South Africa (SA) has a large human immunodeficiency virus (HIV) epidemic but little is known of its effect on those ≥ 60 years of age viz. ‘older-persons’ living with HIV (OPLWH). Numbers in this age group are increasing and are expected to place a greater strain on existing resources.To describe the demographic features and the co-morbidities of OPLWH in Tlokwe. This included an assessment of viral load (VL) suppression and the identification of associations between patient characteristics and clinical outcomes.A retrospective file review was undertaken to cover the period 01 May 2017 to 30 April 2018. Descriptive statistics were applied to demographic and clinical data and to treatment outcomes. Statistically significant associations were subjected to logistic regression analysis.n = 106/191, 55.5%) was the most frequently identified co-morbidity. A CD4 cell count of ≥ 350 cells/mm3 at last assessment correlated positively with VL suppression .Of the 191 participants, 111/191 (58.1%) were female and 167/191 (87.4%) were 60 –70 years of age. Of the participants, 154/191 (81.9%) were virally suppressed (< 400 copies/mL). Hypertension  recommendations viz. 90% viral suppression in PLWH by 2030. Further research is needed to define the evolving long-term needs of OPLWH and to facilitate entry into care of those currently not in care. Over the next 30 years, a growth rate of 218% of older persons, that is from 32 million in 2019 to 101 million in 2050, is predicted for sub-Saharan Africa (SSA).1 Over the same period, South Africa’s (SA) older-person population is likely to increase from 8% currently, to 10.5% in 2030, and to 15.4% in 2050.3 The drivers of this change include lower fertility rates (improved access to contraception), reduced childhood mortality and better access to healthcare for all.4 The number of people living with human immunodeficiency virus (HIV) (PLWH) in SA – including older persons living with HIV (OPLWH) – will also increase. These survival gains have followed the widespread use of antiretroviral therapy (ART) and the implementation of government programmes such as Universal Test and Treat (UTT).5 For many, HIV infection has become a chronic condition.6The term ‘older-persons’ is defined by the United Nations (UN) as persons aged ≥ 60–65 years.7 and trained geriatricians in SA tend to work in academic centres. Medical training centres in SA do not offer sub-speciality training that combines geriatrics and HIV. The lack of trained infectious disease specialists in the sphere of geriatric medicine may pose a problem in future, and primary care clinicians will likely treat these patients, as they do currently. The treatment and care OPLWH need is laborious and complex. The persistence of subclinical inflammation even when a patient is on effective ART leads to persistent immune dysfunction. This is believed to result in cardiovascular dysfunction, end-organ failure and non-AIDS defining malignancy viz. the increase of co-morbid conditions. Old age increases health risks. These include multiple pathologies: drug-drug interactions and the predisposition to drug-toxicity , greater likelihood of neurovascular impairment, frailty and fractures, limited immune recovery , less social security (finances and support) and greater dependency on the state and local health services.8 On the other hand, OPLWH are usually adherent to treatment and likely to follow up at their health care centres. They are likely to remain in their current residence and, thus, are generally contactable. In light of the above, it is necessary for researchers in SA to understand this cohort in all settings in order to develop feasible and sustainable care packages. There is a paucity of data for OPLWH in the SA context.South African doctors are ill equipped to provide care to OPLWH, as they are not adequately trained in gerontology8 Nonetheless, immune reconstitution is often incomplete in this group, despite ART and viral suppression, particularly where presenting nadir CD4 levels, were low.8Identifying HIV in the elderly is important. Benefits include reducing the risk of transmission as many are still sexually active and practise poor prevention strategies. Early entry into care will reduce the risk of opportunistic conditions and aid in the timely diagnosis of co-morbidities. In the SA public sector, OPLWH have access to specialised healthcare and ART at minimal cost. If retained in-care, costs such as hospitalisation and end-of-life care are more readily anticipated and mitigated.10 A retrospective study of 7295 OPLWH  who started ART between 2004 and 2013 found that those ≥ 50 years of age increased from 6% in 2004 to 10% in 2012/2013. These finally constituted 9% of the entire cohort.9 This study assessed only three of SA’s nine provinces and, in particular, excluded the North West Province (NWP). A second study confirmed a significantly higher prevalence of diabetes mellitus (DM) and hypertension (HPT) in its OPLWH: DM, n = 16/262 (6.3%) versus 24/3741 (0.7%) and HPT, n = 55/262 (21.5%) versus 79/3741 (2.2%), p < 0.001, respectively.10Two regional studies provide data on the prevalence and outcome of HIV infection in SA-OPLWH.11 Data from the 2019 mid-year population census described only the 15–49 year age group.12 In 2012, the Human Sciences Research Council (HSRC) reported the general prevalence of HIV in South Africans of ≥ 50 years to be 7.6% (95% CI 6.5–8.8).13The prevalence of HIV infection in Tlokwe’s older citizens is unknown. Those aged ≥ 65 years comprise 5.7% of the population of the town. The objectives of this study were the following:To describe the demographic characteristics of the study populationTo describe their co-morbiditiesTo assess viral load (VL) suppression ratesTo determine the relationship, if any, of patient characteristics to the following four outcomes viz.: VL suppression and immune (CD4 cell count) recovery on ART, loss to follow-up (LTFU) and death.This was a retrospective study of OPLWH undertaken to cover the period 01 May 2017 to 30 April 2018 at three healthcare sites in Tlokwe (Potchefstroom), a town in the NWP of SA. The study subjects were aged ≥ 60 years and were on ART for a minimum of one year prior to the period under review, hence, they had to be initiated on ART prior to 30 April 2017. The three clinics were chosen to represent, as closely as possible, the diversity of people who utilise the public health service in the town.Clinic A: a primary care clinic situated close to the municipal hospital that serves residents and patients referred from hospital clinics. Services provided by the clinic include counselling, HIV testing and the initiation of treatment of HIV. Afrikaans and Setswana are spoken by the majority of patients accessing clinic services.Clinic B: a community health centre serving a predominantly Setswana-speaking population.Clinic C: a community health centre serving both Afrikaans and Setswana-speaking residents.Older persons living with HIV aged ≥ 60 years at their last birthday and with the time of their latest clinic visit being between 01 May 2017 and 30 April 2018.14Older persons living with HIV who had been on ART for at least 12 months prior to the study census that is to include as a minimum a second VL test whilst on ART.Confirmation as an adherence measure, that the patient or a nominated representative of the patient, had collected treatment on their behalf, at the regular three-monthly medicines collection visits in the year under study.Patient clinic file ‘missing’ for the study period under review.Patients who did not meet the inclusion criteria.15 an electronic patient management system, was used to access additional (missing) patient information. Further laboratory data were located on the TrakCare service of the SA National Health Laboratory Services (NHLS). Some data that were more than 1 year old, were excluded as these did not represent the patient’s status at the time of the study census. These data included laboratory values of creatinine, haemoglobin and total cholesterol blood results.A collection sheet developed by the researcher was used to capture data as per the study’s objectives. All information was captured manually and patient identifiers were removed. Data were then transferred to Excel 2016 . Study subjects comprised all available patients recruited from the study sites who fulfilled entry criteria. A prior calculation of the ‘sample size’ was not undertaken. All files were retrieved with the help of data capturers and clerks at the research sites. TIER.Net.,p values were ≤ 0.05 or there were > 0.5 correlations for measures of association, these predictors were entered into a linear or logistic regression model where appropriate. A level of ≤ 0.05 was considered statistically significant. During the initial analysis, the VL and latest CD4 cell count outcomes were assessed as continuous variables as well as clinical categories. Whenever there was a statistically significant relationship between any continuous or categorical outcome in the initial analysis, it was used in the binomial logistic regression model provided that the number of observations was ≥ 10 per cell. The binomial logistic regression model categorised the VL as suppressed (< 400 copies/mL) or unsuppressed (≥ 400 copies/mL) and the latest CD4 cell as high (≥ 350 cells/mm3) or low (< 350 cells/mm³).A list of study definitions can be found in Ethical clearance was granted by both the Human Research Ethics Committee  of the University of the Witwatersrand, Johannesburg (M180304) and the North West Health Research Committee (NW_2018_006). The Tlokwe sub-district Office of the Primary Health Care Manager also granted permission for the research. Owing to the retrospective nature of the study, patient’s anonymised data were evaluated. Consequently, informed consent was waived for this study.n = 38/191 (19.9%), Clinic B, n = 96/191 (50.2%) and Clinic C, n = 57/191 (29.8%). One patient file from Clinic A had to be excluded as this was a duplicate file. Eleven patient files were missing from Clinic B, as were 12 files from Clinic C. An overview of the demographic, treatment, clinical and laboratory characteristics is provided in Data from a total of 191 clinic files of OPLWH were examined. Clinic A provided Out of 157 participants for whom the ART regimens and the latest serum creatinine blood results were available, some 12/150 participants (8%) had an eGFR of ≤ 50 mL/min/1.73m³ whilst on first-line ART. Those on second-line ART showed a low eGFR in 1/7 participants (14.3%). Not a single participant with a serum creatinine of ≤ 100 µmol/L had renal dysfunction as per the chronic kidney disease (CKD)- Epidemiology Collaboration Equation (EPI) equation, whereas 13/36 (36.1%) of those with a creatinine of ≥ 100 µmol/L had renal dysfunction, according to this equation.Twenty-nine out of 34 participants (85.3%) with an unsuppressed VL (≥ 400 copies/mL) remained on a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART regimen, whereas 5/34 (14.7%) were on a second-line regimen with a protease inhibitor (PI) boosted with ritonavir. The PI was lopinavir in all cases. Of the participants with a VL of 400 copies/mL – 999 copies/mL, 14/16 (87.5%) were on a NNRTI first-line regimen, whereas for those with a VL of ≥ 1000 copies/mL, 15/18 (83.3%) were on a NNRTI first-line regimen.n = 16/19, 84.2%) were on first-line ART.The median CD4 cell count improved from a baseline of 279.5 cells/mm³ (IQR 167–433) to 536 cells/mm³ (IQR 337.5–703.5) at the most recent CD4 cell count monitoring visit, resulting in a median improvement of 256.5 cells/mm³. Moreover, some 33% of the cohort had a CD4 cell count of ≥ 350 cells/mm³ at baseline compared to 70.7% at the most recent CD4 cell count monitoring visit. Close to 10% of the cohort still had a CD4 cell count of < 200 cells/mm³ at the latest CD4 cell count monitoring visit. For this group, 10/19 (52.3%) participants had an unsuppressed VL of ≥ 400 cells/mL. This group also showed that 12/19 (63.2%) suffered from a defined co-morbidity. The majority of this group  had a haemoglobin of < 8g/dL, whilst 3/24 (12.5%) had a haemoglobin of 8 g/dL – 12 g/dL and 17/24 (70.8%) had a haemoglobin of ≥ 12g/dL. Total cholesterol blood results were available for 75 participants. Of these, 40/74 (53.3%) had readings of < 5 mmol/L and 35/74 (46.7%) had readings of ≥ 5 mmol/L. For participants who were classified with hypercholesterolaemia, 9/14 (64.3%) had recent total cholesterol readings of ≥ 5 mmol/L whereas 26/61 (42.6%) participants who were not classified to have hypercholesterolaemia had recent total cholesterol readings of ≥ 5 mmol/L.n = 106/191, 55.5%) had HPT. The following other co-morbidities were found: hypercholesterolaemia , DM , CKD , a mental health problem , asthma , post-herpetic neuralgia (PHN) , epilepsy and chronic obstructive airway disease . Six participants (3.1%) had tuberculosis (TB) during the study period and five participants (2.6%) previously had TB. Renal dysfunction was found in 4/7 (57.1%) participants who were classified with CKD.One or more co-morbidity was found in 123/199 (64.4%) participants. Eighty-four participants (44%) had one chronic condition, a number of 34 participants (17.8%) had two chronic conditions and five participants (2.6%) had three chronic conditions. The majority of the participants . Female participants showed 81.7% VL suppression rates compared to 82.3% for male participants. The overall VL suppression rate was 81.9%. There were no strong correlations or meaningful linear regression results amongst the most recent VL, latest CD4 cell count and other continuous variables . During the study period, six participants were LTFU (3.1%) and four died (2.1%) with a mean age of 65.5 years at death. No statistically significant relationships were evident for the outcome LTFU. According to our knowledge, this study was the first to describe patient characteristics and outcomes of PLWH ≥ 60 years old on ART in Tlokwe. Participants 60–69 years old and female participants comprised the largest proportion of our sample. The VL suppression rate in this cohort needs to be improved. Almost two-thirds of our sample had one or more co-morbidity. As a small proportion of participants were LTFU or had died during the study period, it is unsurprising that there were few significant relationships between these outcomes and patient characteristics. In this cohort, a suppressed VL was associated with a good CD4 cell response. A good CD4 cell response was also associated with first-line ART and longer treatment duration.17 Interestingly, the only other study in SSA that showed a female predominance was a recent Ugandan study.18 Studies from other countries in SSA painted a slightly different picture. Auld et al.19 pooled data from seven SSA countries. Male participants aged ≥ 50 years formed the majority of the cohort in six of the seven countries that were studied. Nigeria was the marginal exception, where 51% of participants ≥ 50 years old were female participants. A male predominance was also evident in Burkina Faso20 and Malawi.21 Both studies used the age of ≥ 50 years to define older adults.Participants 60–69 years old and female participants comprised the largest proportion of this study’s sample. Female gender seemed to predominate in South African studies evaluating OPLWH from the age of 50 years old.13 Efforts relating to HIV screening and testing, as well as condom distribution amongst older men, need to be scaled up to ensure they do not continue spreading the infection to their older and younger female sexual partners. Another intervention strategy could include a mass medical male circumcision campaign, aimed specifically at older men.In 2012, the SA National HIV prevalence incidence and behaviour survey reported a higher HIV prevalence in female participants aged 55–60 years, but male participants still predominated in the age categories of 50–55 years and ≥ 60 years, in contrast to our findings. In the aforementioned survey, the proportion of men who reported having more than one sexual partner was eight times that of women. Older men also reported low condom use during their last sexual encounter. These factors may explain why men are more likely to become HIV infected when they are older. On the other hand, women are known to test for HIV more readily than men and are more aware of their status, which could increase their HIV incidence. This was reiterated in the report.The majority of this study cohort had been on ART for ≤ 10 years. It was evident from the file reviews that changing treatment guidelines over the years has had an influence on ART initiation in this population, as they were more likely to be initiated in line with their CD4 cell count values at a later stage of infection. Dates of HIV diagnoses were unavailable for many participants, which made it impossible to report on the timeline from receiving a diagnosis of HIV and initiating treatment. In the era of UTT, ART should be initiated as soon as possible for all those who qualify for it, especially in OPLWH. This could potentially negate a poor immune reconstitution effort and improve the overall clinical status for OPLWH. Moreover, this could limit the spread of the disease to their sexual partners. This may also empower them to learn more about the disease and educate their families about it.22 These findings may warrant more rigorous screening and documentation of kidney function in our setting, especially in light of the fact that CKD is a known risk factor for adverse cardiovascular outcomes.23It may be challenging to comment on the current ART regimen of this cohort, as it was unclear if and when regimens were changed from a stavudine-based regimen for those taking treatment for longer, as per evolving guidelines. It was clear, however, that an NNRTI-based regimen was the most common treatment regimen prescribed for these participants in line with guidelines used at the time. The tenofovir component was not included in 16.2% of participants’ ART and 6.8% of the cohort had renal dysfunction. Only 3.7% of the cohort was classified with CKD. One explanation for the low prevalence of CKD may be that renal function improved when tenofovir was substituted with an agent that is known to be renal protective, and these participants were subsequently not classified as having CKD, but this does not explain the higher percentage of renal dysfunction in this cohort. Another explanation may be that primary care clinicians simply did not diagnose or document CKD in this cohort. The prevalence of CKD was one in five PLWH ≥ 60 years old in a study conducted in 12 French hospitals and was independently associated with an increased 5-year mortality.24 with poor nutritional status strongly associated with mortality.25 The presence of anaemia and poor nutritional status are interconnected, and in this cohort the presence of anaemia was associated with the risk of dying. Unfortunately, height and thus body mass index (BMI) and/or mid-upper arm circumference (MUAC) measurements were not routinely measured in the care of this study’s participants. Haemoglobin levels were also not readily available for this cohort. The weight (median and IQR) nevertheless correlated well with that of participants in another South African study.9 Nutritional status is one of the components that needs to be assessed in a comprehensive geriatric assessment (CGA). This tool includes 11 components that address biomedical, social and economic concerns for HIV care providers relating to OPLWH.24 Recent hospitalisation is a known risk factor for dying in OPLWH, and this was echoed in this study. A meta-analysis showed that those who underwent a CGA whilst hospitalised were more likely to be alive after 12 months than those who did not.25 An explanation for this may be that the teams who performed CGA were more experienced and specialised than the teams who typically worked on the wards. Long-term follow-up also appeared to be more comprehensive in the participants who underwent CGA in the hospital setting. This is a novel tool in HIV care; it has been used successfully in other disciplines and may prove to be a crucial tool in the HIV care sphere pertaining to the ageing population in years to come.26 Hence, there are ample reasons for incorporating anthropometric measures, including those related to nutritional status and anaemia, into the clinical guide for the care of OPLWH. However, clinicians in better resourced settings are struggling to adhere to CGA recommendations24 and its rollout to resource-constrained settings may come with challenges, such as lack of experience with the tool, time and resource limitations and insufficient evidence for its effectiveness in African settings.Knowing the nutritional status of a patient might affect 21% – 82% of treatment decisions,17 In these studies, the prevalence of HPT ranged from 21.5% – 33.3%, the latter percentage being for participants aged ≥ 70 years. In our study population, there were 55.5% of OPLWH on treatment for HPT. The differences may be due to the other studies actively measuring participants’ blood pressure at ART initiation, whereas the current study relied on clinical records and could not account for what might have come first: HIV or HPT. The same could be said about DM, where the prevalence ranged from 2.2% – 6.3% in the other cohorts, compared to 7.9% in the current cohort. Again, conclusive interpretation of these results is elusive because the current study inception was not at ART initiation. It is well established that ART and ageing both accelerate cardiovascular disease risk in older adults.8 Added to the cardiovascular disease burden of HPT, DM and CKD, it stands to reason that older adults require tailor-made interventions to address their cardiovascular health. The administration of a novel polypill  is a potential option to reduce cardiovascular and cancer morbidity and mortality in OPLWH.8Even in this reasonably small cohort, the prevalence of HPT and DM were high compared with other studies.16 Moreover, VL suppression was attained in 86% – 89.5% of older adults in other settings after 12–60 months of treatment. It was perturbing that only 81.9% of this cohort had a suppressed VL, especially as a larger proportion of them were on second-line treatment than found in another South African cohort (5.2% versus 0.88)16; and female participants, who are historically more adherent to treatment, had lower VL suppression rates. Only 5.2% of the cohort were on second-line ART. The rest were still on a NNRTI-based regimen. Moreover, over 85% of those with an unsuppressed VL were still on an NNRTI-based regimen. HIV treatment and monitoring guidelines in SA have changed since this study was conducted. The new guidelines define a suppressed VL as < 50 copies/ml.27 If these criteria were used to assess VL suppression, only 59% of this cohort would be suppressed. Although high-range low-level viraemia (VL 400 copies/mL – 999 copies/mL) in this cohort was low (8.4%), a previous study performed in SA showed a five-times increased risk of virological failure in participants who had VL readings in this range.28 It is imperative to monitor these patients closely and act appropriately if and when true virological failure (VL ≥ 1000 copies/mL) and attenuated CD4 cells count responses develop. Appropriate action, that is changing to a second-line ART regimen, seemed to be lacking in this cohort. There was, likely, treatment failure and the development of resistance to ART in this cohort. This may hamper the 90–90–90 UNAIDS target of achieving a 90% VL suppression rate in all age groups globally by 2030. South Africa currently stands at 87% VL suppression in 54% of all PLWH.29 More attention should be given to OPLWH in order to attain the UNAIDS goals and ensure their overall well-being and prevent the spread of drug-resistant HIV.The VL suppression in this cohort was lower than previously reported in SA.30 found that the median CD4 cell count in OPLWH was 367 cells/mm3 after a median duration of 2.3 years on ART. Similarly, Fatti et al.16 found that OPLWH had a median CD4 cell count of 377 cells/mm3 after 3 years on ART. The median CD4 cell count increased by 256.5 cells/mm3 from the baseline in this cohort. Fatti et al.16 also found that the median CD4 cell count increased from about 100 cells/mm3 after 6 months to over 300 cells/mm3 after 48 months, since ART initiation. It is well-established that CD4 cell recovery is attenuated in OPLWH compared to younger PLWH.30 In this study, it was evident that higher recent CD4 cell counts were more likely in those who had been taking ART for > 5 years  and those on the usual first-line ART . The former may have been an obvious finding because of improved immune reconstitution, the sooner a patient is initiated on ART,8 but further work may be needed to evaluate the latter.Malaza et al.13 it was imperative to assess older age groups and exclude those still eligible to work for future planning of care interventions for these individuals. This is one of the first local studies to use this novel approach. Also, a paucity of data was available on the subject in the NWP according to the researcher’s knowledge, and this is the first study to begin to address this gap. Most previous studies published about OPLWH have compared their response since ART initiation to younger cohorts. The current study did not address this. The sample was chosen conveniently and thus could have introduced selection bias. Also, the retrospective design has disadvantages. Previous prospective studies on the subject could compare baseline characteristics and outcomes in terms of ART initiation and follow-up. This approach was not possible in the current study due to time constraints in terms of data collection, and there were many missing data (e.g. files and blood results) which could have influenced study findings. The sample size was small and this could perhaps be seen as a pilot study for future studies in OPLWH in the NWP. Generalisability was affected by limited patient numbers and the exclusion of a more rural cohort. Unmeasured covariates could have resulted in hidden bias.Most previous studies in the field of OPLWH have defined them to be aged ≥ 50 years. However, seeing as assumptions of life expectancy without HIV and total fertility rates were estimated to be 61.5 years for males and 67.7 years for females in 2019,To our knowledge, this was the first study to assess characteristics and outcomes in older PLWH in the NWP. Older men and women living with HIV need to be approached using different strategies, tailored to their specific needs. There is an urgent need for South African clinicians to consider the implementation of standardised CGA in all OPLWH, as this has the potential to improve outcomes of older patients after hospital admission. Chronic kidney disease needs to be actively excluded in OPLWH as it has major clinical implications, especially in the context of a high burden of other co-morbidities and high cardiovascular morbidity and mortality. Considering the study limitations, further prospective studies with larger samples are necessary in the NWP to confirm or refute the findings of low VL suppression rates in OPLWH.


Despite the effectiveness of cART, people living with HIV still experience an increased risk of serious non-AIDS events, as compared to the HIV negative population. Whether pre-cART microbial translocation (MT) and systemic inflammation might predict morbidity/mortality during suppressive cART, independently of other known risk factors, is still unclear. Thus, we aimed to investigate the role of pre-cART inflammation and MT as predictors of clinical progression in HIV+ patients enrolled in the Icona Foundation Study Cohort.We included Icona patients with ≥2 vials of plasma stored within 6 months before cART initiation and at least one CD4 count after therapy available. Circulating biomarker: LPS, sCD14, EndoCab, hs-CRP. Kaplan-Meier curves and Cox regression models were used. We defined the endpoint of clinical progression as the occurrence of a new AIDS-defining condition, severe non-AIDS condition (SNAEs) or death whichever occurred first. Follow-up accrued from the data of starting cART and was censored at the time of last available clinical visit. Biomarkers were evaluated as both binary (above/below median) and continuous variables .p = 0.056 for median-based model; p = 0.002 for 33% percentile-based model).We studied 486 patients with 125 clinical events: 39 (31%) AIDS, 66 (53%) SNAEs and 20 (16%) deaths. Among the analyzed MT and pro-inflammatory markers, hs-CRP seemed to be the only biomarker retaining some association with the endpoint of clinical progression (i.e. AIDS/SNAEs/death) after adjustment for confounders, both when the study population was stratified according to the median of the distribution (1.51 mg/L) and when the study population was stratified according to the 33% percentiles of the distribution . In particular, the higher the hs-CRP values, the higher the risk of clinical progression (Our data carries evidence for an association between the risk of disease progression after cART initiation and circulating pre-cART hs-CRP levels but not with levels of MT. These results suggest that pre-therapy HIV-driven pro-inflammatory milieu might overweight MT and its downstream immune-activation.The online version contains supplementary material available at 10.1186/s12879-021-06260-y. Despite the unquestioned success of cART in recovering CD4 T-cell count and in preventing disease progression –3, a fewThis is particularly true among patients who initiate cART at advanced disease stages and fail to achieve a significant CD4 recovery upon virologically-suppressive cART –12. GlooPersistently heightened immune activation and inflammation on cART have been associated with both inefficient CD4 recovery –17 and tIn untreated HIV infection, our group and others have shown that the markers of immune activation derived from the systemic translocation of bacterial byproducts through a damaged gut mucosal barrier, mainly lipopolysaccharide (LPS), are independent predictors of disease progression , 24. IntAmong PLWHIV on suppressive cART in North America, markers of innate immune activation and inflammation were much more strongly predictive of mortality than T-cell activation , 30, posNevertheless, whether or not markers of microbial translocation and systemic inflammation pre-cART predict morbidity/mortality during suppressive cART, independently of other known risk factors, is still under debate.Given these premises, we explored the possible associations between circulating markers of microbial translocation  and systemic inflammation (hs-CRP) measured before cART introduction and the risk of long-term disease progression upon cART start in PLWHIV enrolled in the Icona Foundation Study Cohort. Among markers of inflammation, we chose to investigate hs-CRP given its frequent routinary use in the clinical management of PLWHIV, reasoning that it might be an easy and informative biomarker to be exploited in the most personalized clinical management of cART-treated patients.The study population was selected from the Icona  Foundation cohort. Icona is an Italian multicenter prospective observational cohort study, set up in 1997 and including HIV-1 infected subjects . To dateDemographic, viro-immunological and clinical data as well as details on antiretroviral regimen, are registered in an electronic case report form (eCRF). All the clinical events, lab and viro-immunological parameters are registered in the electronic database from the enrollment till the last available follow-up, a follow-up visit is scheduled at least every 6 months.Of all participants in the cohort, we selected a subset of 2376 who on January 01, 2015 had already started cART, had ≥2 vials of plasma stored over the 6 months between entry and the date of cART initiation and ≥ 1 CD4 count after cART initiation. We have then extracted a random sample of 500 patients from this universe. For 24 of these patients (5%) the second vial could not be located and were not eventually included. CD4 count and HIV-RNA are typically measured on the same collected sample, so all patients also had ≥1 viral load during cART. Death and clinical events are recorded from the information on the medical record of the patients. Death records are not linked to national or regional registry and the accuracy of AIDS-defining and non-AIDS events diagnoses are checked by both central and on-site monitoring. Central monitoring to check the accuracy of the data entered is performed every 6 months while on-site monitoring annually. Of all participants in the cohort, we selected a subset of 2376 who on January 01, 2015 had already started cART, had ≥2 vials of plasma stored over the 6 months between entry and the date of cART initiation and ≥ 1 CD4 count after cART initiation. We have then extracted a random sample of 500 patients from this universe. For 24 of these patients (5%) the second vial could not be located and were not eventually included.The Icona Foundation study was approved by the Ethics Committee  of each participating institution. All of the individuals enrolled provided written informed consent at the time of enrolment.On the extracted stored samples, we retrospectively measured plasma levels of microbial translocation markers, such as LPS , sCD14 , EndoCAb  and the pro-inflammatory marker hs-C reactive protein, CRP , according to manufacturers’ instruction. Only one sample per participants stored prior tocART initiation was used.The Limulus amoebocyte lysate (LAL) test, an assay generally used to quantify endotoxin, presents several technical issues, due to reagent contaminations, as well as to the inhibitory nature of some plasma components . The proWe defined a primary composite endpoint of clinical progression as the occurrence of AIDS-defining condition, non-AIDS severe events (SNAEs) or death whichever occurred first. SNAEs included: cardiac decompensation, chronic renal insufficiency , end-stage liver diseases, myocardial infarction, malignancies, pneumonia, end-stage renal diseases (defined as 2 consecutive measurements of eGFR< 60 ml/min at least 3 months apart) and septic infections. More details regarding the exact endpoint-defining events included are provided in Supplementary Table We next defined two alternative composite endpoints after distinguishing non-infectious related events from infectious-related events. The latter group included i) AIDS-defining infections; ii) end-stage liver diseases caused by viral agents; iii) infectious-related malignancies; iii) pneumonia; and iv) sepsis  was used to evaluate the association between MT and systemic inflammation markers and each of the defined endpoints. Participants’ follow-up accrued from the date of starting cART up to one of the endpoint defining events . For those who did not develop any of the endpoint-defining events, was censored at time of last available clinical. Separate Cox regression models were fitted for each of the biomarkers both univariable and after controlling for key baseline time-fixed confounding factors . A final model was also constructed under the assumption that the association with each of the markers could have been further confounded by the remaining markers. Repeated measures of the markers were not available, and this prevented us from planning correction for potential post-baseline confounding.MT and pro-inflammatory markers were evaluated using both a binary variable (above and below median) and as a continuous variable . Dichotomisation was based on the median value of the study population because there are no standardised clinical cut-off values for these markers. For hsCRP we have also a categorization that used the 33% percentile in order to compare the risks between patients with low and intermediate values vs. high. The 66% percentile corresponds to the clinically relevant cut-off of 5.4 mg/l. The natural logarithmic scale was used to reduce variance, increase power and comparability between the results across markers.We also performed a number of sensitivity analyses: i) by repeating the main analysis on the subset of patients who had CD4 count less than 350 cell/mmc before cART starting, ii) after further controlling for mode of HIV transmission, smoking and alcohol consumption, iii) after excluding participants who showed hsCRP levels > 10 mg/L and iv) after restricting to those who had a complete profile for all biomarkers evaluated.We analyzed the data of 486 patients fulfilling the inclusion criteria and overall contributing to 1605 biomarker measures: 278 with LPS, 375 with hs-CRP, 477 with sCD14 and 475 with EndoCAb. Table p = 0.524), sCD14 (p = 0.821), EndoCAb (p = 0.083) and hs-CRP (p = 0.119) strata. Similar results were observed when we restricted the analysis to the 70 infectious-related events (data not shown).Using the primary composite endpoint of clinical progression, 125 progression events were recorded: 10.8 (0.77–14.8)/1000 PYFU new AIDS, 18.3 (14.2–23.3)/1000 PYFU SNAEs, and 5.56 (3.40–8.57)/1000 PYFU deaths, corresponding to 39 (31%) AIDS, 66 (53%) SNAEs and 20 (16%) deaths. Among the 66 SNAEs events we identified: 1 cardiac decompensation, 3 chronic renal insufficiency, 4 liver diseases, 5 myocardial infarctions, 16 malignancies, 1 myelitis, 1 pancreatitis, 11 pneumonia, 22 renal diseases, 2 septic infections. We found no major differences in the Kaplan Meier estimated cumulative probability of disease progression according to plasma LPS  and remained virtually unchanged after further adjustment for the other biomarkers , intermediate (1.2–5.3 mg/L) and high (> 5.3 mg/L). These results confirm those of the above-mentioned analysis and show a dose-response relationship with the outcome: the higher hs-CRP values, the higher the risk of clinical progression . Results of this analysis were similar to those of the main analysis.milieu might differently affect the pathogenesis of infectious and non-infectious related diseases in course of long-term suppressive cART. In this analysis the breakdown of the 70 infectious-related events were as follows: 39 AIDS-defining infections, 5 infectious-related malignancies, 4 viral hepatitis, 2 septic infections, 11 pneumonia and 9 infectious-driven death. Although the association was weaker, possibly because of the reduced statistical power, again, hs-CRP was the biomarkers which was most strongly associated with clinical progression after controlling for confounders and for the other biomarkers , as well as when it was fitted as continuous variable . However, the association was lost after controlling for confounders and for the other biomarkers .Over years of successful cART, serious non-AIDS events (SNAEs) have become the major causes of morbidity and mortality in PLWHIV . DespiteHere we have evaluated the association between pre-therapy systemic inflammation and microbial translocation and clinical outcome measured after cART.milieu might be a more important mediator of long-term HIV-disease progression.Our data show some evidence for an association between pre-therapy circulating hs-CRP, but not microbial translocation, and higher risk of clinical progression after cART initiation, regardless of patients’ key confounding factors such as age and nadir CD4 count, in all suggesting that pre-therapy HIV-driven pro-inflammatory While both IL-6 and D-dimer have been shown to be independently associated with serious non-AIDS conditions or death among HIV-positive adults with suppressed virus , posing Interestingly, by performing the same analysis according to infectious vs non-infectious clinical conditions, a similar yet non-significant association was retained uniquely between hs-CRP and infectious-related events, whereas a much weaker association was shown between EndoCAb and non-infectious diseases. Given that inflammation, as well as endotoxin immunity, has been shown to have a pathogenetic role in both infectious and non-infectious diseases, further studies should specifically address this issue in well-defined cohorts of HIV+ patients on cART.MT and activation/inflammation markers have been associated with mortality and disease progression among cART initiators in some, but not all studies , 45, 46.According to a recent hypothesis , the rooIn our analysis, circulating MT markers failed to predict disease progression even after restricting the analyses to PLWHIV with severe pre-cART CD4 below 350 cell/mmc, suggesting that other factors probably encompass the effect of MT alone in contributing to disease progression. Whilst seemingly divergent from data by Hunt et al.  that demSeveral limitations to our study need to be acknowledged. First, CD4 count nadir of our study population was low (243 cells/mm3 on average) and this could have influenced the results of the analysis. Further data are needed to confirm the role of both pre-therapy inflammation and MT as clinical predictors also in individuals who initiate cART earlier in the infection. Secondly, our results rely on the usual assumption of a correctly specified model  and no unmeasured confounding. We cannot rule out that the lack of association is masked by residual or unmeasured confounding factors. In a sensitivity analysis we further controlled for mode of HIV transmission, alcohol consumption and smoking and none of these adjustments attenuated the association to the null. Third, selection bias could be an issue due to the non-negligible proportion of participants with missing data for one or more of the biomarkers (namely LPS was only available for 278 and hsCRP for 375 participants). However, main characteristics of participants with missing values and risk of outcomes were similar to those of the other analyzed groups suggesting that non-successful testing had occurred at random. Importantly, although all of the tested hypotheses have been pre-specified, many comparisons were performed without controlling for possible inflation of the type I error. Finally, the high quality of care received by patients enrolled in our study could have led to a lower number of clinical events, compared to other studies, possibly limiting the power of the analysis.While our study failed to find an association between LPS and disease progression in our cohort of PLWHIV, it must be acknowledged that LPS measurement might not entirely capture the extent of MT, given its fluctuation during the day and its association with food intake and the fact that repeated measures of the markers post cART initiation were not available. A deeper understanding of the role of MT as cause of inflammation and disease progression in the course of cART could be gained by the comprehensive assessment of additional and reliable markers of both MT and inflammation, including the fungal translocation marker Beta d glucan (BDG) that has proven to maintaining stable plasma levels over 24 h, with stronger association with pro-inflammatory markers –49. AlsoOur analysis suggests that the inflammatory marker hs-CRP measured before cART initiation is a predictor of long-term clinical disease progression. As a consequence, more frequent clinical monitoring and disease-specific screening after cART initiation should be considered for PLWHIV showing high levels of hs-CRP while still untreated.To date, a number of studies have been conducted to evaluate strategies aimed to reduce persistent immune activation on ART, such as cART intensification, treatment of co-infections, the use of anti-inflammatory agents and improvement of immune recovery through cytokine administration (as reviewed in 7 [Additional file 1.


A simple hysterectomy is considered the definitive treatment modality for cervical intraepithelial neoplasia (CIN). However, it is associated with recurrence of vaginal intraepithelial neoplasia (VAIN) of up to 7.4%. We sought to determine recurrence rates of VAIN, in women living with HIV (WLWH) and non-infected women.This was a descriptive retrospective review of patients who received a simple hysterectomy for CIN between January 2015 and December 2017 in Pietermaritzburg.p = 0.164). Virologically suppressed patients had more abnormal cytology (28.1% vs. 0%) compared to the unsuppressed patients. There was a 17.2% and 65.5% loss- to follow-up rates at 6 and 12 months, respectively. Recurrence of premalignant lesions was noted amongst those who had the abdominal approach.Fifty-eight files were reviewed. Forty-two (72.4%) WLWH were seen; amongst those, 76.2% were virally suppressed. Abnormal vault cytology was only seen in patients with CIN grades 2 and 3. The recurrence rates for high-grade squamous intraepithelial lesion (HSIL) were 6.1% and 5.0% at 6 and 12 months, respectively. Human immunodeficiency virus co-infection was associated with 26.2% versus 13.3% of abnormal vault cytology compared to the HIV-negative counterparts (The recurrence rates were comparable to the previous literature. A 6-month cytology follow-up showed no added benefit. Human immunodeficiency virus co-infection didn’t show a statistical significance on the recurrence rates; however, more structured studies are required to address this. Primary health care-based post operative surveillance can be a solution to address high loss to follow-up. Those with abnormal cervical cytology are treated at district hospitals or referred to the next level of care for further intervention. Primary care institutions are of utmost importance in quality implementation of cervical cancer primary and secondary prevention interventions, placing emphasis on the value of ongoing feedback between levels of care. The recommendation is that women who are not HIV infected exit screening at the age of 55 years or at hysterectomy.This was a retrospective study of women who had had a hysterectomy for CIN and follow-up cytology to determine recurrence rates, the impact of hysterectomy route and the impact of HIV co-infection on recurrence rates. Inclusion criteria were all adult women who had had a hysterectomy for premalignant lesions with a clear margin status on histology. Excluded were women who had had hysterectomies for other indications and where histology confirmed invasive cancer. Whilst those who had positive histological margins (11) were excluded from the recurrence analysis, they were included in the analysis of impact of the route. p = 0.05Graphical and descriptive statistics were carried out and bar graphs and tables were produced using Microsoft Statistical Package for the Social Science (SPSS) [AQ6]version 26. Parametric and non-parametric tests were used to determine associations between objectives and study variables. Statistically significant Ethical approval was provided by the Biomedical Research Ethics Committee of University of KwaZulu-Natal . The study was registered with the National Health Research Database (NHRD) of South Africa (KZ_202005_009). The study was using patient records and no direct harm or risk was posed to human subjects.A total of 79 files were retrieved within the study period from 01 January 2015 to 31 December 2017 in the Pietermaritzburg metropolitan area, under uMgungundlovu health district. Fifty-eight files met the inclusion criteria and were analysed. The mean age of the study group participants was 48.9 years with a range of 33 years to 76 years. Parity of the participants ranged between one and nine, with a mean parity of 3.64 children and a median of 3.0. n = 68). A total of five (8.8%) women received two interventions. The most common indication for hysterectomy was persistent high-grade squamous intraepithelial lesion (HSIL) in 43 (74.1%) women. Nine (15.5%) other indications (15.5%) were persistent low grade squamous intraepithelial lesion (LSIL) and women’s requests for hysterectomy (n = 4), and persistent atypical squamous cells – HSIL could not be excluded in five patients. Forty-two (72.4%) patients were living with HIV, 15 (25.9%) of them were non-infected and one patient’s status was unknown at the time of hysterectomy. Amongst the WLWH, 44 (76.2%) had a suppressed viral load, whilst 3 (4.7%) of them were on treatment but their viral load was not suppressed. The remaining 11 (19.0%) had unknown viral loads at time of surgery.The most commonly performed intervention prior to hysterectomy was a large loop excision of the transformation zone (LLETZ) at colposcopy with a frequency of 69.1% , 38 (65.5%) and 49 (84.5%) at 6 months, 12 months and 18 months, respectively. Post hysterectomy vault cytology with NILM results were 39 (79.6%), 15 (75.0%) and 7 (77.8%) at 6 months, 12 months and 18 months, respectively. The recurrence rates for HSIL ranged between 5.0% and 11.1% over a period of 18 months. Only three follow-up samples had no cytological diagnosis. No cytological diagnosis of VAIN was made at 6 months amongst those who had follow-up screening. In the HIV negative group, there was a 6.6% recurrence rate of abnormal cytology. One 50-year-old, HIV-negative patient presented with a vaginal lesion at 12 months follow-up and a punch biopsy confirmed vaginal cancer.p = 1.000). Human immunodeficiency virus infection was associated with higher rates (26.2% vs. 13.3%) of abnormal cytology compared to HIV negative patients, but statistical significance could not be demonstrated (p = 0.164). Abnormal cytology was seen more frequently in virally suppressed patients (28.1% vs. 0%) than in those with unsuppressed viral loads, but this was not statistically significant (p = 0.425). Only patients diagnosed with CIN 2 and 3 at hysterectomy had abnormal cytology at 6 months, 12 months and 18 months follow-up. At 12 months, recurrence rates were 5.3% (n = 19) for both LSIL and HSIL (p = 0.511). Our data showed that all the patients who presented with abnormal vault cytology had been treated with abdominal hysterectomy. There were comparable rates of recurrence at 6 months and 12 months observed in our study.There was no statistically significant association between route of hysterectomy and recurrence rates  recommends annual cytology follow-up for a period of 5 years after hysterectomy.9 The observation of similar recurrence rates at 6 and 12 months in our study suggests that a 12 month follow-up strategy in line with the national guidelines is more cost effective.7 This recommendation incorporates and involves primary care level institutions that will carry out the ongoing screening. The majority of this study population was WLWH and had comparable recurrence rates to other studies (6.1%).4 Only one patient was HIV-negative, had CIN 3 and developed HSIL at the same time interval as the HIV-positive patients. Aberg et al. suggested that HIV infected women should receive cytological or HPV screening following hysterectomy, particularly if there was a history of CIN at or prior to surgery.10 Botha et al. recommend a lifelong annual surveillance of individuals who are co-infected with HIV in the South African population.7The rates of abnormal vault cytology seen in our study were associated with the degree of dysplasia at the time of hysterectomy. Cervical intraepithelial neoplasia 2 and 3 were associated with higher rates of abnormal vault cytology results compared to medium risk premalignant lesions. This observation highlights the need for a more extensive risk-benefit counselling for patients with medium-risk premalignant lesions requesting a hysterectomy and ongoing follow-up compliance counselling to those with high grade lesions at hysterectomy. Cao et al. recommend a lifelong annual follow-up with cytology and HPV screening.11 Based on their findings, they recommended that a vaginal approach be considered for premalignant cervical lesions because of the direct visualisation of the lesion at the time of procedure.11 One hundred percent of abnormal vault cytology was seen in abdominal hysterectomy in our study compared to 0.0% of those who had vaginal hysterectomy. Cheung et al. in China found recurrence rates of 25.0% for the vaginal hysterectomy subgroup compared to 40.0% from the abdominal hysterectomy group.12 Schockaert et al. in Belgium reported recurrence rates of 85.7% and 14.3% for abdominal and vaginal routes, respectively, for VAIN over time in their 2008 retrospective study.1 It seems pertinent to recommend a vaginal approach in patients with premalignant cervical lesions.The majority (89.7%) of this study population was treated with open simple abdominal hysterectomy in comparison to 10.3% patients who received a vaginal hysterectomy. Eleven patients, who were excluded from the study because of positive margins, all had open abdominal hysterectomies. Das et al. in 2005 found a margin positivity rate of 33.3% in the abdominal route compared to the vaginal route, which had only 3.3% positive margins.1 This concerning finding could be because of multiple patient and healthcare system-related factors. A local study looking at follow-up of patients with gestational trophoblastic disease showed that socio-demographic factors, such as long distances travelled by patients, were associated with high loss to follow-up rates.13 This can potentially be mitigated by decentralising vault cytology follow-up to primary care level institutions, which deliver reproductive health services in the community. Although these findings were from a different study group with different follow-up interval protocols, it shares similar socio-demographic characteristics of a low income setting as our study population and the study was conducted in the same institution. These factors should ideally be addressed during pre-operative counselling and an individualised plan be tailored for those who cannot afford to comply with the recommended local protocol.10 Healthcare workers attending to patients treated for premalignant cervical lesions must be familiar with the recurrence rates so as to optimise the quality of follow-up and counselling, and primary care physicians need to be involved.There was a high loss to follow-up rate in our study population. These findings are higher than the findings from a Belgian study which showed a loss to follow-up rate of 24.8% over 103 months at early intervals.7 Annual follow-up as well as the decentralisation of follow-up cytology to primary health care institutions could reduce the loss of follow-up demonstrated in our study by limiting number of visits to higher levels of care and alleviating the socio-economic burden to the population.Short interval follow-up protocols could be another factor leading to high default rates, especially in low resource settings such as ours. Botha et al, similarly to Cao et al., recommend a yearly follow-up guideline for patients treated for pre-malignant lesions.The findings from this study should be interpreted with caution because of its retrospective nature that makes it prone to bias limitations. The small sample size also compromises both clinical and statistical significance of the findings. However, it highlighted the clinical implications of the hysterectomy route for premalignant lesions and the probable socio-demographic challenges related to follow-up. These findings can be used as a platform for further research in the context of low resource settings. This study, in addition, has highlighted a gap in the system pertaining to down-referral patterns. Primary health care providers and tertiary institutions need to be made aware of this gap so that a collaborative strategy can be implemented, to improve referral frameworks geared towards patient retention.The recurrence rates for CIN were comparable to previous literature, particularly in women with a history of CIN grades 2 and 3. The risk is increased despite complete surgical excision. Clinicians need to acknowledge this risk and devise a careful follow-up strategy. Cytology at 6 months did not show added benefit. Human immunodeficiency virus co-infection did not show a statistical significance on the recurrence rates; however, better structured studies are required to address this issue further. High loss to follow-up rates needs a broader and multifactor oriented approach which should include a clear down-referral system to primary care institutions. Further studies are needed to investigate reasons for the high loss to follow-up rates in our population.


Ending the HIV Epidemic: A Plan for America aims to decrease new HIV diagnoses 75% by 2025 and 90% by 2030. To achieve this, we identified patients unable to achieve viral suppression with social-behavioral needs deemed ‘high-hanging fruit.’ Via extensive outreach efforts and creation of shared problem solving, we pursued the goals of rapid and effective treatment leading to viral suppression and prevention of HIV transmission. We (1) exhausted all avenues of outreach to re-engage patients in HIV care and (2) identified personal or social characteristics related to difficulties in visit retention and achieving viral suppression.Of 446 Ryan White-eligible patients seen in an urban, academic medical center, 46 did not achieve and/or maintain viral suppression, and qualified for the study. We conducted a mixed methods survey comprised of both multiple choice and open-ended questions to ascertain what barriers patients face to continuous engagement in care and to achieving viral suppression. We developed a re-engagement outreach cycle which included: text messages and phone calls, electronic messages via patient portal or email, phone call to pharmacy to cross-check contact information, outreach to patients’ emergency contact, and sending a letter by mail.Of 46 participants, 32 were reached and 14 were not found. Sixteen re-engaged in care and of these, 14 completed the survey . Those who completed the survey noted the following barriers to care: poor mental health, financial issues, problems committing to an appointment due to work/family/transportation, and COVID-19. Out of all 46 participants, the 14 who were not found had an overall a higher index of chaos. This index of chaos included, but was not limited to: homelessness, IV drug use, domestic violence, and stigma.Outreach to re-engage in HIV careA. Participants in study, B. Outreach outcomes, C. Common survey themesIntensive efforts are required to re-engage patients, counsel on adherence, and achieve viral suppression. The reasons for lack of engagement in care are real and challenging. Multiple cycles of continuous outreach serve to establish trust, address barriers, and connect to HIV care.All Authors: No reported disclosures


The study aims to assess changes in HIV treatment outcomes for Jamaica after the implementation of the WHO Treat All strategy in January 2017, as well as identify variables associated with clinical stage at diagnosis and viral load status, in order to understand implications for enhancing the HIV clinical cascade and boosting progress towards the UNAIDS 90-90-90 targets.3, or late/ baseline CD4 <350 cells/mm3), 2. viral load status achieved after ART initiation (suppressed/<1000 copies/ml or non-suppressed/ ≥1000 copies/ml). Categorical variables: age/years, gender and health regions, were investigated using multivariable logistic regression. Adjusted odds ratios and 95% confidence intervals are reported.This is a population-based study using the National Treatment Service Information System. The sample consists of persons 15 years and older, placed on treatment before and after Treat All was implemented, across all 4 regional health authorities in Jamaica. Patients were assessed for two binary outcomes: 1. stage at HIV diagnosis (early/baseline CD4 cell count ≧350 cells/mmAfter Treat All, there was an increase in median baseline CD4 results as the proportion of late diagnoses decreased from 60% to 39%. There was a small increase in viral suppression from 76% to 80%, a decrease in baseline viral load testing from 61% to 46% and an increase in the uptake of first viral load testing after starting treatment from 13% to 19%. Males and persons 40+ years had higher odds of late diagnosis before and after Treat All.Jamaica’s HIV program outcomes have improved after Treat All was implemented. ART initiation time significantly decreased. Early diagnosis, viral load testing uptake and viral suppression increased. However, there is a need to implement targeted testing for men and persons over 40 years to decrease the frequency of late diagnosis. As of 2018, Jamaica recorded an adult HIV prevalence of 1.5%, with an estimated 32,617 persons living with HIV (PLHIV) . Compare3 [Treat All has several objectives, including early diagnosis of HIV, immediate initiation of antiretroviral therapy (ART) and viral suppression . Diagnos3 . In 20173 , 12 beca3 . More th3 . Virolog3 .The primary aim of the study is to assess characteristics of PLHIV on treatment, before and after the implementation of the new treatment strategy, by identifying factors associated with the stage at diagnosis and viral load status, in order to understand implications for enhancing the HIV treatment cascade and population based outcomes for Jamaica. Secondary objectives aim to assess changes in ART and viral load testing uptake. This paper is the first in a series of studies which will look at factors associated with improving the HIV treatment cascade and help to suggest programmatic strategies to narrow current gaps.This secondary analysis uses the National Treatment Service Information System (TSIS2). TSIS2 is a centralized case-based database, governed by the Ministry of Health and Wellness (MoHW), Jamaica and currently being used by all HIV treatment sites in Jamaica. TSIS2 stores patient level demographic and clinical data, using over 100 variables . This stThe baseline data extracted included all PLHIV initiating HIV treatment between January 2015-December 2019. The sample was divided into two datasets representing before Treat All implementation (January 2015-December 2016) and after Treat All (January 2017-December 2019)  and an i3), first viral load test date and result (copies/mL). Age was categorized into 3 groups  for the analyses. Two binary outcomes were assessed, each defined by the Clinical Management of HIV Disease Guidelines [The following routinely collected variables were extracted from the TSIS2: gender , age (years), Regional Health Authority (RHA) , first clinic date, first ART date, first CD4 cell count . Patients starting ART with baseline CD4 cell count ≧350 cells/mmiagnosis .First viral load status achieved after starting ART . The results were categorized as suppressed <1000 copies/mL or non-suppressed ≥1000 copies/mL).The samples were stratified by categorical variables: age group, gender and RHA. Sample sizes were small for persons < 15 years of age, so the regression analysis focused on persons 15+ years. We analyzed time to ART initiation based on the time from the first clinic date to ART initiation date. Time to first viral load test was determined by the time from the first ART date to the first viral load test date. Jamaica’s current national treatment guidelines stipulate a first viral load test should be received within 6 months after ART initiation  so, inclAdditionally, the association between HIV stage at diagnosis and viral suppression was also assessed, as shown in Model B.R, version 3.5.3 [No mathematical correction was made for multiple comparisons. Both datasets were analyzed separately using on 3.5.3  and the on 3.5.3 . The ful3 before Treat All to 462 cells/mm3 after Treat All, and the proportion of persons diagnosed early increased from 52.6% to 64.7%. There was also an increase in viral suppression from 37.7% to 51.6% and similarly a noticeable reduction in median first viral load results. A significant decrease in ART initiation time after Treat All  was also reflected.The baseline samples consisted of 2677 PLHIV initiating treatment before Treat All and 5686 after Treat All. Using Equation Model B, late diagnosis was associated with two times higher odds of viral non-suppression before  and after Treat All . This was highly significant.3 to 419 cells/mm3. after Treat All.One of the primary objectives of Treat All is to increase early treatment initiation . Our resDespite the overall decrease in late diagnosis, males were significantly more likely to be diagnosed late before and after the strategy was implemented compared to females. This is consistent with other studies reporting late diagnosis was more common in men than in women, attributed to poor health seeking behaviour , 21, 22.The baseline sample showed a decrease in baseline viral load testing after Treat All (61% vs. 46%) and there was an increase in the uptake of viral load testing after 91–240 days on treatment. This may be explained by the implementation of new national testing guidelines in 2017, which stipulate a first viral load test should be administered 3–6 months after starting treatment . This isThe frequency of persons achieving viral suppression after initiating treatment increased only minimally after Treat All (76% to 80%). So, despite majority of persons diagnosed late before Treat All, most were still able to achieve suppression at the first viral load test. This may speak to the effect of early treatment initiation after diagnosis, as the median time to ART initiation was 7 days before Treat All.Our study shows males and age groups 15–19 and 40+ years were more likely to be virally non-suppressed before and after Treat All. This again may be a result of early treatment. There was a change in the viral load status of PLHIV in NERHA, moving from two times higher odds of viral non-suppression before Treat All to lower odds after Treat All. Using Equation Model B, we also found late diagnosis was significantly associated with viral non-suppression at the first viral load test, both before and after Treat All. While, Treat All is intended to ensure immediate start on ART to improve health outcomes, viral suppression also depends on adherence to treatment. Persons who seek health care services late are more likely to demonstrate poor adherence in keeping with poor health behaviour. This study could not assess adherence, but national data shows Jamaica has only achieved 53% of the global adherence target , so evenDespite the difference in sample size between both scenarios, gender was mostly equally distributed and all four regional health authorities were sampled. While time periods sampled for the two scenarios varied (1 year before Treat All and 2 years after Treat All), the time intervals used for the relevant variables assessed were consistent. However, we acknowledge certain limitations of the data. The dataset was extracted from TSIS2 in February of 2020 and therefore, only provides a snapshot of the patients’ data. The dataset lacked HIV diagnosis dates, so our assessment of time to ART initiation used the time from first clinic date to ART initiation. This assumes the first clinic date is the first encounter with a treatment site and negates possible use for non-HIV related services. Viral load test results after the first test and treatment adherence is also not assessed. Therefore, it is assumed persons on treatment for 91–240 days are consistent in taking medication. Also, we were unable to assess deaths because persons found to be deceased are removed from the database. So, all persons in the sample are considered to be alive. To ensure there would be no overlap of the time periods, persons who were not yet eligible for a first viral load test, those who were eligible but did not receive a test (no test results) and those who received a first viral load test either before or after the study periods were all excluded from the sample. This reduced sample sizes in both scenarios. We recognize the possible effect of a smaller sample size, so the age group 15–19 years has been excluded in the final analysis because of the wider confidence intervals noted and we have used the categories with the largest samples as references in the regression analyses , 26Overall, the time to ART initiation for PLHIV in Jamaica was significantly reduced after implementation of the Treat All Strategy. There was also a decrease in late diagnosis while viral load testing after treatment initiation and viral suppression for those on treatment increased. However, there is a need to examine the effect of laboratory based challenges on viral load testing uptake and the achievement of viral suppression as well as identify service delivery models to improve diagnosis for men and persons over 40 years.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


More than 8,000 functional Cameroonian HIV-1 pol sequences from 1987 to 2020 were studied for DRMs and NOPs. Site-specific amino acid frequencies and quaternary structural features were determined and compared between periods before (≤2003) and after (2004–2020) regional implementation of cART. cART usage in Cameroon induced deep mutation imprints in reverse transcriptase (RT) and to a lower extent in protease (PR) and integrase (IN), according to their relative usage. In the predominant circulating recombinant form (CRF) 02_AG (CRF02_AG), 27 canonical DRMs and 29 NOPs significantly increased or decreased in RT during cART scale-up, whereas in IN, no DRM and only seven NOPs significantly changed. The profound genomic imprints and higher prevalence of DRMs in RT compared to PR and IN mirror the dominant use of reverse transcriptase inhibitors (RTIs) in sub-Saharan Africa and the predominantly integrase strand transfer inhibitor (InSTI)-naïve study population. Our results support the potential of InSTIs for antiretroviral treatment in Cameroon; however, close surveillance of IN mutations will be required to identify emerging resistance patterns, as observed in RT and PR. Population-wide genomic analyses help reveal the presence of selective pressures and viral adaptation processes to guide strategies to bypass resistance and reinstate effective treatment.Combinational antiretroviral therapy (cART) is the most effective tool to prevent and control HIV-1 infection without an effective vaccine. However, HIV-1 drug resistance mutations (DRMs) and naturally occurring polymorphisms (NOPs) can abrogate cART efficacy. Here, we aimed to characterize the HIV-1  Howeverl region . Drug rel region . People l region . Also, nl region . NOPs arl region . Non-clal region . Naturall region .cART programs in sub-Saharan Africa are based on WHO guidelines that have traditionally recommended reverse transcriptase and protease inhibitors  for first- and second-line therapy, and only recently have begun transitioning to integrase strand transfer inhibitor (InSTI) usage in some countries . Effectipol genomic plasticity in RT, PR, and IN regions and dissect the cross-sectional changes in HIV-1 strains in Cameroon over time.While computational methods have been developed for RTIs, PIs, and more recently, for InSTIs, to quantify the genetic barrier to the acquisition of DRMs , populatIn an ecological analysis, 8,130 HIV-1 RT , PR , and IN (802) nucleotide sequences from Cameroonian PLHIV were downloaded from the Los Alamos National Laboratory (LANL) HIV sequence database and studied after a multi-step quality check and selection process to eliminate non-functional, clonal, and poor quality sequences . EthicalStructural modeling was done using UCSF Chimera v1.13.1 , ICM-ProThe funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.P < 0.05. Chord diagrams were generated using the circlize, and correlograms using the corrplot and RColorBrewer packages in program R/RStudio.Mann-Whitney and Kruskal Wallis tests were done to compare mutational frequencies among RT, PR, and IN sequences, which achieved ≥ 93.8% power to detect a 0.5 standard deviation (SD) between groups of ≥ 99 sequences (5% error). Statistical analyses and power calculations were done using the R/RStudio ggplot2 package , Excel , and Grapol regions, with CRF02_AG being the predominant clade , in contrast to only moderate changes in PR (P = 0.07) and IN (P = 0.04)  mutation frequencies in RT  than in PR  and IN . Moreover, when these numbers were compared with the mutation frequencies in the post-cART era (2004–2020), we observed a strongly significant increase in RT ( = 0.04) . In addi = 0.04) . As a re = 0.04) .To assess Cameroon’s treatment-associated mutational changes in more detail, we calculated site-specific amino acid abundances for every position in RT, PR, and IN. We distinguished canonical DRM sites from all remaining sites, and among the latter, we screened all variable (NOP) sites for significantly increasing or decreasing mutations, called treatment-associated mutations . FocusinTo determine the impact of cART scale-up on the HIV-1 NOP landscape and the emergence of treatment-associated mutations, we summarized all significantly changing NOPs over time in RT, PR, and IN –7. CompaTo study whether there was a linkage between the presence of certain mutations, we performed a correlation analysis focusing on mutations that significantly increased from the pre- to post-cART period in Cameroon . In lineBesides CRF02_AG, there has traditionally been a broad diversity of HIV-1 subtypes circulating in Cameroon , 2. UndeIn the quaternary proteins, most canonical DRMs in RT and PR cluster around the drug-binding sites, as shown for the significantly increasing DRMs post-cART in CRF02_AG . The comHaving determined significant changes of DRMs and novel, treatment-associated mutation in Cameroonian RT and PR sequences post-cART, we aimed to assess the cross-sectional mutation profiles over time –12. As apol mutations and genotypic drug resistance in an entire population. In an ecological analysis of pooled viral genomic data from Cameroon where HIV prevalence stands at ∼3.7% in 2021, we used computational and structural methods to assess the genomic plasticity of HIV-1 pol over time and its implication on treatment. Treatment exerts selective pressure on the swarm of viruses present in every patient and the entire population and drives viral adaptation resulting in the emergence of HIV-1 DRMs. The cross-sectional nature of our study on a representative set of 8,130 sequences from Cameroon  enabled us to compare sufficient numbers of mutations and NOPs statistically over time. Fluctuating sample numbers and the inability to follow and assess individuals longitudinally were limitations. Our study revealed high plasticity in HIV-1 pol on the population level, which appears to be profoundly shaped by regionally applied cART protocols. Effective cART in Cameroon started in 2004. Hereafter, substantial scale-ups occurred in 2007 when cART became free of charge for eligible patients (CD4 count < 200 cells/mm3) and with the “test and treat” initiative implemented in 2016. Cameroon’s HIV treatment guidelines have primarily relied on regimens with two NRTIs and one NNRTI, which resulted in an increase in pre-treatment NRTI/NNRTI DRM rates up to >10%, and in patients failing first or second-line cART up to >60%  limits our sequence-based conclusions on InSTI treatment in Cameroon. Between 2017 and November 2020, only three complete and two fragmented IN sequences have been deposited to LANL. The latter two are from the same HIV-1 CRF18_cpx-infected individual who developed multi-drug InSTI resistance in 2017 based on G140A, Q148R, and E157Q DRMs, which further aggravated in 2019 additionally involving E138K/Q and S147G . Our strf region . In addisistance . Most resistance . ConsequThe original contributions presented in the study are included in the article/JNT and RD conceived research goals and analyses. JSB, PY, SD, X-PK, and RD performed formal analyses. RD acquired funding for the project. PY, SD, X-PK, and RD developed methodologies, designed and/or implemented computer codes. AJN, JNT, and RD supervised the research activity and validated the research output. JSB and RD verified the underlying data and prepared figures and tables. JSB, AJN, and RD wrote the manuscript. All authors reviewed and edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The funders had no role in the design or conduct of the study.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Poor antiretroviral therapy (ART) adherence is a challenge to containing the spread of HIV. This is an especially difficult challenge in conflict and post-conflict settings. This study investigates the relationship between attendance in an Orphan and Vulnerable Children program in South Sudan and HIV-related outcomes, including clinic appointment attendance, frequency of viral load testing and viral load suppression rates.Patient records (n = 295) were selected from project-supported clinics in Juba, South Sudan, and analyzed to measure the association between enrollment status and select health outcomes. Data were collected at multiple time points between 2018 and 2019, to measure the strength of relationship between select treatment variables . Given the structure of the data, non-parametric tests were applied to answer the research questions.Analysis revealed three important trends: (1) enrollment in the 4Children project was associated with a statistically significant increase in the frequency of viral load testing; (2) there was an increase in median appointment attendance after program enrollment; and (3) there was improved management of viral load and CD4 count, albeit small, during the time period before and after enrollment.Data from South Sudan suggests that caregivers and children receiving project services saw improvement in treatment-related indicators. After enrolling in the project, overall amount of viral load testing increased from previous counts before enrollment. This suggests that after providing additional services with psychosocial and financial support to patients at the two hospitals in Juba, there was potential that similar interventions can support improved HIV outcomes. After establishing independence in 2011, the Republic of South Sudan has experienced unstable healthcare and population displacement due to civil conflict , 8. AccoTo improve HIV health outcomes and prevent further transmission, regular access to anti-retroviral therapy (ART) and medical care is vital for adults and children with estimates of over 90% adherence needed for optimal viral load levels . In a stWith a breadth of research to suggest support systems, such as psychosocial services from professionals and community lending programs, positively influence ART adherence, the Coordinating Comprehensive Care for Children (4Children) program designed HIV-treatment services incorporating these factors to deliver quality care to vulnerable children and caregivers. 4Children was a six year program, funded by the United States Agency for International Development, designed to improve the health and well-being of vulnerable children affected by HIV and AIDS and other adversities. In South Sudan, 4Children was implemented between 2015 and 2019. 4Children implemented a unique approach to health services for children and adolescents, offering individuals and families from high-density, low income neighborhoods in Juba, services that addressed challenges along the HIV treatment continuum. Services included: (1) group-based training and home visits to provide caregivers support, (2) group-based training, outreach-service delivery,This study examines HIV outcomes within the context of Orphans and Vulnerable Children (OVC) programming. Using project and clinic data, the study was designed to assess the potential for improved quality of care when enrolled in OVC programs. Studies such as these are uncommon in conflict and post-conflict settings. Data can be difficult to collect when issues of the safety and security of patients and clinic staff are at a premium . The 4ChThree questions guided this study:Research question 1: After enrollment in 4Children, did children and caregivers experience any differences in frequency of viral load testing compared to before enrollment?Routine virologic monitoring is critical in HIV treatment and used as a benchmark by medical providers for treatment efficacy in adult and pediatric cases . HoweverResearch question 2: After enrollment, is there a difference in child and caregiver retention in care compared to before the program?Appointment data was collected to understand if additional support such as training and financial assistance could improve retention in care. The program recorded the number of appointments scheduled and the number of appointments attended and calculated attendance rates from the results.Research question 3: What differences, if any, did participants have as it concerns HIV outcomes before enrollment as compared to after enrollment?In order to understand health outcomes, data on CD4 counts and VL were classified into categorical variables to assess participants before and after enrollment in the program. CD4 counts of 500 and above are considered to be in the normal range while viral load copies/ml 1000 and less are considered virally suppressed. Participants with CD4 counts less than 500 or viral load copies/ml greater than 1000 were classified as at-risk. While there are differing opinions as to the utility of these values, particularly as it concerns the use of CD4 counts, there remains utility within resource limited settings . FurtherUsing a data capture tool, 4Children staff collected data from child and adult clinic records. Records were included if the patient was enrolled in the 4Children program, had voluntarily disclosed their HIV-positive status and had accessed care at either Juba Teaching Hospital or Juba Military Hospital. Program staff compiled a list of all enrolled participants who met these criteria (387 adult and 84 child participants). Adult and child participants were not necessarily related. Adult participants were randomly selected from this list to provide the necessary size to conduct reliable statistical tests, based on a standard sample size calculation. This resulted in the collection of 211 adult records. Given the smaller size, data from all 84 child records were collected.Upon identifying the list of participants to be included in the analysis, data on HIV testing, appointments, viral load, and CD4 count in addition to demographics variables were collected. While CD4 percentages were considered for younger participants, these data were not relevant to this study population as all children under age 5 received viral load tests. Data were collected at three timepoints: pre-intervention, 6 months after enrollment, and 12 months after enrollment. The “Pre-intervention” time period varied, depending on patient appointment attendance, ranging from 12 months to several years prior to enrollment. Unique identifiers were assigned to de-identify all participants. Final data collection and reports did not contain names or other personally identifiable information.All data were entered into and analyzed using Stata 16.0. Symmetry tests were used to understand the differences in distribution before and after. As the data were non-parametric and non-symmetric, the sign test was chosen to compare the continuous variables of HIV appointment attendance rate and frequency of viral load and CD4 count testing before and after the 4Children program. Assumptions of equal variances were not met and thus the Wilcoxon signed rank test was not performed in favor of a sign test. Categorical baseline and follow-up risk measurements were compared using the McNemar test to understand any difference in dichotomous risk levels for participants. The McNemar test was run comparing the most recent test result in the program with baseline measurements. All tests were additionally used to analyze differences between age categories of under 18 and 18 years old and over.Participant ages ranged from 1 to 61 years  with 28.5% under 18 years, 70.5% 18 years and older, and 1% who did not identify their age. 71.2% identified as female, 27.5% identified as male, and 1.3% did not have their sex recorded. 57% of those in the program received treatment and services at Juba Military Hospital while 43% received treatment and services at Juba Teaching Hospital. Additionally, 95% of participants in the 4Children program had already begun treatment for HIV before enrollment and 5% started treatment after enrollment.Before enrollment, 59.1% of participants had received testing for viral load or CD4 count. Out of participants who received testing, 43.1% tested for CD4, 16.6% tested for viral load. More than 40% received no test. After enrolling in the 4Children program, 81.7% of participants were tested and had a median viral load of 403 ) at their first viral load test after enrollment. In the time before enrollment, a mean of 8.76 (SD = 7.43) appointments were scheduled for participants and a mean of 8.40 (SD = 7.51) appointments were attended. From the date of 4Children enrollment to the present, a mean of 12.99 (SD = 11.19) appointments were scheduled and a mean of 13.34 (SD = 11.54) appointments were attended.The one-sided test indicated no significance for the hypothesis that median testing frequency was greater before program enrollment , however, median testing frequency appeared to be significantly higher after the participants were enrolled . With a one-sided sign test yielding a p-value of 0.00, the null hypothesis that there was no difference between testing frequency medians was rejected. With more negative signs (156 observed signs) than positive signs (83 observed signs), the results suggest a difference in frequency of VL and CD4 count testing after participants enrolled in the program. As a result, these data suggest a positive, statistically significant relationship between enrollment in the 4Children project and an increase in the frequency of testing. Finally, sign tests were run on age categories under and over 18 years. The two-sided test for 18 years and over yielded a p-value of 0.0049, indicating there was a difference after 4Children enrollment for this age group. Additionally, the two-sided test for under 18 years indicated a difference between before and after  . However, the McNemar test run on patients 18 years old and older produced statistically significant results for risk category differences . It is also important to note that the under 18 years old sample size was smaller than the ages 18 and over sample and this may have affected the results of the test once divided by age category.The data analyzed as part of this study suggest that OVC programs can have important roles to play for caregivers and children affected by HIV/AIDS, particularly within post-conflict settings. Consistent VL testing for HIV patients has been identified as a key tool for medical providers to track and manage a patient’s progression in status and virologic control , 12. AftReducing missed appointments has previously been studied as a means to improve healthcare outcomes and individual-level disparities in HIV , 13, 19.Participation in 4Children also appears to be associated with modest improvements in viral load suppression. While the change observed before and after program enrollment was small and attribution to the intervention was not measured, these findings point to the need for further, rigorous investigations. As viral load testing becomes increasingly accessible in Sub-Saharan Africa , there iOngoing studies examining OVC and HIV treatment programs will continue to explore the link between a variety of support services targeting children and caregivers to better understand circumstances for optimal HIV management. While the results of this analysis are not generalizable nor meant to establish causality, these findings offer preliminary evidence of promising interventions for low-resource and high-instability settings such as South Sudan.The study faced four primary limitations. First, as enrollment in the OVC program did not use random assignment, the results from the study are not generalizable to a wider population. Enrollment in 4Children was voluntary and everyone who participated received the intervention. Second, the sample used for this study is not representative of the wider population. Participants were enrolled into the intervention based on an assessment of their vulnerability but also their location within select geographic areas. The sample size for patients under 18 was also small, which may have resulted in unreliable findings when tests were run on the two different age groups (under and over 18 years old). Third, health facilities only began collecting VL data in April 2017. As such, the study team was unable to do comparisons of viral load for all study participants, as some were enrolled before April 2017 and baseline measurements were collected in CD4 counts. Consequently, data from participants were combined into risk categories rather than using the values of the test results. Fourth, potential limitations to the data could also include the difference between scheduled appointments and attended appointments. Many participants differed in counts between scheduled and attended. This might be due to follow-up appointments generated by the initial scheduled appointments or to participants requesting more appointments. While these are plausible explanations, this could not be confirmed for every participant.The purpose of this study was to explore the relationship between OVC programming and HIV outcomes, all within the context of post-conflict South Sudan. As discussed, important outcomes were achieved during the implementation of this project, including: (1) increased frequency of viral load testing; (2) increased appointment attendance; and (3) modest improvements in viral load suppression. While this study was not designed to measure the impact of the intervention, it helps lay the foundation for future research concerning the direct effect of OVC programming on health outcomes, particularly those occurring within post-conflict settings.