JAIDS Journal of Acquired Immune Deficiency Syndromes最新文献

Background: Rapid linkage to HIV care and antiretroviral therapy (ART) initiation is now the standard of care for treating people with HIV (PWH). Understanding and intervening on barriers to rapid enrollment and ART initiation are needed to meet the goals of the Ending the HIV Epidemic in the U.S. initiative.

Methods: We analyzed 2021 data from the Medical Monitoring Project on characteristics of 455 facilities providing care to a national probability sample of U.S. PWH.

Results: Overall, only 19.9% (95% CI 16.0%-23.9%) of HIV facilities could routinely offer a first appointment in <1 business day (rapid enrollment). The most commonly reported barriers to rapid enrollment were insufficient provider capacity (56%), patient preference (50%), and patients lacking required documents (19%). The most commonly reported documents required for enrollment were positive HIV antibody or detectable viral load (52%), government-issued identification (36%), proof of residence (24%), and proof of income (22%). RWHAP-funded facilities more frequently required these documents than non-RWHAP-funded facilities. Most facilities (73%) were routinely able to obtain a 30-day supply of ART during the first HIV care provider visit (rapid ART initiation). The most commonly reported barriers to rapid ART included unavailable test results (56%), delays in getting medication paid for (49%), unavailable starter packs (36%), inability to afford copayment (31%), and patient preference (29%).

Conclusion: Structural, provider-related, or patient-level barriers may delay rapid clinic enrollment or ART initiation. HIV care programs can benefit from removing barriers to care, easing requirements for clinical enrollment and ART prescriptions, and improving patient readiness.

Background: Black/Latino men who have sex with men (MSM) in the United States have high rates of undiagnosed HIV infection. To assess whether HIV self-testing increases HIV screening among Black/Latino MSM and how HIV self-testing for Black/Latino MSM compares to White MSM, we analyzed data from a 12-month randomized controlled trial.

Methods: Participants were randomized to quarterly allocation of: HIV testing reminders (control, no HIV self-tests), home delivery of rapid HIV self-tests (standard HIV self-test), or home delivery with counseling 24 hours after opening tests (eTest). In this secondary analysis, we used Poisson regression models to evaluate HIV testing rates for the different approaches among Black/Latino MSM compared to White MSM.

Results: Of a final analytical sample of 713 participants, 353 were White MSM and 360 were Black/Latino MSM. In all approaches, we found no evidence of differences in HIV testing between White MSM and Black/Latino MSM. Predicted probabilities indicated higher testing among Black/Latino MSM assigned to the HIV self-test conditions compared to Black/Latino MSM in the control condition. The probabilities of any HIV testing among Black/Latino MSM in the standard HIV self-test, eTest, and control conditions were 92%, 90%, and 58%, respectively (all p<.05).

Conclusions: Results from this randomized controlled trial suggest that Black/Latino MSM use HIV self-tests at high rates and found no evidence that HIV self-test use differs between Black/Latino MSM and White MSM. Implementation science research is needed to increase the availability of HIV self-tests for all MSM, especially underserved populations such as Black/Latino MSM.

Background: Dual regimen dolutegravir/lamivudine (DOL/3TC) showed potent efficacy and favorable safety in both antiretroviral therapy-naive and therapy-experienced patients, but data from real life about naive people with high-level viremia are still lacking.

Methods: We performed a retrospective cohort study of people living with HIV who were naive to antiretroviral therapy, had baseline HIV-1 RNA ranging from 100,000 to 500,000 copies/mL, and initiated DOL/3TC. Virologic efficacy and changes in immunologic parameters after 12 months of treatment were evaluated and compared with highly viremic people living with HIV who started a triple antiretroviral combination.

Results: Inclusion criteria were met by 58 patients with median age of 43.4 years. At baseline, mean HIV RNA was 5.4 log 10 and mean CD4 T lymphocyte count was 488 cells/mm 3 . HIV RNA <50 copies/mL was obtained in 45 patients (77.6% in the intention-to-treat analysis) after 6 months and in 53 patients (91.4%) after 12 months. Reasons for treatment failure were virologic failure in 2 cases and adverse events in 3 cases. No significant changes in median value of lipids were reported, while there was a not significant increase in body weight (+1.18 kg). Virologic and immunologic response at month 12 in patients on DOL/3TC was comparable with that observed in 50 naive patients with high-level viremia and starting a triple antiretroviral therapy.

Conclusions: In this real-life cohort of naive patients with high-level viremia, DOL/3TC was associated with high virologic efficacy and good tolerability after 12 months, supporting use of this dual regimen also in persons with high initial viremia.

Background: People with schizophrenia spectrum disorders are at elevated risk of HIV, and people with both HIV and schizophrenia are at elevated risk of death compared with individuals with either diagnosis alone. Limited research has assessed the HIV care cascade, and in particular retention in care, among people with HIV (PWH) and schizophrenia in the United States.

Methods: This population-based retrospective cohort study used Medicaid claims data to compare retention in HIV care between PWH with schizophrenia (n = 38,217) and matched controls without schizophrenia (n = 29,455) from 2001 to 2012. The primary outcome of annual retention in HIV care was at least 2 tests for CD4 + T-cell count or HIV viral load at least 90 days apart per year. Unadjusted and covariate-adjusted differences in period prevalence of retention among cases and controls were estimated.

Findings: Annual retention in HIV care was 29.9% (95% CI: 29.4 to 30.4%) among people with schizophrenia and 38.5% (95% CI: 37.9 to 39.1%) among controls, representing 8.5% (95% CI: 9.3 to 7.7) lower retention in unadjusted and 9.0% (95% CI: 9.9 to 8.2) lower retention in adjusted estimates for people with HIV and schizophrenia. This disparity varied across states. Over time, retention increased and the disparity between people with and without schizophrenia diminished.

Interpretation: PWH in the United States insured through Medicaid and diagnosed with schizophrenia experience lower retention in HIV care than controls. Suboptimal retention likely drives disparities in HIV-related morbidity and mortality for PWH with schizophrenia, and targeted individual and structural interventions are merited to improve the health of this population.

Background: Suboptimal adherence to pre-exposure prophylaxis (PrEP) limits its global impact, with current evidence mostly from the Global North and lacking Global South perspectives. This meta-analysis synthesizes the rates and determinants of suboptimal adherence to oral PrEP among men who have sex with men (MSM) in both regions.

Methods: We searched for literature describing PrEP adherence and its determinants among MSM globally up until October 2024 to conduct a meta-analysis on the rate and determinants of suboptimal adherence in both regions. The definition of (sub-)optimal adherence was study based.

Results: We included 82 studies in the meta-analysis, with 24, 53, and 5 stemmed from the Global South, North, and global multicenter studies, respectively. Oral PrEP suboptimal adherence is prevalent among MSM PrEP users globally (rate = 0.33, 95% confidence interval [CI]: 0.28 to 0.38) with a significantly higher rate ( P = 0.021) in the Global South (rate = 0.41, 95% CI: 0.33 to 0.50) than in the Global North (rate = 0.29, 95% CI: 0.23 to 0.35). In the Global South, older age (OR = 0.57, 95% CI: 0.37 to 0.87), alcohol use (OR = 1.28, 95% CI: 1.02 to 1.60), and presenting depressive symptoms (OR = 1.47, 95% CI: 1.01 to 2.16) were associated with suboptimal adherence. In the Global North, MSM self-identified as Black (OR = 2.27, 95% CI: 1.31 to 3.95) or Other (OR = 1.36, 95% CI: 1.02 to 1.81), having a university degree (OR = 0.50, 95% CI: 0.34 to 0.73), and presenting depressive symptoms (OR = 2.26, 95% CI: 1.35 to 3.78) were associated with suboptimal adherence. On-demand PrEP users globally demonstrated a higher likelihood of suboptimal adherence (OR = 1.59, 95% CI: 1.18 to 2.14).

Conclusions: Suboptimal adherence to oral PrEP is prevalent among MSM globally, particularly higher in the Global South. Regional differences in determinants highlight the need for tailored interventions. Tailored interventions are required to address mental health with tailored efforts to younger MSM in the Global South, while interventions in the Global North should be tailored to specific subgroups.

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, 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 social determinants of health and mental health that drive inequities in health outcomes among persons with HIV aged 18-24 years.

Background: Preventing HIV infections among adolescents and young adults (AYAs) is crucial for curtailing the epidemic. Oral pre-exposure prophylaxis (PrEP) is a highly effective prevention method increasingly available to this age group in sub-Saharan Africa but population-based data on awareness and use of PrEP among AYAs remains limited.

Methods: Analyzing survey data from 2 rounds of the Rakai Community Cohort Study, an open, population-based cohort, we estimated prevalence ratios associating various sociodemographic characteristics with PrEP awareness and ever-use among 15- to 24-year-olds in south-central Uganda between 2018 and 2023.

Results: Most (62.4%, N = 3308/5301) participants were aware of PrEP as an HIV prevention method but only 1.7% (N = 133/7999) of AYAs had ever used it. Among the 35.5% (N = 2838/7999) of participants meeting PrEP eligibility criteria, ever-use was similarly rare (2.6%, N = 75/2838). Compared with 20 to 24-year-olds, 15 to 19-year-olds were less likely to report awareness [fullyadjPR (prevalence ratio) = 0.82, 95%CI (confidence interval): 0.78, 0.86] or ever-use (fullyadjPR = 0.35, 95%CI: 0.21, 0.58). Participants from fishing communities were more likely to be PrEP-aware (fullyadjPR = 1.22, 95%CI: 1.16, 1.29) or have ever used the prevention method (fullyadjPR = 6.07, 95%CI: 4.10, 8.98) than those from non-fishing communities.

Conclusions: In this cross-sectional study of AYAs in Uganda, awareness of PrEP was common but ever-use was rare, even among the third of respondents who were likely PrEP-eligible. This suggests that prevention policies and barriers besides unawareness of the method impede PrEP initiation. Efforts that target those barriers, particularly for adolescents, are critical for reducing HIV incidence among this priority population.

Background: Fertility desire-based service guided by behavioral theory is a potential strategy to mitigate the HIV transmission risk, while related evidence remains scarce. We examined the long-term effect of theory-guided fertility desire-based services on HIV seroconversion between seropositive and seronegative partners in areas with high HIV prevalence and a cultural emphasis on fertility in China.

Methods: We established a retrospective cohort by recruiting 8653 seropositive partners with seronegative partners between January 1, 2009, and December 31, 2020, in Liangshan, China. The differences in HIV seroconversion between partners who received fertility desire-based services guided by the extended Information-Motivation-Behavioral Skills model and those who did not were estimated, based on multivariable and inverse probability weighting adjusted multivariable Cox regression models. Subgroup analysis was conducted based on participants' demographic and HIV-related characteristics.

Results: Among the 8653 HIV-seropositive partners, 7958 (92.0%) and their seronegative partners received fertility desire-based services. At the end of the 12-year follow-up, 18 seronegative partners who did not receive fertility desire-based services experienced HIV seroconversion (incidence density: 7.4/1000 person-years), while 98 seronegative partners receiving such services exhibited HIV seroconversion (3.4/1000 person-years). Fertility desire-based services significantly reduced the risk of HIV seroconversion according to multivariable (HR = 0.32, 95% CI: 0.19 to 0.53) and inverse probability weighting-adjusted multivariable Cox regression models (HR = 0.48, 95% CI: 0.27 to 0.84). The effect of fertility desire-based services was more pronounced in men and those older than 40 years.

Conclusions: Fertility desire-based services based on the extended Information-Motivation-Behavioral Skills model may help reduce the HIV transmission risk between seropositive and seronegative partners in areas with high HIV prevalence.

Background: Unprotected receptive anal intercourse carries the highest sexual HIV transmission risk. The need for diverse pre-exposure prophylaxis (PrEP) options has encouraged the development of on-demand, topical PrEP products for those preferring nonsystemic or occasional PrEP. We assessed end users' proficiency in preparing tenofovir douches from sachets containing 2 different powder types, lyophilized and spray dried, and evaluated their experience.

Methods: Cisgender adult men with a history of RAI-related douching were consented, screened, and randomized 1:1 to the order of the powder type prepared. All participants prepared at least 3 enema bottles of each powder type. Aliquots from each prepared douche bottle were analyzed for tenofovir (TFV) concentration, osmolality, and pH. User experience and likelihood of future product use were assessed by questionnaire.

Results: Twenty-one eligible participants were enrolled. Most participants reported both products as easy or very easy to prepare and likely or very likely to be used. Participants preferred the lyophilized product. The lyophilized and spray-dried douche bottles prepared met the osmolality specifications 89% and 61% of the time and TFV content specifications 81% and 29% of the time, respectively. Questionnaires indicated the most common challenges were tearing open the sachets and transferring the spray-dried product.

Conclusions: Most participants reported the douches were easy to prepare and indicated likely future use. Although the lyophilized sachets were prepared sufficiently to establish preparation feasibility, the spray-dried sachets often fell outside specifications. Failure analysis provided insights to guide product modifications to improve the proficiency of douche preparation and future product use.