The HIV-1 epidemic: low- to middle-income countries

Disengagement from Care Among People Co-Infected with HIV and HCV: A Scoping Review

Disengagement from care among people with HIV (PWH) and hepatitis C (HCV) increases the risks of adverse health outcomes and poses significant barriers to achieving global HIV and HCV elimination goals. In accordance with the Joanna Briggs Institute framework, a scoping review was conducted to synthesize and highlight existing gaps in the literature on (dis)engagement in care among PWH and HCV. We searched for original studies on (dis)engagement in care among PWH and HCV in high-income countries using eight electronic databases from inception to May 2023. Our search yielded 4462 non-duplicated records, which were scoped to 27 studies. Definitions of (dis)engagement in care were diverse, with considerable heterogeneity in how retention was operationalized and temporally measured. Studies identified predictors of (dis)engagement to be related to drug and substance use (n = 5 articles), clinical factors (n = 5), social and welfare (n = 4), and demographic characteristics (n = 2). When engagement in care was treated as an exposure, it was associated with HCV treatment initiation (n = 3), achieving sustained virological response (n = 2), and maintaining HIV viral suppression (n = 1). Interventions to improve care engagement among PWH and HCV were limited to five studies using cash incentives (n = 1) and individual case management (n = 4). (Dis)engagement in care is a dynamic process influenced by shifting priorities that may 'tip the balance' towards or away from regularly interacting with healthcare professionals. However, inconsistent definitions render cross-study comparisons and meta-analyses virtually impossible. Further research needs to establish a standardized definition to identify patients at high risk of disengagement and develop interventions that leverage the nested HIV/HCV care cascades to retain and recover patients lost from care.

Intimate Partner Violence and HIV Outcomes Among Women Living with HIV in Durban, South Africa

We examined the impact of past-year intimate partner violence (IPV) on HIV outcomes among women living with HIV (WLHIV) in Durban, South Africa. We assessed past-year IPV using the WHO Violence Against Women Questionnaire. We conducted logistic regression to assess associations between demographic variables and IPV at baseline, and between IPV at baseline and longitudinal HIV outcomes. Among 235 WLHIV, 17% reported past-year emotional, physical, or sexual IPV. At baseline, HIV-disclosure to partner was associated with 4.35-fold odds of past-year IPV (95% CI 1.17-16.10) after controlling for children, education, and harmful alcohol use. In the prospective analysis, IPV was associated with not achieving the co-primary outcome of retention in care and viral suppression in univariate (OR = 2.32, 95% CI 1.04-5.18), but not in the multivariate model. In the context of rapid treatment scale-up, the high burden of IPV among WLHIV needs to be prioritized, with an emphasis on disclosure support.

Interaction of social support and depressive symptoms on antiretroviral therapy adherence among people living with HIV in South Africa

Background

Depression consistently emerges as a significant predictor of poor antiretroviral therapy (ART) adherence among adult people living with human immunodeficiency virus (PLHIV). However, a gap exists regarding how social support and depressive symptoms can interact to influence ART adherence among adult PLHIV in South Africa (SA).

Aim

To investigate the interaction between social support and depressive symptoms on ART adherence among adult PLHIV.

Setting

A tertiary hospital in Durban, KwaZulu-Natal province of SA.

Methods

Utilising a quantitative cross-sectional research design along with time location sampling technique (TLS); the study recruited 201 adult patients enrolled in an ART programme.

Results

The results indicated that depressive symptoms were significantly associated with ART adherence with and without the interaction (B = -0.105; odds ratios [OR] 0.901; 95% confidence intervals [CI] = 0.827, 0.981; p = 0.016), while social support was not significantly associated with ART adherence (B = 0.007; OR 1.007; 95%CI = 0.989, 1.025; p = 0.475). However, a statistically significant interaction was found between social support and depressive symptoms (B = -0.006; OR 0.994; 95%CI = 0.989, 1.000; p = 0.037) on ART adherence.

Conclusion

Based on the results, depressive symptoms significantly influenced ART adherence. However, social support did not buffer the adverse effects of clinical depression associated with poor ART adherence.

Contribution

This study provides an evidence-based approach to address gaps in the mental health and social well-being of PLHIV in the context of ART adherence.

Impact of IL-6 and IL-6r variants on HIV-1 susceptibility and progression to AIDS: a case-control study in a Moroccan population

Interleukin-6 (IL-6), a pro-inflammatory cytokine, is an important regulator of the inflammatory immune response. We aimed to assess the association of common single nucleotide polymorphisms (SNPs) in IL-6 (rs1800795 G > C, rs1800797 A > G) and interleukin-6 receptor (IL-6R) (rs2228145 A > C) genes with HIV-1 infection, AIDS progression, and response to treatment. In this case-control study involving 199 individuals living with HIV-1 and 200 HIV-uninfected controls, we conducted genotyping of IL-6/IL-6R SNPs using TaqMan real-time PCR assays. Soluble IL-6 levels were measured using ELISA. No associations were found between the investigated SNPs and HIV infection. However, a significant association was noted between the C-G and G-A haplotypes and susceptibility to HIV-1 infection. Additionally, a significant association was revealed between HIV-1 RNA viral loads and IL-6 SNP G > C in the post-treatment HIV group. Interestingly, we observed a significant association between the investigated SNPs and protection against progression to AIDS, namely the IL-6 G > A SNP in its recessive model and the IL-6R A > C SNP in its codominant and dominant models. Nevertheless, we found no significant differences between IL-6 levels and the different genotypes and alleles of the IL-6 gene either before or after combination antiretroviral therapy. IL-6 promoter haplotypes are associated with susceptibility to HIV-1 infection. Furthermore, IL-6 A > G and IL-6R A > C polymorphisms have been associated with protection against AIDS progression. Interestingly, the IL-6 G > C SNP may affect the response to treatment in people living with HIV-1.

The Inverted U-Shaped Relationship Between Socio-Economic Status and Infections During the COVID-19 Pandemic

Although the World Health Organization has declared that the COVID-19 pandemic no longer qualifies as a global public health emergency, it still needs to explore the response of society to the COVID-19 pandemic. Socio-economic status (SES) was proven to be linearly associated with the COVID-19 pandemic, although this relationship may be more complex due to regional differences. In the study, we analyzed and revealed the effects and mechanisms of SES on infections among low, lower-middle, upper-middle and high SES group (LSG, LMSG, UMSG, and HSG, respectively). The results showed that the relationship between SES and infections was inverted U-shaped, especially in the first three phases. In Phase I, UMSG had the highest number of infections, with an average of 238.31/1M people (95%CI: 135.47-341.15/1M people). In Phases II and III, infections decreased insignificantly with increasing SES (r = -0.01, p = 0.92; r = -0.11, p = 0.22) and the highest number of infections were found in the LMSG. In Phase IV, SES was positively related to the number of infections (r = 0.54, p < 0.001). Furthermore, the nonlinear impact of multiple factors related to SES on the infections explains the complex relationships between SES and infections. SES affected infections mainly through medical resources, demographics and vaccination, and differed across the SES groups. Particularly, demographics could exert an impact on population mobility, subsequently influencing infections in LMSG, with an indirect effect of 0.01 (p < 0.05) in Phase II. This study argues for greater attention to countries with middle SES and the need for future targeted measures to cope with infectious diseases.

Pulmonary hypertension survival and hospitalisations in people living with HIV: a systematic review and meta-analysis

INTRODUCTION

People living with HIV (PLHIV) have a higher risk of developing pulmonary hypertension (PH) with subsequent poorer prognosis. This review aimed to determine the (1) survival outcomes and (2) proportion of emergency department (ED) visits and hospitalisations of PLHIV and PH.

METHODS

We conducted a systematic review and meta-analysis of observational studies reporting survival outcomes for PLHIV and PH. Electronic databases (Medline, EMBASE, PubMed, Web of Science, Global Index Medicus and Cochrane Library), trial registries and conference proceedings were searched until 22 July 2023. We pooled similar measures of effect, assessed apriori subgroups and used meta-regression to determine mortality and associated variables.

RESULTS

5248 studies were identified; 28 studies were included with a total of 5459 PLHIV and PH. The mean survival (95% CI) of PLHIV and PH was 37.4 months (29.9 to 44.8). Participants alive at 1, 2 and 3 years were 85.8% (74.1% to 95.0%), 75.2% (61.9% to 86.7%) and 61.9% (51.8% to 71.6%), respectively. ED visits and hospitalisation rates were 73.3% (32.5% to 99.9%) and 71.2% (42.4% to 94.2%), respectively. More severe disease, measured by echocardiogram, was associated with poorer prognosis (β -0.01, 95% CI -0.02 to 0.00, p=0.009). Survival was higher in high-income countries compared with lower-income countries (β 0.50, 95% CI 0.28 to 0.73, p<0.001) and in Europe compared with the America (β 0.56, 95% CI 0.37 to 0.75, p<0.001).

CONCLUSION

Our study confirms poor prognosis and high healthcare utilisation for PLHIV and PH. Prognosis is associated with country income level, geographic region and PH severity. This highlights the importance of screening in this population.

PROSPERO REGISTRATION NUMBER

CRD42023395023.

Uptake and Persistence on HIV Pre-Exposure Prophylaxis Among Female Sex Workers and Men Having Sex with Men in Kigali, Rwanda: A Retrospective Cross-Sectional Study Design

Background

Although HIV pre-exposure prophylaxis (PrEP) is known for its effectiveness in preventing HIV transmission; there is a global rise in HIV infection rates, particularly prominent in sub-Saharan Africa. This health concern is mostly evident among high-risk groups, namely Female Sex Workers (FSWs) and Men who have Sex with Men (MSMs), both of whom are more susceptible to sexually transmissible infections. This research examined the persistence, uptake, and associated predictors of PrEP utilization within the FSW and MSM populations.

Methods

A cross-sectional study design was conducted involving 4872 individuals from the FSW and MSM groups who were enrolled in a PrEP program across 10 health centers participating in a pilot initiative. The study population was subject to a year-long follow-up period commencing on March 1st, 2019. To evaluate the determinants of PrEP utilization within FSW and MSM groups, bivariate logistic analyses and multivariate logistic regression models were employed.

Results

The findings revealed that the occurrence of PrEP uptake was 45.55% (n=2219) among FSWs and 35.42% (n=17 participants) among MSM. Regarding PrEP persistence, MSM (88.24%, n=15 participants) presented higher PrEP proportion than FSWs (78.5%, n=1742 women). Our findings disclosed that individuals aged 25-34 years (aOR=0.82; 95% CI=0.72-0.93, p=0.002), 35-44 years (aOR=0.83; 95% CI=0.71-0.97, p=0.017), and 55 years and older (OR=0.14; 95% CI=0.04-0.48, p=0.002) exhibited lower likelihoods of having low PrEP uptake than those aged 15-19 years. Moreover, individuals residing with their families (aOR=0.71; 95% CI=0.58-0.87, p<0.001), living with roommates (aOR=0.7; 95% CI=0.5-0.97, p=0.032) displayed lower odds for experiencing low PrEP uptake than their counterparts living alone.

Conclusion

This study highlighted the low uptake of PrEP among participants when compared to previous studies. These results revealed significant influences of age and living conditions on PrEP usage.

COVID-19 infection in people living with HIV

BACKGROUND

Coronavirus disease 2019 (COVID-19) and human immunodeficiency virus (HIV) are intersecting pandemics, with implications for care at an individual and global scale.

SOURCES OF DATA

PubMed search with relevant articles and their references reviewed.

AREAS OF AGREEMENT

COVID-19 has changed the delivery of care to people living with HIV (PLWH). Vaccines are efficacious and safe for PLWH; patient care for symptomatic COVID-19 is similar to that of people without HIV.

AREAS OF CONTROVERSY

It remains unclear whether PLWH experience increased COVID-19-specific mortality. Treatments to reduce severity in early COVID-19 infection lack evidence in PLWH.

GROWING POINTS

The effects of the COVID-19 pandemic on HIV-related morbidity and mortality are yet to be seen. COVID-19 epidemiology among PLWH is complicated by changes to the severe acute respiratory syndrome coronavirus 2, population behaviours and vaccine availability.

AREAS TIMELY FOR DEVELOPING RESEARCH

Global trends in HIV-related morbidity and mortality should be monitored to appreciate the effects of the COVID-19 pandemic. The benefits of early antiviral and/or neutralizing monoclonal antibody (nMAb) treatment for PLWH and nMAb prophylaxis require investigation.

Comprehensive Overview of the Effects of Amaranthus and Abelmoschus esculentus on Markers of Oxidative Stress in Diabetes Mellitus

The use of medicinal plants in the management of diabetes mellitus (DM) is extensively reported. However, there is still very limited information on the role of these plants as markers of oxidative stress in DM. This current review evaluated the effect of Amaranthus spinosus, Amaranthus hybridus, and Abelmoschus esculentus on markers of oxidative stress in rodent models of DM. Current findings indicate that these plants have the potential to reduce prominent markers of oxidative stress, such as serum malondialdehyde and thiobarbituric acid-reactive substances, while increasing enzymes that act as antioxidants, such as superoxide dismutase, catalase, glutathione, and glutathione peroxidase. This may reduce reactive oxygen species and further ameliorate oxidative stress in DM. Although the potential benefits of these plants are acknowledged in rodent models, there is still a lack of evidence showing their efficacy against oxidative stress in diabetic patients. Therefore, we recommend future clinical studies in DM populations, particularly in Africa, to evaluate the potential effects of these plants. Such studies would contribute to enhancing our understanding of the significance of incorporating these plants into dietary practices for the prevention and management of DM.

Understanding clinical outcome measures reported in HIV pregnancy studies involving antiretroviral-naive and antiretroviral-experienced women

HIV infection is a clinically significant public health disease and contributes to increased risk of maternal and fetal morbidity and mortality. HIV pregnancy studies use outcome measures as metrics to show how people with HIV feel, function, or survive. These endpoints are crucial for tracking the evolution of HIV illness over time, assessing the effectiveness of antiretroviral therapy (ART), and comparing outcomes across studies. Although the need for ideal outcome measures is widely acknowledged, selecting acceptable outcome measures for these HIV pregnancy studies can be challenging. We discuss the many outcome measures that have been implemented over time to assess HIV in pregnancy studies, their benefits, and drawbacks. Finally, we offer suggestions for improving the reporting of outcome measures in HIV in pregnancy studies. Medical professionals can best care for pregnant women living with HIV receiving ART by having a thorough understanding of these outcome metrics.

Exploring relationships between HIV programme outcomes and the societal enabling environment: A structural equation modeling statistical analysis in 138 low- and middle-income countries

Countries worldwide have attempted to reduce the incidence of HIV and AIDS associated deaths with varying success, despite significant progress in antiretroviral treatment (ART) and condom use. A chief obstacles is that key populations affected face high levels of stigma, discrimination and exclusion, limiting the successful response to HIV. However, a gap exists in studies demonstrating the moderation effects of societal enablers on overall programme effectiveness and HIV outcomes using quantitative methods.Structural Equation Modeling was used for 138 countries covering a 12-year period to examine how the unfavorable societal enabling environment, including stigma and discrimination, unfavorable legal environment and lack of access to societal justice, gender inequality and other unfavorable development situations affect the effectiveness of HIV programmes and HIV outcomes, while controlling for potentially confounding variables. The results only showed statistical significance when all four societal enablers were modeled as a composite. The findings show the direct and indirect standardized effects of unfavorable societal enabling environments to AIDS-related mortality among PLHIV are statistically significant and positive (0.26 and 0.08, respectively). We hypothesize that this may be because an unfavorable societal enabling environment can negatively affect adherence to ART, quality of healthcare and health seeking behavior. Higher ranked societal environments increase the effect of ART coverage on AIDS related mortality by about 50% in absolute value, that is -0.61 as against -0.39 for lower ranked societal environments. However, mixed results were obtained on the impact of societal enablers on changes in HIV incidence through condom use. Results indicate that countries with better societal enabling environments had fewer estimated new HIV infections and fewer AIDS-related deaths. The failure to include societal enabling environments in HIV response undermines efforts to achieve the 2025 HIV targets, and the related 2030 Sustainable Development indicator to end AIDS, even if sufficient resources are mobilized.

Leveraging mHealth for the Treatment and Management of PLHIV

Objective

The objective of this systematic review was to analyze published literature from the last five years to assess facilitators and barriers to the adoption of mHealth as interventions to treat and manage HIV for PLHIV (people living with HIV). The primary outcomes were physical and mental conditions. The secondary outcomes were behavior based (substance use, care engagement, and healthy habits).

Methods

Four databases (PubMed, CINAHL, Web of Science, and ScienceDirect) were queried on 9/2/2022 for peer-reviewed studies on the treatment and management of PLHIV with mHealth as the intervention. The review was conducted in accordance with the Kruse Protocol and reported in accordance with PRISMA 2020.

Results

Five mHealth interventions were identified across 32 studies that resulted in improvements in physical health, mental health, care engagement, and behavior change. mHealth interventions offer both convenience and privacy, meet a digital preference, increase health knowledge, decrease healthcare utilization, and increase quality of life. Barriers are cost of technology and incentives, training of staff, security concerns, digital literacy gap, distribution of technology, technical issues, usability, and visual cues are not available over the phone.

Conclusion

mHealth offers interventions to improve physical health, mental health, care engagement, and behavior for PLHIV. There are many advantages to this intervention and very few barriers to its adoption. The barriers are strong, however, and should be addressed through policy. Further research should focus on specific apps for younger versus older PLHIV, based on preferences and the digital literacy gap.

Systematic Review of mHealth Interventions for Adolescent and Young Adult HIV Prevention and the Adolescent HIV Continuum of Care in Low to Middle Income Countries

Adolescents and young adults (AYA) in low to middle income countries (LMIC) have poorer outcomes along each step in the HIV continuum of prevention and care compared to younger children or older adults. The use of mHealth technology provides a potentially promising implementation strategy for interventions to remedy these disparities. We therefore conducted a systematic review of the English literature and conference proceedings from January 1, 2000 to April 1, 2021 evaluating mHealth interventions targeting AYA along each step of the HIV continuum of care in LMIC. We identified 27 mHealth interventions across the HIV continuum, with no interventions addressing transition from pediatric to adult care. The majority of studies were single arm, uncontrolled or underpowered, with few randomized trials resulting in mixed and inconclusive outcomes. mHealth interventions have potential to remedy disparities along the HIV continuum of care for AYA in LMIC but larger, powered randomized trials are needed.

HIV and suicide risk across adolescence and young adulthood: an examination of socio-demographic, contextual and psychosocial risk factors for attempted suicide in a longitudinal cohort of ageing adolescents affected by HIV living in the New York City Area

Introduction

As children become adolescents and young adults (AYA), their risk for attempting suicide increases dramatically, with chronic health conditions an important risk factor. This study examined correlates of suicidality across development in AYA living with perinatally acquired HIV (AYALPHIV) and those perinatally HIV‐exposed but uninfected (AYAPHEU).

Methods

Data come from an ongoing longitudinal New York City‐based study (N = 339) with AYALPHIV and AYAPHEU interviewed every 12–18 months from 2003 to 2019 (mean enrolment age = 12 years; current mean age = 27 years). The Diagnostic Interview Schedule for Children (adolescent or young adult version) assessed psychiatric disorders and first‐reported suicide attempt. Generalized estimating equations were used to examine associations between first‐reported suicide attempt and socio‐demographic, contextual and psychosocial correlates measured concurrently across six timepoints.

Results

At enrolment, 51% of participants were female, 72% heterosexual, 60% Black and 50% Latinx. Attempted suicide was significantly higher among AYALPHIV (27%, CI 21–33%) compared to AYAPHEU (16%, CI 10–22%), with an OR of 1.74 (CI 1.04–2.92) in a model adjusting for age. For AYALPHIV, anxiety (OR 2.66, CI 1.46–4.85), mood (OR 3.62, CI 1.49–8.81) and behaviour disorders (OR 5.05, CI 2.15–11.87) and past‐year arrest (OR 3.05, CI 1.26–7.4), negative life events (OR 1.27, CI 1.11–1.46), city stress (OR 2.28, CI 1.46–3.57), pregnancy (OR 2.28, CI 1.08–4.81) and HIV stigma (OR 2.46, CI 1.27–4.75) were associated with increased odds of attempted suicide, while identifying as heterosexual (OR 0.27, CI 0.14–0.52), higher personal (OR 0.45, CI 0.26–0.80) and family self‐concept (OR 0.36, CI 0.22–0.57) were protective. Interactions by HIV status and age were found: substance use was more strongly associated with attempted suicide among AYAPHEU than AYALPHIV, while negative life events and higher religiosity were more strongly associated with increased odds of attempted suicide among AYA ≥ 19 versus ≤ 18 years.

Conclusions

AYALPHIV compared to AYAPHEU faced unique risks for attempted suicide as they age into adulthood, with the highest risk among AYALPHIV experiencing HIV stigma or pregnancy and the highest risk among AYAPHEU with substance use. Assessing for suicide risk and correlates with attention to ageing can inform preventive interventions tailored to meet AYALPHIV and AYAPHEU needs.

Evaluation of HIV-Related Cardiomyopathy in HIV-Positive Patients in Bushehr, Iran

Objectives

In 2020, according to the UNAIDS (Joint United Nations Programme on HIV/AIDS), more than 37 million people lived with human immunodeficiency virus (HIV) infection worldwide. The disease is known to affect several organs, and one of the most affected organs is the heart. Cardiac diseases are highly prevalent among HIV-infected individuals, and recent findings suggest that this could be due to the damage caused by the virus. HIV patients are subject to advanced immunosuppression, which may lead to cardiac muscle damage and, in turn, cardiomyopathy. We aimed to study the incidence of HIV-related cardiomyopathy.

Methods

A pilot cross-sectional study was conducted to assess cardiomyopathy among 200 HIV patients who presented to the Heart Center, Bushehr, Iran. Patients’ files were used to determine the demographic data including age, gender, education, marital status, history of illicit drug use, unsafe/unprotected sexual contact, and whether the patient was a prisoner. Several laboratory data were also collected from these files. Physical examination of the cardiovascular system and echocardiography were also included as part of the evaluation.

Results

Although at least four out of five patients presented with some kind of cardiac damage, including valvular damage and pericardial effusion, none was diagnosed with cardiomyopathy. Valvular dysfunction was detected in 88.5% of the patients. Diastolic dysfunction was found in 7.7% of them. The mean ejection fraction was found to be 58%. In addition to cardiomyopathy, none of the patients developed systolic dysfunction, wall motion abnormality, intra-cardiac mass, or vegetation.

Conclusions

Cardiovascular complications are common among HIV-infected patients. Cardiomyopathy was not detected in our patients. In addition, the most common manifestations that were detected among our patients were valvular heart diseases and pericardial effusion.

The Prevalence of Epstein-Barr Virus in Plasma Cell Neoplasms is Higher in HIV-Positive Individuals

AIMS

Epstein-Barr virus (EBV) is causally associated with many hematolymphoid malignancies. This laboratory-based study aimed to establish the prevalence of EBV in plasma cell neoplasms in a large South African cohort and to determine whether there is any correlation between EBV-positivity and human immunodeficiency virus (HIV) status in patients with plasma cell neoplasms, including plasma cell myeloma and plasmacytoma (solitary plasmacytoma of bone and extraosseous plasmacytoma).

METHODS

This single-institution retrospective study included all patients with a histopathologic diagnosis of plasma cell neoplasm between 2003 and 2020. EBV-expression in the plasma cell neoplasms was assessed by EBV-encoded RNA (EBER) in situ hybridization (ISH) and correlated with HIV status. HIV status was determined by retrieving prior serologic results. Formalin-fixed paraffin-embedded tissue from HIV-unknown patients underwent HIV-1 p24 antibody testing.

RESULTS

Sixteen of 89 plasma cell neoplasms (18%) were EBV-positive. There was a significant correlation between EBV and HIV infection in plasma cell neoplasms, with 6/10 tumors from HIV positive patients showing EBV-positivity in tumor cells. The EBV-positive cohort was significantly younger than the EBV-negative group.

CONCLUSION

EBV-positivity in plasma cell neoplasms in this study is higher than previously reported. The significant occurrence of EBV in plasma cell neoplasms from HIV-positive patients suggests a co-carcinogenic relationship between the two viruses.

A multi-country cross-sectional study to assess predictors of daily versus on-demand oral pre-exposure prophylaxis in youth from South Africa, Uganda and Zimbabwe

INTRODUCTION

Sub-Saharan Africa (SSA) carries the burden of the HIV epidemic, especially among adolescents and young people (AYP). Little is known about pre-exposure prophylaxis (PrEP) uptake and preferences among AYP in SSA. We describe preferences for daily and on-demand PrEP among AYP in South Africa, Uganda and Zimbabwe.

METHODS

A cross-sectional survey was conducted in 2019 among 13- to 24-year olds, capturing socio-demographics, HIV risk behaviours and preferences for daily or on-demand PrEP. Logistic regression models were used to estimate odds ratios, adjusting for site, sex and age.

RESULTS AND DISCUSSION

A total of 1330 participants from Cape Town (n = 239), Johannesburg (n = 200), Entebbe (n = 491) and Chitungwiza (n = 400) were enrolled; 673 (51%) were male, and the median age was 19 years (interquartile range 17-22 years). Of 1287 participants expressing a preference, 60% indicated a preference for on-demand PrEP with differences by site (p < 0.001), sex (p < 0.001) and age group (p = 0.003). On-demand PrEP was most preferred in Entebbe (75%), among males (65%) versus females (54%) and in older participants (62% in 18- to 24-year-olds vs. 47% in 13- to 15-year-olds). After adjusting for site, sex and age group, preference for on-demand PrEP decreased as sex frequency over the past month increased (p-trend = 0.004) and varied with the number of partners in the last 6 months, being least popular among those reporting four or more partners (p = 0.02). Participants knowing further in advance that they were likely to have sex were more likely to prefer on-demand PrEP (p-trend = 0.02). Participants having a larger age gap with their most recent partner and participants whose last partner was a transactional sex partner or client were both less likely to prefer on-demand compared to daily PrEP (p = 0.05 and p = 0.09, respectively). Participants who knew their most recent partner was living with HIV or who did not know the HIV status of their most recent partner were less likely to prefer on-demand PrEP (p = 0.05).

CONCLUSIONS

Our data show that AYP in four SSA communities prefer on-demand over daily PrEP options, with differences seen by site, age and sex. PrEP demand creation needs to be reviewed, optimized and tailored to socio-demographic differences and designed in conjunction with AYP.

Mobile Health Technology Use and the Acceptability of an mHealth Platform for HIV Prevention Among Men Who Have Sex With Men in Malaysia: Cross-sectional Respondent-Driven Sampling Survey

BACKGROUND

The growth in mobile technology access, utilization, and services holds great promise in facilitating HIV prevention efforts through mobile health (mHealth) interventions in Malaysia. Despite these promising trends, there is a dearth of evidence on the use of mHealth platforms that addresses HIV prevention among Malaysian men who have sex with men.

OBJECTIVE

The goal of this study was to gain insight into (1) access and utilization of communication technology (eg, landline phone, internet, mobile phone), (2) acceptability of mHealth-based interventions for HIV prevention services, and (3) preferences regarding the format and frequency of mHealth interventions among Malaysian men who have sex with men.

METHODS

We conducted a cross-sectional survey with Malaysian men who have sex with men between July 2018 and March 2020. Participants were recruited using respondent-driven sampling in the Greater Kuala Lumpur region of Malaysia. We collected information on demographic characteristics, HIV risk-related behaviors, access to and the frequency of use of communication technology, and acceptability of using mHealth for HIV prevention using a self-administered questionnaire with a 5-point scale (1, never; 2, rarely; 3, sometimes; 4, often; 5, all the time).

RESULTS

A total of 376 men participated in the survey. Almost all respondents owned or had access to a smartphone with internet access (368/376, 97.9%) and accessed the internet daily (373/376, 99.2%), mainly on a smartphone (334/376, 88.8%). Participants on average used smartphones primarily for social networking (mean 4.5, SD 0.8), followed by sending or receiving emails (mean 4.0, SD 1.0), and searching for health-related information (mean 3.5, SD 0.9). There was high acceptance of the use of mHealth for HIV prevention (mean 4.1, SD 1.5), including for receiving HIV prevention information (345/376, 91.8%), receiving medication reminders (336/376, 89.4%), screening and monitoring sexual activity (306/376, 81.4%) or illicit drug use (281/376, 74.7%), and monitoring drug cravings (280/376, 74.5%). Participants overwhelmingly preferred a smartphone app over other modalities (eg, text, phone call, email) for engaging in mHealth HIV prevention tools. Preference for app notifications ranged from 186/336 (53.9%), for receiving HIV prevention information, to 212/336 (69.3%), for screening and monitoring sexual activity. Acceptance of mHealth was higher for those who were university graduates (P=.003), living in a relationship with a partner (P=.04), engaged in sexualized drug use (P=.01), and engaged in receptive anal sex (P=.006).

CONCLUSIONS

Findings from this study provide support for developing and deploying mHealth strategies for HIV prevention using a smartphone app in men who have sex with men-a key population with suboptimal engagement in HIV prevention and treatment.

Validation of Brief Condom Use Attitudes Scales for Spanish-Speaking People Who Use Crack Cocaine in El Salvador

People who use crack cocaine (PWUCC) are a population severely impacted by a concentrated epidemic of HIV. Behavioral interventions to prevent and treat HIV among PWUCC have been implemented around the world including in low- and middle-income countries which have been disproportionately affected by HIV. However, few studies have validated and assessed psychometric properties of measures on PWUCC, especially in transnational populations. Our sample was comprised of 1324 PWUCC, Spanish mono-lingual speakers, residing in the metropolitan area of San Salvador, El Salvador. Exploratory factor analysis and subsequent confirmatory factor analysis using statistical softwares SPSS and Amos were conducted on three abbreviated and translated condom use attitude measures (i.e., Condom Use Attitudes Scale-Spanish Short Form, Condom Use Social Norm-Spanish Short Form [CUSN-SSF], Condom Use Self-Efficacy-Spanish Short Form). Convergent validity was examined by computing bivariate correlations between the scales and condom use and sexually transmitted disease diagnosis. Results indicated that a two-factor, 8-item correlated model for the CUAS-SSF scale had an excellent fit and adequate reliability (α = .76). The confirmatory factor analysis for the 5-item CUSN-SSF scale indicated a satisfactory fit with 3 of 6 fit indices indicating adequate fit. Analysis of the two-factor 5-item CUSE-SSF scale indicated satisfactory fit and adequate reliability (α = .84). There were significant correlations between all measures and with self-reported condom use. Results indicate that these brief measures are reliable and valid and can be utilized to assess the effectiveness of HIV risk reduction interventions among Spanish-speaking PWUCC.

How the Term 'Self-Management' is Used in HIV Research in Low- and Middle-Income Countries: A Scoping Review

This scoping review assessed how the term 'self-management' (SM) is used in peer-reviewed literature describing HIV populations in low- and middle-income countries (LMIC). This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. OVID Medline, Embase, CAB Abstracts, and EBSCO CINAHL, Scopus, and Cochrane Library were searched up to September 2021 for articles with SM in titles, key words, or abstracts. Two team members independently screened the titles and abstracts, followed by the full-text. A data extraction tool assisted with collecting findings. A total of 103 articles were included. Since 2015, there has been a 74% increase in articles that use SM in relation to HIV in LMIC. Fifty-three articles used the term in the context of chronic disease management and described it as a complex process involving active participation from patients alongside providers. Many of the remaining 50 articles used SM as a strategy for handling one's care by oneself, with or without the help of community or family members. This demonstrates the varied conceptualizations and uses of the term in LMIC, with implications for the management of HIV in these settings. Future research should examine the applicability of SM frameworks developed in high-income settings for LMIC.

Exploring Preventive Healthcare in a High-Risk Vulnerable Population

This study describes preventive care behaviors and explores opportunities to deliver preventive sexual healthcare to a high-risk vulnerable population. Data from the National HIV Behavioral Surveillance (NHBS) system high-risk heterosexuals (HET) cycle (2019) in Houston, Texas, was used to describe preventive care utilization and assess the relationship between healthcare utilization and sociodemographic characteristics. More than 47% reported having no usual source of healthcare, and 94.6% reported receiving no non-HIV STI testing in the past 12 months. Additionally, many sociodemographic factors were associated with healthcare utilization and having a usual source of healthcare. Future efforts should be targeted at increasing preventive healthcare utilization among high-risk vulnerable populations as well as implementing more preventive sexual healthcare services in the community health centers where these populations most frequently encounter healthcare.

Assessment of NKG2C copy number variation in HIV-1 infection susceptibility, and considerations about the potential role of lacking receptors and virus infection

Human Immunodeficiency Virus (HIV) infection dynamics is strongly influenced by the host genetic background. NKG2C is an activating receptor expressed mainly on Natural Killer (NK) cells, and a polymorphism of copy number variation in the gene coding for this molecule has been pointed as a potential factor involved in HIV infection susceptibility. We evaluated the impact of the NKG2C deletion on HIV-1 susceptibility, with or without HBV/HCV co-infection, in a total of 780 individuals, including 385 HIV-infected patients and 395 healthy blood donors. NKG2C deletion genotyping was performed by standard PCR. To our knowledge, this is the first study to access the impact of complete NKG2C deletion among HIV-infected Brazilian individuals. The frequency of NKG2C deletion (range: 19–22%) was similar in cases and controls. No association of NKG2C deletion with HIV-1 susceptibility or influence on clinical features, HBV or HCV co-infection was observed in the evaluated population. Our findings suggest that NKG2C deletion, and the consequent absence of this receptor expression, does not directly impact HIV susceptibility, HBV/HCV-co-infection in the studied population, suggesting that other signaling pathways might be triggered and perform similar functions in cell activity in the absence of this specific receptor, preventing the development of disadvantageous phenotypes. Larger cohorts and studies involving protein expression are necessary to confirm our findings.

Antiretroviral (ARV) Drug Resistance and HIV-1 Subtypes among Injecting Drug Users in the Coastal Region of Kenya

HIV-1 genetic diversity results into the development of widespread drug-resistant mutations (DRMs) for the first-line retroviral therapy. Nevertheless, few studies have investigated the relationship between DRMs and HIV-1 subtypes among HIV-positive injecting drug users (IDUs). This study therefore determined the association between HIV-1 genotypes and DRMs among the 200 IDUs. Stanford HIV Drug Resistance Database was used to interpret DRMs. The five HIV-1 genotypes circulating among the IDUs were A₁ (25 (53.2%)), A₂ (2 (4.3%)), B (2 (4.3%)), C (9 (19.1%)), and D (9 (19.1%)). The proportions of DRMs were A₁ (12 (52.2%)), A₂ (1 (4.3%)), B (0 (0.0%)), C (5 (21.7%)), and D (5 (21.7%)). Due to the large proportion of drug resistance across all HIV-1 subtypes, surveillance and behavioral studies need to be explored as IDUs may be spreading the drug resistance to the general population. In addition, further characterization of DRMs including all the relevant clinical parameters among the larger population of IDUs is critical for effective drug resistance surveillance.

Effectiveness of conditional cash transfers for uptake and retention in HIV prevention of mother-to-child transmission services in low- and middle-income countries: a systematic review protocol

OBJECTIVE

This systematic review will identify and synthesize evidence on the effectiveness of conditional cash transfers for the uptake and retention in prevention of mother-to-child transmission services in pregnant and/or breastfeeding women with HIV infection in low- and middle-income countries.

INTRODUCTION

Regardless of the effectiveness of prevention of mother-to-child transmission services, uptake and retention in such services remains poor in low- and middle-income countries. This review intends to evaluate the effectiveness of conditional cash transfers in improving uptake and retention in such services for pregnant and/or breastfeeding women with HIV infection.

INCLUSION CRITERIA

This review will consider studies that evaluate the impact of conditional cash transfers on uptake and retention in prevention of mother-to-child transmission services in pregnant and/or breastfeeding women with HIV. Studies will compare conditional cash transfers with no intervention or other interventions. Only studies carried out in low- and middle-income countries will be eligible for inclusion.

METHODS

Eight databases will be searched. Publication status will not be considered as a criterion for inclusion. Studies published in English since 2000 will be considered, because prevention of mother-to-child transmission services were first introduced in that year. Following the search, two independent reviewers will screen titles and abstracts against the inclusion criteria, critically appraise eligible studies for methodological quality using JBI critical appraisal tools, and extract data from included studies using a standardized data extraction tool. Where possible, quantitative data will be pooled using statistical meta-analysis.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021236729.

A Meta-Analytic Review of the Effect of Antiretroviral Therapy on Neurocognitive Outcomes in Adults Living with HIV-1 in Low-and Middle-Income Countries

HIV-associated neurocognitive impairment remains a challenge even in the era of antiretroviral therapy (ART). Over 90% of people living with HIV are in low- and middle-income countries. Hence, it is not surprising that such countries bear a considerable burden of comorbidities like HIV-associated neurocognitive impairment despite an overall increase in life expectancy. The literature suggests differences in patient characteristics, clinical profile, prevalent HIV subtypes, treatment choices, pharmacogenetics, and socioeconomic factors between low- and middle-income countries compared with high-income countries. Therefore, we aimed to evaluate the effect of ART on neurocognitive outcomes in low- and middle-income countries. A comprehensive search of five databases (PubMed, CINAHL, CENTRAL, PsychInfo, Google scholar) for studies published between 1996 to 2020 was performed to identify studies that reported neurocognitive outcomes in ART-treated and ART naïve HIV positive individuals. Two independent reviewers conducted study screening, data extraction, and evaluation of the risk of bias. Pooled effect size estimates (Hedges' g) and 95% CI were computed using random-effects models. Sensitivity analysis, subgroup analysis, meta-regression, and evaluation of publication bias were also conducted. Forty studies (24 cross-sectional, 13 longitudinal studies, and two randomized controlled trials) contributed to a series of meta-analyses. We found significant small to moderate effects of antiretroviral therapy for global cognition (Hedges' g observed = 0.30; 95% CI: 0.15, 0.44; k = 25; p = 0.0003; I² = 92.1%; tau = 0.32; Q = 305.1), executive function (Hedges' g = 0.24, 95%CI: 0.02,0.46; p-0.04; k = 8; I² = 37.5%; tau = 0.23; Q = 11.2), and speed of information processing (Hedges' g = 0.25, 95% CI: 0.05, 0.45; k = 9; p = 0.02; I² = 86.4%; tau = 0.21; Q = 58.9). We found no significant ART effect on attention-working memory, learning and memory, motor function, and verbal fluency. No significant effect was seen with the duration of therapy, efavirenz use, and Central Penetrating Effectiveness (CPE) of antiretroviral therapy. Subgroup analyses identified study design (between-group and within-group; cross-sectional and longitudinal) and normative scores as significant sources of heterogeneity. Meta-regression analysis indicated that nadir CD4 modified the magnitude of ART's effect on cognitive outcomes. Age, gender, and country income-group were not significant moderators. Our findings provide systematic evidence that antiretroviral therapy improves neurocognitive outcomes in the domains of global cognition, executive function and speed of information processing, of people living with HIV in low- and middle-income countries, especially those with advanced immunosuppression. However, these findings are not definitive as they are limited by the probability of publication bias, high heterogeneity, and exclusion of significant confounders. Prospero registration number: CRD42020203791.

Sexual Behaviors and Factors Associated with Condomless Sexual Practice in Colombian Men Who Have Sex with Men at High Risk of HIV Transmission

Men who have sex with men (MSM) have a disproportionate burden of HIV infection worldwide. In Colombia, the prevalence of HIV in MSM is ~ 43 times higher than in the general population (17% vs. 0.4%). This study determined the sexual behaviors, HIV serostatus, and associated factors with condomless sexual practice with both regular and casual partners in 92 MSM from Medellín, Colombia. The subjects were recruited through a community-based approach, and the data were collected by a structured survey and in-depth interviews. Participants were classified into three groups according to the number of sexual partners in the last three months, to compare the sociodemographic conditions and sexual behaviors. Univariate analysis was described by absolute and relative frequencies; bivariate analysis and multivariate logistic regression were used to compare the groups and to explore the associated factors with condomless sexual practice. The overall HIV estimated prevalence was 4.3%, while the estimated prevalence for MSM with > 10 sexual partners in the last three months was 14.8%. This last group showed higher average age, higher percentage of subjects who have had sex with people living with HIV, and increased frequency of previous sexually transmitted infections. Having condomless sex with casual partners was associated with the number of sexual partners in the last three months. This study demonstrates that Colombian MSM continue to have a high risk of HIV infection/transmission and reinforce the need to implement adequate prevention programs, PrEP and guarantee access to treatment for people living with HIV.

Lung Ultrasound Effectively Detects HIV-Associated Interstitial Pulmonary Disease

Objectives To prospectively evaluate lung ultrasound in comparison with radiography and computed tomography (CT) for detecting HIV-related lung diseases. Methods Ultrasound examinations in HIV-positive patients were evaluated by three raters; available conventional imaging was evaluated by another rater. Results were compared with each other and the definite diagnosis. Interrater reliability was calculated for each finding. Results Eighty HIV-positive patients received lung ultrasound examinations; 74 received conventional imaging. The overall sensitivity was 97.5% for CT, 90.7% for ultrasound and 78.1% for radiography. The most common diagnoses were Pneumocystis jirovecii pneumonia (21 cases) and bacterial pneumonia (17 cases). The most frequent and sensitive ultrasonographic findings were interstitial abnormalities indicated by B-lines, independent of the aetiology. Interrater reliability was high for interstitial abnormalities (ICC=0.82). The interrater reliability for consolidations and effusion increased during the study (r=0.88 and r=0.37, respectively). Conclusions Ultrasound is a fast, reliable and sensitive point-of-care tool, particularly in detecting interstitial lung disease, which is common in HIV-associated illness. It does not effectively discriminate between different aetiologies. A longer learning period might be required to reliably identify consolidations and effusions.

The Emerging of CRF01_AE: A Clinical Story and Future HIV/AIDS Situation in Thailand

The HIV epidemic in Thailand in the 1980's compromised the country's socio-economic development. The epidemic first became evident in the community of men with male sexual partners (MSM), and subsequently spread to intravenous drug users (IVDU), female commercial sex workers (CSW) and their male clients, and, ultimately, to their partners and children. The HIV epidemic has devastated the country's working-age population. The extensive negative impact and social stigma associated with the disease do not only have an impact on the victims of HIV but also on their descendants and relatives. An epicenter of the HIV epidemic has been in the northern provinces of Thailand. An HIV-1 subtype CRF01_AE, a complex chimeric virus composed of both A and E subtypes, is prevalent in Northern Thailand. The virus has quickly become a predominant viral strain circulating in Thailand, other neighboring Southeast Asian countries, and China as well as some other countries throughout the world. The epidemiology, evolution, and biology of CRF01_AE offer a unique model for further scientific investigations which would advance the knowledge of and curative strategies against HIV. In addition, Thailand has developed suitable national guidelines on HIV/AIDS treatment and prevention in order to control the epidemic. Effective antiretroviral drugs are, therefore, able to be made available to those who live with HIV. The national surveillance system has also been effective. The great efforts and resources which Thailand has dedicated to the fight against the epidemic have eventually paid off. In 2010, a plan was proposed to eliminate mother-to-child HIV transmission and Thailand has become the first country to be effective in this objective. Thailand therefore has become recognized as being the global leader in HIV prevention and treatment. The experience which Thailand has gained from the past and the current research and management strategies of the HIV epidemic has prepared the country for emerging strains of HIV-1 in the future.

The effectiveness of peer-support for people living with HIV: A systematic review and meta-analysis

BACKGROUND

The practice of involving people living with HIV in the development and provision of healthcare has gained increasing traction. Peer-support for people living with HIV is assistance and encouragement by an individual considered equal, in taking an active role in self-management of their chronic health condition. The objective of this systematic review was to assess the effects of peer-support for people living with HIV.

METHODS

We conducted a systematic review in accordance with international guidelines. Following systematic searches of eight databases until May 2020, two reviewers performed independent screening of studies according to preset inclusion criteria. We conducted risk of bias assessments and meta-analyses of the available evidence in randomised controlled trials (RCTs). The certainty of the evidence for each primary outcome was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

After screening 219 full texts we included 20 RCTs comprising 7605 participants at baseline from nine different countries. The studies generally had low risk of bias. Main outcomes with high certainty of evidence showed modest, but superior retention in care (Risk Ratio [RR] 1.07; Confidence Interval [CI] 95% 1.02-1.12 at 12 months follow-up), antiretroviral therapy (ART) adherence (RR 1.06; CI 95% 1.01-1.10 at 3 months follow-up), and viral suppression (Odds Ratio up to 6.24; CI 95% 1.28-30.5 at 6 months follow-up) for peer-support participants. The results showed that the current state of evidence for most other main outcomes (ART initiation, CD4 cell count, quality of life, mental health) was promising, but too uncertain for firm conclusions.

CONCLUSIONS

Overall, peer-support with routine medical care is superior to routine clinic follow-up in improving outcomes for people living with HIV. It is a feasible and effective approach for linking and retaining people living with HIV to HIV care, which can help shoulder existing services.

TRIAL REGISTRATION

CRD42020173433.

Investigating the impact of HIV on patients with first episode psychosis: a study protocol for a longitudinal cohort study

INTRODUCTION

South Africa (SA) has a high HIV prevalence and limited mental healthcare resources. Neuropsychiatric complications such as psychosis onset in people living with HIV (PLWHIV) remains poorly understood. The study aims to compare the socio-demographic, clinical, substance use, cognitive and trauma profile of PLWHIV presenting with first episode psychosis (FEP) to those with the condition but without HIV.

METHODS AND ANALYSIS

This study will compare presentation, course, and outcome of a cohort of PLWHIV and FEP with a control group recruited over a 3-year period. We will prospectively test the hypothesis that the 2 groups are socio-demographically, clinically and cognitively distinct at illness presentation, with higher trauma burden and poorer outcomes in those with the dual burden of HIV and FEP. FEP participants, confirmed by a structured neuropsychiatric interview, will have their socio-demographic, psychosis, mood, motor, trauma and substance use variables assessed. A neuropsychological battery will be completed to assess cognition, while quality of life, psychotic symptoms and HIV markers will be measured at 3, 6 and 12 months.

ETHICS AND DISSEMINATION

The study protocol has been reviewed and ethics approval obtained from the Biomedical Research Ethics Committee (BC 571/18) of the University of KwaZulu-Natal. The results from this investigation will be actively disseminated through peer-reviewed journal publications and conference presentations.

Subtype-specific differences in Gag-protease replication capacity of HIV-1 isolates from East and West Africa

BACKGROUND

The HIV-1 epidemic in sub-Saharan Africa is heterogeneous with diverse unevenly distributed subtypes and regional differences in prevalence. Subtype-specific differences in disease progression rate and transmission efficiency have been reported, but the underlying biological mechanisms have not been fully characterized. Here, we tested the hypothesis that the subtypes prevalent in the East Africa, where adult prevalence rate is higher, have lower viral replication capacity (VRC) than their West African counterparts where adult prevalence rates are lower.

RESULTS

Gag-protease sequencing was performed on 213 and 160 antiretroviral-naïve chronically infected participants from West and East Africa respectively and bioinformatic tools were used to infer subtypes and recombination patterns. VRC of patient-derived gag-protease chimeric viruses from West (n = 178) and East (n = 114) Africa were determined using a green fluorescent protein reporter-based cell assay. Subtype and regional differences in VRC and amino acid variants impacting VRC were identified by statistical methods. CRF02_AG (65%, n = 139), other recombinants (14%, n = 30) and pure subtypes (21%, n = 44) were identified in West Africa. Subtypes A1 (64%, n = 103), D (22%, n = 35), or recombinants (14%, n = 22) were identified in East Africa. Viruses from West Africa had significantly higher VRC compared to those from East Africa (p < 0.0001), with subtype-specific differences found among strains within West and East Africa (p < 0.0001). Recombination patterns showed a preference for subtypes D, G or J rather than subtype A in the p6 region of gag, with evidence that subtype-specific differences in this region impact VRC. Furthermore, the Gag A83V polymorphism was associated with reduced VRC in CRF02_AG. HLA-A*23:01 (p = 0.0014) and HLA-C*07:01 (p = 0.002) were associated with lower VRC in subtype A infected individuals from East Africa.

CONCLUSIONS

Although prevalent viruses from West Africa displayed higher VRC than those from East Africa consistent with the hypothesis that lower VRC is associated with higher population prevalence, the predominant CRF02_AG strain in West Africa displayed higher VRC than other prevalent strains suggesting that VRC alone does not explain population prevalence. The study identified viral and host genetic determinants of virus replication capacity for HIV-1 CRF02_AG and subtype A respectively, which may have relevance for vaccine strategies.

Preference for daily versus on-demand pre-exposure prophylaxis for HIV and correlates among men who have sex with men: the China Real-world Oral PrEP Demonstration study

INTRODUCTION

This study explores the preference for daily versus on-demand pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in developing countries when both regimens are available.

METHODS

From 11 December 2018 to 19 October 2019, we recruited MSM for an open-label real-world PrEP demonstration study in four major cities in China. Subjects selected their preferred PrEP (oral tenofovir/emtricitabine) regimen (daily vs. on-demand) at recruitment and underwent on-site screening before initiation of PrEP. We used logistic regression to assess preference for daily PrEP and correlates.

RESULTS

Of 1933 recruited MSM, the median age was 29 years, 7.6% was currently married to or living with a female; the median number of male sexual partners was four and 6.1% had used post-exposure prophylaxis (PEP) in the previous six months. HIV infection risk was subjectively determined as very high (>75%) in 7.0% of subjects, high (50% to 75%) in 13.3%, moderate (25% to 49%) in 31.5% and low or none (0% to 24%) in 48.1%. On average, participants preferred on-demand PrEP over daily PrEP (1104 (57.1%) versus 829 (42.9%)) at recruitment. In multivariable analysis, currently being married to or living with a female was associated with 14.6 percentage points lower preference for daily PrEP (marginal effect = -0.146 [95% CI: -0.230, -0.062], p = 0.001); whereas the number of male sexual partners (marginal effect = 0.003 [95% CI: 0.000, 0.005], p = 0.034) and a subjective assessment of being very high risk of HIV infection (vs. low and no risk, marginal effect size = 0.105 [95% CI: 0.012, 0.198], p = 0.027) were associated with increased preference for daily versus on-demand PrEP. Among the 1933 potential participants, 721 (37.3%) did not attend the subsequent on-site screening. Lower-income, lower education level, lower subjective expected risk of HIV infection risk and younger age positively correlated with the absence of on-site screening.

CONCLUSIONS

MSM in China prefer both daily and on-demand PrEP when both regimens are provided free. Social structural factors and subjective risk of HIV infection have significant impacts on PrEP preference and use. The upcoming national PrEP guideline should consider incorporating both regimens and the correlates to help implement PrEP in China.

Aging with HIV in Latin America and the Caribbean: a Systematic Review

PURPOSE OF REVIEW

With the establishment of antiretroviral treatment (ART) programs in low- and middle-income countries, people with HIV (PWH) in Latin America and the Caribbean (LAC) are living longer, subsequently developing chronic non-communicable diseases (NCDs). Few studies focus on the impact of aging among older LAC PWH. This systematic review aims to fill this information gap and understand the burden of aging with HIV in LAC. We identified peer-reviewed literature published in English, Spanish, or Portuguese from several databases to assess currently available evidence on the burden of aging with HIV in LAC and selected six common NCDs found in older PWH (cardiovascular disease [CVD], bone and musculoskeletal [MSK] disorders, cancer, renal disease, neurocognitive impairment [NCI], and depression).

RECENT FINDINGS

Of the 5942 publications reviewed, only 53 articles were found with populations 40 years and older or age-related findings (27 CVD, 13 NCI or depression, 6 MSK disorders, 4 renal disease, 3 cancer). Most (79%) publications were from Brazil with few longitudinal studies on aging with HIV. Prevalence of illnesses such as CVD, NCI, depression, or osteoporosis varied widely depending on the screening instrument utilized and geographic population surveyed. Age was a significant predictor of comorbidity in nearly all studies. Our results demonstrate the need for longitudinal studies and validated screening instruments appropriate for use among PWH in LAC. Understanding the mechanisms behind aging in HIV and the roles of sociocultural factors and genetic diversity specific to LAC is needed to appropriately manage chronic comorbidities as PWH age.

Depression and anxiety as barriers to art initiation, retention in care, and treatment outcomes in KwaZulu-Natal, South Africa

BACKGROUND

Since mental health may influence HIV care among people living with HIV (PLHIV), we sought to evaluate the impact of anxiety and depression on ART initiation and HIV-related outcomes.

METHODS

We conducted a prospective cohort study of PLHIV in the Umlazi Township of KwaZulu-Natal, South Africa. We measured depression using the Patient Health Questionnaire (PHQ-9) and anxiety using the Generalized Anxiety Disorder (GAD-7) scale, both of which have been validated in sub-Saharan Africa, among all patients prior to receiving a positive HIV test. We then followed those who tested HIV+ for 12 months to determine their time to ART initiation, missing clinic visits or refills, retention in care, hospitalization, and death. We used logistic regression models, adjusted for socio-demographic characteristics such as age and sex, to examine the effects of baseline measures of depression and anxiety on ART initiation and HIV treatment outcomes.

FINDINGS

Among 2,319 adult PLHIV, mean age was 33 years (SD=9.3 years), 57% were female, and baseline median CD4 count was 317 cells/mm³ (IQR=175-491 cells/mm³). In univariate analyses, depression was associated with slower rates of ART initiation. In adjusted models, PLHIV with depression had lower odds of initiating ART within 90 days of HIV testing (aOR=0.60, 95% CI=0.46, 0.79, p<0.01), and lower odds of being retained in care (aOR=0.77, 95% CI=0.60, 0.99, p = 0.04). By the end of the 12-month study period, odds of ART initiation among PLHIV with depression were higher than the first 90 days but still significantly lower compared to those without depression (aOR=0.72, 95% CI=0.52, 0.99, p = 0.04). Among PLHIV who initiated ART, depression was associated with a lower odds of missing clinic visits (aOR=0.54, 95% CI= 0.40, 0.73, p<0.01). Anxiety was strongly correlated with depression (r = 0.77, p<0.01) and had similar effects on HIV-related outcomes.

INTERPRETATIONS

The presence of depression is a significant barrier to ART initiation and retention in care among adult PLHIV in South Africa. Mental health screenings around the time of HIV testing may help improve linkage and HIV-related outcomes.

FUNDING

This work was supported by the Infectious Disease Society of America Education & Research Foundation and National Foundation for Infectious Diseases (PKD); Massachusetts General Hospital Executive Committee on Research (PKD); the Harvard University Center for AIDS Research [AI060354] (PKD); and the National Institute of Allergy and Infectious Diseases [AI108293, AI143351] (PKD). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or other funding agencies.

Health beliefs and barriers related to HIV prevention and screening among students of the University of Vlora: a cross-sectional study

Background

Previous researchers have found that young university students can have a high level of knowledge about HIV/AIDS infection, but they are still not utilizing the existing HIV prevention methods. As a result there is a need to determine which factors and barriers influence the use of existing HIV screening and prevention methods among students of the University of Vlora in Albania.

Methods

This was a cross-sectional study conducted among university students in the district of Vlora, Albania from April to June 2018. Stratified, multi-stage sampling technique was used to select randomly study subjects. A structured, self-administered questionnaire was used for data collection. Bivariate and multivariate logistic regression analysis was employed to reflect the relationship between variables.

Results

The mean age of the participants (710) was 20.85 ± 2.1 years. 38% of them believe that chances of getting HIV would not stop them to have sexual intercourse with more than one partner, 69% report that using a condom seems like an insult to their partner. 78% of the students with sexual experience didn’t used Voluntary Counseling and Testing services. The students from the rural area (AOR = 0.50, 95% CI [0.30–0.82]) and those of first academic year (AOR second/first year =2.31, 95% CI [1.33–3.99], AOR third/first year =1.18, 95% CI [0.65–2.13]) were less likely to use HIV service.

Conclusions

The findings reveal that health beliefs and barriers are good predictors of the preventive behaviours toward HIV infection. The survey has provided evidence to suggest that creating awareness about HIV prevention among student community, especially those from non-health sciences and rural areas could contribute to increased uptake of the VCT services, the condom use and to reduce the identified stigmatizing barriers.

Trends and Racial/Ethnic Disparities in the Rates of Pre-eclampsia by HIV Status in the US

BACKGROUND

Preeclampsia and HIV account for a significant proportion of the global burden of disease and pose severe maternal-fetal risks. There is a dearth of literature regarding racial/ethnic disparities in preeclampsia associated with HIV/AIDS in the US.

METHODS

We retrospectively analyzed data from the National Inpatient Sample (NIS) database from 2002 to 2015 on a cohort of hospitalized pregnant women with or without preeclampsia and HIV. Joinpoint regression models were used to identify trends in the rates of preeclampsia among pregnant women living with or without HIV, stratified by race/ethnicity over the study period. We also assessed the association between preeclampsia and various socio-demographic factors.

RESULTS

We analyzed over 60 million pregnancy-related hospitalizations, of which 3665 had diagnoses of preeclampsia and HIV, corresponding to a rate of 0.61 per 10,000. There was an increasing trend in the diagnosis of preeclampsia among hospitalized, pregnant women without HIV across each racial/ethnic category. The highest prevalence of preeclampsia was among non-Hispanic (NH) Blacks, regardless of HIV status.

CONCLUSION

The increase in rates of pre-eclampsia between 2002 and 2015 was mostly noted among pregnant women without HIV. Regardless of HIV status, NH-Blacks experienced the highest discharge prevalence of preeclampsia.

Combating HIV stigma in low- and middle-income healthcare settings: a scoping review

INTRODUCTION

Nearly 40 years into the HIV epidemic, the persistence of HIV stigma is a matter of grave urgency. Discrimination (i.e. enacted stigma) in healthcare settings is particularly problematic as it deprives people of critical healthcare services while also discouraging preventive care seeking by confirming fears of anticipated stigma. We review existing research on the effectiveness of stigma interventions in healthcare settings of low- and middle-income countries (LMIC), where stigma control efforts are often further complicated by heavy HIV burdens, less developed healthcare systems, and the layering of HIV stigma with discrimination towards other marginalized identities. This review describes progress in this field to date and identifies research gaps to guide future directions for research.

METHODS

We conducted a scoping review of HIV reduction interventions in LMIC healthcare settings using Embase, Ovid MEDLINE, PsycINFO and Scopus (through March 5, 2020). Information regarding study design, stigma measurement techniques, intervention features and study findings were extracted. We also assessed methodological rigor using the Joanna Briggs Institute checklist for systematic reviews.

RESULTS AND DISCUSSION

Our search identified 8766 studies, of which 19 were included in the final analysis. All but one study reported reductions in stigma following the intervention. The studies demonstrated broad regional distribution across LMIC and many employed designs that made use of a control condition. However, these strengths masked key shortcomings including a dearth of research from the lowest income category of LMIC and a lack of interventions to address institutional or structural determinants of stigma. Lastly, despite the fact that most stigma measures were based on existing instruments, only three studies described steps taken to validate or adapt the stigma measures to local settings.

CONCLUSIONS

Combating healthcare stigma in LMIC demands interventions that can simultaneously address resource constraints, high HIV burden and more severe stigma. Our findings suggest that this will require more objective, reliable and culturally adaptable stigma measures to facilitate meaningful programme evaluation and comparison across studies. All but one study concluded that their interventions were effective in reducing healthcare stigma. Though encouraging, the fact that most studies measured impact using self-reported measures suggests that social desirability may bias results upwards. Homogeneity of study results also hindered our ability to draw substantive conclusions about potential best practices to guide the design of future stigma reduction programmes.

Global Research on Quality of Life of Patients with HIV/AIDS: Is It Socio-Culturally Addressed? (GAPRESEARCH)

Quality of life (QOL) has been considered as an important outcome indicator in holistic care for HIV-infected people, especially as HIV/AIDS transforms from a fatal illness to a chronic condition. This study aimed to identify trends and emerging topics among research concerning the QOL of people living with HIV/AIDS (PLWHA). The analyzed data were English papers published from 1996 to 2017, searched and extracted from the Web of Science Core Collection. Collaborations between countries and the correlation between the keywords were visualized by VOSviewer while the abstracts’ content was analyzed using exploratory factor analysis and Jaccard’s’ similarity index. There has been an increase in both the number of publications and citations. The United Nations of America leads in terms of paper volume. The cross-nation collaborations are mainly regional. Despite a rather comprehensive coverage of topics relating to QOL in PLWHA, there has evidently been a lack of studies focusing on socio-cultural factors and their impacts on the QOL of those who are HIV-infected. Further studies should consider investigating the role of socio-cultural factors, especially where long-term treatment is involved. Policy-level decisions are recommended to be made based on the consideration of cultural factors, while collaborations between developed and developing nations, in particular in HIV/AIDS-ridden countries, are strongly recommended.

Household-focused interventions to enhance the treatment and management of HIV in low- and middle-income countries: a scoping review

Background

HIV remains a major public health challenge in many low- and middle-income countries (LMICs). The initiation of a greater number of people living with HIV (PLHIV) onto antiretroviral therapy (ART) following the World Health Organization’s ‘universal test and treat’ recommendation has the potential to overstretch already challenged health systems in LMICs. While various mainstream and community-based care models have been implemented to improve the treatment outcomes of PLHIV, little effort has been made to harness the potential of the families or households of PLHIV to enhance their treatment outcomes. To this end, we sought to explore the characteristics and effectiveness of household-focused interventions in LMICs on the management of HIV as measured by levels of adherence, viral suppression and different dimensions of HIV competence. Additionally, we sought to explore the mechanisms of change to explain how the interventions achieved the expected outcomes.

Methods

We systematically reviewed the literature published from 2003 to 2018, obtained from six electronic databases. We thematically analysed the 11 selected articles guided by the population, intervention, comparison and outcome (PICO) framework. Following the generative causality logic, whereby mechanisms are postulated to mediate an intervention and the outcomes, we applied a mechanism-based inferential reasoning, retroduction, to identify the mechanisms underlying the interventions to understand how these interventions are expected to work.

Results

The identified HIV-related interventions with a household focus were multi-component and multi-dimensional, incorporating aspects of information sharing on HIV; improving communication; stimulating social support and promoting mental health. Most of the interventions sought to empower and stimulate self-efficacy while strengthening the perceived social support of the PLHIV. Studies reported a significant positive impact on improving various aspects of HIV competent household – positive effects on HIV knowledge, communication between household members, and improved mental health outcomes of youths living in HIV-affected households.

Conclusion

By aiming to strengthen the perceived social support and self-efficacy of PLHIV, household-focused HIV interventions can address various aspects of household HIV competency. Nevertheless, the role of the household as an enabling resource to improve the outcomes of PLHIV remains largely untapped by public HIV programmes; more research on improving household HIV competency is therefore required.

Trial registration

PROSPERO registration: CRD42018094383.

Genetic diversity and antiretroviral resistance-associated mutation profile of treated and naive HIV-1 infected patients from the Northwest and Southwest regions of Cameroon

BACKGROUND

Antiretroviral therapy (ART) has improved the survival of HIV infected persons. However, rapid scale-up of ART and the high HIV-1 genetic variability, has greatly influenced the emergence of drug-resistant strains. This constitutes a potential threat to achieving the UNAIDS' 90-90-90 goals by 2020. We investigated the prevalent HIV-1 genotypes, drug resistance-associated mutations and assessed some predictors of the occurrence of these mutations.

METHODS

This was a hospital-based cross-sectional study conducted between October 2010 and June 2012. Participants were consecutively enrolled from selected HIV treatment centers of the Southwest and Northwest regions of Cameroon. Viral load was determined with the automated Abbott Real-time HIV-1 m2000rt System. HIV genotyping and antiretroviral resistance mutations analysis were performed using Bayer's HIV-1 TRUGENE™ Genotyping Kit and OpenGene DNA Sequencing system. The drug resistance mutation was interpreted with the Stanford HIV database. Epidemiological data were obtained using pre-tested semi-structured questionnaires.

RESULTS

Of the 387 participants, 239 were successfully genotyped. The median age of these participants was 33 years (interquartile range, IQR: 28-40 years), and a majority (65.7%) were female. A total of 29.3% of the participants were receiving ART. The median duration of ART was 10.5 months (IQR: 4-17.25 months). The median CD4 count and log10 viral load of study participants were 353.5 cells/ml (IQR:145-471) and 4.89 copies/ml (IQR: 3.91-5.55) respectively. CRF02 (A/G) (69%) was the most prevalent subtype followed by G (8.2%) and F (6.7%). Overall, resistance mutations were present in 37.1% of ART-experienced and 10.7% of ART-naive patients. Nucleoside reverse transcriptase inhibitors (NRTI) mutations occurred in 30% of ART-experienced and 2.4% of ART-naïve patients, while non-nucleoside reverse transcriptase inhibitors (NNRTI) mutations occurred in 34.2% of ART-experienced and 10.1% of -naïve patients. M184V (8.4%, 20/239) and K103N (5.4%, 13/239) were the most prevalent mutations. Major protease inhibitor mutations occurred in 3 (1.3%) out of the 239 sequences. The duration of ART independently predicted the occurrence of resistance mutation among ART-experienced patients.

CONCLUSION

The high resistance to NNRTIs, which are the main support to the backbone (NRTIs) first-line antiretroviral regimen in Cameroon, has prompted the need to rollout an integrase strand transfer inhibitor regimen (containing Dolutegravir) with a higher genetic barrier to resistance as the preferred first line regimen.

Ubiquitination and SUMOylation in HIV Infection: Friends and Foes

As intracellular parasites, viruses hijack the cellular machinery to facilitate their replication and spread. This includes favouring the expression of their viral genes over host genes, appropriation of cellular molecules, and manipulation of signalling pathways, including the post-translational machinery. HIV, the causative agent of AIDS, is notorious for using post-translational modifications to generate infectious particles. Here, we discuss the mechanisms by which HIV usurps the ubiquitin and SUMO pathways to modify both viral and host factors to achieve a productive infection, and also how the host innate sensing system uses these post-translational modifications to hinder HIV replication.

Predictors of Safer Conception Practices Among HIV-Infected Women in Northern Nigeria

Background: Persons living with HIV often face discrimination in safe sex and reproductive choices, especially in lowresource settings. This study assessed fertility desires and intentions, risk perception and correlates of ever use of at least one safer conception method among HIV-infected women attending a tertiary health facility in Kano, Nigeria.

Methods: Structured questionnaires were administered to a cross section of 328 of 427 eligible HIV-infected women. Fertility desires and intentions, risk perception and safer conception practice were analyzed. Logistic regression was employed to assess for predictors.

Results: Of the 328 respondents, 150 respondents (45.7%) wanted more children. The proportions of respondents aware of their transmission risk during pregnancy, delivery, and breastfeeding were 69.5%, 75.3%, and 78.9%, respectively. Further, 68.9% of respondents were aware of the prospects of bearing HIV-negative children without infecting their partners. About 64.8% of women were aware of at least one safer conception method. Safer conception methods everused by the participants include: antiretroviral therapy (ART) (36.7%), timed unprotected intercourse with (10.9%), and without pre-exposure prophylaxis (PrEP) (17.2%), intravaginal insemination (7.3%) and intrauterine insemination (4.7%). Safer conception practice was predicted by marital status (married versus single, adjusted odds ratio [AOR]=1.50, 95% CI =1.10-3.55), parity (2-4 versus 0, AOR=12.1, 95% CI=3.7-39.8), occupation (civil servants versus traders, AOR=0.37, 95% CI=0.16-0.86), husband’s serostatus (seroconcordant versus serodiscordant) (AOR=1.51, 95% CI=1.13-4.64), couple contraceptive use (users versus non-users) (AOR=1.62, 95% CI=1.16-5.83) and transmission risk perception (high risk versus low/no risk) (AOR=2.14, 95% CI=1.18-3.90).

Conclusion: We found high levels of fertility desires and intentions and moderate risk perception among a cohort of HIV-infected women in urban Kano, Nigeria. The use of safer conception practices was not common. Our findings underscore the need for healthcare provider capacity building to enhance safer conception counseling and service delivery.

Retention in care and virological failure among adult HIV+ patients on second-line ART in Rwanda: a national representative study

Background

Currently, there is limited evidence on the effectiveness of second-line antiretroviral therapy (ART) in sub-Saharan Africa. To address this challenge, outcomes of second-line protease inhibitor (PI) based ART in Rwanda were assessed.

Methods

A two-stage cluster sampling design was undertaken. 49 of 340 health facilities linked to the open-source electronic medical record (EMR) system of Rwanda were randomly sampled. Data sampling criteria included adult HIV positive patients with documented change from first to second-line ART regimen. Retention in care and treatment failure (viral load above 1000 copies/mL) were evaluated using multivariable Cox proportional hazards and logistic regression models.

Results

A total of 1688 patients (60% females) initiated second-line ART PI-based regimen by 31st December 2016 with a median follow-up time of 26 months (IQR 24–36). Overall, 92.5% of patients were retained in care; 83% achieved VL ≤ 1000 copies/ml, 2.8% were lost to care and 2.2% died. Defaulting from care was associated with more recent initiation of ART- PI based regimen, CD4 cell count ≤500 cells/mm³ at initiation of second line ART and viral load > 1000 copies/ml at last measurement. Viral failure was associated with younger age, WHO stage III&IV at ART initiation, CD4 cell count ≤500 cells/mm³ at switch, atazanavir based second-line ART and receiving care at a health center compared to hospital settings.

Conclusions

A high proportion of patients on second-line ART are doing relatively well in Rwanda and retained in care with low viral failure rates. However, enhanced understandings of adherence and adherence interventions for less healthy individuals are required. Routine viral load measurement and tracing of loss to follow-up is fundamental in resource limited settings, especially among less healthy patients.

Global View of HIV Prevalence in Prisons: A Systematic Review and Meta-Analysis

BACKGROUND

We aimed to estimate the global prevalence of HIV, as well as cross-countries comparison in people who are in prison.

METHODS

We systematically assessed published studies reporting HIV prevalence among prisoners in the world. We searched international datasets banks, including PubMed, SCOPUS, Cumulative Index to Nursing and ISI web of science along with local databases and included original articles reporting data on the prevalence of HIV from 1980 to 2017.

RESULTS

We included 72 studies that reported HIV prevalence for 2,275,930 adult male and female prisoners. The pooled estimate of HIV prevalence was 3.4% (95% CI 3.2%-3.6%); however, the prevalence of HIV across individual studies varied considerably (ranging from 0 in Bosnia and Herzegovina to More than 20% in Iran, Zambia, Spain) and statistical heterogeneity was substantial (I2=0.99, Q=121; P<0.0001). The prevalence of HIV among prisoners in the continents Asia, Africa, North America and Europe was estimated as 3.0% (95% CI 3.3%-4.3 %), 6% (95% CI -0.0%-2.0%), 4% (95% CI 3.0%-4.0%), 5.0% (95% CI 0.0%-11%), respectively.

CONCLUSION

Protecting prisoners' health protects general public health. Successful HIV preventive measures in prisons include provision of HIV education and information; clean needles and syringes; drug treatment; and condoms. Governments have a moral and ethical obligation to prevent the spread of HIV/AIDS in prisons and to provide compassionate care, treatment and support for those infected.

Production and Immunogenicity of Soluble Plant-Produced HIV-1 Subtype C Envelope gp140 Immunogens

The development of effective vaccines is urgently needed to curb the spread of human immunodeficiency virus type 1 (HIV-1). A major focal point of current HIV vaccine research is the production of soluble envelope (Env) glycoproteins which reproduce the structure of the native gp160 trimer. These antigens are produced in mammalian cells, which requires a sophisticated infrastructure for manufacture that is mostly absent in developing countries. The production of recombinant proteins in plants is an attractive alternative for the potentially cheap and scalable production of vaccine antigens, especially for developing countries. In this study, we developed a transient expression system in Nicotiana benthamiana for the production of soluble HIV Env gp140 antigens based on two rationally selected virus isolates (CAP256 SU and Du151). The scalability of the platform was demonstrated and both affinity and size exclusion chromatography (SEC) were explored for recovery of the recombinant antigens. Rabbits immunized with lectin affinity-purified antigens developed high titres of binding antibodies, including against the V1V2 loop region, and neutralizing antibodies against Tier 1 viruses. The removal of aggregated Env species by gel filtration resulted in the elicitation of superior binding and neutralizing antibodies. Furthermore, a heterologous prime-boost regimen employing a recombinant modified vaccinia Ankara (rMVA) vaccine, followed by boosts with the SEC-purified protein, significantly improved the immunogenicity. To our knowledge, this is the first study to assess the immunogenicity of a near-full length plant-derived Env vaccine immunogen.

High HIV-1 prevalence and viral diversity among entry-exit populations at frontier ports of China, 2012-2016: A cross-sectional molecular epidemiology study

The cross border movement of populations would potentially increase the transmission and spread of various diseases including HIV/AIDS, which needed strict surveillance. In the current study, a total of 2,961,530 specimens were collected between 2012 and 2016 from the entry-exit populations at frontier ports of China for epidemiology and molecular epidemiology study. Results showed that HIV-1 prevalence rate among these populations was significantly higher than that of other general populations in China (p < .001). Epidemiological investigation indicated that most of the HIV-1 infected participants were male and young general population, in contrast to intravenous drug users as revealed by previous studies. There were significantly more female, Chinese, and migrant labors in southeastern ports than in northwestern ports (p < .05). Molecular epidemiology study revealed that three subtypes C/BC, CRF01_AE and B dominated, with the emerging of novel unique recombinant forms and drug-resistant viruses among this population. Overall, the results suggests and calls for the shift of HIV-1 prevention projects' focus and the continuous monitoring of HIV-1 molecular epidemiology among entry-exit populations. These findings are useful for the generation of evidence-based biomedical and behavioral prevention programs to HIV/AIDS.

Production of complex viral glycoproteins in plants as vaccine immunogens

Plant molecular farming offers a cost-effective and scalable approach to the expression of recombinant proteins which has been proposed as an alternative to conventional production platforms for developing countries. In recent years, numerous proofs of concept have established that plants can produce biologically active recombinant proteins and immunologically relevant vaccine antigens that are comparable to those made in conventional expression systems. Driving many of these advances is the remarkable plasticity of the plant proteome which enables extensive engineering of the host cell, as well as the development of improved expression vectors facilitating higher levels of protein production. To date, the only plant-derived viral glycoprotein to be tested in humans is the influenza haemagglutinin which expresses at ~50 mg/kg. However, many other viral glycoproteins that have potential as vaccine immunogens only accumulate at low levels in planta. A critical consideration for the production of many of these proteins in heterologous expression systems is the complexity of post-translational modifications, such as control of folding, glycosylation and disulphide bridging, which is required to reproduce the native glycoprotein structure. In this review, we will address potential shortcomings of plant expression systems and discuss strategies to optimally exploit the technology for the production of immunologically relevant and structurally authentic glycoproteins for use as vaccine immunogens.

Evaluation of the Aptima HIV-1 Quant Dx Assay for HIV-1 RNA Quantitation in Different Biological Specimen Types

The search for a cure for HIV infection has highlighted the need for increasingly sensitive and precise assays to measure viral burden in various tissues and body fluids. We describe the application of a standardized assay for HIV-1 RNA in multiple specimen types. The fully automated Aptima HIV-1 Quant Dx assay (Aptima assay) is FDA cleared for blood plasma HIV-1 RNA quantitation. In this study, the Aptima assay was applied for the quantitation of HIV RNA in peripheral blood mononuclear cells (PBMCs; n = 72), seminal plasma (n = 20), cerebrospinal fluid (CSF; n = 36), dried blood spots (DBS; n = 104), and dried plasma spots (DPS; n = 104). The Aptima assay was equivalent to or better than commercial assays or validated in-house assays for the quantitation of HIV RNA in CSF and seminal plasma. For PBMC specimens, the sensitivity of the Aptima assay in the detection of HIV RNA decayed as background uninfected PBMC counts increased; proteinase K treatment demonstrated some benefit in restoring signal at higher levels of background PBMCs. Finally, the Aptima assay yielded 100% detection rates of DBS in participants with plasma HIV RNA levels of ≥35 copies/ml and 100% detection rates of DPS in participants with plasma HIV RNA levels of ≥394 copies/ml. The Aptima assay can be applied to a variety of specimens from HIV-infected subjects to measure HIV RNA for studies of viral persistence and cure strategies. It can also detect HIV in dried blood and plasma specimens, which may be of benefit in resource-limited settings.

GRADE equity guidelines 2: considering health equity in GRADE guideline development: equity extension of the guideline development checklist

OBJECTIVE

To provide guidance for guideline developers on how to consider health equity at key stages of the guideline development process.

STUDY DESIGN AND SETTING

Literature review followed by group discussions and consensus building.

RESULTS

The key stages at which guideline developers could consider equity include setting priorities, guideline group membership, identifying the target audience(s), generating the guideline questions, considering the importance of outcomes and interventions, deciding what evidence to include and searching for evidence, summarizing the evidence and considering additional information, wording of recommendations, and evaluation and use. We provide examples of how guidelines have actually considered equity at each of these stages.

CONCLUSION

Guideline projects should consider the aforementioned suggestions for recommendations that are equity sensitive.