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Collaborative study designs (CSDs) that combine individual-level data from multiple independent contributing studies (ICSs) are becoming much more common due to their many advantages: increased statistical power through large sample sizes; increased ability to investigate effect heterogeneity due to diversity of participants; cost-efficiency through capitalizing on existing data; and ability to foster cooperative research and training of junior investigators. CSDs also present surmountable political, logistical and methodological challenges. Data harmonization may result in a reduced set of common data elements, but opportunities exist to leverage heterogeneous data across ICSs to investigate measurement error and residual confounding. Combining data from different study designs is an art, which motivates methods development. Diverse study samples, both across and within ICSs, prompt questions about the generalizability of results from CSDs. However, CSDs present unique opportunities to describe population health across person, place and time in a consistent fashion, and to explicitly generalize results to target populations of public health interest. Additional analytic challenges exist when analysing CSD data, because mechanisms by which systematic biases (e.g. information bias, confounding bias) arise may vary across ICSs, but multidisciplinary research teams are ready to tackle these challenges. CSDs are a powerful tool that, when properly harnessed, permits research that was not previously possible.

Background: Having 90% of patients on antiretroviral therapy (ART) and achieving an undetectable viral load (VL) is 1 of the 90: 90: 90 by 2020 targets. In this global analysis, we investigated the proportions of adult and paediatric patients with VL suppression in the first 3 years after ART initiation. Methods: Patients from the IeDEA cohorts who initiated ART between 2010 and 2014 were included. Proportions with VL suppression (<1000 copies/ mL) were estimated using (1) strict intention to treat (ITT)-loss to follow-up (LTFU) and dead patients counted as having detectable VL; and (2) modified ITT-LTFU and dead patients were excluded. Logistic regression was used to identify predictors of viral suppression at 1 year after ART initiation using modified ITT. Results: A total of 35,561 adults from 38 sites/16 countries and 2601 children from 18 sites/6 countries were included. When comparing strict with modified ITT methods, the proportion achieving VL suppression at 3 years from ART initiation changed from 45.1% to 90.2% in adults, and 60.6% to 80.4% in children. In adults, older age, higher CD4 count preART, and homosexual/bisexual HIV exposure were associated with VL suppression. In children, older age and higher CD4 percentage pre-ART showed significant associations with VL suppression. Conclusions: Large increases in the proportion of VL suppression in adults were observed when we excluded those who were LTFU or had died. The increases were less pronounced in children. Greater emphasis should be made to minimize LTFU and maximize patient retention in HIV-infected patients of all age groups. ; U.S. National Institutes of Health's National Institute of Allergy and Infectious Diseases ; Eunice Kennedy Shriver National Institute of Child Health and Human Development ; National Cancer Institute ; Centers for Disease Control and Prevention, USA ; Agency for Healthcare Research and Quality, USA ; Health Resources and Services Administration, USA ; Canadian Institutes of Health Research, Canada ; Ontario Ministry of Health and Long Term Care ; Government of Alberta, Canada ; Intramural Research Program of the National Cancer Institute ; Australian Government Department of Health and Ageing ; UNSW, Kirby Inst, Sydney, NSW 2052, Australia ; Johns Hopkins Bloomberg Sch Publ Hlth, Dept Epidemiol, Baltimore, MD USA ; Fdn Huesped, Buenos Aires, DF, Argentina ; Univ Chile, Sch Med, Santiago, Chile ; Fdn Arriaran, Santiago, Chile ; Univ Cape Town, Sch Publ Hlth & Family Med, Cape Town, South Africa ; Childrens Hosp 2, Ho Chi Minh City, Vietnam ; Univ Cape Town, Dept Paediat & Child Hlth, Cape Town, South Africa ; Univ Calgary, Calgary, AB, Canada ; YRGCARE Med Ctr, Madras, Tamil Nadu, India ; Univ Fed Sao Paulo, Pediat Infect Dis Div, Escola Paulista Med, Sao Paulo, Brazil ; Johns Hopkins Univ, Dept Med, Div Infect Dis, Baltimore, MD USA ; Univ Stellenbosch, Dept Med, Div Infect Dis, Cape Town, South Africa ; Tygerberg Hosp, Cape Town, South Africa ; Univ Bern, Inst Social & Prevent Med, Bern, Switzerland ; Univ Fed Sao Paulo, Pediat Infect Dis Div, Escola Paulista Med, Sao Paulo, Brazil ; NCI: U01AI035004 ; NCI: U01AI035039 ; NCI: U01AI035040 ; NCI: U01AI035041 ; NCI: U01AI035042 ; NCI: U01AI037613 ; NCI: U01AI037984 ; NCI: U01AI038855 ; NCI: U01AI038858 ; NCI: U01AI042590 ; NCI: U01AI068634 ; NCI: U01AI068636 ; NCI: U01AI069432 ; NCI: U01AI069434 ; Centers for Disease Control and Prevention, USA: CDC-200-2006-18797 ; Centers for Disease Control and Prevention, USA: CDC-200-2015-63931 ; Agency for Healthcare Research and Quality, USA: 90047713 ; Health Resources and Services Administration, USA: 90051652 ; Canadian Institutes of Health Research, Canada: CBR-86906 ; Canadian Institutes of Health Research, Canada: CBR-94036 ; Canadian Institutes of Health Research, Canada: HCP-97105 ; Canadian Institutes of Health Research, Canada: TGF-96118 ; NCI: P30AI027757 ; NCI: P30AI027763 ; NCI: P30AI027767 ; NCI: P30AI036219 ; NCI: P30AI050410 ; NCI: P30AI094189 ; NCI: P30AI110527 ; NCI: P30MH62246 ; NCI: R01AA016893 ; NCI: R01CA165937 ; NCI: R01DA004334 ; NCI: R01DA011602 ; NCI: R01DA012568 ; NCI: R24AI067039 ; NCI: U01AA013566 ; NCI: U01AA020790 ; NCI: U01AI1031834 ; NCI: U01AI034989 ; NCI: U01AI034993 ; NCI: U01AI034994 ; NCI: M01RR000052 ; NCI: U54MD007587 ; NCI: UL1RR024131 ; NCI: UL1TR000004 ; NCI: UL1TR000083 ; NCI: UL1TR000454 ; NCI: UM1AI035043 ; NCI: Z01CP010214 ; NCI: Z01CP010176 ; NCI: U01AI069907 ; NCI: U01AI069923 ; NCI: U01AI069924 ; NCI: U01AI069918 ; NCI: F31DA037788 ; NCI: G12MD007583 ; NCI: K01A1093197 ; NCI: K23EY013707 ; NCI: K24DA000432 ; NCI: K24AI065298 ; NCI: KL2TR000421 ; NCI: N02CP055504 ; NCI: U01AI103390 ; NCI: U01AI103397 ; NCI: U01AI103401 ; NCI: U01AI103408 ; NCI: U01DA036935 ; NCI: U01HD032632 ; NCI: U10EY008057 ; NCI: U10EY008052 ; NCI: U10EY008067 ; NCI: U24AA020794 ; Web of Science

AbstractIntroductionThe third of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90‐90‐90 targets is to achieve a 90% rate of viral suppression (HIV viral load <1000 HIV‐1 RNA copies/ml) in patients on antiretroviral treatment (ART) by 2020. However, some countries use different thresholds when reporting viral suppression, and there is thus a need for an adjustment to standardize estimates to the <1000 threshold. We aim to propose such an adjustment, to support consistent monitoring of progress towards the "third 90" target.MethodsWe considered three possible distributions for viral loads in ART patients: Weibull, Pareto and reverse Weibull (imposing an upper limit but no lower limit on the log scale). The models were fitted to data on viral load distributions in ART patients in the International epidemiology Databases to Evaluate AIDS (IeDEA) collaboration (representing seven global regions) and the ART Cohort Collaboration (representing Europe), using separate random effects models for adults and children. The models were validated using data from the World Health Organization (WHO) HIV drug resistance report and the Brazilian national ART programme.ResultsModels were calibrated using 921,157 adult and 37,431 paediatric viral load measurements, over 2010–2019. The Pareto and reverse Weibull models provided the best fits to the data, but for all models, the "shape" parameters for the viral load distributions differed significantly between regions. The Weibull model performed best in the validation against the WHO drug resistance survey data, while the Pareto model produced uncertainty ranges that were too narrow, relative to the validation data. Based on these analyses, we recommend using the reverse Weibull model. For example, if a country reports an 80% rate of viral suppression at <200 copies/ml, this model estimates the proportion virally suppressed at <1000 copies/ml is 88.3% (0.800.56), with uncertainty range 85.5–90.6% (0.800.70–0.800.44).ConclusionsEstimates of viral suppression can change substantially depending on the threshold used in defining viral suppression. It is, therefore, important that viral suppression rates are standardized to the same threshold for the purpose of assessing progress towards UNAIDS targets. We have proposed a simple adjustment that allows this, and this has been incorporated into UNAIDS modelling software.

AbstractIntroductionSince 2015, the World Health Organization (WHO) has recommended that all people living with HIV (PLHIV) initiate antiretroviral treatment (ART), irrespective of CD4+ count or clinical stage. National adoption of universal treatment has accelerated since WHO's 2015 "Treat All" recommendation; however, little is known about the translation of this guidance into practice. This study aimed to assess the status of Treat All implementation across regions, countries, and levels of the health care delivery system.MethodsBetween June and December 2017, 201/221 (91%) adult HIV treatment sites that participate in the global IeDEA research consortium completed a survey on capacity and practices related to HIV care. Located in 41 countries across seven geographic regions, sites provided information on the status and timing of site‐level introduction of Treat All, as well as site‐level practices related to ART initiation.ResultsAlmost all sites (93%) reported that they had begun implementing Treat All, and there were no statistically significant differences in site‐level Treat All introduction by health facility type, urban/rural location, sector (public/private) or country income level. The median time between national policy adoption and site‐level introduction was one month. In countries where Treat All was not yet adopted in national guidelines, 69% of sites reported initiating all patients on ART, regardless of clinical criteria, and these sites had been implementing Treat All for a median period of seven months at the time of the survey. The majority of sites (77%) reported typically initiating patients on ART within 14 days of confirming diagnosis, with 60% to 62% of sites implementing Treat All in East, Southern and West Africa reporting same‐day ART initiation for most patients.ConclusionsBy mid‐ to late‐2017, the Treat All strategy was the standard of care at almost all IeDEA sites, including rural, primary‐level health facilities in low‐resource settings. While further assessments of site‐level capacity to provide high‐quality HIV care under Treat All and to support sustained viral suppression after ART initiation are needed, the widespread introduction of Treat All at the service delivery level is a critical step towards global targets for ending the HIV epidemic as a public health threat.

AbstractIntroductionCommon mental disorders (CMDs) are highly prevalent among people with HIV. Integrating mental healthcare into HIV care may improve mental health and HIV treatment outcomes. We describe the reported availability of screening and treatment for depression, anxiety and post‐traumatic stress disorder (PTSD) at global HIV treatment centres participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) Consortium in 2020 and changes in availability at sites in low‐ or middle‐income countries (LMICs) between 2016/2017 and 2020.MethodsIn 2020, 238 sites contributing individual‐level data to the IeDEA Consortium and in 2016/2017 a stratified random sample of IeDEA sites in LMICs were eligible to participate in site surveys on the availability of screening and treatment for CMDs. We assessed trends over time for 68 sites across 27 LMICs that participated in both surveys.ResultsAmong the 238 sites eligible to participate in the 2020 site survey, 227 (95%) participated, and mental health screening and treatment data were available for 223 (98%) sites across 41 countries. A total of 95 sites across 29 LMICs completed the 2016/2017 survey. In 2020, 68% of sites were in urban settings, and 77% were in LMICs. Overall, 50%, 14% and 12% of sites reported screening with a validated instrument for depression, anxiety and PTSD, respectively. Screening plus treatment in the form of counselling was available for depression, anxiety and PTSD at 46%, 13% and 11% of sites, respectively. Screening plus treatment in the form of medication was available for depression, anxiety and PTSD at 36%, 11% and 8% of sites, respectively. Among sites that participated in both surveys, screening for depression was more commonly available in 2020 than 2016/2017 (75% vs. 59%, respectively, p = 0.048).ConclusionsReported availability of screening for depression increased among this group of IeDEA sites in LMICs between 2016/2017 and 2020. However, substantial gaps persist in the availability of mental healthcare at HIV treatment sites across global settings, particularly in resource‐constrained settings. Implementation of sustainable strategies to integrate mental health services into HIV care is needed.

AbstractIntroductionInterruptions in treatment pose risks for people with HIV (PWH) and threaten progress in ending the HIV epidemic; however, the COVID‐19 pandemic's impact on HIV service delivery across diverse settings is not broadly documented.MethodsFrom September 2020 to March 2021, the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium surveyed 238 HIV care sites across seven geographic regions to document constraints in HIV service delivery during the first year of the pandemic and strategies for ensuring care continuity for PWH. Descriptive statistics were stratified by national HIV prevalence (<1%, 1–4.9% and ≥5%) and country income levels.ResultsQuestions about pandemic‐related consequences for HIV care were completed by 225 (95%) sites in 42 countries with low (n= 82), medium (n= 86) and high (n= 57) HIV prevalence, including low‐ (n= 57), lower‐middle (n= 79), upper‐middle (n= 39) and high‐ (n= 50) income countries. Most sites reported being subject to pandemic‐related restrictions on travel, service provision or other operations (75%), and experiencing negative impacts (76%) on clinic operations, including decreased hours/days, reduced provider availability, clinic reconfiguration for COVID‐19 services, record‐keeping interruptions and suspension of partner support. Almost all sites in low‐prevalence and high‐income countries reported increased use of telemedicine (85% and 100%, respectively), compared with less than half of sites in high‐prevalence and lower‐income settings. Few sites in high‐prevalence settings (2%) reported suspending antiretroviral therapy (ART) clinic services, and many reported adopting mitigation strategies to support adherence, including multi‐month dispensing of ART (95%) and designating community ART pick‐up points (44%). While few sites (5%) reported stockouts of first‐line ART regimens, 10–11% reported stockouts of second‐ and third‐line regimens, respectively, primarily in high‐prevalence and lower‐income settings. Interruptions in HIV viral load (VL) testing included suspension of testing (22%), longer turnaround times (41%) and supply/reagent stockouts (22%), but did not differ across settings.ConclusionsWhile many sites in high HIV prevalence settings and lower‐income countries reported introducing or expanding measures to support treatment adherence and continuity of care, the COVID‐19 pandemic resulted in disruptions to VL testing and ART supply chains that may negatively affect the quality of HIV care in these settings.

AbstractIntroductionTransgender women in the United States experience high HIV incidence and suboptimal Pre‐exposure prophylaxis (PrEP) engagement. We sought to estimate PrEP initiation and discontinuation rates and characterize PrEP discontinuation experiences among a prospective cohort of transgender women.MethodsUsing a sequential, explanatory, mixed‐methods design, 1312 transgender women at risk for HIV acquisition were enrolled from March 2018 to August 2020 and followed through July 2022 (median follow‐up 24 months; interquartile range 15–36). Cox regression models assessed predictors of initiation and discontinuation. In‐depth interviews were conducted among 18 participants, including life history calendars to explore key events and experiences surrounding discontinuations. Qualitative and quantitative data were integrated to generate typologies of discontinuation, inform meta‐inferences and facilitate the interpretation of findings.Results21.8% (n = 286) of participants reported taking PrEP at one or more study visits while under observation. We observed 139 PrEP initiations over 2127 person‐years (6.5 initiations/100 person‐years, 95% CI: 5.5–7.7). Predictors of initiation included identifying as Black and PrEP indication. The rate of initiation among those who were PrEP‐indicated was 9.6 initiations/100 person‐years (132/1372 person‐years; 95% CI: 8.1–11.4). We observed 138 PrEP discontinuations over 368 person‐years (37.5 discontinuations/100 person‐years, 95% CI: 31.7–44.3). Predictors of discontinuation included high school education or less and initiating PrEP for the first time while under observation. Four discontinuation typologies emerged: (1) seroconversion following discontinuation; (2) ongoing HIV acquisition risk following discontinuation; (3) reassessment of HIV/STI prevention strategy following discontinuation; and (4) dynamic PrEP use coinciding with changes in HIV acquisition risk.ConclusionsPrEP initiation rates were low and discontinuation rates were high. Complex motivations to stop using PrEP did not consistently correspond with HIV acquisition risk reduction. Evidence‐based interventions to increase PrEP persistence among transgender women with ongoing acquisition risk and provide HIV prevention support for those who discontinue PrEP are necessary to reduce HIV incidence in this population.

AbstractIntroductionWeight gain following antiretroviral therapy (ART) initiation is common, potentially predisposing some persons with HIV (PWH) to cardio‐metabolic disease. We assessed relationships between ART drug class and weight change among treatment‐naïve PWH initiating ART in the North American AIDS Cohort Collaboration on Research and Design (NA‐ACCORD).MethodsAdult, treatment‐naïve PWH in NA‐ACCORD initiating integrase strand transfer inhibitor (INSTI), protease inhibitor (PI) or non‐nucleoside reverse‐transcriptase inhibitor (NNRTI)‐based ART on/after 1 January 2007 were followed through 31 December 2016. Multivariate linear mixed effects models estimated weight up to five years after ART initiation, adjusting for age, sex, race, cohort site, HIV acquisition mode, treatment year, and baseline weight, plasma HIV‐1 RNA level and CD4+ cell count. Due to shorter follow‐up for PWH receiving newer INSTI drugs, weights for specific INSTIs were estimated at two years. Secondary analyses using logistic regression and all covariates from primary analyses assessed factors associated with >10% weight gain at two and five years.ResultsAmong 22,972 participants, 87% were male, and 41% were white. 49% started NNRTI‐, 31% started PI‐ and 20% started INSTI‐based regimens (1624 raltegravir (RAL), 2085 elvitegravir (EVG) and 929 dolutegravir (DTG)). PWH starting INSTI‐based regimens had mean estimated five‐year weight change of +5.9kg, compared to +3.7kg for NNRTI and +5.5kg for PI. Among PWH starting INSTI drugs, mean estimated two‐year weight change was +7.2kg for DTG, +5.8kg for RAL and +4.1kg for EVG. Women, persons with lower baseline CD4+ cell counts, and those initiating INSTI‐based regimens had higher odds of >10% body weight increase at two years (adjusted odds ratio = 1.37, 95% confidence interval: 1.20 to 1.56 vs. NNRTI).ConclusionsPWH initiating INSTI‐based regimens gained, on average, more weight compared to NNRTI‐based regimens. This phenomenon may reflect heterogeneous effects of ART agents on body weight regulation that require further exploration.

IntroductionLatinos living with HIV in the Americas share a common ethnic and cultural heritage. In North America, Latinos have a relatively high rate of new HIV infections but lower rates of engagement at all stages of the care continuum, whereas in Latin America antiretroviral therapy (ART) services continue to expand to meet treatment needs. In this analysis, we compare HIV treatment outcomes between Latinos receiving ART in North America versus Latin America.MethodsHIV‐positive adults initiating ART at Caribbean, Central and South America Network for HIV (CCASAnet) sites were compared to Latino patients (based on country of origin or ethnic identity) starting treatment at North American AIDS Cohort Collaboration on Research and Design (NA‐ACCORD) sites in the United States and Canada between 2000 and 2011. Cox proportional hazards models compared mortality, treatment interruption, antiretroviral regimen change, virologic failure and loss to follow‐up between cohorts.ResultsThe study included 8400 CCASAnet and 2786 NA‐ACCORD patients initiating ART. CCASAnet patients were younger (median 35 vs. 37 years), more likely to be female (27% vs. 20%) and had lower nadir CD4 count (median 148 vs. 195 cells/µL, p<0.001 for all). In multivariable analyses, CCASAnet patients had a higher risk of mortality after ART initiation (adjusted hazard ratio (AHR) 1.61; 95% confidence interval (CI): 1.32 to 1.96), particularly during the first year, but a lower hazard of treatment interruption (AHR: 0.46; 95% CI: 0.42 to 0.50), change to second‐line ART (AHR: 0.56; 95% CI: 0.51 to 0.62) and virologic failure (AHR: 0.52; 95% CI: 0.48 to 0.57).ConclusionsHIV‐positive Latinos initiating ART in Latin America have greater continuity of treatment but are at higher risk of death than Latinos in North America. Factors underlying these differences, such as HIV testing, linkage and access to care, warrant further investigation.

IntroductionMaps are powerful tools for visualization of differences in health indicators by geographical region, but multi‐country maps of HIV indicators do not exist, perhaps due to lack of consistent data across countries. Our objective was to create maps of four HIV indicators in North, Central, and South American countries.MethodsUsing data from the North American AIDS Cohort Collaboration on Research and Design (NA‐ACCORD) and the Caribbean, Central, and South America network for HIV epidemiology (CCASAnet), we mapped median CD4 at presentation for HIV clinical care, proportion retained in HIV primary care, proportion prescribed antiretroviral therapy (ART), and the proportion with suppressed plasma HIV viral load (VL) from 2010 to 2012 for North, Central, and South America. The 15 Canadian and US clinical cohorts and 7 clinical cohorts in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru represented approximately 2–7% of persons known to be living with HIV in these countries.ResultsStudy populations were selected for each indicator: median CD4 at presentation for care was estimated among 14,811 adults; retention was estimated among 87,979 adults; ART use was estimated among 84,757 adults; and suppressed VL was estimated among 51,118 adults. Only three US states and the District of Columbia had a median CD4 at presentation >350 cells/mm3. Haiti, Mexico, and several states had >85% retention in care; lower (50–74%) retention in care was observed in the US West, South, and Mid‐Atlantic, and in Argentina, Brazil, and Peru. ART use was highest (90%) in Mexico. The percentages of patients with suppressed VL in the US South and Northeast were lower than in most of Central and South America.ConclusionsThese maps provide visualization of gaps in the quality of HIV care and allow for comparison between and within countries as well as monitoring policy and programme goals within geographical boundaries.