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Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression. We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA <50 copies/ml. We assessed the impact of treatment arm with a modified intention-to-treat analysis, using multivariable logistic regression controlling for potential confounders. Between August 2013 and October 2015, 762 participants were enrolled; 59 participants transferred to other clinics during the study period, and were excluded as per protocol, leaving 356 in the standard and 347 in the same-day ART groups. In the standard ART group, 156 (44%) participants were retained in care with 12-month HIV-1 RNA <50 copies, and 184 (52%) had <1,000 copies/ml; 20 participants (6%) died. In the same-day ART group, 184 (53%) participants were retained with HIV-1 RNA <50 copies/ml, and 212 (61%) had <1,000 copies/ml; 10 (3%) participants died. The unadjusted risk ratio (RR) of being retained at 12 months with HIV-1 RNA <50 copies/ml was 1.21 (95% CI: 1.04, 1.38; p = 0.015) for the same-day ART group compared to the standard ART group, and the unadjusted RR for being retained with HIV-1 RNA <1,000 copies was 1.18 (95% CI: 1.04, 1.31; p = 0.012). The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain. Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease. This study is registered with ClinicalTrials.gov number NCT01900080.

Adolescents and youth living with HIV have poorer antiretroviral treatment (ART) adherence and viral suppression outcomes than all other age groups. Effective interventions promoting adherence are urgently needed. We reviewed and synthesized recent literature on interventions to improve ART adherence among this vulnerable population. We focus on studies conducted in low- and middle-income countries (LMIC) where the adolescent and youth HIV burden is greatest. Articles published between September 2015 and January 2019 were identified through PubMed. Inclusion criteria were: [1] included participants ages 10–24 years; [2] assessed the efficacy of an intervention to improve ART adherence; [3] reported an ART adherence measurement or viral load; [4] conducted in a LMIC. Articles were reviewed for study population characteristics, intervention type, study design, outcomes measured, and intervention effect. Strength of each study’s evidence was evaluated according to an adapted World Health Organization GRADE system. Articles meeting all inclusion criteria except being conducted in an LMIC were reviewed for results and potential transportability to a LMIC setting. Of 108 articles identified, 7 met criteria for inclusion. Three evaluated patient-level interventions and four evaluated health services interventions. Of the patient-level interventions, two were experimental designs and one was a retrospective cohort study. None of these interventions improved ART adherence or viral suppression. Of the four health services interventions, two targeted stable patients and reduced the amount of time spent in the clinic or grouped patients together for bi-monthly meetings, and two targeted patients newly diagnosed with HIV or not yet deemed clinically stable and augmented clinical care with home-based case-management. The two studies targeting stable patients used retrospective cohort designs and found that adolescents and youth were less likely to maintain viral suppression than children or adults. The two studies targeting patients not yet deemed clinically stable included one experimental and one retrospective cohort design and showed improved ART adherence and viral suppression outcomes. ART adherence and viral suppression outcomes remain a major challenge among adolescents and youth. Intensive home-based case management models of care hold promise for improving outcomes in this population and warrant further research.

Gaps in the HIV care continuum contribute to poor health outcomes and increase HIV transmission. A combination of interventions targeting multiple steps in the continuum is needed to achieve the full beneficial impact of HIV treatment. Link4Health, a cluster-randomized controlled trial, evaluated the effectiveness of a combination intervention strategy (CIS) versus the standard of care (SOC) on the primary outcome of linkage to care within 1 month plus retention in care at 12 months after HIV-positive testing. Ten clusters of HIV clinics in Swaziland were randomized 1:1 to CIS versus SOC. The CIS included point-of-care CD4+ testing at the time of an HIV-positive test, accelerated antiretroviral therapy (ART) initiation for treatment-eligible participants, mobile phone appointment reminders, health educational packages, and noncash financial incentives. Secondary outcomes included each component of the primary outcome, mean time to linkage, assessment for ART eligibility, ART initiation and time to ART initiation, viral suppression defined as HIV-1 RNA < 1,000 copies/mL at 12 months after HIV testing among patients on ART ≥6 months, and loss to follow-up and death at 12 months after HIV testing. A total of 2,197 adults aged ≥18 years, newly tested HIV positive, were enrolled from 19 August 2013 to 21 November 2014 (1,096 CIS arm; 1,101 SOC arm) and followed for 12 months. The median participant age was 31 years (IQR 26-39), and 59% were women. In an intention-to-treat analysis, 64% (705/1,096) of participants at the CIS sites achieved the primary outcome versus 43% (477/1,101) at the SOC sites (adjusted relative risk [RR] 1.52, 95% CI 1.19-1.96, p = 0.002). Participants in the CIS arm versus the SOC arm had the following secondary outcomes: linkage to care regardless of retention at 12 months (RR 1.08, 95% CI 0.97-1.21, p = 0.13), mean time to linkage (2.5 days versus 7.5 days, p = 0.189), retention in care at 12 months regardless of time to linkage (RR 1.48, 95% CI 1.18-1.86, p = 0.002), assessment for ART eligibility (RR 1.20, 95% CI 1.07-1.34, p = 0.004), ART initiation (RR 1.16, 95% CI 0.96-1.40, p = 0.12), mean time to ART initiation from time of HIV testing (7 days versus 14 days, p < 0.001), viral suppression among those on ART for ≥6 months (RR 0.97, 95% CI 0.88-1.07, p = 0.55), loss to follow-up at 12 months after HIV testing (RR 0.56, 95% CI 0.40-0.79, p = 0.002), and death (N = 78) within 12 months of HIV testing (RR 0.80, 95% CI 0.46-1.35, p = 0.41). Limitations of this study include a small number of clusters and the inability to evaluate the incremental effectiveness of individual components of the combination strategy. A combination strategy inclusive of 5 evidence-based interventions aimed at multiple steps in the HIV care continuum was associated with significant increase in linkage to care plus 12-month retention. This strategy offers promise of enhanced outcomes for HIV-positive patients. ClinicalTrials.gov NCT01904994.

Background Uncontrolled hypertension is the leading modifiable risk factor for cardiovascular disease mortality and remains high in low-middle income countries like Haiti. Barriers and facilitators to achieving hypertension control in urban Haiti remain poorly understood. Elucidating these factors could lead to development of successful interventions. Methods We conducted semi-structured interviews with healthcare providers (10) and patients with hypertension (10) from the Haiti Cardiovascular Disease Cohort, using guides developed using the Consolidated Framework for Implementation Research. Participants were recruited using purposive sampling, and thematic content analysis was conducted in NVIVO software. Results At the individual level, barriers to hypertension control included hypertension is asymptomatic, hypertension is due to stress, difficulty changing behaviors within shared households, and fear of becoming dependent on medications. Facilitators included spiritual faith in doctors, high awareness of diet and exercise, belief in medication effectiveness, and family as motivation to treat hypertension. At the inner setting clinic level, barriers included limited physician–patient time during visits, residual stigma around cardiovascular services located on same campus as HIV care, and patient preference for physician guidance. Facilitators included patients treated with respect at clinic, and strong provider-patient rapport. At the outer setting societal level, only barriers were mentioned, including extreme poverty, civil insecurity, and stress making hypertension worse. Conclusions These findings can inform the development of future efforts to design interventions to improve hypertension control in Haiti.

Margaret McNairy and colleagues highlight the need for clinical decision tools to help identify HIV patients who would benefit from tailored services to avoid poor outcomes such as death and loss to follow-up.

Over 18 million adults have initiated life-saving antiretroviral therapy (ART) in resource-poor settings; however, mortality and lost-to-follow-up rates continue to be high among patients in their first year after treatment start. Clinical decision tools are needed to identify patients at high risk for poor outcomes in order to provide individualized risk assessment and intervention. This study aimed to develop and externally validate risk prediction tools that estimate the probability of dying or of being lost to follow-up (LTF) during the year after starting ART. We used a derivation cohort of 7,031 adults age 15-70 years initiating ART from 2007 to 2013 at 6 clinics in Haiti; 242 (3.5%) had documented death and 1,521 (21.6%) were LTF at 1 year after starting ART. The following routinely collected data were used as predictors in two logistic regression models (one to predict death and another to predict LTF): age, gender, weight, CD4 count, WHO Stage, and diagnosis of tuberculosis (TB). The validation cohort consisted of 1,835 adults initiating ART at a different HIV clinic in Haiti during 2012. We assessed model discrimination by measuring the C-statistic, and measured model calibration by how closely the predicted probabilities approximated actual probabilities of the two outcomes. We derived a nomogram and a point-based risk score from the predictive models. The model predicting death within the year after starting ART had a C-statistic of 0.75 (95% CI 0.74 to 0.81). There was no evidence for significant overfitting and the predictions were well calibrated. The strongest predictors of 1-year mortality were male gender, low weight, low CD4 count, advanced WHO stage, and the absence of TB. In the validation cohort, the C-statistic was 0.69 (95% CI 0.59 to 0.77). A point-based risk score for death had a C-statistic 0.73 (95% CI 0.69 to 0.76) and categorizes patients as low risk (<2% risk of death), average risk (3-4%), and high-risk (8-10%) and very high-risk (14-19%) with likelihood ratios to be used in settings where the baseline risk is different from our study population. The model predicting LTF did not discriminate well (C-statistic 0.59). A simple risk-score using routinely collected data can predict 1-year mortality after ART initiation for HIV-positive adults in Haiti. However, predicting lost to follow-up using routinely collected data was not as successful. The next step is to assess whether use of this risk score can identify patients who need tailored services to reduce mortality in resource-poor settings such as Haiti.

Left ventricular hypertrophy (LVH) is one of the strongest predictors of cardiovascular disease (CVD) and mortality; yet the means to diagnose LVH in resource-constrained settings remain limited. The objectives of this study were to determine LVH prevalence by transthoracic echocardiography (TTE) in a high-risk group, and compare TTE vs. electrocardiography (ECG-LVH) for LVH detection. We analyzed enrollment data from the Haiti cardiovascular disease cohort study on adults (≥ 18 years, n  = 3,005) in Port-au-Prince between 2019 and 2021. All participants underwent questionnaires, vital signs, physical exams, and 12-lead ECGs. TTEs were acquired on those with hypertension or exhibiting CVD symptoms ( n  = 1040, 34.7%). TTE-LVH was defined according to the American Society of Echocardiography guidelines and ECG-LVH by Sokolow-Lyon, Cornell, and Limb-Lead Voltage criteria. The prevalence of TTE-LVH was 39.0% (95% CI 36.6–41.5%) and associated with older age. Only 26% of those with TTE-LVH and elevated blood pressure were on antihypertensives. Prevalence of ECG-LVH ranged from 1.9 to 5.0%, and compared to TTE-LVH had low agreement (κ < 0.20), low sensitivity (< 10%) and high specificity (> 90%). These findings indicate a high prevalence of TTE-LVH among high-risk Haitian adults, and poor detection using ECGs compared to TTEs. For those with TTE-LVH, treatment with antihypertensives may reduce the risk of adverse CVD outcomes.

Background Data on women’s reproductive health in settings facing extreme poverty are limited. We describe the reproductive health characteristics across the life course of women living in urban Port-au-Prince, Haiti, and identify factors associated with adverse pregnancy outcomes (APO). Methods Data were sourced from the Haiti Cardiovascular Disease Cohort Study, a population-based observational study in Port-au-Prince. This analysis includes all women who completed a reproductive health questionnaire, which included self-reported age of menarche, menopause, infertility, menstruation abnormalities, and APO, defined as a history of pregnancy loss, preterm births, and pregnancy complications. We performed univariable and multivariable log-binomial regression to identify factors associated with APO. Results Among 1746 women in the parent cohort, 1,163 (66.6%) women reported reproductive health data. The median age was 43 years (IQR 31–55). The median age at menarche was 14 years (IQR 12–16). A downward trend in the age of menarche was observed over time: women born from 1930 to 1970 reported a median age of 15 years, compared to 13 years among women born from 1990 to 2012 ( p  < 0.001). 11% (11.0%; n  = 130) of the participants reported a history of infertility. The median age of reported menopause was 48 years (IQR, 44–50; n  = 540), with approximately 37.4% ( n  = 203) experiencing menopause before the age of 45. Among 1007 women with ≥  one pregnancy, 61.7% ( n  = 623) experienced an APO, and 20.3% ( n  = 206) reported two or more APO. The most common APO was pregnancy loss ( n  = 515, 51.0%), pregnancy complications ( n  = 244, 24.0%), and preterm births ( n  = 132, 13.0%). Factors associated with a history of APO included hypertension, body mass index > 25 kg/m2, higher education, and a moderate perceived stress score. Conclusion Among women living in extreme poverty in Haiti, we found a high prevalence of adverse reproductive health outcomes, namely APO, and a temporal trend of a decreasing age of menarche across time. Adverse reproductive health outcomes have been associated with increased chronic disease, and additional research is needed to establish if these factors are associated with increased cardiometabolic disease in extremely poor settings to identify targets for future prevention and treatment. Plain English summary Data on women’s reproductive healthcare are not readily available in settings of extreme poverty, including Haiti; yet they are essential for improving women’s health in these contexts. We report data from women participants in the population-based Haiti Cardiovascular Disease Cohort Study. We used regression analysis to identify factors associated with adverse pregnancy outcomes. Among 1163 women, the median age was 43 years. The majority (68%, n  = 791) earned less than 1 USD, and 46% ( n  = 530) had only a primary-level education. We noted a statistically significant decline in the age at which women experience their first menstrual period, from 15 years for those born between 1930 and 1970 to 13 years among those born between 1990 and 2012. The median age at menopause was 48 years ( n  = 540). Among women who had one or more pregnancies, the vast majority, 61.7% ( n  = 623), reported experiencing adverse pregnancy outcomes. Factors associated with these outcomes included hypertension, obesity, and stress. Among women living in extreme poverty in urban Haiti, we found that two-thirds experienced one or more adverse pregnancy outcomes. Adverse pregnancy outcomes have been linked to chronic diseases like heart disease and may help identify women at high risk in low-resource settings, allowing for targeted prevention and treatment.

Cardiovascular disease (CVD) is the number one cause of death in low‐income countries including Haiti, with hypertension (HTN) being the leading risk factor. This study aims to identify gaps in the HTN continuum of screening, diagnosis, treatment, and blood pressure (BP) control. Sociodemographic and clinical data were collected from a population‐based sample of adults ≥18 years in Port‐au‐Prince (PAP) from March 2019 to April 2021. HTN was defined as systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or use of antihypertensive medication. Screening was defined as ever having had a BP measurement; diagnosis as previously being informed of a HTN diagnosis; treatment as having taken antihypertensives in the past 2 weeks; and controlled as taking antihypertensives and having BP < 140/90 mmHg. Factors associated with attaining each step in the continuum were assessed using Poisson multivariable regressions. Among 2737 participants, 810 (29% age‐standardized) had HTN, of whom 97% had been screened, 72% diagnosed, 45% treated, and 13% controlled. There were no significant differences across age groups or sex. Obesity (BMI ≥ 30) was a significant factor associated with receiving treatment compared to normal weight (BMI < 25), with a prevalence ratio (PR) of 1.5 (95% CI 1.1–2.0). Having secondary or higher education was associated with higher likelihood of controlled BP (PR 1.9 [95% CI 1.1–3.3]). In this urban Haitian population, the greatest gaps in HTN care are treatment and control. Targeted interventions are needed to improve these steps, including broader access to affordable treatment, timely distribution of medications, and patient adherence to HTN medication.

Hypertension (HTN) is the leading cause of death worldwide, yet only 8% of individuals have controlled blood pressure (BP) in low‐ and middle‐income countries, with particular challenges in humanitarian crisis settings including Haiti. The Haiti Cardiovascular Disease Cohort, an observational population‐based cohort in Port‐au‐Prince, offers a unique opportunity to evaluate the HTN Care Continuum in a setting of extreme poverty and civil unrest. From 2019 to 2021, 3005 adults were enrolled, with BP measured every 6 months and free clinical care provided. HTN was defined as SBP ≥ 140, DBP ≥ 90, or antihypertensive medication use. We assessed screening, awareness, treatment, and BP control (BP < 140/90 on antihypertensives) at enrollment and 24 months. Multivariable Poisson regression identified sociodemographic factors associated with BP control. Of 3005 adults, 878 had HTN at enrollment (median age 57; 62% female; 71% earned < $1/day). Among 568 hypertensive participants with 24‐month follow‐up, awareness increased from 67% to 95%, treatment from 40% to 71%, and BP control from 11% to 32%. Median BP decreased from 150/91 to 138/82 mmHg. Across visits, 67% had ≥ 1 controlled BP and 35% had control at more than half of visits. Younger age (18–39 vs. ≥60 years) was associated with lower BP control (PR: 0.40, 95% CI: 0.18–0.77). Substantial improvements in HTN care, including a threefold rise in BP control and a mean SBP decrease of 12 mmHg, are achievable even in settings of extreme adversity and humanitarian crises. Trial Registration: ClinicalTrials.gov identifier: NCT03892265