Journal of the International AIDS Society最新文献

Introduction: While African countries have expanded access to HIV pre-exposure prophylaxis (PrEP) since 2015, regional targets for PrEP uptake remain unmet. Understanding which populations are prioritized for PrEP at the policy level is an important step in determining the scope of PrEP distribution across Africa and identifying gaps in programme implementation. We reviewed national guidance to characterize populations prioritized for PrEP in Africa.

Methods: Between January and June 2023, we searched for current National HIV Treatment and Prevention Guidelines, National HIV Strategic Plans, and the United States President's Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans (COPs) for all African countries implementing PrEP programmes supported by PEPFAR in 2022. From each document, we summarize the populations prioritized for PrEP within a country and describe PrEP eligibility.

Results: In 2022, 19 African countries implemented PrEP programmes supported by PEPFAR. Eighteen of these countries contributed National Guidelines (2016-2022), 18 contributed National Strategic Plans (2017-2023) and 19 contributed COPs (2022) to this review. Twenty-nine population groups were prioritized for PrEP in these documents. All countries prioritized HIV-serodifferent couples, female sex workers (FSWs), adolescent girls and young women (AGYW), pregnant and breastfeeding women (PBFW) and people who inject drugs (PWID), and most prioritized men who have sex with men (MSM; n = 18), transgender people (n = 18) and people in prisons (n = 17). The remaining 21 populations were prioritized in fewer than two-thirds of countries.

Discussion: FSWs, MSM, PWID, transgender people and people in prisons were typically prioritized for PrEP with no eligibility restrictions. In contrast, most countries had at least one document indicating that HIV-serodifferent couples, AGYW and PBFW were only eligible for PrEP if classified as high risk. Few documents specified how risk was determined, and no document included validated HIV risk assessment tools to guide implementation. We observed similarities in priority populations across countries with different HIV epidemics and inconsistencies in who was prioritized for PrEP within a country's own set of policy documents.

Conclusions: Understanding how PrEP prioritization policies impact HIV incidence in different epidemiologic settings is critical for strengthening PrEP implementation across the continent.

Introduction: Antiretroviral therapy (ART) initiation, regardless of CD4 count, has been recommended in Thailand since 2014, with same-day initiation recommended since 2021. We assessed HIV treatment outcomes among Thai people living with HIV (PLHIV) by the time from HIV diagnosis to ART initiation under the Universal Health Coverage (UHC) programme and identified factors associated with virological failure (VF).

Methods: PLHIV aged ≥15 years initiating ART between 2014 and 2022 were included from the UHC database. We categorized participants into four groups using the duration from HIV diagnosis to ART initiation: (1) ≤ 7 days (same-day ART); (2) 8 days to <1 month; (3) 1-3 months; and (4) >3 months. Viral load (VL) was measured 6 months after starting ART, and annually thereafter. VF was defined as VL ≥1000 copies/ml. Factors associated with VF were analysed using competing risk models considering death and loss to follow-up (LTFU) as competing events.

Results: Among 252,239 PLHIV who started ART, the median age at initiation was 34 years (interquartile range [IQR]: 26-43 years). The median (IQR) pre-ART CD4 count was 233 (76-420) cells/mm³. ART initiation occurred within 7 days for 25% (17% on the same day, 8% in 2-7 days), 24% in 8 days to <1 month, 23% in 1-3 months and 28% in >3 months. ART initiation within 7 days increased from 20% (2014-2016) to 32% (2021-2022). VF occurred with a rate of 3.11 (95% CI 3.07-3.159) per 100 person-years (PYs). PLHIV initiating ART 8 days to 1 month were at lower risk of VF (aSHR 0.52, 95% CI 0.50-0.54) when compared to ART initiation >3 months. ART initiation within 7 days resulted in the lowest mortality (6%: 1.28 [95% CI 1.24-1.32] per 100 PYs), but the highest rate of LTFU (12%: 2.69 [95% CI 2.63-2.75] per 100 PYs) when compared to other ART initiation groups.

Conclusions: Although ART initiation within 7 days has increased in Thailand, the overall rate of early initiation remains low. ART initiation within 1 month significantly lowered the risk of VF. ART initiation within 7 days significantly reduced mortality. To further optimize health outcomes, innovative strategies are urgently needed to promote earlier ART initiation in Thailand.

Introduction: WHO's Integrated Care for Older People (ICOPE) proposes we measure the functional construct of intrinsic capacity (IC) to monitor and identify individuals with age-associated vulnerabilities. Assessments of IC may be useful to address the evolving, non-HV care needs of ageing people with HIV (PWH). However, to date, its utility within the context of HIV has not been assessed.

Methods: Participants included 200 PWH attending out-patient care (2021-2023) in Universiti Malaya Medical Centre, Malaysia and 101 community controls aged 35 years and above. The ICOPE framework was adapted to derive aggregate IC scores (ranging 0-6) encompassing the five domains of cognition, sensory (hearing and vision), mobility, mood and vitality. Multivariable analyses were used to explore the association of IC scores in PWH with multiple health outcomes including frailty, difficulties performing instrumental activities of daily living (IADL) and inflammatory markers. Area under the receiver operator characteristic (AUC-ROC) was calculated to predict frailty and IADL deficits in the current cohort and an independent cohort of 275 PWH from Hong Kong (HK).

Results: Median (interquartile range, IQR) age among PWH and controls were 50 (42-56) and 50 (39-59) years, respectively. There were more males among PWH (83% vs. 56%, p<0.001). All PWH received antiretroviral therapy (ART) for a median duration of 11 (8-14) years. Aggregate IC scores were lower in PWH but not significantly different compared to controls, (5.4 vs. 5.6, p = 0.093) and PWH performed significantly worse than controls only in the cognitive domain. Aggregate IC scores in PWH was independently associated with frailty (OR 0.17 95% CI 0.07-0.42, p<0.001), IADL deficits (OR 0.25 95% CI 0.14-0.46, p<0.001) and all other patient-reported outcomes assessed. Aggregate IC scores correlated with IL-6 but not sCD14 and sCD163 levels. IC scores performed well in identifying PWH with frailty (AUC-ROC ≥ 0.80) in the HK and Malaysian cohorts but more modestly (AUC-ROC ≥ 0.64) for IADL deficits.

Conclusions: IC is a good composite measure to monitor non-HIV, age-associated physical and social vulnerabilities in PWH on ART and should complement disease-based monitoring in routine HIV care. Assessments of IC should be validated in larger, longitudinal cohorts of PWH from diverse settings.

Introduction: Long-acting injectable cabotegravir (CAB-LA) for pre-exposure prophylaxis significantly reduced HIV acquisition in HPTN 084. We report on the safety and CAB-LA pharmacokinetics in pregnant women during the blinded period of HPTN 084.

Methods: Participants were randomized 1:1 to either active cabotegravir (CAB) plus tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) placebo or active TDF/FTC plus CAB placebo. Pregnancy testing was performed at each visit; participants with a positive test had study product withheld and were offered open-label TDF/FTC. Pregnancies were confirmed on two tests at least 4 weeks apart. All participants with a positive pregnancy test prior to November 5, 2020 are included in this analysis. Pregnancy incidence, maternal adverse event (AE) incidence, pregnancy outcomes (including composite outcome of spontaneous abortion <20 weeks, intrauterine foetal death or stillbirth ≥20 weeks, premature birth <37 weeks, or small for gestational age) were assessed. The apparent terminal phase half-life (t_1/2app) of CAB-LA in pregnant women in HPTN 084 was compared to non-pregnant women from the phase 2a HPTN 077 trial. Multivariable models assessed associations with t_1/2app. RESULTS: Fifty-seven pregnancies (30 CAB-LA, 27 TDF/FTC) were confirmed over 3845 person-years [py] (incidence 1.5/100 py, 95% CI 1.1-1.9). CAB-LA group participants had a median 342 days (IQR 192, 497) of CAB-LA exposure prior to pregnancy detection. Grade 2 or higher maternal AE incidence did not differ by study arm (CAB 157, 95% CI 91-271 per 100 py vs. TDF/FTC 217, 95% CI 124-380 per 100 py; p = 0.256). Most pregnancies (81%) resulted in live births (25 CAB-LA, 22 TDF/FTC). Composite poor pregnancy outcomes did not differ significantly by group (CAB 6/30 vs. TDF/FTC 4/27; p = 0.476). No congenital anomalies were observed. The CAB t_1/2app geometric mean was 52.8 days (95% CI 40.7-68.4) in pregnant women compared to 60.3 days (95% CI 47.7-76.3; p = 0.66) in non-pregnant women; neither pregnancy nor body mass index were significantly associated with t_1/2app.

Conclusions: CAB-LA concentrations post-cessation of injections were generally well tolerated in pregnant women. The t_1/2app was comparable between pregnant and non-pregnant women. Ongoing studies will examine the safety and pharmacology of CAB-LA in women who choose to continue CAB-LA through pregnancy and lactation.

Introduction: In 2010, China launched the 10-year National Syphilis Prevention and Control Program to curb the spread of syphilis by integrating syphilis screening and treatment with HIV services. Herein, we aimed to evaluate changes in the prevalence of syphilis among people living with HIV (PLHIV) in China.

Methods: We conducted this systematic review and meta-analysis by searching the PubMed, Embase, Web of Science, China Biomedical Literature, China National Knowledge Infrastructure, Wanfang and CQVIP databases from inception to 1 June 2024 to obtain relevant articles. A total of 75 studies were ultimately included. We used a DerSimonian‒Laird random effects model to estimate the prevalence and 95% confidence interval of syphilis among PLHIV.

Results: The overall prevalence of syphilis among PLHIV in China was 18.6% (95% CI 16.5-21.0). Regional differences (R² = 15.29%) were observed in the prevalence rates: 22.2% (18.9-25.8) in the eastern region, 19.0% (15.1-23.8) in the central region and 14.0% (11.1-17.5) in the western region. The prevalence decreased from 22.8% (18.4-27.9) before 2010 to 17.0% (14.6-19.6) in 2010 and thereafter (R² = 5.82%). Among PLHIV via homosexual transmission, the prevalence of syphilis was 24.9% (21.3-28.9), which significantly declined from 33.8% (27.5-40.8) to 21.4% (18.3-24.9) in 2010 and thereafter (R² = 22.35%). The prevalence of syphilis was significantly higher in men living with HIV than in women living with HIV (pooled odds ratio 1.67, 95% CI 1.29-2.15), with the highest prevalence in the eastern region (2.55, 95% CI 1.80-3.59).

Discussion: The prevalence of syphilis among PLHIV, particularly in cases of homosexual transmission, has declined. There was a correlation between the prevalence of syphilis and regional economic conditions, with a greater burden in developed eastern coastal areas. Additionally, the risk of syphilis differed across sexes, with men living with HIV having a higher risk.

Conclusions: There has been preliminary success in the control of syphilis among PLHIV, but there is still a long way to go to meet the WHO's 2030 syphilis prevention and control goal. Syphilis prevention measures should be integrated into broader health policies and development plans, particularly in high-burden regions and populations.