JAIDS Journal of Acquired Immune Deficiency Syndromes最新文献

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

Methods: We analyzed 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 2219 CLHIV, 30% were diagnosed with HIV at birth. Median follow-up from birth was 38 months [interquartile range (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.

Background: Community-academic partnerships (C-APs) have been central to advancements in HIV research over the past 4 decades and were specifically called for in the national Ending the HIV Epidemic (EHE) initiative. Community engagement in research, particularly in HIV research, plays a critical role in prioritizing community needs in all stages of HIV research and intervention implementation.

Methods: To address the known gaps in building strong C-APs, 2 EHE Implementation Science Consultation Hubs collaboratively facilitated 2 webinars with a panel of expert community leaders. The panel discussions explored (1) what researchers need to know to create equitable C-APs and (2) best practices for navigating power in C-APs. After the webinars, we conducted a quantitative analysis of the 131 EHE research projects partnered with community-based organizations or faith-based organizations between 2019 and 2023 to examine the community engagement in research relationships between EHE academic researchers and implementation partners.

Results: Community panelists identified areas for academic researchers to prioritize, including building relationships with community partners, engaging equitably in partnership processes, sharing use of resources, and paying attention to community history. The quantitative analysis found 58% of EHE researchers are in new collaborations, lasting 2 years or less, with their implementation partner, and have not yet established robust partnerships.

Conclusions: This study identifies strategies for strengthening community engagement in HIV research and sustaining equitable C-APs for existing EHE supplement recipients that can be integrated into future EHE research and implementation strategies to help end the HIV epidemic in the United States.

Background: HIV continues to disproportionately affect men who have sex with men (MSM) in the United States. 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 3 diverse settings in the United States from 2018 to 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, 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, Black/African American and H/L individuals were 56% and 54%, respectively, less likely to demonstrate PrEP persistence at 6-and 12-months compared with 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% confidence interval: 0.93 to 0.98).

Conclusions: 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 United States.

Background: Although rapid antiretroviral therapy (ART) and same-day pre-exposure prophylaxis models (henceforth "rapid START") are feasible, acceptable, and cost-effective in various contexts, significant barriers have hindered their broader implementation and scalability in the United States. Ryan White-funded clinics are cornerstones for HIV services, yet strategies are urgently needed to facilitate equitable rapid START adoption across contexts. This study aimed to identify common factors influencing rapid START to inform strategies applicable throughout jurisdictional settings.

Methods: The Network for Implementation Science in HIV examined the current implementation of rapid START among diverse Ryan White Part A-D-funded organizations across seven Ending the HIV Epidemic jurisdictions across the United States. Semistructured interviews (n = 13) were administered from March 2023 to August 2024, with HIV leadership across jurisdictions to identify rapid START implementation determinants and strategies to catalyze rapid START delivery. Data were deductively analyzed using the Consolidated Framework for Implementation Research.

Results: Prominent barriers to rapid ART implementation across settings included provider/patient hesitancy and awareness gaps, siloed care systems, and funding complexities. Prominent implementation facilitators included learning collaboratives, technology integration, and clear contracting language. Key constraints to same-day pre-exposure prophylaxis implementation included funding inequities and suboptimal client/patient awareness, whereas enablers included integrated care models, availability of starter packs, and medication-assistance programs.

Conclusions: Several consistent key barriers and facilitators spanned multiple Ending the HIV Epidemic jurisdictions despite contextual differences (eg, Medicaid expansion). Collaborative efforts between system leaders and service providers were universally characterized as essential for equitable adoption and penetration of rapid START models.

Background: Health care providers are critical for successful implementation of HIV preexposure prophylaxis (PrEP), but barriers to PrEP provision persist. Researchers must engage with providers to understand how to optimize PrEP delivery across settings. Yet researcher-provider collaborations can be challenging. To offer guidance on engaging providers in PrEP implementation research, we synthesized the experiences of researchers working with different types of providers on studies related to PrEP implementation that were funded as part of the US Ending the HIV Epidemic (EHE) initiative.

Setting: Geographic areas designated as high priority by the EHE initiative.

Methods: We defined providers broadly, including physicians, pharmacists, health educators, and peer navigators. Using thematic analysis from collaborative case reports by EHE study teams, we synthesized strategies, challenges, and successes related to provider engagement, with categorization into three stages of research: study development, recruitment, and data collection.

Results: Among 17 research teams invited, 9 contributed. Findings suggested that extensive resources (eg, time, professional networks, financial, and nonfinancial incentives) are required to engage clinical and nonclinical providers across all stages of PrEP implementation research, with the most intensive strategies required for recruiting clinical providers who are not yet providing PrEP. However, when effective strategies are deployed, this investment of resources can yield rich insights into PrEP implementation.

Conclusions: The lessons learned by the investigators in our study can be applied to future EHE-funded projects, other HIV-prevention studies, and studies in other areas of health research to improve engagement of providers during all stages of the research process.

Background: Ending the HIV Epidemic strategies include rapid ART Initiation (R-ART), rapid pre-exposure prophylaxis (R-PrEP), and status neutral approaches (status neutral), but implementation across heterogeneous settings in the United States is not well characterized.

Setting: Ryan White (RW)-funded HIV treatment clinics located in select Ending the HIV Epidemic priority areas in the United States.

Methods: Clinics were sent a survey to assess experiences offering R-ART, R-PrEP, and status neutral (collectively called "rapid START"). Primary outcomes were rapid START adoption and characteristics of implementing vs. nonimplementing clinics. Secondary outcomes included perceptions, barriers, and facilitators of R-ART and R-PrEP.

Results: The response rate was 48% (40 of 83). The 40 respondents represented 57 clinics who reported providing HIV-related services to more than 70,000 individuals annually. R-ART uptake was 85% (range 43%-100%), status neutral 65% (range 57%-75%), and R-PrEP 60% (range 0%-88%). No rural-identifying organizations reported offering R-ART or R-PrEP compared with 96% and 76% of urban-identifying organizations, respectively. Positive perceptions of acceptability, appropriateness, and feasibility for R-ART and R-PrEP were high among all levels of implementation and strongest among those offering R-ART and R-PrEP. The most frequent barriers to R-ART were provider- and clinic-level and for R-PrEP were system-level (lack of insurance coverage) followed by patient-, provider-, and clinic-level issues.

Conclusion: This survey of diverse RW-funded clinics shows high uptake of R-ART and significant if less consistent uptake of R-PrEP and status neutral. Future research should focus on identifying broadly implementable strategies to expand adoption along with tailored approaches, especially in areas with lower health care access.

Background: The National HIV/AIDS Strategy for the United States 2022-2025 emphasized carceral settings for the first time in the national strategy. Centering impacted people can take many forms and is critical to improving the HIV care continuum among people with carceral system involvement (CSI) to meet national Ending the HIV Epidemic goals.

Methods: We provide a narrative synthesis of the barriers and facilitators of including people with CSI in different aspects of the research process across 5 Ending the HIV Epidemic studies. Data were collected from each team using a data collection form with open-ended questions. A qualitative thematic analysis identified strategies, barriers, and facilitators across studies.

Findings: Major barriers to including people with CSI in research included institutional policies surrounding participant compensation and hiring practices, as well as a misalignment between the study objectives and the perceived needs of participants. Successful strategies for including people with CSI as part of the research team included providing training, support, and space for emotional processing and self-care to aid in managing the vicarious trauma and boundary setting that are unavoidable parts of this work. Successful strategies for including people with CSI as research participants include flexible research protocols and providing material support for participants in addition to cash payments for participation.

Conclusions: It is imperative to create sustainable and equitable, community-engaged research practices that continue to center CSI populations during their involvement in all aspects of HIV-related research studies.

Background: The Veterans Aging Cohort Study (VACS) Index is a summary measure of routinely obtained clinical variables that predicts numerous health outcomes. Because there are currently no tools to predict acute kidney injury (AKI) in people with HIV (PWH), we investigated the association of preadmission VACS Index with hospital AKI in PWH.

Methods: We conducted an observational study of PWH hospitalized in a New York City health system between 2010 and 2019. The VACS Index, calculated using outpatient laboratory values within 8-365 days of admission, was examined continuously and in quartiles. Multivariable Cox proportional hazards models, adjusting for sociodemographic factors, comorbidities, and ICU admission, determined the association of the VACS Index with AKI.

Results: Among 1186 PWH, median age was 53 years, 43.5% were women, 86.2% were Hispanic or Black, 23.1% were coinfected with hepatitis C, and 65% were virally suppressed (<200 copies/mL). Overall AKI incidence was 20.9%. The proportion with AKI was higher by increasing VACS Index quartile: 10.7%, 18.6%, 28.1%, and 60.7% in quartiles 1-4, respectively. There was a graded, independent association of VACS Index quartile with AKI. Compared with those in the lowest quartile, the adjusted relative hazard of AKI was 1.55, 1.92, and 3.07 times higher in quartiles 2-4, respectively ( P for trend <0.001).

Conclusions: Preadmission VACS Index is associated with hospital AKI. Use of the VACS Index may allow for early identification of PWH at risk for AKI and initiation of preventative strategies. These findings should be externally validated in other health systems, including its predictive performance in specific hospital settings.

Introduction: Few data are available on the forgiveness of 2-drug (2DR) or low-barrier 3-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 2-center retrospective observational study enrolled all people with HIV 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 used to test the impact of baseline variables and adherence on the achievement of virological suppression.

Results: In total, 1258 adult people with HIV were enrolled, 368 in 3TC/DTG and 890 in FTC/TAF/RPV. Most were men (71%), with a median age of 51 years (IQR 43-58 years) and a median CD4 nadir of 305 cells/mcL (IQR 132-485). Median cohort follow-up was 4558 persons/year. Median adherence, as calculated from PDC, was of 0.98 (IQR 0.93-1). Regardless of the treatment group, a PDC of 0.8 was sufficient to achieve HIV-RNA levels below 200 copies/mL in almost all study participants. With the same level of adherence, >90% of study participants achieved HIV-RNA below 50 copies/mL. PDC ( P < 0.0001), Italian origin ( P < 0.0001), and male sex ( P = 0.038) were significantly correlated with achieving <200 copies/mL.

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

Introduction: Implementation studies include both recipient populations, who will benefit from the study's evidence-based intervention, and study populations, who will participate in the intervention and contribute data to implementation outcomes. Decision making around inclusion criteria for the study population and whether to include the recipient population have significant implications for study design. We present 3 case studies of HIV prevention implementation studies that feature diverse study populations and describe the decision-making process around defining study populations to share generalizable lessons for the field.

Methods: We identified recipient and study populations for each study, described decision making regarding inclusion and exclusion criteria, and identified implications for measuring study aims.

Results: HIV prevention interventions focus on pre-exposure prophylaxis uptake and HIV testing in settings such as emergency departments, obstetrics/gynecology clinical practices, and free HIV testing sites. These studies were designed to inform scale-up of intervention strategies based on effectiveness, affordability, and feasibility. Decisions about whom to include in the study populations were based on context, strategies, and implementation outcomes.

Discussion: We identified important considerations across projects, including study context, strategies, and approaches. These factors can inform decisions around defining study populations to ensure successful measurement of study aims and sustainability of implementation outcomes.