Epidemiology of HIV in the United States

Cancer Treatment Decision-Making for People Living With HIV: Physician-Reported Barriers, Facilitators, and Recommendations

BACKGROUND

Compared with the general cancer population, people living with HIV (PLWH) and cancer are less likely to receive treatment and have significantly elevated cancer-specific mortality for many common cancer types. Physician recommendations drive the cancer therapy that patients receive, yet there is limited information assessing how cancer treatment decisions are made for people living with HIV and cancer. We sought to understand oncologist decision-making in PLWH and cancer by eliciting barriers, facilitators, and recommendations for enhancing care delivery.

SETTING

Participants were recruited between May 2019 and May 2021 from one academic medical center in the western United States (n = 13), another in the southeastern United States (n = 7), and community practices nationwide (n = 5).

METHODS

Using an inductive qualitative approach, we conducted in-depth interviews with 25 oncologists from two academic medical centers and community practices.

RESULTS

Facilitators of cancer care delivery included readily available information regarding HIV status and stage, interdepartmental communication, and antiviral therapy adherence. Barriers included a lack of formal education on HIV malignancies, perceptions of decreased life expectancy, fear of inadvertent disclosure, and drug-drug interactions. Recommendations included improved provider communication, patient social and mental health resources, and continuing education opportunities.

CONCLUSION

The study revealed drivers of cancer treatment decision-making, highlighting physician-reported barriers and facilitators, and recommendations to support treatment decision-making. This is the first known study examining oncologists' perceptions of caring for PLWH. Given that cancer is a leading cause of death among PLWH, there is an urgent need to improve care and outcomes.

National Estimates of Prevalence, Time-Trend, and Correlates of Smoking in US People Living with HIV (NHANES 1999-2016)

OBJECTIVE

Approximately one in four deaths among people living with HIV (PLWH) in the United States can be attributed to cigarette smoking. Using a nationally representative sample of PLWH, this study examines the prevalence, time-trends, and correlates of current cigarette smoking among PLWH compared to people without HIV.

DESIGN

Secondary analysis of population-based cross-sectional biobehavioral survey.

METHODS

Data were pooled from the 1999-2016 National Health and Nutrition Examination Survey (NHANES). All adults (20-59 years) who self-reported their smoking status and were tested for HIV (HIV+ = 152; HIV- = 26 305) were included in the analysis. Prevalence with 95% confidence interval (95% CI), trend analysis by year and group (HIV+/HIV-), and multivariable logistic regression analyses were performed with the complex survey design adjustments.

RESULTS

Overall, 47.0% of PLWH were current smokers compared to 25.5% of those without HIV. From 1999 to 2016, the decline in smoking in PLWH was comparable to those without HIV (10.7% vs. 8.0%). PLWH smokers were more likely than PLWH nonsmokers to be substance users (adjusted odds ratio [aOR] = 17.52; 95% CI = 2.04 to 27.8). Compared to smokers without HIV, PLWH smokers were more likely to be older (1.10; 1.06 to 1.14), males (7.96; 2.50 to 25.40), non-Hispanic Black (10.45; 4.13 to 26.45), with depression (Patient Health Questionnaire-9 sum score ≥5) (3.79; 1.22 to 11.79), and less likely to be gay (0.02; 0.00 to 0.07).

CONCLUSION

Cigarette smoking among PLWH is a major public health problem in the United States. Targeted and tailored smoking cessation interventions that incorporate assessment and treatment of depression and co-occurring substance use are critical for PLWH, especially among those who are disproportionately affected by smoking and HIV (sexual minority).

IMPLICATIONS

This study offers important research implications in four areas:1. The decline in smoking among PLWH over 18 years has been modest, and half of PLWH are still smokers.2. More resources and efforts should be allocated to reduce cigarette smoking among PLWH.3. There is a critical need to develop and test culturally tailored smoking cessation interventions for minority subgroups who are most impacted by HIV infection and smoking (non-Hispanic Blacks and men who have sex with men)4. Smoking cessation interventions designed for PLWH should incorporate assessment and treatment of depression and substance use.

Stopping, starting, and sustaining HIV antiretroviral therapy: a mixed-methods exploration among African American/Black and Latino long-term survivors of HIV in an urban context

Background

Although periods of HIV antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained. Yet, little is known about factors that contribute to such ART non-persistence among long-term HIV survivors. The present study applied a convergent parallel mixed-methods design to explore the phenomena of stopping/starting and sustaining ART, focusing on low-socioeconomic status African American or Black and Latino persons living with HIV (PLWH) who face the greatest challenges.

Methods

Participants (N = 512) had poor engagement in HIV care and detectable HIV viral load. All received structured assessments and N = 48 were randomly selected for in-depth interviews. Quantitative analysis using negative binomial regression uncovered associations among multi-level factors and the number of times ART was stopped/started and the longest duration of sustained ART. Qualitative data were analyzed using a directed content analysis approach and results were integrated.

Results

Participants were diagnosed 18.2 years ago on average (SD = 8.6), started ART a median five times (Q1 = 3, Q3 = 10), and the median longest duration of sustained ART was 18 months (Q1 = 6, Q3 = 36). Factors associated with higher rates of stops/starts were male sex, transgender identity, cannabis use at moderate-to-high-risk levels, and ART- and care-related stigma. Factors associated with lower rates of stops/starts were older age, more years since diagnosis, motivation for care, and lifetime injection drug use (IDU). Factors associated with longer durations of sustained ART were Latino/Hispanic ethnicity, motivation for ART and care, and recent IDU. Factors associated with a shorter duration were African American/Black race, alcohol use at moderate-to-high-risk levels, and social support. Qualitative results uncovered a convergence of intersecting risk factors for stopping/starting ART and challenges inherent in managing HIV over decades in the context of poverty. These included unstable housing, which contributed to social isolation, mental health distress, and substance use concerns, the latter prompting selling (“diverting”) ART. Primarily complementary quantitative and qualitative findings described mechanisms by which risk/protective factors operated and ways PLWH successfully restart and/or sustain ART.

Conclusions

The field focuses substantially on ART adherence, but greater attention to reducing the frequency of ART non-persistence is needed, along with creating social/structural conditions favorable for sustained ART.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10464-x.

Longitudinal assessment of abnormal Papanicolaou test rates among women with HIV

OBJECTIVE

To describe longitudinal changes in the prevalence of abnormal Papanicolau testing among women living with HIV.

DESIGN

Prospective cohort study with sequential enrollment subcohorts.

METHODS

Four waves of enrollment occurred in the Women's Interagency HIV Study, the US women's HIV cohort (1994-1995, 2001-2002, 2011-2012, 2013-2015). Pap testing was done at intake, with colposcopy prescribed for any abnormality. Rates of abnormal Pap test results (atypical squamous cells of uncertain significance or worse) and cervical intraepithelial neoplasia grade 2 (CIN2) or worse were calculated. Logistic regression models assessed changes in prevalence across cohorts after controlling for severity of HIV disease and other risk factors for abnormal Pap tests.

RESULTS

The unadjusted prevalence of any Pap abnormality was 679/1769 (38%) in the original cohort, 195/684 (29%) in the 2001-2002 cohort, 46/231 (20%) in the 2011-2012 cohort, and 71/449 (16%) in the 2013-2015 cohort. In multivariable analysis, compared with risk in the 1994-1995 cohort, the adjusted risk in the 2001-2002 cohort was 0.79 (95% CI 0.59-1.05), in the 2011-2012 cohort was 0.67 (95% CI 0.43-1.04), and in the 2013-2015 cohort was 0.41 (95% CI 0.27-0.62) with P for trend less than 0.0001.

CONCLUSION

Rates of abnormal cytology among women with HIV have fallen during the past two decades.

Drug-drug interactions and clinical considerations with co-administration of antiretrovirals and psychotropic drugs

Psychotropic medications are frequently co-prescribed with antiretroviral therapy (ART), owing to a high prevalence of psychiatric illness within the population living with HIV, as well as a 7-fold increased risk of HIV infection among patients with psychiatric illness. While ART has been notoriously associated with a multitude of pharmacokinetic drug interactions involving the cytochrome P450 enzyme system, the magnitude and clinical impact of these interactions with psychotropics may range from negligible effects on plasma concentrations to life-threatening torsades de pointes or respiratory depression. This comprehensive review summarizes the currently available information regarding drug-drug interactions between antiretrovirals and pharmacologic agents utilized in the treatment of psychiatric disorders-antidepressants, stimulants, antipsychotics, anxiolytics, mood stabilizers, and treatments for opioid use disorder and alcohol use disorder-and provides recommendations for their management. Additionally, overlapping toxicities between antiretrovirals and the psychotropic classes are highlighted. Knowledge of the interaction and adverse effect potential of specific antiretrovirals and psychotropics will allow clinicians to make informed prescribing decisions to better promote the health and wellness of this high-risk population.

Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare

We evaluated associations between levels of alcohol use and HIV care continuum components using national Veterans Aging Cohort Study data for all patients with HIV and AUDIT-C screening (2/1/2008-9/30/2014). Poisson regression models evaluated associations between alcohol use levels (non-drinking, low-, medium-, high-, and very high-level drinking) and: (1) engagement with care (documented CD4 cells/µl or viral load copies/ml labs), (2) ART treatment (≥ 1 prescription), and (3) viral suppression (HIV RNA < 500 copies/ml) within one year. Among 33,224 patients, alcohol use level was inversely associated with all care continuum outcomes (all p < 0.001). Adjusted prevalence of care engagement ranged from 77.8% (95% CI 77.1-78.4%) for non-drinking to 69.1% (66.6-71.6%) for high-level drinking. The corresponding range for ART treatment was 74.0% (73.3-74.7%) to 60.1% (57.3-62.9%) and for viral suppression was 57.3% (56.5-58.1%) to 38.3% (35.6-41.1%). Greater alcohol use is associated with suboptimal HIV treatment across the HIV care continuum.

Latent Growth Curve Modeling of Non-Injection Drug Use and Condomless Sexual Behavior from Ages 18 to 21 in Gay, Bisexual, and Other YMSM: The P18 Cohort Study

BACKGROUND

HIV/AIDS continues to be a health disparity faced by sexual minority men, and is exacerbated by non-injection drug use.

OBJECTIVES

We sought to delineate growth in non-injection drug use and condomless sex in a sample of racially and economically diverse of gay, bisexual, and other young men who have sex with men (YMSM) as they emerged into adulthood between the ages of 18 and 21 and who came of age in the post-HAART era.

METHODS

Behavioral data on drug use and condomless sex, collected via a calendar based technique over 7 waves of a cohort study of 600 YMSM, were analyzed using latent growth curve modeling to document patterns of growth in these behaviors, their associations, and the extent to which patterns and associations are moderated by race/ethnicity and socioeconomic status.

RESULTS

Significant growth was noted in the frequencies of condomless oral and anal intercourse, alcohol to intoxication, marijuana use, and inhalant nitrate use. High levels of association were noted between all behaviors across time but associations did not differ by either race/ethnicity or socioeconomic status. The link between drug use and risky sexual behavior continue to be evident in YMSM with significant increases in these behaviors demonstrated as YMSM transition between adolescence and young adulthood. Conclusions/Importance: Healthcare for a new generation of sexual minority males must address the synergy of these behaviors and also nest HIV prevention and care within a larger context of sexual minority health that acknowledges the advances made in the last three decades.

Inhibitors of HIV-1 Attachment: The Discovery and Development of Temsavir and its Prodrug Fostemsavir

Human immunodeficiency virus-1 (HIV-1) infection currently requires lifelong therapy with drugs that are used in combination to control viremia. The indole-3-glyoxamide 6 was discovered as an inhibitor of HIV-1 infectivity using a phenotypic screen and derivatives of this compound were found to interfere with the HIV-1 entry process by stabilizing a conformation of the virus gp120 protein not recognized by the host cell CD4 receptor. An extensive optimization program led to the identification of temsavir (31), which exhibited an improved antiviral and pharmacokinetic profile compared to 6 and was explored in phase 3 clinical trials as the phosphonooxymethyl derivative fostemsavir (35), a prodrug designed to address dissolution- and solubility-limited absorption issues. In this drug annotation, we summarize the structure-activity and structure-liability studies leading to the discovery of 31 and the clinical studies conducted with 35 that entailed the development of an extended release formulation suitable for phase 3 clinical trials.

Infectious Disease Issues in Underserved Populations

Infectious disease has a major impact on the health outcomes of underserved populations and is reported at significantly higher rates among these populations compared with the general population. Overcoming barriers and obstacles to health care access is key to addressing the disparity regarding the prevalence of infectious disease. Enhancing cultural competency and educating practitioners about underserved populations' basic health needs; optimizing health insurance for the underserved; increasing community resources; and improving access to comprehensive, continuous, compassionate, and coordinated health care are strategies for diminishing the burden of infectious disease in underserved populations.

Psychosocial stressors and alcohol use, severity, and treatment receipt across human immunodeficiency virus (HIV) status in a nationally representative sample of US residents

BACKGROUND

Human immunodeficiency virus (HIV) is stigmatized and disproportionately impacts vulnerable populations. Thus, people living with HIV (PLWH) may have greater exposure to psychosocial stressors than those without HIV. Exposure to psychosocial stressors may increase alcohol use and serve as barriers to alcohol treatment receipt. The authors evaluate whether psychosocial stressors and alcohol use, symptom severity, and treatment receipt vary across HIV status in a general population sample of US residents and assess whether psychosocial stressors mediate identified associations.

METHODS

Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were used to assess associations between HIV status and psychosocial stressors (perceived stress, alcohol-related stigma, and perceived discrimination based on race/ethnicity, sexual orientation, or sex) and alcohol-related outcomes (any use, heavy drinking, symptom severity, and treatment receipt). For each outcome, regression models were fit and iteratively adjusted for sociodemographic characteristics and comorbidities. Indirect effects of HIV on alcohol-related outcomes through stressors were estimated to assess mediation when main effects were significant.

RESULTS

Among 34,653 NESARC Wave 2 respondents, 161 were PLWH. PLWH were more likely than those without HIV to experience discrimination and had higher levels of perceived stress than those without HIV (P values <.05), but the 2 groups did not differ regarding alcohol-related stigma. PLWH were less likely to use alcohol and had similar rates of heavy drinking relative to participants without HIV, but alcohol symptom severity and treatment receipt were greater among PLWH. Perceived stress but not discrimination mediated associations.

CONCLUSIONS

Findings from this first study of variation in psychosocial stressors and alcohol use, severity, and treatment receipt across HIV status further highlight PLWH as a population that is particularly vulnerable to experiences of psychosocial stress and certain adverse alcohol-related outcomes. Future longitudinal research is needed in a larger sample of PLWH to identify intervention targets.

Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions

Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

Targeting modulates audiences' brain and behavioral responses to safe sex video ads

Video ads promoting condom use are a key component of media campaigns to stem the HIV epidemic. Recent neuroimaging studies in the context of smoking cessation, point to personal relevance as one of the key variables that determine the effectiveness of public health messages. While minority men who have sex with men (MSM) are at the highest risk of HIV infection, most safe-sex ads feature predominantly Caucasian actors in heterosexual scenarios. We compared brain respons of 45 African American MSM to safe sex ads that were matched (i.e. 'Targeted') to participants' sexual orientation and race, and 'Untargeted' ads that were un matched for these characteristics. Ad recall, perceived 'convincingness' and attitudes towards condom use were also assessed. We found that Targeted ads were better remembered than the Untargeted ads but perceived as equally convincing. Targeted ads engaged brain regions involved in self-referential processing and memory, including the amygdala, hippocampus, temporal and medial prefrontal cortices (MPFC) and the precuneus. Connectivity between MPFC and precuneus and middle temporal gyrus was stronger when viewing Targeted ads. Our results suggest that targeting may increase cognitive processing of safe sex ads and justify further prospective studies linking brain response to media public health interventions and clinical outcomes.

Sexual Orientation and All-Cause Mortality Among US Adults Aged 18 to 59 Years, 2001-2011

To determine whether sexual minorities have an earlier mortality than do heterosexuals, we investigated associations between sexual orientation assessed in the 2001 to 2010 National Health and Nutrition Examination Surveys (NHANES) and mortality in the 2011 NHANES-linked mortality file. Mortality follow-up time averaged 69.6 months after NHANES. By 2011, 338 individuals had died. Sexual minorities evidenced greater all-cause mortality than did heterosexuals after adjusting for demographic confounding. These effects generally disappeared with further adjustment for NHANES-detected health and behavioral differences.

Alcohol Use and HIV Testing in a National Sample of Women

The HIV/AIDS epidemic continues to disproportionately affect racial and ethnic minority groups and women in the United States. Prevention research suggests that reduced alcohol use and increased HIV testing are associated with lower incidence of HIV transmission among high-risk populations. Multivariable logistic regression analyses of the 2009 National Health Interview Survey data were performed for a national sample of 15,470 adult women to examine the relationship between alcohol use and likelihood of HIV testing. There is a significant association between level of alcohol use and HIV testing. Women who identified as heavy drinkers and moderate drinkers were significantly less likely to report ever testing for HIV. Findings add to the limited literature on the association between alcohol use and HIV testing behaviors among women. Given the incidence of HIV among women, this study highlights the importance of HIV testing, especially for alcohol-using women.

Toward a more accurate estimate of the prevalence of hepatitis C in the United States

Data from the 2003-2010 National Health and Nutrition Examination Survey (NHANES) indicate that about 3.6 million people in the United States have antibodies to the hepatitis C virus, of whom 2.7 million are currently infected. NHANES, however, excludes several high-risk populations from its sampling frame, including people who are incarcerated, homeless, or hospitalized; nursing home residents; active-duty military personnel; and people living on Indian reservations. We undertook a systematic review of peer-reviewed literature and sought out unpublished presentations and data to estimate the prevalence of hepatitis C in these excluded populations and in turn improve the estimate of the number of people with hepatitis C in the United States. The available data do not support a precise result, but we estimated that 1.0 million (range 0.4 million-1.8 million) persons excluded from the NHANES sampling frame have hepatitis C virus antibody, including 500,000 incarcerated people, 220,000 homeless people, 120,000 people living on Indian reservations, and 75,000 people in hospitals. Most are men. An estimated 0.8 million (range 0.3 million-1.5 million) are currently infected. Several additional sources of underestimation, including nonresponse bias and the underrepresentation of other groups at increased risk of hepatitis C that are not excluded from the NHANES sampling frame, were not addressed in this study.

CONCLUSION

The number of US residents who have been infected with hepatitis C is unknown but is probably at least 4.6 million (range 3.4 million-6.0 million), and of these, at least 3.5 million (range 2.5 million-4.7 million) are currently infected; additional sources of potential underestimation suggest that the true prevalence could well be higher.

The Contribution of Missed Clinic Visits to Disparities in HIV Viral Load Outcomes

OBJECTIVES

We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history.

METHODS

We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values.

RESULTS

Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level.

CONCLUSIONS

Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV.

Reaching the unreached: treatment as prevention as a workable strategy to mitigate HIV and its consequences in high-risk groups

While there have been significant advances in curbing the HIV disease epidemic worldwide, there continues to be significant number of incident cases with 2.3 million new infections in the year 2012 alone. Treatment as prevention (TasP), which involves the use of antiretroviral drugs to decrease the likelihood of HIV illness, death and transmission from infected individuals to their noninfected sexual and /or drug paraphernalia-sharing injecting partners, must be incorporated into any HIV prevention strategy that is going to be successful on a large scale. Especially in resource-limited settings, the focus of the prevention approach should be on high-risk groups who contribute disproportionately to community HIV transmission, including people who inject drugs (PWID), men who have sex with men (MSM) and sex workers. Innovative strategies including integrated care services adapted to different patient care settings have to and can be employed to reach these at-risk populations.

Association of KIR3DL1/S1 and HLA-Bw4 with CD4 T cell counts in HIV-infected Mexican mestizos

Certain genotypic combinations of killer-cell immunoglobulin-like receptors (KIR) and human leukocyte antigens (HLA) have been associated with favourable outcomes after exposure to human immunodeficiency virus in Caucasoid and African populations. Human immunodeficiency virus (HIV) infection is characterized by a rapid exhaustion of CD4 cells, which results in impaired cellular immunity. During this early phase of infection, it is thought that the natural killer (NK) cells represent the main effector arm of the host immune response to HIV. This study investigates whether KIR and HLA factors are associated to CD4 T cell numbers after HIV infection in Mexican mestizos as assessed at the time of initial medical evaluation and subsequent clinical follow-up. KIR and HLA-B gene carrier frequency differences were compared between groups of patients stratified by CD4 T cell numbers as assessed during their first medical evaluation (a point in time at which all patients were anti-retroviral therapy naïve). In addition, the influence that these genetic factors have on averaged historical CD4 cell counts in patients subjected to follow-up (mostly therapy-experienced) was also evaluated. Our results suggest a protective role for the HLA-Bw4 and KIR3D + Bw4 combination in both therapy-naïve and therapy-experienced patients. This report furthers our understanding on the way that immune genes modulate HIV disease progression in less-studied human populations such as the Mexican mestizos with a special focus on CD4 T cell number and behaviour.

Update on the Epidemiology and Prevention of HIV/AIDS in the United States

This update on the epidemiology and prevention of HIV in the United States is intended to provide contextual background that will help inform an understanding of recent developments in the domestic HIV epidemic. We describe the epidemiology of HIV disease in the US and the HIV continuum of care based on data collected primarily through HIV surveillance systems led by the Centers for Disease Control and Prevention including HIV incidence, prevalence, comorbidities and death. Populations and geographic regions disparately impacted by HIV are also highlighted. The HIV prevention armamentarium is also described including behavioral approaches to prevention, the emerging availability of biomedical prevention interventions such as pre-exposure prophylaxis, and structural and population-level interventions including treatment as prevention. Finally gaps in our understanding of the epidemic are underscored and suggestions for future epidemiologic research are proposed.

HIV testing and clinical status upon admission to a specialized health care unit in Pará, Brazil

OBJECTIVE

To analyze the clinical and laboratory characteristics of HIV-infected individuals upon admission to a reference health care center.

METHODS

This cross-sectional study was conducted between 1999 and 2010 on 527 individuals with confirmed serological diagnosis of HIV infection who were enrolled in an outpatient health care service in Santarém, PA, Northern Brazil. Data were collected from medical records and included the reason for HIV testing, clinical status, and count of peripheral CD4+ T lymphocytes upon enrollment. The data were divided into three groups, according to the patient’s year of admission – P1 (1999-2002), P2 (2003-2006), and P3 (2007-2010) – for comparative analysis of the variables of interest.

RESULTS

In the study group, 62.0% of the patients were assigned to the P3 group. The reason for undergoing HIV testing differed between genders. In the male population, most tests were conducted because of the presence of symptoms suggesting infection. Among women, tests were the result of knowledge of the partner’s seropositive status in groups P1 and P2. Higher proportion of women undergoing testing because of symptoms of HIV/AIDS infection abolished the difference between genders in the most recent period. A higher percentage of patients enrolling at a more advanced stage of the disease was observed in P3.

CONCLUSIONS

Despite the increased awareness of the number of HIV/AIDS cases, these patients have identified their serological status late and were admitted to health care units with active disease. The HIV/AIDS epidemic in Pará presents specificities in its progression that indicate the complex characteristics of the epidemic in the Northern region of Brazil and across the country.

The impact of sporotrichosis in HIV-infected patients: a systematic review

Sporotrichosis is a fungal infection of man and animals caused by Sporothrix complex. It usually presents as a lymphocutaneous form, but disseminated disease may occur. Given the paucity of data about HIV/AIDS and sporotrichosis co-infection, a systematic review of reported cases of HIV-associated sporotrichosis found via Pubmed (1984-2013) was done. A total of 39 papers were included, and 58 patients' data analyzed. Thirty-three (56.9 %) cases were from Brazil and 18 (31 %) from the USA. Patients' mean age was 37.8 ± 10.4 years; males predominated (84.5 %). The median CD4(+) cell count was 97 cells/mm(3). The most common clinical forms were disseminated and disseminated cutaneous with 33 (56.9 %) and 10 (17.5 %) patients, respectively. There was a correlation between CD4(+) count and clinical categories (p = 0.002). Mortality was 30 % and there was a correlation between central nervous system involvement and death (p < 0.001).

Impact of a routine, opt-out HIV testing program on HIV testing and case detection in North Carolina sexually transmitted disease clinics

BACKGROUND

The impact of routine, opt-out HIV testing programs in clinical settings is inconclusive. The objective of this study was to estimate the impact of an expanded, routine HIV testing program in North Carolina sexually transmitted disease (STD) clinics on HIV testing and case detection.

METHODS

Adults aged 18 to 64 years who received an HIV test in a North Carolina STD clinic from July 1, 2005, through June 30, 2011, were included in this analysis, dichotomized at the date of implementation on November 1, 2007. HIV testing and case detection counts and rates were analyzed using interrupted time series analysis and Poisson and multilevel logistic regression.

RESULTS

Preintervention, 426 new HIV-infected cases were identified from 128,029 tests (0.33%), whereas 816 new HIV-infected cases were found from 274,745 tests postintervention (0.30%). Preintervention, HIV testing increased by 55 tests per month (95% confidence interval [CI], 41-72), but only 34 tests per month (95% CI, 26-42) postintervention. Increases in HIV testing rates were most pronounced in women and non-Hispanic whites. A slight preintervention decline in case detection was mitigated by the intervention (mean difference, 0.01; 95% CI, -0.02 to 0.05). Increases in case detection rates were observed among women and non-Hispanic blacks.

CONCLUSIONS

The impact of a routine HIV screening in North Carolina STD clinics was marginal, with the greatest benefit among persons not traditionally targeted for HIV testing. The use of a preintervention comparison period identified important temporal trends that otherwise would have been ignored.

The status of the National HIV Surveillance System, United States, 2013

The burden of HIV disease in the United States is monitored by using a comprehensive surveillance system. Data from this system are used at the federal, state, and local levels to plan, implement, and evaluate public health policies and programs. Implementation of HIV reporting has differed by area, and for the first time in early 2013, estimated data on diagnosed HIV infection were available from all 50 states, the District of Columbia, and six U.S. dependent areas. The newly available data for the entire U.S. as well as several other key changes to the surveillance system support the need to provide an updated summary of the status of the National HIV Surveillance System.

Encephalitis hospitalization rates and inpatient mortality in the United States, 2000-2010

Background

Encephalitis rates by etiology and acute-phase outcomes for encephalitis in the 21^st century are largely unknown. We sought to evaluate cause-specific rates of encephalitis hospitalizations and predictors of inpatient mortality in the United States.

Methods

Using the Nationwide Inpatient Sample (NIS) from 2000 to 2010, a retrospective observational study of 238,567 patients (mean [SD] age, 44.8 [24.0] years) hospitalized within non-federal, acute care hospitals in the U.S. with a diagnosis of encephalitis was conducted. Hospitalization rates were calculated using population-level estimates of disease from the NIS and population estimates from the United States Census Bureau. Adjusted odds of mortality were calculated for patients included in the study.

Results

In the U.S. from 2000–2010, there were 7.3±0.2 encephalitis hospitalizations per 100,000 population (95% CI: 7.1–7.6). Encephalitis hospitalization rates were highest among females (7.6±0.2 per 100,000) and those <1 year and >65 years of age with rates of 13.5±0.9 and 14.1±0.4 per 100,000, respectively. Etiology was unknown for approximately 50% of cases. Among patients with identified etiology, viral causes were most common (48.2%), followed by Other Specified causes (32.5%), which included predominantly autoimmune conditions. The most common infectious agents were herpes simplex virus, toxoplasma, and West Nile virus. Comorbid HIV infection was present in 7.7% of hospitalizations. Average length of stay was 11.2 days with mortality of 5.6%. In regression analysis, patients with comorbid HIV/AIDS or cancer had increased odds of mortality (odds ratio [OR]  = 1.70; 95% CI: 1.30–2.22 and OR = 2.26; 95% CI: 1.88–2.71, respectively). Enteroviral, postinfectious, toxic, and Other Specified causes were associated with lower odds vs. herpes simplex encephalitis.

Conclusions

While encephalitis and encephalitis-related mortality impose a considerable burden in the U.S. in the 21^st Century, the reported demographics of hospitalized encephalitis patients may be changing.

Dolutegravir does not affect methadone pharmacokinetics in opioid-dependent, HIV-seronegative subjects

BACKGROUND

Dolutegravir (DTG) is an investigational integrase inhibitor for treatment of HIV infection. As intravenous drug use is a common risk factor for HIV, this study evaluated the effect of DTG on the pharmacokinetics (PK) of methadone.

METHODS

This was an open-label, 2-period study in adult, opioid-dependent, HIV-seronegative subjects. Subjects received their current individual methadone doses once daily for 3 days (Period 1) followed by DTG 50mg twice daily (BID) for 5 days while continuing their stable methadone therapy (Period 2). Serial PK samples for R- and S-methadone were collected after each Period. Pharmacodynamic (PD) measures and safety assessments were obtained throughout the study. Non-compartmental PK analysis was performed, and geometric least-squares mean ratios and 90% confidence intervals were generated.

RESULTS

Plasma exposures of total, R-, and S-methadone were not affected by co-administration of DTG. Mean ratios for AUC were 0.98, 0.95, and 1.01 for total, R-, and S-methadone, respectively, alone compared with in combination with DTG. No statistically significant differences were noted between the 2 treatment periods in methadone PD measures. The combination of DTG and methadone was well tolerated. No deaths, serious adverse events, or grade 3/4 adverse events occurred. No clinically significant changes in laboratory values, vital signs, or electrocardiograms were observed.

CONCLUSION

Co-administration of methadone with repeat doses of DTG 50mg BID had no effect on total, R-, and S-methadone PK or on methadone-induced PD markers. No dose adjustment in methadone is required when given in combination with DTG.

Racial/ethnic disparities in antiretroviral treatment among HIV-infected pregnant Medicaid enrollees, 2005-2007

OBJECTIVES

We examined racial/ethnic differences in prenatal antiretroviral (ARV) treatment among 3259 HIV-infected pregnant Medicaid enrollees.

METHODS

We analyzed 2005-2007 Medicaid claims data from 14 southern states, comparing rates of not receiving ARVs and suboptimal versus optimal ARV therapy.

RESULTS

More than one third (37.3%) had zero claims for ARV drugs. Three quarters (73.4%) of 346 Hispanic women received no prenatal ARVs. After we adjusted for covariates, Hispanic women had 3.89 (95% confidence interval = 2.58, 5.87) times the risk of not receiving ARVs compared with Whites. Hispanic women often had only 1 or 2 months of Medicaid eligibility, perhaps associated with barriers for immigrants. Less than 3 months of eligibility was strongly associated with nontreatment (adjusted odds ratio = 29.0; 95% confidence interval = 13.4, 62.7).

CONCLUSIONS

Optimal HIV treatment rates in pregnancy are a public health priority, especially for preventing transmission to infants. Medicaid has the surveillance and drug coverage to ensure that all HIV-infected pregnant women are offered treatment. States that offer emergency Medicaid coverage for only delivery services to pregnant immigrants are missing an opportunity to screen, diagnose, and treat pregnant women with HIV, and to prevent HIV in children.

Active Drug-Using Women Use Female-Initiated Barrier Methods to Reduce HIV/STI Risk: Results from a Randomized Trial

Background. We tested an original, woman-focused intervention, based on body empowerment, and female-initiated barrier methods, including the female condom (FC) and cervical barriers. Methods. Eligible women were >= 18 years of age, HIV seronegative, and active drug users, reporting 30% or greater unprotected sex acts. Both controls (C) and intervention (I) participants received enhanced HIV/STI harm reduction counseling. I participants underwent 5 additional weekly group sessions. We compared change in frequency of unprotected vaginal intercourse across arms at 12 months. Results. Among 198 enrolled women, over 95% completed followup. Two-thirds were African-American; most of them used crack, had a primary partner, and reported sex exchange. In paired t-tests from baseline to followup, the frequency of unprotected vaginal sex dropped significantly for I (primary P < 0.00, nonprimary P < 0.002) and C (primary P < 0.008, nonprimary P < 0.000) arms with all partners. The difference in change across arms was of borderline significance for primary partner (P = 0.075); no difference was seen for nonprimary partner (P = 0.8). Use of male condom and FC increased with both partner types over time, but more consistently among I women. Conclusion: The “value-added” impact of the intervention was observed mainly with primary partners. Body knowledge with routine FC counseling should be incorporated into interventions for drug-using women.

A degenerative retinal process in HIV-associated non-infectious retinopathy

HIV retinopathy is the most common non-infectious complication in the eyes of HIV-positive individuals. Oncotic lesions in the retinal nerve fiber layer, referred to as cotton wool spots (CWS), and intraretinal (IR) hemorrhages are frequently observed but are not unique to this pathology. HIV-positive patients have impaired color vision and contrast sensitivity, which worsens with age. Evidence of inner-retinal lesions and damage have been documented ophthalmoscopically, however their long term structural effect has not been investigated. It has been hypothesized that they may be partially responsible for loss of visual function and visual field. In this study we utilized clinical data, retinal imaging and transcriptomics approaches to comprehensively interrogate non-infectious HIV retinopathy. The methods employed encompassed clinical examinations, fundus photography, indirect ophthalmoscopy, Farmsworth-Munsell 100 hue discrimination testing and Illumina BeadChip analyses. Here we show that changes in the outer retina, specifically in the retinal pigment epithelium (RPE) and photoreceptor outer segments (POS) contribute to vision changes in non-infectious HIV retinopathy. We find that in HIV-positive retinae there is an induction of rhodopsin and other transcripts (including PDE6A, PDE6B, PDE6G, CNGA1, CNGB1, CRX, NRL) involved in visual transduction, as well as structural components of the rod photoreceptors (ABCA4 and ROM1). This is consistent with an increased rate of renewal of rod outer segments induced via increased phagocytosis by HIV-infected RPE previously reported in culture. Cone-specific transcripts (OPN1SW, OPN1LW, PDE6C, PDE6H and GRK7) are uniformly downregulated in HIV positive retina, likely due to a partial loss of cone photoreceptors. Active cotton wool spots and intraretinal hemorrhages (IRH) may not affect photoreceptors directly and the interaction of photoreceptors with the aging RPE may be the key to the progressive vision changes in HIV-positive patients.

Barriers and Facilitators of Online Patient Portals to Personal Health Records Among Persons Living With HIV: Formative Research

Background

Federal meaningful use standards are promoting adoption of online portals to personal health records (PHRs). However, relatively little is known regarding barriers and facilitators for vulnerable groups such as persons living with human immunodeficiency virus (PLWH).

Objective

The objective of this study was to assess barriers and facilitators to use of online PHRs among PLWH.

Methods

We conducted formative research using a written waiting room survey among 120 PLWH regarding barriers and facilitators of portal PHR use. We supplemented findings with data collected from a PLWH focus group, where some members had personal experience with use of a portal.

Results

The survey had 90 respondents. Eight PLWH participated in the focus group. Most patients (77/90, 86%) reported having at least some experience using the Internet and most expressed interest in features offered by the portal. Notably, 70% (63/90) expressed some interest in being taught how to use it to communicate with their provider. Focus group themes reinforced these findings, but also voiced concern regarding access to private computers.

Conclusions

Many PLWH in our sample have experience using computers and most are interested in PHR features. However, computer or broadband access and privacy are important barriers.

Basic body knowledge in street-recruited, active drug-using women enrolled in a "body empowerment" intervention trial

BACKGROUND

Drug-using women remain at high risk for HIV infection. Female condoms (FC) have proven potential and cervical barriers have promise to reduce HIV risk; their effective use may be boosted by familiarity and confidence about female anatomy. Women with high levels of crack cocaine use were assessed for their knowledge about reproductive anatomy, HIV/STI risk, as well as cancer screening behaviors.

METHODS

Women were recruited for a randomized trial of a behavioral intervention via mobile vans in Philadelphia known for high crack use and sex exchange. Knowledge and behavioral data on 198 women were collected via interviewer-administered questionnaire. Women were randomized into control (n=99) and intervention (n=99) arms. Five weekly, small-group, intervention sessions stressed "body empowerment" and teaching use of female-initiated barrier methods. Follow-up body knowledge data were collected at 12 months. Changes in and correlates of body knowledge were analyzed and compared.

RESULTS

Most participants were African-American (66%); their mean age was 39.6 years. At baseline, 44% of the sample erroneously believed women have sex and urinate from the same place; 62% erroneously believed that tampons could get lost in the abdominal cavity. Only 27% knew douching increased STI transmission risk; only 10% knew condoms reduce cervical cancer risk. At follow-up, overall body knowledge improved substantially, across both arms. Race was associated with high body knowledge at baseline but not at follow-up.

CONCLUSIONS

Knowledge favoring use of women-initiated methods and cervical cancer prevention was very low in this hard-to-reach sample. Body knowledge improved substantially with enhanced voluntary counseling and testing (VCT) as well as the women-focused intervention. Body knowledge education must be targeted and tailored to drug-using women.

Improvement in the health of HIV-infected persons in care: reducing disparities

BACKGROUND

Despite advances in human immunodeficiency virus (HIV) treatment, major challenges remain in achieving access, retention, and adherence. Our inner-city HIV clinical practice in Baltimore has a diverse patient population with high rates of poverty, black race, and injection drug use (IDU), providing us the opportunity to compare health process and outcomes.

METHODS

Using data collected in a clinical HIV cohort in Baltimore, we compared receipt of combination antiretroviral therapy (ART), HIV type 1 (HIV-1) RNA, CD4, incidence of opportunistic illness, and mortality from 1995 to 2010. Comparisons were made of these outcomes by HIV risk group, sex, and race (black, white).

RESULTS

From 1995 to 2010, we followed 6366 patients comprising 27 941 person-years (PY) of follow-up. By 2010, 87% of patients were receiving ART; median HIV-1 RNA was <200 copies/mL, median CD4 was 475 cells/mm(3), opportunistic illness rates were 2.4 per 100 PY, and mortality rates were 2.1 per 100 PY, with no differences by demographic or HIV risk group. The only differences were that the IDU risk group had a median CD4 that was 79 cells/mm(3) lower and HIV-1 RNA 0.16 log(10 )copies/mL higher compared with other risk groups (P < .01). In 2009 a 28-year-old HIV-infected person was estimated to have 45.4 years of life remaining, which did not differ by demographic or behavioral risk group.

DISCUSSION

Our results emphasize that advances in HIV treatment have had a positive impact on all affected demographic and behavioral risk groups in an HIV clinical setting, with an expected longevity for HIV-infected patients that is now 73 years.

Piloting a system for behavioral surveillance among heterosexuals at increased risk of HIV in the United States

Objectives:

During the past decade, the number and proportion of reported HIV cases in the United States acquired through heterosexual contact has increased markedly. CDC employs the National HIV Behavioral Surveillance System (NHBS) to monitor risk behaviors and HIV prevalence in high-risk populations. To identify a target population for conducting NHBS among heterosexuals at increased risk for HIV (NHBS-HET), CDC designed, implemented and evaluated a pilot study.

Methods:

The pilot study was conducted in 25 US metropolitan statistical areas in 2006-7. We recruited men and women who reported sex with at least one opposite-sex partner during the past year for a behavioral survey and HIV test. We investigated the relationship between newly diagnosed HIV infection and individual risk behaviors, sexual network characteristics, and social-structural characteristics to arrive at a definition of a heterosexual at increased risk of HIV.

Results:

Of 14,750 participants in the analysis, 207 (1.4%) had newly diagnosed HIV infection. Using low socioeconomic status (SES) as a criterion for defining a heterosexual at increased risk for HIV resulted in optimal rates of HIV prevalence, specificity, sensitivity and practicality.

Conclusions:

Results from the NHBS pilot study underscore the key role of social factors as determinants of HIV infection risk among U.S. heterosexuals, and low SES was incorporated into the definition of a heterosexual at increased risk for HIV in NHBS-HET cycles. Future cycles of NHBS-HET will help tailor prevention programs for those populations most at risk of HIV in the US.

The HIV Epidemic: High-Income Countries

The HIV epidemic in higher-income nations is driven by receptive anal intercourse, injection drug use through needle/syringe sharing, and, less efficiently, vaginal intercourse. Alcohol and noninjecting drug use increase sexual HIV vulnerability. Appropriate diagnostic screening has nearly eliminated blood/blood product-related transmissions and, with antiretroviral therapy, has reduced mother-to-child transmission radically. Affected subgroups have changed over time (e.g., increasing numbers of Black and minority ethnic men who have sex with men). Molecular phylogenetic approaches have established historical links between HIV strains from central Africa to those in the United States and thence to Europe. However, Europe did not just receive virus from the United States, as it was also imported from Africa directly. Initial introductions led to epidemics in different risk groups in Western Europe distinguished by viral clades/sequences, and likewise, more recent explosive epidemics linked to injection drug use in Eastern Europe are associated with specific strains. Recent developments in phylodynamic approaches have made it possible to obtain estimates of sequence evolution rates and network parameters for epidemics.

Estimating design effect and calculating sample size for respondent-driven sampling studies of injection drug users in the United States

Respondent-driven sampling (RDS) has become increasingly popular for sampling hidden populations, including injecting drug users (IDU). However, RDS data are unique and require specialized analysis techniques, many of which remain underdeveloped. RDS sample size estimation requires knowing design effect (DE), which can only be calculated post hoc. Few studies have analyzed RDS DE using real world empirical data. We analyze estimated DE from 43 samples of IDU collected using a standardized protocol. We find the previous recommendation that sample size be at least doubled, consistent with DE = 2, underestimates true DE and recommend researchers use DE = 4 as an alternate estimate when calculating sample size. A formula for calculating sample size for RDS studies among IDU is presented. Researchers faced with limited resources may wish to accept slightly higher standard errors to keep sample size requirements low. Our results highlight dangers of ignoring sampling design in analysis.

HIV transmission rate modeling: a primer, review, and extension

Several mathematical modeling studies based on the concept of "HIV transmission rates" have recently appeared in the literature. The transmission rate for a particular group of HIV-infected persons is defined as the mean number of secondary infections per member of the group per unit time. This article reviews the fundamental principles and mathematics of transmission rate models; explicates the relationship between these models, Bernoullian models of HIV transmission, and mathematical models based on the concept of the "reproductive rate of infection"; describes an extension of existing transmission rate models to better incorporate the positive impact of HIV treatment; and discusses the limitations of the transmission rate modeling approach. Results from the extended transmission rate model indicate that approximately 51.6% of new sexually-transmitted infections in the US are due to the transmission risk behaviors of infected persons who are unaware of their infection, including 10.9% due to persons in the acute phase of HIV infection. Findings from this study suggest that significant reductions in HIV incidence likely will require a combination of increased antibody testing, enhanced early detection of acute HIV infection, appropriate medical care and antiretroviral medicine adherence counseling, and behavioral risk reduction interventions.

HIV testing: the cornerstone of HIV prevention efforts in the USA

An estimated 1.2 million persons in the USA are infected with HIV, of whom approximately 20% are unaware they are infected. HIV testing and knowledge of HIV serostatus have important individual and public health benefits, including reduction of morbidity, mortality and HIV transmission. Although testing is the necessary first step to prevention, more than half of the US adult population has never been tested for HIV. However, this proportion is increasing due to revised national recommendations to make HIV testing a routine part of healthcare, expansion of testing efforts at local, state and national levels, and progress in the development and adoption of new testing technologies. In this article, we describe the essential role of HIV testing as a public health prevention strategy, examine recent advances in HIV testing technologies and testing implementation, and identify future directions for HIV testing in the USA.

Abandonment of Antiretroviral Therapy among HIV-Positive Patients Attended at the Reference Center for HIV/AIDS in Vitória, Brazil

This study evaluates the risk factors for the abandonment of antiretroviral therapy (ART) among patients receiving care in an AIDS clinic in Vitória, Brazil. We conducted a case–control study of patients with AIDS attending a reference center for sexually transmitted disease (STD)/AIDS. A total of 62 patients, who abandoned therapy in 2008, and 188 HIV-infected patients answered an interview including demographic, social, and clinical characteristics. Risk factors associated with abandon in univariate analysis were entered into logistic regression models. A total of 250 patients were included in the study. Groups were similar regarding age, gender, and monthly income. In the final multivariate model, illicit drug use (adjusted odds ratio [AOR], 2.3; 95% confidence interval [CI], 1.03-5.07), previous abandon of medication (AOR 38.6; 95% CI 10.49-142.25), last CD4 count <200 cells/mm3 (AOR 1.5; 95% CI 1.03-2.10), and viral load higher than 1000 copies/mL (AOR 2.0 (95% CI 1.34-3.09) were independent predictors of abandonment of ART. In addition to the clinical indicators, behavioral factors remained important throughout the multivariate analysis in our study.

Non-conventional practices and immune functioning among individuals receiving conventional care for HIV

OBJECTIVE

to examine the relationships among non-conventional practices, adherence and immune functioning in individuals with HIV.

METHODS

92 participants completed an interview on non-conventional practices (complementary and alternative medicines (CAM), psychosocial therapies, and religious practice). They also completed the Psychiatric Symptom Index and the AIDS Clinical Trials Group Adherence Follow-up Questionnaire. Medical chart reviews determined CD4 count and viral load.

RESULTS

Hierarchical logistic regressions revealed religious practice was associated with adherence and CAM was associated with viral load.

CONCLUSION

Participation in non-conventional practices in HIV populations may lead to positive health and health behaviors. Clinical implications are discussed.