Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Cost Analysis of the Positive Health Check Intervention to Suppress HIV Viral Load and Retain Patients in HIV Clinical Care

CONTEXT

Digital video-based behavioral interventions are effective tools for improving HIV care and treatment outcomes.

OBJECTIVE

To assess the costs of the Positive Health Check (PHC) intervention delivered in HIV primary care settings.

DESIGN, SETTING, AND INTERVENTION

The PHC study was a randomized trial evaluating the effectiveness of a highly tailored, interactive video-counseling intervention delivered in 4 HIV care clinics in the United States in improving viral suppression and retention in care. Eligible patients were randomized to either the PHC intervention or the control arm. Control arm participants received standard of care (SOC), and intervention arm participants received SOC plus PHC. The intervention was delivered on computer tablets in the clinic waiting rooms. The PHC intervention improved viral suppression among male participants. A microcosting approach was used to assess the program costs, including labor hours, materials and supplies, equipment, and office overhead.

PARTICIPANTS

Persons with HIV infection, receiving care in participating clinics.

MAIN OUTCOME MEASURES

The primary outcome was the number of patients virally suppressed, defined as having fewer than 200 copies/mL by the end of their 12-month follow-up.

RESULTS

A total of 397 (range across sites [range], 95-102) participants were enrolled in the PHC intervention arm, of whom 368 participants (range, 82-98) had viral load data at baseline and were included in the viral load analyses. Of those, 210 (range, 41-63) patients were virally suppressed at the end of their 12-month follow-up visit. The overall annual program cost was $402 274 (range, $65 581-$124 629). We estimated the average program cost per patient at $1013 (range, $649-$1259) and the cost per patient virally suppressed at $1916 (range, $1041-$3040). Recruitment and outreach costs accounted for 30% of PHC program costs.

CONCLUSIONS

The costs of this interactive video-counseling intervention are comparable with other retention in care or reengagement interventions.

Characterizing Unhealthy Alcohol Use Patterns and Their Association with Alcohol Use Reduction and Alcohol Use Disorder During Follow-Up in HIV Care

Outcomes of PWH with unhealthy alcohol use, such as alcohol use reduction or progression to AUD, are not well-known and may differ by baseline patterns of unhealthy alcohol use. Among 1299 PWH screening positive for NIAAA-defined unhealthy alcohol use in Kaiser Permanente Northern California, 2013-2017, we compared 2-year probabilities of reduction to low-risk/no alcohol use and rates of new AUD diagnoses by baseline use patterns, categorized as exceeding: only daily limits (72% of included PWH), only weekly limits (17%), or both (11%), based on NIAAA recommendations. Overall, 73.2% (95% CI 70.5-75.9%) of re-screened PWH reduced to low-risk/no alcohol use over 2 years, and there were 3.1 (95% CI 2.5-3.8%) new AUD diagnoses per 100 person-years. Compared with PWH only exceeding daily limits at baseline, those only exceeding weekly limits and those exceeding both limits were less likely to reduce and likelier to be diagnosed with AUD during follow-up. PWH exceeding weekly drinking limits, with or without exceeding daily limits, may have a potential need for targeted interventions to address unhealthy alcohol use.

Beyond Antiretroviral Treatment: Patterns and Factors Associated With Composite Medication Adherence Before and During the COVID-19 Pandemic in Patients With HIV With Multiple Chronic Conditions

BACKGROUND

Polypharmacy for multiple chronic conditions (MCCs) poses an increasing challenge in people with HIV (PWH). This research explores medication adherence in PWH with MCCs before and during COVID-19.

SETTING

Kaiser Permanente Mid-Atlantic States.

METHODS

Medical and pharmacy records of a continuously enrolled cohort (September 2018-September 2021) of adult PWH were used. To estimate medication adherence, monthly proportion of days covered (PDC) was measured individually for antiretrovirals (ARVs), diabetes medications (DMs), renin-angiotensin antagonists (RASMs), and statins (SMs) and combined into composite measures (CMs) with and without ARVs. Descriptive statistics, time-series models, and multivariable population-averaged panel general estimating equations were used to profile trends, effects, and factors associated with adherence.

RESULTS

The cohort (n = 543) was predominantly 51-64 years old (59.3%), Black (73.1%), male (69.2%), and commercially insured (65.4%). Two-thirds (63.7%) of patients were taking medications in 2 medication groups (ie, ARVs and either DMs, RASMs, or SMs), 28.9% were taking medications in 3 medication groups, and 7.4% were taking medications in all 4 medication groups. Overall, PDC for CMs without ARVs was 77.2% and 70.2% with ARVs. After March 2020, negative monthly trends in PDC were observed for CMs without ARVs (β = -0.1%, P = 0.003) and with ARVs (β = -0.3%, P = 0.001). For CMs with ARVs, Black race (aOR = 0.5; P < 0.001; ref: White) and taking medications for 3 medication groups (aOR = 0.8; P < 0.02; ref: 2) were associated with lower adherence.

CONCLUSION

Decreasing medication adherence trends were observed during the COVID-19 pandemic with variations among population subgroups. Opportunity exists to improve medication adherence for non-White populations and those taking medications for MCCs beyond ARVs.

Risk of Nonkeratinocyte Skin Cancers in People Living with HIV during the Era of Antiretroviral Therapy

Antiretroviral therapy may alter susceptibility to nonkeratinocyte skin cancers (NKSCs) by improving immunity in people living with HIV. Using linked data from HIV and cancer registries in 12 states/regions in the United States during the antiretroviral therapy era (1996‒2018), we calculated standardized incidence ratios for 27 NKSCs, comparing incidence with that of the general population. Risk factors for NKSCs were evaluated using Poisson regression. There were 2,743 NKSCs diagnosed in 585,706 people living with HIV followed for 4,575,794 person-years. Kaposi sarcoma was the most common cancer (82%), followed by melanoma (12%) and cutaneous lymphoma (2.6%). Incidence was elevated for virus-related NKSCs: Kaposi sarcoma (standardized incidence ratio = 147, 95% confidence interval = 141‒153), diffuse large B-cell lymphoma (standardized incidence ratio = 5.19, 95% confidence interval = 3.13‒8.11), and Merkel cell carcinoma (standardized incidence ratio = 3.15, 95% confidence interval = 1.93‒4.87); elevated incidence for diffuse large B-cell lymphoma and Merkel cell carcinoma was observed only among people living with HIV with a previously acquired immunodeficiency syndrome diagnosis. Kaposi sarcoma risk was highest among men who have sex with men. Incidence was not increased for melanoma, adnexal carcinomas, and sarcomas. Melanoma and Merkel cell carcinoma arose disproportionately on sun-exposed skin, supporting a role for UVR in their development. In conclusion, risk for most NKSCs was similar to that of the general population during the antiretroviral therapy era, suggesting that people living with HIV without NKSC risk factors may not require intensive skin surveillance.

Evaluation of Statin Prescribing Practices and Predictors of Statin Underutilization in Persons With HIV

BACKGROUND

Persons with HIV (PWH) have an increased risk of cardiovascular disease (CVD) compared with those without HIV. Despite the increased risk, PWH are less likely to be prescribed statin therapy compared with the general population. The purpose of this study is to describe the statin prescribing practices of an outpatient HIV clinic and identify potential predictors of statin underutilization.

METHODS

This study was a retrospective, single-center chart review of PWH ages 40-79 years receiving care at an HIV clinic. Statin eligibility, statin prescribing practices, and appropriateness of statin therapy were evaluated. Logistical regression analyses were conducted to assess for predictors of underutilization of statin therapy.

RESULTS

Of the 606 patients, statin therapy was indicated in 362 patients (60%). Among those with a statin indication, 60.2% were prescribed appropriate statin therapy, 11.6% were prescribed statin therapy but not at the indicated intensity, and 28.2% were not prescribed statin therapy. Tobacco use ( P = 0.0023) was identified as a predictor of statin underutilization. The odds of statin prescribing were higher for those with clinical atherosclerotic CVD ( P = 0.004) and hypertension ( P = 0.017).

CONCLUSION

Statin underutilization was significantly higher in PWH smoking tobacco and PWH without atherosclerotic CVD or low-density lipoprotein-cholesterol 190 mg/dL or higher. In addition, this study highlights the need for more robust CVD prevention efforts in PWH. Identifying predictors of statin underutilization may aid in elucidating where gaps in cardiovascular prevention care may exist.

Support for Trauma-informed Care Implementation Among Ryan White HIV Clinics in the Southeastern United States

Trauma histories are common among people with HIV and associated with poor HIV outcomes, underscoring the importance of integrating trauma-informed care (TIC) into HIV services. As part of the quantitative phase of an explanatory sequential mixed-methods study, we assessed individual and clinic-wide support (using the Attitudes Related to Trauma-informed Care-45 (ARTIC-45)) and factors influencing TIC support through surveys with 152 administrators, providers, and staff from 38 Ryan White Clinics (RWCs) in the Southeastern US. Mean responses to the ARTIC-45 Personal and System Support Subscales were 5.18 (SE = 0.09; range 1-7) and 4.45 (SE = 0.16; range 1-7), respectively. In bivariate analysis, higher personal and system support were associated with strong clinic leadership culture (personal support: β = 0.08, t-value = 2.66, p = 0.009; system support: β = 0.16, t-value = 4.71, p < 0.001) and lower staff burnout (personal support: β=-0.05, t-value=-3.10, p = 0.002; system support: β=-0.07, t-value=-3.63, p < 0.001). System support was also associated with rural clinic setting (β = 0.61, t-value = 2.34, p = 0.021), strong staff culture (β = 0.14, t-value = 4.70, p = < 0.001), and resource availability (β = 0.16, t-value = 5.76, p < 0.001), and negatively associated with academic clinic setting (β=-0.52, t-value=-2.25, p = 0.026). Thus, while there is encouraging individual support for TIC, RWCs need tools (training and/or resources) to foster leadership and staff culture and trauma support to enable their transition to trauma-informed HIV care.

Update in Human Immunodeficiency Virus and Aging

Effective and consistent antiretroviral therapy has enabled people with human immunodeficiency virus (HIV) (PWH) to survive longer than previously encountered earlier in the epidemic. Consequently, PWH are subject to the struggles and clinical conditions typically associated with aging. However, the aging process in PWH is not the same as for those who do not have HIV. There is a complex interplay of molecular, microbiologic, and pharmacologic factors that leads to accelerated aging in PWH; this leads to increased risk for certain age-related comorbidities requiring greater vigilance and interventions in routine care.

Shared Decision-Making Concerning Anal Cancer Screening in Persons With Human Immunodeficiency Virus

BACKGROUND

Anal high-grade squamous intraepithelial lesion (aHSIL) is the immediate precursor of anal cancer. Anal cytology is a recommended screening test to identify aHSIL among people with human immunodeficiency virus (HIV; PWH). Heterogeneity of risk for invasive anal cancer among PWH suggests the value of a shared decision-making framework regarding screening.

METHODS

Using a longitudinal HIV cohort with a comprehensive anal cancer screening program, we estimated the adjusted probabilities of having aHSIL on the first anal cytology. We used logistic regression models with inverse probability weighting to account for differential screening in the cohort and to construct a predicted probability nomogram for aHSIL. Sensitivity analysis was performed to estimate aHSIL prevalence corrected for misclassification bias.

RESULTS

Of 8139 PWH under care between 2007 and 2020, 4105 (49.8%) underwent at least 1 anal cytology test. First-time cytology aHSIL was present in 502 (12.2%) PWH. The adjusted probability of having aHSIL varied from 5% to 18% depending on patient characteristics. Prespecified factors in the aHSIL prediction model included nadir CD4 cell count, ethnicity, race, age, sex, gender identity, and HIV risk factors. The ability of the model to discriminate cytological aHSIL was modest, with an area under the curve of 0.63 (95% confidence interval, .60-.65).

CONCLUSIONS

PWH are at increased risk for aHSIL and invasive anal cancer. Risk, however, varies by patient characteristics. Individual risk factor profiles predictive of aHSIL can be modeled and operationalized as nomograms to facilitate shared decision-making conversations concerning anal cancer screening.

Development and validation of an instrument for the evaluation of HIV care in Primary Health Care

OBJECTIVE

To develop and validate an instrument to evaluate the decentralization process of care for People Living with HIV in Primary Health Care.

METHOD

Methodological study, developed in four stages: elaboration of the logical model based on the triad Structure-Process-Outcomes; development of the instrument; content validation by expert judges and technical reviewers; and semantic validation. Online questionnaires were used, and the Kappa index was used for analysis.

RESULTS

The instrument with 68 items and 8 factors was submitted to validation by expert judges who recommended the exclusion of 3 items and the alteration of 2 factors. In the validation by technical reviewers, 2 items were excluded and 6 factors were highlighted; the agreement index was ≥0.75. In the semantic validation, 87.3% of the judges answered "totally agree" for the items presented.

CONCLUSION

The instrument is validated for its content, has 63 items and has the potential to assess the care provided for people living with HIV in Primary Health Care.

Assessment and Diagnosis of HIV-Associated Dementia

The modern combined antiretroviral treatment (cART) for human immunodeficiency virus (HIV) infection has substantially lowered the incidence of HIV-associated dementia (HAD). The dominant clinical features include deficits in cognitive processing speed, concentration, attention, and memory. As people living with HIV become older, with high rates of comorbidities and concomitant treatments, the prevalence and complexity of cognitive impairment are expected to increase. Currently, the management of HAD and milder forms of HAND is grounded on the best clinical practice, as there is no specific, evidence-based, proven intervention for managing cognitive impairment. The present article acknowledges the multifactorial nature of the cognitive impairments found in HIV patients, outlining the current concepts in the field of HAD. Major areas of interest include neuropsychological testing and neuroimaging to evaluate CNS status, focusing on greater reliability in the exclusion of associated diseases and allowing for earlier diagnosis. Additionally, we considered the evidence for neurological involvement in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the impact of the coronavirus (COVID-19) pandemic, with wider consequences to population health than can be attributed to the virus itself. The indirect effects of COVID-19, including the increased adoption of telehealth, decreased access to community resources, and social isolation, represent a significant health burden, disproportionately affecting older adults with dementia who have limited social networks and increased functional dependence on the community and health system. This synopsis reviews these aspects in greater detail, identifying key gaps and opportunities for researchers and clinicians; we provide an overview of the current concepts in the field of HAD, with suggestions for diagnosing and managing this important neurological complication, which is intended to be applicable across diverse populations, in line with clinical observations, and closely representative of HIV brain pathology.

Updates on HIV and Kidney Disease

PURPOSE OF REVIEW

With the advent of antiretroviral therapy, HIV infection has become a chronic disease in developed countries.

RECENT FINDINGS

Non-HIV-driven risk factors for kidney disease, such as APOL1 risk variants and other genetic and environmental factors, have been discovered and are better described. Consequently, the field of HIV-associated kidney disease has evolved with greater attention given to traditional risk factors of CKD and antiretroviral treatment's nephrotoxicity. In this review, we explore risk factors of HIV-associated kidney disease, diagnostic tools, kidney pathology in HIV-positive individuals, and antiretroviral therapy-associated nephrotoxicity.

Cardiovascular Disease Among Persons Living With HIV: New Insights Into Pathogenesis and Clinical Manifestations in a Global Context

Widespread use of contemporary antiretroviral therapy globally has transformed HIV disease into a chronic illness associated with excess risk for disorders of the heart and circulatory system. Current clinical care and research has focused on improving HIV-related cardiovascular disease outcomes, survival, and quality of life. In high-income countries, emphasis on prevention of atherosclerotic coronary artery disease over the past decade, including aggressive management of traditional risk factors and earlier initiation of antiretroviral therapy, has reduced risk for myocardial infarction among persons living with human immunodeficiency virus-1 infection. Still, across the globe, persons living with human immunodeficiency virus-1 infection on effective antiretroviral therapy treatment remain at increased risk for ischemic outcomes such as myocardial infarction and stroke relative to the persons without HIV. Unique features of HIV-related cardiovascular disease, in part, include the pathogenesis of coronary disease characterized by remodeling ectasia and unusual plaque morphology, the relative high proportion of type 2 myocardial infarction events, abnormalities of the aorta such as aneurysms and diffuse aortic inflammation, and HIV cerebrovasculopathy as a contributor to stroke risk. Literature over the past decade has also reflected a shift in the profile and prevalence of HIV-associated heart failure, with a reduced but persistent risk of heart failure with reduced ejection fraction and a growing risk of heart failure with preserved ejection fraction. Cardiac magnetic resonance imaging and autopsy data have emphasized the central importance of intramyocardial fibrosis for the pathogenesis of both heart failure with preserved ejection fraction and the increase in risk of sudden cardiac death. Still, more research is needed to better characterize the underlying mechanisms and clinical phenotype of HIV-associated myocardial disease in the current era. Across the different cardiovascular disease manifestations, a common pathogenic feature is that HIV-associated inflammation working through different mechanisms may amplify underlying pathology because of traditional risk and other host factors. The prevalence and phenotype of individual cardiovascular disease manifestations is ultimately influenced by the degree of injury from HIV disease combined with the profile of underlying cardiometabolic factors, both of which may differ substantially by region globally.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2022 Recommendations of the International Antiviral Society-USA Panel

Importance

Recent advances in treatment and prevention of HIV warrant updated recommendations to guide optimal practice.

Objective

Based on a critical evaluation of new data, to provide clinicians with recommendations on use of antiretroviral drugs for the treatment and prevention of HIV, laboratory monitoring, care of people aging with HIV, substance use disorder and HIV, and new challenges in people with HIV, including COVID-19 and monkeypox virus infection.

Evidence Review

A panel of volunteer expert physician scientists were appointed to update the 2020 consensus recommendations. Relevant evidence in the literature (PubMed and Embase searches, which initially yielded 7891 unique citations, of which 834 were considered relevant) and studies presented at peer-reviewed scientific conferences between January 2020 and October 2022 were considered.

Findings

Initiation of antiretroviral therapy (ART) is recommended as soon as possible after diagnosis of HIV. Barriers to care should be addressed, including ensuring access to ART and adherence support. Integrase strand transfer inhibitor-containing regimens remain the mainstay of initial therapy. For people who have achieved viral suppression with a daily oral regimen, long-acting injectable therapy with cabotegravir plus rilpivirine given as infrequently as every 2 months is now an option. Weight gain and metabolic complications have been linked to certain antiretroviral medications; novel strategies to ameliorate these complications are needed. Management of comorbidities throughout the life span is increasingly important, because people with HIV are living longer and confronting the health challenges of aging. In addition, management of substance use disorder in people with HIV requires an evidence-based, integrated approach. Options for preexposure prophylaxis include oral medications (tenofovir disoproxil fumarate or tenofovir alafenamide plus emtricitabine) and, for the first time, a long-acting injectable agent, cabotegravir. Recent global health emergencies, like the SARS-CoV-2 pandemic and monkeypox virus outbreak, continue to have a major effect on people with HIV and the delivery of services. To address these and other challenges, an equity-based approach is essential.

Conclusions and Relevance

Advances in treatment and prevention of HIV continue to improve outcomes, but challenges and opportunities remain.

Construção e validação de instrumento avaliativo para atendimento ao HIV na Atenção Primária à Saúde

RESUMO Objetivo: construir e validar um instrumento de avaliação do processo de descentralização do atendimento às pessoas vivendo com HIV para Atenção Primária à Saúde. Métodos: estudo metodológico, desenvolvido em quatro etapas: elaboração do modelo lógico baseado na tríade Estrutura-Processo-Resultados; construção do instrumento; validação de conteúdo por juízes especialistas e revisores técnicos; e validação semântica. Utilizaram-se questionários on-line e, para análise, o índice de Kappa. Resultados: o instrumento, com 68 itens e 8 fatores, foi submetido à validação por juízes especialistas que recomendaram a exclusão de 3 itens e mudança de 2 fatores. Na validação por revisores técnicos, foram excluídos 2 itens e pontou-se 6 fatores, o índice de concordância foi ≥0,75. Na validação semântica 87,3% responderam “concordo totalmente” para os itens apresentados. Conclusões: O instrumento encontra-se validado quanto ao conteúdo, possui 63 itens e potencial para avaliação do atendimento às pessoas vivendo com HIV na Atenção Primária à Saúde.

Treatment Regimens and Care Models for Older Patients Living with HIV: Are We Doing Enough?

With improved access to antiretroviral therapy throughout the world, people are aging with HIV, and a large portion of the global population of people with HIV (PWH) is now age 50 or older. Older PWH experience more comorbidities, aging-related syndromes, mental health challenges, and difficulties accessing fundamental needs than the population of older adults without HIV. As a result, ensuring that older PWH are receiving comprehensive healthcare can often be overwhelming for both PWH and the providers. Although there is a growing literature addressing the needs of this population, gaps remain in care delivery and research. In this paper, we suggest seven key components to any healthcare program designed to address the needs of older people with HIV: management of HIV, comorbidity screening and treatment, primary care coordination and planning, attention to aging related-syndromes, optimization of functional status, support of behavioral health, and improved access to basic needs and services. We review many of the difficulties and controversies related to the implementation of these components, which include the absence of screening guidelines for this population and the challenges of care integration, and we suggest key next steps.

Electrocautery ablation therapy for anal intraepithelial carcinoma: A study protocol

BACKGROUND

Anal cancer is a human papillomavirus-related cancer. Screening with high-resolution anoscopy (HRA) and subsequent therapeutic intervention are increasingly recognized as the standard procedure for anal cancer. Generally, lesions suspected as being high-grade squamous intraepithelial lesions are biopsied and treated if they are grade 2 or 3 anal intraepithelial neoplasia (AIN). According to several studies, electrocautery ablation for grade 2 or 3 AIN is highly effective. However, relapse within and outside the targeted areas after the intervention is a clinical problem. In Japan, electrocautery ablation is not available at most facilities. Therefore, this study aims to investigate the efficacy and safety of electrocautery ablation.

METHODS

This single-arm, open-label, pilot intervention study will investigate the efficacy and safety of electrocautery ablative therapy using high-frequency medical devices. Patients diagnosed with grade 2 or 3 AIN will be included and will receive ablation treatment. Then, they will be followed up at 3 and 6 months after the procedure for HRA-guided sextant biopsy. To reduce the possibility of missed lesions before and after the intervention, we will perform HRA-guided sextant biopsy routinely. In this study, a sextant biopsy is defined as at least 6 biopsies in all directions, regardless of abnormal findings under HRA. The primary outcome is the recurrence rate at 6 months, and the secondary outcomes are the adverse event and recurrence rates at 3 months.

CONCLUSION

This pilot study will provide data on the effectiveness and safety of electrocautery ablation as a treatment for grade 2 or 3 AIN.

Hepatitis B immunization data of patients living with HIV/AIDS: a multi-centre study

OBJECTIVES

Human immunodeficiency virus (HIV) and hepatitis B virus (HBV) are the two leading viruses that cause the greatest number of virus-related morbidities in the world. HIV/HBV coinfection is correlated with high morbidity and mortality. For this particular reason hepatitis B vaccination is crucial for people living with HIV.

METHODS

Patients who are being followed-up for HIV/AIDS and who have received a hepatitis B vaccine in 4 HIV clinics over a 5-year time period have been studied. Our multi-centered, retrospective, cross-sectional and observational study investigates factors that affect hepatitis B vaccination immune response of individuals living with HIV. The patients have been studied for the parameters such as age, sex, CD4 count at the time of diagnosis or vaccination, HIV-RNA levels, comorbidities, vaccine dosage, success of immunization after vaccination, and the demographics of the patients who have and have not developed immunity.

RESULTS

Of 645 patients that are being followed-up in our clinics, 158 received hepatitis B vaccine; 39 of these 158 patients have been excluded from the study because they did not fulfil the inclusion criteria. Finally, 119 patients were evaluated in the study, 17 of the patients (14.3%) were females and 102 (85.7%) were males. The median age was 41.11 ± 10.09 (min-max: 18-75). Twenty-three of the patients (19.3%) were at the stage of AIDS during diagnosis while 80.7% were at the stage of HIV infection. Ninety-one of the patients (76.5%) have been administered a single dose hepatitis B vaccine on the standard 0, 1st, 6th month vaccination schedule, whereas 23.5% were administered a double dose on the same vaccination schedule. When further evaluated to find whether the patient was able to develop sufficient immunity (anti-HBs ≥ 10), it was found that the immune response was statistically significantly higher in the patients whose CD4 count was greater than 200 at the time of the first diagnosis and vaccination (p = 0.05 and p = 0.001, respectively). The patients have also been evaluated according to the number of doses they received (1 vs. 2). The immune response of the patients who received two doses was statistically significantly higher (p = 0.041).

CONCLUSION

We can conclude that in the patients with CD4 count less than 200 at the time of their diagnosis and vaccination a high dose recombinant hepatitis B vaccine should definitely be administered as the normal dose and higher dose have similar side effect profiles and the higher dose provides greater immunity.

Long-Term Evaluation of Changes in Kidney Function after Switching from Tenofovir Disoproxil Fumarate to Tenofovir Alafenamide in Patients Living with HIV

Tenofovir is one of the most widely used medications for HIV treatment and is administered as either tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF). Use of TAF is preferred as it is associated with fewer negative impacts on renal function; however, long-term follow-up beyond 96 weeks is limited. A retrospective chart review of patients ≥18 years who received TDF-containing anti-retroviral therapy (ART) for ≥6 months and then switched to a TAF-containing regimen between 1 December 2015 and 1 January 2020 is presented. The primary objective was to evaluate changes in kidney function as measured by eGFR and Scr. The secondary objective was to evaluate changes in lipids. Among the 142 patients identified, the median age was 66 years old with a median follow-up of 3.6 years. The change in kidney function was a median increase in Scr of 0.1 mg/dL and a decrease in eGFR of -8 mL/min/1.73 m². The change in lipid panels at the end of the medication use evaluation endpoint was a decrease in total cholesterol, LDL, HDL, and triglycerides of -2.5, -0.1, -0.6, and -9 mmol/L, respectively. There was no clinically meaningful difference in kidney function as measured by eGFR or Scr, nor was there any clinically meaningful difference in lipid panels in patients switched from TDF to TAF-containing ART. Our observations suggest that the favorable impact of TAF on kidney function is sustained for at least 44 months after conversion from TDF.

A Comparative Analysis of Different HIV Viral Load Suppression Definitions Among Clients Receiving Care in the Miami-Dade Ryan White HIV/AIDS Program

The study's objective was to examine variations in viral load (VL) suppression definitions among clients in the Ryan White Program (RWP). Data from clients enrolled in the RWP during 2017 were examined to calculate the proportion of virally suppressed clients using three definitions: recent viral suppression, defined as having a suppressed VL (< 200 copies/mL) in the last test in 2017; maintained viral suppression, having a suppressed VL for both the first and last tests in 2017; and sustained viral suppression, having all tests in 2017 showing suppression. Relative differences across all three definitions were computed. Recent viral suppression measures were higher than maintained and sustained viral suppression measures by 7.0% and 10.1%, respectively. Significant relative differences in definitions by demographic, socioeconomic and clinical status were observed. It may be beneficial for care planning to report not only estimates of recent viral suppression but maintained and sustained viral suppression as well.

Prevalence of Anal High-Risk Human Papilloma Virus Infection and Abnormal Anal Cytology among Women Living with HIV

Background: Women living with human immunodeficiency virus (HIV), WLWHs, are at high risk of developing anal cancer associated with high-risk human papilloma virus infection (HR-HPV). We analyzed the prevalence of anal HR-HPV infection and abnormal anal cytology in a cohort of WLWHs and assessed the risk factors for anal HR-HPV infection. Methods: We present a single-center, observational cross-sectional study. WLWHs who underwent anal cytology and anal human papilloma virus (HPV) testing were selected. High-resolution anoscopy was performed in cases of abnormal anal cytology. All suspicious lesions were biopsied. A univariate and multivariate logistic regression model was used to analyze risk factors for abnormal anal screening. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Results: In total, 400 WLWHs were studied. Of them, 334 met the eligibility criteria and were enrolled in the study. Abnormal anal cytology was detected in 39.5% of patients, and anal HR-HPV in 40.1%, with HPV 16 in 33 (26.6%) of them. Concomitant HR-HPV cervical infection was the only independent risk factor for HR-HPV anal infection (OR 1.67 95% CI, p < 0.001). Conclusions: WLWHs have a high prevalence of HR-HPV anal infection and anal cytologic abnormalities. HR-HPV cervical infection is the main predictor of HR-HPV anal infection.

The Role of the Social Determinants of Health on Engagement in Physical Activity or Exercise among Adults Living with HIV: A Scoping Review

Physical activity (PA) and exercise are an effective rehabilitation strategy to improve health outcomes among people living with HIV (PLWH). However, engagement in exercise among PLWH can vary. Our aim was to characterize the literature on the role of social determinants of health (SDOH) on engagement in PA or exercise among adults living with HIV. We conducted a scoping review using the Arksey and O'Malley Framework. We searched databases between 1996 and 2021. We included articles that examined PA or exercise among adults with HIV and addressed at least one SDOH from the Public Health Agency of Canada Framework. We extracted data from included articles onto a data extraction charting form, and collated results using content analytical techniques. Of the 11,060 citations, we included 41 articles, with 35 studies involving primary data collection 23 (66%) quantitative, 8 (23%) qualitative, and four (11%) mixed methods. Of the 14,835 participants, 6398 (43%) were women. Gender (n = 24 articles), social support (n = 15), and income and social status (n = 14) were the most commonly reported SDOH in the literature with the majority of studies addressing only one SDOH. Future research should consider the intersection between multiple SDOH to better understand their combined impact on engagement in PA or exercise among PLWH.

Utilization of Recommended Preventive Health Screenings Between Transgender and Cisgender Older Adults in Sexual and Gender Minority Communities

ObjectivesTransgender older adults are among the most health disparate populations in the United States; they also face some of the most significant barriers in accessing high quality, affordable, preventive healthcare services. We compare utilization rates of eight recommended preventive health screenings for adults aged 50 and older, by gender identity. Methods: We analyzed data from 2514 lesbian, gay, bisexual, and transgender adults aged 50 and older, testing associations between gender identities and screening service utilizations by applying a series of multivariate logistic regression analyses, controlling for sociodemographics. Results: Compared to cisgender LGB participants, transgender participants had significantly lower odds to have met four of the recommended screenings. Transgender men had significantly lower odds than transgender women to have met two of the recommended screenings. Discussion: Increasing transgender older adults' access to preventative health screening tests is critical to reduce the health burden in this aging population.

The impact of depression and post-traumatic stress symptoms on physical health perceptions and functional impairment among sexual minority men living with HIV with histories of trauma

Mental health symptoms may compromise health-related quality of life (HRQOL), including among men who have sex with men (MSM) living with HIV, who experience high rates of trauma and other stressors. This study sought to examine the relative contributions of post-traumatic stress disorder (PTSD) symptoms, depression symptoms, and biological indices of HIV disease status on HRQOL in this population. Participants were 79 MSM with HIV (49% White; 35% Black; 8% Hispanic/Latinx) with trauma histories (52% met current PTSD diagnostic criteria). HRQOL outcomes were general perceptions of health (0-100 visual analog scale) and functional disability (WHODAS 2.0). Dominance analysis was applied to examine the relative share of variance in these outcomes accounted for by PTSD symptom severity, depression symptom severity, viral suppression status, and CD4 count. Depression symptom severity accounted for 70% and 92% of variance in perceived health, respectively, across models (p's < 0.05). Both PTSD symptom severity (45%) and depression symptom severity (43%) scores also accounted for significant variance in functional disability (p's < 0.05). Medical indices of HIV disease progression did not explain significant variance in HRQOL in any model. A trauma-informed approach may aid clinicians in interpreting reports of health and physical functioning in MSM with HIV.

Identification of CD8+ T cell subsets that normalize in early-treated people living with HIV receiving antiretroviral therapy

Background

Although combined antiretroviral therapy (cART) has decreased the mortality associated with HIV infection, complete immune reconstitution is not achieved despite viral suppression. Alterations of CD8⁺ T cells and some of their subpopulations, such as interleukin (IL)-17-producing cells, are evidenced in treated individuals and are associated with systemic inflammation and adverse disease outcomes. We sought to evaluate if different CD8⁺ T cell subsets are differentially normalized during a clinical follow-up of people living with HIV (PLWH) receiving suppressive cART.

Methods

We explored the changes in the frequencies, activation/exhaustion phenotypes (HLA-DR, CD38, PD-1, and TIM-3), and function (total and HIV-specific cells expressing CD107a, perforin, granzyme B, interferon [IFN]-γ and IL-17) of CD8⁺ T cells from early-treated PLWH receiving cART in a 1-year follow-up, using a multidimensional flow cytometry approach.

Results

Despite continuous cART-induced viral suppression and recovery of CD4⁺ T cells, after a 1-year follow-up, the CD8⁺ T cell counts, CD4:CD8 ratio, PD-1 expression, and IL-17 production by CD8⁺ T cells exhibited incomplete normalization compared with seronegative controls. However, the proportion of CD8⁺ T cells with an exhausted phenotype (co-expressing PD-1 andTIM-3), and cells co-expressing cytotoxic molecules (Perforin and Granzyme B), reached normalization.

Conclusions

Although suppressive cART achieves normalization of CD4⁺ T cell counts, only particular subsets of CD8⁺ T cells are more rapidly normalized in PLWH receiving cART, which could be routinely used as biomarkers for therapy efficiency in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-022-00465-0.

A comparison of high-grade cervical abnormality risks in women living with and without human immunodeficiency virus undergoing routine cervical-cancer screening

As the US moves increasingly towards using human papillomavirus (HPV) testing with or without concurrent cytology for cervical cancer screening, it is unknown what the corresponding risks are following a screening result for women living with HIV (WLWH), which will dictate the optimal clinical follow-up. Therefore, using medical records data from Kaiser Permanente Northern California, which introduced triennial HPV and cytology co-testing in women aged 30-64 years in 2003, we compared risks of cervical intraepithelial neoplasia grade 2 (CIN2) or more severe diagnoses (CIN2+) in women not known to have HIV (HIV[-] women) (n = 67,488) frequency matched 111:1 on age and year of the first co-test to the 608 WLWH (n = 608). WLWH were more likely to test HPV positive (20.2% vs. 6.5%, p < 0.001) and have non-normal cytology (14.1% vs. 4.1%, p < 0.001) than HIV[-] women. Five-year CIN2+ risks for all WLWH and HIV[-] women were 3.5% (95%CI = 2.0-5.0%) and 1.6% (95%CI = 1.5-1.8%) (p = 0.01), respectively. Five-year CIN2+ risks for WLWH with positive HPV and non-normal cytology, positive HPV and normal cytology, negative HPV and non-normal cytology, and negative HPV and normal cytology were 24.9% (95%CI = 13.4-36.4%), 3.0% (95%CI = 0.0-7.4%), 3.6 (95%CI = 0.0-9.8%) and 0.3% (95%CI = 0.0-0.8%), respectively. Corresponding 5-year CIN2+ risks for HIV[-] women were 26.6% (95%CI = 24.6-28.7%), 8.5% (95%CI = 7.2-9.9%), 1.9% (95%CI = 1.0-2.8%), and 0.5% (95%CI = 0.4-0.6%), respectively. Thus, in this healthcare setting, the main cause in overall CIN2+ risk differences between WLWH and HIV[-] women was the former was more likely to screen positive and once the screening result is known, it may be reasonable to manage both populations similarly.

Postoperative Outcomes following a Multidisciplinary Approach to HIV-positive Breast Cancer Patients

Improvements in human immunodeficiency virus (HIV) treatment resulted in drastic increases in the lifespan of HIV-positive individuals, resulting in higher rates of non-AIDS-defining cancers. We describe our postoperative outcomes in HIV+ breast cancer (BC) patients, highlighting our multidisciplinary experience with this high-risk population.

Tobacco Use and Treatment of Tobacco Dependence Among People With Human Immunodeficiency Virus: A Practical Guide for Clinicians

More than 40% of people with human immunodeficiency virus (PWH) in the United States smoke tobacco cigarettes. Among those on antiretroviral therapy, smoking decreases life expectancy more than human immunodeficiency virus (HIV) itself. Most PWH who smoke want to quit, but tobacco dependence treatment has not been widely integrated into HIV care. This article summarizes the epidemiology of tobacco use among PWH, health consequences of tobacco use and benefits of cessation in PWH, and studies of treatment for tobacco dependence among the general population and among PWH. We provide practical guidance for providers to treat tobacco dependence among PWH. A 3-step Ask-Advise-Connect framework includes asking about tobacco use routinely during clinical encounters, advising about tobacco cessation with emphasis on the benefits of cessation, and actively connecting patients to cessation treatments, including prescription of pharmacotherapy (preferably varenicline) and direct connection to behavioral interventions via telephone quitline or other means to increase the likelihood of a successful quit attempt.

Sero-positivity, risks, and morbidity from Varicella-Zoster Virus (VZV) infections in an adult PWH (people with HIV) cohort from 2000-2020

Background

Varicella-zoster virus (VZV) infection disproportionately affects people with HIV (PWH), primarily presenting as herpes zoster. However, VZV seroprevalence, its association with zoster, and clinical outcomes remain understudied in era of modern antiretroviral therapy (ART). We assessed VZV seroprevalence, rates of VZV illness, and associated health care costs in a large cohort of PWH over 20 years.

Methods

We performed retrospective chart reviews of patients followed at a regional HIV clinic from January 1, 2000, to December 31, 2020. Serological, immunization, clinical, and costing data were extracted from in-house databases. VZV-related inpatient admissions, emergency department (ED), and urgent care (UC) visits were identified using relevant International Classification of Disease (ICD-10) codes and validated where possible by 2 physicians. Health care utilization costs were adjusted to 2020 Canadian dollars.

Results

Of 3006 PWH, VZV serology was available for 2628; of these, 2503 (95.2%) were seropositive. Only 39% of known seronegative patients were subsequently immunized for varicella. During 29 768 years of patient follow-up, 38 hospitalizations and 138 ED/UC visits due to VZV infection were identified. Most occurred in VZV-seropositive PWH <50 years of age (82%) who were unimmunized (99.2%) and not on ART (64.8%). Nearly 25% of hospitalizations were due to laboratory-confirmed VZV meningitis/encephalitis. The average admission cost was CDN$33 001; the total measured cost of VZV illness was CDN$1 258 718.

Conclusions

Despite ART and vaccines for chickenpox and shingles, VZV still caused significant costs and morbidity for PWH, occurring at younger ages and often as encephalitis/meningitis. Supporting ART adherence may reduce VZV illness and hospitalization costs in PWH, and the cost-effectiveness of expanding shingles vaccine use warrants further study.

A Descriptive Analysis of Cancer Screening Health Literacy Among Black Women Living with HIV in Baltimore, Maryland

Background:

Black women living with HIV (WLH) have the highest HIV infection rate, cervical cancer mortality, and the lowest cancer screening use compared to other groups. However, there is a gap in knowledge about cancer screening health literacy in the Black WLH population.

Objective:

The purpose of this study was to assess the level of cancer screening health literacy, and to identify factors associated with health literacy among Black WLH.

Methods:

This study used baseline data from a community-based randomized controlled trial for a health literacy intervention called CHECC-uP (community-based health literacy intervention for cancer control). We recruited a convenience sample of Black WLH (N = 123) who understand English and had no Pap testing in the prior 12 months. The outcome was cancer screening health literacy measured with a validated health literacy tool—Assessment of Health Literacy in Cancer Screening. Predictors included age, marital status, education, income, and insurance type. The association between cancer screening health literacy and predictors was assessed with multivariate logistic regression.

Key Results:

Almost one-half (49.6%) of study participants had a reading level at or below sixth grade. Older age (adjusted odds ratio [aOR] 1.05) and higher educational levels (aOR 5.13) were significantly associated with higher cancer screening health literacy among our sample of Black WLH in bivariate and multivariate analyses.

Conclusions:

Educational materials and other approaches to empower patients should be tested with patients who have low health literacy to ensure efficacy. [HLRP: Health Literacy Research and Practice. 2022;6(3):e175–e181.]

Plain Language Summary:

Using a cancer screening health literacy tool, we found that about one-half of the Black WLH in the study had a reading level at or below sixth grade. Age and education level were related to their reading levels among the women. Researcher and clinicians need to test educational materials and other approaches with patients who have low health literacy to make sure they work.

A Missed Opportunity: Extragenital Screening for Gonorrhea and Chlamydia Sexually Transmitted Infections in People with HIV in a Southeastern Ryan White HIV/AIDS Program Clinic Setting

Background

Guidelines recommend annual screening for gonorrhea/chlamydia in sexually active people with HIV at multiple sites (urogenital, oropharyngeal, rectal). In the first year of multisite screening at our Ryan White HIV/AIDS Program clinic, we studied (1) sexual history documentation rate, (2) sexually transmitted infection (STI) screening rate, (3) characteristics associated with STIs, (4) the percentage of extragenital STIs that would have been missed without multisite screening.

Methods

Participants were ≥14 years old with ≥1 in-person medical visit at our clinic in 2019. Descriptive analyses were performed, and adjusting for number of sites tested, a log-binomial model was used to estimate the association between characteristics and STI diagnosis in men.

Results

In this cohort (n = 857), 21% had no sexual history recorded. Almost all STI diagnoses were among males (99.3%). 68% (253/375) received appropriate urogenital testing, 63% (85/134) received appropriate oropharyngeal testing, and 69% (72/105) received appropriate rectal testing. In male participants with ≥1 STI test (n = 347), Hispanic ethnicity and detectable HIV viral load were associated with an STI diagnosis. Of those diagnosed with an STI who had multisite testing, 96% (n = 25/26) were positive only at an extragenital site.

Conclusions

Screening rates were similar across all anatomical sites indicating no obvious bias against extragenital testing. In males, STIs were more frequently diagnosed in people who identify as Hispanic and those with detectable viral loads which may indicate more condomless sex in these populations. Based on infections detected exclusively at extragenital sites, our clinic likely underdiagnosed STIs prior to implementation of multisite screening.

Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer

BACKGROUND

The incidence of anal cancer is substantially higher among persons living with the human immunodeficiency virus (HIV) than in the general population. Similar to cervical cancer, anal cancer is preceded by high-grade squamous intraepithelial lesions (HSILs). Treatment for cervical HSIL reduces progression to cervical cancer; however, data from prospective studies of treatment for anal HSIL to prevent anal cancer are lacking.

METHODS

We conducted a phase 3 trial at 25 U.S. sites. Persons living with HIV who were 35 years of age or older and who had biopsy-proven anal HSIL were randomly assigned, in a 1:1 ratio, to receive either HSIL treatment or active monitoring without treatment. Treatment included office-based ablative procedures, ablation or excision under anesthesia, or the administration of topical fluorouracil or imiquimod. The primary outcome was progression to anal cancer in a time-to-event analysis. Participants in the treatment group were treated until HSIL was completely resolved. All the participants underwent high-resolution anoscopy at least every 6 months; biopsy was also performed for suspected ongoing HSIL in the treatment group, annually in the active-monitoring group, or any time there was concern for cancer.

RESULTS

Of 4459 participants who underwent randomization, 4446 (99.7%) were included in the analysis of the time to progression to cancer. With a median follow-up of 25.8 months, 9 cases were diagnosed in the treatment group (173 per 100,000 person-years; 95% confidence interval [CI], 90 to 332) and 21 cases in the active-monitoring group (402 per 100,000 person-years; 95% CI, 262 to 616). The rate of progression to anal cancer was lower in the treatment group than in the active-monitoring group by 57% (95% CI, 6 to 80; P = 0.03 by log-rank test).

CONCLUSIONS

Among participants with biopsy-proven anal HSIL, the risk of anal cancer was significantly lower with treatment for anal HSIL than with active monitoring. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT02135419.).

Receipt of Baseline Laboratory Testing Recommended by the HIV Medicine Association for People Initiating HIV Care, United States, 2015-2019

Background

The HIV Medicine Association of the Infectious Disease Society of America publishes Primary Care Guidance for Persons with Human Immunodeficiency Virus. We assessed receipt of recommended baseline tests among newly diagnosed patients initiating HIV care.

Methods

The Medical Monitoring Project is a Centers for Disease Control and Prevention survey designed to produce nationally representative estimates of behavioral and clinical characteristics of adults with diagnosed HIV in the United States. We analyzed data for 725 participants in the 2015–2019 data collection cycles who received an HIV diagnosis within the past 2 years and had ≥1 HIV provider visit. We estimated the prevalence of having recommended tests after the first HIV provider visit and between 3 months before and 3/6 months after the first HIV provider visit and estimated prevalence differences of having 4 combinations of tests by sociodemographic and clinical characteristics.

Results

Within 6 months of care initiation, HIV monitoring tests were performed for 91.3% (95% CI, 88.7%–93.8%) of patients; coinfection blood tests, 27.5% (95% CI, 22.5%–32.4%); site-based STI tests, 59.7% (95% CI, 55.4%–63.9%); and blood chemistry and hematology tests, 50.8% (95% CI, 45.8%–55.8%). Patients who were younger, gay, or bisexual were more likely to receive site-based STI tests, and patients receiving care at Ryan White HIV/AIDS Program (RWHAP)–funded facilities were more likely than patients at non-RWHAP-funded facilities to receive all test combinations.

Conclusions

Receipt of recommended baseline tests among patients initiating HIV care was suboptimal but was more likely among patients at RWHAP-funded facilities. Embedding clinical decision support in HIV provider workflow could increase recommended baseline testing.

Multimorbidity Burden and Incident Heart Failure Among People With and Without HIV: The HIV-HEART Study

Objective

To examine the association between multimorbidity burden and incident heart failure (HF) among people with HIV (PWH) and people without HIV (PWoH).

Patients and Methods

The HIV-HEART study is a retrospective cohort study that included adult PWH and PWoH aged 21 years or older at Kaiser Permanente between 2000 and 2016. Multimorbidity burden was defined by the baseline prevalence of 22 chronic conditions and was categorized as 0-1, 2-3, and 4 or more comorbidities on the basis of distribution of the overall population. People with HIV and PWoH were followed for a first HF event, all-cause death, or up to the end of follow-up on December 31, 2016. Using Cox proportional hazard regression, hazard ratios and 95% CIs were calculated to examine the association between multimorbidity burden and incident HF among PWH and PWoH, separately.

Results

The prevalences of 0-1, 2-3, and 4 or more comorbidities were 83.3%, 13.0%, and 3.7% in PWH (n=38,868), and 82.2%, 14.3%, and 3.5% in PWoH (n=386,586), respectively. After multivariable adjustment, compared with people with 0-1 comorbidities, the hazard ratios of incident HF associated with 2-3 and 4 or more comorbidities were 1.33 (95% CI, 1.04-1.71) and 2.41 (95% CI, 1.78-3.25) in PWH and 2.10 (95% CI, 1.92-2.29) and 4.09 (95% CI, 3.64-4.61) in PWoH, respectively.

Conclusion

Multimorbidity was associated with a higher risk of incident HF among PWH and PWoH, with more prominent associations in PWoH and certain patient subgroups. The identification of specific multimorbidity patterns that contribute to higher HF risk in PWH may lead to future preventative strategies.

Prevention and Initial Management of HIV Infection

Since July 2017, when In the Clinic last addressed management of HIV infection, there have been meaningful improvements in our ability to prevent HIV and to manage patients living with HIV. New approaches to preexposure prophylaxis and more effective treatments have made the elimination of HIV infection a feasible goal. The federal "Ending the HIV Epidemic" initiative aims at a 90% reduction in new HIV diagnoses by 2030. This article provides updated information on how clinicians should use these improvements to manage their patients who are at risk for HIV infection or are newly diagnosed with HIV.

Bacterial Sexually Transmitted Infection Incidence Among Southern Men Who Have Sex With Men With Human Immunodeficiency Virus in the Treatment as Prevention Era, 2014-2019

In this retrospective analysis of men who have sex with men with human immunodeficiency virus (HIV) in the South from 2014 through 2019, incident bacterial sexually transmitted infections (STIs) increased regardless of virologic control. Clinicians should prioritize STI screening and management in primary HIV care.

Access to Medications for Opioid Use Disorder for Persons With Human Immunodeficiency Virus in the United States: Gaps in Coverage by State AIDS Drug Assistance Programs

Life-saving medications for opioid use disorder are inaccessible for people with human immunodeficiency virus relying on the AIDS Drug Assistance Programs (ADAP) in 40% of jurisdictions. Funding/policies should address this through increasing access through ADAP and the Ryan White HIV/AIDS Program (RWHAP), partnerships between RWHAP and substance use programs, and other state/federal initiatives.

Evaluation of the implementation and effectiveness of a mobile health intervention to improve outcomes for people with HIV in the DC Cohort: a study protocol for a cluster randomized controlled trial

Background

Gaps remain in achieving retention in care and durable HIV viral load suppression for people with HIV in Washington, DC (hereafter DC). Although people with HIV seeking care in DC have access to a range of supportive services, innovative strategies are needed to enhance patient engagement in this setting. Mobile health (mHealth) interventions have shown promise in reaching previously underengaged groups and improving HIV-related outcomes in various settings.

Objective

This study will evaluate the implementation and effectiveness of a clinic-deployed, multifeature mHealth intervention called PositiveLinks (PL) among people with HIV enrolled in the DC Cohort, a longitudinal cohort of people with HIV receiving care in DC. A cluster randomized controlled trial will be conducted using a hybrid effectiveness-implementation design and will compare HIV-related outcomes between clinics randomized to PL versus usual care.

Methods

The study aims are threefold: (1) We will perform a formative evaluation of PL in the context of DC Cohort clinics to test the feasibility, acceptability, and usability of PL and tailor the platform for use in this context. (2) We will conduct a cluster randomized controlled trial with 12 DC Cohort clinics randomized to PL or usual care (n=6 [50%] per arm) and measure the effectiveness of PL by the primary outcomes of patient visit constancy, retention in care, and HIV viral load suppression. We aim to enroll a total of 482 participants from DC Cohort clinic sites, specifically including people with HIV who show evidence of inconsistent retention in care or lack of viral suppression. (3) We will use the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to measure implementation success and identify site, patient, provider, and system factors associated with successful implementation. Evaluation activities will occur pre-, mid-, and postimplementation.

Results

Formative data collection was completed between April 2021 and January 2022. Preliminary mHealth platform modifications have been performed, and the first round of user testing has been completed. A preimplementation evaluation was performed to identify relevant implementation outcomes and design a suite of instruments to guide data collection for evaluation of PL implementation throughout the trial period. Instruments include those already developed to support DC Cohort Study activities and PL implementation in other cohorts, which required modification for use in the study, as well as novel instruments designed to complete data collection, as guided by the CFIR and RE-AIM frameworks.

Conclusions

Formative and preimplementation evaluations will be completed in spring 2022 when the trial is planned to launch. Specifically, comprehensive formative data analysis will be completed following data collection, coding, preliminary review, and synthesis. Corresponding platform modifications are ready for beta testing within the DC Cohort. Finalization of the platform for use in the trial will follow beta testing.

Trial Registration

ClinicalTrials.gov NCT04998019; https://clinicaltrials.gov/ct2/show/NCT04998019

International Registered Report Identifier (IRRID)

PRR1-10.2196/37748

Metabolic Consequences of Antiretroviral Therapy

PURPOSE OF REVIEW

This review reports on published studies describing metabolic changes associated with antiretroviral therapy (ART) to treat HIV disease including a historical perspective of earlier ART agents, but with the main focus on newer ART agents currently in use.

RECENT FINDINGS

Studies from different countries around the world have shown that integrase inhibitor (INSTI)-based regimens as well as tenofovir alafenamide (TAF) are associated with weight gain, with women and people of black race at especially high risk. Some studies preliminarily suggest worsened metabolic outcomes associated with this weight gain including adverse effects on glucose homeostasis. Antiretroviral therapy can affect weight, adipose tissue, glucose, and lipids. As obesity is prevalent and increasing among people with HIV, awareness of risk factors for weight gain, including the ART medications associated with greater weight gain, are needed in order to inform prevention efforts. Further research is needed to better understand the long-term health consequences of INSTI- and TAF-associated weight increases.

Screening for Chagas disease should be included in entry-to-care testing for at-risk people with HIV living in the United States

Chagas disease screening of at-risk populations is essential to identify infected individuals and facilitate timely treatment before end-organ damage occurs. Co-infected people with HIV (PWH) are at risk for dangerous sequelae, specifically Trypanosoma cruzi reactivation disease. Recently published national recommendations indicate that at-risk PWH, particularly those from endemic areas or born to women from endemic areas, should be screened via a sensitive anti-T. cruzi IgG assay. However, immunocompromised patients with negative serologic results may warrant further investigation. Reactivation should be suspected in at-risk, untreated PWH with low CD4 cell counts presenting with acute neurologic or cardiac symptoms; these patients should be promptly evaluated and treated. One pragmatic solution to improve Chagas disease screening among PWH and thereby reduce T. cruzi -related morbidity and mortality is to incorporate Chagas disease screening into the panel of tests routinely performed during the entry-to-care evaluation for at-risk PWH.

A global effort to dissect the human genetic basis of resistance to SARS-CoV-2 infection

SARS-CoV-2 infections display tremendous interindividual variability, ranging from asymptomatic infections to life-threatening disease. Inborn errors of, and autoantibodies directed against, type I interferons (IFNs) account for about 20% of critical COVID-19 cases among SARS-CoV-2-infected individuals. By contrast, the genetic and immunological determinants of resistance to infection per se remain unknown. Following the discovery that autosomal recessive deficiency in the DARC chemokine receptor confers resistance to Plasmodium vivax, autosomal recessive deficiencies of chemokine receptor 5 (CCR5) and the enzyme FUT2 were shown to underlie resistance to HIV-1 and noroviruses, respectively. Along the same lines, we propose a strategy for identifying, recruiting, and genetically analyzing individuals who are naturally resistant to SARS-CoV-2 infection.

Gay and Bisexual Men Who Report Anal Sex Stigma Alongside Discomfort Discussing Anal Sex with Health Workers Are Less Likely to Have Ever Received an Anal Examination or Anal Swab

Purpose: We sought to determine whether stigma toward anal sexuality was associated with having ever received an anal examination or anal swab among gay and bisexual men (GBM). Methods: In 2017, we conducted a cross-sectional online survey with 1513 adult cisgender GBM living in the United States. We used structural equation modeling to test whether the Anal Sex Stigma Scales (a validated measure comprising provider stigma, self-stigma, and silence) was negatively associated with lifetime receipt of anorectal examination or anal swabbing by a medical provider. The model assessed mediation by respondents' comfort discussing anal sex practices with health workers and adjusted for possible confounders. Results: As hypothesized, anal sex stigma was associated with less comfort discussing anal sex (β = -0.44, 95% confidence interval [CI]: -0.50 to -0.38, p < 0.001), and greater comfort was associated with greater likelihood of screening (β = 0.28, 95% CI: 0.19 to 0.37, p < 0.001). The model demonstrated good fit (root mean square error of approximation = 0.045, comparative fit index, and Tucker-Lewis index each = 0.99) and adjusted for everyday discrimination, social support specific to anal sex, age, income, education, medical coverage, outness, and ethnic/racial identification. Collectively, model variables accounted for 48% of the variance in screening (p < 0.001). Conclusion: GBM who endorsed less anal sex stigma reported greater comfort discussing anal sex with health workers and were more likely to have ever received anal health screening by a medical provider. To improve anal health and cancer prevention among GBM, anal sex stigma and related discomfort discussing anal sex with health workers are targets for intervention.