Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study

Hustling and suffering: Male sex workers and HIV interventions in Kenya

Participating in and working for HIV interventions is both a source of both pride and suffering for many men who have sex with men (MSM) who engage in low-paying sex work in Kenya. Drawing on ongoing intermittent ethnographic research conducted among MSM sex workers since 2010, we analyse the relationship between hope and resilience on one hand, and narratives of suffering and hustling on the other. We show how HIV technologies that provide spaces for visibility and mobilising, such as new treatment regimes, accompanying support groups and training programmes, as well as activist led organisations, allow MSM sex workers to contribute to national and global HIV responses with a sense of both pride and shared suffering. We argue that pride, suffering and hustling are central to male sex workers' identity, solidarity and resilience. Attempts to build resilience among MSM sex workers and other highly marginalised people at continued risk for HIV would be advised to take their complex ambivalences towards health and rights-based interventions into account.

GBTQ+ safe sex entanglements: Finding the bacterial in the age of resistant STIs and prevention innovation

Few studies have explored community experiences of our increasingly resistant bacterial landscape, and, in the sphere of sexually transmissible infections (STIs) and antimicrobial resistance, there is even greater absence of community-centred research. This is despite a growth in STI transmission worldwide, which, alongside accelerated resistance, will disproportionately affect GBTQ+ (gay, bisexual, trans, queer+) populations. In this article, drawing on semi-structured interviews conducted in 2024 with 49 cisgender and trans gay and bisexual men, trans women and gender diverse people, we explore contemporary GBTQ+ safe sex practices as they relate to the growing threat of antibiotic resistant STIs in Australia. Key themes identified were the pharmaceutical turn in safe sex practices, the tensions this produced, the complexities of condom use, and the influence of biographies on safe sex practices. We illustrate how the turn toward pharmaceutical solutions has reconfigured and continues to reconfigure safe sex, giving rise to pleasures that were hitherto 'off-limits' to many. However, escalating antibiotic resistance threatens to again alter community practices and relationships to STI prevention measures. Drawing on Barad, we develop these themes to theoretically conceptualise safe sex as not fixed, but as an entanglement that is relationally and iteratively (re)configured through the connections between objects, subjectivities, practices, temporalities, and the human-microbial dynamics entailed therein. Findings suggest public health and clinical communication about resistance should speak to population concerns about gut health, resistance vis-à-vis Doxy-PEP, changing definitions of safe sex, and the importance of pleasure.

Viral kinetics among persons living with HIV (PLWH) on Dolutegravir-based antiretroviral Regimen: A retrospective and prospective analysis from selected HIV clinics in Ghana

BACKGROUND

Dolutegravir (DTG)-based antiretroviral therapy has demonstrated superior efficacy, tolerability, and durability when compared to other HIV treatment regimens. However, monitoring viral kinetics is critical for determining treatment efficacy and making sound judgments. The purpose of this study was to assess viral kinetics in people living with HIV (PLWH) on DTG-based ART and identify characteristics related to virologic response in the Cape Coast Metropolis, Ghana.

METHODS

Among people living with HIV (PLWH) attending HIV clinics between January 2020 and December 2023, a prospective and retrospective analysis of viral kinetics and clinical data were carried out. Data on viral loads, clinical laboratory results, ART regimen, and sociodemographic data were gathered. Viral loads analysis was undertaken using the COBAS AmpliPrep/COBAS TaqMan HIV-1 test, v2.0. Univariate and multivariate analyses were carried out to assess the variables related to virologic response.

RESULTS

Complete data was obtained for a total of 902 PLWH in this study. The average age was 45 ± 15.30 years, and 72.62% were female. The majority, 89.02% (835/902), had been on the DTG+3TC+TDF regimen. Over 60% had undetectable viral loads (<50 copies/mL). Univariate analysis shows a significant relationship between gender and virologic response, with females having a lower likelihood of virologic failure (OR: 0.60, 95% CI: 0.39-0.93, p-value = 0.024). In multivariate analysis, the duration of ART had various relationships with virologic response, with the odds ratio for two years reaching near significance (OR: 1.88, 95% CI: 0.98-3.59, p = 0.057). PLWH with viral loads >1000 copies/mL were 11.20% (101/902) while viral suppression, which was at detectable limits (>50 - ≤ 1000 cp/mL), was 13.08% (118/902) showing high rates of viral suppression.

CONCLUSION

The presence of virologic failures was of concern despite the high rates of viral suppression that DTG-based ART demonstrated. Undetectable viral suppression was higher than detectable viral suppression. Regular monitoring of viral kinetics, adherence, and comorbidities is essential to meeting the United Nations program on HIV/AIDS (UNAIDS) 95-95-95 targets and providing efficient therapeutic approaches for PLWH.

Treatment of Advanced HIV in the Modern Era

Antiretroviral therapy has transformed human immunodeficiency virus (HIV) infection from a fatal illness into a manageable chronic condition. However, despite remarkable progress, the HIV epidemic remains a global health challenge, with ambitious targets such as 95-95-95 by 2030 at risk of being unmet. While antiretroviral therapy availability has expanded worldwide, gaps persist, including unawareness of HIV status, inconsistent medication uptake, and limited engagement in care across diverse settings. Advanced HIV represents a particularly challenging yet underexplored aspect of HIV care. Its definition is complex, complicating efforts to address the needs of this vulnerable population. This review characterizes advanced HIV populations, defines them by spectra of immune suppression, antiretroviral therapy exposure, and drug resistance, and explores contemporary approaches to their management, with a particular focus on drug resistance and its clinical implications in modern HIV care. It highlights the unique challenges faced by individuals presenting late to care, those with limited care engagement, and aging populations with long-term exposure to HIV and antiretroviral therapy. By defining these populations, refining our understanding of advanced HIV, and addressing the diverse needs of affected individuals, providers can enhance outcomes and develop strategies to overcome barriers to care. Bridging these critical gaps is essential to advancing global efforts to end the HIV epidemic, both in the USA and worldwide.

Age and Race Disparities in Viral Suppression and the Moderating Effect of Substance Use Among Men Who Have Sex with Men Living with HIV

Viral suppression is essential for individuals living with HIV, as it is linked to improved clinical outcomes and long-term health. Research has documented age and racial disparities in HIV viral suppression. Men who have sex with men (MSM) are particularly affected by HIV infections, especially in the Southern United States. Studies indicate that substance use among people with HIV in the U.S. presents significant barriers to engaging in HIV care. This study investigated the relationships between age, race, MSM status, and viral suppression among men living with HIV (MLWH), who participated in the Helping HAND program at an academic medical center in a Southern state. The analysis included 746 male participants, primarily Black/African American. The results showed that increases in age were positively associated with a greater likelihood of viral suppression, even after adjusting for harmful or hazardous drinking, problematic substance use, race, and MSM status. Younger MSM participants were less likely to achieve viral suppression than older MSM participants. In this male only sample, neither race nor MSM status was found to be related to viral suppression. Additionally, harmful or hazardous drinking and problematic substance use did not moderate the associations between age, race, or MSM and viral suppression. These findings highlight disparities in viral suppression across different age groups among men living with HIV. The results emphasize the need for targeted outreach initiatives specifically designed for younger age cohorts living with HIV, including MSM.

Diagnoses of sexually transmissible infections in HIV-serodiscordant male couples in Australia, Brazil and Thailand

Background In an era of biomedical prevention of HIV transmission, prevention of sexually transmissible infections (STIs) remains a priority for male HIV-serodiscordant couples. Three common STIs in populations of gay and bisexual men are chlamydia, gonorrhoea and syphilis. Methods We examined the incidence of these three infections in 343 male HIV-serodiscordant couples in Australia, Brazil and Thailand. The couples participated in a prospective, observational cohort study that included regular STI testing and behavioural surveys for HIV-negative partners (HNP). Results HIV-positive partners (HPP; IR=22.9/100person-years, 95% CI: 19.3-27.0) had a higher incidence rate of any STI (22.9/100person-years, 95% CI: 19.3-27.0) compared with HNP (14.9/100person-years, 95% CI: 12.1-18.3). It was more common for only the HPP (n =107/343, 7.1%) or only the HNP (n =60, 4.0%) to have an STI than for both to have an STI (n =29/343, 1.9%). Higher STI incidence was associated with vocational education (HNP: aHR=2.19, P =0.005), full-time employment (HPP: aHR=1.61, P =0.016), living in Brazil (HPP: aHR=1.85, P =0.017) or Thailand (HPP: aHR=1.98, P =0.008), having anal sex with other partners (HNP: aHR=2.42, P =0.003; HPP: aHR=2.87, P P =0.044). Lower STI incidence was associated with age >40 years (HNP: aHR=0.49, P =0.021; HPP: aHR=0.46, P =0.006), full-time employment (HNP: aHR=0.56, P =0.016) and >5years since first sex with the study partner (HNP: aHR=0.50, P =0.036). Conclusions There were differences in STI diagnoses within HIV-serodiscordant couples, particularly based on their agreements about sex outside the relationship. Interventions aimed at strengthening these agreements with commitments to STI testing could be effective in reducing the incidence of STIs.

Updates to HIV Transmission Rate Estimates Along the HIV Care Continuum in the United States, 2019

BACKGROUND

In 2019, there were an estimated 1.2 million persons with HIV (PWH) and 35,100 new infections in the United States. The HIV care continuum has a large influence on transmission dynamics.

METHODS

We updated Progression and Transmission of HIV 3.0, an agent-based simulation model, to estimate 2019 HIV transmission rates and distribution of transmissions by the HIV care continuum, race/ethnicity, transmission group, and age group.

RESULTS

In 2019, the estimated transmission rate in the United States was 2.94 new infections per 100 person-years ( inf/100p-y) . Transmission rates decreased along the HIV care continuum; the highest transmission rate was associated with persons with acute HIV infection and unaware of their HIV status at 16.35 inf/100p-y , followed by PWH (nonacute) and unaware of their HIV status (9.52), persons aware of their HIV status and not in care (5.96), persons receiving HIV care (on antiretroviral therapy) but not virally suppressed (4.53), and persons virally suppressed (0). The highest transmission rate by transmission group was among men who have sex with men at 3.68 inf/100p-y . Transmission rates decreased as age increased and are similar by race/ethnicity, after accounting for the HIV care continuum.

CONCLUSIONS

Our results support a continued emphasis on helping PWH move along the care continuum through early diagnosis, linkage to care, and adherence to ART, resulting in viral suppression to reduce HIV transmissions. Furthermore, efforts should focus on reducing disparities in the provision of HIV prevention and care services, particularly for populations disproportionally affected by HIV.

Long-Acting Injectable Antiretroviral Therapy for Treatment of Human Immunodeficiency Virus: A Review

PURPOSE OF REVIEW

Long-acting injectable (LAI) antiretroviral therapy (ART) for treatment of HIV-1 are approved both as a complete treatment regimen (cabotegravir/rilpivirine) and as an additional treatment option (lenacapavir) for those with multidrug resistant HIV-1. Here, we review the data supporting these approvals, pharmacokinetics, and additional patient populations that many benefit from LAI ART.

RECENT FINDINGS

Persons with HIV and adherence challenges as well as those in low-and-middle income countries have high rates of adherence and viral suppression with LAI ART. LAI cabotegravir/rilpivirine (CAB/RPV) offers an alternative treatment approach to daily oral ART for people with HIV-1 infection that is associated with high rates of patient satisfaction when compared to daily oral ART. LAI CAB/RPV is currently only approved in those with HIV-1 viral suppression, however recent data support the use of LAI ART in populations with adherence challenges. Furthermore, given high rates of NNRTI resistance globally, CAB/RPV is not recommended in low-and-middle income countries presently, although this recommendation is likely to change based on recently published data. More research is needed among groups that may benefit from long-acting treatments for HIV-1.

Progress towards the UNAIDS 2030 HIV prevention target in New South Wales, Australia: a population-based study

Background

The UNAIDS ending AIDS strategy includes a 2030 prevention target of a 90% reduction in new infections from 2010. We report progress towards this goal in gay, bisexual and other men who have sex with men (GBM) in New South Wales (NSW), Australia.

Methods

We report HIV notification data for people newly diagnosed by exposure category, with a focus on GBM who comprised more than three-quarters of diagnoses. We report HIV testing, pre-exposure prophylaxis, HIV treatment, and undetectable viral load based on surveys of community-based GBM and data from a sentinel surveillance network of 50 clinics. We report trends between 2010 and 2022, including by geography grouped by postcodes with high-, medium- and low-prevalence of gay residents. Trends were assessed using the chi-square test for linear trend.

Findings

Statewide, annual notifications declined by 56% in GBM, and declines were much greater in inner-Sydney postcodes with a high percentage of gay residents compared to postcodes with a low percentage (88% and 32%). Among community-recruited GBM, annual HIV testing and PrEP uptake increased over time and by 2022 were higher in the high- (91% and 82%) than low-gay prevalence postcodes (78% and 61%). In the clinic sample, HIV testing and PrEP use increased but there was no evidence that they differed by geography. In both samples, among GBM living with HIV, the percentages on HIV treatment and with undetectable viral load increased over time, and by 2022 were greater than 95%.

Interpretation

HIV notifications in GBM in NSW have dropped by more than half since 2010. In inner Sydney areas with a high prevalence of gay men, prevention uptake was highest, and the decline in notifications approached 90%. Declines in HIV notifications were more modest elsewhere, and prevention uptake lower. Currently available prevention interventions, if extended population-wide, can enable a 90% reduction in new HIV infections in GBM, consistent with the ending AIDS target.

Funding

This project was funded by the National Health and Medical Research Council and the NSW Ministry of Health.

Experiences with HIV stigma, among other barriers, in oral healthcare settings in Türkiye

Oral healthcare settings can be a challenging environment for people with HIV. Combined with problematic insurance policies, insufficient health literacy, and higher treatment fees, HIV stigma contributes to barriers when accessing oral healthcare. We conducted a descriptive study via an online survey with open-ended questions to understand the experiences of people with HIV in oral healthcare settings. The survey was administered by non-governmental organizations. Thematic analysis was used to analyze the data via a critical realist approach. Seventy-five participants responded to survey between August and September 2023. Thematic analysis yielded three main themes: occurrences of stigma in healthcare, coping with HIV stigma and anxiety, and barriers beyond stigma. Participants reported a problematic understanding of HIV literature and stigma among dentists, which was manifested as excessive precaution measures, denial of care, unnecessary referrals, gossiping, discriminatory remarks and disclosure of HIV status without consent. This was reflected in people with HIV as self-stigma, fear of healthcare workers and avoidance of healthcare services. Advancements in dental education and post-qualification training are needed in infection control and ethics, while people with HIV need health education to preserve their rights and sustain good health and well-being to prevent adverse outcomes.

Empowerment through knowledge: Qualitative perceptions of 'undetectable equals Untransmittable' among people living with HIV and tuberculosis in South Africa

INTRODUCTION

Undetectable equals untransmittable (U=U) is an education campaign promoting science that people living with human immunodeficiency virus (HIV) who maintain an undetectable viral load cannot transmit HIV to others. Researchers theorize that undetectable equals untransmittable messaging will decrease HIV stigma by reducing fears of HIV transmission and providing evidence to dismantle discriminatory policies. However, little is known about how people with HIV in South Africa interpret the results of their viral load tests, undetectable equals untransmittable messaging, or its impact on stigma.

METHODS

This qualitative study explored knowledge and interpretation of viral suppression, and undetectable equals untransmittable among people with HIV and rifampicin-resistant tuberculosis in South Africa. We further explored whether undetectable equals untransmittable messaging influences HIV-related stigma. Thirty participants were recruited for serial qualitative interviews, conducted at baseline, 3-month, and 6-month visits. A multi-national team used reflexive thematic analysis to develop and interpret code relationships.

RESULTS

All participants were Black African, age on average was 36 years, 63.3 % were male, and half were undetectable at baseline with a median 6.2 years since HIV diagnosis. Four themes were identified that built on one another over time, (1) limited knowledge of viral suppression and undetectable equals untransmittable; (2) perceived lack of clinical integration of viral suppression and undetectable equals untransmittable; (3) Changing perceptions of viral suppression and application to individual health; and (4) endorsement of undetectable equals untransmittable and activation towards health partnership. Most participants had not heard of viral suppression or undetectable equals untransmittable at the initial interview. There was limited integration of viral suppression or undetectable equals untransmittable into clinic visits fueling a perception that viral suppression was solely a tool for verification of adherence. Over time, participants came to understand the significance of viral suppression and undetectable equals untransmittable, which empowered participants to take a more active role in their HIV management and request changes from the healthcare system.

CONCLUSIONS

Participants found optimism and empowerment through individualized HIV education even though undetectable equals untransmittable messaging had little impact on stigma. There are structural barriers in the South African healthcare system that limit access to tailored health education. By leveraging community health workers and enrolled nurses, HIV clinics can improve education access without overtaxing a resource strained healthcare system. These results identify a variety of opportunities for health system strengthening that build on the global momentum of undetectable equals untransmittable.

Barriers and facilitators of adherence to long-term antiretroviral treatment in Kampala, Uganda

Few qualitative studies have evaluated adherence to long-term antiretroviral treatment (ART) in sub-Saharan Africa. We explored adherence barriers and facilitators among PLWH on long-term ART (≥10 years in Kampala)., We conducted 22 in-depth interviews with 16 purposively selected PLWHs on long-term ART and six purposively selected healthcare providers at the Infectious Diseases Institute ART clinic.,. Interviews with PLWH explored their perspectives regarding; comprehension of ART adherence, ART adherence experiences, and adherence barriers and facilitators. Provider interviews covered: perceived ART adherence barriers and facilitators and how to reinforce and support ART adherence. Qualitative data were analyzed using a deductive content analytic approach. The median age of PLWH was 52 years [IQR] 39 - 65). Most (63%) had been on ART for 15-20 years, 50% were male, and 38% had treatment supporters. Both providers and PLWH on long-term ART emphasized the importance of adhering to prescribed medication to suppress HIV. Adherence facilitators: (i) Achieving sustained viral suppression improved overall health and motivated PLWH to maintain long-term adherence. (ii) Spousal treatment partners, financial support from adult children for transportation to clinic appointments, and the desire to fulfill social responsibilities were also adherence motivators. (iii) Policy changes, such as providing multi-month drug refills and community ART delivery, were effective strategies for promoting adherence. Adherence barriers: (i) Financial constraints - lack of money for transportation - often resulting in delayed or missed appointments to the clinic. (ii) Work obligations that conflicted with clinic appointments negatively impacted long-term ART adherence. (iii) Pill fatigue and avoidance of adherence counseling sessions by PLWH with detectable viral load exacerbated non-adherence. Familial support and differentiated ART delivery had a mutually beneficial effect on long-term adherence. Future studies should evaluate the unique adherence needs of this rapidly growing ART-experienced population and identify the most efficient strategies for adherence support.

Bayesian mixture models for phylogenetic source attribution from consensus sequences and time since infection estimates

In stopping the spread of infectious diseases, pathogen genomic data can be used to reconstruct transmission events and characterize population-level sources of infection. Most approaches for identifying transmission pairs do not account for the time passing since the divergence of pathogen variants in individuals, which is problematic in viruses with high within-host evolutionary rates. This prompted us to consider possible transmission pairs in terms of phylogenetic data and additional estimates of time since infection derived from clinical biomarkers. We develop Bayesian mixture models with an evolutionary clock as a signal component and additional mixed effects or covariate random functions describing the mixing weights to classify potential pairs into likely and unlikely transmission pairs. We demonstrate that although sources cannot be identified at the individual level with certainty, even with the additional data on time elapsed, inferences into the population-level sources of transmission are possible, and more accurate than using only phylogenetic data without time since infection estimates. We apply the proposed approach to estimate age-specific sources of HIV infection in Amsterdam tranamission networks among men who have sex with men between 2010 and 2021. This study demonstrates that infection time estimates provide informative data to characterize transmission sources, and shows how phylogenetic source attribution can then be done with multi-dimensional mixture models.

Real-world clinical and economic outcomes from rapid start antiretroviral therapy in HIV: systematic review and meta-analysis

OBJECTIVE

We aimed to synthesize clinical and economic outcomes of rapid start versus nonrapid antiretroviral therapy (ART) in people with HIV (PWH) in real-world settings.

METHODS

A search was conducted in PubMed, Embase, Web of Science, and ProQuest from January 2017 to January 2023, supplementing a previous search by Ford et al . in 2018. Observational studies investigating clinical or economic outcomes of rapid start ART versus nonrapid ART in PWH were included. Clinical outcomes were mortality, loss-to-follow-up (LTFU), and viral suppression. Economic outcomes were incremental cost-effectiveness ratio (ICER) values and per patient per month (PPPM) costs. Meta-analyses using random-effects models were performed for clinical outcomes, whereas qualitative syntheses were conducted for economic outcomes. The quality of clinical and economic studies was assessed.

RESULTS

Sixty-two studies were included. The pooled adjusted risk ratio (aRR) for mortality demonstrated a significant reduction in risk of mortality among participants who received rapid start ART compared with nonrapid ART [0.80, 95% confidence interval (CI), 0.65-0.98]. For LTFU at 6 and 12 months, the pooled aRR showed increased LTFU for rapid start ART (1.33, 95% CI, 1.15-1.55 and 1.18, 95% CI, 0.74-1.89 respectively). All cost-effectiveness studies reported cost-saving or cost-effective findings. The PPPM costs of rapid start ART across the first 36 months of treatment were consistently lower than nonrapid ART.

CONCLUSION

Rapid ART is associated with reduced mortality and is cost-effective compared with nonrapid ART in real-world settings. Clinicians and policymakers should consider these findings to facilitate rapid start of ART in PWH. Further research on LTFU in PWH is needed.

Determinants of HIV viral load suppression rates in Amhara region, Ethiopia with a large number of internally displaced people

Background

The Amhara region in Ethiopia has been affected by a war that led to displacement of millions of people. This study was conducted with the objectives of evaluating HIV viral suppression rates, assessing viral load (VL) testing turnaround time (TAT) and pilot testing of a new webapp to make VL results available in real time while the health system is affected by large numbers of internally displaced people (IDP).

Methods

Data was obtained from 7 HIV VL testing centers that serve 378 anti-retroviral treatment centers. Viral load (VL) suppression rates and VL result turnaround time (TAT) were used as markers of effectiveness of HIV control.

Findings

A total of 98,957 records were analyzed. Patients at three of the seven VL testing sites including Debre-Birehan Referral Hospital (aOR 1.87, 95 CI [1.63-2.14]), Debre-Markos Referral Hospital (aOR 1.76, 95 CI [1.61-1.93]) and University of Gonder (aOR 2.28, 95 CI [2.07-2.51]) had increased risk of virologic failure. TAT between the time VL results were available to the time results were mailed to treatment centers was ≤ 1 week for 61,148 (63.4%) and 2 weeks for 25,172 (26.1%) tests. TAT vary among the 7 VL testing centers.

Interpretation

In a region with large numbers of IDP, virologic failure is more common in older age groups. VL and TAT vary by testing centers which could be reflective of ART default and delay in courier mail driven by internal displacement.

Evidence of zero-risk transmission of HIV in the era of antiretroviral therapy: A systematic review and meta-analyses

OBJECTIVE

This systematic review aimed to assess the evidence on sexual transmission of HIV in high-income settings between serodiscordant couples where the index partner infected with HIV is on antiretroviral therapy.

STUDY DESIGN

Systematic review and meta-analyses.

METHODS

We performed a systematic search in four databases: Embase, MEDLINE, The Cochrane Library, and Web of Science on September 24, 2022. We assessed the risk of bias with ROBINS-I and pooled estimates in meta-analyses using a Poisson regression model with a random effect of the study and population size. The study protocol was pre-registered at PROSPERO. The study involved high-income countries.

RESULTS

The search identified 6886 studies, of which six were included for review. Altogether, studies reported zero linked transmissions among 2383 couples, more than 160,000 acts of intercourse, and 3578 couple years. The risk estimate from overall meta-analyses was 0.000 95%CI (0.000-0.103) per 100 couple-years.

CONCLUSION

This systematic review and meta-analyses provide epidemiological evidence for a low risk of HIV transmission under antiretroviral therapy in high-income countries and thus cannot reject the theoretical "treatment as prevention" paradigm.

The Predictive Value of Lactate Dehydrogenase for Viral Suppression in Newly Diagnosed People Living With HIV on Antiretroviral Therapy: A Retrospective Cohort Study

Purpose

Rapid initiation of antiretroviral therapy (ART) in people living with HIV (PLWH) is crucial for achieving viral suppression and improving clinical outcomes. Serum lactate dehydrogenase (LDH) levels serve as a readily accessible and rapid clinical biomarker, has significant predictive potential in various viral diseases. This study aims to evaluate the predictive value of LDH levels for viral suppression in the context of rapid ART initiation.

Patients and Methods

LDH levels were measured in 393 newly diagnosed PLWH who received rapid initiation of ART and were subsequently followed up. The PLWH were stratified based on tertile LDH levels and study endpoints. Kaplan-Meier analysis was conducted to generate survival curves, and Cox regression analysis was utilized to confirm the independent prognostic factors for viral suppression.

Results

The overall viral suppression rate was 94.1%. Compared to the low LDH tertile, the middle and high LDH tertiles exhibited longer times to first viral suppression (38 vs 84 vs 88 days, respectively, P < 0.001). Kaplan-Meier analysis revealed that PLWH in high LDH tertile showed the worst prognosis for viral suppression (Log rank test, P<0.001). Multivariate Cox regression analysis identified LDH tertile as a significant predictor of viral suppression (HR = 0.714, 95% CI = 0.553-0.922, P = 0.010 for middle vs low tertile; HR = 0.575, 95% CI = 0.443-0.747, P < 0.001 for high vs low tertile).

Conclusion

LDH levels function as a prognostic indicator for predicting the timing of viral suppression in PLWH on ART. A comprehensive evaluation of LDH levels is beneficial in establishing risk stratification in the context of rapid ART initiation.

U=U: "Undetectable Equals Untransmittable" Perceptions Among Men Who Have Sex With Men Active Duty Service Members: A Cross-Sectional Study

ABSTRACT

Undetectable = Untransmittable (U=U) is a key message emphasizing that antiretroviral therapy suppresses HIV and prevents its sexual transmission. However, dissemination of U=U varies among health care providers, potentially leading to knowledge gaps among patients. Little research exists on the understanding of U=U among active duty men who have sex with men (MSM) in the U.S. military. Our cross-sectional, online study examines 222 active duty MSM to determine prevalence of accurate knowledge of U=U and demographic predictors of misinformation. Participants received a pre-exposure prophylaxis (PrEP) overview and were asked to indicate if the statement "Undetectable equals Untransmittable" was true or false. Although the majority accurately understood U=U (70%; n = 156), approximately 30% did not ( n = 66); a binary logistic regression revealed lower U=U understanding among White, bisexual, unmarried, and Marines/Navy participants. Standardized education on U=U is crucial for resolving knowledge gaps and combating stigmas surrounding HIV treatment.

Comparison of the Performance of Commercially Available Quantitative Viral Load Assays Using Clinical Samples from Patients from Regions Where Distinct HIV-1 Subtypes Co-Circulate: Potential Implications for Patient Management

HIV RNA plasma viral load (VL) is the standard surrogate marker to monitor response to antiretroviral treatment (ART). We compared the linearity, repeatability, and concordance of six commercially available HIV RNA VL platforms using clinical samples from patients from Brazilian sites where different HIV-1 subtypes co-circulate. A total of 150 plasma samples from each city were collected in Curitiba, Southern Brazil (subtype C), São Paulo (subtype B), and Santos (BF recombinants), Southeast Brazil. Platforms were VERSANT® Siemens HIV RNA 1.0 (kPCR); VERSANT® Siemens HIV-1 RNA 3.0 (bDNA); Abbott Real-Time HIV-1; NucliSens EasyQ® HIV-1 v2.0 Biomerieux; COBAS® TaqMan®, Roche; and artus HIV Virus-1 RT-PCR, QIAGEN. OptiQuant HIV-1 RNA quantification panel was used to compare VL linearity, using samples containing 50, 500,5,000, 50,000, 500,000, and 5,000,000 HIV copies/mL. HIV RNA panels with subtypes A, B, C, D, F, G, H, circulating recombinant form (CRF)1, and CRF2 were utilized. A high degree of linearity and repeatability was demonstrated for all platforms. When compared with a subtype B reference sample, 17 of 54 (31.48%) samples diverged by more than 0.5 log10 copies/mL. Except for the Roche platform, all platforms underestimated subtype C VLs. A total of 743 (82.6%) valid results were obtained with samples from São Paulo, 707 (78.6%) from Santos, and 673 (74.8%) from Curitiba (São Paulo vs. Santos, p = .03; São Paulo vs. Curitiba, p = .00006; Santos vs. Curitiba, p = .06). The number of discordant samples between different methodologies when VL was undetectable in one method and detectable in the other ranged from 1.25% (Abbot vs. Siemens) to 44.8% (Abbott vs. Biomerieux). Finding samples with undetectable VL in one method and a high VL in another might have important individual and public health consequences. Standardization of VL measurements, particularly for non-B subtypes infections, especially subtype C, is necessary to maximize the individual and public health benefits of ART globally.

Update on HIV Chemoprevention

Despite rapid advances in the field of HIV prevention and treatment, unacceptably high global HIV incidence rates highlight the ongoing need for effective HIV prevention interventions for populations at risk for HIV acquisition. This article provides an updated review of the current data surrounding HIV prevention strategies, including treatment as prevention (TasP), preexposure prophylaxis (PrEP), and postexposure prophylaxis (PEP), as well as advances in sexually transmitted infection biomedical prevention. This review provides an overview of the multiple PrEP modalities that are available globally, such as oral PrEP, injectable cabotegravir, and the dapivirine vaginal ring, and describes their respective clinical trials, efficacies, and regulatory approvals. We also discuss ongoing research into novel PrEP agents, such as broadly neutralizing antibodies, and efforts toward HIV vaccine development.

Specialty pharmacy services compared with community-based pharmacy services on HIV viral load

OBJECTIVES

People with human immunodeficiency virus (HIV) (PWH) on antiretroviral therapy (ART) with viral load (VL) suppression eliminate the risk of sexual transmission. Many factors including decreased ART adherence and medication access barriers decrease the success of treatment as an HIV prevention strategy. ART access may be enhanced with specialty pharmacy services (SPS), but the impact compared with community-based practices is variably reported. This study aimed to compare the impact of specialty vs community pharmacies on medication adherence via VL assessment.

DESIGN

This retrospective cohort medical record study investigated whether the use of specialty pharmacies compared with community-based practices improves VL suppression. A record review was performed to collect the most recent HIV VL Demographic data collected included age range, race, ethnicity, and patient-reported gender identity. Pharmacy type was determined via review of prescription refill history linked to the medical record.

SETTING AND PARTICIPANTS

Patients included were enrolled in the Ryan White HIV/AIDS Program (RWHAP) (May 31, 2022, to May 30, 2023) at an HIV/infectious diseases academic medical center clinic.

OUTCOME MEASURES

An undetectable VL was defined as the most recent HIV VL being < 50 copies/mL or suppressed as < 200 copies/mL.

RESULTS

A total of 1631 PWH were eligible, 179 were excluded, and 1452 were included in the analysis; 91.3% were virologically suppressed (n = 1326) with an undetectable VL in 83.3% (n = 1210). When adjusting for age, self-reported gender identity, race, and ethnicity, PWH using SPS were more likely to have a suppressed (adjusted odds ratio [AOR] 1.469 [95% CI 1.007-2.142]) and undetectable VL (AOR 1.396 [95% CI 1.051-1.854]), respectively, than the use of community-based practices.

CONCLUSIONS

The use of specialty compared with community-based pharmacies had a statistically significant, yet modest association with VL suppression in PWH enrolled in RWHAP services in this single academic medical center retrospective analysis. Further studies are needed to determine whether mail-order services, specifically those without specialty service support, are sufficient for high rates of virologic control.

CD24-Fc resolves inflammation and rescues CD8 T cells with polyfunctionality in humanized mice infected with HIV-1 under cART

The persistence of HIV-1 reservoirs during combination anti-retroviral therapy (cART) leads to chronic immune activation and systemic inflammation in people with HIV (PWH), associating with a suboptimal immune reconstitution as well as an increased risk of non-AIDS events. This highlights the needs to develop novel therapy for HIV-1 related diseases in PWH. In this study, we assessed the therapeutic effect of CD24-Fc, a fusion protein with anti-inflammatory properties that interacts with danger-associated molecular patterns (DAMPs) and siglec-10, in chronic HIV-1 infection model using humanized mice undergoing suppressive cART. Our findings show that CD24-Fc treatment significantly reduced inflammation and immune hyperactivation in vivo when combined with cART. CD24-Fc mediated resolution of inflammation was associated with improved recovery of CD4 T cells, reduced immune activation, restored central memory T cells and reversal of immune cell exhaustion phenotype. Notably, CD24-Fc treatment rescued CXCR5+ CD8 central memory T cell (TCM) which correlated with increased polyfunctionality in HIV-specific T cells in humanized mice and in cultured peripheral blood mononuclear cells (PBMCs) from PWH. This restoration of CXCR5+ memory CD8 T cells was associated with HIV replication inhibition, delayed viral rebound and reduced HIV-1 pathogenesis upon cART cessation. This study suggests that CD24-Fc treatment could represent a promising new therapeutic strategy for managing chronic systemic inflammation and associated diseases in PWH.

Sexual satisfaction among people living with HIV in the era of biomedical prevention: enduring impacts of HIV-related stigma?

Background People living with HIV (PLHIV) have historically faced a range of challenges negotiating satisfying sex lives in the context of virus transmission risks and HIV-related stigma. We examine the experience of sexual satisfaction among PLHIV in an era of pre-exposure prophylaxis (PrEP) and undetectable=untransmissible (U=U)/treatment as prevention. Methods Data are derived from HIV Futures 9, a cross-sectional survey of PLHIV in Australia conducted between December 2018 and May 2019. Logistic regression was used to identify factors associated with sexual satisfaction, including awareness of/engagement with U=U and PrEP as well as experiences that denote HIV-related stigma. Results Over half (56.5%) of the total sample (n =715) reported they were not satisfied with their sex lives. Those who avoided sex because of their HIV status (44.4%) were more likely to report sexual dissatisfaction, as were those who were aged 50 years or over and those with worse self-reported health. Participants who expressed a concern about their drug use were more likely to report sexual dissatisfaction when compared with those who expressed no such concern. Conclusions Concerns about HIV continue to be present in the lives of PLHIV and can interrupt or undermine intimate and sexual relationships. Although biomedical prevention technologies such as PrEP and antiretroviral therapy may alleviate anxiety relating to onward transmission of HIV, these findings indicate that concerns about HIV status, which may be related to experiences of stigma, are still adversely associated with enjoyment of sex for those living with HIV.

The effects of HIV self-testing on HIV incidence and awareness of status among men who have sex with men in the United States: Insights from a novel compartmental model

BACKGROUND

The OraQuick In-Home HIV self-test represents a fast, inexpensive, and convenient method for users to assess their HIV status. If integrated thoughtfully into existing testing practices, accompanied by efficient pathways to formal diagnosis, self-testing could enhance both HIV awareness and reduce HIV incidence. However, currently available self-tests are less sensitive, particularly for recent infection, when compared to gold-standard laboratory tests. It is important to understand the impact if some portion of standard testing is replaced by self-tests. We used a compartmental model to evaluate the effects of self-testing in diverse scenarios among gay, bisexual and other men who have sex with men (MSM) in the United States for the period 2020-2030, and to understand which scenarios maximize the advantages of self-testing.

METHODS

We introduced a novel 4-compartment model for HIV self-testing. We employed the model under different screening rates, self-test proportions, and delays to diagnosis for those identified through self-tests to determine the potential effects of self-testing on HIV incidence and awareness of status when applied to the US MSM population. We studied scenarios in which self-tests supplement laboratory-based tests, with no replacement, and scenarios in which some replacement occurs. We also examined how future improvements in self-test sensitivity may affect our results.

RESULTS

When HIV self-tests are supplemental rather than substitutes for laboratory-based testing, self-testing can decrease HIV incidence among MSM in the US by up to 10 % and increase awareness of status among MSM from 85 % to 91 % over a 10-year period, provided linkage to care and formal diagnosis occur promptly following a positive self-test (90 days or less). As self-tests replace a higher percentage laboratory-based testing algorithms, increases in overall testing rates were necessary to ensure reductions in HIV incidence. However, such needed increases were relatively small (under 10 % for prompt engagement in care and moderate levels of replacement). Improvements in self-test sensitivity and/or decreases in the detection period may further reduce any necessary increases in overall testing by up to 40 %.

CONCLUSIONS

If properly utilized, self-testing can provide significant long-term reductions to HIV incidence and improve awareness of HIV status. Ensuring that self-testing increases overall testing and that formal diagnosis and engagement in care occur promptly following a positive self-test are necessary to maximize the benefits of self-testing. Future improvements in self-test sensitivity and reductions in the detection period would further reduce HIV incidence and the potential risks associated with replacing laboratory tests with self-tests.

Improving HIV testing, linkage, and retention in care among South African men through U = U messaging: A study protocol for two sequential hybrid type 1 effectiveness-implementation randomized controlled trials

BACKGROUND

Increasing HIV testing and treatment coverage among people living with HIV (PLHIV) is essential for achieving global HIV epidemic control. However, compared to women, cis-gender heterosexual men living with HIV are significantly less likely to know their HIV status, initiate anti-retroviral therapy (ART) and achieve viral suppression. This is particularly true in South Africa, where men are also at increased risk of mortality resulting from AIDS-related illnesses. While there is growing knowledge of Treatment as Prevention or the concept Undetectable = Untransmittable (U = U) among PLHIV in Western and high-income countries, the reach and penetration of the U = U message in sub-Saharan Africa remains limited, and few studies have evaluated the impact of accessible and relatable U = U messages on ART initiation and adherence. To address these gaps, rigorous evaluations of interventions that incorporate U = U messages are needed, especially among men in high prevalence settings.

METHODS

Building on our U = U messages that we previously developed for men using behavioral economics insights and a human-centered design, we will conduct two sequential hybrid type 1 effectiveness-implementation trials to evaluate the impact of U = U messages on men's uptake of community-based HIV testing and ART initiation (Trial 1), and retention in care and achievement of viral suppression (Trial 2). For trial 1, a cluster randomized trial will be implemented with HIV testing service site-days (each day at one testing site) randomized to U = U or standard-of-care (SoC) messages inviting men to test for HIV. For trial 2, an individual-level randomized control trial will be implemented, with men initiating ART at six government clinics randomized to receive U = U counselling or SoC treatment adherence messaging. We will incorporate a multi-method evaluation to inform future implementation of U = U messaging interventions. The study will be conducted in the Buffalo City Metro Health District of the Eastern Cape Province and in the Cape Town Metro Health District in the Western Cape Province in South Africa.

DISCUSSION

These trials are the first to rigorously evaluate the impact of U = U messaging on HIV testing uptake, ART initiation and achievement of viral suppression among African men. If effective, these messaging interventions can shape global HIV testing, treatment and adherence counselling guidelines and practices.

Narrative Coherence and Relational Agency: Unraveling Transitions Into and Out of Alberta Correctional Facilities for People Living With HIV

Incarcerated populations in Canada face significant health and social challenges during transitions into and out of correctional facilities. These transitions around facilities pose disproportionate barriers to care for people living with HIV. Further research is crucial to comprehend these challenges and reimagine care concepts for people who experience structural marginalization. In this article, experiences of transitions into and out of Alberta correctional facilities for people living with HIV are explored using narrative inquiry. Conducted in a Western Canadian city from 2021 to 2022, the inquiry revolved around two men living with HIV and a history of incarceration. Through co-creating field texts and narrative accounts, their unique experiences of transitions were explored through a collaborative process of analysis. Narrative threads from Bruce and Kyle showcased a lack of narrative coherence and the presence of tensions in their lives, while also emphasizing relational agency. The findings provide avenues for health, social, and justice practitioners who support and care for individuals living with HIV and a history of incarceration to think differently about transitions. By highlighting the importance of attending to the unique identities of individuals and relationships from a position of relational agency, the study advances our understanding of transitions. Recommendations for practice and policy include (a) fostering relational agency among practitioners; (b) challenging conventional views of transitions around correctional settings; (c) incorporating peer-based programming into support services; and (d) reconsidering health, justice, and social systems to better support communities disproportionately affected by high rates of incarceration and HIV.

Acceptability, facilitators, and barriers to a hypothetical HIV vaccine in the pre-exposure prophylaxis era

Little is known about the pre-implementation context for a preventive HIV vaccine. We conducted interviews of individuals in Philadelphia recruited at Penn clinics and community-based organizations serving LGBTQ-identifying persons of color who 1) were cisgender men who had sex with men, or were transgender-identified, 2) had a sexually transmitted infection in the last 12 months, or sex with multiple partners within the last two weeks. We assessed acceptability, facilitators, and barriers to a hypothetical HIV vaccine using an integrated analysis approach. We interviewed 30 individuals between 2/2023-9/2023. Participants were supportive of an HIV vaccine and reported that they would strongly consider receiving one if one became available. Participants contextualized a hypothetical vaccine with the current HIV prevention context, primarily pre-exposure prophylaxis (PrEP), indicating that they would evaluate any future vaccine in comparison to their experience within the PrEP landscape.Reported facilitators for a hypothetical HIV vaccine included vaccine access, knowledge, and understanding; their risk for HIV exposure; and perceived benefits of the vaccine. Barriers included lack of understanding of the purpose of a vaccine, stigma surrounding HIV and sexual practices that may surface towards people who seek vaccination, and potential issues with effectiveness, side effects, or lack of availability.

Ending AIDS as a public health threat: the imperative for clear messaging on U=U, viral suppression, and zero risk

To end AIDS as a public health threat by 2030, we must leverage both the impactful message of U=U (undetectable equals untransmittable) and viral suppression to improve the wellbeing of individuals living with HIV, increase engagement with HIV services, and reduce barriers such as stigma, discrimination, and criminalisation. This message requires clear and unambiguous evidence-based narratives that emphasise the message that there is zero risk of sexual transmission when an undetectable viral load is maintained and negligible risk when viral suppression (as defined by 200-1000 copies per mL) is maintained. Dissemination of this information to individuals living with or affected by HIV, health-care workers, communities, the general public, and policy makers will increase awareness and credibility of this message and challenge deep-seated misperceptions. Furthermore, understanding the impact of this evidence underscores the necessity to urgently prioritise universal access to quality care, including viral load testing; leverage community leadership to address structural barriers; and monitor for ongoing success. Responsible and equitable messaging, which includes attention to women and marginalised groups, should be used to realise benefits for personal wellbeing and work towards an AIDS-free future.

Retention in care and antiretroviral therapy adherence among Medicaid beneficiaries with HIV, 2001-2015

Disparities in HIV care by socioeconomic status, place of residence, and race/ethnicity prevent progress toward epidemic control. No study has comprehensively characterized the HIV care cascade among people with HIV enrolled in Medicaid - an insurance source for low-income individuals in the US. We analyzed data from 246,127 people with HIV enrolled in Medicaid 2001-2015, aged 18-64, living in 14 US states. We estimated the monthly prevalence of four steps of the care cascade: retained in care/adherent to ART; retained/not adherent; not retained/adherent; not retained/not adherent. Beneficiaries were retained in care if they had an outpatient care encounter every six months. Adherence was based on medication possession ratio. We estimated prevalence using a non-parametric multi-state approach, accounting for death as a competing event and for Medicaid disenrollment using inverse probability of censoring weights. Across 2001-2015, the proportion of beneficiaries with HIV who were retained/ART adherent increased, overall and in all subgroups. By 2015, approximately half of beneficiaries were retained in care, and 42% of beneficiaries were ART adherent. We saw meaningful differences by race/ethnicity and region. Our work highlights an important disparity in the HIV care cascade by insurance status during this time period.

Evolving molecular HIV clusters revealed genotype-specific dynamics in Guangzhou, China (2008-2020)

OBJECTIVES

This study investigated the genotype-specific dynamics of molecular HIV clusters (MHCs) in Guangzhou, China, aiming to enhance HIV control.

METHODS

HIV pol sequences from people with HIV (PWH) in Guangzhou (2008-2020) were obtained for genotyping and molecular network creation. MHCs were identified and categorized into three types: emerging, growing, or stable. Clustering rates, proportions of cluster types, and members within each type were calculated and their trends were assessed using joinpoint regression.

RESULTS

Among 8395 PWH, the most prevalent HIV-1 genotypes were CRF07_BC (39.7%) and CRF01_AE (32.6%). The genotype composition has been stable since 2012 (Ps > 0.05). The overall clustering rate was 43.3%, with significant variations across genotypes (P < 0.001), indicating genotype-specific transmission fitness. Significant declines in overall and genotype-specific clustering rates toward the end of 2020 (Ps < 0.05), potentially offer support for HIV control efforts in reducing local infections. The continuously increasing proportions of stable clusters and the gradually decreasing proportions of emerging and growing clusters (either Ps < 0.05 or Ps > 0.05) suggest a trend toward stable molecular network structure. However, growing clusters exhibited CRF55_01B, CRF07_BC, and CRF59_01B dominance that indicate their priority for interventions.

CONCLUSION

The evolving MHCs highlight the genotype-specific cluster dynamics, providing fresh insights for enhanced prevention and control strategies.

Condom Failure Among HIV-Negative Men in Serodiscordant Relationships in Australia, Brazil, and Thailand

Condoms continue to be used by many gay, bisexual, and other men who have sex with men (GBM) to reduce the risk of HIV transmission. However this is impacted by condom failure events, defined here as condom breakage and slippage. In a prospective, observational cohort study of 343 HIV serodiscordant male couples recruited through high HIV caseload clinics and hospitals between 2012 and 2016 in Australia, Brazil, and Thailand, condom failure rates and associated factors were analysed, including with the study partner versus other sexual partners. There were 717 reported instances of condom failure from an estimated total of 25,831 sex acts with condoms, from over 588.4 participant years of follow up. Of the HIV-negative partners (n = 343) in the study, more than a third (n = 117, 36.7%) reported at least one instance of condom failure with any partner type during study follow-up. Condom failure with their study partner was reported by 91/343 (26.5%) HIV-negative partners, compared with 43/343 (12.5%) who reported condom failure with other partners. In total, there were 86 events where the HIV-negative partner experienced ano-receptive condom failure with ejaculation, representing 12.0% of all failure events. In multivariable analysis, compared to Australia, HIV-negative men in Brazil reported a higher incidence risk rate of condom failure (IRR = 1.64, 95%CI 1.01-2.68, p = 0.046) and HIV-negative men who reported anal sex with other partners reported an increased risk of condom failure compared with men who only had sex with their study partner (IRR = 1.89, 95%CI 1.08-3.33, p = 0.025). Although at least one event of condom failure was reported by a significant proportion of participants, overall condom failure events represented a small proportion of the total condom protected sex acts.

Acetylsalicylic acid inhibition of the lipoxygenase pathway: Implications for HIV prevention

BACKGROUND

1.5 million new HIV infections occurred in 2021, suggesting new prevention methods are needed. Inflammation increases the risk for HIV acquisition by attracting HIV target cells to the female genital tract (FGT). In a pilot study, acetylsalicylic acid (ASA/Aspirin) decreased the proportion of FGT HIV target cells by 35 %. However, the mechanism remains unknown.

METHODS

Women from Nairobi, Kenya took low-dose ASA (81 mg) daily for 6-weeks. Free oxylipins in the plasma were quantified by high-performance liquid chromatography-tandem mass spectroscopy.

RESULTS

Oxylipins from 9 fatty acid substrates were detected, with more than one analyte from 4 substrates reduced post-ASA. Summary analysis found ASA downregulated cyclooxygenase and lipoxygenase but not cytochrome P450 activity with a lower n-6/n-3 oxylipin profile, reflecting reduced inflammation post-ASA.

CONCLUSIONS

Inflammation is associated with increased lipoxygenase activity and HIV risk. Our data suggests ASA reduces inflammation through downregulation of oxylipins. Understanding how ASA reduces inflammation may lead to novel HIV prevention approaches.

Stigma, support, and messaging for people recently diagnosed with HIV: a qualitative study

Background Despite advances in antiretroviral treatment and the message of undetectable equals untransmittable (U=U), there remain challenges related to stigma and quality of life for people living with HIV. This study aimed to understand the experiences of people recently diagnosed with HIV at a clinical service, to guide insights into how to improve care and support in the contemporary treatment era. Methods This qualitative study involved semi-structured interviews with individuals diagnosed with HIV between 2016 and 2021 at RPA Sexual Health service (a sexual health clinic in Sydney, Australia), or who were referred to the clinic directly after diagnosis. Participants were recruited through a short survey questionnaire between May 2022 and May 2023, and interviews were transcribed and analysed thematically. Results Fourteen participants were interviewed for the study, eight of whom were born outside of Australian or Aotearoa New Zealand. We found that diagnosis was still a shocking event requiring careful support; that there was ongoing stigma, shame, and reduced sexual confidence following diagnosis; and that beyond initial diagnosis, some people would benefit from ongoing support and education about key concepts regarding HIV treatment. Conclusion Our study suggests that HIV diagnosis remains disruptive, and sexual stigma is a key issue negatively impacting quality of life. Health providers can mitigate these issues by supporting the ongoing psychosocial needs of people with HIV in the early period of adjusting to HIV diagnosis, and referring to peer-based and other services. Initiating conversations about sex and dating and checking understandings of key health messages over time may promote improved care.

Identification of antibody targets associated with lower HIV viral load and viremic control

BACKGROUND

High HIV viral loads (VL) are associated with increased morbidity, mortality, and on-going transmission. HIV controllers maintain low VLs in the absence of antiretroviral therapy (ART). We previously used a massively multiplexed antibody profiling assay (VirScan) to compare antibody profiles in HIV controllers and persons living with HIV (PWH) who were virally suppressed on ART. In this report, we used VirScan to evaluate whether antibody reactivity to specific HIV targets and broad reactivity across the HIV genome was associated with VL and controller status 1-2 years after infection.

METHODS

Samples were obtained from participants who acquired HIV infection in a community-randomized trial in Africa that evaluated an integrated strategy for HIV prevention (HPTN 071 PopART). Controller status was determined using VL and antiretroviral (ARV) drug data obtained at the seroconversion visit and 1 year later. Viremic controllers had VLs <2,000 copies/mL at both visits; non-controllers had VLs >2,000 copies/mL at both visits. Both groups had no ARV drugs detected at either visit. VirScan testing was performed at the second HIV-positive visit (1-2 years after HIV infection).

RESULTS

The study cohort included 13 viremic controllers and 64 non-controllers. We identified ten clusters of homologous peptides that had high levels of antibody reactivity (three in gag, three in env, two in integrase, one in protease, and one in vpu). Reactivity to 43 peptides (eight unique epitopes) in six of these clusters was associated with lower VL; reactivity to six of the eight epitopes was associated with HIV controller status. Higher aggregate antibody reactivity across the eight epitopes (more epitopes targeted, higher mean reactivity across all epitopes) and across the HIV genome was also associated with lower VL and controller status.

CONCLUSIONS

We identified HIV antibody targets associated with lower VL and HIV controller status 1-2 years after infection. Robust aggregate responses to these targets and broad antibody reactivity across the HIV genome were also associated with lower VL and controller status. These findings provide novel insights into the relationship between humoral immunity and viral containment that could help inform the design of antibody-based approaches for reducing HIV VL.

"I Don't Feel Judged, I Don't Feel Less of a Person" - Engaged and Supportive Providers in the HIV Care Experiences of Black Sexual Minority Men Living with HIV

Background

Black sexual minority men (BSMM) in the Southern region of the United States experience a disproportionate burden of HIV. Research findings suggest that having supportive patient-provider relationships are critical for sustained HIV care engagement. The present study explores the role of supportive healthcare providers in the care engagement among BSMM living with HIV (BSMM+) in the US South.

Methods

Semi-structured qualitative interviews were conducted with BSMM+ in Texas (n=27) to explore perceived barriers and facilitators of sustained care engagement. Interviews lasted 60 minutes on average, were transcribed, coded, and analyzed using applied thematic analysis.

Findings

Participants described how important having relationships with engaged and supportive HIV care and service providers is to sustained engagement in care and positive HIV clinical outcomes. Supportive providers were characterized as non-judgmental, meeting patients' needs, and making patients feel "seen". Less supportive providers were described as making their patients "feel like a number" and having lack of follow through on proposed support and resources. Supportive providers were associated with increased care engagement of their patients while less supportive providers often led to patients switching providers, losing touch with services, and getting off track with their care.

Discussion

We found that among BSMM+ an important facilitator of sustained care engagement was having positive, affirming, and knowledgeable healthcare providers, while negative and dismissive experiences with providers was a notable barrier to care engagement. This work highlights the need for a scale up of comprehensive, ongoing trainings in patient-centered and person-first communication for providers. Further, manageable provider caseloads can facilitate more thorough patient interactions where tailored HIV care and education can be provided in a safe and non-judgmental environment.

Key findings from the 2023 'ACT NOW on Global HIV Migration, Mobility and Health Equity' community forum

Background People living with HIV continue to face laws, policies, and practices that impact their potential for travel and migration. These laws include: mandatory HIV testing and involuntary disclosure of HIV; lack of access to affordable HIV-related health care, treatment and counselling during the migration process; deportation of foreign nationals living with HIV; and restrictions on the length of stays. Methods HIV migration laws were the topic of a half-day community forum held as part of the 12th International AIDS Society Conference on HIV Science held in Brisbane, Australia, in July 2023. Over 150 delegates attended and, after a series of presentations, delegates were invited to participate in structured, facilitated conversations about issues related to policy, health and law concerning migration of people living with HIV. In this paper, we report on key themes from those discussions and identify areas for ongoing investigation. Results Advocates recommended the removal of unfair and unjust migration laws and policies that contribute to HIV stigma and discrimination; updated migration policies that reflect the current context and cost of biomedical approaches to HIV management and prevention; expanded and equitable access to HIV-related care regardless of migration or residency status; and the development of advocacy networks to promote changes to migration policies. Conclusions Laws limiting the migration of people living with HIV actively discourage individuals from seeking HIV testing, treatment and care. Ultimately, restrictive migration laws and policies undermine global efforts to end AIDS as a public health concern and to virtually eliminate HIV transmission by 2030.

Assessing the HIV care continuum among transgender women during 11 years of follow-up: results from the Netherlands' ATHENA observational cohort

INTRODUCTION

Transgender women are at increased risk of acquiring HIV. Earlier studies reported lower retention in HIV care, antiretroviral therapy uptake, adherence and viral suppression. We assessed the stages of the HIV care continuum of transgender women in the Netherlands over an 11-year period. In addition, we assessed new HIV diagnoses and late presentation, as well as disengagement from care, between 2011 and 2021.

METHODS

Using data from the Dutch national ATHENA cohort, we separately assessed viral suppression, as well as time to achieving viral suppression, among transgender women for each year between 2011 and 2021. We also assessed trends in new HIV diagnoses and late presentation (CD4 count of <350 cells/µl and/or AIDS at diagnosis), and disengagement from care.

RESULTS

Between 2011 and 2021, a total of 260 transgender women attended at least one HIV clinical visit. Across all years, <90% of transgender women were virally suppressed (207/239 [87%] in 2021). The number of new HIV diagnoses fluctuated for transgender women (ptrend = 0.053) and late presentation was common (ranging between 10% and 67% of new HIV diagnoses). Of the 260 transgender women, 26 (10%) disengaged from care between 2011 and 2021 (incidence rate = 1.10 per 100 person-years, 95% confidence interval = 0.75-1.61).

CONCLUSIONS

Between 2011 and 2021, less than 90% of transgender women linked to HIV care were virally suppressed. Late presentation at the time of diagnosis and disengagement from care were common. Efforts are needed to identify barriers to early HIV diagnosis and to optimize the different steps across the care continuum for transgender women.

Evaluating the delivery of care by telemedicine for incarcerated people living with HIV: a cohort study

BACKGROUND

The use of telemedicine has grown significantly since the COVID-19 pandemic and has the potential to improve access to specialized care for otherwise underserved populations. Incarcerated people living with HIV (PLWH) could potentially benefit from expanded access to HIV care through telemedicine.

METHODS

All PLWH who were incarcerated within the Tennessee Department of Corrections and received care through the HIV telemedicine clinic at Regional One Hospital between 5/1/2019 through 2/28/2022 were identified from the electronic health records (EHR). Demographics, laboratory data, vaccine history, and treatment outcomes were abstracted from the EHR. Retention in care and viral suppression were defined using Centers for Disease Control and Prevention definitions.

RESULTS

Of the 283 incarcerated PLWH receiving care from this telemedicine clinic, 78% remained retained in care and 94% achieved or maintaining viral suppression at 12 months. Many preventative care measures remained unperformed or undocumented, including vaccinations and testing for concurrent sexually transmitted infections. There were 56 patients (20%) found to have chronic hepatitis C in this population, with 71% either cured or still on treatment in this study period.

CONCLUSIONS

Retention in care and viral suppression rates were excellent among incarcerated PLWH receiving telemedicine care for their HIV. HIV related primary health care screenings and vaccinations, however, were less consistently documented and represent areas for improvement.

Impact of HIV preexposure prophylaxis prescriptions on HIV diagnoses in New York City

BACKGROUND

HIV preexposure prophylaxis (PrEP) has proven to be efficacious and effective in preventing HIV infections, but few studies have reported its impact in the real world.

METHODS

We conducted an ecological analysis and compared the trends in HIV PrEP prescriptions with the trends in age-adjusted HIV diagnosis rates in New York City (NYC). Joinpoint regression analyses were used to identify any temporal trends in HIV diagnosis rates in NYC.

RESULTS

The number of people filling at least one PrEP prescription in NYC increased from 2551 in 2014 to 35 742 in 2022. The overall age-adjusted HIV diagnosis rate steadily decreased from 48.1 per 100 000 in 2003 to 17.1 per 100 000 in 2022. After the rollout of PrEP, accelerated decreases were detected in some subpopulations including white men [2014-2019 annual percentage change (APC): -16.6%; 95% confidence interval (CI) -22.7 to -10.0], Asian/Pacific Islander men (2016-2022 APC: -9.8%), men aged 20-29 years (2017-2020 APC: -9.4%) and 40 -49 years (2014-2020 APC: -12.2%), Latino/Hispanic people aged 40-49 years (2015-2020 APC: -13.0%), white people aged 20-29 years (2012-2022 APC: -11.4%) and 40-49 years (2014-2018 APC: -27.8%), and Asian/Pacific Islander people aged 20-29 years (2017-2022 APC: -13.0%).

CONCLUSION

With a high coverage, PrEP can have a long-term impact in reducing HIV infections in a population, but if preexisting social determinants that contribute to racial, ethnic, and gender inequities are not well addressed, the implementation of PrEP can exacerbate these inequalities.

Awareness of U = U among Sexual and Gender Minorities in Brazil, Mexico, and Peru: Differences According to Self-reported HIV Status

The slogan Undetectable equals Untransmittable (U = U) communicates that people living with HIV (PLHIV) who are on antiretroviral therapy (ART) will not transmit HIV to their sexual partners. We describe awareness of U = U among sexual and gender minorities (SGM) living in Brazil, Mexico, and Peru by self-reported HIV status (PLHIV, negative, unknown) during 2021 using an online survey. We estimated two models using Poisson regression for each population group: Model A including socio-demographic factors (country, gender, age, race, education, and income), and then Model B including taking ART (for PLHIV) or risk behavior, ever-taking PrEP, and HIV risk perception (for HIV-negative or of unknown HIV status). A total of 21,590 respondents were included (Brazil: 61%, Mexico: 30%, Peru: 9%). Among HIV-negative (74%) and unknown status (12%), 13% ever used PrEP. Among PLHIV (13%), 93% reported current use of ART. Awareness of U = U was 89% in both Brazil and Mexico, which was higher than in Peru 64%. Awareness of U = U was higher among PLHIV (96%) than HIV-negative (88%) and HIV-unknown (70%). In multivariate models, PLHIV with lower education were less aware of U = U, while those taking ART were more aware. Among HIV-negative, non-cisgender, lower income, and those with lower education had lower awareness of U = U, while individuals ever using PrEP had higher awareness. In conclusion, awareness of U = U varied by HIV status, socio-demographic characteristics, and HIV risk behavior. The concept of U = U should be disseminated through educational strategies and include a focus on SGM to combat HIV stigma.

HIV-1 low-level viraemia predicts virological failure in first-line and second-line ART-experienced individuals in India: A retrospective longitudinal study

OBJECTIVE

To study the prevalence of low-level viraemia (LLV) and its association with virological failure (VF).

METHODS

We conducted a retrospective analysis of 3498 participants at YRG CARE, Chennai, India (2013-2018) on antiretroviral therapy (ART) for ≥6 months with two or more plasma viral load (pVL) measurements. Results were stratified for those with pVL <1000 copies/mL: fully suppressed (FS) (pVL <40), low-LLV (pVL 40-199), mid-LLV (pVL 200-399), and high-LLV (pVL 400-999). The study assessed the association with VF (pVL >1000 copies/mL) using Cox proportional hazard model.

RESULTS

Among 3498 participants, 2965 (84.8%) were FS and 533 (15.2%) were LLV. During the follow-up, 348 (10%) experienced VF, with 222 (6.3%) experienced after LLV (42% of LLV) and 126 (3.6%) experienced after FS (4.3% of FS). When compared with FS, those with LLV had a greater risk of VF [adjusted hazard ratio (aHR) = 12.7; 95% confidence interval (CI): 10.2-15.9]. First-line participants had a higher VF incidence (aHR = 15.8, 95% CI: 11.4-21.9) than second-line participants (aHR = 5.6, 95% CI: 4.1-7.7). Those with high-LLV had the highest VF risk (aHR = 22.856, 95% CI: 15.204-34.359 vs. aHR = 8.186, 95% CI: 5.564-12.043, for first-line vs. second-line participants, respectively), followed by those with mid-LLV (aHR = 13.375, 95% CI: 8.327-21.483 vs. aHR = 6.261, 95% CI: 4.044-9.695) and low-LLV (aHR = 12.976, 95% CI: 7.974-21.118 vs. aHR = 4.158, 95% CI: 2.826-6.119).

CONCLUSIONS

The prevalence of LLV was intermediate in our study population. There was a higher risk of VF among individuals with LLV, and this risk increased with the increasing levels of LLV. Close monitoring of individuals experiencing LLV could help in the early identification of VF.

Messaging About HIV Transmission Risk When Viral Load Is Undetectable: Reactions and Perceived Accuracy Among US Sexual Minority Men

BACKGROUND

Scientific evidence indicates that HIV viral suppression to an undetectable level eliminates sexual transmission risk ("Undetectable=Untransmittable" or "U=U"). However, U=U messaging has been met with skepticism among sexual minority men (SMM) and others. In this survey-based experiment, we manipulated messaging about HIV risk and examined reactions and perceived message accuracy among US SMM.

METHODS

SMM living with HIV (n = 106) and HIV-negative/status-unknown SMM (n = 351) participated in an online survey (2019-2020). Participants were randomly assigned to 1 of 3 messaging conditions, which varied by level of HIV sexual transmission risk associated with an undetectable viral load (No Risk [U=U]/Low Risk/Control). Participants reported reactions, message accuracy, and reasons for perceiving inaccuracy. We coded open-response data (reactions and reasons) into conceptual categories (eg, "Enthusiasm"). We compared reactions, accuracy ratings, and reasons by condition and serostatus.

RESULTS

In the No Risk Condition, common reactions were Enthusiasm (40.0%), Skepticism/Disagreement (20.0%), and Agreement (19.4%), reactions common to comparison conditions. A higher percentage of HIV-negative/status-unknown participants (24.1%) expressed Skepticism/Disagreement in the No Risk Condition compared with other conditions (3.2%-9.7%). Participants living with HIV were more likely than HIV-negative/status-unknown participants to perceive the message as accurate in all conditions. In the No Risk Condition, common reasons for perceiving inaccuracy were Risk Misstated (46.1%), Oversimplified/Caveats Needed (17.1%), and Personal Unfamiliarity/Uncertainty (14.5%), reasons common to comparison conditions. Across conditions, 10.3% of participants attributed message inaccuracy to undetectable being misdefined.

CONCLUSION

Most SMM reacted favorably to U=U messaging. However, many-especially HIV-negative/status-unknown SMM-expressed skepticism. Interventions are needed to enhance U=U understanding and acceptance.

The cost-effectiveness of integrating simplified HCV testing into HIV pre-exposure prophylaxis (PrEP) and treatment services among men who have sex with men in Taiwan

Background

Simplified hepatitis C virus (HCV) testing integrated into existing HIV services has the potential to improve HCV diagnoses and treatment. We evaluated the cost-effectiveness of integrating different simplified HCV testing strategies into existing HIV pre-exposure prophylaxis (PrEP) and treatment services among men who have sex with men (MSM) in Taiwan.

Methods

Mathematical modeling was used to assess the cost-effectiveness of integrating simplified HCV tests (point-of-care antibody, reflex RNA, or immediate point-of-care RNA) with HCV treatment into existing HIV prevention and care for MSM from a healthcare perspective. The impact of increasing PrEP and HIV treatment coverage among MSM in combination with these HCV testing strategies was also considered. We reported lifetime costs (2022 US dollars) and quality-adjusted life years (QALYs) and calculated incremental cost-effectiveness ratios (ICERs) with a 3% annual discounting rate.

Findings

Point-of-care HCV antibody and reflex RNA testing are cost-effective compared to current HCV testing in all PrEP and HIV treatment coverage scenarios (ICERs <$32,811/QALY gained). Immediate point-of-care RNA testing would be only cost-effective compared to the current HCV testing if coverage of HIV services remained unchanged. Point-of-care antibody testing in an unchanged HIV services coverage scenario and all simplified HCV testing strategies in scenarios that increased both HIV PrEP and treatment coverage form an efficient frontier, indicating best value for money strategies.

Interpretation

Our findings support the integration of simplified HCV testing and people-centered services for MSM and highlight the economic benefits of integrating simplified HCV testing into existing services for MSM alongside HIV PrEP and treatment.

Funding

This study was made possible as part of a research-funded PhD being undertaken by HJW under the UNSW Sydney Scientia scholarship and was associated with the Rapid Point of Care Research Consortium for infectious disease in the Asia Pacific (RAPID), which is funded by an NHMRC Centre for Research Excellence. JG is supported by a National Health and Medical Research Council Investigator Grant (1176131).

Investigating the Moderating Effect of HIV Status Disclosure on the Link Between Discrimination Experience and Psychological Distress Among People Living with HIV in Japan Infected Through Sexual Contact

BACKGROUND

There is a scarcity of research on the potential impact of disclosing HIV status to friends and family in moderating the adverse effects of discrimination on the mental health of people living with HIV (PLWH). This study assessed the experiences of discrimination and HIV status disclosure among PLWH in Japan, and evaluated their potential associations with psychological distress.

METHOD

Data were derived from a nationwide cross-sectional survey of PLWH conducted in Japan between 2019 and 2020. The interaction effects of HIV-related discrimination and HIV status disclosure on the psychological distress were examined using logistic and linear regression analyses.

RESULTS

The median age of the 804 respondents was 46 years old. Most respondents were male and 85.4% (687/804) identified as homosexuals or bisexuals. A total of 12.7% (102/804) of the respondents reported that they had recently experienced discrimination because of their HIV status. Experience of HIV-related discrimination was independently associated with high psychological distress (adjusted OR 2.02; 95% CI, 1.15-3.57), and HIV status disclosure to friends partially weakened the association between discrimination and the level of psychological distress (regression coefficient -3.115; p = 0.004).

CONCLUSION

While measures that aim to end discrimination remain vital, increasing the opportunities of PLWH to communicate with friends they feel comfortable disclosing their HIV status may also be helpful in protecting their mental health.

Changing how the third 95 is counted: suitable indicators for measuring U = U with findings from Taiwan

INTRODUCTION

The World Health Organisation has implemented multiple HIV prevention policies and strived to achieve the 90-90-90 goal by 2020, achieving the 95-95-95 goal by 2030, which refers to 95% of patients living with HIV knowing their HIV status, 95% of patients living with HIV receiving continual care and medication, and 95% of patients living with HIV exhibiting viral suppression. However, how to measure the status of viral suppression varies, and it is hard to indicate the quality of HIV care. The study aimed to examine the long-term viral load suppression in these cases and explore potential factors affecting the control of long-term viral load.

METHODS

This study analyzed viral load testing data from HIV patients who are still alive during the period from notification up to 2019-2020. Three indicators were calculated, including durable viral suppression, Viremia copy-years, and Viral load > 1,500 copies/ml, to assess the differences between them.

RESULTS

Among the 27,706 cases included in the study, the proportion of persistent viral load suppression was 87%, with 4% having viral loads exceeding 1,500 copies/ml. The average duration from notification to viral load suppression was 154 days, and the geometric mean of annual viral replication was 90 copies*years/ml. Regarding the last available viral load measurement, 96% of cases had an undetectable viral load. However, we observed that 9.3% of cases, while having an undetectable viral load for their last measurement, did not show consistent long-term viral load suppression. An analysis of factors associated with non-persistent viral load suppression revealed higher risk in younger age groups, individuals with an educational level of high school or below, injection drug users, cases from the eastern region, those seeking care at regional hospitals, cases with drug resistance data, individuals with lower healthcare continuity, and those with an initial CD4 count below 350 during the study period.

CONCLUSIONS

The recommendation is to combine it with the indicator of sustained viral load suppression for a more accurate assessment of the risk of HIV transmission within the infected community.

HIV-related public stigma in the era of "Undetectable = Untransmittable": a population-based study in Hong Kong

BACKGROUND

While global efforts are increasingly relying upon biomedical advancements such as antiretroviral therapy and pre-exposure prophylaxis (PrEP) to end the HIV epidemic, HIV-related stigma remains a concern. This study aimed to assess the general public's awareness and perception of "Undetectable = Untransmittable" (U = U) and PrEP, and the patterns of public stigma towards people living with HIV (PLWH) and their determinants in an Asian Pacific city.

METHODS

A population-based, self-administrated online survey was conducted between 10-20 March 2023. All adults aged ≥ 18 years and currently living in Hong Kong were eligible. Participants' socio-demographic characteristics, awareness and perception of U = U and PrEP, as well as HIV-related stigma drivers, experience and practices were collected. Latent class analysis was used to delineate population subgroups based on their stigma profiles as reflected by 1.) fear of infection, 2.) concern about socioeconomic ramification of the disease, 3.) social norm enforcement, 4.) perceived stigma in the community, and 5.) stigmatising behaviours and discriminatory attitudes. Memberships of identified subgroups were then correlated with sociodemographic factors, awareness and perception of U = U and PrEP, using multinominal logistic regression.

RESULTS

Responses from a total of 3070 participants (55% male; 79% aged 18-54) were analysed. A majority, 69% and 81%, indicated that they had never heard of U = U and PrEP respectively, and only 39-40% of participants perceived these to be effective in protection from HIV. Four distinct subgroups were identified, namely "Low stigma" (37%), "Modest stigma" (24%), "Moderate stigma" (24%), and "High stigma" (15%). Compared with "Low stigma", lack of awareness of and/or negative perceptions towards U = U and/or PrEP, not knowing any PLWH were associated with increased odds of higher stigma group membership. Lower educational level and not in employment were associated with increased odds of membership in "Moderate stigma" and "High stigma". While older people were more likely to belong to "High stigma", female were more likely to belong to "Moderate stigma". "Modest stigma" included more younger people who were economically active.

CONCLUSION

Two-thirds of participants endorsed modest-to-high HIV-related stigma, suggesting the prevalence of HIV-related stigma was high among the general population in Hong Kong. Tailored interventions targeting specific stigma drivers and manifestations of individuals as reflected from the stigma profiles of distinct subgroups could form an important strategy for stigma reduction.

Behaviour changes following HIV diagnosis among men who have sex with men in the era of treatment as prevention: data from a prospective study

We described the longitudinal changes in sexual behaviour and associated factors among newly diagnosed with HIV men who have sex with men participating in a prospective observational study from a London HIV clinic (2015-2018). Participants self-completed questionnaires at baseline, months 3 and 12. Information collected included socio-demographic, sexual behaviour, health, lifestyle and social support. Trends in sexual behaviours over one year following diagnosis and associated factors were assessed using generalized estimating equations with logit link. Condomless sex (CLS) dropped from 62.2% at baseline to 47.6% at month-three but increased again to 61.8% at month-12 (p-trend = 0.790). Serodiscordant-CLS increased between month-three and month-12 (from 13.1% to 35.6%, p-trend < 0.001). The prevalence of serodiscordant-CLS with high risk of transmitting to their partners at month-three was 10.7%. CLS was higher among men who reported recreational drug use (adjusted Odds Ratio (aOR) 3.03, 95%CI 1.47-6.24, p = 0.003), those with undetectable viral load (aOR 2.17, 95%CI 1.22-3.84, p = 0.008) and those who agreed with a statement "condoms are not necessary when HIV viral load is undetectable" (aOR 3.41, 95%CI 1.58-7.38, p = 0.002). MSM continued to engage in CLS after HIV diagnosis, which coincided with U = U publications and increased throughout the study.

Retention in care and antiretroviral therapy adherence among Medicaid beneficiaries with HIV, 2001-2015

Disparities in HIV care by socioeconomic status, place of residence, and race/ethnicity prevent progress toward epidemic control. No study has comprehensively characterized the HIV care cascade among people with HIV enrolled in Medicaid - an insurance source for low-income individuals in the US. We analyzed data from 246,127 people with HIV enrolled in Medicaid 2001-2015, aged 18-64, living in 14 US states. We estimated monthly prevalence of four steps of the care cascade: retained in care/adherent to ART; retained/not adherent; not retained/adherent; not retained/not adherent. Beneficiaries were retained in care if they had an outpatient care encounter every six months. Adherence was based on medication possession ratio. We estimated prevalence using a non-parametric multi-state approach, accounting for death as a competing event and for Medicaid disenrollment using inverse probability of censoring weights. Across 2001-2015, the proportion of beneficiaries with HIV who were retained/ART adherent increased, overall and in all subgroups. By 2015, approximately half of beneficiaries were retained in care, and 42% of beneficiaries were ART adherent. We saw meaningful differences by race/ethnicity and region. Our work highlights an important disparity in the HIV care cascade by insurance status during this time period.

Prevalence and risk factors of sexually transmitted infections in the setting of a generalized HIV epidemic-a population-based study, western Kenya

BACKGROUND

Sexually transmitted infections (STIs) cause adverse health outcomes, including increasing HIV acquisition/transmission risk. We analyzed data from an HIV biomarker and behavioral survey to estimate STI prevalence, and explore associated factors in the setting of a generalized HIV epidemic in Siaya County, western Kenya.

METHODS

Data were collected in March-September 2022 through face-to-face interviews using structured questionnaires; records from 9643 sexually active participants aged 13+ years were included in the analysis. We calculated weighted self-reported STI prevalence, by sex, age, and HIV status and explored associated factors using multivariable logistic regression.

RESULTS

Median age was 37 years and 59.9% were female; HIV prevalence was 18.0%. Overall STI prevalence was 1.8%; 1.5-fold higher among males vs. females, and 2.6-fold higher among participants living with HIV vs. those without. HIV status and multiple sexual partners were independently associated with STI in both sexes. Mind-altering substance use and being circumcised were associated with STI among males.

CONCLUSIONS

This study estimates STI prevalence in the setting of high HIV prevalence. Findings underscore the importance of: effective STI screening in HIV clinics and HIV testing and counseling in STI clinics; screening and counseling on substance use, and HIV pre-exposure prophylaxis; and intensive sexual health counseling in male circumcision programmes.