Different transmission routes and the risk of advanced HIV disease: A systematic review and network meta-analysis of observational studies

Comprehensive insights into herbal P-glycoprotein inhibitors and nanoformulations for improving anti-retroviral therapy efficacy

The worldwide HIV cases were 39.0 million (33.1-45.7 million) in 2022. Due to genetic variations, HIV-1 is more easily transmitted than HIV-2 and favours CD4 + T cells and macrophages, producing AIDS. Conventional HIV drug therapy has many drawbacks, including adherence issues leading to resistance, side effects that lower life quality, drug interactions, high costs limiting global access, inability to eliminate viral reservoirs, chronicity requiring lifelong treatment, emerging toxicities, and a focus on managing infections. Conventional dosage forms have bioavailability issues due to intestinal P-glycoprotein (P-gp) efflux, which can reduce anti-retroviral drug efficacy and lead to resistance. Use of phyto-constituents with P-gp regulating actions has great benefits for semi-synthetic modification to create formulations with greater bioavailability and reduced toxicity, which improves drug effectiveness. Lipid-based nanocarriers, solid lipid nanoparticles, nanostructured lipid carriers, polymer-based nanocarriers, and inorganic nanoparticles may inhibit P-gp efflux. Employing potent P-gp inhibitors within nanocarriers as a Trojan horse approach can enhance the intracellular accumulation of anti-retroviral drugs (ARDs), which are substrates for efflux transporters. This technique increases oral bioavailability and offers lower-dose options, boosting HIV patient compliance and lowering costs. Molecular docking of the inhibitor with P-gp may anticipate optimum binding and function, allowing drug efflux to be minimised.

Evaluation of factors associated with high advanced HIV disease and mortality in Southwestern China: a retrospective cohort study, 2005-2020

OBJECTIVES

To assess the prevalence, all-cause mortality and determinants of advanced HIV disease (AHD) or severe immunosuppression (SIS) in the rural-urban communities of Southwestern China.

STUDY DESIGN

Retrospective cohort study.

METHOD

Data on HIV/AIDS cases reported in 2005-20 were collected from Case Report System. A binary logistic regression model assessed the risk factors of AHD/SIS prevalence. Survival curves across rural-urban regions were compared using Kaplan-Meier estimates and log-rank tests. Determinants of all-cause mortality were identified using the Cox proportional hazard model.

RESULTS

Among 14,533 newly diagnosed HIV/AIDS patients, 7497 (51.6%) presented with AHD and 2564 (17.6%) with SIS. Compared with urban patients, rural patients had a higher prevalence of AHD (56.7% vs 40.7%) and SIS (20.1% vs 12.4%), all-cause mortality (AHD 12.3 vs 5.6, SIS 16.3 vs 5.5, per 100 person-years). Their 5-year survival probability (AHD 59.5% vs 77.1%; SIS 54.4% vs 76.3%) and mean survival time (AHD 106.5 vs 140.6 months, SIS 95.3 vs 144.2 months, p < 0.0001) were lower. Rural patients had an increased risk of SIS prevalence (adjusted odds ratios 1.45, 95% confidence interval [CI] 1.28-1.64; p < 0.0001) and mortality of the total cohort (adjusted hazard ratios 1.41, 95% CI 1.29-1.55; p < 0.0001), AHD cohort (1.38, 1.24-1.54; p < 0.0001), and SIS cohort (1.49, 1.23-1.81; p < 0.0001).

CONCLUSIONS

A high prevalence of AHD/SIS was a severe phenomenon that caused high mortality in rural areas. A regional point-of-care strategy targeting AHD/SIS detection and management is essential for reducing the mortality risk.

Advanced HIV disease and associated attrition after re-engagement in HIV care in Myanmar from 2003 to 2019: a retrospective cohort study

BACKGROUND

The burden of advanced HIV disease (AHD) and predictors of outcomes among people living with HIV (PLHIV) re-engaging in care are not well known.

METHODS

We conducted a retrospective cohort study of PLHIV who re-engaged in care after being lost to follow-up (LFU), from 2003 to 2019, in Myanmar. We calculated the incidence rates of attrition after re-engagement and performed Cox regression to identify risk factors for attrition.

RESULTS

Of 44 131 PLHIV who started antiretroviral treatment, 12 338 (28.0%) were LFU at least once: 7608 (61.6%) re-engaged in care, 4672 (61.4%) with AHD at re-engagement. The death and LFU rates were 2.21-fold (95% CI 1.82 to 2.67) and 1.46-fold (95% CI 1.33 to 1.61) higher among patients who re-engaged with AHD (p>0.001). Death in patients who re-engaged with AHD was associated with male sex (adjusted HR [aHR] 2.63; 95% CI 1.31 to 5.26; p=0.006), TB coinfection (aHR 2.26; 95% CI 1.23 to 4.14; p=0.008) and sex work (aHR 7.49, 95% CI 2.29 to 22.52; p<0.001). History of intravenous drug use was identified as a predictor of being LFU.

CONCLUSIONS

Re-engagement in HIV care in Myanmar is frequent and those who re-engage carry a high burden of AHD. As AHD at re-engagement is associated with higher attrition rates, implementation of differentiated interventions that enable earlier linkage to care and prompt identification and management of AHD in this population is necessary.

Health inequalities in infectious diseases: a systematic overview of reviews

OBJECTIVES

The aim of this systematic overview of reviews was to synthesise available evidence on inequalities in infectious disease based on three dimensions of inequalities; inclusion health groups, protected characteristics and socioeconomic inequalities.

METHODS

We searched MEDLINE, Embase, Web of Science and OpenGrey databases in November 2021. We included reviews published from the year 2000 which examined inequalities in the incidence, prevalence or consequences of infectious diseases based on the dimensions of interest. Our search focused on tuberculosis, HIV, sexually transmitted infections, hepatitis C, vaccination and antimicrobial resistance. However, we also included eligible reviews of any other infectious diseases. We appraised the quality of reviews using the Assessment of Multiple Systematic Reviews V.2 (AMSTAR2) checklist. We conducted a narrative data synthesis.

RESULTS

We included 108 reviews in our synthesis covering all the dimensions of inequalities for most of the infectious disease topics of interest, however the quality and volume of review evidence and consistency of their findings varied. The existing literature reviews provide strong evidence that people in inclusion health groups and lower socioeconomic status are consistently at higher risk of infectious diseases, antimicrobial resistance and incomplete/delayed vaccination. In the protected characteristics dimension, ethnicity, and sexual orientation are important factors contributing to inequalities across the various infectious disease topics included in this overview of reviews.

CONCLUSION

We identified many reviews that provide evidence of various types of health inequalities in different infectious diseases, vaccination, and antimicrobial resistance. We also highlight areas where reviews may be lacking. The commonalities in the associations and their directions suggest it might be worth targeting interventions for some high risk-groups that may have benefits across multiple infectious disease outcomes rather than operating purely in infectious disease siloes.

Determinants of therapy failure among adults on first-line antiretroviral therapy in Asmara, Eritrea: a multicenter retrospective matched case-control study

BACKGROUND

Information on treatment failure (TF) in People living with HIV in a data-poor setting is necessary to counter the epidemic of TF with first-line combined antiretroviral therapies (cART) in sub-Saharan Africa (SSA). In this study, we examined the risk factors associated with TF in Asmara, Eritrea from 2001 to 2020.

METHODS

A multicenter, retrospective 1:2 matched (by age and gender) case-control study was conducted in four major hospitals in Asmara, Eritrea on adults aged ≥ 18 years who were on treatment for at least 6 months. Cases were patients who fulfills at least one of the WHO therapy failure criterion during the study period. Controls were randomly selected patients on first-line treatment and plasma viral load < 1000 copies/ml in their latest follow-up measurement. Multivariable logistic regression analysis was conducted to identify risk factors for TF. All P-values were 2-sided and the level of significance was set at P < 0.05 for all analyses.

RESULTS

Of the 1068 participants (356 cases; 712 controls), 585 (54.7%) were females. The median age at treatment initiation was 46 years [interquartile range (IQR): 39-51]. Median time to combined antiretroviral therapy (cART) failure was 37 months (IQR = 24-47). In the multivariate analysis, factors associated with increased likelihood of TF included initial nucleoside reverse transcriptase inhibitors (NRTI) backbone (Zidovudine + Lamivudine (AZT + 3TC): adjusted odds ratio (aOR) = 2.70, 95% Confidence interval (CI): 1.65-4.41, P-value < 0.001), (Abacavir + lamivudine (ABC + 3TC): aOR = 4.73, 95%CI: 1.18-18.92, P-value = 0.028], and (Stavudine + Lamivudine (D4T + 3TC): aOR = 5.00; 95% CI: 3.03-8.20, P-value < 0.001) in comparison to Emtricitabine and Tenofovir diproxil fumarate (FTC + TDF). Additional associations included prior exposure to cART (aOR = 2.28, 95%CI: 1.35-3.86; P- value = 0.002), record of sub-optimal drug adherence (aOR = 3.08, 95%CI: 2.22-4.28; P < 0.001), ambulatory/bedridden at presentation (aOR = 1.61, 95%CI: 1.12-4.28; P-value = 0.010), presence of comorbidities (aOR = 2.37; 95%CI: 1.36-4.10, P-value = 0.002), duration of cART (< 5 years: aOR: 5.90; 95% CI: 3.95-8.73, P-value < 0.001), and use of SMX-TMP prophylaxis (aOR = 2.00, 95%CI, 1.44-2.78, P-value < 0.001).

CONCLUSION

Our findings underscore the importance of optimizing cART adherence, diversification of cART regimens, and interventions directed at enhancing early HIV diagnosis, prompt initiations of treatment, and improved patient-focused monitoring of treatment response.

Malaria prevalence in HIV-positive children, pregnant women, and adults: a systematic review and meta-analysis

Background

Malaria in human immunodeficiency virus (HIV)-positive patients is an ever-increasing global burden for human health. The present meta-analysis summarizes published literature on the prevalence of malaria infection in HIV-positive children, pregnant women and adults.

Methods

This study followed the PRISMA guideline. The PubMed, Science Direct, Google Scholar, Scopus and Cochrane databases were searched for relevant entries published between 1 January 1983 and 1 March 2020. All peer-reviewed original papers evaluating the prevalence of malaria among HIV-positive patients were included. Incoherence and heterogeneity between studies were quantified by the I2 index and Cochran’s Q test. Publication and population biases were assessed with funnel plots, and Egger’s regression asymmetry test.

Results

A total of 106 studies were included in this systematic review. The average prevalence of malaria among HIV-positive children, HIV-positive pregnant women and HIV-positive adults was 39.4% (95% confidence interval [CI]: 26.6–52.9), 32.3% (95% CI = 26.3–38.6) and 27.3% (95% CI = 20.1–35.1), respectively. In adult patients with HIV, CD4+ (cluster of differentiation 4) < 200 cells/µl and age < 40 years were associated with a significant increase in the odds of malaria infection (odds ratio [OR] = 1.5, 95% CI = 1.2–1.7 and OR = 1.1, 95% CI = 1–1.3, respectively). Antiretroviral therapy (ART) and being male were associated with a significant decrease in the chance of malaria infection in HIV-positive adults (OR = 0.8, 95% CI = 0.7–0.9 and OR = 0.2, 95% CI = 0.2–0.3, respectively). In pregnant women with HIV, CD4+ count < 200 cells/µl was related to a higher risk for malaria infection (OR = 1.5, 95% CI = 1.1–1.9).

Conclusions

This systematic review demonstrates that malaria infection is concerningly common among HIV-positive children, pregnant women and adults. Among HIV-positive adults, ART medication and being male were associated with a substantial decrease in infection with malaria. For pregnant women, CD4+ count of < 200 cells/µl was a considerable risk factor for malaria infection.

Graphical Abstract

Cultural and religious determinants of HIV transmission: A qualitative study with people living with HIV in Belu and Yogyakarta, Indonesia

As a part of a larger qualitative study to understand HIV-risk factors and impacts on people living with HIV (PLHIV) (52 women and 40 men) in Belu and Yogyakarta, Indonesia, this paper reports the influences of cultural practices and religious beliefs on sexual relationships and behaviours of participants as contributors for HIV transmission. This study was conducted from June to December 2020. Data collection was conducted using one-one-one in-depth interviews. Participants were recruited using the snowball sampling technique. Data analysis was guided by a qualitative data analysis framework. The findings showed that cultural practices in Belu related to the use of bride wealth, managing spousal disputes, marriage, and condom use, influenced spousal relationships and sexual behaviours or practices which contributed to HIV transmission. Javanese cultural practices and expectation of an ‘ideal wife’, Islamic religious beliefs about expected husband-wife relationships, forbidden premarital sex, and the participants’ individual interpretation of their religious beliefs about condom use spousal sexual relations, also influenced spousal sexual relations and behaviours, which supported HIV transmission among the participants. The findings indicate the need for HIV education programs that address cultural practices and religious beliefs for community members and population groups to enhance their understanding about HIV, condom use, and how cultural practices and religious beliefs play a role in HIV transmission. The findings also indicate the need for involvement of religious leaders in HIV education programs to bring insights to people and help them interpret their religious beliefs in health promoting ways. Future studies that explore different aspects of culture and religion which may contribute to HIV transmission are recommended.

Patient characteristics and determinants of CD4 at diagnosis of HIV in Mexico from 2008 to 2017: a 10-year population-based study

BACKGROUND

In 2007-2012 the Mexican government launched the National HIV program and there was a major change in HIV policies implemented in 2013-2018, when efforts focused on prevention, increase in early diagnosis and timely treatment. Still, late HIV diagnosis is a major concern in Mexico due to its association with the development of AIDS development and mortality. Thus, the objectives of this study were to identify the determinants of late HIV diagnosis (i.e. CD4 count less than 200 cells/mm3) in Mexico from 2008 to 2017 and to evaluate the impact of the 2013-2017 National HIV program.

METHODS

Using patient level data from the SALVAR database, which includes 64% of the population receiving HIV care in Mexico, an adjusted logistic model was conducted. Main study outcomes were HIV late diagnosis which was defined as CD4 count less than 200 cells/mm3 at diagnosis.

RESULTS

The study included 106,830 individuals newly diagnosed with HIV and treated in Mexican public health facilities between 2008 and 2017 (mean age: 33 years old, 80% male). HIV late diagnosis decreased from 45 to 43% (P < 0.001) between 2008 and 2012 and 2013-2017 (i.e. before and after the implementation of the 2013-2017 policy). Multivariable logistic regressions indicated that being diagnosed between 2013 and 2017 (odds ratio [OR] = 0.96 [95% Confidence interval [CI] [0.93, 0.98]) or in health facilities specialized in HIV care (OR = 0.64 [95% CI 0.60, 0.69]) was associated with early diagnosis. Being male, older than 29 years old, diagnosed in Central East, the South region of Mexico or in high-marginalized locality increased the odds of a late diagnosis.

CONCLUSIONS

The results of this study indicate that the 2013-2017 National HIV program in Mexico has been marginally successful in decreasing the proportion of individuals with late HIV diagnosis in Mexico. We identified several predictors of late diagnosis which could help establishing health policies. The main determinants for late diagnosis were being male, older than 29 years old, and being diagnosed in a Hospital or National Institute.

A retrospective study of survival and risk factors for mortality among people living with HIV who received antiretroviral treatment in a resource-limited setting

BACKGROUND

The availability and accessibility of effective antiretroviral therapy (ART) for people living with HIV (PLWH) has substantially improved in the past two decades in resource-limited settings. Therefore, evaluation of survival is needed in the current setting.

METHOD

We retrospectively analyzed secondary data of the national AIDS program database from national health security region number 4 among PLWH who were ART-naive between January 2014 and December 2018. All PLWH were followed until December 2019 to evaluate their survival status and possible risk factors related to death.

RESULTS

A total of 42,229 PLWH were identified, of which 14,053 were ART-naive and thus enrolled in the study. Sixty-seven percent were male, the mean ± SD age was 35 ± 12 years, and the median (IQR) baseline CD4 count was 162 (44-353) cells/mm3. Regarding medical care benefits, 46% had a universal health coverage scheme, 34% had a national social security scheme, and 2% had a civil servants medical benefit scheme. A total of 2142 (15%) mortalities occurred during the total follow-up period of 28,254 patient-years. The mortality rate was 7.5 (95% CI 7.2-7.9) per 100 person-years. Survival rates at 1, 2, 3, 4 and 5 years after HIV registration were 88.2% (95% CI 87.6-88.7%), 85.3% (95% CI 84.6-85.9%), 82.9% (95% CI 81.9-83.4%), 81.3% (95% CI 80.5-82.0%) and 75.1% (95% CI 73.5-76.8%), respectively. The Cox proportional hazards model showed that all-cause mortality was associated with a history of ART switching (HR = 7.06, 95% CI 4.53-11.00), major opportunistic infections during ART (HR = 1.93, 95% CI 1.35-2.77), baseline CD4 count ≤ 200 vs. > 500 cells/mm3 (HR = 4.00, 95% CI 1.45-11.11), age ≥ 50 vs. < 30 years (HR = 1.77, 95% CI 1.12-2.78), and receiving nevirapine-based regimens(HR = 1.43, 95% CI 1.04-1.97).

CONCLUSIONS

This study demonstrated the substantial mortality rate over the consecutive 5 years of the follow-up period among PLWH who received ART in a resource-limited setting. Early case finding and prompt initiation of ART as well as continuous HIV care are a cornerstone to improve survival.

Phylodynamic analysis reveals changing transmission dynamics of HIV-1 CRF01_AE in Japan from heterosexuals to men who have sex with men

BACKGROUND

HIV-1 circulating recombinant form (CRF) 01_AE is the second major subtype in Japan. Our previous study indicated that CRF01_AE was predominantly circulating in heterosexuals/injecting drug users (IDUs). With implications of increased CRF01_AE infections among men who have sex with men (MSM), this study sought to investigate whether the transmission dynamics of CRF01_AE infections in Japan have changed.

METHODS

Sequences from 8032 newly diagnosed HIV-1-infected individuals were analysed. For 614 (7.6%) of CRF01_AE cases, clusters were identified and categorised by transmission risks. Median times to the most recent common ancestors (tMRCA) were estimated.

RESULTS

The individuals were predominantly Japanese (64%) and male (72%). MSM became the predominant transmission risk from 2014. Thirty transmission clusters (TCs) and 48 pairs, including 40% of individuals, were identified. MSM were approximately five times more likely to be in a TC compared to heterosexuals, and were the major contributors to TCs. tMRCA data suggest that MSM TCs emerged from 1996 and became predominant around 2000.

CONCLUSIONS

CRF01_AE has spread among MSM, with frequent and continuous cluster formations, and MSM has become the predominant transmission risk. Our study suggested that CRF01_AE transmission has shifted from heterosexuals/IDUs to MSM. Prevention measures targeting key populations should be considered for controlling CRF01_AE spread.

Prevalence of and factors associated with advanced HIV disease among newly diagnosed people living with HIV in Guangdong Province, China

INTRODUCTION

A high proportion of people living with HIV (PLHIV) present for care with advanced HIV disease (AHD), which is detrimental to "90-90-90" targets to end AIDS by 2030. This study aimed to explore the prevalence of and factors related to AHD among newly diagnosed PLHIV in Guangdong Province, China.

METHODS

Newly diagnosed PLHIV were recruited from six cities in Guangdong Province from May 2018 to June 2019. AHD was defined as an initial CD4 count <200 cells/µL or an AIDS-defining event within one month of HIV diagnosis. Data from a questionnaire and the national HIV surveillance system were used to explore the potential factors related AHD.

RESULTS

A total of 400 of 997 newly diagnosed PLHIV were defined as having AHD with a proportion of 40.1%. After adjusting for statistically significant variables in univariate analysis, multivariable logistic regressions showed that individuals aged 30 to 39 years (adjusted odds ratio (aOR) = 1.77, 95% confidence interval (CI): 1.13 to 2.79) and ≥50 years (aOR = 1.98, 95% CI: 1.15 to 3.43) were at a higher risk of AHD than those aged 18 to 29 years. Participants diagnosed by voluntary counselling and testing (VCT) clinics were less likely to have AHD (aOR = 0.67, 95% CI: 0.48 to 0.94) than those diagnosed at medical facilities. Participants who had ever considered HIV testing (aOR = 0.66, 95% CI: 0.45 to 0.98) and who had high social support (aOR = 0.73, 95% CI: 0.55 to 0.97) were at a lower risk of AHD, whereas participants who had HIV-related symptoms within one year before diagnosis were at a higher risk of AHD (aOR = 2.09, 95% CI: 1.58 to 2.77). The most frequent reason for active HIV testing was "feeling sick" (42.4%, 255/601), and the main reason for never considering HIV testing was "never thinking of getting HIV" (74.0%, 542/732).

CONCLUSIONS

Low-risk perception and a lack of awareness of HIV-related symptoms resulted in a high proportion of AHD in Guangdong Province, especially among the elderly, those diagnosed at medical facilities and those with low social support. Strengthening AIDS education and training programmes to scale up HIV testing through provider-initiated testing and counselling in medical facilities and VCT could facilitate early HIV diagnosis.