Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis

Modeling the HIV epidemic in MSM in Cyprus: reaching only the 95-95-95 cascade of care targets fails to reduce HIV incidence by 90% in 2030

National responses should be improved and accelerated to meet the target of ending the Acquired ImmunoDeficiency Syndrome (AIDS) epidemic by 2030. In the Republic of Cyprus, Men who have Sex with Men (MSM) are disproportionately affected by Human Immunodeficiency Virus (HIV), accounting approximately for half of all annual HIV diagnoses. This study assesses the evolution of HIV incidence in MSM in Cyprus until 2030 using a model calibrated to Cypriot epidemiological data. Four scenarios were examined: status quo, two scenarios focusing on introducing Pre-Exposure Prophylaxis (PrEP), and a 90% HIV incidence reduction scenario. Reaching only the 95-95-95 HIV cascade of care targets among MSM would reduce HIV incidence by 48.6% by 2030 compared to 2015. Initiating a PrEP intervention only for high risk MSM would cause a modest further reduction in HIV incidence. To meet the 90% reduction target, PrEP should be expanded to both high and medium risk MSM and, after 2025, behavioral interventions should be implemented so as high-risk MSM gradually move to the medium-risk category. Cyprus will not reach the HIV incidence reduction target by 2030 unless PrEP is gradually promoted and delivered to all high and medium risk MSM along with awareness and behavioral interventions.

Quantifying the impact of cascade inequalities: a modelling study on the prevention impacts of antiretroviral therapy scale-up in Eswatini

Background

Inequalities in the antiretroviral therapy (ART) cascade across subpopulations remain an ongoing challenge in the global HIV response. Eswatini achieved the UNAIDS 95-95-95 targets by 2020, with differentiated programs to minimize inequalities across subpopulations, including for female sex workers (FSW) and their clients. We sought to estimate additional HIV infections expected in Eswatini if cascade scale-up had not been equal, and under which epidemic conditions these inequalities could have the largest influence.

Methods

Drawing on population-level and FSW-specific surveys in Eswatini, we developed a compartmental model of heterosexual HIV transmission which included eight subpopulations and four sexual partnership types. We calibrated the model to stratified HIV prevalence, incidence, and ART cascade data. Taking observed cascade scale-up in Eswatini as the base-case-reaching 95-95-95 in the overall population by 2020-we defined four counterfactual scenarios in which the population overall reached 80-80-90 by 2020, but where FSW, clients, both, or neither were disproportionately left behind, reaching only 60-40-80. We quantified relative additional cumulative HIV infections by 2030 in counterfactual vs base-case scenarios. We further estimated linear effects of viral suppression gap among FSW and clients on additional infections by 2030, plus effect modification by FSW/client population sizes, rates of turnover, and HIV prevalence ratios.

Results

Compared with the base-case scenario, leaving behind neither FSW nor their clients led to the fewest additional infections by 2030: median (95% credible interval) 14.9 (10.4, 18.4)% vs 26.3 (19.7, 33.0)% if both were left behind-a 73 (40, 149)% increase. The effect of lower cascade on additional infections was larger for clients vs FSW, and both effects increased with population size and relative HIV incidence.

Conclusions

Inequalities in the ART cascade across subpopulations can undermine the anticipated prevention impacts of cascade scale-up. As Eswatini has shown, addressing inequalities in the ART cascade, particularly those that intersect with high transmission risk, could maximize incidence reductions from cascade scale-up.

Cost-effectiveness of the prevention of parent-to-child transmission guidelines of HIV in India

Background

One of the modes of transmission of HIV infection in India is from mother-to-child. In 2014, Prevention of Parent-to-child Transmission (PPTCT) guidelines of HIV in India were implemented which included shifting from Option A to Option B and B+. The aim of the present study was to evaluate health and cost related outcomes after implementation of these new guidelines.

Methods

A decision analytical model was used to compare the PPTCT Option A with the new WHO Option of B and B+. Transmissions in serodiscordant couples and infants at 18 months were considered as health outcomes. The estimation of the cost for PPTCT services and HIV treatment was done using Costing Tool for Elimination Initiatives (CTEI) developed by National Center for Global Health and Medicine (NCGM).

Results

The reduction in transmission rates in HIV infants was 33%. In serodiscordant couples the reduction in risk of HIV transmission from Option A to Option B and B+ was 72% and 87%, respectively. The incremental cost-effectiveness ratio (ICER) per quality adjusted life years (QALY) gained by averting infant infection, and for both infant and partner was US$ 238 and US$ 181 for Option B and US$ 1265 and US$ 947 for Option B+, respectively.

Conclusion

It was found that Options B and B+ are more cost-effective as compared to option A. This effectiveness further increases when prevention of partner infections in Option B and B+ is taken into account.

Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era

Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.

Integrating 'undetectable equals untransmittable' into HIV counselling in South Africa: the development of locally acceptable communication tools using intervention mapping

BACKGROUND

The global campaign for "Undetectable equals Untransmittable" (U = U) seeks to spread awareness of HIV treatment as prevention, aiming to enhance psychological well-being and diminish stigma. Despite its potential benefits, U = U faces challenges in Sub-Saharan Africa, with low awareness and hesitancy to endorse it. We sought to develop a U = U communications intervention to support HIV counselling in primary healthcare settings in South Africa.

METHODS

We used Intervention Mapping (IM), a theory-based framework to develop the "Undetectable and You" intervention for the South African context. The six steps of the IM protocol were systematically applied to develop the intervention including a needs assessment consisting of a systematic review and qualitative research including focus group discussions (FGD) and key informant (KI) interviews. Program objectives and target population were determined before designing the intervention components and implementation plan.

RESULTS

The needs assessment indicated low global U = U awareness, especially in Africa, and scepticism about its effectiveness. Lay counsellors and clinic managers stressed the need for a simple and standardized presentation of U = U addressing both patients' needs for encouragement and modelling of U = U success but also clear guidance toward ART adherence behaviour. Findings from each step of the process informed successive steps. Our final intervention consisted of personal testimonials of PLHIV role models and their partners, organized as an App to deliver U = U information to patients in primary healthcare settings.

CONCLUSIONS

We outline an intervention development strategy, currently in evaluation stage, utilizing IM with formative research and input from key U = U stakeholders and people living with HIV (PLHIV).

Understanding effective post-test linkage strategies for HIV prevention and care: a scoping review

INTRODUCTION

Following HIV testing services (HTS), the World Health Organization recommends prompt linkage to prevention and treatment. Scale-up of effective linkage strategies is essential to achieving the global 95-95-95 goals for maintaining low HIV incidence by 2030 and reducing HIV-related morbidity and mortality. Whereas linkage to care including same-day antiretroviral therapy (ART) initiation for all people with HIV is now routinely implemented in testing programmes, linkage to HIV prevention interventions including behavioural or biomedical strategies, for HIV-negative individuals remains sub-optimal. This review aims to evaluate effective post-HTS linkage strategies for HIV overall, and highlight gaps specifically in linkage to prevention.

METHODS

Using the five-step Arksey and O'Malley framework, we conducted a scoping review searching existing published and grey literature. We searched PubMed, Cochrane Library, CINAHL, Web of Science and EMBASE databases for English-language studies published between 1 January 2010 and 30 November 2023. Linkage interventions included as streamlined interventions-involving same-day HIV testing, ART initiation and point-of-care CD4 cell count/viral load, case management-involving linkage coordinators developing personalized HIV care and risk reduction plans, incentives-financial and non-financial, partner services-including contact tracing, virtual-like social media, quality improvement-like use of score cards, and peer-based interventions. Outcomes of interest were linkage to any form of HIV prevention and/or care including ART initiation.

RESULTS

Of 2358 articles screened, 66 research studies met the inclusion criteria. Only nine linkage to prevention studies were identified (n = 9/66, 14%)-involving pre-exposure prophylaxis, voluntary medical male circumcision, sexually transmitted infection and cervical cancer screening. Linkage to care studies (n = 57/66, 86%) focused on streamlined interventions in the general population and on case management among key populations.

DISCUSSION

Despite a wide range of HIV prevention interventions available, there was a dearth of literature on HIV prevention programmes and on the use of messaging on treatment as prevention strategy. Linkage to care studies were comparatively numerous except those evaluating virtual interventions, incentives and quality improvement.

CONCLUSIONS

The findings give insights into linkage strategies but more understanding of how to provide these effectively for maximum prevention impact is needed.

Molecular epidemiology to aid virtual elimination of HIV transmission in Australia

The Global UNAIDS 95/95/95 targets aim to increase the percentage of persons who know their HIV status, receive antiretroviral therapy, and have achieved viral suppression. Achieving these targets requires efforts to improve the public health response to increase access to care for those living with HIV, identify those yet undiagnosed with HIV early, and increase access to prevention for those most at risk of HIV acquisition. HIV infections in Australia are among the lowest globally having recorded significant declines in new diagnoses in the last decade. However, the HIV epidemic has changed with an increasing proportion of newly diagnosed infections among those born outside Australia observed in the last five years. Thus, the current prevention efforts are not enough to achieve the UNAIDS targets and virtual elimination across all population groups. We believe both are possible by including molecular epidemiology in the public health response. Molecular epidemiology methods have been crucial in the field of HIV prevention, particularly in demonstrating the efficacy of treatment as prevention. Cluster detection using molecular epidemiology can provide opportunities for the real-time detection of new outbreaks before they grow, and cluster detection programs are now part of the public health response in the USA and Canada. Here, we review what molecular epidemiology has taught us about HIV evolution and spread. We summarize how we can use this knowledge to improve public health measures by presenting case studies from the USA and Canada. We discuss the successes and challenges of current public health programs in Australia, and how we could use cluster detection as an add-on to identify gaps in current prevention measures easier and respond quicker to growing clusters. Lastly, we raise important ethical and legal challenges that need to be addressed when HIV genotypic data is used in combination with personal data.

Antifungal Susceptibility and Candida sp. Biofilm Production in Clinical Isolates of HIV-Positive Brazilian Patients under HAART Therapy

The aim of the present study was to characterize biofilms formed by Candida spp. clinical isolates (n = 19), isolated from the oral mucosa of HIV-positive patients. For characterizing the biofilms formed by several Candida sp. strains, isolated from HIV-positive patients, in terms of formed biomass, matrix composition and antifungal susceptibility profile, clinical isolates (n = 19) were collected from oral mucosa and identified. The biofilm of the samples was cultured with fluconazole (1250 mg/L), voriconazole (800 mg/L), anidulafungin (2 mg/L) or amphotericin B (2 mg/L). Afterwards, the quantification of the total biomass was performed using crystal violet assay, while the proteins and carbohydrates levels were quantified in the matrix. The results showed a predominance of C. albicans, followed by C. krusei. Around 58% of the Candida spp. biofilm had susceptibility to fluconazole and voriconazole (800 mg/L), 53% to anidulafungin and 74% to amphotericin B. C. krusei presented both the lowest and the highest biofilm matrix contents in polysaccharides and proteins. The low resistance to antifungal agents reported here was probably due to the fact that none of the participants had a prolonged exposure to these antifungals. A predominance of less virulent Candida spp. strains with low or no resistance to antifungals was observed. This can be attributed to a low fungal selective pressure. This most probably happened due to a low fungal selective pressure but also due to a good adherence to HAART therapy, which guarantees a stable and stronger immune patient response.

Designing effective U = U communication strategies considering the needs of PLHIV, their partners, and healthcare worker constraints in South African clinics

INTRODUCTION

We sought to understand the Undetectable = Untransmittable (U = U) communication needs of persons living with HIV (PLHIV) and barriers to U = U communication among healthcare providers (HCPs) in South Africa.

METHODS

We conducted five focus group discussions (FGDs) with HCPs (N = 42) including nurses and counsellors from primary healthcare clinics (PHCs) in the Gauteng and Free State Provinces of South Africa, three FGDs (N = 27) with PLHIV recruited by snowball sampling from civil society organizations, and 27 in-depth interviews (IDIs) with recently diagnosed PLHIV in Johannesburg. IDIs and FGDs were audio recorded, transcribed, translated to English, and analysed thematically.

RESULTS

PLHIV were largely unaware and sceptical of U = U as the message appeared to contradict the mainstream HIV prevention clinical guidance. The low viral load (VL) knowledge further reduced confidence in U = U. PLHIV need support and guidance on the best approaches for sharing U = U information and disclosing their VL status to their partners, highlighting the central role of community understanding of U = U and VL to mediate the desired stigma reduction, social acceptance and emotional benefits of U = U for PLHIV. HCPs were uneasy about sharing U = U due to concerns about risk compensation and ART non-adherence and worried about enabling any ensuing HIV transmission. HCPs also need a simple, unambiguous, and consistent narrative for U = U, integrated with other HIV prevention messages. PLHIV and HCPs alike recommended a patient-centred approach to communicating U = U, focusing primarily on attaining viral suppression and emphasizing that condomless sex is only safe during periods of ART adherence.

CONCLUSIONS

These data highlight the need for simple U = U communication support targeting both HCP and PLHIV. Culturally appropriate communication materials, with training and ongoing mentorship of the clinic staff, are essential to improve patient-centred U = U communication in clinics.

Trends in Time Spent Viremic Among Persons Newly Diagnosed With HIV in San Francisco

OBJECTIVE

To examine trends in time spent viremic and initiation into antiretroviral treatment (ART) among persons newly diagnosed with HIV in San Francisco.

METHODS

Using HIV surveillance data, we included persons diagnosed with HIV during 2012-2020, a San Francisco resident at HIV diagnosis, alive 12 months after HIV diagnosis, and had ≥2 viral load tests within 12 months after diagnosis. Percent person-time spent (pPT) >200, pPT >1500, and pPT >10,000 copies per milliliter was calculated during the 12 months after HIV diagnosis. Multivariate regression models assessed the year of diagnosis and time spent above each viral threshold and year of diagnosis and ART initiation within 0-7 days (rapid), 8-365 days (delayed), or no ART initiation.

RESULTS

Of 2471 new HIV diagnoses in San Francisco from 2012 to 2020, 1921 (72%) were included. Newly diagnosed persons spent a mean of 40.4% pPT >200, 32.4% pPT >1,500%, and 23.4% pPT >10,000 copies per milliliter; 33.8% had rapid ART initiation, 57.3% delayed, and 9% had no ART initiation. After adjustment, persons diagnosed in years 2014-2015, 2016-2017, 2018-2019, and 2020 were associated with less time spent above all viral thresholds and lower risk of delayed or no ART initiation compared with those diagnosed in 2012-2013. Greater time above thresholds correlated with injection drug use, ages 25-29 and 30-39 years, and homelessness.

CONCLUSIONS

Percent time spent above each viremic level decreased significantly, whereas rapid ART initiation increased among newly diagnosed persons from 2014 through 2020 compared with 2012-2013. Population differences in time spent unsuppressed highlight the need for targeted interventions to reduce new HIV infections and improve health.

Experiences of stigma and HIV care engagement in the context of Treat All in Rwanda: a qualitative study

BACKGROUND

'Treat All' policies recommending immediate antiretroviral therapy (ART) soon after HIV diagnosis for all people living with HIV (PLHIV) are now ubiquitous in sub-Saharan Africa. While early ART initiation and retention is effective at curtailing disease progression and transmission, evidence suggests that stigma may act as a barrier to engagement in care. This study sought to understand the relationships between HIV stigma and engagement in care for PLHIV in Rwanda in the context of Treat All.

METHODS

Between September 2018 and March 2019, we conducted semi-structured, qualitative interviews with adult PLHIV receiving care at two health centers in Kigali, Rwanda. We used a grounded theory approach to data analysis to develop conceptual framework describing how stigma influences HIV care engagement in the context of early Treat All policy implementation in Rwanda.

RESULTS

Among 37 participants, 27 (73%) were women and the median age was 31 years. Participants described how care engagement under Treat All, including taking medications and attending appointments, increased their visibility as PLHIV. This served to normalize HIV and use of ART but also led to high levels of anticipated stigma in the health center and community at early stages of treatment. Enacted stigma from family and community members and resultant internalized stigma acted as additional barriers to care engagement. Nonetheless, participants described how psychosocial support from care providers and family members helped them cope with stigma and promoted continued engagement in care.

CONCLUSIONS

Treat All policy in Rwanda has heightened the visibility of HIV at the individual and social levels, which has influenced HIV stigma, normalization, psychosocial support and care engagement in complex ways. Leveraging the individual and community support described by PLHIV to deliver evidence-based, peer or provider-delivered stigma reduction interventions may aid in attaining Treat All goals.

The long-term impact and value of curative therapy for HIV: a modelling analysis

INTRODUCTION

Curative therapies (CTx) to achieve durable remission of HIV disease without the need for antiretroviral therapy (ART) are currently being explored. Our objective was to model the long-term health and cost outcomes of HIV in various countries, the impact of future CTx on those outcomes and the country-specific value-based prices (VBPs) of CTx.

METHODS

We developed a decision-analytic model to estimate the future health economic impacts of a hypothetical CTx for HIV in countries with pre-existing access to ART (CTx+ART), compared to ART alone. We modelled populations in seven low-and-middle-income countries and five high-income countries, accounting for localized ART and other HIV-related costs, and calibrating variables for HIV epidemiology and ART uptake to reproduce historical HIV outcomes before projecting future outcomes to year 2100. Health was quantified using disability-adjusted life-years (DALYs). Base case, pessimistic and optimistic scenarios were modelled for CTx+ART and ART alone. Based on long-term outcomes and each country's estimated health opportunity cost, we calculated the country-specific VBP of CTx.

RESULTS

The introduction of a hypothetical CTx lowered HIV prevalence and prevented future infections over time, which increased life-years, reduced the number of individuals on ART, reduced AIDS-related deaths, and ultimately led to fewer DALYs versus ART-alone. Our base case estimates for the VBP of CTx ranged from $5400 (Kenya) up to $812,300 (United States). Within each country, the VBP was driven to be greater primarily by lower ART coverage, lower HIV incidence and prevalence, and higher CTx cure probability. The VBP estimates were found to be greater in countries where HIV prevalence was higher, ART coverage was lower and the health opportunity cost was greater.

CONCLUSIONS

Our results quantify the VBP for future curative CTx that may apply in different countries and under different circumstances. With greater CTx cure probability, durability and scale up, CTx commands a higher VBP, while improvements in ART coverage may mitigate its value. Our framework can be utilized for estimating this cost given a wide range of scenarios related to the attributes of a given CTx as well as various parameters of the HIV epidemic within a given country.

Identification of novel inhibitors of Neisseria gonorrhoeae MurI using homology modeling, structure-based pharmacophore, molecular docking, and molecular dynamics simulation-based approach

MurI is one of the most significant role players in the biosynthesis of the peptidoglycan layer in Neisseria gonorrhoeae (Ng). We attempted to highlight the structural and functional relationship between Ng-MurI and D-glutamate to design novel molecules targeting this interaction. The three-dimensional (3D) model of the protein was constructed by homology modeling and the quality and consistency of generated model were assessed. The binding site of the protein was identified by molecular docking studies and a pharmacophore was identified using the interactions of the control ligand. The structure-based pharmacophore model was validated and employed for high-throughput virtual screening and molecular docking to identify novel Ng-MurI inhibitors. Finally, the model was optimized by molecular dynamics (MD) simulations and the optimized model complex with the substrate glutamate and novel molecules facilitated us to confirm the stability of the protein-ligand docked complexes. The 100 ns MD simulations of the potential lead compounds with protein confirmed that the modeled complexes were stable. This study identifies novel potential compounds with good fitness and docking scores, which made the interactions of biological significance within the protein active site. Hence, the identified compounds may act as new leads to design and develop Ng-MurI inhibitors.Communicated by Ramaswamy H. Sarma.

'With this study, we have hope that something is coming': community members' perceptions of HIV cure-related research in Durban, South Africa - a qualitative focus group study

BACKGROUND

Developing a cure for HIV remains a global scientific priority. In 2022, the Females Rising through Education, Support and Health (FRESH) cohort launched an HIV cure-related trial involving an analytical treatment interruption (ATI) in Durban, South Africa.

OBJECTIVES

To explore community perspectives about HIV cure-related research.

METHODS

Between July-August 2022, we conducted three focus groups with community members. We transcribed audio recordings verbatim and used content analysis to analyze the data.

RESULTS

Twenty community members (13 women and 7 men) participated in three focus groups (HIV status not included). Participants viewed HIV cure-related research as a way to address the issue of defaulting on (not taking) HIV treatment. Participants expressed hesitancy around ATIs, since these contradict longstanding treatment adherence messages. Participants shared concerns around the risk of side effects from experimental interventions balanced against potential efficacy. They advocated for trial participants to have the right to decide whether to inform their sex partners about their HIV status and ATI participation, rather than research teams making disclosure mandatory. Focus group participants also emphasized the importance of using simple language to explain HIV cure-related research.

CONCLUSIONS

With HIV cure trials set to launch across Africa in the future, there is a critical need to better understand and respond to local community needs and preferences and to adopt this as standard practice prior to regional trial implementation.

2-Hydroxypropyl-β-Cyclodextrin Treatment Induces Modest Immune Activation in Healthy Rhesus Macaques

Experimental simian immunodeficiency virus (SIV) infection of Asian macaques is an excellent model for HIV disease progression and therapeutic development. Recent coformulations of nucleoside analogs and an integrase inhibitor have been used for parenteral antiretroviral (ARV) administration in SIV-infected macaques, successfully resulting in undetectable plasma SIV RNA. In a cohort of SIVmac239-infected macaques, we recently observed that administration of coformulated ARVs resulted in an unexpected increase in plasma levels of soluble CD14 (sCD14), associated with stimulation of myeloid cells. We hypothesized that the coformulation solubilizing agent Kleptose (2-hydroxypropyl-β-cyclodextrin [HPβCD]) may induce inflammation with myeloid cell activation and the release of sCD14. Herein, we stimulated peripheral blood mononuclear cells (PBMCs) from healthy macaques with HPβCD from different commercial sources and evaluated inflammatory cytokine production in vitro. Treatment of PBMCs resulted in increased sCD14 release and myeloid cell interleukin-1β (IL-1β) production-with stimulation varying significantly by HPβCD source-and destabilized lymphocyte CCR5 surface expression. We further treated healthy macaques with Kleptose alone. In vivo, we observed modestly increased myeloid cell activation in response to Kleptose treatment without significant perturbation of the immunological transcriptome or epigenome. Our results demonstrate a need for vehicle-only controls and highlight immunological perturbations that can occur when using HPβCD in pharmaceutical coformulations. IMPORTANCE SIV infection of nonhuman primates is the principal model system for assessing HIV disease progression and therapeutic development. HPβCD has recently been incorporated as a solubilizing agent in coformulations of ARVs in SIV-infected nonhuman primates. Although HPβCD has historically been considered inert, recent findings suggest that HPβCD may contribute to inflammation. Herein, we investigate the contribution of HPβCD to healthy macaque inflammation in vitro and in vivo. We observe that HPβCD causes an induction of sCD14 and IL-1β from myeloid cells in vitro and demonstrate that HPβCD stimulatory capacity varies by commercial source. In vivo, we observe modest myeloid cell activation in blood and bronchoalveolar lavage specimens absent systemic immune activation. From our findings, it is unclear whether HPβCD stimulation may improve or diminish immune reconstitution in ARV-treated lentiviral infections. Our results demonstrate a need for vehicle-only controls and highlight immunological perturbations that can occur when using HPβCD in pharmaceutical coformulations.

A process and impact evaluation of a peer-led HIV self-management program

There is evidence that people with HIV (PWH) receive health-related benefits from having peer support and learning self-management skills. This evaluation assessed the effect of The Positive Life Workshop (TPLW)-a 7-session peer-led HIV self-management program-on psychosocial and HIV treatment outcomes. The overall sample included 1360 PWH who completed TPLW during 3/2015-2/2019. Surveys were administered before and after the program, and three months following program completion. Analyses examined changes in outcomes from pre-test to both post-test and 3-month follow-up using non-parametric tests. Subgroup analyses were conducted for 406 participants with ≥ 1 characteristic of the priority population for TPLW (i.e., recent HIV diagnosis, not taking antiretroviral therapy (ART), suboptimal ART adherence, unsuppressed viral load). In the overall sample, there were statistically significant improvements in HIV-related knowledge, social support, patient self-advocacy, and confidence in self-management between pre-test and post-test/3-month follow-up assessment. Analyses for the priority population showed significant increases from pre-test to 3-month follow-up in the proportion of participants who were ≥ 90 % adherent to ART (59-83 %, p < 0.01) and virally suppressed (42 % to 66 %, p < 0.01). The findings suggest the importance of ensuring HIV self-management interventions reach vulnerable populations of PWH who struggle with initiating and maintaining HIV-related health-promoting behaviors.

Implementation and effectiveness of a linkage to HIV care intervention in rural South Africa (ANRS 12249 TasP trial)

BACKGROUND

Timely linkage to care and ART initiation is critical to decrease the risks of HIV-related morbidity, mortality and HIV transmission, but is often challenging. We report on the implementation and effectiveness of a linkage-to-care intervention in rural KwaZulu-Natal, South Africa.

METHODS

In the ANRS 12249 TasP trial on Universal Testing and Treatment (UTT) implemented between 2012-2016, resident individuals ≥16 years were offered home-based HIV testing every six months. Those ascertained to be HIV-positive were referred to trial clinics. Starting May 2013, a linkage-to-care intervention was implemented in both trial arms, consisting of tracking through phone calls and/or home visits to "re-refer" people who had not linked to care to trial clinics within three months of the first home-based referral. Fidelity in implementing the planned intervention was described using Kaplan-Meier estimation to compute conditional probabilities of being tracked and of being re-referred by the linkage-to-care team. Effect of the intervention on time to linkage-to-care was analysed using a Cox regression model censored for death, migration, and end of data follow-up.

RESULTS

Among the 2,837 individuals (73.7% female) included in the analysis, 904 (32%) were tracked at least once, and 573 of them (63.4%) were re-referred. Probabilities of being re-referred was 17% within six months of first referral and 31% within twelve months. Compared to individuals not re-referred by the intervention, linkage-to-care was significantly higher among those with at least one re-referral through phone call (adjusted hazard ratio [aHR] = 1.82; 95% confidence interval [95% CI] = 1.47-2.25), and among those with re-referral through both phone call and home visit (aHR = 3.94; 95% CI = 2.07-7.48).

CONCLUSIONS

Phone calls and home visits following HIV testing were challenging to implement, but appeared effective in improving linkage-to-care amongst those receiving the intervention. Such patient-centred strategies should be part of UTT programs to achieve the UNAIDS 95-95-95 targets.

Insights into HIV-1 Transmission Dynamics Using Routinely Collected Data in the Mid-Atlantic United States

Background: Molecular epidemiological approaches provide opportunities to characterize HIV transmission dynamics. We analyzed HIV sequences and virus load (VL) results obtained during routine clinical care, and individual’s zip-code location to determine utility of this approach. Methods: HIV-1 pol sequences aligned using ClustalW were subtyped using REGA. A maximum likelihood (ML) tree was generated using IQTree. Transmission clusters with ≤3% genetic distance (GD) and ≥90% bootstrap support were identified using ClusterPicker. We conducted Bayesian analysis using BEAST to confirm transmission clusters. The proportion of nucleotides with ambiguity ≤0.5% was considered indicative of early infection. Descriptive statistics were applied to characterize clusters and group comparisons were performed using chi-square or t-test. Results: Among 2775 adults with data from 2014−2015, 2589 (93%) had subtype B HIV-1, mean age was 44 years (SD 12.7), 66.4% were male, and 25% had nucleotide ambiguity ≤0.5. There were 456 individuals in 193 clusters: 149 dyads, 32 triads, and 12 groups with ≥ four individuals per cluster. More commonly in clusters were males than females, 349 (76.5%) vs. 107 (23.5%), p < 0.0001; younger individuals, 35.3 years (SD 12.1) vs. 44.7 (SD 12.3), p < 0.0001; and those with early HIV-1 infection by nucleotide ambiguity, 202/456 (44.3%) vs. 442/2133 (20.7%), p < 0.0001. Members of 43/193 (22.3%) of clusters included individuals in different jurisdictions. Clusters ≥ four individuals were similarly found using BEAST. HIV-1 viral load (VL) ≥3.0 log10 c/mL was most common among individuals in clusters ≥ four, 18/21, (85.7%) compared to 137/208 (65.8%) in clusters sized 2−3, and 927/1169 (79.3%) who were not in a cluster (p < 0.0001). Discussion: HIV sequence data obtained for HIV clinical management provide insights into regional transmission dynamics. Our findings demonstrate the additional utility of HIV-1 VL data in combination with phylogenetic inferences as an enhanced contact tracing tool to direct HIV treatment and prevention services. Trans-jurisdictional approaches are needed to optimize efforts to end the HIV epidemic.

Fee for home delivery and monitoring of antiretroviral therapy for HIV infection compared with standard clinic-based services in South Africa: a randomised controlled trial

BACKGROUND

Home delivery and monitoring of antiretroviral therapy (ART) is convenient, overcomes logistical barriers, and could increase individual ART adherence and viral suppression. With client payment and sufficient health benefits, this strategy could be scalable. The aim of the Deliver Health Study was to test the acceptability and efficacy of a user fee for home ART monitoring and delivery.

METHODS

We conducted a randomised trial, the Deliver Health Study, of a fee for home delivery of ART compared with free clinic ART delivery in South Africa. People with HIV who were 18 years or older and clinically stable (including CD4 count >100 cells per μL and WHO HIV stage 1-3) were randomly assigned to: (1) fee for home delivery and monitoring of ART, including community ART initiation if needed; or (2) clinic-based ART (standard of care). The one-time fee for home delivery (ZAR 30, 60, and 90; equivalent to US$2, 4, 6) was tiered on the basis of participant income. The primary outcomes were recorded fee payment and acceptability assessed via questionnaire. The key virological secondary outcome was viral suppression with the difference between study groups assessed through robust Poisson regression including participants with viral load measured at exit (modified intention-to-treat analysis). This trial is registered on ClinicalTrials.gov (NCT04027153) and is complete, with analyses ongoing.

FINDINGS

From Oct 7, 2019, to Jan 30, 2020, 162 participants were enrolled; 82 were randomly assigned to the fee for home delivery group and 80 to the clinic-based group, with similar characteristics at baseline. Overall, 87 (54%) participants were men, 101 (62%) were on ART, and 98 (60%) were unemployed. In the home delivery group, 40 (49%), 33 (40%), and nine (11%) participants qualified for the ZAR 30, 60, and 90 fee, respectively. Median follow-up was 47 weeks (IQR 43-50) with 96% retention. 80 (98%) participants paid the user fee, with high acceptability and willingness to pay. In the modified intention-to-treat analysis of 155 (96%) participants who completed follow-up, fee for home delivery and monitoring statistically significantly increased viral suppression from 74% to 88% overall (RR 1·21, 95% CI 1·02-1·42); and from 64% to 84% among men (1·31, 1·01-1·71).

INTERPRETATION

Among South African adults with HIV, a fee for home delivery and monitoring of ART significantly increased viral suppression compared with clinic-based ART. Clients' paying a fee for home delivery and monitoring of ART was highly acceptable in the context of low income and high unemployment, and improved health outcomes as a result. Home ART delivery and monitoring, potentially with a user fee to offset costs, should be evaluated as a differentiated service delivery strategy to increase access to care.

FUNDING

National Institutes of Mental Health.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

Could widespread use of antiviral treatment curb the COVID-19 pandemic? A modeling study

BACKGROUND

Despite the development of safe and effective vaccines, effective treatments for COVID-19 disease are still urgently needed. Several antiviral drugs have shown to be effective in reducing progression of COVID-19 disease.

METHODS

In the present work, we use an agent-based mathematical model to assess the potential population impact of the use of antiviral treatments in four countries with different demographic structure and current levels of vaccination coverage: Kenya, Mexico, United States (US) and Belgium. We analyzed antiviral effects on reducing hospitalization and death, and potential antiviral effects on reducing transmission. For each country, we varied daily treatment initiation rate (DTIR) and antiviral effect in reducing transmission (AVT).

RESULTS

Irrespective of location and AVT, widespread antiviral treatment of symptomatic adult infections (20% DTIR) prevented the majority of COVID-19 deaths, and recruiting 6% of all adult symptomatic infections daily reduced mortality by over 20% in all countries. Furthermore, our model projected that targeting antiviral treatment to the oldest age group (65 years old and older, DTIR of 20%) can prevent over 30% of deaths. Our results suggest that early antiviral treatment (as soon as possible after inception of infection) is needed to mitigate transmission, preventing 50% more infections compared to late treatment (started 3 to 5 days after symptoms onset). Our results highlight the synergistic effect of vaccination and antiviral treatment: as the vaccination rate increases, antivirals have a larger relative impact on population transmission. Finally, our model projects that even in highly vaccinated populations, adding antiviral treatment can be extremely helpful to mitigate COVID-19 deaths.

CONCLUSIONS

These results suggest that antiviral treatments can become a strategic tool that, in combination with vaccination, can significantly reduce COVID-19 hospitalizations and deaths and can help control SARS-CoV-2 transmission.

"It comes altogether as one:" perceptions of analytical treatment interruptions and partner protections among racial, ethnic, sex and gender diverse HIV serodifferent couples in the United States

BACKGROUND

Most HIV cure-related studies involve interrupting antiretroviral treatment to assess the efficacy of pharmacologic interventions - also known as analytical treatment interruptions (ATIs). ATIs imply the risk of passing HIV to sexual partners due to the loss of undetectable HIV status. There has been a notable lack of attention paid to perceptions of ATIs among racial, ethnic, sex and gender minorities, and HIV serodifferent couples. These populations are among those most impacted by HIV in the United States. Future HIV cure research paradigms should equitably include considerations from these groups.

METHODS

From August - October 2020, we conducted in-depth interviews with 10 racial, ethnic, sex, and gender minority HIV serodifferent couples in geographically diverse regions of the United States to understand their perspectives about ATIs and partner protection measures to prevent secondary HIV transmissions because of participation in ATI studies. We used framework analysis to analyze the qualitative data.

RESULTS

Of the 10 couples recruited, four identified as a gay couple, two as a gay and bisexual couple, two as a heterosexual couple, one as a gay and queer couple, and one as a queer couple. We found that HIV serodifferent couples in our study viewed ATIs as contradicting HIV treatment adherence messages. Couples expressed discomfort around ATIs in HIV cure research. They were concerned with the return of HIV detectability and worried ATIs might result in secondary HIV transmission. Participants were strongly in favor of using a range of partner protection measures during ATIs that included PrEP, HIV risk reduction counseling, and alternatives for penetrative sex practices. Couples also recommended that sex partners be consulted or involved as part of ATI trials.

CONCLUSIONS

Our findings highlight new potential opportunities and strategies to mitigate risk of HIV transmission during ATIs among key groups historically under-represented in HIV cure research. Findings also underscore the relational aspects of ATI trials. We provide preliminary considerations for planning ATI trials with diverse HIV serodifferent partners. Future studies should continue to explore these issues among other types of partnerships, cultures, and socio-cultural settings.

Sexual and Relationship Benefits of a Safer Conception Intervention Among Men with HIV Who Seek to Have Children with Serodifferent Partners in Uganda

Many men with HIV (MWH) in Uganda desire children, yet seldom receive reproductive counseling related to HIV care. Because men are under engaged in safer conception programming, they miss opportunities to reap the benefits of these programs. The objective of this sub-analysis was to explore the relationship and intimacy benefits of integrating safer conception counseling and strategies into HIV care, an emergent theme from exit interviews with men who participated in a pilot safer conception program and their partners. Twenty interviews were conducted with MWH who desired a child in the next year with an HIV-uninfected/status unknown female partner, and separate interviews were conducted with female partners (n = 20); of the 40 interviews, 28 were completed by both members of a couple. Interviews explored experiences participating in The Healthy Families program, which offered MWH safer conception counseling and access to specific strategies. Data were analyzed using thematic analysis. Three major subthemes or "pathways" to the relationship and intimacy benefits associated with participation in the program emerged: (1) improved dyadic communication; (2) joint decision-making and power equity in the context of reproduction; and (3) increased sexual and relational intimacy, driven by reduced fear of HIV transmission and relationship dissolution. These data suggest that the intervention not only helped couples realize their reproductive goals; it also improved relationship dynamics and facilitated intimacy, strengthening partnerships and reducing fears of separation. Directly addressing these benefits with MWH and their partners may increase engagement with HIV prevention strategies for conception.

The Effect of HIV Programs in South Africa on National HIV Incidence Trends, 2000-2019

BACKGROUND

Recent studies have shown HIV incidence declines at a population level in several African countries. However, these studies have not directly quantified the extent to which incidence declines are attributable to different HIV programs.

METHODS

We calibrated a mathematical model of the South African HIV epidemic to age- and sex-specific data from antenatal surveys, household surveys, and death registration, using a Bayesian approach. The model was also parameterized using data on self-reported condom use, voluntary medical male circumcision (VMMC), HIV testing, and antiretroviral treatment (ART). Model estimates of HIV incidence were compared against the incidence rates that would have been expected had each program not been implemented.

RESULTS

The model estimated incidence in 15-49 year olds of 0.84% (95% CI: 0.75% to 0.96%) at the start of 2019. This represents a 62% reduction (95% CI: 55% to 66%) relative to 2000, a 47% reduction (95% CI: 42% to 51%) relative to 2010, and a 73% reduction (95% CI: 68% to 77%) relative to the incidence that would have been expected in 2019 in the absence of any interventions. The reduction in incidence in 2019 because of interventions was greatest for ART and condom promotion, with VMMC and behavior change after HIV testing having relatively modest impacts. HIV program impacts differed significantly by age and sex, with condoms and VMMC having greatest impact in youth, and overall incidence reductions being greater in men than in women.

CONCLUSIONS

HIV incidence in South Africa has declined substantially since 2000, with ART and condom promotion contributing most significantly to this decline.

Could widespread use of antiviral treatment curb the COVID-19 pandemic? A modeling study

Despite the development of safe and effective vaccines, effective treatments for COVID-19 disease are still desperately needed. Recently, two antiviral drugs have shown to be effective in reducing hospitalizations in clinical trials. In the present work, we use an agent-based mathematical model to assess the potential population impact of the use of antiviral treatments in four countries, corresponding to four current levels of vaccination coverage: Kenya, Mexico, United States (US) and Belgium, with 1.5, 38, 57 and 74% of their populations vaccinated. For each location, we varied antiviral coverage and antiviral effect in reducing viral load (25, 50, 75 or 100% reduction). Irrespective of location, widespread antiviral treatment of symptomatic infections (≥50% coverage) is expected to prevent the majority of COVID-19 deaths. Furthermore, even treating 20% of adult symptomatic infections, is expected to reduce mortality by a third in all countries, irrespective of the assumed treatment efficacy in reducing viral load. Our results suggest that early antiviral treatment is needed to mitigate transmission, with early treatment (within two days of symptoms) preventing 50% more infections compared to late treatment (started on days 3 to 5 after developing symptoms). Our results highlight the synergistic effect of vaccination and antiviral treatment: as vaccination rate increased, antiviral treatment had a bigger impact on overall transmission. These results suggest that antiviral treatments can become a strategic tool that, in combination with vaccination, can significantly control SASRS-CoV-2 transmission and reduce COVID-19 hospitalizations and deaths.

Reducing Disparities: A Virtual Quality Improvement Collaborative Resulted in Better Health Outcomes for 4 Target Populations Disproportionately Affected by HIV

CONTEXT

Although viral suppression rates have recently increased among people with HIV, specific populations still experience disparities in health outcomes, a priority in the national response to end the HIV epidemic.

PURPOSE

The end+disparities ECHO Collaborative, a quality improvement initiative among HIV providers in the United States from June 2018 to December 2019, created virtual communities of practice to measurably increase viral suppression rates in populations disproportionately affected by HIV: men who have sex with men of color, Black/African American and Latina women, youth aged 13 to 24 years, and transgender people.

METHODS

Participating Ryan White HIV/AIDS Program-funded providers prioritized their improvement efforts to focus on one target population and joined virtual affinity sessions with other providers focused on that population for guidance by subject matter experts and exchanges with peer providers. During 9 submission cycles, providers reported their viral suppression data for the preceding 12 months.

MAIN OUTCOME MEASURES

The principal outcome measures were changes in viral suppression rates among 4 target populations and changes in viral suppression gaps compared with the rest of HIV-infected patients served by the same agency.

RESULTS

A total of 90 providers were included in the data analyses with an average of 110 775 reported patients, out of which 19 442 represented the targeted populations. The average viral suppression rates for agency-selected populations increased from 79.2% to 82.3% (a 3.9% increase), while the remaining caseload increased at a lower rate from 84.9% to 86.1% (a 1.4% increase). The viral suppression gap was reduced from 5.7% to 3.8%, a 33.5% reduction. Improvements were found across all target populations.

CONCLUSIONS

The collaborative demonstrated improved health outcomes and reductions in HIV-related health disparities, moving toward ending the HIV epidemic. The model of utilizing low-cost videoconferencing technologies to create virtual communities of learning is well suited to mitigate other disease-related disparities, nationally and abroad.

UK guideline for the use of HIV post-exposure prophylaxis 2021

We present the updated British Association for Sexual Health and HIV (BASHH) guidelines for post-exposure prophylaxis (PEP) to HIV following sexual exposures, occupational exposures and other nonoccupational exposures in the community. This serves as an update to the 2015 BASHH guideline on PEP following sexual exposures and the 2008 Expert Advisory Group on AIDS guidelines on HIV PEP. We aim to provide evidence-based guidance on best clinical practice in the provision, monitoring and support of PEP for the prevention of HIV acquisition following sexual, occupational and other nonoccupational exposures in the community. The guideline covers when to prescribe PEP, what antiretroviral agents to use and how to manage PEP. This includes (i) evidence of PEP efficacy; (ii) evidence relating to individual-level efficacy of antiretroviral therapy to prevent the sexual transmission of HIV; (iii) data on the detectable (transmissible) prevalence of HIV in specific populations; (iv) risk of HIV transmission following different types of sexual and occupational exposure; (v) baseline risk assessment; (vi) drug regimens and dosing schedules; (vii) monitoring PEP; (viii) baseline and follow-up blood-borne virus testing; (ix) the role of PEP within broader HIV prevention strategies, for example, HIV pre-exposure prophylaxis (PrEP). The guideline also covers special scenarios such as PEP in pregnancy, breastfeeding and chronic hepatitis B virus infection, and when PEP should be considered in people using HIV PrEP. The guidelines are aimed at clinical professionals directly involved in PEP provision and other stakeholders in the field. A proforma to assist PEP consultations is included. A public consultation process was undertaken prior to finalizing the recommendations.

Prevalence of HIV-1 drug resistance in Eastern European and Central Asian countries

BACKGROUND

Eastern Europe and Central Asia (EECA) is one of the regions where the HIV epidemic continues to grow at a concerning rate. Antiretroviral therapy (ART) coverage in EECA countries has significantly increased during the last decade, which can lead to an increase in the risk of emergence, transmission, and spread of HIV variants with drug resistance (DR) that cannot be controlled. Because HIV genotyping cannot be performed in these countries, data about HIV DR are limited or unavailable.

OBJECTIVES

To monitor circulating HIV-1 genetic variants, assess the prevalence of HIV DR among patients starting antiretroviral therapy, and reveal potential transmission clusters among patients in six EECA countries: Armenia, Azerbaijan, Belarus, Russia, Tajikistan, and Uzbekistan.

MATERIALS AND METHODS

We analyzed 1071 HIV-1 pol-gene fragment sequences (2253-3369 bp) from patients who were initiating or reinitiating first-line ART in six EECA counties, i.e., Armenia (n = 120), Azerbaijan (n = 96), Belarus (n = 158), Russia (n = 465), Tajikistan (n = 54), and Uzbekistan (n = 178), between 2017 and 2019. HIV Pretreatment DR (PDR) and drug resistance mutation (DRM) prevalence was estimated using the Stanford HIV Resistance Database. The PDR level was interpreted according to the WHO standard PDR survey protocols. HIV-1 subtypes were determined using the Stanford HIV Resistance Database and subsequently confirmed by phylogenetic analysis. Transmission clusters were determined using Cluster Picker.

RESULTS

Analyses of HIV subtypes showed that EECA, in general, has the same HIV genetic variants of sub-subtype A6, CRF63_02A1, and subtype B, with different frequencies and representation for each country. The prevalence of PDR to any drug class was 2.8% in Uzbekistan, 4.2% in Azerbaijan, 4.5% in Russia, 9.2% in Armenia, 13.9% in Belarus, and 16.7% in Tajikistan. PDR to protease inhibitors (PIs) was not detected in any country. PDR to nucleoside reverse-transcriptase inhibitors (NRTIs) was not detected among patients in Azerbaijan, and was relatively low in other countries, with the highest prevalence in Tajikistan (5.6%). The prevalence of PDR to nonnucleoside reverse-transcriptase inhibitors (NNRTIs) was the lowest in Uzbekistan (2.8%) and reached 11.1% and 11.4% in Tajikistan and Belarus, respectively. Genetic transmission network analyses identified 226/1071 (21.1%) linked individuals, forming 93 transmission clusters mainly containing two or three sequences. We found that the time since HIV diagnosis in clustered patients was significantly shorter than that in unclustered patients (1.26 years vs 2.74 years). Additionally, the K103N/S mutation was mainly observed in clustered sequences (6.2% vs 2.8%).

CONCLUSIONS

Our study demonstrated different PDR prevalence rates and DR dynamics in six EECA countries, with worrying levels of PDR in Tajikistan and Belarus, where prevalence exceeded the 10% threshold recommended by the WHO for immediate public health action. Because DR testing for clinical purposes is not common in EECA, it is currently extremely important to conduct surveillance of HIV DR in EECA due to the increased ART coverage in this region.

Antiretroviral Treatment Sharing among Female sex Workers Living with HIV in eThekwini (Durban), South Africa: Drivers and Implications for Treatment Success

In South Africa, 62% of female sex workers (FSW) are estimated to be living with HIV. Qualitative research indicates that FSW share antiretroviral therapy (ART) with peers to surmount treatment barriers. We quantitatively described ART sharing, its correlates, and its relationship with viral suppression (VS) among FSW living with HIV in eThekwini, South Africa. Among FSW on ART (n = 890), 30% ever shared (gave and/or received) ART. Sharing ART was more likely among those with higher levels of alcohol use, illicit drug use, depression severity, and physical/sexual violence in the adjusted model. There was a positive, dose-response relationship between number of pills given to peers in the last 30 days and VS likelihood (aPR: 1.05, 95% CI: 1.02, 1.08; p < 0.01). Giving pills may strengthen peer relationships, which may facilitate ART adherence. ART distribution through peer networks holds promise as a context-appropriate intervention for improving ART adherence among FSW in this setting.

A province-wide HIV initiative to accelerate initiation of treatment-as-prevention and virologic suppression in British Columbia, Canada: a population-based cohort study

BACKGROUND

In 2010, HIV treatment as prevention (TasP), encompassing widespread HIV testing and immediate initiation of free antiretroviral treatment (ART), was piloted under the Seek and Treat for Optimal Prevention of HIV/AIDS initiative (STOP) in British Columbia, Canada. We compared the time from HIV diagnosis to treatment initiation, and from treatment initiation to first virologic suppression, before (2005-2009) and after (2010-2016) the implementation of STOP.

METHODS

In this population-based cohort study, we used longitudinal data of all people living with an HIV diagnosis in BC from 1996 to 2017. We included those aged 18 years or older who had never received ART and had received an HIV diagnosis in the 2005-2016 period. We defined the virologic suppression date as the first date of at least 2 consecutive test results within 4 months with a viral load of less than 200 copies/mL. Negative binomial regression models assessed the effect of STOP on the time to ART initiation and suppression, adjusting for confounders. All p values were 2-sided, and we set the significance level at 0.05.

RESULTS

Participants who received an HIV diagnosis before STOP (n = 1601) were statistically different from those with a diagnosis after STOP (n = 1700); 81% versus 84% were men (p = 0.0187), 30% versus 15% had ever injected drugs (p < 0.0001), and 27% versus 49% had 350 CD4 cells/μL or more at diagnosis (p < 0.0001). The STOP initiative was associated with a 64% shorter time from diagnosis to treatment (adjusted mean ratio 0.36, 95% confidence interval [CI] 0.34-0.39) and a 21% shorter time from treatment to suppression (adjusted mean ratio 0.79, 95% CI 0.73-0.85).

INTERPRETATION

In a population with universal health coverage, a TasP intervention was associated with shorter times from HIV diagnosis to treatment initiation, and from treatment initiation to viral suppression. Our results show accelerating progress toward the United Nations' 90-90-90 target of people with HIV who have a diagnosis, those who are on antiretroviral therapy and those who are virologically suppressed, and support the global expansion of TasP to accelerate the control of HIV/AIDS.

Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa

Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.

Machine Learning Algorithms Using Routinely Collected Data Do Not Adequately Predict Viremia to Inform Targeted Services in Postpartum Women Living With HIV

BACKGROUND

Adherence to antiretroviral treatment (ART) among postpartum women with HIV is essential for optimal health and prevention of perinatal transmission. However, suboptimal adherence with subsequent viremia is common, and adherence challenges are often underreported. We aimed to predict viremia to facilitate targeted adherence support in sub-Saharan Africa during this critical period.

METHODS

Data are from PROMISE 1077BF/FF, which enrolled perinatal women between 2011 and 2014. This analysis includes postpartum women receiving ART per study randomization or country-specific criteria to continue from pregnancy. We aimed to predict viremia (single and confirmed events) after 3 months on ART at >50, >400, and >1000 copies/mL within 6-month intervals through 24 months. We built models with routine clinical and demographic data using the least absolute shrinkage and selection operator and SuperLearner (which incorporates multiple algorithms).

RESULTS

Among 1321 women included, the median age was 26 years and 96% were in WHO stage 1. Between 0 and 24 months postpartum, 42%, 31%, and 28% of women experienced viremia >50, >400, and >1000 copies/mL, respectively, at least once. Across models, the cross-validated area under the receiver operating curve ranged from 0.74 [95% confidence interval (CI): 0.72 to 0.76] to 0.78 (95% CI: 0.76 to 0.80). To achieve 90% sensitivity predicting confirmed viremia >50 copies/mL, 64% of women would be classified as high risk.

CONCLUSIONS

Using routinely collected data to predict viremia in >1300 postpartum women with HIV, we achieved moderate model discrimination, but insufficient to inform targeted adherence support. Psychosocial characteristics or objective adherence metrics may be required for improved prediction of viremia in this population.

Integrating PrEP delivery in public health family planning clinics: a protocol for a pragmatic stepped wedge cluster randomized trial in Kenya

Background

Adolescent girls and young women account for a disproportionate fraction of new HIV infections in Africa and are a priority population for HIV prevention, including provision of pre-exposure prophylaxis (PrEP). Anchoring PrEP delivery to care settings like family planning (FP) services that women already access routinely may offer an efficient platform to reach HIV at-risk women. However, context-specific implementation science evaluation is needed.

Methods

The Family Planning Plus Project is a prospective, pragmatic implementation evaluation, designed as a stepped wedge, cluster randomized trial, at 12 clinics in Kenya. In collaboration with the Kenya Ministry of Health and Kisumu County Department of Health, we will introduce integration of HIV risk screening and PrEP delivery in public health FP clinics. The core multifaceted implementation strategies to integrate PrEP in FP clinics will include: (1) PrEP delivery by existing FP clinic staff, (2) health provider training, (3) PrEP technical assistance to coach and mentor providers, (4) joint supervision with Kisumu County health officials, and (5) stakeholder engagement. All core components of PrEP delivery—including screening for HIV risk, HIV testing, dispensing, adherence and risk reduction counseling, assessment of side effects, and provision of refills, or safety assessment—will be conducted by existing FP clinic staff as part of a standard care service package. The goal is to catalyze sustainable scale-up within existing infrastructures beyond the project. We will rigorously evaluate implementation outcomes and impact, using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, and we will use Organizational Readiness for Implementing Change (ORIC) and the Consolidated Framework for Implementation Science Research (CFIR) to assess readiness to implement and contextual enablers and barriers of implementation, including how clinics innovate efficient delivery systems.

Discussion

Anchoring PrEP delivery to existing FP systems and staffing has tremendous potential to address barriers that women face in accessing HIV prevention and PrEP care, including lack of time, cost, and stigma of visiting a facility solely for HIV prevention. The FP Plus Project will initiate preparation for full-scale and sustainable model of integration of comprehensive HIV prevention services, including PrEP implementation, in public health FP clinics in low-income settings.

Trial registration

Registered with ClinicalTrials.gov on December 14, 2020: NCT04666792

Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana

BACKGROUND

A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake.

METHODS

We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables.

RESULTS

Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.

Determinants of viral load non-suppression among adolescents in Mbale District, Eastern Rural Uganda

BACKGROUND

Adolescents are lagging behind in the "third 95" objective of the Joint United Nations Program on HIV/AIDS requiring 95% of individuals on antiretroviral therapy (ART) to have viral load (VL) suppression. This study aimed to describe factors associated with viral non-suppression among adolescents in Mbale district, Uganda.

METHODS

We conducted a retrospective review of routinely collected HIV programme records. Data such as age, education, ART Regimen, ART duration, WHO Clinical stage, comorbidities, etc., were extracted from medical records for the period January 2018 to December 2018. Descriptive analysis was done for continuous variables using means and frequencies to describe study sample characteristics, and to determine the prevalence of outcome variables. We used logistic regression to assess factors associated with VL non-suppression among adolescents.

RESULTS

The analysis included 567 HIV-infected adolescents, with 300 (52.9%) aged between 13 to 15 years, 335 (59.1%) female, and mean age of 15.6 years (interquartile range [IQR] 13.5-17.8. VL non-suppression was 31.4% (178/567). Male sex (AOR = 1.78, 95% CI 1.06, 2.99; p < 0.01), age 16-19 years (AOR = 1.78, 95% CI 1.06, 2.99; p < 0.05), No formal education (AOR = 3.67, 95% CI 1.48-9.09; p < 0.01), primary education (AOR = 2.23, 95% CI 1.05-2.32; p < 0.01), ART duration of > 12 months to 5 years (AOR = 3.20, 95% CI 1.31-7.82; p < 0.05), ART duration > 5 years (AOR = 3.47, 95% CI 1.39- 8.66; p < 0.01), WHO Clinical Stage II (AOR = 0.48, 95% CI: 0.28, 0.82; p < 0.01), second-line ART regimen (AOR = 2.38, 95% CI 1.53-3.72; p < 0.001) and comorbidities (AOR = 3.28, 95% CI 1.20-9.00; p < 0.05) were significantly associated with viral non-suppression.

CONCLUSIONS

VL non-suppression among adolescents was almost comparable to the national average. VL non-suppression was associated with being male, age 16-19 years, education level, duration on ART therapy, WHO Clinical Staging II, second-line ART regimen, and presence of comorbidities. Adolescent-friendly strategies to improve VL suppression e.g. peer involvement, VL focal persons to identify and actively follow-up non-suppressed adolescents, patient education on VL suppression and demand creation for ART are needed, especially for newly-initiated adolescents and adolescents on ART for protracted periods, to foster attainment of the UNAIDS 95-95-95 targets.

Use of fourth-generation rapid combined antigen and antibody diagnostic tests for the detection of acute HIV infection in a community centre for men who have sex with men, between 2016 and 2019

Objective

To assess the use of fourth-generation rapid diagnostic tests in identifying acute infection of Human Immunodeficiency Virus (HIV).

Methods

BCN Checkpoint promotes sexual health among men who have sex with men (MSM), with a focus on diagnosing HIV early, initiating combined antiretroviral treatment (cART) promptly, and recommending regular repeat testing for those who have tested negative. This cross-sectional study included all test results obtained at the centre between 25 March 2016 and 24 March 2019. The Alere™ HIV Combo (now rebranded to Determine™ HIV Ultra, from Abbott) was used to detect p24 antigen (p24 Ag) and/or immunoglobulin M (IgM) and G (IgG) antibodies to HIV-1/HIV-2 (HIV Ab). Rapid polymerase chain reaction (PCR) confirmatory testing and Western blot (WB) were performed for clients with a positive rapid test result. Confirmed HIV cases were promptly referred to the HIV unit for care and cART prescription.

Results

A total of 12,961 clients attended BCN Checkpoint during the study and 27,298 rapid tests were performed. 450 tests were found to be reactive, of which 430 confirmed as HIV-positive, representing a prevalence of 3.32%. Four confirmed cases (0.93%) were detected as “p24 Ag only”, nine (2.09%) as “both p24 and HIV Ab” and 417 (96.98%) as “HIV Ab only”. The “p24 Ag only” group had a 1-log higher viral load than the other groups and initiated treatment on the following working day. Overall, there were 20 false-positive results (0.07% and 4.44% of total and reactive tests, respectively), of which 10 positive for “p24 Ag only” and 10 for “HIV Ab only”.

Conclusions

Four Acute HIV Infections (AHI), with very high viral loads, have been detected with the “p24 Ag only” while the HIV Ab were still absent. Referral to the HIV unit and initiation of cART on the following working day contributed to improving persons’ health and to reduce HIV transmission chain.

Progress toward HIV elimination goals: trends in and projections of annual HIV testing and condom use in Africa

OBJECTIVES

To estimate trends in and projections of annual HIV testing and condom use at last higher-risk sex and to calculate the probability of reaching key United Nations Programme on AIDS (UNAIDS)'s target.

DESIGN

We included 114 nationally-representative datasets in 38 African countries from Demographic and Health Surveys and Multiple Indicator Cluster Surveys with 1 456 224 sexually active adults age 15-49 from 2003 to 2018.

METHODS

We applied Bayesian mixed effect models to estimate the coverage of annual HIV testing and condom use at last higher-risk sex for every country and year to 2030 and the probability of reaching UNAIDS testing and condom use targets of 95% coverage by 2030.

RESULTS

Seven countries saw downward trends in annual HIV testing and four saw decreases in condom use at higher-risk sex, whereas most countries have upward trends in both indicators. The highest coverage of testing in 2030 is predicted in Swaziland with 92.6% (95% credible interval: 74.5-98.1%), Uganda with 90.5% (72.2-97.2%), and Lesotho with 90.5% (69.4%-97.6%). Meanwhile, Swaziland, Lesotho, and Namibia will have the highest proportion of condom use in 2030 at 85.0% (57.8-96.1%), 75.6% (42.3-93.6%), and 75.5% (42.4-93.2%). The probabilities of reaching targets were very low for both HIV testing (0-28.5%) and condom use (0-12.1%).

CONCLUSIONS

We observed limited progress on annual HIV testing and condom use at last higher-risk sex in Africa and little prospect of reaching global targets for HIV/AIDS elimination. Although some funding agencies are considering withdrawal from supporting Africa, more attention to funding and expanding testing and treatment is needed in this region.

Antiretroviral Therapy Use and HIV Transmission Among Discordant Couples in Nonresearch Settings in Kigali, Rwanda

BACKGROUND

Antiretroviral therapy (ART) efficacy for HIV prevention among discordant couples has been demonstrated in clinical trials. Effectiveness outside of research settings is less well understood.

METHODS

HIV-discordant couples were enrolled in couples' testing and follow-up at 20 government clinics in Kigali from 2010 to 2014. We performed viral linkage analysis on seroconverting couples to determine infection sources (intracouple vs. extracouple). Antiretroviral therapy use in index partners was collected at baseline and during follow-up by self-report with verification of government medical records.

RESULTS

A total of 3777 HIV-discordant couples were identified and followed up at government health clinics. Fifty-four incident HIV infections were identified, of which 36 were confirmed linked to the index partner, 4 were unlinked, and 14 were unknown. Among the 50 linked or unknown transmission pairs, 38% occurred among couples in which the index partner was on ART (HIV incidence rate of 0.63/100 person-years), whereas 62% occurred among couples in which the index partner was not on ART (HIV incidence rate of 5.51/100 person-years; adjusted rate ratio, 6.9). HIV acquisition was higher in women than in men with non-ART using index partners (P < 0.001).

CONCLUSIONS

Couples in a government clinic couples' HIV testing and follow-up program in Rwanda had an 89% reduction in HIV incidence when index partners were using ART, slightly lower than efficacy estimates from randomized trials. Antiretroviral therapy for prevention should be prioritized for key populations including discordant couples identified via couples' voluntary counseling and testing, with increased efforts to improve uptake, adherence, and viral load monitoring.

Early ART Initiation Improves HIV Status Disclosure and Social Support in People Living with HIV, Linked to Care Within a Universal Test and Treat Program in Rural South Africa (ANRS 12249 TasP Trial)

We investigated the effect of early antiretroviral treatment (ART) initiation on HIV status disclosure and social support in a cluster-randomized, treatment-as-prevention (TasP) trial in rural South Africa. Individuals identified HIV-positive after home-based testing were referred to trial clinics where they were invited to initiate ART immediately irrespective of CD4 count (intervention arm) or following national guidelines (control arm). We used Poisson mixed effects models to assess the independent effects of (a) time since baseline clinical visit, (b) trial arm, and (c) ART initiation on HIV disclosure (n = 182) and social support (n = 152) among participants with a CD4 count > 500 cells/mm³ at baseline. Disclosure and social support significantly improved over follow-up in both arms. Disclosure was higher (incidence rate ratio [95% confidence interval]: 1.24 [1.04; 1.48]), and social support increased faster (1.22 [1.02; 1.46]) in the intervention arm than in the control arm. ART initiation improved both disclosure and social support (1.50 [1.28; 1.75] and 1.34 [1.12; 1.61], respectively), a stronger effect being seen in the intervention arm for social support (1.50 [1.12; 2.01]). Besides clinical benefits, early ART initiation may also improve psychosocial outcomes. This should further encourage countries to implement universal test-and-treat strategies.

"What if they are pre-conception? What should we do?": Knowledge, practices, and preferences for safer conception among women living with HIV and healthcare providers in Gaborone, Botswana

Safer conception interventions that address HIV care, treatment, and prevention for HIV-affected couples are increasingly available in sub-Saharan Africa. Botswana, an HIV endemic country, is yet to offer formal safer conception services although universal test-and-treat approaches mean that increasing numbers of young, sexually active people living with HIV will start treatment and likely desire childbearing. In order to advance the safer conception discussion in Botswana, it is necessary to understand the current safer conception knowledge, practices, and preferences of healthcare providers and women living with HIV (WLHIV). We conducted qualitative in-depth interviews with 10 HIV healthcare providers and 10 WLHIV in Gaborone. Interviews were analyzed using a phenomenological approach. Safer conception knowledge was limited and safer conception discussions were rare. Healthcare provider and WLHIV preferences were at odds, with providers preferring WLHIV to initiate safer conception discussions, and WLHIV desiring providers to initiate safer conception discussions. Quotes from women and providers highlight deeper issues about power dynamics, concerns about stigma among women, and provider fears about promoting pregnancy. Providers emphasized the need for guidelines and training in order to improve the provision of safer conception counseling. These findings point to areas where safer conception in Botswana can be improved. Both WLHIV and providers would benefit from having information about a range of safer conception methods and approaches. In addition, since WLHIV felt hesitant about initiating safer conception conversations and feared stigma, and because putting the onus for starting safer conception discussions on women is a reversal of normal roles and power structures, providers must take the lead and routinely initiate fertility desire and safer conception discussions. Assisting healthcare providers with clear safer conception guidelines and training would improve the provision of accurate safer conception counseling and facilitate reproductive choice.

Food insecurity predicts loss to follow-up among people living with HIV in Senegal, West Africa

The goals of this study were to assess retention on antiretroviral therapy (ART) and to identify predictors of loss to follow-up (LTFU) among people living with HIV (PLHIV) in Senegal. HIV-positive individuals presenting for initiation of ART in Dakar and Ziguinchor were enrolled and followed for 12 months. Data were collected using interviews, clinical evaluations, laboratory analyses, chart review, and active patient tracing. Of the 207 individuals enrolled, 70% were female, 32% had no formal education, and 28% were severely food insecure. At the end of the follow-up period, 58% were retained on ART, 15% were deceased, 4% had transferred care, 5% had migrated, and 16% were lost to follow-up. Enrollment in Ziguinchor (OR 2.71 [1.01–7.22]) and severe food insecurity (OR 2.55 [1.09–5.96]) were predictive of LTFU. Sex, age, CD4 count, BMI <18.5, country of birth, marital status, number of children, household size, education, consultation with traditional healers, transportation time, and transportation cost were not associated with LTFU. The strongest predictor of severe food insecurity was lack of formal education (OR 2.75 [1.30–5.80]). Addressing the upstream drivers of food insecurity and implementing strategies to enhance food security for PLHIV may be effective approaches to reduce LTFU and strengthen the HIV care cascade in the region.

Genital Shedding of Human Immunodeficiency Virus Type-1 (HIV) When Antiretroviral Therapy Suppresses HIV Replication in the Plasma

BACKGROUND

During antiretroviral treatment (ART) with plasma HIV RNA below the limit of quantification, HIV RNA can be detected in genital or rectal secretions, termed discordant shedding (DS). We hypothesized that proliferating cells produce virions without HIV replication.

METHODS

ART-naive Peruvians initiating ART were observed for DS over 2 years. HIV env and pol genomes were amplified from DS. Antiretrovirals and cytokines/chemokines concentrations were compared at DS and control time points.

RESULTS

Eighty-two participants had ART suppression. DS was detected in 24/82 (29%) participants: 13/253 (5%) cervicovaginal lavages, 20/322 (6%) seminal plasmas, and 6/85 (7%) rectal secretions. HIV RNA in DS specimens was near the limit of quantification and not reproducible. HIV DNA was detected in 6/13 (46%) DS cervicovaginal lavages at low levels. Following DNase treatment, 5/39 DS specimens yielded HIV sequences, all without increased genetic distances. Women with and without DS had similar plasma antiretroviral levels and DS in 1 woman was associated with inflammation.

CONCLUSIONS

HIV RNA and DNA sequences and therapeutic antiretroviral plasma levels did not support HIV replication as the cause of DS from the genital tract. Rather, our findings infer that HIV RNA is shed due to proliferation of infected cells with virion production.

Modelling the effect of market forces on the impact of introducing human immunodeficiency virus pre-exposure prophylaxis among female sex workers

Pre-exposure prophylaxis (PrEP) to prevent human immunodeficiency virus (HIV) enables female sex workers (FSWs) to protect themselves from HIV without relying on clients using condoms. Yet, because PrEP reduces HIV risk, financial incentives to not use condoms may lead to risk compensation: reductions in condom use and/or increases in commercial sex, and may reduce the price of unprotected sex. In this analysis, we integrate market forces into a dynamic HIV transmission model to assess how risk compensation could change the impact of PrEP among FSWs and clients. We parameterise how sexual behavior may change with PrEP use among FSWs using stated preference data combined with economic theory. Our projections suggest the impact of PrEP is sensitive to risk compensatory behaviors driven by changes in the economics of sex work. Condom substitution could reduce the impact of PrEP on HIV incidence by 55%, while increases in the frequency of commercial sex to counter decreases in the price charged for unprotected sex among PrEP users could entirely mitigate the impact of PrEP. Accounting for competition between PrEP users and nonusers exacerbates this further. Alternative scenarios where increases in unprotected sex among PrEP users are balanced by decreases in non-PrEP users have the opposite effect, resulting in PrEP having much greater impact. Intervention studies need to determine how HIV prevention products may change the economics of sex work and provision of unprotected sex to enable a better understanding of their impact.

Rate of HIV Seroconversion Among Seronegative Male Partners Living with HIV Positive Women in Addis Ababa, Ethiopia, 2019: A Retrospective Cohort Study

Objective

This study aimed to assess rate of HIV seroconversion and predictors among seronegative male partners living with HIV-positive women in Addis Ababa, Ethiopia, 2019.

Methods

Institutional-based retrospective cohort was used to conduct the study. All eligible 227 sample medical records were used for the study. Kaplan–Meier analysis was used to estimate seroconversion time. Cox proportional-hazard regression was used to identify predictor variables.

Results

In this study, 227 seronegative male partners living with HIV-positive women were followed for 60 months retrospectively and 38 (16.7%) seroconversion was observed. The overall seroconversion rate was 6.4 (95%CI: 4.64–8.76) per 100 person-year observation. Time of antiretroviral therapy (ART) initiation, CD4 level, condom use, and having history of pregnancy after being diagnosed as discordant were identified significant predictors of seroconversion.

Conclusion

The risk of HIV transmission from seropositive partner to seronegative partner in a discordant couple is poorly controlled. Seronegative partners in discordant a couple can be seropositive at any time with influence of predictors unless proper protective measures, counseling, and follow-up are given emphasis.

Did sexual behaviour differences between HIV infection and treatment groups offset the preventative biological effects of ART roll-out in Zimbabwe?

Declines in HIV incidence have been slower than expected during the roll-out of antiretroviral treatment (ART) services in sub-Saharan African populations suffering generalized epidemics. Using data from a population-based, open cohort HIV sero-survey (2004-13), we found evidence for initial reductions in sexual activity and multiple sexual partnerships, followed by increases during the period of ART scale-up in areas of high HIV prevalence in Manicaland, east Zimbabwe. Recent population-level increases in condom use were also recorded, but largely reflected high use by the rapidly growing proportion of HIV-infected individuals on treatment. Sexual risk behaviour increased in susceptible uninfected individuals and in untreated (and therefore more infectious) HIV-infected men, which may have slowed the decline in HIV incidence in this area. Intensified primary HIV prevention programmes, together with strengthened risk screening, referral, and support services following HIV testing, could help to maximize the impact of 'test-and-treat' programmes in reducing new infections.

Modelling the impact of an HIV testing intervention on HIV transmission among men who have sex with men in China

OBJECTIVES

An intervention developed through participatory crowdsourcing methods increased HIV self-testing among men who have sex with men [MSM; relative risk (RR) = 1.89]. We estimated the long-term impact of this intervention on HIV transmission among MSM in four cities (Guangzhou, Shenzhen, Jinan and Qingdao).

METHODS

A mathematical model of HIV transmission, testing and treatment among MSM in China was parameterized using city-level demographic and sexual behaviour data and calibrated to HIV prevalence, diagnosis and antiretroviral therapy (ART) coverage data. The model was used to project the HIV infections averted over 20 years (2016-2036) from the intervention to increase self-testing, compared with current testing rates.

RESULTS

Running the intervention once would avert < 2.2% infections over 20 years. Repeating the intervention (RR = 1.89) annually would avert 6.4-10.7% of new infections, while further increases in the self-testing rate (hypothetical RR = 3) would avert 11.7-20.7% of new infections.

CONCLUSIONS

Repeated annual interventions would give a three- to seven-fold increase in long-term impact compared with a one-off intervention. Other interventions will be needed to more effectively reduce the HIV burden in this population.

The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models

Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.

CDC's Community-Based Organization Behavioral Outcomes Project: Perspectives for Researchers, Implementers and Funders

Behavioral interventions have been a crucial tool for the prevention of HIV transmission since early in the epidemic. The Centers for Disease Control and Prevention (CDC) has provided funding for evidence-based behavioral interventions (EBIs) at health departments and community-based organizations (CBOs) since 2004. From 2006 to 2015, CDC funded 25 CBOs to evaluate one or more of seven EBIs designed to prevent HIV through the Community-based Organization Behavioral Outcomes Project (CBOP) as implemented outside of a research setting. For each EBI, CBOP showed that most HIV risk behaviors improved after the intervention, and improvements were similar to those observed in research studies. Our findings show that behavioral interventions can be successfully implemented in real-world settings. Although the focus of HIV prevention has largely shifted toward biomedical interventions in recent years, successful implementation often depends on behavioral components. Lessons from CBOP can inform future efforts to develop and implement behavioral interventions for HIV and other areas of public health.

The Magnitude and Associated Factors of Consistent Condom Utilization Among ART Users in Hawassa City, Sidama, Ethiopia

BACKGROUND

Antiretroviral therapy (ART) introduction has sharply decreased mortality and morbidity rates among HIV-infected patients and resulted in longer and healthier lives among people living with HIV. Hence, the aim of this study is to determine the level of consistent condom use and associated factors among ART users in Hawassa City.

METHODS

Cross-sectional study design triangulated with qualitative phenomenology was used. One hospital and one health center were selected by simple random sampling and proportional to size allocation was used to assign participants to each health facility. Accordingly, 358 study subjects were selected. Adjusted odds ratio (AOR) with 95% confidence interval was used to implicate significant factors. Thematic content analysis was used and narrative report writing with a quote was used to present qualitative data.

RESULTS

The prevalence of consistent condom utilization in this study was 51.4%. Sex (AOR= 4.20, 95% CI: 2.386, 7.41), residence (AOR=3.55, 95% CI: 1.81, 6.99) educational status (AOR=0.4, 95% CI: 0.196, 0.946), perception on ART's does not reduction of HIV transmission (AOR=1.96, 95% CI: 1.12, 3.43), rate of counseling (AOR=0.37, 95% CI: 0.17, 0.84) and use condom to prevent pregnancy (AOR=4.53, 95% CI: 2.11, 9.73) were found to be independent predictors of consistent condom utilization among ART users. Refusal by husbands, decrement in satisfaction, gender difference with more women than men willing to use consistently and religious reasons were factors associated with inconsistent condom utilization in the qualitative study.

CONCLUSION AND RECOMMENDATION

Consistent condom utilization among ART users was low. Sex, residence, educational status, perception towards ART were significantly associated with consistent condom utilization. Moreover, husband refusal, religious reason, decrement in satisfaction on the qualitative study were associated with non-consistent use of a condom. The importance of consistent condom use should be well addressed in HIV/AIDS patients, to prevent transmission and multiple infections of HIV.