Current Opinion in HIV and AIDS最新文献

Purpose of review: Patient centered care (PCC) in human immunodeficiency virus (HIV) care systems in sub-Saharan Africa (SSA) may improve outcomes for persons with HIV (PWH). We review the progress the region has made in promoting PCC and highlight some of the implementation challenges and potential areas of research.

Recent findings: Studies show growing interest in promoting PCC across HIV care programs in SSA. Effective implementation of PCC, however, is hampered by: (1) lack of consensus on the conceptualization of PCC, including definition, frameworks, measures, and implementation strategies; (2) limited regional studies on the adoption and sustainability of PCC interventions; and (3) healthcare structural challenges including limited capital and human resources, poor provider-patient dynamics, high provider turnover, and lack of continuity in care. Recent studies in the region have focused on identifying key PCC domains addressable in resource limited settings, understanding the PCC experiences and expectations of PWH and their providers, and testing innovative interventions. We highlight the need for additional studies to address the existing gaps.

Summary: We discuss the progress and challenges of implementing PCC in HIV care settings in SSA as well as the need for additional research to ensure that proposed PCC interventions have optimal impact.

Purpose of review: Nongovernmental organizations (NGOs) are pivotal to the HIV response, supporting access to HIV services since the start of the epidemic. Against the backdrop of the impact of NGOs, is the recognition of the unique role that local NGOs bring to the HIV response, drawing from their deep understanding of the context and knowledge of local health problems.

Recent findings: The Centre for Infectious Disease Research in Zambia (CIDRZ) is one such NGO. Through various implementation science research and programs, CIDRZ has supported the Zambian government's HIV response. As Zambia moves closer to epidemic control, understanding reasons for patient disengagement from care and patient preferences for HIV care demonstrated by CIDRZ have contributed to global and national HIV treatment and care guidelines.

Summary: This paper offers a case study for how NGOs like CIDRZ can serve as health system-wide catalyst to identify, integrate, and scale up evidence-based practices for HIV prevention, care, and treatment. It draws from the public health literature, CIDRZ extensive program and research experience and implementation science theory, to illustrate key strategies that can be deployed by local NGOs to spark innovation, quality improvement, and support governments to achieve and sustain HIV epidemic control.

Purpose of review: Globally, approximately 38.4 million people who are navigating complex lives, are also living with HIV, while HIV incident cases remain high. To improve the effectiveness of HIV prevention and treatment service implementation, we need to understand what drives human behaviour and decision-making around HIV service use. This review highlights current thinking in the social sciences, emphasizing how understanding human behaviour can be leveraged to improve HIV service delivery.

Recent findings: The social sciences offer rich methodologies and theoretical frameworks for investigating how factors synergize to influence human behaviour and decision-making. Social-ecological models, such as the Behavioural Drivers Model (BDM), help us conceptualize and investigate the complexity of people's lives. Multistate and group-based trajectory modelling are useful tools for investigating the longitudinal nature of peoples HIV journeys. Successful HIV responses need to leverage social science approaches to design effective, efficient, and high-quality programmes.

Summary: To improve our HIV response, implementation scientists, interventionists, and public health officials must respond to the context in which people make decisions about their health. Translating biomedical efficacy into real-world effectiveness is not simply finding a way around contextual barriers but rather engaging with the social context in which communities use HIV services.

Purpose of review: Understanding stigma is important for improving HIV care services and gaps in HIV service delivery have been attributed to stigma. This review article synthesizes recent evidence on stigma and its implications for HIV service design and delivery. Given the intersectional nature of stigma, we will focus on HIV stigma as well as related forms of stigma based on one's race, sexual identity, gender identity and other identities.

Recent findings: Stigma remains a barrier to achieving equity in HIV services. Individualistic measures of stigma remain influential and are associated with barriers to accessing HIV health services. Recent work also highlights stigma measured at a structural level and its impact on HIV services contexts. Individuals situated at intersections of marginalized identities continue to face greatest injustices, and although intersectional approaches have been adapted to design services at a micro level, few focus on structural change. Recent evidence for mitigating stigma indicates some success for psychosocial interventions that target internalized stigma. Furthermore, community-led approaches show promise in addressing stigma that manifests in HIV health services settings.

Summary: Interventions that address individual-level stigma and structural stigma are needed. Theoretical and applied antistigma research is needed to make HIV services more equitable.

Purpose of review: A paradigm shift is needed in how we think about biomedical HIV prevention product effectiveness. Often, we expect randomized trial findings to be generalizable across populations and settings where products will be delivered, without consideration of key contextual drivers that could impact effectiveness. Moreover, researchers and policy-makers generally discount products with varied effect sizes across contexts, rather than explicating the drivers of these differences and using them to inform equitable product choice and delivery. We conducted a review of the recent HIV prevention research to advance considerations of context in choices of when, why, and how to implement biomedical HIV prevention products, with a particular focus on daily oral preexposure prophylaxis (PrEP) and the dapivirine vaginal ring (DPV).

Recent findings: Findings across recent studies of PrEP and DPV emphasize that products that do not work well in one context might be highly desirable in another. Key contextual drivers of PrEP and DPV effectiveness, use, and implementation include population, health system, cultural, and historical factors. We recommend conceptualization, measurement, and analysis approaches to fully understand the potential impact of context on prevention product delivery. Execution of these approaches has real-world implications for HIV prevention product choice and could prevent the field from dismissing biomedical HIV prevention products based on trial findings alone.

Summary: Ending the HIV epidemic will require tailored, person-centered, and equitable approaches to design, implement, and evaluate HIV prevention products which necessitates considerations of context in ongoing research and implementation.

Purpose of review: Recent years have seen major investments into HIV cure research, seeking a permanent cure or remission. The purpose of this review is to consider how this important research agenda could be broadened to include issues of acceptability and appropriateness for different populations.

Recent findings: We discuss how the definitions of cure such as functional cure (remission) or complete cure (viral elimination) could be interpreted differently by various populations. We also discuss the different methods of cure and the importance of including Africa in cure research to ensure that emerging remedies could be trialled and utilized on the continent that bears the brunt of the AIDS pandemic.

Summary: We propose that the social science research of HIV cure acceptability should be done concurrently with the basic and clinical sciences, to ensure that cure methods consider stakeholder preferences.

Purpose of the review: Not all T-cell responses against HIV are created equally and responses of certain epitope specificities have been associated with superior control of infection. These insights have spurred the development of a wide range of immunogen sequences, each with particular advantages and limitations.

Recent findings: We review some of the most advanced designs that have reached or are close to reaching human clinical trials, with a special focus on T-cell immunogen developed for therapeutic use. We also touch upon the importance of how immunogens are delivered and point out the lamentable fact that there is essentially no alignment between different designs and vaccine regimens, which is a major hindrance to accelerated advances in the field.

Summary: The design of an immunogen able to induce T-cell responses of adequate specificity and functionality is subject of a wide range of preclinical and clinical studies. Few designs have shown promise to date, but emerging data highlight the critical contribution of specificity to effective antiviral activity in vivo .

Purpose of review: The epidemiology of liver disease in people living with HIV has evolved since the arrival of effective hepatitis C virus (HCV) treatment. Nonalcoholic fatty liver disease (NAFLD) in HIV patients is highly prevalent while hepatitis D, hepatitis E, and occult hepatitis B remain underappreciated. We discuss mechanisms of fibrosis in HIV and review clinical outcomes of HIV-associated liver diseases.

Recent findings: HIV-HCV co-infection is receding as a cause of progressive liver disease, but fibrosis biomarkers after HCV treatment remain elevated. Antiretroviral therapy (ART) with anti-hepatitis B virus (HBV) activity promotes stable liver disease, but oversimplifying ART regimens in unrecognized suppressed HBV may lead to activation of HBV. A high prevalence of fibrosis and rapid progression of fibrosis are seen in HIV-associated NAFLD, with visceral fat as a major risk factor. Newer ART such as integrase strand inhibitors may have limited intrinsic hepatoxicity but do increase weight, which may secondarily lead to hepatic steatosis. Promising therapies for HIV-associated NAFLD include tesamorelin and CCR5 blockade agents.

Summary: Our understanding of the natural history and pathogenesis of liver diseases in HIV has advanced and adapted to the changing landscape of liver disease in this population. Future research should evaluate long-term clinical and histological outcomes, prevention strategies, and treatment options to improve morbidity and mortality in HIV-related liver diseases.