Prevention of HIV-1 infection with early antiretroviral therapy

30 years of HIV therapy: Current and future antiviral drug targets

Significant advances in treatment have turned HIV-1 into a manageable chronic condition. This has been achieved due to highly active antiretroviral therapy (HAART), involving a combination regimen of medications, including drugs that target Reverse Transcriptase, Protease, Integrase, and viral entry, explored in this review. This paper also highlights novel therapies, such as Lenacapavir, and avenues toward functional cure targeting the CCR5 co-receptor, including the Δ32 mutation. Challenges of HAART include lifelong adherence, toxicity, drug interactions, and drug resistance. Future therapeutic strategies may focus on underexplored antiviral targets. HIV-1 Tat and Rev proteins have essential HIV-1 regulatory functions of transcriptional elongation of the viral long terminal repeat and nuclear export of intron-containing HIV-1 RNA, respectively. These non-enzymatic proteins should thus be investigated to identify small molecules that inhibit HIV-1 replication, without causing undue toxicity. Continued innovation is essential to address therapeutic gaps and bring us closer to a potential HIV-1 cure.

Effect of Mental Health Care Visits on HIV Care Outcomes

To improve the quality of life for people living with HIV (PLWH), it is vital their treatment plans closely follow the HIV care continuum. However, many barriers, such as mental health disorders (MHD), can complicate treatment. Patients being treated for HIV with comorbid MHD are more likely to not be retained in care and maintain an unsuppressed viral load. As PLWH and people vulnerable to acquiring HIV are more commonly diagnosed with MHD in comparison to the general population, it is important that steps to mitigate the possible effects of MHD are addressed during treatment. This study examines how minimal mental health care in a safety-net hospital system in the U.S. South can show benefits in retaining patients throughout their treatment of HIV. The results showed that older individuals retained a higher level of viral suppression when they followed up regularly with a mental health care provider during treatment. In addition, regardless of age, the higher the number of mental health care visits a patient attended during treatment, the higher the likelihood of viral suppression. By incorporating mental health care into the HIV treatment plan, the patients who met at least one of these criteria had better treatment outcomes and progressed further along the HIV care continuum.

Evaluation of a new human immunodeficiency virus antigen and antibody test using light-initiated chemiluminescent assay

Objectives

The goal of this study is to evaluate the analytical and clinical performance of a new human immunodeficiency virus antigen and antibody (HIV Ag/Ab) test using light-initiated chemiluminescent assay (LiCA®) and compare it with the well-established Architect® HIV Ag/Ab combo assay in a clinical setting.

Methods

We used banked samples and national reference controls to identify the ability to detect HIV Ag/Ab and different viral subtypes. Thirteen seroconversion panels were tested to evaluate early detection of HIV. A total of 21,042 patient samples were collected to compare the diagnostic performance of LiCA® with Architect®. Screening-reactive results were confirmed by Western blotting and nucleic acid testing.

Results

Total imprecision was within 2.49%-6.56%. The C5-C95 interval was within -10.20%-7.67% away from C50. The limit of detection for p24 antigen was <1.00 IU/mL. Using national reference panels and banked sample pools, LiCA® successfully detected all negative and positive controls in line with the criteria, and all HIV-positive specimens containing different viral subtypes. In 13 seroconversion panels, LiCA® detected reactive results on average 5.73 days (95% CI: 3.42-8.04) after the initial RNA test results were confirmed positive, which was 1.27 days earlier (-3.75 to 1.21) compared to Architect®. Paired comparisons in 21,042 clinical patient samples demonstrated that LiCA® detected HIV Ag/Ab with a slightly better performance in sensitivity (100.00% vs. 99.65%), specificity (99.85% vs. 99.81%), negative predictive value (NPV, 100.00% vs. 99.99%), and positive predictive value (PPV, 89.84% vs. 87.85%) than Architect®. Total agreement between two assays was 99.67% with a kappa value of 0.89.

Conclusion

LiCA® HIV Ag/Ab is a precise and highly sensitive assay for measuring HIV-1 p24 antigen and HIV-1/2 antibodies with differentiated S/Co values of Ag/Ab. The assay is appropriate for use in the clinical routine test for the early detection of HIV.

Longitudinal Viral Load Clustering for People With HIV Using Functional Principal Component Analysis

Background: Longitudinal measures of viral load (VL) are critical in monitoring the HIV status. While multiple lab indicators exist for monitoring measures of VL, research on clustering historical/longitudinal VL measures is limited. Analyzing longitudinal VL patterns rather than aggregated measures offers deeper insights into HIV status. This study uses functional data clustering to classify longitudinal VL patterns and characterize each cluster by demographics, comorbidities, social behaviors, and CD4 count. Methods: Adult PWH diagnosed from 2005 to 2015 in South Carolina with a 5-year minimum follow-up were included. We compared functional principal component analysis (FPCA), K-means, hierarchical clustering, and Gaussian mixture models for classification and found FPCA yielded the best results. ANOVA was used to compare VL characteristics, demographics, comorbidities, substance uses, and longitudinal CD4 count across clusters. Results: Results obtained from FPCA could best distinguish the characteristics and patterns into four clusters. A total of 5916 PWH were grouped into long-term VS group (Cluster 1, 17.3%), short-term VS group (Cluster 2, 29.8%), suboptimal VS group (Cluster 3, 28.3%), and viral failure group (Cluster 4, 24.9%). In the long-term VS group with an average of 11-year follow-up, PWH displayed sustained VS (95.3%) and lower mean CD4 count (95.3%) than other clusters. The short-term VS group had shorter follow-up (6 years), more comorbidities (31.4%), and lower percentage of time with low CD4 count (79.9%). In suboptimal VS group, PWH were mostly under 30 years old (44.8%) and Black (77.2%), with relatively lower mean VL (92.9%) and lower VR history (18.4%). In the viral failure group, PWH had higher mean VL (40.6%) and lower mean CD4 count (34.7%). Discussion: The findings highlight the impact of continuous clustering in understanding the distinct viral profiles of PWH and emphasize the importance of tailored treatment and insights to target interventions for all PWH.

Dynamics of Mpox in an HIV endemic community: A mathematical modelling approach

During the 2022 monkeypox (Mpox) outbreak in non-endemic countries, sexual transmission was identified as the dominant mode of transmission, and particularly affected the community of men who have sex with men (MSM). This community experienced the highest incidence of Mpox cases, exacerbating the public health burden they already face due to the disproportionate impact of HIV. Given the simultaneous spread of HIV and Mpox within the MSM community, it is crucial to understand how these diseases interact. Specifically, since HIV is endemic within this population, understanding its influence on the spread and control of Mpox is essential. In this study, we analyze a mechanistic mathematical model of Mpox to explore the potential impact of HIV on the dynamics of Mpox within the MSM community. The model considered in this work incorporates the transmission dynamics of the two diseases, including antiretroviral therapy (ART) for HIV. We assumed that HIV was already endemic in the population at the onset of the Mpox outbreak. Through our analysis, we derived the Mpox invasion reproduction number within an HIV-endemic setting and established the existence and local asymptotic stability of the Mpox-free equilibrium under these conditions. Furthermore, we demonstrated the existence and local asymptotic stability of an Mpox-endemic equilibrium in an HIV-endemic regime. Notably, our findings revealed that the model exhibits a backward bifurcation, a phenomenon that may not have occurred in the absence of HIV within the population. The public health significance of our results is that the presence of HIV in the MSM community could hinder efforts to control Mpox, allowing the disease to become endemic even when its invasion reproduction number is below one. Additionally, we found that Mpox might be more challenging to control in scenarios where HIV increases susceptibility to Mpox. Finally, consistent with previous studies, our analysis confirms that reducing sexual contact can be effective for controlling the spread of Mpox within the MSM community.

Functionally-informed fine-mapping identifies genetic variants linking increased CHD1L expression and HIV restriction in monocytes

Human Immunodeficiency Virus Type 1 (HIV) set-point viral load is a strong predictor of disease progression and transmission risk. A recent genome-wide association study in individuals of African ancestries identified a region on chromosome 1 significantly associated with decreased HIV set-point viral load. Knockout of the closest gene, CHD1L, enhanced HIV replication in vitro in myeloid cells. However, it remains unclear if HIV spVL associated variants are associated with CHD1L gene expression changes. Here we apply a heuristic fine-mapping approach to prioritize combinations of variants that explain the majority of set-point viral load variance and identify variants likely driving the association. We assess the combined impact of these variants on CHD1L regulation using publicly available sequencing studies, and test the relationship between CHD1L expression and set-point viral load using imputed CHD1L expression from monocytes. Taken together, this work characterizes genetically regulated CHD1L expression and further expands our knowledge of CHD1L-mediated HIV restriction in monocytes.

Rapid viral suppression using integrase inhibitors during acute HIV-1 infection

BACKGROUND

Antiretroviral therapy (ART) is recommended for all individuals with HIV infection, including those with acute HIV-1 infection (AHI). While recommendations are similar to those for chronic infection, efficacy data regarding treatment of acute HIV is limited.

METHODS

This was a single arm, 96-week study of a once-daily integrase inhibitor (INSTI)-based regimen using elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (EVG/COBI/FTC/TDF) in AHI. Primary endpoint was proportion of participants with HIV-1 RNA <200 copies/mL and <50 copies/mL by treatment weeks 24 and 48, respectively. We also examined time to viral suppression and weight gain after treatment initiation. Outcomes and characteristics were compared with a historical AHI cohort using a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen with efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF).

RESULTS

Thirty-three participants with AHI were enrolled with 31 available for analyses. Most were African American (61%) and men who have sex with men (73%). Median age was 26 (IQR 22-42). Demographics were similar between the two AHI cohorts. By Week 24, 100% in the INSTI and 99% in the NNRTI cohort were <200 copies/mL; by Week 48, 100% in both cohorts were <50 copies/mL. Time to viral suppression was shorter in the INSTI cohort (median 54 versus 99 days). Mean weight change was similar with a 3.6 kg increase in the INSTI cohort and 2.4 kg in the NNRTI cohort at 96 weeks.

CONCLUSIONS

INSTI-based ART during AHI resulted in rapid and sustained viral suppression. Over 96 weeks, weight increased in the INSTI-based cohort but was similar to weight increase in a historical NNRTI-based AHI cohort.

Surveying the Literature on Implementation Determinants and Strategies for HIV Structural Interventions: A Systematic Review Protocol

Background

Despite improvements in HIV prevention, treatment, and surveillance, vast disparities remain in access, uptake, and adherence of evidence-based interventions. These disparities are most pronounced among racially, sexually, and gender minoritized populations, as well as among those living in poverty and/or who use injectable drugs. Structural interventions, or interventions that target social and structural determinants of health like housing, transportation, or income, are needed to increase access to, use of, and adherence to HIV EBIs to advance the aims of the national Ending the HIV Epidemic initiative. However, it is unclear to what extent barriers and facilitators of structural interventions have been identified in the U.S. and what implementation strategies and adjunctive interventions have been developed to enhance their delivery.

Methods

To identify what implementation determinants, implementation strategies, and adjunctive interventions have been identified for HIV structural interventions, we carried out a broad database search between May and July 2024, identifying a total of 8,098 articles. We will use a multi-step process to identify articles to include in the systematic review. We will use natural language processing to identify articles for exclusion, followed by manual text review and extraction using COVIDENCE software. Literature on determinants will be coded according to the Consolidated Framework for Implementation Research. Implementation strategies and adjunctive interventions will be coded according to the Expert Recommendations for Implementing Change, the Theoretical Domains Framework, and COM-B. We will descriptively analyze determinants, implementation strategies, and adjunctive interventions, use natural language processing for thematic analysis of determinants, implementation strategies, and adjunctive interventions, and provide narrative description of implementation strategies and adjunctive interventions.

Discussion

This systematic review will identify key barriers and facilitators for HIV structural intervention implementation strategies, including multi-level approaches to address disparities among marginalized populations. Findings will provide insights for advancing equitable, scalable interventions to support the goals of the Ending the HIV Epidemic initiative.

Systematic review registration

CRD42024554315.

Hepatitis C Treatment and Behavioral Risk Among Men Who Have Sex With Men With HIV: Comparing Interferon and Direct-Acting Antiviral Eras

BACKGROUND

Little is known about the effect of hepatitis C virus (HCV) treatment on sexual risk behavior among men who have sex with men (MSM) with HIV by treatment type (interferon [IFN]-based vs direct-acting antiviral [DAA]-based).

SETTING

MSM with HIV and recently acquired HCV infection enrolled in the MSM Observational Study of Acute Infection with hepatitis C (MOSAIC) cohort.

METHODS

Using data from 2009 to 2018, we evaluated risk behavior through a validated HCV risk score (where ≥2 indicated high risk) and its individual risk behaviors. Levels of risk behavior before, during, and after treatment were modeled for each treatment episode using linear and logistic regression with Generalized Estimating Equations adjusting for DAA availability and number of reinfections.

RESULTS

One hundred forty MSM with a median age of 45 years (interquartile range = 40-49) yielded 180 treatment episodes (n = 131 IFN-based, n = 49 DAA-based). Adjusted mean risk score before, during, and after treatment was 2.4 (95% confidence interval [CI] = 2.1 to 2.6), 0.9 (95% CI = 0.8 to 1.0), and 1.7 (95% CI = 1.5 to 1.8), respectively. Before treatment, no differences in mean HCV risk score or proportion of specific behaviors were found between the regimen groups. During treatment, MSM treated with DAAs had a higher average risk score and proportion of receptive condomless anal sex, sharing toys and unprotected fisting than those treated with IFN. After treatment, the proportion sharing straws were significantly higher in MSM treated with DAAs than in MSM treated with IFN.

CONCLUSIONS

MSM treated with DAAs, compared with MSM treated with IFN, had higher levels of HCV-related risk behavior during treatment. The higher risk of HCV reinfection in the DAA-era underscores the need for ongoing HCV testing and behavioral interventions against HCV.

Neuroglial responses to bacterial, viral, and fungal neuroinfections

Evidence regarding the host's response to peripheral pathogens in humans abound, whereas studies on the pathogenesis of central nervous system-penetrating infections are relatively scarce. However, given the spate of epidemic and pandemic neuroinfections in the 21st century, the field has experienced a renewed interest lately. This chapter discusses a timely and exciting topic on the roles of glial cells, mainly microglia and astrocytes, in neuroinvasive infections. This chapter considered fungal, viral, and bacterial neuroinfections, X-raying their neuroinvasiveness, neurotropism, and neurovirulence before focusing on specific examples notable for each category, including Escherichia coli, Cryptococcus neoformans, and SARS-CoV-2. These infections are renowned worldwide for a high case-fatality rate, leaving many survivors with life-long morbidity and others with a bleak future neurologic prognosis. Importantly, the chapter discusses possible ways microglia and astrocytes are culpable in these infections and provides approaches by which they can be manipulated for therapeutic purposes, identifying viable research gaps in the process. Additionally, it offers a synopsis of ongoing works considering microglial selective targeting to attenuate the pathology, morbidity, and mortality associated with these neuroinfections. Considering that microglia and astrocytes are first responders in the central nervous system, targeting these glial cells could be the game changer in managing existing and emerging neuroinvasive infections.

Motivational Enhancement System for Adherence for Adolescents and Young Adults Newly Recommended to Start Antiretroviral Therapy

BACKGROUND

Adolescents and young adults (AYAs) (age 13-24 years) accounted for 20% of HIV diagnoses in the United States and 6 dependent areas in 2020. Optimal treatment adherence during adolescence and young adulthood decreases the pool of infectious individuals during the risky sexual activity commonly reported among AYAs living with HIV.

METHODS

Adolescents and young adults newly recommended to start antiretroviral therapy (ART) were recruited, nationally, from 7 clinical sites. At each clinical site, participants were randomized to receive a 2-session (baseline and 1 month) online intervention. For the Motivational Enhancement System for Health (MESA) intervention condition, based on the principles of motivational interviewing, participants received ART information and personalized feedback + ART standard of care (n = 86), while for the System for Health (SH) control condition, participants received information on healthy eating and physical activity + ART standard of care (n = 66).

RESULTS

Adherence was 21% greater in the MESA intervention group compared with the SH control group at 6 months. In addition, the MESA intervention group was significantly more adherent during the postintervention, and was more likely to maintain viral suppression up to 12 months after initiating ART if both doses of the intervention were received compared with the SH control group.

CONCLUSIONS

A brief, scalable online computer-delivered intervention shows promise for achieving long-term health outcomes because of improved adherence when intervention occurs early in the course of treatment.

TRIAL REGISTRATION

NCT02761746.

Longitudinal assessments of viral rebound among people with HIV in South Carolina: a population-based cohort study

Routinely monitoring viral rebound (VR) is important in the life course of people with HIV (PWH). This study examined risk factors for time to the first VR, the number of VRs and their association with VR history in men who have sex with men (MSM). It includes 8176 adult PWH diagnosed from January 2005 to December 2018, followed until July 2021. We used the Cox model for time to the first VR, the Poisson model for a number of VRs, and logistic regression for VR history in MSM. Younger individuals (50-59 years vs 18-29 years, aHR: 0.43, 95% CI: [0.34, 0.55]) were more likely to experience VR. Black individuals (Black vs White, IRR: 1.61, 95% CI [1.38, 1.88]) had more VR, while MSM (MSM vs Heterosexual, IRR: 0.68, 95% CI: [0.57, 0.81]) was negatively associated with number of VsR. Furthermore, individuals engaging illicit drug use (IDU) (aOR: 1.50, 95% CI: [1.03, 2.17]) were more likely to experience VR in the MSM subgroup. This study highlighted the alarming risk factors related to VR among PWH. Tailored intervention should also be deployed for young, Black MSM patients with substance use for more effective and targeted public health strategies concerning VR.

Effect of a Male-Targeted Digital Decision Support Application Aimed at Increasing Linkage to HIV Care Among Men: Findings from the HITS Cluster Randomized Clinical Trial in Rural South Africa

Linkage to HIV care remains suboptimal among men. We investigated the effectiveness of a male-targeted HIV-specific decision support app, Empowering People through Informed Choices for HIV (EPIC-HIV), on increasing linkage to HIV care among men in rural South Africa. Home-Based Intervention to Test and Start (HITS) was a multi-component cluster-randomized controlled trial conducted among 45 communities in uMkhanyakude, KwaZulu-Natal. The development of EPIC-HIV was guided by self-determination theory and human-computer interaction design to increase intrinsic motivation to seek HIV testing and care among men. EPIC-HIV was offered in two stages: EPIC-HIV 1 at the time of home-based HIV counseling and testing (HBHCT), and EPIC-HIV 2 at 1 month after a positive HIV diagnosis if not linked to care. Sixteen communities were randomly assigned to the arms to receive EPIC-HIV, and 29 communities to the arms without EPIC-HIV. Among all eligible men, we compared linkage to care (initiation or resumption of antiretroviral therapy after > 3 months of care interruption) at local clinics within 1 year of a home visit, ascertained from individual clinical records. Intention-to-treat analysis was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., financial incentives) and clustering at the community level. We also conducted a satisfaction survey for EPIC-HIV 2. A total of 13,894 men were eligible (i.e., aged ≥ 15 years and resident in the 45 communities). The mean age was 34.6 (±16.8) years, and 65% were married or in an informal union. Overall, 20.7% received HBHCT, resulting in 122 HIV-positive and 6 discordant tests. Among these, 54 men linked to care within 1 year after HBHCT. Additionally, of the 13,765 eligible participants who did not receive HBHCT or received HIV-negative results, 301 men linked to care within 1 year. Overall, only 13 men received EPIC-HIV 2. The proportion of linkage to care did not differ between the arms randomized to EPIC-HIV and those without EPIC-HIV (adjusted risk ratio = 1.05; 95% CI:0.86-1.29). All 13 men who used EPIC-HIV 2 reported the app was acceptable, user-friendly, and useful for getting information on HIV testing and treatment. The reach was low, although the acceptability and usability of the app were very high among those who engaged with it. Enhanced digital support applications could form part of interventions to increase knowledge of HIV treatment among men. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.

Healthcare Providers' Perspective on HIV Testing and Hypothetical mHealth-connected Linkage to Care Among Men who have Sex with Men (MSM) in South Carolina

BackgroundHIV continues to be an important public health concern in South Carolina (SC). However, an examination of providers' willingness to use mHealth technologies to address ongoing barriers to HIV care and prevention strategies, particularly among men who have sex with men (MSM) is currently lacking in SC. We therefore explored HIV care providers' perceptions of HIV testing and treatment uptake among MSM, and providers' willingness to use mHealth technology to address barriers to HIV testing and treatment in SC.MethodsBetween August and December 2021, we conducted semistructured virtual interviews with 10 HIV care providers recruited purposively based on their experience (2-11 years of service) providing HIV-related services to MSM in peri-urban (n = 7) and rural (n = 3) SC. The interviews were audio recorded, lasted 40-70 min, and were transcribed verbatim. The interview transcripts were analyzed inductively.ResultsFive themes emerged from the analysis: (a) challenges to HIV testing services; (b) concerns about HIV knowledge and status in the MSM community; (c) mixed feelings about HIV self-testing; (d) providers' perception of HIV treatment uptake and retention; and (e) potential of mHealth technology for the delivery of HIV care. Overall, participants reported limited resources, homophobia, medical mistrust, distance, medical costs, and HIV-related stigma as major barriers to HIV testing and treatment uptake in their localities (especially in rural areas). Particularly, they reported that MSM experience significant stigma associated with their sexual orientation and HIV.ConclusionsGiven barriers to care such as stigma and lack of access to care still impede MSM from receiving appropriate HIV services, mHealth-connected approaches could potentially address the barriers to HIV testing and care among MSM and improve their health outcomes. This is key to ending the HIV epidemic in SC and the United States by 2030.

Update on HIV Chemoprevention

Despite rapid advances in the field of HIV prevention and treatment, unacceptably high global HIV incidence rates highlight the ongoing need for effective HIV prevention interventions for populations at risk for HIV acquisition. This article provides an updated review of the current data surrounding HIV prevention strategies, including treatment as prevention (TasP), preexposure prophylaxis (PrEP), and postexposure prophylaxis (PEP), as well as advances in sexually transmitted infection biomedical prevention. This review provides an overview of the multiple PrEP modalities that are available globally, such as oral PrEP, injectable cabotegravir, and the dapivirine vaginal ring, and describes their respective clinical trials, efficacies, and regulatory approvals. We also discuss ongoing research into novel PrEP agents, such as broadly neutralizing antibodies, and efforts toward HIV vaccine development.

Perceived neighborhood disorder and achieving HIV viral suppression among adults living with HIV: A cross-sectional study

Adherence to antiretroviral therapy (ART) is crucial for achieving and maintaining viral suppression in people living with HIV (PLWH). While individual factors affecting HIV viral suppression have been extensively studied, there is less attention on community-level factors, specifically perceived neighborhood disorder. This study aims to assess the relationship between perceived neighborhood disorder and achieving virologic suppression among people living with HIV. One hundred and eighty-eight PLWH 18 years of age and older from two HIV clinics completed a cross-sectional study. We assessed perceptions of neighborhood disorder, ART self-efficacy, social support, alcohol and drug use, depression, HIV stigma, provider-patient relationship, demographics, and length at the zip code. HIV viral loads were obtained from the clinical record. The analysis involved the use of Fisher's Exact test, Spearman's Rank test, Wilcoxon rank sum test, and Firth logistic regression. All analyses were conducted using STATA 17. Most participants were male (79%), white (62%), and identified as non-Hispanic (66%). Individuals with no perceived neighborhood disorder had median scores of 10 for integration and perseverance in ART self-efficacy. Those with high perceived disorder displayed decreased scores of 8.4 and 8.3 for integration and perseverance respectively. Both integration and perseverance showed statistically significant negative correlations with perceived neighborhood disorder, (Spearman's rho -0.2966; p<0.000 and -0.2387; p = 0.0010 respectively). Individuals with virologic suppression (n = 167) reported significantly lower perceived neighborhood disorder scores (median = 0.9 [IQR: 0.2-2.0]) compared to those without virologic suppression (n = 10, median = 3.2 [IQR: 2.4-4], p = 0.0012). The study highlights a notable correlation between perceived neighborhood disorder, ART adherence self-efficacy, and virologic suppression. This indicates that improving HIV treatment outcomes needs to extend beyond individual-level factors and include strategies to address neighborhood-level conditions. Public health policies and programs should consider the broader social and environmental contexts in which people living with HIV reside.

The Impact of HIV on B Cell Compartment and Its Implications for COVID-19 Vaccinations in People with HIV

HIV causes intense polyclonal activation of B cells, resulting in increased numbers of spontaneously antibody-secreting cells in the circulation and hypergammaglobulinemia. It is accompanied by significant perturbations in various B cell subsets, such as increased frequencies of immature/transitional B cells, activated memory B cells, atypical memory B cells, short-lived plasmablasts and regulatory B cells, as well as by decreased frequencies of resting memory and resting naïve B cells. Furthermore, both memory and antigen-inexperienced naïve B cells show exhausted and immune-senescent phenotypes. HIV also drives the expansion and functional impairment of CD4+ T follicular helper cells, which provide help to B cells, crucial for the generation of germinal center reactions and production of long-lived plasma and memory B cells. By suppressing viral replication, anti-retroviral therapy reverses the virus-induced perturbations and functional defects, albeit inadequately. Due to HIV's lingering impact on B cells, immune senescence and residual chronic inflammation, people with HIV (PWH), especially immune non-responders, are immunocompromised and mount suboptimal antibody responses to vaccination for SARS-CoV-2. Here, we review how functionally and phenotypically distinct B cell subsets are induced in response to a vaccine and an infection and how HIV infection and anti-retroviral therapy (ART) impact them. We also review the role played by HIV-induced defects and perturbations in B cells in the induction of humoral immune responses to currently used anti-SARS-CoV-2 vaccines in PWH on ART. We also outline different strategies that could potentially enhance the vaccine-induced antibody responses in PWH. The review will provide guidance and impetus for further research to improve the immunogenicity of these vaccines in this human population.

Use of machine learning approaches to predict transition of retention in care among people living with HIV in South Carolina: a real-world data study

Maintaining retention in care (RIC) for people living with HIV (PLWH) helps achieve viral suppression and reduce onward transmission. This study aims to identify the best machine learning model that predicts the RIC transition over time. Extracting from the enhanced HIV/AIDS reporting system, this study included 9765 PLWH from 2005 to 2020 in South Carolina. Transition of RIC was defined as the change of RIC status in each two-year time window. We applied seven classifiers, such as Random Forest, Support Vector Machine, eXtreme Gradient Boosting and Long-short-term memory, for each lagged response to predict the subsequent year's RIC transition. Classification performance was assessed using balanced prediction accuracy, the area under the curve (AUC), recall, precision and F1 scores. The proportion of the four categories of RIC transition was 13.59%, 29.78%, 9.06% and 47.57%, respectively. Support Vector Machine was the best approach for every lag model based on both the F1 score (0.713, 0.717 and 0.719) and AUC (0.920, 0.925 and 0.928). The findings could facilitate the risk augment of PLWH who are prone to follow-up so that clinicians and policymakers could come up with more specific strategies and relocate resources for intervention to keep them sustained in HIV care.

Sub-Saharan Africa's Contribution to Clinical Trials in International Acute Coronary Syndromes and Heart Failure Guidelines

Background

There is a growing burden of acute coronary syndrome (ACS) and heart failure (HF) in sub-Saharan Africa (SSA), yet outcomes remain poor compared to high-income countries. The European Society of Cardiology (ESC) international guidelines are pivotal to the delivery of evidence-based care; however, their representation of populations from SSA remains unclear.

Objectives

The purpose of the study was to evaluate the representation of populations from SSA in randomized controlled trials (RCTs) that inform ESC ACS and HF guidelines.

Methods

We systematically analyzed pharmacotherapeutic RCTs contributing to the 2021 ESC HF and 2023 ACS guidelines, extracting data from ClinicalTrials.gov. We assessed the proportion of RCTs that included contributions from countries in each World Bank income group, focusing on the involvement of SSA countries and examining temporal trends.

Results

Among the RCTs underpinning the ESC HF guidelines (n = 119) and ACS guidelines (n = 343), 75.9% were conducted exclusively in high-income countries. Middle-income countries were included in 22.2% of the trials, but none featured low-income countries. Within SSA, only South Africa was represented, contributing to 14.2% of HF and 8.2% of ACS RCTs. The number of HF RCTs involving populations from SSA has risen, from 2.6% in the 1990s to 50% post-2020 (P for trend< 0.05). For ACS RCTs, the proportion of trials involving populations in SSA increased from 1.8% pre-1990 to 23.4% during 2000 to 2009 (P for trend = 0.003), then declined to 11.3% in the following decade.

Conclusions

There is a marked underrepresentation of SSA countries in ACS and HF pharmacotherapy RCTs. South Africa is the sole contributor from the region, which may affect applicability and generalizability of global guidelines to populations in SSA.

Implementation of routine HIV testing policy in medical admissions in the sultanate of Oman: An experience from the Middle East

OBJECTIVES

To tackle the issue of late HIV diagnosis in the country, the Ministry of Health (MOH) in Oman introduced a national policy of routine opt-out HIV in medical admission units in September 2022. We hereby report the implementation and outcomes of this policy.

METHOD

All patients aged 16-65 years admitted to a medical ward in secondary and local hospitals were offered an HIV test regardless of their symptoms by medical doctors, with training and support from HIV teams. A retrospective review for the period from September 2022 to September 2023 was conducted to determine the HIV testing rate and outcomes of those testing HIV seropositive.

RESULT

Over 12 months, there were 23,399 admissions; 6889 had HIV tests. Thirty-two patients (0.46 %) were diagnosed with HIV; all of them were new diagnoses. Two cases were diagnosed during seroconversion. 12 cases had AIDS-defining illnesses. Four contacts were tested HIV positive. Twenty-five out of 28 alive patients are on ART.

CONCLUSION

This is the first national policy of a routine opt-out HIV in medical admission units in the MENA region. Our experience showed that, even in low HIV prevalence and high HIV stigma settings, this policy is feasible, acceptable, and effective.

Technology-Based Interventions, with a Stepped Care Approach, for Reducing Sexual Risk Behaviors and Increasing PrEP Initiation Among Transgender and Gender Expansive Youth and Young Adults

TechStep was a technology-based trial, with a stepped care approach, to reduce sexual risks and increase PrEP uptake among transgender and gender expansive youth and young adults (15-24 years old). From October 2019 to September 2021, 254 participants were randomized into: 1) Text (n = 82), or 2) Webapp (n = 87), or 3) Control (n = 85). At the 3-month follow-up assessment, those randomized to Text and Webapp and did not demonstrate improvement on primary outcomes were re-randomized to receive virtual eCoaching (Text + or Webapp +), or to remain in their initial condition without eCoaching. Results showed no effect on condomless encounters at 6-month, the primary endpoint, when comparing the Webapp + (0.33 decrease; 95%CI: -0.01, 0.67, p-value = 0.057) or the Text + (0.27 decrease; 95%CI: -0.13, 0.68, p-value = 0.181) conditions to the Control condition. However, in secondary analyses, condomless encounters were significantly reduced for Text compared to Control. The rate of PrEP uptake was low for all study arms.Trial registration: Clinical Trials # NCT04000724 (registered June 26, 2019).

Understanding the impact of HIV on mpox transmission in the MSM population: A mathematical modeling study

The recent mpox outbreak (in 2022-2023) has different clinical and epidemiological features compared with previous outbreaks of the disease. During this outbreak, sexual contact was believed to be the primary transmission route of the disease. In addition, the community of men having sex with men (MSM) was disproportionately affected by the outbreak. This population is also disproportionately affected by HIV infection. Given that both diseases can be transmitted sexually, the endemicity of HIV, and the high sexual behavior associated with the MSM community, it is essential to understand the effect of the two diseases spreading simultaneously in an MSM population. Particularly, we aim to understand the potential effects of HIV on an mpox outbreak in the MSM population. We develop a mechanistic mathematical model of HIV and mpox co-infection. Our model incorporates the dynamics of both diseases and considers HIV treatment with anti-retroviral therapy (ART). In addition, we consider a potential scenario where HIV infection increases susceptibility to mpox, and investigate the potential impact of this mechanism on mpox dynamics. Our analysis shows that HIV can facilitate the spread of mpox in an MSM population, and that HIV treatment with ART may not be sufficient to control the spread of mpox in the population. However, we showed that a moderate use of condoms or reduction in sexual contact in the population combined with ART is beneficial in controlling mpox transmission. Based on our analysis, it is evident that effective control of HIV, specifically through substantial ART use, moderate condom compliance, and reduction in sexual contact, is imperative for curtailing the transmission of mpox in an MSM population and mitigating the compounding impact of these intertwined epidemics.

Examining the Accuracy of Self-Reported Antiretroviral Therapy Adherence Using a Visual Analog Scale Among Opioid-Dependent People Living with HIV

Evidence indicates that regular assessment of antiretroviral therapy (ART) adherence is necessary to promote adherence and achieve viral suppression. Self-reported adherence using a visual analog scale (VAS) has been used extensively to measure ART adherence. However, less is known about the accuracy of the VAS for measuring ART adherence among opioid-dependent people living with HIV. In this study, we aimed to evaluate the accuracy of the VAS in measuring ART adherence in opioid-dependent people living with HIV who are enrolled in a methadone maintenance program (MMP). This study was conducted within a larger randomized controlled trial among opioid-dependent people living with HIV (N = 109) who were enrolled in an inner-city MMP. Self-reported VAS ART adherence data were compared to pharmacy refill data, which is a more objective measure. Self-reported VAS ratings and pharmacy refill behavior were significantly correlated at the 6-month post-intervention mark (r = 0.349, p = 0.006) but not at any other time point (i.e., pre-intervention, post-intervention, 3-months, and 9-months post-intervention). Based on the pharmacy refill data, participants did not consistently adhere to their ART medication but self-reported high adherence on the VAS. The self-report VAS may not be an accurate measure for assessing ART adherence among opioid-dependent persons living with HIV and enrolled in a MMP. Based on our findings, it may be more accurate to use pharmacy refill information or other objective measures to quantify ART adherence over extended periods for this patient population.

HIV-1 M group subtype classification using deep learning approach

Traditionally, the classification of HIV-1 M group subtypes has depended on statistical methods constrained by sample sizes. Here HIV-1-M-SPBEnv was proposed as the first deep learning-based method for classifying HIV-1 M group subtypes via env gene sequences. This approach overcomes sample size challenges by utilizing artificial molecular evolution techniques to generate a synthetic dataset suitable for machine learning. Employing a convolutional Autoencoder embedded with two residual blocks and two transpose residual blocks, followed by a full connected neural network block, HIV-1-M-SPBEnv simplifies complex, high-dimensional DNA sequence data into concise, information-rich, low-dimensional representations, achieving exceptional classification accuracy. Through independent data set validation, the precision, accuracy, recall and F1 score of the HIV-1-M-SPBEnv model predictions were all 100 %, confirming its capability to accurately identify all 12 subtypes of the HIV-1 M group. Deployed through a web server, it provides seamless HIV-1 M group subtype prediction capabilities for researchers and clinicians. HIV-1-M-SPBEnv web server is accessible at http://www.hivsubclass.com and all the code is available at https://github.com/pengsihua2023/HIV-1-M-SPBEnv.

Conceptualizations of Mental Health Among Young Black Gay, Bisexual, and Other Men (YB-GBMSM) Who Have Sex With Men Who Are Living With HIV

Young Black gay, bisexual, and other men who have sex with men who are living with HIV are at an increased risk of experiencing poor mental health due to their exposures to intersectional stigma and discrimination, but often do not seek traditional mental health care. We qualitatively explored conceptualizations of mental health through interviews with 40 participants and analyzed our data using a phenomenology-informed approach. Participants conceptualized mental health as having inward-facing (cultivation of a healthy relationship with oneself, maintaining a peaceful state of mind, lack of depressed mood) and outward-facing components (goal-oriented behavior, resilient coping mechanisms). Some participants espoused an internal locus of control over one's mental state, while others focused on structural or environmental factors as key drivers of mental health. Our findings suggest that provider trainings and service integration, consistent with a more holistic conception of mental health, could help providers support well-being among this population.

Probability of Starting Two-Drug Regimen (2DR) vs. Three-Drug Regimen (3DR) in ART-Naïve and ART-Experienced Person with HIV (PWH) Across the First Wave of COVID-19 Pandemic

Background: This study examined the impact of the COVID-19 lockdown on antiretroviral therapy (ART) prescriptions among persons living with HIV (PWH) in Italy. Methods: Data from the ICONA cohort included ART-naïve individuals who started ART between January 2019 and December 2022, and ART-experienced individuals who started new ART with HIV RNA ≤50 cps/mL from January 2016 to December 2022. The analysis focused on the proportion of PWH starting or switching to dual (2DR) versus triple (3DR) ART regimens. Comparisons were made using Chi-square and Kruskal-Wallis tests, with logistic regression (LR) to assess associations, adjusting for sex and age. Results: Among 2481 ART-naïve PWH, 17% were female, with a median age of 40. Using 2020 as the comparator (the lockdown year), the odds ratio (OR) from fitting a LR showed a reduced probability of prescribing 2DR both before and after 2020. The proportion of PWH starting 2DR was 9% in 2019, 18% in 2020, 13% in 2021, and 10% in 2022. Among 12,335 ART-experienced PWH, 20% were female, with a median age of 47. The proportion switching to 2DR rose from 24% in 2016 to 38% in 2020, 62% in 2021, and 65% in 2022, showing a >3-fold higher probability to be switched to 2DR instead of 3DR in recent years (2021-2022). Conclusions: For ART-naive PWH, 2DR initiation did not decrease during the 2020 lockdown but changed in the following years, possibly indicating shifts in clinical practice or resuming HIV services. For ART-experienced PWH, 2DR prescriptions increased significantly over time, especially for INSTI-based regimens.

A Human Immunodeficiency Virus Type 1 Risk Assessment Tool for Women Aged 15-49 Years in African Countries: A Pooled Analysis Across 15 Nationally Representative Surveys

BACKGROUND

Women in Africa disproportionately acquire human immunodeficiency virus type 1 (HIV-1). Understanding which women are most likely to acquire HIV-1 can guide focused prevention with preexposure prophylaxis (PrEP). Our objective was to identify women at the highest risk of HIV-1 and estimate PrEP efficiency at different sensitivity levels.

METHODS

Nationally representative data were collected from 2015 through 2019 from 15 population-based household surveys. This analysis included women aged 15-49 who tested HIV-1 seronegative or had recent HIV-1. Least absolute shrinkage and selection operator regression models were fit with 28 variables to predict recent HIV-1. Models were trained on the full population and internally cross-validated. Performance was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, and number needed to treat (NNT) with PrEP to avert 1 infection.

RESULTS

Among 209 012 participants, 248 had recent HIV-1 infection, representing 118 million women and 402 000 (95% confidence interval [CI], 309 000-495 000) annual infections. Two variables were retained: living in a subnational area with high HIV-1 viremia and having a sexual partner living outside the home. The full-population AUC was 0.80 (95% CI, .76-.84); cross-validated AUC was 0.79 (95% CI, .75-.84). At 33% sensitivity, 130 000 cases could be averted if 7.9 million women were perfectly adherent to PrEP; NNT would be 61. At 67% sensitivity, 260 000 cases could be averted if 25.1 million women were perfectly adherent; NNT would be 96.

CONCLUSIONS

This risk assessment tool was generalizable, predictive, and parsimonious with trade-offs between reach and efficiency.

Psychometric Properties of Measuring Antiretroviral Therapy Adherence Among Young Latino Sexual Minority Men With HIV: Ecological Momentary Assessment and Electronic Pill Dispenser Study

Background

Increasing HIV rates among young Latino sexual minority men (YLSMM) warrant innovative and rigorous studies to assess prevention and treatment strategies. Ecological momentary assessments (EMAs) and electronic pill dispensers (EPDs) have been used to measure antiretroviral therapy (ART) adherence repeatedly in real time and in participants' natural environments, but their psychometric properties among YLSMM are unknown.

Objective

The study's objective was to assess the concurrent validity, acceptability, compliance, and behavioral reactivity of EMAs and EPDs among YLSMM with HIV.

Methods

A convenience sample of 56 YLSMM with HIV with suboptimal ART adherence, aged 18-34 years, was recruited into a 28-consecutive-day EMA study. Concurrent validity was analyzed by comparing median ART adherence rates and calculating Spearman correlations between ART adherence measured by EMA, EPD, and baseline retrospective validated 3-item and single-item measures. Acceptability was assessed in exit interviews asking participants to rate EMA and EPD burden. Compliance was assessed by computing the percent lost to follow-up, the percent of EMAs missed, and the percentage of days the EPD was not opened that had corresponding EMA data self-reporting adherence to ARTs. Behavioral reactivity was assessed by computing the median change in ART adherence during the study period, using generalized mixed models to assess whether the cumulative number of EMAs completed and days of EPD use predicted ART adherence over time, and by asking participants to rate perceived reactivity using a Likert scale.

Results

EMA ART adherence was significantly correlated with baseline validated 3-item (r=0.41, P=.003) and single-item (r=0.52, P<.001) measures, but correlations were only significant for participants that reported EMA was not burdensome. Correlations for EPD ART adherence were weaker but significant (r=0.36, P=.009; r=0.34, P=.01, respectively). Acceptability was high for EMAs (48/54, 89%) and EPDs (52/54, 96%) per self-report. Loss to follow-up was 4% (2/56), with the remaining participants completing 88.6% (1339/1512) of study-prompted EMAs. The percentage of missed EMA surveys increased from 5.8% (22/378) in week 1 of the study to 16.7% (63/378) in week 4. Of 260 days when EPDs were not opened, 68.8% (179) had a corresponding EMA survey self-reporting ART adherence. Reactivity inferred from the median change in ART adherence over time was 8.8% for EMAs and -0.8% for EPDs. Each completed EMA was associated with 1.03 odds (95% CI 1-1.07) of EMA ART adherence over time, and each day of EPD use with 0.97 odds (95% CI 0.96-0.99) of EPD ART adherence over time. Self-reported perceived behavioral reactivity was 39% for EMAs and 35% for EPDs.

Conclusions

This study provides evidence of concurrent validity with retrospective validated measures for EMA- and EPD-measured ART adherence among YLSMM, when participant burden is carefully considered, without significant behavioral reactivity. While acceptability and compliance of EMAs and EPDs were high overall, noncompliance increased over time, suggesting respondent fatigue.

Renewing Our Focus on Vulnerable Populations Among People Living with HIV

The global HIV landscape has changed over the past few decades, with great milestones achieved in both HIV treatment and prevention [...].

Predictors of consistent condom use among male construction workers who have engaged in concurrent sex with regular sex partners, casual sex partners, and sex workers over a 3-month period

This study investigates the predictors of consistent condom use among male construction workers in South Africa who reported concurrent sexual relationships with regular partners, casual partners, and sex workers over a 3-month period. A cross-sectional survey was used to collect data from a convenience sample of 450 male workers across 18 construction work sites in the Western Cape province. Of these, 245 (54%) indicated that they had engaged in sex with all three partner types during the 3-month study period. Hierarchical multiple linear regression was then used to assess consistent condom use as a function of demographic, experiential, behavioural and cognitive characteristics. Three statistically significant predictors of consistent condom use were identified: perceived control over condom use (β = 0.252, p < 0.001), positive attitude toward condom use (β = 0.154, p < 0.05) and fear of HIV infection (β = 0.121, p < 0.05). These findings highlight the high prevalence of sexual concurrency among study participants. It also suggests that amid declining condom use, interventions which focus on enhancing an individuals' condom application skills and efficacy, that foster positive attitudes toward condom use and that strategically incorporate fear-based messaging within a multilevel framework may potentially increase condom use among individuals in concurrent sexual relationships.

Dynamics of HIV transmission among men who have sex with men in Taiwan: a mathematical modeling study

BACKGROUND

In Taiwan, the human immunodeficiency virus (HIV) is primarily transmitted among men who have sex with men (MSM). We believe that the primary source of heterogeneity influencing transmission is from whether the infected individuals engage in behaviors that promote transmission. Therefore, we differentiated and modeled the statuses of infected individuals, estimated parameters, and predicted future infection trends to better understand HIV transmission dynamics among MSM.

METHODS

We devised a computational approach to accurately estimate the number of infectious individuals during early surveillance years in Taiwan using monthly data of newly diagnosed patients with HIV from January 2005 to December 2006. Subsequently, using annual incident cases from 2005 to 2019, we estimated the susceptibility rate, transmission rates, and duration of risk and conducted short-term forecasts of HIV infection among MSM through mathematical modeling based on the susceptible-infected-removed model. Parameters and their values, such as HIV and acquired immunodeficiency syndrome (AIDS) transmission rates and removal rates, were also estimated.

RESULTS

A total of 850 infectious individuals with HIV were identified in 2005. From 2005 to 2019, approximately 0.68% (95% confidence interval: 0.64-0.71%) of Taiwan's male population were estimated to be susceptible to HIV infection via MSM. The transmission rate did not significantly differ between individuals with HIV and AIDS (0.0110 and 0.107 per 10,000 individuals, respectively). The average infection duration between infection and AIDS onset was 4.5 years and between AIDS onset and death was 2.1 years. In 2019, the proportion of infectious infected individuals continuously decreased. By 2026, only 11.85% and 10.21% of individuals with HIV and AIDS, respectively, will be infectious.

CONCLUSIONS

Our study presents a new dynamic mathematical model for estimating infectious HIV cases among MSM in Taiwan. By accounting for the heterogeneity of infectious HIV/AIDS within the MSM population, we effectively estimated the number of infections during early surveillance years and implement concentrated measures, thereby reducing infectious HIV/AIDS cases, which contributes to the overall reduction in HIV/AIDS cases. With these estimations, identifying target populations and implementing effective intervention measures at appropriate times can be improved.

Narrative Coherence and Relational Agency: Unraveling Transitions Into and Out of Alberta Correctional Facilities for People Living With HIV

Incarcerated populations in Canada face significant health and social challenges during transitions into and out of correctional facilities. These transitions around facilities pose disproportionate barriers to care for people living with HIV. Further research is crucial to comprehend these challenges and reimagine care concepts for people who experience structural marginalization. In this article, experiences of transitions into and out of Alberta correctional facilities for people living with HIV are explored using narrative inquiry. Conducted in a Western Canadian city from 2021 to 2022, the inquiry revolved around two men living with HIV and a history of incarceration. Through co-creating field texts and narrative accounts, their unique experiences of transitions were explored through a collaborative process of analysis. Narrative threads from Bruce and Kyle showcased a lack of narrative coherence and the presence of tensions in their lives, while also emphasizing relational agency. The findings provide avenues for health, social, and justice practitioners who support and care for individuals living with HIV and a history of incarceration to think differently about transitions. By highlighting the importance of attending to the unique identities of individuals and relationships from a position of relational agency, the study advances our understanding of transitions. Recommendations for practice and policy include (a) fostering relational agency among practitioners; (b) challenging conventional views of transitions around correctional settings; (c) incorporating peer-based programming into support services; and (d) reconsidering health, justice, and social systems to better support communities disproportionately affected by high rates of incarceration and HIV.

Telehealth Challenges, Opportunities, and Policy Recommendations for Rural Older Adults Living with HIV in the United States

Over one million people in the United States (U.S.) are living with HIV. People living with HIV in the rural South experience delayed HIV treatment and increased mortality risks. Access challenges and HIV stigma exacerbate care disengagement for rural people living with HIV (PLH). This study examines the applicability and feasibility of telehealth to provide HIV care for older adults in the rural U.S. South. Semi-structured interviews were conducted with 27 key informants with expertise in HIV care and community engagement in high rural HIV burden states. Results indicate that telehealth challenges exist for older rural PLH to receive HIV care, such as lack of internet access and low technology literacy. Phone calls can be a simple and effective telehealth option for older rural PLH, as they align with their care preferences, mitigate care barriers, and show promise increasing care engagement. When warranted, complex telehealth options for older rural PLH require tailored approaches, such as portable medical instruments allowing real-time data sharing during home visits or tablet distribution from the clinic. Findings suggest that policy makers and providers support the reimbursement and use of audio-only telehealth services, expand broadband infrastructure and affordability in rural areas, and implement tailored telehealth interventions.

A Transdiagnostic Treatment to Improve Biomedical and Syndemic Outcomes in People Living With HIV

People living with HIV (PLWH) experience a range of co-occurring psychosocial stressors, mental health symptoms, and structural barriers (e.g., "syndemics") that can impair their ability to adhere to medical recommendations for treatment. This has consequences for their health and the health of others as nonadherence increases the likelihood of unsuppressed HIV viral load, and therefore the ability to transmit HIV to others. Transdiagnostic treatment, or treatment not focused on a single mental health condition, can efficiently address a range of mental health problems by skills training to reduce symptoms. Additionally, cognitive behavioral and problem-solving approaches can be used to address larger, structural factors by helping individuals navigate systemic challenges using evidence-based skills. This article describes the development of a transdiagnostic treatment for PLWH and illustrates the application of the treatment through case examples. This treatment might be appropriate for integration into an HIV clinic or within an outpatient setting when working with a patient who is experiencing syndemic conditions and living with HIV.

Redlining and Time to Viral Suppression Among Persons With HIV

Importance

Structural racism in the US is evidenced in the discriminatory practice of historical racial redlining when neighborhoods were valued, in part, based on the community's racial and ethnic compositions. However, the influence of these systemic practices in the context of the HIV epidemic is not well understood.

Objective

To assess the effect of redlining on time to viral suppression among people newly diagnosed with HIV.

Design, Setting, and Participants

Observational study that included individuals diagnosed with HIV from January 1, 2011, to December 31, 2019, in New Orleans, Louisiana. At the time of their HIV diagnosis, these individuals lived in neighborhoods historically mapped by the Home Owners' Loan Corporation (HOLC). The HOLC lending risk maps classified neighborhoods into 1 of 4 color-coded grades: A (best), B (still desirable), C (definitely declining), and D (hazardous).

Main Outcome and Measures

The primary outcome of interest was time to viral suppression (estimated as the time from the diagnosis date to the date of the first recorded viral load that was <200 copies/mL). Individual-level demographic factors were used to evaluate time to viral suppression along with a neighborhood measure of gentrification (based on US census tract-level characteristics for educational attainment, housing development and value, and household income) and a Cox gamma frailty model with census tract used as the frailty term.

Results

Of 1132 individuals newly diagnosed with HIV, 871 (76.9%) were men and 620 (54.8%) were 25 to 44 years of age. Of the 697 individuals living in historically redlined neighborhoods (HOLC grade D), 100 (14.6%) were living in neighborhoods that were gentrifying. The median time to viral suppression was 193 days (95% CI, 167-223 days) for persons with HIV living in redlined neighborhoods compared with 164 days (95% CI, 143-185 days) for the 435 persons with HIV living in HOLC grade A, B, or C (nonredlined) neighborhoods. Among persons with HIV living in gentrifying neighborhoods, those living in redlined neighborhoods had a longer time to viral suppression compared with persons living in nonredlined neighborhoods (hazard ratio, 0.54 [95% CI, 0.36-0.82]).

Conclusions and Relevance

These findings suggest the enduring effects of systemic racism on present-day health outcomes among persons with HIV. Regardless of their neighborhood's contemporary level of gentrification, individuals diagnosed with HIV while living in historically redlined neighborhoods may experience a significantly longer time to viral suppression.

Retention in care and antiretroviral therapy adherence among Medicaid beneficiaries with HIV, 2001-2015

Disparities in HIV care by socioeconomic status, place of residence, and race/ethnicity prevent progress toward epidemic control. No study has comprehensively characterized the HIV care cascade among people with HIV enrolled in Medicaid - an insurance source for low-income individuals in the US. We analyzed data from 246,127 people with HIV enrolled in Medicaid 2001-2015, aged 18-64, living in 14 US states. We estimated the monthly prevalence of four steps of the care cascade: retained in care/adherent to ART; retained/not adherent; not retained/adherent; not retained/not adherent. Beneficiaries were retained in care if they had an outpatient care encounter every six months. Adherence was based on medication possession ratio. We estimated prevalence using a non-parametric multi-state approach, accounting for death as a competing event and for Medicaid disenrollment using inverse probability of censoring weights. Across 2001-2015, the proportion of beneficiaries with HIV who were retained/ART adherent increased, overall and in all subgroups. By 2015, approximately half of beneficiaries were retained in care, and 42% of beneficiaries were ART adherent. We saw meaningful differences by race/ethnicity and region. Our work highlights an important disparity in the HIV care cascade by insurance status during this time period.

Including the Household: Individual, Community and Household Factors Affecting Antiretroviral Therapy Adherence After ART Initiation in Cape Town, South Africa

Antiretroviral therapy (ART) adherence is crucial for health outcomes of people living with HIV (PLHIV), influenced by a complex interplay of individual, community, and household factors. This article focuses on the influence of household factors, as well as individual and community factors, on ART adherence among PLHIV in Cape Town who have recently initiated ART. Baseline data for a cluster-randomized controlled trial were collected from 316 PLHIV in 12 districts in Cape Town between 6th May 2021 and 22nd May 2022. Zero-inflated Poisson models, with cluster-adjusted standard errors, were used to analyse the association between individual, household, and community factors and ART adherence measures. At the household-level, household support was associated with both better self-rated adherence (exp(β) = 0.81, z =  - 4.68, p < 0.001) and fewer days when pills were missed (exp(β) = 0.65, z =  - 2.92, p = 0.003). Psychological violence (exp(β) = 1.37, z = 1.97, p = 0.05) and higher household asset scores (exp(β) = 1.29, z =  - 2.83, p = 0.05) were weakly associated with poorer ART adherence. At the individual-level, male gender (exp(β) = 1.37, z = 3.95, p < 0.001) and reinitiating ART (exp(β) = 1.35, z = 3.64, p < 0.001) were associated with worse self-rated ART adherence; higher education levels (exp(β) = 0.30 times, z =  - 3.75, p < 0.001) and better HIV knowledge (exp(β) = 0.28, z =  - 2.83, p = 0.005) were associated with fewer days where pills were missed. At the community-level, community stigma was associated with worse self-rated ART adherence (exp(β) = 1.24, z = 3.01, p = 0.003). When designing interventions to improve ART adherence, household, individual and community factors should all be considered, particularly in addressing gender-based disparities, reducing stigma, tackling violence, and enhancing household support.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

Identifying the HIV-Resistance-Related Factors and Regulatory Network via Multi-Omics Analyses

For research on HIV/AIDS, it is important to elucidate the complex viral-host interaction, host dependency factors (HDFs), and restriction factors. However, the regulatory network of HIV-resistance-related factors remains not well understood. Therefore, we integrated four publicly available HIV-related transcriptome datasets, along with three datasets on HIV-infection-related DNA methylation, miRNA, and ChIP-seq, to predict the factors influencing HIV resistance and infection. Our approach involved differential analysis, functional annotation, and protein-protein interaction network analysis. Through comprehensive analyses, we identified 25 potential HIV-resistance-related genes (including shared EGF) and 24 HIV-infection-related hub genes (including shared JUN). Additionally, we pinpointed five key differentially methylated genes, five crucial differentially expressed microRNAs, and five significant pathways associated with HIV resistance. We mapped the potential regulatory pathways involving these HIV-resistance-related factors. Among the predicted factors, RHOA, RAD51, GATA1, IRF4, and CXCL8 have been validated as HDFs or restriction factors. The identified factors, such as JUN, EGF, and PLEK, are potential HDFs or restriction factors. This study uncovers the gene signatures and regulatory networks associated with HIV-1 resistance, suggesting potential targets for the development of new therapies against HIV/AIDS.

Contributions of the Community-Based Organization Program Funded by the Centers for Disease Control and Prevention to Linkage to HIV Medical Care

OBJECTIVE

Linkage to HIV medical care is important in the continuum of HIV care and health outcomes for people with HIV. The objective of this analysis was to identify how the community-based organization (CBO) program contributes to linkage to HIV medical care among people with newly diagnosed HIV in the Centers for Disease Control and Prevention's (CDC's) HIV testing program.

METHODS

We analyzed HIV linkage-to-care data submitted to CDC from 2019 through 2021. Linkage was defined as confirmation that an individual attended their first HIV medical care appointment within 30 days of their HIV test date. We included in the analysis data submitted from the health department (HD) program that included 61 state and local HDs in the United States, Puerto Rico, and the US Virgin Islands and the CBO program that included 150 CBOs.

RESULTS

The CBO program linked a higher proportion of people to HIV medical care within 30 days of diagnosis (86.7%) than the HD program (73.7%). By population group, the proportion linked in the CBO program was higher than the proportion linked in the HD program among men who have sex with men (prevalence ratio [PR] = 1.13; P < .001), men who have sex with men/people who inject drugs (PR = 1.29; P < .001), transgender people (PR = 1.28; P < .001), and those reporting no sexual contact or injection drug use (PR = 1.34; P < .001). In the Cox proportional hazards model, time to linkage in the CBO program was significantly shorter than in the HD program (hazard ratio = 0.63; P < .001).

CONCLUSION

This analysis shows that the CBO program fills a vital need in linking newly diagnosed HIV-positive people to HIV medical care, which is important in the HIV care continuum and for viral suppression.

Evolving molecular HIV clusters revealed genotype-specific dynamics in Guangzhou, China (2008-2020)

OBJECTIVES

This study investigated the genotype-specific dynamics of molecular HIV clusters (MHCs) in Guangzhou, China, aiming to enhance HIV control.

METHODS

HIV pol sequences from people with HIV (PWH) in Guangzhou (2008-2020) were obtained for genotyping and molecular network creation. MHCs were identified and categorized into three types: emerging, growing, or stable. Clustering rates, proportions of cluster types, and members within each type were calculated and their trends were assessed using joinpoint regression.

RESULTS

Among 8395 PWH, the most prevalent HIV-1 genotypes were CRF07_BC (39.7%) and CRF01_AE (32.6%). The genotype composition has been stable since 2012 (Ps > 0.05). The overall clustering rate was 43.3%, with significant variations across genotypes (P < 0.001), indicating genotype-specific transmission fitness. Significant declines in overall and genotype-specific clustering rates toward the end of 2020 (Ps < 0.05), potentially offer support for HIV control efforts in reducing local infections. The continuously increasing proportions of stable clusters and the gradually decreasing proportions of emerging and growing clusters (either Ps < 0.05 or Ps > 0.05) suggest a trend toward stable molecular network structure. However, growing clusters exhibited CRF55_01B, CRF07_BC, and CRF59_01B dominance that indicate their priority for interventions.

CONCLUSION

The evolving MHCs highlight the genotype-specific cluster dynamics, providing fresh insights for enhanced prevention and control strategies.

Condom Failure Among HIV-Negative Men in Serodiscordant Relationships in Australia, Brazil, and Thailand

Condoms continue to be used by many gay, bisexual, and other men who have sex with men (GBM) to reduce the risk of HIV transmission. However this is impacted by condom failure events, defined here as condom breakage and slippage. In a prospective, observational cohort study of 343 HIV serodiscordant male couples recruited through high HIV caseload clinics and hospitals between 2012 and 2016 in Australia, Brazil, and Thailand, condom failure rates and associated factors were analysed, including with the study partner versus other sexual partners. There were 717 reported instances of condom failure from an estimated total of 25,831 sex acts with condoms, from over 588.4 participant years of follow up. Of the HIV-negative partners (n = 343) in the study, more than a third (n = 117, 36.7%) reported at least one instance of condom failure with any partner type during study follow-up. Condom failure with their study partner was reported by 91/343 (26.5%) HIV-negative partners, compared with 43/343 (12.5%) who reported condom failure with other partners. In total, there were 86 events where the HIV-negative partner experienced ano-receptive condom failure with ejaculation, representing 12.0% of all failure events. In multivariable analysis, compared to Australia, HIV-negative men in Brazil reported a higher incidence risk rate of condom failure (IRR = 1.64, 95%CI 1.01-2.68, p = 0.046) and HIV-negative men who reported anal sex with other partners reported an increased risk of condom failure compared with men who only had sex with their study partner (IRR = 1.89, 95%CI 1.08-3.33, p = 0.025). Although at least one event of condom failure was reported by a significant proportion of participants, overall condom failure events represented a small proportion of the total condom protected sex acts.

Time to viral load suppression and its predictors among people living with HIV on antiretroviral therapy in Gebi Resu zone, Afar Region, Ethiopia, 2023

Objective

This study aimed to estimate the time to viral load suppression and identify its predictors among HIV patients receiving antiretroviral therapy (ART) in the Gebi Resu zone, Afar Region, Ethiopia, 2023.

Setting

The study was conducted at public health facilities in the Gebi Resu zone of the Afar region.

Study design

This study is a facility-based, retrospective follow-up study.

Study participants

This study included 298 people living with HIV who were receiving ART services at selected health facilities in the Gebi Resu zone. Data were collected by reviewing patient records using a structured checklist. Bivariate and multivariate Cox regression analyses were conducted to assess the relationship between variables and control for confounders.

Results

The incidence rate of viral load suppression was 9.46 per 100 person-months. The median time to viral load suppression was 7.7 months, with an interquartile range of 3.8 months (IQR = 6.47-10.27). Patients at clinical stages 3 and 4 [AHR = 0.67, 95%CI (0.47, 0.96)], those who received cotrimoxazole prophylaxis therapy [AHR = 1.47, 95%CI (1.12, 1.92)], and patients with poor drug adherence [AHR = 0.40, 95%CI (0.18, 0.90)] were significantly associated with time to viral load suppression among people on antiretroviral therapy.

Conclusion

The time to viral load suppression and the median time to viral load suppression among people living with HIV on ART were shorter than those observed in many developing and developed countries. Clinical stage, cotrimoxazole prophylaxis therapy, and drug adherence were significant predictors of viral load suppression.

Rapid identification of novel indolylarylsulfone derivatives as potent HIV-1 NNRTIs via miniaturized CuAAC click-chemistry-based combinatorial libraries

This article presents the rapid identification of novel indolylarylsulfone (IAS) derivatives as potent non-nucleoside reverse transcriptase inhibitors (NNRTIs) for HIV-1 through a miniaturized click-chemistry-based combinatorial library approach. Utilizing copper(i)-catalyzed azide-alkyne cycloaddition (CuAAC), a reliable and biocompatible click chemistry technique, the researchers synthesized and characterized a series of IAS derivatives. Several compounds selected through the in situ enzyme inhibition assay demonstrated promising activity in subsequent cellular level tests. Notably, compound C1N4 displayed the most potent anti-HIV-1 IIIB activity with an EC50 of 0.024 μM and low cytotoxicity (CC50 > 215.88 μM). Molecular docking studies provided insights into the binding mode of these novel compounds within the NNIBP, aiding in the structure-based design of future NNRTIs. The findings underscore the potential of click chemistry in the discovery of new anti-HIV agents with improved efficacy and safety profiles.

A Risk Prediction Model to Identify People Living with HIV Who are High-risk for Disengagement from Care after HIV Diagnosis in South Africa

The provision of ART in South Africa has transformed the HIV epidemic, resulting in an increase in life expectancy by over 10 years. Despite this, nearly 2 million people living with HIV are not on treatment. The objective of this study was to develop and externally validate a practical risk assessment tool to identify people with HIV (PWH) at highest risk for attrition from care after testing. A machine learning model incorporating clinical and psychosocial factors was developed in a primary cohort of 498 PWH. LASSO regression analysis was used to optimize variable selection. Multivariable logistic regression analysis was applied to build a model using 80% of the primary cohort as a training dataset and validated using the remaining 20% of the primary cohort and data from an independent cohort of 96 participants. The risk score was developed using the Sullivan and D'Agostino point based method. Of 498 participants with mean age 35.7 years, 192 (38%) did not initiate ART after diagnosis. Controlling for site, factors associated with non-engagement in care included being < 35 years, feeling abandoned by God, maladaptive coping strategies using alcohol or other drugs, no difficulty concentrating, and having high levels of confidence in one's ability to handle personal challenges. An effective risk score can enable clinicians and implementers to focus on tailoring care for those most in need of ongoing support. Further research should focus on potential strategies to enhance the generalizability and evaluate the implementation of the proposed risk prediction model in HIV treatment programs.

Acetylsalicylic acid inhibition of the lipoxygenase pathway: Implications for HIV prevention

BACKGROUND

1.5 million new HIV infections occurred in 2021, suggesting new prevention methods are needed. Inflammation increases the risk for HIV acquisition by attracting HIV target cells to the female genital tract (FGT). In a pilot study, acetylsalicylic acid (ASA/Aspirin) decreased the proportion of FGT HIV target cells by 35 %. However, the mechanism remains unknown.

METHODS

Women from Nairobi, Kenya took low-dose ASA (81 mg) daily for 6-weeks. Free oxylipins in the plasma were quantified by high-performance liquid chromatography-tandem mass spectroscopy.

RESULTS

Oxylipins from 9 fatty acid substrates were detected, with more than one analyte from 4 substrates reduced post-ASA. Summary analysis found ASA downregulated cyclooxygenase and lipoxygenase but not cytochrome P450 activity with a lower n-6/n-3 oxylipin profile, reflecting reduced inflammation post-ASA.

CONCLUSIONS

Inflammation is associated with increased lipoxygenase activity and HIV risk. Our data suggests ASA reduces inflammation through downregulation of oxylipins. Understanding how ASA reduces inflammation may lead to novel HIV prevention approaches.

A Qualitative Study of Transportation-Related Barriers to HIV Care in South Carolina

OBJECTIVES

Addressing structural barriers to care for people living with human immunodeficiency virus (HIV) in the southern United States is critical to increase rates of viral suppression and to reduce existing HIV disparities. This qualitative study aimed to describe transportation-related barriers experienced by people living with HIV in South Carolina, understand perceived effects of transportation vulnerability on HIV care, and explore strategies used by individuals to overcome transportation-related challenges.

METHODS

We conducted semistructured interviews with 20 people living with HIV from South Carolina who were either reengaging in HIV care after a prolonged absence (>9 months) or in care but with a detectable viral load (ie, >200 copies/mL). All people living with HIV reported transportation vulnerability. A deductive/inductive approach was used to identify transportation-related barriers perceived to negatively affect HIV care. We also identified strategies and resources described by people living with HIV as helpful in addressing transportation challenges.

RESULTS

Participants described a range of transportation-related barriers to HIV care, including lack of access to reliable, safe, and affordable transportation, as well as stigma due to HIV and socioeconomic statuses. These barriers were reported to negatively affect engagement in care and worsen both physical and mental health. Participants indicated flexible clinic policies and instrumental support from family and friends were useful in overcoming barriers.

CONCLUSIONS

This study offers insight for the development of transportation interventions to improve equitable access to HIV care for people living with HIV in South Carolina. It also calls attention to the ways in which transportation vulnerability, HIV-related stigma, and disability status intersect to create unique challenges for some people living with HIV.

Experience of the national cohort of pregnant women with HIV and their children in Spain: temporal trends in vertical transmission of HIV and associated infections

INTRODUCTION

The vertical transmission rate (VTR) of HIV has decreased to less than 2% in high-income countries, in spite of which perinatal infections continue to occur. We present data from the national cohort of pregnant women living with HIV and their children in Spain. The objectives were to describe the characteristics of this population, evaluate the VTR of HIV, the safety of antiretroviral therapy (ART) and the prevalence of coinfection.

PATIENTS AND METHODS

Multicentre prospective, observational and descriptive study with participation of 62 hospitals. The sample included pegnant women living with HIV whose children were born between January 2020 and December 2022. We collected prospective data on the characteristics of mothers and children using an online questionnaire (REDCap web application).

RESULTS

The study included 414 mother-child dyads. Most mothers were immigrants (227/349; 65.1%). The main route of HIV infection was heterosexual transmission (160/402; 39.8%), followed by vertical transmission (44/402; 10.9%). The diagnosis was made before conception in 313/389 women (80.4%), 394/402 (98%) received ART during pregnancy and 356/402 (89.3%) had an undetectable viral load at the time of delivery. The delivery was vaginal in 230/388 children (59.3%). The proportion of preterm birth was 11.1%. The most frequent neonatal prophylaxis approach was monotherapy with zidovudine (358/414; 86.5%). There were 3 cases of vertical transmission of HIV (95% CI, 0%-1.54%). Only one newborn was breastfed.

CONCLUSIONS

At present, most women living with HIV in Spain receive the diagnosis before conception, are of foreign ancestry and achieve good control of the infection. Although the VTR is very low in Spain, there are still infections that could be prevented with early diagnosis and treatment.

Enhanced Oral Pre-exposure Prophylaxis (PrEP) Implementation for Ugandan Fisherfolk: Pilot Intervention Outcomes

Mobile populations such as fisherfolk show high HIV incidence and prevalence. We pilot-tested implementation strategies to enhance pre-exposure prophylaxis (PrEP) uptake and adherence in the context of healthcare outreach events in two mainland fisherfolk communities on Lake Victoria, Uganda from September 2021 to February 2022. The implementation strategies included PrEP adherence supporters (selected from PrEP users' social networks), community workshops (to address misconceptions and stigma, and empower PrEP advocacy), and check-in calls (including refill reminders). PrEP medical records data were collected from 6-months pre-intervention to 6-months post-intervention. Qualitative interviews with 20 PrEP users (10 who continued, 10 who discontinued), 9 adherence supporters, and 7 key partners (providers, community leaders) explored acceptability. Percentages of PrEP initiators (of those eligible) were significantly higher during the intervention (96.5%) than 6-months before the intervention (84.5%), p < 0.0001; percentages of PrEP users who persisted (i.e., possessed a refill) 6-months post-initiation (47.9% vs. 6.7%) and had at least 80% PrEP coverage (based on their medication possession ratio) from the initiation date to 6-months later (35.9% vs. 0%) were higher during versus pre-intervention, p < 0.0001. A comparison fisherfolk community with better healthcare access had lower uptake (78.3%; p < 0.0001) and persistence at 6-months (34.0%; p < 0.001), but higher coverage during the intervention period (70.4%; p < 0.0001). Qualitative data suggested the strategies promoted PrEP use through reduced stigma and misconceptions. The intervention bundle cost was $223.95, $172.98, and $94.66 for each additional person for PrEP initiation, persistence, and coverage, respectively. Enhanced community-based PrEP implementation that fosters a supportive community environment can improve PrEP use in mobile populations without easy access to healthcare. (NCT05084716).

A Web-Based Antiretroviral Therapy Adherence Intervention (Thrive With Me) in a Community-Recruited Sample of Sexual Minority Men Living With HIV: Results of a Randomized Controlled Study

BACKGROUND

Most new HIV infections are attributed to male-to-male sexual contact in the United States. However, only two-thirds of sexual minority men living with HIV achieve an undetectable viral load (UVL). We tested a web-based antiretroviral therapy adherence intervention called Thrive with Me (TWM) with core features that included medication self-monitoring and feedback, HIV and antiretroviral therapy information, and a peer-to-peer exchange.

OBJECTIVE

We assessed the efficacy of TWM on HIV UVL among adult (aged ≥18 years) sexual minority men. Moreover, we assessed the impact of overall engagement and engagement with specific intervention features on HIV UVL.

METHODS

In total, 401 sexual minority men (mean age 39.1, SD 10.8 y; 230/384, 59.9% African American) in New York City were recruited between October 2016 and December 2019 and randomized to receive TWM (intervention) or a weekly email newsletter (control) for 5 months. Computerized assessments occurred at baseline and months 5, 11, and 17. The primary outcome was a dichotomous measure of HIV UVL (≤20 copies/μL). Generalized estimating equations with robust SEs were used to assess the effect of the TWM intervention on HIV UVL over the follow-up period in an unadjusted model and a model adjusted for baseline differences and then stratified by baseline recent drug use urinalysis. In secondary analyses, generalized linear models were used to estimate risk differences in the association of overall engagement with TWM (the sum of the number of days participants accessed ≥1 screen of the TWM intervention out of a possible 150 days) and engagement with specific TWM components on HIV UVL throughout the 17-month intervention period.

RESULTS

Participant retention was 88.5% (355/401; month 5), 81.8% (328/401; month 11), and 80.3% (322/401; month 17). No consistent differences in HIV UVL were found between those randomized to receive TWM or the control at the 5- (difference-in-differences [DD]=-7.8, 95% CI -21.1 to 5.5), 11- (DD=-13.9, 95% CI -27.7 to 0.04), or 17-month (DD=-8.2, 95% CI -22.0 to 5.7) time points, or when stratified by baseline recent drug use. However, those TWM-assigned participants with high overall levels of engagement (in the upper 25th percentile) were more likely to have an HIV UVL at the end of the 5-month active intervention period compared to those with low engagement (below the 75th percentile; risk difference=17.8, 95% CI 2.5-33.0) or no engagement (risk difference=19.4, 95% CI 3.3-35.5) in the intervention. Moreover, high engagement with the peer-to-peer exchange was associated with HIV UVL over time in unadjusted models.

CONCLUSIONS

TWM did not have overall impacts on HIV UVL; however, it may assist some sexual minority men who are highly engaged with this web-based intervention in achieving HIV viral suppression.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02704208; https://clinicaltrials.gov/study/NCT02704208.

Evaluating the impact of HIV pre-exposure prophylaxis on pregnancy, infant, and maternal health outcomes in Malawi: PrIMO study protocol

BACKGROUND

Incident HIV during the perinatal period significantly impedes elimination of Mother-to-Child HIV Transmission (eMTCT) efforts. Pre-Exposure Prophylaxis (PrEP) effectively reduces HIV acquisition, and new agents like injectable Cabotegravir (CAB-LA) offer potential advantages for pregnant and breastfeeding women. The Pregnancy, Infant, and Maternal health Outcomes (PrIMO) study will compare rates of composite adverse pregnancy outcomes, and infant adverse events, growth and neurodevelopment between mother-infant dyads receiving CAB-LA and those receiving oral PrEP in Malawi.

METHODS

PrIMO is an observational cohort study involving: (1) the development of a PrEP Pregnancy Registry for longitudinal surveillance of pregnant women on PrEP in Malawi; and (2) the enrolment of a prospective safety cohort of 621 pregnant women initiating oral PrEP or CAB-LA and their subsequent infants. The registry will include all women continuing or initiating PrEP during pregnancy across targeted sites in Lilongwe and Blantyre districts. The safety cohort will enrol a subset of those women and their infants from Bwaila District Hospital in Lilongwe, Malawi. We hypothesize that CAB-LA's safety will be comparable to daily oral PrEP regarding adverse pregnancy outcomes, maternal/infant adverse events, and infant development. Participants in the cohort will choose either oral PrEP or CAB-LA and will be followed until 52 weeks post-delivery. Safety data will be collected from all mother-infant pairs and qualitative interviews will be conducted with a subset of purposively selected women (n = 50) to assess the acceptability of each PrEP modality.

DISCUSSION

The PrIMO study will provide critical data on the safety of CAB-LA in pregnant and breastfeeding women and their infants. Results will guide clinical recommendations as the Malawi Ministry of Health prepares for the rollout of CAB-LA to this population. Evaluation of Registry implementation will inform its expansion to a nationwide safety monitoring system for PrEP use during pregnancy, with implications for similar systems in the region.

TRIAL REGISTRATION NUMBER

NCT06158126. The study was prospectively registered (5 December 2023) in ClinicalTrials.gov.