Strategy of planning HIV/AIDS fight in Ukraine: a review

HIV epidemic in Ukraine remains a nationwide problem. The current epidemiological situation does not yet give grounds to talk about a significant decrease in the load associated with HIV/AIDS in Ukraine. Predicting the further spread of the epidemic throughout the country is becoming more and more complicated due to the crisis socio-economic phenomena and the deterioration of the situation in the eastern regions of Ukraine. Objective — to substantiate the ways of optimization of monitoring, diagnosis and treatment of HIV infection as the basis for a strategy of overcoming the HIV/AIDS epidemic in the public health system in Ukraine; expanding treatment of HIV-infected patients using modern approaches and standards; volumes and algorithms of cooperation of specialists from different branches in the provision of treatment services to patients with skin diseases and sexually transmitted infections. Materials and methods. We analyzed: 1) documents of international policy in the field of public health; 2) the latest changes in the documents of the state policy in the field of health care of Ukraine; 3) international strategies and approaches to overcoming the HIV epidemic; 4) WHO strategies for applying public health approaches to tackling the HIV epidemic; 5) the dynamics of the incidence of skin and venereal diseases in Ukraine and the virtual creation of an epidemiological situation in the absence of integrative relations between individual health care services; 6) modeling and forecasting with account of all available relevant data as an important source of information for monitoring national and global HIV epidemics, as well as managing the prevention and treatment programs. Results and discussion. Based on the review of statistical information, key directions are presented for further strengthening of the system of monitoring and evaluation to strengthen the control over the HIV epidemic in Ukraine, as well as optimize specific treatment. At the present stage of the implementation of medical reforms, final revision and improvement are required of existing strategies and policies for organizing a response to the HIV epidemic in Ukraine, as well as the search for new ways and tools that can be mobilized in the health care system by increasing the efficiency of the use of existing resources, introducing new forms of management and coordination of actions. Conclusions. Bringing national standards in line with the best world practices in the field of HIV counteraction contributes to the effective planning of the need for specific therapy in order to ensure a sustainable response to the HIV epidemic in Ukraine, the use of a «treat all» approach with effective and safe antiretroviral therapy. The optimization is based on the principles of public health as having the highest priority and effectiveness in comparison with individual approaches to the prevention, treatment and support of people with chronic diseases. The principle of maintaining balanced treatment regimens helps to reduce dependence on donor funding in the context of limited resources in Ukraine, as well as ensure the achievement of Fast track goals and adherence to the UNAIDS strategy.

HIV epidemic in a province of the Brazilian Amazon region: Temporal trend analysis

Background: Although considerable progress has been made over the last decades, human immunodeficiency virus (HIV) incidence and acquired immunodeficiency syndrome (AIDS) mortality rates have remarkably increased in the Brazilian Amazon region. Here, we employed temporal analysis to determine the impact of public policies on the HIV epidemic in the state of Pará, Brazil, which has the second highest HIV incidence rate in the Amazon region.Design and Methods: This is an ecological study conducted in the state of Pará, employing secondary data of HIV/AIDS cases notified to the Information System for Notifiable Diseases, 2007–2018. The following epidemiological variables were collected: year of notification, municipality of residence, age, sex, education, exposure category, and HIV/AIDS diagnostic criteria. The study population was composed of 21,504 HIV/AIDS cases. The HIV/AIDS incidence rates were analyzed employing the temporal trend analysis (TTA) followed by the chi-square test and residue analysis to determine the association between the epidemiological variables and time series periods.Results: A total of 50% of the notifications were composed of AIDS cases. TTA identified two periods in HIV/AIDS incidence, with stabilization of cases in the first period (G1, 2007–2012) and an upward trend in the second period (G2, 2012–2018). The most prevalent epidemiological characteristics in G2 (versus G1) were as follows: young people, brown skin color, higher schooling, and homosexuals.Conclusion: Public policy to control HIV infection in the Brazilian Amazon region has been partially effective. HIV screening tests and treatment should be made widely available to eradicate HIV infection in the Amazon region by 2030.

Using large-scale respondent driven sampling to monitor the end of an HIV epidemic among persons who inject drugs in Hai Phong, Viet Nam

Aims To describe the use of large-scale respondent driven sampling (RDS) surveys to demonstrate the “end of an HIV epidemic” (HIV incidence < 0.5/100 person-years) among persons who inject drugs (PWID) in a middle-income country. Large sample sizes are needed to convincingly demonstrate very low incidence rates. Methods 4 large surveys (Ns approximately 1500 each) were conducted among PWID in Hai Phong, Vietnam in 2016–2019. Respondent driven sampling (RDS) with a modification to add snowball sampling was used for recruiting participants. HIV incidence was measured through recency testing, repeat participants across multiple surveys and in a cohort study of PWID recruited from the surveys. RDS analytics (time to equilibria and homophilies for major variables) were used to assess similarities/differences in RDS only versus RDS plus snowball recruiting. Characteristics were compared among respondents recruited through standard RDS recruitment versus through snowball sampling. An overall assessment of the robustness of RDS to modification was made when adding a snowball sampling recruitment. Results RDS recruiting was very efficient in the first 5 weeks of each survey with approximately 180 respondents recruited per week. Recruiting then slowed considerably, and snowball sampling (permitting an individual respondent to recruit large numbers of new respondents) was added to the existing RDS recruiting. This led to recruiting within 13–14 weeks of 1383, 1451, 1444 and 1268 respondents, close to the target of 1500 respondents/survey. Comparisons of participants recruited through standard RDS method and respondents recruited through snowball methods showed very few significant differences. RDS analytics (quickly reaching equilibria, low homophilies) were favorable for both RDS recruited and total numbers of participants in each survey. DRug use and Infections in ViEtnam (DRIVE) methods have now been officially adopted in other provinces. Conclusions RDS appears to be quite robust with respect to adding a modest number of participants recruited through snowball sampling. Large sample sizes can provide compelling evidence for “ending an HIV epidemic” to policy makers in a PWID population in a middle income country setting.

Peculiarities of the Spread of HIV infection among Urban and Rural Residents of the Tyumen Region

Relevance. The geographical spread of HIV infection among the population of various administrative territories is very heterogeneous. The Tyumen region, due to its vast territory and the significant remoteness of some areas from the regional center, is of particular interest in the framework of considering the territorial features of the spread of HIV.Aims. To consider peculiarities of the spread of hiv infection among urban and rural residents of the Tyumen region in 1993–2019.Materials & Methods. Statistical data of the «Center for the Prevention and Control of AIDS» in the period from 1993 to 2019, annual form No. 61 «Information on the contingents of HIV patients» for 2006–2019, materials of the state report «On the sanitary and epidemiological situation in the Tyumen region» for 2013–2019. Methods of epidemiological observation were used in the work: analytical and descriptive-evaluative with the use of methods of retrospective and operational analysis and statistical methods.Results and Discussions. A specific feature of the spread of HIV infection among urban and rural residents is the tendency to exceed the regional incidence rate in a number of territories. Analysis of epidemiological data for the period under review showed that all territories of the region are involved in the epidemiological process of HIV infection, and in a number of territories the prevalence rate exceeds the average Russian level. HIV prevalence as of December 31, 2019 was 728.2 per 100 thousand people in Russia. In 17 administrative territories of the Tyumen region the infection rate is higher than the national average level and is per 100 thousand population in the city of Tobolsk – 1903.3, in the districts of Uvat – 1486.2, Tobolsk – 1440.5, Nizhnetavda – 1354.9, Tyumen – 1344.1, Yalutorovsk – 1327.6), in the city. Tyumen – 1249.3, in the districts: Vagay – 1195.2, Zavodoukovsky – 1119.2, in Ishim – 951.8, in the districts: Yarkovsky – 889.6, Vikulovsky – 881.3, Yurginsky – 846.9, Ishimsky district – 842.1, Aromashevsky – 851.6, Isetovsky – 754.4, Uporovsky district – 734.7.Conclusions. The HIV epidemic in the Tyumen region is determined by its economic and geographic location and by the presence of exceptional epidemiologically significant prerequisites for the intensive spread of HIV, in particular, by the routes through which large quantities of drugs are illegally transported (drug trafficking from the northeast).

870. Coverage, Cost Sharing, and Out-of-Pocket Costs for Single-Tablet HIV Antiretroviral Regimens in Qualified Health Plans in the United States, 2018-2020

Background A key pillar of the US “Ending the HIV Epidemic” (EHE) plan is rapidly providing antiretroviral therapy (ART) to achieve viral suppression. However, access to ART is hindered by discriminatory benefit design through non-coverage, adverse tiering (including pricier cost sharing via coinsurance instead of copays), and excessive and arbitrary utilization management for ART, all of which make rapid access to HIV treatment challenging. To understand how ACA Qualified Health Plan (QHP) formularies adapt in response to new ART single tablet regimens (STRs), we analyzed QHP coverage of two first-line STRs: dolutegravir/abacavir/lamivudine (Triumeq; approved 2014) and bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy; approved 2018). Methods For all QHPs offered in the 2018-2020 ACA Marketplaces, we analyzed Biktarvy and Triumeq coverage, cost sharing, and out-of-pocket (OOP) costs at state, regional, and EHE priority jurisdiction levels. Figure 1. Qualified Health Plan Coverage of Triumeq and Biktarvy by State, 2018-2020 Results For 2018, 2019, and 2020, respectively, we identified 19,533, 17,007, and 21,547 QHPs. In 2018, 26 states had &lt; 50% of QHPs covering Biktarvy, and 9 states had 0%. Conversely, 41 states had 100% of QHPs covering Triumeq, and only 2 states had &lt; 50% (Fig. 1). Biktarvy coverage improved from 2018-2020, especially in the Midwest (27% to 88%). Improvements were driven by increased coverage with copay except in the South, where coverage with copay remained stagnant and coverage with coinsurance increased (22% to 33%) (Fig. 2). Biktarvy coverage increased in EHE jurisdictions from 74% to 90%, driven by increased coverage with coinsurance (20% to 34%) (Fig. 3). Although Biktarvy had a higher national average wholesale price than Triumeq (&4,073 vs. &3,639 per month in 2020, respectively), monthly OOP cost trends only differed regionally in the Midwest and did not differ by EHE priority jurisdiction status (Fig. 4). Figure 2. Qualified Health Plan Coverage and Cost Sharing for Triumeq and Biktarvy by Region, 2018-2020 Figure 3. Qualified Health Plan Coverage and Cost Sharing for Triumeq and Biktarvy by “Ending the HIV Epidemic” Priority Jurisdiction Status, 2018-2020 Figure 4. Monthly Out-of-Pocket Cost for Qualified Health Plan Premium and Triumeq or Biktarvy by Cost Sharing Type and (A) Region or (B) “Ending the HIV Epidemic” Priority Jurisdiction Status, 2018-2020 Conclusion STR coverage remains heterogenous across the United States. Over time, coverage of the newer STR increased, but many QHPs in EHE jurisdictions still required coinsurance. Access to newer ART regimens may be slowed by delayed QHP coverage or complex negotiations with manufacturers about formulary inclusion as ART options become more competitive, even if patients are insulated from cost differences. Disclosures Kathleen A. McManus, MD, MSCR, Gilead Sciences, Inc. (Research Grant or Support, Shareholder)

Can we talk about price with patients when choosing antiretroviral therapy? A survey with people living with HIV and prescribers in France

ObjectiveThe aim of this study was to evaluate people living with HIV (PLWH) and HIV specialist prescribers’ perception of discussing antiretroviral therapy (ART) price in PLWH’s care and the acceptability of choosing or switching to various types of less expensive ARTs.DesignCross-sectional surveys (one in a convenience sample of PLWH and one in a voluntary response sample of HIV specialist prescribers).Setting and participantsThe surveys were conducted among PLHW attending an HIV clinic in the North of Paris (cohort of 4922 PLWH in 2016), and HIV specialists working in French HIV clinics (210 across 12 districts/28), between January and June 2016.MethodSelf-administered questionnaires were constructed using data collected during focus groups with PLWH and prescribers. Pretests were carried out to select the questions and items. Descriptive analyses of the 129 complete questionnaires of PLWH and 79 of prescribers are presented.ResultsAmong PLWH, 128/129 were on ART and 54% (69/128) gave a fair estimation of the price of their current regimen. Among prescribers, 24% (19/79) thought that their patients knew this price. Taking into account the price of ART was not perceived as a negative step in the history of French response to HIV epidemic for 53% (68/129) of PLWH and 82% (65/79) of prescribers. Seventy-seven PLWH (60%) would agree to switch to less expensive antiretroviral regimens (as effective and with similar adverse events) if pills were bigger; 42 (33%) if there were more daily doses, and 37 (29%) if there were more pills per dose; prescribers were more circumspect.ConclusionA high proportion of PLWH gave a fair estimate of their ART price and this seemed unexpected by HIV specialists. Consideration of drug prices when choosing ART was perceived as conceivable by PLWH and prescribers if effectiveness and tolerance were also considered.

841. Survey of Current HIV and HCV Policies and Practices in Prisons and Jails Serving High-Risk Geographic Hotspots

Background The goal of the U.S. “Ending the HIV Epidemic” (EHE) initiative is to reduce new HIV infections by 90% within 10 years by focusing resources on high-risk geographic “hotspots.” (Figure 1). The criminal justice system bears a disproportionate burden of HIV, yet EHE lacks specific mention of correctional settings for intervention. We conducted a survey study of current HIV and HCV care practices in prisons and jails serving EHE hotspots. Figure 1 Priority jurisdictions for the “Ending the HIV Epidemic” Initiative which include counties, rural states, and territories with the highest HIV burden, together accounting for more than 50 percent of new HIV diagnoses in recent years. Source: Division of HIV/AIDS Prevention, Centers for Diseases Control and Prevention, https://www.cdc.gov/endhiv/jurisdictions.html Methods An online survey on HIV/HCV testing, prevention, treatment, and surveillance was sent to Medical Directors or designees at 26 state prison systems and 37 county or city jails serving EHE hotspots in Spring 2021. Results Twenty-five responses were received (10/26 prisons, 15/37 jails) for an overall response rate of 40%. Routine HIV testing, defined as testing offered to all persons without known infection, was conducted in 76% of facilities (9/10 prisons, 10/15 jails), with policies of “opt-out” in 44% (5/10 prisons, 6/15 jails), “opt-in” in 20% (2/10 prisons, 3/15 jails), and “mandatory” in 12% of facilities (2/10 prisons, 1/15 jails). Most facilities (80%) provided HIV testing upon inmate request. For HIV prevention, education programs and/or treatment for opioid-use disorder was available in 76% of facilities, but PrEP and condoms were only available in 24% and 16%, respectively. All facilities reported providing antiretroviral therapy and 88% provided a short (3- to 30-day) supply upon discharge. Routine testing for HCV was conducted in 52% of facilities (7/10 prisons, 6/15 jails), with policies of “opt-out” in 36% (5/10 prisons, 4/15 jails), “opt-in” in 12% (1/10 prisons, 2/15 jails), and “mandatory” in one prison. Most facilities (80%) provided HCV testing upon inmate request. In 8/10 prisons and 6/15 jails, HCV treatment with direct-acting antivirals was continued if initiated prior to incarceration. Treatment for new diagnoses of HCV was less common (16-44%) and depended on expected length of incarceration. Conclusion In prisons and jails serving HIV “hotspot” regions, critical opportunities for improved HIV and HCV testing, treatment, prevention, and linkage-to-care services remain. Given these findings, we support the broader inclusion of the justice system as an integral component of the EHE initiative. Disclosures All Authors: No reported disclosures