenced by a four-fold increase in rapid plasma reagin (RPR) after past successful treatment, were reviewed. RESULTS: Incident syphilis was identified 249 times in 194 HIV-infected individuals. There were 36 individuals with repeated infections (28.5% of episodes). Following a prior decline in annual incident syphilis rates, the rates have tripled from 8.08/1000 patient-years (95% confidence interval (CI): 4.14-14.75) in 2011, to 27.04 per 1000 person-years (95% CI: 19.45-36.76) in 2016. Half of the syphilis episodes were asymptomatic. Patients diagnosed with syphilis were twice as likely not to be taking ART and had a higher likelihood of having plasma HIV RNA viral loads > 1000 copies/mL (19%). Incident syphilis was seen predominantly in Caucasians (72%, P < 0.001), males (94%, P < 0.001) and men who have sex with men (MSM) as their HIV risk activity (75%, P < 0.001). CONCLUSIONS: We have highlighted the importance of a regular syphilis screening program in HIV-infected individuals demonstrated by increasing rates of incident syphilis in our region. Targeted preventative strategies should be directed towards HIV-infected populations identified at highest risk, including; MSM, prior alcohol abuse, prior recreational drug use and those with prior syphilis diagnoses.

Healthcare contacts among patients lost to follow-up in HIV care: review of a large regional cohort utilizing electronic health records.

In the United States 40% of HIV patients are lost to follow-up (LTFU) following linkage to HIV care and an estimated 30-61% of new HIV transmissions are attributed to this group. To characterize those LTFU and healthcare contacts they make, we retrospectively analyzed a large regional HIV cohort in Calgary, Canada, utilizing a province-wide electronic health record. Adults engaged in HIV care between January 2010 and August 2014 who had >12 months without HIV clinic contact were identified as LTFU. Of 1928 individuals engaged in care, 176 became LTFU with 64% having no healthcare contacts, 20% receiving HIV care elsewhere, and 16% making non-HIV healthcare contacts. Those LTFU making non-HIV healthcare contacts did so a median of six times (interquartile range 2-8), 76% attending emergency departments (ED). Compared to those retained in care, LTFU patients were younger (median age 43 versus 47 years), had lower CD4+ cell counts (median 420 versus 500 × 106/l) and more commonly resided outside of the centralized HIV clinic's city (odds ratio 4.58) (all p < 0.01). Our finding that a majority of those LTFU did not make healthcare contacts suggests that community and HIV clinic-based relinkage programs are needed. For those LTFU who make healthcare contacts enhanced ED-based relinkage programs could engage a majority.

Reporting on the prevalence of antiretroviral drug resistance in a regional HIV population over 20 years: a word of caution.

BACKGROUND: Failure to achieve complete viral suppression with antiretroviral drugs (ARV) may lead to uncontrolled HIV replication, ARV resistance and negative outcomes. Monitoring and reporting of HIV resistance trends is important but problematic. We examined prevalent resistance rates in an HIV population over 20 years and document how rates may appear to vary greatly based solely on which parameters are utilized. METHODS: We determined the annual use of genotypic antiretroviral resistance testing (GART) from 1995 to 2014 for all patients receiving HIV care in southern Alberta, Canada, and the presence of resistance mutations in those tested. The impact on prevalent resistance rates of using cumulative or latest GART was also determined. RESULTS: Between 1995 and 2014, the number of patients with GART increased from <1% to 71%. Prevalent resistance in patients with GART decreased from a high of 52% in 2003 to 25.8% in 2014. However, if prevalence rates were reported using all active patients as denominator, including those without GART, prevalence increased from 0.7% to 18.5%. Prevalence rates were 7% to 9% higher in any given year if cumulative GART rather than latest GART results were used. CONCLUSIONS: While prevalence resistance rates are decreasing, the precise rates being reported may vary due to increasing number of patients tested annually, using either the entire population as denominator or only patients with GART, and using either last or cumulative GART. Defining these parameters is critical if prevalence is to be compared over time or between HIV populations.

Understanding the delay in starting antiretroviral therapy despite recent guidelines for HIV patients retained in care.

Despite strong evidence of a clinical benefit from initiating antiretroviral therapy (ART) immediately after diagnosis some patients remain ART naïve. We examined explanations, over a four-year period in a centralized HIV clinical cohort under universal health care, for newly diagnosed patients, while being fully engaged and retained in HIV care, delaying ART initiation for >180 days following their HIV diagnosis. All patients followed at the Southern Alberta Clinic, Calgary, Canada between 1 January 2010 and 1 January 2014 were included and followed until they moved, were lost to follow-up, died or until 1 January 2015. Of 269 patients, 56 (21.8%) deferred ART >180 days; 26 (9.7%) remained ART naïve until the end of the study. Patients delaying or deferring ART were younger, Canadian-born, and with higher CD4 counts (p < .01). "No clinical urgency" especially for patients with higher CD4 counts, was most often listed for deferring ART, however when ART was offered "patient not ready", "unstable substance use", "difficulties adjusting" or "wanting to wait" were often cited regardless of CD4 levels. At times ART, when offered, was adamantly declined by the patient. The physician's assessment of a patient's ability to adhere to lifelong ART was an issue in some cases. While structural or financial issues may impact ART initiation, our results suggest that, even in an environment of free and easy access to ART, many challenges still exist at the implementation stage. Intense efforts in both patient and physician education will be required if the benefits of early ART as recommended by the WHO in their recent guidelines, are to be achieved at the individual and population level.