CROI 2016 Abstract eBook

Abstract Listing

Poster Abstracts

1025 ART Coverage and Viral Load in Tanzania: Bukoba Combination Prevention Baseline Study Sarah E. Porter 1 ; Duncan MacKellar 1 ; RachelWeber 2 ; Haruka Maruyama 3 ; Sherri Pals 1 ; Gretchen Antelman 4 ; Oscar Ernest 5 ; Robert Josiah 6 ; Jessica Justman 7 1 CDC, Atlanta, GA, USA; 2 CTS Global, Inc, Assigned to US CDC, Dar es Salaam, Tanzania; 3 ICAP at Columbia Univ, Dar es Salaam, Tanzania; 4 Elizabeth Glaser Pediatric AIDS Fndn, Dar es Salaam, Tanzania; 5 ICAP at Columbia Univ, Bukoba, Tanzania; 6 Natl AIDS Control Prog, Dar es Salaam, Tanzania; 7 ICAP at Columbia Univ, New York, NY, USA Background: The Bukoba Combination Prevention Study is an evaluation of a two-year HIV prevention program in Bukoba Municipality, Kagera Region, Tanzania. A population- based baseline survey took place November 2013-January 2014 prior to program implementation. The program aim is to reduce new HIV infections through improving uptake of HIV testing and counselling (HTC), linkage to HIV care, and anti-retroviral therapy (ART) initiation. Methods: All persons aged 18-49 years residing in 53 randomly selected enumeration areas (EAs) were eligible for the study. Enrolled participants were interviewed about past HIV tests and current HIV status. For those who reported HIV-positive status, interviewers ascertained current ART use by observing a pill bottle or clinical care card. All participants were offered HTC after the interview, and CD4 and viral load (VL) tests were conducted for those who tested HIV-positive. Viral suppression (VS) was defined as VL <1000 c/ml. Wald chi-square tests accounting for EA-level clustering were used to evaluate differences in proportions. All analysis is unweighted. Results: Of the 5,696 household residents who were contacted and eligible, 5,397 (95%) enrolled in the study. HTC was accepted by 4,797 (89%) participants, and 436 (9%) of those tested HIV-positive. Men in the sample had lower HIV prevalence than women (6% vs 11%, p<.001). Among those who tested HIV-positive, 166 (38%) were aware of their diagnosis and 55 (13%) were using ART. A lower proportion of men were aware of their diagnosis (31% vs 41%, p=.052). Among HIV-positive participants, median CD4 was 486 (IQR 326-679) cells/mm 3 and median VL was 22,989 (IQR 120-100,515) c/ml. Among ART non-users, 107 (28%) had CD4 ≤350 cells/mm 3 and were ART-eligible under national guidelines, and 196 (52%) had CD4 ≤500 cells/mm 3 . Among ART users, 52 (95%) had VS. Conclusions: In this population-based survey of a large urban area of Tanzania, HIV prevalence for both sexes was higher than the regional and national prevalence. While a high proportion of ART users had VS, the majority of participants who tested HIV-positive were unware of their diagnosis, and ART usage was uncommon overall. The insufficient ART coverage in this community underscores the need for effective testing and linkage-to-care strategies, including targeted methods to test and link men. The combination prevention program that is underway has the potential to increase the prevalence of VS by improving HIV testing coverage and expanding ART initiation criteria. 1026 Heterogeneity in Local Population Viremia Despite >50% Suppression in East Africa Vivek Jain 1 ; Dathan Byonanebye 2 ;Teri Liegler 1 ; Dalsone Kwarisiima 3 ; Norton Sang 4 ; Edwin Charlebois 1 ; Maya Petersen 5 ; Moses R. Kamya; DianeV. Havlir 1 ; for the SEARCH Collaboration 1 Univ of California San Francisco, San Francisco, CA, USA; 2 Makerere Univ Coll of Hlth Scis, Kampala, Uganda; 3 Makerere Univ-Univ of California San Francisco Rsr Collab, Kampala, Uganda; 4 Kenya Med Rsr Inst, Nairobi, Kenya; 5 Univ of California Berkeley, Berkeley, CA, USA Background: Prior reports estimate 25% of HIV+ populations in Sub-Saharan Africa are virally suppressed. To better understand VL metrics, assess major drivers of transmission in East Africa, and inform global epidemic modeling, we studied individuals and discordant couples and determined 1) % of adults with viral suppression, 2) heterogeneity of communities, 3) local prevalence of viremia in communities (which expresses transmission risk from random contacts), and 4) VL suppression in male-female discordant couples. Methods: In 303,461 persons in 30 Ugandan and Kenyan communities (N~10,000 each; HIV prevalence 10.1%; SEARCH Study:NCT01864683), we determined HIV serostatus in 117,711/132,030 (89%) of stable adult residents. We measured plasma VL (Abbott) in 74% of HIV+ adults and calculated the %with VL that was: 1) undetectable <500 c/mL; 2) low, 500-10,000 c/mL; 3) moderate, 10,001-100,000 c/mL; and 4) high, ≥100,000 c/mL. In communities, we estimated the local prevalence of viremia (% of adults [regardless of HIV status] with detectable VL). Predictors of undetectable VL were evaluated via logistic regression. Male-female couples were self-identified pairs in one household. Results: VL was undetectable in 4,490/8,828 (50.9%) of all adults and in 3,427/4,202 (82%) of adults on ART by self report. VL was low, moderate and high in 14.9%, 21.7%, and 12.5% of adults, respectively. Predictors of undetectable VL included region (W. Uganda: odds ratio (OR) 1.34 [95% CI, 1.14-1.58] and Kenya: OR 1.49 [1.29-1.72] vs. E. Uganda), older age (OR 3.26 [2.55-4.17] for age 30-40 vs. 15-20), female (OR 1.48 [1.34-1.63]), and higher wealth (OR 1.52 [1.32-1.77] for highest vs. lowest quintile). Local population prevalence of viremia was higher in Kenya (range 2.1%-11.2%, median 5.6%) than in Uganda (range 0.5%-5.3%, median 2.3%). Discordancy existed in 492/16,023 (3.1%) of Ugandan and 859/8,616 (10.0%) of Kenyan couples. In 58% of Ugandan and 53% of Kenyan discordant couples, the HIV+ partner was viremic. In 14% and 15%, respectively, the HIV+ partner had VL>100K, indicating marked transmission risk. Conclusions: In this large population VL assessment in Uganda and Kenya, >50% of HIV+ adults had undetectable VL. However, nearly 5-10% of the entire adult population of some Kenyan communities had HIV viremia, and >50% of all Ugandan and Kenyan discordant couples had one partner with viremia. Thus, although half of all HIV+ adults have undetectable VL, there are localized groups with high potential transmission risk. 1027 High Rate of Viral Suppression in Late Mortality on First-Line ART in Uganda/Zimbabwe David I. Dolling 1 ; Pontiano Kaleebu 2 ; Peter Nkurunziza 2 ; Moira Spyer 1 ; Charles Gilks 3 ; Deenan Pillay 4 ; Ruth Goodall 1 ; for the DARTVirology Group 1 Med Rsr Council Clinical Trials Unit at Univ Coll London, London, UK; 2 Med Rsr Council/Uganda Virus Rsr Inst Uganda Rsr Unit on AIDS, Entebbe, Uganda; 3 Sch of Pop Hlth, Univ of Queensland, Herston, Australia; 4 Africa Cntr for Hlth and Pop Studies, Mtubatuba, South Africa Background: Early mortality (<48 wks) after ART initiation in resource-limited settings is well recognised, but less well understood are the causes of later mortality, which are widely assumed to be due to virological failure (VF) or non-adherence. We investigated HIV viral load (VL) in patients who died after 48 weeks of continuous first-line ART in the DART study. Methods: The DART trial randomised 3,316 Ugandan and Zimbabwean patients to laboratory monitoring (LCM; CD4 cell count every 12 weeks) or clinically driven monitoring (CDM). Prospective VL testing was not undertaken. Previous analyses found that low pre-ART CD4 cell count was strongly associated with higher mortality during the first year of ART, which was predominantly from infectious causes. All late mortalities had stored plasma samples from the closest visit to the date of death retrospectively tested for VL. Logistic regression models were used to determine predictors of mortality with virological suppression (VS) status (VL<200 copies/mL) in patients who died. Fractional polynomials were used for continuous variables, but non-linear risk was not found. Results: 210/382 (55%) deaths during the DART study occurred after week 48; 112 were on continuous first-line and 78 on second-line ART. The late mortality rate was low (10.7/1,000 PY). VL data were available for 105/112 (94%) mortalities at a median (IQR) of 10 (6-14) weeks before death. 43/105 (41%) patients were virologically suppressed (VS) at the time of death. VF deaths were more often due to opportunistic infections (26% vs 12%;p=0.09). CD4 cell count was significantly lower at the time of death in patients with VF than VS (Median: 62 vs 238 cells/mm 3 ; p<0.001) and a greater proportion had CD4<100 cells/mm 3 (66% vs 19%). In multivariate logistic regression analyses (Table), patients in the CDM arm had reduced odds of 0.28 (95% CI: 0.11 – 0.68) death with VS, with no evidence of a change over time. The odds of death with VS were almost 4 times higher for each additional 100 cells/mm 3 increase in baseline CD4 count. Gender, age, initial ART regimen, CD4 cell count at week 48, baseline VL and opportunistic infections were not associated with VS at death in multivariate analyses. Conclusions: 40% of late deaths on ART occurred without VL criteria for treatment switch being fulfilled. There were significantly more deaths with VS among patients who received CD4 cell count monitoring. Further research is required to elucidate the cause of deaths in those without VF.

Poster Abstracts

438

CROI 2016