JAIDS Journal of Acquired Immune Deficiency Syndromes最新文献

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 sexually transmitted infection (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 χ 2 tests and calculated prevalence ratios using log binomial models stratified by PrEP usage. Analyses were restricted to individuals with an HIV-negative status.

Results: Integrated testing was completed for 69% of individuals on PrEP and 39% of 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: Pre-exposure prophylaxis (PrEP) usage has slowly increased in the United States, but significant disparities persist across race, ethnicity, sex, gender, age, and geography. Determinants of PrEP inequities include stigma and medical mistrust, lack of patient-centered services, lack of access to clinical care, and organizational resistance to change-within a health care system that neglects these barriers.

Methods: We describe 5 implementation strategies to providing PrEP in nontraditional settings to underserved populations, using an equity-based approach to address key structural determinants. The alternative settings used in these Ending the HIV Epidemic projects (community-based organizations, telePrEP, mobile clinics, pharmacies, emergency departments) were chosen for the setting characteristics and their serving structurally underserved populations.

Results: Community-based organizations have earned trust within communities and can serve as hubs for comprehensive sexual health services, including PrEP. Telehealth, which expanded significantly because of COVID-19, can help overcome transportation and scheduling barriers to PrEP access. Mobile clinics can also broaden PrEP delivery by bringing tailored services directly to communities, often providing shorter wait times and extended hours. Pharmacists can prescribe PrEP in certain states through legislation or collaborative practice agreements, offering a convenient, community-based option. Emergency departments provide an alternative site for PrEP delivery, with the potential to reach individuals not currently engaged in regular care.

Conclusion: These alternative PrEP approaches can expand options for accessing PrEP and alleviate key barriers to care in traditional settings, although they may not eliminate all inequities. Offering more choices increases the likelihood that a broader population will be reached, thereby enhancing overall access to PrEP.

Abstract: People who have behavioral health disorders are disproportionately represented among people with HIV and those likely to be diagnosed with HIV. Despite repeated calls for the past decade for the integration of behavioral health into the HIV Care Continuum, findings from priority jurisdictions show these efforts lag. We present 5 examples of efforts to integrate behavioral health services into the HIV Care Continuum, across regions and populations in Ending the HIV Epidemic priority regions. Across diverse settings, care provision-screening, assessment, referrals, and treatments-remains insufficient. Consistent, ongoing actions are needed to address the compounded consequences of the HIV and behavioral health synergistic epidemics, or syndemic. The studies in this article involved local communities, provider groups, and people with lived experience of trauma, serious mental illness, neuropsychological disorder, substance use disorder, and HIV. These example studies reveal significant unmet needs for behavioral health care and/or HIV prevention and treatment in these priority communities. A common finding among these examples was that the success of interventions hinges on the extent to which interventions are tailored to local contexts and the specific needs of historically underserved populations, including Black women, the socioeconomically disadvantaged, LGBTQIA+ individuals, and people with serious mental illness and/or substance use disorders. We suggest recommendations for how Ending the HIV Epidemic efforts can be optimized to adapt and implement integrated HIV and behavioral health care to advance national goals.

Background: People living with HIV in the United States are overrepresented in the criminal-legal system and experience unique barriers to engagement in HIV care postincarceration. Individuals who are criminal-legal involved (CLI) experience worse HIV care outcomes compared to the general population. Interventions aiming to improve engagement and retention in HIV care for CLI populations are urgently needed. This study aims to highlight an array of NIH-funded research projects across the United States leveraging implementation science to investigate and design interventions aimed at addressing social determinants of health and improving HIV care outcomes among CLI populations in the United States.

Setting: United States.

Methods: In September 2023, the National Institutes of Health funded 47 new implementation research projects as part of the Ending the HIV Epidemic initiative, including 10 projects focused on addressing HIV among CLI populations. This paper highlights several projects that are addressing the social determinants of health affecting CLI populations living with HIV in the United States.

Project overview: The funded projects use innovative, community-engaged approaches to investigate and design interventions to address social determinants of health among CLI populations living with HIV including health care access, legal needs, social support, and holistic needs.

Conclusions: We believe these projects will substantially contribute to the evidence base to aid the development of guidelines and the implementation of programs that can be adopted and adapted by a wide range of settings working toward improving the health and wellness of CLI people living with HIV.

Background: Previous studies have estimated preexposure prophylaxis (PrEP) use among persons with commercial health insurance and Medicaid. However, data are lacking regarding PrEP use among those with Medicare.

Methods: Using a previously developed algorithm, we estimated the number of Medicare beneficiaries (MBs) with fee-for-service claims who were prescribed PrEP from 2014 to 2021. The analysis was stratified by age, sex, and race/ethnicity. We also examined trends in PrEP prevalence by U.S. state and demographic characteristics during 2014-2021.

Results: The number of Medicare PrEP users increased 11-fold, from 388 in 2014 to 4685 in 2021. MBs prescribed PrEP were predominantly younger men, White persons, residing in the south or west regions, living with a disability, and dually eligible for both Medicare and Medicaid. The prevalence of PrEP prescriptions among MBs increased 12-fold, from 9.7 per million in 2014 to 120.0 per million in 2021. Black/African American persons had the highest prevalence of PrEP use, followed by Hispanic/Latino and White persons in 2021. The District of Columbia had the highest prevalence of PrEP use compared with other U.S. states in 2021. Significant increasing trends in PrEP use were observed across sex, age groups, and race/ethnicity.

Conclusions: Disparities in PrEP uptake existed across MB demographic subgroups from 2014 to 2021. Public health interventions are needed to increase PrEP access and utilization, particularly among women, younger MBs, Black persons, and Hispanic persons, including those with Medicare. Strategies and policies to expand PrEP use are essential for optimal HIV prevention in the United States.

Background: The United States has made significant progress toward achieving the goals of its Ending the HIV Epidemic initiative. However, systematic reviews on HIV implementation research have identified problems regarding strategy specification that limit the research's transparency and replicability, and in turn limit improvements regarding HIV care in real-world practice.

Methods: The strategies timeline, activities, and resources (STAResources) Table, developed as part of the substance abuse treatment to HIV Care II Project, was completed for it and 3 other HIV implementation research projects funded by the National Institute of Health. Each evaluated it in terms of the extent to which it addressed prior recommendations on strategy specification; issues related to rigor and reproducibility; and the extent to which it seemed pragmatic, simple, adaptable, relevant, helpful, useful, acceptable, appropriate, suitable, applicable, and fitting. Each was rated on a 4-point scale (0 = not at all; 1 = a little; 2 = moderately, and 3 = very much).

Results: Overall, the STAResources Table was rated favorably. It received a mean of 3.0 (SD = 0) in terms of being pragmatic, relevant, helpful, acceptable, appropriate, and applicable. The Strategies Timeline, Activities, and Rationale (STARationale) Table emerged during the process and was also rated favorably.

Conclusions: To help the Ending the HIV Epidemic initiative achieve its goals, there is a critical need for transparent and replicable implementation research on identifying the most effective strategies for equitably implementing evidence-based practices within real-world settings. Addressing this need, the Strategies Timeline and Activities Reporting (STAReporting)Tables are pragmatic tools for helping improve the transparency and replicability of implementation strategy research.

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 the uptake of PrEP and ongoing disparities in HIV incidence in the United States.

Methods: In an online survey of GBMSM in the United States, 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.

Objective: The objective of this study is to define the neuropsychiatric challenges including developmental delay, cognitive impairment, and psychiatric illness faced by children with perinatally acquired HIV.

Data sources: Nine databases were searched on May 30, 2023: MEDLINE, Embase, and PsycINFO (all through Ovid SP); CINAHL and Child Development and Adolescent Studies (through EBSCO); the Web of Science Core Collection; Scopus; ProQuest Dissertations and Theses Global; and WHO Global Index Medicus. No limits were applied. Search strategies incorporated keywords and thesaurus headings to describe children and adolescents aged 0-25 years with perinatally acquired HIV and terms to describe the spectrum of neuropsychiatric impairment.

Study selection: Entries were reviewed by 2 independent reviewers. Studies were included if they involved a population of children with perinatally acquired HIV and investigated a neurologic or psychiatric outcome.

Main outcome measures: Hypothesis that children with pHIV would have more neuropsychiatric challenges than children without pHIV was formulated before the study. Main outcome measures include incidence and severity of cognitive impairment, developmental delay, and psychiatric illness in children with pHIV.

Results: Forty-five studies on cognitive impairment were included of which 8 studies were included for meta-analysis and demonstrated a standardized mean difference of -0.508 where children without HIV had higher cognitive scores (95% CI: -0.7903 to -0.2272). In total, 15 studies on developmental delay were included, of which 9 were included for meta-analysis and demonstrated, for motor delay, a standardized mean difference (SMD) of -0.794 where children without HIV achieved higher motor function scores (95% CI: -0.9986 to -0.590) and for cognitive delay an SMD of -0.697 where children without HIV achieved higher cognitive function scores (95% CI: -0.976 to -0.417). In total, 39 studies on psychiatric illness were included with an odds ratio for anxiety and depression of 1.105, suggesting that children with HIV had slightly higher odds of developing anxiety or depression, however, this result was not significant (95% CI: 0.778 to 1.571).

Conclusions: Children with perinatally acquired HIV may have a greater cognitive impairment, motor and cognitive delay, and would likely benefit from tailored approaches to improve their outcomes.

Background: Pre-exposure prophylaxis (PrEP) for HIV prevention has been available since 2012, but uptake remains disappointing and inequitable. Furthermore, there is little evidence on the effectiveness of interventions to increase PrEP demand among priority populations in the United States. The objectives of this article were to describe how consumer perceptions of PrEP vary by distinct population groups and identify gaps in PrEP awareness, knowledge, and interest.

Methods: We synthesized evidence-based interventions to improve demand for PrEP in populations heavily burdened by HIV. The focus centered on consumer factors, how people's awareness of PrEP, especially people who are likely to benefit, influences PrEP uptake.

Results: Awareness and equity in PrEP use among vulnerable populations in the United States remain low because of both demand-side obstacles and accessibility challenges. Designing an effective package of interventions to increase demand for PrEP involves integrating strategies that address awareness, knowledge, interest/motivation, and access.

Conclusions: The underutilization of PrEP among the 1.2 million individuals who could benefit from it highlights the need for effective demand creation to reduce disparities. To effectively increase awareness of the benefits of PrEP requires consideration of the characteristics of the target population and the structural inequalities that contribute to PrEP-related disparities. Demand creation activities can increase awareness, correct misconceptions, provide knowledge, and help people decide whether PrEP is a good fit for them. The utilization of implementation science frameworks is essential to address demand generation and supply-side barriers to PrEP use.