Prevention of HIV-1 infection with early antiretroviral therapy

Patterns in Mental Health Symptoms, Substance Use, and Viral Suppression in People with HIV: A Clustering Analysis

Mental health conditions and substance use are prevalent among people with HIV (PWH), are correlated with one another, and associate with viral non-suppression independently; their joint association with viral non-suppression may be under-studied because of data sparsity. We conducted a machine learning-based clustering analysis to characterize groups of patient-reported mental health symptoms and substance use based on their relationship with HIV viral suppression. Participants in the Johns Hopkins HIV Clinical Cohort reported symptoms of depression, anxiety, and post-traumatic stress, and recent use of alcohol, cocaine, amphetamine, non-prescribed opioids, and cannabis (2013-2023). We fit a random forest model with the viral suppression status as the outcome against self-reported items as predictors and used a forest-derived similarity measure to group participants into three clusters. The cluster with the lowest viral suppression rate (74.5%) had the highest depression symptom score (median score 4, interquartile interval [IQI] 1-8) and anxiety symptom score (median score 2, IQI 0-7) along with the greatest prevalence of recent cocaine (99.9%) and opioid (28.0%) use. The cluster with the highest HIV viral suppression rate (81.1%) had the lowest depression symptom score (median 1, IQI 0-4) and anxiety symptom score (median 0, IQI 0-2) and lowest proportion of recent cocaine (0%) and opioid (2.5%) use. Clinically meaningful groups of PWH with heterogenous mental health and substance use characteristics were formed using a machine learning-based clustering approach. PWH with mental health symptoms and substance use represent an important subpopulation for interventions to improve antiretroviral treatment outcomes.

Joint HIV and hepatitis C virus phylogenetic analyses signal network overlap among women engaged in sex work and men who purchase sex

BackgroundTransmission of HIV and hepatitis C virus (HCV) are heavily influenced by complex interactions within sexual or injecting networks where risk behaviors occur. In Ukraine, women engaged in sex work (WSW) and men who purchase sex (MWPS) are disproportionately affected by both viruses. The aim of our study was to the investigate the influence of underlying networks on transmission of HIV and HCV.MethodsA cross-sectional integrated bio-behavioural survey was implemented among 560 WSW and 370 MWPS representative of sex work hotspots in Dnipro, Ukraine (December 2017 to March 2018). A portion of the HIV reverse transcriptase gene (n = 13; 62% WSW, 38% MWPS) and HCV NS5B gene (n = 46; 70% WSW, 30% MWPS) were sequenced from dried blood spot specimens. Tip-to-tip distances on phylogenetic trees were used to infer phylogenetic clusters for identifying potential transmission clusters.ResultsPhylogenetic analyses identified two HIV clusters containing four sequences (50% WSW; 50% MWPS) and 11 HCV clusters containing 31 sequences - the majority comprising infections in WSW (83.9%). Nearly half (45.4%) of HCV clusters contained at least one WSW with a history of injecting drugs.ConclusionsJoint analyses of HIV and HCV signal overlap in sex work and injecting networks in Ukraine, suggesting implications for the comprehensive coverage of prevention programs for WSW including harm reduction services. Conducting phylogenetic analyses with HCV may provide a more complete appraisal of underlying transmission networks than HIV alone, particularly in the context of high HIV treatment coverage yielding viral suppression.

Health Economics Evaluation of Bictegravir/Emtricitabine/Tenofovir for a First-Line Treatment of HIV-1 Infection in China

Purpose

This study aims to evaluate the economic value of Bictegravir/emtricitabine/tenofovir (B/F/TAF) as a first-line treatment for HIV-1 infection in China, where such evaluations are currently lacking.

Patients and Methods

We developed a monthly-cycle Markov model to evaluate the economics of B/F/TAF versus dolutegravir/lamivudine (DTG/3TC) as a first-line ART for adult HIV-1 patients over a lifelong time. The social costs, quality-adjusted life years (QALYs), incremental net monetary benefit (INMB), and incremental cost-effectiveness ratio (ICER) have been analyzed using health economic methods. Sensitivity analyses were conducted for the result validation. Taking into account the transmissibility of HIV, we have developed a scenario within a dynamic model across the entire population in China, to conduct a health economic evaluation of the two drugs over 30 years. Model precision was tested using relative standard deviation (RSD).

Results

In the Markov model, B/F/TAF had higher per-person costs compared to DTG/3TC ($44,381.33 vs $42,160.13), but also resulted in greater QALYs (11.6771 vs 11.5389), leading to a per-person INMB of $3072.26 (WTP = 3GDP) and an ICER of $16,052.42 per QALY. Uncertainty analyses confirmed the robustness of these results. The dynamic model further indicated that B/F/TAF was both cost-benefit and cost-effective, with a per-person INMB of $7.33 (WTP = 3GDP) and an ICER of $7,953.72 per QALY, although it exhibited a higher RSD.

Conclusion

After adopting the B/F/TAF regimen in China, the cost-benefit and cost-effectiveness of HIV prevention and treatment have significantly improved. We should advocate for B/F/TAF as the first-line treatment to enhance HIV management.

Universal "Test and Treat" for HIV Had Little Effect on Outcomes, but Missed Clinic Visits Threaten Success of Botswana's National Antiretroviral Treatment Program

In 2016, Botswana changed the policy to institute universal "test and treat" (UTT) in people with human immunodeficiency virus or HIV (PWH). It is unclear whether these policy changes have yielded any clinical benefits or harms. We conducted a retrospective cohort analysis of PWH aged ≥18 years to compare patient outcomes in individuals who received antiretroviral treatment (ART) under (1) the introduction of UTT and (2) rapid versus delayed ART start, at two clinics in Gaborone, Botswana, between 2014 and 2020. Multivariate logistic regression and propensity score models were used to control for potential confounding and selection bias. Of the 2008 participants who had a complete plasma HIV RNA at 1 year following ART initiation, 59 (2.9%) experienced virologic failure, and 665 (33.1%) were lost to follow-up (LTFU). Higher LTFU was recorded in UTT than in delayed ART period (43% vs 31%, p < 0.001); the same trend was upheld on further examination treating all LTFU as treatment failure (47% vs 37%, p < 0.001). In adjusted models, neither the UTT policy: odds ratio (OR) 1.91 [95% confidence interval (CI): 0.90, 3.56] nor rapid ART start: OR 1.31 (95% CI: 0.75, 2.34) was associated with viral failure. UTT was not associated with LTFU: OR 1.04, 95% CI (0.75, 1.45). Missed clinic visits were associated with viral failure regardless of policy period: OR 1.17 (95% CI: 1.03, 1.31) or rapid start: OR 1.20 (95% CI: 1.07,1.35). Neither UTT policy nor rapid ART start was associated with any one of the composite unfavorable outcomes. However, missing clinic visits was an independent risk factor for unfavorable outcomes.

Effects of improved partner notification on the transmission of HIV and N. gonorrhoea among men who have sex with men: a modelling study

Objectives Men who have sex with men (MSM) are disproportionally affected by HIV in the Netherlands. Partner notification (PN) is an important element in controlling the transmission of sexually transmitted infections (STIs) and HIV. We investigated the effects of improving PN on the transmission of HIV and Neisseria gonorrhoeae (NG) among MSM in the Netherlands. Methods We developed an agent-based model that describes the transmission of HIV and NG among MSM. In the baseline scenario, 14.3% and 29.8% of casual and steady partners of the index case get notified and tested for HIV/STI after 3 weeks (percentage notified and tested (PNT)). We examined the following scenarios: (1) increase PNT to 41% for both partner types; (2) decrease the time between the index and the partners tested to 1 week and (3) combine scenarios 1 and 2. Effects are expressed as cumulative change from the baseline simulation over 15 years. Results Increasing PNT could lead to a decrease in gonorrhoea cases of 45% (IQR 39.9% to 49.9%), with an increase in the number of HIV/STI tests of 4.4% (IQR 1.6% to 7.3%), but no change in HIV infections (-5.4%; IQR -21% to 7.9%). Decreasing the time between tests could lead to a change in new NG infections of -14.2% (IQR -17.2% to -10%), no change in HIV infections (8.2%; IQR -1.3% to 20%) or in the number of HIV/STI tests performed (-0.4%; IQR -1.5 to 0.6%). Scenario 3 led to a change in NG infections of -56.8% (IQR -63.8% to -47.4%), no change in HIV infections (11.5%; IQR -11.1% to 33.9%) or in the number of HIV/STI tests (-0.5%; IQR: -4.9% to 4.3%). Conclusions Increasing the percentage of sexual partners notified and tested for HIV/STI may have only a small effect on HIV but could reduce the number of new NG infections substantially. However, it could lead to an increase in the number of HIV/STI tests performed.

Daily Factors Associated with Antiretroviral Therapy Adherence Among Young Latino Sexual Minority Men with HIV: A 28-Day Daily Diary Study

We assessed the relationship between same-day and next-day antiretroviral therapy (ART) adherence and adherence self-efficacy, daily routine disruptions, mental health, sleep, social support, substance use, and contextual factors in an ecological momentary assessment (EMA) study. Twenty-eight days of data from a convenience sample of 54 18-34-year-old young Latino sexual minority men (YLSMM) was used in generalized mixed models. Participants adhered to ARTs on 96% of 1,306 person-days. Daily motivation to stay healthy, to prevent HIV transmission, and ART self-efficacy were associated with same-day adherence. Routine disruptions, poor sleep, and drug use were associated with same-day non-adherence. Stress was associated with next-day non-adherence, and increased routine disruptions with non-adherence. Findings suggest an opportunity to design and test innovative interventions for YLSMM to improve ART adherence that increase daily adherence motivation and self-efficacy and provide real-time assistance during changes in routine, poor sleep, drug use, and stress.

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.

Impact of HIV Pretreatment Drug Resistance on Secondary Transmission Through Treatment Dropout: A Prospective Population-Based Study in Southwestern China

Objective

Discontinuation of antiretroviral treatment (ART) raised drug resistance and failure of Human Immunodeficiency Virus (HIV) virological suppression. The study aimed to assess the relationship between pretreatment drug resistance (PDR) and ART dropout, as well as the relationship between HIV treatment dropout and HIV secondary transmission.

Methods

This study included all eligible participants from a local surveillance database in southwestern China between 2014 and 2021. The PDR prevalence trend was assessed using trend Chi-square tests within a consecutive cross-sectional design (N = 3060). Cox proportional hazards model was used to investigate the relationship between PDR and the risk of treatment dropout within a cohort design. Generalized Estimating Equations model was applied to explore the association between treatment dropout and HIV secondary transmission within a longitudinal genetic network study design. (N = 5094).

Results

The overall PDR prevalence was 6.2%, analyzing a study sample of 3060 individuals with HIV/AIDS. Specifically, the prevalence of PDR to non-nucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs), and protease inhibitors (PIs) was 3.6%, 1.4%, and 1.1%, respectively. Yearly difference in prevalence was not identified. The independent association between PDR to NNRTIs and treatment dropout was significant (adjusted hazard ratio: 2.55, 95% CI 1.52-4.29). Among 5094 newly diagnosed HIV cases, participants who dropped out did not show a significant difference in HIV secondary transmission compared to those not on ART (adjusted odds ratio: 1.15, 95% CI 0.74-1.79).

Conclusion

PDR to NNRTIs may contribute to HIV secondary transmission through treatment dropout. It is imperative to offer comprehensive and advanced HIV care for all individuals with HIV, enhance treatment and medication adherence, and closely monitor PDR prevalence.

Potent HIV‑1 protease inhibitors containing oxabicyclo octanol-derived P2-ligands: Design, synthesis, and X‑ray structural studies of inhibitor-HIV-1 protease complexes

We describe here the design, synthesis, and X-ray structural studies of a new class of HIV-1 protease inhibitors containing 8-oxabicyclo[3.2.1]octanol-derived P2 ligands. We investigated the functional effect of these stereochemically defined fused-poly cyclic ligands on enzyme inhibition and antiviral activity in MT-2 cells. The tricyclic core of 8-oxabicyclo[3.2.1]octan-6-ol is designed to interact with the residues in the S2 subsite of HIV-1 protease. The syntheses of the ligands were carried out using the [5+2]-cycloaddition as the key step. Several inhibitors exhibited potent enzyme inhibitory activity. High resolution room-temperature X-ray structures of inhibitor-bound HIV-1 protease were determined. These structures provided important molecular insights for further design and optimization of inhibitor potency.

Use of healthcare services preceding HIV diagnosis - missed opportunities for earlier diagnosis, Finland, 1996 to 2019

BackgroundHIV testing based on indicator conditions is recommended to diagnose HIV earlier.AimOur aim was to assess opportunities for earlier diagnosis of HIV.MethodThis is a retrospective study on people living with HIV (PLWH) included in the national HIV register. We collected data on public primary outpatient healthcare (PHC) (2011-2019), secondary and tertiary outpatient healthcare (STHC), and all inpatient care (1996-2019) from the Care Register for Health Care from the presumed acquisition, estimated by CD4+ T-cell count at diagnosis, until the diagnosis of HIV.ResultsOf 907 PLWH diagnosed between 2011 and 2019, 522 (58%) had ≥ 1 healthcare contact at any level between HIV acquisition and > 30 days before diagnosis. At least one European Centre for Disease Prevention and Control (ECDC) indicator condition was recorded for 119 (23% of 522), and 112 (21%) were born in a high-prevalence country. In total, 384 of 907 (42%) had visited a PHC physician, and 58% of those with CD4+ T-cell count < 200 cells/μL at diagnosis. Of 2,082 PLWH diagnosed between 1996 and 2019, 869 (42%) had STHC outpatient contacts > 30 days before diagnosis, 18% with ≥ 1 ECDC indicator condition, and 367 (18%) had been hospitalised, 20% with ≥ 1 ECDC indicator condition. The most common ECDC indicator conditions > 30 days before diagnosis at all levels of healthcare were pneumonia, sexually transmitted infections, unexplained fever, herpes zoster, pregnancy and lymphadenopathy.ConclusionWe recommend enhancing indicator condition-based HIV testing by all healthcare providers, particularly for gonorrhoea, syphilis and, for persons younger than 50 years, also herpes zoster and lymphadenopathy.

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.

Transgender Women in India: A Syndemic and Intersectional Framework Addressing HIV Care Gaps

The prevalence of HIV among transgender women (TGW) in India is disproportionately high, estimated at 4% to 8% in comparison with the national average of 0.2%. Despite free antiretroviral therapy (ART) provided by the government, TGW encounter multilevel barriers-including stigma, poverty, and lack of gender-affirming care-that hinder HIV care access and retention. Existing behavioral frameworks fail to address the compounded effects of systemic oppression on the health of TGW with HIV in India. We present a conceptual framework integrating syndemic theory and intersectionality to examine structural and syndemic factors shaping HIV care barriers. Informed by key informants-including TGW with HIV, community leaders, health providers, and Indian researchers-the framework highlights how systemic marginalization, particularly through discriminatory policies, shapes social position and exacerbates inequities in HIV care outcomes. It also underscores the role of community mobilization and collective action in overcoming these barriers. The framework provides a foundation for interventions tailored to the needs of TGW. By centering community-driven strategies and addressing structural inequities, it offers a pathway to improve HIV care engagement and health outcomes among TGW in India. (Am J Public Health. Published online ahead of print May 1, 2025:e1-e9. https://doi.org/10.2105/AJPH.2025.308046).

Association Between Dynamic Viral Rebound and Longitudinal Measures of Viral Load/CD4 Counts Among People with HIV in South Carolina

Monitoring HIV viral rebound (VR) is crucial, as it indicates an increased risk of infection, transmission, disease progression, and drug resistance. This study aims to identify the association between dynamic VR and historical viral load (VL)/CD4 count measures. Fifteen-year South Carolina population-based electronic health record data were used for the study. VR was defined as the return of detectable levels of VL (>200 copies/mL) after stable viral suppression (VS) (two consecutive VS, i.e., VL ≤200 copies/mL). A generalized linear mixed model was used to evaluate the association between dynamic VR and historical time-dependent predictors, such as nadir CD4 count and comorbidities, within a year prior to each VR. Subgroup analysis for men who have sex with men (MSM) was also conducted. Among 8,185 people with HIV (PWH), 1,173 (14.3%) had a history of VR. Lower nadir CD4 count (≥500 vs. <200 cells/µL; adjusted odds ratio [aOR]: 0.51, 95% confidence interval [CI]: [0.43, 0.60]), younger age (>60 years old vs. 18-30 years old; aOR: 0.43, 95% CI: [0.29, 0.63]), and being Black (Black vs. White; aOR: 1.58, 95% CI: [1.34, 1.85]) were associated with a higher risk of VR, while MSM (MSM vs. heterosexual; aOR: 0.81, 95% CI: [0.67, 0.96]) were associated with decreased VR risk. The rate of VR among PWH in South Carolina is significant. Within-1-year VL/CD4 test is critical for identifying PWH at risk for VR. Tailored interventions are needed for PWH at risk for VR to achieve sustained suppression and better health outcomes.

INSTIs-centered antiviral regimens for first-line treatment of HIV/AIDS: a network meta-analysis and cost-effectiveness analysis

OBJECTIVE

This study evaluates the efficacy, safety, and cost-effectiveness of INSTI-based antiretroviral regimens compared to the national standard first-line treatment EFV/3TC/TDF for HIV/AIDS in China. The aim is to guide clinical decision-making and improve HIV/AIDS prevention and treatment.

METHODS

A network meta-analysis was conducted using ADDIS software on data from domestic and international randomized controlled trials comparing INSTI-based regimens with EFV/3 TC/TDF. Additionally, a Markov model assessed the cost-effectiveness of the representative INSTI regimen B/F/TAF (Bictegravir/Emtricitabine/Tenofovir Alafenamide) against EFV/3 TC/TDF. Costs and health outcomes were measured in US Dollars ($) and Quality-Adjusted Life Years (QALYs), respectively, evaluating incremental cost-utility ratios (ICERs) against a willingness-to-pay threshold of 1.5 times GDP per capita.

RESULTS

Seventeen trials involving 12,620 patients were analyzed. INSTI regimens showed no significant efficacy or safety advantages over EFV/3 TC/TDF but offered better drug resistance, adherence, and quality of life improvements. Economic analysis from the patient perspective showed that B/F/TAF had an ICER of $12,714.29/QALY, which is below the willingness-to-pay threshold, indicating cost-effectiveness. From the healthcare system perspective, B/F/TAF's ICER was $23,052.77/QALY, which is above the threshold, suggesting it is not cost-effective from this perspective. Sensitivity analyses confirmed these findings, with drug costs for B/F/TAF and the probability of CD4 count increase post-EFV/3TC/TDF treatment being the largest influencing factors. Additionally, probabilistic sensitivity analysis indicated that B/F/TAF has a varying probability of economic viability depending on the willingness-to-pay threshold, highlighting its potential value in specific economic contexts.

CONCLUSION

INSTI-based regimens are as effective and safe as the national standard but offer additional benefits in drug resistance and patient compliance. B/F/TAF is economically viable from the patient perspective but does not present a cost-utility advantage from the healthcare system perspective. This study underscores the need for considering both clinical and economic factors in selecting first-line HIV/AIDS treatments in China.

Effects of a Faith-Based, Multilevel Intervention on HIV-Related Stigma and HIV Knowledge Among African American Church-Affiliated Populations

BACKGROUND

HIV-related stigmas contribute to HIV disparities, which faith-based organizations could address, but few studies have measured faith-based HIV intervention effects on HIV-related stigmas.

METHODS

Taking It to the Pews (TIPS) is a multilevel, religiously tailored HIV prevention intervention developed and implemented with faith leaders. Over 12 months, trained church health liaisons implemented the TIPS Toolkit (e.g., HIV sermon guides and responsive readings, testimonials) with the primary aim of increasing HIV testing. A cluster randomized controlled trial with 14 predominantly African American churches in Kansas City, MO, compared TIPS to a non-tailored, multilevel HIV education intervention; both intervention and comparison groups offered church-based HIV testing events with the local health department. We examined whether TIPS affected HIV stigma among congregants and community members, specifically, HIV discomfort (5-item scale), anticipated HIV stigma (4-item scale), and overall HIV stigma (11-item scale), while controlling for known correlates of HIV stigma.

RESULTS

We recruited 1491 church and community members at 14 churches. Compared to standard HIV education, TIPS did not decrease HIV discomfort or overall HIV stigma and did increase anticipated HIV stigma. A secondary analysis found that among intervention participants, intervention exposure was associated lower stigma and higher HIV knowledge, with HIV testing events and information from health professionals or HIV + people being particularly influential.

CONCLUSION

Direct contact with health professionals and HIV + people can help reduce stigma among church-affiliated populations, but broader exposure and strategies are needed for congregation-level stigma. Stigma reduction and HIV testing may have synergistic effects in faith-based settings.

Traditional and psychosocial factors associated with non-communicable diseases among people living with HIV in Cambodia: a cross-sectional study

We examined traditional and psychosocial factors associated with self-reported diabetes, hypertension, raised cholesterol, and multimorbidity among 4,089 people living with HIV in Cambodia. Participants were recruited from 20 antiretroviral therapy (ART) clinics across nine provinces and the capital city in 2021. Multiple logistic regression analyses assessed the associations between sociodemographic variables, HIV-related information, and psychosocial factors with the outcome variables. The prevalence of diabetes, hypertension, and raised cholesterol were 7.8%, 16.9%, and 6.6%, respectively. Non-adherence to ART (adjusted odds ratio [aOR]: 1.55, 95% confidence interval [CI]: 1.04-2.32), low self-efficacy in attending ART clinics regularly (aOR: 2.02, 95% CI: 1.16-3.53), and poor quality of life (aOR: 1.48, 95% CI: 1.13-1.94) were significantly associated with all outcomes. Interestingly, lower perceived social support was significantly associated with lower odds of hypertension (aOR: 0.52, 95% CI: 0.33-0.83) and multimorbidity (aOR: 0.40, 95% CI: 0.20-0.80). Past experiences with HIV-related stigma and discrimination were significantly associated with a higher likelihood of diabetes (aOR: 1.97, 95% CI: 1.23-3.15) and multimorbidity (aOR: 1.87, 95% CI: 1.23-2.85). Community-based interventions to enhance peer support and reduce stigma and discrimination may help decrease non-communicable diseases (NCDs), and integrating HIV and NCD programs could improve healthcare access among people living with HIV.

Model-based evaluation of the impact of a potential HIV cure on HIV transmission dynamics

The development of an HIV cure is a global health priority, with the target product profile (TPP) for an HIV cure guiding research efforts. Using a mathematical model calibrated to data from men who have sex with men (MSM) in the Netherlands, we assessed whether an effective cure could help end the HIV epidemic. Following the TPP, we evaluated two scenarios: (i) HIV remission, where the virus is suppressed in an individual without ongoing antiretroviral therapy (ART) but may rebound, and (ii) HIV eradication, which aims to completely remove the virus from the individual. Here, we show that sustained HIV remission (without rebound) or HIV eradication could reduce new HIV infections compared to a scenario without a cure. In contrast, transient HIV remission with a risk of rebound could increase new infections if rebounds are not closely monitored, potentially undermining HIV control efforts. Our findings emphasize the critical role of cure characteristics in maximizing cure benefits for public health and highlight the need to align HIV cure research with public health objectives to end the HIV epidemic.

A modeling study of pre-exposure prophylaxis to eliminate HIV in Taiwan by 2030

BACKGROUND

The necessity of pre-exposure prophylaxis (PrEP) for ending the global AIDS epidemic by 2030 remains controversial. In Taiwan, the HIV epidemic predominantly affects young, sexually active men who have sex with men (MSM). This study aimed to model the impact and cost-effectiveness of a high-coverage oral emtricitabine/tenofovir PrEP program in Taiwan from an HIV elimination perspective.

METHODS

We applied stochastic and risk/age-structured deterministic modeling to assess the impact of PrEP scale-up on the basic reproduction number (R0) and the trajectory of the HIV epidemic in Taiwan, respectively. Both models were parameterized using the national HIV registry and cascade data. Cost-effectiveness was evaluated from a societal perspective.

RESULTS

Here we show that an intensive HIV test-and-treat strategy targeting HIV-positive individuals alone would substantially decrease HIV transmission but is not sufficient to eliminate the HIV epidemic among MSM at the estimated mixing level. In contrast, a PrEP program covering 50% of young, sexually active, high-risk, HIV-negative MSM would suppress HIV's R0 below 1, facilitating its elimination. It would also reduce HIV incidence to levels below the World Health Organization's HIV elimination threshold (1/1000 person-years) by 2030 and is highly cost-saving, yielding a benefit-cost ratio of 7.16. The program's effectiveness and cost-effectiveness remain robust even under conditions of risk compensation (i.e., no condom use among PrEP users), imperfect adherence (75%), or low-level emtricitabine/tenofovir resistance (1%).

CONCLUSION

Our findings strongly support scaling up PrEP for young, sexually active, high-risk, HIV-negative MSM as a critical strategy to end the HIV epidemic in Taiwan and globally.

Impact of CD4+ T cell and TCR repertoires on SARS-CoV-2-Specific antibody responses in PLWH following COVID-19 vaccination

In people living with human immunodeficiency virus (HIV, PLWH), the coronavirus disease 2019 (COVID-19) vaccine often results in a limited humoral immune response. While a reduced absolute CD4+ T cell count is a known factor, other determinants remain unclear. To investigate variables influencing the differential antibody response to the COVID-19 vaccine in PLWH, 43 HIV-1/AIDS patients receiving antiretroviral therapy (ART) and 2 doses of the COVID-19 vaccine were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific immunoglobulin G (IgG) levels and neutralizing antibody (NAb) titers. A retrospective analysis was also performed, examining immune reconstitution and epidemiological history, including annual CD4+ T-cell counts and the duration of HIV-1 infection. To further elucidate the role of CD4+ T cells in the antibody response to the COVID-19 vaccine, next-generation sequencing was used to analyze the T cell receptor (TCR) profiles of CD4+ T cells from twelve representative individuals. The results showed that the SARS-CoV-2-specific antibody response in PLWH was not solely determined by the current CD4+ T cell count, the progression of immune reconstitution and the TCR profile of CD4+ T cells also played significant roles. These findings provide critical insights into the multifaceted roles of CD4+ T cells in SARS-CoV-2-specific antibody responses in PLWH following COVID-19 vaccination.

Impact of Switching to Long-Acting Injectable Cabotegravir Plus Rilpivirine on Rectal HIV-1 RNA Shedding and Implications for Transmission Risk

BACKGROUND

The impact of long-acting injectable cabotegravir plus rilpivirine (CAB/RPV) on rectal human immunodeficiency virus 1 (HIV-1) RNA dynamics and the factors associated with viral shedding remain poorly understood.

METHODS

This prospective study evaluated HIV-1 RNA dynamics by analyzing sequential paired plasma and rectal fluid samples from virologically suppressed individuals who transitioned from oral antiretroviral therapy (ART) to every-2-month CAB/RPV (preceded or not by oral lead-in), over a 9-month follow-up period. RPV trough concentrations were measured in 384 rectal samples.

RESULTS

In total, 597 plasma and 561 rectal samples from 90 participants were analyzed. HIV-1 RNA >50 (>1.69 log10) copies/swab was detected in 14.7% (59/401) of rectal samples (42.2% of participants) during intramuscular CAB/RPV, and in 17.5% (28/160) of rectal samples (29% of participants) during oral ART. Median detectable rectal HIV-1 RNA level during intramuscular ART was 362 (range, 133-2216) copies/swab. The frequency and quantity of rectal shedding did not differ between groups with/without oral lead-in. No correlation was observed between rectal shedding and detectable plasma HIV-1 RNA. Median rectal RPV concentration was 3.07 (quartile 1-quartile 3, 2.83-3.35) log10 ng/swab, 1.6-fold above the 90% maximum effective concentration (EC90) for rectal tissue, and did not correlate with rectal HIV-1 RNA levels. Rectal shedding was associated with plasma pre-ART HIV-1 RNA >5 log10 in multivariate Cox regression, but was unrelated to established predictors of virological failure with CAB/RPV.

CONCLUSIONS

Rectal HIV-1 shedding is common during bimonthly intramuscular CAB/RPV treatment and is also observed with oral ART. Shedding was independent of concurrent plasma HIV-1 RNA and rectal RPV concentrations, and was associated with pre-ART viral load.

The impact of a comprehensive strategy on HIV treatment continuum in a highly endemic area of China: an interrupted time series analysis

BACKGROUND

A comprehensive strategy encompassing universal testing and strengthened treatment was promoted to address the severe HIV epidemic in Liangshan. This study aimed to assess the impact of this strategy on HIV treatment continuum.

METHODS

Interrupted time series (ITS) analysis was utilized to evaluate the impact of a comprehensive strategy on HIV treatment outcomes in Liangshan from 2014 to 2021 utilizing data from China's HIV/AIDS Comprehensive Response Information Management System (CRIMS). Poisson or quasi-Poisson segmented regression models were applied to estimate the trends and immediate changes in key outcomes, including the proportion of 30-day antiretroviral therapy (ART) initiation, the proportion of 6-month follow-up, and the proportion of viral suppression, following the strategy's implementation in January 2018. The analysis was stratified by sex, age, transmission route, and region, with areas classified as key areas and non-key areas based on an HIV prevalence threshold of 1%.

RESULTS

A total of 37,888 people living with HIV (PLHIV) were identified during the study period, with an increase in diagnoses following comprehensive strategy implementation. Most cases involved males, aged 15-34 years, residents of key areas, and individuals infected through heterosexual transmission. There was a significant increase of 2.50-fold in 30-day ART initiation (incidence rate ratio [IRR] 2.501, 95% CI: 1.694-3.694), 34.0% in 6-month follow-up (1.340, 95% CI: 1.234-1.456), and 17.7% in viral suppression (1.177, 95% CI: 1.068-1.296) in the first month of comprehensive strategy implementation. Over time, all three indicators displayed an upward trend, and by December 2021, their predicted values significantly increased, exceeding the expected levels by 60.3% (IRR 1.603, 95% CI: 1.108-2.318), 62.9% (1.629, 95% CI: 1.430-1.855), and 50.6% (1.506, 95% CI: 1.223-1.855), respectively. Subgroup analysis revealed that while the strategy's effects on these outcomes were generally consistent, the magnitude of improvement varied. Residents of key areas exhibited more significant increases in 30-day ART initiation, while residents of non-key areas, particularly those aged ≥ 60 years, displayed smaller increases in the proportion of 6-month follow-up, and no significant change in the proportion of viral suppression, with a slightly lower average.

CONCLUSIONS

The implementation of a comprehensive strategy substantially improved timely ART initiation, follow-up care after ART and viral suppression for PLHIV in Liangshan, with consistent enhancements across various subpopulations. It is imperative to strengthen comprehensive strategy in non-key areas of Liangshan, and to promote these strategies in other similar regions in order to enhance health benefits for patients.

Impact of increasing CD4 count threshold eligibility for antiretroviral therapy initiation on advanced HIV disease and tuberculosis prevalence and incidence in South Africa: an interrupted time series analysis

INTRODUCTION

We investigated the impact of increasing CD4 count eligibility for antiretroviral therapy (ART) initiation on advanced HIV disease (AHD) and tuberculosis (TB) prevalence and incidence among people living with HIV (PLHIV) in South Africa.

METHODS

We conducted an interrupted time series analysis with de-identified data of PLHIV aged ≥15 years initiating ART between April 2012 and February 2020 at 65 primary healthcare clinics in KwaZulu-Natal, South Africa. Outcomes included monthly proportions of new ART initiators presenting with AHD (CD4 count <200 cells/µL) and TB disease. We created a cohort of monthly ART initiators without TB and evaluated the cumulative incidence of TB within 12 months follow-up. We used segmented binomial regression models to estimate relative risks (RR) of outcomes, allowing for a step and slope change after expanding the ART initiation CD4 count eligibility from <350 to <500 cells/µL in January 2015 and following Universal Test and Treat (UTT) implementation in September 2016.

RESULTS

Among 209 984 participants, median age was 32 (range: 26-38), and 141 499 (67.4%) were female. After January 2015, the risk of AHD at initiation decreased in step by 25.0% (RR=0.750, 95% CI 0.688 to 0.812) and further reduced by 26.9% following UTT implementation (RR=0.731, 95% CI 0.681 to 0.781). The risk of TB at initiation also decreased in step by 27.6% after January 2015 (RR=0.724, 95% CI 0.651 to 0.797) and further decreased by 17.4% after UTT implementation (RR=0.826, 95% CI 0.711 to 0.941) but remained stable among initiators with AHD. Among the incidence cohort, we saw a step decrease in the risk of new TB by 31.4% (RR=0.686, 95% CI 0.465 to 0.907) following UTT implementation. Among the incidence cohort with AHD, there was weak evidence of a step decrease in the risk of new TB (RR=0.755, 95% CI 0.489 to 1.021), but the slope decreased by 9.7% per month (RR=0.903, 95% CI 0.872 to 0.934) following UTT implementation.

CONCLUSIONS

Our data support the added benefit of decreased TB co-burden with expanded ART access. Early diagnosis and immediate linkage to care should be prioritised among PLHIV.

Blood-Borne Infection Prevention in Combat Sports: Position Statement of the Association of Ringside Physicians

ABSTRACT

The Association of Ringside Physicians (ARP) emphasizes the importance of screening combat sports athletes for blood-borne infections, including hepatitis B, HIV, and hepatitis C, to mitigate transmission risks and ensure participant safety. Although transmission of hepatitis B and C and HIV in combat sports is rare, protecting athletes is of utmost importance. It is the recommendation of the ARP that all fighters participating in combat sports, in which the presence of blood is a common occurrence and is allowed during competition, should undergo testing for HIV, hepatitis B (HBV), and hepatitis C (HCV). Testing should be conducted using serum samples, because rapid tests are not considered acceptable for accurate results. Testing for HBV, HCV, and HIV should optimally be done within 3 months of competition, but within 6 months is acceptable. Athletes whose tests suggest active HBV, HCV, or HIV infection should be disqualified from competition in sports where blood is common and allowed. Athletes with cured prior HCV infection may be cleared for competition in all combat sports. Athletes with prior HBV infection and no detectable HBV DNA in blood can be cleared for competition in all combat sports. Athletes with latent HBV infection with detectable HBV DNA in blood have a small risk of disease reactivation, so they should not be cleared.

Increasing Sustained Viral Suppression Among Youth Living with HIV: A Randomized Controlled Trial of Stepped Care Intervention

This study aimed to decrease viral load (VL) to increase viral suppression (VS) among youth living with HIV (YLH) ages 12-24. This study was a stepped care randomized controlled trial. Sixty-eight YLH with established infection, without VS, and with at least two follow-ups (N = 68) were randomized to a control condition (n = 25) or a stepped care intervention (n = 43), and repeatedly assessed for up to 24 months. Both conditions received referrals for health services and a daily automated text-messaging and monitoring intervention (AMMI). YLH in stepped care who were unsuppressed at 4-month assessments stepped up to peer support and later to coaching. Random effects regressions examined VL trajectories over time as well as trajectories of secondary outcomes. There was significant evidence suggesting a different longitudinal trajectory of VLs for the two conditions. The control condition had improved VLs at about 12 months and then started to return to higher VLs. The stepped-care condition improved over the same time period and remained relatively stable. We estimated that the average VL was lower in the stepped care condition at 24 months, but we cannot claim a statistically significant difference between conditions. Both intervention groups appeared to have positive intervention impacts suggesting some benefits of the AMMI intervention. The improvement in VL at 24 months for stepped care compared to the control condition are suggestive of a viable intervention strategy that warrants further study.

Barriers to Retention in Care among Adults with HIV in Developed Countries: An Integrative Review

Focusing on factors hindering viral suppression is essential for improving the health outcomes of people with Human Immunodeficiency Virus (HIV) and working towards ending the HIV/AIDS epidemic. The aim of this integrative review is to create an overview of barriers to retention in care among adults with HIV living in developed countries. Based on a systematic literature search across EMBASE, PubMed, Scopus, CINAHL, and PsycInfo, 4,089 studies of various methodology were identified. A total of 52 studies met the inclusion criteria. Quality assessment was performed using the Mixed Method Appraisal Tool. Based on thematic analysis, the following five main themes were identified as most common barriers to retention in care: financial challenges, logistical challenges, stigma, mental health problems, and substance use. The integrative review highlights that various factors can hinder retention in care and underscores that strategies to promote retention in care should be person-centered and targeted the individual person's barriers to retention in care.

Prevalence of drug resistance mutations in low-level viremia patients under antiretroviral therapy in Southwestern China: a cross-sectional study

OBJECTIVES

This study aimed to evaluate the prevalence and characteristics of drug resistance mutations (DRMs) in patients with low-level viremia (LLV) in Southwestern China, as it has become a growing challenge in AIDS clinical practice.

METHODS

This cross-sectional study was performed in Yunnan Province, Southwestern China. LLV was defined as 50-999 copies/mL of plasma viral load with antiretroviral therapy (ART) for at least 6 months. HIV-1 DRM detection used validated in-house protocol.

RESULTS

A total of 470 sequences were obtained, and 13 HIV-1 genotypes were identified, among which CRF08_BC (47.5%), CRF07_BC (22.3%) and CRF01_AE (10.0%) subtypes were the most prevalent. The overall prevalence of DRMs was 45.7% (215/470), and the prevalence of DRMs to non-nucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs) and protease inhibitors (PIs) was 39.4% (185/470), 20.6% (97/470) and 5.3% (25/470), respectively. The most common NNRTI-associated mutations were K103N (16.0%), E138A (6.6%), V179D (6.6%) and P225H (4.9%), and those in NRTIs were M184V (17.0%), D67N (3.4%) and K65R (3.0%). PI-associated mutations were infrequent, occurring in less than 1.8% of cases. The prevalence of NNRTI-associated mutations (K101E and Y188C) was found to be statistically significant among various LLV groups. Additionally, significant variations were observed in the prevalence of NNRTI-associated mutations (V106I, V106M, E138A and P225H), NRTI-associated mutation (K65R) and PI-associated mutations (L33F and Q58E) across different subtypes.

CONCLUSIONS

The prevalence of DRMs in ART-experienced patients with LLV was high, and HIV-1 genotypes exhibited diversity in Yunnan Province. These findings indicate that regular DRM monitoring during LLV episodes was essential for effective clinical treatment and management in this region.

Association between substance use disorders and sustained viral suppression: a longitudinal analysis among people with HIV in South Carolina

OBJECTIVES

Substance use disorders (SUDs) are a significant public health concern across the United States and may pose a risk to achieving sustained viral suppression (SVS) in people with HIV (PWH). This study aims to examine the association between SUDs and SVS among PWH.

DESIGN

Using electronic health records from the South Carolina Department of Health, we conducted a retrospective study of adults with HIV who were diagnosed between January 2006 and December 2019.

METHODS

The impact of SUDs on SVS was assessed using generalized linear mixed model. Potential confounders included age, sex, chronic diseases history, etc. Stepwise selection was performed to decide the confounders included in the final model, and the optimal correlation structure was determined by Akaike information criterion.

RESULTS

Of the 9412 eligible participants, 7481 (79.48%) had reached SVS status during their follow-up periods. SUDs related to alcohol [adjusted odds ratio (AOR) = 1.70, 95% confidence interval (CI): 1.46-1.98], cannabis (AOR = 1.62, 95% CI: 1.35-1.95), cocaine (AOR = 1.95, 95% CI: 1.60-2.37), opioid (AOR = 1.91, 95% CI: 1.13-3.23), and tobacco (AOR = 1.80, 95% CI: 1.69-1.92) were negatively associated with SVS. Individuals with chronic conditions such as cardiovascular disease (AOR = 0.31, 95% CI: 0.29-0.33), diabetes (AOR = 0.49, 95% CI: 0.41-0.59), and cancer (AOR = 0.47, 95% CI: 0.38-0.58) showed a higher likelihood of maintaining SVS.

CONCLUSION

This large cohort study of PWH with extended follow-up highlights the negative impact of SUDs on maintaining SVS. Long-term strategies for reducing substance use could support SVS in PWH.

Employment Status and HIV Viral Load in Chilean Adult Population: A Propensity Score Analysis

We set out to investigate the potential impact of unemployment on HIV viral load in individuals living with HIV at the biggest HIV-related healthcare centre in Chile. We analysed a cross-sectional dataset of 803 adults living with HIV on antiretroviral therapy. The main exposure was employment status. The outcome, detectable HIV viral load, was operationalised using a cut-off of HIV viral load at 20 copies/mL. We applied a propensity score method, the inverse probability of treatment weighting to control for measured confounders. We found that 219 (27.3%) of participants were unemployed. Being unemployed was associated with increased odds of being detectable (OR = 1.78, 95%CI = 1.18-2.71) compared to being employed. Additionally, we found that those unemployed and non-adherents have higher odds of being detectable (OR = 2.53, 95%CI = 1.18-5.41). Unemployment status may influence HIV viral load. However, further research is needed to determine and understand the social structure behind those relationships in the Chilean people living with HIV.

The Impact of a Couple-Based Intervention on One-Year Viral Suppression Among Pregnant Women Living With HIV and Their Male Partners in Malawi: A Randomized Controlled Trial

INTRODUCTION

Couple-based behavioral interventions (CBIs) have been associated with improved HIV virological outcomes for pregnant women and their male partners living with HIV in observational settings, but have never been tested in a randomized controlled trial (RCT).

SETTING

Bwaila District Hospital Antenatal Clinic (Lilongwe, Malawi).

METHODS

An RCT was conducted among 500 pregnant women living with HIV (index clients) randomized 1:1 to the standard of care (SOC) or CBI and followed for 1 year. The CBI offered an initial session for index clients, HIV-assisted partner notification, 2 enhanced couple counseling and testing sessions, illustrated materials, and antiretroviral therapy pickup for either couple member at the antenatal clinic. At 12 months, viral load among index clients and male partners with HIV was measured. Risk differences (RD) and 95% confidence intervals (CIs) compared viral suppression (<1000 copies/mL) between arms.

RESULTS

The mean index client age was 26.6 years; most were married or cohabiting (93.3%). Index client viral suppression was 6.5% higher in the CBI arm (88.0%) than in the SOC arm (81.6%). Male partner viral suppression was 16.2% higher in the CBI arm (73.6%) than the SOC arm (57.4%). Overall, couple viral suppression was 7.8% higher (CI: 0.5% to 15.1%, P = 0.04) in the CBI arm (84%) than in the SOC arm (76.0%). Social harms were rare (3.6%) and comparable between arms ( P = 0.8).

CONCLUSIONS

This CBI had a positive impact on couple viral suppression. Scaling this CBI to antenatal clients with HIV and their male partners could improve HIV outcomes among expecting families.

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.

The Longitudinal Impact of Psychosocial Syndemic Variables on Adherence to Antiretroviral Therapy Among People With HIV in Brazil, Thailand, and Zambia: An Analysis by HIV Transmission Groups in HPTN 063

In the field of HIV prevention and care, most studies of HIV syndemic problems are cross-sectional, few differentiate by HIV transmission groups, and few focus on people living with HIV (PWH). We analyzed one-year longitudinal data of 692 sexually active PWH (heterosexual men [HM], heterosexual women [HW], and men who have sex with men [MSM]) in care from Brazil, Thailand, and Zambia. Syndemic scores (0-3+) included stimulant use, polydrug use, depression, alcohol use, and fear of discrimination. Overall, syndemic scores were associated with lower ART adherence over time, but this differed across sexual transmission categories. For HM and HW, those with 2 or 3+ syndemic problems had lower odds of ART adherence than those with none. However, for MSM, the association between syndemic scores and ART adherence was not significant. While syndemic problems generally predicted suboptimal ART adherence among PWH, the association appears nuanced across subgroups.

Population-Level Risks for HIV Mortality During the COVID-19 Pandemic in the United States by Demographic Characteristics and Medicaid Access, 2020‒2021

Objectives. To evaluate the impact of the COVID-19 pandemic on HIV mortality rates with a focus on demographic predictors and Medicaid access. Methods. Using Wide-Ranging Online Data for Epidemiologic Research, we conducted a descriptive study comparing HIV mortality in the United States 2 years before the COVID-19 pandemic (2018-2019) and the initial 2 years of the pandemic (2020-2021), and identifying HIV mortality factors during the pandemic. Results. During the first 2 years of the pandemic, crude HIV death rates increased and then decreased marginally. COVID-19 and HIV together contributed to 11% of the HIV death rate. While African Americans had a higher HIV mortality rate, there was a slight decrease during the pandemic. Nonelderly adults in Medicaid expansion states had lower HIV mortality than those in nonexpansion states. Conclusions. Contrary to initial concerns, we found no substantial increase in HIV mortality. A slight decrease was observed with persisting racial disparities in mortality and lower mortality in states that expanded Medicaid. Public Health Implications. The study findings can inform the development of policies to address demographic disparities in HIV mortality through targeted system-level interventions for vulnerable populations, such as Medicaid expansion and Ryan White Program services. (Am J Public Health. 2025;115(4):579-587. https://doi.org/10.2105/AJPH.2024.307916).

Low CD4 count was characterized in recent HIV CRF01_AE infection and it rapidly increased to reach a peak in the first year since ART initiation

BACKGROUND

Currently, most people living with HIV (PLWH) in China have a strong awareness of diagnosis and treatment in the early stage of HIV infection. Subtype-specific virological and immunological features of recently infected PLWH have not yet been elucidated.

METHODS

Data including CD4 count and viral load (VL) of 1508 anti-retroviral therapy (ART) -naïve PLWH were obtained from the HIV Database and comparatively analyzed among PLWH with different HIV subtypes. The infection status of 402 newly diagnosed and ART-naïve PLWH from a cohort of men who have sex with men (MSM) in China was evaluated using diagnosis records and LAg-Avidity EIA. Based on partial pol genes, HIV genotypes in 120 recent, 68 long-term, and 54 chronic infections were identified. The CD4 count, CD8 count, and VL, as well as trajectories of dynamic CD4 counts during ART of local PLWH with different HIV subtypes, were compared using non-parametric tests.

RESULTS

For the HIV database, the CD4 count in PLWH with CRF01_AE was lower than that in PLWH with CRF07_BC or subtype B. For the recently infected local PLWH, CRF01_AE was the dominant HIV subtype (65.83%), followed by CRF07_BC (18.33%) and subtype B (15.83%). Recent CRF01_AE infections showed a lower baseline CD4 count than CRF07_BC infections. During ART for recently infected PLWH, the CD4 count in the CRF01_AE group rapidly increased to reach a peak at the end of the first year post-ART, while the CD4 count in the CRF07_BC group increased slowly to reach a plateau at the end of the third year. The CD4 count in the subtype B group increased significantly to reach a plateau within the first two years and then its trajectory overlapped with that of the CRF07_BC group at the end of the third year post-ART.

CONCLUSIONS

CRF01_AE rapidly reduced CD4 count during the recent HIV infection. The CD4 count of the recently infected individuals with CRF01_AE increased sharply and reached its highest level of recovery within the first year of ART initiation. This study revealed an important time point for estimating CD4 count recovery post-ART in individuals with different HIV subtypes.

Mobile Health Tool to Capture Social Determinants of Health and Their Impact on HIV Treatment Outcomes Among People Who Use Drugs: Pilot Feasibility Study

Background

Active substance use, food or housing insecurity, and criminal legal system involvement can disrupt HIV care for people living with HIV and opioid use disorder (OUD). These social determinants of health are not routinely captured in clinical settings.

Objective

We evaluated whether real-time reports of social and behavioral factors using a smartphone app could predict viral nonsuppression and missed care visits to inform future mobile health interventions.

Methods

We enrolled 59 participants from the AIDS Linked to the Intravenous Experience (ALIVE) Study in Baltimore, Maryland, into a 12-month substudy between February 2017 and October 2018. Participants were eligible if they had OUD and had either a measured HIV RNA ≥1000 copies/mL or a ≥1-month lapse in antiretroviral therapy in the preceding 2 years. Participants received a smartphone and reported HIV medication adherence, drug use or injection, and several disruptive life events, including not having a place to sleep at night, skipping a meal due to lack of income, being stopped by police, being arrested, or experiencing violence on a weekly basis, through a survey on a mobile health app. We described weekly survey completion and investigated which factors were associated with viral nonsuppression (HIV RNA ≥200 copies/mL) or a missed care visit using logistic regression with generalized estimating equations adjusted for age, gender, smartphone comfort, and drug use.

Results

Participants were predominantly male (36/59, 61%), Black (53/59, 90%), and had a median of 53 years old. At baseline, 16% (6/38) were virally unsuppressed. Participants completed an average of 23.3 (SD 16.3) total surveys and reported missing a dose of antiretroviral therapy, using or injecting drugs, or experiencing any disruptive life events on an average of 13.1 (SD 9.8) weekly surveys over 1 year. Reporting use of any drugs (adjusted odds ratio [aOR] 2.3, 95% CI 1.4-3.7), injecting drugs (aOR 2.3, 95% CI 1.3-3.9), and noncompletion of all surveys (aOR 1.6, 95% CI 1.1-2.2) were associated with missing a scheduled care visit over the subsequent 30 days. Missing ≥2 antiretroviral medication doses within 1 week was associated with HIV viral nonsuppression (aOR 3.7, 95% CI: 1.2-11.1) in the subsequent 30 days.

Conclusions

Mobile health apps can capture risk factors that predict viral nonsuppression and missed care visits among people living with HIV who have OUD. Using mobile health tools to detect sociobehavioral factors that occur prior to treatment disengagement may facilitate early intervention by health care teams.

Promoter Methylation of HIV Coreceptor-Related Genes CCR5 and CXCR4: Original Research

The persistence of human immunodeficiency virus (HIV) within viral reservoirs poses significant challenges to eradication efforts. Epigenetic alterations, including DNA methylation, are potential factors influencing the latency and persistence of HIV. This study details the development and application of techniques to assess CpG methylation in the promoter regions of the CCR5 and CXCR4 genes, which are key HIV-1 coreceptors. Using both Sanger sequencing and pyrosequencing methods, we examined 51 biological samples from 17 people living with HIV at three time points: baseline (week 0) and post-antiretroviral therapy (ART) at weeks 24 and 48. Our results revealed that CXCR4 promoter CpG sites were largely unmethylated, while CCR5 promoter CpGs exhibited significant variability in methylation levels. Specifically, CCR5 CpG 1 showed a significant decrease in methylation from week 0 to week 48, while CXCR4 CpG 3 displayed a significant decrease between week 0 and week 24. These differences were statistically significant when compared with non-HIV-infected controls. These findings demonstrate distinct methylation patterns between CCR5 and CXCR4 promoters in people living with HIV over time, suggesting that epigenetic modifications may play a role in regulating the persistence of HIV-1. Our techniques provide a reliable framework for assessing gene promoter methylation and could be applied in further research on the epigenetics of HIV.

Factors affecting viral suppression or rebound in people living with HIV and receiving antiretroviral therapy in Ghana

Introduction

Regular viral load (VL) testing for people living with HIV (PLWH) is key to attaining the Joint United Nations Program on HIV/AIDS (UNAIDS) Fast-Track 95-95-95 target to end the HIV epidemic by 2030. However, VL testing remains sporadic in routine HIV care in the majority of resource-limited settings, including Ghana, except when provided through research initiatives. In this study, we measured VL among PLWH in Ghana at regular intervals and investigated factors affecting viral suppression (VS) and rebound.

Methods

We analyzed data from a hospital-based cohort enrolled in our HIV cure research. Participants were recruited from three hospitals in the Greater Accra region of Ghana. Demographic characteristics were obtained from participants' folders, while CD4+ T cell counts and VLs were measured from blood samples collected at baseline, 6 months, and 18 months.

Results

The study participants were predominantly women (68%) with a median age of 45 years (IQR: 21-76 years). A total of 52% of participants had been on antiretroviral therapy (ART) for more than 6 years, and 74% were following dolutegravir-based regimens. At baseline, 74% of participants had a VL of <50 copies/mL, which increased to 88% at 18 months, with 80% having a CD4+ T cell count of >350 cells/μl. Age group [<40 vs. > 40 years] (OR 2.35, 95% CI; 1.21-4.58, p = 0.012), CD4+ T cell count [>350 vs. < 350 cells/μl] (OR 4.35, 95% CI; 2.32-8.18, p < 0.001), and ART regimen [NVP based vs. DTG based] (OR 7.00, 95% CI; 1.15-42.57, p = 0.034) were associated with VS of <50 copies/mL. The overall viral rebound rate was estimated at 13.61 per 1,000 person-months (95% CI 10.52-17.74), with decreasing rates over time. Lower educational levels (up to Junior High School) were significantly associated with viral rebound (p = 0.011).

Conclusion

A key feature of our study was measuring VL at three time points over 2 years, which may explain the high VS levels observed. Viral rebound was linked to low education levels, highlighting the need for targeted education for PLWH with junior high school (JHS) education or less. Regular VL monitoring and the implementation of measures to prevent viral rebound, particularly among PLWH with lower education levels, will help Ghana move closer to attaining the third "95" of the UNAIDS 95-95-95 target by 2030.

Estimating HIV incidence in Türkiye: results from two mathematical models

BACKGROUND

The number of HIV patients has been decreasing globally due to world-wide efforts to end this epidemic; however, HIV incidence has been significantly increasing in Türkiye in the last five years. This study aimed to develop mathematical models to analyze and forecast HIV incidence and prevalence in Türkiye up to 2030.

METHODS

First, we utilized a Bernoulli model and estimated the annual HIV incidence for risk groups such as heterosexuals (HET), men who have sex with men (MSM), persons who inject drugs (PWID) and female sex workers (FSW). We then developed a dynamic compartmental model of HIV transmission and progression to estimate the incidence of HIV from 2024 to 2030 and further determine the continuum of care levels, such as the proportion of people living with diagnosed HIV and the proportion of people receiving antiretroviral treatment. We also conducted sensitivity analyses for both models on key parameters to explore the robustness of our results.

RESULTS

The Bernoulli model indicates that the majority of HIV incidence is driven by two primary risk groups: men who have sex with men (MSM) (41%) and high-risk heterosexuals (HET) (38%). While the risk of HIV transmission is high for people who inject drugs (PWID) (0.07%) and female sex workers (FSW) (0.85%), their contribution to total incidence is lower due to their smaller population sizes. Results from the dynamic compartmental model predict that both the incidence of HIV and the number of HIV-related deaths will continue to rise over the next decade. HIV incidence is projected to reach 27,036 cases in 2025 and increase 2.9-times to 105,202 cases by 2030. According to our models, a significant portion of the HIV-positive population remains undiagnosed (49%), and individuals at high risk of HIV transmission (41% of estimated HIV incidence) are the primary drivers of the epidemic.

CONCLUSIONS

The number of HIV cases could significantly increase with existing prevention efforts, and HIV could become a major public health threat in the near future in Türkiye.

The effect of antidepressant treatment on viral suppression among people with HIV diagnosed with depression in an urban clinic

OBJECTIVE

To estimate the effect of antidepressant initiation on viral nonsuppression among people with HIV (PWH) with clinically recognized, untreated depression.

DESIGN

Retrospective, observational cohort study.

METHODS

We included clinical diagnoses of depression from January 2012 to June 2022 among PWH in the Johns Hopkins HIV Clinical Cohort without another serious psychiatric illness who had initiated antiretroviral therapy. We excluded diagnoses less than 90 days from a prior diagnosis, antidepressant prescription, or greater than one mental health visits. We estimated the association between initiating an antidepressant within 1 month of the index depression diagnosis and viral load nonsuppression (>200 copies/ml) on the first viral load 3-12 months subsequent. We adjusted for a comprehensive set of demographic and clinical confounders.

RESULTS

We included 2346 depression diagnoses among 946 patients; patients initiated an antidepressant following 16%. The risk of viral nonsuppression in the absence of antidepressant treatment was 15.6% [95% confidence interval (CI): 13.1-18.4]. Antidepressant initiation was not associated with viral nonsuppression (risk difference: 0.5%; 95% CI: -3.7 to 4.8) or secondary outcomes: improvement or resolution of depressive symptoms or adherence to scheduled clinic visits.

CONCLUSION

In this sample of patients with as-yet-untreated depression, in a setting with co-located, low-barrier psychiatric services, antidepressant treatment was not associated with improved viral suppression. Pharmacologic management of depression has documented benefits in other studies. However, there may be a subset of PWH with depression who have been previously unsuccessfully treated with antidepressants who are less likely to respond to approved pharmacologic options and who require different interventions to improve their viral suppression.

HIV and Syphilis Prevalence, Trends and Factors Affecting HIV Testing Among Female Sex Workers in Morocco

We investigate factors affecting ever HIV testing and HIV testing in the past 12 months among female sex workers (FSW) in Agadir, Rabat, Fes, and Tangier, Morocco over four rounds of HIV biological and behavioral surveillance surveys (2012, 2016, 2019, and 2023). Findings are used to inform programmatic and policy responses and provide information to monitor epidemic trends. The 2012, 2016, 2019, and 2023 FSW surveys were carried out by the Ministry of Health and Social Protection National AIDS Program, and the National Institute of Hygiene with support from UNAIDS and the Global Fund. HIV prevalence decreased with no evidence of significant declining trends over time in Agadir, Fes, and Tangier, and increased with evidence of a strong linear trend in Rabat. Syphilis prevalence showed a strong linear decrease in all four cities. Ever had an HIV test and having had an HIV test in the past 12 months showed evidence of a strong linear trend increase for all cities. We found that ever had HIV testing and had an HIV test in the past 12 months were associated with experiences of sexual violence, condom possession, and HIV knowledge. Despite the progress made in containing HIV in Morocco, the concentration of HIV remains higher in marginalized groups, such as FSW, and continued efforts to improve and expand the quality of existing HIV services are needed. Investigamos los factores que afectan las pruebas de VIH y las pruebas de VIH en los últimos 12 meses entre mujeres trabajadoras sexuales (MTS) en Agadir, Rabat, Fez y Tánger, Marruecos, durante cuatro rondas de encuestas de vigilancia biológica integrada del VIH (2012, 2016, 2019 y 2023). Los hallazgos se utilizan para informar respuestas programáticas y políticas y proporcionar información para monitorear las tendencias epidémicas. Las encuestas de MTS de 2012, 2016, 2019 y 2023 fueron realizadas por el Programa Nacional contra el SIDA del Ministerio de Salud y Protección Social y el Instituto Nacional de Higiene con el apoyo de ONUSIDA y el Fondo Mundial. La prevalencia del VIH disminuyó sin evidencia de tendencias decrecientes significativas a lo largo del tiempo en Agadir, Fez y Tánger, y aumentó con evidencia de una fuerte tendencia lineal en Rabat. La prevalencia de la sífilis mostró una fuerte disminución lineal en las cuatro ciudades. Para los casos donde alguna vez se realizaron una prueba de VIH en la vida y se realizó una prueba de VIH en los últimos 12 meses mostraron evidencia de una fuerte tendencia lineal de aumento en todas las ciudades. Además, descubrimos que dichos casos se asociaron con experiencias de violencia sexual, o que estaban en posesión de condones y conocimiento del VIH. A pesar de los avances logrados en la contención del VIH en Marruecos, la concentración del VIH sigue siendo mayor en los grupos marginados, como las MTS, y se necesitan esfuerzos continuos para mejorar y ampliar la calidad de los servicios de VIH existentes.

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.

Generalized Treatment as Prevention Plus Focused Pre-Exposure Prophylaxis Is the Key to Controlling HIV/AIDS

Treatment as Prevention (TasP) and Pre-Exposure Prophylaxis (PrEP) are both widely recognized as essential biomedical tools to control HIV/AIDS. TasP calls for the immediate initiation of fully subsidized and supported antiretroviral therapy (ART) following HIV diagnosis. TasP effectively prevents progression to AIDS, and premature AIDS-related deaths among people living with HIV (PLWH), and simultaneously renders HIV non-transmissible, thus preventing onward HIV transmission. In addition, PrEP has proven effective against HIV transmission among high-risk individuals who are adherent to the regimen. PrEP traditionally consists of two antiretrovirals given orally as one pill daily: originally, tenofovir-DF plus emtricitabine (TDF-FTC), and later, tenofovir-AF (TAF) plus FTC (more recently, other options have become available, including long-acting parenteral formulations; however, these are still of limited availability). Over the last two decades, the province of British Columbia has rolled out TasP among all PLWH, and starting in 2018, PrEP was added as a strategy to reach individuals most at risk of acquiring HIV to further accelerate progress in addressing HIV/AIDS as a public health threat. Our "generalized TasP + focused PrEP" program proved to be synergistic (or multiplicative) as it relates to reducing the HIV effective reproduction number (Re). TasP lowers HIV incidence by reducing the pool of individuals able to transmit HIV, which is dependent on the extent of community plasma viral load (pVL) suppression. Meanwhile, PrEP reduces the number of potential new infections among those most susceptible to acquiring HIV in the community, independent of viral load suppression among PLWH. Our results strongly support widespread implementation of the combination of "generalized TasP + focused PrEP" strategy and underscore the importance of long-term monitoring of Re at a programmatic level to identify opportunities for optimizing TasP and PrEP programs. This approach aligns with the United Nations goal of "Ending HIV/AIDS as a pandemic by 2030", both in Canada and globally.

Temporal trends from HIV diagnosis to ART initiation among adults living with HIV in the Asia-Pacific (2013-2023)

INTRODUCTION

Data on the impact of World Health Organization (WHO)'s guideline changes and COVID-19 on ART initiation in the Asia-Pacific remain scarce. This study described temporal trends from HIV diagnosis to ART initiation from 2013 to 2023 and its associated factors.

METHODS

Adults (≥ 18 years) diagnosed with HIV after 2013 in a regional observational cohort were included. Fine and Gray competing risk regression examined predictors of ART initiation (≥ 3 antiretroviral medications), accounting for those lost to follow-up or deceased before treatment considered as competing risks.

RESULTS

Among 14,968 participants, most were male (70.1%), with a median age of 36 years (interquartile range [IQR]: 28-44). At HIV diagnosis, median CD4 count was 208 cells/µL (IQR: 69-395), and median viral load was 86,296 copies/mL (IQR: 13,186-392,000). Over 85% of participants had initiated ART during the study period. Median time from HIV diagnosis to ART initiation differed across years of HIV diagnosis: 51 days (2013-2015), 28 days (2016-2019), and 26 days (≥ 2020). Factors associated with shorter time to ART initiation were higher country income-level (upper-middle: sub-distribution hazard ratio [SHR] = 1.34, 95% CI: 1.28, 1.40; high: SHR = 1.35, 95% CI: 1.28, 1.43; vs. lower-middle); HIV transmission via male-to-male contact (SHR = 1.06, 95% CI: 1.02, 1.11) or injection drug use (SHR = 1.23, 95% CI: 1.09, 1.38; vs. heterosexual contact); and later years of HIV diagnosis (2016-2019: SHR = 1.33, 95% CI: 1.28, 1.38; ≥ 2020: SHR = 1.40, 95% CI: 1.33, 1.48; vs. 2013-2015). Those with higher CD4 counts had longer time to ART start (350-499 cells/µL: SHR = 0.76, 95% CI: 0.67, 0.86; > 500 cells/µL: SHR = 0.55, 95% CI: 0.49, 0.61; vs. CD4 < 200 cells/µL).

CONCLUSION

Time to ART initiation from HIV diagnosis decreased after 2016, aligning with evolving WHO guidelines, and did not appear to be impacted by COVID-19. Optimizing treatment initiation during the treat-all era is crucial, especially among those with higher CD4 counts.

New treatment strategies in HIV/AIDS infection and the impact of treatment adherence on the quality of life of people living with HIV

OBJECTIVE

The aim of the study was the assessment of adherence to antiretroviral (ARV) treatment in a population of people living with HIV (PWH), improving the awareness of PWH, drawing attention to the risk of developing HIV drug resistance and subsequent treatment failure.

METHODS

The basic cohort consisted of PWH followed up long-term at the HIV centre of the University Hospital Pilsen. Adherence to treatment was assessed by ARV levels. Nucleoside analogs were determined in urine by high pressure liquid chromatography (HPLC), in relation to clinical data, viral load (HIV RNA), and absolute CD4 and CD8 T cell counts. To assess mental and physical state of the patients, a modified SF-36 questionnaire was used to measure social relationships, education and ability to relax.

RESULTS

From a group of 131 PWH, 18 (13.7%) with zero levels and 113 (86.3%) with any detectable ARV levels were followed for 6-12 months. A statistically significant lower viral load was demonstrated in patients who adhered to the treatment at the time of the test as indicated by ARV levels in the urine. CD4 T lymphocyte values in adherent patients were, as expected, statistically significantly higher. A significant difference for CD8 T lymphocyte was not demonstrated. A survey assessed subjective factors influencing the degree of adherence. PWH consider important: quality care enabling trust, low risk of developing opportunistic infections, self-sufficiency, quality of sleep, managing leisure activities, and good family relationships. Quality of life evaluation and satisfaction in the monitored areas were similar in both groups of PWH.

CONCLUSIONS

Non-adherence leads to deterioration of CD4 and viral load levels and may be the cause of the development of HIV drug resistance and treatment failure on the part of the patient. PWH with zero or low urinary nucleoside levels were repeatedly instructed about the need for regular and sustained medication use. Regular checks with a laboratory examination service are needed to detect early emergence of resistance and side effects of the treatment, which are initially only detectable in the laboratory.

Risk Factors for Viral Non-suppression Among Youth Living with HIV in Nigeria: Findings from the iCARE Nigeria Study

Viral suppression with antiretroviral therapy (ART) is a critical component of UNAIDS objectives to end the HIV epidemic. Youth living with HIV (YLH) have worse viral suppression rates than adults. The aim of this study was to identify risk factors for viral non-suppression among YLH in Nigeria. A secondary analysis of enrollment data from the iCARE Nigeria study, collected April-October 2021 for 541 YLH comprised demographic, psychosocial, behavioral, clinical variables, and viral load quantification. Viral non-suppression was defined as viral load ≥ 200 copies/mL. Generalized linear models using Akaike information criterion for selection of indicator variables in a stepwise approach were used to determine the risk factors for viral non-suppression. The final analytic sample was 491 and the proportion of non-suppressed participants at baseline was 40%. In the final model, substance use (other than alcohol, tobacco and/or cannabis) (aOR = 3.20 [95% CI: 1.05, 10.34]), missed medication doses (aOR = 1.09 [95% CI: 1.04, 1.15]), and a higher number of self-reported medication barriers (e.g., forgot, busy, change in routine) (aOR = 1.08 [95% CI: 1.00, 1.16]) were associated with a higher likelihood of viral non-suppression. Being prescribed a first-line regimen (aOR = 0.28 [95% CI: 0.17, 0.44]), disclosure to at least one brother (aOR = 0.64 [95% CI: 0.42, 0.97]), and higher treatment outcome expectancies (e.g., taking medication will improve health) (aOR = 0.81 [95% CI: 0.66, 0.98]), were all associated with a lower likelihood of viral non-suppression. Viral non-suppression among YLH in Nigeria is associated with psychosocial and behavioral factors, including missed doses, medication barriers, treatment outcome expectancies, and disclosure, that are potential targets for intervention to achieve ART goals.

Preventing HIV in women in Africa

HIV incidence is declining globally, but around half of all new infections are in sub-Saharan Africa-where adolescent girls and young women bear a disproportionate burden of new infections. Those who sell sex are at particularly high risk. Despite declining incidence rates and availability of effective biomedical prevention tools, we are not on track, globally or in Africa, to achieve UNAIDS 2025 prevention targets. For those at risk, interventions that strengthen their motivation, capabilities and access to all available HIV prevention technologies are critical-for adolescent girls and women in particular, but also for epidemic control more broadly. Exciting possibilities for scaling up new and highly effective prevention technologies are close, but delivery, implementation and financing models need to be developed and urgently evaluated, in partnership with communities, or these opportunities may be lost. Here, we discuss the evolving landscape of biomedical prevention technologies for women in Africa, their implementation and financing, as well as priorities for HIV prevention research in this setting.

The effect of a combined mHealth and community health worker intervention on HIV self-management

OBJECTIVE

To identify demographic, social, and clinical factors associated with HIV self-management and evaluate whether the CHAMPS intervention is associated with changes in an individual's HIV self-management.

METHOD

This study was a secondary data analysis from a randomized controlled trial evaluating the effects of the CHAMPS, a mHealth intervention with community health worker sessions, on HIV self-management in New York City (NYC) and Birmingham. Group comparisons and linear regression analyses identified demographic, social, and clinical factors associated with HIV self-management. We calculated interactions between groups (CHAMPS intervention and standard of care) over time (6 and 12 months) following the baseline observation, indicating a difference in the outcome scores from baseline to each time across groups.

RESULTS

Our findings indicate that missing medical appointments, uncertainty about accessing care, and lack of adherence to antiretroviral therapy are associated with lower HIV self-management. For the NYC site, the CHAMPS showed a statistically significant positive effect on daily HIV self-management (estimate = 0.149, SE = 0.069, 95% CI [0.018 to 0.289]). However, no significant effects were observed for social support or the chronic nature of HIV self-management. At the Birmingham site, the CHAMPS did not yield statistically significant effects on HIV self-management outcomes.

DISCUSSION

Our study suggests that CHAMPS intervention enhances daily self-management activities for people with HIV at the NYC site, indicating a promising improvement in routine HIV care.

CONCLUSION

Further research is necessary to explore how various factors influence HIV self-management over time across different regions.

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.

Adherence Definitions, Measurement Modalities, and Psychometric Properties in HIV, Diabetes, and Nutritional Supplementation Studies: A Scoping Review

Measuring adherence has been a priority for researchers to help inform effective care for patients regularly consuming medications for chronic conditions. As a widely accepted "gold standard" adherence measure or operational definition does not exist, studies measure adherence using different modalities, which may lead to different conclusions about adherence patterns. The purpose of the scoping review was to identify modalities used to measure adherence to HIV medication, diabetes medication, and nutritional supplementation and explore the variation in adherence definitions, measurement modalities, and psychometric properties being reported across studies. Comprehensive searches were performed in PubMed, Scopus, and PsycINFO from January 2012 to January 2022. We included studies reporting psychometric properties of adherence/compliance to HIV medication, diabetes medication, or nutritional supplements. In total, we included 88 studies in the review. The 8-item Morisky Medication Adherence Scale (MMAS-8) was the most frequently used self-reported measure. We found almost no relationship between country income level and triangulation levels. The operational definition of adherence fell into four categories: numerical, dichotomous, ranked ordinal, and undefined. The amount of variation in an adherence definition category within a modality depended on whether the measures within the modality could be assessed numerically and whether widely accepted cutoffs existed for the measure. Across studies, 46 (52%) reported both validity and reliability, 28 (31%) reported validity only, and 14 (16%) reported reliability only. Fourteen types of validity and six types of reliability were identified across the studies. Measuring adherence accurately and reliably continues to be a challenge for research in HIV, diabetes, and nutritional supplementations. When reporting adherence measurements, we suggest including adherence results from multiple measures and modalities, presenting adherence results numerically, and reporting multiple types of validity and reliability.

Incidence of opportunistic diseases after the "treat all" strategy: 10 years cohort for HIV

High active anti-retroviral therapy (HAART) has improved the life expectancy of people living with HIV/AIDS (PLWHA) and reduced the development of opportunistic diseases, supporting a strategy introduced in 2014, which sought to enhance prevention with early treatment and for all. This was a retrospective and comparative cohort study before and after the implementation of "treat all" strategy, based on primary and secondary data, extracted from the medical records followed at the Specialized Care Service between 2009 and 2018 and from public databases. Of the 892 patients selected, 790 were active, 28 abandoned treatment and 40 died, 92%, 3.3% and 4.7%, respectively. About 440 (51.2%) started follow-up between 2009 and 2013, before the "treat all" strategy, and 417 (48.9%) started follow-up after 2014, when the national recommendation was already the "treat all" strategy. A total of 508 (58.2%) male patients were counted, the mean age was 33.5 years on the date of entry, most of them had a total of 8 to 11 years of study (21.1%) and about 6.5% of the patients were illiterate. The main routes of HIV transmission were heterosexual intercourse (67.95%) and MSM (men who have sex with men) (31%). The mean CD4 cell count at presentation was 392 cells/mm3 and 23% of participants had a CD4 count less than 200 cells/mm3. Elevated levels of viral load were found at entry, with 30% having at least 100,000 copies/mL. During the ten years of observation, there were 245 episodes of opportunistic diseases. The five most common opportunistic diseases during the study period were tuberculosis (28.6%), herpes zoster (23.3%), oral candidiasis (15.5%), neurotoxoplasmosis (11.4%) and pneumocystosis (6.1%). Forty patients died during the study period, 4.7% of the total. There was a reduction in opportunistic infections in the second group of the study, especially for oral candidiasis (p = 0.03), as well as a better response to LogCV treatment (1.28±1.97). It is concluded that the diagnosis and treatment strategy has shown over the years an effective reduction in opportunistic infections.

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.