Antiretroviral Therapy Prescription Research Articles

Do HIV Care Outcomes Differ by Provider Type?

We compared HIV care outcomes by HIV provider type to inform efforts to strengthen the HIV provider workforce. United States. We analyzed data from Center for Disease Control and Prevention's Medical Monitoring Project collected during June, 2019-May, 2021 from 6323 adults receiving HIV medical care. Provider types include infectious disease physicians only (ID physicians), non-ID physicians only, nurse practitioners only, physician assistants only, and ID physicians plus nurse practitioners and/or physician assistants (mixed providers). We measured patient characteristics, social determinants of health, and clinical outcomes, including retention in care; antiretroviral therapy prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia, and syphilis testing; satisfaction with HIV care; and HIV provider trust. Compared with patients of ID physicians, higher percentages of patients of other provider types had characteristics and social determinants of health associated with poor health outcomes and received HIV care at Ryan White HIV/AIDS Program-funded facilities. After accounting for these differences, most outcomes were not meaningfully different; however, higher percentages of patients of non-ID physicians, nurse practitioners, and mixed providers were retained in care (6.5, 5.6, and 12.7 percentage points, respectively) and had sexually transmitted infection testing in the past 12 months, if sexually active (6.9, 7.4, and 13.5 percentage points, respectively). Most HIV outcomes were equivalent across provider types. However, patients of non-ID physicians, nurse practitioners, and mixed providers were more likely to be retained in care and have recommended sexually transmitted infection testing. Increasing delivery of comprehensive primary care by ID physicians and including primary care providers in ID practices could improve HIV primary care outcomes.

Antiretroviral therapy prescribing in the real-world and impact on cancer risk.

Antiretroviral therapy prescribing in the real-world and impact on cancer risk.

Polypharmacy and potential drug–drug interactions among people living with HIV in the era of integrase strand transfer inhibitor-based antiretroviral therapy

We aimed to investigate the prevalence of polypharmacy and potential drug-drug interactions (DDIs) and the associated factors with DDIs among people living with HIV (PLWH) in the modern era of antiretroviral therapy (ART). This cross-sectional study included PLWH who had been on ART for at least 3 months at two designated hospitals for HIV care in Taiwan. All ART and non-ART prescriptions were collected from the NHI-MediCloud System and screened for DDIs using the University of Liverpool HIV drug interactions database. A case-control analysis was conducted to investigate the factors associated with DDIs. From June 2021 to August 2022, 1007 PLWH were included. Their median age was 40 years (interquartile range, 33-49) and 96.2% were taking INSTI-based ART. The proportions of PLWH with at least 1 non-communicable diseases and polypharmacy were 50.0% and 18.7%, respectively. Seven (0.7%) PLWH had red-flagged DDIs, and 159 (15.8%) had amber-flagged DDIs. In multivariable models, the prevalence of DDIs was higher in PLWH with an older age (aOR, per 1-year increase, 1.022), number of co-medications (aOR, 1.097), use of boosted INSTI-based ART (versus unboosted INSTI, aOR, 8.653), and concomitant medications in the category of alimentary tract and metabolism (aOR, 11.058) and anti-neoplastic and immunomodulating agents (aOR, 14.733). In the INSTI era, the prevalence of potential DDIs was lower than previously noted, but remained substantial. Clinicians should routinely monitor DDIs, especially in older PLWH, those with increased number of co-medications, and those who are taking booster-containing ART or medications from specific categories.

Clinical outcomes after extended 12-month antiretroviral therapy prescriptions in a community-based differentiated HIV service delivery programme in South Africa: a retrospective cohort study.

There is an urgent need for more efficient models of differentiated antiretroviral therapy (ART) delivery for people living with HIV (PLHIV), with the World Health Organization calling for evidence to guide whether annual ART prescriptions and consultations (12M scripts) should be recommended in global guidelines. We assessed the association between 12M scripts (allowed temporarily during the COVID-19 pandemic) versus standard 6-month prescriptions and consultations (6M scripts) and clinical outcomes. We performed a retrospective cohort study using routine, de-identified data from 59 public clinics in KwaZulu-Natal, South Africa. We included PLHIV aged ≥18 years with a recent suppressed viral load (VL) who had been referred for community ART delivery with 6M or 12M scripts. We used modified Poisson regression to compare 12-month retention-in-care (≤90 days late for all visits) and viral suppression (<50 copies/ml) between prescription groups. Among 27,148 PLHIV referred for community ART during Jun-Dec 2020, 57.4% received 12M scripts. The median age was 39 years and 69.4% were women. Age, sex, prior community ART use and time on ART were similar across groups. However, more of the 12M script group had dolutegravir-based regimens (60.0% vs. 46.3%). The median (interquartile range) number of clinic visits in the year of follow-up was 1(1-1) in the 12M group and 2(2-3) in the 6M group. Retention was 94.6% (95% confidence interval [CI]: 94.2%-94.9%) among those receiving 12M scripts and 91.8% (95% CI: 91.3%-92.3%) among those with 6M scripts. 17.1% and 16.9% of clients in the 12M and 6M groups were missing follow-up VL data, respectively. Among those with VLs, 92.4% (95% CI: 92.0%-92.9%) in the 12M group and 91.4% (95% CI: 90.8%-92.0%) in the 6M group were suppressed. After adjusting for age, sex, ART regimen, time on ART, prior community ART use and calendar month, retention (adjusted risk ratio [aRR]: 1.03, 95% CI: 1.01-1.05) and suppression (aRR: 1.00, 95% CI: 0.99-1.01) were similar across groups. Among PLHIV referred for community ART with a recent suppressed VL, the use of 12M scripts reduced clinic visits without impacting short-term clinical outcomes. 12M scripts should be considered for differentiated service delivery programmes.

Hepatitis B Virus Prevalence and Mother-to-Child Transmission Risk in an HIV Early Intervention Cohort in KwaZulu-Natal, South Africa.

HIV and hepatitis B virus (HBV) prevalence are both high in KwaZulu-Natal, South Africa. HIV coinfection negatively affects HBV prognosis and can increase the likelihood of HBV mother-to-child transmission (MTCT). In an early HIV infant treatment intervention cohort of HIV-transmitting mother-child pairs in KwaZulu-Natal, we characterized maternal HBV prevalence and screened infants at risk. Infants were treated for HIV MTCT at birth, and combination regimens incidentally active against HBV were initiated within 21 days. Maternal samples (N = 175) were screened at birth for HBV infection (HBV surface antigen [HBsAg]), exposure to HBV (HBV anti-core IgG), and vaccination responses (HBV anti-S positive without other HBV markers). Infants of mothers who were HBV positive were screened for HBsAg at 1 and 12 months. Evidence of HBV infection was present in 8.6% (n = 15) of maternal samples. Biomarkers for HBV exposure were present in 31.4% (n = 55). Evidence of HBV vaccination was uncommon in mothers (8.0%; n = 14). Despite prescription of antiretroviral therapy (ART) active against HBV, HBV DNA was detectable in 46.7% (7/15) of mothers who were HBsAg positive. Three mothers had HBV viral loads >5.3 log10 IU/mL, making them high risk for HBV MTCT. Screening of available infant samples at 1 month (n = 14) revealed no cases of HBV MTCT. At 12 months, we identified 1 HBV infection (1/13), and serologic evidence of vaccination was present in 53.8% (7/13) of infants. This vulnerable cohort of HIV-transmitting mothers had a high prevalence of undiagnosed HBV. Early infant ART may have reduced the risk of MTCT in high-risk cases. Current HBV guidelines recommend ART prophylaxis, but these data underline the pressing need to increase availability of birth dose vaccines.

Patient perspectives of antiretroviral pharmacy services: A cross-sectional cohort study.

Adherence to antiretroviral therapy (ART) remains the main predictor of sustained HIV virologic suppression for people with HIV (PWH). Mail-order pharmacy services are often offered to patients as an alternative option to traditional pharmacy services. Some payers mandate ART to be dispensed from specific mail-order pharmacies regardless of patient choice complicating ART adherence for patients affected by social disparities. Yet, little is known about patient perspectives regarding mail-order mandates. Eligible patients of the HIV program at University of Nebraska Medical Center with experience receiving ART from both a local and mail-order pharmacy were invited to complete a 20-question survey with three core sections: experiences/perspectives on local and mail-order pharmacy settings; pharmacy attributes rankings; and pharmacy preference. Paired t-tests and Mann-Whitney tests were used to compare the agreement scores of pharmacy attributes. Sixty patients (N = 146; 41.1%) responded to the survey. Mean age was 52 years. Most were male (93%) and White (83%). The majority of participants were on ART for HIV treatment (90%) and 60% were using mail-order pharmacies for their prescription services. Significant scoring differences (p<0.05) were observed for all pharmacy attributes favoring local pharmacies. Refilling ease was the most important attribute noted. More respondents (68%) preferred local pharmacies versus mail-order pharmacies. Payer associated mail-order pharmacy mandates were experienced by 78% with half believing the mandates impacted their medical care negatively. In this cohort study, respondents preferred local pharmacies compared to mail-order pharmacy for ART prescription services and noted ease of refilling as the most important pharmacy attribute. Two-thirds of respondents believed mail-order pharmacy mandates negatively affected their health. Insurance payers should consider the removal of mail-order pharmacy mandates to allow patient choice of pharmacy, which may help remove barriers to ART adherence and improve long-term health outcomes.

Birth Country Influences the Choice of Antiretroviral Therapy in HIV-Infected Individuals: Experience From a French HIV Centre.

To assess whether antiretroviral therapy (ART) prescriptions differ between naive and virally suppressed HIV patients born in France (PBFs) and in Sub-Saharan Africa (PBSSAs). Observational single-center study. We included all PBFs and PBSSAs who entered into care at Pitié-Salpêtrière Hospital, Paris, France, from 01/01/2000 to 31/12/2018, with plasma HIV-RNA>200 copies/mL. We first compared the initial ART in naive PBFs and PBSSAs. Second, we compared the last-prescribed ART (including drug-reduced ART: daily 2-drug regimens, daily 1-drug regimens and intermittent 3-drug regimens) in virally suppressed PBFs and PBSSAs, by focusing on patients in care in 2018 with HIV-RNA <50 copies for at least 24 months. A univariable and multivariable logistic regression model was used to assess the impact of geographical origin on ART prescriptions. A total of 1944 naive patients were included (915 PBSSAs and 1029 PBFs). PBSSAs were more frequently women, hepatitis B coinfected, with a lower pretherapeutic CD4 T-cell count, and most had tuberculosis at HIV diagnosis. After adjustment for confounders, PBSSAs were more likely to receive a first-line protease inhibitor-based regimen (OR 1.61, 95% CI: 1.31 to 1.98), and less likely to receive an integrase inhibitor-based regimen (OR 0.61, 95% CI: 0.42 to 0.88). Of the 968 virally suppressed patients (431 PBSSAs and 537 PBFs), PBSSAs were less likely to receive drug-reduced ART, including 2-drug regimens and intermittent three-drug regimens (OR 0.48, 95% CI: 0.36 to 0.65). Differences in ART prescriptions between PBSSAs and PBFs were not only explained by different clinical and virologic situations. Personal motivations of doctors in choosing ART according to country of birth need to be explored.

Association of Race and Ethnicity With Initial Prescription of Antiretroviral Therapy Among People With HIV in the US

Integrase strand transfer inhibitor (INSTI)-containing antiretroviral therapy (ART) is currently the guideline-recommended first-line treatment for HIV. Delayed prescription of INSTI-containing ART may amplify differences and inequities in health outcomes. To estimate racial and ethnic differences in the prescription of INSTI-containing ART among adults newly entering HIV care in the US and to examine variation in these differences over time in relation to changes in treatment guidelines. Retrospective observational study of 42 841 adults entering HIV care from October 12, 2007, when the first INSTI was approved by the US Food and Drug Administration, to April 30, 2019, at more than 200 clinical sites contributing to the North American AIDS Cohort Collaboration on Research and Design. Combined race and ethnicity as reported in patient medical records. Probability of initial prescription of ART within 1 month of care entry and probability of being prescribed INSTI-containing ART. Differences among non-Hispanic Black and Hispanic patients compared with non-Hispanic White patients were estimated by calendar year and time period in relation to changes in national guidelines on the timing of treatment initiation and recommended initial treatment regimens. Of 41 263 patients with information on race and ethnicity, 19 378 (47%) as non-Hispanic Black, 6798 (16%) identified as Hispanic, and 13 539 (33%) as non-Hispanic White; 36 394 patients (85%) were male, and the median age was 42 years (IQR, 30 to 51). From 2007-2015, when guidelines recommended treatment initiation based on CD4+ cell count, the probability of ART initiation within 1 month of care entry was 45% among White patients, 45% among Black patients (difference, 0% [95% CI, -1% to 1%]), and 51% among Hispanic patients (difference, 5% [95% CI, 4% to 7%]). From 2016-2019, when guidelines strongly recommended treating all patients regardless of CD4+ cell count, this probability increased to 66% among White patients, 68% among Black patients (difference, 2% [95% CI, -1% to 5%]), and 71% among Hispanic patients (difference, 5% [95% CI, 1% to 9%]). INSTIs were prescribed to 22% of White patients and only 17% of Black patients (difference, -5% [95% CI, -7% to -4%]) and 17% of Hispanic patients (difference, -5% [95% CI, -7% to -3%]) from 2009-2014, when INSTIs were approved as initial therapy but were not yet guideline recommended. Significant differences persisted for Black patients (difference, -6% [95% CI, -8% to -4%]) but not for Hispanic patients (difference, -1% [95% CI, -4% to 2%]) compared with White patients from 2014-2017, when INSTI-containing ART was a guideline-recommended option for initial therapy; differences by race and ethnicity were not statistically significant from 2017-2019, when INSTI-containing ART was the single recommended initial therapy for most people with HIV. Among adults entering HIV care within a large US research consortium from 2007-2019, the 1-month probability of ART prescription was not significantly different across most races and ethnicities, although Black and Hispanic patients were significantly less likely than White patients to receive INSTI-containing ART in earlier time periods but not after INSTIs became guideline-recommended initial therapy for most people with HIV. Additional research is needed to understand the underlying racial and ethnic differences and whether the differences in prescribing were associated with clinical outcomes.

Comparison of Virological Efficacy of DTG/ABC/3TG and B/F/TAF Regimens and Discontinuation Patterns in Persons Living with Advanced HIV in the Era of Rapid ART: A Retrospective Multicenter Cohort Study.

International treatment guidelines recommend the rapid initiation of antiretroviral therapy (ART) with bictegravir (B)/emtricitabine (F)/tenofovir alafenamide (TAF) and dolutegravir (DTG)-based regimens for treatment-naïve persons living with HIV (PLWH) irrespective of their disease stage. However, we lack evidence of the virological efficacy, virological failure, and tolerability of coformulated B/F/TAF and DTG/ABC/3TC regimens in persons living with advanced HIV (PLWAH; defined as persons with a CD4+ count of < 200cells/μL or an AIDS-related opportunistic illness [AOI] at or before ART initiation) in the era of rapid ART. This retrospective multicenter study enrolled treatment-naïve PLWAH initiating ART with coformulated DTG/ABC/3TC or B/F/TAF in 2019-2020. Viral suppression at week48 was analyzed using FDA snapshot analysis. Between-regimen differences in time to viral suppression (< 50copies/mL), virological failure, and regimen discontinuation were examined using a Cox proportional hazards model. Analysis was also performed using time to regimen discontinuation due to adverse reactions (ARs) as the outcome. We enrolled 162 patients, including 61.1% on DTG/ABC/3TC and 38.9% on B/F/TAF. At week48 after ART initiation, 73.47% on DTG/ABC/3TC and 85.71% on B/F/TAF achieved viral suppression (P = 0.178). We identified no between-regimen differences in time to viral suppression or virological failure, regardless of pre-ART viral load. Compared with the DTG/ABC/3TC group, regimen discontinuation was less prevalent in the B/F/TAF group (adjusted hazard ratio = 0.23, 95%CI 0.06-0.85, P = 0.027). The main reason for discontinuation in both groups was ARs (61.9% in the DTG/ABC/3TC and 50% in the B/F/TAF, P = 0.877), of which skin manifestations were the most common in both groups (61.5% in the DTG/ABC/3TC and 50% in the B/F/TAF, P = 0.756). DTG/ABC/3TC, same-day ART prescription, and AOI were risk factors for AR or virological failure-related regimen discontinuation. In the real world, the risk of regimen discontinuation was higher in PLWAH on coformulated DTG/ABC/3TC than in those on B/F/TAF, with no difference in viral suppression or virological failure. Given the findings concerning the effect of same-day ART prescription and AOIs on AR or virological failure-related regimen discontinuation, individualized approaches to PLWAH are necessary.

Cisgender women with HIV in the United States: how have HIV care continuum outcomes changed over time? 2015-2020.

To evaluate HIV care continuum trends over time among women with HIV (WWH). The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States. We used 2015-2019 MMP data collected from 5139 adults with diagnosed HIV infection who identified as cisgender women. We calculated weighted percentages with 95% confidence intervals (CIs) for all characteristics and estimated annual percentage change (EAPC) and the associated 95% CI to assess trends. EAPCs were considered meaningful from a public health perspective if at least 1% with P values less than 0.05. Among cisgender women with diagnosed HIV infection during 2015-2019, 58.8% were Black or African American (95% CI 54.4-63.3), 19% were Hispanic/Latina (95% CI 14.7-23.2), and 16% were Non-Hispanic White (95% CI 14.1-17.9) persons. There was a meaningful increase in the percentage who ever had stage 3 HIV disease from 55.8% (95% CI 51.0-60.5) in 2015 to 61.5% (95% CI 58.1-64.8) in 2019 (EAPC 1.7%; CI 1.5-1.9; P < 0.001). There were no meaningful changes over time among women, overall, in retention in care, antiretroviral therapy (ART) prescription, ART adherence, missed appointments, or recent or sustained viral suppression. The HIV care continuum outcomes among WWH did not meaningfully improve from 2015 to 2019, raising a concern that Ending the HIV Epidemic in the US (EHE) initiative goals will not be met. To improve health and reduce transmission of HIV among WWH, multifaceted interventions to retain women in care, increase ART adherence, and address social determinants of health are urgently needed.

Brief Report: Role of Gender-Affirming Hormonal Care in HIV Care Continuum Outcomes When Comparing Transgender Women With Cisgender Sexual Minority Men.

Transgender women (transwomen) are frequently conflated with cisgender sexual minority men (cis-SMM) in HIV research. We examined the impact of socioeconomic and health conditions, and gender-affirming hormones in comparing HIV-related outcomes between cis-SMM and transwomen. Large tertiary care health system in the Bronx, NY. Retrospective cohort study of people with HIV receiving care in 2008-2017. We compared retention in care, antiretroviral therapy (ART) prescription, and viral suppression between cis-SMM and transwomen, using modified Poisson regression, adjusting for demographic and clinical factors. Transwomen were further stratified by receipt of estrogen prescription. We included 166 transwomen (1.4%), 1936 cis-SMM (17%), 4715 other cisgender men (41%), and 4745 cisgender women (41%). Transwomen were more likely to have public insurance (78% vs 65%) and mental health (49% vs 39%) or substance use (43% vs 33%) diagnoses than cis-SMM. Compared with cis-SMM, transwomen prescribed estrogen (67% of transwomen) were more likely to be retained [adjusted risk ratio (aRR) 1.15, 95% confidence interval (CI) 1.08 to 1.23), prescribed ART (aRR 1.06, CI 1.01 to 1.11), and virally suppressed (aRR 1.08, CI 1.01 to 1.16). Transwomen not prescribed estrogen were less likely to be retained (aRR 0.92, CI 0.83 to 1.02), prescribed ART (aRR 0.90, CI 0.82 to 0.98), or virally suppressed (aRR 0.85, CI 0.76 to 0.95). In the context of HIV, socioeconomic factors, comorbidities, and gender-affirming care distinguish transwomen from cis-SMM. Compared with cis-SMM, transwomen who were prescribed estrogen had better HIV care continuum outcomes; transwomen not prescribed estrogen had worse outcomes. These differences should be accounted for in HIV-related research.

An evaluation of nine culturally tailored interventions designed to enhance engagement in HIV care among transgender women of colour in the United States.

IntroductionTransgender women (TW) worldwide have a high prevalence of HIV, and TW with HIV encounter numerous healthcare barriers. It is critical to develop evidence‐informed interventions to improve their engagement in healthcare to achieve durable viral suppression (VS). We evaluated whether participation in one of nine interventions designed specifically for TW was associated with improved engagement in HIV care among transgender women of colour (TWC).MethodsBetween 2013 and 2017, nine US organizations implemented nine distinct and innovative HIV care engagement interventions with diverse strategies, including: individual and group sessions, case management and navigation, outreach, drop‐in spaces, peer support and/or incentives to engage TWC with HIV in care. The organizations enrolled 858 TWC, conducted surveys, captured intervention exposure data and extracted medical record data. Our evaluation of the interventions employed a pre‐post design and examined four outcomes—any HIV care visit, antiretroviral therapy (ART) prescription, retention in HIV care and VS (both overall and among those with a clinic visit and viral load test), at baseline and every 6 months for 24 months. We employed logistic generalized estimating equations to assess the relative odds of each outcome at 12 and 24 months compared to baseline.ResultsOverall, 79% of participants were exposed to at least one intervention activity. Over 24 months of follow‐up, participants received services for a median of over 6 hours (range: 3–69 hours/participant). Compared to baseline, significantly (p<0.05) greater odds were demonstrated at both 12 and 24 months for three outcomes: prescription of ART (ORs: 1.42 at 12 months, 1.49 at 24 months), VS among all participants (ORs: 1.49, 1.54) and VS among those with a clinic visit and viral load test (ORs: 1.53, 1.98). The outcomes of any HIV care visit and retention in HIV care had significantly greater odds (ORs: 1.38 and 1.58, respectively) only at 12 months compared to baseline.ConclusionsThese evaluation results illustrate promising approaches to improve engagement in HIV care and VS among TWC with HIV. Continued development, adaptation and scale‐up of culturally tailored HIV care interventions for this key population are necessary to meet the UNAIDS 95‐95‐95 goals.

Evaluating Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes: Quantitative Findings from the Ryan White HIV/AIDS Program Special Projects of National Significance Black Men Who Have Sex with Men Initiative.

The Black Men who have Sex with Men (MSM) Initiative was implemented at eight sites to engage and retain Black MSM in HIV medical care and supportive services (SS) by addressing their behavioral health (BH) care needs. Using a pre-post design and generalized logistic mixed-effects models adjusting for patient-level random effects, site, baseline age, and baseline mental health status, we evaluated whether participants experienced increased postintervention attainment of (1) Awareness of HIV medical care, BH care, and SS; (2) Screening, referral, linkage, receipt, and engagement in HIV care, BH care, and SS; and (3) Retention, antiretroviral therapy prescription, and suppressed viral load. Among 758 evaluated participants, the proportion of participants who were aware of, screened for, screened positive for, and referred to BH and SS, retention in care (72% to 79%), and viral load suppression (68% to 75%) increased between baseline and postintervention. Among participants who screened positive and received BH services were statistically more likely to be linked to [OR, 1.34 (95% CI: 1.08-1.66)] and retained in [OR, 1.36 (95% CI: 1.00-1.83)] care. Among those who screened positive and received SS were statistically more likely to be retained in care [OR, 1.54 (95% CI: 1.07-2.22)]. Measures of linkage to care declined significantly during the study period, perhaps because of COVID-19 that delayed in-person care. This study suggests that interventions designed to increase utilization of BH services and SS can be effective at improving retention in care and viral load suppression among Black MSM, at least among those currently using HIV services.

Аdverse events underlying antiretroviral therapy in children with HIV infection

Introduction. Human immunodeficiency virus infection can alter properties of blood vessels in children and increase the risk of development of cardiovascular diseases in the future. Today the actual contribution of the effects of both HIV infection and antiretroviral therapy into such changes remains unknown. Objective. We seek to assess adverse events, including metabolic disorders (dyslipidemias), underlying antiretroviral therapy, and to determine the relation between metabolic disorders and intima injury in children receiving antiretroviral therapy (ART).Materials and methods. The adverse events were investigated within the framework of a prospective and retrospective study. The study included evaluation of biochemical parameters in relation to the therapeutic regimen; calculation of atherogenic index of plasma; and determination of incidence of dyslipidemia in children. In addition to standard tests, children on ART were evaluated for insulin resistance (using HOMA-IR) and submitted to diagnostic imaging including Doppler ultrasonography of brachiocephalic arteries and veins.Results. Children on protease inhibitor-based ART have higher total cholesterol, LDL and triglyceride levels in comparison to both children on NNRTI-based ART and children who do not receive ART. LDL levels in children on long-term ART remained within the tolerance range and were clearly higher than those in children who did not receive ART. Carotid IMT was higher in children on NNRTI-based ART in comparison to those who received protease inhibitor-based therapy; and the correlation analysis conducted revealed positive correlation between the age and carotid IMT: The later ART was prescribed, the greater IMT was, which most likely was attributable to HIV effects.Conclusion. Prescription of antiretroviral therapy at an older age results in changes in the intima-media complex, which may give evidence to vasoprotective effects of the therapy. Since HIV is directly involved in causing injury to the intima, it is advisable to start managing HIV infection in children as soon as they are diagnosed with the infection; and children to whom ART is prescribed at an older age and who develop dyslipidemia should be additionally evaluated by medical imaging with Doppler ultrasonography with carotid IMT measurement.

Toward Ending the HIV Epidemic: Temporal Trends and Disparities in Early ART Initiation and Early Viral Suppression Among People Newly Entering HIV Care in the United States, 2012-2018.

In 2012, the US Department of Health and Human Services updated their HIV treatment guidelines to recommend antiretroviral therapy (ART) for all people with HIV (PWH) regardless of CD4 count. We investigated recent trends and disparities in early receipt of ART prescription and subsequent viral suppression (VS). We examined data from ART-naïve PWH newly presenting to HIV care at 13 North American AIDS Cohort Collaboration on Research and Design clinical cohorts in the United States during 2012-2018. We calculated the cumulative incidence of early ART (within 30 days of entry into care) and early VS (within 6 months of ART initiation) using the Kaplan-Meier survival function. Discrete time-to-event models were fit to estimate unadjusted and adjusted associations of early ART and VS with sociodemographic and clinical factors. Among 11 853 eligible ART-naïve PWH, the cumulative incidence of early ART increased from 42% in 2012 to 82% in 2018. The cumulative incidence of early VS among the 8613 PWH who initiated ART increased from 83% in 2012 to 93% in 2018. In multivariable models, factors independently associated with delayed ART and VS included non-Hispanic/Latino Black race, residence in the South census region, being a male with injection drug use acquisition risk, and history of substance use disorder (SUD; all P ≤ .05). Early ART initiation and VS have substantially improved in the United States since the release of universal treatment guidelines. Disparities by factors related to social determinants of health and SUD demand focused attention on and services for some subpopulations.

Comprehensive Process Mapping and Qualitative Interviews to Inform Implementation of Rapid Linkage to HIV Care Programs in a Mid-Sized Urban Setting in the Southern United States.

Rapid antiretroviral therapy (ART) initiation, in which people living with HIV start ART within days of diagnosis, is a key component of the US Ending the HIV Epidemic initiative. The Memphis Metropolitan Statistical Area ranked fourth in the United States for the highest HIV incidence per 100,000 population in 2018. Rapid ART programs are limited in the Memphis Metropolitan Statistical Area, and our objective was to identify local implementation barriers. We conducted participatory process mapping and in-depth interviews to detail steps between HIV testing at the municipal health department's Sexually Transmitted Infections Clinic and ART prescription from a nearby high-volume Ryan White-funded HIV Clinic. Process mapping identified 4 modifiable, rate-limiting rapid ART barriers: (1) requiring laboratory-based confirmatory HIV results, (2) eligibility documentation requirements for Ryan White-funded services, (3) insufficient HIV Clinic medical provider availability, and (4) variability in ART initiation timing among HIV Clinic providers. Staff at both sites highlighted suboptimal communication and sense of shared management between facilities, limited resources to address important social determinants of health, and lack of Medicaid expansion in Tennessee as key barriers. In-depth interview themes negatively affecting rapid ART initiation included clinic burden; provider knowledge, attitudes, and beliefs; and client psychosocial needs. Our preimplementation work identified modifiable and systemic barriers to systems flow and patient-level outcomes. This work will inform the design and implementation of a locally relevant rapid ART program in Memphis, a community disproportionately affected by the HIV epidemic.

Role of the HIV-1 Reservoir to Maintain Viral Suppression in a Simplified Strategy for the Long-Term Management of HIV-1 Infection (The SIMPL’HIV Trial)

HIV-1 reservoir size and dynamics are promising parameters to ensure the safe prescription of simplified maintenance antiretroviral therapy in chronically HIV-1 infected patients. In the SIMPL’HIV trial, HIV-1 DNA was quantified in peripheral blood mononuclear cells obtained at baseline and week 48 to investigate changes over time and evidence of a predictive relationship to maintain HIV-1 RNA &amp;lt;20 copies/ml. Measurements were available for 175 patients, with no differences observed between treatment strategies. Findings showed that baseline HIV-1 DNA was lower in those with durable HIV-1 RNA &amp;lt;20 copies/ml compared with patients with incomplete viral suppression over 48 weeks.

Perception of HIV physicians in Spain towards diagnosis and management of neuropsychiatric comorbidities in people with HIV.

ObjectivesDespite the importance of neuropsychiatric comorbidities (NPCs) in people with HIV, the degree of physician compliance with recommendations for diagnosis and management is unknown. This study assessed the perceptions, knowledge, skills, and attitudes of physicians regarding the diagnosis and management of NPCs in people with HIV in hospital settings in Spain.MethodsThis was a cross‐sectional study including non‐psychiatrist HIV specialist physicians responsible for antiretroviral therapy (ART) prescription and clinical care of ≥50 people with HIV/month, who completed an online survey of 34 questions.ResultsThe 115 physicians who completed the survey (totally) agreed that assessing mental health was relevant (97.4%) and that NPCs were underdiagnosed (76.6%) and were very/fairly sensitized (67.8%). However, they reported receiving little/no training on the detection of NPCs (64.3%). Physicians considered that patients underreported NPCs (53.9%) and that alcohol (94.8%), recreational substances (97.4%), and tobacco consumption (95.6%) were (very) relevant. Physicians agreed that NPCs were difficult to identify (52.2%) and that few tools were available (53.0%) and failed to use questionnaires (79.1%) and follow guidelines (77.4%) for the detection of NPCs. The main reasons precluding appropriate diagnosis and evaluation were lack of proactive attitudes and specific training and limited visit time. Upon detection of NPCs, physicians referred patients to the in‐house psychiatry/psychology centre (61.7%), adjusted ART to minimize interactions (96.5%), and managed NPCs in conjunction with mental health professionals (71.3%).ConclusionsPhysicians in hospital settings in Spain were aware of the relevance of NPC diagnosis and their underdiagnosis. However, they still failed to routinely evaluate NPCs, follow guideline recommendations, and use questionnaires, highlighting opportunities for improved NPC detection and management in people with HIV.

Observed CD4 counts at entry into HIV care and at antiretroviral therapy prescription by age in the USA, 2004-18: a cohort study.

Adults aged 50 years or older comprise a majority of people with HIV in the USA. Our objective was to describe observed differences by age in CD4 count at entry into HIV care, timing of antiretroviral therapy (ART) prescription, and CD4 count at time of ART prescription before (2004-11) and during (2012-18) the current era of universal treatment. For this descriptive study, we calculated median (IQR) CD4 count at entry into care, days from entry into care to ART prescription, and CD4 count at time of ART prescription among patients enrolled in US-based clinical cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD; see appendix). We excluded participants with no CD4 count recorded at entry into care, medical records that suggested previous ART use, or previous AIDS diagnosis. All calculations were stratified by age (≥50 and 18-50 years) and calendar year. Of 35 293 ART-naive adult participants entering care between Jan 1, 2004 and Dec 31, 2018, 5794 (16%) were women and 29 499 (84%) were men; 15817 (45%) were Black, 11566 (33%) were White, 5538 (16%) were Hispanic (any race), 737 (2%) were Asian or Pacific Islander, 152 (0.4%) were Indigenous, and 98 (0.3%) were multiracial. Median age at entry into care was 39 years (IQR 29-49); 8004 (23%) were aged 50 years or older. Of 29 141 participants initially prescribed ART, 7274 (25%) were aged 50 years or older. From 2004 to 2018, median CD4 count at entry into care increased from 228 cells per µL (IQR 80-422) to 295 cells per µL (134-489) among adults aged 50 years and older, and from 297 cells per µL (119-480) to 378 cells per µL (202-564) among adults younger than 50 years. Median days from entry into care to ART prescription declined from 56 (IQR 17-658) to 6 (0-15) among adults older than 50 years, and from 61 (17-509) to 6 (0-16) among adults younger than 50 years. Median CD4 count at time of ART prescription increased from 139 cells per µL (IQR 59-257) to 311 cells per µL (137-504) among adults aged 50 years or older, and from 166 cells per µL (49-287) to 377 cells per µL (198-564) among adults younger than 50 years. Before the release of universal treatment guidelines by the US Department of Health and Human Services in 2012, median time to ART prescription was already falling, leading to increases in median CD4 count at ART prescription for both age groups; both measures continued to improve in the treat-all era. However, median CD4 counts, both at entry into care and at ART prescription, among adults aged 50 years and older were lower than those of adults younger than 50 years throughout the study period. Furthermore, even into the treat-all era, over half of adults aged 50 years and older entered care with CD4 counts of less than 350 cells per µL, potentially because of factors including immunosenescence, delayed HIV diagnosis, and late presentation to care. Given that age-related immunological changes might not be fully avoidable, targeted strategies for increasing HIV risk awareness, routine testing, and immediate linkage to HIV care at diagnosis are particularly essential for this population. US National Institutes of Health grant U01AI069918.

A sub-group evaluation of the multi-month dispensing strategy for differentiated HIV care: is personalization of care guidelines warranted in Haiti?

BackgroundDifferentiated care strategies are rapidly becoming the norm for HIV care delivery globally. Building upon an interest in tailoring antiretroviral therapy (ART) delivery for client-centered needs, the Ministry of Health and Population in Haiti formally endorsed multiple-month dispenses (MMD) in the 2016 national ART guidelines This study explores heterogeneity in retention in care with MMD for specific Haitian populations living with HIV and evaluates if a targeted algorithm for optimal ART prescription intervals is warranted in Haiti.MethodsThis study included ART-naïve individuals who started ART on or after January 1st, 2017 in Haiti. To identify subgroups in which to explore heterogeneity of retention, we implemented a double-lasso regression method to determine which individual characteristics would define the subgroups. Characteristics evaluated for potential subgroup definition included: sex, age category, WHO clinical stage, and body mass index category. We employed instrumental variable models to estimate the causal effect of increasing ART dispensing length on ART retention, by client subgroup. The outcome of interest was retention in care after one year in treatment. We then estimated the marginal effect of a 30-day increase to ART dispensing length to retention in care for each of these subgroups.ResultsThere was evidence for heterogeneity in the effect of extending ART dispensing intervals on retention by WHO clinical stage. We observed significant improvements to retention in care at one year with a 30-day increase in ART dispense length for all subgroups defined by WHO clinical stages 1-4. The effects ranged from a 14.7% increase (95% CI: 12.4-17.0) to the likelihood of retention for people with HIV in WHO stage 1 to a 21.6% increase (95% CI: 18.7-24.5) to the likelihood of retention for those in WHO stage 3.ConclusionsAll the subgroups defined by WHO clinical stage experienced a benefit of extending ART intervals to retention in care at one year. Though the effect did differ slightly by WHO stage, the effects went in the same direction and were of similar magnitude. Therefore, a standardized recommendation for MMD among those living with HIV and new on ART is appropriate for Haiti treatment guidelines.