JAIDS Journal of Acquired Immune Deficiency Syndromes最新文献

Background: In sub-Saharan Africa, pediatric and adult treatment programs have not met the needs of youth living with HIV (15-24 years), whose enrollment in antiretroviral treatment (ART) programs is much lower than that of adults. To inform targeted interventions, we analyzed factors associated with ART use among youth in Uganda.

Methods: Data were from 42 communities between 2011 and 2020 (5 survey rounds) from the Rakai Community Cohort Study, an open, population-based cohort. Among youth, we assessed trends in ART use over time and demographic characteristics and sexual behaviors associated with ART use.

Results: Youth (N = 1518) contributed 2101 person-visits. ART coverage increased over time with 8% of men and 11% of women on ART in 2011-2013 and 45% and 68%, respectively, on ART in 2018-2020 (AORwomen vs. men=2.57; 95% CI: 1.72 to 3.84). Youth with 2 or more sexual partners compared with youth with 0-1 sexual partner were less likely to be on ART (men AOR = 0.40; 0.19-0.82; women AOR = 0.54; 0.41-0.72). Youth who reported consistent condom use were more likely to be on ART (men AOR = 2.94; 95% CI: 1.14 to 7.57; women AOR = 1.70; 95% CI: 1.00 to 2.88).

Conclusions: In this longitudinal study, ART use among youth increased over time, yet at 63% remained well below UNAIDS 95-95-95 goals, thus depriving many of lifesaving treatment. Those engaging in fewer protective sexual behaviors had lower ART use, thus further increasing risk of future HIV transmission. Targeted efforts are needed to ensure rapid initiation of ART and continued engagement among this vulnerable population.

Background: Effective implementation of evidence-based HIV prevention interventions continues to be a challenge in the United States, and the field is increasingly turning to implementation science for solutions. As such, it is critical to expand the current implementation science vocabulary - and its taxonomy of implementation strategies - to increase its relevance and utility for front-line implementers.

Setting: Community-based health centers providing HIV prevention services in the Southeastern US.

Method: We conducted a collective case-study analysis, combining document review and qualitative interviews with program directors, clinicians, and other providers (N = 30) at five sites. We employed an inductive and iterative analytic approach to specify and categorize strategies, and then conducted in-depth cross-case analysis to derive a practice-driven taxonomy of HIV prevention implementation strategies.

Results: From an initial matrix of 264 activities, we identified 50 strategies common across sites. In contrast to existing implementation science frameworks, the majority (68%, n = 34) of strategies were designed to impact implementation outcomes (e.g., acceptability, adoption, feasibility) for patients. We present a practice-driven taxonomy of these strategies, operationalized according to implementation science literature, but with terminology that more directly relates to implementers.

Conclusions: Findings demonstrate the feasibility and utility of this method for developing a practice-driven implementation science vocabulary for HIV prevention. Our evidence-based taxonomy provides a framework for implementers seeking data about the universe of strategies they might consider for their own programs, and increases researchers' ability to measure and evaluate the effectiveness of implementation strategies being enacted in practice settings.

Background: HIV/AIDS has been a global health crisis for over four decades. Network models, which simulate human behavior and intervention impacts, have become an essential tool in guiding HIV prevention strategies and policies. However, no comprehensive survey of network models in HIV research has been conducted. This paper fills that gap, offering a summary of past work and future directions to engage more researchers and inform policy related to eliminating HIV.

Setting: Network models explicitly represent interactions between individuals, making them well-suited to study HIV transmission dynamics. Two primary modeling paradigms exist: a mechanistic approach from applied mathematics and a statistical approach from the social sciences. Each has distinct strengths and weaknesses, which should be understood for effective application to HIV research.

Methods: We conducted a systematic review of network models used in HIV research, detailing the model types, populations, interventions, behaviors, datasets, and software employed, while identifying potential future research directions.

Results: Network models are particularly valuable for studying behaviors central to HIV transmission, such as partner selection and treatment adherence. Unlike traditional models, they focus on indi- vidual behaviors, aligning them with clinical practice. However, more accurate network data are needed for better model calibration and actionable insights.

Conclusion: This paper serves as a point of reference for HIV researchers interested in applying network models and understanding their limitations. To our knowledge, this is the most comprehensive review of HIV network models to date.

Background: Implementation science has been heralded as a critical strategy for ending the HIV epidemic (EHE), and the United States (US) has made a tremendous financial investment in implementation research. However, several dynamics in its development and organization may alienate front-line implementers and recapitulate some of the same missteps that have stymied past translational work.

Setting: Increasing the accessibility and relevance of HIV implementation science for front-line implementers (e.g., health department and health systems directors, clinic administrators, program managers, clinicians, and other providers) is critical.

Methods: We review current challenges to the meaningful inclusion of front-line implementers in implementation science research, and consider specific changes to language, frameworks, and methods that would maximize the accessibility and relevance of the field.

Results: Our analysis suggests the need for greater attention to implementation strategies most relevant to front-line implementers, i.e., those focused on intervention recipients. We propose a novel, multi-layer framework for conceptualizing the strategies necessary to achieve HIV implementation outcomes by organizations, providers, and recipients. There is a compelling rationale to adopt incentive structures that prioritize research questions most important for practice.

Conclusions: Maximizing the impact of implementation science on EHE goals requires: (a) expanding the focus of implementation science to include more recipient-focused implementation strategies; (b) developing and applying frameworks that better reflect the experience and needs of front-line implementers; (c) using language most relevant and applicable to practice, and (d) prioritizing actionable research questions that directly address the needs and concerns of those doing implementation work.

Background: Sexual and gender minorities (SGM) bear a high burden of HIV. The age of anal sexual debut may influence HIV care engagement. Our objective was to evaluate this relationship to help healthcare providers promote and anticipate future HIV care engagement among at-risk SGM.

Methods: The TRUST/RV368 study provided HIV testing and treatment at SGM-friendly clinics in Abuja and Lagos, Nigeria. Self-reported age of sexual debut was dichotomized as <16 or ≥16 years. Multivariable logistic models estimated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the association of sexual debut with 1) prior HIV testing history, 2) HIV testing at the clinics, 3) initiation of antiretroviral therapy (ART) within 6 months of a clinic diagnosis, 4) viral suppression within 12 months of ART initiation.

Results: Of the 2,680 participants, 30% (n=805) reported a sexual debut <16 years. Those with an <16-year debut had significantly more receptive sex partners, condomless sex, and transactional sex (all p<0.01) and were 24% less likely to have tested for HIV before enrollment (aOR: 0.76; CI: 0.62-0.93). However, <16-year debut was not associated with HIV testing, receiving ART or achieving viral suppression once engaged with TRUST/RV368 (all p>0.05).

Conclusions: SGM with <16-year debut engaged in behaviors that could increase HIV risk and were less likely to have a history of HIV testing. However, once enrolled in SGM-friendly clinics, uptake of HIV care was not associated with <16-year debut, suggesting that SGM-friendly care models may promote HIV care engagement.

Background: Despite high oral pre-exposure prophylaxis (PrEP) uptake among young heterosexual cisgender women, early discontinuation is frequent. It is unclear whether this aligns with potential HIV exposure.

Methods: Young women 16-25 years and ≥1 of their male partners were enrolled in separate but linked longitudinal HIV PrEP studies in Kampala, Uganda from 2018-2021. Data on sexual behavior, PrEP use, STI positivity, and Y chromosome DNA (Yc DNA; a marker for condomless sex) were collected at enrollment and quarterly visits. Potential HIV exposure was defined as one of the following in the past 3 months: any STI, detection of Yc DNA, condomless vaginal sex, or multiple sex partners. Alignment between potential HIV exposure and PrEP use by participants was examined using GEE regression.

Results: 88 young women (median age=20.6, IQR 19.5-22.0) and 124 male partners (median age=23.5, IQR 21.0-26.0) were included. Women and men were dispensed PrEP in 66.9% and 60.5% of their first linked visits, respectively. PrEP dispensation was more common when women or men self-reported condomless vaginal sex and multiple sex partners, or when women had Yc DNA detected in vaginal swabs. Men's self-report of multiple partners (aPR=1.56, p=0.012) and the detection of Yc DNA (aPR=1.52, p=0.040) were significantly associated with women's PrEP dispensation.

Conclusions: Women and their male partners may align their PrEP use with their HIV risk behaviors, providing some reassurance that PrEP discontinuation in young people often aligns with sexual behavior. Greater attention to measurement of and mismatches in PrEP discontinuation and potential HIV exposure is needed.

Background: Studies suggest that the use of race-specific pulmonary function reference equations may obscure racial inequities in respiratory health. Whether removing race from the interpretation of pulmonary function would influence analyses of HIV and pulmonary function is unknown.

Setting: Pulmonary function measurements from 1,067 men (591 with HIV) in the Multicenter AIDS Cohort Study (MACS) and 1,661 women (1,175 with HIV) in the Women's Interagency HIV Study (WIHS) were analyzed.

Methods: Percent-of-predicted values for spirometry and single-breath diffusing capacity of carbon monoxide (DLCO) measurements were generated with race-specific reference equations derived from the National Health and Nutrition Examination Survey and with the race-neutral application of reference equations derived from the Global Lung Function Initiative database. Regression models were used to evaluate the association between HIV and percent-of-predicted measures of pulmonary function. Alpaydin's F test was used to compare how well these values predicted self-reported respiratory health-related quality of life.

Results: Persons with HIV were observed to have significantly lower percent-of-predicted DLCO than those without HIV but no significant differences in spirometric measures of pulmonary function, regardless of whether a race-specific or race-neutral approach was used. Among men, but not women, the race-neutral application of reference equations to generate percent-of-predicted DLCO values performed better for predicting respiratory-related quality of life.

Conclusion: The race-neutral application of pulmonary function reference equations continues to identify lung function impairment in persons with or at risk for HIV and, for DLCO, may be superior to the use of race-specific reference equations in identifying clinically relevant impairments.

Purpose: This study, conducted as part of the Keep It Up! (KIU!) 3.0 trial, compares the implementation costs of two strategies - centralized direct-to-consumer (DTC) marketing and decentralized distribution via community-based organizations (CBO) - in delivering an evidence-based online HIV prevention program.

Methods: We conducted interviews and collected data to identify and quantify all costs for both delivery strategies. Costs were then categorized into start-up and ongoing (time-dependent and variable) costs and assigned dollar values based on established micro-costing protocols.

Results: In the DTC arm (1,468 enrollees), the program was implemented from October 2019 through August 2022. Total ongoing costs including overhead and excluding start-up costs were $735,953, averaging $501 per participant. Start-up costs were $398,384 ($376,393 for content design and development and $21,991 for other costs), time-dependent costs were $219,177 ($149 per participant), and variable costs were $491,658 ($335 per participant). In the CBO arm (656 enrollees across 22 sites), KIU! was implemented for a two-year period between October 2019 and December 2022. Total ongoing costs including overhead and excluding start-up costs were $2,780,682 ($4,239 per participant). Start-up costs were $511,528 ($401,141 for content design and development and $110,386 for other costs), time-dependent costs were $1,926,958 ($2,937 per participant), and variable costs were $256,543 ($391 per participant).

Conclusion: The DTC arm demonstrated a lower overall cost and a lower cost per participant compared to distribution via the CBO arm. Understanding these cost dynamics is pivotal for guiding decisions on program sustainability and determining funding requirements for future large-scale implementation.

Background: In 2019, a 5-year pre-exposure prophylaxis (PrEP) program started in the Netherlands, in which up to 8500 men who have sex with men (MSM) can obtain PrEP and 3-monthly consultations with HIV/STI testing.

Setting: We assessed the impact of the PrEP program on transmission of HIV and Neisseria gonorrhea (NG) among MSM in the Netherlands and examined prospective variations of the program after 2024.

Methods: We used an agent-based model to estimate the effect of the PrEP program. For hypothetical prospective PrEP programs starting in 2024, we varied the capacity (8,500; 12,000; 16,000 participants) and consultation frequency (3-monthly; 6-monthly; 70% 3-monthly and 30% 6-monthly).

Results: At a capacity of 8,500 participants and 3-monthly consultations, the PrEP program could lead to 3,140 [95% credible interval (95% CrI): 1,780-4,780] and 27,930 (95% CrI: 14,560-46,280) averted HIV and NG infections, requiring 316,050 (95% CrI: 314,120-317,580) consultations. At a capacity of 16,000 participants, the programs with 3-monthly consultations and 6-monthly consultations could lead to comparable number of averted HIV [3,940 (95% CrI: 2,420-5,460), and 3,900 (2,320-5,630) respectively] and NG infections [29,970 (95% CrI: 15,490-50,350), and 29,960 (95% CrI: 13,610-50,620) respectively], while requiring substantially different number of consultations: 589,330 (95% CrI: 586,240-591,160) and 272,590 (95% CrI: 271,770-273,290), respectively.

Conclusions: Continuation of a PrEP program could lead to a substantial reduction in HIV and NG transmission. More infections could be averted if the number of participants is increased. In turn, the consultation frequency could be reduced without reducing the number of averted infections if capacity is increased.