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Browsing by Author "Luz, Paula M."
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Item Delayed presentation of HIV among older individuals: a growing problem(Elsevier, 2022) Justice, Amy C.; Goetz, Matthew B.; Stewart, Cameron N.; Hogan, Brenna C.; Humes, Elizabeth; Luz, Paula M.; Castilho, Jessica L.; Nash, Denis; Brazier, Ellen; Musick, Beverly; Yiannoutsos, Constantin; Malateste, Karen; Jaquet, Antoine; Cornell, Morna; Shamu, Tinei; Rajasuriar, Reena; Jiamsakul, Awachana; Althoff, Keri N.; Biostatistics and Health Data Science, Richard M. Fairbanks School of Public HealthLate presentation for care is a major impediment to the prevention and effective treatment of HIV infection. Older individuals are at increased risk of late presentation, represent a growing proportion of people with late presentation, and might require interventions tailored to their age group. We provide a summary of the literature published globally between 2016-21 (reporting data from 1984-2018) and quantify the association of age with delayed presentation. Using the most common definitions of late presentation and older age from these earlier studies, we update this work with data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, focusing on data from 2000-19, encompassing four continents. Finally, we consider how late presentation among older individuals might be more effectively addressed as electronic medical records become widely adopted.Item Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis(Oxford University Press, 2021) Brazier, Ellen; Tymejczyk, Olga; Zaniewski, Elizabeth; Egger, Matthias; Wools-Kaloustian, Kara; Yiannoutsos, Constantin T.; Jaquet, Antoine; Althoff, Keri N.; Lee, Jennifer S.; Caro-Vega, Yanink; Luz, Paula M.; Tanuma, Junko; Niyongabo, Théodore; Nash, Denis; Medicine, School of MedicineBackground: The World Health Organization's Treat-All guidance recommends CD4 testing before initiating antiretroviral therapy (ART), and routine viral load (VL) monitoring (over CD4 monitoring) for patients on ART. Methods: We used regression discontinuity analyses to estimate changes in CD4 testing and VL monitoring among 547 837 ART-naive patients enrolling in human immunodeficiency virus (HIV) care during 2006-2018 at 225 clinics in 26 countries where Treat-All policies were adopted. We examined CD4 testing within 12 months before and VL monitoring 6 months after ART initiation among adults (≥20 years), adolescents (10-19 years), and children (0-9 years) in low/lower-middle-income countries (L/LMICs) and high/upper-middle-income countries (H/UMICs). Results: Treat-All adoption led to an immediate decrease in pre-ART CD4 testing among adults in L/LMICs, from 57.0% to 48.1% (-8.9 percentage points [pp]; 95% CI: -11.0, -6.8), and a small increase in H/UMICs, from 90.1% to 91.7% (+1.6pp; 95% CI: 0.2, 3.0), with no changes among adolescents or children; decreases in pre-ART CD4 testing accelerated after Treat-All adoption in L/LMICs. In L/LMICs, VL monitoring after ART initiation was low among all patients in L/LMICs before Treat-All; while there was no immediate change at Treat-All adoption, VL monitoring trends significantly increased afterwards. VL monitoring increased among adults immediately after Treat-All adoption, from 58.2% to 61.1% (+2.9pp; 95% CI: 0.5, 5.4), with no significant changes among adolescents/children. Conclusions: While on-ART VL monitoring has improved in L/LMICs, Treat-All adoption has accelerated and disparately worsened suboptimal pre-ART CD4 monitoring, which may compromise care outcomes for individuals with advanced HIV.