ABSTRACT
Background: After COVID-19 shelter-in-place (SIP) orders on 3/16/2020, viral suppression (VS) rates initially decreased within a safety-net HIV clinic in San Francisco, with greater decreases among homeless people living with HIV (PLWH). We sought to understand if (1) proactive outreach to provide social services, (2) scaling up of in-person visits for most patients and drop-in visits at the clinic, and (3) expansion of housing programs could reverse this decline. Methods: We assessed VS 24 months before and 13 months after SIP using mixed-effects logistic regression and propensity score methods, followed by interrupted time series (ITS) analysis to examine changes in the rate of viral suppression per month. Loss to follow-up was assessed via active clinic outreach and tracing using Kaplan-Meier methods. Results: The cohort contained 1816 patients with a median age of 51;12% female, 14% unstably housed, and 15% with CD4+-cell counts <200 cells/mm3. The adjusted odds of VS increased 1.34-fold following the intervention (95% CI: 1.21-1.46), with similar results using inverse probability weighting (adjusted odds ratio (AOR) 1.31;95% CI: 1.17-1.46). Results from the ITS analysis show that the odds of VS continuously increased by 1.05-fold per month over the post-intervention period (95% CI: 1.01-1.08, Figure). Proactive phone outreach successfully reached 90.0% of the clinic to offer services. The one-year cumulative loss to follow-up rate was 3.2% (95% CI: 2.5-3.9%). The proportion of total attended visits that were telephone visits decreased from a maximum of 64.9% to a minimum of 10.1% at the end of the analysis period. The rate of viral load monitoring decreased by 15% after the institution of SIP (95% CI: 0.83-0.88). Among homeless PLWH, the AOR for VS was 1.70 (95% CI: 1.24-2.34) and there was a 5.9% increase in VS per month using ITS methods (95% CI: 1.0-12.3%). Conclusion: After an initial destabilization in VS in a large safety-net clinic following SIP orders, the VS rate increased following scale-up of in-person visits, clinic outreach to patients, intensification of social services during this time, and access to COVID-related housing programs. The loss to follow-up rate was similar or lower compared to prior years. Maintaining in-person care for underserved patients, with flexible telemedicine options, along with provision of social services and permanent expansion of housing assistance programs, will be needed to support VS among underserved populations during the COVID-19 pandemic.
ABSTRACT
Background: Despite longstanding guidelines endorsing isoniazid preventive therapy (IPT) for persons with HIV, uptake is low across sub-Saharan Africa. Mid-level health managers oversee IPT programs nationally;interventions aimed at this group have not been tested. Methods: We conducted a cluster randomized trial in Uganda among district-level health managers from 2017-2021. The unit of randomization was groups of 4-7 managers. Our intervention convened managers into mini-collaboratives facilitated by Ugandan TB/HIV experts and provided business leadership/management training, SMS platform access, and data feedback. The primary outcome was IPT initiation rates among adults with HIV in health facilities overseen by participants over 2 years (2019-2021). We compared incidence rates using cluster-level targeted minimum loss-based estimation. We conducted pre-specified analyses that excluded Q3-2019 to understand intervention effects independent of a national "100-day push" of IPT tied to a financial contingency during Q3-2019. Qualitative interviews were analyzed to ascertain mechanisms of intervention action. Results: Managers from 82/82 eligible districts (61% of Uganda's 135 districts) were enrolled and randomized: 43 districts to intervention, 39 to control. After one year, in 5-point-Likert quantitative surveys, intervention-group managers demonstrated greater increases in familiarity with IPT (by +0.47 points (95%CI:0.14-0.80)) and knowledge of IPT efficacy (+0.59 points (95%CI:0.06-1.12)) as compared to control. Intervention-group managers reported improved within-district communication and inter-district collaboration and feeling empowered to better manage frontline providers, in contrast to control, in qualitative interviews. Over two years, the IPT initiation rate was 0.74 vs. 0.65 starts/person-year in intervention vs control: incidence rate ratio (IRR)=1.14 (95%CI:0.88-1.46;p=0.16). Excluding Q3-2019, IPT initiation was higher in intervention vs control: 0.32 vs. 0.25 starts/person-year (IRR=1.27, 95%CI:1.00-1.61, p=0.03;Figure). Conclusion: Though overall IPT initiation rates were not significantly higher with the mid-level manager intervention in this cluster randomized trial, rates were significantly higher compared to control when excluding the massive MoH-led "100-day IPT push" in both arms. The higher rates were sustained during the COVID-19 pandemic, suggesting benefits of targeted leadership and management training for mid-level health managers.
ABSTRACT
Tuberculosis (TB) remains a main driver of morbidity and mortality among people with HIV along with other opportunistic infections. This review summarizes key highlights related to TB, and other opportunistic infections in HIV as well as studies from the virtual 2021 Conference on Retroviruses and Oppoprtunitstic Infections evaluating outcomes among HIV-COVID-19 coinfected patients.
ABSTRACT
Background: The COVID-19 pandemic has resulted in disruptions to HIV prevention and care services access throughout the US. We sought to evaluate the impact of service disruption from the COVID-19 pandemic response on key Getting to Zero San Francisco (GTZSF) HIV prevention and care metrics of HIV antibody (Ab) and HIV viral load (VL) testing, Pre-exposure prophylaxis (PrEP) use, and the continuum of HIV care. Methods: Reports of positive and negative HIV Ab testing from 4 laboratories and a large community testing site (CTS), and HIV VL testing for people living with HIV reported to the San Francisco Department of Public Health were included. We compared the number of HIV Ab and VL tests, and PrEP visits at the CTS each month from January-October 2020 with the corresponding months in 2019. The continuum of HIV care was calculated for new HIV diagnoses in January-June 2020 compared to the same period in 2019. Results: From January-October 2020, the mean number of monthly laboratorybased HIV Ab tests decreased from 4,400/month in 2019 to 3,644/month in 2020 (Table);and from 1,382/month to 766/month at the CTS. April 2020 had the lowest number of HIV tests, a reduction of 54% in laboratory reporting and 88% in the CTS compared with April 2019;there was a partial rebound through October 2020. While the number of positive HIV tests was lower per month in 2020 compared with 2019, the proportion HIV positive remained stable throughout the study period (2020: Range 0.9-1.4%;2019: Range 1.1-1.6%). HIV VL testing also declined in 2020 similar to the trend of HIV testing with the largest decline (57%) in April 2020. Overall, PrEP visits at the CTS declined more than 31% in the study period;the largest decline (90%) occurred in April 2020 with partial rebound through October 2020. From January to June 2020, 75 new HIV diagnoses were identified, compared with 101 in 2019. Linkage to care within 1 month was 93% in 2020 and 97% in 2019;HIV viral suppression within 6 months was 75% in 2020 and 76% in 2019. Conclusion: We have observed substantial reductions in HIV Ab and VL testing during the COVID-19 pandemic, and likely decreased HIV case finding. PrEP care engagement also declined dramatically;however rapid linkage to care and viral suppression after HIV diagnosis remained robust. Continued monitoring of key HIV prevention and care metrics is essential to assessing the complex impact of COVID-19 on the GTZSF goals, and developing tailored mitigation responses.
ABSTRACT
Due to COVID-19, this year marked the first virtual Conference on Retrovi-ruses and Opportunistic Infections (CROI) in the conference’s 27-year history. There were important studies presented that provided new insights into the prevention, diagnosis, and treatment of tuberculosis (TB) and other HIV coinfections. Highlights related to TB and HIV coinfections from this year’s meeting are reviewed below.