JAIDS Journal of Acquired Immune Deficiency Syndromes最新文献

Background: HIV continues to disproportionately impact men who have sex with men (MSM) in the United States (US). Pre-exposure prophylaxis (PrEP) is effective, but disparities persist. Limited studies have conducted systematic evaluations of social determinants of health (SDOH) and their effects on PrEP persistence among MSM.

Setting: We enrolled MSM into a prospective observational cohort to assess progression through the PrEP care continuum. We enrolled patients from three diverse US settings from 2018-2022.

Methods: We explored the impact of SDOH on PrEP persistence (defined as successfully obtaining PrEP prescriptions and/or clinical documentation of retention in PrEP care) at 6- and 12-months using multilevel, mixed-effects logistic models.

Results: A total of N=300 MSM were enrolled. Median age was 28 years; 40% were Black/African American (B/AA), and 11% were Hispanic/Latino (H/L). PrEP persistence was 84.7% and 49.3% at 6- and 12-months, respectively. In the unadjusted analysis, B/AA and H/L individuals were 56% and 54%, respectively, less likely to demonstrate PrEP persistence at 6- and 12-months compared to white/non-H/L individuals. Findings were no longer significant after adjusting for economic stability and educational attainment. Individuals with higher levels of internalized homophobia were less likely to persist on PrEP. Every 1-unit increase on a validated measure of internalized homophobia was independently and negatively associated with PrEP persistence (adjusted odds ratio = 0.95, 95% CI: 0.93-0.98).

Conclusion: SDOH are important predictors of racial and ethnic disparities in PrEP persistence among MSM. Addressing these factors could help mitigate racial disparities in PrEP persistence in the US.

Background: Persons aged 13-24 years are a priority population in the National HIV/AIDS Strategy. Young adults with HIV have poorer health outcomes-including not being retained in care, antiretroviral nonadherence, and not being virally suppressed-than other persons with HIV.

Setting: Centers for Disease Control and Prevention's Medical Monitoring Project data collected June 2018 through May 2022.

Methods: We compared demographic characteristics, social determinants of health (SDOH), and mental health between persons aged 18-24 years with HIV versus persons aged ≥25 years with HIV. Among those aged 18-24 years, we analyzed total and unmet needs for ancillary services, defined as those that support care engagement, viral suppression, and overall health and well-being among people with HIV.

Results: Persons aged 18-24 years were more likely to have a household income <100% of the federal poverty level (48% vs. 39%), and experience unstable housing or homelessness (37% vs. 18%) or hunger/food insecurity (29% vs. 18%) than those aged ≥25 years. Persons aged 18-24 years had higher median HIV stigma scores (40 vs. 29) and were more likely to experience symptoms of generalized anxiety disorder (21% vs. 15%) than those aged ≥25 years. Of persons aged 18-24 years, 96% had a need for ≥1 ancillary service, of whom 56% had ≥1 unmet need; unmet needs were highest for subsistence services (53%) and non-HIV medical services (41%).

Conclusions: Addressing unmet needs for subsistence and non-HIV medical services could help reduce disparities in SDOH and mental health that drive inequities in health outcomes among persons with HIV aged 18-24 years.

Introduction: There are persistent race- and ethnicity-based disparities in HIV incidence among gay and bisexual men who have sex with men (GBMSM) in the United States, partially driven by inequities in distribution of pre-exposure prophylaxis (PrEP). We assessed how additional modalities of PrEP beyond daily oral might affect uptake of PrEP and ongoing disparities in HIV incidence in the US.

Methods: In an online survey of GBMSM in the US, we presented participants with descriptions of each PrEP modality. Among GBMSM not willing to use daily oral PrEP, we assessed willingness to use on-demand or long-acting injectable (LA) PrEP. Among GBMSM using daily oral PrEP, we assessed willingness to switch to on-demand or LA PrEP.

Results: Among GBMSM who were not willing to use daily oral PrEP, most were also not willing to use either on-demand or LA PrEP. In adjusted analyses, Hispanic/Latino, non-Hispanic/Latino Black, and non-Hispanic/Latino GBMSM of other races were more willing to use LA PrEP than non-Hispanic/Latino White GBMSM; none of the adjusted prevalence ratios was statistically significant. Most GBMSM currently taking daily oral PrEP reported a preference for staying on that regimen. Among those interested in switching, most were interested in on-demand PrEP.

Conclusions: Most GBMSM not willing to use daily oral PrEP are also not willing to use other modalities of PrEP; most GBMSM who are currently using daily oral PrEP prefer to continue using that dosing strategy. Our results suggest that differential preferences in modalities of PrEP will not exacerbate existing disparities in PrEP distribution or HIV incidence.

Background: Community-level social vulnerabilities may affect HIV outcomes. This analysis assessed the association between county-level social vulnerability and CDC-funded HIV testing program outcomes.

Setting: HIV testing data from 60 state and local health departments and 119 community-based organizations were submitted to CDC during 2020-2022.

Methods: HIV testing data were combined with county-level Minority Health Social Vulnerability Index, which measures economic, medical, and social vulnerability. We calculated absolute and relative disparity measures for HIV testing program outcomes (i.e., HIV positivity, linkage to medical care, interview for partner services, referral to PrEP providers) between high and low social vulnerability counties. We compared differences in HIV testing program outcomes by demographic factors and test site type.

Results: The majority (85.8%) of the 4.9 million tests were conducted in high social vulnerability counties. HIV positivity (1.1%) and linkage to medical care after a new diagnosis (77.5%) were higher in high social vulnerability counties. However, interview for partner services after a new diagnosis (72.1%) and referrals to PrEP providers among eligible HIV-negative persons (48.1%) were lower in high social vulnerability counties. Additionally, the relative disparity in HIV testing program outcomes varied by demographic factors and test site type.

Conclusion: CDC-funded HIV testing programs reach the most vulnerable communities. However, testing outcomes vary by community vulnerability, demographic factors, and test site type. Continued monitoring of the relationship between county-level social vulnerability and HIV testing program outcomes would guide HIV testing efforts and allocate resources effectively to achieve the national goal of ending the HIV epidemic.

Background: In the United States, up to 75% of primary care patients go untested for HIV each year, and nearly two-thirds of adults report never having been tested for HIV. Integrated HIV and STI testing, combining these tests into a single visit, is recommended as a status neutral approach to prevention.

Setting: Over 200 New York State Department of Health-funded primary care clinics, hospitals, health centers and community-based organizations funded to conduct integrated screening.

Methods: We analyzed weekly testing data from December 2022 to January 2024 to prospectively evaluate whether integrated HIV and STI testing events and results occurred within 30 days of each other. We also assessed group differences in integrated testing by sex at birth, gender, race/ethnicity, risk, organization type, and pre-exposure prophylaxis (PrEP) status using Pearson's Chi-square tests and calculated prevalence ratios using log binomial models stratified be PrEP usage. Analyses were restricted to individuals with an HIV-negative status.

Results: Integrated testing was completed for 69% for individuals on PrEP and 39% for those not taking PrEP, with significant differences observed across all client-specific categories at p < 0.001. Except for age group, variations in integrated screening levels by client characteristics were similar by PrEP status. Individuals who identified as female at birth, as non-Hispanic Black, without an elevated risk, and those tested in non-hospital settings were significantly less likely to experience integrated screening. HIV-test reactivity was 0.04% among integrated testers and 0.15% for HIV-only testers. STI-test reactivity was 4.9% among integrated testers and 7.8% for STI-only testers.

Conclusions: A significant gap was identified in integrated testing among providers specifically funded to perform it, resulting in missed opportunities for identification of HIV and other sexually transmitted infections. Integrating HIV and STI testing at a systems level will require significant changes to the perceived individual- and provider-level risks and benefits associated with testing.

Background: Neuropsychiatric adverse events (NPAEs) are associated with several antiretrovirals. Doravirine (DOR), a non-nucleoside reverse transcriptase inhibitor indicated for HIV-1 treatment, does not interact significantly with known neurotransmitter receptors in vitro. First-line therapy with DOR-based regimens resulted in significantly fewer NPAEs than efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF) and similar rates to those of ritonavir-boosted darunavir (DRV/r) with 2 nucleos(t)ide reverse transcriptase inhibitors (NRTIs) through Week 96 of the phase 3 DRIVE-AHEAD and DRIVE-FORWARD studies, respectively.

Methods: In DRIVE-AHEAD (NCT02403674) and DRIVE-FORWARD (NCT02275780), treatment-naive adults randomly received DOR/lamivudine/TDF or EFV/FTC/TDF and DOR + 2 NRTIs or DRV/r + 2 NRTIs, respectively, for a 96-week double-blind phase; afterward, participants could continue or switch to a DOR-based regimen for a 96-week open-label extension.

Results: Overall, 269 and 233 participants in DRIVE-AHEAD and DRIVE-FORWARD, respectively, switched to a DOR-based regimen. At Week 96, 26 and 15 participants randomized to EFV/FTC/TDF and DRV/r + 2 NRTIs, respectively, had ongoing NPAEs, resolving by Week 192 in 73% (19/26) and 40% (6/15) of participants switching to a DOR-based regimen. New-onset NPAEs were reported by 9% (25/269) and 8% (18/233) of participants; by Week 192, new-onset NPAEs were resolved and/or resolving in 60% (15/25) and 61% (11/18) of participants.

Conclusions: In both trial extensions, NPAEs persisted in 3-4% of participants 96 weeks after switching to a DOR-based regimen, possibly representing the background rate for these events. This suggests DOR-based therapy may be a good option for adults with baseline neuropsychiatric symptoms or those experiencing NPAEs with other antiretrovirals.

Introduction: Little is known about the clinical status of persons with HIV (PWH) who re-engage in care after an interruption. We evaluated the immunological and clinical characteristics of individuals re-engaging in care within the Swiss HIV Cohort Study.

Methods: Participants who re-engaged in care after an interruption >14 months with a viral load ≥100 copies/mL were classified as having interrupted ART. We defined late re-engagement as re-engaging with a CD4 cell count of <350 cells/µL or a new CDC stage C disease. Linear and logistic regression models with restricted cubic splines were used to estimate the mean CD4 cell count at re-engagement and the probability of late re-engagement as a function of care interruption duration.

Results: Of 14,864 participants with a median follow-up of 10.2 years (IQR 4.7-17.2 years), 2,768 (18.6%) interrupted care, of whom 1,489 (53.8%) re-engaged. Among those re-engaging, 62.3% had interrupted ART. For participants who interrupted ART, the mean CD4 count declined from 374 cells/µL (95% CI 358-391 cells/µL) before the interruption to 250 cells/µL (95% CI 221-281 cells/µL) among those re-engaging after 14 months, and to 185 cells/µL (95% CI 160-212 cells/µL) among those re-engaging after 60 months. The estimated risk of late re-engagement in care was 68.6% (95% CI 62.3-74.4%) for participants who interrupted ART for 14 months and 75.2% (95% CI 68.9-80.6%) for those who interrupted ART for 60 months.

Conclusion: Although HIV care interruptions are not very common in Switzerland, the majority of PWH re-engaging after interrupting ART return with late-stage HIV.

Background: Data on tuberculosis (TB) incidence and risk factors among children living with HIV (CLHIV) in the universal ART era are limited.

Methods: We analysed routinely-collected data on TB diagnoses for CLHIV age ≤5 years, born 2018-2022, in the Westen Cape, South Africa. We examined factors associated with TB diagnosis, with death and loss to follow-up as competing events.

Results: Among 2,219 CLHIV, 30% were diagnosed with HIV at birth. Median follow-up from birth was 38 months (IQR 24-50); 90% started antiretroviral therapy (ART). TB was diagnosed in 28% of CLHIV (n=626/2219); 62% were first diagnosed before/within 3 months of ART start ('TB before ART') and 38% >3 months after ART start ('TB after ART'). Of those with 'TB before ART' (n=390), median age at HIV diagnosis was 13 months (IQR:6-22); median time between HIV and TB diagnoses was 5 days (IQR:0-31). 'TB before ART' was associated with older age at HIV diagnosis and advanced/severe immunodeficiency. Of those with 'TB after ART' (n=258), median age at HIV diagnosis was 2 months (IQR 0-8) and median time from ART start to TB diagnosis was 12 months (IQR:7-21). 'TB after ART' was associated with increased viral load and advanced/severe immunosuppression (time-updated). Overall, 5% (n=112/2219) of CLHIV died, 36% of whom were diagnosed with TB (median time from TB diagnosis to death: 58 days; IQR:17-191).

Conclusions: Young CLHIV in this setting have high TB-associated morbidity and mortality. Efforts to improve early HIV and TB diagnosis, viral suppression and TB preventive therapy are needed.

Introduction: Few data are available about the forgiveness of two-drug (2DR) or low-barrier three-drug antiretroviral regimens. The aim of this study is to evaluate the real-life forgiveness of lamivudine/dolutegravir (3TC/DTG) and emtricitabine/tenofovir alafenamide/rilpivirine (FTC/TAF/RPV).

Methods: A two center retrospective observational study enrolled all people with HIV (PWH) treated with 3TC/DTG or FTC/TAF/RPV. Adherence was measured as the proportion of days covered (PDC) by drug supply. Binary logistic regression was applied to test the impact of baseline variables and adherence on the achievement of virological suppression.

Results: 1258 adult PWH were enrolled, 368 in 3TC/DTG and 890 in RPV/F/TAF. Most were males (71 %), with median age of 51 years (IQR 43-58 years) and median CD4 nadir of 305 cells/mcL (IQR 132-485). The median cohort follow-up totaled 4558 persons/year. Median adherence, as calculated from PDC, was of 0.98 (IQR 0.93-1). Irrespective of the treatment group, a PDC as low as 0.8 was sufficient to obtain HIV-RNA below 200 copies/mL in almost all study participants. The same adherence value also allowed the achievement of HIV-RNA below 50 copies/mL in > 90% of study participants. PDC (P < 0.0001), Italian origin (P < 0.0001) and male sex (P = 0.038) significantly correlated to the achievement of < 200 copies/mL.

Conclusions: In this study, we found a similar and high grade of forgiveness in the INSTI-based 2-drug regimen 3TC/DTG and in the NNRTI-based 3-drug regimen FTC/TAF/RPV.