HIV and women in the USA: what we know and where to go from here

An Integrative Review of the Literature Examining Sexual Relationship Power, Depressive Symptoms, Silencing the Self, and HIV Vulnerability for Women in the United States

ABSTRACT

The purpose of our integrative review was to synthesize the literature examining relationships between depressive symptoms, silencing the self (STS), sexual relationship power (SRP), and HIV vulnerability among women in the United States. Literature searches were conducted through CINAHL, MEDLINE, PsycINFO, SCOPUS, Sociological Abstracts, and SocINDEX. Integrative review methodology of Whittemore and Knafl guided the review process, and 37 articles met inclusion criteria. The Theory of Gender and Power, modified by Wingood and DiClemente, was the guiding framework to organize and synthesize findings. Primary findings suggest that depressive symptoms, STS, and SRP in relationships may individually influence women's vulnerability for acquiring HIV, yet research lags behind. Evidence documenting relationships between these factors is insufficient to draw generalizable conclusions. Findings suggest that the current literature on this topic does not reflect those women most highly affected by HIV and those who identify as African American or Black in the Southeast region of the United States.

Organizational readiness to implement bundled interventions to increase HIV linkage and retention in care and treatment: results from the Black Women First (BWF) initiative

BACKGROUND

Evidence-based and evidence-informed interventions designed to address gaps in the HIV care continuum have the potential to improve HIV care and treatment. However, inadequate organizational readiness can derail intervention uptake, prevent the integration of interventions, and contribute to suboptimal HIV treatment outcomes. This study sought to understand organizational readiness to implement bundled interventions for Black women with HIV and inform facilitators and barriers to implementation.

METHODS

We conducted a mixed methods readiness assessment across 12 sites participating in the Black Women First (BWF) initiative to gauge preparedness to implement bundled interventions. Readiness was assessed using the organizational readiness for implementing change (ORIC) scale, and two open-ended questions examined facilitators and barriers. Associations between participant and organizational level factors were evaluated using linear models with clustering by site at baseline, 6- and 12-months. Pre-implementation interviews were conducted with staff virtually and transcripts were managed in NVivo. Directed content analysis was used to explore implementation barriers and facilitators.

FINDINGS

Sites demonstrated high levels of organizational readiness at baseline; overall organizational readiness for implementing change (ORIC) (mean 56.4, median 59, interquartile range [IQR] 5) and subscales of the ORIC change efficacy (mean 32.4, median 35, IQR 4), change commitment (mean 24, median 25, IQR 1), which is consistent with willingness and capability to implement bundled interventions for Black women with HIV. Organizational readiness remained high at 6- and 12-month follow-up periods. Staff role was significantly associated with organizational readiness (p = 0.007), change efficacy (p = 0.006), and change commitment (p = 0.020) at 6 months. Qualitative analysis indicated strategic planning and assessment (e.g., team coordination and the development of workflows to support implementation); organizational change through network weaving across silos within the organization, and communications systems that engage external partners, as well as resources available for hiring and training, supported readiness. Collaborative leadership and organizational buy-in, staff motivation, and partnerships facilitated implementation processes.

CONCLUSIONS

Organizations in the BWF initiative have high levels of organizational readiness reflecting willingness and capability to implement bundled interventions for Black women with HIV. Future research should examine the relationship between readiness and clinical outcomes.

Missing voices: building women living with HIV's meaningful engagement in HIV clinical and cure research

Women living with HIV are consistently under-represented in HIV clinical trials, including cure trials. Little is known about how cisgender women living with HIV in Australia perceive HIV cure research, their level of trust in research institutions/staff, and factors salient to participation in HIV cure trials. Semi-structured interviews were conducted with women living with HIV and clinicians working with women living with HIV to investigate motivations and barriers to gender-equitable representation in HIV clinical research. Participant motivations for participation included altruistic desires to benefit younger women, and to optimise resulting interventions. Women living with HIV expressed optimism that a cure would dispel HIV-related stigma and brings about substantial material improvement to their lives. Reluctance to participate related to concerns regarding potential side-effects, antiretroviral treatment interruption, and impacts on fertility. Unfamiliarity with trials, confidentiality concerns and logistical difficulties were also cited. Lastly, onerous eligibility criteria, clinicians' assumptions about women's willingness and ability to meaningfully provide consent to participation were cited as barriers which could be addressed. Bolstering women's participation in HIV cure research requires consideration of factors relating to reproductive health, analytical treatment interruption, and recruitment. Engaging women living with HIV in trial design and promotion may help overcome these issues.

HIV, HIV-Specific Factors, and Myocardial Disease in Women

BACKGROUND

People with human immunodeficiency virus (HIV) (PWH) have an increased risk of cardiovascular disease (CVD). Cardiac magnetic resonance (CMR) has documented higher myocardial fibrosis, inflammation, and steatosis in PWH, but studies have mostly relied on healthy volunteers as comparators and focused on men.

METHODS

We investigated the associations of HIV and HIV-specific factors with CMR phenotypes in female participants enrolled in the Women's Interagency HIV Study's New York and San Francisco sites. Primary phenotypes included myocardial native (n) T1 (fibro-inflammation), extracellular volume fraction (fibrosis), and triglyceride content (steatosis). Associations were evaluated with multivariable linear regression, and results pooled or meta-analyzed across centers.

RESULTS

Among 261 women with HIV (WWH, N = 362), 76.2% had undetectable viremia at CMR. For the 82.8% receiving continuous antiretroviral therapy (ART) in the preceding 5 years, adherence was 51.7%, and 69.4% failed to achieve persistent viral suppression (40.7% with peak viral load <200 cp/mL). Overall, WWH showed higher nT1 than women without HIV after full adjustment. This higher nT1 was more pronounced in those with antecedent or current viremia or nadir CD4+ count <200 cells/μL, with the latter also associated with higher extracellular volume fraction. WWH and current CD4+ count <200 cells/μL had less cardiomyocyte steatosis. Cumulative exposure to specific ART showed no associations.

CONCLUSIONS

Compared with sociodemographically similar women without HIV, WWH on ART exhibit higher myocardial fibro-inflammation, which is more prominent with unsuppressed viremia or CD4+ lymphopenia. These findings support the importance of improved ART adherence strategies, along with better understanding of latent infection, to mitigate cardiac end-organ damage in this population.

Keeping it real: A descriptive analysis of HIV testing history, PrEP awareness, and PrEP use among Black cisgender women in Middle Tennessee, 2018

INTRODUCTION

HIV disproportionately affects Black/African American women in the United States, particularly in the southern states, including Tennessee. Despite this, limited research and intervention are targeting this population, especially regarding biomedical prevention technologies such as pre-exposure prophylaxis (PrEP). This study aims to describe the HIV testing history of a sample of Black women in middle Tennessee, assess their awareness and potential for adopting modern HIV prevention technologies like PrEP, and explore the dyadic and social factors that influence their HIV prevention awareness and use.

THEORY

The Precaution Adoption Process Model (PAPM) is employed to understand how individuals progress through decision-making stages when adopting new health behaviors, especially related to novel interventions.

METHODS

For survey development and deployment, this cross-sectional survey study engaged the Nashville Health Disparities Coalition and the Resident Association for the Metropolitan Developmental Housing Association in Nashville. Eligible participants included African American and Black women aged 18 and above. The survey collected demographic information, HIV testing history, reasons for testing or not testing, dyadic HIV risk factors, awareness, and use of rapid HIV testing and PrEP, and social norms related to these prevention technologies.

RESULTS AND DISCUSSION

Age significantly influenced HIV testing history, emphasizing the importance of regular screening, especially among older women. Dyadic factors such as concurrency and having a shared male partner were associated with differences in testing behavior. Awareness of both rapid HIV testing and PrEP was limited among participants, highlighting the need for increased education and awareness campaigns specifically highlighting benefits to Black women. Social norms, particularly recommendations from healthcare providers, played a crucial role in influencing women's willingness to adopt these prevention technologies. [Increasing routine HIV testing and awareness of PrEP, especially among women in non-monogamous relationships, is essential in reducing HIV disparities among Black women.] IMPLICATIONS: Healthcare providers play a crucial role in initiating and recommending HIV testing and PrEP among Black women, emphasizing the importance of patient-provider relationships and ongoing conversations about prevention strategies. This study underscores the importance of community-engaged research in addressing HIV disparities and highlights the potential for partnerships between medical centers and community organizations in the fight against HIV.

CDC Prioritizes HIV Prevention and Treatment to Reduce HIV Disparities Among Cis-Gender Black Women

To succeed in ending the HIV epidemic in the United States, the Centers for Disease Control and Prevention (CDC) focuses on delivering combinations of scientifically proven, cost-effective, and scalable interventions to priority populations. Systemic factors continue to contribute to persistent health disparities and disproportionately higher rates of HIV diagnosis in some communities. The National HIV/AIDS Strategy has designated cis-gender Black women (CgBW) as a priority population to address the racial and ethnic inequities in HIV. This report presents the portfolio of projects, programs, and initiatives funded by the CDC's Division of HIV Prevention (DHP) to address disparities in HIV and improve health and QOL among CgBW. These funded activities include the development, planning, and implementation of HIV prevention programs, mass media campaigns, and behavioral interventions focused on CgBW. This report also summarizes DHP's community engagement, capacity building, and partnership efforts, and highlights research and surveillance activities focusing on CgBW. Finally, this report outlines future directions for CDC's efforts to improve access to HIV testing, treatment, and prevention for CgBW in the United States.

Hospital readmissions among adults living with and without HIV in the US: findings from the Nationwide Readmissions Database

Background

Thirty-day hospital readmission measures quality of care, but there are limited data among people with HIV (PWH) and people without HIV (PWoH) in the era of universal recommendation for antiretroviral therapy. We descriptively compared 30-day all-cause, unplanned readmission risk between PWH and PWoH.

Methods

A retrospective cohort study was conducted using the 2019 Nationwide Readmissions Database (2019/01/01-2019/12/31), an all-payer database that represents all US hospitalizations. Index (initial) admissions and readmissions were determined using US Centers for Medicare & Medicaid Services definitions. Crude and age-adjusted risk ratios (aRR) comparing the 30-day all-cause, unplanned readmission risk between PWH to PWoH were estimated using random effect logistic regressions and predicted marginal estimates. Survey weights were applied to all analyses.

Findings

We included 24,338,782 index admissions from 18,240,176 individuals. The median age was 52(IQR = 40-60) years for PWH and 61(IQR = 38-74) years for PWoH. The readmission risk was 20.9% for PWH and 12.2% for PWoH (age-adjusted-RR:1.88 [95%CI = 1.84-1.92]). Stratified by age and sex, young female (age 18-29 and 30-39 years) PWH had a higher readmission risk than young female PWoH (aRR = 3.50 [95%CI = 3.11-3.88] and aRR = 4.00 [95%CI = 3.67-4.32], respectively). While the readmission risk increased with age among PWoH, the readmission risk was persistently high across all age groups among PWH. The readmission risk exceeded 30% for PWH admitted for hypertensive heart disease, heart failure, and chronic kidney disease.

Interpretation

PWH have a disproportionately higher risk of readmission than PWoH, which is concerning given the aging profile of PWH. More efforts are needed to address readmissions among PWH.

Funding

US National Institutes of Health.

Sexual and Reproductive Justice and Health Equity for LGBTQ+ Women

LGBTQ+ women have long been overlooked in sexual and reproductive health research. However, recent research has established that LGBTQ+ women have unique and specific needs that need to be addressed in order to improve effectiveness of sexual health education and practice with this historically and presently underserved population. Informed by a reproductive justice framework coupled with liberation psychology theory, this review discusses the current state of sexual and reproductive health and technologies among LGBTQ+ women. In particular, we focus on a range of HIV prevention and reproductive technologies and their use and promotion, including the internal condom, abortion, oral contraceptives, dapivirine ring, HIV pre-exposure prophylaxis, intrauterine device, and other less studied options, such as the contraceptive sponge. Grounded in an intersectional framing, this review acknowledges the intersecting systems of oppression that affect multiply marginalized women inequitably and disproportionately. A sociohistorical, critical lens is applied to acknowledge the well-documented racist origins of reproductive health technologies and ongoing coercive practices that have led to medical mistrust among marginalized and stigmatized communities, particularly racialized LGBTQ+ women, women with disabilities, and women who are poor or incarcerated. Moreover, we discuss the urgent need to center LGBTQ+ women in research and clinical care, community-engaged health promotion efforts, affirming non-heteronormative sexual health education, and health policies that prioritize autonomy and dismantle structural barriers for this population. We conclude with recommendations and future directions in this area to remedy entrenched disparities in health.

The Impact of Human Immunodeficiency Virus on Women in the United States

Substantial improvements have been made in reducing HIV incidence rates among women in the United States. However, numerous disparities affect women's risk of HIV acquisition, in addition to affecting treatment outcomes for women living with HIV. As people with HIV continue to live longer due to antiretroviral therapy, clinicians must be cognizant of various health, financial, and social implications that can affect HIV self-management. Successfully ending the HIV epidemic will require more targeted approaches on prevention, linkage to care, and treatment while also addressing underlying factors that affect women's engagement in HIV-related services across the HIV care continuum.

Mental Health and Treatment Engagement among Low-Income Women of Color Living with HIV

Low-income women of color are disproportionately more likely to contract HIV, struggle with treatment adherence, and have compromised health as a result of HIV infections in comparison to White and more affluent women. The current study is a secondary analysis aimed at examining the association between stress, symptoms of depression, trauma exposure, healthcare engagement, and adherence self-efficacy, among low-income women of color with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS). Structural equation modeling is used to identify latent mental health symptoms that may influence one another, as well as outcomes involving treatment engagement. Participants contributing to this dataset (n = 134) were low income, women of color (primarily African American) living with HIV or AIDS, receiving care at a major medical center in the northeastern United States. Findings indicate significant indirect associations between perceived stress and the outcome of medical appointment attendance. Significant mediators of this indirect relationship include depressive symptoms, parenting stress, and adherence self-efficacy. Implications for health and behavioral health practice and policy interventions are drawn. Areas in need of future research are identified.

All-cause mortality before and after DAA availability among people living with HIV and HCV: An international comparison between 2010 and 2019

BACKGROUND

Among people living with HIV and hepatitis C virus (HCV), people who inject drugs (PWID) have historically experienced higher mortality rates. Direct-acting antivirals (DAA), which have led to a 90 % HCV cure rate independently of HIV co-infection, have improved mortality rates. However, DAA era mortality trends among PWID with HIV/HCV remain unknown. Using data from the International Collaboration on Hepatitis C Elimination in HIV Cohorts (InCHEHC), we compared pre/post-DAA availability mortality changes in three groups: PWID, men who have sex with men (MSM), and all other participants.

METHODS

We included InCHEHC participants with HIV/HCV followed between 2010 and 2019 in Canada, France, the Netherlands, Spain, and Switzerland. All-cause mortality hazard was compared in the three groups, using Cox proportional hazards regression models adjusted for sex, age, advanced fibrosis/cirrhosis, and pre/post DAA availability.

RESULTS

Of the 11,029 participants, 76 % were men, 46 % were PWID, baseline median age was 46 years (interquartile range [IQR] = 40;51), and median CD4 T-cell count was 490 cells/mm3 (IQR = 327;689). Over the study period (median follow-up = 7.2 years (IQR = 3.7;10.0)), 6143 (56 %) participants received HCV treatment, 4880 (44 %) were cured, and 1322 participants died (mortality rate = 1.81/100 person-years (PY) [95 % confidence interval (CI)=1.72-1.91]). Overall, PWID had higher mortality rates than MSM (2.5/100 PY [95 % CI = 2.3-2.6] vs. 0.8/100 PY [95 % CI = 0.7-0.9], respectively). Unlike women with other transmission modes, those who injected drugs had a higher mortality hazard than men who did not inject drugs and men who were not MSM (adjusted Hazard-Ratio (aHR) [95 % CI] = 1.3[1.0-1.6]). Post-DAA availability, mortality decreased among MSM in the Netherlands, Spain, and Switzerland and increased among PWID in Canada (aHR [95 % CI] = 1.73 [1.15-2.61]).

CONCLUSION

Post-DAA availability, all-cause mortality did not decrease in PWID. Determinants of cause-specific deaths (drug-related, HIV-related, or HCV-related) need to be identified to explain persistently high mortality among PWID in the DAA era.

Direct-to-patient digital diagnostics in primary care: Opportunities, challenges, and conditions necessary for responsible digital diagnostics

BACKGROUND

Diagnostics are increasingly shifting to patients' home environment, facilitated by new digital technologies. Digital diagnostics (diagnostic services enabled by digital technologies) can be a tool to better respond to the challenges faced by primary care systems while aligning with patients' and healthcare professionals' needs. However, it needs to be clarified how to determine the success of these interventions.

OBJECTIVES

We aim to provide practical guidance to facilitate the adequate development and implementation of digital diagnostics.

STRATEGY

Here, we propose the quadruple aim (better patient experiences, health outcomes and professional satisfaction at lower costs) as a framework to determine the contribution of digital diagnostics in primary care. Using this framework, we critically analyse the advantages and challenges of digital diagnostics in primary care using scientific literature and relevant casuistry.

RESULTS

Two use cases address the development process and implementation in the Netherlands: a patient portal for reporting laboratory results and digital diagnostics as part of hybrid care, respectively. The third use case addresses digital diagnostics for sexually transmitted diseases from an international perspective.

CONCLUSIONS

We conclude that although evidence is gathering, the often-expected value of digital diagnostics needs adequate scientific evidence. We propose striving for evidence-based 'responsible digital diagnostics' (sustainable, ethically acceptable, and socially desirable digital diagnostics). Finally, we provide a set of conditions necessary to achieve it. The analysis and actionable guidance provided can improve the chance of success of digital diagnostics interventions and overall, the positive impact of this rapidly developing field.

HIVepsilon-seq-scalable characterization of intact persistent proviral HIV reservoirs in women

IMPORTANCE

The lack of a reliable method to accurately detect when replication-competent HIV has been cleared is a major challenge in developing a cure. This study introduces a new approach called the HIVepsilon-seq (HIVε-seq) assay, which uses long-read sequencing technology and bioinformatics to scrutinize the HIV genome at the nucleotide level, distinguishing between defective and intact HIV. This study included 30 participants on antiretroviral therapy, including 17 women, and was able to discriminate between defective and genetically intact viruses at the single DNA strand level. The HIVε-seq assay is an improvement over previous methods, as it requires minimal sample, less specialized lab equipment, and offers a shorter turnaround time. The HIVε-seq assay offers a promising new tool for researchers to measure the intact HIV reservoir, advancing efforts towards finding a cure for this devastating disease.

Understanding why racial/ethnic inequities along the HIV care continuum persist in the United States: a qualitative exploration of systemic barriers from the perspectives of African American/Black and Latino persons living with HIV

BACKGROUND

Racial/ethnic inequities along the HIV care continuum persist in the United States despite substantial federal investment. Numerous studies highlight individual and social-level impediments in HIV, but fewer foreground systemic barriers. The present qualitative study sought to uncover and describe systemic barriers to the HIV care continuum from the perspectives of African American/Black and Latino persons living with HIV (PLWH) with unsuppressed HIV viral load, including how barriers operated and their effects.

METHODS

Participants were African American/Black and Latino PLWH with unsuppressed HIV viral load (N = 41). They were purposively sampled for maximum variability on key indices from a larger study. They engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed. Data were analyzed using directed content analysis.

RESULTS

Participants were 49 years old, on average (SD = 9), 76% were assigned male sex at birth, 83% were African American/Black and 17% Latino, 34% were sexual minorities (i.e., non-heterosexual), and 22% were transgender/gender-nonbinary. All had indications of chronic poverty. Participants had been diagnosed with HIV 19 years prior to the study, on average (SD = 9). The majority (76%) had taken HIV medication in the six weeks before enrollment, but at levels insufficient to reach HIV viral suppression. Findings underscored a primary theme describing chronic poverty as a fundamental cause of poor engagement. Related subthemes were: negative aspects of congregate versus private housing settings (e.g., triggering substance use and social isolation); generally positive experiences with health care providers, although structural and cultural competency appeared insufficient and managing health care systems was difficult; pharmacies illegally purchased HIV medication from PLWH; and COVID-19 exacerbated barriers. Participants described mitigation strategies and evidenced resilience.

CONCLUSIONS

To reduce racial/ethnic inequities and end the HIV epidemic, it is necessary to understand African American/Black and Latino PLWH's perspectives on the systemic impediments they experience throughout the HIV care continuum. This study uncovers and describes a number of salient barriers and how they operate, including unexpected findings regarding drug diversion and negative aspects of congregate housing. There is growing awareness that systemic racism is a core determinant of systemic barriers to HIV care continuum engagement. Findings are interpreted in this context.

Barriers and facilitators to retention in care and treatment adherence among racially/ethnically diverse women with HIV in South Florida: a qualitative study

Women, particularly those from racial/ethnic minority groups, experience disparities in HIV care and treatment, and in achieving viral suppression. This study identified barriers and facilitators influencing retention in HIV care and treatment adherence among women belonging to racial/ethnic minority groups. We conducted semi-structured interviews with 74 African American, Hispanic/Latina and Haitian cisgender women receiving care from the Ryan White HIV/AIDS Program in Miami-Dade County, Florida in 2019. Data were analyzed using a thematic analysis approach. The most salient barriers faced by women were competing life priorities, mental health and substance use issues, medication-related concerns and treatment burden, negative experiences with HIV care services, transportation and parking issues and stigma and discrimination. Important facilitators identified by women included taking personal responsibility for health, social support, and patient-friendly and supportive HIV care services. Our findings suggest that HIV care could be enhanced for this population by understanding the non-HIV needs of the women in care, provide more flexible and relevant services in response to the totality of these needs, and simplify and expand access to care and supportive services.

Persistence in a pharmacist-led, same-day PrEP program in Mississippi: a mixed-methods study

INTRODUCTION

Mississippi has one of the highest rates of HIV in the United States but low PrEP uptake. Understanding patterns of PrEP use can improve PrEP initiation and persistence.

METHODS

This is a mixed-method evaluation of a PrEP program in Jackson, Mississippi. Between November 2018-December 2019, clients at high risk for HIV attending a non-clinical testing site were referred to a pharmacist for same-day PrEP initiation. The pharmacist provided a 90-day PrEP prescription and scheduled a follow-up clinical appointment within three months. We linked client records from this visit to electronic health records from the two largest PrEP clinics in Jackson to determine linkage into ongoing clinical care. We identified four distinct PrEP use patterns, which we used for qualitative interview sampling: 1) filled a prescription and linked into care within three months; 2) filled a prescription and linked into care after three months; 3) filled a prescription and never linked into care; and 4) never filled a prescription. In 2021, we purposively sampled patients in these four groups for individual interviews to ascertain barriers and facilitators to PrEP initiation and persistence, using guides informed by the Theory of Planned Behavior.

RESULTS

There were 121 clients evaluated for PrEP; all were given a prescription. One-third were less than 25 years old, 77% were Black, and 59% were cisgender men who have sex with men. One-quarter (26%) never filled their PrEP prescription, 44% picked up the prescription but never linked into clinical care, 12% linked into care at some point after three months (resulting in a gap in PrEP coverage), and 18% linked into care within 3 months. We interviewed 26 of 121 clients. Qualitative data revealed that cost, stigmas related to sexuality and HIV, misinformation about PrEP, and perceived side effects were barriers to uptake and persistence. Individuals' desire to stay healthy and the support of PrEP clinic staff were facilitators.

CONCLUSIONS

The majority of individuals given a same-day PrEP prescription either never started PrEP or stopped PrEP within the first three months. Addressing noted barriers of stigma and misinformation and reducing structural barriers may increase PrEP initiation and persistence.

Achieving the "Ending the HIV Epidemic in the U.S." incidence reduction goals among at-risk populations in the South

INTRODUCTION

Antiretroviral medication coverage remains sub-optimal in much of the United States, particularly the Sothern region, and Non-Hispanic Black or African American persons (NHB) continue to be disproportionately impacted by the HIV epidemic. The "Ending the HIV Epidemic in the U.S." (EHE) initiative seeks to reduce HIV incidence nationally by focusing resources towards the most highly impacted localities and populations. This study evaluates the impact of hypothetical improvements in ART and PrEP coverage to estimate the levels of coverage needed to achieve EHE goals in the South.

METHODS

We developed a stochastic, agent-based network model of 500,000 individuals to simulate the HIV epidemic and hypothetical improvements in ART and PrEP coverage.

RESULTS

New infections declined by 78.6% at 90%/40% ART/PrEP and 94.3% at 100%/50% ART/PrEP. Declines in annual incidence rates surpassed 75% by 2025 with 90%/40% ART/PrEP and 90% by 2030 with 100%/50% ART/PrEP coverage. Increased ART coverage among NHB MSM was associated with a linear decline in incidence among all MSM. Declines in incidence among Hispanic/Latino and White/Other MSM were similar regardless of which MSM race group increased their ART coverage, while the benefit to NHB MSM was greatest when their own ART coverage increased. The incidence rate among NHB women declined by over a third when either NHB heterosexual men or NHB MSM increased their ART use respectively. Increased use of PrEP was associated with a decline in incidence for the groups using PrEP. MSM experienced the largest absolute declines in incidence with increasing PrEP coverage, followed by NHB women.

CONCLUSIONS

Our analysis indicates that it is possible to reach EHE goals. The largest reductions in HIV incidence can be achieved by increasing ART coverage among MSM and all race groups benefit regardless of differences in ART initiation by race. Improving ART coverage to > 90% should be prioritized with a particular emphasis on reaching NHB MSM. Such a focus will reduce the largest number of incident cases, reduce racial HIV incidence disparities among both MSM and women, and reduce racial health disparities among persons with HIV. NHB women should also be prioritized for PrEP outreach.

Sex and Race Disparities in Mortality and Years of Potential Life Lost Among People With HIV: A 21-Year Observational Cohort Study

Background

Since the availability of antiretroviral therapy, mortality rates among people with HIV (PWH) have decreased; however, this does not quantify premature deaths among PWH, and disparities persist.

Methods

We examined all-cause and premature mortality among PWH receiving care at the Vanderbilt Comprehensive Care Clinic from January 1998 to December 2018. Mortality rates were compared by demographic and clinical factors, and adjusted incidence rate ratios (aIRRs) were calculated using multivariable Poisson regression. For individuals who died, age-adjusted years of potential life lost (aYPLL) per total person-years living with HIV were calculated from US sex-specific life tables, and sex and race differences were examined using multivariable linear regression.

Results

Among 6531 individuals (51% non-Hispanic [NH] White race, 40% NH Black race, 21% cis-gender women, 78% cis-gender men) included, 956 (14.6%) died. In adjusted analysis, PWH alive in the most recent calendar era (2014-2018) had decreased risk of mortality compared with those in the earliest calendar era (1998-2003; aIRR, 0.22; 95% CI, 0.17-0.29), and women had increased risk of death compared with men (aIRR, 1.31; 95% CI, 1.12-1.54). Of those who died, Black women had the highest aYPLL (aIRR, 592.5; 95% CI, 588.4-596.6), followed by Black men (aIRR, 470.7; 95% CI, 468.4-472.9), White women (aIRR, 411.5; 95% CI, 405.6-417.4), then White men (aIRR, 308.6; 95% CI, 308.0-309.2). In adjusted models, higher YPLL remained associated with NH Black race and cis-gender women, regardless of HIV risk factor.

Conclusions

Despite marked improvement over time, sex disparities in mortality as well as sex and race disparities in YPLL remained among PWH in this cohort.

PrEP Acceptance among Eligible Patients Attending the Largest PrEP Clinic in Jackson, Mississippi

Compared to other states in the United States, Mississippi has the lowest uptake of PrEP relative to the number of people newly diagnosed with HIV in the state. Open Arms Healthcare Center is the largest provider of PrEP in Mississippi, and has systematically documented PrEP eligibility, offers, and acceptance (ie, agreed to undergo a clinical PrEP evaluation) from 2017 to mid-2020. In encounter-based analyses, we examined factors associated with PrEP acceptance. Among 721 encounters where patients were eligible for PrEP, staff offered PrEP at 680 (94%) of encounters (526 unique individuals); individuals accepted a PrEP offer at 58% of encounters. Accepting a PrEP offer was lowest (15.8%) among transgender/non-binary individuals and highest (93.3%) among individuals who reported having sex partners living with HIV. This clinic's model worked to offer PrEP to a highly impacted population, though there is a need to enhance PrEP acceptance for key groups such as transgender/non-binary individuals.

'It changes everything': the impact of HIV-related stigma on sexual health and intimacy among African American women

Little is known about the experiences of sexual health and intimacy among African American women living with HIV, who account for more than 50% of the women living with HIV in the USA. Public discourse surrounding the sexual health of this population often centres on HIV prevention and transmission. Medical advances such as antiretroviral therapy, biomedical interventions to prevent transmission, and treatment as prevention campaigns highlight the changing trajectory of the illness and the need for a more comprehensive examination of sexuality in relation to HIV-related disease. HIV-related stigma has been found to play a pivotal role in these experiences impacting the self-perceptions, interpersonal relationships and sexual behaviours of women living with HIV. This study utilised a phenomenological approach to examine the ways in which HIV-related stigma impacts the sexual health and experiences of intimacy among African American women living with HIV. In depth, semi-structured qualitative interviews with 16 African American women in Upstate New York revealed three emergent themes: (1) rejecting relationships; (2) navigating relationships; and (3) processing sexuality. Findings from the study highlight the ways in which HIV-related stigma affects the sexual health of African American women living with HIV and subsequently results in the renegotiation of sexuality.

Understanding young Black women's socialisation and perceptions of sexual and reproductive health

Although sexual and reproductive health inequities acutely and disproportionately affect Black women in the USA, there are few studies that consider the sociocultural context in which Black women transition to adulthood and develop their sexuality. The objective of this study was to describe the lived realities of young Black women to elucidate how the sociocultural context informs their current perceptions of sexual and reproductive health. We conducted phenomenological interviews with 22 Black women aged 18-29 years to elicit their life stories. The main categories identified in the findings include how the sociocultural environment informs the self-concept; how the sociocultural environment informs early learning about sexual health; and how together these experiences inform women's development of a sexual self-concept. Three main groupings of experiences were identified relative to women's sexual self-concept: fear-based disease and pregnancy prevention; a deeper understanding of bodies and sexuality beyond disease and pregnancy prevention; and sexual pleasure and fulfilment as a priority. To address ongoing sexual and reproductive health inequities that particularly disadvantage young Black women, health systems and interventions should address the sociocultural contexts in which young Black women develop and manage their sexual health.

Mechanisms linking gender-based violence to worse HIV treatment and care outcomes among women in the United States

OBJECTIVE

To test whether substance use mediates the associations between gender-based violence (GBV) and suboptimal adherence to antiretroviral therapy (ART), and GBV and poor engagement in care, among women living with HIV (WLHIV) in the United States (US).

DESIGN

We analyzed longitudinal data collected among 1717 WLHIV in the Women's Interagency HIV Study (WIHS).

METHODS

From 2013 to 2017, WLHIV completed semi-annual assessments on GBV, substance use, and HIV treatment and care. Adjusted multilevel logistic regression models were built to estimate the impact of GBV on; suboptimal (<95%) adherence and at least one missed HIV care appointment without rescheduling in the past 6 months. Mediation analyses were performed to test whether heavy drinking and illicit drug use mediated the associations between GBV and the two HIV outcomes.

RESULTS

The mean age was 47 (standard deviation = 9), 5% reported experiencing GBV, 17% reported suboptimal adherence and 15% reported at least one missed appointment in the past 6 months. Women who experienced GBV had a significantly higher odds of suboptimal adherence [adjusted odds ratio (aOR) = 1.99; 95% confidence interval (CI) = 1.40-2.83] and missed appointments (aOR = 1.92, 95% CI = 1.32-2.33). Heavy drinking and illicit drug use mediated 36 and 73% of the association between GBV and suboptimal adherence and 29 and 65% of the association between GBV and missed appointments, respectively.

CONCLUSIONS

Substance use is an underlying mechanism through which GBV affects outcomes along the HIV care continuum among WLHIV in the US. To optimize HIV treatment and care among women, interventions should address the combined epidemics of substance use, violence, and HIV.

Historical Perspective of Pediatric Health Disparities in Infectious Diseases: Centuries in the Making

Coronavirus (COVID-19) laid bare the disproportionate effects of infectious agents on vulnerable communities. However, historically, infectious diseases have long been known to affect certain communities to a greater extent than others. The mechanisms behind these differences are multifactorial, and lie less in biological susceptibility and instead more on socioeconomic factors and other social determinants of health. This article highlights health disparities in common infections such as respiratory syncytial virus, tuberculosis, HIV, syphilis, and influenza and will use lessons learned from previous pathogens and infectious disease disparities in vulnerable populations to provide context to the COVID-19 pandemic.

Impact of daily, oral pre-exposure prophylaxis on the risk of bacterial sexually transmitted infections among cisgender women: a systematic review and narrative synthesis

Background: There are concerns that the use of pre-exposure prophylaxis (PrEP) may result in an increased incidence of sexually transmitted infections (STIs). Evidence for this is mixed and has mostly been based on reviews focussed on gay and bisexual men and transgender women, while none have summarised evidence in cisgender women. Methods: We conducted a systematic review to explore whether daily, oral PrEP use is associated with changes in bacterial STI occurrence (diagnoses or self-reported) and/or risk among HIV seronegative cisgender women (ciswomen). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. Results: We included 11 full text articles in a narrative synthesis, with the studies published between 2012 and 2021. The studies were mostly based in Africa (n=7, 63.6%) and reported on 3168 ciswomen using PrEP aged 16-56 years. Studies had marked differences in variables, including measurements and definitions (e.g., STI type) and limited data available looking specifically at ciswomen, principally in studies with both male and female participants. The limited evidence suggests that PrEP use is not associated with increased STI rates in ciswomen generally; however, adolescent girls and young women in Sub Saharan Africa have a higher prevalence of bacterial STIs prior to PrEP initiation, compared to adult ciswomen and female sex workers. Conclusions: We suggest future PrEP research make efforts to include ciswomen as study participants and report stratified results by gender identity to provide adequate data to inform guidelines for PrEP implementation. PROSPERO registration: CRD42019130438.

U.S. Women Need the Dapivirine Ring, Too: FDA as Structural Barrier to HIV Prevention for Women

The dapivirine monthly vaginal ring-a discreet, anti-HIV microbicide created specifically for women-has received a positive scientific opinion by the European Medicines Agency and is included in the WHO HIV prevention guidelines. It has received regulatory approvals in several countries in southern and eastern Africa. During the review of the New Drug Application that was submitted in December 2020, FDA advised the developer, International Partnership for Microbicides, that it was unlikely to be approved in the United States; the application has since been withdrawn. This commentary will present the case for FDA approval for the dapivirine ring. Advocacy is urgently needed to protect U.S. women's access to user-controlled HIV prevention technologies, consistent with both global regulatory decisions to date and with a reproductive justice framework. Women continue to need the fullest range of HIV prevention methods to integrate into their lives in the most practical and effective way possible.

Influence of Material Deprivation on Clinical Outcomes Among People Living with HIV in High-Income Countries: A Systematic Review and Meta-analysis

Despite developments in HIV treatment and care, disparities persist with some not fully benefiting from improvements in the HIV care continuum. We conducted a systematic review to explore associations between social determinants and HIV treatment outcomes (viral suppression and treatment adherence) in high-income countries. A random effects meta-analysis was performed where there were consistent measurements of exposures. We identified 83 observational studies eligible for inclusion. Social determinants linked to material deprivation were identified as education, employment, food security, housing, income, poverty/deprivation, socioeconomic status/position, and social class; however, their measurement and definition varied across studies. Our review suggests a social gradient of health persists in the HIV care continuum; people living with HIV who reported material deprivation were less likely to be virologically suppressed or adherent to antiretrovirals. Future research should use an ecosocial approach to explore these interactions across the lifecourse to help propose a causal pathway.

Impact of daily, oral pre-exposure prophylaxis on the risk of bacterial sexually transmitted infections among cisgender women: a systematic review and narrative synthesis

Background: There are concerns that the use of pre-exposure prophylaxis (PrEP) may result in an increased incidence of sexually transmitted infections (STIs). Evidence for this is mixed and has mostly been based on reviews focussed on gay and bisexual men and transgender women, while none have summarised evidence in cisgender women. Methods: We conducted a systematic review to explore whether daily, oral PrEP use is associated with changes in bacterial STI occurrence (diagnoses or self-reported) and/or risk among HIV seronegative cisgender women (ciswomen). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. Results: We included 11 full text articles in a narrative synthesis, with the studies published between 2012 and 2021. The studies were mostly based in Africa (n=7, 63.6%) and reported on 3168 ciswomen using PrEP aged 16-56 years. Studies had marked differences in variables, including measurements and definitions (e.g., STI type) and limited data available looking specifically at ciswomen, principally in studies with both male and female participants. The limited evidence suggests that PrEP use is not associated with increased STI rates in ciswomen generally; however, adolescent girls and young women in Sub Saharan Africa have a higher prevalence of bacterial STIs prior to PrEP initiation, compared to adult ciswomen and female sex workers. Conclusions: We suggest future PrEP research make efforts to include ciswomen as study participants and report stratified results by gender identity to provide adequate data to inform guidelines for PrEP implementation. PROSPERO registration: CRD42019130438.

Short report: Characterizing HIV care among a clinical sample of transgender women living with HIV

INTRODUCTION

This study aimed to characterize and identify factors associated with HIV care among transgender (trans) women living with HIV (TWLWH) in two urban centres in Canada.

METHODS

Retrospective data were collected from clinic charts of TWLWH aged 16 years and older across seven family medicine, endocrinology and/or HIV clinics in Montreal and Toronto, Canada, from 2018 to 2019 (n = 86). We assessed the proportion of individuals being ever engaged in HIV care [defined as having any recorded antiretroviral therapy (ART) regimen and/or viral load], current ART use, and most recent viral load (suppressed [<200 copies/ml] vs. unsuppressed) overall and compared across subgroups using χ² tests.

RESULTS

All TWLWH in our sample [100.0%, 95% confidence interval (CI): 95.8-100.0%] were engaged in HIV care; most (93.0%, 95% CI: 85.4-97.4%) were currently using ART and most (93.4%, 95% CI: 85.3-97.8%) with complete data (n = 71/76) were virally suppressed. A higher proportion of trans women of colour (100.0%) reported current ART use compared with white trans women (76.9%, p = 0.017). A higher proportion of those with no documented history of injection drug use (IDU; 96.6%) were virally suppressed compared with those with a history of IDU (66.7%, p = 0.022). Although not statistically significant, 96.2% of those currently reporting feminizing hormone use were virally suppressed, compared with 85.0% of those not reporting use (p = 0.202).

CONCLUSIONS

Once engaged in HIV care, TWLWH in Canada appear to have excellent ART use and viral suppression. Findings can be leveraged to identify target populations to enhance HIV care and to further explore the relationship between gender-affirming medical care and HIV care.

Considerations for Increasing Racial, Ethnic, Gender, and Sexual Diversity in HIV Cure-Related Research with Analytical Treatment Interruptions: A Qualitative Inquiry

Despite disproportionate incidence and prevalence of HIV among transgender individuals, cisgender women, and racial and ethnic minority groups, all remain underrepresented in HIV cure research. As HIV cure trials are scaled up, there is emerging research on ways to mitigate risks of HIV acquisition for sexual partners of analytical treatment interruption (ATI) trial participants. As such, it is imperative that HIV cure researchers consider the implications of implementing ATIs in populations that are disproportionately affected by HIV, but largely underrepresented in trials to date. In this qualitative study, we sought to derive triangulated perspectives on the social and ethical implications regarding ATIs and partner protection strategies during ATIs among under-represented populations. We conducted 21 in-depth interviews with 5 types of informants: bioethicists, community members [people living with HIV (PLWH) and their advocates], biomedical HIV cure researchers, sociobehavioral scientists, and HIV care providers. We analyzed the data using conventional content analysis and reduced the data to important considerations for implementing ATI trials in diverse communities and settings. Our study revealed the following key themes: (1) attention must be paid to gender and power dynamics in ATI trials; (2) ATI trials should be designed and implemented through the lenses of intersectionality and equity frameworks; (3) ATI trials may have both positive and negative effects on stigma for PLWH and their partners; and (4) partnership dynamics should be considered when designing ATI protocols. Our study generated actionable considerations that could be implemented in ATI trials to promote their acceptability to communities that have been underrepresented in HIV cure research to date. Research teams must invest in robust community and stakeholder engagement to define best practices. Paying attention to representation and equity will also promote better and more equitable implementation of HIV cure strategies once these become ready for rollout.

“I do the she and her”: A qualitative exploration of HIV care providers’ considerations of trans women in gender-specific HIV care

Objectives:

Women of all genders, including cisgender (cis) and transgender (trans) women, experience social and structural drivers of HIV inequities and pervasive barriers to HIV care. Yet, little is known about how HIV care providers address gender diversity in health care. Through a critical feminist lens informed by intersectionality theory, medical anthropology, and critical sociology, we explored (1) how do HIV care providers describe women living with HIV’s care needs and barriers; (2) what are their perspectives on optimal HIV care for women; and (3) to what extent do these conceptualizations include/exclude trans women.

Methods:

Utilizing a community-based exploratory qualitative study design, we conducted 60–90 minute semi-structured individual interviews from March 2019–April 2020 with eight HIV care providers (n = 4 social service providers; n = 4 physicians) practicing across seven counties representative of rural, suburban, and urban Michigan, United States. Data were analyzed utilizing a reflexive thematic approach.

Results:

Three overarching themes emerged: (1) Emphasis on (different) clinical needs: key considerations in cis and trans women’s HIV care; (2) Recognition of the structural: barriers to HIV care affecting women of all genders; and (3) Proposed solutions: piecing together individual, social, and organizational interventions to increase access to HIV care that may benefit women living with HIV of all genders but are disproportionately framed as being for cis women. While HIV care providers recognized both cis and trans women living with HIV’s clinical care needs and structural barriers to care, they rarely envisioned optimal HIV care inclusive of gender affirmation and structural interventions.

Conclusions:

Findings suggest that HIV care providers can avoid reducing gender to biology and making assumptions about reproductive care needs, endocrinological care needs, caregiving responsibilities, and other life circumstances; provide gender-affirming medical care; and address structural barriers to HIV care to enhance intersectional and structurally focused gender-affirming—that is, trans-inclusive—women-centered HIV care.

A multidimensional examination of psychological distress among Latina mothers with and without HIV

The Latino population is disproportionally affected by HIV in the United States. Latina women, in particular, have significantly higher rates of HIV diagnosis than their White counterparts. Latinas with HIV who are primary family caregivers face multidimensional challenges from caregiving demands to stressors related to chronic illness, acculturation, family functioning, and socioeconomic disparities, which may contribute to higher psychological distress than Latina mothers without HIV. However, to date, scant research has focused on the mental health needs of Latina mothers living with HIV (MLHs) and how these needs are similar or different to Latina mothers without HIV. Thus, using a multidimensional approach we: (a) examined the associations between HIV status, acculturation, family functioning, socioeconomic status, and psychological distress among Latina mothers and (b) identified how these associations differed between Latina mothers with and without HIV. Cross-sectional, self-reported data were obtained via face-to-face interviews from 221 Latina MLHs and 116 Latina neighborhood control mothers (NCMs) living without HIV in Los Angeles, California. Results from multivariate ordinary least square regressions showed that higher acculturation was associated with psychological distress among MLHs, whereas higher levels of family conflict and education were associated with psychological distress among NCMs. Findings highlight the differential mental health needs of Latina mothers based on HIV status. Our study findings provide social work implications for culturally responsive interventions that can address multidimensional stressors experienced by marginalized Latinas MLHs.

Enduring stigma and precarity: A review of qualitative research examining the experiences of women living with HIV in high income countries over two decades

The lived experience of HIV for women remains poorly understood. In particular, there has been little attention to the consequences for women living with HIV (WLHIV) of changing social, epidemiological, biomedical and policy contexts, or to the implications of long-term treatment and aging for the current generation of HIV-positive women. We reviewed qualitative research with WLHIV in selected high-income countries (Australia, Canada, New Zealand, the UK and the USA) to identify the most prevalent experiences of HIV for women and trends over time. Our synthesis highlights the relative consistency of experiences of a diverse sample of WLHIV, particularly the enduring prevalence of gendered HIV-related stigma, sociostructural barriers to healthcare and support, and negative encounters with health professionals. We also identified gaps in knowledge. Understanding women's experiences, particularly their changing needs and strategies for coping as they live long-term with HIV, is key to effective support and services for WLHIV.

Call to action: how can the US Ending the HIV Epidemic initiative succeed?

With more than 1·2 million people living with HIV in the USA, a complex epidemic across the large and diverse country, and a fragmented health-care system marked by widening health disparities, the US HIV epidemic requires sustained scientific and public health attention. The epidemic has been stubbornly persistent; high incidence densities have been sustained over decades and the epidemic is increasingly concentrated among racial, ethnic, and sexual and gender minority communities. This fact remains true despite extraordinary scientific advances in prevention, treatment, and care-advances that have been led, to a substantial degree, by US-supported science and researchers. In this watershed year of 2021 and in the face of the COVID-19 pandemic, it is clear that the USA will not meet the stated goals of the National HIV/AIDS Strategy, particularly those goals relating to reductions in new infections, decreases in morbidity, and reductions in HIV stigma. The six papers in the Lancet Series on HIV in the USA have each examined the underlying causes of these challenges and laid out paths forward for an invigorated, sustained, and more equitable response to the US HIV epidemic than has been seen to date. The sciences of HIV surveillance, prevention, treatment, and implementation all suggest that the visionary goals of the Ending the HIV Epidemic initiative in the USA might be achievable. However, fundamental barriers and challenges need to be addressed and the research effort sustained if we are to succeed.

Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis: Implications for Medical Student Training

There is growing evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition. However, in the United States, approximately only 4% of people who could benefit from PrEP are currently receiving it, and it is estimated only 1 in 5 physicians has ever prescribed PrEP. We conducted a scoping review to gain an understanding of physician-identified barriers to PrEP provision. Four overarching barriers presented in the literature: Purview Paradox, Patient Financial Constraints, Risk Compensation, and Concern for ART Resistance. Considering the physician-identified barriers, we make recommendations for how physicians and students may work to increase PrEP knowledge and competence along each stage of the PrEP cascade. We recommend adopting HIV risk assessment as a standard of care, improving physician ability to identify PrEP candidates, improving physician interest and ability in encouraging PrEP uptake, and increasing utilization of continuous care management to ensure retention and adherence to PrEP.