A new cascade of HIV care for the era of "treat all".
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ABSTRACT:
SUBMITTER: Fox MP
PROVIDER: S-EPMC5388465 | biostudies-literature | 2017 Apr
REPOSITORIES: biostudies-literature
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A new cascade of HIV care for the era of "treat all".
Fox Matthew P MP Rosen Sydney S
PLoS medicine 20170411 4
Matthew Fox and Sydney Rosen discuss a cascade of HIV care adapted to WHO-recommended antiretroviral therapy irrespective of CD4 cell count. ...[more]
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Project description:Japan has been known as a low HIV-prevalence country with a concentrated epidemic among high-risk groups. However, it has not been determined whether Japan meets the 90-90-90 goals set by the Joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO). Moreover, to date, the HIV care cascade has not been examined. We estimated the total number of diagnosed people living with HIV/AIDS (PLWHA) (n = 22,840) based on legal reports to the Ministry of Health, Labour and Welfare by subtracting the number of foreigners who left Japan (n = 2,273) and deaths (n = 2,321) from the cumulative diagnosis report (n = 27,434). The number of total undiagnosed PLWHA was estimated by age and sex specific HIV-positive rates observed among first-time blood donors between 2011-2015 in Japan. Our estimates show that 14.4% (n = 3,830) of all PLWHA (n = 26,670) were undiagnosed in Japan at the end of 2015. The number of patients retained in care (n = 20,615: 77.3% of PLWHA), the percentage of those on antiretroviral therapy (n = 18,921: 70.9% of PLWHA) and those with suppressed viral loads (<200 copies/mL; n = 18,756: 70.3% of PLWHA) were obtained through a questionnaire survey conducted in the AIDS Core Hospitals throughout the country. According to these estimates, Japan failed to achieve the first two of the three UNAIDS/WHO targets (22,840/26,670 = 85.6% of HIV-positive cases were diagnosed; 18,921/22,840 = 82.8% of those diagnosed were treated; 18,756/18,921 = 99.1% of those treated experienced viral suppression). Although the antiretroviral treatment uptake and success after retention in medical care appears to be excellent in Japan, there are unmet needs, mainly at the surveillance level before patients are retained in care. The promotion of HIV testing and treatment programs among the key affected populations (especially men who have sex with men) may contribute to further decreasing the HIV epidemic and achieving the UNAIDS/WHO targets in Japan.
| S-EPMC5358866 | biostudies-literature
Project description:PurposeThe PopART for Youth (P-ART-Y) study was nested within the HPTN 071 (PopART) trial, a three-arm community randomized trial in 21 communities in Zambia and South Africa. The P-ART-Y study evaluated the acceptability and uptake of a combination HIV prevention package among young people. We report on the HIV care cascade for adolescents aged 10-19 years from 14 communities receiving the full HIV prevention package in Zambia and South Africa.MethodsAdolescents were offered participation in the PopART intervention, which included universal home-based HIV testing, linkage to care, antiretroviral therapy (ART) adherence, and other services. Data were collected from September 2016 to December 2017, covering the third round (R3) of the intervention.ResultsWe enumerated (listed) 128,241 adolescents (Zambia: 95,295 and South Africa: 32,946). Of the adolescents offered HIV testing, 81.9% accepted in Zambia and 70.3% in South Africa. Knowledge of HIV status was higher among older adolescents and increased from 31.4% before R3 to 88.3% at the end of R3 in Zambia and from 28.3% to 79.5% in South Africa. Overall, there were 1,710 (1.9%) adolescents identified as living with HIV by the end of R3 (515 new diagnoses and 1,195 self-reported). Of the new diagnoses, 335 (65.0%) were girls aged 15-19 years. The median time to initiate ART was 5 months. ART coverage before and after R3 increased from 61.3% to 78.7% in Zambia and from 65.6% to 87.8% in South Africa, with boys having higher uptake than girls in both countries.ConclusionsThe PopART intervention substantially increased coverage toward the first and second UNAIDS 90-90-90 targets in adolescents.
| S-EPMC8022105 | biostudies-literature
Project description:Purpose of the reviewIn 2015, antiretroviral therapy (ART) was recommended for all people living with HIV (PLHIV) regardless of CD4 count ("Treat All"). To better understand how to improve linkage to care under these new guidelines, we conducted a systematic review of studies evaluating linkage interventions in Sub-Saharan Africa under Treat All.Recent findingsWe identified 14 eligible articles and qualitatively analyzed the effectiveness of the interventions. Increases in linkage were reported by supply-side and counseling interventions. Mobile testing and economic incentives did not increase linkage. Given the lag time between adoption and implementation, only two of the studies were conducted in a Treat All setting. None of the interventions specifically focused on re-linking PLHIV who had disengaged from care. Future studies must design interventions that target not only newly diagnosed or treatment naïve PLHIV, but should explicitly focus on PLHIV who have disengaged from care.
| S-EPMC10655251 | biostudies-literature
Project description:Since pembrolizumab, an anti-programmed death-1 (PD-1) antibody, showed a dramatic response to immunogenic cancers with microsatellite instability-high (MSI-H) and/or deficient mismatch repair (dMMR) in the pilot clinical trial KEYNOTE-016, subsequent studies have confirmed durable responses of anti-PD-1 inhibitors for MSI-H/dMMR solid tumors. As immunotherapy is described as a "game changer," the therapeutic landscape for MSI-H/dMMR solid tumors including gastrointestinal cancers has changed considerably in the last decade. An MSI/MMR status has been established as the predictive biomarker for immune checkpoint blockades, playing an indispensable role in the clinical practice of patients with MSI-H/dMMR tumors. Immunotherapy is also now investigated for locally advanced MSI-H/dMMR gastrointestinal cancers. Despite this great success, a few populations with MSI-H/dMMR gastrointestinal cancers do not respond to immunotherapy, possibly due to the existence of intrinsic or acquired resistance mechanisms. Clarifying the underlying mechanisms of resistance remains a future task, whereas attempts to overcome resistance and improve the efficacy of immunotherapy are currently ongoing. Herein, we review recent clinical trials with special attention to MSI-H/dMMR gastrointestinal cancers together with basic/translational findings, which provide their rationale, and discuss perspectives for the further therapeutic development of treatment in this field.
| S-EPMC10093684 | biostudies-literature
Project description:Women in South Africa who use alcohol and other drugs face multiple barriers to HIV care. These barriers make it difficult for women to progress through each step in the HIV treatment cascade from diagnosis to treatment initiation and adherence. This paper examines correlates of HIV status, newly diagnosed HIV status, and use of antiretroviral therapy (ART).Outreach workers recruited sexually active Black African women who used substances in Pretoria as part of a U.S. National Institutes of Health-funded geographically clustered randomized trial examining the effect of an intervention to reduce alcohol and drug use as well as sexual risk behaviors. To address the question of interest in the current investigation, cross-sectional baseline data were used. At study enrollment, all participants (N = 641) completed an interview, and underwent rapid HIV testing and biological drug screening. Those who tested positive for HIV and were eligible for ART were asked about their barriers to initiating or adhering to ART. Bivariate and multivariable logistic regression analyses were conducted to determine correlates of HIV status, newly diagnosed HIV, and ART use.At enrollment, 55% of participants tested positive for HIV, and 36% of these women were newly diagnosed. In multivariable analyses of the entire sample, women who had completed 10th grade were less likely to be living with HIV (OR 0.69; CI 0.48, 0.99) and those from the inner city were more likely to be living with HIV (OR 1.83; CI 1.26, 2.67). Among HIV-positive participants, women were less likely to be newly diagnosed if they had ever been in substance abuse treatment (OR 0.15; CI 0.03, 0.69) or used a condom at last sex (OR 0.58; CI 0.34, 0.98) and more likely to be newly diagnosed if they were physically assaulted in the past year (OR 1.97; CI 1.01, 3.84). Among women eligible for ART, fewer were likely to be on treatment (by self-report) if they had a positive urine test for opiates or cocaine (OR 0.27; CI 0.09, 0.80).These results, although cross-sectional, provide some guidance for provincial authorities to address barriers to HIV care for sexually active, substance-using vulnerable women in Pretoria. Targeting the inner city with prevention campaigns, expanding and improving substance abuse treatment programs, linking clients with simultaneous HIV testing and treatment, and targeting women who have experienced sexual assault and violence may help the government achieve the UNAIDS 90-90-90 treatment target. Clinical Trials.gov NCT01497405 registered on December 1, 2011.
| S-EPMC5405464 | biostudies-literature
Project description:Youth living with HIV are at higher risk than adults of disengaging from HIV care. Differentiated models of care such as community delivery of antiretroviral therapy (ART) may improve treatment outcomes. We investigated outcomes across the HIV cascade among youth accessing HIV services in a community-based setting. This study was nested in a cluster-randomised controlled trial (CHIEDZA: Clinicaltrials.gov, Registration Number: NCT03719521) conducted in three provinces in Zimbabwe and aimed to investigate the impact of a youth-friendly community-based package of HIV services, integrated with sexual and reproductive health services for youth (16-24 years), on population-level HIV viral load (VL). HIV services included HIV testing, ART initiation and continuous care, VL testing, and adherence support. Overall 377 clients were newly diagnosed with HIV at CHIEDZA, and linkage to HIV care was confirmed for 265 (70.7%, 234 accessed care at CHIEDZA and 31 with other providers); of these 250 (94.3%) started ART. Among those starting ART at CHIEDZA who did not transfer out and had enough follow up time (>6 months), 38% (68/177) were lost-to-follow-up within six months. Viral suppression (HIV Viral Load <1000 copies/ml) among those who had a test at 6 months was 90% (96/107). In addition 1162 clients previously diagnosed with HIV accessed CHIEDZA; 714 (61.4%) had a VL test, of whom 565 (79.1%) were virally suppressed. This study shows that provision of differentiated services for youth in the community is feasible. Linkage to care and retention during the initial months of ART was the main challenge and needs concerted attention to achieve the ambitious 95-95-95 UNAIDS targets.
| S-EPMC10880981 | biostudies-literature
Project description:BackgroundHigh patient turnover presents challenges and opportunity to provide hepatitis C virus (HCV) care in US jails (remand facilities). This study describes the HCV care cascade in the New York City (NYC) jail system during the direct-acting antiviral (DAA) treatment era.MethodsPatients admitted to the NYC jail system from January 2014 through December 2017 were included in this retrospective cohort analysis. We describe rates of screening, diagnosis, linkage to jail-based care, and treatment among the overall cohort, and among subgroups with long jail stays (≥120 days) or frequent stays (≥10 admissions). The study protocol was approved by a third-party institutional review board (BRANY, Lake Success, NY).FindingsAmong the 121,371 patients in our analysis, HCV screening was performed in 40,219 (33%), 4665 (12%) of whom were viremic, 1813 (39%) seen by an HCV clinician in jail, and 248 (5% of viremic patients) started on treatment in jail. Having a long stay (adjusted risk ratio [aRR] 8·11, 95% confidence interval [CI] 6·98, 9·42) or frequent stays (aRR 1·51, 95% CI 1·04, 2·18) were significantly associated with being seen by an HCV clinician. Patients with long stays had a higher rate of treatment (14% of viremic patients). Sustained virologic response at 12 weeks was achieved in 147/164 (90%) of patients with available virologic data.InterpretationJail health systems can reach large numbers of HCV-infected individuals. The high burden of HCV argues for universal screening in jail settings. Length of stay was strongly associated with being seen by an HCV clinician in jail. Treatment is feasible among those with longer lengths of stay.FundingNone.
| S-EPMC7599312 | biostudies-literature
Project description:BACKGROUND:Aiming to eliminate HIV infection, UNAIDS has set a global "90-90-90" target by 2020. We sought to construct a 6-stages HIV Cascade of Care (CoC) in Greece, overall and by risk group, to assess risk-group and stage-specific progress in achieving the UNAIDS target. PATIENTS AND METHODS:Combining data from the HIV/AIDS surveillance system and a population-based HIV cohort study, the CoC included: i) number of people living with HIV (PLHIV) by end of 2013; ii) proportion of PLHIV ever diagnosed; iii) proportion of diagnosed linked-to-care iv) proportion of linked-to-care ever initiating antiretroviral therapy (ART); v) proportion of treated who retained-in-care vi) proportion of those retained-in-care who were virally suppressed (?200 copies/mL) at their last visit (01/07/2012-31/12/2013). RESULTS:In 2013, 14147 PLHIV were in Greece. Overall, proportions of each stage in the cascade were: 78.4% diagnosed; 86% linked-to-care; 78.5% initiated ART; 86.4% retained-in-care, and 87.1% virally suppressed. Totally, 42.6% of all PLHIV were virally suppressed. The percentage diagnosed was lower among heterosexual men and women (heterosexuals) than in MSM (men who have sex with men) or PWID (people who inject drugs). Most MSM were linked to care (97.2% of diagnosed) while a substantial proportion of PWID were not (80.8% of diagnosed). Once treated, PWID remained in care in similar proportions to MSM. Unlike PWID, a high proportion of the retained in care MSM and heterosexuals achieved viral suppression. CONCLUSIONS:At the end of 2013, we identified gaps in the HIV CoC in Greece, which differed across risk groups. Targeted interventions are critical in optimizing early diagnosis and timely linkage. A 6-stage CoC, stratified by risk group, can inform strategic public health planning in improving HIV treatment outcomes.
| S-EPMC6237384 | biostudies-other
Project description:INTRODUCTION:The HIV Strategy in New South Wales (NSW) Australia aims to virtually eliminate HIV transmission by 2020. We estimated the 2016 HIV diagnosis and care cascade for the state of NSW, with a focus on introducing population-based data to improve data quality and assess progress towards the UNAIDS 90-90-90 targets. METHODS:To estimate the number of people living with diagnosed HIV (PLDHIV) we used NSW data from the Australian National HIV Registry, enhanced by surveillance among people recently diagnosed with HIV to improve migration estimates. The number of undiagnosed PLHIV was estimated using back-projection modelling by CD4 count at diagnosis. De-duplicated prescription claims data were obtained from the Australian Pharmaceutical Benefits Scheme (PBS), and were combined with an estimate for those ineligible, to determine the number of PLDHIV on antiretroviral therapy (ART). Data from a clinic network with 87% coverage of PLDHIV in NSW enabled the estimation of the number on ART who had HIV suppression. RESULTS AND DISCUSSION:We estimated that 10,110 PLHIV resided in NSW in 2016 (range 8400 to 11,720), among whom 9230 (91.3%) were diagnosed, and 8490 (92.0% of those diagnosed) were receiving ART. Among PLDHIV receiving ART, 8020 (94.5%) had suppressed viral load (<200 HIV-1 RNA copies/mL). Overall, 79.3% of all PLHIV had HIV virological suppression. CONCLUSION:NSW has met each of the UNAIDS 90-90-90 targets. The enhanced surveillance methods and data collection systems improved data quality. Measuring and meeting the 90-90-90 targets is feasible and could be achieved in comparable parts of the world.
| S-EPMC5909111 | biostudies-other
Project description:Three decades of extensive work in the HIV field have revealed key viral and host cell factors controlling proviral transcription. Various models of transcriptional regulation have emerged based on the collective information from in vitro assays and work in both immortalized and primary cell-based models. Here, we provide a recount of the past and current literature, highlight key regulatory aspects, and further describe potential limitations of previous studies. We particularly delve into critical steps of HIV gene expression including the role of the integration site, nucleosome positioning and epigenomics, and the transition from initiation to pausing and pause release. We also discuss open questions in the field concerning the generality of previous regulatory models to the control of HIV transcription in patients under suppressive therapy, including the role of the heterogeneous integration landscape, clonal expansion, and bottlenecks to eradicate viral persistence. Finally, we propose that building upon previous discoveries and improved or yet-to-be discovered technologies will unravel molecular mechanisms of latency establishment and reactivation in a "new era".
| S-EPMC7291205 | biostudies-literature