Psychiatric risk factors for HIV disease progression: the role of inconsistent patterns of antiretroviral therapy utilization

A Web-Based Antiretroviral Therapy Adherence Intervention (Thrive With Me) in a Community-Recruited Sample of Sexual Minority Men Living With HIV: Results of a Randomized Controlled Study

BACKGROUND

Most new HIV infections are attributed to male-to-male sexual contact in the United States. However, only two-thirds of sexual minority men living with HIV achieve an undetectable viral load (UVL). We tested a web-based antiretroviral therapy adherence intervention called Thrive with Me (TWM) with core features that included medication self-monitoring and feedback, HIV and antiretroviral therapy information, and a peer-to-peer exchange.

OBJECTIVE

We assessed the efficacy of TWM on HIV UVL among adult (aged ≥18 years) sexual minority men. Moreover, we assessed the impact of overall engagement and engagement with specific intervention features on HIV UVL.

METHODS

In total, 401 sexual minority men (mean age 39.1, SD 10.8 y; 230/384, 59.9% African American) in New York City were recruited between October 2016 and December 2019 and randomized to receive TWM (intervention) or a weekly email newsletter (control) for 5 months. Computerized assessments occurred at baseline and months 5, 11, and 17. The primary outcome was a dichotomous measure of HIV UVL (≤20 copies/μL). Generalized estimating equations with robust SEs were used to assess the effect of the TWM intervention on HIV UVL over the follow-up period in an unadjusted model and a model adjusted for baseline differences and then stratified by baseline recent drug use urinalysis. In secondary analyses, generalized linear models were used to estimate risk differences in the association of overall engagement with TWM (the sum of the number of days participants accessed ≥1 screen of the TWM intervention out of a possible 150 days) and engagement with specific TWM components on HIV UVL throughout the 17-month intervention period.

RESULTS

Participant retention was 88.5% (355/401; month 5), 81.8% (328/401; month 11), and 80.3% (322/401; month 17). No consistent differences in HIV UVL were found between those randomized to receive TWM or the control at the 5- (difference-in-differences [DD]=-7.8, 95% CI -21.1 to 5.5), 11- (DD=-13.9, 95% CI -27.7 to 0.04), or 17-month (DD=-8.2, 95% CI -22.0 to 5.7) time points, or when stratified by baseline recent drug use. However, those TWM-assigned participants with high overall levels of engagement (in the upper 25th percentile) were more likely to have an HIV UVL at the end of the 5-month active intervention period compared to those with low engagement (below the 75th percentile; risk difference=17.8, 95% CI 2.5-33.0) or no engagement (risk difference=19.4, 95% CI 3.3-35.5) in the intervention. Moreover, high engagement with the peer-to-peer exchange was associated with HIV UVL over time in unadjusted models.

CONCLUSIONS

TWM did not have overall impacts on HIV UVL; however, it may assist some sexual minority men who are highly engaged with this web-based intervention in achieving HIV viral suppression.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02704208; https://clinicaltrials.gov/study/NCT02704208.

Global prevalence of depressive symptoms among people living with HIV/AIDS: a systematic review and meta-analysis of the past five years

A clear and accurate assessment of depressive symptoms among people living with HIV/AIDS (PLWHA) in the past five years is essential to help develop reasonable and sound interventions to improve their depressive symptoms. PubMed, Web of Science, MEDLINE, Cochrane, Embase, CINAHL, and APA were searched from 1 January 2017 to 12 April 2022. The data were analyzed using STATA 15 Software to pool the global prevalence of depressive symptoms in PLWHA. Ultimately, 103785 PLWHA from 81 original studies were included. The pooled analysis showed that the global prevalence of depressive symptoms in PLWHA over the past five years was 0.35 (95% CI: 0.31-0.38), with differences in depressive symptoms in PLWHA by geographic location, gender, assessment instruments, alcohol use, smoking, marriage, co-morbid disease, financial situation, and educational level. Scientific and timely public health interventions should be developed among PLWHA to improve their depressive symptoms and thereby improve mental health and clinical outcomes.

Overamped: Stimulant Use and HIV Pathogenesis

PURPOSE OF REVIEW

In the era of HIV treatment as prevention (TasP), more clarity is needed regarding whether people with HIV who use stimulants (i.e., methamphetamine, powder cocaine, and crack cocaine) display elevated HIV viral load and greater immune dysregulation.

RECENT FINDINGS

Although rates of viral suppression have improved in the TasP era, stimulant use was independently associated with elevated viral load in 23 of 28 studies included in our review. In the 12 studies examining other HIV disease markers, there was preliminary evidence for stimulant-associated alterations in gut-immune dysfunction and cellular immunity despite effective HIV treatment. Studies generally focused on documenting the direct associations of stimulant use with biomarkers of HIV pathogenesis without placing these in the context of social determinants of health. Stimulant use is a key barrier to optimizing the effectiveness of TasP. Elucidating the microbiome-gut-brain axis pathways whereby stimulants alter neuroimmune functioning could identify viable targets for pharmacotherapies for stimulant use disorders. Examining interpersonal, neighborhood, and structural determinants that could modify the associations of stimulant use with biomarkers of HIV pathogenesis is critical to guiding the development of comprehensive, multi-level interventions.

Long-Term Effect of Group Support Psychotherapy on Depression and HIV Treatment Outcomes: Secondary Analysis of a Cluster Randomized Trial in Uganda

OBJECTIVE

We aimed to determine the effect of group support psychotherapy (GSP) compared with group HIV education (GHE) on depression and HIV treatment outcomes 24 months after treatment. We further aimed to investigate the mediating role of depression and antiretroviral therapy (ART) adherence in the relationship between GSP and viral load suppression.

METHODS

Thirty HIV clinics across three districts were randomly assigned to deliver either GSP or GHE for depression. Depression and optimal (≥95%) ART adherence was assessed at baseline and 6, 12, 18, and 24 months after treatment. Viral load was drawn from the medical charts at baseline and 12 and 24 months after treatment. Multilevel mixed-effects regression models and generalized structural equation modeling were used to estimate 24-month outcomes and mediation effects.

RESULTS

Participants ( N = 1140) were enrolled from HIV clinics offering either GSP ( n = 578 [51%]) or GHE ( n = 562 [49%]). Fewer GSP than GHE participants met the criteria for depression at 24 months after treatment (1% versus 25%; adjusted odds ratio [aOR] = 0.002, 95% confidence interval [CI] = 0.0002-0.018). More GSP than GHE participants reported optimal (≥95%) ART adherence (96% versus 88%; aOR = 20.88, 95% CI = 5.78-75.33) and improved viral suppression (96% versus 88%; aOR = 3.38, 95% CI = 1.02-11.02). The indirect effects of GSP through sequential reduction in depression and improvement in ART adherence at 12 months may partially explain the higher viral suppression rates at 24 months in GSP than GHE groups.

CONCLUSION

In settings where the HIV epidemic persists, depression treatment with GSP may be critical for optimal HIV treatment outcomes.Trial Registration: The Pan African Clinical Trials Registry, number PACTR201608001738234.

Preferences of Young Black Gay, Bisexual, and Other Men Who Have Sex with Men Regarding Integration of HIV and Mental Health Care Services

Optimization of mental health service use is critical to HIV care engagement among young Black gay, bisexual, and other men who have sex with men (YB-GBMSM). Clinic-level interventions to integrate HIV and mental health services have been proposed; however, patient perspectives on such care models are often lacking. We conducted a mixed-methods study consisting of surveys (N = 100) and qualitative in-depth interviews (n = 15) with YB-GBMSM recruited from two Ryan White-funded HIV clinics in Atlanta, Georgia. Most participants (70%) agreed that integration of HIV and mental health services was beneficial to them. Thirty-six percent (36%) desired a higher level of integration than what they perceived was currently available in their clinic setting, 51% believed their clinic was already optimally integrated, and 13% preferred less integration. In the qualitative interviews, participants discussed their support for potential integration strategies such as training HIV providers to prescribe antidepressants, closer in-clinic proximity of HIV and mental health providers, and use of patient navigators to help patients access mental health care and remind them of appointments. Perceived benefits of care integration included easier access to mental health services, enhanced overall well-being, and improved HIV care engagement. In summary, YB-GBMSM were supportive of integrating HIV and mental health services, with varying individual preferences regarding the degree and operationalization of this integration. Improving integration of mental health and HIV services, and tailoring modes of service delivery to individual preferences, has the potential to improve both general well-being and HIV care engagement in this high priority population.

The associations of incarceration and depression with healthcare experiences and utilization among Black men who have sex with men in HPTN 061

Associations of incarceration with healthcare access and utilization among Black sexual minority men (BSMM) and differences in association among those with and without pre-incarceration symptoms of depression were measured. Secondary analysis using survey data from the longitudinal cohort HIV Prevention Trials Network 061 study was conducted among 1553 BSMM from six major U.S. cities from 2009 to 2011. We used modified log-binomial regression with robust standard errors to estimate associations of incarceration (reported at 6 month follow-up) on next six-month healthcare utilization and access (reported at the 12 month follow-up). We tested the significance of baseline depressive symptoms by incarceration interaction and reported differences in associations when observed. Participants with a history of incarceration were more likely to have depressive symptoms at baseline compared to those without. Recent incarceration was associated with almost twice the risk of mistrust in healthcare providers and emergency room utilization. Among men reporting depressive symptoms, a history of incarceration was associated with almost tripled risk of reporting providers do not communicate understandably. Among those with depression, one in five reported a missed visit regardless of incarceration status.

Burden and Correlates of Mental Health Symptoms Among Young Black Gay, Bisexual, and Other Men Who Have Sex with Men Engaged in HIV Care in Atlanta

Mental health comorbidities are prevalent among young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) living with HIV and can adversely impact HIV-related outcomes. We conducted a cross-sectional survey study with 100 YB-GBMSM recruited from two HIV care centers in Atlanta, and constructed multivariable logistic and linear regression models to examine correlates of depression, anxiety, trauma symptoms, and general well-being. In adjusted models, full-time employment was associated with fewer depressive symptoms, while HIV stigma and substance use were associated with higher levels of depressive symptoms. Younger age and full-time employment were negatively associated with severe anxiety, while HIV stigma was positively associated with severe anxiety and trauma symptoms. Trust in physicians, lower HIV stigma, full-time employment, and lack of substance use were associated with higher average general well-being scores. In conclusion, we found high frequency of depressive, anxiety, and trauma-related symptoms among this sample of YB-GBMSM living with HIV. Unemployment, substance use, and HIV stigma emerged as particularly salient correlates of psychological morbidity, suggesting a need for structural and community-level interventions to address mental health in this population.

Advancing behavioral interventions for African American/Black and Latino persons living with HIV using a new conceptual model that integrates critical race theory, harm reduction, and self-determination theory: a qualitative exploratory study

BACKGROUND

Rates of participation in HIV care, medication uptake, and viral suppression are improving among persons living with HIV (PLWH) in the United States. Yet, disparities among African American/Black and Latino PLWH are persistent, signaling the need for new conceptual approaches. To address gaps in services and research (e.g., insufficient attention to structural/systemic factors, inadequate harm reduction services and autonomy support) and improve behavioral interventions, we integrated critical race theory, harm reduction, and self-determination theory into a new conceptual model, then used the model to develop a set of six intervention components which were tested in a larger study. The present qualitative study explores participants' perspectives on the study's acceptability, feasibility, and impact, and the conceptual model's contribution to these experiences.

METHODS

Participants in the larger study were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City (N = 512). We randomly selected N = 46 for in-depth semi-structured interviews on their experiences with and perspectives on the study. Interviews were audio-recorded and professionally transcribed verbatim, and data were analyzed using directed qualitative content analysis.

RESULTS

On average, participants were 49 years old (SD = 9) and had lived with HIV for 19 years (SD = 7). Most were male (78%) and African American/Black (76%). All had taken HIV medication previously. Challenging life contexts were the norm, including poverty, poor quality/unstable housing, trauma histories exacerbated by current trauma, health comorbidities, and substance use. Participants found the study highly acceptable. We organized results into four themes focused on participants' experiences of: 1) being understood as a whole person and in their structural/systemic context; 2) trustworthiness and trust; 3) opportunities for self-reflection; and 4) support of personal autonomy. The salience of nonjudgment was prominent in each theme. Themes reflected grounding in the conceptual model. Participants reported these characteristics were lacking in HIV care settings.

CONCLUSIONS

The new conceptual model emphasizes the salience of systemic/structural and social factors that drive health behavior and the resultant interventions foster trust, self-reflection, engagement, and behavior change. The model has potential to enhance intervention acceptability, feasibility, and effectiveness with African American/Black and Latino PLWH.

Effect of the COVID-19 Pandemic on Stimulant Use and Antiretroviral Therapy Adherence Among Men Who Have Sex With Men Living With HIV: Qualitative Focus Group Study

BACKGROUND

Evidence suggests that economic, social, and psychological circumstances brought about by the COVID-19 pandemic may have a serious impact on behavioral health. Men who have sex with men (MSM) are disproportionally impacted by HIV and stimulant use, the co-occurrence of which heightens HIV transmission risk and undermines nationwide treatment strategies as prevention efforts for ending the HIV epidemic. There is a paucity of information regarding the potential impact of the COVID-19 pandemic on the substance use and HIV medication adherence in this key vulnerable population-MSM who use stimulants and are living with HIV.

OBJECTIVE

The aim of this qualitative study was to identify ways in which the COVID-19 pandemic has affected stimulant use and antiretroviral therapy (ART) adherence among a sample of MSM living with HIV.

METHODS

Two focus groups were conducted in August 2020 via videoconferencing technology compliant with the Health Insurance Portability and Accountability Act. Potential participants from an established research participant registry at State University of New York Downstate Health Sciences University were invited and screened for study participation on the basis of inclusion criteria. A semistructured interview guide was followed. A general inductive approach was used to analyze the data. Findings in two general areas of interest, the impact of the COVID-19 pandemic on stimulant use and ART adherence, emerged directly from the raw data.

RESULTS

A total of 12 ethnically diverse participants over the age of 25 years took part in the study. Results were heterogeneous in terms of the effects of the pandemic on both stimulant use and ART adherence among MSM living with HIV. Some men indicated increased or sustained stimulant use and ART adherence, and others reported decreased stimulant use and ART adherence. Reasons for these behavioral changes ranged from concerns about their own health and that of their loved ones to challenges brought about by the lack of daily structure during the lockdown phase of the pandemic and emotion regulation difficulties.

CONCLUSIONS

The COVID-19 pandemic has had a differential impact on stimulant use and ART medication adherence among MSM living with HIV. The reasons for behavioral change identified in this study may be salient intervention targets to support ART medication adherence and lower stimulant use among MSM in the aftermath of the of the COVID-19 pandemic, as well as beyond.

Finding Sunshine on a Cloudy Day: A Positive Affect Intervention for Co-Occurring Methamphetamine Use and HIV

Among sexual minority men (i.e., gay, bisexual, and other men who have sex with men) living with HIV, those who use methamphetamine experience profound health disparities. Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS) is an evidence-based, 5-session, individually delivered positive affect intervention adapted for sexual minority men living with HIV who use methamphetamine. ARTEMIS was designed to amplify the benefits of evidence-based substance use interventions such as contingency management (CM) with this high-priority population. Delivering ARTEMIS during CM has been shown to assist participants in reducing stimulant use, increasing positive affect, and achieving durable reductions in HIV viral load. We describe the theoretical underpinnings of the ARTEMIS intervention, provide details of the training and session protocols with a case example, and discuss implications for future applications in research and clinical settings.

Stimulant use interventions may strengthen 'Getting to Zero' HIV elimination initiatives in Illinois: Insights from a modeling study

OBJECTIVE(S)

Getting to Zero (GTZ) is an Illinois-based HIV elimination initiative. GTZ identifies younger Black men who have sex with men (YBMSM) as a population who have experienced disproportionate HIV incidence. Rising stimulant use among YBMSM has been determined to impede engagement in the HIV prevention and treatment continua for reducing onward HIV transmission. Given the limited development of dedicated or culturally appropriate interventions for this population, this modeling study explores the impact of stimulant use on HIV incidence among YBMSM and assesses the impact of interventions to treat stimulant use on downstream HIV transmission to achieve GTZ goals.

METHODS

A previously developed agent-based network model (ABNM), calibrated using data for YBMSM in Illinois, was extended to incorporate the impact of stimulant use (methamphetamines, crack/cocaine, and ecstasy) on sexual networks and engagement in HIV treatment and prevention continua. The model simulated the impact of a residential behavioral intervention (BI) for reducing stimulant use and an outpatient biomedical intervention (mirtazapine) for treating methamphetamine use. The downstream impact of these interventions on population-level HIV incidence was the primary intervention outcome.

RESULTS

Baseline simulated annual HIV incidence in the ABNM was 6.93 [95% Uncertainty Interval (UI): 6.83,7.04] per 100 person years (py) and 453 [95% UI: 445.9,461.2] new infections annually. A residential rehabilitation intervention targeted to 25% of stimulant using persons yielded a 27.1% reduction in the annual number of new infections. Initiating about 50% of methamphetamine using persons on mirtazapine reduced the overall HIV incidence among YBMSM by about 11.2%. A 30% increase in antiretroviral treatment (ART) and preexposure prophylaxis (PrEP) uptake in the non-stimulant using YBMSM population combined with a 25% uptake of BI for stimulant using persons produces an HIV incidence consistent with HIV elimination targets (about 200 infections/year) identified in the GTZ initiative.

CONCLUSIONS

Behavioral and biomedical interventions to treat stimulant use, in addition to expanding overall ART and PrEP uptake, are likely to enhance progress towards achieving GTZ goals.

"It's how we get to know each other": Substance use, connectedness, and sexual activity among men who have sex with men who are living with HIV

BACKGROUND

Among MSM, substance use increases risk for acquiring HIV and is associated with sub-optimal engagement in HIV-related care. Most research related to substance use and sexual activity among MSM focuses on identifying and reducing risk of HIV acquisition and transmission rather than pleasure and agency. However, substance use may also facilitate sexual pleasure and build community, which could be particularly meaningful for individuals who cope with intersecting stigmas related to the disease, sexual identity, and drug use.

METHODS

To explore the ways in which substance use both promotes and hinders positive sexual expression and healthy sexual relationships, we conducted a secondary analysis of 33 semi-structured qualitative interviews with MSM living with HIV who were poorly engaged in care and reported recent substance use.

RESULTS

Thematic analysis revealed that substance use was perceived as: (1) a potential pathway to intimacy and enhanced sexual experiences; (2) a tool to help access partners and gain entry to a community; and (3) a source of empowerment, though some noted that it sometimes came at the cost of sexual disempowerment and unbalanced relationships.

CONCLUSIONS

Clinically, our results suggest that the complex motivations for substance use during sexual activity need to be carefully considered and discussed with patients, especially when attempting to decrease problematic use as a pathway to improved HIV self-care.

HIV-Related Stigma, Sexual Identity, and Depressive Symptoms Among MSM Living With HIV in China: A Moderated Mediation Modeling Analysis

Depression is one of the biggest health issues among men who have sex with men (MSM) living with HIV, where sexual identity might play an intricate role. Yet, findings of the relationship between sexual identity and depression were mixed and few studies explored its underlying mechanisms. This study aimed to examine the association between sexual identity and depression, and the potential mediating role of HIV-related stigma and moderating role of age. A cross-sectional survey was conducted among 203 MSM living with HIV in Guangxi, China. Participants provided information on sexual identity, depression, HIV-related stigma, and background information. Descriptive statistics, bivariate analysis, and path analysis were applied to examine our hypotheses. Bivariate analysis demonstrated that participants who self-identified as gay reported a lower level of HIV-related stigma and depression. Path analysis revealed an insignificant direct effect of identifying as gay on depression. Yet, the indirect pathway was significant, with identifying as gay being associated with a lower level of HIV stigma and thus a lower level of depression. This indirect effect was moderated by age. The conditional indirect effect was significant in the younger group yet ceased in the older group. The study provided information to better understand the effect of sexual identity on mental health among stigmatized sexual and gender minorities by highlighting the mediating effect of HIV-related stigma and the protective effect of age. Interventions targeting mental health of MSM living with HIV might consider placing greater emphasis on addressing HIV-related stigma among younger MSM.

Tina's ParTy line: Polysubstance use patterns in sexual minority men living with HIV who use methamphetamine

INTRODUCTION

This cross-sectional study examined the associations of demographic, structural and psychological factors with distinct typologies of polysubstance use in sexual minority men (SMM) living with HIV who use methamphetamine.

METHODS

In total, 161 SMM living with HIV who reported methamphetamine use in the past 3 months were recruited in San Francisco from 2013 to 2017 for a randomised controlled trial. A latent class analysis was conducted by leveraging baseline measures of self-reported use of 15 substances in the past 3 months as well as validated screening measures of hazardous alcohol and cannabis use. Correlates of latent class membership were examined using a three-step categorical latent variable logistic regression.

RESULTS

Four typologies of substance use were identified: (i) methamphetamine use only (43%); (ii) methamphetamine and crack-cocaine use (22%); (iii) party and play use-methamphetamine, gamma-hydroxybutyrate and amyl nitrites (i.e. poppers) with erectile dysfunction drugs (31%); and (iv) high polysubstance use (4%). SMM of colour and those with a history of incarceration were more commonly classified as engaging in methamphetamine and crack-cocaine use compared to party and play use. Men with higher sexual compulsivity scores were more commonly classified as engaging in party and play use and polysubstance use.

DISCUSSION AND CONCLUSIONS

There is substantial heterogeneity in polysubstance use patterns among SMM living with HIV who use methamphetamine. This will inform the development of tailored substance use interventions addressing the unique needs of SMM of colour and targeting sexual compulsivity as a prominent comorbidity for some men.

Unbiased Metabolomics Links Fatty Acid Pathways to Psychiatric Symptoms in People Living with HIV

Psychiatric symptoms are prevalent in people living with HIV (PLWH), especially depression, anxiety, impulsivity, and substance use. Various biological mechanisms might play a role in the occurrence of psychiatric symptoms in this population. A hypothesis free, data-driven metabolomics approach can further our understanding of these mechanisms. In this study, we identified metabolic pathways associated with impulsivity, depression and substance use in 157 PLWH. First, Spearman’s rank correlations between metabolite feature intensities and psychiatric symptom levels were calculated, while controlling for age, gender and body mass index. Subsequently, a mummichog pathway analysis was performed. Finally, we analyzed which individual metabolites drove the observed effects. In our cohort of PLWH, fatty acid-related pathways were associated with both depressive as well as impulsive symptomatology. Substance use showed most extensive metabolic associations, and was positively associated with short chain fatty acids (SCFA’s), and negatively associated with glutamate levels. These findings suggest that PUFA metabolism might be associated with both internalising and externalising symptomatology in PLWH. Furthermore, glutamate and SCFA’s—microbiome derivatives with known neuroactive properties—might be involved in substance use in these patients. Future studies should explore potential causal mechanisms involved and whether these findings are HIV-specific.

An autoregressive cross-lagged model unraveling co-occurring stimulant use and HIV: Results from a randomized controlled trial

BACKGROUND

Evidence-based interventions are needed to address the use of stimulants such as methamphetamine as a driver of onward HIV transmission and faster clinical HIV progression among sexual minority men. Prior randomized controlled trials with people living with HIV who use substances indicate that financial incentives provided during contingency management (CM) are effective for achieving short-term reductions in stimulant use and HIV viral load. However, the benefits of CM are often not maintained after financial incentives for behavior change end.

PURPOSE

Data from a recently completed randomized controlled trial with 110 sexual minority men living with HIV who use methamphetamine was leveraged to examine mediators of the efficacy of a positive affect intervention for extending the benefits of CM.

METHODS

An autoregressive cross-lagged model was fit to determine if reductions in HIV viral load were mediated by intervention-related increases in positive affect and decreases in stimulant use measured in four waves over 15 months.

RESULTS

Higher baseline positive affect predicted significantly lower self-reported stimulant use immediately following the 3-month CM intervention period, even after controlling for self-reported stimulant use at baseline. Moreover, decreased stimulant use emerged as an independent predictor of long-term reductions HIV viral load at 15 months, even after adjusting for HIV viral load at baseline and the residual effect of the positive affect intervention.

CONCLUSIONS

Findings underscore the importance of durable reductions in stimulant use as a primary intervention target that is essential for optimizing the clinical and public health benefits of HIV treatment as prevention.

Longitudinal Associations of Syndemic Conditions with Antiretroviral Therapy Adherence and HIV Viral Suppression Among HIV-Infected Patients in Primary Care

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA <400 copies/mL) using multilevel logistic regression. Comparing patients with each other, odds of ART adherence were 61.6% lower per between-patient syndemic condition [adjusted odds ratio (AOR) = 0.384; 95% confidence interval (CI), 0.362-0.408]; comparing patients with themselves, odds of ART adherence were 36.4% lower per within-patient syndemic condition (AOR = 0.636 95% CI, 0.606-0.667). Odds of viral suppression were 29.3% lower per between-patient syndemic condition (AOR = 0.707; 95% CI, 0.644-0.778) and 27.7% lower per within-patient syndemic condition (AOR = 0.723; 95% CI, 0.671-0.780). Controlling for the effects of adherence (AOR = 5.522; 95% CI, 4.67-6.53), each additional clinic visit was associated with 1.296 times higher odds of viral suppression (AOR = 1.296; 95% CI, 1.22-1.38), but syndemic conditions were not significant. Deploying effective interventions within clinics to identify and treat syndemic conditions and bolster ART adherence and continued engagement in care can help control the HIV epidemic, even within academic medical settings in the era of increasingly potent ART.

Interventions Addressing Depression and HIV-Related Outcomes in People with HIV

PURPOSE OF REVIEW

People with HIV (PWH) are more likely to experience depression than those without HIV. Depression is not only distressing and interfering in and of itself, but it is also consistently associated with non-adherence to antiretroviral treatment (ART). Accordingly, research and clinical priorities require updated knowledge about interventions that address depression in PWH.

RECENT FINDINGS

Twenty efficacy trials and nine pilot studies since a 2009 review emerged in the literature review search. Of these, 11 and 6 respectively had a depression-related inclusion criterion. The intervention strategies included individual psychotherapy (n=6), group therapy (n=6), telehealth (n=3), and antidepressant medication (n=5). Generally, these interventions demonstrated acute efficacy for improving depression symptoms in PWH, with some also addressing ART non-adherence. However, not all studies collected follow-up data. Furthermore, trials that addressed depression but did not specifically address non-adherence did not also show adherence improvements. Existing interventions for depression have demonstrated efficacy in PWH, and these may have both positive mental and physical health outcomes. Future trials should measure and boost longer-term effects. It would be useful to incorporate adherence interventions into depression treatment to improve self-care behaviors and health outcomes.

Intersecting internalized stigmas and HIV self-care among men who have sex with men and who use substances

RATIONALE

Men who have sex with men (MSM) are disproportionately affected by HIV, substance use, and stigma related to co-existing or intersecting identities that are stigmatized or devalued by society (e.g., being a sexual minority male, a person living with HIV, or a person who uses substances). Evidence indicates that when stigma is internalized it may act as a barrier to engagement in self-care behaviors.

OBJECTIVE

Gaining a better understanding of how intersecting internalized stigmas affect HIV self-care among MSM who use substances.

METHODS

To investigate these relationships, we conducted semi-structured qualitative interviews until we reached thematic saturation (n = 33) with HIV + MSM who use substances and were sub-optimally engaged in HIV care. Interviews inquired about identity, internalized stigmas, substance use, HIV self-care behaviors, and interrelationships between concepts.

RESULTS

Our sample was 61% African American and 76% reported annual incomes of ≤$20,000. Approximately half of the participants explicitly described how intersecting internalized stigmas impacted their sense of self and their behavior. The overwhelming majority conveyed that internalized stigma related to substance use was the most burdensome and was considered a barrier to HIV self-care behaviors. Participants also described internalized stigmas related to HIV and sexual orientation, as well as race, effeminateness, poverty, and housing instability, which together impacted their psychological wellbeing and HIV self-care.

CONCLUSIONS

Our results indicate a need for clinicians to consider and address intersecting internalized stigmas, particularly internalized stigma related to substance use, to both reduce substance use and improve HIV self-care among MSM who use substances and are sub-optimally engaged in HIV care.

Understanding disparities in viral suppression among Black MSM living with HIV in Atlanta Georgia

INTRODUCTION

Due to factors associated with structural racism, Black men who have sex with men (MSM) living with HIV are less likely to be virally suppressed compared to white MSM. Most of these data come from clinical cohorts and modifiable reasons for these racial disparities need to be defined in order to intervene on these inequities. Therefore, we examined factors associated with racial disparities in baseline viral suppression in a community-based cohort of Black and white MSM living with HIV in Atlanta, GA.

METHODS

We conducted an observational cohort of Black and white MSM living with HIV infection in Atlanta. Enrolment occurred from June 2016 to June 2017 and men were followed for 24 months; laboratory and behavioural survey data were collected at 12 and 24 months after enrolment. Explanatory factors for racial disparities in viral suppression included sociodemographics and psychosocial variables. Poisson regression models with robust error variance were used to estimate prevalence ratios (PR) for Black/white differences in viral suppression. Factors that diminished the PR for race by ≥5% were considered to meaningfully attenuate the racial disparity and were included in a multivariable model.

RESULTS

Overall, 26% (104/398) of participants were not virally suppressed at baseline. Lack of viral suppression was significantly more prevalent among Black MSM (33%; 69/206) than white MSM (19%; 36/192) (crude Prevalence Ratio (PR) = 1.6; 95% CI: 1.1 to 2.5). The age-adjusted Black/white PR was diminished by controlling for: ART coverage (12% decrease), housing stability (7%), higher income (6%) and marijuana use (6%). In a multivariable model, these factors cumulatively mitigated the PR for race by 21% (adjusted PR = 1.1 [95% CI: 0.8 to 1.6]).

CONCLUSIONS

Relative to white MSM, Black MSM living with HIV in Atlanta were less likely to be virally suppressed. This disparity was explained by several factors, many of which should be targeted for structural, policy and individual-level interventions to reduce racial disparities.

Blue Monday: Co-occurring Stimulant Use and HIV Persistence Predict Dysregulated Catecholamine Synthesis

BACKGROUND

This longitudinal study examined whether co-occurring stimulant use and HIV disease processes predicted greater risk for depression via dysregulated metabolism of amino acid precursors for neurotransmitters.

METHODS

In total, 110 sexual minority men (ie, gay, bisexual, and other men who have sex with men) living with HIV who had biologically confirmed recent methamphetamine use were enrolled in a randomized controlled trial. The kynurenine/tryptophan (K/T) and phenylalanine/tyrosine (P/T) ratios were measured over 15 months to index dysregulated metabolism of amino acid precursors for serotonin and catecholamines. Markers of gut-immune dysregulation such as lipopolysaccharide binding protein and soluble CD14 (sCD14), HIV persistence in immune cells (ie, proviral HIV DNA), and stimulant use were examined as predictors. These bio-behavioral measures, including the K/T and P/T ratios, were also examined as predictors of greater risk for depression over 15 months.

RESULTS

Higher time-varying sCD14 levels (β = 0.13; P = 0.04) and time-varying detectable viral loads (β = 0.71; P < 0.001) were independent predictors of a higher K/T ratio. Time-varying reactive urine toxicology results for stimulants (β = 0.53; P < 0.001) and greater proviral HIV DNA at baseline (β = 0.34; P < 0.001) independently predicted an increased P/T ratio. Greater time-varying, self-reported methamphetamine use uniquely predicted higher odds of screening positive for depression (Adjusted Odds Ratio = 1.08; 95% confidence interval: 1.01 to 1.17).

CONCLUSIONS

Ongoing stimulant use and HIV persistence independently predict dysregulated metabolism of amino acid precursors for catecholamines, but this did not explain amplified risk for depression.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

INTRODUCTION

Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

METHODS

Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

RESULTS

Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

CONCLUSIONS

Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

Accumulation of HIV-1 Drug Resistance Mutations and Methamphetamine Use

BACKGROUND

Antiretroviral therapy (ART) non-adherence and methamphetamine use are associated with higher HIV drug resistance prevalence. How they affect drug resistance mutations accumulation is less studied.

OBJECTIVE

We assessed factors associated with drug resistance mutations accumulation.

METHODS

We evaluated HIV chronically-infected patients from a clinic-based research cohort on first-line ART regimens with genotype results within 30 days of baseline. Methamphetamine use and ART adherence were self-reported at each study visit. High ART adherence was defined as 0-5% missed doses in the last 30 days.

RESULTS

One-hundred twenty-five patients contributed 496 study visits. At baseline, 81% of patients reported high ART adherence; 90% reported no methamphetamine use in the prior 4 months, 8% used monthly or less and 2% used daily or weekly. Methamphetamine users and non-users had similarly high ART adherence (p=0.93). Adjusted incidence rate ratio (aIRR) of drug resistance mutations accumulation was 2.04 (95% CI 0.64, 6.46) for daily/weekly users and 1.71 (95% CI 0.66, 4.42) for patients with monthly or less users, compared to non-users. aIRR was 0.71 (95% CI 0.44, 1.15) with >5-10% missed ART doses and 1.21 (95% CI 0.80, 1.83) with >10% missed doses compared to 0-5% missed doses.

CONCLUSION

We found no strong evidence for the effect of methamphetamine use and ART adherence on drug resistance mutations accumulation. Research cohort patients may have been more engaged in care and treatment adherent than non-cohort patients. Our findings suggest methamphetamine use might not lead to treatment failure among HIV patients who are otherwise engaged in care.

Tryptophan degradation is associated with risk-taking propensity in methamphetamine users with treated HIV infection

Few studies have examined neuroimmune pathways that could contribute to impulsivity in people living with HIV who use substances. Eighty-four methamphetamine-using, sexual minority men with an undetectable HIV viral load were administered the Balloon Analogue Risk Task (BART), a behavioral measure of risk-taking propensity. We examined the associations between kynurenine/tryptophan ratio and phenylalanine/tyrosine ratio with BART scores using multiple linear regression. A higher kynurenine/tryptophan ratio was independently associated with greater BART scores (beta = 0.25; 95% CI = 0.05-1.23; p = 0.034). The phenylalanine/tyrosine ratio was not significantly associated with BART scores. Findings support the need for further research to elucidate the neuroimmune mechanisms linking tryptophan degradation with impulsivity to catalyze the development novel pharmacologic treatments for people living with HIV who use methamphetamine.

Psychosocial Well-Being and HIV-Related Immune Health Outcomes among HIV-Positive Older Adults: Support for a Biopsychosocial Model of HIV Stigma and Health

Evidence suggests that psychosocial stress negatively impacts immunological health in HIV-positive individuals. However, few studies have explored this association in substance-using older adults living with HIV (OALWH). We evaluated the effect of depression, loneliness, substance use problems, and HIV stigma on primary markers of immune function in a sample of 120 OALWH with substance-related issues. HIV stigma correlated with the greatest number of factors, including depression, loneliness, and substance use problems. Older age and antiretroviral adherence were associated with viral suppression, which was in turn associated with higher percentage of CD4 count. Multivariate path analyses demonstrated that lower HIV stigma and viral suppression were the only factors independently associated with higher percentage of CD4 count, with a significant indirect effect of adherence on CD4 through viral suppression. HIV stigma emerged as the most salient factor associated with both psychosocial well-being and immune health in the current study, suggesting that it is a critical factor to consider in future interventions for the rapidly growing population of OALWH.

Identifying Opportunities for Collaboration Across the Social Sciences to Reach the 10-10-10: A Multilevel Approach

BACKGROUND

The national and global strategy to combat HIV, often referred to as the "90-90-90," aims to diagnose 90% of people living with HIV, get 90% of those diagnosed onto antiretroviral treatment (ART), and achieve viral suppression in 90% of those on ART. The remaining 10-10-10 who will be undiagnosed, not on ART, or not virally suppressed, include vulnerable persons and populations most affected by social determinants of health. Given their foci on the social determinants of health at the individual, social, and structural levels, social scientists are in a prime position to help reach the 10-10-10. A potentially effective way for social scientists to achieve this goal is to examine the issues that affect the 10-10-10 using a multilevel framework, to understand at what levels their own approaches fit within such a multilevel framework, and to seek intentional collaborations with other social scientists who may work at different levels but whose approaches may complement their own within multilevel collaborations.

APPROACH

The present article describes how a multilevel framework can guide collaboration across disciplines within the social sciences toward the common goal of reaching the 10-10-10.

CONCLUSIONS

Within a multilevel framework, social scientists can work collaboratively to address the needs of individuals among the 10-10-10 within the social and structural contexts (eg, social norms, stigma, poverty, and barriers to care) that affect their health. Such an approach draws on the unique strengths and approaches of different social-science disciplines while also building capacity for individuals most affected by social determinants of health.

Stimulant Use and Study Protocol Completion: Assessing the Ability of Men Who Have Sex with Men to Collect Dried Blood Spots for Laboratory Measurement of HIV Viral Load

Stimulant use is associated with higher HIV viral load (VL) and sexual HIV transmission risk among men who have sex with men (MSM) living with HIV. There is little research on willingness of drug users living with HIV to fully participate in studies, especially those involving self-collection of biomarker data. This study presents findings from an at-home dried blood spot collection study measuring laboratory-quantified VL among U.S. HIV-positive MSM who reported high-risk sexual behavior and/or suboptimal antiretroviral therapy (ART) adherence to assess the association between drug-use behavior and (1) ability to complete a study protocol and (2) VL outcomes. Among recruited participants (n = 766), 35% reported stimulant drug use (amphetamines, cocaine, crack, crystal meth, ecstasy, or a combination of stimulant drugs), 39% reported using other drugs (heroin, marijuana, prescription opioids, and others), and 27% reported no drug use in the past 3 months. In all, 61% of enrolled participants completed the study protocol. Stimulant drug users were less likely (ARR 0.84; 95% CI 0.72-0.98) to complete the protocol than other drug users. Furthermore, other drug users were significantly less likely than non-drug users (ARR 0.52; 95% CI 0.28-0.97) to have an HIV VL result ≥ 1500 copies/mL. This study provides important estimates regarding the likelihood of participation in biomedical research activities among HIV-positive MSM with varying drug-use behaviors, showing that it is feasible to conduct such biomedical studies with drug-using MSM who report high-risk sexual behavior and struggle with their ART adherence.

Depression and HIV Disease Progression: A Mini-Review

Background

Depression is the most common mental disorder and a leading cause of disability, which commonly presents unexplained psychological and physical symptoms. Depression and HIV/AIDS are commonly comorbid. This review provides an insight into the effect of depression on disease progression among people living with HIV.

Methods

A search for relevant articles was conducted using a database like MEDLINE, Scopus, PsycINFO and CINAHL. Peer-reviewed English journals published between 2015 and 2019 were included in the review.

Results

A total of eight studies conducted in different settings were included in the review. This review has found that psychosocial, neurohormonal and virologic factors associated with depression affect HIV disease progression. Yet, the chronicity of depression, absence of the hormones that have a buffer effect on depression and lack of examination if depression is a predictor, or an outcome of disease progression, were some of the gaps that require further investigation.

Conclusion

Considerably, more research is needed to better understand the effect of mental disorder, especially depression, on HIV disease progression to AIDS and future interventions should, therefore, concentrate on the integration of mental health screening in HIV clinical setup.

Randomized controlled trial of a positive affect intervention to reduce HIV viral load among sexual minority men who use methamphetamine

INTRODUCTION

In the era of HIV treatment as prevention (TasP), evidence-based interventions that optimize viral suppression among people who use stimulants such as methamphetamine are needed to improve health outcomes and reduce onward transmission risk. We tested the efficacy of positive affect intervention delivered during community-based contingency management (CM) for reducing viral load in sexual minority men living with HIV who use methamphetamine.

METHODS

Conducted in San Francisco, this Phase II randomized controlled trial tested the efficacy of a positive affect intervention for boosting and extending the effectiveness of community-based CM for stimulant abstinence to achieve more durable reductions in HIV viral load. From 2013 to 2017, 110 sexual minority men living with HIV who had biologically confirmed, recent methamphetamine use were randomized to receive a positive affect intervention (n = 55) or attention-control condition (n = 55). All individual positive affect intervention and attention-control sessions were delivered during three months of community-based CM where participants received financial incentives for stimulant abstinence. The 5-session positive affect intervention was designed to provide skills for managing stimulant withdrawal symptoms as well as sensitize individuals to natural sources of reward. The attention-control condition consisted of neutral writing exercises and self-report measures.

RESULTS

Men randomized to the positive affect intervention displayed significantly lower log10 HIV viral load at six, twelve and fifteen months compared to those in the attention-control condition. Men in the positive affect intervention also had significantly lower risk of at least one unsuppressed HIV RNA (≥200 copies/mL) over the 15-month follow-up. There were concurrent, statistically significant intervention-related increases in positive affect as well as decreases in the self-reported frequency of stimulant use at six and twelve months.

CONCLUSIONS

Delivering a positive affect intervention during community-based CM with sexual minority men who use methamphetamine achieved durable and clinically meaningful reductions in HIV viral load that were paralleled by increases in positive affect and decreases in stimulant use. Further clinical research is needed to determine the effectiveness of integrative, behavioural interventions for optimizing the clinical and public health benefits of TasP in sexual minority men who use stimulants such as methamphetamine.

Stimulant Use and Viral Suppression in the Era of Universal Antiretroviral Therapy

BACKGROUND

HIV-positive persons who use stimulants such as methamphetamine experience difficulties navigating the HIV care continuum that undermine the benefits of antiretroviral therapy (ART). However, few studies have examined the association of stimulant use with viral suppression in the era of universal ART.

SETTING

Zuckerberg San Francisco General Hospital.

METHODS

HIV-positive persons participating in a clinical cohort study and taking ART completed assessments every 4-6 months. The exposure was the cumulative, time-varying proportion of assessments with any self-reported stimulant use. The time-varying outcome, HIV viral suppression (ie, <200 copies/mL), was measured at assessments or extracted from the clinical record.

RESULTS

In total, 1635 HIV-positive participants on ART contributed 17,610 person-visits over a median of 2.3 [interquartile range (IQR) = 1.0-5.3] years of follow-up. Participants were middle-aged (median = 45.0; IQR = 38.0-52.0), predominantly white (57%), sexual minority men (78%), with a median CD4 T-cell count of 409 (IQR = 225-640) cells/mm at enrollment. Significant increases in odds of viral suppression over time were less pronounced among stimulant users compared with nonusers, particularly before the advent of universal ART. Increasing odds of viral suppression were paralleled by declining stimulant use over time. In the universal ART era, increasing odds of viral suppression were observed at lower levels of stimulant use, but not when participants reported using stimulants at every visit.

CONCLUSIONS

Although ART benefits are still not achieved as rapidly in stimulant users, this disparity is not as large in the era of universal ART.

A Pilot Study of a Mobile App to Support HIV Antiretroviral Therapy Adherence Among Men Who Have Sex with Men Who Use Stimulants

APP+ is a theoretically-grounded mobile app intervention to improve antiretroviral (ART) adherence among men who have sex with men (MSM) who use stimulants. We assessed the feasibility and acceptability of APP+ in a six-month randomized controlled trial among a national sample of 90 MSM recruited online; secondarily, we examined changes in self-reported ART adherence by study arm. Retention at the final assessment was 82%, and acceptability ratings were comparable to other technology-based interventions. MSM in the APP+ group reported higher self-reported percentage ART adherence in the past 30 days at the four-month timepoint compared to a no-treatment control group (89.0% vs. 77.2%). However, once access to the app was removed after month four, group differences in ART adherence diminished by month six. APP+ may be a potentially promising intervention approach for MSM living with HIV who use stimulants but would require enhancements to optimize acceptability and demonstrate more sustained effects.

Pilot Randomized Controlled Trial of a Syndemics Intervention with HIV-Positive, Cocaine-Using Women

This pilot randomized controlled trial examined the feasibility and acceptability of a Syndemics intervention targeting the intersection of stimulant use, trauma, and difficulties with HIV disease management in cocaine-using women. All participants received contingency management (CM) for 3 months with financial incentives for stimulant abstinence during thrice-weekly urine screening and refilling antiretroviral medications monthly. Sixteen participants were randomized to complete four expressive writing (n = 9) or four neutral writing (n = 7) sessions delivered during the CM intervention period. Completion rates for writing sessions were high (15 of 16 women completed all four sessions) and engagement in CM urine screening was moderate with women randomized to expressive writing providing a median of 11 non-reactive urine samples for stimulants. There were non-significant trends for those randomized to expressive writing to provide more CM urine samples that were non-reactive for stimulants, report greater decreases in severity of cocaine use, and display reductions in log10 HIV viral load at 6 months. Although the Syndemics intervention was feasible and acceptable to many women, qualitative interviews with eligible participants who were not randomized identified structural and psychological barriers to engagement. Further clinical research is needed to test the efficacy of Syndemics interventions with HIV-positive, cocaine-using women.

HIV-Related Stigmatization and Medication Adherence: Indirect Effects of Disclosure Concerns and Depression

BACKGROUND

Stigmatization due to HIV status may interfere with disease management among persons living with HIV (PLWHA) by heightening serostatus disclosure concerns and vulnerability to depressive symptoms.

PURPOSE

In this cross-sectional study, indirect effects of disclosure concerns and depressive symptoms were examined for the association of stigma to treatment adherence (medication and clinic appointment adherence) in an outpatient sample of PLWHA.

METHOD

Participants (N = 179; 47% White, 41% African-American; 35% MSM) completed measures of stigma-related experiences, concerns about disclosing HIV status, depression, and medication adherence; clinic appointment attendance was obtained from chart data.

RESULTS

Stigma had an indirect effect on medication adherence (but not clinic attendance) via disclosure concerns. Stigma had indirect effects on both medication adherence and clinic attendance via depressive symptoms. In path analyses including both disclosure concerns and depressive symptoms, combined indirect effects emerged for both medication adherence and clinic attendance. There was a significant indirect pathway from stigma to disclosure concerns to depression to clinic attendance, whereas the positioning of the mediators was swapped for the significant indirect pathway from stigma to medication adherence.

CONCLUSIONS

These analyses provide evidence that stigmatizing experiences negatively affect treatment adherence through the indirect effects of disclosure concerns and depressive symptoms. Disclosure concerns and depressive symptoms are two mechanisms worthy of further research to enhance understanding of the association between stigma and treatment adherence difficulties.

Risk factors for antiretroviral therapy (ART) discontinuation in a large multinational trial of early ART initiators

OBJECTIVE

We aimed to investigate potential causes of higher risk of treatment interruptions within the multicountry Strategic Timing of AntiRetroviral Treatment (START) trial in 2015.

METHODS

We defined baseline as the date of starting antiretroviral therapy (ART) and a treatment interruption as discontinuing ART for at least 2 weeks. Participants were stratified by randomization arm and followed from baseline to earliest end date of the initial phase of START, death, date of consent withdrawn or date of first treatment interruption. Cox regression was used to calculate hazard ratios and 95% confidence intervals for factors that may predict treatment interruptions in each arm.

RESULTS

Of the 3438 participants who started ART, 2286 were in the immediate arm and 1152 in the deferred arm. 12.9% of people in the immediate arm and 10.5% of people in the deferred arm experienced at least one treatment interruption by 3 years after starting ART. In adjusted analyses, age [hazard ratio for 35-50 years: 0.75 (95% confidence interval: 0.59-0.97) and >50 years: 0.53 (0.33-0.80) vs. <35 years], education status [hazard ratio for postgraduate education vs. less than high-school education (0.23 (0.10-0.50))] and region [hazard ratio for United States vs. Europe/Israel (3.16 (2.09-4.77))] were significantly associated with treatment interruptions in the immediate arm. In the deferred arm, age and education status were significantly associated with treatment interruptions.

CONCLUSION

Within START, we identified younger age and lower educational attainment as potential causes of ART interruption. There is a need to strengthen adherence advice and wider social support in younger people and those of lower education status.

Skating on thin ice: stimulant use and sub-optimal adherence to HIV pre-exposure prophylaxis

Introduction

Stimulant and heavy alcohol use are prevalent and associated with elevated risk for HIV seroconversion among men who have sex with men (MSM) and transgender women. In addition, each can pose difficulties for antiretroviral adherence among people living with HIV. Scant research has examined the associations of stimulant and heavy alcohol use with adherence to daily oral pre‐exposure prophylaxis (PrEP) among MSM and transgender women. To address this gap in the literature, we evaluated the hypothesis that stimulant use and binge drinking are prospectively associated with sub‐optimal PrEP adherence.

Methods

We analysed data from participants in a nested case‐cohort in the iPrEx open label extension. Stimulant use (i.e. powder cocaine, crack‐cocaine, cocaine paste, methamphetamine, cathinone) and binge drinking (i.e. ≥5 drinks in a single day) in the last 30 days were assessed. Baseline urine was tested for stimulants using immunoassays to reduce misclassification. Sub‐optimal adherence was defined as tenofovir drug concentrations in dried blood spots less than 700 fmol per punch, indicative of less than four doses per week. We tested the prospective association of stimulant use and binge drinking with sub‐optimal adherence at the 4‐week follow‐up visit.

Results and Discussion

Data from 330 participants were analysed. The majority of the participants were MSM (89%) with a median age at baseline of 29 years (interquartile range 24 to 39). Approximately 16% (52/330) used stimulants and 22% (72/330) reported binge drinking in the last 30 days. Stimulant users had fivefold greater odds of sub‐optimal PrEP adherence compared to non‐users in adjusted analysis (adjusted odds ratio [aOR] 5.04; [95% CI 1.35 to 18.78]). Self‐reported binge drinking was not significantly associated with sub‐optimal adherence after adjusting for stimulant use and baseline confounders (aOR 1.16 [0.49 to 2.73]). Depressive symptoms, being transgender, and number of sex partners were also not significantly associated with sub‐optimal PrEP adherence (p > 0.05).

Conclusions

Stimulant use is a risk factor for sub‐optimal PrEP adherence in the month following PrEP initiation. Comprehensive prevention approaches that reduce stimulant use may optimize PrEP adherence. Creating adherence plans that specifically address PrEP dosing in the context of ongoing stimulant use should also be considered.

Immunologic Restoration of People Living with Human Immunodeficiency Virus on Highly Active Anti-retroviral Therapy in Ethiopia: The Focus of Chronic Non-Communicable Disease Co-Morbidities

Background:

The life expectancy of people living with Human Immunodeficiency Virus (HIV) has dramatically improved with the much-increased access to antiretroviral therapy. Consequently, a larger number of people living with HIV are living longer and facing the increased burden of non-communicable diseases. This study assessed the effect of chronic non-communicable disease(s) and co-morbidities on the immunologic restoration of HIV infected patients on highly active antiretroviral therapy.

Methods:

A nested case-control study was conducted among people living with HIV at Jimma University Medical Center from February 20 to August 20, 2016. Cases were HIV infected patients living with chronic non-communicable diseases and controls were people living with HIV only. Patient-specific data were collected using a structured data collection tool to identify relevant information. Data were analyzed using the Statistical Package for Social Science version 20.0. Logistic regressions were used to identify factors associated with outcome. Statistical significance was considered at p-value <0.05. A patient's written informed consent was obtained after explaining the purpose of the study.

Results:

A total of 240 participants (120 cases and 120 controls) were included in the analysis. Prevalence of hypertension was 12.50%, and diabetes was 10.84%. About 10.42% of study participants were living with multi-morbidity. At baseline, the mean (±SD) age of cases was 42.32±10.69 years, whereas it was 38.41±8.23 years among controls. The median baseline CD4+ cell count was 184.50 cells/µL (IQR: 98.50 - 284.00 cells/µL) for cases and 177.0 cells/µL (IQR: 103.75 - 257.25 cells/µL) for controls. Post-6-months of highly active antiretroviral therapy initiation, about 29.17% of cases and 16.67% of controls had poor immunologic restoration. An average increase of CD4+ cell count was 6.4cells/µL per month among cases and 7.6 cells/µL per month among controls. Male sex [AOR, 3.51; 95% CI, 1.496 to 8.24; p=0.004], smoking history [AOR, 2.81; 95% CI, 1.072, to 7.342; p=0.036] and co-morbidity with chronic non-communicable disease(s) [AOR, 3.99; 95% CI, 1.604 to 9.916; p=0.003)] were independent predictors of poor immunologic restoration.

Conclusions:

Chronic non-communicable disease(s) have negative effects on the kinetics of CD4+ cell count among HIV-infected patients who initiated antiretroviral therapy. So the integration of chronic non-communicable disease-HIV collaborative activities will strengthen battle to control the double burden of chronic illnesses.

Determining the Roles that Club Drugs, Marijuana, and Heavy Drinking Play in PrEP Medication Adherence Among Gay and Bisexual Men: Implications for Treatment and Research

Researchers have established that substance use interferes with anti-retroviral medication adherence among gay and bisexual men (GBM) living with HIV. There is limited parallel examination of pre-exposure prophylaxis (PrEP) adherence among HIV-negative GBM. We conducted retrospective 30-day timeline follow-back interviews and prospective semi-weekly diary data for 10 weeks with 104 PrEP-using GBM, half of whom engaged in club drug use (ketamine, ecstasy, GHB, cocaine, or methamphetamine)-generating 9532 days of data. Participants reported their day-by-day PrEP, club drug, marijuana, and heavy alcohol use (5 + drinks in one sitting). On average, club drug users were no more likely to miss a dose of PrEP than non-club drug users (M = 1.6 doses, SD = 3.0, past 30 days). However, we found that club drug use (at the event level) increased the odds of missing a dose on the same day by 55% and the next day (e.g., a "carryover effect") by 60%. Further, missing a dose on one day increased the odds of missing a dose the following day by eightfold. We did not identify an event-level effect of marijuana use or heavy drinking on PrEP adherence. Our data suggest club drug users could have greater protective effects from daily oral or long-acting injectable PrEP compared to a time-driven PrEP regimen because of the concurrence of club drug use and PrEP non-adherence.

Prevalence of and factors associated with major depressive disorder among HIV-positive individuals in Guangdong, China

BACKGROUND

People living with HIV may suffer from mental disorders. We aimed to explore the prevalence of and factors associated with major depressive disorder (MDD) among HIV-positive individuals in Guangdong, China, about which little is known.

METHODS

A cross-sectional study was conducted to recruit HIV-positive individuals from the Centers for Disease Prevention and Control of Guangzhou, Zhongshan, and Yangjiang from September 2007 to September 2008. Data were collected by questionnaires. MDD was diagnosed and assessed by two psychiatrists using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Patient Edition (SCID-I/P) based on the DSM-IV criteria. Multiple logistic regression analyses were conducted to explore the factors associated with MDD.

RESULTS

The prevalences of lifetime MDD and current MDD among the 339 included participants were 22.71% (95% confidence interval [CI]: 18.25-27.17%) and 12.09% (95%CI: 8.62%-15.57%), respectively. The results of multiple logistic regression showed that patients with AIDS had a higher risk of lifetime MDD (odds ratio [OR] = 2.69, 95%CI: 1.38-5.26) and current MDD (OR = 3.51, 95%CI: 1.59-7.75) than HIV-infected individuals. Participants with more number of negative life events were more likely to have lifetime MDD (OR = 2.33, 95%CI: 1.34-4.06) and current MDD (OR = 3.77, 95%CI: 1.76-8.09) than individuals with fewer negative life events. Individuals with higher score of social support were less likely to have lifetime MDD (OR = 0.45, 95%CI: 0.26-0.80) and current MDD (OR = 0.46, 95%CI: 0.21-0.97) than individuals with less social support.

CONCLUSIONS

The prevalence of MDD was high among HIV-positive individuals in China. AIDS diagnosis, decreased social support, and an increased number of negative life events were risk factors for MDD.

The Longitudinal Effects of Non-injection Substance Use on Sustained HIV Viral Load Undetectability Among MSM and Heterosexual Men in Brazil and Thailand: The Role of ART Adherence and Depressive Symptoms (HPTN 063)

The effect of non-injection substance use on HIV viral load (VL) is understudied in international settings. Data are from HPTN063, a longitudinal observational study of HIV-infected individuals in Brazil, Thailand, and Zambia, with focus on men with VL data (Brazil = 146; Thailand = 159). Generalized linear mixed models (GLMM) assessed whether non-injection substance use (stimulants, cannabis, alcohol, polysubstance) was associated with VL undetectability. ART adherence and depressive symptoms were examined as mediators of the association. In Thailand, substance use was not significantly associated with VL undetectability or ART adherence, but alcohol misuse among MSM was associated with increased odds of depression (AOR = 2.75; 95% CI 1.20, 6.32, p = 0.02). In Brazil, alcohol misuse by MSM was associated with decreased odds of undetectable VL (AOR = 0.34; 95% CI 0.13, 0.92, p = 0.03). Polysubstance use by heterosexual men in Brazil was associated with decreased odds of ART adherence (AOR = 0.25; 95% CI 0.08, 0.78, p = 0.02). VL suppression appears attainable among non-injection substance users. Substance use interventions among HIV-positive men should address depression, adherence, and VL undetectability.

Psychosocial Correlates of Monocyte Activation and HIV Persistence in Methamphetamine Users

This cross-sectional study investigated the associations of psychosocial factors relevant to recovery from substance use disorders with monocyte activation and HIV persistence in a sample of 84 HIV-positive, methamphetamine-using sexual minority men with undetectable HIV viral load (<40 copies/mL). We examined if psychosocial factors were associated with decreased soluble CD14 (sCD14) and lower proviral HIV DNA. Multiple linear regression models adjusted for age, anti-retroviral therapy regimen, and CD4+ T-cell count. Time on ART was also included in models examining proviral HIV DNA. Greater self-efficacy for managing methamphetamine triggers and higher social support for abstinence were independently associated with lower sCD14. Greater social support for abstinence was also independently associated with lower proviral HIV DNA. Psychosocial factors relevant to recovery from substance use disorders are associated with lower monocyte activation and decreased proviral HIV DNA. Findings underscore the need for longitudinal research to identify plausible mechanisms linking psychosocial factors and substance use with biological processes relevant to HIV pathogenesis.

Over the influence: The HIV care continuum among methamphetamine-using men who have sex with men

BACKGROUND

HIV-positive persons who use stimulants such as methamphetamine experience greater difficulties in navigating the HIV care continuum. In the era of HIV treatment as prevention (TasP), little is known about the prevalence and correlates of success along the HIV care continuum among people who use stimulants.

SETTING

San Francisco, California USA METHODS: Cross-sectional study that enrolled 129 HIV-positive men who have sex with men (MSM) from 2013 through 2017 who had biologically confirmed, recent methamphetamine use. Multivariable logistic regressions were built to identify correlates of success across the HIV care continuum.

RESULTS

Although two-thirds (87/129) of participants had undetectable HIV viral load (<40 copies/mL), only one-in-four (32/129) reported taking at least 90% of their antiretroviral therapy (ART). Those who were homeless in the past year (adjusted odds ratio [aOR] = 0.20; 95% CI = 0.06-0.65) had 80% lower odds of being undetectable and adherent to ART. Substance use disorder treatment was associated with 77% lower odds of being engaged in HIV care (aOR = 0.23; 95% CI = 0.06-0.84) but also close to 3-fold greater odds of being adherent to ART (aOR = 2.91; 95% CI = 1.12-7.60).

CONCLUSION

Despite the fact that many HIV-positive, methamphetamine-using MSM are able to achieve undetectable viral load in this sample, difficulties with ART adherence threaten to undermine the clinical and public health benefits of TasP. Expanded efforts to boost the effectiveness of TasP in this population should focus on meeting the unique needs of homeless individuals, optimizing ART adherence, and facilitating the integration of HIV care with substance use disorder treatment.

Social Capital, Depressive Symptoms, and HIV Viral Suppression Among Young Black, Gay, Bisexual and Other Men Who Have Sex with Men Living with HIV

Social capital, the sum of an individual's resource-containing social network connections, has been proposed as a facilitator of successful HIV care engagement. We explored relationships between social capital, psychological covariates (depression, stigma and internalized homonegativity), and viral suppression in a sample of young Black gay, bisexual and other men who have sex with men (YB-GBMSM). We recruited 81 HIV-positive YB-GBMSM 18-24 years of age from a clinic setting. Participants completed a cross-sectional survey, and HIV-1 viral load (VL) measurements were extracted from the medical record. Sixty-five percent (65%) were virally suppressed (HIV-1 VL ≤ 40 copies/ml). Forty-seven percent (47%) had a positive depression screen. Depressive symptoms affected viral suppression differently in YB-GBMSM with lower vs. higher social capital (p = 0.046, test for statistical interaction between depression and social capital). The odds of viral suppression among YB-GBMSM with lower social capital was 93% lower among those with depressive symptoms (OR 0.07, p = 0.002); however, there was no association between depressive symptoms and viral suppression among those with higher social capital. Our results suggest that social capital may buffer the strong negative effects of depressive symptoms on clinical outcomes in YB-GBMSM living with HIV. In addition to treating depression, there is a role for interventions to augment social capital among YB-GBMSM living with HIV as a strategy for enhancing care engagement.

Recent stimulant use and leukocyte gene expression in methamphetamine users with treated HIV infection

Stimulant use may accelerate HIV disease progression through biological and behavioral pathways. However, scant research with treated HIV-positive persons has examined stimulant-associated alterations in pathophysiologic processes relevant to HIV pathogenesis. In a sample of 55 HIV-positive, methamphetamine-using sexual minority men with a viral load less than 200 copies/mL, we conducted RNA sequencing to examine patterns of leukocyte gene expression in participants who had a urine sample that was reactive for stimulants (n = 27) as compared to those who tested non-reactive (n = 28). Results indicated differential expression of 32 genes and perturbation of 168 pathways in recent stimulant users. We observed statistically significant differential expression of single genes previously associated with HIV latency, cell cycle regulation, and immune activation in recent stimulant users (false discovery rate p < 0.10). Pathway analyses indicated enrichment for genes associated with inflammation, innate immune activation, neuroendocrine hormone regulation, and neurotransmitter synthesis. Recent stimulant users displayed concurrent elevations in plasma levels of tumor necrosis factor - alpha (TNF-α) but not interleukin 6 (IL-6). Further research is needed to examine the bio-behavioral mechanisms whereby stimulant use may contribute to HIV persistence and disease progression.

Methamphetamine-associated dysregulation of the hypothalamic-pituitary-thyroid axis

Methamphetamine and HIV impair thyroid function, but few studies have investigated their combined effects on thyroid dysregulation. This study examined the associations of methamphetamine use alone and in combination with HIV on thyroid function among men in South Florida. Measures of thyroid function in methamphetamine-using, HIV-infected (METH+HIV+; n = 127) and HIV-negative (METH+HIV-; n = 46) men who have sex with men (MSM) were compared to non-methamphetamine-using, HIV-negative men (METH-HIV-; n = 136). Thyroid function was dysregulated in methamphetamine-using MSM, irrespective of HIV status. Both meth-using groups had greater odds of abnormal thyroid stimulating hormone levels and significantly higher mean free triiodothyronine (T3) levels. Elevated free T3 was associated with greater depressive symptoms. Overall, outcomes have important implications for assessment of thyroid function in methamphetamine users, particularly among those presenting with depression.

Intervention to Increase HIV Testing Among Substance-Using Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Young men who have sex with men (YMSM) and transgender people in the Detroit Metro Area are the only risk group for whom the incidence of HIV and sexually transmitted infections (STI) has increased since 2000, with HIV incidence nearly doubling among youth. Substance use (including alcohol), which is relatively frequent among YMSM and transgender people, creates barriers to the optimal delivery of HIV prevention and care services. Standard HIV counseling, testing, and referral (CTR) is limited in providing strategies to identify and address substance use. Hence, in its current form, CTR may not be serving the prevention needs of substance-using YMSM and transgender people. Brief counseling interventions, grounded in principles of motivational interviewing, may offer a mechanism to meet the HIV prevention and care needs of substance-using YMSM and transgender people.

OBJECTIVE

This prospective, 4-arm, factorial randomized controlled trial aims to examine the efficacy of an motivational interviewing-based substance use brief intervention (SUBI) on participants' substance use and engagement in HIV prevention.

METHODS

The research implements a prospective randomized controlled trial (Project Swerve) of 600 YMSM and transgender people recruited both online and in person. Eligibility criteria include participants who (1) are between the ages of 15 to 29 years, (2) live in the Detroit Metro Area, (3) self-identify as a man or transgender man or woman, (4) have had sexual contact with a man in the 6 months before enrollment, (5) self-report binge drinking or any substance use in the 3 months before enrollment, and (6) self-report an unknown or negative HIV status upon enrollment. Participants are randomized to receive, 3-months apart starting at baseline, 2 individual sessions. Sessions are CTR-only, SUBI-only, CTR followed by SUBI, or SUBI followed by CTR.

RESULTS

Project Swerve was launched in April 2017 and enrollment is ongoing.

CONCLUSIONS

Incorporating a SUBI that utilizes the principles of motivational interviewing into HIV CTR provides an opportunity to tailor counseling services for YMSM and transgender people to address additional client barriers to HIV and STI testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02945436; http://clinicaltrials.gov/ct2/show/NCT02945436 (Archived by WebCite at http://www.webcitation.org/6yFyOK57w).

HIV Pre-exposure Prophylaxis (PrEP) Uptake and Retention Among Men Who Have Sex with Men in a Community-Based Sexual Health Clinic

In a community-based clinic serving men who have sex with men in San Francisco, California, this study characterized key steps of the pre-exposure prophylaxis (PrEP) cascade and identified correlates of retention in care. In total, 344 patients were evaluated for PrEP. Three-fourths (78%) of those who sought PrEP services initiated PrEP. The overall cumulative incidence of discontinuing PrEP at 13 months was 38%. Men with a sexually transmitted infection (STI) were 44% less likely to be retained (adjusted hazard ratio [aHR] 0.56, 95% confidence interval [0.33-0.95]). Comprehensive retention efforts for men with STIs are crucial to optimize the benefits of PrEP.

Syndemic effect of mental illness and substance use on viral suppression among recently-incarcerated, HIV-infected individuals in the CARE+ Corrections study

Few studies on HIV-related syndemics of co-occurring and mutually reinforcing psychosocial conditions have assessed clinical outcomes in criminal justice (CJ)-involved populations. Baseline data from the CARE+ Corrections study were used to quantify co-occurring mental illness and substance use and examine syndemic effects on viral suppression among 106 CJ-involved HIV-infected individuals. Ninety-one (86%) reported a mental illness diagnosis, 30 (28%) reported hazardous alcohol use, and 61 (58%) were drug dependent. Eighteen (17%) experienced all three conditions. Drug dependence was clustered with mental illness (prevalence odds ratio [POR] 3.20, 95% CI 1.01-10.14) and hazardous alcohol use (POR 2.61, 95% CI 1.03-6.56). The association between syndemic score, representing the number of conditions reported by each individual, and viral suppression was not statistically significant, although 86% of participants with none of these conditions were virally suppressed, compared to 56% of those with all three (p = 0.56). Mental illness and substance use were concentrated in this sample, indicating a need for integrated care services.

Suicidal Ideation Persists Among Individuals Engaged in HIV Care in the Era of Antiretroviral Therapy

Little research has focused on suicidality in the era of successful antiretroviral therapy among those engaged in HIV care. We performed a study of 648 clinic patients who completed a psychological and behavioral annual assessment in 2012. Depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9), suicidal ideation was measured by the last item of the scale. Anxiety symptoms were measured using the Generalized Anxiety Disorder-7 questionnaire (GAD-7). HIV biomedical markers were abstracted from medical records. Suicidal ideation was reported among 13% (n = 81) of the sample. Individuals endorsing suicidality were more likely to have unsuppressed viral loads, moderate to severe anxiety symptoms and consider themselves to be homeless (p < 0.01 for all). After adjusting for confounders, homeless individuals and those endorsing moderate to severe anxiety symptoms had higher odds of reporting suicidality. Results suggest basic needs must be met to complement HIV management efforts. Furthermore, better understanding of how psychological distress symptoms are expressed and how to manage them may better inform barriers to HIV management.

Syndemic Indicators Predict Poor Medication Adherence and Increased Health Care Utilization for Urban HIV-Positive Men Who Have Sex with Men

Research on men who have sex with men (MSM) has uncovered psychosocial factors (syndemic indicators) that are associated additively with poor health. To test these relations in a sample of HIV-positive MSM, we enrolled 166 patients from two HIV clinics. We investigated relations between syndemic indicators and outcomes including medication nonadherence, condomless anal sex (CAS), and healthcare utilization. A large proportion of participants reported each syndemic indicator: polysubstance use 43%, suicide attempt 28%, childhood sexual abuse 39%, partner abuse 64%. Analyses confirmed an additive effect, whereby endorsing 1+ indicator was associated with increased odds of medication nonadherence and medical hospitalization.