Characterizing Human Immunodeficiency Virus Antiretroviral Therapy Interruption and Resulting Disease Progression Using Population-Level Data in British Columbia, 1996-2015

Depressive Symptoms, the Impact on ART Continuation, and Factors Associated with Symptom Improvement Among a Cohort of People Living with HIV in British Columbia, Canada

Depressive symptoms among people living with HIV (PLWH) are associated with poorer overall health outcomes. We characterized depressive symptoms and improvements in symptomology among PLWH (≥ 19 years old) in British Columbia (BC), Canada. We also examined associations between depressive symptomology and antiretroviral therapy (ART) treatment interruptions. Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10), within a longitudinal cohort study with three surveys administered 18-months apart. We used multivariable logistic regression to model factors associated with improvements in depressive symptoms (CES-D-10 scores from ≥ 10 to < 10). Of the 566 participants eligible for analysis 273 (48.2%) had CES-D scores indicating significant depressive symptoms (score ≥ 10) at enrollment. Improvements in symptoms at first follow-up were associated with greater HIV self-care on the Continuity of Care Scale (adjusted odds ratio: 1.17; 95% CI 1.03-1.32), and not having a previously reported mental health disorder diagnosis (aOR 2.86; 95% CI 1.01-8.13). Those reporting current cocaine use (aOR 0.33; 95% CI 0.12-0.91) and having a high school education, vs. less than, (aOR 0.25; 95% CI 0.08-0.82) had lower odds of improvement in depressive symptomatology. CES-D scores ≥ 10 were not significantly associated with ART treatment interruptions during follow-up (aOR: 1.08; 95% CI:0.65-1.8). Supporting greater self-care and consideration of mental health management strategies in relation to HIV may be useful in promoting the wellbeing of PLWH who experience depressive symptoms.

Translating and disseminating a localised economic model to support implementation of the 'Ending the HIV Epidemic' initiative to public health policymakers

Background

Despite significant progress in HIV treatment and prevention, the US remains far from its goal of 'Ending the HIV Epidemic' by 2030. Economic models using local data can synthesise the evidence to help policymakers allocate HIV resources efficiently, but persistent research-to-practice gaps remain. Little is known about how to facilitate the use of economic modelling data among local public health policymakers in real-world settings.

Aims and objectives

To explore the dissemination of results from a locally-calibrated economic model for HIV prevention and treatment and identify the factors influencing potential uptake of the model for public health decision making at the local level.

Methods

Four virtual focus groups with 26 local health department policymakers in Baltimore, Miami, Seattle, and New York City were held between July 2020 and May 2021. Qualitative content analysis of transcripts identified key themes around using the localised economic model in policy decisions.

Results

Participants were interested in using local data in their decisions to allocate resources for HIV prevention/treatment. Six themes emerged: 1) importance of understanding local policy context; 2) health equity considerations; 3) using evidence to support current priorities; 4) difficulty of changing strategies, even incrementally; 5) bang for the incremental buck (efficiency) vs. previous impact; and 6) community values.

Conclusion and relevance

To optimise acceptance and use of results from economic models, researchers should engage with local community members and public health decision makers early to understand budgetary and community priorities. Participants prioritised evidence that supports their existing strategies, considers budgets and funding streams, and improves health equity; however, real-world budget constraints and conflicting interests serve as barriers to implementing model recommendations and reaching national goals.

Treatment interruptions and community connectedness among gbMSM living with HIV in Metro Vancouver, Canada

HIV treatment interruptions are a major public health concern that demonstrate a lack of engagement in care and is detrimental to the health of people living with HIV. Community connectedness have demonstrated a protective effect for psychosocial health but are not well understood for HIV treatment outcomes. We explored associations between community connectedness and treatment interruptions among gay, bisexual and other men who have sex with men (gbMSM) living with HIV in Vancouver, British Columbia. We analyzed survey data from the Momentum Health Study and identified treatment interruptions through data linkages with the provincial HIV Drug Treatment Program as episodes lasting more than 60 days beyond an expected antiretroviral therapy refill date from February 2012 to July 2019. We built a mixed-effects logistic regression model, adjusting for confounders. Of 213 gbMSM living with HIV, 54 experienced treatment interruption (25.4%) over a median five-year follow-up. Multivariable results found the number gbMSM who spoken to in the past month (aOR = 0.995; 95% CI = 0.991, 1.000 (per 100-unit increase)) and attending a gay community meeting more than once per month (aOR = 0.32; 95% CI = 0.11, 0.89) were associated with lower odds of treatment interruptions. These results highlight the importance of social connections in facilitating effective HIV care.

A case report of clinical implications of a delayed antiretroviral therapy switch in a patient with multiple treatment interruptions

The Namibia national antiretroviral therapy guidelines recommend that patients living with HIV who interrupt antiretrovirals and in the process disengage from care be restarted on their usual antiretroviral therapy regimen upon return. We introduce a 39-year-old male patient on first-line antiretroviral therapy, namely, tenofovir disoproxil fumarate, lamivudine and efavirenz, from 2015 to 2019 (4 years), who returned to care after the fourth episode of interrupting his treatment, though his adherence to antiretroviral therapy was deemed poor. Thus, he presented with severe immunosuppression and an AIDS-defining condition. Hence, he was switched to second-line antiretroviral therapy, treated with fluconazole for oesophageal candidiasis and reinitiated on cotrimoxazole prophylaxis. The client is currently clinically stable with a suppressed viral load. Medical and drug history taking with an emphasis on the previous history of treatment failure in patients returning to care are paramount in guiding the choice of future prescriptions of antiretrovirals. The multiple antiretroviral therapy interruptions from the patient and the delay in decision-making on the side of the clinician to switch treatments contributed to the emergence of an AIDS-defining condition.

Evaluation of a Public Health Referral System to Re-Engage Individuals Living With HIV Who Have Interrupted Antiretroviral Therapy in British Columbia, Canada

BACKGROUND

In 2016, the British Columbia HIV/AIDS Drug Treatment Program modified its prescriber alert system for antiretroviral therapy (ART) interruptions to include referrals to regional public health nursing teams for direct outreach support for those who remain off treatment for 4 months or longer. We evaluated clinically relevant outcomes of this Re-Engagement and Engagement in Treatment for Antiretroviral Interrupted and Naïve populations (RETAIN) initiative, in comparison to previous time-periods.

METHODS

We analyzed ART interruptions triggering alerts in pre-RETAIN (July 2013-April 2016) and post-RETAIN periods (May 2016-October 2017) with follow-up continuing until October 2018. We compared the proportions of those who restarted ART and achieved viral suppression in pre-RETAIN and post-RETAIN periods and the time to ART restart using generalized estimating equations. Cox proportional hazards modelling was used to examine associations with time-to-ART-restart.

RESULTS

A total of 1805 individuals experienced ART interruptions triggering 3219 alerts; 2050 in pre-RETAIN and 1169 in post-RETAIN periods. Participants were predominantly men (74%) and had a median duration of ART of 5 years. Among persons who remained interrupted >4 months after an ART interruption alert was sent, the median time from interruption to ART re-initiation declined from 8.7 months to 7.4 months (P < 0.001) from pre-to post-RETAIN periods. Interruptions in the post-RETAIN era were associated with an increased hazard of restarting ART (adjusted hazard ratio 1.51; 95% CI: 1.34 to 1.69).

CONCLUSIONS

Public health referrals shortened the length of ART interruptions after alerts sent to prescribers had not resulted in re-engagement. Similar programs should be considered in other jurisdictions.

Can the combination of TasP and PrEP eliminate HIV among MSM in British Columbia, Canada?

INTRODUCTION

In British Columbia (BC), the HIV epidemic continues to disproportionally affect the gay, bisexual and other men who have sex with men (MSM). In this study, we aimed to evaluate how Treatment as Prevention (TasP) and pre-exposure prophylaxis (PrEP), if used in combination, could lead to HIV elimination in BC among MSM.

METHODS

Considering the heterogeneity in HIV transmission risk, we developed a compartmental model stratified by age and risk-taking behaviour for the HIV epidemic among MSM in BC, informed by clinical, behavioural and epidemiological data. Key outcome measures included the World Health Organization (WHO) threshold for disease elimination as a public health concern and the effective reproduction number (R_e). Model interventions focused on the optimization of different TasP and PrEP components. Sensitivity analysis was done to evaluate the impact of sexual mixing patterns, PrEP effectiveness and increasing risk-taking behaviour.

RESULTS

The incidence rate was estimated to be 1.2 (0.9-1.9) per 1000 susceptible MSM under the Status Quo scenario by the end of 2029. Optimizing all aspects of TasP and the simultaneous provision of PrEP to high-risk MSM resulted in an HIV incidence rate as low as 0.4 (0.3-0.6) per 1000 susceptible MSM, and an R_e as low as 0.7 (0.6-0.9), indicating that disease elimination was possible when TasP and PrEP were combined. Provision of PrEP to younger MSM or high-risk and younger MSM resulted in a similar HIV incidence rate, but an R_e with credible intervals that crossed one.

CONCLUSION

Further optimizing all aspects of TasP and prioritizing PrEP to high-risk MSM can achieve the goal of disease elimination in BC. These results should inform public health policy development and intervention programs that address the HIV epidemic in BC and in other similar settings where MSM are disproportionately affected.

A co-interaction model of HIV and syphilis infection among gay, bisexual and other men who have sex with men

We developed a mathematical model to study the co-interaction of HIV and syphilis infection among gay, bisexual and other men who have sex with men (gbMSM). We qualitatively analysed the model and established necessary conditions under which disease-free and endemic equilibria are asymptotically stable. We gave analytical expressions for the reproduction number, and showed that whenever the reproduction numbers of sub-models and co-interaction model are less than unity, the epidemics die out, while epidemics persist when they are greater than unity. We presented numerical simulations of the full model and showed qualitative changes of the dynamics of the full model to changes in the transmission rates. Our numerical simulations using a set of reasonable parameter values showed that: (a) both diseases die out or co-exist whenever their reproduction number is less than or exceed unity. (b) HIV infection impacts syphilis prevalence negatively and vice versa. (c) one possibility of lowering the co-infection of HIV and syphilis among gbMSM is to increase both testing and treatment rates for syphilis and HIV infection, and decrease the rate at which HIV infected individuals go off treatment.

Combined estimation of disease progression and retention on antiretroviral therapy among treated individuals with HIV in the USA: a modelling study

BACKGROUND

Accurately estimating HIV disease progression and retention on antiretroviral therapy (ART) can help inform interventions to control HIV microepidemics and mathematical models used to inform health-resource allocation decisions. Our objective was to estimate the monthly probabilities of on-ART CD4 T-cell count progression, mortality, ART dropout, and ART reinitiation using a continuous-time multistate Markov model. We also aimed to validate health-state transition probability estimates to ensure they accurately reproduced the regional HIV microepidemics across the USA.

METHODS

In our modelling study, we considered a cohort of patients from the HIV Research Network, a consortium of 17 adult and paediatric HIV-care providers located in the northeastern (n=8), southern (n=5), and western (n=4) regions of the USA. Individuals aged 15 years or older who were in HIV care (defined as one CD4 test and one HIV-care visit in a calendar year period) with at least one ART prescription between Jan 1, 2010, and Dec 31, 2015, were included in the analysis. We used continuous-time multistate Markov models to estimate transitions between CD4 strata and between on-ART and off-ART states. We examined and adjusted for differences in probability of transition by region, race or ethnicity, sex, HIV risk group, and other baseline clinical indicators.

FINDINGS

The median age of the 32 242 individuals included in the analysis was 44 years (interquartile range 35-51). Over a median follow-up of 4·9 years (2·6-6·0), 8614 (26·7%) of 32 242 people interrupted ART and 1325 (4·1%) of 32 242 people died. Women, men who have sex with men, and individuals with no previous ART experience had greater increases in CD4 cell counts, whereas black people and people who inject drugs had increased probabilities of ART dropout and faster disease progression. Regardless of CD4 strata, individuals had increased hazard for ART dropout if they were from the south (adjusted hazard ratio [aHR] range from 1·91, 95% CI 1·71-2·13, to 2·45, 2·29-2·62) or the west (aHR range from 1·29, 1·10-1·51, to 1·66, 1·51-1·82) of the USA, compared with individuals from the northeast USA.

INTERPRETATION

Our results show heterogeneities in disease progression during ART and probability of ART retention across race and ethnicity, HIV risk groups, and regions. These differences should be viewed as targets for intervention and should be incorporated in mathematical models of regional HIV microepidemics in the USA.

FUNDING

US National Institutes of Health, Agency for Healthcare Research and Quality, and Health Resources and Services Administration.

Experiences of the HIV Cascade of Care Among Indigenous Peoples: A Systematic Review

Indigenous leaders remain concerned that systemic oppression and culturally unsafe care impede Indigenous peoples living with HIV from accessing health services that make up the HIV cascade of care. We conducted a systematic review to assess the evidence related to experiences of the HIV care cascade among Indigenous peoples in Australia, Canada, New Zealand, and United States. We identified 93 qualitative and quantitative articles published between 1996 and 2017 reporting primary data on cascade outcomes disaggregated by Indigenous identity. Twelve involved data from Australia, 52 from Canada, 3 from New Zealand and 26 from United States. The majority dealt with HIV testing/diagnosis (50). Relatively few addressed post-diagnosis experiences: linkage (14); retention (20); treatment initiation (21); adherence (23); and viral suppression (24). With the HIV cascade of care increasingly the focus of global, national, and local HIV agendas, it is critical that culturally-safe care for Indigenous peoples is available at all stages.

Antisense RNA: the new favorite in genetic research

Antisense RNA molecule represents a unique type of DNA transcript that comprises 19-23 nucleotides and is complementary to mRNA. Antisense RNAs play the crucial role in regulating gene expression at multiple levels, such as at replication, transcription, and translation. In addition, artificial antisense RNAs can effectively regulate the expression of related genes in host cells. With the development of antisense RNA, investigating the functions of antisense RNAs has emerged as a hot research field. This review summarizes our current understanding of antisense RNAs, particularly of the formation of antisense RNAs and their mechanism of regulating the expression of their target genes. In addition, we detail the effects and applications of antisense RNAs in antivirus and anticancer treatments and in regulating the expression of related genes in plants and microorganisms. This review is intended to highlight the key role of antisense RNA in genetic research and guide new investigators to the study of antisense RNAs.