JAIDS Journal of Acquired Immune Deficiency Syndromes最新文献

Background: Despite broad access to antiretroviral therapy in sub-Saharan Africa (SSA), neurocognitive comorbidities remain common among people with HIV (PWH). Multiple lines of evidence link cognitive performance to inflammatory plasma biomarkers. This study examined this relationship within a robust sample in SSA.

Methods: PWH and people without HIV (PWoH) aged 18 years or older, enrolled in the prospective African Cohort Study from 2013 to 2016 at multiple sites across Kenya, Nigeria, Tanzania, and Uganda, and underwent clinical evaluation. A neuropsychological battery assessed cognitive performance. Blood samples collected were analyzed by immunoassay. Using multivariable linear regression, we characterized associations between cognitive Z-scores and biomarker levels.

Results: Participants included PWoH (17%, n = 473), PWH with suppressed viremia (44%, n = 1199), and PWH with unsuppressed viremia (exceeding 100 copies/mL, 39%, n = 1065). Across groups, PWH with suppressed viremia were significantly older (means = 37.1, 41.9 and 37.5, respectively, P < 0.001). Among PWH, 3 biomarkers (CXCL10, CCL2, and sCD25) showed inverse relationships to cognitive performance on all measures (β = -0.163, β = -0.133, and β = -0.204, respectively, P < 0.05). Inflammation did not relate to cognitive performance in PWoH. Examining individual neuropsychological test performance, the Grooved Pegboard, measuring psychomotor speed and manual dexterity, displayed the strongest associations with key biomarkers (CCL2 β = -0.252, sCD25 β = -0.293, and CXCL10 β = -0.214, P < 0.01).

Conclusions: In SSA, inflammatory markers associated with worse cognitive performance in both viremic and suppressed PWH.

Introduction: Curable sexually transmitted infections (STIs) cause morbidity for women and increase HIV transmission and acquisition. To address barriers to STI care, we are implementing STI testing integrated with HIV prevention and contraceptive services in hair salons in urban South Africa.

Methods: Women attending hair salons are offered oral HIV pre-exposure prophylaxis (PrEP), hormonal contraception, and testing for gonorrhea, chlamydia, trichomoniasis, and syphilis within an ongoing pilot trial. Participants with positive STI results are offered treatment at the salon or local clinic. Demographics, symptoms, and risk factors are collected using structured questionnaires.

Results: Of 125 women enrolled and taking PrEP and/or contraceptives in the hair salons (median age 26 years, 28.8% living with HIV), 121 (96.8%) accepted STI testing and 117 (93.6%) had complete results. Nearly half (47.8%) reported a primary sex partner ≥5 years older, 32.2% thought their partner had other partners, and 62.6% reported never using condoms. In total, 42 of 117 women (35.9%) had at least 1 STI: 7.7% gonorrhea, 21.4% chlamydia, 4.3% trichomoniasis, and 9.4% syphilis. Only 8 of 42 (19.0%) women with an STI reported symptoms. In adjusted models, having an STI was associated with perceived male partner concurrency ( P = 0.049). Among women with any STI, 38 of 42 (90.5%) elected treatment at the salon.

Conclusions: STI testing in hair salons in South Africa reaches women with risk factors for STIs and HIV, seems acceptable and feasible, and reveals a high STI prevalence. Hair salons may serve as novel venues to increase the reach of STI testing to women at risk for HIV and STIs.

Clinical trials registration: NCT04222504.

Background: Pregnant people with HIV (PWH) often experience loss to follow-up and viral nonsuppression after delivery, contributing to morbidity and HIV transmission. The COVID-19 pandemic disrupted health systems and exacerbated health disparities, including for PWH and their infants. To improve perinatal HIV outcomes, we implemented a perinatal care program in September 2020 that offered multidisciplinary home visits through a mobile integrated health (MIH) unit within a large, safety-net health care system in Atlanta, GA.

Methods: We analyzed data collected from PWH who delivered 1 year before (August 31, 2019-August 31, 2020; pre-implementation) to 6 months after (September 1, 2020-February 28, 2021; post-implementation) MIH implementation to compare HIV clinical outcomes. We evaluated barriers, facilitators, and patient preferences through exit surveys with MIH program participants.

Results: Overall, 32 (53%) delivered before and 28 (47%) PWH delivered after MIH implementation; most were non-Hispanic Black. Three-fourths who delivered post-MIH used MIH, mostly (62%) for postpartum obstetric visits. HIV visit attendance within 3 months and retention in care at 6 months of delivery were significantly higher post-implementation ( P = 0.04). Participants noted that the MIH program significantly improved appointment scheduling and access to health care services during the pandemic ( P < 0.05). Participants highly rated the preferability, convenience, safety, and use of the MIH program for future pregnancies.

Conclusions: Implementation of a perinatal MIH program for PWH and their infants led to significant improvement in engagement in HIV care after delivery. Our findings demonstrate that novel, interdisciplinary programming can fill critical gaps in care delivery, including during periods of health care disruption.

Background: The impact on infant bone, growth, and renal health of in utero and breast milk exposure to contemporary antiretroviral treatment (ART) remains unclear.

Methods: Six hundred forty-three pregnant women with HIV in 9 countries in Africa, Asia, and the Americas were randomized to start ART with dolutegravir (DTG) + emtricitabine (FTC)/tenofovir alafenamide (TAF), DTG + FTC/tenofovir disoproxil fumarate (TDF), or efavirenz (EFV)/FTC/TDF between 14 and 28 weeks' gestation and continued for 50 weeks postpartum. Pairwise comparisons used 2-sample t tests of mean week 26 infant bone mineral content (BMC) assessed by dual-energy X-ray absorptiometry in a subset; mean infant z-scores for length-for-age z-score (LAZ), weight-for-age z-score (WAZ), and weight-for-length (WLZ) at 26 and 50 weeks; and mean infant creatinine and estimated creatinine clearance at birth and 26 weeks.

Results: Five hundred seventy-seven infants were included in the growth analysis, and 169 in the dual-energy X-ray absorptiometry analysis. Week 26 infant spine BMC was significantly lower in the EFV/FTC/TDF arm (133.5 g) than in the DTG + FTC/tenofovir alafenamide [143.4 g; mean difference (95% confidence intervals): 0.22 (0.02, 0.42) g] and DTG + FTC/TDF [137.4; mean difference (95% confidence interval): 0.20 (0.01, 0.40) g] arms. Mean LAZ and WAZ scores through week 50 were also significantly lower in the EFV/FTC/TDF versus DTG arms, but not WLZ. Infant obesity was rare (2%-4%) and similar between arms. There was no apparent by-arm difference in infant creatinine or estimated creatinine clearance through week 50 ( P -values ≥ 0.18).

Conclusions: It is reassuring that maternal DTG-based ART during pregnancy and breastfeeding was associated with higher infant spine BMC, better growth, and less stunting than EFV/FTC/TDF.

Background: In 2019, South Africa's Antiretroviral Therapy (ART) Treatment Guidelines replaced efavirenz with dolutegravir in first-line ART.

Setting: We assessed the impact of this national guideline change on retention and viral suppression in the Themba Lethu Clinical Cohort, Johannesburg, South Africa. We applied a regression discontinuity design in a prospective cohort study of 1654 adults living with HIV initiating first-line ART within 12 months (±12 months) of the guideline change.

Methods: We compared outcomes in individuals presenting just before and after the guideline change and estimated intention-to-treat effects on initiating a dolutegravir- vs efavirenz-based regimen. Primary outcomes were retention and viral suppression. Participants were defined as retained in care if a visit took place within ±3 months of the 6-month end point. Viral suppression was defined as having a viral load ≤1000 copies/mL 3 months before and up to 6 months after the 6-month end point.

Results: The 2019 guideline change led to an increase in uptake of dolutegravir. We noted a 26.6 percentage point increase in the proportion initiating dolutegravir [95% Confidence Interval (CI): 14.1 to 38.6]. We saw a small increase in viral suppression [Risk Difference (RD): 7.4 percentage points; 95% CI: -1.6 to 16.5] and no change in retention (RD: -1.7 percentage points; 95% CI: -13.9 to 10.5) at 6 months, though our findings were imprecise.

Conclusions: Our estimates suggest early uptake of the revised treatment guidelines after implementation. Despite this, there was no meaningful change in viral suppression and retention rates at 6 months.

Introduction: Pre-exposure prophylaxis (PrEP) cannot meaningfully affect the HIV epidemic in the United States without improving access to PrEP and reducing PrEP disparities among gay, bisexual, and other men who have sex with men (GBM), especially GBM of color. A patient-centered approach to increase PrEP options will offer better PrEP solutions to GBM. We sought to understand how GBM prefer current and emerging PrEP modalities.

Methods: We conducted a national online survey among adult GBM to determine preferences for current and emerging PrEP modalities (daily, on-demand, and monthly oral, subcutaneous and intramuscular injectable, implantable, and rectal douche) and perceived barriers, based on their lived experiences. We determined PrEP modality preferences and associations using multivariable exploded logit regression model.

Results: In total, 723 GBM completed the survey. The largest proportion preferred monthly oral PrEP (n = 207, 28.6%), and more than half preferred some form of oral PrEP. Race was significantly associated with PrEP modality preference, and Black GBM preferred daily oral PrEP most. Side effects, health care visits, administration route, and frequency influenced PrEP preferences. PrEP and HIV knowledge, and HIV risk were associated with PrEP modality choice. GBM considered out-of-pocket cost and side effects as the significant barriers to PrEP care.

Conclusions: Monthly oral PrEP was most preferred with oral options preferred more than other modalities. Black GBM most preferred daily oral PrEP, which could be because of lack of familiarity with the emerging products. Future PrEP provision must include patient-centered prevention plans that include enhanced education and counseling to promote use of newer agents.

Background: The US National HIV/AIDS Strategy prioritizes improving quality of life (QoL) among people with HIV (PWH) but co-occurrence of different aspects of QoL is not well described. We developed and applied a novel, multi-item assessment of poor QoL among PWH and examined associations with selected outcomes.

Setting: 2018-2021 CDC Medical Monitoring Project data on 15,855 U.S. PWH.

Methods: The poor QoL index, measured by the number of indicators of poor QoL experienced included: poor/fair self-rated health, unmet needs for mental health services, and subsistence needs (hunger/food insecurity, unstable housing/homelessness, and unemployment). Score distributions were analyzed alongside data on individual QoL indicators. Associations with selected adverse outcomes were assessed, including not being retained in care, missing ≥1 HIV medical appointments, missing ≥1 ART dose, not having sustained viral suppression, and having ≥1 emergency room visit or ≥1 hospitalization.

Results: Overall, 55.1% of PWH had ≥1 indicator of poor QoL; 8.4% had ≥3 indicators. Over a quarter (26.5%) of people who inject drugs experienced ≥3 indicators of poor QoL. A large percentage of people aged 18-24 years had subsistence needs; 36.4% of Black women had poor/fair self-rated health. After adjusting for age, race/ethnicity, and sex, higher poor QoL index scores-and each indicator of poor QoL-were associated with worse outcomes.

Conclusions: We demonstrated the utility in using the poor QoL index to identify those at higher risk of experiencing health challenges. Expanding national recommendations to include this QoL assessment could help in meeting National HIV/AIDS Strategy goals for improving PWH's well-being.

Objective: To explore the lived experiences of community health workers (CHW) engaged in efforts toward the elimination of vertical transmission (EVT) of HIV and to assess the impact of a capacity-building training intervention.

Design: The study consisted of (1) a qualitative assessment of lived experiences of CHWs; (2) a capacity-building training intervention responsive to identified needs; and (3) assessment of the training intervention using pre- and postintervention questionnaires.

Methods: Focus group discussions and semistructured key informant interviews in addition to CHW training sessions for HIV/EVT were held in 1 rural and 1 semiurban setting in Uganda, based on training materials developed by the World Health Organization and the United States Agency for International Development (USAID). We used standardized pre- and postintervention questionnaires to assess comprehensive knowledge and accepting attitudes toward HIV.

Results: Qualitative exploration of the lived experience of 152 CHWs in 10 focus group discussions and 4 key informant interviews revealed several themes: (1) CHWs as bridges between health system and community; (2) CHW assets (tacit knowledge and shared social networks); (3) CHW challenges (stigma, secrecy, and ethical quandaries); (4) favorable community reception; and (5) need for continuing education and reinforcement of skills. In response to identified needs, a capacity-building intervention was designed and implemented with 143 CHWs participating in 10 sessions. The proportion of participants with comprehensive knowledge of HIV increased from 45% to 61% ( P = 0.006), and the proportion endorsing accepting attitudes increased from 63% to 76% ( P = 0.013).

Conclusion: CHWs are potentially valuable players in global EVT efforts. Ongoing training is needed to support community-level initiatives.

Background: Self-perceived HIV risk influences pre-exposure prophylaxis (PrEP) use, although few data on risk perception are available among pregnant women. We evaluated HIV risk perception and PrEP uptake among pregnant women in Kenya.

Methods: We used data from a randomized trial evaluating universal versus risk-based PrEP delivery models at 20 antenatal clinics in Kenya (NCT03070600). Pregnant women enrolled were offered PrEP at any gestational age. A validated risk score for predicting HIV acquisition among perinatal women defined high HIV risk. HIV risk perception was assessed by asking "What is your gut feeling about how likely you are to get infected with HIV?" without a specified timeframe and dichotomized as low ("extremely/very unlikely") versus high ("extremely/somewhat likely/very likely"). All women in the universal PrEP offer arm were included in the analysis.

Results: Among 2250 pregnant women, the median age was 24 years (interquartile range 21-28), 81% were married, and 22% did not know their partner's HIV status. Overall, 27% of women had high HIV risk scores of whom 61% self-perceived high risk. Among women with high HIV risk scores (n = 617), 69% declined PrEP; those who self-perceived low risk were more likely to decline than those with high risk perception (82% vs. 60%, adjusted prevalence ratio = 1.35, 95% confidence interval: 1.17-1.55, P < 0.001). Declining PrEP was associated with late gestational age at PrEP offer and with monogamous marriage among women with high HIV risk scores ( P < 0.05).

Conclusions: Declining PrEP was common among pregnant women with high HIV risk, especially those who self-perceived low HIV risk. Refining risk perception may encourage PrEP uptake.