Background Initiation of antiretroviral therapy (ART) in the advanced stages of HIV infection remains a major challenge in sub-Saharan Africa. This study was conducted to better understand barriers and enablers to timely ART initiation in Rwanda where ART coverage is high and national ART eligibility guidelines first expanded in 2007–2008. Methods Using data on 6326 patients (≥15 years) at five Rwandan clinics, we assessed trends and correlates of CD4+ cell count at ART initiation and the proportion initiating ART with advanced HIV disease (CD4+ <200 cells/µl or WHO stage IV). Results Out of 6326 patients, 4486 enrolling in HIV care initiated ART with median CD4+ cell count of 211 cells/µl [interquartile range: 131–300]. Median CD4+ cell counts at ART initiation increased from 183 cells/µl in 2007 to 293 cells/µl in 2011–2012, and the proportion with advanced HIV disease decreased from 66.2 to 29.4%. Factors associated with a higher odds of advanced HIV disease at ART initiation were male sex [adjusted odds ratios (AOR) = 1.7; 95% confidence interval (CI): 1.3–2.1] and older age (AOR46–55+ vs. <25 = 2.3; 95% CI: 1.2–4.3). Among those initiating ART more than 1 year after enrollment in care, those who had a gap in care of 12 or more months prior to ART initiation had higher odds of advanced HIV disease (AOR = 5.2; 95% CI: 1.2–21.1). Conclusion Marked improvements in the median CD4+ cell count at ART initiation and proportion initiating ART with advanced HIV disease were observed following the expansion of ART eligibility criteria in Rwanda. However, sex disparities in late treatment initiation persisted through 2011–2012, and appeared to be driven by later diagnosis and/or delayed linkage to care among men.

Introduction “Treat All” – the treatment of all people with HIV, irrespective of disease stage or CD4 cell count – represents a paradigm shift in HIV care that has the potential to end AIDS as a public health threat. With accelerating implementation of Treat All in sub‐Saharan Africa (SSA), there is a need for a focused agenda and research to identify and inform strategies for promoting timely uptake of HIV treatment, retention in care, and sustained viral suppression and addressing bottlenecks impeding implementation. Methods The Delphi approach was used to develop consensus around research priorities for Treat All implementation in SSA. Through an iterative process (June 2017 to March 2018), a set of research priorities was collectively formulated and refined by a technical working group and shared for review, deliberation and prioritization by more than 200 researchers, implementation experts, policy/decision‐makers, and HIV community representatives in East, Central, Southern and West Africa. Results and discussion The process resulted in a list of nine research priorities for generating evidence to guide Treat All policies, implementation strategies and monitoring efforts. These priorities highlight the need for increased focus on adolescents, men, and those with mental health and substance use disorders – groups that remain underserved in SSA and for whom more effective testing, linkage and care strategies need to be identified. The priorities also reflect consensus on the need to: (1) generate accurate national and sub‐national estimates of the size of key populations and describe those who remain underserved along the HIV‐care continuum; (2) characterize the timeliness of HIV care and short‐ and long‐term HIV care continuum outcomes, as well as factors influencing timely achievement of these outcomes; (3) estimate the incidence and prevalence of HIV‐drug resistance and regimen switching; and (4) identify cost‐effective and affordable service delivery models and strategies to optimize uptake and minimize gaps, disparities, and losses along the HIV‐care continuum, particularly among underserved populations. Conclusions Reflecting consensus among a broad group of experts, researchers, policy‐ and decision‐makers, PLWH, and other stakeholders, the resulting research priorities highlight important evidence gaps that are relevant for ministries of health, funders, normative bodies and research networks.

As part of the System Linkages and Access to Care Initiative, 12 HIV service delivery organizations in New York implemented one of the following three interventions to improve linkage to and retention in HIV care at their site: Peer Support, Appointment Procedures, and Anti-Retroviral Treatment and Access to Services. Aggregate process measure data describing intervention delivery, in conjunction with qualitative findings to help explain barriers and facilitators to achieving full implementation were examined. Process data from the interventions showed shortcomings in the percentage of eligible patients who went on to be enrolled, and the number of enrollees who ultimately received the components of the interventions. Factors identified in qualitative interviews that facilitated implementation and intervention delivery included: concerted buy-in and coordination of staff, building upon existing infrastructure including ensuring sufficient staff capacity, and allowing adaptability of certain parts of the intervention to better fit patient needs and clinical settings.

Objective Expanded HIV testing coverage could result in earlier diagnosis of HIV, along with reduced morbidity, mortality, and onward HIV transmission. Design Longitudinal analysis of aggregate, population-based surveillance data within New York City (NYC) ZIP codes. Methods We examined new HIV diagnoses and recent HIV testing to examine whether changes in recent HIV testing coverage (last 12 months) were associated with changes in late HIV diagnosis rates within NYC ZIP codes during 2003–2010, a period of expansion of HIV testing in NYC. Results Overall, recent HIV testing coverage increased from 23% to 31% during 2003–2010, while the rate of late HIV diagnoses decreased from 14.9 per 100,000 to 10.6 per 100,000 population. Within ZIP codes, each 10% absolute increase in recent HIV testing coverage was associated with a 2.5 per 100,000 absolute decrease in the late HIV diagnosis rate. ZIP codes with the largest changes in HIV testing coverage among men were more likely to have the largest (top quartile) declines in late HIV diagnosis rates among men (adjusted odds ratio [aOR]men=4.0; 95%CI=1.5–10.8), as compared with ZIP codes with no or small changes in HIV testing coverage. However, this association was not significant for women (aORwomen=1.4 95% CI=0.50–4.3). Significant geographic disparities in late HIV diagnosis rates persisted in 2009/10. Conclusions Increases in recent HIV testing coverage may have reduced late HIV diagnoses among men. Persistent geographic disparities underscore the need for continued expansion of HIV testing to promote earlier HIV diagnosis.

Therapeutic study, level V.

Existing data dissemination structures primarily rely on top-down approaches. Unless designed with the end user in mind, this may impair data-driven clinical improvements to Human Immunodeficiency Virus (HIV) prevention and care. In this study, we implemented a data visualization activity to create region-specific data presentations collaboratively with HIV providers, consumers of HIV care, and New York State (NYS) Department of Health AIDS Institute staff for use in local HIV care decision-making. Data from the NYS HIV Surveillance Registry (2009-2013) and HIV care facilities (2010-2015) participating in a Health Resources and Services Administration (HRSA) Systems Linkages and Access to Care project were used. Each data package incorporated visuals for: linkage to HIV care, retention in care and HIV viral suppression. End-users were vocal about their data needs and their capacity to interpret public health data. This experience suggests that data dissemination strategies should incorporate input from the end user to improve comprehension and optimize HIV care.

Introduction. In New York State (NYS), young adults account for the largest number of new human immunodeficiency virus (HIV) infections and struggle to seek and remain in HIV care. Digital interventions and access to peer support have demonstrated positive influences on the HIV care continuum and health outcomes. The New York State Department of Health (NYS DOH) developed YGetIt? (YGI) that combines a mobile application, GET!, peer navigation (PEEPs), and a compelling digital comic series, “Tested,” to facilitate the timely entry of young people into HIV care, to prevent vulnerable youth from dropping out of care, and to achieve sustained viral load suppression among those in care. This article describes the development and early implementation of the YGI digital intervention. Intervention design. GET! provided a high level of confidentiality and security, ease of access, and Wi-Fi accessibility. YGI enrolled 113 HIV-positive participants from a clinical setting who were individually randomized at a 1:1 ratio to receive access to GET! plus PEEPs (n = 53) or the app alone (n = 60). Lessons learned. For recruitment, staff and organization buy-in was essential to the success of the intervention, and building relationships was critical. GET! development was an iterative process. Peer Engagement Educator Professionals (PEEPs) who were tech savvy, representative of the priority population, and had shared life experience with participants were most impactful. Interest in apps declines over time and participants in the APP alone arm were less engaged. Conclusion. GET! is a communication and engagement tool that supports HIV care and may serve as a model for like digital interventions.

70% of individuals with HIV in the United States are 50 years or older. These individuals’ HIV is often well-managed, but they have acquired several comorbidities, including cardiovascular disease, non-AIDS defining cancers, renal disease, osteoporosis, liver disease, and neurocognitive disorders. Existing literature provides little guidance on structuring services to meet this burgeoning population’s complex clinical and aging-related needs. To inform an approach, between April 2015 and June 2018, we conducted 13 exploratory qualitative group discussions with patients, providers and administrators receiving or providing HIV services in New York’s Hudson Valley. We also conducted a retrospective electronic medical record chart review (n=50) of individuals &gt;50 years receiving HIV care in 2017 at a Hudson Valley federally qualified health center (FQHC) to describe subspecialty referrals. Analysis of discussion groups highlighted challenges with initial access, the quality of encounters, and consistent follow-up. Patients thought ‘ageism’ contributed to poorer care quality, though extensive experience navigating the system was an advantage. The EMR review revealed patients receiving two referrals on average to (most commonly) ophthalmology/optometry (14%), gastroenterology (12%), dental (9%), cardiology (9%), and orthopedics (8%). Only half (54%) of scheduled referral appointments were attended. Documented barriers included insurance/costs, transportation, patient refusal, and fear of HIV disclosure. Findings suggest there are HIV-specific and non-specific barriers for older individuals with HIV, including perceived perceptions of aging. We have initiated a pilot study to investigate multilevel barriers and enablers to optimal comorbidity management. Gerontological insights brought to this analysis will support developing aging-appropriate clinical practices for this population.