CROI 2019 Abstract eBook

Abstract eBook

Poster Abstracts

As regimen-sparing becomes less critical, in some settings the operational efficiency of early switching might outweigh the regimen-sparing which results from confirming failure.

University of Calgary, Calgary, AB, Canada Background: Background-The continuum of care (i.e. engagement, retention, treatment, viral suppression) is usually reported using cross-sectional data that often underestimates each stage, especially viral suppression rates. Recently, longitudinal approaches have been developed to address cumulative effects of HIV viral burden, however, these measures may further underestimate viral burden if ‘churn’ (the movements in/out of a population) are not taken into consideration. We examined the impact of churn on cumulative HIV viral burden over a 2 year period in a population under care. Methods: Methods-All HIV+ patients followed at the Southern Alberta clinic in 2016/2017 with ≥1 clinic visit and >1 viral loads were included. Patients were grouped into 5 categories-i) continuously followed; ii) newly diagnosed entering care; iii) previously diagnosed patients moving into care; iv) patients who formally moved out of care; and v) patients followed then disengaged from care. We determined the number of days patients spend with a suppressed (≤200copies/ml); unsuppressed (>200), and transmittable (>1500) viral loads. Results: Results-1498 (78%) of 1915 patients followed in 2016/2017 had suppressed VL for the entire 2 years; 22% had at least one unsuppressed VL, 19% had at least one transmittable VL. 88% of patients continuously followed had suppressed VL, 12% at least one unsuppressed VL and 10% ever transmittable. 90% of newly diagnosed patients entering the population had unsuppressed VL however most quickly became suppressed after initiating treatment (mean time – 62 days). 35% of patients entering from elsewhere presented with a transmittable VL. Of patients formally moving out of the population, 92%were suppressed prior to moving. Patients disengaging from care (n=106) had the highest rate of unsuppressed/transmittable VL of 54% and 49% respectively. Overall, of 1,168,782 total days followed, 92%were spent suppressed, 8.2% unsuppressed (105,011 days), and 6.6% (84,085 days) transmittable. Patients disengaging from care, although accounting for only 5.5% of all patients, accounted for 34% of days spent unsuppressed and 37% transmittable. Conclusion: Conclusions-Churn adds complexity to reporting HIV viral burden but provides nuance as patients entering or leaving the population contribute disproportionally to overall viral suppression rates. Longitudinal approaches to HIV viral burden provide different perspectives on who may be driving the local HIV epidemic. 1059 RESUPPRESSION AFTER VIREMIA VERSUS VIROLOGIC FAILURE IN KHAYELITSHA, SOUTH AFRICA Jonathan Euvrard 1 , Amir Shroufi 2 , Meg Osler 1 , Katherine Hilderbrand 1 , Laura Trivino Duran 2 , Andrew Boulle 1 1 University of Cape Town, Cape Town, South Africa, 2 MSF, Cape Town, South Africa Background: Routine viral load (VL) testing is the recommended strategy for monitoring the effectiveness of antiretroviral therapy (ART) and identifying individuals on failing regimens. For patients with a VL >1000 copies/ml, a VL 3m later (preceded by enhanced adherence support) is recommended to confirm virological failure (VF) prior to switch to second-line. While one justification for this strategy is that suppression can be achieved without a change of regimen, Little information exists as to the durability of any re-suppression achieved, and some advocate for earlier switching based on a single elevated VL for both clinical and operational reasons as cost and safety of second-line regimens improve. Methods: We included adults ≥15 years old initiating first-line ART between April 2010–March 2018 at 3 provincial primary healthcare clinics in Khayelitsha, South Africa. We estimated the probability and durability of re-suppression following initial viraemia (VR) and VF at different durations on ART in the subset of patients in continuous care. Results: Of 4005 patients who experienced VR or VF, 2194 (54.8%) re- suppressed in median 29.4 (IQR 17.3-45.8) months after ART initiation. VF patients were less likely to re-suppress (HR 0.90; 95%CI 0.83-0.98) compared to VR patients. Among patients who re-suppressed and had at least one subsequent VL, 175 (12.1%) of 1 446 and 305 (24.8%) of 1228 patients who had VR and VF respectively experienced subsequent viraemia (aHR 2.40 for VF vs VR; 95%CI 1.85-3.10) adjusting for sex, baseline CD4, age, TB and pregnancy status. By 24 months after re-suppression 17.8% and 38.5% of VR and VF respectively patients had experienced viraemia (Figure). Conclusion: A substantial and nearly comparable proportion of patients with VR or VF go on to re-suppress, despite programme expansion and variable adherence support after initial viraemia. The durability of re-suppression in those with VF was, however, appreciably lower than in those with VR.

Poster Abstracts

1060 HIGH AWARENESS BUT UNCERTAIN BELIEF IN U=U AMONG PROVIDERS AND COUPLES IN KENYA Kenneth Ngure 1 , Fernandos K. Ongolly 2 , Annabell Dollah 3 , Kenneth K. Mugwanya 4 , Merceline Awuor 5 , Elizabeth M. Irungu 4 , Nelly R. Mugo 2 , Elizabeth A. Bukusi 3 , Jennifer F. Morton 4 , Josephine Odoyo 3 , Elizabeth Wamoni 2 , Gena Barnabee 4 , Kathryn Peebles 4 , Gabrielle O’Malley 4 , Jared Baeten 4 1 Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya, 2 Kenya Medical Research Institute, Nairobi, Kenya, 3 KEMRI-UCSF, Kisumu, Kenya, 4 University of Washington, Seattle, WA, USA, 5 Kenya Medical Research Institute, Kisumu, Kenya Background: Sustained viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission. Scientific and popular messaging has framed this elimination of risk in concepts such as treatment as prevention (TasP) and Undetectable = Untransmittable (U=U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART among health providers and HIV serodiscordant couples in Kenya. Methods: The Partners Scale-up Project is evaluating PrEP delivery to HIV uninfected individuals in serodiscordant relationships in 24 public HIV clinics in Central and Western Kenya. We conducted semi-structured in-depth interviews with 69 health providers and 35 HIV uninfected people in serodiscordant relationships receiving PrEP services. Transcripts were coded using framework analysis. Results: Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as ‘very low’, ‘minimal’, ‘like zero’ to describe HIV transmission risk after viral suppression: but did not use the words ‘no risk.’ Additionally, providers reportedly found viral load results helpful when counseling clients on the ‘very low risk’ of HIV transmission after viral suppression. Others believed that U=U works, but only in the context of consistent condom use but concerns were expressed that communicating this message to HIV infected persons would lead them to engaging in multiple sexual relationships. Other providers reported avoiding counseling on risk of HIV transmission even after viral suppression for fear in case a seroconversion occurred they would be blamed. Similarly, members of HIV serodiscordant couples reported being informed about U=U by the providers but they did not believe/trust the message. Even after the HIV infected partners reached viral suppression, most HIV uninfected members of couples reported unwillingness to stop PrEP while others reported that they would use condoms if they stopped PrEP.

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