Jeremy Ross

Loss to Follow-up Trends in Hiv-positive Patients Receiving Antiretroviral Treatment in Asia From 2003 to 2013

Introduction: Over time, there has been a substantial improvement in antiretroviral treatment (ART) programs, including expansion of services and increased patient engagement. We describe time trends in, and factors associated with, loss to follow-up (LTFU) in HIV-positive patients receiving ART in Asia. Methods: Analysis included HIV-positive adults initiating ART in 2003–2013 at 7 ART programs in Asia. Patients LTFU had not attended the clinic for ≥180 days, had not died, or transferred to another clinic. Patients were censored at recent clinic visit, follow-up to January 2014. We used cumulative incidence to compare LTFU and mortality between years of ART initiation. Factors associated with LTFU were evaluated using a competing risks regression model, adjusted for clinical site. Results: A total of 8305 patients were included. There were 743 patients LTFU and 352 deaths over 26,217 person-years (pys), a crude LTFU, and mortality rate of 2.83 (2.64–3.05) per 100 pys and 1.34 (1.21–1.49) per 100 pys, respectively. At 24 months, the cumulative LTFU incidence increased from 4.3% (2.9%–6.1%) in 2003–05 to 8.1% (7.1%–9.2%) in 2006–09 and then decreased to 6.7% (5.9%–7.5%) in 2010–13. Concurrently, the cumulative mortality incidence decreased from 6.2% (4.5%–8.2%) in 2003–05 to 3.3% (2.8%–3.9%) in 2010–13. The risk of LTFU reduced in 2010–13 compared with 2006–09 (adjusted subhazard ratio = 0.73, 0.69–0.99). Conclusions: LTFU rates in HIV-positive patients receiving ART in our clinical sites have varied by the year of ART initiation, with rates declining in recent years whereas mortality rates have remained stable. Further increases in site-level resources are likely to contribute to additional reductions in LTFU for patients initiating in subsequent years.

Socio-economic status and risk of tuberculosis: a case-control study of HIV-infected patients in Asia

SETTING Tuberculosis (TB) is the most common human immunodeficiency virus (HIV) related opportunistic infection and cause of acquired immune-deficiency syndrome related death. TB often affects those from a low socio-economic background. OBJECTIVE To assess the socio-economic determinants of TB in HIV-infected patients in Asia. DESIGN This was a matched case-control study. HIV-positive, TB-positive cases were matched to HIV-positive, TB-negative controls according to age, sex and CD4 cell count. A socio-economic questionnaire comprising 23 questions, including education level, employment, housing and substance use, was distributed. Socio-economic risk factors for TB were analysed using conditional logistic regression analysis. RESULTS A total of 340 patients (170 matched pairs) were recruited, with 262 (77.1%) matched for all three criteria. Pulmonary TB was the predominant type (n = 115, 67.6%). The main risk factor for TB was not having a university level education (OR 4.45, 95%CI 1.50-13.17, P = 0.007). Burning wood or coal regularly inside the house and living in the same place of origin were weakly associated with TB diagnosis. CONCLUSIONS These data suggest that lower socio-economic status is associated with an increased risk of TB in Asia. Integrating clinical and socio-economic factors into HIV treatment may help in the prevention of opportunistic infections and disease progression.

Changes in renal function with long-term exposure to antiretroviral therapy in HIV-infected adults in Asia

Renal disease is common among people living with human immunodeficiency virus (HIV). However, there is limited information on the incidence and risk factors associated with renal dysfunction among this population in Asia.

Barriers to mental healthcare and treatment for people living with HIV in the Asia-Pacific

Mental illness is a leading cause of disability in South East Asia among those 15 to 49 years of age, with over 7.6 million disability-adjusted life-years lost in 2016 alone [1]. Regional studies have found that as much as 40% of adults attending outpatient HIV clinics in Asia-Pacific countries have depression [2,3]. Concomitant mental illness is associated with late antiretroviral therapy (ART) initiation and lack of timely viral suppression in people living with HIV (PLHIV) [4,5]. However, integration of mental health and HIV care is uncommon in the region. In a survey of global IeDEA (International epidemiology Databases to Evaluate AIDS) clinical sites, only 43% of those in the Asia-Pacific reported screening for depression, 39% for substance use disorders, 11% for posttraumatic stress disorder and 29% for any other mental disorder – overall, representing the lowest levels of mental health assessments across this global consortium [6]. Unfortunately, this is not surprising in the light of data from the World Health Organization’s (WHO) Mental Health Atlas that shows there are 2.5 mental health workers per 100,000 people in the South East Asia region and 10 per 100,000 in the Western Pacific region, which compares to 50 per 100,000 in the European region [7]. There are three key barriers to increasing the pool of providers who can screen, diagnose and treat mental illness among Asia-Pacific PLHIV.

Mortality following diagnosis of tuberculosis in HIV-infected patients in Asia

A Jiamsakul , E Yunihastuti, K Van Nguyen, TP Merati, CD Do, R Ditangco, S Ponnampalavanar, F Zhang, S Kiertiburanakul, M-P Lee, A Avihingasanon, OT Ng, BL Sim, W Wong, J Ross and M Law The Kirby Institute, University of New South Wales, Sydney, NSW, Australia, Working Group on AIDS, Faculty of Medicine, University of Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia, National Hospital for Tropical Diseases, Hanoi, Vietnam, Faculty of Medicine, Udayana University & Sanglah Hospital, Bali, Indonesia, Bach Mai Hospital, Hanoi, Vietnam, Research Institute for Tropical Medicine, Manila, The Philippines, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, Beijing Ditan Hospital, Capital Medical University, Beijing, China, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, Queen Elizabeth Hospital, Hong Kong, China, HIV-NAT, The Thai Red Cross AIDS Research Centre and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore, Hospital Sungai Buloh, Sungai Buloh, Malaysia, Taipei Veterans General Hospital, Taipei, Taiwan and TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand

Early suboptimal ART adherence was associated with missed clinical visits in HIV-infected patients in Asia

ABSTRACT Missed clinic visits can lead to poorer treatment outcomes in HIV-infected patients. Suboptimal antiretroviral therapy (ART) adherence has been linked to subsequent missed visits. Knowing the determinants of missed visits in Asian patients will allow for appropriate counselling and intervention strategies to ensure continuous engagement in care. A missed visit was defined as having no assessments within six months. Repeated measures logistic regression was used to analyse factors associated with missed visits. A total of 7100 patients were included from 12 countries in Asia with 2676 (37.7%) having at least one missed visit. Patients with early suboptimal self-reported adherence <95% were more likely to have a missed visit compared to those with adherence ≥95% (OR = 2.55, 95% CI(1.81–3.61)). Other factors associated with having a missed visit were homosexual (OR = 1.45, 95%CI(1.27–1.66)) and other modes of HIV exposure (OR = 1.48, 95%CI(1.27–1.74)) compared to heterosexual exposure; using PI-based (OR = 1.33, 95%CI(1.15–1.53) and other ART combinations (OR = 1.79, 95%CI(1.39–2.32)) compared to NRTI+NNRTI combinations; and being hepatitis C co-infected (OR = 1.27, 95%CI(1.06–1.52)). Patients aged >30 years (31–40 years OR = 0.81, 95%CI(0.73–0.89); 41–50 years OR = 0.73, 95%CI(0.64–0.83); and >50 years OR = 0.77, 95%CI(0.64–0.93)); female sex (OR = 0.81, 95%CI(0.72–0.90)); and being from upper middle (OR = 0.78, 95%CI(0.70–0.80)) or high-income countries (OR = 0.42, 95%CI(0.35–0.51)), were less likely to have missed visits. Almost 40% of our patients had a missed clinic visit. Early ART adherence was an indicator of subsequent clinic visits. Intensive counselling and adherence support should be provided at ART initiation in order to optimise long-term clinic attendance and maximise treatment outcomes.

Cardiovascular disease and cardiovascular disease risk in HIV-positive populations in the Asian region

Introduction: Cardiovascular diseases (CVD) are becoming more prevalent in HIV-infected populations as they age largely due to improved treatment outcomes. Assessment of CVD risk and CVD risk factors in HIV-positive populations has focused on high income settings, while there are limited studies evaluating CVD in HIV-positive populations in the Asian region. Materials and Methods: We provided an overview of the prevalence and incidence of CVD and its risk factors in adult HIV-positive populations, and of the strategies currently in place for CVD management in the Asian region. Results: Studies from the Asian region showed that CVD and CVD risk factors, such as dyslipidaemia, elevated blood glucose, obesity and smoking, are highly prevalent in HIV-positive populations. A number of studies suggested that HIV infection and antiretroviral therapy may contribute to increased CVD risk. National HIV treatment guidelines provide some directions regarding CVD risk prevention and management in the HIV-infected population, however, they are limited in number and scope. Conclusion: Development and consolidation of guidelines for integrated CVD and HIV care are essential to control the burden of CVD in HIV-positive populations. To inform guidelines, policies and practice in the Asian region, research should focus on exploring appropriate CVD risk screening strategies and estimating current and future CVD mortality and morbidity rates.

The treatment outcomes of antiretroviral substitutions in routine clinical settings in Asia; Data from the TREAT Asia HIV Observational Database (TAHOD):

Although substitutions of antiretroviral regimen are generally safe, most data on substitutions are based on results from clinical trials. The objective of this study was to evaluate the treatment outcomes of substituting antiretroviral regimen in virologically suppressed HIV‐infected patients in non‐clinical trial settings in Asian countries.

Hiv and Aging: Demographic Change in the Asia-pacific Region

BACKGROUND Today, an estimated 5.1 million people are living with HIV in the Asia and Pacific region and antiretroviral treatment (ART) coverage more than doubled, from 19% in 2010 to 41% in 2015.1 With this rapid scale-up of effective ART, mortality of people living with HIV/AIDS (PLWHA) continues to decrease.2–5 In addition, age at diagnosis has increased over time.4,6 Thus, a growing proportion of HIVpositive individuals are now over the age of 50 years.4,7,8 Widespread consensus exists that HIV and/or its treatment affects the process of adult aging and the development of non-AIDS disorders, including cardiovascular disease, cancer, kidney disease, liver disease, osteopenia or osteoporosis, and neurocognitive disease typically associated with advanced age.9–11 The demonstrated higher prevalence of such age-associated noncommunicable comorbidities among HIV-positive patients over 50 years compared with HIVnegative peers,12 contributes to increased medical complexity of care.11 To further improve clinical care pathways and to prepare for future challenges of stable older patients on ART, it will be essential to estimate the numbers and needs of such patients in care. The aim of this study was to project the likely age distribution of PLWHA at treatment sites in Asia participating in the TREAT Asia HIV Observational Database Low Intensity Transfer (TAHOD-LITE) study to further understand and quantify the changing demographics of HIV and aging at these sites.

Factors associated with pre-treatment HIV RNA: application for the use of abacavir and rilpivirine as the first-line regimen for HIV-infected patients in resource-limited settings

Background Abacavir and rilpivirine are alternative antiretroviral drugs for treatment-naïve HIV-infected patients. However, both drugs are only recommended for the patients who have pre-treatment HIV RNA <100,000 copies/mL. In resource-limited settings, pre-treatment HIV RNA is not routinely performed and not widely available. The aims of this study are to determine factors associated with pre-treatment HIV RNA <100,000 copies/mL and to construct a model to predict this outcome. Methods HIV-infected adults enrolled in the TREAT Asia HIV Observational Database were eligible if they had an HIV RNA measurement documented at the time of ART initiation. The dataset was randomly split into a derivation data set (75% of patients) and a validation data set (25%). Factors associated with pre-treatment HIV RNA <100,000 copies/mL were evaluated by logistic regression adjusted for study site. A prediction model and prediction scores were created. Results A total of 2592 patients were enrolled for the analysis. Median [interquartile range (IQR)] age was 35.8 (29.9–42.5) years; CD4 count was 147 (50–248) cells/mm3; and pre-treatment HIV RNA was 100,000 (34,045–301,075) copies/mL. Factors associated with pre-treatment HIV RNA <100,000 copies/mL were age <30 years [OR 1.40 vs. 41–50 years; 95% confidence interval (CI) 1.10–1.80, p = 0.01], body mass index >30 kg/m2 (OR 2.4 vs. <18.5 kg/m2; 95% CI 1.1–5.1, p = 0.02), anemia (OR 1.70; 95% CI 1.40–2.10, p < 0.01), CD4 count >350 cells/mm3 (OR 3.9 vs. <100 cells/mm3; 95% CI 2.0–4.1, p < 0.01), total lymphocyte count >2000 cells/mm3 (OR 1.7 vs. <1000 cells/mm3; 95% CI 1.3–2.3, p < 0.01), and no prior AIDS-defining illness (OR 1.8; 95% CI 1.5–2.3, p < 0.01). Receiver-operator characteristic (ROC) analysis yielded area under the curve of 0.70 (95% CI 0.67–0.72) among derivation patients and 0.69 (95% CI 0.65–0.74) among validation patients. A cut off score >25 yielded the sensitivity of 46.7%, specificity of 79.1%, positive predictive value of 67.7%, and negative predictive value of 61.2% for prediction of pre-treatment HIV RNA <100,000 copies/mL among derivation patients. Conclusion A model prediction for pre-treatment HIV RNA <100,000 copies/mL produced an area under the ROC curve of 0.70. A larger sample size for prediction model development as well as for model validation is warranted.