Linkage to HIV care and its determinants in the late HAART era: a systematic review and meta-analysis

Cost-effectiveness of screening and treating alcohol use and depression among people living with HIV in Zimbabwe: a mathematical modeling study

BACKGROUND

Alcohol use disorder (AUD) and major depressive disorder (MDD) drive HIV transmission in many sub-Saharan African settings. The impact of screening and treating AUD and MDD on HIV outcomes is unknown. We aimed to identify the cost-effectiveness of AUD and MDD interventions in Zimbabwe, and their potential contribution to reaching Zimbabwe's Ending the HIV Epidemic 2030 goal.

METHODS

Using a validated HIV compartmental transmission model in Zimbabwe, we compared four policy scenarios: prevention as usual (baseline); implement AUD screening (using AUDIT) and treatment (motivational interviewing and cognitive-behavioral therapy); implement MDD screening (using PHQ-9) and treatment (cognitive-behavioral therapy); and implement screening and treatment for both. Outcomes were HIV incidence projections, infections averted through 2030, quality-adjusted life-years gained, cost per infection averted, and cost per QALY gained. Analyses considered "spillover," when treatment for AUD also results in an improvement in MDD and the converse. Sensitivity analyses identified cost reductions necessary for AUD and MDD interventions to be as cost-effective as other HIV interventions, particularly the scale-up of long-acting PrEP.

RESULTS

AUD and MDD combined will be responsible for 21.1% of new HIV infections in Zimbabwe by 2030. Without considering spillover, compared to the baseline, MDD intervention can reduce new infections by 5.4% at $2039/infection averted and $3186/QALY. AUD intervention can reduce new infections by 5.8%, but at $2,968/infection averted and $4753/QALY, compared to baseline. Both MDD and AUD interventions can reduce new infections by 11.1% at $2810/infection averted and $4229/QALY, compared to baseline. Considering spillover, compared to the baseline, MDD intervention can reduce new infections by 6.4% at $1714/infection averted and $2630/QALY. AUD intervention can reduce new infections by 7.4%, but at $2299/infection averted and $3560/QALY compared to baseline. Both MDD and AUD interventions can reduce new infections by 11.9% at $2247/infection averted and $3382/QALY compared to baseline. For MDD intervention to match the cost-effectiveness of scaling long-acting PrEP, the cost of MDD intervention would need to be reduced from $16.64 to $12.88 per person.

CONCLUSIONS

Implementing AUD and MDD interventions can play an important role in HIV reduction in Zimbabwe, particularly if intervention cost can be decreased while preserving effectiveness.

Efficacy of assisted partner services for people who inject drugs in Kenya to identify partners living with HIV and hepatitis C virus infection: a prospective cohort study

BACKGROUND

People who inject drugs are at increased risk of both HIV and hepatitis C virus (HCV) infections but face barriers to testing and engagement in care. Assisted partner services are effective in locating people with HIV but are understudied among people who inject drugs. We assessed whether assisted partner services could be used to find, test for HIV and HCV infections, and link to care the partners of people who inject drugs in Kenya.

METHODS

In this prospective study at eight sites offering harm-reduction services in Kenya, we enrolled people aged 18 years or older who inject drugs and were living with HIV (index participants) between Feb 27, 2018, and Nov 1, 2021. Index participants provided information about their sexual and injecting partners (ie, anyone with whom they had had sexual intercourse or injected drugs in the previous 3 years), and then community-embedded peer educators located partners and referred them for enrolment in the study (partner participants). All participants underwent testing for HCV infection, and partner participants also underwent HIV testing. Index and partner participants with HIV but who were not on antiretroviral therapy (ART) were linked with treatment services, and those positive for HCV were linked to treatment with direct-acting antivirals. We calculated the number of index participants whom we needed to interview to identify partner participants with HIV and HCV infection.

FINDINGS

We enrolled 989 people living with HIV who inject drugs, who mentioned 4705 sexual or injecting partners. Of these 4705 partners, we enrolled 4597 participants, corresponding to 3323 unique individuals. 597 (18%) partner participants had HIV, of whom 506 (85%) already knew their status. 358 (71%) of those who knew they were HIV positive were virally suppressed. 393 (12%) partner participants were HCV antibody positive, 213 (54%) of whom had viraemia and 104 (26%) of whom knew their antibody status. 1·66 (95% CI 1·53-1·80) index participants had to be interviewed to identify a partner with HIV, and 4·24 (3·75-4·85) had to be interviewed to find a partner living with HIV who was unaware of their HIV status, not on ART, or not virally suppressed. To find a partner seropositive for HCV who did not know their antibody status, 3·47 (3·11-3·91) index participants needed to be interviewed. Among the 331 index and partner participants living with HIV who were not on ART at enrolment, 238 (72%) were taking ART at 6-month follow-up. No adverse events were attributed to study procedures.

INTERPRETATION

Use of assisted partner services among people with HIV who inject drugs was safe and identified partners with HIV and HCV infections. Assisted partner services was associated with increased uptake of ART for both index participants and partners.

FUNDING

US National Institutes of Health.

Systematic Review and Meta-analysis of Linkage to HIV Care Interventions in the United States, Canada, and Ukraine (2010-2021)

We conducted a systematic review and meta-analysis of interventions targeting linkage to HIV care in the US, Canada, and Europe. We searched six databases (PubMed, Embase, Cochrane Library, Web of Science and CINAHL). Inclusion criteria were English language studies in adults in the US, Canada, or Europe, published January 1, 2010 to January 1, 2021. We synthesized interventions by type and linkage to care outcome. The outcome was cumulative incidence of 3-month linkage. We estimated cumulative incidence ratios of linkage with 95% confidence intervals (CIs). We screened 945 studies; 13 met selection criteria (n = 1 from Canada, n = 1 from Ukraine, n = 11 from the US) and were included after full text review (total 37,549 individuals). The cumulative incidence of 3-month linkage in the intervention group was 0.82 (95% CI 0.68-0.94) and control group 0.71 (95% CI 0.50-0.90); cIR of linkage for intervention versus control was 1.30 (95% CI 1.13, 1.49). Interventions to improve linkage to care after HIV diagnosis warrant further attention.

Promoting HIV care continuum outcomes among people who use drugs and alcohol: a systematic review of randomized trials evaluating behavioral HIV care interventions published from 2011 to 2023

BACKGROUND

Substance use remains a robust predictor of HIV infection and a serious impediment to HIV care continuum progression for people living with HIV. The primary research question of this systematic review is focused on understanding the extent to which behavioral HIV care interventions have been efficacious in helping people who live with HIV and who use substances along the HIV care continuum.

METHODS

Using PubMed and ProQuest databases, we performed a systematic review of randomized trials of behavioral HIV care continuum interventions among people who use substances published from 2011 to August 2023, since the beginning of the treatment-as-prevention era.

RESULTS

We identified 11 studies (total participants: N = 5635), ten intentionally targeting substance-using populations. Four studies involved samples using ≥ 1 substance (e.g., alcohol, opioids, stimulants, marijuana); four involved injection drug use; one involved methamphetamine use; and one involved alcohol use. One study targeted a population with incidental substance use (i.e., alcohol, injection drug use, non-injection drug use reported in most participants). Each study defined one or more HIV care outcomes of interest. Viral suppression was an outcome targeted in 9/11 studies, followed by uptake of antiretroviral therapy (ART; 7/11), ART adherence (6/11), retention in care (5/11), and linkage to care (3/11). While most (nine) of the studies found significant effects on at least one HIV care outcome, findings were mostly mixed. Mediated (2/11) and moderated (2/11) effects were minimally examined.

CONCLUSIONS

The results from this systematic review demonstrate mixed findings concerning the efficacy of previous HIV care interventions to improve HIV care continuum outcomes among people who use substances. However, heterogeneity of study components (e.g., diversity of substances used/assessed, self-report vs. objective measures, attrition) prevent broad deductions or conclusions about the amenability of specific substance-using populations to HIV care intervention. More coordinated, comprehensive, and targeted efforts are needed to promote and disentangle intervention effects on HIV care continuum outcomes among substance-using populations.

County-level variations in linkage to care among people newly diagnosed with HIV in South Carolina: A longitudinal analysis from 2010 to 2018

BACKGROUND

Timely linkage to care (LTC) is key in the HIV care continuum, as it enables people newly diagnosed with HIV (PNWH) to benefit from HIV treatment at the earliest stage. Previous studies have found LTC disparities by individual factors, but data are limited beyond the individual level, especially at the county level. This study examined the temporal and geographic variations of county-level LTC status across 46 counties in South Carolina (SC) from 2010 to 2018 and the association of county-level characteristics with LTC status.

METHODS

All adults newly diagnosed with HIV from 2010 to 2018 in SC were included in this study. County-level LTC status was defined as 1 = "high LTC (≥ yearly national LTC percentage)" and 0 = "low LTC (< yearly national LTC percentage)". A generalized estimating equation model with stepwise selection was employed to examine the relationship between 29 county-level characteristics and LTC status.

RESULTS

The number of counties with high LTC in SC decreased from 34 to 21 from 2010 to 2018. In the generalized estimating equation model, six out of 29 factors were significantly associated with LTC status. Counties with a higher percentage of males (OR = 0.07, 95%CI: 0.02~0.29) and persons with at least four years of college (OR = 0.07, 95%CI: 0.02~0.34) were less likely to have high LTC. However, counties with more mental health centers per PNWH (OR = 45.09, 95%CI: 6.81~298.55) were more likely to have high LTC.

CONCLUSIONS

Factors associated with demographic characteristics and healthcare resources contributed to the variations of LTC status at the county level. Interventions targeting increasing the accessibility to mental health facilities could help improve LTC.

HIV treatment, antiretroviral adherence and AIDS mortality in people who inject drugs: a scoping review

BACKGROUND

People who inject drugs (PWID) are a key population for the prevention and care of HIV infection.

METHODS

This scoping review covers recent (post-2010) systematic reviews on engagement of PWID in sequential stages of HIV care from uptake, to achieving viral suppression, and to avoiding AIDS-related mortality.

RESULTS

We found that data on engagement of PWID into antiretroviral therapy (ART) were particularly scarce, but generally indicated very low engagement in ART. Studies of adherence and achieving viral suppression showed varying results, with PWID sometimes doing as well as other patient groups. The severity of social, medical and psychiatric disability in this population poses significant treatment challenges and leads to a marked gap in AIDS mortality between PWID and other population groups.

CONCLUSIONS

Given the multi-level barriers, it will be difficult to reach current targets (UNAIDS fast-track targets of 95-95-95) for ART for PWID in many locations. We suggest giving priority to reducing the likelihood that HIV seropositive PWID will transmit HIV to others and reducing morbidity and mortality from HIV infection and from other comorbidities.

Timely linkage to care among men who have sex with men newly diagnosed with HIV: A structural equation model integrated HIV-related stigma framework

HIV prevalence among men who have sex with men in China has increased dramatically, and timely linkage to care after being diagnosed with HIV is important to treatment success. This cross-sectional study aims to utilize structural equation modeling to test a hypothesized model of timely linkage to care adapted from the HIV-related stigma framework. Data were collected from 257 men who have sex with men living with HIV. The proportion of participants with timely linkage to care within one month was 63.42%. The model result showed a good fit. Higher HIV-related stigma was significantly associated with a lower level of social support, mental health, maladaptive coping (three mechanism variables), and attitude toward linkage to care. Higher CD4⁺ T-cell count, disclosure of HIV positivity to sexual partners, and greater convenience of accessing care were related to timely linkage to care (p< 0.05). These model results suggest that enhancing attention to family reactions and social support are needed for further research and interventions to accelerate newly diagnosed people's access to HIV care in China.

Exploring the Impacts of Alcohol and Other Drug Use on HIV Care Among Older African American Adults in Kentucky: A Constructivist Grounded Theory Study

ABSTRACT

This grounded theory study examined the use of alcohol and other drugs (AOD) on the management of HIV disease among 27 older African Americans (≥50 years). Interview transcripts were analyzed using constructivist grounded theory analytic techniques. Participants reported facing (a) environmental impacts of AOD use and (b) discrimination from the health care system. The analysis revealed six phases of AOD use, occurring at various stages of the HIV care continuum: (a) linking AOD use as the cause of HIV diagnosis, (b) having AOD use facilitate denial of HIV, (c) experiencing problematic use as a barrier to care engagement, (d) "testing the waters," (e) relying on AIDS service organizations and medical providers, and (f) changing or maintaining patterns of AOD use to maintain engagement with care. Recommendations include assessing a patient's AOD use in relationship to the care continuum to evaluate patients' experiences and barriers within systems of care.

Integrating Financial Incentives for Viral Load Suppression into HIV Care Coordination Programs: Considerations for Development and Implementation

CONTEXT

Interventions that support durable viral load suppression (VLS) among people living with HIV (PLWH) who face barriers to treatment adherence are needed to maintain optimal individual health, prevent new HIV infections, and advance health equity. Efficacy trials indicate that financial incentives (FIs) are a promising strategy for promoting VLS, although less is known about their implementation in "real-world" settings. This article describes considerations for the development and implementation of FI interventions identified in existing literature, and how they informed the scale-up of a multilevel treatment adherence support program designed to increase VLS among PLWH in New York City.

PROGRAM

The Undetectables VLS Program comprises a social marketing campaign and a "tool kit" of evidence-based HIV treatment adherence strategies, including quarterly FIs ($100) that patients receive for achieving or maintaining an undetectable viral load (<200 copies/mL; also referred to as VLS). The intervention was developed and pilot tested by Housing Works Community Healthcare and the University of Pennsylvania from 2014 to 2016. Initial findings from the pilot evaluation showed a statistically significant positive effect on VLS.

IMPLEMENTATION

The New York City Department of Health and Mental Hygiene contracted with 7 agencies across New York City to scale up The Undetectables Program over a 3-year period (2016-2019) by integrating the program into existing services for PLWH.

EVALUATION PLANS

Quality indicators (eg, percentage of clients who received an FI each quarter; percentage of clients who were virally suppressed at 90 days postenrollment) will be used to measure program performance and impact over time.

DISCUSSION

Recommendations for implementing FIs for PLWH include packaging FIs with client-centered, evidence-based adherence strategies, incorporating FIs into existing service delivery systems, and obtaining organization-wide buy-in to facilitate their implementation. Implementation science research is needed to identify strategies to effectively implement and sustain evidence-based FI interventions.

Ending the HIV epidemic in the USA: an economic modelling study in six cities

BACKGROUND

The HIV epidemic in the USA is a collection of diverse local microepidemics. We aimed to identify optimal combination implementation strategies of evidence-based interventions to reach 90% reduction of incidence in 10 years, in six US cities that comprise 24·1% of people living with HIV in the USA.

METHODS

In this economic modelling study, we used a dynamic HIV transmission model calibrated with the best available evidence on epidemiological and structural conditions for six US cities: Atlanta (GA), Baltimore (MD), Los Angeles (CA), Miami (FL), New York City (NY), and Seattle (WA). We assessed 23 040 combinations of 16 evidence-based interventions (ie, HIV prevention, testing, treatment, engagement, and re-engagement) to identify combination strategies providing the greatest health benefit while remaining cost-effective. Main outcomes included averted HIV infections, quality-adjusted life-years (QALYs), total cost (in 2018 US$), and incremental cost-effectiveness ratio (ICER; from the health-care sector perspective, 3% annual discount rate). Interventions were implemented at previously documented and ideal (90% coverage or adoption) scale-up, and sustained from 2020 to 2030, with outcomes evaluated until 2040.

FINDINGS

Optimal combination strategies providing health benefit and cost-effectiveness contained between nine (Seattle) and 13 (Miami) individual interventions. If implemented at previously documented scale-up, these strategies could reduce incidence by between 30·7% (95% credible interval 19·1-43·7; Seattle) and 50·1% (41·5-58·0; New York City) by 2030, at ICERs ranging from cost-saving in Atlanta, Baltimore, and Miami, to $95 416 per QALY in Seattle. Incidence reductions reached between 39·5% (26·3-53·8) in Seattle and 83·6% (70·8-87·0) in Baltimore at ideal implementation. Total costs of implementing strategies across the cities at previously documented scale-up reached $559 million per year in 2024; however, costs were offset by long-term reductions in new infections and delayed disease progression, with Atlanta, Baltimore, and Miami projecting cost savings over the 20 year study period.

INTERPRETATION

Evidence-based interventions can deliver substantial public health and economic value; however, complementary strategies to overcome social and structural barriers to HIV care will be required to reach national targets of the ending the HIV epidemic initiative by 2030.

FUNDING

National Institutes of Health.

Comparative analysis of HIV sequences in real time for public health

PURPOSE OF REVIEW

The purpose of this study is to summarize recent advances in public health applications of comparative methods for HIV-1 sequence analysis in real time, including genetic clustering methods.

RECENT FINDINGS

Over the past 2 years, several groups have reported the deployment of established genetic clustering methods to guide public health decisions for HIV prevention in 'near real time'. However, it remains unresolved how well the readouts of comparative methods like clusters translate to events that are actionable for public health. A small number of recent studies have begun to elucidate the linkage between clusters and HIV-1 incidence, whereas others continue to refine and develop new comparative methods for such applications.

SUMMARY

Although the use of established methods to cluster HIV-1 sequence databases has become a widespread activity, there remains a critical gap between clusters and public health value.

Systemic Factors and Barriers That Hamper Adequate Data Collection on the HIV Epidemic and Its Associated Inequalities in Countries With Long-Term Armed Conflicts: Lessons From Colombia

Although advances in treatment and diagnosis have transformed HIV into a chronic disease in high-income countries, a spectrum of structural, political, sociocultural, and health system barriers hamper early diagnosis and timely treatment of HIV in many middle- and low-income countries. In most Latin American countries, in spite of the great improvement in access to antiretroviral therapy, a large proportion of individuals infected with HIV do not know their status. In Colombia, the Joint United Nations Programme on HIV/AIDS currently estimates a much larger number of HIV cases than the number reported by Colombian authorities. Potential reasons for underdiagnosis and underreporting include sociocultural factors such as social stigma, restrictions in access to health care, a lack of public health research and robust surveillance systems, and the particular recent history and social situation related to the armed conflict the country has suffered through for several decades. Lessons from Colombia may be helpful in monitoring, understanding, and tackling the HIV epidemic in countries with long-term armed conflicts.