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Fostering citizen-engaged HIV implementation science 促进公民参与的艾滋病实施科学。
IF 4.6 1区 医学 Q2 IMMUNOLOGY Pub Date : 2024-07-05 DOI: 10.1002/jia2.26278
Benedict Xin Hao Tan, Shao Yuan Chong, Daniel Weng Siong Ho, Ye Xuan Wee, Muhammad Hafiz Jamal, Rayner Kay Jin Tan

Introduction

Successful implementation of evidence-based practices depends on contextual factors like stakeholder engagement, the socio-political environment, resource availability, and stakeholders’ felt needs and preferences. Nevertheless, inequities in implementation exist and undermine efforts to address HIV in marginalized key populations. Implementation science shows promise in addressing such inequities in the HIV response, but can be limited without meaningful engagement from citizens or communities.

Discussion

We define the concept of a citizen-engaged HIV implementation science as one that involves citizens and communities deeply in HIV implementation science activities. In this commentary, we discuss how citizen science approaches can be leveraged to spur equity in HIV implementation science. Drawing on three areas previously defined by Geng and colleagues that serve to drive impactful implementation science in the HIV response, we discuss how citizens can be engaged when considering “whose perspectives?”, “what questions are being asked?” and “how are questions asked?”. With respect to “whose perspectives?” a citizen-engaged HIV implementation science would leverage participatory methods and tools, such as co-creation, co-production and crowdsourcing approaches, to engage the public in identifying challenges, solve health problems and implement solutions. In terms of “what questions are being asked?”, we discuss how efforts are being made to synthesize citizen or community-led approaches with existing implementation science frameworks and approaches. This also means that we ensure communities have a say in interrogating and deconstructing such frameworks and adapting them to local contexts through participatory approaches. Finally, when considering “how are questions asked?”, we argue for the development and adoption of broad, guiding principles and frameworks that account for dynamic contexts to promote citizen-engaged research in HIV implementation science. This also means avoiding narrow definitions that limit the creativity, innovation and ground-up wisdom of local citizens.

Conclusions

By involving communities and citizens in the development and growth of HIV implementation science, we can ensure that our implementation approaches remain equitable and committed to bridging divides and ending AIDS as a public health threat. Ultimately, efforts should be made to foster a citizen- and community-engaged HIV implementation science to spur equity in our global HIV response.

导言:循证实践的成功实施取决于相关因素,如利益相关者的参与、社会政治环境、资源可用性以及利益相关者的需求和偏好。然而,实施过程中的不公平现象依然存在,并破坏了为解决边缘化关键人群的艾滋病问题所做的努力。实施科学在解决艾滋病应对措施中的不平等方面展现出了希望,但如果没有公民或社区的有意义参与,实施科学的作用就会受到限制:我们将 "公民参与的艾滋病防治实施科学 "这一概念定义为:公民和社区深入参与艾滋病防治实施科学活动的科学。在本评论中,我们将讨论如何利用公民科学方法来促进艾滋病实施科学的公平性。借鉴耿晓峰及其同事之前定义的三个领域,我们讨论了在考虑 "谁的观点?"、"提出了什么问题?"和 "如何提出问题?"时,如何让公民参与进来。关于 "谁的观点?",公民参与的艾滋病防治实施科学将利用参与式方法和工具,如共同创造、共同生产和众包方法,让公众参与确定挑战、解决健康问题和实施解决方案。在 "提出什么问题?"方面,我们讨论了如何努力将公民或社区主导的方法与现有的实施科学框架和方法相结合。这也意味着,我们要确保社区在质疑和解构此类框架方面拥有发言权,并通过参与式方法使其适应当地情况。最后,在考虑 "如何提出问题?"时,我们主张制定和采用广泛的指导原则和框架,以考虑到动态环境,促进公民参与艾滋病实施科学研究。这也意味着要避免狭隘的定义,因为狭隘的定义会限制当地公民的创造力、创新力和基层智慧:通过让社区和公民参与艾滋病实施科学的发展和成长,我们可以确保我们的实施方法保持公平,并致力于弥合分歧和消除艾滋病对公共健康的威胁。最终,我们应努力促进公民和社区参与的艾滋病实施科学,以促进全球艾滋病应对措施的公平性。
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引用次数: 0
Using FRAME to characterize provider-identified adaptations to a stepped care intervention for adolescents and youth living with HIV in Kenya: a mixed methods approach 使用 FRAME 描述提供者对肯尼亚青少年艾滋病感染者阶梯式护理干预措施的适应性:一种混合方法。
IF 4.6 1区 医学 Q2 IMMUNOLOGY Pub Date : 2024-07-05 DOI: 10.1002/jia2.26261
Nok Chhun, Dorothy Oketch, Kawango Agot, Dorothy I. Mangale, Jacinta Badia, James Kibugi, Wenwen Jiang, Mary Kirk, Barbra A. Richardson, Pamela K. Kohler, Grace John-Stewart, Kristin Beima-Sofie

Introduction

The Data-informed Stepped Care (DiSC) study is a cluster-randomized trial implemented in 24 HIV care clinics in Kenya, aimed at improving retention in care for adolescents and youth living with HIV (AYLHIV). DiSC is a multi-component intervention that assigns AYLHIV to different intensity (steps) of services according to risk. We used the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to characterize provider-identified adaptations to the implementation of DiSC to optimize uptake and delivery, and determine the influence on implementation outcomes.

Methods

Between May and December 2022, we conducted continuous quality improvement (CQI) meetings with providers to optimize DiSC implementation at 12 intervention sites. The meetings were guided by plan-do-study-act processes to identify challenges during early phase implementation and propose targeted adaptations. Meetings were audio-recorded and analysed using FRAME to categorize the level, context and content of planned adaptations and determine if adaptations were fidelity consistent. Providers completed surveys to quantify perceptions of DiSC acceptability, appropriateness and feasibility. Mixed effects linear regression models were used to evaluate these implementation outcomes over time.

Results

Providers participated in eight CQI meetings per facility over a 6-month period. A total of 65 adaptations were included in the analysis. The majority focused on optimizing the integration of DiSC within the clinic (83%, n = 54), and consisted of improving documentation, addressing scheduling challenges and improving clinic workflow. Primary reasons for adaptation were to align delivery with AYLHIV needs and preferences and to increase reach among AYLHIV: with reminder calls to AYLHIV, collaborating with schools to ensure AYLHIV attended clinic appointments and addressing transportation challenges. All adaptations to optimize DiSC implementation were fidelity-consistent. Provider perceptions of implementation were consistently high throughout the process, and on average, slightly improved each month for intervention acceptability (β = 0.011, 95% CI: 0.002, 0.020, p = 0.016), appropriateness (β = 0.012, 95% CI: 0.007, 0.027, p<0.001) and feasibility (β = 0.013, 95% CI: 0.004, 0.022, p = 0.005).

Conclusions

Provider-identified adaptations targeted improved integration into routine clinic practices an

简介以数据为依据的阶梯式护理(DiSC)研究是一项分组随机试验,在肯尼亚的 24 家艾滋病护理诊所实施,旨在提高青少年艾滋病感染者(AYLHIV)的护理率。DiSC 是一项多成分干预措施,根据风险程度为青少年艾滋病病毒感染者分配不同强度(步骤)的服务。我们使用 "适应性和修改报告扩展框架"(FRAME)来描述医疗服务提供者对 DiSC 的实施所做的适应性调整,以优化吸收和实施,并确定其对实施结果的影响:2022年5月至12月期间,我们与医疗服务提供者举行了持续质量改进(CQI)会议,以优化12个干预地点的DiSC实施。会议以 "计划-实施-研究-行动 "流程为指导,旨在确定早期实施过程中的挑战,并提出有针对性的调整建议。对会议进行录音,并使用 FRAME 进行分析,以对计划调整的水平、背景和内容进行分类,并确定调整是否忠实一致。提供者填写了调查问卷,以量化对 DiSC 可接受性、适宜性和可行性的看法。我们使用混合效应线性回归模型来评估这些随时间推移的实施结果:在 6 个月的时间里,每个机构的医疗服务提供者参加了 8 次 CQI 会议。共有 65 项调整被纳入分析。大多数调整都集中在优化诊所内的DiSC整合(83%,n = 54),包括改进文档、解决日程安排难题和改进诊所工作流程。进行调整的主要原因是根据青少年艾滋病毒感染者的需求和偏好提供服务,并扩大青少年艾滋病毒感染者的覆盖范围:给青少年艾滋病毒感染者拨打提醒电话,与学校合作确保青少年艾滋病毒感染者参加诊所预约,以及解决交通难题。为优化 DiSC 的实施而进行的所有调整都是忠实一致的。在整个实施过程中,提供者对实施效果的评价一直很高,平均而言,每个月的干预可接受性(β = 0.011,95% CI:0.002,0.020,p = 0.016)、适当性(β = 0.012,95% CI:0.007,0.027,p 结论:提供者对实施效果的评价略有提高:医疗服务提供者确定的适应性目标是更好地融入常规诊所实践,并旨在减少 AYLHIV 所特有的获得服务的障碍。对适应类型和适应原理进行描述可丰富我们对实施环境的理解,并在推广到新环境时提高调整实施策略的能力。
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引用次数: 0
Gestational weight gain and adverse birth outcomes in South African women with HIV on antiretroviral therapy and without HIV: a prospective cohort study 南非接受抗逆转录病毒治疗和未接受抗逆转录病毒治疗的感染艾滋病毒妇女的妊娠体重增加与不良分娩结局:一项前瞻性队列研究。
IF 4.6 1区 医学 Q2 IMMUNOLOGY Pub Date : 2024-06-26 DOI: 10.1002/jia2.26313
Hlengiwe P. Madlala, Landon Myer, Jennifer Jao, Hayli Geffen, Mushi Matjila, Azetta Fisher, Demi Meyer, Erika F. Werner, Gregory Petro, Susan Cu-Uvin, Stephen T. McGarvey, Angela M. Bengtson

Introduction

Outside of pregnancy, evidence shows that persons with HIV initiating or switching to dolutegravir (DTG)-based antiretroviral therapy (ART) experience greater weight gain compared to those on other ART classes. However, there are few data on the impact of DTG-based ART on gestational weight gain (GWG) in sub-Saharan Africa where HIV is most common. According to the National Academy of Medicine (NAM), GWG below and above NAM guidelines is associated with adverse birth outcomes. Therefore, the objective of this study was to describe GWG by HIV status and ART regimen, and examine the associations with adverse birth outcomes.

Methods

We enrolled pregnant women with HIV (WHIV) and without HIV (≥18 years) in a peri-urban primary healthcare facility in Cape Town, South Africa between 2019 and 2022. GWG was study-measured at 24–28 (baseline) and 33–38 weeks gestation and converted to GWG rate (kg/week) in accordance with NAM guidelines. GWG z-scores were generated using the INTEGROWTH-21 and US standards to account for differing lengths of gestation. Birth outcome data were obtained from medical records. Associations of GWG z-score with adverse birth outcomes were assessed using multivariable linear or log-binomial regression.

Results

Among 292 participants (48% WHIV), median age was 29 years (IQR, 25–33), median pre-pregnancy body mass index (BMI) was 31 kg/m2 (IQR, 26–36) and 20% were primiparous at baseline. The median weekly rate of GWG was 0.30 kg/week (IQR, 0.12–0.50), 35% had GWG below NAM standards (59% WHIV) and 48% had GWG above NAM standards (36% WHIV). WHIV gained weight more slowly (0.25 vs. 0.37 kg/week, p<0.01) than women without HIV. Weekly rate of GWG did not differ by ART regimen (DTG-based ART 0.25 vs. efavirenz-based ART 0.27 kg/week, p = 0.80). In multivariable analyses, GWG z-score was positively associated with continuous birth weight (mean difference = 68.53 95% CI 8.96, 128.10) and categorical high birth weight of >4000 g (RR = 2.18 95% CI 1.18, 4.01).

Conclusions

Despite slower GWG among WHIV, nearly half of all women gained weight faster than recommended by the NAM. GWG was positively associated with infant birth weight. Interventions to support healthy GWG in sub-Saharan Africa are urgently needed.

导言:有证据表明,在妊娠期外,开始或转用基于多罗替拉韦(DTG)的抗逆转录病毒疗法(ART)的艾滋病病毒感染者与接受其他抗逆转录病毒疗法的艾滋病病毒感染者相比,体重增加幅度更大。然而,在 HIV 最常见的撒哈拉以南非洲地区,有关基于 DTG 的抗逆转录病毒疗法对妊娠体重增加 (GWG) 的影响的数据却很少。根据美国国家医学科学院(NAM)的研究,GWG 低于或高于 NAM 指南与不良出生结果有关。因此,本研究的目的是根据 HIV 感染状况和抗逆转录病毒疗法来描述 GWG,并研究其与不良分娩结局之间的关联:我们在 2019 年至 2022 年期间在南非开普敦的一个近郊初级医疗保健机构招募了感染 HIV 的孕妇(WHIV)和未感染 HIV 的孕妇(≥18 岁)。研究测量了妊娠 24-28 周(基线)和 33-38 周的 GWG,并根据 NAM 指南转换为 GWG 率(千克/周)。GWG z-分数根据 INTEGROWTH-21 和美国标准生成,以考虑不同的妊娠期。出生结果数据来自医疗记录。采用多变量线性回归或对数二项式回归评估 GWG z 分数与不良出生结局的关系:在 292 名参与者(48% WHIV)中,年龄中位数为 29 岁(IQR,25-33),孕前体重指数(BMI)中位数为 31 kg/m2(IQR,26-36),基线时 20% 为初产妇。每周体重增长速度的中位数为 0.30 千克/周(IQR,0.12-0.50),35% 的人的体重增长速度低于 NAM 标准(59% WHIV),48% 的人的体重增长速度高于 NAM 标准(36% WHIV)。WHIV 的体重增加速度更慢(0.25 vs. 0.37 kg/周,p4000 g (RR = 2.18 95% CI 1.18, 4.01)):尽管 WHIV 的 GWG 增重较慢,但仍有近一半的妇女的体重增长速度快于 NAM 建议的速度。GWG 与婴儿出生体重呈正相关。在撒哈拉以南非洲地区,迫切需要采取干预措施来支持健康的 GWG。
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引用次数: 0
Navigating grey areas in HIV and mental health implementation science 在艾滋病和心理健康实施科学的灰色地带航行。
IF 4.6 1区 医学 Q2 IMMUNOLOGY Pub Date : 2024-06-25 DOI: 10.1002/jia2.26271
Audrey Harkness, Ali Giusto, Alison B. Hamilton, Raul U. Hernandez-Ramirez, Donna Spiegelman, Bryan J. Weiner, Rinad S. Beidas, Michaela E. Larson, Sheri A. Lippman, Milton L. Wainberg, Justin D. Smith

Introduction

Implementation science (IS) offers methods to systematically achieve the Ending the HIV Epidemic goals in the United States, as well as the global UNAIDS targets. Federal funders such as the National Institutes of Mental Health (NIMH) have invested in implementation research to achieve these goals, including supporting the AIDS Research Centres (ARCs), which focus on high-impact science in HIV and mental health (MH). To facilitate capacity building for the HIV/MH research workforce in IS, “grey areas,” or areas of IS that are confusing, particularly for new investigators, should be addressed in the context of HIV/MH research.

Discussion

A group of IS experts affiliated with NIMH-funded ARCs convened to identify common and challenging grey areas. The group generated a preliminary list of 19 grey areas in HIV/MH-related IS. From the list, the authors developed a survey which was distributed to all ARCs to prioritize grey areas to address in this paper. ARC members across the United States (N = 60) identified priority grey areas requiring clarification. This commentary discusses topics with 40% or more endorsement. The top grey areas that ARC members identified were: (1) Differentiating implementation strategies from interventions; (2) Determining when an intervention has sufficient evidence for adaptation; (3) Integrating recipient perspectives into HIV/MH implementation research; (4) Evaluating whether an implementation strategy is evidence-based; (5) Identifying rigorous approaches for evaluating the impact of implementation strategies in the absence of a control group or randomization; and (6) Addressing innovation in HIV/MH IS grants. The commentary addresses each grey area by drawing from the existing literature (when available), providing expert guidance on addressing each in the context of HIV/MH research, and providing domestic and global HIV and HIV/MH case examples that address these grey areas.

Conclusions

HIV/MH IS is key to achieving domestic and international goals for ending HIV transmission and mitigating its impact. Guidance offered in this paper can help to overcome challenges to rigorous and high-impact HIV/MH implementation research.

导言:实施科学(IS)提供了在美国系统地实现 "结束艾滋病毒流行 "目标以及联合国艾滋病规划署全球目标的方法。为实现这些目标,美国国立精神卫生研究所(NIMH)等联邦资助机构对实施研究进行了投资,包括支持艾滋病研究中心(ARCs),该中心的重点是在艾滋病和精神卫生(MH)领域开展高影响力的科学研究。为促进艾滋病/精神健康研究人员在实施研究方面的能力建设,应在艾滋病/精神健康研究的背景下解决实施研究中的 "灰色地带 "或令人困惑的领域,尤其是对新研究人员而言:由隶属于 NIMH 资助的 ARC 的 IS 专家组成的小组召开了会议,以确定常见和具有挑战性的灰色领域。该小组初步列出了 19 个与 HIV/MH 相关的 IS 灰色领域。根据这份清单,作者编写了一份调查问卷,并分发给所有艾滋病研究中心,以便在本文中优先解决灰色领域的问题。美国各地的 ARC 成员(N = 60)确定了需要优先澄清的灰色领域。本评论将讨论获得 40% 或更多认可的主题。ARC 成员确定的首要灰色领域是(1) 将实施策略与干预措施区分开来;(2) 确定干预措施何时有足够证据进行调整;(3) 将受助者观点纳入 HIV/MH 实施研究;(4) 评估实施策略是否以证据为基础;(5) 在没有对照组或随机化的情况下,确定评估实施策略影响的严格方法;以及 (6) 解决 HIV/MH IS 补助金中的创新问题。本评论通过借鉴现有文献(如果有的话)来解决每个灰色领域,为在 HIV/MH 研究背景下解决每个灰色领域提供专家指导,并提供国内和全球 HIV 和 HIV/MH 案例来解决这些灰色领域:艾滋病毒/MH 基础设施服务是实现国内和国际目标,杜绝艾滋病毒传播和减轻其影响的关键。本文提供的指导有助于克服在开展严谨、高影响力的 HIV/MH 实施研究方面遇到的挑战。
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引用次数: 0
Tobacco smoking, smoking cessation and life expectancy among people with HIV on antiretroviral therapy in South Africa: a simulation modelling study 南非接受抗逆转录病毒疗法的艾滋病病毒感染者吸烟、戒烟和预期寿命:模拟建模研究。
IF 4.6 1区 医学 Q2 IMMUNOLOGY Pub Date : 2024-06-25 DOI: 10.1002/jia2.26315
Acadia M. Thielking, Kieran P. Fitzmaurice, Ronel Sewpaul, Stavroula A. Chrysanthopoulou, Lotanna Dike, Douglas E. Levy, Nancy A. Rigotti, Mark J. Siedner, Robin Wood, A. David Paltiel, Kenneth A. Freedberg, Emily P. Hyle, Krishna P. Reddy

Introduction

As access to effective antiretroviral therapy (ART) has improved globally, tobacco-related illnesses, including cardiovascular disease, cancer and chronic respiratory conditions, account for a growing proportion of deaths among people with HIV (PWH). We estimated the impact of tobacco smoking and smoking cessation on life expectancy among PWH in South Africa.

Methods

In a microsimulation model, we simulated 18 cohorts of PWH with virologic suppression, each homogenous by sex, initial age (35y/45y/55y) and smoking status (current/former/never). Input parameters were from data sources published between 2008 and 2022. We used South African data to estimate age-stratified mortality hazard ratios: 1.2−2.3 (females)/1.1−1.9 (males) for people with current versus never smoking status; and 1.0−1.3 (females)/1.0−1.5 (males) for people with former versus never smoking status, depending on age at cessation. We assumed smoking status remains unchanged during the simulation; people who formerly smoked quit at model start. Simulated PWH face a monthly probability of disengagement from care and virologic non-suppression. In sensitivity analysis, we varied smoking-associated and HIV-associated mortality risks. Additionally, we estimated the total life-years gained if a proportion of all virologically suppressed PWH stopped smoking.

Results

Forty-five-year-old females/males with HIV with virologic suppression who smoke lose 5.3/3.7 life-years compared to PWH who never smoke. Smoking cessation at age 45y adds 3.4/2.4 life-years. Simulated PWH who continue smoking lose more life-years from smoking than from HIV (females, 5.3 vs. 3.0 life-years; males, 3.7 vs. 2.6 life-years). The impact of smoking and smoking cessation increase as smoking-associated mortality risks increase and HIV-associated mortality risks, including disengagement from care, decrease. Model results are most sensitive to the smoking-associated mortality hazard ratio; varying this parameter results in 1.0−5.1 life-years gained from cessation at age 45y. If 10−25% of virologically suppressed PWH aged 30−59y in South Africa stopped smoking now, 190,000−460,000 life-years would be gained.

Conclusions

Among virologically suppressed PWH in South Africa, tobacco smoking decreases life expectancy more than HIV. Integrating tobacco cessation interventions into HIV care, as endorsed by the World Health Organization, could substantially improve life expecta

导言:随着有效抗逆转录病毒疗法(ART)在全球范围内的普及,与烟草相关的疾病,包括心血管疾病、癌症和慢性呼吸道疾病,在艾滋病病毒感染者(PWH)的死亡人数中所占比例越来越大。我们估算了吸烟和戒烟对南非艾滋病感染者预期寿命的影响:在微观模拟模型中,我们模拟了 18 组病毒学抑制的感染者,每组感染者的性别、初始年龄(35 岁/45 岁/55 岁)和吸烟状况(目前吸烟/曾经吸烟/从不吸烟)均相同。输入参数来自 2008 年至 2022 年间发布的数据源。我们使用南非的数据估算了年龄分层死亡率危险比:根据戒烟时的年龄,目前吸烟与从不吸烟者的危险比为 1.2-2.3(女性)/1.1-1.9(男性);曾经吸烟与从不吸烟者的危险比为 1.0-1.3(女性)/1.0-1.5(男性)。我们假设吸烟状况在模拟期间保持不变;曾经吸烟的人在模型开始时戒烟。模拟的感染者每月面临脱离治疗和病毒学抑制的概率。在敏感性分析中,我们改变了与吸烟相关和与 HIV 相关的死亡风险。此外,我们还估算了在所有病毒学抑制的感染者中,如果有一部分人停止吸烟,所获得的总寿命年数:结果:与从不吸烟的艾滋病感染者相比,病毒学抑制的 45 岁女性/男性艾滋病感染者吸烟会损失 5.3/3.7 个生命年。45 岁戒烟可增加 3.4/2.4 个寿命年。继续吸烟的模拟感染者因吸烟而损失的寿命比因感染艾滋病毒而损失的寿命更长(女性,5.3 比 3.0 寿命;男性,3.7 比 2.6 寿命)。吸烟和戒烟的影响随着吸烟相关死亡风险的增加而增加,而 HIV 相关死亡风险(包括脱离护理)的降低而降低。模型结果对与吸烟相关的死亡率危险比最为敏感;改变该参数可使 45 岁戒烟者获得 1.0-5.1 个生命年。如果南非30-59岁的病毒学抑制的感染者中有10%-25%的人现在戒烟,将获得190,000-460,000年的寿命:结论:在南非病毒得到抑制的艾滋病感染者中,吸烟比艾滋病病毒更容易缩短预期寿命。正如世界卫生组织所认可的那样,将戒烟干预纳入艾滋病护理可大幅提高预期寿命。
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引用次数: 0
Beating the odds: medicines alone will not stop HIV 战胜困难:仅靠药物无法阻止艾滋病毒的传播。
IF 4.6 1区 医学 Q2 IMMUNOLOGY Pub Date : 2024-06-25 DOI: 10.1002/jia2.26321
Beatriz Grinsztejn, Cristina Mussini, Claudia Cortes, Darrell H. S. Tan, Nittaya Phanuphak

In the past 20 years, the world has made significant medical progress in addressing HIV. Groundbreaking HIV treatment and prevention options, such as pre-exposure prophylaxis (PrEP), are increasingly used around the world. As of 2023, 29.8 million of the 39 million people living with HIV (PLWH) globally were receiving HIV treatment [1]. Access to PrEP has increased over 1000% from 2019 to 2022. This increased use of treatment and prevention options has resulted in an almost 60% reduction in new HIV acquisitions in children in 2022 compared to 2010, the lowest since the 1980s, and in almost three-quarters of PLWH in 2022 having suppressed plasma viraemia; though eastern Europe, central Asia and the Middle East and North Africa have reported increases in new HIV acquisitions.

Indeed, while the global data are encouraging, progress for key populations (KPs)—gay and other men who have sex with men (MSM), sex workers, transgender people and people who inject drugs (PWID) and migrants—is particularly uneven despite their increased vulnerability to HIV. In 2023, outside of sub-Saharan Africa, the majority of new HIV acquisitions were among KPs [1]. PrEP coverage among KPs in low- and middle-income countries is typically under 5% [1]. Antiretroviral therapy coverage and retention in care are lower for sex workers, transgender people and PWID compared to the general population [1].

Medicines alone will not close this gap. KPs need enabling legal and policy environments to support their access to and uptake of HIV- and other health-related services. In discriminatory and punitive legal and policy environments, KPs avoid HIV-related services for fear of harassment, discrimination or reporting to law enforcement by healthcare workers. In Argentina, a study found that transgender people who experienced stigma in healthcare settings were three times more likely to avoid seeking healthcare than those who had not experienced stigma [2].

The consequences of a punitive and discriminatory legal and policy environment on KPs and their health are staggering. MSM in countries that criminalize same-sex relations are more than twice as likely to be living with HIV compared to those in countries without such criminal penalties [3]. A study conducted in 10 countries in sub-Saharan Africa found that HIV prevalence among sex workers was 7.17 times higher in countries where sex work was criminalized compared to countries where it was not criminalized [4]. A 2017 systematic review found that 80% of included studies reported that criminalization of drug possession had a negative impact on PWID's access to HIV prevention, treatment, care and support services [5].

Yet, no country in the world has repealed laws criminalizing all KP behaviours, including laws related to sex work, possession of small amounts of drugs for personal use, same-sex sexual be

其次,所有艾滋病毒与健康计划都必须纳入法律和政策改革[11]。例如,处理艾滋病毒与健康问题的国家协调机制不仅应有意识地纳入卫生专家和卫生部官员,还应纳入法律和政策专家以及司法部和执法部官员。公共卫生工作者和研究人员需要与法律和政策专家合作,共同设计、实施和评估艾滋病毒规划工作。最后,需要为法律和政策改革工作分配更多相关的艾滋病毒防治资金。2022 年,在可利用的艾滋病毒资源总额中,只有约 5%用于解决人权问题的计划;政策对话;减少污名化、歧视和基于性别的暴力;以及与艾滋病毒有关的法律服务[1]。此外,对艾滋病毒的资助需要扩大到政府卫生部门和以提供服务为重点的民间社会组织以外的领域,包括致力于法律和政策改革的相关民间社会组织。预防和治疗对策必须通过法律和政策改革加以优化,这也是我们工作的一部分。此外,我们必须支持由金伯利进程领导的改革法律和政策环境的努力,确保我们作为医疗服务提供者和倡导者的角色与支持法律改革之间的明确分工。艾滋病医生》一书:来自流行病的声音:口述历史》一书强调了医生在面对不确定性和死亡时所发挥的关键作用[12]。同样,我们现在必须发出自己的声音,并与那些参与法律和政策改革的人合作,以确保所有 KPs 都能获得服务。所有作者都对报告发表了意见,并批准了最终版本。BG 由国家技术与科学发展委员会 (CNPq) 和卡洛斯-查格斯-菲略基金会 (Carlos Chagas Filho Foundation for Research Support in the State of Rio de Janeiro, FAPERJ) 资助。
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引用次数: 0
Intervention strategies to improve adherence to treatment for selected chronic conditions in sub-Saharan Africa: a systematic review 改善撒哈拉以南非洲某些慢性病患者坚持治疗的干预策略:系统综述。
IF 4.6 1区 医学 Q2 IMMUNOLOGY Pub Date : 2024-06-25 DOI: 10.1002/jia2.26266
Siphamandla Bonga Gumede, John B. F. de Wit, Willem D. F. Venter, Annemarie M. J. Wensing, Samanta Tresha Lalla-Edward

Introduction

Evidence-based intervention strategies to improve adherence among individuals living with chronic conditions are critical in ensuring better outcomes. In this systematic review, we assessed the impact of interventions that aimed to promote adherence to treatment for chronic conditions.

Methods

We systematically searched PubMed, Web of Science, Scopus, Google Scholar and CINAHL databases to identify relevant studies published between the years 2000 and 2023 and used the QUIPS assessment tool to assess the quality and risk of bias of each study. We extracted data from eligible studies for study characteristics and description of interventions for the study populations of interest.

Results

Of the 32,698 total studies/records screened, 2814 were eligible for abstract screening and of those, 497 were eligible for full-text screening. A total of 82 studies were subsequently included, describing a total of 58,043 patients. Of the total included studies, 58 (70.7%) were related to antiretroviral therapy for HIV, 6 (7.3%) were anti-hypertensive medication-related, 12 (14.6%) were anti-diabetic medication-related and 6 (7.3%) focused on medication for more than one condition. A total of 54/82 (65.9%) reported improved adherence based on the described study outcomes, 13/82 (15.9%) did not have clear results or defined outcomes, while 15/82 (18.3%) reported no significant difference between studied groups. The 82 publications described 98 unique interventions (some studies described more than one intervention). Among these intervention strategies, 13 (13.3%) were multifaceted (4/13 [30.8%] multi-component health services- and community-based programmes, 6/13 [46.2%] included individual plus group counselling and 3/13 [23.1%] included SMS or alarm reminders plus individual counselling).

Discussion

The interventions described in this review ranged from adherence counselling to more complex interventions such as mobile health (mhealth) interventions. Combined interventions comprised of different components may be more effective than using a single component in isolation. However, the complexity involved in designing and implementing combined interventions often complicates the practicalities of such interventions.

Conclusions

There is substantial evidence that community- a

导言:改善慢性病患者坚持治疗的循证干预策略对于确保更好的治疗效果至关重要。在这篇系统性综述中,我们评估了旨在促进慢性病患者坚持治疗的干预措施的影响:我们系统地检索了 PubMed、Web of Science、Scopus、Google Scholar 和 CINAHL 数据库,以确定 2000 年至 2023 年间发表的相关研究,并使用 QUIPS 评估工具来评估每项研究的质量和偏倚风险。我们从符合条件的研究中提取了有关研究特征的数据,并对相关研究人群的干预措施进行了描述:在筛选出的 32,698 项研究/记录中,2814 项符合摘要筛选条件,其中 497 项符合全文筛选条件。随后共纳入了 82 项研究,共描述了 58043 名患者。在所有纳入的研究中,58 项(70.7%)与艾滋病抗逆转录病毒疗法有关,6 项(7.3%)与抗高血压药物有关,12 项(14.6%)与抗糖尿病药物有关,6 项(7.3%)侧重于一种以上疾病的药物治疗。根据所描述的研究结果,共有 54/82 篇(65.9%)报告了治疗依从性的改善,13/82 篇(15.9%)没有明确的结果或界定的结果,而 15/82 篇(18.3%)报告了研究组间没有显著差异。这 82 篇出版物描述了 98 种独特的干预措施(有些研究描述了一种以上的干预措施)。在这些干预策略中,有 13 项(13.3%)是多方面的(4/13 [30.8%]基于医疗服务和社区的多成分计划,6/13 [46.2%]包括个人咨询和小组咨询,3/13 [23.1%]包括短信或警报提醒和个人咨询):讨论:本综述中介绍的干预措施包括从坚持咨询到移动医疗(mhealth)干预等更复杂的干预措施。由不同部分组成的综合干预措施可能比单独使用一个部分更有效。然而,设计和实施综合干预措施所涉及的复杂性往往使此类干预措施的实际操作变得更加复杂:大量证据表明,基于社区和家庭的干预措施、数字健康干预措施和依从性咨询干预措施可以改善慢性病患者的服药依从性。未来的研究应回答是否可以利用现有的干预措施来制定不那么复杂的多方面坚持用药干预策略。
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引用次数: 0
INcentives and ReMINDers to Improve Long-Term Medication Adherence (INMIND): impact of a pilot randomized controlled trial in a large HIV clinic in Uganda 提高长期用药依从性的激励和再提醒(INMIND):在乌干达一家大型艾滋病诊所开展的随机对照试验的影响。
IF 4.6 1区 医学 Q2 IMMUNOLOGY Pub Date : 2024-06-25 DOI: 10.1002/jia2.26306
Sebastian Linnemayr, Mary Odiit, Barbara Mukasa, Ishita Ghai, Chad Stecher

Introduction

Habits are a common strategy for successfully countering medication non-adherence, yet existing interventions do not support participants during the long habit formation period, resulting in high attrition. We test a novel intervention combining text messages and incentives with anchoring to support antiretroviral therapy (ART) pill-taking habits.

Methods

In a randomized, parallel controlled trial, a sample of 155 participants 18 years and older who initiated ART within 3 months were recruited at Mildmay Uganda between October 2021 and April 2022. All participants were educated on the anchoring strategy and chose an anchor, that is existing routines, to pair with pill-taking. Participants were randomized to either usual care (C = 49), daily text message reminders to follow their anchoring plan (Messages group; T1 = 49) or messages and incentives conditional on pill-taking in line with their anchor (Incentives group; T2 = 57). Assessments occurred at baseline, month 3 (end of intervention) and month 9 (end of observation period). The primary outcomes are electronically measured mean adherence and pill-taking consistent with participants’ anchor time.

Results

The primary outcome of pill-taking in line with the anchoring plan was higher in the Incentives group during the 3-month intervention (12.2 p.p. [95% CI: 2.2 22.2; p = .02]), and remained significantly higher after the incentives were withdrawn (months 4−6 (14.2 p.p. [95% CI 1.1 27.2; p = .03]); months 7−9 (14.1 p.p. [95% CI −0.2 28.5; p = .05])). Mean adherence was higher in both treatment groups relative to the control group during the intervention (T1 vs. C, p = .06; T2 vs. C, p = .06) but not post-intervention.

Conclusions

The promising approach of using incentives to support habit formation among ART treatment initiators needs to be evaluated in a fully powered study to further our understanding of the habit formation process and to evaluate its cost-effectiveness.

简介:习惯是成功应对不坚持服药的常用策略,但现有干预措施无法在漫长的习惯养成期为参与者提供支持,从而导致高流失率。我们测试了一种新颖的干预方法,它将短信和激励措施与锚定相结合,以支持抗逆转录病毒疗法(ART)患者养成服药习惯:在一项随机平行对照试验中,2021 年 10 月至 2022 年 4 月期间,我们在乌干达米尔德梅招募了 155 名 18 岁及以上、在 3 个月内开始接受抗逆转录病毒疗法的参与者。所有参与者都接受了关于锚定策略的教育,并选择了一个锚点,即现有的常规习惯,与服药搭配。参与者被随机分配到常规护理组(C = 49)、每日短信提醒遵循锚定计划组(信息组;T1 = 49)或根据锚定计划服药的信息和奖励组(奖励组;T2 = 57)。评估分别在基线、第 3 个月(干预结束)和第 9 个月(观察期结束)进行。主要结果是电子测量的平均依从性和与参与者锚定时间一致的服药情况:结果:在为期 3 个月的干预期间,激励组按照锚定计划服药的主要结果较高(12.2 p.p. [95% CI: 2.2 22.2; p = .02]),并且在取消激励后仍然显著较高(第 4-6 个月(14.2 p.p. [95% CI 1.1 27.2; p = .03]);第 7-9 个月(14.1 p.p. [95% CI -0.2 28.5; p = .05]))。在干预期间,两个治疗组的平均坚持率均高于对照组(T1 vs. C,p = .06;T2 vs. C,p = .06),但干预后的坚持率没有提高:使用激励措施支持抗逆转录病毒疗法初学者形成习惯的方法很有前景,需要在一项完全有效的研究中进行评估,以加深我们对习惯形成过程的了解,并评估其成本效益。
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引用次数: 0
Factors associated with PrEP-era HIV seroconversion in a 4-year U.S. national cohort of n = 6059 sexual and gender minority individuals who have sex with men, 2017−2022 2017-2022 年,在 n = 6059 名性与性别少数群体男男性行为者的 4 年美国全国队列中,与 PrEP 时期艾滋病毒血清转换相关的因素
IF 4.6 1区 医学 Q1 Medicine Pub Date : 2024-06-25 DOI: 10.1002/jia2.26312
Christian Grov, Yan Guo, Drew A. Westmoreland, Alexa B. D'Angelo, Chloe Mirzayi, Michelle Dearolf, Pedro Carneiro, Meredith Ray, David Pantalone, Adam W. Carrico, Viraj V. Patel, Sarit A. Golub, Sabina Hirshfield, Donald R. Hoover, Denis Nash

Introduction

Community-based cohort studies of HIV seroconversion can identify important avenues for enhancing HIV prevention efforts in the era of pre-exposure prophylaxis (PrEP). Within individuals, one can assess exposure and outcome variables repeatedly and with increased certainty regarding temporal ordering. This cohort study examined the association of several risk factors with subsequent HIV seroconversion.

Methods

We report data from a 4-year study (2017−2022) of 6059 HIV seronegative sexual and gender minority individuals who have sex with men who had indications for-, but were not using-, PrEP at enrolment. Participants completed repeat exposure assessments and self-collection of biospecimens for HIV testing. We examined the roles of race and ethnicity, socio-economic status, methamphetamine use and PrEP uptake over the course of follow-up in relation to HIV seroconversion.

Results

Over 4 years, 303 of the participants seroconverted across 18,421 person-years (incidence rate = 1.64 [95% CI: 1.59−1.70] per 100 person-years). In multivariable discrete-time survival analysis, factors independently associated with elevated HIV seroconversion risk included being Black/African American (adjusted risk ratio [aRR]: 2.44, 1.79−3.28), Hispanic/Latinx (1.53, 1.19−1.96), housing instability (1.58, 1.22−2.05) and past year methamphetamine use (3.82, 2.74−5.33). Conversely, time since study enrolment (24 vs. 12 months, 0.67, 0.51−0.87; 36 months, 0.60, 0.45−0.80; 48 months, 0.48, 0.35−0.66) and higher education (master's degree or higher vs. less than or equal to high school, 0.36, 0.17−0.66) were associated with reduced seroconversion risk. Compared to non-PrEP users in the past 2 years without a current clinical indication, those who started PrEP but then discontinued had higher seroconversion risk, irrespective of clinical indication (3.23, 1.74−6.46) or lack thereof (4.30, 1.85−9.88). However, those who initiated PrEP in the past year (0.14, 0.04−0.39) or persistently used PrEP in the past 2 years (0.33, 0.14−0.74) had a lower risk of seroconversion. Of all HIV seroconversions observed during follow-up assessments (12, 24, 36 and 48 months), methamphetamine was reported in the 12 months prior 128 (42.2%) times (overall).

Conclusions

Interventions that acknowledge race and ethnicity, economic variables such as education and housing instability, and methamphetamine use are critically needed. Not only a

引言 以社区为基础的艾滋病血清转换队列研究可以确定在暴露前预防疗法(PrEP)时代加强艾滋病预防工作的重要途径。在个体内部,我们可以重复评估暴露和结果变量,并提高时间排序的确定性。这项队列研究考察了几个风险因素与后续 HIV 血清转换的关系。 方法 我们报告了一项为期 4 年(2017-2022 年)的研究数据,研究对象是 6059 名 HIV 血清阴性的性少数群体和性别少数群体男男性行为者,他们在入组时具有 PrEP 适应症,但并未使用 PrEP。参与者完成了重复暴露评估和自我采集生物样本进行 HIV 检测。我们研究了种族和民族、社会经济地位、甲基苯丙胺使用情况以及在随访过程中使用 PrEP 与 HIV 血清转换之间的关系。 结果 4 年间,303 名参与者在 18,421 人年中发生了血清转换(发生率 = 1.64 [95% CI: 1.59-1.70]/100人年)。在多变量离散时间生存分析中,与 HIV 血清转换风险升高独立相关的因素包括黑人/非裔美国人(调整风险比 [aRR]:2.44,1.79-3.28)、西班牙裔/拉丁裔(1.53,1.19-1.96)、住房不稳定(1.58,1.22-2.05)和过去一年使用甲基苯丙胺(3.82,2.74-5.33)。与此相反,加入研究的时间(24 个月对 12 个月,0.67,0.51-0.87;36 个月,0.60,0.45-0.80;48 个月,0.48,0.35-0.66)和高等教育程度(硕士学位或更高对高中以下,0.36,0.17-0.66)与血清转换风险降低有关。与过去两年中未使用过 PrEP 但目前没有临床指征的人相比,那些开始使用 PrEP 但后来又停止使用的人血清转换风险更高,无论是否有临床指征(3.23,1.74-6.46)或没有临床指征(4.30,1.85-9.88)。然而,在过去一年中开始使用 PrEP(0.14,0.04-0.39)或在过去两年中持续使用 PrEP(0.33,0.14-0.74)的人血清转换风险较低。在随访评估期间(12、24、36 和 48 个月)观察到的所有艾滋病毒血清转换者中,有 128 人(42.2%)报告在 12 个月前吸食过甲基苯丙胺(总体)。 结论 急需采取干预措施,承认种族和民族、经济变量(如教育和住房不稳定性)以及甲基苯丙胺的使用。不仅需要采取干预措施让个人参与 PrEP 治疗,而且鉴于这些群体中血清转换的风险极高,还必须采取干预措施留住他们,并让那些可能脱离治疗的人重新参与治疗。
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引用次数: 0
Including transgender populations in mathematical models for HIV treatment and prevention: current barriers and policy implications 将变性人纳入艾滋病治疗和预防数学模型:当前的障碍和政策影响。
IF 6 1区 医学 Q1 Medicine Pub Date : 2024-06-12 DOI: 10.1002/jia2.26304
Diana M. Tordoff, Arjee Restar, Brian Minalga, Atlas Fernandez, Dobromir Dimitrov, Ann Duerr, the Seattle Trans and Nonbinary Sexual Health (STARS) Advisory Board

Introduction

Mathematical models of HIV have been uniquely important in directing and evaluating HIV policy. Transgender and nonbinary people are disproportionately impacted by HIV; however, few mathematical models of HIV transmission have been published that are inclusive of transgender and nonbinary populations. This commentary discusses current structural challenges to developing robust and accurate trans-inclusive models and identifies opportunities for future research and policy, with a focus on examples from the United States.

Discussion

As of April 2024, only seven published mathematical models of HIV transmission include transgender people. Existing models have several notable limitations and biases that limit their utility for informing public health intervention. Notably, no models include transgender men or nonbinary individuals, despite these populations being disproportionately impacted by HIV relative to cisgender populations. In addition, existing mathematical models of HIV transmission do not accurately represent the sexual network of transgender people. Data availability and quality remain a significant barrier to the development of accurate trans-inclusive mathematical models of HIV. Using a community-engaged approach, we developed a modelling framework that addresses the limitations of existing model and to highlight how data availability and quality limit the utility of mathematical models for transgender populations.

Conclusions

Modelling is an important tool for HIV prevention planning and a key step towards informing public health interventions, programming and policies for transgender populations. Our modelling framework underscores the importance of accurate trans-inclusive data collection methodologies, since the relevance of these analyses for informing public health decision-making is strongly dependent on the validity of the model parameterization and calibration targets. Adopting gender-inclusive and gender-specific approaches starting from the development and data collection stages of research can provide insights into how interventions, programming and policies can distinguish unique health needs across all gender groups. Moreover, in light of the data structure limitations, designing longitudinal surveillance data systems and probability samples will be critical to fill key research gaps, highlight progress and provide additional rigour to the current evidence. Investments and initiatives like Ending the HIV Epidemic in the United States can be further expanded and are highly needed to prioritize and value transg

导言:艾滋病毒的数学模型在指导和评估艾滋病毒政策方面具有独特的重要性。变性人和非二元人群受到艾滋病毒的影响尤为严重;然而,目前已发表的艾滋病毒传播数学模型中,很少包含变性人和非二元人群。这篇评论以美国的实例为重点,讨论了当前在开发强大而准确的跨性别包容性模型方面所面临的结构性挑战,并指出了未来研究和政策的机遇:截至 2024 年 4 月,仅有七个已发表的艾滋病毒传播数学模型包含变性人。现有模型存在一些明显的局限性和偏差,限制了其为公共卫生干预提供信息的效用。值得注意的是,没有任何模型包括变性男性或非二元个人,尽管这些人群受到艾滋病毒的影响比顺性人群更大。此外,现有的 HIV 传播数学模型并不能准确地代表变性人的性网络。数据的可用性和质量仍然是开发准确的跨性别艾滋病毒数学模型的重大障碍。利用社区参与的方法,我们开发了一个建模框架,以解决现有模型的局限性,并强调数据可用性和质量如何限制了数学模型对跨性别人群的实用性:建模是艾滋病毒预防规划的重要工具,也是为变性人群体的公共卫生干预措施、规划和政策提供信息的关键步骤。我们的建模框架强调了准确的跨性别数据收集方法的重要性,因为这些分析对公共卫生决策的相关性在很大程度上取决于模型参数化和校准目标的有效性。从研究的开发和数据收集阶段开始,就采用性别包容和性别特定的方法,可以深入了解干预措施、计划和政策如何区分所有性别群体的独特健康需求。此外,鉴于数据结构的局限性,设计纵向监测数据系统和概率样本对于填补关键研究空白、突出进展和为现有证据提供更多严谨性至关重要。像美国 "消除艾滋病毒流行 "这样的投资和倡议可以进一步扩大,而且亟需在各种供资结构、目标和成果措施中优先考虑和重视跨性别人群。
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引用次数: 0
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Journal of the International AIDS Society
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