New HIV diagnoses among adults aged 50 years or older in 31 European countries, 2004-15: an analysis of surveillance data

Overlooked cases of HIV infection: An Italian tale of missed diagnostic opportunities

BACKGROUND

Late diagnoses are still a cause of increased HIV-related morbidity and mortality despite the availability of highly effective treatments. The aim of this study was to identify indicator conditions (ICs) in late presenters with HIV infection (LPs) that may represent missed opportunities of undertaking earlier HIV testing.

METHODS

The medical records of LPs referred to a specialist clinic in Milan, Italy, between 2011 and 2017 were reviewed to assess the frequency of ICs during the five years preceding diagnosis. Logistic regression analysis was used to investigate the factors associated with missed opportunities of making an earlier diagnosis.

RESULTS

The analysis considered 203 LPs (60.6% of the patients newly diagnosed as having HIV infection during the study period). Most had had ≥1 medical encounter in the five years before diagnosis, and 54 (26.6%) had been diagnosed as having ≥1 IC without undergoing HIV testing. The most frequent ICs were herpes zoster (19.8%), constitutional symptoms (17.4%) and lympho/thrombocytopenia (12.8%), and the missed opportunities for testing occurred in the settings of primary care (44.9%), specialist medical (38.2%) or surgical services (11.3%), and emergency departments (5.6%). Twenty-five (53.2%) of the 47 subjects with a non AIDS-defining IC had AIDS at the time of the diagnosis of HIV infection. Subjects aged >60 years were at increased risk of missed diagnostic opportunities (aOR 4.80, p = 0.008).

CONCLUSION

Implementing IC-guided HIV testing in non-specialist settings is an essential means of reducing late diagnoses of HIV infection even in the case of older subjects.

The role of mobility in sexual risk behaviour and HIV acquisition among sub-Saharan African migrants residing in two European cities

BACKGROUND

Migrants from high endemic countries accounted for 18% of newly diagnosed HIV infections in Europe in 2017. Knowledge on the link between HIV risk and post-migration travels and their impact on HIV acquisition is scarce, but critical to inform prevention. This study aims to explore risky sexual behaviour and HIV-acquisition among sub-Saharan African migrants, and to assess post-migration mobility as a determinant of sexual risk behaviour.

METHODS

Data from two cross-sectional bio-behavioural surveys to assess HIV-prevalence conducted in Lisbon and Antwerp were analysed to explore migration-related characteristics, travel patterns, and sexual risk taking in the host country and abroad. Bi- and multivariate associations were estimated through adjusted odds ratios and 95% confidence intervals; multivariable logistic regression determined factors associated with condomless sexual intercourse.

RESULTS

Among N = 1508 participants above 18 years (58% males), 68% travelled post-migration (49.2% reported intercourse abroad). The overall proportion of condomless sex at last sexual intercourse was high (68.1%). The odds of condomless sex in the host country was five times higher when the last sexual intercourse abroad was also condomless [OR:5.32; 95%CI:2.98-9.25]. About half of the travellers reported concurrency, i.e. a regular partner in the host country while having other sexual partners abroad. Almost three percent of the participants reported being HIV+, but 5% had a reactive HIV test-result, with similar proportions among travellers and non-travellers. Also, among the n = 75 participants with reactive HIV test-results, condomless sex occurred (n = 40) and was associated with mobility.

CONCLUSIONS

Sub-Saharan African migrants are mobile and engage in sexual risk behaviours in the countries of residence and while travelling, increasing risk of post-migration HIV-acquisition. A transnational perspective on HIV prevention and sexual health promotion is needed for effectively reducing migrants' HIV risk related to their mobility.

Trends in HIV testing in the UK primary care setting: a 15-year retrospective cohort study from 2000 to 2015

OBJECTIVES

To estimate trends in HIV testing, positivity and prevalence in UK primary care for 2000-2015 as part of a wider investigation into reasons for late diagnosis of HIV.

DESIGN

Retrospective cohort study using the Clinical Practice Research Datalink (CPRD) which is derived from computerised clinical records produced during consultations in primary care.

SETTING

404 general practices in England.

PARTICIPANTS

5 979 598 adults aged ≥16 years registered between 2000 and 2015 with 45 093 761 person years of observation.

OUTCOMES

Annual HIV testing rates, proportion of positive tests and prevalence of HIV-infected people recorded in primary care 2000-2015.

RESULTS

HIV testing in primary care increased from 2000 to 2010, but then declined. Testing was higher in females than in males and in those aged 16-44 years compared with older adults. Rates per 100 000 in women aged 16-44 years were 177 (95% CI 167 to 188); 1309 (95% CI 1282 to 1336); 1789 (95% CI 1757 to 1821) and 839 (95% CI 817 to 862) in 2000, 2005, 2010 and 2015, respectively, and for non-pregnant women: 22.5 (95% CI 19 to 26); 134 (95% CI 125 to 143); 262 (95% CI 250 to 275); 190 (95% CI 179 to 201). For men aged 16-44 years rates were: 26 (95% CI 22 to 29); 107 (95% CI 100 to 115); 196 (95% CI 185 to 206); 137 (95% CI 127 to 146). Over the study period, there were approximately two positive results per 1000 HIV tests. Men were eightfold more likely to test positive than women. The percentage of HIV diagnoses among adults recorded in CPRD may be as low as 55% in London and 67% in the rest of the UK.

CONCLUSIONS

HIV testing rates in primary care peaked in 2010 and subsequently declined. Access to testing was higher for women despite the prevalence of HIV being higher in men.

IMPLICATIONS AND FURTHER RESEARCH NEEDED

Opportunities remain in primary care for increasing HIV testing to prevent costly late diagnoses and decrease HIV transmission. Interventions to improve targeting of tests and increase adherence to HIV testing guidelines are needed in primary care.

Newly diagnosed cases of HIV in those aged 50 years and older and those less than 50: 2008-2017

Background

Canada's population is aging, with nearly forty percent of Canadians aged 50 years or more. As the population ages, unique challenges related to health are becoming evident, including increasing rates of sexually transmitted and bloodborne infections. Understanding the epidemiology of HIV in older adults is important to guide prevention and control programs.

Objective

To assess trends in newly diagnosed cases of HIV in Canada among those aged 50 years and older (≥50 years) and those aged less than 50 (<50 years), and to compare their basic demographic characteristics and exposure categories for the period of 2008 to 2017.

Methods

National surveillance of HIV is conducted by the Public Health Agency of Canada through voluntary submission of data by provincial/territorial public health authorities. Descriptive analyses were conducted on reported cases of HIV between January 1, 2008, to December 31, 2017 to compare the demographic profiles and exposure category for the two age groups.

Results

Between 2008 and 2017, the proportion of newly diagnosed HIV cases among those ≥50 years increased from 15.1% to 22.8%. The HIV diagnosis rates for both older males and older females increased over time, with a relatively higher increase for females. A higher proportion of newly diagnosed HIV cases were male in the older group (81.2%) compared to the younger group (74.6%). Among both older and younger males, the most common exposure category for HIV was being gay, bisexual and other men who have sex with men (gbMSM), followed by heterosexual contact and injection drug use; however, the relative proportions varied by age with the gbMSM category being higher in the <50 group.

Conclusion

In Canada, over 20% of all newly diagnosed cases of HIV are now in people 50 years of age and older. HIV testing and prevention initiatives, historically aimed at younger populations, may not have the same impact for older populations. These data can be used to inform future public health actions designed to address HIV in older populations.

Association between syphilis seroprevalence and age among blood donors in Southern China: an observational study from 2014 to 2017

OBJECTIVE

This study investigated the association between syphilis seroprevalence and age among blood donors, and described the distribution of serological titres among syphilis-infected donors, aiming to confirm the syphilis epidemic characteristics and to promote effective interventions for older adults.

METHODS

Data were obtained from the Shenzhen Programme for Syphilis Prevention and Control in 2014-2017. Blood samples were screened using the ELISAs, and confirmed using the Treponema pallidum particle agglutination assay (TPPA) and toluidine red unheated serum test (TRUST).

RESULTS

Among 394 792 blood donors, 733 tested TPPA and TRUST positive (active infection), and 728 tested only TPPA positive (historical infection). The overall prevalence of syphilis seropositivity was 370.1 per 100 000 (95% CI 351.1 to 389.0 per 100 000); the prevalence of active infection was 185.7 per 100 000 (95% CI 172.2 to 199.1 per 100 000). People aged ≥45 years displayed a prevalence of 621.8 per 100 000 in syphilis seropositivity and 280.5 per 100 000 in active infection, which were 3.8 times and 2.4 times higher than that for people aged <25 years, respectively. The prevalence of syphilis seropositivity (χ²_trend=311.9, p _trend<0.001) and active infection (χ²_trend=72.1, p _trend<0.001) increased significantly with age. After stratification by gender and year of donation, the increasing trend of prevalence with age remained (p _trend<0.05), except for the prevalence of active infection in males and females in 2014. About 16.3% of donors with active infection and aged ≥45 years had a TRUST titre of ≥1∶8, lower than that of patients aged <25 years (51.3%) and 25-34 years (34.1%).

CONCLUSIONS

The findings confirm the high prevalence of syphilis among older adults, and suggest the need to increase awareness among healthcare providers and deliver more targeted prevention interventions for older adults to promote early testing.

Higher Risks of Virologic Failure and All-Cause Deaths Among Older People Living with HIV in Chongqing, China

Older people living with HIV (PLWH) may have delayed diagnosis and access to care and therefore have poorer disease outcomes. Little is known about HIV care and disease outcomes among older PLWH in China. This retrospective cohort study used data from all adult HIV/AIDS cases during 1988-2017 in Chongqing, China from two national databases. We compared demographic and behavioral profiles, HIV care, virologic suppression, and mortality between two age groups of 18-49 and ≥50 years. Multivariate logistic and cox regression analyses were used to calculate adjusted odds ratio (AOR) and adjusted hazard ratio (AHR) among older versus younger PLWH. Of 46,580 adult HIV/AIDS cases, 76.1% were men and 38.2% were 50 years of age or older. The proportion of older cases in men increased from 2.4% in 2002 to 51.8% in 2017, and in women from 3.3% to 57.9%. Older PLWH had a lower CD4 count than their younger counterparts at HIV diagnosis (median 323 vs. 391 cells/μL; p < .001). The average time from HIV diagnosis to initiation of antiretroviral therapy (ART) were 6.3 months among older and 12.8 months among younger PLWH (p < .001). Nearly one tenth (9.6%) had virologic failure within 12 months of ART initiation, and the odds of virologic failure among older PLWH was 80% higher [AOR 1.8; 95% confidence interval (CI), 1.1-3.0] than among younger ones after controlling for calendar year of initiating ART and other covariates. The mortality rate within 12 months of initiating ART was 9.8 deaths per 100 person years, and the risk of mortality among older PLWH was three times among younger ones (AHR, 3.1; 95% CI, 2.1-4.6). Older people represented an increasing proportion of new HIV/AIDS cases and were more likely to have virologic failure and mortality within 12 months of ART initiation.

Elderly HIV-positive women: A gender-based analysis from the Multicenter Italian "GEPPO" Cohort

Background

HIV-positive patients are facing age-and disease-related comorbidities. Since gender differences in viro-immunological, clinical and therapeutic features have been described, aim of this analysis was to explore such differences in elderly HIV-positive females compared to males coming from the same cohort.

Design

Cross-sectional study.

Setting

Ten Infectious Diseases Center participating to a new multicenter Italian geriatric Cohort aiming at describing health transition over time in HIV-positive individuals.

Participants

HIV-positive patients aged ≥65 years old.

Measurements

We recorded clinical, viro-immunological and therapeutical data.

Results

We included 210 women (17%) out of 1237 patients. Compared to males, elderly females were less likely to present a HIV-RNA <50 copies/mL (74.3% vs. 81.8%, OR 0.64, 95%CI 0.44–0.93); they showed higher CD4+/CD8+ ratio (p = 0.016). Combined antiretroviral therapy (cART) strategies were similar between genders (p>0.05), although women were less likely to be treated with protease Inhibitors (PIs) (p = 0.05); specifically, in triple-drug regimens females received less PIs (28% vs 38% p = 0.022) and more integrase inhibitors (30% vs. 20% p = 0.012). Bone disease was more common in females (p<0.001) while males presented more frequently cardiovascular disease (CVD) (p<0.001). In females with bone disease, PIs and boosted regimens (38% vs. 53.7% p = 0.026 and 30.4 vs 44.0% p = 0.048 respectively) were prescribed less frequently. Polypharmacy was common and similar in both genders (20% vs. 22.8%, p = >0.05). A higher use of lipid-lowering drugs (20.5% vs. 14.8%, p = 0.04) was observed in females and yet they were less likely to receive anti-thrombotic agents (18.6% vs. 26.3%, p = 0.019) even when CVD was recorded (57.1% vs. 83.1%, p = 0.018). In multivariate analysis, we found that female gender was independently associated with a higher CD4+/CD8+ ratio but not with virological suppression

Conclusions

Elderly HIV-positive women display a worse virologic response despite a better immune reconstitution compared to males. The burden of comorbidities as well as the medications received (including cART) may slightly differ according to gender. Our data suggest that more efforts and focused interventions are needed in this population.

Dopaminergic impact of cART and anti-depressants on HIV neuropathogenesis in older adults

The success of combination antiretroviral therapy (cART) has transformed HIV infection into a chronic condition, resulting in an increase in the number of older, cART-treated adults living with HIV. This has increased the incidence of age-related, non-AIDS comorbidities in this population. One of the most common comorbidities is depression, which is also associated with cognitive impairment and a number of neuropathologies. In older people living with HIV, treating these overlapping disorders is complex, often creating pill burden or adverse drug-drug interactions that can exacerbate these neurologic disorders. Depression, NeuroHIV and many of the neuropsychiatric therapeutics used to treat them impact the dopaminergic system, suggesting that dopaminergic dysfunction may be a common factor in the development of these disorders. Further, changes in dopamine can influence the development of inflammation and the regulation of immune function, which are also implicated in the progression of NeuroHIV and depression. Little is known about the optimal clinical management of drug-drug interactions between cART drugs and antidepressants, particularly in regard to dopamine in older people living with HIV. This review will discuss those interactions, first examining the etiology of NeuroHIV and depression in older adults, then discussing the interrelated effects of dopamine and inflammation on these disorders, and finally reviewing the activity and interactions of cART drugs and antidepressants on each of these factors. Developing better strategies to manage these comorbidities is critical to the health of the aging, HIV-infected population, as the older population may be particularly vulnerable to drug-drug interactions affecting dopamine.

Changing trends in the disease burden of primary liver cancer caused by specific etiologies in China

Background

Liver cancer is a commonly diagnosed malignancy in China. The etiologies of liver cancer are widely known, although studies on temporal trends in liver cancer caused by specific etiologies are rare.

Methods

Data on the incidence and mortality of liver cancer were retrieved from the Global Burden of Diseases Study 2017. The estimated annual percentage change (EAPC) was used to quantify temporal trends in the age‐standardized incidence rate (ASIR) and the age‐standardized mortality rate (ASMR) of liver cancer from 1990 to 2017.

Results

Nationwide, the number of incident cases of liver cancer increased from 258 000 in 1990 to 515 900 in 2017. The ASIR decreased from 27.16 per 100 000 to 26.04 per 100 000 during this period, with an EAPC of −0.64 (95% confidence interval [CI] −0.84, −0.44). The number of deaths increased from 245 300 in 1990 to 418 200 in 2017, and the ASMR decreased from 26.72 to 21.30 (EAPC = −1.16, 95% CI −1.35, −0.97). The most pronounced decreases in the ASIR and ASMR were observed in liver cancer due to hepatitis B and in people aged 15‐49 years.

Conclusions

Since the extensive efforts for prevention of hepatitis B virus infection, the incidence of liver cancer due to hepatitis B has significantly decreased. However, liver cancer due to hepatitis C, NASH, and other causes remains a major public health concern. Additional preventive strategies tailored to liver cancer are needed to further reduce its disease burden in China.

Age-related factors influence HIV testing within subpopulations: a cross-sectional survey of MSM within the Celtic nations

OBJECTIVES

Despite a recent fall in the incidence of HIV within the UK, men who have sex with men (MSM) continue to be disproportionately affected. As biomedical prevention technologies including pre-exposure prophylaxis are increasingly taken up to reduce transmission, the role of HIV testing has become central to the management of risk. Against a background of lower testing rates among older MSM, this study aimed to identify age-related factors influencing recent (≤12 months) HIV testing.

METHODS

Cross-sectional subpopulation data from an online survey of sexually active MSM in the Celtic nations-Scotland, Wales, Northern Ireland and Ireland (n=2436)-were analysed to compare demographic, behavioural and sociocultural factors influencing HIV testing between MSM aged 16-25 (n=447), 26-45 (n=1092) and ≥46 (n=897).

RESULTS

Multivariate logistic regression demonstrated that for men aged ≥46, not identifying as gay (OR 0.62, CI 0.41 to 0.95), location (Wales) (OR 0.49, CI 0.32 to 0.76) and scoring higher on the personalised Stigma Scale (OR 0.97, CI 0.94 to 1.00) significantly reduced the odds for HIV testing in the preceding year. Men aged 26-45 who did not identify as gay (OR 0.61, CI 0.41 to 0.92) were also significantly less likely to have recently tested for HIV. For men aged 16-25, not having a degree (OR 0.48, CI 0.29 to 0.79), location (Republic of Ireland) (OR 0.55, CI 0.30 to 1.00) and scoring higher on emotional competence (OR 0.57, CI 0.42 to 0.77) were also significantly associated with not having recently tested for HIV.

CONCLUSION

Key differences in age-related factors influencing HIV testing suggest health improvement interventions should accommodate the wide diversities among MSM populations across the life course. Future research should seek to identify barriers and enablers to HIV testing among the oldest and youngest MSM, with specific focus on education and stigma.

Lipid profile improvement in virologically suppressed HIV-1-infected patients switched to dolutegravir/abacavir/lamivudine: data from the SCOLTA project

Introduction: Metabolic disorders are common amongst HIV-infected patients. Data from real-life setting on the impact of DTG/ABC/3TC in virologically suppressed HIV-infected patients are scarce.

Methods: We investigated the modification of metabolic profile including fasting glucose, lipid profile and markers of insulin resistance (IR) in experienced patients switching from a boosted protease inhibitors (bPI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen to DTG/ABC/3TC in a prospective, observational, multicenter study.

Results: We enrolled 131 HIV-infected patients, of whom 91 (69.5%) males, mean age was 50.5±10.6 years. CDC stage was A in 66 (50.4%) patients, of whom 91 (69.5%) had acquired HIV through sexual contacts. The previous regimen was bPI-based in 79 patients (60.3%) and NNRTI-based in 52 (39.7%). Patients switching from NNRTI showed a significant reduction at week 24 in total cholesterol (TC) and low-density lipoprotein cholesterol (LDL). Triglycerides/high-density lipoprotein cholesterol (TG/HDL) ratio, HDL, median TG and TG/HDL ratio did not show significant modification during follow-up times. Among patients switching from a bPI, we observed a significant reduction in TC and LDL at both follow-up times and a slight increase in HDL. Triglycerides/HDL ratio, median TG and TG/HDL ratio showed a decrease over time that became significant at weeks 24 and 48. Blood glucose levels did not significantly vary during the observation period in patients switching from both bPI and NNRTI-based regimens.

Conclusion: Our data suggest an improvement in lipid profile and TG/HDL ratio in pretreated HIV-1-infected patients who switched to DTG/ABC/3TC over 48 weeks, especially in those previously receiving a bPI-based regimen.

Perceived sexual self-control and condom use with primary and casual sex partners: age and relationship agreement differences in a Portuguese sample

OBJECTIVE

Consistent condom use is still not ideal. Research showed that perceived sexual self-control is associated with greater likelihood of using condoms. However, this association seems to vary according to age and relationship agreement (i.e. non-consensual non-monogamy, NCNM vs. consensual non-monogamy, CNM).

DESIGN

Cross-sectional study with 307 heterosexual users of a dating web site for romantically involved individuals (81.8% men; M_age = 42.24, SD = 9.65, range: 23-76 years). All individuals were in a romantic relationship (M_length = 13.47 years, SD = 9.39).

MEASURES

Demographic information, perceived sexual self-control, condom use frequency (casual sex partners; primary partner in the last 3 months) and relationship agreement.

RESULTS

Independently of relationship agreement, perceived sexual self-control was positively associated with condom use frequency with casual sex partners among younger and middle age participants, but not older ones (>49 years). Regarding the primary partner, a similar pattern emerged for CNM participants. In contrast, no significant association between perceived sexual self-control and condom use frequency with the primary partner emerged for NCNM individuals, regardless of age.

CONCLUSION

Our findings can inform evidence-based strategies to promote consistent condom use as an effective behaviour to prevent sexually transmitted infections, especially among older and NCNM individuals.

Burden of Exposure to Potential Interactions Between Antiretroviral and Non-Antiretroviral Medications in a Population of HIV-Positive Patients Aged 50 Years or Older

BACKGROUND

As HIV-infected patients aged 50 years or older are at increased risk of comorbidities and multidrug treatments, we examined their exposure to the potential drug-drug interactions (PDDIs) of antiretroviral (ARV) and other medications.

METHODS

This cross-sectional study involved the patients aged 50 years or older receiving ARV and non-ARV medications at our clinic. PDDIs were identified using the University of Liverpool HIV Drug Interaction Checker. Logistic regression models were used to assess risk factors for PDDIs. The American Geriatrics Society Beers Criteria were used to identify potentially inappropriate medications (PIMs).

RESULTS

A total of 395 (53.9%) of 744 patients showed ≥1 PDDI: 47.4% ≥ 1 amber-PDDI (comedications requiring appropriate management) and 5.6% ≥ 1 red-PDDI (contraindicated comedications). A higher risk of PDDIs was associated with the use of ≥5 medications (P < 0.001), of antiosteoporotics (P < 0.001), calcium channel blockers (P < 0.001), anti-benign prostatic hypertrophy agents (P < 0.001), hypnotics/sedatives (P = 0.022), and anticoagulants (P = 0.006). A higher risk of red-PDDIs was associated with the use of antacids (P < 0.001), anti-benign prostatic hypertrophy agents (P < 0.001) and antipsychotics (P = 0.023). The use of nucleoside reverse transcriptase inhibitor + nonnucleoside reverse transcriptase inhibitor and nucleoside reverse transcriptase inhibitor + integrase strand transfer inhibitor rather than protease inhibitor-based regimens was associated with a reduced risk of PDDIs (P < 0.001). Overall, 119 (16.0%) patients were receiving PIMs (mainly hypnotics/sedatives) and 49 (41.2%) of them had PDDIs able to increase the blood levels of these medications.

CONCLUSIONS

Older patients with HIV are highly exposed to PDDIs between ARVs and comedications. The knowledge of their complete medication regimens and the screening for PDDIs and PIMs is therefore crucial to prevent drug-related adverse outcomes in this population.

The Global Impact of HIV on Sexual and Gender Minority Older Adults: Challenges, Progress, and Future Directions

According to Joint United Nations Programme on HIV/AIDS (UNAIDS) data, 36.9 million people are living with HIV worldwide. Older adults, those aged 50 years and older, with HIV are increasing worldwide; however, the prevalence and incidence differ substantially across regions. The purpose of this article is to provide an overview of how HIV is impacting older adults globally, with a focus on sexual and gender minority older adults. The article is organized using the eight geographical regions from UNAIDS, with information on the prevalence and incidence among older adults. Among sexual and gender minority older adults, key risks are identified, including laws that criminalize same-sex relationships; issues of stigma and fear; and the concomitant lack of access and barriers to HIV testing, treatment, and prevention. Progress within each region toward the UNAIDS 90-90-90 targets is included, and suggestions for future directions of research and service delivery are made.

Preferences for HIV testing services among men who have sex with men in the UK: A discrete choice experiment

BACKGROUND

In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare.

METHODS AND FINDINGS

Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world.

CONCLUSIONS

Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free.

Pre-exposure Prophylaxis for HIV Infection in the Older Patient: What can be Recommended?

Over the past 15 years, a significant increase in new HIV/AIDS diagnoses has been observed in the elderly population. This new epidemiological shift has been attributed to a longer sex life, lifestyle and changes in sexual behavior, poor sexual health education, and misconceptions about the absence of sexually transmitted disease in later life. Although many biomedical and behavioral interventions have proven useful to prevent sexually transmitted infections and HIV, pre-exposure prophylaxis (PrEP) has been shown to be the most successful biomedical intervention to prevent HIV in high-risk individuals. This approach is based on delivering a fixed dose of tenofovir disoproxil fumarate (300 mg), alone or combined with emtricitabine (300/200 mg) daily or on demand, before and after sexual intercourse. Despite the consistent number of clinical trials proving the effectiveness and safety of this strategy, no studies have focused specifically on elderly people. These individuals, who may benefit substantially from (PrEP), are at a higher risk of experiencing side effects secondary to tenofovir exposure. This review critically discusses the efficacy and safety of PrEP in people aged over 50 years and translates the knowledge of tenofovir management in patients with HIV into monitoring and stopping rules to be used in this special population. We provide practical recommendations to properly identify PrEP candidates among older adults. Furthermore, we define correct case management before and during PrEP  delivery, and we suggest stopping rules and alternative sexually transmitted infection prevention strategies.

HIV infection across aging: Synergistic effects on intrinsic functional connectivity of the brain

The objective of the study was to examine additive and synergistic effects of age and HIV infection on resting state (RS) intra- and inter-network functional connectivity (FC) of the brain. We also aimed to assess relationships with neurocognition and determine clinical-, treatment-, and health-related factors moderating intrinsic brain activity in aging HIV-positive (HIV+) individuals. The current report presents data on 54 HIV+ individuals (age M = 41, SD = 12 years) stabilized on cART and 54 socio-demographically matched healthy (HIV-) comparators (age M = 43, SD = 12 years), with cohort education mean of 16 years (SD = 12). Age at seroconversion ranged 20-55 years old. ANOVA assessed additive and synergistic effects of age and HIV in 133 ROIs. Bivariate statistics examined relationships of FC indices vulnerable to age-HIV interactions and neurocognitive domains T-scores (attention, executive, memory, psychomotor, semantic skills). Multivariate logistic models determined covariates of FC. This study found no statistically significant age-HIV effects on RS-FC after correcting for multiple comparisons except for synergistic effects on connectivity within cingulo-opercular network (CON) at the trending level. However, for uncorrected RS connectivity analyses, we observed HIV-related strengthening between regions of fronto-parietal network (FPN) and default mode network (DMN), and particular DMN regions and sensorimotor network (SMN). Simultaneously, FC weakening was observed within FPN and between other regions of DMN-SMN, in HIV+ vs. HIV- individuals. Ten ROI pairs revealed age-HIV interactions, with FC decreasing with age in HIV+, while increasing in controls. FC correlated with particular cognitive domains positively in HIV+ vs. negatively in HIV- group. Proportion of life prior-to-after HIV-seroconversion, post-infection years, and treatment determined within-FPN and SMN-DMN FC. In sum, highly functioning HIV+/cART+ patients do not reveal significantly altered RS-FC from healthy comparators. Nonetheless, the current findings uncorrected for multiple comparisons suggest that HIV infection may lead to simultaneous increases and decreases in FC in distinct brain regions even in patients successfully stabilized on cART. Moreover, RS-fMRI ROI-based analysis can be sensitive to age-HIV interactions, which are especially pronounced for inter-network FC in relation to neurocognition. Aging and treatment-related factors partially explain RS-FC in aging HIV+ patients.

Changing epidemiological patterns of HIV and AIDS in China in the post-SARS era identified by the nationwide surveillance system

Background

China has made substantial progress in tackling its HIV and AIDS epidemic. But the changing patterns of HIV and AIDS incidence based on the longitudinal observation data were rarely studied.

Methods

The reporting incidence (RI) and mortality data on HIV and AIDS in China covering 31 provinces from 2004 to 2014 were collected from the Chinese Public Health Science Data Center. To decompose the time-series data, Empirical Mode Decomposition (EMD) was applied to properly describe the trends of HIV and AIDS incidence. A mathematical model was used to estimate the relative change of incidence among provinces and age groups.

Results

A total of 483,010 newly HIV infections and 214,205 AIDS cases were reported between 2004 and 2014 nationwide. HIV infection increased from 13,258 in 2004 (RI 1.02 per 100,000 person years) to 74,048 in 2014 (RI 5.46 per 100,000). The number of AIDS cases increased from 3054 in 2004 (RI 0.23 per 100,000) to 45,145 in 2014 (RI 3.33 per 100,000). The overall relative changes for HIV infection and AIDS incidence were 1.11 (95% confidence interval [CI] 1.10–1.13) and 1.28 (95% CI 1.23–1.33), respectively. The relative increase for HIV and AIDS RI was higher in northwest provinces while lower in Henan, Xinjiang, Guangxi and Yunnan. The overall relative changes for HIV infection were 1.12 (95% CI 1.11–1.14) in males and 1.10 (95% CI 1.06–1.13) in females. For AIDS RI, the relative increases were 1.31 (95% CI 1.26–1.36) in males and 1.22 (95% CI 1.17–1.28) in females. The lowest relative increase was detected among young adults, while the largest relative increase (odds ratio [OR] > 1.30) was detected in people aged 55 years or above.

Conclusions

HIV and AIDS showed an increasing trend in China from 2004 to 2014, respectively, but the epidemic tended to be under control among provinces and young people that used to have a high HIV and AIDS incidence. Northwest China and older people could be new “hop-spots” for HIV and AIDS risk.

Exogenous steroid-induced hypoadrenalism in a person living with HIV caused by a drug-drug interaction between cobicistat and intrabursal triamcinolone

We report a diagnosis of exogenous steroid-induced hypoadrenalism in a person living with HIV caused by a drug-drug interaction (DDI) between intrabursal triamcinolone and the pharmacokinetic booster cobicistat. A 53-year-old woman living with HIV, managed with dolutegravir and cobicistat-boosted darunavir, presented to the orthopaedic clinic with worsening hip pain. She was diagnosed with greater trochanteric pain syndrome (GTPS) of the hip and was treated with intrabursal injection of bupivacaine and triamcinolone. Seven days following this injection, she presented with Cushingoid features, an undetectable cortisol and was diagnosed with exogenous steroid-induced hypoadrenalism. Cobicistat is a cytochrome P450 3A inhibitor and in this case inhibited clearance of intrabursal triamcinolone, leading to exogenous glucocorticoid excess and adrenal suppression. This is the first report to describe this predictable DDI with cobicistat following intrabursal glucocorticoid injection. This case highlights the complexities in managing non-HIV-related chronic morbidities in people living with HIV.

The epidemiology of hepatitis B and hepatitis C infections in China from 2004 to 2014: An observational population-based study

Viral hepatitis is a major public health concern in China, but data on national epidemiological characteristics are lacking. We collected reporting incidence data on hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in China from 2004 to 2014. Empirical mode decomposition (EMD) was performed to accurately describe the reporting incidence trends of HBV and HCV. A mathematical model was used to estimate the relative change in incidence across provinces and age groups. Nationwide, a total of 916 426 hepatitis B cases and 39 381 hepatitis C cases were recorded in 2004; the reporting incidences of HBV and HCV were 70.50/100 000 and 3.03/100 000, respectively. The overall relative changes in HBV and HCV reporting incidences in China from 2004 to 2014 were 0.98 (95% CI 0.96-1.00, P = .082) and 1.16 (95% CI 1.12-1.20, P < .001), respectively. Thirteen provinces experienced decline in HBV reporting incidence. Most provinces exhibited an increasing trend in HCV reporting incidence. People aged ≤24 displayed a significant descending trend in HBV reporting incidence; people aged ≥55 exhibited a significant increasing trend. For HCV infection, the reporting incidence increased in all age groups except the 10-14 age group. In China, the majority of provinces have experienced decline or remained stable in HBV infection but show significant increases in HCV infection. Children and adolescents are well protected from HBV infection, while relatively higher increasing rates are found among older people. HCV is much more prevalent among older people, although its emergence has shifted to younger age groups.

Factors associated with testing for HIV in people aged ≥50 years: a qualitative study

Background

Despite a decline in the number of new HIV infections in the UK overall, the number and proportion of new HIV diagnoses in people aged ≥50 years continues to increase. People aged ≥50 years are disproportionately affected by late diagnosis, which is associated with poorer health outcomes, increased treatment complexity and increased healthcare costs. Late HIV diagnosis also has significant public health implications in terms of onward HIV transmission. It is not fully understood what factors affect the decision of an older person to test for HIV. The aim of this study was to identify factors associated with testing for HIV in people aged ≥50 years who tested late for HIV.

Methods

We interviewed 20 people aged ≥50 years diagnosed late with HIV to identify factors associated with HIV testing. Interviews were audio recorded, transcribed verbatim and thematically analysed.

Results

Seven themes associated with HIV testing in people aged ≥50 years were identified: experience of early HIV/AIDS campaigns, HIV knowledge, presence of symptoms and symptom attribution, risk and risk perception, generational approaches to health and sexual health, stigma, and type of testing and testing venue.

Conclusion

Some factors associated with testing identified in this study were unique to older individuals. People aged ≥50 years often do not perceive themselves to be at risk of HIV. Further, stigma and a lack of knowledge of how to access HIV testing suggest a need for health promotion and suggest current sexual health services may need to adapt to better meet their needs.

Non-AIDS-related comorbidities in people living with HIV-1 aged 50 years and older: The AGING POSITIVE study

OBJECTIVE

To characterize the profile of non-AIDS-related comorbidities (NARC) in the older HIV-1-infected population and to explore the factors associated with multiple NARC.

METHODS

This was a multicentre, cross-sectional study including HIV-1-infected patients aged ≥50 years, who were virologically suppressed and had been on a stable antiretroviral therapy (ART) regimen for at least 6 months. A multiple regression model explored the association between demographic and clinical variables and the number of NARC.

RESULTS

Overall, 401 patients were enrolled. The mean age of the patients was 59.3 years and 72.6% were male. The mean duration of HIV-1 infection was 12.0 years and the median exposure to ART was 10.0 years. The mean number of NARC was 2.1, and 34.7% of patients had three or more NARC. Hypercholesterolemia was the most frequent NARC (60.8%), followed by arterial hypertension (39.7%) and chronic depression/anxiety (23.9%). Arterial hypertension and diabetes mellitus were the most frequently treated NARC (95.6% and 92.6% of cases, respectively). The linear regression analysis showed a positive relationship between age and NARC (B=0.032, 95% confidence interval 0.015-0.049; p=0.0003) and between the duration of HIV-1 infection and NARC (B=0.039, 95% confidence interval 0.017-0.059; p=0.0005).

CONCLUSIONS

A high prevalence of NARC was found, the most common being metabolic, cardiovascular, and psychological conditions. NARC rates were similar to those reported for the general population, suggesting a larger societal problem beyond HIV infection. A multidisciplinary approach is essential to reduce the burden of complex multi-morbid conditions in the HIV-1-infected population.

Effects of age, HIV, and HIV-associated clinical factors on neuropsychological functioning and brain regional volume in HIV+ patients on effective treatment

It is yet unclear if people infected with human immunodeficiency virus (HIV+) on stable, combined antiretroviral therapies (cARTs) decline with age at the same or greater rate than healthy people. In this study, we examined independent and interactive effects of HIV, age, and HIV-related clinical parameters on neuropsychological functioning and brain regional volume in a sizable group of Polish HIV+ men receiving cART. We also estimated the impact of nadir CD4 cell count, CD4 cell count during participation in the study, duration of HIV infection, or duration of cART along with age. Ninety-one HIV+ and 95 control (HIV-) volunteers ages 23-75 completed a battery of neuropsychological tests, and 54 HIV+ and 62 HIV- of these volunteers participated in a brain imaging assessment. Regional brain volume in the cortical and subcortical regions was measured using voxel-based morphometry. We have found that HIV and older age were independently related to lower attention, working memory, nonverbal fluency, and visuomotor dexterity. Older age but not HIV was associated with less volume in several cortical and subcortical brain regions. In the oldest HIV+ participants, age had a moderating effect on the relationship between the duration of cART and visuomotor performance, such as that older age decreased speed of visuomotor performance along with every year on cART. Such results may reflect the efficacy of cART in preventing HIV-associated brain damage. They also highlight the importance of monitoring neuropsychological functioning and brain structure in HIV+ patients. This is particularly important in older patients with long adherence to cART.

Where do we diagnose HIV infection? Monitoring new diagnoses made in nontraditional settings in England, Wales and Northern Ireland

OBJECTIVES

The objectives of the study were to describe 10-year trends in HIV diagnosis setting and to explore predictors of being diagnosed outside a sexual health clinic (SHC).

METHODS

Analyses of national HIV surveillance data were restricted to adults (aged ≥ 15 years) diagnosed in 2005-2014 in England, Wales and Northern Ireland. Logistic regression identified factors associated with diagnosis outside an SHC (2011-2014).

RESULTS

Between 2005 and 2014, 63 599 adults were newly diagnosed with HIV infection; 83% had a diagnosis setting reported. Most people were diagnosed in SHCs (69%) followed by: medical admissions/accident and emergency (A&E; 8.6%), general practice (6.4%), antenatal services (5.5%), out-patient services (3.6%), infectious disease units (2.7%) and other settings (4.0%). The proportion of people diagnosed outside SHCs increased from 2005 to 2014, overall (from 27% to 32%, respectively) and among men who have sex with men (MSM) (from 14% to 21%) and black African men (from 25% to 37%) and women (from 39% to 52%) (all trend P < 0.001). Median CD4 increased across all settings, but was highest in SHCs (384 cells/μL) and lowest in medical admissions/A&E (94 cells/μL). Predictors of being diagnosed outside SHCs included: acquiring HIV through heterosexual contact [adjusted odds ratio (aOR) 1.99; 95% confidence interval (CI) 1.81-2.18] or injecting drug use (aOR: 3.28; 95% CI: 2.56-4.19; reference: MSM), being diagnosed late (< 350 cells/μL) (aOR: 2.55; 95% CI: 2.36-2.74; reference: diagnosed promptly) and being of older age at diagnosis (35-49 years: aOR: 1.60; 95% CI: 1.39-1.83; ≥ 50 years: aOR: 2.48; 95% CI: 2.13-2.88; reference: 15-24 years).

CONCLUSIONS

The proportion of HIV diagnoses made outside SHCs has increased over the past decade in line with evolving HIV testing guidelines. However, the rate of late diagnosis remains high, indicating that further expansion of testing is necessary, as many people may have had missed opportunities for earlier diagnosis.