Antiretroviral Therapy for the Prevention of HIV-1 Transmission

Impacts of a multipronged initiative with community HIV clinics to support retention and re-engagement in HIV care

BACKGROUND

Despite advances in HIV treatment, gaps in care retention threaten the individual health of people with HIV (people) and public health efforts to end the HIV epidemic.

OBJECTIVE

This project aimed to identify and address gaps in retention and support re-engagement in care.

METHODS

A multipronged initiative at five community HIV clinics and community-based organizations (CBOs) included patient, healthcare professional (HCP), and community-focused interventions. Patient-oriented interventions included instructional videos for patients to view before appointments and conversation guides about barriers to care for patients to use with staff during appointments. HCP-oriented interventions included baseline surveys assessing clinic practices and challenges and audit-feedback sessions to review survey findings and devise plans to improve retention strategies. Community-oriented interventions included education sessions co-led by clinics and CBOs, micro-learning engagements at community events, and social media campaigns covering topics related to HIV care. Data were collected through surveys administered before and after patient- and HCP-oriented interventions and community education sessions, follow-up surveys administered after micro-learning engagements, and reach of social media campaigns.

RESULTS

Patient-oriented interventions led to improvements in patient-reported empowerment and confidence in their ability to remain in care. HCPs also reported improvements in patient intake and follow-up processes after audit-feedback sessions. Community interventions reached over 1,000 community members combined, with education sessions and micro-learning engagements uncovering key barriers to HIV care and leading to improvements in knowledge and awareness of local HIV services.

CONCLUSION

This multipronged initiative demonstrates how patient, HCP, and community-oriented education can support retention and re-engagement in care.

Estimation of Lifetime Costs Among Insured Persons with HIV in the United States

BACKGROUND/OBJECTIVE

With recent advances in human immunodeficiency virus (HIV) management and prevention, it is critical to understand the lifetime costs (LTC) of HIV. The objective of the study was to evaluate all-cause LTC, annual costs and healthcare resource utilization (HCRU) among persons with HIV (PWH) versus a matched non-HIV cohort in the United States (US).

METHODS

This observational study included persons (≥ 18 years) with an HIV diagnosis, antiretroviral treatment (ART), and continuous enrollment (CE) within each year (2018-2023) in the PWH cohort, and with no HIV diagnosis/ART and CE in the non-HIV cohort, identified using a US commercial claims database (IQVIA PharMetrics® Plus). Cohorts were matched 1:3 on age, sex, geographic region, and health plan. Undiscounted LTC, discounted LTC (95% confidence interval [CI]) and annual costs were computed in 2022 US dollars (USD) for ages 18-75 years. Annual inpatient, outpatient, emergency room, and outpatient pharmacy utilization and costs were compared.

RESULTS

Person counts ranged from 45,465 to 54,530 in the PWH cohort and 136,395 to 163,590 in the non-HIV cohort from 2018 to 2023. Mean undiscounted LTC were $2,895,020 (CI 2,847,453-2,947,867) and $482,522 (CI 453,114-513,44) for PWH and non-HIV cohorts, respectively, with an incremental cost difference of $2,412,498 (CI 2,354,674-2,474,024). Mean discounted LTC were $1,299,210 (CI 1,279,397-1,321,458) and $181,481 (CI 169,392-194,036) for PWH and non-HIV cohorts, respectively, with an incremental cost difference of $1,117,729 (CI 1,093,606-1,143,350). Mean annual total costs were six to seven times higher among PWH than the non-HIV cohort each year; with higher costs among older persons. HCRU was higher among PWH.

CONCLUSIONS

Among a sample of primarily commercially insured US adults, HIV conferred an estimated incremental LTC difference of over $2.4 million (undiscounted) and $1.1 million (discounted), with annual costs being six to seven times higher for PWH compared to non-HIV persons.

Knowledge about biomedical HIV prevention among healthcare workers: A cross-sectional study in Europe and Central Asia

BACKGROUND

Knowledge of HIV prevention among healthcare workers, such as undetectable equals untransmittable (U=U), post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) can hold implications for patient care and the HIV epidemic. Understanding the level of knowledge about HIV prevention among healthcare workers can provide information to enhance the effectiveness and equity of HIV prevention, treatment and care.

METHODS

An online survey was conducted to collect data on HIV knowledge among clinical and non-clinical healthcare workers in 54 countries in Europe and Central Asia between September and December of 2023. Knowledge was measured using questions asking respondents to agree or disagree with correct statements about HIV transmission and prevention. Four main outcome variables assessed knowledge among healthcare workers about U=U, PrEP, PEP and a combined outcome measuring overall knowledge level. Fixed-effects logistic and Poisson regression models assessed whether sociodemographic factors, professional characteristics and experiences with people living with HIV were associated with knowledge about these topics. Additionally, we assessed the impact of having ever received training on infection control and training on HIV stigma and discrimination on healthcare workers' knowledge of U=U, PEP and PrEP.

RESULTS

Among 18 348 healthcare workers, correct knowledge of U=U was reported by 61.25%, PEP by 55.70% and PrEP by 40.74%. A composite of correct knowledge across all topics was achieved by 31.29% of participants. Key sociodemographic and professional determinants influencing increased knowledge included being a man, of younger age and a medical doctor. Increased knowledge was also associated with having more experience caring for people with HIV, including working in an HIV care or infectious diseases department, and having cared for a higher number of people living with HIV in the past year. Having ever received training on infection control that included PEP and training on HIV stigma and discrimination was associated with increased knowledge in all areas. Across all determinants, respondents living in Western Europe reported higher knowledge about biomedical HIV prevention.

INTERPRETATION

Substantial knowledge gaps in HIV prevention were found among healthcare workers in Europe and Central Asia. Suboptimal knowledge and sociodemographic and professional differences warrant targeted training initiatives and interventions for improving healthcare workers' knowledge of HIV. The non-representative nature of the sample limits the generalizability of the findings.

Study Protocol(s) for Antiretroviral Improvement among Medicaid EnrolleeS (AIMS): A Cluster-Randomized Controlled Trial Leveraging Real-time Administrative Claims to Support Antiretroviral Prescription Adherence

INTRODUCTION

Retention in care and antiretroviral therapy (ART) adherence are major clinical and public health challenges in the treatment of HIV in the United States. Traditional data to care (D2C) approaches use health department surveillance data to promote retention in HIV care, with challenges in the timeliness of data and inconclusive findings. Earlier identification of people with HIV who are at risk of loss from care-such as when an ART prescription is not filled-represents a new direction for D2C (D2C-Rx or prescription-based D2C).

METHODS

We designed the Antiretroviral Improvement among Medicaid EnrolleeS (AIMS) study, a D2C-Rx initiative in Virginia, which leveraged real-time administrative claims from Virginia Medicaid and HIV surveillance data from Virginia Department of Health (April 2023-June 2024). AIMS was a statewide cluster-randomized, controlled trial comparing a phased, multi-level program of support (intervention) to usual care, among Virginia Medicaid enrollees without current ART prescriptions. Support included a provider-level component for those with no prior ART prescription and patient-level component for those with a > 30-90-day late ART prescription refill(s). We hypothesized that AIMS would increase HIV viral suppression and improve ART adherence at 12 months compared to usual care. We describe the original study protocol and discuss changes implemented to the study design and program implementation. We also consider key methodologic contributions, as well as limitations and challenges to patient- and provider-level enrollment, such as ART prescription data accuracy.

ETHICS AND DISSEMINATION

This study was reviewed and approved by the Institutional Review Board of Virginia Commonwealth University (HM20018229).

REGISTRATION

The trial is registered at clinicaltrials.gov (NCT05477485).

HIV multidrug class resistance prediction with a time sliding anchor approach

Motivation

The emergence of multidrug class resistance (MDR) in Human Immunodeficiency Virus (HIV) is a rare but significant challenge in antiretroviral therapy (ART). MDR, which may arise from prolonged drug exposure, treatment failures, or transmission of resistant strains, accelerates disease progression and poses particular challenges in resource-limited settings with restricted access to resistance testing and advanced therapies. Early prediction of future MDR development is important to inform therapeutic decisions and mitigate its occurrence.

Results

In this study, we employ various machine learning classifiers to predict future resistance to all four major antiretroviral drug classes using features extracted from clinical HIV sequence data. We systematically explore several variations of the problem that differ in the pre-existing resistance level and the temporal gap between sample collection and observed MDR occurrence. Our models show the ability to predict multidrug class resistance even in the most challenging variations, albeit at a reduced accuracy. Feature importance analysis reveals that our models primarily utilize known drug resistance mutations for easier classification tasks, but rely on new mutations for the difficult task of distinguishing four class drug resistance from three class drug resistance.

Availability and implementation

All analysis was performed using the Euresist Integrated DataBase (EIDB). Researchers wishing to reproduce, validate or extend these findings can request access to the latest EIDB release via the Euresist Network.

The global HIV response at a crossroads: protecting gains and advancing sustainability amid funding disruptions

The global HIV response faces a crisis as abrupt funding cuts, particularly from the USA, threaten decades of progress. Governments across Africa report widespread disruptions in essential services, including HIV testing, treatment, and prevention. Reliance on previously stable partnerships and external funding has left many programmes vulnerable to sudden financial shock. Achieving self-reliance will require national health system integration, streamlined service delivery, digital health solutions to extend health system functions, and diversified funding sources, including greater mobilisation of domestic resources, innovative financing, and impact investment. Although some countries have made major strides towards self-reliance, urgent actions are needed to protect against harms to individuals and communities due to service delivery interruptions. Governments should lead efforts to integrate the continuum of HIV services into broader health systems, and donors should pivot towards strategic support, including technical assistance and catalytic funding for commodities and services that mitigate harms. Without decisive action, funding disruptions could result in catastrophic increases in infections and mortality, undermining the global HIV response for the next generation.

Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV - CDC Recommendations, United States, 2025

Nonoccupational postexposure prophylaxis (nPEP) for HIV is recommended when a nonoccupational (e.g., sexual, needle, or other) exposure to nonintact skin or mucous membranes that presents a substantial risk for HIV transmission has occurred, and the source has HIV without sustained viral suppression or their viral suppression information is not known. A rapid HIV test (also referred to as point-of-care) or laboratory-based antigen/antibody combination HIV test is recommended before nPEP initiation. Health care professionals should ensure the first dose of nPEP is provided as soon as possible, and ideally within 24 hours, but no later than 72 hours after exposure. The initial nPEP dose should not be delayed due to pending results of any laboratory-based testing, and the recommended length of nPEP course is 28 days. The recommendations in these guidelines update the 2016 nPEP guidelines (CDC. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV - United States, 2016. Atlanta, GA: US Department of Health and Human Services, CDC; 2017). These 2025 nPEP guidelines update recommendations and considerations for use of HIV nPEP in the United States to include newer antiretroviral (ARV) agents, updated nPEP indication considerations, and emerging nPEP implementation strategies. The guidelines also include considerations for testing and nPEP regimens for persons exposed who have received long-acting injectable ARVs in the past. Lastly, testing recommendations for persons who experienced sexual assault were updated to align with the most recent CDC sexually transmitted infection treatment guidelines. These guidelines are divided into two sections: Recommendations and CDC Guidance. The preferred regimens for most adults and adolescents are now bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine). However, the regimen can be tailored to the clinical circumstances. Medical follow-up for persons prescribed nPEP also should be tailored to the clinical situation; recommended follow-up includes a visit at 24 hours (remote or in person) with a medical provider, and clinical follow-up 4-6 weeks and 12 weeks after exposure for laboratory testing. Persons initiating nPEP should be informed that pre-exposure prophylaxis for HIV (PrEP) can reduce their risk for acquiring HIV if they will have repeat or continuing exposure to HIV after the end of the nPEP course. Health care professionals should offer PrEP options to persons with ongoing indications for PrEP and create an nPEP-to-PrEP transition plan for persons who accept PrEP.

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.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Low-level viraemia as a risk factor for virologic failure in children and adolescents living with HIV on antiretroviral therapy in Tanzania: a multicentre, retrospective cohort study

INTRODUCTION

Viral load (VL) of 1000 copies/ml or greater is commonly used to define virologic failure (VF) in children and adolescents living with HIV (CALHIV) in low- and middle-income countries (LMICs). However, evidence in adults suggests that low-level viraemia (LLV) (VL 50-999 copies/ml) increases the risk of subsequent VF. There is limited research on LLV in CALHIV.

METHODS

This study retrospectively reviewed VL data from Baylor College of Medicine Children's Foundation-Tanzania (sites in Mbeya and Mwanza) collected between January 2015 and December 2022. CALHIV (0-19 years) on antiretroviral therapy for ≥6 months with at least one VL <50 copies/ml plus ≥2 subsequent VLs were included. VF was defined as both VL ≥1000 and ≥200 copies/ml. Multivariable Cox regression models were used to assess the association between LLV and VF, reporting adjusted hazard ratios (aHR) with 95% confidence intervals (CI).

RESULTS

Among 2618 CALHIV included in the outcome analysis (median age 13.2 years, 52.5% female), 81.9% were on first-line dolutegravir-based regimens and LLV was found in 40.5%. CALHIV with LLV had an increased risk of VF with aHRs of 1.63 (CI 1.38-1.91) (VL ≥1000 copies/ml) and 3.85 (3.33, 4.46) (VL ≥200 copies/ml). When stratifying by LLV (50-199, 200-399 and 400-999 copies/ml), all levels were associated with increased risk for VF (VL ≥1000 copies/ml) with aHRs of 1.39 (1.13, 1.69), 1.69 (1.33, 2.16) and 2.03 (1.63, 2.53). When VF was defined as VL ≥200 copies/ml, the corresponding aHRs were 1.41 (1.15, 1.72), 7.99 (6.68, 9.57) and 9.37 (7.85, 11.18).

CONCLUSIONS

LLV is associated with a greater risk of VF in CALHIV. The risk of VF increases with higher levels of LLV. This study provides further evidence for revising guidelines in LMICs that define VF as VL ≥1000 copies/ml.

Acute retroviral syndrome

PURPOSE OF REVIEW

To review the most important recent literature on the definition, epidemiology, clinical presentation, pathogenesis and treatment of the acute retroviral syndrome (ARS), a constellation of nonspecific symptoms and transient illness occuring in at least 50% of persons shortly after HIV acquisition. ARS is driven by initial rapid HIV viral replication and dissemination after acquisition, followed by immune activation and massive systemic inflammation. A more detailed understanding of ARS is important for the implementation of early detection efforts, treatment and public health strategies to control HIV.

RECENT FINDINGS

Recent research has provided deeper insights into ARS. Key findings include associations of ARS with heightened immune activation and elevated levels of IFNγ and multiple other cytokines, particularly IP-10, as well as with higher viral load and more severe CD4 + depletion during acute infection. These negative impacts can be mitigated by early antiretroviral therapy initiation and long-term outcomes are generally similar in treated individals with or without ARS.

SUMMARY

Current findings underscore the importance of early detection and intervention in ARS to mitigate long-term health impacts and inform the development of targeted therapeutic strategies.

HIV testing acceptance and its associated factors among key and priority populations in Harar town, Harari region, Eastern Ethiopia

BACKGROUND

Globally, Human immunodeficiency virus (HIV) testing service acceptance increased impressively in every regions. In spite of this fact, in the majority of the Sub-Saharan African countries more than half of the people living with Human immunodeficiency virus are not aware of their sero-status. Particularly, key and priority populations are understudied compared to other population segment. Therefore, this study aimed to identify the magnitude and factors associated with Human immunodeficiency virus testing service acceptance among key and priority populations in Harar town, Eastern Ethiopia from March 15 to April 15, 2024.

METHODS

A Community-based Cross-sectional study was employed among randomly selected 388 key and priority populations in Harar town. A simple random sampling technique was used to obtain the study participants. Data was collected using the structured questionnaire developed from different similar and relevant literatures. Data entered into EpiData version 3.0 and exported to STATA Version 15.00for analysis. Binary logistic regression was employed to identify the associated predictor variables with outcome variables and adjusted odd ratio was used to report the effect size.

RESULT

The overall HIV testing service acceptance rate was 82.5% (95% CI: 78%, 86%). After adjusting for all potential confounders using multivariate logistic regression and finally being orthodox Christian followers (AOR = 3.65 95% CI: 1.41, 9.46), those had history of visiting health facility with their partner/s for any service (AOR = 3.24 95% CI: 1.22,8.56), being sex workers (SWs) (AOR = 15.43 95% CI: 2.18, 109.4), respondents who knew the place where the HIV testing service exist (AOR = 8.28 95% CI: 1.7, 40.27) and had no fear of known by others (AOR = 4 95% CI: 1.46, 10.92), who believed that HIV is not curable (AOR = 4.61 95% CI: 1.48, 14.26) and who had family or community support (AOR = 2.74 95% CI: 1.1, 7.1) were significantly associated with HIV testing acceptance.

CONCLUSION

In conclusion, this study highlighted several factors were significantly associated with HIV testing acceptance, including being orthodox Christian, sex worker, having history of visiting health facility with their partner/s for any service, knowing place where HIV testing service exist, having no fear of known by others, knowing that HIV is not curable disease and having family or community support. The finding emphasis that the role of individual perceptions and social/community support in influencing of HIV testing service uptake. Addressing these misconceptions and fostering enabling environments for the key and priority populations in the future public health strategies may enhance the efforts of the prevention and control of HIV spread.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Global Legal Environment for LGBTQ+ Sexuality and Public Health

In 2023 the Supreme Court of Mauritius cited human rights and public health arguments to strike down a colonial-era law criminalizing consensual same-sex sex. The parliament of Singapore recently did the same through legislative means. Are these aberrations or a shifting global consensus? This article documents a remarkable shift international legal shift regarding LGBTQ+ sexuality. Analysis of laws from 194 countries across multiple years demonstrates a clear, ongoing trend toward decriminalization globally. Where most countries criminalized same-sex sexuality in the 1980s, now two-thirds of countries do not criminalize under law. Additionally, 28 criminalizing countries in 2024 demonstrate a de facto policy of non-enforcement, a milestone towards legal change that all of the countries that have fully decriminalized since 2017 have taken. This has important public health effects, with health law lessons for an era of multiple pandemics. But amidst this trend, the reverse is occurring in some countries, with a counter-trend toward deeper, harsher criminalization of LGBTQ+ sexuality. Case studies of Angola, Singapore, India, Botswana, Mauritius, Cook Islands, Gabon, and Antigua and Barbuda show many politically- and legally-viable pathways to decriminalization and highlight actors in the executive, legislative, and judicial arenas of government and civil society engaged in legal change.

Pre-Human Immunodeficiency Virus (HIV) α4β7hi CD4+ T Cells and HIV Risk Among Heterosexual Individuals in Africa

BACKGROUND

CD4+ T cells expressing α4β7 are optimal targets for human immunodeficiency virus (HIV) infections, with higher pre-HIV α4β7hi expression linked to increased HIV acquisition and progression in South African women. However, similar associations were not observed in men who have sex with men or people who inject drugs in the Americas, indicating need for further research.

METHODS

This retrospective case-control study enrolled heterosexual men and women from South Africa (HIV Vaccine Trials Network [HVTN] 503) and East Africa (Partners Preexposure Prophylaxis/Couples' Observational Study [PP/COS]), quantifying α4β7 expression on CD4+ T cells as a predictor of subsequent HIV risk using flow cytometry analyses.

RESULTS

Associations between α4β7hi expression and HIV acquisition varied across cohorts. In HVTN 503, women had a higher risk estimate compared to men, but this was not significant. In PP/COS, α4β7hi expression was generally protective, particularly in Ugandans. Additionally, α4β7hi expression inversely correlated with peak viral load in PP/COS but not in HVTN 503; in the latter cohort, α4β7hi expression was inversely correlated with the CD4/CD8 ratio and predicted rapid CD4+ T-cell decline, similar to what was observed previously in South Africa.

CONCLUSIONS

These findings suggest that α4β7hi expression on CD4+ T cells may not predict HIV acquisition and progression in all contexts, which may be due to cohort effects, modes of transmission, viral clade, or other factors.

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.

Sero-prevalence of cryptococcal antigen and its immune-virological correlates in HIV-1 positive individuals: a prospective cross-sectional study

BACKGROUND

Cryptococcal infection remains a leading cause of mortality among HIV-1-positive individuals, particularly in regions with limited access to antiretroviral therapy and diagnostics. This study aimed to assess Cryptococcal Antigen (CrAg) seroprevalence and its immune-virological correlates among ART-naïve and ART-experienced HIV-1 positive individuals.

METHODS

This prospective cross-sectional study was conducted from May 2023 to August 2024 at Edo State University Teaching Hospital, Nigeria. Blood samples were analyzed for CD4 + T-cell counts using a Partec™ CyFlow analyzer, HIV-1 viral load using the COBAS® AmpliPrep/COBAS® TaqMan® Test, and CrAg detection with the Immy Latex-Crypto Antigen Lateral Flow Assay.

RESULTS

Among 229 HIV-1 positive individuals, 72.5% were aged 15-20 years, and 69% were female. Most (68.6%) were ART-experienced, while 31.4% were ART-naïve. Severe immunosuppression (CD4 + < 200 cells/mm³) was present in 64.6%, and 71.2% had viral loads > 1,000 copies/mL. Cryptococcal infection (CI) prevalence was 10.04%. No significant link was found between CI and age or gender, but ART-naïve status, low CD4 + counts, and high viral loads were significantly associated with CI. ART-naïve individuals had higher viral loads (median 4.95 vs. 4.19 log10 copies/mL, p = 0.00). A stronger inverse correlation between CD4 + counts and viral load was observed in ART-experienced patients (r = -0.535).

CONCLUSIONS

These findings emphasize the necessity for routine Cryptococcal screening, particularly in ART-naïve and severely immunocompromised individuals, to facilitate timely interventions and improve clinical outcomes.

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.

B-OK: a visual and tactile tool for improving HIV mental models in a United States urban center

Lack of adherence to antiretroviral therapy (ART) and poor retention in care are significant barriers to ending HIV epidemics. Treatment adherence support effectiveness may be constrained by limited understanding of the benefits of ART. We evaluated a visual and tactile tool, the B-OK Bottles ("B-OK"), that incorporates human-centered design and behavioral economics principles and is designed to change and strengthen mental models about HIV. We enrolled 118 adults living with HIV who were clients of medical case managers in Philadelphia. All participants completed a pre-intervention survey, a B-OK intervention and a post-intervention survey. A subset (N = 52) completed qualitative interviews. Co-primary outcomes were differences pre- to post-intervention for 11 questions about HIV awareness, knowledge, attitudes, intentions and perception. Qualitative interviews were assessed using an integrated analysis approach. Participants had a median age of 55 years (IQR 47-60), 65% were male sex (N = 77), and 72% identified as non-Hispanic Black (N = 85). B-OK was associated with improved awareness and understanding of HIV terminology, changes in HIV treatment attitudes, and increased intention to rely on HIV treatment for transmission prevention. Qualitative interview results aligned with the quantitative findings. These findings provide a strong rationale to further evaluate the potential for B-OK to improve HIV treatment adherence support.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

People who inject drugs and men who have sex with men living with HIV in India experience low probability of viral rebound and high levels of persistent viremia during the first 12 months of antiretroviral therapy

People who inject drugs (PWID) and men who have sex with men (MSM) in India are disproportionately affected by HIV and experience challenges achieving sustained viral suppression. We evaluated probabilities of suppression over time and characteristics associated with persistent viremia and viral rebound among MSM and PWID living with HIV (PLHIV) using 12 months of data collected between 2017-2019 from a cluster-randomized trial across 16 cities in India. To assessprobabilities of suppression, we fit logistic transition models with generalized estimating equations. To assess correlates of persistent viremia and viral rebound, we fit multivariable multilevel logistic regression models. Of 750 PWID, 88% were male and 14% completed high school. Of 850 MSM, 29% completed high school and 54% were married. 46% of PWID and 67% of MSM maintained viral suppression once achieved. Probabilities of viral rebound decreased over time. The probability of newly achieving suppression decreased, from 33%-12% after six months among PWID and 60%-13% among MSM. Among PWID, correlates of persistent viremia included lower education, employment, homelessness, and active injection. Among MSM, hazardous alcohol use was associated with viremia and viral rebound. Treatment engagement and support efforts need to be intensified to encourage PLHIV to achieve life-long suppression.

HIV-1 Vif disrupts phosphatase feedback regulation at the kinetochore, leading to a pronounced pseudo-metaphase arrest

Virion Infectivity Factor (Vif) of the Human Immunodeficiency Virus type 1 (HIV-1) targets and degrades cellular APOBEC3 proteins, key regulators of intrinsic and innate antiretroviral immune responses, thereby facilitating HIV-1 infection. While Vif's role in degrading APOBEC3G is well-studied, Vif is also known to cause cell cycle arrest, but the detailed nature of Vif's effects on the cell cycle has yet to be delineated. In this study, we employed high-temporal resolution single-cell live imaging and super-resolution microscopy to monitor individual cells during Vif-induced cell cycle arrest. Our findings reveal that Vif does not affect the G2/M boundary as previously thought. Instead, Vif triggers a unique and robust pseudo-metaphase arrest, distinct from the mild prometaphase arrest induced by Vpr. During this arrest, chromosomes align properly and form the metaphase plate, but later lose alignment, resulting in polar chromosomes. Notably, Vif, unlike Vpr, significantly reduces the levels of both Protein Phosphatase 1 (PP1) and 2 A (PP2A) at kinetochores, which regulate chromosome-microtubule interactions. These results unveil a novel role for Vif in kinetochore regulation that governs the spatial organization of chromosomes during mitosis.

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.

Joinpoint regression and age period cohort analysis of global and Chinese HIV incidence trends from 1990 to 2021

In China and globally, to analyze the temporal trends of HIV incidence and age, period and cohort effects from 1990 to 2021. A Joinpoint regression model was applied to analyze the time-varying trends of standardized HIV incidence rates worldwide and in China from 1990 to 2021, using data from the Global Burden of Disease Study 2021. The study also explored the effects of age, period, and cohort on HIV incidence trends. From 1990 to 2021, the global standardized incidence of AIDS increased initially and then declined, with females experiencing a higher disease burden than males. In China, the burden was greater in males than females. The age-period-cohort model revealed that the global risk of AIDS incidence peaked between ages 60 and 69, while in China, it was highest between ages 75 and 79. From 1990 to 2021, the global and Chinese standardized incidence rates of AIDS generally followed an increasing trend before declining, with notable gender differences and the highest incidence rates observed in older populations. It is important to address the issues related to AIDS among the elderly and develop targeted health policies to reduce societal burdens and improve public health.

Does travel time matter?: predictors of transportation vulnerability and access to HIV care among people living with HIV in South Carolina

BACKGROUND

People living with HIV (PLHIV) in the southern United States (US) are at high risk for poor outcomes across the HIV care continuum leading to low rates of viral suppression. Understanding structural barriers to care-including transportation vulnerability-is critical to improve HIV outcomes. This study investigated relationships between travel time to HIV care, transportation vulnerability, and HIV care disruptions to inform future transportation interventions for PLHIV residing in South Carolina and other southern US states.

METHODS

A total of 160 PLHIV (N = 160) were recruited from a large immunology center in South Carolina. Participants reported on transportation experiences, transportation vulnerabilities, and residence. Differences in sociodemographic characteristics, transportation vulnerabilities, and HIV care disruptions were compared across travel time groups (< 15, 15-30, and > 30 min from residential location to the HIV clinic) using Mantel-Haenszel Chi-Square tests. Multivariable logistic regression tested our a priori hypothesis that travel time would predict HIV care disruptions.

RESULTS

A majority of participants were aged 45-64 years old (54.4%), single (77.0%), male (63.8%), and Black (77.5%). Nearly 20% of participants lived < 15 min from their HIV clinic, 59.1% lived 15-30 min, and 21.4% lived > 30 min away. PLHIV who had to travel > 30 min to HIV care were more likely than those living < 15 min away to report transportation vulnerability (73.5% vs. 51.6%, p = 0.048), missed HIV care appointments (64.7% vs. 41.9%, p = 0.049), and transportation challenges that prevented them from seeing HIV care providers (67.7% vs. 39.4%; p = 0.014). Adjusted odds ratios (AOR) show that PLHIV who had to travel > 30 min were more likely to experience transportation-related disruptions to HIV care, including being late to appointments (AOR 5.25, 95% CI:1.06-25.92), missing appointments (AOR 3.85, 95% CI:1.04-15.89), and being unable to see HIV providers (AOR 7.06, 95% CI:0.59-14.89).

CONCLUSIONS

In South Carolina-a rural southern state with a disproportionate burden of HIV-long travel time (> 30 min) to HIV care is associated with care disruptions, including more missed visits. Transportation interventions, as well as other efforts to expand rural access to HIV care, are urgently needed to ensure that all PLHIV are able to engage in consistent HIV care in order to reach and maintain viral suppression.

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.

Incentivizing adherence to pre-exposure prophylaxis for HIV prevention: a randomized pilot trial among male sex workers in Mexico

Low adherence to preventative medications against life-long health conditions is a major contributor to global morbidity and mortality. We implemented a pilot randomized controlled trial in Mexico to measure the extent to which conditional economic incentives help male sex workers increase their adherence to pre-exposure prophylaxis (PrEP) for HIV prevention. We followed n = 110 male sex workers over 6 months. At each quarterly visit (at months 0, 3, and 6), all workers received a $10 transport reimbursement, a free 3-month PrEP supply, and completed socio-behavioral surveys. The primary outcome was an objective biomarker of medication adherence based on tenofovir (TFV) drug concentration levels in hair collected at each visit. Individuals randomized to the intervention received incentives based on a grading system as a function of PrEP adherence: those with high (> 0.043 ng/mg TFV concentration), medium (0.011 to 0.042 ng/mg), or low (< 0.011 ng/mg) adherence received $20, $10, or $0, respectively. Six-month pooled effects of incentives on PrEP adherence were analyzed using population-averaged gamma generalized estimating equation models. We estimated heterogeneous treatment effects by sex worker characteristics. The incentive intervention led to a 28.7% increase in hair antiretroviral concentration levels over 6 months consistent with increased PrEP adherence (p = 0.05). The effect of incentives on PrEP adherence was greater for male sex workers who were street-based (vs. internet) workers (p < 0.10). These pilot findings suggest that modest conditional economic incentives could be effective, at scale, for improving PrEP adherence among male sex workers, and should be tested in larger implementation trials. ClinicalTrials.gov Identifier: NCT03674983.

Socio-economic status and adherence to HIV preventive and therapeutic interventions: exploring the mediating role of food insecurity among men who have sex with men and transgender and non-binary persons from Brazil

INTRODUCTION

Brazil offers free-of-charge antiretroviral therapy (ART) for people living with HIV (PLWH) as well as oral pre-exposure prophylaxis (PrEP) through its national health system. Adherence to ART and to PrEP is essential to achieving the expected benefits of virologic suppression and prevention of HIV acquisition, respectively. Brazil has experienced worsening social inequalities, exacerbated by the COVID-19 pandemic, leading to increases in food insecurity especially among vulnerable populations. We explored whether food insecurity mediated the association of socio-economic status on adherence to ART/PrEP.

METHODS

Adult men who have sex with men (MSM) and transgender and non-binary persons (TGNB) living in Brazil (May-September/2021) voluntarily participated in a cross-sectional online study advertised on dating apps and social media. Participants living with HIV reporting ART use and participants with HIV-negative status reporting daily oral PrEP use were eligible for the analysis. Self-report of ART adherence was measured by the WebAd-Q instrument (3-items/past week) plus a visual analogue scale. Self-report of PrEP adherence was measured by the number of days the person took PrEP in the past week. The 8-item Brazilian Scale of Food Insecurity (EBIA) was used to measure food insecurity (higher scores indicate more severe food insecurity). Two structural equation models were used to assess the direct and indirect effects of variables on ART adherence among PLWH and on PrEP adherence among people using PrEP.

RESULTS

In total, 1230 PLWH were using ART, and 991 individuals with HIV-negative status were using daily oral PrEP. The median age of PLWH was 37 years (HIV negative: 34 years), most were cismen (98%). More PLWH reported moderate/severe food insecurity (21.7%; HIV negative: 12.9%). Self-report of ART adherence (measured by WebAd-Q, past 7 days) was 55.7% (PrEP adherence: 93.3%). In the two models, socio-economic status had an effect on adherence that was mediated through food insecurity: higher socio-economic status was associated with lower food insecurity, and higher food insecurity was associated with lower adherence.

CONCLUSIONS

Our findings suggest that the provision of socio-economic support could help PLWH and people at higher vulnerability to HIV acquisition by improving their adherence to ART or PrEP, and ultimately populations through decreased HIV transmissions.

CD4 T cell counts are inversely correlated with anti-cluster A antibodies in antiretroviral therapy-treated PLWH

While antiretroviral therapy efficiently suppresses viral replication, inflammation and immune dysfunction persist in some people living with HIV-1 (PLWH). Soluble gp120 (sgp120) has been detected in PLWH plasma and its presence is linked to immune dysfunction. It was reported that sgp120 binding to CD4 on uninfected bystander CD4 + T cells sensitizes them to antibody-dependent cellular-cytotoxicity (ADCC) mediated by non-neutralizing antibodies present in PLWH plasma. Using three independent PLWH cohorts, we observed that non-neutralizing anti-cluster A antibodies are negatively associated with CD4 + T cell counts. Anti-CD4BS antibodies blocked the coating of uninfected bystander cells by sgp120, thereby preventing their elimination by ADCC. Supporting a protective role of anti-CD4BS antibodies, PLWH having these antibodies didn't show a negative association between CD4 T cell counts and anti-cluster A. Our results reveal that anti-cluster A antibodies are associated with immune dysfunction in PLWH and anti-CD4BS antibodies might have a beneficial impact in these individuals.

Voluntary HIV Testing and Counselling Initiatives in Occupational Settings: A Scoping Review

Voluntary HIV testing and counselling (VCT) in the workplace could reach population groups who may be at risk for HIV but may not readily seek out testing from other services. We conducted a scoping review to understand (a) the nature of evidence related to initiatives and interventions for vocationally active adults on VCT in occupational settings, and (b) any facilitators and barriers to the delivery of and/or engagement with VCT initiatives/interventions in the workplace. JBI scoping review methodology was followed. The protocol was pre-registered. Included studies focused on vocationally active adults (population), VCT interventions or initiatives (concept), and workplaces in any sector or country (context). The review included studies published after 2000, in English, and of any research design. Studies relating to mandatory workplace HIV screening were excluded. MEDLINE, CINAHL, Scopus, PsycINFO, and the Cochrane Central Register of Control Trials were searched. Sources of grey literature included Google Scholar and governmental and organisational websites. One reviewer screened titles and abstracts; a second reviewer independently screened 10%. Data extraction utilised a modified JBI data extraction tool. We identified 17 studies reporting on 12 workplace VCT interventions (20,985 participants, 15-70 years). Studies were conducted in eight countries between 2001 and 2022. Interventions were delivered in organisations of different types, sizes and sectors. Testing included rapid blood tests and oral fluid self-tests. Where reported, the average on-site HIV testing uptake rate was 63%, and the average linkage to care rate was 86.85%. Views of workers, employers and service providers were largely positive. Barriers included being male, masculinity-driven workplace culture, HIV-related stigma, poor knowledge, low risk perceptions, lack of time and low support. Facilitators included on-site testing for convenience and accessibility, rapid and free tests, organisational, managerial and peer support, and embedding HIV tests within general health checks. Evaluation methods varied, although randomised trial designs were uncommon. Despite the limited number of studies, the workplace appears to be a viable route to the delivery of community-based VCT, albeit barriers should be addressed. Reporting quality of interventions and associated evaluations is variable and could be improved with the use of appropriate checklists.

Target product profile for cell-based and gene-based therapies to achieve a cure for HIV

This target product profile (TPP) highlights the minimal and optimal characteristics for ex-vivo and in-vivo cell and gene therapy-based products aimed at achieving an HIV cure (ie, durable antiretroviral-free viral control). The need for an effective, safe, scalable, affordable, accessible, and acceptable cure for HIV infection remains a major global priority. The possibilities for cell and gene therapy-based products for an HIV cure are rapidly expanding. In a multi-stakeholder consensus process of clinical experts and civil society, including representatives from low-income and middle-income countries, participants generally agreed on the optimal targets, whereas consensus on the minimal targets was not reached on every parameter. There was less agreement on the minimal targets for ex-vivo than in-vivo therapies given the complexity of ex-vivo interventions. The TPP is planned to be updated at regular intervals. Building a TPP, such as this one, is an important process for stakeholder engagement and aligning ambitions for the development of products that are acceptable to both clinicians and civil society.

Direct collaboration between hospitals and NGOs, an essential tool to reinforce linkage to care in people living with HIV

With the aim of improving access and engagement to healthcare in people living with HIV (PLHIV), in 2022 Gregorio Marañón Hospital and the NGO COGAM developed a circuit for recruitment and referral to hospital. Program targeted PLHIV who were neither receiving antiretroviral treatment (ART) nor on medical follow-up (FU); but also, individuals at risk who underwent screening tests at the NGO and, if positive, were referred for confirmation. The result was an increase in annual new PLHIV seen in hospital by reaching a population who were, essentially, young men (94% male, median age 30 years), migrants (95%) with recent diagnosis of HIV (median 5 years) and who were recently arrived in Spain (median 5 months). Most of them hadn´t healthcare coverage (78%). In multivariate analysis, that included all PLHIV seen for the first time in the ID Unit between 2019 and 2022, lack of healthcare coverage was the only independent predictor of lost to FU that reached statistical significance (HR 5.19, CI 2.76-9.47). Furthermore, time from HIV diagnosis to ART initiating was shortened from 14 to 6 days without affecting linkage to care. Our conclusion is that collaboration with NGOs reinforce diagnosis, FU, and adherence to ART for PLHIV.

Beliefs of Pentecostal pastors on the use of antiretroviral treatment among Pentecostal Christians living with HIV in a suburb of Cape Town-South Africa: a community health systems lens

The global public health community accepts antiretroviral therapy (ART) for controlling and managing human immunodeficiency virus (HIV). However, within some communities, claims of faith or miraculous healing of HIV and acquired immunodeficiency syndrome (AIDS) by Pentecostal pastors continue to spark controversies. This paper reports on an exploratory qualitative study to explore the beliefs held by Pentecostal pastors regarding the use of ART among Pentecostal Christians who are living with HIV. Twenty (20) purposively selected Pentecostal pastors from two informal settlements in Cape Town, South Africa, participated in the study. Open-ended, semi-structured, in-depth individual interviews were conducted on their religious beliefs concerning ART adherence. Interviews were conducted in English, audiotaped and transcribed verbatim before being imported into the Atlas.ti 2023 software program for thematic data analysis. Since our study was guided by the relational community health system model a hybrid deductive-inductive thematic analysis was used. Two contrasting themes about the influence of the religious beliefs of Pentecostal pastors were identified. The first theme and its associated subthemes highlight the lack of basic HIV and ART knowledge among pastors. Consequently, these pastors tend to nudge their Christians to rely more on faith and spiritual healing at the expense of adherence to ART. The second theme and its related sub-themes suggest that some pastors possess some basic HIV knowledge and understand the role of ART and how it works. This group of pastors advise their congregants to use ART and other healthcare services in tandem with spiritual rituals, faith and prayers. Our findings highlight the need for functional community-based structures, such as community health committees and health facility management committees, in settings where complex interaction within the belief systems, practices and norms of some stakeholders can influence people's health-seeking behaviours such as adherence to chronic medications like ART.

Ultrasensitive detection of intact SARS-CoV-2 particles in complex biofluids using microfluidic affinity capture

Measuring virus in biofluids is complicated by confounding biomolecules coisolated with viral nucleic acids. To address this, we developed an affinity-based microfluidic device for specific capture of intact severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Our approach used an engineered angiotensin-converting enzyme 2 to capture intact virus from plasma and other complex biofluids. Our device leverages a staggered herringbone pattern, nanoparticle surface coating, and processing conditions to achieve detection of as few as 3 viral copies per milliliter. We further validated our microfluidic assay on 103 plasma, 36 saliva, and 29 stool samples collected from unique patients with COVID-19, showing SARS-CoV-2 detection in 72% of plasma samples. Longitudinal monitoring in the plasma revealed our device's capacity for ultrasensitive detection of active viral infections over time. Our technology can be adapted to target other viruses using relevant cell entry molecules for affinity capture. This versatility underscores the potential for widespread application in viral load monitoring and disease management.

Surveying the Literature on Implementation Determinants and Strategies for HIV Structural Interventions: A Systematic Review Protocol

Background

Despite improvements in HIV prevention, treatment, and surveillance, vast disparities remain in access, uptake, and adherence of evidence-based interventions. These disparities are most pronounced among racially, sexually, and gender minoritized populations, as well as among those living in poverty and/or who use injectable drugs. Structural interventions, or interventions that target social and structural determinants of health like housing, transportation, or income, are needed to increase access to, use of, and adherence to HIV EBIs to advance the aims of the national Ending the HIV Epidemic initiative. However, it is unclear to what extent barriers and facilitators of structural interventions have been identified in the U.S. and what implementation strategies and adjunctive interventions have been developed to enhance their delivery.

Methods

To identify what implementation determinants, implementation strategies, and adjunctive interventions have been identified for HIV structural interventions, we carried out a broad database search between May and July 2024, identifying a total of 8,098 articles. We will use a multi-step process to identify articles to include in the systematic review. We will use natural language processing to identify articles for exclusion, followed by manual text review and extraction using COVIDENCE software. Literature on determinants will be coded according to the Consolidated Framework for Implementation Research. Implementation strategies and adjunctive interventions will be coded according to the Expert Recommendations for Implementing Change, the Theoretical Domains Framework, and COM-B. We will descriptively analyze determinants, implementation strategies, and adjunctive interventions, use natural language processing for thematic analysis of determinants, implementation strategies, and adjunctive interventions, and provide narrative description of implementation strategies and adjunctive interventions.

Discussion

This systematic review will identify key barriers and facilitators for HIV structural intervention implementation strategies, including multi-level approaches to address disparities among marginalized populations. Findings will provide insights for advancing equitable, scalable interventions to support the goals of the Ending the HIV Epidemic initiative.

Systematic review registration

CRD42024554315.

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

ABSTRACT

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

Violence as an obstacle to HIV medication adherence and viral suppression: A daily diary investigation among adolescent boys

For the 1.6 million adolescents currently living with HIV, adherence to antiretroviral therapy (ART) is vitally important for reducing HIV-associated morbidity and mortality, and for preventing onward HIV transmission. Unfortunately, ART adherence is particularly low among adolescents. One important barrier to adherence is exposure to violence; however, the impact of cumulative versus acute exposure to violence on adherence is unclear. We tested whether violence exposure was associated with ART adherence and viral load over a one-year period among adolescent boys living with HIV in Soweto, South Africa. Participants (N = 239) completed weekly ecological momentary assessment (EMA) surveys of their recent experiences with violence and ART adherence. They provided biological samples at baseline and at the one-year follow-up to measure viral load. Higher average exposure to violence over the course of the study year was significantly associated with lower ART adherence (i.e., a cumulative impact). When we restricted violence exposure to intimate partner violence only, we found that participants were significantly less likely to take their HIV medication on days when they experienced physical intimate partner violence (i.e., an acute impact). We also found a significant positive association between exposure to violence over the course of the study and participants' viral load at follow-up, even after controlling for baseline viral load. Our findings suggest that violence impacts two important HIV care outcomes through multiple pathways and highlight the importance of differentiating cumulative versus acute victimization in violence research. To improve health outcomes among adolescents with HIV and prevent new infections, it will be necessary to include boys in violence prevention and support services and to address violence exposure in HIV care.

HIV-1 viral decay in blood and semen in antiretroviral-naïve adults initiating dolutegravir/lamivudine vs. bictegravir/emtricitabine/tenofovir alafenamide

BACKGROUND

Co-formulated dolutegravir and lamivudine (DTG/3TC) is recommended as the first-line antiretroviral therapy (ART); however, the data on the viral decay in seminal plasma (SP) and blood plasma (BP), as well as changes in inflammatory biomarkers in BP, remain limited among antiretroviral-naïve people with HIV (PWH) receiving DTG/3TC. A prospective observational cohort study was conducted to compare the impact of DTG/3TC vs. bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) on viral decay kinetics and changes in inflammatory biomarkers in antiretroviral-naïve PWH.

METHODS

Newly diagnosed PWH who initiated BIC/FTC/TAF (n=57) or DTG/3TC (n=43) were enrolled. BP and SP were collected at 0, 4, 12, 24, and 48 weeks after ART initiation. The primary endpoint was viral suppression of HIV-1 in BP and SP at week 48. Secondary endpoints included changes in HIV-1 DNA levels and inflammatory biomarkers over the 48-week follow-up.

RESULTS

Overall, 96 (96.0%) PWH completed the 48-week follow-up (DTG/3TC, n=40; BIC/FTC/TAF, n=56). Viral suppression rates in BP and SP were comparable in the BIC/FTC/TAF and DTG/3TC groups in the per-protocol analyses at week 48 (BP, 96.4% vs. 100%, P=0.519; SP, 100% vs. 100%, P>0.999). Both regimens demonstrated similar effectiveness in reducing HIV-1 RNA levels in BP (3.0 vs. 3.1 log10 copies/mL) and SP (0.9 vs. 1.2 log10 copies/mL). There were no statistically significant differences in the reductions in HIV-1 DNA levels and changes in inflammatory biomarkers over the 48-week follow-up.

CONCLUSION

These findings indicated comparable effectiveness of DTG/3TC vs. BIC/FTC/TAF in achieving viral suppression in BP and SP, and similar changes in inflammatory biomarkers in BP.

MicroRNAs and human viral diseases: A focus on the role of microRNA-29

The viral replication can impress through cellular miRNAs. Indeed, either the antiviral responses or the viral infection changes through cellular miRNAs resulting in affecting many regulatory signaling pathways. One of the microRNA families that is effective in human cancers, diseases, and viral infections is the miR-29 family. Members of miR-29 family are effective in different viral infections as their roles have appeared in regulation of immunity pathways either in innate immunity including interferon and inflammatory pathways or in adaptive immunity including activation of T-cells and antibodies production. Although miR-29a affects viral replication by suppressing antiviral responses, it can inhibit the expression of viral mRNAs via binding to their 3'UTR. In the present work, we discuss the evidence related to miR-29a and viral infection through host immunity regulation. We also review roles of other miR-29 family members by focusing on their role as biomarkers for diagnosing and targets for viral diseases management.

Community Perspectives on Optimizing Community Health Volunteer Roles for HIV Prevention Services in Kenya and Uganda

Community health workers (CHWs) play a significant role in supporting health services delivery in communities with few trained health care providers. There has been limited research on ways to optimize the role of CHWs in HIV prevention service delivery. This study explored CHWs' experiences with offering HIV prevention services [HIV testing and HIV pre- and post-exposure prophylaxis (PrEP and PEP)] during three pilot studies in rural communities in Kenya and Uganda, which aimed to increase biomedical HIV prevention coverage via a structured patient-centered HIV prevention delivery model. In-depth semi-structured interviews were conducted from November 2021 to March 2022 with CHWs (N = 8) and their clients (N = 18) in the Sustainable East Africa Research in Community Health (SEARCH) SAPPHIRE study. A seven-person multi-regional team coded and analyzed data using a thematic analysis approach. CHWs offered clients PrEP and PEP refills, adherence monitoring, counseling on medications, and phone consultations. Clients reported CHWs maintained close interpersonal relationships with clients, and demonstrated trustworthiness and professionalism. Some clients reported that community members trusted the authenticity of CHWs, while others expressed concerns about the CHWs' ability to maintain confidentiality, and felt that some community members would be uncomfortable receiving HIV services from them. CHWs valued the expansion of their role to include prevention services but expressed concerns about balancing competing demands of CHW responsibilities, income-generating activities, and family roles. CHWs were well accepted as HIV prevention service providers despite contextual challenges. CHWs need ongoing training support. Establishing structures for remunerating CHWs in health systems could improve their performance and retention.

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

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

Effect of a Male-Targeted Digital Decision Support Application Aimed at Increasing Linkage to HIV Care Among Men: Findings from the HITS Cluster Randomized Clinical Trial in Rural South Africa

Linkage to HIV care remains suboptimal among men. We investigated the effectiveness of a male-targeted HIV-specific decision support app, Empowering People through Informed Choices for HIV (EPIC-HIV), on increasing linkage to HIV care among men in rural South Africa. Home-Based Intervention to Test and Start (HITS) was a multi-component cluster-randomized controlled trial conducted among 45 communities in uMkhanyakude, KwaZulu-Natal. The development of EPIC-HIV was guided by self-determination theory and human-computer interaction design to increase intrinsic motivation to seek HIV testing and care among men. EPIC-HIV was offered in two stages: EPIC-HIV 1 at the time of home-based HIV counseling and testing (HBHCT), and EPIC-HIV 2 at 1 month after a positive HIV diagnosis if not linked to care. Sixteen communities were randomly assigned to the arms to receive EPIC-HIV, and 29 communities to the arms without EPIC-HIV. Among all eligible men, we compared linkage to care (initiation or resumption of antiretroviral therapy after > 3 months of care interruption) at local clinics within 1 year of a home visit, ascertained from individual clinical records. Intention-to-treat analysis was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., financial incentives) and clustering at the community level. We also conducted a satisfaction survey for EPIC-HIV 2. A total of 13,894 men were eligible (i.e., aged ≥ 15 years and resident in the 45 communities). The mean age was 34.6 (±16.8) years, and 65% were married or in an informal union. Overall, 20.7% received HBHCT, resulting in 122 HIV-positive and 6 discordant tests. Among these, 54 men linked to care within 1 year after HBHCT. Additionally, of the 13,765 eligible participants who did not receive HBHCT or received HIV-negative results, 301 men linked to care within 1 year. Overall, only 13 men received EPIC-HIV 2. The proportion of linkage to care did not differ between the arms randomized to EPIC-HIV and those without EPIC-HIV (adjusted risk ratio = 1.05; 95% CI:0.86-1.29). All 13 men who used EPIC-HIV 2 reported the app was acceptable, user-friendly, and useful for getting information on HIV testing and treatment. The reach was low, although the acceptability and usability of the app were very high among those who engaged with it. Enhanced digital support applications could form part of interventions to increase knowledge of HIV treatment among men. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.

Hardships and Perceived Barriers to Medical Care Among Newly Diagnosed People With HIV During the COVID-19 Pandemic

Purpose of the researchA major consequence of the COVID-19 pandemic was a disruption of medical care in the United States. Using cross-sectional data from an ongoing randomized clinical trial, we examined severity of COVID-related hardships and other factors that might have influenced newly diagnosed people with HIV's (PWH's) receipt of care during the initial years of the pandemic (2020-22).Major findingsIn a sample of 29 newly diagnosed PWH presenting for care at three geographically diverse medical clinics in the United States, results showed that most patients (72.4%) reported that obtaining an HIV medical appointment during the pandemic was "easy." Correlational analyses found that COVID-related hardships were significantly related to overall health and functioning, as well as experiences of discrimination.ConclusionsTaken together, these findings align with previous results to show that already vulnerable populations were particularly affected by service disruptions, but that many patients were able to access care despite the pandemic.

Factors associated with HIV viremia in transgender women and transvestites in five Brazilian capitals, 2019-2021: a multicenter study

OBJECTIVE

To analyze factors associated with detectable HIV viremia among transgender women/transvestites (TWT) in five Brazilian capitals.

METHODS

: This was a cross-sectional study using data from a sample of TWT with HIV-positive serology and detectable viral load (VL), between 2019 and 2021. The dependent and independent variables were, respectively: viral load measurement, socioeconomic/demographic characteristics; alcohol/drug use; and self-perceived mental health. Poisson regression with robust variance was used.

RESULTS

: A total of 425 TWT tested positive for HIV and underwent VL measurement, 179 (42.0%) presented detectable viremia. Factors positively associated with detectability were: younger age (PR=2.26; 95%CI 1.13;4.51), poorer housing conditions (PR=2.72; 95%CI 1.30;5.68) and poor/very poor mental health (PR=1.70; 95%CI 1.08;2.66). The use of antiretroviral drugs was a protective factor against detectability (PR=0.29; 95%CI 0.30;0.61).

CONCLUSION

The factors associated with unsuppressed viral load highlight vulnerability related to gender identity that have a negative impact, despite the majority of participants being on antiretroviral therapy (ART).

MAIN RESULTS

People aged 20-29 who were homeless or unstable and those who reported poor or very poor mental health were more likely to have a detectable viral load. ARV drug use was a protective factor.

IMPLICATIONS FOR SERVICES

The identification of predictors for detectable viral load enables the design of appropriate strategies for monitoring and linking vulnerable people to health services, ensuring effective implementation.

PERSPECTIVES

It is necessary to develop educational strategies that take into account important social issues to improve awareness about undetectable viral load in HIV prevention among the transgender population, especially among younger people.