CROI 2017 Abstract e-Book

Abstract eBook

Poster and Themed Discussion Abstracts

1 The Johns Hopkins Univ Sch of Med, Baltimore, MD, USA, 2 Fred Hutchinson Cancer Rsr Cntr, Seattle, WA, USA, 3 YRG CARE, Chennai, India, 4 Univ of Zimbabwe, Harare, Zimbabwe, 5 Inst de Pesquisa Clinica Evandro Chagas, Rio de Janeiro, Brazil, 6 Univ of North Carolina at Chapel Hill, Chapel Hill, NC, USA Background: In May 2011, an interim analysis of the HIV Prevention Trials Network (HPTN) 052 trial showed that early initiation of antiretroviral therapy (ART) prevented 96% of genetically-linked HIV infections in serodiscordant couples. ART was then offered to all index participants and the trial continued until May 2015. This report describes virologic outcomes in index participants who initiated ART in HPTN 052. Methods: Virologic outcomes were evaluated in three study groups: (1) early ART arm (ART initiation at enrollment, CD4 350-550 cells/mm3), (2) delayed ART armwith ART initiation before May 2011 (ART initiation at CD4 <250 cells/mm3 or with an AIDS-defining illness), and (3) delayed ART armwith ART initiation after May 2011 (with ART initiation at any CD4 cell count). Viral suppression was defined as two consecutive viral loads ≤400 copies/mL. Virologic failure was defined as two consecutive viral loads >1,000 copies/mL >24 weeks after ART initiation. Results: There was no significant difference in virologic outcomes in the three study groups (early ART arm [N=832]; delayed ART arm before May 2011 [N=204]; delayed ART arm after May 2011 [N=530]). Longer time to viral suppression was associated with higher baseline (pre-ART) viral load (p<0.0001), age (<25 years; compared to 25-39 years, p=0.0006, compared to ≥40 years, p=0.0002), and region (Africa; compared to Asia, p=0.005). Virologic failure was associated with higher baseline CD4 cell count (p=0.02), lack of viral suppression by 6 months (p<0.0001), age (<25 years; compared to ≥40 years, p=0.0005), region (Americas; compared to Africa, p=0.001), and education (none; compared to primary or secondary-schooling, p=0.004 and compared to post-secondary schooling, p=0.002). Conclusion: Higher baseline CD4 cell count and higher baseline viral load were associated with worse virologic outcomes. Demographic factors such as age, region, and education were also associated with time to viral suppression and ART failure. In this study, awareness of the interim findings of the trial (personal health benefits and lower risk of HIV transmission with early ART initiation) did not improve virologic outcomes in those who initiated ART at higher CD4 cell counts. Additional resources may be needed to optimize treatment outcomes, especially among younger individuals and those who start ART at higher CD4 cell counts. 1003 USERS MAY LACK CONFIDENCE IN ART FOR HIV PREVENTION: A QUALITATIVE ANALYSIS Monique A. Wyatt 1 , Emily E Pisarski 1 , Jared Baeten 2 , Renee Heffron 2 , Edith Nakku-Joloba 3 , Timothy R. Muwonge 4 , Elly T Katabira 3 , Connie L. Celum 2 , Norma C. Ware 1 1 Harvard Univ, Boston, MA, USA, 2 Univ of Washington, Seattle, WA, USA, 3 Makerere Univ, Kampala, Uganda, 4 Infectious Diseases Inst, Kampala, Uganda Background: Antiretroviral-based approaches to HIV prevention have been shown to reduce new infections in both clinical trials and demonstration settings. To achieve optimal uptake of these strategies and anticipate barriers to effective rollout, it is critical to understand users’ perspectives on the use of antiretroviral treatment (ART) for prevention of HIV transmission. We explored serodiscordant couples’ understandings of and feelings about treatment as prevention (TasP) using qualitative data from the Partners Demonstration Project (PDP). Methods: The PDP employed an integrated delivery strategy of daily oral pre-exposure prophylaxis (PrEP) and ART for serodiscordant couples in Kenya and Uganda. PrEP use was time-limited and discontinued after HIV-infected partners had been on ART for 6 months. Multiple in-depth interviews were conducted with a subset of 48 couples from the Kampala, Uganda site (N interviews=189). Interview topics included: (a) purpose and meanings of PrEP and ART; (b) adherence; (c) experiences of PrEP discontinuation; and (d) understandings of TasP. Interviews were inductively analyzed to identify themes representing couples’ understandings of and feelings about using ART for prevention of HIV transmission. Categories were developed to represent the themes. Results: Serodiscordant couples generally understood that ART prevents HIV transmission to uninfected partners. However, some individuals doubted that ART alone was “enough” to protect against HIV acquisition. Lack of confidence in ART for prevention took the following forms: (1) Concerns about the effectiveness of ART for prevention in the absence of other methods of protection (i.e., PrEP, condoms); (2) Misunderstandings about how viral suppression and sustained ART use lead to a reduction in infectiousness and HIV risk; (3) Uncertainty about partners’ adherence to ART stemming from distrust in the relationship; and (4) A preference for multiple methods of protection used simultaneously. Conclusion: Our findings suggest a lack of confidence in TasP among serodiscordant couples arising from unfamiliarity with new biomedical prevention strategies and reluctance to rely on partners for HIV prevention. Improved messaging about how ART works to achieve viral suppression and reduce transmission, along with supportive counseling, may address underlying concerns about HIV risk, helping to alleviate fears and increase trust in ART to prevent HIV. 1004 UPTAKE AND ADAPTATION OF COMMUNITY ADHERENCE GROUPS IN ZAMBIA Monika Roy 1 , Mpande Mukumbwa-Mwenechanya 2 , Emilie Efronson 2 , Mwansa Lumpa 2 , Anjali Sharma 2 , Izukanji Sikazwe 2 , Nancy Padian 3 , Carolyn Bolton Moore 4 , Elvin Geng 1 , Charles Holmes 5 1 Univ of California San Francisco, San Francisco, CA, USA, 2 Cntr for Infectious Disease Rsr in Zambia, Lusaka, Zambia, 3 Univ of California Berkeley, Berkeley, CA, USA, 4 Cntr for Infectious Disease Rsr in Zambia, Lusaka, Zambia, 5 Johns Hopkins Univ, Baltimore, MD, USA Background: The community adherence group (CAG) is a community-based HIV treatment model promoted to improve long-term retention in care. It combines clinical visit spacing, group drug-pick up and distribution in the community, and peer social support to reduce the high opportunity costs of clinic visits and promote patient self-management. Although existing data suggest that retention is higher in CAGs compared to facility-based care, the overall public health impact of CAGs depends on the fraction of eligible patients who take up the model. Methods: We evaluated uptake and adaptation of CAGs in an ongoing cluster randomized trial of the CAG model using an implementation cascade for individuals offered CAGs. A systematic sample of eligible patients (HIV+, on ART > 6 months, not acutely ill, CD4 >=200/µl) were offered CAG participation between May 19, and July 31, 2016 at five primary care facilities in three provinces in Zambia. We recorded number of persons that were a) offered CAG group membership, b) accepted membership, c) successfully placed into a CAG group d) retained during assembly e) attended first CAG group meeting. Reasons for not accepting a CAG and number, mechanism, and sustainability of CAG group formation were documented. We characterized adaptation by documenting changes to intended group size (n=6) and drug-pick up frequency. Results: Among 603 individuals, 543(90%) accepted, 495(82%) were placed into a CAG, 479(79%) were retained during assembly, and 478(79%) attended their first CAG group meeting. CAG acceptance varied by site (range:80-97%, median:92%) as did the proportion of those placed into CAGs among those who accepted (range:79-100%, median:91%). The primary documented reasons for not accepting a CAG included fear of HIV status disclosure in the community and concern over needing to find members to join their group. Of those who accepted CAG participation, 170(31%) were male, median age was 45 years [IQR:39-52], and median time on ART was 5.5 years [IQR:2.9-7.9]. Of 84 CAG groups formed, 74(88%) formed autonomously, 29(35%) adapted group size, and 82(98%) were sustained until the first meeting. Frequency of drug-pickup was adapted at one site frommonthly to bimonthly. Conclusion: Results of our evaluation document overall high, but heterogeneous uptake of the CAG intervention. Further evaluation of site-specific challenges with patient acceptance of the CAG model and CAG group formation are needed in order to optimize the public health benefit of this model at scale. 1005 ASSESSING RETENTION IN A CLUSTER RANDOMIZED TRAIL TO ACCELERATE ART INITIATION Richard Katuramu 1 , Fred Semitala 2 , Gideon Amanyire 1 , Jennifer Namusobya 1 , Leatitia Kampiire 1 , Jeanna Wallenta 3 , David Glidden 3 , Moses R. Kamya 2 , Diane V. Havlir 3 , Elvin Geng 3 1 Makerere Univ Joint AIDS Prog, Kampala, Uganda, 2 Makerere Univ Coll of Hlth Scis, Kampala, Uganda, 3 Univ of California San Francisco, San Francisco, CA, USA Background: Antiretroviral therapy (ART) initiation among treatment eligible HIV patients in Africa who have presented for clinical care is often delayed, but concerns exists that accelerating initiation – especially to the same day as ART eligibility – may compromise retention. We previously reported a cluster randomized trial in Uganda showing an increase in the ART initiation on the same day of eligibility from 18% to 71% after introduction of coaching, point of care technology and a reputational incentive. We now report the effect of same day ART initiation on retention using randomized intervention as an instrumental variable.

Poster and Themed Discussion Abstracts

CROI 2017 433