Low bone mineral density (BMD) has been described in children and young people with perinatally acquired HIV (PHIV), which may be related to both traditional (e.g. low body mass index and malnutrition) and HIV-related risk factors (e.g. longstanding exposure to HIV and antiretroviral therapy [ART], with immune suppression, chronic immune activation and inflammation). Here, we evaluate BMD in a U.K. cohort of young people with PHIV by age and ART.
This longitudinal, observational study was conducted at a U.K. tertiary PHIV service between November 2018 and March 2022. Bone health was assessed in 130 individuals aged 15–19 (n = 50), 20−24 (n = 50) and 25 years and older (n = 30) by dual-energy X-ray absorptiometry, bone mineralization and turnover markers. Low BMD was defined as lumbar spine (LS) and/or femur-BMD z-score below −2, relative to age, sex and ethnicity-matched U.K. population-based normative controls. Two-year follow-up evaluation was performed in those aged 15−19 (n = 42) and 20−24 years (n = 43) at enrolment, which included a group who switched from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF) ART at baseline. Bayesian logistic regression models examined predictors of low BMD and the effect of ART-backbone on BMD accrual.
At baseline, 57% were female and 82% of black ethnicity, with 31 (24%) on TDF-ART. Sixteen (12%) had low baseline BMD. Over a median follow-up duration of 26 (interquartile range [IQR] 25–29) months, BMD accrual was lower-than-expected in those aged 15−19 years (mean change LS-BMD z-score −0.15 (standard deviation [SD] 0.44)), when compared to normative controls. No associations were seen with HIV parameters or the ART regimen. Participants who switched to TAF-ART had similar BMD accrual 26 (IQR 24–32) months post switch, when compared to those on non-TAF/TDF-ART (mean change LS-BMD z-score TAF −0.01 [SD 0.41] vs. non-TAF/TDF −0.03 [SD 0.54]).
While rates of low BMD were reassuringly low in this cohort, lower-than-expected BMD accrual was observed in younger individuals, relative to normative controls. Overall, BMD accrual on TAF-ART was non-inferior to non-TAF/TDF-ART.
Key populations (KP), including men who have sex with men, people who inject drugs, sex workers, transgender people and people in closed settings, are disproportionately affected by HIV and face structural and legal barriers to care. While community-led responses are central to reaching KP, services are often disease-specific and disconnected from national primary healthcare (PHC) systems. PHC, defined by WHO as a whole-of-society approach to delivering integrated and person-centred services, is rarely designed to meet the broader health needs of KP, who also experience high burdens of non-communicable diseases, mental health conditions and violence. This paper describes three service delivery models, supported by PEPFAR, that integrate HIV and PHC services for KP in Vietnam, Nigeria and Eswatini.
The three models are community-led, client-centred, and tailored to KP health and social needs. Each integrates HIV services—including testing, antiretroviral therapy, viral load monitoring, pre-exposure prophylaxis (PrEP) and advanced HIV disease management—alongside broader PHC services such as mental healthcare, sexual and reproductive health, non-communicable disease screening and tuberculosis services. All models include structural and community-based interventions such as gender-based violence support, stigma reduction, peer navigation and economic empowerment. These services are delivered in safe, trusted spaces by multidisciplinary teams including peer and clinical providers. While the models demonstrate alignment with PHC principles (accessibility, cultural competence, continuity and community empowerment), challenges remain related to integration within national health systems, financing and provider training. Recent U.S. global health policy shifts, including reductions in funding for KP-specific programming and limited PrEP access, pose additional threats to programme sustainability and client trust.
Integrated models of HIV and PHC for KP can improve access, engagement and health outcomes across a range of services. They represent promising approaches for addressing intersecting health and structural needs, particularly in settings where stigma and criminalization persist. Sustained progress will require inclusion of KP in PHC policies and planning, protection of community-led services and domestic financing strategies that ensure continuity in the face of shifting donor priorities.
Scaling up pre-exposure prophylaxis (PrEP) for HIV among men who have sex with men (MSM) and transgender women (TGW) in the Asia-Pacific region has been slow. We identified the drivers of PrEP use and forecasted PrEP uptake given different PrEP programmes for MSM and TGW living in 15 countries and territories in Asia and Australia.
Separate online discrete choice experiment surveys for MSM and TGW were distributed in 15 Asian countries and territories and Australia between May and November 2022. We used random parameters logit models to estimate the relative importance of service attributes and predicted PrEP uptake for different programme configurations.
Among 21,943 participants included in the MSM survey and 1522 in the TGW survey, the mean age was 31.7 (±9.5) years and 28.1 (±7.0) years, respectively. Cost emerged as the primary driver of PrEP use for MSM and TGW across countries, followed by the type of PrEP. When switching from the least preferred PrEP programme (i.e. very high service fee, PrEP implant, rare kidney problems as side effects of PrEP and a 2-monthly clinic visit) to an optimal programme (i.e. free access to PrEP via peer-led community clinics which offered sexually transmitted infection [STI] testing, and a 6–12 monthly visit), the predicted PrEP uptake could improve by over 50% for MSM in Australia, China, Hong Kong SAR China, Japan, the Philippines, Taiwan (China) and Thailand, and 37% for TGW. Compared to those at lower risk of HIV, free access was more preferred by MSM at a higher risk of HIV, while telehealth was more preferred by TGW at a substantial risk of HIV.
Tailoring services to local contexts, including ensuring affordability, preferred type of PrEP and providing differentiated services, could accelerate the uptake of PrEP among MSM and TGW in Asia and Australia. Novel innovations, such as STI and HIV self-testing, should be explored as alternatives to conventional testing, given that most MSM and TGW prefer less frequent clinic visits and long-acting PrEP options.
People with HIV (PWH) have a high burden of mental health disorders, which contribute to increased mortality due to elevated rates of physical illness, suicide or fatal accidents. Additionally, mental health disorders can adversely affect antiretroviral therapy (ART) adherence, leading to increased HIV-related mortality. This study aims to quantify the difference in mortality between PWH who have a mental health disorder and PWH without mental health disorders in South Africa (SA) and North America (NA).
This cohort study includes PWH aged 18 years or older who initiated ART between 2000 and 2021 at a national private-sector HIV programme in SA and 13 programmes in the United States and Canada. Mental health disorders were diagnosed according to ICD-10 codes F10-F99, which include psychotic disorders, bipolar disorders, depression, anxiety and substance use disorders. We estimated life-years lost (LYL) associated with mental health disorders, quantifying the average difference in remaining life expectancy between individuals diagnosed with a mental health disorder and those without such diagnoses.
The study included 119,785 participants from SA (57.4% female, median age 39 years) and 142,044 from NA (85.0% male, median age 43 years). In SA, 57,999 (48.4%) were diagnosed with a mental health disorder, compared with 93,518 (65.8%) in NA. In SA, the LYL associated with any mental health disorder were 3.42 years (95% CI 2.42−4.28) in males and 2.95 years (0.67−5.95) in females. Corresponding figures for NA were 4.16 years (3.71−4.59) in males and 4.64 years (2.93−6.05) in females. In both regions, LYL were higher for psychotic and substance use disorders than for depression and anxiety. Losses were primarily due to natural deaths at CD4 counts ≥200 cells/µl, with considerable contributions at CD4 counts <200 cells/µl. Unnatural causes also contributed to the loss of life-years in males from SA and males and females from NA.
PWH affected by mental health disorders experience higher mortality, primarily from natural causes. LYL were associated with both immunosuppression and higher CD4 levels. Improved management of HIV and physical comorbidities among PWH affected by mental health disorders may enhance their prognosis.
Socio-demographic and geographic disparities in HIV prevalence, uptake of HIV testing and access to antiretroviral therapy (ART) persist in high HIV burden countries. Understanding demographic, spatial and temporal factors can guide interventions.
We analysed 108 geo-referenced population-based surveys conducted over 2000–2023 across 33 African countries, involving 2.3 million respondents. Multilevel Bayesian logistic regression models assessed associations between HIV outcomes (HIV prevalence, recent HIV testing and ART coverage) and socio-demographic characteristics (age, education, place of residence, relative wealth), geographic location (country, district) and time trends. Separate models were estimated for men and women in central, eastern, southern and western Africa.
Inequalities in HIV risk and access to testing and treatment services were driven by differences in educational attainment and within-country variations. In southern Africa, women with tertiary education had a 12%-point lower HIV prevalence (95% Credible Interval [CrI]: −27% to −2%) than those with less than primary education. In eastern Africa, they had a 13%-points (95% CrI: 2−22%) higher probability of recent HIV testing. Associations with relative wealth were weaker and more heterogeneous: in southern Africa, HIV prevalence shifted over time from higher to lower wealth quintiles, and adolescent girls and young women became the most frequently tested age group. In central Africa, wealthier men maintained higher recent testing and ART coverage levels. District-level variations accounted for disparities in HIV outcomes. In western Africa, the expected difference in ART coverage between individuals with similar socio-demographic characteristics living in different districts was 14%-points (95% CrI: 3−32%) for men and 10%-points (95% CrI: 3−27%) for women.
Disparities in HIV outcomes are strongly associated with differences in education, and across districts of the same country. Higher education levels are associated with lower HIV prevalence, greater testing and higher ART coverage, while districts with limited services sustain higher population viraemia. Despite the scale-up of HIV prevention and treatment programmes, important disparities remain, and renewed education-centred and geographically targeted efforts are needed to close gaps.
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