8th IAS Conference on HIV Pathogenesis, Treatment & Prevention 19–22 July 2015, Vancouver, Canada

Sensitive assays are needed for detection of residual HIV in patients with undetectable plasma viral loads to determine if eradication strategies are effective. The gold standard quantitative viral outgrowth assay (QVOA) underestimates the magnitude of the viral reservoir, while sensitive PCR‐based assays lack the ability to distinguish replication competent from defective virus. We sought to determine whether xenograft of leukocytes from HIV‐1 infected patients with undetectable plasma viral loads into severely immunocompromised mice would result in viral amplification and measurable viral loads within the aberrant murine host.

To identify mechanisms that control immune reconstitution and the size of the inducible HIV reservoir, we performed whole blood transcriptional and metabolic profiling of subjects from the CLIF and UCSF SCOPE cohorts. These cohorts included subjects who increased CD4 counts post cART (IR) or stayed B350/mm 3 after three years of cART (INR). Methods: We performed unsupervised analysis of gene expression data using hierarchical clustering to identify class and supervised analysis using statistical filtering to identify gene signatures and pathway activity differentially expressed between classes. Multivariate analysis based on Sparse Partial Least Regression was used to determine if Group membership correlated with plasma metabolites measured by LC-MS/GC-MS. A gene-based classifier was developed to identify INR groups using the pamr package. Results: Two groups of INR subjects were identified by whole blood gene expression and pathway analysis. INR-A had the highest levels of IL-6, sCD14, FOXO3 and STAT1 expression, and highest levels of oxidative stress and mitochondrial dysfunction. Pathway analysis showed that INR-A failed to activate the NF-kB pathway, TLR-MyD88 signalling and proinflammatory modules yet upregulated expression of the p38 MAPK pathway, IRF-3, IRF-4 and IL-10 associated with a tolerogenic myeloid response. In contrast, INR-B was characterized by an unrestrained proinflammatory response including the upregulation of multiple TLRs, STAT1, IRF1 and IRF8 associated with Type I/II IFN responses. Plasma metabolites including carnitines, bacterial metabolites and cholesterol also segregated between the two INR groups and correlated with gene expression including FOXO3A and STAT-1. TILDA, a measure of the inducible HIV reservoir; revealed that INR-A subjects had higher levels than INR-B and IR's. As CD4 counts and plasma biomarkers of inflammation/immune activation fail to distinguish the two INR groups, we developed a 352 gene-based classifier that accurately identified patient groups (AUC of 0.81 by ROC analysis) in an independent test cohort (UCSF SCOPE) including those that had the highest levels of HIV reservoir. Conclusions: Identifying pathways that control immune reconstitution and the size of the inducible HIV reservoir paves the way to the development of therapeutic strategies that can lead to eradication of HIV.
http://dx.doi.org/10.7448/IAS.18. 5.20323 MOAA0105LB HIV-1 virological remission for more than 11 years after interruption of early initiated antiretroviral therapy in a perinatally infected child Introduction: Durable HIV-1 remission after interruption of combined antiretroviral therapy (cART) has been reported in some adults who started cART during primary HIV-1 infection. The in utero HIV-1infected ''Mississippi child'' exhibited transient viral control after interrupting very early-initiated cART. However, viraemia rebounded 27 months later, leaving unclear the possibility of obtaining longterm post-treatment remission in vertically infected children. Here, we report the case of a perinatally HIV-1-infected adolescent who shows unprecedented virological remission more than 11 years after cART discontinuation. Methods: HIV-RNA and CD4' T-cell counts have been monitored since birth. Ultrasensitive HIV-RNA, peripheral blood mononuclear cell (PBMC)-associated HIV-DNA, flow-cytometry-assessed frequency of HIV-specific CD8' T cells, CD8' T-cell-mediated HIV suppression, reactivation of the CD4' T-cell reservoir were evaluated after 10 and 11 years of control off therapy. Plasma concentrations of antiretrovirals were determined by tandem mass spectrometry. Introduction: Cell-associated unspliced (CA-US) HIV RNA is an important marker of the HIV reservoir and a common primary endpoint in clinical trials of latency reversing agents in HIV-infected subjects on antiretroviral therapy (ART). We observed large baseline variation in CA-US HIV RNA in a recent clinical trial of disulphiram and hypothesized that these changes were due to circadian-related alterations in CD4' T-cell composition, gene regulation or anticipatory stress.
Methods: Blood was collected on three occasions (B1, B2 and B3) from HIV-infected subjects (n030) on suppressive ART prior to any intervention. B3 was collected immediately prior to administration of disulphiram. We measured CA-US HIV RNA and DNA by real-time PCR and plasma HIV RNA (using a single copy assay) by droplet digital PCR. Plasma cortisol and thyroid-stimulating hormone (TSH) levels were quantified by ELISA. PBMC were stained with live-dead dye and antibodies to CD3, CD4, CD8, CD45RA, CCR7, CD27, CD38, HLA-DR, acetylated lysine and acetylated histone-3 and were analyzed by flow cytometry. Data were assessed for normality and then analyzed with Wilcoxon matched-pairs signed rank tests and paired t-tests. Results: CA-US RNA was higher in blood collected at B3 compared to B1 and B2 (median 85.63 vs. 28.14 and 34.87 copies/million CD4' Tcell equivalents; both, p B0.001). There were little differences in HIV DNA or plasma HIV RNA at these times. B3 was collected earlier in the day compared to B1 and B2 (mean 8.28 am vs. 11.38 am and 10.21 am; both, pB0.001). Other parameters that were significantly higher at B3 compared to B1 and B2 were cortisol (p 00.001 and 0.011); TSH (p 00.023 and 0.004); CD8'CD38'HLA-DRÁ T cells (both, p B0.001) and CD4'CD38'HLA-DRÁ T cells, which were elevated at B3 compared to B2 (p00.012). There were no significant differences in the percentage of T-cell subsets or histone acetylation in the blood collected at these time points.
Conclusions: Time-associated variation in CA-US HIV RNA seen in HIV-infected subjects on suppressive ART was not associated with significant alterations in CD4' T-cell subset composition and was suggestive of circadian changes in HIV RNA transcription. Diurnal changes in CA-US HIV RNA may need to be considered in the design of future cure intervention trials.
http://dx.doi.org/10.7448/IAS.18. 5.20567 MOAA0202 Treatment with anti-a4b7 integrin antibody reduces virus-mediated gastrointestinal pathology by targeting distinct mucosal tissues Introduction: Our laboratory has recently demonstrated that in vivo administration of a monoclonal anti-a4b7 antibody (a4b7-mAb) during acute SIV infection following (1) intravenous, (2) intra-rectal or (3) repeated low-dose intra-vaginal SIV challenge lead to markedly lower gastro-intestinal tissue viral loads compared to rhesus macaques (RM) treated with a control mAb. The purpose of the present study was to compare the tissues that served as primary targets of viral infection in the a4b7-mAb versus control mAb-treated RM, in order to identify mechanisms by which a4b7-mAb antibody reduces virus-mediated gastrointestinal pathology.
Methods: Groups of 12Á16 RM were administered a rhesus a4b7-mAb monoclonal antibody or an isotype-matched control rhesus IgG mAb (50 mg/kg) intravenously (i.v.) starting on day -1 and then every three weeks after infection. Each monkey was then repeatedly challenged with a low-dose SIVmac251 intra-vaginally or a single highdose intrarectally.
Results: Intravenous administration of a4b7-mAb blocked the detection of a4b7 on CD4' T cells in the blood, cervicovaginal tissue and gut-associated lymphoid tissue (GALT) throughout the period of mAb administration. Viral DNA was reduced in GALT biopsies of the a4b7-mAb treated RMs compared to those treated with control mAb Introduction: A recent marked increase in the proportion of HIVinfected individuals older than 50 highlights the need to study the impact of ageing on HIV pathogenesis. HIV-associated non-AIDS (HANA) conditions, such as cardiovascular disease, diabetes, osteoporosis and dementia are more prevalent in older HIV-infected populations than young adults. The microbiome in saliva and the oral cavity has been studied as a window into pathogenesis in ageing populations. Although disruption of the oral microbiome (dysbiosis) has been linked to various human conditions and diseases associated with ageing, the role of age-related dysbiosis in the development of opportunistic infections and HANA conditions in HIV patients is not well understood. Methods: We utilize 16S rRNA-based pyrosequencing to compare the salivary microbiome in three groups: chronically HIV-infected women enrolled in the Women's Interagency HIV Study who are (1) !50 years old (ageing), or (2) B35 years old (young adult) and (3) healthy age-matched uninfected women. We also examine correlations between dysbiosis of the salivary microbiome, disease progression and opportunistic oral infections.
Results: HIV infection results in dysbiosis of the salivary microbiome that is enhanced in ageing individuals and characterized by increased abundance of pathogenic bacteria and a decline in healthy probiotic microbes. Higher proportions of Prevotella, Staphylococcus, Moryella, Peptostreptococcus, Ruminococcus and Oribacterium were detected in both ageing and young adult HIV infected women than in uninfected controls. Prevotella, Moryella and Oribacterium increases were higher in ageing than in young HIV patients. HIV infection in older patients was associated with greater salivary shedding of Epstein Barr Virus (EBV). Increased EBV shedding, higher peripheral HIV burden and reduced CD4' T cell counts correlated with increases in Prevotella and decreases in probiotic Lactobacillus. Patients with opportunistic oral infections also showed enhanced salivary levels of Porphyromonas, Lachnospira and Actinobacillus, and reduced Streptococcus.
Conclusions: Age, severity of disease progression and emergence of opportunistic infections all contribute to various degrees in increasing the pathogenic footprint of the oral microbiome during chronic HIV infection. The study findings provide new insights into age-related dysbiosis of the salivary microbiome and its role in HIV pathogenesis and lay critical groundwork for future expanded investigations.
http://dx.doi.org/10.7448/IAS.18. 5.20325 MOAA0204 Serum-derived bovine immunoglobulin isolate increases peripheral and mucosal CD4 T cell count in patients with HIV enteropathy Introduction: A multi-centre trial in HIV-enteropathy was conducted to evaluate the impact of serum-derived bovine immunoglobulin isolate (SBI) on markers of peripheral and mucosal immunity and gastrointestinal (GI) symptoms as previously reported.
Methods: Patients (pts) on long-term suppressive antiretroviral treatment (ART) with HIV-enteropathy were randomized to receive SBI 2.5 vs. 5.0 g BID or placebo (PBO) during a four-week lead-in phase followed by SBI 2.5 vs. 5.0 g BID for 20 weeks. Evaluations included plasma biomarkers for inflammation, peripheral CD4 counts and pt-reported surveys on GI symptoms. Eight pts underwent duodenal biopsies to examine mucosal immunity.
Results: A total of 103 pts (SBI 2.5 g; n 0 34; SBI 5.0 g; n 0 33; PBO: n 0 36 continued 2.5 vs. 5.0 g (n 0 18 each)) were enrolled (31% female; 61% black; mean age 51 years). Mean duration of HIV, ART and enteropathy was over 15, 5 and 5 years, respectively. All cohorts showed a reduction in abnormal stool frequency (p 0 0.0001) from baseline (BL) to week 4; however between group analysis was not significant. This reduction was maintained for pts receiving SBI through 24 weeks. The 2.5 and 5.0 g cohorts were combined for zonulin and CD4 analysis. The mean plasma zonulin levels significantly increased (p B 0.0001) for pts receiving SBI through 24 weeks. Median peripheral CD4 counts increased significantly from BL to week 24 in patients in the lowest baseline CD4 quartile (308 to 386 cells/mL, p 0 0.002), while no significant change was observed among subjects in the combined SBI cohorts during this time period. This compromised subgroup also experienced greater increases in CD4 counts at week-4 than PBO pts (median '42 vs. (17 cells/mL, p 0 0.02). Duodenal CD4 densities increased from 217 to 329 cells/ mm 2 (median increase of 145 cells/mm 2 (p 0 0.02)) in biopsies obtained from eight pts, consistent with earlier findings. Duodenal crypt cells expressing Ki67 decreased in 6/7 pts from 41 to 24% (p 0 0.08, n 0 7) which correlated with the decreased number of Paneth cells per crypt (p 0 0.048).
Conclusions: Oral SBI may be a novel strategy to restore mucosal immunity and systemic immune reconstitution among pts who have not achieved normal CD4 counts despite prolonged suppressive ART.
Introduction: Disruption of the mucosal epithelium during immunodeficiency lentivirus infections permits translocation of microbial products into the circulation, causing systemic immune activation and driving disease progression. However, the specific effects of microbial products in liver, as a blood-filtering organ, are unclear. Methods: In this study, we investigated the effects of simian immunodeficiency virus (SIV) infection of rhesus macaques on microbial translocation in the liver by immunohistochemistry. We also compared liver infiltration by myeloid dendritic cells (mDCs), trafficking to the liver by lymphocytes, and liver-resident natural killer (NK) cell frequencies, phenotypes and functions in naïve and chronically SIVmac239-or SIVmac251-infected rhesus macaques using flow cytometry.
Results: In livers of normal rhesus macaques, very low levels of bacteria and lipopolysaccharide (LPS) were detectable, but increased up to 20-fold in chronically SIV-infected animals. Increased microbial products in the liver of infected macaques was associated with the production of the chemoattractant, CXCL16, by mDCs. Subsequently, lymphocytes expressing the CXCL16 receptor, CXCR6, were mobilized in blood and hypercytotoxic NK cells were recruited to the liver. Microbial accumulation, mDC activation and hepatic cytotoxic NK cell frequency were all significantly correlated with markers of liver damage. Conclusions: Collectively, these data indicate that SIV-associated accumulation of microbial products in the liver initiates a cascade of innate immune activation resulting in liver damage. These findings have implications for the liver pathology associated with HIV, especially in instances of coinfection with HCV. http://dx.doi.org/10.7448/IAS.18.5.20568

MOAB0101
Field evaluation of point-of-care testing for early infant diagnosis in Cape Town, South Africa unrelated to treatment, with no deaths or AEs leading to treatment discontinuation. At Week 24, the median increase in serum creatinine was '0.08 mg/dL in E/C/F/TAF participants, with and '0.10 mg/dL in STB participants, with median eGFR decreases of (17.0 and (18.0 mL/min/1.73 m 2 , respectively, consistent with COBI's inhibition of renal tubular creatinine secretion. Proteinuria (any grade) occurred in 26% of E/C/F/TAF participants vs. 52% of STB participants, with Grade 2 or higher proteinuria occurring in 4% vs. 21% of participants, respectively. Of those participants with BMD measurements at Week 24, the median increase in spine BMD was '1.98% in E/C/F/TAF participants, with a decrease of ]4% in 3/41 participants (7%), versus a median decrease of (1.29% in the STB cohort, with a decrease of ]4% in 6/20 participants (30%). Spine HA Z-scores decreased by (0.02 and (0.21 respectively. Conclusions: Compared with STB, E/C/F/TAF exhibited similar effects on eGFR, a lower incidence and severity of proteinuria, and a median increase in spine mineralization. Both STRs were well-tolerated through 24 weeks. These findings support INSTI-based STRs as initial HIV-1 treatment in adolescents and suggest that TAF could offer safety advantages in paediatric populations. Introduction: Management of TB in HIV patients in Eastern Europe (EE) is challenged by high MDR-TB prevalence, low rates of drug susceptibility testing (DST) and poor access to ART. We report 1-year mortality estimates from a multi-regional (EE, Western Europe (WE) and Latin America (LA)) cohort study. Methods: Deaths within 12 months of starting TB therapy (baseline) among consecutive HIV patients with TB in 2011Á2013 were classified as being TB-related or not. Risk factors for all-cause and TB-related death were assessed using standard survival analysis methods. Results: Among 1410 patients starting TB therapy (EE0835, WE0319, LA0256), 257 (18%) died within 12 months of baseline; 170 (66%) of these were TB-related. The cumulative probability of all-cause and TBrelated death at 12 months was 29, 5 and 11% (pB0.001) and 22, 1 and 4% (pB0.001) in EE, WE and LA respectively. In EE, fewer patients were on cARTat 12 months (68% vs. 90% and 85%, pB0.001), and many were treated without access to baseline DST (66% vs. 37% and 69%, pB0.001). Among those with DST, the empiric treatment regimen (composed when DST results were not yet known) included B3 active TB-drugs in 36, 7 and 9% (EE,WE, LA, pB0.001); of those 81, 46 and 86% had MDR-TB. Patients who started B3 active drugs were at excess risk of dying from TB compared to patients starting ]3 active drugs Abstract MOAB0203ÁFigure 1. TB-related death among HIV-positive patients according to the number of active drugs used as part of empiric TB therapy.
Conclusions: There is an elevated risk of death from TB in HIV patients managed in EE compared to WE and LA. This is partly explained by modifiable risk factors including low rates of DST, hampering the optimized choice of TBdrugs ina setting of high MDR-TB prevalence.Our data call for urgent action to improve the care of HIV/TB patients in EE. Introduction: Despite being preventable and curable, tuberculosis (TB) remains the leading cause of morbidity and mortality of people living with HIV (PLHIV). The past decade has seen considerable scale-up of collaborative TB/HIV activities, however, implementation remains suboptimal. Closer inspection at each stage of the cascade of TB/HIV care is warranted to assess the gaps and to identify opportunities for strengthened service delivery in order to eliminate HIV-associated TB mortality. Methods: Data were downloaded from the Global TB Programme Database on 22/01/2015 on the latest available TB treatment outcomes (2012 cohort), disaggregated by HIV status, from reporting high TB/HIV burden countries in the WHO African Region, along with related data on the implementation of collaborative TB/HIV activities. Data were analysed and missed opportunities identified. Results: Fourteen countries reported the required outcome data, accounting for some 570,000 HIV-positive incident TB cases, (Table 1), or 63% of the African burden and 49% of the global burden in 2012. More than 50,000 reported HIV-positive TB cases died or were lost to follow-up, representing 18% of evaluated cases, compared with 11% of evaluated HIV-negative TB cases, (Figure 1). Of the estimated HIV-positive TB cases almost 260,000 (46%) went unreported, (Table 1). Among registered TB patients, 11% (around 80,000) did not have an HIV test in the TB register. In eight countries that reported, there was a gap of over 1,700,000 reported as not having received a TB screen, (53% of the 3,300,000 people in HIV care). Among notified HIV-positive TB cases, 42% (nearly 130,000) were not reported as receiving ART. Only five of the 14 countries reported providing Isoniazid Preventive Therapy (IPT) to people newly registered in HIV care. In the four countries that reported a denominator, 69% (some 900,000) people newly enrolled in HIV care did not receive IPT.
Conclusions: This analysis highlights some considerable gaps in the care cascade, resulting from suboptimal implementation and/or recording and reporting. In order to prevent disproportionate TB mortality among PLHIV, countries are encouraged to scrutinize weaknesses in the care cascade at every level to enhance early detection of HIVassociated TB, timely ART initiation and scaled-up TB prevention. http://dx.doi.org/10.7448/IAS.18.5.20337

MOAB0205LB
Empiric TB therapy does not decrease early mortality compared to isoniazid preventive therapy in adults with advanced HIV initiating ART: results of ACTG A5274 (REMEMBER study) Introduction: Strategies for reducing the high early mortality seen among patients initiating antiretroviral therapy ART in resourcelimited settings (RLS) are urgently needed. We hypothesized that given the high burden of tuberculosis (TB) in these settings, empiric TB treatment among patients at high risk for death would reduce early mortality. Methods: REMEMBER (Reducing Early Mortality and Early Morbidity by Empiric Tuberculosis Treatment Regimens) is a multicountry randomized clinical trial comparing two management strategies: ART'empiric 4 drug TB therapy (Empiric) vs. ART'isoniazid preventive therapy (IPT) in HIV-infected individuals with CD4 count B50 cells/mm 3 . Participants were screened for TB prior to entry using symptom screen, locally available diagnostics per standard of care, and GeneXpert when available. The study was stratified according to CD4 count ( B25 vs. ]25 cells/mm 3 ) and poor prognostic factors (body mass index B18.5, haemoglobin B8 g/dl, recent hospitalization). The primary endpoint was survival (death or unknown status) at 24 weeks postrandomization, and KaplanÁMeier estimates of the endpoint rates across arms were compared by the z-test.
Results: Of 1368 participants screened, 850 (62%) were randomized; 53% were male, 90% were black and median (quartiles) age was 36 (30Á42) years. The median (quartiles) CD4 count at study entry was 18 cells/mm 3 (9,32). At week 24, both arms had the same primary endpoint rate of 5.2% (95% CI: 3.5Á7.8% for Empiric and 3.4Á7.8% for IPT) with an absolute risk difference of (0.06% (95% CI: (3.05 to 2.94%). Primary endpoint rates were similar across arms for the stratification factors and for other secondary outcomes: viral load B400 copies/mL was achieved in 84% Empiric and 85% IPT; Grade 3 or 4 symptoms occurred in 12% Empiric and 11% IPT; Grade 3 or 4 laboratory abnormalities in 23% both arms; and new clinical events in 49% Empiric and 51% IPT. HIV-infected index participants had CD4 cell counts between 350 and 550 cells/mm 3 at enrolment. Index participants were randomized to receive ART at enrolment (early arm) or when their CD4 cell count fell to 5250 cells/mm 3 or they developed an AIDS-defining illness (delayed arm).
The primary analysis was based on genetically linked viral transmission events. When interim analysis in May 2011 demonstrated the benefits of early ART, ART was offered to all index participants in the delayed arm (N Engl J Med 2011;365:493Á505); the study then continued otherwise unchanged.
Results: At the end of the trial, 1171 (66%) of 1763 couples remained in follow-up (603/886 early arm; 568/877 delayed arm). Index participants were followed for 9822 person-years (py). ART was initiated by all 886 index participants in the early arm and 785 (90%) of 877 index participants in the delayed arm. Before ART was offered to all index participants, there was 1 linked infection in the early ART arm (4 total infections/1776 py) and 35 linked infections in the delayed arm (42 total infections/1757 py). After ART was offered to index participants in both study arms, there were two linked infections in the early arm (15 total infections/2537 py) and six linked infections in the delayed arm (17 total infections/2412 py). Only seven linked infections were diagnosed while the index participant was receiving ART: four infections were diagnosed shortly after the index participant started ART and three were diagnosed after ART failure. These findings demonstrate that HIV transmission is very unlikely when viral replication is suppressed.
Conclusions: The previously reported efficacy of early ART for HIV prevention was sustained for the duration of the HPTN 052 study. ART, combined with counselling and provision of condoms provides durable, highly effective protection from HIV transmission in serodiscordant couples. Introduction: For antiretroviral treatment (ART) programs to have a preventive impact, the proportion of HIV-infected people being treated should be high. In 2012, seven years after the beginning of ART programs in the South-African township of Orange Farm, we measured the proportion of HIV' who were virally suppressed, especially among age groups highly exposed to HIV (women 18Á29 years and men 25Á34 years).
Methods: A community-based cross-sectional representative survey conducted in 2012 among 3293 men and 3473 women. Study procedures included a face-to-face questionnaire and collection of blood samples that were tested for HIV, 10 antiretroviral drugs (ARVs) and HIV-viral load (VL).
Conclusions: In Orange Farm, in the 2005Á2012 period, ART programs were sub-optimal and, among HIV', proportion of viral suppression was low, especially among the highly-exposed age groups. This suggests that, up to 2012, ART programs may not have substantially impacted HIV incidence. However, our study showed at community level that, when effectively taken, ARVs present a high effectiveness in suppressing VL.
http://dx.doi.org/10.7448/IAS.18. 5.20338 MOAC0103 A mathematical model to determine potential costs and benefits of increasing antiretroviral therapy coverage in female sex workers: the case of Panama Introduction: Panama adopted Treatment as Prevention (TasP) in February 2014 and is now seeking efficient and effective ways to expand antiretroviral therapy (ART) coverage in key populations. We developed a mathematical model to determine the ART coverage and associated costs required to meet HIV incidence reduction targets for the female sex worker (FSW) population, which has a 1.6% HIV prevalence. Methods: The Government of Panama, British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University are collaborating to develop mathematical models for informing Panama's TasP strategy. Quantitative and qualitative information was collected from national reports, key informant interviews and focus groups with civil society to inform a compartmental HIV transmission model incorporating disease progression and treatment. The model was calibrated and validated for 2013. Estimated FSW population size is 17,000 and according to the Global AIDS Response Progress report, current ART coverage for both FSW and the hard-to-reach client population is about 47%. Annual ART cost/individual is US$625. Simulation scenarios for meeting 50, 70 or 90% reduction in HIV incidence in FSW in 15 years assumed ART expansion either for FSW and their clients (Scenario 1) or for FSW only (Scenario 2). Results: ART expansion for FSW costs slightly more in Scenario 1 than 2. However, overall for both populations of FSW and clients, more infections are averted and treatment programme costs are lower for the strategy targeting FSW only (see Table 1). Furthermore, initial aggressive expansion of ART coverage leads to overall cost savings and a more effective means of averting new infections (see Figure 1). The result of no action compared to the 90% Scenario 2 strategy would be 170% more HIV infections and 50% more treatment costs over 15 years.
Conclusions: Rapid expansion of TasP for female sex workers in Panama would avert infections and treatment costs already within 15 years. Initial short-term investment to increase ART coverage would be offset by long-term savings. Since Panama adopted TasP, UNAIDS has announced the 90Á90Á90 targets for HIV diagnosis, treatment and suppression, which call for an even more rapid reduction in incidence. Ongoing analyses are evaluating costs and outcomes of reaching the new targets by 2020. Introduction: HIV treatment guidelines are recommending ART at increasingly higher CD4 counts for maximizing individual and population benefits. However, the expansion of ART use may be at the expense of optimal adherence. We report on adherence and virological suppression when initiating ART at different CD4 thresholds within the Treatment as Prevention (ANRS 12249) trial of universal home-based testing and immediate ART initiation in rural KwaZulu-Natal. Methods: Using data of a cluster-randomized trial of immediate ART versus initiation according to current national guidelines (CD4 5 350 cells/mm 3 ), we compared adherence levels ( ]95% vs. B95%) measured using a visual analogue scale (VAS) and pill count (PC) and virological suppression at six months (B400 c/mL) according to CD4 count at ART initiation through logistic regression models, adjusting for possible confounders (age, sex, marital status, education and employment). Results: During March 2012ÁMay 2014, 601 participants who were not on ART entered care in trial clinics; 382 initiated ART; 254 have completed ]6 months on ART, 227 of whom had six months HIV RNA data and were included in analyses. One hundred sixty-nine were women; median (IQR) age and CD4 at ART initiation were 35 years (28,46) and 313 cells/mm 3 (206, 513). Adherence ]95% at six months was high (88 and 83% by PC and VAS, respectively) with no evidence that this was associated with CD4 at initiation (aOR 0 0.97 per 100 cells/mm 3

MOAC0105LB
Community-based HIV testing and linkage effectively delivers combination HIV prevention: results from a multisite randomized trial Introduction: To have a population impact in generalized HIV epidemics in Africa, high coverage of combination HIV prevention strategies that reduce the susceptibility of uninfected persons and the infectiousness of infected persons is needed. Communitybased HIV testing and counselling, with linkage to care and prevention, is a potential delivery platform for combination HIV prevention.
Methods: We conducted a multisite programme of community-based HIV testing and counselling, linkage to HIV care, and demand creation for voluntary medical male circumcision (VMMC) in rural communities in KwaZulu-Natal, South Africa and Sheema district, Uganda. HIV testing was done at home or through mobile units. HIV-positive persons were randomly allocated to linkage to care strategies: clinic facilitation by lay-counsellors at the initial clinic visit, lay-counsellor follow-up visits at home, or standard clinic referral. HIV-negative uncircumcised men were randomized to VMMC demand creation strategies: lay counsellor follow-up visits at home, SMS reminders, or standard VMMC promotion at the time of testing. Results: Between June 2013 and February 2015, 15,332 persons received HIV testing and counselling. Among 1325 HIV-positive persons randomized to linkage strategies, the overall clinic linkage was high (93%). Compared to standard linkage, lay counsellor clinic facilitation increased linkage to care (RR 01.09, 95% CI: 1.05Á1.13), and home follow-up visits increased antiretroviral therapy (ART) initiation (RR 01.23, 95% CI: 1.02Á1.47). In all arms, ART initiation was limited by bottlenecks in service delivery at the clinics, although 67% of those eligible initiated ART by nine months. Overall, 82% of persons initiating ART achieved viral suppression without significant difference between study arms. Of 750 HIV-negative uncircumcised men randomized to VMMC promotion strategies, the uptake of circumcision was 41% by month 3. Compared to standard messages, VMMC uptake was significantly higher in the SMS promotion (RR 01.72, 95% CI: 1.36Á2.17) and lay counsellor follow-up arms (and RR01.67, 95% CI: 1.29Á2.14).
Conclusions: Community-based HIV testing and linkage to care and prevention effectively deliver combination HIV prevention. Simple strategies, such as SMS reminders or lay-counsellor visits, increase linkage for ART initiation and male circumcision. Community-based strategies require integration with efficient clinical services, and Introduction: In 2011, results from an interim analysis of the HPTN 052 trial demonstrated that early antiretroviral therapy (ART) was highly effective for the prevention of HIV transmission from HIVinfected adults (index participants) to their HIV-uninfected sexual partners. All index participants were offered ART after May 2011; the trial ended in May 2015. This report describes the analysis of partner infections in HPTN 052. Methods: HIV from index-partner pairs was analyzed. Phylogenetic methods were used to compare HIV pol sequences from indexpartner pairs and controls. Linkage probability was further assessed by comparing the genetic distances between pol sequences (Bayesian analysis). Selected samples were also analyzed using next generation sequencing (envy region). Three infections that occurred close to the time of index ART initiation were analyzed by BEAST and serologic methods to determine the probable timing of HIV transmission. This abstract presents provisional findings based on data available as of May 2015.
Results: Seventy-five partner infections were confirmed (64 in Africa, 6 in Asia, 5 in the Americas), including 39 described previously (JID 2011;204:1918Á1926). Linkage status was determined for 70 cases (five cases failed analysis). Of these 70 cases, 26 (37%) were classified as unlinked (the partner was most likely infected from someone other than the index participant), and 44 (63%) were classified as linked (the index was most likely the source of the partner?s HIV infection). In 7 of the 44 linked cases, the partner seroconverted while the index was receiving study ART. In four of these seven cases, the partner seroconverted shortly after the index started ART, likely before the index was virally suppressed. In the remaining three cases, the partner seroconverted when the index was not virally suppressed due to ART failure.
Conclusions: Laboratory and statistical methods were used to identify and characterize linked partner infections in HPTN 052. Seven linked infections were observed in partners after index participants started study ART: four occurred shortly after ART initiation and three occurred in the setting of ART failure. The timing of the linked transmission events supports the model that HIV transmission is very unlikely in the setting of viral suppression. http://dx.doi.org/10.7448/IAS.18.5.20484

MOAC0201
Post prevention of mother-to-child-transmission: 30-months outcomes in the Malawian ''Option B' programme'' Introduction: Under the Option B' PMTCT strategy, HIV-infected pregnant and breastfeeding women initiate lifelong ART. Long-term retention after weaning is unknown. We examine treatment outcomes for up to 30-months after ART initiation. Methods: We examined cumulative incidence of mortality, no followup after ART initiation, loss to follow-up after the first follow-up visit (LTF), treatment discontinuation and retention in the Malawian ''Option B' programme.' '  Estimating the cost of these PMTCT regimens is essential. We estimated the cost of Option A in Zimbabwe, which was rolled out in 2011. These data also represent baseline estimates to assess the cost-effectiveness of Option B', rolled out in Zimbabwe in late 2013.
Methods: We conducted a cross-sectional survey of 157 randomly selected health facilities offering PMTCT services in 5 of 10 provinces in Zimbabwe. In each facility, we collected data on the output and cost of PMTCT services, including staff and supplies for the whole year and for each month of 2013. We also assessed the time allocation of staff providing these services. We estimated the average cost of PMTCT services per facility and for specific services in the PMTCT cascade such as HIV testing and antiretroviral prophylaxis. We also examined the variation in costs by the type of provider. 40% of the variation in the cost per pregnant woman tested can be explained by number of HIV' women on ART/ARV, as was 50% of the variation in prophylaxis and treatment costs (see Figure).
Conclusions: These findings are the first empirical estimations of PMTCT programmes costs in Zimbabwe. Given limited resources, calls for the elimination of MTCT have challenged the international community to optimize the use of resources to increase coverage of PMTCT priority services. Information about costs is essential to determine the highest possible quality HIV services at the lowest feasible cost and thus maximize efficiency.

MOAC0302LB
Acceptability and feasibility of a novel approach to promote HIV testing in sexual and social networks using HIV self-tests Introduction: Identifying interventions to increase men's uptake of HIV testing in sub-Saharan Africa is essential for the success of combination prevention strategies, including treatment as prevention. HIV self-testing is an emerging approach with high acceptability, but limited evidence exists on optimal strategies for distributing selftests and reaching men in particular. This study explored a novel approach of providing multiple self-tests to women with high HIV incidence to promote HIV testing among their sexual partners. HIV-infected specimens with HCV antibody results, 34 (94%) were HCV co-infected. The NS5B gene was sequenced for 119 HCV-infected persons. Genotype 1a (n 082) was most common, followed by genotype 3a (n029), 2b (n05) and 1b (n 03). Three unique clusters of HCV strains were identified (Cluster 1, n 045; Cluster 2, n09; Cluster 3, n0 7; Figure, At 1,3,5,7 and 10 years, overall rates of mortality were 4.2, 6.8, 9.0, 10.8 and 13.6% respectively. LTFU rates for the same periods were 2.4, 6.8, 10.9, 14.8 and 24.2% respectively; 62% remained in active care at 10 years ( Figure 1). At the end of follow up, 85% of active patients had VL B 400 copies/mL (Haiti excluded because VL not regularly measured) and median CD4 increased from 153 to 517 cells/mm 3 . After 10 years, only 11% of patients remained active and on their first HAART regimen, 13% were on their second, 12% were on their third and 23% were on their fourth or more regimen. Heterogeneity in outcomes between sites was substantial.
Conclusions: Despite advanced disease and use of mostly old antiretrovirals, a large proportion of first HAART initiators in these Latin American cohorts were alive, in active control, with substantial immune recovery and virologic suppression after 10 years. Early death was a problem as well as persistent LTFU and frequent change of therapy. Introduction: The integration of HIV-care into primary health care (PHC) clinics is a strategy to expand access to antiretroviral therapy (ART). However, integration may compromise PHC service delivery within weak health systems. We designed a study to examine changes in PHC service provision (pre and post-integration) in publicsector PHC clinics in Free State, South Africa. Methods: We analyzed administrative data on 15 PHC indicators. The data were collected monthly over a critical four year period as integration was implemented into 131 PHC clinics representing a catchment population of 1.5 million. We defined integration as the month and year the PHC clinic provided comprehensive HIV-care, from testing to treatment to follow-up. We utilized interrupted time series analysis at 918 and 930 months from HIV integration in each clinic to identify changes in PHC services post-integration. We conducted sensitivity analyses with linear mixed effect models to study the relationship between HIV service indicators and the PHC indicators. Results: The number of patients receiving ART in the 131 PHC clinics studied increased from 121 (April 2009) to 57,958 (March 2013). We did not observe any changes in service indicators for 11 of the 15 PHC indicators we examined, However, we did observe decreases in population-level immunization coverage after integration by 0.98% (SE 0 0.25, p B 0.001) at 918 months and by 1.31% (SE 0 0.16, p B 0.001) at 930 months. Clinic level immunization coverage also decreased by 33 infants per 100,000 patients (SE 0 8, p B 0.001) at 930 months. None of these changes were associated with the number of HIV patients at the clinics. We also observed decreases in total clinic visits per year for adults and children under five years old. Conclusions: Despite an extraordinary increase in patients accessing ART in PHC clinics during our study period, the vast majority of PHC indicators remained unchanged. Our findings suggest that the integration of HIV-care into public-sector PHC clinics is a viable strategy through which to expand access to ART. However, further research is needed to understand how immunization coverage is affected.
http://dx.doi.org/10.7448/IAS.18. 5.20348 MOAD0105LB Implementation scale up of the Adherence Club model of care to 30,000 stable antiretroviral therapy patients in the Cape Metro: 2011Á2014 district in turn piloted, using a collaborative quality improvement approach and then adopted the model of care. Few data on largescale implementation of novel models of care exist. We describe the implementation scale-up across the district highlighting key efficiencies and context-specific adaptations to the model. Methods: We describe the scale-up from January 2011 to December 2014. Data from routine electronic monitoring of the ART programme provide the total number of ART patients retained in care (RIC) while monitoring of AC participation is reported monthly by each AC. Results: AC implementation expanded over the four-year period with the number of patients retained in AC care increasing annually from 5675 in December 2011 to 30,790 in December 2014 ( Figure 1). By December 2014, ACs were offered at 76.1% of ART facilities (51/76) with only 7.5% of ART patients in care at a facility where ACs were not operating. The proportion of patients receiving ART within an AC grew from 7.3% in 2011 to 25.0% by the end of 2014 ( Figure 1). Conclusions: Over a four-year period, the AC model of care was widely accepted and expanded to support a quarter of all patients receiving ART in the district. Adaptations to the model of care supported implementation within the various facility contexts. Some facilities offered ACs at the facility while others decentralized the model to outreach community and home venues. Most used various lay cadres of staff, while some used nurses to facilitate the groups. The model offered efficiencies both to patients and the health system. For ACs to expand to provide quality care to a greater proportion of ART patients, appropriate resources are required. Further research is needed to evaluate the outcomes of AC patients. Introduction: Treatment of HIV infection with antiretrovirals reduces individuals' plasma viral loads to undetectable levels and in turn decreases the risk of transmission. Despite epidemiological evidence supporting the efficacy of ''Treatment as Prevention,'' quantifying this success remains a significant challenge. Phylogenetic analysis of viral sequence data can yield crucial insights into epidemic processes, including transmission dynamics. We sought to evaluate the impact of treatment on HIV transmission rates in British Columbia (BC), Canada, using phylogenetic methods. Methods: We recovered 27,296 anonymized HIV protease and RT sequences from 7747 HIV patients in BC from the BC Centre for Excellence in HIV/AIDS database. Sequences were annotated with: sample collection date, treatment status at sample collection, date of first antiretroviral treatment and risk factor (intravenous drug use (IDU), men having sex with men (MSM) and heterosexual (HET)). Codons associated with known drug resistance were censored from the alignment prior to tree inference. We inferred a set of 1000 maximum likelihood phylogenetic trees. We calculated a lineage level phylogenetic branching rate for each HIV lineage in the trees, which provides an approximate measure of transmission rates. We stratified branching rates by treatment experience and risk factor.
To assess the impact of treatment on onward transmission of HIV, we compared the mean HIV branching rate between treatmentexperienced and treatment-naive lineages across the BC epidemic as a whole and among risk factors. Results: Phylogenetic branching rates were significantly lower among treatment-experienced HIV lineages relative to treatment-naive lineages (p B 0.001), implying reduced rates of HIV transmission in the former. Importantly, treatment experienced lineages had significantly lower HIV branching rates irrespective of HIV transmission risk factor (p B 0.001 for IDU, MSM and HET) or exposure to different antiretroviral drug classes (p B 0.001 NRTI, NNRTI, PI), suggesting these results are not driven by penetrance of health care into particular risk groups or therapeutic regimens. Conclusions: Our results provide independent evidence that antiretroviral HIV treatment has limited the onward transmission of HIV to new hosts. These results are based on a lineage level measure, are measured phylogenetically rather than epidemiologically and are replicated both across different risk exposure categories and different treatment regimens. Introduction: Sexual HIV-1 infection requires penetration of the virus across the mucosal barrier and the establishment of infection in target cells. It is widely accepted that only one or a small number of HIV-1 clones is successfully transmitted from the donor to the recipient. However, little is known about the phenotypic properties of the transmitted virus and the influence the phenotype plays in the genetic bottleneck selection process. Here we evaluated possible phenotypic differences between acute and chronic HIV-1 that may effect transmission fitness. Methods: We compared the genetic diversity of HIV-1 isolates from the female genital tract with isolates from the blood of the same donor by 454 pyrosequencing of the env region. Furthermore, we generated chimeric viruses from acute and chronic envelope genes using a yeast-based cloning strategy. The chimeric clones were then evaluated for host cell entry and receptor efficiency, sensitivity to entry inhibitors and for replication fitness in PBMCs, T cells and macrophages. Additionally we evaluated the transmission fitness across mucosal tissues by multi-virus competitions. Results: Both acute and chronic HIV-1 clones showed similar cell entry and receptor efficiency, sensitivity to inhibitors and replication fitness. Sequence analysis revealed that primary infection in the cervix resulted in a highly genetically diverse HIV-1 population, while only one or a few HIV-1 clones are in matched blood. Analysis of mixed competitions of acute and chronic HIV-1 env-clones in ex vivo tissue models revealed higher transmission fitness of acute isolates than chronic. We observed that higher transmission fitness was related to a reduced number of conserved N-linked glycans on the envelope of acute viruses. Conclusions: Chronic HIV-1 isolates appear to stay and replicate in the mucosal tissue, while acute isolates are preferentially bound by tissue residing dendritic cells/langerhans cells (DCs/LCs) and are subsequently transmitted to T cells. High levels of mannose binding proteins in tissue and lectins on epithelial cells may be responsible for a passive selection process of HIV-1 with fewer glycans for transmission due to reduced lectin binding. Introduction: HLA-driven HIV-1 immune escape mutations that persist following transmission could gradually spread in the viral population, compromising host antiviral immunity over time. We investigate the extent and correlates of escape mutation accumulation in HIV-1 Polymerase (Pol) sequences in North America from 1979 to present. Methods: HIV-1 RNA Pol and HLA class I genotyping was performed on 338 Historic (1979Á1989) and 278 Modern (2001Á2011) specimens from Boston, New York, San Francisco and Vancouver. HLA-associated polymorphisms were defined according to published lists. Historic and modern datasets were also investigated for the presence for novel HLA-associated mutations using phylogenetically-informed methods. Ancestral reconstruction of the HIV-1 epidemic founder sequence was performed using bayesian evolutionary analysis by sampling trees (BEAST) and Hypothesis testing using Phylogenies (HyPhy). Results: The estimated HIV-1 epidemic founder sequence dated to Â1969 and was near-identical to the modern subtype B consensus, suggesting no historic selective sweeps have occurred to shift the population consensus. No HLA-associated polymorphisms unique to the historic dataset were identified. Nevertheless, pairwise sequence diversity of modern HIV-1 sequences was approximately two-fold greater than historic sequences, with diversification predominating at HLA-associated sites (p B 0.0002). N 0 20 published HLA-associated polymorphisms were investigated for spread over time. Overall, their median ''background'' frequencies (in individuals lacking the restricting HLA) were 6.6% vs. 16.8% in historic and modern eras respectively (p 0 0.0004); polymorphism frequencies in reconstructed pre-1979 ancestral sequences were also consistent with gradual spread (p B 0.01). No correlation was observed between HLA allele frequency and relative spread of its associated polymorphisms (r 0 ( 0.13, p 0 0.8); rather, polymorphisms restricted by protective HLA alleles exhibited greater relative spread than those restricted by non-protective alleles (r 0 0.83, p 0 0.0047). Despite these overall increases, the frequency of many polymorphisms (e.g. B*51associated RT-I135T) remained consistent throughout the eras. Moreover, at the whole-sequence level, the median extent of adaptation of the typical circulating modern HIV-1 Pol sequence to the average North American host remains 0%, indicating a low overall risk of acquiring HIV-1 harbouring adaptations to one's HLA profile. Conclusions: Immune escape mutations in HIV-1 Pol have spread significantly in the population since the genesis of the North American epidemic; however, these changes are unlikely to herald immediate consequences for host antiviral immunity on this continent. Introduction: Dolutegravir is an integrase inhibitor that has shown a high genetic barrier against the emergence of resistant strains. No resistance substitution has been observed in treatment-naïve individuals treated with this drug. In tissue culture experiments, we have identified the R263K resistance substitution as a signature substitution for HIV resistance against dolutegravir, an observation that was later confirmed in highly treatment-experienced individuals. Given the importance of DNA integration in the establishment of HIV persistence, we tested the ability of dolutegravir-resistant HIV strains to integrate within human DNA. Methods: We used an Alu-mediated quantitative PCR to measure levels of integration of dolutegravir-resistant variants in primary human PBMCs. Levels of integration were normalized using the bactin gene. These experiments were performed using subtype B and C viruses. Results: Our results show that dolutegravir-resistant variants are impaired in their ability to integrate within human DNA. The integration levels of subtype B and C R263K variants were decreased by 30% and 40% compared to WT viruses, respectively. More important, the addition of several secondary substitutions failed to restore integration to a level comparable to WT and, in some cases, further lowered integration to only 20% of WT. Conclusions: The relative inability of dolutegravir-resistant variants to integrate within human DNA may contribute to a progressive decrease in the viral reservoir of individuals who develop these substitutions. http://dx.doi.org/10.7448/IAS.18.5.20352

TUAA0105
HIV-1 integrase variants retarget proviral integration and are associated with disease progression complex (TCC) and catalyzes viral genome insertion into the host chromatin. Methods: We combined structural information on the Prototype Foamy Virus TCC with conservation in retroviral IN protein alignments to determine aa-tDNA base contacts. We generated HIV-1 variants based on the observed variability at these positions, assessed replication capacities and performed integration site sequencing to reveal their integration preferences. Finally, we examined their effect on disease progression in a chronic HIV-1 subtype C infection cohort. Results: We identified retroviral IN amino acids affecting molecular recognition in the TCC and resulting in distinct local tDNA nucleotide biases. These residues also determine the propensity of the virus to integrate into flexible tDNA sequences. Remarkably, natural polymorphisms IN S119G and IN R231G retarget viral integration away from gene dense regions. Precisely these variants were associated with rapid disease progression in a chronic HIV-1 subtype C infection cohort. Introduction: The RV144 trial had a vaccine efficacy of 31%, and IgG antibodies to HIV-1 Envelope (Env) amino acid positions 120Á204 were identified as a predictor of decreased risk of infection. The IgG responses were binding to scaffolded Env antigen comprising the variable loops 1 and 2, flanked by partial regions of the first and second conserved domains. Since HLA class II molecules are expressed on antigen-presenting cells and modulate CD4 T-cell stimulation of antibody production by B cells, we tested whether HLA allotypes influenced vaccine response and efficacy. Methods: HLA-DRB1, DQB1 and DPB1 were genotyped in 760 individuals. Direct associations of 31 HLA class II alleles on Env (120Á204)-specific IgG were compared using linear regression models. Interaction of HLA with IgG response to Env (120Á204) was tested for an effect on acquisition by logistic regression. Results: Higher levels of Env (120Á204) IgG antibody directly correlated with the presence of DPB1*13 (p 0 0.002, q 0 0.05). Env (120Á204)-specific IgG antibody levels also associated with decreased risk of HIV-1 infection only with the presence of DPB1*13 (OR 0 0.29 per 1-SD increase, p 0 0.006). Both of these findings were replicated with Env antigens across multiple viral subtypes. Vaccine efficacy increased to 71% among individuals that were DPB1*13' and had higher levels of Env (120Á204)-specific IgG levels relative to the placebos. To delineate the anti-Env antibody responses in DPB1*13' individuals, we screened overlapping peptides to Env (120Á204). Frequency and magnitude of IgG response specifically to Env peptide positions 119Á133, which are involved in Env binding to CD4, associated with both presence of DPB1*13 and protection from HIV-1 acquisition among individuals with a DPB1*13 allele. Further evidence that immune responses induced by vaccination in individuals carrying DPB1*13 are different from those without DPB1*13 was apparent in significant viral sequence differences specifically in infected vaccine recipients with DPB1*13. Conclusions: DPB1*13-associated immune responses to vaccination is associated with decreased risk of HIV-1 acquisition. The specific differences in vaccine-induced responses elicited by individuals with HLA-DPB1*13 should be examined to determine the mechanism of protection of the vaccine. Understanding this HLA class II restricted mechanism will enable improved HIV vaccine design. Introduction: Nuclease-mediated gene editing in hematopoietic stem cells (HSCs) holds great promise in the cure of HIV infection, but little information is available regarding the feasibility of this approach in large animal models. To better evaluate the function of HSCs following gene editing, we have engineered cells with disrupted CCR5 alleles and assessed engraftment following autologous transplant in the pigtailed macaque, M. nemestrina. Disrupted CCR5 alleles in this model should directly protect against infection with simian/human immunodeficiency virus (SHIV). We are evaluating the extent to which CCR5-disrupted cell progeny engraft in macaques and testing whether these cells impede infection by SHIV. Methods: Zinc finger nucleases (ZFNs) are used to target the CCR5 locus in macaque HSCs. Engraftment and persistence of these autologous stem cells and stem cell-derived lymphoid and myeloid cells are measured ex vivo and in vivo. Animals are challenged with SHIV virus containing an HIV envelope; to approximate the status of an HIV ' patient, three-drug combination antiretroviral therapy (cART) is initiated following viral set point. Animals reach undetectable levels of plasma viremia prior to autologous transplant with gene-edited cells. Results: CCR5 targeting experiments yield up to 60% gene disruption in CD34 ' cells ex vivo, translating to approximately 5% steady state bulk disruption in vivo. Gene-disrupted cells demonstrate long-term, multilineage engraftment in macaques, including comparable levels of disruption in CD3 ' , CD20 ' , CD14 ' and granulocyte subsets. We also observe biallelic disruption of CCR5 in colony forming assays. Importantly, this approach is equally feasible in SHIV-naïve and in SHIV-infected, cART-suppressed animals. During robust SHIV replication, our preliminary data suggest that CCR5-deleted cells undergo positive selection in vivo.
Conclusions: This is the first demonstration of successful long-term multilineage engraftment of ZFN-edited, CCR5-deleted HSCs in a non-human primate (NHP) transplantation model. Our strategy results in robust levels of target gene disruption in vivo, yet does not impair HSC engraftment or differentiation. CCR5-deleted cells can undergo positive selection following challenge with SHIV. Our model enables the evaluation of novel therapeutic approaches not only in the context of acute HIV exposure, but also in the clinically relevant setting of pre-existing latent HIV infection. Introduction: A sterilizing cure for HIV-1/AIDS requires a strategy that eliminates all or at least some critical regions of the HIV-1 genome including the promoter positioned within the 5' LTR of the viral genome from cells serving as a stable reservoir for HIV-1, that is, resting CD4' T-lymphocytes, macrophages and brain microglia, with no adverse impact on the host cells. Methods: We have tailored CRISPR/Cas9 gene editing by bioinformatic screening, surveyor assay, and whole genome sequencing and have successfully developed a series of guide RNAs (gRNAs) that, in complex with Cas9 nuclease, effectively and safely eliminate integrated copies of HIV-1 proviral DNA in several human cell culture models. We assessed the impact of our gene editing strategy on viral transcription and replication by measuring the level of a GFP reporter and viral p24, upon reactivation of virus from the latent stage by treatment with phorbol myristate acetate (PMA) and trichostatin A (TSA). Results: We demonstrated inactivation of HIV-1 gene expression and replication in latently infected T-lymphocytes and promonocytic human cell lines as well as microglial cells upon excising the proviral DNA fragment corresponding to the entire coding sequence of HIV-1 spanning the 5' to 3' LTRs from the host chromosome by the CRISPR/Cas9 approach. Further, we demonstrate that the presence of LTR-specific multiplex of guide RNAs in cells expressing Cas9 acts as an efficient inhibitor blocking new HIV-1 infection. Conclusions: Our findings suggest that the strategy involving the newly developed CRISPR/Cas9 serves as a promising platform that can be advanced for eradication of HIV-1 and a cure for AIDS.  Methods: Surface expression of TIGIT and PD-1 on T cells was measured by flow cytometry from 103 HIV-infected participants (non-controllers (n 020), elite controllers (n020), antiretroviral (ART) suppressed (n 039), acutely infected (n 024)) and 20 ageand gender-matched HIV-uninfected controls. Quantified cell associated HIV (CA-HIV) DNA and RNA from purified CD4 ' T cells. Functional characterization of TIGIT ' T cells was performed, and ex vivo HIV-specific cytokine and proliferative responses were assessed in the presence of mAb targeting TIGIT and/or PD-1 pathways (anti-TIGIT mAb and anti-PD-L1 mAb). Results: In controls, a median of 28.05% of CD8 ' T cells was TIGIT ' (IQR 24.43,39.15). In comparison, we found a significant expansion of TIGIT ' CD8 ' T cells during chronic (median 57.1%, IQR 42. 6, 63.45; pB0.0001) and a non-significant trend in acute HIV infection (40.40%, IQR 28.3, 47.8; p00.08). TIGIT expression remained elevated despite viral suppression and associated with CD4 ' CA-HIV DNA. TIGIT ' and TIGIT ' PD-1 ' CD8 ' T cells inversely correlated with CD4 count (p 00.0016, r0(0.658; p 00.0024, r 0(0.385, respectively). TIGIT was expressed on !50% HIV-specific CD8 ' T cells; however, TIGIT ' T cells failed to produce cytokines in response to HIV antigens. Single blockade of TIGIT led to a significant increase of interferon gamma response to HIV Gag compared to no blockade (p 00.027). Co-blockade of TIGIT and PD-L1 led to greater restoration of HIV-specific CD8 ' T-cell proliferative responses (4.10%, IQR 1.46,22.28)  Introduction: Unbiased shRNA library screens have been used to identify novel genes and pathways that are required to maintain HIV latency and/or play an essential role in HIV transcription. One of the most prominent and robust ''hits'' was the oestrogen receptor type 1 (ESR-1). Methods: The activities of ESR-1 agonists, antagonists and oestrogen on proviral reactivation were studied in transformed and primary cell models of latency and in patient cells. Results: Specific antagonists of ESR-1, such as Tamoxifen and Fulvestrant, are weak proviral activators but sensitize latently infected cells to very low doses of the proviral activators TNF-a (NF-kB inducer) and SAHA (HDAC inhibitor). By contrast, a selective ESR-1 agonist propylpyrazoletriol and the broader spectrum ESR-1 agonist diethylstilbestrol strongly suppress both TNF-a and SAHA reactivation. In contrast to the ESR-1 antagonists, ESR-2 antagonists were not effective inducers of HIV expression in cell models. Co-activator 3 (SRC-3) is an upstream modulator of ESR-1, which was also identified as a hit in the shRNA screen. Blocking of SRC-3 by its inhibitor Gossypol also induces latent proviruses. Consistent with these results, specific knock-down of ESR-1 in Jurkat 2D10 cells with shRNA constitutively reactivates the latent provirus. In the HAART-treated patient samples, there was a modest increase of spliced HIV env mRNA when resting memory cells were treated with the ESR antagonists Fulvestrant or Tamoxifen alone. Proviral reactivation by ESR antagonists was synergistically increased by SAHA. By contrast, b-estradiol at concentrations in the physiological range led to dramatic reductions in proviral reactivation efficiencies. This is consistent with earlier observations that high levels of b-estradiol can block HIV replication. Conclusions: ESR-1 is a pharmacologically attractive target that can be exploited in the design of therapeutic strategies aimed at eradication of the latent reservoir. Our results show that drugs targeting ESR-1 can be used to either promote the re-activation of latent proviruses (antagonists) or limit their responses (agonists). The profound effects of b-estradiol on HIV reservoir reactivation suggest that there may be gender-specific differences in HIV reservoirs and highlight the need to tailor latency reactivation strategies for both men and women. Introduction: Asian HIV-infected patients generally experience higher systemic exposure to HIV protease inhibitors (PIs). We compared the efficacy and safety of switching to lower versus standard dose of atazanavir/ritonavir (ATV/r) in virologically suppressed second-line patients. Methods: Patients with plasma HIV-RNA (pVL) B50 copies/mL, ALT B200 IU/L and creatinine clearance (Crcl) ]60 mL/min while using PI-based regimens were randomized to ATV/r 200/100 mg (A200) vs. ATV/r 300/100 mg (A300) once daily with 2NRTIs at 14 sites in Thailand. Patients were followed every 12 weeks until week-48. Virological failure (VF) was defined as had confirmed pVL !200 copies/mL. Patients in ATV200 with VF resumed standard dose PI-based regimens.
Treatment groups were regarded as non-inferior if the lower limit of the 95% confidence interval (95% CI) for the difference in VF was above (10% in an intention-to-treat (ITT) analysis at 48 weeks. Results: A total of 559 patients were randomized (ATV200; N 0 279 vs. ATV300; N 0 280). At baseline, 85% used lopinavir/ritonavir, mean age was 42 years, body weight was 59 kg, CD4 was 539 cells/ mm 3 and total bilirubin was 0.85 mg/dL. At week 48, by ITT, the proportion of patients in ATV200 vs. ATV300 with pVL B200 copies/mL (difference, 95% CI) was 97.1% vs. 96.4% (0.68, (2.29 to 3.65), the proportions with pVL B50 copies/mL were 93.4% vs. 91.7% (1.71, (2.67 to 6.09). In per-protocol analyses, the proportions with pVL B200 copies/mL were 98.5% vs. 99.2% ( (0.72, (2.6 to 1.16). Only one ATV200 recipient developed major resistance (I50 L) to ATV. Discontinuation from randomized therapy was 8 (2.9%) in ATV200 (1 death, 2 VF, 1 jaundice, 2 rash, 2 others) and 21 (7.5%) in ATV300 (2 deaths, 7 jaundice, 7 rash, 5 others) (p 0 0.01). At week-48, there was no difference between treatment arms in CD4, total cholesterol, triglyceride and Crcl (all p ! 0.1). Comparing ATV200 vs. ATV300, the number (%) of patients with total bilirubin !3.2 mg/dL was 27 (10%) vs. 46 (17%) respectively (p 0 0.017). Conclusions: A lower dose of ATV/r-based regimens in Thais is noninferior compared to standard dose ATV/r. Higher dose ATV was associated with higher rates of treatment discontinuation. ATV/r 200/100 mg can be recommended as part of routine care for Asian adults who have well-controlled HIV infection on a PI-based regimen. Introduction: Despite a favourable efficacy and safety profile, TDFbased regimens may be associated with renal toxicity and reduced bone mineral density (BMD). TAF is a novel tenofovir prodrug in which TFV plasma levels are 90% lower than seen with TDF, thereby reducing off-target side effects. Week 48 data in patients switching to a once-daily fixed dose combination regimen containing elvitegravir 150 mg, cobicistat 150 mg, emtricitabine 200 mg and TAF 10 mg (E/ C/F/TAF) are described. Methods: Virologically suppressed adults (HIV-1 RNA B50 copies/ mL) with normal renal function taking one of four different TDFbased regimens for at least 48 weeks were randomized 2:1 to receive E/C/F/TAF or to retain their prior TDF-based regimen. Following randomization, all treatments were open-label. Results: Of 1196 patients completing at least 48 weeks of treatment, 799 received E/C/F/TAF and 397 received their prior TDF regimen: E/ C/F/TDF, 31.9%; EFV/FTC/TDF, 26.1%; ATV/RTV ' FTC/TDF, 26.8%; ATV/COBI ' FTC/TDF, 15.0%. Virologic success B50 copies/mL occurred in 95.6% on E/C/F/TAF and 92.9% on FTC/TDF ' 3rd Agent (weighted difference: 2.7%; 95% CI: (0.3% to '5.6%), with virologic failure in 1.1% and 1.3% of patients, respectively. General safety was similar between the arms. The mean percent change (SD) in hip BMD: '1.95% (3.0) for E/C/F/TAF and (0.14% (3.0) for FTC/ TDF ' 3rd Agent (p B 0.001); the mean percent change (SD) in spine BMD: '1.86% (3.1) for E/C/F/TAF and (0.11% (3.7) for FTC/ TDF ' 3rd Agent (p B 0.001). There were no cases of Fanconi Syndrome on E/C/F/TAF and one case on FTC/TDF ' 3rd Agent. For patients on either a COBI or RTV boosted regimen prior to randomization, the estimated GFR increased 1.8 mL/min for E/C/F/ TAF and decreased 3.7 mL/min for FTC/TDF ' 3rd Agent (p B 0.001). As shown in the table, multiple measures of quantitative proteinuria, including tubular proteinuria, had statistically significant improvements for patients switching to E/C/F/TAF as compared with those retaining their prior TDF-based regimen. Conclusions: These 48 week data demonstrate that patients who switch from a TDF-based regimen to E/C/F/TAF maintain high efficacy, have statistically significant increases in BMD and have statistically significant improvements in multiple tests of renal function, as compared with patients remaining on their prior TDF-based regimen. Introduction: Doravirine (DOR), an investigational NNRTI with a novel resistance profile, was compared with efavirenz (EFV) in a double-blind, randomized, 2-part study in ART-naïve HIV-infected patients who also received tenofovir/emtricitabine (TDF/FTC). In Part 1 (dose selection), DOR at 25, 50, 100 and 200 mg QD showed rates of virologic suppression similar to EFV 600 mg QD; DOR 100 mg was selected for ongoing evaluation. Part 2 enrolled additional patients to receive DOR 100 mg or EFV. Using data from Parts 1 ' 2 combined, DOR 100 mg showed significantly fewer CNS AEs than EFV at week 8.

Methods:
Week 24 efficacy and safety results were analyzed for all patients who received DOR 100 mg or EFV in Part 1 (n 0 42 per group) and Part 2 (n 0 66 per group) combined. Patients were stratified at randomization by screening RNA 5 or !100,000 copies/ mL. Primary endpoints were the proportion of patients with HIV RNA B40 c/mL (efficacy) and the proportion of patients with prespecified CNS events (safety). Results: Of the 108 patients randomized and treated per group, mean baseline RNA was 4.6 log 10 c/mL in both the DOR and EFV groups, and mean CD4 counts were 432 and 448 cells/mm 3 , respectively. Discontinuations in the DOR and EFV groups, respectively, were 4.6 and 12.0%. The most common drug-related clinical AEs in the DOR and EFV groups, respectively, were nausea (7.4%; 5.6%), dizziness (6.5%; 25.0%), abnormal dreams (5.6%; 14.8%), nightmares (4.6%; 8.3%) and sleep disorder (3.7%; 6.5%). Drug-related AEs leading to discontinuation were hallucination for DOR (n 0 1) and dysesthesia, hallucination, drug eruption, dizziness and disturbance in attention for EFV (n 0 5). The most common CNS AEs (all causality) were dizziness (DOR 9.3%; EFV 27.8%), insomnia (7.4%; 2.8%), abnormal dreams (6.5%; 17.6%) and nightmares (6.5%; 8.3%). Lab abnormalities of Grade 2 or greater were uncommon in both groups. Conclusions: DOR 100 mg qd demonstrated antiretroviral activity and immunological effect similar to EFV (each with TDF/FTC) and was generally safe and well tolerated during 24 weeks of treatment in ART-naïve, HIV-1 infected patients. Introduction: Raltegravir (RAL), though currently category C in pregnancy and not recommended for use in newborns, has been used in exceptional cases for prevention of mother-to-child-transmission (PMTCT). We report on the outcomes of 14 infants exposed in utero to RAL and the first newborn to be treated with RAL for six weeks for PMTCT. Methods: Infants born to mothers treated with RAL during pregnancy from the Centre Maternel et Infantile sur le Sida (CMIS) mother-child cohort between 2010 and 2014 were included in the study. RAL levels were tested on the first available stored plasma sample after birth, and in the treated newborn, therapeutic drug monitoring was done at weekly intervals. Results: In RAL-exposed infants, RAL was given to mothers at standard dosing of 400 mg BID, started at a mean GA of 30 weeks (range pre-conception-37.5 weeks). Indications for RAL included drug resistance and/or detectable viral load in the third trimester. Mean GA was 38.5 weeks (91.76), and mean birthweight was 3200 g (9540). There were no clinical adverse events noted among RALexposed infants (mean follow-up time 119 weeks, range 48Á144), and all were confirmed HIV negative. RAL levels tested in two exposed newborns at 16 and 30 hours of life were detectable at 0.9345 mg/L and 0.0381 mg/L, respectively, and undetectable in six other infants tested at days 4Á14. RAL granules for suspension (Merck, special access) were obtained for prophylaxis of a term newborn (39 weeks GA) from a mother with multidrug-resistant virus and started at 1.5 mg/kg BID, along with zidovudine and lamivudine at standard doses. RAL levels were consistently above the targeted trough for treatment (0.02 mg/L) ( Table 1) for the duration of therapy. RAL was well tolerated and at follow-up, the infant was confirmed HIV negative. Conclusions: RAL in late pregnancy had no adverse effects on infants exposed in utero. RAL treatment in the newborn at doses of 1.3Á1.6 mg/kg BID was well tolerated and resulted in therapeutic drug levels. Given detectable levels of RAL in the first 30 hours of life in exposed infants, the timing and role of RAL in PMTCT should further be considered. Introduction: BMS-955176 is a second-generation HIV-1 maturation inhibitor that targets the HIV-1 Gag polyprotein, inhibiting the last protease cleavage event between capsid protein p24 and spacer peptide 1, resulting in the release of immature, non-infectious virions. Ten days of BMS-955176 monotherapy resulted in maximum median declines in HIV-1 RNA that plateaued at Â1.64 log 10 c/mL at Introduction: Both protease inhibitors (PI) and non-nucleoside reverse transcriptase inhibitors (NNRTI) have been associated with acute hepatotoxicity, but their long-term effect on liver fibrosis remains uncertain. We explored rates of change in liver fibrosis as measured by the aspartate-to-platelet ratio index (APRI) among HIV-hepatitis C (HCV) co-infected users of modern PI-or NNRTI-based regimens.
Methods: Data from a Canadian prospective multicentre cohort were analyzed for 397 HCV PCR' persons who initiated antiretroviral therapy in or after 2000, with regimens at cohort entry comprised of a backbone of either Tenofovir/Emtricitabine or Abacavir/Lamivudine with a PI or NNRTI as the anchor agent. The natural logarithm of the APRI score was the outcome of interest. Three multivariate linear regression analyses with generalized estimating equations were performed. Analysis 1 (intention-to-treat) used baseline exposure to PI or NNRTI; analysis 2 (per protocol) was restricted to persons with a viral load under 1000 copies/mL and censored participants when the class of anchor agent was changed; analysis 3 (as treated) allowed for changes in the class of anchor agent during follow-up. Results: At cohort entry, 74% of participants were male, the median age was 44 years and 56% had used alcohol in the past six months. Therapy was started a median of 1.9 years before cohort entry (IQR: 0.3, 5.0), 70% used a PI and 69% were on a backbone of Tenofovir/Emtricitabine. PI use was associated with a median increase in APRI per 5 years of 16% (95% CI: 3%, 30%) in Analysis 1, 16% (95% CI: 0%, 32%) in Analysis 2 and 13% (95% CI: (1%, 27%) in Analysis 3. NNRTI use was not significantly associated with change in APRI in any of the three analyses, as shown in the Table. Conclusions: PI use seems to be associated with a faster progression of liver fibrosis, as measured by the median change in APRI score over five years. The consistency of estimates across the three analyses suggests that this is not the result of the type of patients using PI-based regimens, although we could not account for all patient characteristics influencing the choice of an anchor agent. Introduction: Historically HIV co-infection was considered a negative predictor of HCV response to treatment with interferon/ribavirin (IFN/RBV). For sofosbuvir-based regimens, HIV/HCV patients have achieved similar sustained virologic response (SVR) rates as HCV mono-infected patients. We evaluated the safety and efficacy of the IFN-free, RBV-free, single tablet regimen of ledipasvir/sofosbuvir (LDV/SOF) in HCV genotype 1 or 4 patients co-infected with HIV-1 in the Phase 3 ION-4 study. Methods: HCV treatment naïve and experienced HIV co-infected patients on stable, approved antiretroviral (ARV) regimens were enrolled and received LDV/SOF (90 mg/400 mg) once daily for 12 weeks. Patients with compensated cirrhosis were eligible. Permitted concomitant ARVs included tenofovir and emtricitabine (TDF ' FTC) with raltegravir (RAL), efavirenz (EFV) or rilpivirine (RPV). Safety evaluations included adverse event (AE) and standard laboratory parameter monitoring in addition to enhanced renal toxicity monitoring, CD4 count and HIV-1 RNA levels. The primary efficacy endpoint was SVR12.
In the TURQUOISE-I trial, response rates were 94 and 91% in this population when treated for 12 and 24 weeks, respectively. We report the week 12 post-treatment sustained virologic response rates (SVR12) by baseline characteristics. Methods: Patients were randomized to receive OBV/PTV/r ' DSV ' RBV for 12 (N 0 31) or 24 weeks (N 0 32). Eligible patients in this open-label study were treatment-naïve or pegIFN/RBV-experienced with or without cirrhosis, had CD4' count ]200 cells/mm 3 or CD4 ' % ]14%, and plasma HIV-1 RNA suppressed while receiving a stable atazanavir-or raltegravir-inclusive antiretroviral (ART) regimen. Results: Sixty-three patients were enrolled, of whom 92% were male, 24% black race, 19% with compensated cirrhosis and 16% with a prior null response to pegIFN/RBV treatment. Two patients in the 12week treatment group (1 withdrawn consent, 1 HCV relapse), and three in the 24-week treatment group (1 on-treatment virologic breakthrough, 2 post-treatment HCV re-infections) did not achieve SVR12. The patients with on-treatment breakthrough and relapse were both genotype 1a-infected with prior null response to pegIFN/ RBV and had F4 fibrosis (cirrhosis). High SVR12 rates were achieved in patients with historically difficult-to-cure characteristics including those with IL28B non-CC genotype, high viral load, prior treatment failure and advanced liver disease (Table 1). Lower baseline CD4' T-cell counts did not negatively affect SVR12 rates. The regimen was well tolerated with no discontinuation due to adverse event or serious adverse event.
Conclusions: In HCV genotype 1 patients co-infected with HIV-1, OBV/PTV/r ' DSV ' RBV achieved high rates of SVR12 regardless of baseline host, viral and disease characteristics whether treated with 12 or 24 weeks of therapy. Introduction: The fixed-dose combination of grazoprevir (GZR, MK-5172, 100 mg, an NS3/4 protease inhibitor)/elbasvir (EBR, MK-8742, 50 mg, an NS5A inhibitor), an interferon-free, ribavirin-free, once-daily tablet has shown robust efficacy and safety in diverse populations. C-EDGE co-infection is an on-going phase-III study evaluating GZR/EBR among treatment-naïve, HIV/HCV co-infected patients with GT1, 4, or 6. Methods: Enrolled patients were on a stable antiretroviral (ARV) regimen (tenofovir or abacavir, and lamivudine or emtricitabine; and either raltegravir, dolutegravir or rilpivirine) with a CD4 !200 cells/ mm 3 and an HIV RNA B20 copies/mL, or were HIV treatment-naive with CD4 !500 cells/mm 3 and VL B50,000 copies/mL. All patients received open-label GZR/EBR for 12 weeks. The primary efficacy endpoint was sustained virologic response at follow-up week 12 (SVR12). Adherence was assessed using electronic study medication diaries and pharmacokinetic (PK) assessment. All patients underwent testing for HCV resistance associated variants (RAVs) at baseline, and at failure and follow-up in those with virologic failure. Phylogenetic analysis was performed to distinguish relapse from reinfection. N0Number of subjects included in the analysis. n (%) 0Number of subjects who achieved SVR12 and the percentage calculated as (n/N)*100. c Two subjects were lost to follow-up; one patient was discontinued for taking a prohibited concomitant medication, and one subject's FW12 visit was outside the analysis window. d At baseline in the NSSA gene, one of the relapses had L31M/L RAV and one of the relapses had the Y93S RAV. The other three relapses had the WT NSSA gene at baseline. Introduction: All-oral regimen with daclatasvir (DCV; NS5A replication complex inhibitor)'sofosbuvir (SOF; NS5B polymerase inhibitor)9weight-based ribavirin (RBV) has demonstrated high sustained virologic response (SVR) rates in HCV mono-infected patients. This analysis reports SVR4 and SVR12 results from an ongoing multicentre compassionate use programme (ATU) in France. Methods: HIV-HCV co-infected patients with advanced liver disease from 221 centres have been included since March 2014. All patients received DCV'SOF QD for 12 or 24 weeks, with RBV added at the physician's discretion. Baseline characteristics, virological response rates and adverse events were collected through a standardized form. We report interim SVR rates at 4 and 12 weeks after the end of treatment for patients who have completed treatment to date. Results: Of 562 patients enrolled, 73.8% were males, median age was 52.3 years (30Á74), 395 (71.0%) were cirrhotic and 460 (82.6%) were treatment-experienced. Child Pugh was A085.4%, B012.9%, C 01.7%. Genotype distribution was as follows: 387 GT1 (69.7%), 2 GT2 (0.4%), 72 GT3 (13.0%), 93 GT4 (16.8%) and 1 GT6 (0.1%), 7 missing data. Median HCV-RNA was 6.10 logUI/mL (1.08Á7.97). Combined antiretroviral therapy included: NRTI in 88%, PI in 36.4%, NNRTI in 23% and INI in 63.7% of the patients. Baseline median CD4 count was 551/mm 3 (0Á1922). HIV-RNA was undetectable in 505 patients (98.4%). RBV was added to DCV'SOF in 67 patients (12.0%). Treatment duration was 24 weeks in 478 (85.1%) and 12 weeks in 84 (14.9%) patients.
Methods: An open-label, matched-pair, cluster randomized controlled trial (CAPRISA 007) was undertaken in 3217 consenting male (n 01517) and female (n01700) grade 9 and 10 students. A locally developed HIV prevention programme, My Life! My Future!, was actively implemented in all 14 schools. Seven schools (n 01592 students) were randomly assigned to receive; in addition, cash incentives (maximum of $175 over two years) for fulfilling any combination of four conditions; annual HIV testing, performance in school tests, participation in My Life! My Future!, and a written report on their community involvement project. HSV-2 and HIV serology was undertaken at baseline, 12 months and 24 months. In the intent-to-treat analysis, incidence rate ratios (IRRs) and p-values were adjusted for the matched-pair cluster design. Results: HSV-2 prevalence at baseline was 9.0% in CCI schools and 7.3% in control schools. During follow-up, there were 319 new HSV-2 infections, with an incidence rate of 6.2 per 100 person-years in CCI Introduction: Low uptake of male circumcision has been a major challenge to scaling-up and maximizing the HIV prevention impact of voluntary medical male circumcision (VMMC) services in eastern and southern Africa. There is limited evidence on effective demand creation strategies for VMMC that address reported barriers to male circumcision. Building on insights from behavioural economics, we assessed whether providing compensation for opportunity costs of time or lottery-based rewards can increase VMMC uptake among men in Nyanza Province, Kenya. Methods: Uncircumcised men aged 21Á39 years were provided information on VMMC services and randomized in 1:1:1 ratio to two intervention groups or a control group. One intervention group was offered compensation of US$12.50 conditional on VMMC uptake. Compensation was provided in the form of food vouchers valid at shops in the study region. A second intervention group was offered the opportunity to participate in a lottery with high-value prizes upon undergoing circumcision. The primary outcome was VMMC uptake within three months. Results: Among 903 participants enrolled, those randomized to receive compensation of US$12.50 had the highest VMMC uptake (8.4%, 26/308), followed by those receiving lottery-based rewards (3.3%, 10/302) and those in the control group (1.3%, 4/299). Logistic regression analysis showed that compared to the control group, the US$12.50 group had significantly higher VMMC uptake (Adjusted odds ratio (AOR) 7.1; 95% CI 2.4Á20.8). Participants in the lotterybased rewards group were not significantly more likely to become circumcised than participants in the control group (AOR 2.5; 95% CI 0.8Á8.1). The effect of providing compensation of US$12.50 was largest among participants who were contemplating circumcision at the time of enrolment. Conclusions: Providing conditional economic compensation was effective in increasing circumcision uptake among men in a short time period. The results are consistent with studies showing that small incentives can modify health behaviours by addressing barriers such as opportunity costs of time and present-biased decisionmaking. Contrary to findings from studies in high-income countries, lottery-based rewards did not significantly increase circumcision uptake. Testing economic interventions in other settings and applying them to different HIV behaviours can be useful for assessing the generalizability of the findings. Introduction: Homelessness has been identified as an important structural barrier to effective antiretroviral therapy (ART) utilization among HIV-infected people who use drugs (PWUD). However, the potential effect of reducing homelessness on viral suppression rates at the community level is unknown. We used an imputation-based marginal modelling approach to estimate change in the prevalence of viral suppression among HIV-infected PWUD, if homelessness were eliminated from the population. Methods: We used data from a cohort study of community-recruited PWUD in Vancouver, Canada. Of note, HIV/AIDS treatment and care is provided free of charge in this setting. Persons were eligible to participate if they were HIV-infected and used an illicit drug in the month prior to enrolment. We assessed self-reported baseline housing status in the past six months. Viral suppression was defined as HIV RNA viral load B50 copies per mm 3 at first study visit. We estimated the effect of homelessness on viral suppression using modified-Poisson regression, adjusting for demographics, socioeconomic characteristics, trauma history, depression, addiction treatment and other confounders. Then, a marginal modelling approach was applied. First, we imputed the outcome probability for each individual while manipulating the exposure (homelessness) to never exposed, and then averaged these probabilities across the population. Bootstrapping was conducted to calculate 95% confidence limits. with high levels of intrinsic motivation to adhere to ART may require less external motivation, such as cash incentives. In addition, PLHIV who disproportionally value the present and heavily discount the future may be less likely to adhere to ART, a behaviour with future benefits and present costs. We measured these constructs among antiretroviral therapy (ART) initiates at four HIV care and treatment clinics in Shinyanga Region, Tanzania. Methods: We analyzed data collected from in-person interviews between December 2013 and December 2014 with food-insecure, HIV-infected adults who initiated ART in the past 90 days. Temporal discount rate, the rate at which individuals discount future costs and benefits, was measured using a bidding process to assess the acceptable percent increase of a hypothetical monetary offer they would receive in three months compared to a smaller amount received today. Future health expectations were assessed for one year from now, and intrinsic motivation for ART adherence was measured as the mean score (range: 0Á3) on a Likert-scale using questions in the Treatment Self-Regulation Questionnaire.
Conclusions: These data indicate high levels of both intrinsic motivation for ART adherence and optimism towards future health among food-insecure ART initiates in Tanzania, suggesting that interventions designed to strengthen and sustain intrinsic motivation may be appropriate. The high discount rates indicate a greater focus on the present; thus, interventions aiming to overcome the shortterm cost barriers to adherence and care (e.g. time, transport and competing needs) in order to achieve future gains may be highly effective among this population. Introduction: The South African disability grant (DG) has been theorized to incentivize poor recovery by tying grant receipt to AIDS sickness. Prior to 2008, many official guidelines defined qualifying AIDS disability as a CD4 count below 200 mmHg, and this recommendation persists unofficially. We make two predictions: 1) The population distribution of CD4 counts will have an observable discontinuity with excess mass just below the CD4 qualification threshold of 200 mmHg, and 2) individuals receiving the grant will recover more slowly around this threshold than those who do not, due to threat of grant loss. Methods: The analysis utilizes a two-stage panel regression methodology to absorb individual trends and identify differential recovery rates around the CD4 threshold of 200 mmHg. (1) All individuals approached for pre-screening who were age 18 or older, male at birth, lived in the State, self-reported HIV negative status and reported having at least one male sexual partner in last 12 months.
(2) Includes all individuals approached at pre-screening (1) who: a) reported 2 or more male condomless anal sex partners OR anal sex with HIV positive partner OR STD diagnosis in last 12 months; and b) had a negative HIV test results.
(3) Individuals who enrolled the study.
(4) Decline represents the sum of refusals in all steps. Indivuduals who agreed to participate but did not show up at the screen or enrollment visit were considered as declining. Oral Abstracts 53 or the partner did not know when he last tested (48% vs. 40%, p 0 0.02). Of 222 men with HIV-positive partners, 60 and 64% decided whether to have sex/use condoms based on their partners' ART use or VL, respectively. CAI with an HIV-positive partner was more common among men who reported ART/VL serosorting compared to those who did not (79% vs. 57%, p 0 0.03), but testing newly positive for HIV was less common among men who reported ART/VL serosorting compared to men who did not (1/120 (1%) vs. 2/23 (9%)).
Conclusions: Among Seattle MSM, nuanced seroadapative behaviours such as ART/VL serosorting and using the recency of a partner's HIV test to inform sexual decision-making are common. The high prevalence of these behaviours suggests they could impact HIV incidence rates, but the individual-and population-level effects of these behaviours are uncertain.

TUAC0402
Efficacy of a network intervention in reducing HIV incidence among people who inject drugs in Ukraine: preliminary results from a clustered randomized trial Introduction: HIV incidence among people who inject drugs (PWID) in Ukraine is among the highest in the world. We assessed the efficacy of two interventions, a network-based peer intervention combined with HIV testing and counselling (T/C combined; experimental condition, N 0 614) versus HIV testing and counselling alone (T/C alone; control condition, N 0 592), in reducing HIV incidence among PWID. Methods: Between 2010 and 2014, 1205 HIV-seronegative PWID were recruited from street settings in Odessa, Donetsk and Nikolayev. We used a clustered randomized design that consisted of 611 networks and included: peer-leaders; first wave network members; and second wave network members. Participants were randomly assigned to interventions in groups of 16 and interviewed at baseline, 6 and 12 months. Interviewers and HIV tester/counsellors were not blinded to intervention. Cox regression was used to compare HIV incidence between groups, incorporating GEE to account for clustering.
Results: Preliminary results suggest that mean age and duration of injection was 31.8 and 11.7 years, respectively; 75% were male. In the past 30 days, 43% injected daily, 46% always injected with others, 78% had ]1 sex partner. HIV incidence was 19.0 per 100 personyears (py) in the experimental condition compared to 31.8 per 100 py in the control condition (p B 0.001). PWID in the experimental condition had a 39% reduced hazard for HIV seroconversion versus the control group (p B 0.001). With each year increase in age, the hazard increased by 5% (pB0.001), and with each injection episode in the past 30 days, the hazard increased by 0.6% (p 0 0.02). Those who were sexually active in the last 30 days had a 26% reduced hazard (p 0 0.03).
Conclusions: The combined network-based peer intervention and was more efficacious in reducing HIV incidence among PWID in Ukraine than T/C alone. Programme experience with this approach in Vietnam is limited. Therefore, the acceptability and feasibility of this approach was assessed in two high-burden provinces. We present preliminary ART outcomes. Methods: Village health workers, PWID peer educators, and health staff were educated on the new approach and the benefits and risks of immediate ART initiation. Since April 2014, HTC has been recommended to PWID every six months, and immediate ART, that is, initiation irrespective of CD4 count, has been offered to PWID living with HIV in Thai Nguyen and Thanh Hoa provinces. Following consent, PWID were followed for 12 months. HIV viral load (VL) was assessed before ART start (baseline) and at months 6 and 12. Introduction: There is extensive documentation of the direct clinical benefits of antiretroviral therapy (ART) adherence leading to plasma HIV RNA-1 viral load suppression. However, very little is known about the social, socio-economic and ancillary clinical benefits of ART adherence, particularly among people who use illicit drugs (PWUD). Methods: We used longitudinal data from a prospective cohort of community-recruited HIV-positive PWUD in Vancouver, Canada, a setting of free and universal access to HIV care. Participant data were linked to comprehensive HIV clinical monitoring and ART dispensation records. We developed a series of generalized linear mixed effects models, adjusting for potential confounders. Models examine whether, among ART-exposed individuals, becoming optimally adherent to ART medication (i.e. ]95% using a validated measure of pharmacy dispensation) resulted in associated social, socio-economic and ancillary clinical benefits, such as relationship initiation, transitioning out of homelessness, entering employment, ceasing involvement in illegal or prohibited income generation activity (e.g. street-based income generation, sex work, drug dealing or other illegal activities) and enrolling in addiction treatment.

TUAC0406LB
Modelling the impact of improvements in the cascade of care for chronic hepatitis C among people who inject drugs (PWID) in Montré al, Canada tolerability raises the question of whether treatment could be used to prevent HCV transmission. Our objective was to assess how improvements in the cascade of care can impact future HCV incidence, prevalence and complications among PWID in Montré al.

Methods:
We used a dynamic model to simulate HCV transmission and natural history among active PWID in Montréal from 2015. The reference scenario (scenario 1) was the current cascade of care including new DAA as standard treatment (see Table 10). HCV prevalence and incidence after 10 years and the number of liver complications avoided after 40 years were estimated under different conditions: decreased time from chronic infection to diagnosis (scenario 2), greater adherence to treatment (scenario 3), improved treatment rate (scenarios 4 and 5) and a combination of these interventions (scenario 6). Due to a lack of data on time to linkage to care (time between diagnosis and first consultation related to hepatitis C), simulations considered three such intervals: one, three and five years. A thousand simulations were performed per scenario. Results: Scenarios 2 and 3 showed similar results for HCV prevalence (53.3Á59.5%) and incidence (9.1Á10.3/100 p-y) after 10 years, and less than a 3.4% difference in the number of liver complications after 40 years relative to the reference scenario. Improving access to treatment (scenarios 4 and 5) demonstrated a great decrease in all outcomes. When combining all interventions (scenario 6), prevalence and incidence decreased until 26.9% and 4.9/100 p-y, respectively, and the number of liver complications until 39.3%, depending on the time to linkage to care. Results: Failure to initiate care constituted the largest but most rapidly declining category of HIV mortality, predicted to decline from 47% of HIV-associated deaths in 2015 to 37% in 2020. Late initiation was the second-largest and declined more slowly because increasing CD4 counts at initiation were partially offset by growing numbers of patients initiating care. LTFU was the third-largest but the most rapidly-growing category of HIV mortality. Programmatic data about re-initiation of care is lacking, but under the assumption that half of patients LTFU will re-initiate care, deaths LTFU were not expected to surpass deaths due to late initiation by 2020. Those receiving care constituted 3% of HIV-associated deaths, mostly among those receiving treatment rather than in pre-ART care. This proportion remained constant over time because the growing population on treatment was offset by improvements in treatment quality, such as expansion of virological monitoring and availability of second-line regimens.
Conclusions: More data are required to fully characterize the spatial heterogeneities and dynamics of the care cascade. Nevertheless, trends revealed by model-based triangulation were consistent with findings in well-studied populations such as demographic surveillance sites. Failure to access care remains the largest but most rapidly declining category of HIV mortality. http://dx.doi.org/10.7448/IAS.18.5.20384

TUAD0102
Optimizing tools for measuring short-term antiretroviral adherence from pharmacy refill data to predict virologic outcomes in resource-limited settings Introduction: Estimates of adherence to antiretroviral therapy (ART) using pharmacy refill data have outperformed self-report and can identify patients at risk for virologic failure, especially in settings where viral load testing is limited. Uncertainty exists about the best method to estimate adherence using pharmacy refill data and the optimal duration of data to predict virologic outcomes.
Methods: We identified individuals over 18 on first and second line ART from a national private sector (Aid for AIDS) and regional public sector (Khayelitsha) programme. The area under (AUC) the receiver operating characteristic (ROC) curves for virologic suppression (VS) (viral load B 400 copies/mL) was used to compare three short-term adherence estimate methods: 1) ''crude'' Á refills divided by months, 2) ''average'' Á days ART dispensed plus unused ART from prior dispensing divided by interval duration, and 3) ''gap'' Á interval duration less the number of days without ART coverage, divided by interval duration. The ''gap'' method is different to the ''average'' method as it does not allow the adherence estimate to be artificially increased by additional ART dispensed after a possible ''gap'' in ART coverage. The interval for pharmacy refill varied from 3 to 12 months. Results: We included 56,472 individuals from the private programme (median 1.7 years, 65% female) and 24,466 from the public programme (median 2.1 years, 65% female). The ''gap'' method consistently outperformed the other two methods (see Figure 1). In the public programme, the ''gap'' method was 12% less potent due to significant data capture errors. Longer pharmacy refill intervals outperformed shorter intervals (''gap'' ROC 0.837 (12 months), 0.812 (3 months)) in the more powered private dataset. When further separated by regimen line, the ''gap'' method for second line was superior but the ROC AUCs estimates did not vary by the pharmacy refill interval. We identified possible cut-points for virological failure (VL ! 1000 copies/mL) in the private programme: 80 and 72% for first and second line therapy. respectively. Conclusions: Adherence measures that identify gaps in pharmacy data were superior and consistent across programs and regimen Methods: We used stepped wedge cluster randomization to institute a Data-to-Care programme in Seattle-King County, Washington, DC, USA. We attempted to provide the intervention to all eligible persons in the county, initiated in a randomly assigned order based on cases' medical provider (the cluster). Eligible persons had 1) no CD4 or viral load (VL) reported for ]12 months or 2) VL !500 and CD4B350 at last report. Programme staff contacted patients to offer assistance relinking to HIV care and treatment. The primary study outcome was time to viral suppression (first VL B200 reported to surveillance), starting from the programme implementation date. The secondary outcome was care relinkage (first VL or CD4 reported). We used Cox Proportional Hazards to compare outcomes during control periods (before initiation of each case's provider cluster) to intervention periods (after initiation of the cluster). We censored cases at the time of ascertainment of relocation or death, or end of the observation period. The intention-to-treat (ITT) analysis included all eligible cases; the modified ITT (mITT) analysis excluded cases found to have died or moved. Results: The ITT and mITT analyses included 1008 and 824 persons, respectively ( Figure). Study staff provided the individual intervention to 165 persons, of whom 73% relinked to care within one month and 70% achieved viral suppression within six months. The incidence rate Oral Abstracts 61 (IR) of viral suppression was higher during the intervention versus control periods, but the difference was not statistically significant (Table). The HR associated with the intervention was higher among persons with last VL !500 in the past year than persons with no labs in the past year.
Conclusions: Data-to-Care programmes can relink some persons to HIV care, but the effect of these programmes may be limited by the large numbers of persons who have moved, died or cannot be reached, and the rate of relinkage to care in the absence of the intervention. Focusing on persons with recently reported unsuppressed VLs rather than a gap in lab reports may be more effective and efficient. Results: Comparison of the intervention and control sites indicated that clients in m2m-supported health facilities showed improved uptake of PMTCT services (see Table 1). Introduction: Novel strategies are needed to increase retention in, and adherence to prevention of mother-to-child HIV transmission (PMTCT) services, and ultimately enhance PMTCT implementation effectiveness in sub-Saharan Africa.
Objective: To determine whether small, increasing cash payments conditioned on attending scheduled clinic visits and receiving proposed services can increase the proportion of HIV-infected pregnant women who attend PMTCT visits and adhere to available PMTCT services through six weeks postpartum. Methods: Newly diagnosed HIV-infected women, 532 weeks pregnant, were recruited at antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned in a 1:1 ratio to an intervention group that received compensation on the condition they attend scheduled clinic visits and accept offered PMTCT services ($5 plus $1 increment at each subsequent visit) or to a control group that received usual care. Outcomes assessed included: retention in care measured by loss-to-follow-up (LTFU), and adherence to PMTCT services (attend all scheduled clinic visits and accept proposed services) through six weeks postpartum. Analysis was by intention to treat. The study is registered with clinicaltrials.gov: NCT01838005. Results: Between April 2013 and August 2014, 612 potential participants were identified, 545 were screened and 433 were enrolled and randomized ( Figure 1). Participants in the two groups had similar

Introduction: Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) partnered with the Children's Investment Fund Foundation (CIFF) and
Zimbabwe Ministry of Health and Child Care (MOHCC) to roll out the WHO 2010 and later 2013 prevention of mother-to-child HIV transmission (PMTCT) guidelines. EGPAF, MOHCC and CIFF developed a ''critical path'' with a prioritized set of performance indicators, with population-based targets, that are the main drivers of impact. The indicators are reviewed quarterly, as they largely draw on routine monitoring data. If performance is lagging in a particular indicator, a diagnosis is undertaken to identify the reason and corrective action explored. Critical path indicators and results for quarter 2, 2012 are in Figure 1. The EGPAF-CIFF goal was to reduce mother-to-child transmission (MTCT) of HIV from about 25% in 2009 to less Â9% by 2015.
Methods: Health facilities (HFs) were supported to implement the guidelines through training and mentoring during site support visits, among other assistance. PMTCT data were collected quarterly from all supported HFs, and performance of each indicator compared with established targets during data-driven programme reviews held by EGPAF, partner programme officers and MOHCC district staff. Reasons for under-performance and improvement strategies were identified and implemented in subsequent quarters through mentoring and coaching of HF staff to improve service provision and patient follow-up. Methods: The study randomized clusters and evaluated three interventions: 1) community leader engagement (participation in the Community Leaders Institute, mentoring to engage in community action); 2) Community Days and dialogues (community event with structured dialogues on MNCH/PMTCT, and provision of health services) and 3) male and female MCH classes (set of four structured sessions led by peer facilitators). This sub-study analyzed early ACCLAIM results on earlier access to ANC services. Baseline gestational age (GA) data at first ANC visit were collected from health facilities before implementation and quarterly after implementation. We compared proportions of women attending ANC during first half of pregnancy ( 520 weeks' gestation) at baseline and 6Á12 months after interventions.
Results: A total of 277 trained community leaders held !7000 community meetings and engaged!27,000 individuals in dialogues at Community Days, identifying and addressing barriers, misperceptions and harmful gender norms. The proportion of women attending ANC 520 weeks' gestation across the three countries increased by 36% from baseline; this trend was significant across the quarters observed (p B0.0001).
Conclusions: In our study, community based interventions have resulted in significant greater than one-third increase in ANC 520 weeks' gestation in three African countries. On-going data analysis will provide data on the full potential of open community dialogues by trained community leaders to change community norms and health-seeking behaviours such as early access to ANC and MCH/ PMTCT services. site of viral entry. However, the ratio of IgG to IgA varies between compartments. In this study, we compared the antiviral properties of IgG and IgA antibodies with the same epitope specificity at ratios found in genital secretions. Subsequently, we investigated whether the combination of antibody recognizing discrete epitopes but from the same isotype resulted in improved antiviral activities. Methods: CH31, b12, 2F5 and 7B2 mAbs binding to soluble HIV-1 BaL gp140 Env and kinetics parameters of these interactions were determined by competitive enzyme-linked immunosorbent assay and Bio-Layer Interferometry (BLI). HIV-1 BaL virus capture by the panel of mAbs was quantified by p24 ELISA, antibody mediated viral aggregation (AMVA) was determined using Nanoparticle Tracking Analysis (NTA) and neutralization activity by TZM-bl neutralization assay.
Results: We demonstrated that IgGs captured significantly more virions than IgAs, and this was correlated with higher association rate constants whereas dIgA presented the ability to mediate viral aggregation. Strikingly, the combination of dIgA and IgG recognizing the same epitope did not elicit any additive effects. In contrast, IgG prevented dIgA binding to HIV-1 BaL gp140 Env and its ability to capture and aggregate HIV-1 BaL virions. However, mixtures of IgGs or dIgAs recognizing distinct epitopes but from the same isotype resulted in synergistic effects with higher proportions of captured viruses; antibody mediated viral aggregates and neutralization activities.
Conclusions: This study compared the ability of IgG and dIgA to prevent HIV-1 infection with respect to the ratio IgG and dIgA found in genital secretions. Collectively, these results suggest that the combination of antibody targeting different epitopes provides enhanced general antiviral activities. Nonetheless, antibody binding to the same epitope but of different isotypes may lead to competition and inhibition of antiviral functions. http://dx.doi.org/10.7448/IAS.18.5.20393

WEAA0102
Anti-V3/glycan and anti-MPER neutralizing antibodies, but not anti-V2/glycan-site antibodies are strongly associated with higher anti-HIV-1 neutralization breadth and potency   Introduction: The ''kick and kill'' strategy for the cure of chronic HIV-1 infection involves unmasking cells harbouring the latent viral reservoir followed by their immune elimination. We hypothesize that a broad priming of de novo rather than memory HIV-1 specific cytotoxic T-lymphocytes (CTL) will be required to effectively target the autologous HIV-1 reservoir, and that this ''kill'' can be best achieved using specifically programmed type-1 dendritic cells (DC1). Methods: Mature, IL-12p70 producing DC1 were generated using a combination of either TNFa, IL-1b, poly IC, IFNa and IFNg or CD40L and IFNg. Mature, IL-12 deficient DC were generated using either a combination of TNFa, IL-1b, IL-6 and PGE2 or CD40L alone. CD8 ' T cells were purified from HIV-1 negative donors, and both naive (primary) and memory CD8 ' T cells were isolated from HIV-1 infected Multicenter AIDS Cohort Study participants who were on virus-suppressive cART for several years. These cells were stimulated with autologous DC loaded with HIV-1 Gag peptides or autologous AT2-inactivated HIV-1. Resulting CTL activity was assessed by IFNg ELISPOT and antiviral cytotoxicity assays targeting autologous HIV-1 infected CD4 ' T cells.
Results: DC1 proved far superior to the IL-12-deficient DC for inducing primary CTL responses in both infected and uninfected donors. Importantly, DC1 required CD40L ''help'' at the onset of priming cultures for successful CTL induction and expansion. Both primary and memory CTL each responded to distinct autologous HIV-1 Gag peptides with robust IFNg production. However, a broader targeting of known MHC class I-restricted epitopes was achieved by the primary CTL responders than the memory cells. Importantly, despite substantial IFNg production by both T cell subsets, the primary CD8 ' T cells were significantly superior to restimulated memory T cells in eradicated HIV-1 infected CD4 ' T cells in the CTL assays.
Conclusions: We demonstrate that naïve T cells from HIV-1 infected persons on cART have the repertoire and ability to be primed by high IL-12p70-producing DC1 to effectively target the HIV-1 reservoir, while memory CTL responses are suboptimal. These findings highlight the importance of directing HIV-1 curative strategies towards the induction of de novo rather than memory HIV-1-specific CTL responses.  Conclusions: Our studies demonstrate that RA-mediated imprinting for gut-homing is associated with HIV permissiveness in CCR6' but not CCR6-T-cells and reveal molecular mechanisms underlying these differences. These findings will orient the discovery of new therapeutic strategies aimed at limiting HIV permissiveness, and subsequently the size of HIV reservoirs, specifically in gut-homing Th17 cells. Introduction: Infants bear a high burden of HIV-1 and tuberculosis (TB) infections, especially in sub-Saharan Africa. We previously demonstrated that the double auxotroph Mycobacterium tuberculosis (Mtb) strain mc 2 6435, engineered to co-express SIV Gag, was safe and immunogenic in neonatal macaques. Here, we tested the efficacy of an oral mc 2 6435 prime/intramuscular MVA-SIV boost regimen to protect against repeated low-dose oral SIVmac251 challenge in infant macaques. Methods: The study included 75 infant rhesus macaques. Mockvaccinated infants (n015) received saline. Vaccinated animals (n060) received attenuated auxotroph Mtb-vaccines with or without SIV gag/ env inserts (n053) orally, or BCG (n07) intradermally at birth at nine weeks, infants were exposed to a once-weekly low-dose oral SIVmac-251 challenge regimen. Plasma viraemia was determined by real-time PCR. Cellular immune activation was determined by flow cytometric analysis in blood and tissues, soluble plasma markers were measured with a Procarta 37plex. Statistical analysis for risk-per-SIV exposure was determined by SAS and Kaplan-Meier plots; immune parameters were analyzed using Kruskal-Wallis with multiple Dunn's comparison.
Results: A single administration of the mc 2 6435 vaccine at birth induced persistent immune activation that was associated with oral SIV acquisition after fewer challenges compared to mock-vaccinated infants. The human BCG vaccine resulted in similar enhanced acquisition of SIV, and BCG-vaccinated infants showed higher peak viraemia compared to mock-and Mtb-vaccinated infant macaques. The potential for enhanced oral SIV acquisition was independent of the mycobacterial vaccine strain, immunization route and boost regimen.
Analysis of blood and tissue samples revealed that both Mtb and BCG vaccines induced immune activation of myeloid cell populations and CD4 ' T cells, potential target cells of SIV. Immune activation was detected as early as three weeks post-vaccination and persisted for several months. chronically treated patients, however these were higher than those found in LTNP (Figure 1a and 1b). Interestingly, similar levels of integrated HIV-1 DNA were found in Recent SRCV compared to the Chronic ART cohort (p 0 0.104), confirming very fast seeding of the reservoir (Figure 1b). Levels of usRNA were significantly lower in early compared to chronically treated cohort (p 0 0.007), indicating a lower transcriptional activity in early treated patients and similar to LTNP (p 0 0.615). Furthermore, early treated patients exhibited a higher CD4/CD8 ratio as compared to chronically treated patients (p 0 0.009), suggesting lower levels of residual immune activation.
Conclusions: Our data demonstrate that long-term early treated patients have smaller reservoir size as compared to patients treated during chronic infection, however not reaching levels found in LTNP. Interestingly, the reservoir dynamics in terms of 2-LTR and usRNA as well as the CD4/CD8 ratio in early treated patients are comparable to LTNP. Lower AUC 0Á24 week for HIV RNA was also associated with nonreactive 2G EIA at week 24 (p 5 0.001, Figure 1). Seroreversion was uncommon. One of 23 individuals with reactive 2G EIA at baseline was non-reactive at week 24; 11 of 207 demonstrated transient 2G EIA reactivity at week 12.
Conclusions: Approximately 40% of individuals who initiated treatment in AHI maintained non-reactivity to 2G EIA after 24 weeks of ART. Rapid ART initiation and HIV RNA decline as well as low HIV RNA and high CD4 at baseline predicted subsequent serological non-reactivity. HIV serologic non-reactivity is likely due to low viral burden, further supporting the benefits of early initiation of ART. Introduction: The goal of HAART, in established HIV infection, is to obtain virological success (plasma HIV-RNA level (pVL) B 40 copies/mL) associated with CD4 increase at 24 weeks of treatment (W24). Therefore, we analyzed whether such W24 end-point is also pertinent for patients treated for primary HIV infection (PHI). Methods: We conducted a 10-year retrospective analysis of the immuno-virological response in 55 adults receiving HAART within three months after diagnosis of PHI. Genotypic resistance tests were performed before HAART and at W24 for patients with virological failure (VF) as well as HAART plasma concentrations. Results: Patients were mostly men (n = 48, 87%), White European (n = 50, 91%), MSM (n = 29, 52%) and mean age 35.9 years. At baseline, mean pVL was 2.6.10 6 cp/mL (8.10 3 to !10 7 ) and mean CD4 count 479/mm 3 (77Á1003). Patients were mostly infected with subtype B HIV-1 (n = 30, 54%). Due to the evolution of treatment recommendations over the 10-year study period, nine different combinations of HAART were used, including mostly TDF/FTC (n = 38, 69%) and a protease inhibitor as third agent (n = 49, 89%). At W24, 44/55 (80%) patients had pVL B 40cp/mL, whereas 11/55 (20%) had low residual pVL (45Á391 cp/mL; mean: 155). In these latter patients, we observed neither mutation associated with resistance nor inefficient drug concentration. VF was correlated in univariate analysis with a significantly higher mean baseline pVL (p = 0.03) and a significantly lower mean baseline CD4 count (p = 0.04) than patients with undetectable pVL at W24. There was no relationship between age, sex, ethnicity, source of contamination, HAART combination or VF at W24. Conclusions: Our results show that 24 weeks is too short to achieve virological success in patients with high pre-treatment pVL associated with low CD4 count. These data highlight that the usual W24 endpoint to conclude virological success may not be appropriate in PHI. Conclusions: This is the first study to examine the independent effect of social cohesion on client condom refusal among sex workers in the global north. Findings suggest that community collectivization and sex worker-led empowerment efforts can have a direct protective effect on HIV risk reduction and shifting social norms among clients in the sex industry. Given public health and human rights concerns around new Canadian laws introduced this year to further criminalize sex workers' ability to work together (C-36), these findings highlight the urgent need for legal reforms and a structural framework that better promotes sex workers' ability to more formally collectivize, including sex worker-led efforts in the HIV response. FSWs during non-working hours. Detailed notes were taken as FSWs discussed their expenditures, income-generation and saving and borrowing strategies. We also collected quantitative financial diary data from a sub-sample (n 0 33) of FSWs. Women who kept financial diaries did so for six weeks, meeting weekly with researchers to systematically discuss and record all financial transactions. Participant observation notes were coded and analyzed using qualitative thematic analysis. Data from financial diaries were analyzed using descriptive statistics.
Results: All women in our sample reported sex work as their primary source of income; many supplemented their income with cash gifts and modest loans from clients, family or peer FSWs. Food, clothing and transportation accounted for the highest amounts of relativelyfixed spending. Around one-quarter of all expenses were related to costs of sex work (e.g. ''work'' clothing, beauty care, personal hygiene products, right to work payments, police pay-offs, etc.). Qualitatively, both income and expenditures were reported to fluctuate monthly (e.g. around pay day), seasonally (e.g. around holidays) and unexpectedly (e.g. illness or financial shocks   ), however, self-reported ART coverage among HIV-positive FSW was just 39% (Figure 1). After adjusting for time since HIV diagnosis, women who had intimate partners and had not disclosed their HIV status to them were over 50% less likely to be on ART than FSW not in relationships (Table 1). Mothers and women with fewer clients per month were also statistically significantly less likely to be on treatment than nonmothers or FSW with more clients in the adjusted analyses. Among treatment eligible FSW not on ART, 16/61 (26.2%) had previously been initiated but were no longer taking ART. Conclusions: HIV testing was common among FSW in this setting, and awareness of HIV status was relatively high, however, efforts are needed to improve ART uptake and retention in this population. Though viral suppression data were not available, this likely represents additional fall-out from the care cascade. Disclosure to partners and family appear to be key barriers to treatment uptake. Building HIV disclosure skills and efficacy may help to improve health outcomes for FSW living with HIV and prevent onward transmission. Introduction: There are few data on patient outcomes from community-based models to deliver antiretroviral therapy (ART), with previous research focused on models for home-based delivery. We describe outcomes of ART patients decentralized to communitybased adherence clubs (CACs) and compare outcomes with patients managed within a facility-based model.

Methods: This analysis included 8150 adults initiating ART from 2002Á
2012 at a public sector clinic in Gugulethu, South Africa, followed until the end of 2013. From June 2012, stable patients (ART ! 12 months, suppressed viral load) were referred to CACs. Kaplan-Meier methods estimated time to outcomes among CACs stratified by gender and age (youth: 15Á24 years of age and older patients: !25 years of age). Long-term follow-up (LTFU) was compared between CACs and facilitybased care using proportional hazards models with time-varying covariates and inverse probability weights of CAC participation. Results: Of the 2113 patients (68.8% female, 7.4% youth) decentralized to a CAC, 94% were retained on ART after 12-months. After the first CAC visit, LTFU among CAC patients was 5.6 and 6.4% at 12months ( Figure 1a) and viral rebound 2.2 and 1.5% (Figure 1c), for men and women, respectively. LTFU was higher in CACs among youth compared to older patients (Figure 1b) At referral, all RAPID-eligible or -ineligible patients with new diagnosis received a standard package of multidisciplinary services for social support, education, risk and stigma reduction; labs were drawn; and regular provider follow-up was arranged. The RAPID intervention consisted of 1) same-day access to an on-call provider; 2) a five-day ART supply facilitated by and 3) an accelerated process for insurance benefits. Focusing on a July 2013ÁDecember 2014 programme period, survival analysis was used to compare time to achieving viral load (VL) B200 copies/mL between patients receiving and not receiving the RAPID intervention, and also between these patients and historical controls from two eras of ART provision at SFGH: pre-RAPID universal (2010Á2013) and CD4-guided (2006Á2009). Results: We studied 227 newly diagnosed outpatients receiving RAPID (n 039), universal (n0149) or CD4-guided (n 039) ART. No patients had private insurance and 27% were homeless; mean (range) CD4 was 381(2Á1031)/mm 3 and VL 4.6 (1.6Á7.0) log 10 cp/ mL. Time to VL B200 cp/mL was significantly faster in RAPID patients versus both contemporaneous and historical controls (p B0.001; see Figure). Median (IQR) time to VL B200 for RAPID ART was 56 (40Á87)  A child with a score of one or more had eight times odds (95% CI: 6Á11) of testing HIV positive with a sensitivity of 80% (95% CI: 75Á 85), specificity of 66% (95% CI: 64Á67). Sensitivity was higher in those aged 10 years or more (86% vs. 70%, p = 0.001). Overall, we needed to test 11 children to identify one HIV positive. Conclusions: The algorithm maintained its integrity and demonstrated that it is a sensitive tool screening older children at risk of  Results: By December 2014, 1340 (84%) of 1600 ART providing health facilities and 17,238 health workers were trained on the new guidelines. There was 1.4-fold increase in the number of HIV infected children newly initiated on ART from 5540 in JuneÁDec 2013 to 9145 in JanÁJune 2014. The increase was greater among children aged 5Á14 years and 2Á4 years (2.4 and 1.4 fold, respectively); however, there was no change among the under two year old's ( see Figure 1). Pregnant adolescents constituted 2.5% (229/9145) of children less than 15 years of age enrolled on ART in JanÁJune 2014. Paediatric ART coverage has increased from 22% (43,481/193,500) in December 2013 to 27% (51,305/193,500) in June 2014. Conclusions: Expanding eligibility criteria increases initiation of older children on ART but to enrol those who are at higher risk of disease progression/mortality, more work needs to be done to improve early infant diagnosis (EID) and early case detection.
http://dx.doi.org/10.7448/IAS.18. 5.20413 WEAD0204 Immunization practice and vaccine safety perception in centres caring for children with prenatally acquired HIV: results from the Pediatric European Network for Treatment of AIDS survey Introduction: Perinatally HIV-infected children are more susceptible to vaccine preventable infections and vaccine induced immunity is less robust than in healthy children because of precocious waning of protective immunity. For this high risk population it is important to design specific vaccine schedules to define correct dosing and to set accurate correlates of protection. This survey was performed to give an overview of current vaccinations practice among paediatricians looking after vertically HIV-infected children.
Methods: An online questionnaire regarding vaccination practices in HIV-infected children was completed by investigators from the PENTA network. Data were collected between November 2013 and March 2014.
Results: A total of 88 experts in the management of paediatric HIVinfection from 46 different units looking after 2465 patients completed the questionnaire. The majority of units (72%) did not perform routine childhood immunizations in HIV centres. Vaccination histories were incomplete for 40% of the studied population. Influenza, pneumococcal conjugate vaccine and human papilloma vaccine immunizations are widely administered (93, 89 and 83% of units, respectively). Varicella and Rotavirus vaccinations are less recommended (61 and 24% of the units, respectively). Monitoring of vaccine responses is employed in 72% of centres. Serology appears to be the most feasible assay among the different centres (90%), mostly performed with immune-enzymatic assays. Conclusions: Vaccination practices for perinatally HIV-infected children still vary widely between countries. A crucial issue is the incomplete adherence to varicella vaccine. Indeed only in few countries varicella vaccination is universally recommended for children at national. More efforts should be made to standardize mandatory and recommended vaccinations, as well as to guide timing of serological assays. The majority of units carry out immuno-enzymatic tests to evaluate specific antibody levels. However, methods vary with different cut-offs of protection and units of measurement employed. Moreover, especially in high risk groups (e.g. children who started late HAART or performed vaccinations before treatment), researches on the development of novel methods to assess protective immunity and accurate correlates of protection are needed. The ultimate goal will be to design individualized vaccine schedules, developed on therapeutic and immunological features of individual patients, optimizing the chances of them gaining robust long-term vaccine induced protection. http://dx.doi.org/10.7448/IAS.18.5.20414

WEAD0205LB
Lower ANC attendance and PMTCT uptake in adolescent versus adult pregnant women in Kenya Control and Prevention, Nairobi, Kenya. 5 Kenyatta National Hospital, Nairobi, Kenya. 6 Kenya Medical Research Institute, Nairobi, Kenya. Presenting author email: kronen@fhcrc.org Introduction: Although rates of pregnancy and HIV infection are high among Kenyan adolescent women, their engagement in Prevention of Mother-to-Child HIV Transmission (PMTCT) services is poorly characterized. We hypothesized that adolescent women show lower engagement in the PMTCT cascade than adult women, from antenatal care (ANC) attendance to HIV testing and antiretroviral (ARV) uptake. Methods: We conducted a nationally representative cross-sectional survey of mothers attending 120 maternal child health clinics selected by probability-proportionate-to-size-sampling in Kenya in JulyÁDecember 2013, with a secondary survey oversampling HIVpositive mothers in 30 clinics. Self-report questionnaires verified by clinic booklets recorded ANC attendance, HIV testing, ARV use and maternal characteristics. Data were compared between adolescent (age B20) and adult mothers. Differences in maternal characteristics were assessed by Chi-square test. Logistic regression was used to analyze ANC attendance and HIV testing among all women and ARV uptake among HIV-positive women. Results: Among 2521 mothers surveyed, 278 (12.8%) were adolescents. Adolescents were less likely than adults to have above primary education ( . Among 2359 women who attended ]1 ANC visit and were not known to be HIV-positive prior to pregnancy, 2298 (96.1%) received HIV testing during pregnancy. Testing rates were not significantly different between adolescents and adults. Among 288 HIV-positive women who attended ]1 ANC visit and were not on HAART prior to pregnancy, 20 (6.9%) were adolescents, and 243 (84.4%) used any ARVs for PMTCT. Adolescents were less likely to use ARVs than adults (65.0% vs. 85.8%, OR[95% CI]00.31 [0.12Á0.81]). Conclusions: Adolescent mothers showed poorer ANC attendance and lower uptake of ARVs for PMTCT. This calls for further study on barriers to ANC and PMTCT services among adolescent women and development of targeted interventions to improve uptake and retention of this vulnerable population through the PMTCT cascade. Methods: We conducted a population-level analysis of HRU for individuals having received a CD4 test after HIV diagnosis. All individuals 18 years or older in British-Columbia in the modern HAART-era (post-September 2006) were included. Using linked comprehensive administrative health databases in a probabilistic model-based clustering analysis with 14 HRU measures, we estimated parameters by maximum likelihood using the expectation maximization (EM) algorithm. Individuals with estimated parameters maximizing the probability of belonging to a similar HRU cluster were classified with each other, and the optimal number of clusters was estimated by the Bayesian Information Criterion. The analysis was conducted across CD4 count stratification ( !200 cells/mm 3 ; B200 cells/mm 3 ). Results: Our study included 941 individuals with at least one year follow-up (median age 40, 21% female) and with a CD4 count obtained between September 1st, 2006 and March 31st, 2011. Individuals with CD4 B 200 clustered in two HRU patterns. The high cost cluster (N 0 68; mean $18,169(SD$21,432)), driven by lengthy HIV-related emergency hospitalization stays (76.5% with ! 7 days), had costs more than double the low cost cluster (N 0 147; $6811($13,592)). Individuals with CD4 ! 200 were best classified in four clusters. The high cost cluster (N 0 74; $15,831($19,180)) was characterized by non-HIV ER hospitalizations (100% ] 1 day, 55.4% ! 7 days) and high prevalence of mental health issues. The second highest cost cluster (N 0 60; $5058($5152)) was characterized by short-term non-HIV elective hospitalizations (48.3% 0 1 day). The two lower cost clusters both had no hospitalizations; the higher (N 0 425; $3378($6454)) with much more frequent physician visits and medication use than the lowest cost cluster (N 0 167; $1291($7969)). Conclusions: Even within relatively homogeneous cohorts in terms of disease progress at time of linkage to HIV care, individuals were found to have heterogeneous HRU patterns. Identifying classes of individuals according to HRU can help inform clinical response, as well as the design of public health interventions to optimize HIV care. Background: HIV prevalence is declining in all key affected populations in Armenia (people who inject drugs, men who have sex with men, prisoners and female sex workers); however, there are increases among labour groups who seasonally migrate to countries of higher HIV prevalence. We conducted a modelling study to assess the impact of optimizing the national strategic plan to minimize HIV incidence and AIDS-related deaths by 2020. We determined optimal funding levels for all programs to best achieve the strategic plan and, in particular, examined the outcomes required for migrant programs to warrant increased funding. Methods: We used the Optima model to perform epidemiological and economic analyses. Demographic, epidemiological, behavioural and HIV programme cost data were obtained for Armenia from 2000 to 2014 and used to inform the model. Through internal and external consultations, assumptions were generated on what coverage levels among targeted populations could be attained for different investments, as well as their expected outcomes. A sensitivity analysis on migrant HIV testing and counselling programs was conducted around assumptions based on observed data. Results: According to Optima's optimization algorithm, shifts in funding allocations are required to minimize incidence and deaths by 2020. The largest emphasis should be on antiretroviral therapy (ART), as optimal allocations nearly doubled the investment in treatment from 17 to 24% of the total budget. This is projected to avert almost 25% of new infections and 50% of AIDS-related deaths by 2020 compared to levels if 2013 spending were maintained. We show that funding for seasonal migrant programs should be maintained through to 2020 at 5% of the total budget. Sensitivity analysis demonstrated that these programs are cost-effective to fund if the coverage threshold for HIV testing and counselling for seasonal migrants, as illustrated in Figure 1B, can be achieved. Conclusions: Optimization of HIV/AIDS investment in Armenia could significantly reduce HIV incidence and AIDS-related deaths by 2020, particularly by focusing more on antiretroviral therapy. We have also identified thresholds for programme performance, prior to their scale-up, which can be used to evaluate whether they should be scaled-up or down in the future.

WEAD0303
Has performance-based financing accelerated progress towards controlling the HIV epidemic? An impact evaluation of Mozambique's HIV-focused PBF programme Yogesh Rajkotia; Omer Zang; Pierre Nguimkeu and Iva Djurovic ThinkWell, Maputo, Mozambique. Presenting author email: yrajkotia@collaborativedev.com Introduction: As performance-based financing (PBF) gains global traction, evidence around its effectiveness to accelerate the elimination of HIV is needed. We evaluated the impact of a PBF programme implemented by Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), on the provision of HIV, PMTCT and MCH services. We also examined the temporal effects of PBF to better understand its lifecycle both in terms of onset and duration of effect. Finally, we evaluated the impact of PBF on non-incentivized services. Methods: The impacts of PBF in Gaza (South) and Nampula (North) provinces were analyzed using a retrospective observational study design in which PBF provinces were matched with control provinces Eighteen indicators related to HIV, PMTCT and MCH services were reviewed. Due to regional heterogeneity, we evaluated the North and South as separate experiments. Beginning January 2011, up to eleven quarters of data from 134 PBF facilities after matching (84 North and 50 South) were used. Data sources include PBF programme data and health management information system data. Our econometric framework employed a multi-period, multi-group difference-in-difference model on data that was matched using propensity scoring. The regression design employed a generalized linear mixed model with both fixed and random effects, fitted using the seemingly-unrelated regression (SUR) technique. Results: PBF resulted in positive impacts on MCH, PMTCT, and paediatric HIV programme outcomes. The majority of the 18 indicators responded to PBF (77% North and 66% South), with at least half of the indicators demonstrating a statistically significant increase in average output of more than 50% relative to baseline. Most adult HIV (excluding pregnant women) initiation and retention indicators did not respond to PBF. On average, it took six quarters of implementation for PBF to take effect, and impact was generally sustained thereafter. Indicators were not sensitive to price, but rather inversely correlated to the level of effort associated with marginal output. No negative impacts on incentivized indicators nor spill-over effects on non-incentivized indicators were observed. Conclusions: The PBF programme in Mozambique has shown to produce large, sustained increases in the provision of PMTCT, paediatric HIV and MCH and should be considered as a powerful alternative to traditional input-based financing.  in switching after detection of treatment failure, possibility of treatment interruptions, background mortality and monitoring strategies. We applied the model to all countries in sub-Saharan Africa assuming 12 scenarios that combine different future ART scaleup scenarios (accelerated until universal coverage; stable; no future scale-up), monitoring (routine viral load monitoring in all or only selected countries), and retention and switching (including or excluding possibility of treatment drop-out and delayed switching). The input parameters were chosen to fit the numbers of patients on first-and second-line ART in 2005Á2013 to observed estimates. Results: If the scale-up of ART is accelerated across the region, patients are retained in care, switching is immediate, and all countries implement routine viral load monitoring, the number of patients on second-line ART will increase to 4.1 million by 2030 (17% of all patients on ART). In a scenario with a stable scale-up and realistic drop-out and switching delay, the corresponding numbers were 2.8 million (15%) with universal routine viral load monitoring, and 2.2 million (12%) with routine viral load monitoring only in selected countries.
Conclusions: We expect that by 2030, 2Á3 million people will receive second-line ART in sub-Saharan Africa, but the number of patients in need may be over four million. Routine viral load monitoring, timely switching and minimizing treatment interruptions will further increase the number of patients on second-line ART. Introduction: The private sector is a key HIV service provider in Kenya, but few data on the cost of private service provision are available. The lack of cost data has inhibited the design of reimbursement mechanisms and health insurance packages, as well as policy decisions on private sector financing. This study estimated unit costs for private sector HIV services disaggregated by facility type and level, as a contribution to ongoing efforts to implement health insurance products covering HIV services. Methods: Cost and service volume data were collected from 149 private sector facilities in 2013 as part of a nationwide systematic sampling of public and private healthcare costing study supported by GIZ, the USAID-funded Strengthening Health Outcomes Through the Private Sector (SHOPS) Project Kenya, and the Ministry of Health. The MASH (Management Accounting System for Hospitals) tool was used to analyze data. Multiple facilities were eliminated due to lack of complete data with only 60 used. Results: Average unit costs per inpatient day and per outpatient visit were generated by sector and facility levels 2Á4 (as defined by Kenya Norms and Standards 2006). HIV specific unit costs estimated included for HIV counselling and testing (HCT) services and provision of ART. The authors estimated operational costs, but were unable to estimate capital costs following lack of data. Average outpatient visits ranged from Ksh. 689 to 1036 in level 2 and level 4, respectively. ART visit costs ranged from Ksh. 1575 to 3660 across the facilities sampled. HCT visit services ranged from Ksh. 537 to 1151 across level 2 and 4 facilities, respectively.

Conclusions:
The study contributed to health financing policy discussions in the provision and financing of HIV services in Kenya. Data generated was presented to insurers and providers who expressed intentions of using it for decision making. Possible applications include design of HIV care inclusive insurance products and advising reimbursement decisions regarding the same. Providers offering HIV services can also use it to benchmark their efficiency. Due to poor record keeping in most facilities, only 60 of the 149 facilities had enough data for analysis. There's a need to support facilities to improve record keeping. Introduction: A putative case of transmission of an X4 HIV strain from a CCR5wt/wt donor to a homozygous CCR5D32/D32 recipient was retrospectively identified in the Vancouver Injection Drug Users Study. We collected longitudinal intrahost deep-sequence data and applied ancestral phylogenetic reconstruction methods to characterize HIV transmission and evolution in this rare event.
Methods: Pairwise genetic distances separating donor and recipient bulk plasma HIV gag, pol, nef and env-V3 sequences were the lowest in the cohort (e.g. 0.0027 substitutions/nuc site in Gag vs. cohort median 0.06), identifying them as a putative transmission pair. The estimated transmission date (ETD), calculated as the midpoint of the recipient's last HIV-negative and first positive dates, was Aug/01. Donor plasma/Peripheral blood mononuclear cells (PBMCs) were available at (13, (7, (1 and '35 months from ETD; recipient plasma/PBMCs were available '5, '6 and '12 months from ETD. Env-V3 from plasma-RNA and PBMC-DNA were triplicate amplified, pooled equally and deep-sequenced (Roche 454). BEAST and HyPhy were used to reconstruct phylogenies, estimate multiplicity of infection and reconstruct transmitted/founder (T/F) viruses from plasma-derived deep sequences from donor and recipient.
Results: Despite infection with the same X4 HIV strain, donor CD4 count was 20 cells/mm 3 within 1.5 years of infection whereas the recipient's remained !270 cells/mm 3 . Donor/recipient plasma viral loads were comparable (Â4.5 Log). All 10 ancestral reconstructions were consistent with transmission of a single X4 T/F virus between May and August 2001. The estimated T/F virus sequence was identical to the co-dominant variant (36%) observed in the recipient's first ('5 month) timepoint. This sequence was also observed in 0.09% of donor plasma and 33.5% of PBMC at month (1, suggesting minority variant transmission. In the donor, reversion of Â60% of the total plasma virus population to an R5 phenotype occurred by 50 months postinfection; in contrast, the recipient's dominant V3 sequence steadily diversified over time but remained consistently X4. Conclusions: Results highlight the utility of phylogenetic reconstruction applied to deep-sequence data to characterize T/F viruses and intra-host evolution in transmission pairs. Differential CD4 depletion and V3 evolution in these individuals, despite acquisition of a nearidentical X4 strain, underscores the critical role of host genetics on HIV evolution/pathogenesis. Most KIR genes were more protective for EUR individuals than for AMI individuals. KIR'HLA-Bw4 combinations were more frequent in individuals with EUR component (p B0.05) while KIR'HLA-C1 combinations were more frequent in AMI individuals (p B0.05). Interestingly, the previously observed protective associations KIR3DS1/3DL1'HLA-Bw4 80Ille were not evident, neither in the entire cohort, nor in EUR individuals. KIR2DS4 in combination with HLA-C1 seemed to be protective for individuals with higher EUR component.
Conclusions: This is the first time that differences in HIV disease progression associated with genetic stratification are shown in a single population. Further studies involving fine stratification of genetically diverse populations, exploring expression of other genes involved in HIV control are warranted to understand differences observed in this study. http://dx.doi.org/10.7448/IAS.18.5.20421

MOPDA0103
Dasatinib preserves SAMHD1 antiviral activity in CD4' T cells treated with IL-7 Introduction: HIV-1 post-integration latency in quiescent CD4'T cells is responsible for viral persistence despite antiretroviral treatment. It was proposed that the increase in proviral load in HIV-infected patients after IL-7 treatment was due to homeostatic proliferation of memory CD4'T cells. We determined previously that IL-7 increased HIV-1 infection through phosphorylation and subsequent inactivation of the restriction factor SAMHD1. Now we analyzed SAMHD1 phosphorylation in PBMC from patients enrolled in ACTG 5214 study (NTC00099671), in order to elucidate the role of IL-7 in HIV-1 proviral integration and persistence and whether this could be related to SAMHD1 inactivation. In addition, we determined that the tyrosinekinase inhibitor Dasatinib preserved SAMHD1 antiviral activity, avoiding IL-7-mediated HIV-1 infection. Methods: PBMC samples obtained from 10 patients enrolled in ACTG 5214 study (NTC00099671), collected before (day 0) and 4 after administration of IL-7. PBMCs obtained from two patients diagnosed with chronic myeloid leukaemia (CML), on chronic treatment with Dasatinib. Resting CD4'T cells from healthy donors obtained by negative selection from PBMCs. Phosphorylation of SAMHD1 at T592 was determined by immunoblotting and flow cytometry. Proviral integration was analyzed by TaqMan qPCR. Dasatinib (BMS-354825, Sprycel) was provided by Bristol-Meyers Squibb.
Results: 1) IL-7 (1 nM) induced SAMHD1 phosphorylation, interfering with its antiviral activity. 2) IL-7-mediated SAMHD1 phosphorylation greatly increased HIV-1 infection in purified CD4'T cells, increasing early and late retrotranscription, as well as proviral integration. 3) A significant increase in pSAMHD1 was observed in central memory CD4'T cells from HIV-infected patients treated with IL-7 (ACTG 5214). 4) Dasatinib completely inhibited SAMHD1 phosphorylation at 75 nM, interfering with HIV-1 retrotranscription and consequently, with proviral integration. 5) CD4'T cells from patients with CML treated with Dasatinib showed lower expression of SAMHD1 phosphorylated. Conclusions: By inducing SAMHD1 phosphorylation, IL-7 increases susceptibility of resting CD4'T lymphocytes to infection, leading to HIV persistence. SAMHD1 regulation plays a central role in the establishment of HIV-1 reservoirs and represents a major target for therapeutic intervention. Dasatinib is the first compound currently used in clinic that has been described to preserve the antiviral function of an innate factor such as SAMHD1. We have identified a footprint of viral Tat expression in latent HIV infected cells. Suboptimal levels of Tat arise from an IRESmediated translation of chimeric cell-HIV mRNAs that arise from alternative splicing of read-through mRNA transcripts from cellular promoters adjacent to latent integrated provirus. To simulate the role of RNA-processing pathways in HIV latency, we recapitulated the low level Tat-expression from cellular-provirus read-through transcripts present in HIV latency reporter cells that express low-level Tat using the native IRES that underlies the first coding tat exon and a second, different Click-Beetle-Luciferase, expressed from a CMV-IE promoter to test specificity. Novel compounds and drug combinations were screened to identify HIV-specific drugs that synergize with this latent-viral signature. HIV-specific activation was further examined in T-cell models. Methods: We screened 5600 compounds in a known drug library and a library comprising of 114,000 drug-like compounds using a 293. IRES HIV-specific reporter cell line that contained CMV-CBG/LTR-CBR luciferase reporter system. Hits were identified that activated the LTR-CBR while having a minimal effect on the CMV-CBG reporter. A rigorous selection verification included 11-point titration in the normal and counter-screen assay cell lines, in dsRED-expressing J-Lat cells, and activity in primary cell models of latent HIV. Results: From this screening cascade, two known BET bromodomain and four HDAC inhibitors were found to significantly and specifically activate LTR promoter whereas compounds such as Vorinostat exhibited non-specific activity and increased global transcription. Several drug combinations that target different mechanisms implicated in HIV-1 latency were found to synergistically reactivate the virus with high potency. Importantly, seven novel compound classes were identified in the 114,000 compound library screens. Analogues of these seven classes were obtained and examined in 11-point assay with CMV-CBG/LTR-CBR reporter cell lines and 106 compounds gave a clear indication of early structure-activity relationships.
Conclusions: Seven novel classes of HIV-specific latency purging drugs were found that activate HIV provirus in synergy with a low intrinsic expression of HIV RNA and Tat. These novel small molecule leads warrant further development to iteratively enhance their HIV-1 specificity and potency. We also identified new drug combinations that synergistically activate expression from the latent HIV-1 LTR. http://dx.doi.org/10.7448/IAS.18.5.20423

MOPDA0105
HIV rebound and meningoencephalitis following ART interruption after allogeneic hematopoietic stem cell transplant: an investigation of the source of HIV rebound Introduction: Allogeneic hematopoietic stem cell transplant (alloHSCT) with uninterrupted antiretroviral therapy (ART) is being investigated as a component of HIV eradication strategies. In the two ''Boston patients,'' alloHSCT resulted in the disappearance of HIV in peripheral blood. However, after analytical ART interruption, viral rebound occurred. Proposed sources of HIV rebound include the latent reservoir in resting CD4'T cells and tissue macrophages. We present the case of an HIV-infected patient, who received alloHSCT for leukaemia and experienced acute retroviral syndrome after selfdiscontinuing ART post-alloHSCT. Methods: Resting memory CD4'T-cells obtained 16 and 1 week prior to alloHSCT were used in a limiting-dilution viral outgrowth assay (VOA) in which each well that demonstrates viral growth contains a single replication-competent viral clone. The pol region of virus from positive VOA supernatants was sequenced. Rebound virus from blood and cerebrospinal fluid (CSF) was also analyzed using deep-sequencing (Roche 454) of pol. Sequences were aligned and maximum likelihood analysis was performed using the GTR'G model of evolution with 100 bootstrapping pseudoreplicates.

Results:
The patient had undetectable plasma HIV and achieved 100% donor chimerism at week 12 post-alloHSCT, but then became non-adherent with ART. At five months, the patient presented with fever and meningoencephalitis. Plasma and CSF HIV levels were 25,500 and 17,000 copies/mL, respectively. Before alloHSCT, 31 sequences were isolated from the VOA. At rebound, 14,645 and 5003 sequence reads were obtained from CSF and blood respectively and were combined into consensus sequences using a cut-off of!0.2% of total sequence reads. An identical sequence found at both pre-alloHSCT timepoints accounted for 9/31 (29%) of independent VOA sequences. This sequence grouped with the plasma and CSF viral rebound sequences in a monophyletic clade with high sequence homology. Conclusions: Despite 100% donor chimerism in peripheral blood, ART interruption led to HIV rebound in plasma and CSF. Rebound virus was identical to a pre-alloHSCT isolate which compromised nearly 1/3 of the latent CD4'T-cell reservoir sampled. This unique case suggests that recipient cells persist at early time-points after alloHSCT and that a single viral population latent in resting memory CD4'T cells can re-establish infection. http://dx.doi.org/10.7448/IAS.18.5.20424

MOPDA0106LB
Assay to measure the latent reservoir of replication-competent HIV-1 in suppressed patients based on ultra deep sequencing different proviruses are genetically distinct, since the assay involves a bulk culture. Methods: To analyze viruses derived from different VOA culture wells scored as p24 positive, the viral samples derived from different culture wells were assigned with a specific Barcode and subjected to sequence analysis of the V1ÁV3 region of env sequences using the Primer ID-based paired-end MiSeq platform. A total of nine patient samples, two acute and seven chronic, were analyzed by UDS. Phylogenetic trees were generated by using consensus sequences created from sequences with the identical Primer ID and were used to detect distinct viral lineages present in the individual culture supernatant. For chronic patient samples, IUPM values were determined by using distinct viral lineages detected and the adjusted number of patient-derived resting CD4' T cells used for VOA.
Results: Approximately 50% of the viral lineages derived from each chronic patient were distinct. In contrast, all viral lineages derived from each acute patient were homogeneous. When IUPM values determined by UDS analysis were compared to the IUPM values obtained from VOA, we observed approximately twofold higher IUPM values than the IUPM values determined by VOA. We also observed a significant positive correlation between the number of viral lineages observed per well and the number of resting T cells present per well.

Conclusions:
The results suggest that approximately 50% of the viral lineages induced from different cells derived from chronic patients were distinct. Thus, the UDS assay is applicable for samples derived from chronic patients. The multiplexing ability of the assay improves the efficiency for the throughput capacity. Introduction: Bacterial vaginosis (BV) is associated with an increased risk of HIV transmission, and intravaginal practices (IVP), the practice of cleansing the vagina for hygienic, health or sexuality reasons, is the primary risk factor for developing BV. This study examines the relationship between BV, IVP and lower genital HIV shedding in HIV infected women in Zambia. Methods: Participants were HIV-1 infected women, older than 18 years and living in Lusaka, Zambia. Participants completed audio computer administered self-interviews questionnaires assessing demographic, sexual risk factors and IVP. BV was diagnosed by gram stain of vaginal secretions using Nugent criteria. HIV-1 plasma viremia and genital shedding was assessed by measuring HIV-1 RNA in plasma and cervico vaginal lavages using real time PCR. Results: One hundred and twenty-eight HIV-1 infected women were enrolled. Mean age was 37 years (range 24Á60). Most had a stable male sex partner (126; 98%), and the majority of male partners had HIV infection (86; 67%). About one third (44; 34%) reported more than one partner in the prior year. All participants had engaged in IVP in the prior month, and over 90% used IVP daily. Ninety-eight participants (76%) had abnormal vaginal flora (Nugent score of 4Á10); and 80 (62%) had BV (Nugent score 7Á10). HIV-1 plasma viremia was detected in 26 participants (20%) (median08.4 log copies/mL, range0 3.9Á14.5). HIV-1 genital shedding was detected in 18 participants (14%) (median06.7 log copies/mL, range03.6Á12.7). In multivariate analysis, daily IVP were associated with BV (OR07.9, CI01.54Á40.8, pB0.01) and plasma viremia was associated with HIV-1 genital Introduction: Eighty percent of HIV-positive (HIV') women are of childbearing age, therefore access to effective, safe contraception is essential. Generally, intrauterine device (IUD) provide safe, effective contraception but historically, IUDs were contraindicated in HIV' women due to concerns regarding infection. Data in HIV' women are scarce. The goal was to assess rate of complications for IUS insertion in HIV' women.
Methods: IUDs insertions in HIV' women were offered at Oak Tree Clinic (the provincial referral centre for HIV' women and children) since 2009, following strict clinical evaluations for eligibility. Criteria used for insertion were: not planning a pregnancy for at least one year; requesting a reversible contraceptive, wanted/needed to avoid oestrogen-based methods and CD4 !150. STD screening was done in all cases. Demographic information collected included: age, CD4, ARV at insertion and purpose of IUD (contraception vs. cycle control).
Results: Data was reviewed from 44 sequential women given IUDs from 2009 to 2014 with ages 17Á 48. CD4 count 160Á1230 (median 590); 32/44 (73%) had viral loads B40 c/ml, 9 women had detectable VL between 89Á126,908 c/ml. 7 were not on ARV therapy. 2 were on ARV but struggled with adherence and were detectable. 3/44 had a copper IUD. 40/44 had a hormonal IUD. 1 had a hormonal followed by a copper IUD. 3 IUDs were inserted for menorrhagia. 1 IUD was for combined therapeutic and contraceptive purposes. 5 requested the hormonal IUD removed not related to reproductive plans. 1 refused reinsertion when the expired hormonal IUD was removed. Complications included four IUD expulsions (9%) (three spontaneous; one partial within the cervix). The rate of expulsion in general population is 6%. One IUD was removed by hysteroscopy due to upward migration of strings and myometrial embedment. One IUD accidentally pulled out during intercourse and required emergent reinsertion of a new device. No IUD related infections or other serious complications occurred, regardless of CD4 count. Conclusions: In this small series of HIV' women, IUDs were safe and well tolerated. This method of contraception should remain an option for HIV' women if close follow up of short and long term complications can be followed. http://dx.doi.org/10.7448/IAS.18.5.20426

MOPDB0103
Effectiveness of contraception for HIV-infected women using antiretroviral therapy: combined data from three longitudinal studies Introduction: Ensuring safe, effective contraception for women with HIV-1 is a public health imperative. Some data suggest that antiretroviral therapy (ART) may diminish the effectiveness of certain contraceptive methods, particularly implants. Methods: Combining data from 5282 HIV-infected women participating in three longitudinal studies (Partners in Prevention HSV/HIV Transmission Study, Couples Observation Study and Partners PrEP Study) from seven countries in Africa between 2004 and 2012, we calculated incident pregnancy rates among women using different contraceptive methods (implant, injectable and oral) and compared those to rates among women using no contraception. Multivariable Cox regression models controlled for confounding factors, and the interaction between each contraceptive method and ART use was tested to assess if ART diminished contraceptive effectiveness.
Conclusions: In this large prospective evaluation of three studies, modern contraceptive methods were highly effective in reducing pregnancy risk in HIV-infected women, including those concurrently using ART. While limited evidence from other studies suggests that some ART agents could diminish the effectiveness of contraceptive implants, these data emphasize that implantable contraception is highly effective compared to no contraception and more so than shorter-acting methods such as injectables and oral pills.

MOPDC0102
Reducing stigma and increasing HIV testing with a health information intervention, a cluster-randomized trial from Malawi travel far from home for HIV testing to avoid being seen. Such stigma may be exacerbated by unawareness of the public benefit of ART, that is, its capacity to reduce HIV transmission by 96%. We evaluated an information experiment designed to increase HIV testing rates by reducing stigma. Methods: We conducted a cluster-randomized controlled trial in Malawi. We held community health information meetings in all villages. In control villages (n062), we provided information on the private benefits of ART, including its potential to prolong life and reverse AIDS symptoms. In intervention villages (n 060), the public benefit of ART was discussed in addition to the control message.
Results: Among those aged 15Á49, there was a significantly larger uptake of HIV testing in the intervention villages (intervention 2.6% vs. control 1.6%; p00.0035), according to routinely collected data from 18 health facilities over a period of three months after the intervention. This effect was significant for men and women, and larger when corrected for spill-overs. The intervention led to a large shift in beliefs about ART, as measured by a survey five months after the intervention. Respondents in intervention villages were more likely to report accepting attitudes towards sexual partners on ART. High beliefs about the public benefit of ART were associated with significantly more tests at nearby clinics. HIV testing decisions were predicted by a respondent?s perception of his/her community's beliefs about ART. These observations strongly suggest that the effect of the intervention on HIV testing uptake is mediated by a reduction in stigma.

Conclusions:
The results demonstrate that stigma between sexual partners is a significant barrier to HIV testing, and that providing new information on the effect of ART on HIV transmission can increase testing uptake. Men randomized to self-testing reported using an average of 3.9 selftests during follow-up. Self-testing was non-inferior to clinic-based testing with respect to markers of HIV acquisition risk. At the final study visit, 5.4% of MSM randomized to self-testing were diagnosed with a bacterial STI compared with 12.2% of control participants (risk difference 0(6.8%; 95% CI 0(16 to '1.6%). There were no significant differences between the two arms in the proportion of men reporting non-concordant CAI or the reported number of male CAI partners in the last three months at 9 and 15 months.
Conclusions: Access to free HIV self-testing increased testing frequency among high risk MSM and did not impact sexual risk behaviour or STI acquisition. Methods: We conducted a pilot study to explore feasibility and acceptability of offering home-based, self-conducted HIV testing for transwomen. Fifty HIV-negative transwomen in San Francisco were provided with OraQuick oral HIV self-test kits and asked to utilize the tests once a month for three months. Survey data were collected at baseline, one month and three months. In-depth-interviews (IDIs) were conducted with 11 participants at their final visit to learn more about self-testing experiences, barriers to self-testing and how the self-test might fit into an expanded pool of testing options. Results: Self-testing was both feasible and acceptable: following the first test 94% reported the test easy to use; 93% said the results were easy to read; and 91% said they would recommend the self-test to others. Acceptability remained high at three months. Approximately 25% used the test kit with others present and 68% reported preference for self-tests versus clinic-based testing. IDIs revealed tension between a desire for the privacy afforded by self-testing and a desire for the social and resource support offered at health facilities. While most participants were comfortable accessing services and had been tested recently (88% in the past year), IDIs revealed apprehension about being seen at HIV-testing clinics. Qualitative data also indicated that partner testing was of interest and that the cost of the kits could discourage future utilization. Background: HIV self-testing (HIVST) can potentially increase uptake of testing in a low-cost, confidential and non-stigmatizing manner. Rigorous evaluation of instructional materials for accurate selftesting has rarely been conducted. In preparation for implementation and scale-up of HIVST in Zimbabwe, we have adapted and iteratively refined instructional materials to support self-testing. Here we present results from our evaluation of these materials through supervised self-testing. Methods: Participants were recruited at an HIV testing clinic using convenience sampling. They were given the instructional materials and left alone to complete their self-test and record the result. Confirmatory rapid testing after HIVST, and pre-and post-test questionnaires to evaluate their experience were conducted. The testing process was video recorded and videos analyzed using checklists. Data were evaluated weekly and IEC materials iteratively refined accordingly to optimize accuracy. HIV invalid 5 7 0 *One was a participant transcription error Á she was clear in her post-HIVST interview that she thought she was HIV negative. The second was someone on ART who tested negative via self-test and positive in confirmatory testing.
Background: Partner notification (PN) for control of sexually transmitted infections (STIs) is a public health strategy which notifies the partners of infected individuals of their possible exposure to disease. PN has rarely been used in sub-Saharan Africa as an HIV prevention intervention. In Cameroon, patients newly diagnosed with HIV do not usually receive assistance in notifying their sex partners leading to low partner disclosure and poor partner involvement in prevention of mother-to-child transmission (PMTCT

MOPDD0101
The effect of opiate substitution therapy on healthcare utilization and engagement among HIV-infected people who inject drugs in Ukraine Background: Eastern Europe and Central Asia face a rapidly escalating HIV epidemic driven by injection drug use (IDU). We evaluate the role of opioid substitution treatment (OST) in engaging HIVinfected people who inject drugs (PWID) in care and the effect of OST on utilization of medical services.
Methods: Cross-sectional study of healthcare utilization in the past six months among 296 randomly sampled HIV-infected opioiddependent PWID conducted in healthcare clinics in 2010 across Ukraine. Participants categorized as therapeutic on OST if on OST for at least three consecutive months prior to the past six months or as not taking OST if not on any OST in the past nine months. Based on this criterion, 24 individuals were excluded. Results: The 65% on OST (177/272) were less likely to be below the poverty line or live alone and more likely to be married or have gone to prison (p B0.05). The two groups did not differ significantly in terms of age, gender, or education. Those on OST had more years of opioid injection but were less likely to have injected in the past 30 days, to have engaged in poly-substance abuse, or to have ever overdosed on drugs (p B0.01). In the past six months, those on OST were less likely to seek emergency care (72% vs. 84%, pB0.05) and had fewer mean emergency care visits (2.77 vs. 4.57, pB0.02) with no significant differences in mean ambulatory visits (1.78 vs. 0.59, p00.11) or hospitalizations (0.53 vs. 0.34, p00.36). Those on OST were more likely to be engaged in HIV care, as evidenced by higher rates of antiretroviral therapy ART (37% vs. 26%, p 00.08), recent CD4 testing (82% vs. 60%, pB0.01), and recent TB testing (95% vs. 71%, pB0.01). Number of self-reported symptoms was higher in the non-OST group compared to those on OST (10.46 vs. 7.75, p B0.01). Limitations include cross-sectional design and potential for recall and social desirability biases.
Conclusions: Despite higher rates of incarceration and more years of opioid injection, those therapeutic on OST were less likely to seek emergency care than those not on OST and more likely to be engaged in HIV care with fewer overall symptoms. http://dx.doi.org/10.7448/IAS.18.5.20435

MOPDD0102
The effects of opioid substitution treatment and highly active antiretroviral therapy on the cause-specific risk of mortality among injection drug using people living with HIV/AIDS Background: Prior studies indicate that opioid substitution treatment (OST) reduces the risk of mortality and improves the odds of accessing highly active antiretroviral therapy (HAART), however the relative effects of these treatments for injection drug using people living with HIV/AIDS (PLHIV) are unclear. We aim to determine the independent and joint effects of OST and HAART on mortality, by cause, within a population of injection drug using PLHIV initiating HAART. Methods: We used a linked population-level administrative database for British Columbia, Canada (1996Á2010) to form a cohort of injection drug using PLHIV. We selected all individuals identified as HIV-positive and either having a history of OST at initial HAART receipt, as indicated by methadone or buprenorphine dispensation records in the BC PharmaNet database or having an indication of injection drug use before HIV infection, as indicated in the HIV testing database. We employed time-to-event analytic methods, including competing risks models, proportional hazards models with time-varying covariates, and marginal structural models, to identify the independent and joint effects of OST and HAART on all-cause, as well as drug-and HIV-related mortality, controlling for covariates.

MOPDD0104
Low threshold services for females who inject drugs: reducing gender inequities in methadone enrolment Background: In 2011, the government of Tanzania established methadone assisted therapy (MAT) to combat the dual epidemic of HIV and injection drug use. However, enrolment of females who inject drugs into MAT has lagged behind that of males. To address this inequity, the methadone clinic at Mwananyamala Regional Referral Hospital (MRRH) introduced low threshold services for females in January 2013, allowing women to bypass the historically required attendance at community-based organizations prior to enrolment. Furthermore, existing female clients were encouraged to recruit their peers and one-day of the week was set aside for enrolling female clients only. Methods: We conducted an interrupted time-series study to evaluate the impact of implementing low threshold services for females enrolling into MAT, using de-identified, routinely collected data from November 2012 to October 2014 at MRRH. Prais-winsten regression models were utilized to estimate the mean change in the proportion of clients that were female and the weekly number of females enrolling, adjusting for male enrolment and a period of MAT enrolment interruption form JulyÁNovember 2013. Results: Overall, 759 clients enrolled into the methadone clinic during the study period. Of those enrolling, the mean age was 34 years. The mean number of people enrolling into methadone during the study period was 8 clients (95% CI: 7,9) per week. After implementation of low threshold services, the proportion of female clients increased from 14% (95% CI: 13%, 15%) to 24% (95% CI: 23%, 25%; p00.001), but after the enrolment interruption, the proportion of female methadone clients decreased slightly to 22% (21Á22%). Adjusting for male enrolment, the mean number of females enrolling per week was 2 (95% CI: 1Á3; p00.001) people per week higher as compared to before implementation. Following the enrolment stoppage, the average number of female enrollees was comparable to pre-intervention (mean change: 0; 95% CI:Á1, 1; p 00.442). Conclusions: Implementation of low threshold services improved enrolment into the methadone programme among women, thereby increasing the proportion of female methadone clients. However, the gains in enrolment were attenuated after an enrolment interruption, highlighting the importance of programme stability with this group of clients. Introduction: Among illicit drug users, renewed efforts to reduce high levels of HIV/AIDS-related morbidity and mortality and curb rates of viral transmission rely, in part, on earlier initiation of antiretroviral therapy (ART). However, there are concerns that starting treatment prior to immunosuppression for members of harder-to-treat groups could contribute to lower levels of treatment adherence and lead to impaired virologic response. Thus, we sought to evaluate trends in CD4 cell count at ART initiation over time and rates of subsequent virologic response among HIV-positive illicit drug users during a community-wide Treatment-as-Prevention campaign in Vancouver, Canada. Methods: We used data from the ACCESS study, an ongoing longitudinal cohort of HIV-positive illicit drug users linked to comprehensive HIV clinical monitoring and pharmacy dispensation records. In this retrospective study, we included all individuals who initiated ART from 2005 onwards. We used multivariable logistic regression to evaluate differences in mean CD4' cell count at initiation by year of initiation. To estimate time to plasma HIV-1 RNA viral load B50 copies/mL by CD4 cell count at ART initiation, we used KaplanÁMeier and Cox proportional hazards methods. Conclusions: We observed substantial increases in CD4 cell count at initiation over time coincident with a community-wide TasP-based initiative. Individuals initiating ART earlier in the disease course exhibited higher rates of optimal virologic response. These findings support earlier initiation of ART among illicit drug users to reduce levels of HIV/AIDS-associated morbidity and mortality and rates of viral transmission.
Besides, the finding of higher peripheral and CSF activation/ inflammation in H-CSF group indicate a more complex scenario, where both districts cooperate in maintaining the inflammation within CNS, possibly affecting neuronal function, and therefore deserves further investigations. Introduction: Dysregulated type I interferon (IFN) responses contribute to immunopathology in chronic HIV infection, therefore it is critical to dissect the molecular mechanisms underlying HIVstimulated IFN production. We examined the spatiotemporal regulation of IFN secretion by plasmacytoid dendritic cells (pDC), specialized cells that secrete high levels of IFN upon HIV recognition by Toll-like receptor (TLR) 7. We showed previously that intracellular trafficking of HIV to early endosomes is associated with potent IFN secretion but minimal NF-kB signalling, resulting in suboptimal pDC maturation; however, how HIV trafficking is determined and the causal link between HIV subcellular localization and differential TLR signalling are currently unknown. Methods: Human pDC were purified from peripheral blood and were stimulated with GFP labelled: HIV, HIV pseudotyped with influenza hemagglutinin envelope (HA-HIV), and PR8 influenza. TLR7 expressing HEK NF-kB reporter cells, stably transfected with CD4 mutants with cytoplasmic tails directing trafficking to early endosomes (EE) or lysosomes, were activated with HIV and controls. Analysis included ELISA, flow cytometry and florescent microscopy. Cells were imaged using the Advanced Precision imaging system and images were analyzed using ImageJ. Results: We compared the effects and spatiotemporal trafficking in pDC of HIV, influenza and HA-HIV. We demonstrate that HA-HIV strongly activates maturation pathways (NF-kB) in pDC and traffics rapidly to lysosomes, similarly to influenza but unlike HIV, suggesting that viral envelope directs trafficking and resultant phenotype of ssRNA virions in pDC. We studied HIV-CD4 interactions in a HEK reporter cell system expressing TLR7 with functional NF-kB signalling, which we cotransfected with CD4 mutants whose cytoplasmic tails either directed CD4 trafficking to EE or lysosomes. We show that wild type (WT) CD4 localizes to EE, whereas CD4 mutated with either DEC-205 or LAMP1 tail localizes to lysosomes. HIV traffics to EE in WT CD4 expressing TLR7 HEK cells and fails to stimulate NF-kB signalling, whereas HIV traffics to lysosomes in DEC-205/LAMP1 expressing TLR7 HEK cells and stimulates NF-kB signalling, suggesting that rerouting of HIV (via CD4) to lysosomal compartments triggers NF-kB rather than IFN pathways. Conclusions: CD4 receptor mediated endocytosis targeting early endosomes determines HIV intracellular localization and observed interferon-producing phenotype of HIV-activated pDCs. Introduction: Plasmacytoid dendritic cells (pDCs) constitute a major source of type-I interferon (IFN-I) production during acute HIV infection. Their activation results primarily from TLR7-mediated sensing of HIV-infected cells. BST2/Tetherin is a restriction factor that suppresses HIV release by cross-linking virions at the cell-surface. HIV-1 overcomes BST2 antiviral activity through Vpu, which partially downregulates BST2 cell-surface expression. Apart from its direct antiviral activity, BST2 was shown to bind the ILT7 pDC-specific inhibitory receptor and repress IFN-I production by activated pDCs. Here, we examined whether Vpu-mediated BST2 antagonism could modulate innate sensing of HIV-infected cells by pDCs. Methods: PBMCs or isolated pDCs were co-cultured with T cells infected with wild type or Vpu-defective HIV-1 and innate sensing was evaluated by monitoring IFN-I production. BST2-mediated activation of ILT7 signalling was analyzed using an ILT7-reporter cell system. Results: We show that Vpu attenuates the production of IFN-I during sensing of HIV-1 infected cells by pDCs. This control of innate sensing by Vpu could be prevented by: 1) depletion of BST2 from infected donor cells; 2) depletion of ILT7 in pDCs; or 3) blocking BST2-ILT7 interaction using anti-BST2 antibodies or soluble ILT7. Using a BST2 mutant that cannot cross-link budding virions but yet retains the capacity to repress IFN-I production by pDCs, we show that virion trapping on infected donor cells prevents BST2 from eliciting an inhibition of IFN-I production by pDCs. Interestingly, confocal microscopy analysis of virus producing cells reveals that in presence of Vpu there is a residual pool of surface BST2, which is excluded from viral budding sites and thus potentially accessible for interaction with ILT7 on pDCs. Lastly, using an ILT7 reporter cell system, we provide evidence that Vpu-mediated BST2 antagonism modulates the levels of available surface BST2 capable of engaging and activating ILT7 upon cell-to-cell contact.
Conclusions: Overall, this study sheds light on a novel Vpu-BST2 interaction that allows HIV to control innate sensing of infected cells by pDCs via the negative signalling exerted by the ILT7-BST2 pair. This mechanism of innate immune evasion is likely to be critical for efficient viral dissemination and establishment of viral reservoirs during acute infection. Introduction: HIV-1 latency is a multifactorial process resulting by the interplay between cellular transcription factors and the viral regulatory protein Tat. We have previously described the interferoninducible restriction factor TRIM22 as a suppressor of basal and phorbol ester-dependent LTR-mediated transcription independently of NF-kB and of Tat/TAR interaction. As basal HIV-1 transcription is mainly driven by the binding of the cellular transcription factor Sp1, we have investigated whether TRIM22 could interfere with such Sp1driven transcriptional activation of HIV-1 LTR. Methods: 293T cells, lacking of endogenous TRIM22, were cotransfected with a TRIM22-expressing plasmid together with reporters vectors driven by the HIV-1 promoter containing either wild-type or mutated Sp1 binding sites or lacking of either one or two sites; reporter expression was assessed 48 hours post-transfection. Endogenous TRIM22 was knocked-down (KD) in SupT1 cells that were subsequently infected with HIV-1 molecular clones engineered to be dependent on an incorporated Tet-On gene expression system for activation of transcription while being independent of Tat/TAR interaction. Virus replication was monitored up to 32 days postinfection. Cell extracts from TRIM22-transfected 293T was subjected to 1) immunoprecipitation, 2) Western blotting, 3), DNA pull-down and 4) chromatin immunoprecipitation (ChIP). Results: TRIM22 overexpression suppressed Sp1-driven transcription of HIV-1, as its inhibitory activity was lost in the absence of Sp1 binding sites. In contrast, TRIM22 KD increased the replication of infectious clones that were exclusively dependent upon Sp1 binding to the promoter. Furthermore, immunoprecipitation experiments showed that TRIM22 and Sp1 can interact physically although this interaction does not affect the level of expression of endogenous Sp1 or its phosphorylation state. TRIM22 did not directly bind to the HIV-1 LTR by either in vitro pull-down experiments or in ChIP experiments, however TRIM22 expression drastically prevented the binding of Sp1 to the HIV-1 LTR. Conclusions: TRIM22 inhibits Sp1-dependent transcription by interacting with Sp1 and preventing its binding to the HIV-1 LTR. Our findings bear relevance for the discovery of new pharmacological approaches aimed at targeting the reservoir of cells latently infected with replication-competent proviruses.  (TRIM22) is an E3 ubiquitin ligase with activity against HIV-1: high levels of TRIM22 expression are associated with reduced viral set-point following acute HIV-1 infection. The TRIM22 gene has been greatly shaped by positive selection, and its expression is sensitive to retroviral infection, Type I and Type 2 interferon. The mechanism by which TRIM22 exerts its antiviral effect is poorly understood. Further, the impact of TRIM22 genetic variation in the context of HIV-2 disease is unknown. Methods: To test the hypotheses that TRIM22 expression antagonizes HIV-2 infection and that polymorphisms in TRIM22 significantly modulate this effect, we conducted three studies. Firstly, TRIM22 was genotyped in 60 HIV-2 patients, comparing viral controllers and rapid progressors, and a similar number of age and sex matched controls from the same community in rural Guinea-Bissau. Using regression modelling, polymorphisms were analysed alongside immunological and virological data. Secondly, a model of TRIM22 was constructed using computational methods and the polymorphisms observed in vivo were mapped and analysed. Finally, baseline cDNA and protein levels of TRIM22 from C8166 cells were measured using quantitative RT-PCR and flow cytometry respectively. The cells were subsequently infected with HIV-2, and measurements repeated to determine whether TRIM22 gene expression is sensitive to HIV-2 infection. Results: The data show that TRIM22 polymorphisms rs1063303 and rs7935564 are significantly associated with HIV-2 acquisition and disease progression. Further, polymorphisms observed in vivo cluster in functional regions that our modelling studies suggest may interact with the HIV-2 capsid. Finally, we show that TRIM22 gene expression is upregulated in the presence of HIV-2, in a lymphocyte cell line. Conclusions: Taken together, our data show that TRIM22 expression is sensitive to HIV-2 infection and that polymorphisms in TRIM22 genes are significantly associated with HIV-2 acquisition and disease progression. Further the study has computationally characterized positively selected polymorphisms observed in vivo and the data show that these polymorphisms have the potential to significantly alter protein structure and function. These data provide the first analysis of TRIM genetic variation in the context of HIV-2 infection. Introduction: During chronic viral infections, high antigenic load continually stimulates T cells resulting in T-cell exhaustion. Exhausted T cells increase the expression of negative checkpoint inhibitors such as PD-1, which raise the threshold for activation and contribute to suppressed immune responses. Another recently discovered immune checkpoint receptor, TIGIT, is upregulated on T cells in neoplasms and chronic LCMV infection. We hypothesize that TIGIT functions as a negative checkpoint receptor marking dysfunctional T cells during SIV infection and that modulation of TIGIT would restore anti-SIV-specific T-cell responses. Methods: Spleen, lymph node (LN) and PBMCs from SIV-naïve and SIV-infected rhesus macaques (RMs) were examined for surface expression of TIGIT. In vitro cytokine production was assessed via intracellular cytokine staining. Proliferative capacity was determined through CFSE dilution assays in the presence of antibodies blocking TIGIT and PD-1 pathways (anti-TIGIT mAb and anti-PD-L1 mAb). Results: TIGIT expression was significantly upregulated on CD8 ' T cells derived from the spleen and LN but not on PBMC in SIV-infected animals. The frequency of TIGIT ' CD8 ' T cells in the LN significantly correlated with SIV viral load, and TIGIT expression was driven primarily by g-chain cytokines such as IL-2. TIGIT was expressed on approximately 40% of SIV-specific CD8 ' T cells, even in animals with full cART suppression of viral replication. While Ki-67 expression did not differ between TIGIT ' and TIGIT ( CD8 ' T cells, TIGIT -CD8 ' T cells produced significantly more IFN-g compared to TIGIT ' CD8 ' T cells. Single and dual blockade of TIGIT and/or PD-1 signalling pathways restored proliferative capacity of SIV-specific T cells in vitro. Conclusions: TIGIT is a negative checkpoint receptor that marks a novel population of functionally exhausted SIV-specific CD8 ' T cells and is associated with SIV disease progression. The enhancement of virus-specific T-cell proliferative responses in the presence of single or dual blockade of TIGIT and/or PD-1 suggests that targeting the TIGIT pathway is a viable therapeutic approach to reverse T-cell dysfunction. Given the high sequence homology of rhesus and human TIGIT, this provides a platform to further investigate TIGIT, along with other checkpoint inhibitors, as potential targets for mediating a functional cure for HIV. http://dx.doi.org/10.7448/IAS.18.5.20561

TUPDB0101
Prolongation of QTc interval in HIV-infected individuals compared to the general population is not caused by antiretroviral therapy Introduction: Accelerated bone mineral density (BMD) loss occurs during the first two years of ART. Few studies have evaluated subsequent BMD changes, especially compared to uninfected controls. Methods: ACTG A5318 performed one follow-up site-specific dualenergy x-ray absorptiometry (DXA) in HIV-infected individuals who had received baseline and follow-up DXAs during the randomized treatment trial A5202/A5224s. As controls, we obtained DXA results from uninfected participants enrolled in BACH/Bone and WIHS cohorts. Repeated measures analyses compared BMD change rate between HIV-infected and uninfected, adjusting for age, sex, race and body mass index (BMI). In the HIV-infected group, we performed multivariable analyses evaluating association of HIV-specific (baseline and time-updated CD4 and viral load), HIV treatment-related (randomized ART regimen, cumulative tenofovir (TDF) exposure) and non-HIV related factors (age, sex, race, relevant concomitant medication use, BMI, total lean body mass) on BMD change rate. Results: Baseline characteristics between HIV infected (n 097) and HIV-uninfected (n 0630) participants were generally similar: median age, 40 versus 46; % female, 14 versus 14; % black, 34 versus 35; median BMI, 24 versus 29; and median years between first and last DXA, 7.5 versus 6.9. Seventy-one percent of HIV-infected participants were on TDF at last DXA. Compared to controls, HIV-infected individuals had significantly greater adjusted BMD decline rate at lumbar spine (LS) and total hip (TH) during the first 96 weeks of ART (both pB0.001). Subsequently, on follow-up DXA, HIV infection remained significantly associated with greater adjusted BMD decline rate at LS ((0.29%/year; 95% CI: (0.49, (0.09; p 00.005) but not at TH (p 00.63). In the HIV group, the rate of BMD decline slowed after the first 96 weeks of ART (0Á96 weeks vs. Late Change: LS: (0.75%/year vs. (0.19%/year, p00.04; TH: (1.29%/year vs. (0.30%/year, pB0.001). During the late period, no HIV-related characteristic was associated with BMD loss, but lower total lean body mass (and not BMI) was associated with greater BMD loss at LS and TH (both pB0.001). Conclusions: Although the rate of BMD decline slowed after the first 96 weeks after ART initiation in HIV-infected persons, the rate of bone loss at the lumbar spine was still significantly greater than HIVuninfected controls. http://dx.doi.org/10.7448/IAS.18.5.20446

TUPDB0104
Prevalence of non-alcoholic fatty liver disease and liver fibrosis among perinatally HIV-infected Asian adolescents with history of transaminitis Introduction: New diagnoses of HIV-1 infections among people who inject drugs (PWID) increased in Athens metropolitan area, Greece during 2011. Our aim was to identify potential cross-group transmissions between PWID and other risk groups using molecular methods. Methods: HIV-1 subtypes were determined for 711 HIV-1(') PWID sampled during 2011Á2014. Cross-group transmissions among the PWID were those that originated from other groups as estimated by phylogenetic trees. Specifically cross-group transmissions corresponded to viral lineages from PWID that didn't fall into the outbreak transmission networks or the PWID recombinants. Further phylogenetic analyses were conducted for the sequences from cross-group transmissions. Results: Among the 711 HIV-1(') PWID, 630 (88.6%) sequences fell within four IDU transmission networks belonging to CRF14_BG (n 0356, 50.1%), CRF35_AD (n 0123, 17.3%), subtype B (n 0106, 14.9%) and A (n045, 6.3%); 48 (6.8%) were recombinants consisting of partial regions originating from the PWID-specific clades. On the other hand, sequences from 33 (4.6%) PWID didn't belong either to the PWID transmission networks or the recombinants, suggesting that they are evidence of potential cross-group transmissions. Phylogenetic analyses (n 028) for subtypes A and B detected most frequently among the cross-group transmissions suggested that most of these infections originated from non-PWID transmission networks in Greece and the former Soviet Union countries (A FSU ). Specifically we found that nine (75.0%) of the subtype B infections originated from Greece, whereas eight (50.0%) and seven (43.8%) of subtype A strains were of A FSU and Greek origin, respectively ( Figure 6). The gender distribution didn't differ significantly between those infected within PWID networks (F: n 099; M: n 0579) or the cross-group transmissions (F: n07; M: n026). Conclusions: During the four year period of the HIV-1 outbreak among the PWID in Athens metropolitan area, we estimated that 33 (4.6%) of the infections in this group are due to cross-group infections. Notably, half of these cross-group infections due to subtype A originate from the large IDU epidemic in Eastern Europe (A FSU ). For subtype B, however, the majority of cross-group infections originated from Greece. Introduction: In Pakistan, people who inject drugs (PWID) have a high HIV prevalence ( Â27%), and the prevalence among sex workers (SW) has recently increased. There is considerable geographic heterogeneity of HIV prevalence, which may reflect multiple subepidemics with unique trajectories, characterized by specific risk contexts, behaviours and sexual or syringe-sharing networks. This study uses genetic clustering to identify and characterize these HIV subepidemics of ongoing transmission. Methods: Mapping and integrated behavioural and biological surveillance took place among 16,756 PWID and male (MSW), hijra (HSW) and female (FSW) SW across Pakistan in 2011. Of the 1637 persons who tested HIV positive (9.8%), we were able to analyze gp41 sequences from 1153. These sequences were aligned to a reference sequence: HXB2. We identified sequences that were highly similar (51% pairwise Tamura Nei 93 genetic distance) and deemed these persons potential transmission partners. Transmission clusters were constructed by connecting persons who share potential transmission partners. Clusters were characterized in terms of high risk population group membership and city. Logistic regression was used for tests of statistical significance. Results: The prevalence of HIV was determined to be 27.3%, 5.2%, 1.6% and 0.6% among PWID, HSW, MSW and FSW, respectively. Of the 1153 sequences, 652 were clustered (56.5%) in 87 unique clusters ranging in size from 2 to 96 sequences. Average cluster size was 7.5 (s.d.015), although clusters of two predominated. Compared with MSW, PWID were more likely to be clustered (odds ratio01.6, p00.01). Larger clusters were more likely to span multiple cities and include SW, with an average mixed PWID/SW cluster size of 23.6, compared with cluster sizes of five or two for clusters composed entirely of PWID or SW, respectively. Most PWID who were in clusters were in large clusters of nine or more individuals, whereas HSW and MSW tended to be in clusters of diverse sizes.
Abstract TUPDC0101ÁFigure 1. Phylogenetic tree of subtype A sequences from PWIDs with evidence for cross-group transmissions plus sequences from the Greek epidemic sampled during 1999Á 2013 and a randomly selected global sample.
Introduction: The HIV epidemic among men who have sex with men (MSM) is expanding at an alarming rate in Asia. Understanding the dynamics of HIV-1 transmission among MSM through viral sequence analyses may provide essential information on the origin of viral lineages and the characteristics of disease spread. Methods: We determined transmission networks of HIV-1 among MSM across countries in East and Southeast Asia. A total of 1856 HIV-1 polymerase gene sequences were obtained from TREAT Asia Studies to Evaluate Resistance-Monitoring (TASER-M) sites in Hong Kong, Thailand, Malaysia and the Philippines between 2006 and 2011. Time-stamped sequence datasets of HIV-1 subtype B (n0144) and CRF01_AE (n0186) from antiretroviral-naive MSM were identified and subjected to spatiotemporal analysis using Bayesian phylodynamic methods. A transmission network was defined as a phylogenetic cluster ( ]2 isolates) supported by !90% bootstrap values and Bayesian posterior probability value of 1 at the tree node. Results: Phylogenetic reconstructions showed that 68% of HIV-1 subtype B and 46% of CRF01_AE sequences were grouped in 50 transmission networks of various sizes (mean size 05.6, range 0 2Á32 sequences), with subtype B sequences having a higher tendency to form a network (pB0.0001). With additional representative sequences from China, Mongolia and Myanmar from the Los Alamos National Laboratory HIV Sequence Database, 34 networks involving 154 subtype B-infected individuals and 16 networks involving 125 CRF01_AE-infected individuals were observed. Location mapping showed that the MSM networks in East and Southeast Asia were mostly localized (78%) in their respective countries, with 22% spanned beyond a single country. Genealogy-based analysis to estimate the divergence time for each transmission network indicated the continued emergence of new networks over the past three decades. The uninterrupted growth of sub-epidemics of various cluster sizes suggests the role of transmission networks as a continuous driving force of the epidemic among MSM in Asia. Conclusions: Despite expanded access to antiretroviral therapy in Asia, our analysis showed continued regional emergence of recent HIV-1 subtype B and CRF01_AE networks among MSM. Strategies such as early diagnosis and treatment as prevention to reduce transmission risks among sero-discordant partners need to be expanded across the region. Taking into consideration that Georgia is the country, where HIV prevalence is concentrated among men who have sex with men (MSM) and information on the size of this key population was lacking, we conducted the study using seven different population size estimation methods in Tbilisi, Georgia. We want to focus on a new method proposed by Dombrowski among methamphetamine users in 2012. This represents capture-recapture using network sampling technique. Among MSM, we first time applied this method with few modifications. Methods: Modified capture-recapture requires singe sample, which for our study was 210 MSM 18 years and older recruited through Respondent Driven Sampling. The study participants were asked about their personal characteristics (approximate height, weight, hair colour and ethnicity) and so called ''telefunken codes'' derived from the last four digits of their own mobile number. In difference to the original method that used six personal identifiers, we dropped eye Methods: We examined the relationship between anticipated HIV stigma at individual and community levels on recent HIV testing, stratified by gender, using data from a population-based sample of 1126 adults aged 18Á35 residing in 22 villages in Mpumalanga, South Africa. Anticipated HIV stigma, or expectations of discrimination should one become HIV positive, was measured using a 9-item scale and dichotomized as any versus no stigma. Community-level stigma was defined as the proportion of individuals within each village reporting any anticipated stigma. We assessed associations of community and individual stigma and HIV testing for men and women. We then used multi-level regression models to estimate the potential effect of changing community-level stigma to improve testing uptake using the g-computation algorithm. Analyses were weighted to account for the survey design.
Results: Men tested less frequently (OR 0.22, 95% CI 0.14Á0.33) and reported more individual anticipated stigma (OR 5.1, 95% CI 2.6Á 10.1) than women. Men reporting no individual-level stigma (vs. some) were 48% more likely to have tested (p 00.08). For women, testing behaviour was not associated with individual anticipated stigma but for each percentage point reduction in community-level stigma the likelihood of testing increased by 3% (p 00.03). We modelled gains in HIV testing at different levels of community stigma ( Figure 1). For example, results indicate a potential 15% intervention gain in HIV testing among women if community-level stigma decreased by 5%. Changing community-level stigma did not result in significant gains for men.
Conclusions: Our data indicates that HIV-related stigma influences HIV testing for men and women through different pathways. Stigma reduction programs may need to consider gender differences and tailor activities to the target population. Longitudinal research is needed to confirm projections and direction of effect. Results: Structural barriers to male participation in community health campaigns led to reduced participation in CHCs and HBT: informal sector labour opportunities for men often require extended absences from rural households. Participants reported for example that during planting season, men needed to guard fields from monkeys from dawn until nightfall; in lakeshore communities, fishermen travel long distances and off-load fish at multiple beaches, using multiple residences and temporary lodgings. Community leaders were critical in outreach to promote CHC attendance, but power differentials between elder and younger men may have contributed to heterogeneous mobilization. Cultural factors including male gender norms counter to health-seeking behaviours, and valorizing risk-taking, also Introduction: The mothers2mothers' (m2m) Mentor Mother programme empowers pregnant women and new mothers to make informed decisions about their maternal and reproductive health as well as their infants' health, through provision of peer education and psychosocial support. The m2m's 2013 annual evaluation showed that discordancy was negatively associated with the uptake of paediatric prevention of mother-to-child transmission (PMTCT) services. HIVpositive mothers who knew their male partners were HIV-negative were less likely to bring their infants for PCR testing at 6Á8 weeks (OR 00.60, p00.005), or for a follow-up test at 18 months (OR 00.75, p00.017), compared to mothers who knew their partners were HIV-positive. The aim of this study is to further investigate the role that knowledge of one's partner's HIV status plays in the uptake of paediatric PMTCT services.
Methods: Secondary analysis of m2m's 2013 internal programme evaluation data was conducted. Data comprised of a representative random sample of 5592 HIV-positive clients' longitudinal records (routinely maintained by Mentor Mothers), enrolled from March through May 2012 in six African countries. The relationship between knowledge of partner status and uptake of paediatric PMTCT services was investigated through bivariate analysis (chi-square) and binary logistic regression analysis using STATA 12.
Results: Knowledge of partner HIV status was significantly associated with uptake of paediatric PMTCT services. Mothers who knew their partner's HIV status were more likely to take up paediatric PMTCT services compared to those who did not know their partner's status. The likelihood of improved uptake of PMTCT services was the highest among mothers who knew they were in a concordant relationship. There was no significant relationship between knowledge of partner status and uptake of infant ART.
Conclusions: Additional primary research on the effects of concordancy and discordancy on PMTCT outcomes is recommended. Our secondary analysis suggests that uptake of paediatric PMTCT services is more likely to occur amongst clients who know that they are in a concordant relationship. This evidence supports m2m's inclusion of a tailored serodiscordant couples education and support intervention to facilitate mutual disclosure of HIV status in partners, especially in the context of Option B', thus improving outcomes in the postnatal care cascade. laboratory-adapted strains of HIV-1. This proposal aims to investigate how the high degree of HIV-1 genetic diversity impacts Nef function. Methods: An HIV-1 based lentiviral expression system was used to express Nef proteins from 10 group M subtypes (A1, A2, B, C, F1, F2, G, H, J and K) in the context of an HIV-1 infection. T cell lines were infected with pseudoviruses encoding Nef proteins and analyzed for surface levels of CD28 and MHC-I using fluorescent antibody staining and flow cytometry. Alternatively, CD4 cell surface levels were measured by transfecting CD4 ' HeLa cells with expression plasmids encoding Nef-GFP fusion proteins followed by fluorescent antibody staining and flow cytometry. Nef expression was determined by a combination of western blot analysis and flow cytometry to measure fluorophore fused Nef proteins. Introduction: Viral diversity provides a major challenge in the development of a vaccine against HIV-1. A potential target for HIV-1 vaccines is gp120 envelope protein, which is involved in viral entry and is a target of the host immune system. It has been shown that Envelope characteristics have a role to play in disease progression. However some studies have demonstrated conflicting results. In this study, we aim to analyze HIV-1gp120 characteristics, specifically: potential N-glycosylation sites, amino acid sequence length and net electric charge in cell associated and cell free RNA derived from recently and chronically infected individuals in Botswana.
Methods: This was a retrospective study using stored samples collected from treatment naïve HIV-1C infected cohorts at Botswana Harvard AIDS Institute Partnership, representing recently infected and long term infection as determined by serological assays for recency and longitudinal follow up. A 1200 base pairs fragment of V1 to V5 region of gp120 was amplified by nested PCR and sequenced on both strands using Big Dye Technology in proviral DNA and cell free RNA. Potential N-glycosylation sites were determined using Los Alamos HIV sequence database while subtype was assigned using REGA HIV subtyping tool.
Results: There was a significant increase in amino acid sequence length of V2 (p 00.027) and V4 (p 00.0099) in proviral DNA in the chronic stage as compared to the recent stage of infection. Similar changes were also observed in cell free RNA in V4 (p 00.0074).
In addition, the number of potential N-linked glycosylation sites in proviral DNA was significantly increased in chronic infection in V4 (p 00.0253). No significant changes in net electric charges were observed. There was an association between viral load and V4 region (p B0.001). All samples were classified as subtype C.
Conclusions: The increase in amino acid sequence length and potential N-Glycosylation sites in the V2 and V4 region may be essential in disease progression. Introduction: Follicular T helper cells (Tfh), a subset of CD4 T lymphocytes, are essential for B-cell activation and provide help to B cells in the production of antigen-specific antibodies. Although several studies have analyzed the dynamics of Tfh cells in the context of AIDS by analyzing peripheral blood and LNs of HIV-infected patients, paradoxically, none of these studies in HIV/SIV infection have addressed the role of Tfh cells in the primary organ of B-cell activation, the spleen. Methods: To address these questions, we have infected rhesus macaques with SIVmac251 (20 AID50). Animals were killed at different time points post-infection and lymphoid organs were recovered. Tfh cells (PD-1 high CXCR5 ' ) and CD4' T cell subsets were monitored by flow cytometry. Concomitantly, B-cell subsets were also analyzed. CD4 T-cell subsets were sorted and SIV DNA was quantified by RT-PCR.
Results: Herein, we demonstrated for the first time that the percentages and numbers of splenic Tfh cells decrease early during the acute phase in macaques infected with SIV. This profound loss and abnormal differentiation of Tfh is also associated with the loss of memory B-cell subsets. Moreover, SIV DNA is detected in splenic Tfh cells early after infection. Finally, our results showed that the frequency of splenic Tfh and memory B cells are higher in slowprogressor compared to rapid progressor RMs at the chronic phase.
Conclusions: Altogether, our results demonstrate the drastic depletion of splenic memory B cells, which might be related to the loss of fully maturated Tfh cells. Introduction: HIV acquisition among sub-Saharan migrants living in Europe has long been considered to predominantly occur before migration because of generalized HIV epidemics in sub-Saharan African countries. Recent evidence suggests that a substantial proportion have acquired HIV while they were living in Europe. In the UK, this proportion was recently estimated at 31% using a CD4-based modelling approach. Such an estimate is not currently available for France. Methods: We estimated the proportion of sub-Saharan migrants who acquired HIV infection after their arrival in France using life-event and clinical information on a random sample of HIV-infected hospital outpatients born in sub-Saharan Africa in Paris region. We assumed that HIV infection had probably been acquired in France if at least one of the following life-event criterion was fulfilled: 1) HIV diagnosis !10 years after arrival in France, 2) ]1 negative HIV test in France, and 3) sexual debut after arrival in France. If none of these criteria was fulfilled, we estimated the duration from HIV infection based on first CD4 count measurement using statistical modelling. Infection was assigned in France if, out of 500 durations estimated for each individual, !50% (median scenario) or !95% (conservative scenario) fell within the period while individuals were living in France.
Results: Of the 898 HIV-infected adults born in sub-Saharan Africa included in the analysis, we estimated that 49% (95% confidence interval: 45Á53) in the median scenario and 35% (31Á39) in the conservative scenario acquired HIV while living in France. This proportion was lower for women than men (30% (25Á35) vs. 44% (37Á51) in the conservative scenario) and increased with duration in France. Communities were classified as lakeside fish landing sites (n 04), agrarian (n 027) or trading communities (n 09) based upon occupation analysis. HIV prevalence was geospatially mapped using Bayesian methods and variability across and within community classifications was characterized. Differences in risk behaviours between communities were assessed using modified Poisson regression models.

Conclusions
Results: There was large variation in HIV prevalence, ranging from 9 to 43%, across communities (see Figure below). Fish landing sites had a mean HIV prevalence of 41% (range: 37Á43%). Mean HIV prevalence in trading communities was 17% with substantial variability (range: 11Á22%) and 14% in agrarian communities, also with substantial variability (range: 9Á26%). Agrarian and trading communities in close proximity (B18 km) to fishing landing sites had HIV prevalence ranging from 11 to 26%. Overall, HIV prevalence was higher among women than men (p 00.01), and the disparity was greatest in the fish landing sites (49% vs. 34%). The proportion of males and females reporting 04 sex partners in the last year was 6.4 (95% CI: 4.1Á11.0) and 3.2 (95% CI: 2.7Á3.8) times higher in fishing communities than in the agrarian/trading population, respectively. Levels of consistent condom use with non-marital partners were significantly lower in the fish landing sites (RR 00.80, 95% CI: 0.69Á0.94).
Conclusions: Large variations in HIV prevalence and risk factors across communities in rural Rakai underscores the need for a granular approach to HIV prevention and response based on local assessment of HIV burden and risks and locally tailored interventions that may include targeting of high risk groups such as those in fish landing sites. Introduction: Early diagnosis and treatment of HIV improves patient outcomes and minimizes risk of transmission. Provider-initiated testing and counselling (PITC) is an effective case-finding strategy, but implementation models vary. Malawi Ministry of Health (MOH) guidelines recommend routine opt-out PITC, in line with WHO recommendations for countries with generalized epidemics, but little is known about its implementation. Our objective was to assess PITC implementation in Malawi.
Methods: We conducted a cross-sectional study of PITC implementation at 118 clinics and wards within 12 MOH facilities in central Malawi during JuneÁJuly 2014. Qualitative data detailing PITC practices was collected through structured interviews with 71 providers who conduct HIV testing at their facility, and characterized using standardized definitions ( Figure 1). Quantitative data describing patient visits and HIV tests recorded during 2013 was abstracted from MOH HIV testing reports.
Results: Variable models of PITC were reported across facilities and departments (Table 1)