Conference Material > Abstract
Aung A, Mamba C, Ntshalintshali N, Mpala Q, Mthethwa-Hleza S, et al.
MSF Scientific Days International 2020: Research. 2020 May 26
INTRODUCTION
Acute HIV infection (AHI) cannot be detected with routine point-of-care antibody tests and is rarely diagnosed in resource-limited settings. However, characteristics of AHI, including its non-specific clinical presentation accompanied by high levels of plasma viraemia, may contribute to uncontrolled onward transmission within high-prevalence settings. Improving early detection of AHI in such settings could conceivably contribute to reducing onward transmission and thus impact on HIV elimination goals. We aimed to assess the programmatic feasibility of identifying and treating AHI patients in Eswatini, which has already achieved 90-90-90 targets.
METHODS
From March to December 2019, adults aged 16-49 years and attending outpatient departments at Nhlangano Health Center were screened for symptoms suggestive of AHI, including fever, sore throat, and current symptoms of a sexually transmitted infection. Individuals were enrolled into the study on testing negative or inconclusive for HIV using serial rapid diagnostic tests (RDT) Alere Determine™ HIV-1/2 (Abbott, USA) and Uni-Gold™ HIV (Trinity Biotech, Ireland), and on referral from HIV pre- and post-exposure prophylaxis programmes, if AHI was suspected. AHI was diagnosed using the Xpert platform (Cepheid, Sunnyvale, USA) to perform quantitative HIV RNA detection. Patients with AHI were offered immediate initiation of antiretroviral therapy (ART), follow-up care, and assisted partner notification.
ETHICS
This study was approved by the National Health Research and Review Board, Eswatini, and the MSF Ethics Review Board.
RESULTS
Of 2177 patients initially screened, 997 (46%) had symptoms suggestive of AHI. Of those, 611 (61%) patients were enrolled and tested with Xpert to assay HIV RNA viral load; this included n=586 because their HIV RDT test was negative; n=12 because HIV RDT was inconclusive; and seven and six were presumptive AHI cases identified in the pre- and post-exposure prophylaxis programmes respectively. Of those enrolled, 26 (4.3%) had a detectable HIV viral load. Median viral load was 4.70 log10 (interquartile range (IQR), 3.70-5.96). The most common complaints of those with AHI were fever, sore throat, headache, genital discharge and lower abdominal pain. 16 (62%) patients initiated ART. After two weeks, eight of 11 patients who were followed up had a suppressed viral load below 1000 copies/ml, and by three months, all patients who were on treatment achieved virological suppression. CD4 count was scheduled at every visit and among those with available test results, the median CD4 count was 476 cells/mm3 (IQR 305-768, n=16) at ART initiation, 522 cells/mm3 (IQR 426-713, n=eight) at one month, and 406 cells/mm3 (IQR 400-452, n=five) at three months. Only 11 partners were notified through the index patient; nine of them were HIV-negative and offered prevention methods, and two were HIV-positive.
CONCLUSION
Identifying and treating AHI in a routine outpatient setting can contribute to linkage with prompt HIV diagnosis and treatment. Conceivably, this could help contribute towards epidemic control in high HIV incidence settings. However, contact tracing and rapid linkage to care are vital challenges that need to be addressed.
CONFLICTS OF INTEREST
None declared.
Acute HIV infection (AHI) cannot be detected with routine point-of-care antibody tests and is rarely diagnosed in resource-limited settings. However, characteristics of AHI, including its non-specific clinical presentation accompanied by high levels of plasma viraemia, may contribute to uncontrolled onward transmission within high-prevalence settings. Improving early detection of AHI in such settings could conceivably contribute to reducing onward transmission and thus impact on HIV elimination goals. We aimed to assess the programmatic feasibility of identifying and treating AHI patients in Eswatini, which has already achieved 90-90-90 targets.
METHODS
From March to December 2019, adults aged 16-49 years and attending outpatient departments at Nhlangano Health Center were screened for symptoms suggestive of AHI, including fever, sore throat, and current symptoms of a sexually transmitted infection. Individuals were enrolled into the study on testing negative or inconclusive for HIV using serial rapid diagnostic tests (RDT) Alere Determine™ HIV-1/2 (Abbott, USA) and Uni-Gold™ HIV (Trinity Biotech, Ireland), and on referral from HIV pre- and post-exposure prophylaxis programmes, if AHI was suspected. AHI was diagnosed using the Xpert platform (Cepheid, Sunnyvale, USA) to perform quantitative HIV RNA detection. Patients with AHI were offered immediate initiation of antiretroviral therapy (ART), follow-up care, and assisted partner notification.
ETHICS
This study was approved by the National Health Research and Review Board, Eswatini, and the MSF Ethics Review Board.
RESULTS
Of 2177 patients initially screened, 997 (46%) had symptoms suggestive of AHI. Of those, 611 (61%) patients were enrolled and tested with Xpert to assay HIV RNA viral load; this included n=586 because their HIV RDT test was negative; n=12 because HIV RDT was inconclusive; and seven and six were presumptive AHI cases identified in the pre- and post-exposure prophylaxis programmes respectively. Of those enrolled, 26 (4.3%) had a detectable HIV viral load. Median viral load was 4.70 log10 (interquartile range (IQR), 3.70-5.96). The most common complaints of those with AHI were fever, sore throat, headache, genital discharge and lower abdominal pain. 16 (62%) patients initiated ART. After two weeks, eight of 11 patients who were followed up had a suppressed viral load below 1000 copies/ml, and by three months, all patients who were on treatment achieved virological suppression. CD4 count was scheduled at every visit and among those with available test results, the median CD4 count was 476 cells/mm3 (IQR 305-768, n=16) at ART initiation, 522 cells/mm3 (IQR 426-713, n=eight) at one month, and 406 cells/mm3 (IQR 400-452, n=five) at three months. Only 11 partners were notified through the index patient; nine of them were HIV-negative and offered prevention methods, and two were HIV-positive.
CONCLUSION
Identifying and treating AHI in a routine outpatient setting can contribute to linkage with prompt HIV diagnosis and treatment. Conceivably, this could help contribute towards epidemic control in high HIV incidence settings. However, contact tracing and rapid linkage to care are vital challenges that need to be addressed.
CONFLICTS OF INTEREST
None declared.
Conference Material > Abstract
Aung A, Daka M, Tamrat A, Gwitima T, Chidhuro T, et al.
MSF Scientific Days International 2021: Innovation. 2021 May 20
WHAT CHALLENGE OR OPPORTUNITY DID YOU TRY TO ADDRESS? WERE EXISTING SOLUTIONS NOT AVAILABLE OR NOT GOOD ENOUGH?
The COVID-19 pandemic has prompted lockdown measures in many places, but patients continued to travel for essential health services. Since COVID-19 has potentially adverse health outcomes among patients with drug-resistant tuberculosis (DR-TB), innovative strategies for medication adherence that minimise travel and the chance of exposure are needed.
WHY DOES THIS CHALLENGE OR OPPORTUNITY MATTER – WHY SHOULD MSF ADDRESS IT?
Historically, directly observed therapy (DOT) has been provided in health facilities, requiring patient travel, or by community treatment supporters (CTS), who travel to patients. The World Health Organisation (WHO) recommends the use of digital methods to support treatment adherence. In response to the COVID-19 pandemic and in collaboration with the National Tuberculosis Control Program (NTCP), we implemented video/virtually observed therapy (VOT) in Shiselweni, Eswatini in May 2020. This allowed the daily observation of patients taking their medication to be done using video messages rather than in-person.
DESCRIBE YOUR INNOVATION AND WHAT MAKES IT INNOVATIVE
The aim of VOT is to support patients with drug adherence using a secured smartphone application. Patients were provided with a sim-implanted, application-installed smartphone with monthly internet subscription and shown how to take and share videos. Nurses reviewed the videos through a web-based dashboard, assessed adherence, and provided feedback. Videos could not be recovered from the smartphone and were retained for a maximum of 45 days on the server.
WHO WILL BENEFIT (WHOSE LIFE / WORK WILL IT IMPROVE?) AND WERE THEY INVOLVED IN THE DESIGN?
Patients who were eligible for VOT (living in network coverage area, smartphone literate, and consented to share videos of themselves) were registered on the web-based platform, which generated login details for the application called SureAdhere©. Those that did not meet the eligibility criteria continued with DOT, provided by community treatment supporters or family treatment supporters.
WHAT OBJECTIVES DID YOU SET FOR THE PROJECT – WHAT DID YOU WANT TO ACHIEVE AND HOW DID YOU DEFINE AND MEASURE SUCCESS (IMPROVED SERVICE, LOWER COST, BETTER EFFICIENCY, BETTER USER EXPERIENCE, ETC.)?
We reviewed patient adherence every month and followed the user experience to understand future scale up. Medical teams and patients also benefitted from instant communication using the application.
WHAT DATA DID YOU COLLECT TO MEASURE THE INNOVATION AGAINST THESE INDICATORS AND HOW DID YOU COLLECT IT? INCLUDE IF YOU DECIDED TO CHANGE THE INDICATORS AND WHY.
The number of patients using VOT for adherence support was collected routinely in the monthly TB register. Individual adherence levels were shown in adherence calendars on the web-based dashboard and nurses produced monthly adherence levels for the VOT cohort.
HOW DID YOU ANALYSE THIS DATA TO UNDERSTAND TO WHAT EXTENT THE INNOVATION ACHIEVED ITS OBJECTIVES? DID THIS INCLUDE A COMPARISON TO THE STATUS QUO OR AN EXISTING SOLUTION?
We retrospectively analysed data to assess VOT uptake among the total DR-TB treatment cohort. Adherence was classified into levels: excellent (100%), good (>90%), or moderate (<90%).
WERE THERE ANY LIMITATIONS TO THE DATA YOU COLLECTED, HOW YOU COLLECTED IT OR HOW YOU ANALYSED IT, OR WERE THERE ANY UNFORESEEN FACTORS THAT MAY HAVE INTERFERED WITH YOUR RESULTS?
We were unable to compare our results with the adherence levels of patients using conventional DOT since routine DOT data was not collected electronically. Some delays in video transmission were experienced due to connectivity issues.
WHAT RESULTS DID YOU GET?
In May 2020, 18 (43%) of 42 patients fulfilled the eligibility criteria and started VOT, increasing to 25 (61%) of 41 patients in November 2020. Two patients using VOT completed treatment with successful outcomes. An adherence level of perfect was observed in all patients undergoing VOT during May and June 2020. Adherence decreased monthly until October 2020 at which 20 (77%) of 26 patients had excellent adherence, four (15%) had good adherence, and two (8%) had moderate adherence. In November 2020, 20 (80%) of 25 patients had perfect adherence and five (20%) had good adherence.
COMPARING THE RESULTS FROM YOUR DATA ANALYSIS TO YOUR OBJECTIVES, EXPLAIN WHY YOU CONSIDER YOUR INNOVATION A SUCCESS OR FAILURE?
We were able to provide adherence support despite the pandemic outbreak. Although average adherence levels did not remain excellent for all patients, the majority of patients achieved favourable adherence, and we were able to quantify adherence using this method.
TO WHAT EXTENT DID THE INNOVATION BENEFIT PEOPLE’S LIVES / WORK?
We implemented VOT relatively swiftly after lockdown measures began in Eswatini, thereby providing timely adherence support to patients with DR-TB.
WHAT ARE THE NEXT STEPS FOR THE INNOVATION ITSELF (SCALE UP, IMPLEMENTATION, FURTHER DEVELOPMENT, DISCONTINUED)?
Uptake of VOT among patients with DR-TB was improving although maintaining perfect adherence was difficult. VOT will be included as an adherence support method for all eligible patients in upcoming research on oral short-course treatment for DR-TB.
IS THE INNOVATION TRANSFERABLE OR ADAPTABLE TO OTHER SETTINGS OR DOMAINS?
The application is straightforward, and the dashboard can be used to easily identify adherence problems to allow for prompt patient support. It gives a clear overview of adherence levels and has enabled direct communication between the patients and healthcare workers.
WHAT BROADER IMPLICATIONS ARE THERE FROM THE INNOVATION FOR MSF AND / OR OTHERS (CHANGE IN PRACTICE, CHANGE IN POLICY, CHANGE IN GUIDELINES, PARADIGM SHIFT)?
In this context, VOT was used to minimise the possibility of physical exposure to SARS-CoV-2 and to overcome COVID-19 travel restrictions. However, the NTCP are interested in using VOT as the standard of care adherence monitoring method for eligible patients in DR-TB programmes.
WHAT OTHER LEARNINGS FROM YOUR WORK ARE IMPORTANT TO SHARE?
VOT was well-received by patients and healthcare workers, although a proportion of patients still preferred in-person DOT. Controlling monthly internet usage and restricting the use of other smartphone applications were required. Data protection advice was sought at headquarters level. Access to the VOT application is password-protected and we are confident that privacy and confidentiality have been respected according to ethics guidelines.
ETHICS
This description and evaluation of an innovation project fulfilled the exemption criteria set by the MSF Ethics Review Board. It was conducted with permission from Monica Rull, Medical Director, Operational Centre Geneva, MSF
The COVID-19 pandemic has prompted lockdown measures in many places, but patients continued to travel for essential health services. Since COVID-19 has potentially adverse health outcomes among patients with drug-resistant tuberculosis (DR-TB), innovative strategies for medication adherence that minimise travel and the chance of exposure are needed.
WHY DOES THIS CHALLENGE OR OPPORTUNITY MATTER – WHY SHOULD MSF ADDRESS IT?
Historically, directly observed therapy (DOT) has been provided in health facilities, requiring patient travel, or by community treatment supporters (CTS), who travel to patients. The World Health Organisation (WHO) recommends the use of digital methods to support treatment adherence. In response to the COVID-19 pandemic and in collaboration with the National Tuberculosis Control Program (NTCP), we implemented video/virtually observed therapy (VOT) in Shiselweni, Eswatini in May 2020. This allowed the daily observation of patients taking their medication to be done using video messages rather than in-person.
DESCRIBE YOUR INNOVATION AND WHAT MAKES IT INNOVATIVE
The aim of VOT is to support patients with drug adherence using a secured smartphone application. Patients were provided with a sim-implanted, application-installed smartphone with monthly internet subscription and shown how to take and share videos. Nurses reviewed the videos through a web-based dashboard, assessed adherence, and provided feedback. Videos could not be recovered from the smartphone and were retained for a maximum of 45 days on the server.
WHO WILL BENEFIT (WHOSE LIFE / WORK WILL IT IMPROVE?) AND WERE THEY INVOLVED IN THE DESIGN?
Patients who were eligible for VOT (living in network coverage area, smartphone literate, and consented to share videos of themselves) were registered on the web-based platform, which generated login details for the application called SureAdhere©. Those that did not meet the eligibility criteria continued with DOT, provided by community treatment supporters or family treatment supporters.
WHAT OBJECTIVES DID YOU SET FOR THE PROJECT – WHAT DID YOU WANT TO ACHIEVE AND HOW DID YOU DEFINE AND MEASURE SUCCESS (IMPROVED SERVICE, LOWER COST, BETTER EFFICIENCY, BETTER USER EXPERIENCE, ETC.)?
We reviewed patient adherence every month and followed the user experience to understand future scale up. Medical teams and patients also benefitted from instant communication using the application.
WHAT DATA DID YOU COLLECT TO MEASURE THE INNOVATION AGAINST THESE INDICATORS AND HOW DID YOU COLLECT IT? INCLUDE IF YOU DECIDED TO CHANGE THE INDICATORS AND WHY.
The number of patients using VOT for adherence support was collected routinely in the monthly TB register. Individual adherence levels were shown in adherence calendars on the web-based dashboard and nurses produced monthly adherence levels for the VOT cohort.
HOW DID YOU ANALYSE THIS DATA TO UNDERSTAND TO WHAT EXTENT THE INNOVATION ACHIEVED ITS OBJECTIVES? DID THIS INCLUDE A COMPARISON TO THE STATUS QUO OR AN EXISTING SOLUTION?
We retrospectively analysed data to assess VOT uptake among the total DR-TB treatment cohort. Adherence was classified into levels: excellent (100%), good (>90%), or moderate (<90%).
WERE THERE ANY LIMITATIONS TO THE DATA YOU COLLECTED, HOW YOU COLLECTED IT OR HOW YOU ANALYSED IT, OR WERE THERE ANY UNFORESEEN FACTORS THAT MAY HAVE INTERFERED WITH YOUR RESULTS?
We were unable to compare our results with the adherence levels of patients using conventional DOT since routine DOT data was not collected electronically. Some delays in video transmission were experienced due to connectivity issues.
WHAT RESULTS DID YOU GET?
In May 2020, 18 (43%) of 42 patients fulfilled the eligibility criteria and started VOT, increasing to 25 (61%) of 41 patients in November 2020. Two patients using VOT completed treatment with successful outcomes. An adherence level of perfect was observed in all patients undergoing VOT during May and June 2020. Adherence decreased monthly until October 2020 at which 20 (77%) of 26 patients had excellent adherence, four (15%) had good adherence, and two (8%) had moderate adherence. In November 2020, 20 (80%) of 25 patients had perfect adherence and five (20%) had good adherence.
COMPARING THE RESULTS FROM YOUR DATA ANALYSIS TO YOUR OBJECTIVES, EXPLAIN WHY YOU CONSIDER YOUR INNOVATION A SUCCESS OR FAILURE?
We were able to provide adherence support despite the pandemic outbreak. Although average adherence levels did not remain excellent for all patients, the majority of patients achieved favourable adherence, and we were able to quantify adherence using this method.
TO WHAT EXTENT DID THE INNOVATION BENEFIT PEOPLE’S LIVES / WORK?
We implemented VOT relatively swiftly after lockdown measures began in Eswatini, thereby providing timely adherence support to patients with DR-TB.
WHAT ARE THE NEXT STEPS FOR THE INNOVATION ITSELF (SCALE UP, IMPLEMENTATION, FURTHER DEVELOPMENT, DISCONTINUED)?
Uptake of VOT among patients with DR-TB was improving although maintaining perfect adherence was difficult. VOT will be included as an adherence support method for all eligible patients in upcoming research on oral short-course treatment for DR-TB.
IS THE INNOVATION TRANSFERABLE OR ADAPTABLE TO OTHER SETTINGS OR DOMAINS?
The application is straightforward, and the dashboard can be used to easily identify adherence problems to allow for prompt patient support. It gives a clear overview of adherence levels and has enabled direct communication between the patients and healthcare workers.
WHAT BROADER IMPLICATIONS ARE THERE FROM THE INNOVATION FOR MSF AND / OR OTHERS (CHANGE IN PRACTICE, CHANGE IN POLICY, CHANGE IN GUIDELINES, PARADIGM SHIFT)?
In this context, VOT was used to minimise the possibility of physical exposure to SARS-CoV-2 and to overcome COVID-19 travel restrictions. However, the NTCP are interested in using VOT as the standard of care adherence monitoring method for eligible patients in DR-TB programmes.
WHAT OTHER LEARNINGS FROM YOUR WORK ARE IMPORTANT TO SHARE?
VOT was well-received by patients and healthcare workers, although a proportion of patients still preferred in-person DOT. Controlling monthly internet usage and restricting the use of other smartphone applications were required. Data protection advice was sought at headquarters level. Access to the VOT application is password-protected and we are confident that privacy and confidentiality have been respected according to ethics guidelines.
ETHICS
This description and evaluation of an innovation project fulfilled the exemption criteria set by the MSF Ethics Review Board. It was conducted with permission from Monica Rull, Medical Director, Operational Centre Geneva, MSF
Journal Article > ResearchFull Text
Trop Med Int Health. 2019 October 1; Volume 24 (Issue 10); 1243-1258.; DOI:10.1111/tmi.13299
Kerschberger B, Telnov A, Yano N, Cox HS, Zabsonre I, et al.
Trop Med Int Health. 2019 October 1; Volume 24 (Issue 10); 1243-1258.; DOI:10.1111/tmi.13299
OBJECTIVES
Provision of drug-resistant tuberculosis (DR-TB) treatment is scarce in resource-limited settings. We assessed the feasibility of ambulatory DR-TB care for treatment expansion in rural Eswatini.
METHODS
Retrospective patient-level data were used to evaluate ambulatory DR-TB treatment provision in rural Shiselweni (Eswatini), from 2008 to 2016. DR-TB care was either clinic-based led by nurses or community-based at the patient's home with involvement of community treatment supporters for provision of treatment to patients with difficulties in accessing facilities. We describe programmatic outcomes and used multivariate flexible parametric survival models to assess time to adverse outcomes. Both care models were costed in supplementary analyses.
RESULTS
Of 698 patients initiated on DR-TB treatment, 57% were women and 84% were HIV-positive. Treatment initiations increased from 27 in 2008 to 127 in 2011 and decreased thereafter to 51 in 2016. Proportionally, community-based care increased from 19% in 2009 to 77% in 2016. Treatment success was higher for community-based care (79%) than clinic-based care (68%, P = 0.002). After adjustment for covariate factors among adults (n = 552), the risk of adverse outcomes (death, loss to follow-up, treatment failure) in community-based care was reduced by 41% (adjusted hazard ratio 0.59, 95% CI: 0.39-0.91). Findings were supported by sensitivity analyses. The care provider's per-patient costs for community-based (USD13 345) and clinic-based (USD12 990) care were similar.
CONCLUSIONS
Ambulatory treatment outcomes were good, and community-based care achieved better treatment outcomes than clinic-based care at comparable costs. Contextualised DR-TB care programmes are feasible and can support treatment expansion in rural settings.
Provision of drug-resistant tuberculosis (DR-TB) treatment is scarce in resource-limited settings. We assessed the feasibility of ambulatory DR-TB care for treatment expansion in rural Eswatini.
METHODS
Retrospective patient-level data were used to evaluate ambulatory DR-TB treatment provision in rural Shiselweni (Eswatini), from 2008 to 2016. DR-TB care was either clinic-based led by nurses or community-based at the patient's home with involvement of community treatment supporters for provision of treatment to patients with difficulties in accessing facilities. We describe programmatic outcomes and used multivariate flexible parametric survival models to assess time to adverse outcomes. Both care models were costed in supplementary analyses.
RESULTS
Of 698 patients initiated on DR-TB treatment, 57% were women and 84% were HIV-positive. Treatment initiations increased from 27 in 2008 to 127 in 2011 and decreased thereafter to 51 in 2016. Proportionally, community-based care increased from 19% in 2009 to 77% in 2016. Treatment success was higher for community-based care (79%) than clinic-based care (68%, P = 0.002). After adjustment for covariate factors among adults (n = 552), the risk of adverse outcomes (death, loss to follow-up, treatment failure) in community-based care was reduced by 41% (adjusted hazard ratio 0.59, 95% CI: 0.39-0.91). Findings were supported by sensitivity analyses. The care provider's per-patient costs for community-based (USD13 345) and clinic-based (USD12 990) care were similar.
CONCLUSIONS
Ambulatory treatment outcomes were good, and community-based care achieved better treatment outcomes than clinic-based care at comparable costs. Contextualised DR-TB care programmes are feasible and can support treatment expansion in rural settings.
Journal Article > ResearchFull Text
J Acquir Immune Defic Syndr; JAIDS. 2021 December 15; Volume 88 (Issue 5); 506-517.; DOI:10.1097/QAI.0000000000002794
Kerschberger B, Aung A, Mpala Q, Ntshalintshali N, Mamba C, et al.
J Acquir Immune Defic Syndr; JAIDS. 2021 December 15; Volume 88 (Issue 5); 506-517.; DOI:10.1097/QAI.0000000000002794
BACKGROUND
The lack of acute and early HIV infection (AEHI) diagnosis and care contributes to high HIV incidence in resource-limited settings. We aimed to assess the yield, predict and diagnose AEHI, and describe AEHI care outcomes in a public sector setting in Eswatini.
SETTING
This study was conducted in Nhlangano outpatient department, from March 2019 to March 2020.
METHODS
Adults at risk of AEHI underwent diagnostic testing for AEHI with the quantitative Xpert HIV-1 viral load (VL) assay. AEHI was defined as the detection of HIV-1 VL on Xpert and either a HIV-seronegative/HIV-serodiscordant third-generation antibody-based rapid-diagnostic test (RDT) result. First, the cross-sectional analysis obtained the yield of AEHI and established a predictor risk score (PRS) for the prediction of AEHI using Lasso logistic regression. Second, diagnostic accuracy statistics described the ability of the fourth-generation antibody/p24 antigen-based Alere™HIV-Combo RDT to diagnose AEHI (vs Xpert VL testing). Third, we described AHI care outcomes of AEHI-positive patients using survival analysis.
RESULTS
Of 795 HIV-seronegative/HIV-serodiscordant outpatients recruited, 30 (3.8%, 95%CI 2.6-5.3%) had AEHI. The PRS contained several factors (HIV-serodiscordant RDT, women, feeling at risk of HIV, swollen glands, fatigue) and had a sensitivity and specificity of 83.3% and 65.8% to predict AEHI. The HIV-Combo RDT had a sensitivity and specificity of 86.2% and 99.9% to diagnose AEHI. Of 30 AEHI-positive patients, the 1-month cumulative treatment initiation was 74% (95%CI 57-88%), and the 3-month viral suppression (<1000 copies/mL) was 87% (67-98%).
CONCLUSION
AEHI diagnosis and care appears possible in resource-limited settings.
The lack of acute and early HIV infection (AEHI) diagnosis and care contributes to high HIV incidence in resource-limited settings. We aimed to assess the yield, predict and diagnose AEHI, and describe AEHI care outcomes in a public sector setting in Eswatini.
SETTING
This study was conducted in Nhlangano outpatient department, from March 2019 to March 2020.
METHODS
Adults at risk of AEHI underwent diagnostic testing for AEHI with the quantitative Xpert HIV-1 viral load (VL) assay. AEHI was defined as the detection of HIV-1 VL on Xpert and either a HIV-seronegative/HIV-serodiscordant third-generation antibody-based rapid-diagnostic test (RDT) result. First, the cross-sectional analysis obtained the yield of AEHI and established a predictor risk score (PRS) for the prediction of AEHI using Lasso logistic regression. Second, diagnostic accuracy statistics described the ability of the fourth-generation antibody/p24 antigen-based Alere™HIV-Combo RDT to diagnose AEHI (vs Xpert VL testing). Third, we described AHI care outcomes of AEHI-positive patients using survival analysis.
RESULTS
Of 795 HIV-seronegative/HIV-serodiscordant outpatients recruited, 30 (3.8%, 95%CI 2.6-5.3%) had AEHI. The PRS contained several factors (HIV-serodiscordant RDT, women, feeling at risk of HIV, swollen glands, fatigue) and had a sensitivity and specificity of 83.3% and 65.8% to predict AEHI. The HIV-Combo RDT had a sensitivity and specificity of 86.2% and 99.9% to diagnose AEHI. Of 30 AEHI-positive patients, the 1-month cumulative treatment initiation was 74% (95%CI 57-88%), and the 3-month viral suppression (<1000 copies/mL) was 87% (67-98%).
CONCLUSION
AEHI diagnosis and care appears possible in resource-limited settings.