Ending AIDS as a public health threat by 2030: Time to reset targets for 2025

Modeling the HIV epidemic in MSM in Cyprus: reaching only the 95-95-95 cascade of care targets fails to reduce HIV incidence by 90% in 2030

National responses should be improved and accelerated to meet the target of ending the Acquired ImmunoDeficiency Syndrome (AIDS) epidemic by 2030. In the Republic of Cyprus, Men who have Sex with Men (MSM) are disproportionately affected by Human Immunodeficiency Virus (HIV), accounting approximately for half of all annual HIV diagnoses. This study assesses the evolution of HIV incidence in MSM in Cyprus until 2030 using a model calibrated to Cypriot epidemiological data. Four scenarios were examined: status quo, two scenarios focusing on introducing Pre-Exposure Prophylaxis (PrEP), and a 90% HIV incidence reduction scenario. Reaching only the 95-95-95 HIV cascade of care targets among MSM would reduce HIV incidence by 48.6% by 2030 compared to 2015. Initiating a PrEP intervention only for high risk MSM would cause a modest further reduction in HIV incidence. To meet the 90% reduction target, PrEP should be expanded to both high and medium risk MSM and, after 2025, behavioral interventions should be implemented so as high-risk MSM gradually move to the medium-risk category. Cyprus will not reach the HIV incidence reduction target by 2030 unless PrEP is gradually promoted and delivered to all high and medium risk MSM along with awareness and behavioral interventions.

State of HIV costing in Latin America and the Caribbean: a systematic literature review

Objectives

To summarize available data on unit costs for human immunodeficiency virus (HIV) testing, prevention, and care interventions in Latin America and the Caribbean.

Methods

We conducted a systematic literature review of costing studies published between 2012 and 2024, and selected those reporting empirically measured costing data. The available data were categorized according to predefined intervention categories and compared by time and place. We also explored variations in unit costs by intervention type.

Results

Of 1 746 studies identified, 22 met the inclusion criteria, which provided 103 unique unit cost estimates from nine countries. About 50% of the included studies were published between 2019 and 2021. Antiretroviral therapy services had the most cost data available (39% of unit costs), followed by inpatient care (27%) and HIV testing (24%). Considerable cost variations were observed both within and between interventions.

Conclusions

Our analysis underscores the need for accurate and reliable cost data to support HIV budgeting and decision-making efforts. We identified several gaps in the availability of cost data and emphasize the importance of presenting results more effectively by incorporating key contextual variables. Given the challenges of shrinking budgets and sustainability risks, robust evidence is indispensable to inform priority setting and budget allocation for HIV services.

Occupational post-exposure prophylaxis among healthcare workers: a scoping review of factors affecting optimal utilization

INTRODUCTION

Post-exposure prophylaxis (PEP) is an efficacious prevention method when initiated promptly after an HIV exposure. Yet, PEP has been underutilized, even among healthcare workers (HCWs) with occupational exposure in sites with PEP policies and procedures and access to PEP medications. It is important to understand the dynamics of uneven PEP use in what appears to be an optimal context to better protect the health and wellbeing of HCWs.

METHODS

We conducted a scoping review to elucidate factors influencing HCWs' use of PEP after occupational exposure. We searched PubMed, PsychInfo and Google Scholar for peer-reviewed literature published in English from 2014 to 2022 using the terms HIV, postexposure/post-exposure prophylaxis, acceptability, healthcare workers, and values and preferences. An inductive narrative review of the resulting 53 studies identified core themes.

RESULTS

Nearly all studies (96%) with various HCW types and settings occurred in low- and middle-income countries (LMICs) in Africa and Asia. Identified themes arrayed along a trajectory of PEP use experience: awareness/knowledge; acceptability; availability/access; uptake/use; adherence/completion. Across studies, awareness of PEP for HIV prevention was high, knowledge about drug regimens and healthcare facility policies was moderate to low; acceptability of PEP was moderate to high; PEP's perceived accessibility/availability was inconsistent and varied by geographic location and setting; HCWs' uptake of PEP was low, affected by not knowing how to report an exposure and being unaware of PEP availability; and adherence/completion of PEP regimens was moderate to low, impeded by side effects and a belief that completing regimens was unnecessary to avert seroconversion. HCWs consistently expressed concern about HIV stigma.

DISCUSSION

Findings are limited by the inconsistent use of constructs across studies and a lack of clarity about reporting exposure events. Multi-level approaches are needed to address the interplay of individual, social and structural barriers that diminish HCWs' PEP use. Improved training, incident reporting, 24-hour access to non-stigmatizing PEP services and monitoring of adherence/completion are essential to optimizing HCWs' PEP use.

CONCLUSIONS

Lessons from HCWs' experience in LMICs may inform understanding of PEP under-use among people in these settings with non-occupational exposures.

Food insecurity and its severity among adults receiving antiretroviral therapy in health facilities, northcentral Ethiopia: a multi-facility-based cross-sectional study

Background

Food insecurity plays a crucial role in predicting the spread of HIV due to the adverse effects of coping mechanisms adopted to mitigate it. However, there is a scarcity of context-specific evidence regarding food insecurity among HIV-infected adults. Therefore, this study aimed to assess the context-specific magnitude of food insecurity and associated factors among adults receiving antiretroviral therapy (ART) in health facilities in the North Shewa Zone, Ethiopia, ultimately contributing to the achievement of the 95-95-95 HIV treatment target in the local context.

Methods

A multi-facility cross-sectional study was conducted among 865 HIV-infected adults receiving ART and being followed up for their treatment. We included health facilities that provide ART, including four hospitals and six health centers. A log-binomial regression model was fitted to identify the association between food insecurity and independent variables. Adjusted prevalence ratios (APRs) with a 95% confidence interval were computed to measure the strength of the association.

Results

In this study, 290 (33.7, 95% CI: 30.60, 36.91) of the HIV-infected adults studied had food insecurity during their treatment and follow-up, of which 152 (52.41, 95% CI: 46.64, 58.13) and 110 (37.93%, CI: 32.50, 43.68) of them were found to have severe and moderate forms of food insecurity, respectively. We found that being younger (APR = 2.27, 95% CI: 1.12, 4.60), being female (APR = 1.87, 95% CI: 1.03, 3.39), lacking formal education (APR = 10.79, 95% CI: 14.74, 24.58), having lower educational status (APR = 5.99, 95% CI: 2.65, 13.54), being a daily laborer (APR = 6.90, 95% CI: 2.28, 20.85), having low monthly income (APR = 1.89, 95% CI: 1.11, 3.22), advanced WHO clinical stage (APR = 2.34, 95% CI: 1.08, 5.10), and receiving ART for less than 4 years (AOR = 2.28, 95% CI: 1.09, 4.74) were significantly associated with a high proportion of food insecurity among HIV-infected adults.

Conclusion

The magnitude of food insecurity among HIV-infected adults receiving ART was high, with an extremely high magnitude of severe food insecurity. The finding suggests the need for culture- and context-specific nutritional interventions to address the gender dynamics of food insecurity, attention to the early stage of ART, and the integration of strategies to improve educational status and enhance income-generation activities of HIV-infected adults. This requires an emphasis on the link between food insecurity and HIV in Ethiopia's national food and nutrition policy.

Assessing Direct and Spillover Effects of Intervention Packages in Network-randomized Studies

BACKGROUND

Intervention packages may result in a greater public health impact than single interventions. Understanding the separate impact of each component on the overall package effectiveness can improve intervention delivery.

METHODS

We adapted an approach to evaluate the effects of a time-varying intervention package in a network-randomized study. In some network-randomized studies, only a subset of participants in exposed networks receive the intervention themselves. The spillover effect contrasts average potential outcomes if a person was not exposed to themselves under intervention in the network versus no intervention in a control network. We estimated the effects of components of the intervention package in HIV Prevention Trials Network 037, a Phase III network-randomized HIV prevention trial among people who inject drugs and their risk networks using marginal structural models to adjust for time-varying confounding. The index participant in an intervention network received a peer education intervention initially at baseline, then boosters at 6 and 12 months. All participants were followed to ascertain HIV risk behaviors.

RESULTS

There were 560 participants with at least one follow-up visit, 48% of whom were randomized to the intervention, and 1,598 participant visits were observed. The spillover effect of the boosters in the presence of initial peer education training was a 39% rate reduction (rate ratio = 0.61; 95% confidence interval = 0.43, 0.87).

CONCLUSIONS

These methods will be useful for evaluating intervention packages in studies with network features.

Prevalence trends of anemia impairment in adolescents and young adults with HIV/AIDS

BACKGROUND

Anemia is a common complication of HIV/AIDS, particularly in adolescents and young adults across various countries and regions. However, little is known about the changing prevalence trends of anemia impairment in this population over time.

METHODS

Data on anemia in adolescents and young adults with HIV/AIDS from 1990 to 2019 were collected from the Global Burden of Disease. Prevalence was calculated by gender, region, and country for individuals aged 10-24, and trends were measured using estimating annual percentage changes (EAPC).

RESULTS

Globally, the prevalence of adolescents and young adults with HIV/AIDS increased from 103.95 per 100,000 population in 1990 to 203.78 in 2019. However, anemia impairment has decreased over the past three decades, with a global percentage decreasing from 70.6% in 1990 to 34.7% in 2019, mainly presenting as mild to moderate anemia and significantly higher in females than males. The largest decreases were observed in Central Sub-Saharan Africa, North America, and Eastern Sub-Saharan Africa, with EAPCs of -2.8, -2.34, and -2.17, respectively. Tajikistan (78.76%) and Madagascar (74.65%) had the highest anemia impairment percentage in 2019, while China (16.61%) and Iceland (13.73%) had the lowest. Anemia impairment was closely related to sociodemographic index (SDI) levels, with a high proportion of impairment in low SDI regions but a stable decreasing trend (EAPC = -0.37).

CONCLUSION

Continued anemia monitoring and management are crucial for patients with HIV, especially in high-prevalence regions and among females. Public health policies and interventions can improve the quality of life and reduce morbidity and mortality.

Characteristics and influencing factors of anticipated HIV stigma among HIV-negative/unknown MSM in China: A regression mixture model

BACKGROUND

Anticipated HIV stigma among men who have sex with men's (MSM) has a severe negative effect on their physical and mental health wellbeing and hence requires specific attention. The current study aims to identify the characteristics and the psychosocial influencing factors of anticipated HIV stigma in MSM using regression mixture model (RMM) and to determine the cut-off point of the seven-item Anticipated HIV Stigma Questionnaire (AHSQ) using the receiver operating characteristic (ROC) analysis.

METHODS

A cross-sectional study was conducted among HIV-negative/unknown MSM from Blued online platform in China from December 16th, 2020 to March 1st, 2021, enrolling 1394 participants. Data were collected on demographic characteristics, perceived social support, anticipated HIV stigma, depressive symptoms, and HIV knowledge. Latent profile analysis was performed to identify different profiles of anticipated HIV stigma level. Chi-square test, analysis of variance, and RMM analysis were conducted to explore the influencing factors in different profiles. ROC analyses were carried out to identify the cut-off value of anticipated stigma.

RESULTS

Among the participants, three profiles of anticipated stigma were identified: "low anticipated HIV stigma" (12.0%), "moderate anticipated HIV stigma" (52.1%), and "severe anticipated HIV stigma" (35.9%). RMM analysis showed that higher income and higher levels of knowledge were positively associated with moderate anticipated HIV stigma, whereas full-time job and social support were negatively associated with moderate anticipated HIV stigma; higher income, depressive symptoms, and knowledge were positively associated with severe anticipated HIV stigma, whereas minor ethnicity and social support were negatively associated with severe anticipated HIV stigma. ROC curve of the AHSQ showed that the optimal cut-off value of ≥16 could indicate positive anticipated HIV stigma.

CONCLUSION

The study focuses on the level of anticipated HIV stigma and its psycho-socio influencing factors among HIV-negative/unknown MSM. It provides evidence for implementing relevant psychological interventions to HIV-negative/unknown MSM.

Assessing Direct and Spillover Effects of Intervention Packages in Network-Randomized Studies

Intervention packages may result in a greater public health impact than single interventions. Understanding the separate impact of each component in the overall package effectiveness can improve intervention delivery. We adapted an approach to evaluate the effects of a time-varying intervention package in a network-randomized study. In some network-randomized studies, only a subset of participants in exposed networks receive the intervention themselves. The spillover effect contrasts average potential outcomes if a person was not exposed themselves under intervention in the network versus no intervention in a control network. We estimated effects of components of the intervention package in HIV Prevention Trials Network 037, a Phase III network-randomized HIV prevention trial among people who inject drugs and their risk networks using Marginal Structural Models to adjust for time-varying confounding. The index participant in an intervention network received a peer education intervention initially at baseline, then boosters at 6 and 12 months. All participants were followed to ascertain HIV risk behaviors. There were 560 participants with at least one follow-up visit, 48% of whom were randomized to the intervention, and 1,598 participant-visits were observed. The spillover effect of the boosters in the presence of initial peer education training was a 39% rate reduction (Rate Ratio = 0.61; 95% confidence interval= 0.43, 0.87). These methods will be useful to evaluate intervention packages in studies with network features.

Antiviral potency of long-acting islatravir subdermal implant in SHIV-infected macaques

Treatment nonadherence is a pressing issue in people living with HIV (PLWH), as they require lifelong therapy to maintain viral suppression. Poor adherence leads to antiretroviral (ARV) resistance, transmission to others, AIDS progression, and increased morbidity and mortality. Long-acting (LA) ARV therapy is a promising strategy to combat the clinical drawback of user-dependent dosing. Islatravir (ISL) is a promising candidate for HIV treatment given its long half-life and high potency. Here we show constant ISL release from a subdermal LA nanofluidic implant achieves viral load reduction in SHIV-infected macaques. Specifically, a mean delivery dosage of 0.21 ± 0.07 mg/kg/day yielded a mean viral load reduction of -2.30 ± 0.53 log10 copies/mL at week 2, compared to baseline. The antiviral potency of the ISL delivered from the nanofluidic implant was higher than oral ISL dosed either daily or weekly. At week 3, viral resistance to ISL emerged in 2 out of 8 macaques, attributable to M184V mutation, supporting the need of combining ISL with other ARV for HIV treatment. The ISL implant produced moderate reactivity in the surrounding tissue, indicating tolerability. Overall, we present the ISL subdermal implant as a promising approach for LA ARV treatment in PLWH.

Impact of differentiated service delivery models on retention in HIV care and viral suppression among people living with HIV in sub-Saharan Africa: A systematic review and meta-analysis of randomised controlled trials

Differentiated service delivery (DSD) models, such as adherence clubs (ACs), are client-centred approaches where clinically stable people living with HIV (PLHIV) meet to receive various services, including psychosocial support, brief symptoms screening, and refills of antiretroviral medications, among others. We conducted a review to assess the impact of DSD models, including ACs, on sustaining retention in care (RC) and achieving viral suppression (VS) among PLHIV in sub-Saharan Africa. The review protocol was registered in PROSPERO (CRD42023418988). We searched the literature from PubMed, Scopus, Web of Science, Embase and Google Scholar from their inception through May 2023. Eligible randomised controlled trials of adherence clubs were reviewed to assess impact on retention and viral suppression. Random effect models were used to estimate the risk ratios (RR) and 95% confidence intervals (CI). The literature search yielded a total of 1596 records of which 16 randomised clinical trials were determined to be eligible. The trials were conducted in diverse populations among adults and children with a total of 13,886 participants. The RR between any DSD models and standard of care (SoC) was 1.09 (95% CI: 1.08-1.11, I2 : 0%, p: <0.96) and 1.01 (95% CI: 1.00-1.02, I2 : 0%, p: <0.85) for RC and VS, respectively. The RR between ACs and SoC was 1.01 (95% CI: 0.96-1.07, I2 : 84%, p: <0.01) and 1.02 (95% CI: 0.98-1.07, I2 : 77%, p: <0.01) for RC and VS, respectively. DSD models, including ACs, show comparable effectiveness to SoC in maintaining care and achieving viral suppression for stable PLHIV. To maximise adoption, an implementation science approach is crucial for designing effective strategies and overcoming challenges.

Epidemiological characteristics of HIV transmission in southeastern China from 2015 to 2020 based on HIV molecular network

Objective

HIV/AIDS remains a global public health problem, and understanding the structure of social networks of people living with HIV/AIDS is of great importance to unravel HIV transmission, propose precision control and reduce new infections. This study aimed to investigate the epidemiological characteristics of HIV transmission in Fujian province, southeastern China from 2015 to 2020 based on HIV molecular network.

Methods

Newly diagnosed, treatment-naive HIV/AIDS patients were randomly sampled from Fujian province in 2015 and 2020. Plasma was sampled for in-house genotyping resistance test, and HIV molecular network was created using the HIV-TRACE tool. Factors affecting the inclusion of variables in the HIV molecular network were identified using univariate and multivariate logistic regression analyses.

Results

A total of 1,714 eligible cases were finally recruited, including 806 cases in 2015 and 908 cases in 2020. The dominant HIV subtypes were CRF01_AE (41.7%) and CRF07_BC (38.3%) in 2015 and CRF07_BC (53. 3%) and CRF01_AE (29.1%) in 2020, and the prevalence of HIV drug resistance was 4.2% in 2015 and 5.3% in 2020. Sequences of CRF07_BC formed the largest HIV-1 transmission cluster at a genetic distance threshold of both 1.5 and 0.5%. Univariate and multivariate logistic regression analyses showed that ages of under 20 years and over 60 years, CRF07_BC subtype, Han ethnicity, sampling in 2015, absence of HIV drug resistance, married with spouse, sampling from three cities of Jinjiang, Nanping and Quanzhou resulted in higher proportions of sequences included in the HIV transmission molecular network at a genetic distance threshold of 1.5% (p < 0.05).

Conclusion

Our findings unravel the HIV molecular transmission network of newly diagnosed HIV/AIDS patients in Fujian province, southeastern China, which facilitates the understanding of HIV transmission patterns in the province.

Exposure to Armed Conflict and HIV Risk Among Rwandan Women

This article focuses on the link between past exposure to violence and a critical public health issue in sub-Saharan Africa: HIV-positive status in women of reproductive age. Specifically, we use biosocial data from the Rwandan Demographic and Health Survey (2005‒2014) to assess how the timing and intensity of women's exposure to the war and genocide in Rwanda (1990‒1994) may be associated with their HIV status. We find significant differences in risk across age cohorts, with the late adolescence cohort (women born in 1970‒1974, who were aged 16‒20 at the start of the conflict) having the highest risk of being HIV positive 10‒20 years after the violence, even after controlling for current socioeconomic and demographic characteristics. Women who reported two or more sibling deaths, excluding those related to maternal mortality, during the conflict years also had higher odds of being HIV positive, net of cohort and control variables. Age at first sexual intercourse and number of lifetime sexual partners partially-but not fully-explain the associations between cohort and sibling deaths and HIV. These findings advance research related to armed conflict and population health and indicate that experiencing conflict during key stages of the life course and at higher intensity may affect women's long-term sexual health.

An HIV-1/HIV-2 Chimeric Envelope Glycoprotein Generates Binding and Neutralising Antibodies against HIV-1 and HIV-2 Isolates

The development of immunogens that elicit broadly reactive neutralising antibodies (bNAbs) is the highest priority for an HIV vaccine. We have shown that a prime-boost vaccination strategy with vaccinia virus expressing the envelope glycoprotein gp120 of HIV-2 and a polypeptide comprising the envelope regions C2, V3 and C3 elicits bNAbs against HIV-2. We hypothesised that a chimeric envelope gp120 containing the C2, V3 and C3 regions of HIV-2 and the remaining parts of HIV-1 would elicit a neutralising response against HIV-1 and HIV-2. This chimeric envelope was synthesised and expressed in vaccinia virus. Balb/c mice primed with the recombinant vaccinia virus and boosted with an HIV-2 C2V3C3 polypeptide or monomeric gp120 from a CRF01_AG HIV-1 isolate produced antibodies that neutralised >60% (serum dilution 1:40) of a primary HIV-2 isolate. Four out of nine mice also produced antibodies that neutralised at least one HIV-1 isolate. Neutralising epitope specificity was assessed using a panel of HIV-1 TRO.11 pseudoviruses with key neutralising epitopes disrupted by alanine substitution (N160A in V2; N278A in the CD4 binding site region; N332A in the high mannose patch). The neutralisation of the mutant pseudoviruses was reduced or abolished in one mouse, suggesting that neutralising antibodies target the three major neutralising epitopes in the HIV-1 envelope gp120. These results provide proof of concept for chimeric HIV-1/HIV-2 envelope glycoproteins as vaccine immunogens that can direct the antibody response against neutralising epitopes in the HIV-1 and HIV-2 surface glycoproteins.

Costs and Cost-Effectiveness of Biomedical, Non-Surgical HIV Prevention Interventions: A Systematic Literature Review

BACKGROUND

Considerable evidence on the costs and cost-effectiveness of biomedical, non-surgical interventions to prevent human immunodeficiency virus (HIV) transmission has been generated over the last decade. This study aims to synthesize findings and identify remaining knowledge gaps to suggest future research priorities.

METHODS

A systematic literature review was carried out in August 2020 using the MEDLINE, Embase, Global Health and EconLit databases to retrieve economic evaluations and costing studies of oral pre-exposure prophylaxis (PrEP), injectable long-acting PrEP, vaginal microbicide rings and gels, HIV vaccines and broadly neutralizing antibodies. Studies reporting costs from the provider or societal perspective were included in the analysis. Those reporting on behavioural methods of prevention, condoms and surgical approaches (voluntary medical male circumcision) were excluded. The quality of reporting of the included studies was assessed using published checklists.

RESULTS

We identified 3007 citations, of which 87 studies were retained. Most were set in low- and middle-income countries (LMICs; n = 53) and focused on the costs and/or cost-effectiveness of oral PrEP regimens (n = 70). Model-based economic evaluations were the most frequent study design; only two trial-based cost-effectiveness analyses and nine costing studies were found. Less than half of the studies provided practical details on how the intervention would be delivered by the health system, and only three of these, all in LMICs, explicitly focused on service integration and its implication for delivery costs. 'Real-world' programme delivery mechanisms and costs of intervention delivery were rarely considered. PrEP technologies were generally found to be cost-effective only when targeting high-risk subpopulations. Single-dose HIV vaccines are expected to be cost-effective for all groups despite substantial uncertainty around pricing.

CONCLUSIONS

A lack of primary, detailed and updated cost data, including above-service level costs, from a variety of settings makes it difficult to evaluate the cost-effectiveness of specific delivery modes at scale, or to evaluate strategies for services integration. Closing this evidence gap around real-world implementation is vital, not least because the strategies targeting high-risk groups that are recommended by PrEP models may incur substantially higher costs and be of limited practical feasibility in some settings.

Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi

BACKGROUND

Data remain scarce on the costs of HIV services for key populations (KPs). The objective of this study was to bridge this gap in the literature by estimating the unit costs of HIV services delivered to KPs in the LINKAGES program in Kenya and Malawi. We estimated the mean total unit costs of seven clinical services: post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), HIV testing services (HTS), antiretroviral therapy (ART), sexually transmitted infection (STI) services, sexual and reproductive health (SRH) services, and management of sexual violence (MSV). These costs take into account the costs of non-clinical services delivered alongside clinical services and the pre-service and above-service program management integral to the LINKAGES program.

METHODS

Data were collected at all implementation levels of the LINKAGES program including 30 drop-in-centers (DICs) in Kenya and 15 in Malawi. This study was conducted from the provider's perspective. We estimated economic costs for FY 2019 and cost estimates include start-up costs. Start-up and capital costs were annualized using a discount rate of 3%. We used a combination of top-down and bottom-up costing approaches. Top-down methods were used to estimate the costs of headquarters, country offices, and implementing partners. Bottom-up micro-costing methods were used to measure the quantities and prices of inputs used to produce services in DICs. Volume-weighted mean unit costs were calculated for each clinical service. Costs are presented in 2019 United States dollars (US$).

RESULTS

The mean total unit costs per service ranged from US$18 (95% CI: 16, 21) for STI services to US$635 (95% CI: 484, 785) for PrEP in Kenya and from US$41 (95% CI: 37, 44) for STI services to US$1,240 (95% CI 1156, 1324) for MSV in Malawi. Clinical costs accounted for between 21 and 59% of total mean unit costs in Kenya, and between 25 and 38% in Malawi. Indirect costs-including start-up activities, the costs of KP interventions implemented alongside clinical services, and program management and data monitoring-made up the remaining costs incurred.

CONCLUSIONS

A better understanding of the cost of HIV services is highly relevant for budgeting and planning purposes and for optimizing HIV services. When considering all service delivery costs of a comprehensive HIV service package for KPs, costs of services can be significantly higher than when considering direct clinical service costs alone. These estimates can inform investment cases, strategic plans and other budgeting exercises.

Changing co-morbidity and increasing deprivation among people living with HIV: UK population-based cross-sectional study

BACKGROUND

The great success of HIV treatments means that, increasingly, people living with HIV (PLHIV) are growing old enough to develop age-associated comorbid conditions. We investigated the evolution of comorbid conditions and demographics among PLHIV in England.

METHODS

In a cross-sectional study linking Clinical Practice Research Datalink (CPRD) primary care, hospitalization, death registry and Index of Multiple Deprivation data, we measured the prevalence of 304 individual health conditions, categorized into 47 condition groups (36 non-communicable, 11 communicable). Using logistic regression, we calculated odds ratios (ORs) for the likelihood of each condition and condition group in 2015 versus 2008, adjusting for age, sex and deprivation.

RESULTS

In 2015, there were 964 CPRD-registered PLHIV compared with 1987 in 2008; 62% were male and 38% female in both cohorts. The 2015 cohort was older, with 51.1% aged 45-64 years and 7.2% aged 65-84 years compared with 31.8% and 3.2%, respectively, in 2008. Deprivation was higher in 2015, at 23.9% (quintile 4) and 28.7% (quintile 5) compared with 5.8% and 6.6%, respectively, in 2008. Of 36 non-communicable condition groups, 14 (39%) occurred in ≥ 10% of PLHIV in 2015, of which seven were more likely in 2015 than in 2008: renal-chronic-kidney-disease [odds ratio (OR) = 1.96 (95% CI: 1.33-2.90); endocrine-obesity [OR = 1.76 (1.12-2.77)]; rheumatology [OR = 1.64 (1.30-2.07)]; dermatology [OR = 1.55(1.29-1.85)]; genito-urinary-gynaecological [OR = 1.44(1.18-1.76)]; eyes-ears/nose/throat [OR = 1.31(1.08-1.59)]; and gastro-intestinal conditions [OR = 1.28 (1.04-1.58)]. Two condition groups, respiratory-chronic-obstructive-pulmonary-disease [OR = 0.36 (0.19-0.69)] and endocrine-diabetes [OR = 0.49 (0.34-0.70)], were less likely in 2015. Ten out of 11 communicable infectious condition groups were less likely in 2015.

CONCLUSIONS

Although infections in PLHIV have fallen, chronic non-communicable comorbidity is increasingly prevalent. Alongside the marked increases in deprivation and ageing, this study suggests that socio-economic measures in addition to healthcare provision are needed to achieve holistic health for PLHIV.

HIV virologic response, patterns of drug resistance mutations and correlates among adolescents and young adults: A cross-sectional study in Tanzania

BACKGROUND

The emergence of HIV drug resistance mutations (DRMs) is of significant threat to achieving viral suppression (VS) in the quest to achieve global elimination targets. We hereby report virologic outcomes and patterns of acquired DRMs and its associated factors among adolescents and young adults (AYA) from a broader HIV drug resistance surveillance conducted in Tanzania.

METHODS

Data of AYA was extracted from a cross-sectional study conducted in 36 selected facilities using a two-stage cluster sampling design. Dried blood spot (DBS) samples were collected and samples with a viral load (VL) ≥1000 copies/mL underwent genotyping for the HIV-1 pol gene. Stanford HIV database algorithm predicted acquired DRMs, Fisher's exact test and multivariable logistic regression assessed factors associated with DRMs and VS, respectively.

FINDINGS

We analyzed data of 578 AYA on antiretroviral therapy (ART) for 9-15 and ≥ 36 months; among them, 91.5% and 88.2% had VS (VL<1000copies/mL) at early and late time points, respectively. Genotyping of 64 participants (11.2%) who had VL ≥1000 copies/ml detected 71.9% of any DRM. Clinically relevant DRMs were K103N, M184V, M41L, T215Y/F, L210W/L, K70R, D67N, L89V/T, G118R, E138K, T66A, T97A and unexpectedly absent K65R. Participants on a protease inhibitor (PI) based regimen were twice as likely to not achieve VS compared to those on integrase strand transfer inhibitors (INSTI). The initial VL done 6 months after ART initiation of ≥1000copies/mL was the primary factor associated with detecting DRMs (p = .019).

CONCLUSIONS

VS amongst AYA is lower than the third UNAIDs target. Additionally, a high prevalence of ADR and high levels of circulating clinically relevant DRMs may compromise the long-term VS in AYA. Furthermore, the first VL result of ≥1000copies/ml after ART initiation is a significant risk factor for developing DRMs. Thus, strict VL monitoring for early identification of treatment failure and genotypic testing during any ART switch is recommended to improve treatment outcomes for AYA.

[Adherence to antiretroviral therapy by people living with HIV/AIDS in Florianópolis, Santa Catarina State, Brazil]

Adherence to antiretroviral therapy (ART) is essential to control HIV infections and avoid clinical complications and the development of resistant HIV strains. Several Brazilian municipalities have committed themselves to the 90-90-90 target, which aims at diagnosing 90% of HIV/AIDS cases, treating 90% of them, and virally suppressing 90% of them. However, only three Brazilian studies have assessed adherence to ART from secondary dispensing data. This study aimed to estimate the prevalence of adherence to treatment in the Municipality of Florianópolis, Santa Catarina State, Brazil, examining its association with demographic, health access, and clinical characteristics. A cross-sectional study was conducted using secondary national data from electronic medical records and Medication Logistic Control System (SICLOM) and Laboratory Test Control System (SISCEL) regarding people living with HIV/AIDS in the municipality from April 2020 to March 2021. We found an about 85% prevalence of adherence to ART. White men with follow-ups both in primary and secondary care showed greater adherence to treatment. Age and number of consultations directly related to adherence. Decentralizing care for users living with HIV/AIDS is the way to more comprehensive care but technical and ethical challenges still require solutions. Professional training, correct network referrals, and attention to confidentiality issues must be reinforced to expand treatment adherence.

MyTPill: study protocol for a cross-over randomised controlled trial comparing novel strategies to monitor antiretroviral adherence among HIV+ prescription opioid users

INTRODUCTION

Adherence to HIV antiretroviral therapy (ART) remains the cornerstone of HIV treatment. For individuals with suboptimal adherence, electronic adherence monitoring (EAM) technologies have become an important component of multimodal adherence support strategies. Most EAM technologies detect pillbox opening, and therefore, assume but cannot verify actual ingestion of oral medication. In contrast, a digital pill system (ID-capsule manufactured by etectRX, here named My/Treatment/Pill) measures directly ingestion of medications. Identifying the superior method to measure ART adherence would improve virological suppression by enabling the delivery of real-time interventions to support ART adherence, particularly in high-risk populations.

METHODS AND ANALYSIS

Cross-over, randomised trial with 1:1 variable block size randomisation comparing two EAM systems in prescription opioid-using HIV+patient on once daily oral bictegravir, emtricitabine and tenofovir alafenamide regimens and detectable viral load >200 copies/mL within 30 days of screening (n=80). The primary outcome is once daily ART adherence measurement efficacy as assessed by comparing the accuracy of each EAM system as measured by concordance of the respective EAM systems to dried blood spot ART concentrations. Secondary outcomes are the identification of multilevel factors that are prevalent in the target population most closely linked to ART non-adherence and EAM non-adherence.

ETHICS AND DISSEMINATION

This protocol was approved by the institutional review boards of participating sites (The Ohio State University, The Fenway Institute and the University of Miami). Data will be presented at scientific conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03978793.

A Cost-effectiveness Analysis of a Mobile Phone-Based Integrated HIV-Prevention Intervention Among Men Who Have Sex With Men in China: Economic Evaluation

BACKGROUND

Mobile phone-based digital interventions have been shown to be a promising strategy for HIV prevention among men who have sex with men (MSM).

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of a mobile phone-based digital intervention for HIV prevention among MSM in China from the perspective of a public health provider.

METHODS

The cost-effectiveness of the mobile phone-based digital intervention was estimated for a hypothetical cohort of 10,000 HIV-negative MSM who were followed for 1 year. A model was developed with China-specific data to project the clinical impact and cost-effectiveness of two mobile phone-based digital strategies for HIV prevention among MSM. The intervention group received an integrated behavioral intervention that included 1) individualized HIV infection risk assessment, 2) recommendation of centers testing for HIV and other STIs, 3) free online order of condoms and HIV and syphilis self-test kits and 4) educational materials about HIV/AIDS. The control group was only given educational materials about HIV/AIDS. Outcomes of interest were the number of HIV infections among MSM averted by the intervention, intervention costs, cost per HIV infection averted by the mobile phone-based digital intervention, and quality-adjusted life-years (QALYs). Univariate and multivariate sensitivity analyses were also conducted to examine the robustness of the results.

RESULTS

It is estimated that the intervention can prevent 48 MSM from becoming infected with HIV and can save 480 QALYs. The cost of preventing 1 case of HIV infection was US $2599.87, and the cost-utility ratio was less than 0. Sensitivity analysis showed that the cost-effectiveness of the mobile phone-based digital intervention was mainly impacted by the average number of sexual behaviors with each sexual partner. Additionally, the higher the HIV prevalence among MSM, the greater the benefit of the intervention.

CONCLUSIONS

Mobile phone-based digital interventions are a cost-effective HIV-prevention strategy for MSM and could be considered for promotion and application among high-risk MSM subgroups.

HIV prevention for the next decade: Appropriate, person-centred, prioritised, effective, combination prevention

UNAIDS and a broad range of partners have collaborated to establish a new set of HIV prevention targets to be achieved by 2025 as an intermediate step towards the sustainable development target for 2030.The number of new HIV infections in the world continues to decline, in part due to the extraordinary expansion of effective HIV treatment. However, the decline is geographically heterogeneous, with some regions reporting a rise in incidence. The incidence target that was agreed for 2020 has been missed.A range of exciting new HIV prevention technologies have become available or are in the pipeline but will only have an impact if they are accessible and affordable and delivered within systems that take full account of the social and political context in which most infections occur. Most new infections occur in populations that are marginalised or discriminated against due to structural, legal, and cultural barriers.The new targets imply a new approach to HIV prevention that emphasises appropriate, person-centred, prioritised, effective, combination HIV prevention within a framework that reduces existing barriers to services and acknowledges heterogeneity, autonomy, and choice.These targets have consequences for people working in HIV programmes both for delivery and for monitoring and evaluation, for health planners setting local and national priorities, and for funders both domestic and global. Most importantly, they have consequences for people who are at risk of HIV exposure and infection.Achieving these targets will have a huge impact on the future of the HIV epidemic and put us back on track towards ending AIDS as a public health threat by 2030.

Integrating HIV and substance misuse services: a person-centred approach grounded in human rights

Integrating HIV-related care with treatment for substance use disorder provides an opportunity to better meet the needs of people living with these conditions. People with substance use disorder are rendered especially vulnerable by prevailing policies, structural inequalities, and stigmatisation. In this Series paper we analyse existing literature and empirical evidence from scoping reviews on integration designs for the treatment of HIV and substance use disorder, to understand barriers to and facilitators of care integration and to map ways forward. We discuss how approaches to integration address two core gaps in current models: a failure to consider human rights when incorporating the perspectives of people living with HIV and people who use drugs, and a failure to reflect critically on structural factors that determine risk, vulnerability, health-care seeking, and health equity. We argue that successful integration requires a person-centred approach, which is grounded in human rights, treats both concerns holistically, and reconnects with underlying social, economic, and political inequalities.

The best backbone for HIV prevention, treatment, and elimination: Emtricitabine+tenofovir

The advent of antiretroviral combination therapy has significantly impacted the HIV/AIDS epidemic. No longer a death sentence, HIV infection can be controlled and suppressed using cocktail therapies that contain two or more small molecule drugs. This review aims to highlight the discovery, development, and impact of one such molecule, namely, emtricitabine (FTC, emtriva), which is one of the most successful drugs in the fight against HIV/AIDS and has been taken by over 94% of individuals infected with HIV in the USA. We also pay tribute to Dr. John C. Martin, former CEO and Chairman of Gilead Sciences, who unexpectedly passed away in 2021. A true visionary, he was instrumental in delivering FTC, as part of combination therapy with TDF (tenofovir, viread) to the global stage. As the fight to eradicate HIV marches on, we honor Dr. Martin's legacy of collaboration, achievement, and hope.

Evidence-based policymaking when evidence is incomplete: The case of HIV programme integration

Jan Hontelez and co-authors discuss the use of different types of evidence to inform HIV program integration.

Modeling the epidemiological impact of the UNAIDS 2025 targets to end AIDS as a public health threat by 2030

BACKGROUND

UNAIDS has established new program targets for 2025 to achieve the goal of eliminating AIDS as a public health threat by 2030. This study reports on efforts to use mathematical models to estimate the impact of achieving those targets.

METHODS AND FINDINGS

We simulated the impact of achieving the targets at country level using the Goals model, a mathematical simulation model of HIV epidemic dynamics that includes the impact of prevention and treatment interventions. For 77 high-burden countries, we fit the model to surveillance and survey data for 1970 to 2020 and then projected the impact of achieving the targets for the period 2019 to 2030. Results from these 77 countries were extrapolated to produce estimates for 96 others. Goals model results were checked by comparing against projections done with the Optima HIV model and the AIDS Epidemic Model (AEM) for selected countries. We included estimates of the impact of societal enablers (access to justice and law reform, stigma and discrimination elimination, and gender equality) and the impact of Coronavirus Disease 2019 (COVID-19). Results show that achieving the 2025 targets would reduce new annual infections by 83% (71% to 86% across regions) and AIDS-related deaths by 78% (67% to 81% across regions) by 2025 compared to 2010. Lack of progress on societal enablers could endanger these achievements and result in as many as 2.6 million (44%) cumulative additional new HIV infections and 440,000 (54%) more AIDS-related deaths between 2020 and 2030 compared to full achievement of all targets. COVID-19-related disruptions could increase new HIV infections and AIDS-related deaths by 10% in the next 2 years, but targets could still be achieved by 2025. Study limitations include the reliance on self-reports for most data on behaviors, the use of intervention effect sizes from published studies that may overstate intervention impacts outside of controlled study settings, and the use of proxy countries to estimate the impact in countries with fewer than 4,000 annual HIV infections.

CONCLUSIONS

The new targets for 2025 build on the progress made since 2010 and represent ambitious short-term goals. Achieving these targets would bring us close to the goals of reducing new HIV infections and AIDS-related deaths by 90% between 2010 and 2030. By 2025, global new infections and AIDS deaths would drop to 4.4 and 3.9 per 100,000 population, and the number of people living with HIV (PLHIV) would be declining. There would be 32 million people on treatment, and they would need continuing support for their lifetime. Incidence for the total global population would be below 0.15% everywhere. The number of PLHIV would start declining by 2023.