Secondary HIV prevention: novel intervention approaches to impact populations most at risk

Clinical Outcomes After Acute Coronary Syndromes or Revascularization Among People Living With HIV: A Systematic Review and Meta-Analysis

Importance

Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately.

Objective

To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group.

Data Sources

Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023.

Study Selection

Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event.

Data Extraction and Synthesis

Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis.

Main Outcome and Measures

The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure.

Results

A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1 531 117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and β-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62).

Conclusions and Relevance

These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.

Management care improvement of people living with HIV: definition of a targeted clinical pathway in a University Hospital of South Italy

BACKGROUND AND AIM

In the world 37,9 billions live with Human Immunodeficiency Virus and, despite the availability of retroviral therapy, they have an higher risk to acquire other infectious diseases and to develop severe complications. According to several guidelines their immunization is crucial but only some center have developed a specific scheduled pathway and vaccination coverage is very low.  Aim of this study is: a)incentivize the active and free of charge offer of vaccines and increase of immunization coverage; b) application and implementation of a shared clinical pathway avoiding reluctance, embarrassment or shame by patients for their condition; d) instauration of an empathic relationship between doctor and patient; e) evaluation of side effects.

METHODS

A prospective study was conducted from October 2019 to February 2020 at the University Hospital G. Martino of Messina. Inclusion criteria were: age over 18; absence of other diseases; absence of immunization against HBV or HAV; CD4 count for live attenuated viral vaccines of 350/uL and for other vaccine 200/uL. A specific scheduled pathway was adopted for every patient. Statistical analysis was performed with Excel software.

RESULTS

86 patients were enrolled (74.4% were males, 79.1% were Italian; mean age=4013.3 SD).  An increase in administration was observed between 2018 and 2019 (+164.3% for flu and for other vaccines +370%).  The higher increase was observed for HPV one. No-one received DTpa, MMRV or Zoster vaccine.

CONCLUSIONS

The undertook clinical pathway showed the relevance of specific management of these patients and the need to increase the vaccination offer.

Computer-based alcohol reduction intervention for alcohol-using HIV/HCV co-infected Russian women in clinical care: study protocol for a randomized controlled trial

BACKGROUND

Russia has a high prevalence of human immunodeficiency virus (HIV) infections. In 2018, over one million persons were living with HIV (PLWH); over a third were women. A high proportion of HIV-infected women are co-infected with hepatitis C virus (HCV), and many consume alcohol, which adversely affects HIV and HCV treatment and prognosis. Despite the triple epidemics of alcohol use, HIV and HCV, and the need for interventions to reduce alcohol use among HIV/HCV co-infected women, evidence-based alcohol reduction interventions for this vulnerable population are limited. To address this gap, we developed a clinical trial to evaluate the efficacy of a computer-based intervention to reduce alcohol consumption among HIV/HCV co-infected women in clinical care.

METHODS

In this two-arm parallel randomized controlled trial, we propose to evaluate the efficacy of a culturally adapted alcohol reduction intervention delivered via a computer for HIV/HCV co-infected Russian women. The study population consists of women 21-45 years old with confirmed HIV/HCV co-infection who currently use alcohol. Intervention efficacy is assessed by a novel alcohol biomarker, ethyl glucuronide (EtG), and biomarkers of HIV and HCV disease progression. Women are randomized to trial conditions in a 1:1 allocation ratio, using a computer-generated algorithm to develop the assignment sequence and concealment of allocation techniques to minimize assignment bias. Women are randomized to either (1) the computer-based alcohol reduction intervention or (2) the standard-of-care control condition. We will use an intent-to-treat analysis and logistic and linear generalized estimating equations to evaluate intervention efficacy, relative to the standard of care, in enhancing the proportion of women with a laboratory-confirmed negative EtG at each research study visit over the 9-month follow-up period. Additional analyses will evaluate intervention effects on HIV (viral load and CD4+ levels) and HCV markers of disease progression (FibroScan).

DISCUSSION

The proposed trial design and analysis provides an appropriate conceptual and methodological framework to assess the efficacy of the computer-based intervention. We propose to recruit 200 participants. The intervention, if efficacious, may be an efficient and cost-effective alcohol reduction strategy that is scalable and can be readily disseminated and integrated into clinical care in Russia to reduce women's alcohol consumption and enhance HIV/HCV prognosis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03362476 . Registered on 5 December 2017.

Evaluation of an HIV prevention intervention for women living with HIV

It is estimated that 23% of the adults and adolescents living with HIV in the United States are female. The Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC) funds evidence-based interventions (EBIs) to reduce HIV risk behaviors, including HIV prevention programs for people living with HIV and their partners. While EBIs have been shown to be effective in controlled research environments, there are limited data on intervention implementation in real-world settings. Women Involved in Life Learning from Other Women (WILLOW) is a four-session small-group intervention that targets heterosexual women aged 18-50 who are living with HIV. This evaluation assessed changes in participants' HIV knowledge, attitudes, beliefs and risk behaviors. A repeated measures design was used to collect participant risk behaviors at baseline, and again at three and six months post-intervention. Changes in attitudes, beliefs, and risk behaviors were assessed using generalized estimating equations. After participation in WILLOW, participants reported increased HIV knowledge, attitudes and beliefs, being more supportive of condom use, and reduced prevalence of HIV risk behaviors. Findings suggest that the WILLOW intervention can be successfully delivered by community-based organizations to reduce HIV risk behaviors among members of this high-risk population.

A Pilot Intervention Trial to Promote Sexual Health and Stress Management Among HIV-Infected Men Who Have Sex with Men

Men who have sex with men (MSM) experience HIV disparities. This study pilot-tested a two session, group-delivered intervention to promote sexual health and stress management skills for HIV-infected MSM. Participants (N = 80) were randomized to an immediate or delayed intervention condition. Analyses of covariance examined intervention efficacy. Compared to the delayed condition, intervention condition participants reported: greater HIV transmission knowledge (p < .001), higher HIV disclosure self-efficacy (p = .004), stronger intentions to refuse unprotected sex (p = .05), decreased frequency of unprotected anal or oral sex (p = .03), decreased perceived stress levels (p = .03), and higher coping self-efficacy (p = .003). Differences in the number of unprotected anal sex episodes, condom attitudes, and level of social support did not differ between conditions. Findings provide evidence of intervention acceptability and suggest the brief intervention may enhance stress management skills and modify sexual risk behavior antecedents for HIV-infected MSM.

Gender Moderates the Association of Depressive Symptoms to Sexual Risk Behavior Among HIV-Positive African-American Outpatients

Previous research has reported an association between depressive symptoms and sexual risk behavior. The purpose of this study was to explore whether gender moderates this association in a sample of HIV-positive African-Americans. Participants (N = 93) self-reported depressive symptoms (Center for Epidemiological Studies-Depression Scale; CES-D), and sexual risk behavior for the past 4 months. Analyses revealed that the depressive symptoms-by-gender interaction was associated with condomless sex and substance use proximal to sex. When analyses were stratified by gender, depressive symptoms were associated with condomless sex and frequency of substance use only for women. We conclude that depressive symptoms may be a more powerful sexual risk factor among women relative to men.

Alcohol Use, Partner Characteristics, and Condom Use Among HIV-Infected Russian Women: An Event-Level Study

OBJECTIVE

Alcohol use is a prominent factor correlated with HIV risk behavior engagement. Hazardous drinking is prevalent among Russian women and may contribute to decreased condom use. Event-based studies suggest that HIV risk behaviors may vary based on situational factors including partner characteristics and alcohol use. This study investigated the effect of situational factors on condom use during the most recent sexual encounter among a sample of HIV-infected Russian women.

METHOD

HIV-infected women (n = 239; mean age = 30.0 years) receiving medical care in St. Petersburg, Russia, completed an audio computer-assisted self-interview that assessed characteristics of their last sexual encounter. Multivariable logistic regression examined the associations between the following situational factors: (a) alcohol use, (b) partner type, (c) partner's serostatus, and (d) partner's alcohol use on whether a condom was used for vaginal and/or anal sex during the last sexual encounter.

RESULTS

A total of 54.0% engaged in unprotected vaginal and/or anal sex during their last sexual encounter. In an adjusted logistic regression model, unprotected sex did not differ by participants' alcohol use (adjusted odds ratio [AOR] = 0.72, 95% CI [0.29, 1.8]) but was more likely with partners who had consumed alcohol (AOR = 2.3, 95% CI [1.1, 5.2]) and HIV-infected partners (AOR = 2.8, 95% CI [1.6, 4.9]) and less likely to occur in the context of nonsteady partnerships (AOR= 0.36, 95% CI [0.13, 0.99]).

CONCLUSIONS

More stable, steady relationships with HIV-infected partners who consumed alcohol were associated with greater likelihood of noncondom use. Results highlight the need to address the intersection of alcohol and sexual risk engagement within the context of HIV-infected women's relationships.

Intimacy versus isolation: a qualitative study of sexual practices among sexually active HIV-infected patients in HIV care in Brazil, Thailand, and Zambia

The success of global treatment as prevention (TasP) efforts for individuals living with HIV/AIDS (PLWHA) is dependent on successful implementation, and therefore the appropriate contribution of social and behavioral science to these efforts. Understanding the psychosocial context of condomless sex among PLWHA could shed light on effective points of intervention. HPTN 063 was an observational mixed-methods study of sexually active, in-care PLWHA in Thailand, Zambia, and Brazil as a foundation for integrating secondary HIV prevention into HIV treatment. From 2010–2012, 80 qualitative interviews were conducted with PLWHA receiving HIV care and reported recent sexual risk. Thirty men who have sex with women (MSW) and 30 women who have sex with men (WSM) participated in equal numbers across the sites. Thailand and Brazil also enrolled 20 biologically-born men who have sex with men (MSM). Part of the interview focused on the impact of HIV on sexual practices and relationships. Interviews were recorded, transcribed, translated into English and examined using qualitative descriptive analysis. The mean age was 25 (SD = 3.2). There were numerous similarities in experiences and attitudes between MSM, MSW and WSM across the three settings. Participants had a high degree of HIV transmission risk awareness and practiced some protective sexual behaviors such as reduced sexual activity, increased use of condoms, and external ejaculation. Themes related to risk behavior can be categorized according to struggles for intimacy and fears of isolation, including: fear of infecting a sex partner, guilt about sex, sexual communication difficulty, HIV-stigma, and worry about sexual partnerships. Emphasizing sexual health, intimacy and protective practices as components of nonjudgmental sex-positive secondary HIV prevention interventions is recommended. For in-care PLWHA, this approach has the potential to support TasP. The overlap of themes across groups and countries indicates that similar intervention content may be effective for a range of settings.

Recent advances (2011-2012) in technology-delivered interventions for people living with HIV

Technology is rapidly advancing and becoming a cost effective option for intervention delivery particularly for isolated and hard to reach populations, such as people living with HIV/AIDS. A systematic review was conducted to identify recent technology based interventions for people living with HIV. The review yielded 12 studies that were grouped by the health behavior that it addressed and then the type of technology utilized. The majority of studies reviewed focused on medication adherence and used several different technologies to deliver the intervention including SMS/text messaging, cell phones and computers. This review identified several gaps in the literature particularly the lack of technology-based interventions focusing on engagement and retention to care as well as sexual risk reduction. Suggestions for future research based on these findings are provided.