BackgroundSince 2007, Guatemala integrated STI clinical service with an HIV prevention model into four existing public health clinics to prevent HIV infection, known as the VICITS strategy. We present the first assessment of VICITS scale-up, retention, HIV and STI prevalence trends, and risk factors associated with HIV infection among Female Sex Workers (FSW) attending VICITS clinics in Guatemala.MethodsDemographic, behavioral and clinical data were collected using a standardized form. Data was analyzed by year and health center. HIV and STI prevalence were estimated from routine visits. Retention was estimated as the percent of new users attending VICITS clinics who returned for at least one follow-up visit to any VICITS clinic within 12 months. Separate multivariate logistic regression models were conducted to investigate factors associated with HIV infection and program retention.ResultsDuring 2007–2011 5,682 FSW visited a VICITS clinic for the first-time. HIV prevalence varied from 0.4% to 5.8%, and chlamydia prevalence from 0% to 14.3%, across sites. Attending the Puerto Barrios clinic, having a current syphilis infection, working primarily on the street, and using the telephone or internet to contact clients were associated with HIV infection. The number of FSW accessing VICITS annually increased from 556 to 2,557 (361%) during the period. In 2011 retention varied across locations from 7.7% to 42.7%. Factors negatively impacting retention included current HIV diagnosis, having practiced sex work in another country, being born in Honduras, and attending Marco Antonio Foundation or Quetzaltenango clinic sites. Systematic time trends did not emerge, however 2008 and 2010 were characterized by reduced retention.ConclusionsOur data show local differences in HIV prevalence and clinic attendance that can be used to prioritize prevention activities targeting FSW in Guatemala. VICITS achieved rapid scale-up; however, a better understanding of the causes of low return rates is urgently needed.

Background Pre-treatment HIV drug resistance (HIVDR) to NNRTIs has consistently increased in low-/middle-income countries during the last decade. Objectives To estimate the prevalence of pre-treatment HIVDR and acquired HIVDR among persons living with HIV (PLHIV) on ART for 12 ± 3 months (ADR12) and ≥48 months (ADR48) in Honduras. Patients and methods A nationwide cross-sectional survey with a two-stage cluster sampling was conducted from October 2016 to November 2017. Twenty-two of 54 total ART clinics representing >90% of the national cohort of adults on ART were included. HIVDR was assessed for protease and reverse transcriptase Sanger sequences using the Stanford HIVdb tool. Results A total of 729 PLHIV were enrolled; 26.3% (95% CI 20.1%–33.5%) ART initiators reported prior exposure to antiretrovirals. Pre-treatment HIVDR prevalence was 26.9% (95% CI 20.2%–34.9%) to any antiretroviral and 25.9% (19.2%–33.9%) to NNRTIs. NNRTI pre-treatment HIVDR was higher in ART initiators with prior exposure to antiretrovirals (P = 0.001). Viral load (VL) suppression rate was 89.7% (85.1%–93.0%) in ADR12 and 67.9% (61.7%–73.6%) in ADR48. ADR12 to any drug among PLHIV with VL ≥1000 copies/mL was 86.1% (48.9%–97.6%); 67.1% (37.4%–87.5%) had HIVDR to both NNRTIs and NRTIs, and 3.8% (0.5%–25.2%) to PIs. ADR48 was 92.0% (86.8%–95.3%) to any drug; 78.1% (66.6%–86.5%) to both NNRTIs and NRTIs, and 7.3% (1.8%–25.1%) to PIs. Conclusions The high prevalence of NNRTI pre-treatment HIVDR observed in Honduras warrants consideration of non-NNRTI-based first-line regimens for ART initiation. Programmatic improvements in HIVDR monitoring and adherence support may also be considered.

IntroductionIn Guatemala, data regarding HIV epidemics doesn’t show much data about indigenous population, although nearly 50% of the population in Guatemala are indigenous. In metropolitan area, MSM HIV prevalence is around 9%. But there is not data about HIV prevalence in indigenous MSM. This data is the first report in this important group.MethodsCross-sectional data analysis from October 2015 to July 2016. MSM were recruited as part of the implementation of Global Fund projects. Activities were implemented in three department of the Guatemalan highlands: Sololá, Totonicapan and Chimaltenango. Recruitment was performed by peers, by face-to-face or using social networks. Rapid HIV testing was performed in-site and confirmation in reference laboratory, STI were evaluated by syndromic management. Data was analysed using Stata 13.Results1196 MSM were tested for HIV and 293 had STI evaluation. 42% lived in Chimaltenango and 19% in Solola. Median age was 22 years old (IQR 19–26); 40.3% of them self-reported as indigenous, 11% of them K’iche’ and 10% kakchiquel. 60% of them had high school or higher education, 58 HIV cases were diagnosed, for a global HIV prevalence of 4.8%. In indigenous MSM HIV prevalence was higher (5.1 vrs 4.9, no difference). In K’iche’ MSM (N:156) HIV prevalence was higher (4.2%) than in kakchiquel (3.9%), but no difference. 18% had an STI, the most prevalent were anal warts (13%).ConclusionHIV prevalence in indigenous MSM is lower than reported in Guatemala city, however is a major public health problem not previously reported in Guatemala. Population representative studies in the highlands are needed to asses HIV prevalence in MSM, as well to improve current interventions.

Different explanations exist on how HIV-1 subtype B spread in Central America, but the role of Guatemala, the Central American country with the highest number of people living with the virus, in this scenario is unknown. We investigated the evolutionary history and spatiotemporal dynamics of HIV-1 subtype B in Guatemala. A total of 1,047 HIV-1 subtype B pol sequences, from newly diagnosed ART-naïve, HIV-infected Guatemalan subjects enrolled between 2011 and 2013 were combined with published subtype B sequences from other Central American countries (n = 2,101) and with reference sequences representative of the BPANDEMIC and BCAR lineages from the United States (n = 465), France (n = 344) and the Caribbean (n = 238). Estimates of evolutionary, demographic, and phylogeographic parameters were obtained from sequence data using maximum likelihood and Bayesian coalescent-based methods. The majority of Guatemalan sequences (98.9%) belonged to the BPANDEMIC clade, and 75.2% of these sequences branched within 10 monophyletic clades: four also included sequences from other Central American countries (BCAM-I to BCAM-IV) and six were mostly (>99%) composed by Guatemalan sequences (BGU clades). Most clades mainly comprised sequences from heterosexual individuals. Bayesian coalescent-based analyses suggested that BGU clades originated during the 1990s and 2000s, whereas BCAM clades originated between the late 1970s and mid 1980s. The major hub of dissemination of all BGU, and of BCAM-II, and BCAM-IV clades was traced to the Department of Guatemala, while the root location of BCAM-I and BCAM-III was traced to Honduras. Most Guatemalan clades experienced initial phases of exponential growth (0.23 and 3.6 year-1), followed by recent growth declines. Our observations suggest that the Guatemalan HIV-1 subtype B epidemic is driven by dissemination of multiple BPANDEMIC founder viral strains, some restricted to Guatemala and others widely disseminated in the Central American region, with Guatemala City identified as a major hub of viral dissemination. Our results also suggest the existence of different sub-epidemics within Guatemala for which different targeted prevention efforts might be needed.

Introduction A nationally representative HIV drug resistance (HIVDR) survey in Nicaragua was conducted to estimate the prevalence of pretreatment HIVDR (PDR) among antiretroviral therapy (ART) initiators and acquired HIVDR among people living with HIV (PLHIV) who had received ART for 12 ± 3 months (ADR12) and ≥48 months (ADR48). Methods A nationwide cross‐sectional survey with a two‐stage cluster sampling was conducted from March to November 2016. Nineteen of 45 total ART clinics representing >90% of the national cohort of adults on ART were included. ART initiators were defined as PLHIV initiating or reinitiating first‐line ART. HIVDR was assessed for protease, reverse transcriptase and integrase Sanger sequences using the Stanford HIVdb algorithm. Viral load (VL) suppression was defined as <1000 copies/mL. Results were weighted according to the survey design. Results and discussion A total of 638 participants were enrolled (PDR: 171; ADR12: 114; ADR48: 353). The proportion of ART initiators with prior exposure to antiretrovirals (ARVs) was 12.3% (95% CI: 5.8% to 24.3%). PDR prevalence to any drug was 23.4% (95% CI: 14.4% to 35.6%), and 19.3% (95% CI: 12.2% to 29.1%) to non‐nucleoside reverse transcriptase inhibitors (NNRTI). NNRTI PDR was higher in ART initiators with previous ARV exposure compared with those with no exposure (76.2% vs. 11.0%, p < 0.001). Protease inhibitors (PI) and integrase strand transfer inhibitors PDR was not observed. VL suppression rate was 77.8% (95% CI: 67.1% to 85.8%) in ADR12 and 70.3% (95% CI: 66.7% to 73.8%) in ADR48. ADR12 prevalence to any drug among PLHIV without VL suppression was 85.1% (95% CI: 66.1% to 94.4%), 82.4% to NNRTI and 70.2% to nucleoside reverse transcriptase inhibitors (NRTI). ADR48 prevalence to any drug among PLHIV without VL suppression was 75.5% (95% CI: 63.5% to 84.5 %), 70.7% to NNRTI, 59.4% to NRTI and 4.6% to PI. Conclusions Despite implementation challenges yielding low‐precision HIVDR estimates, high rates of NNRTI PDR were observed in Nicaragua, suggesting consideration of non‐NNRTI‐based first‐line regimens for ART initiators. Strengthened HIVDR monitoring, systematic VL testing, and improved ART adherence support are also warranted.

Introducción. Las metas globales para controlar la epidemia de HIV contemplan que la carga viral sea indetectable en 90 % de las personas en tratamiento. El costo de la medición de la carga viral en lotes de muestras puede reducirse y, así, aumentar la cobertura cuando los recursos son limitados; sin embargo, su eficacia disminuye al aumentar la prevalencia del fracaso del tratamiento antirretroviral.Objetivo. Evaluar estrategias para disminuir la proporción de pacientes con fracaso del tratamiento anti-rretroviral en los lotes de muestras y, de esta manera, aumentar el ahorro en las pruebas de carga viral.Materiales y métodos. Las estrategias evaluadas fueron: a) la organización de los lotes de muestras según el esquema de tratamiento antirretroviral, y b) la exclusión de aquellos pacientes con antecedente reciente de fracaso del tratamiento antirretroviral, aquellos con menos de 12 meses de tratamiento antirretroviral y aquellos sin tratamiento antirretroviral previo. Los resultados de los lotes se compararon con los resultados individuales.Resultados. El valor diagnóstico negativo fue similar para los pacientes con esquema de primera línea (100,0 %; IC95% 99,5-100,0) o de segunda línea de tratamiento (99,4 %; IC95% 96,9-99,9). La incidencia del fracaso del tratamiento antirretroviral fue menor en los pacientes con tratamiento de primera línea (p<0,01), lo cual permitió un mayor ahorro en las pruebas de laboratorio en este grupo (74,0 %; IC95% 71,0-76,7) que en los pacientes con tratamiento de segunda línea (50,9 %; IC95% 44,4-57,3) (p<0,01).Conclusión. La selección de las muestras que se incluyeron en los lotes para determinar la carga viral del HIV según el tipo de esquema de tratamiento, permitió maximizar el porcentaje de ahorro en pruebas de laboratorio.

Background HIV drug resistance (HIVDR) can negatively impact the effectiveness of ART, increasing the number of AIDS-associated deaths, new HIV infections, and ART programme costs. Objective Estimate the prevalence of pretreatment HIVDR (PDR) among ART initiators and the prevalence of viral load (VL) suppression and acquired HIVDR among individuals receiving ART for 12 ± 3 months (ADR12) and ≥48 months (ADR48) in El Salvador. Patients and methods Nationally-representative cross-sectional PDR, ADR12, and ADR48 surveys were conducted among adults living with HIV from October 2018 to August 2019, following WHO-recommended methods. Demographic and clinic data and blood specimens were collected. Results 260 participants were enrolled in the PDR survey, 230 in the ADR12 survey and 425 in the ADR48 survey. 27.0% (95% CI: 17.1–39.9%) ART initiators had PDR to efavirenz or nevirapine. The prevalence of VL suppression was 88.8% (83.1–92.8) in ADR12 and 80.5% (76.6–84.0) in ADR48 surveys. Among PLHIV receiving a first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART regimen and with unsuppressed VL, the prevalence of ADR to efavirenz or nevirapine was 72.0% (39.1–91.2) and 95.0% (72.0–99.3) in the ADR 12 and ADR48 surveys, respectively. ADR12 to boosted protease inhibitors (PI/r) or integrase strand transfer inhibitors (INSTI) was not observed. ADR48 to PI/r was 1.3% (0.4–4.9) and 2.1% (0.8–5.6) to INSTI. Conclusion Programmatic improvements in ART delivery are urgently needed in El Salvador to address the high levels of resistance to efavirenz or nevirapine among ART initiators and the low VL suppression prevalence among individuals on treatment.

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