Era Of Antiretroviral Treatment Research Articles

Survival of patients with Kaposi's sarcoma in the South African antiretroviral treatment era: A retrospective cohort study.

When South Africa (SA) implemented its antiretroviral therapy (ART) programme in 2004, the model for treating HIV-positive Kaposi's sarcoma (KS) patients shifted from symptomatic palliation to potential cure. To evaluate survival and changes over time in AIDS-KS patients treated at a tertiary academic hospital oncology unit (the Steve Biko Academic Hospital medical oncology unit) in Pretoria, SA, in the context of ART availability in SA. We conducted a retrospective review of electronic and paper records of KS patients who accessed cancer care between May 2004 and September 2012. We used Kaplan-Meier survival functions to estimate 1- and 2-year survival, and Cox regression models to identify changes over time and prognostic factors. Our study included 357 AIDS-KS patients, almost all of whom were black Africans (n=353, 98.9%); 224 (62.7%) were men. The median age at cancer diagnosis was 37 (interquartile range (IQR) 30 - 43) years, and the median baseline CD4+ count was 242 (IQR 130 - 403)cells/µL. Most patients received ART (n=332, 93.0%) before or after KS diagnosis; 169 (47.3%) were treated with chemotherapy and 209 (58.6%) with radiation therapy. Mortality was 62.7% lower (adjusted hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.19 - 0.73) in the late (2009 - 2012) than in the early (2004 - 2008) ART period. Receiving chemotherapy (adjusted HR 0.3, 95% CI 0.15 - 0.61) and poor-risk AIDS Clinical Trials Group KS stage (adjusted HR 2.88, 95% CI 1.36 - 6.09) predicted mortality. Our results show that large national ART roll-out programmes can successfully reduce KS-related mortality at the individual patient level. If ART coverage is extended, KS-associated morbidity and mortality are likely to drop.

Opportunistic and other intestinal parasites infections among HIV-positive patients in the era of combination antiretroviral therapy and preventive treatment in Ouagadougou, Burkina Faso

Background: One of the particularities of human immunodeficiency virus (HIV) infection in the tropics is its frequent association with parasitic diseases so frequent in this area. Aim: The aim of this study was to update the epidemiological and clinical profile of intestinal parasites among HIV-positive patients in the era of combination antiretroviral therapy (ART) and preventive treatment in Ouagadougou, Burkina Faso. Materials and Methods: A cross-sectional study was conducted in a single health care system, Yalgado Ouédraogo University hospital, between January 2013 and December 2014. A total of 131 HIV-infected patients were included in the study. Blood and Stool samples were collected for CD4 counts and for intestinal parasitic examination using direct, formol-ether concentration, a concentration method using sodium chloride solution, modified Ziehl-Neelsen and Weber modified trichrome. Odds ratio was calculated to estimate the risk attributable to different factors with confidence intervals. Chi-square (X2) or Fisher’s Exact Test statistical analysis was used to test level of significance at p<0.05 using SPSS 20.0.0. Results: A prevalence of 73.3% of intestinal parasites was recorded. Most of the parasitic infections were protozoa (97.9%) with few helminths (2.1%). Cryptosporidium spp. (29.2%), was the most commonly found parasite followed by Entamoeba coli (23.9%) and Isospora belli (21.9%). There were 76 cases (78.5%) of single infection and 20 cases (21.5%) of mixed infection. Paradoxically, patients who use preventive treatment were more infected with opportunistic parasites (p= 0.05, OR=2.16, 95% CI= 1.06-4.40). In multivariate analysis, patients with diarrhea (OR=4.04, 95% CI=1.94-8.41), and illiterate (OR=3.70, 95% CI=1.68-8.14) had higher risk of opportunistic parasites. The diarrheic patients were 0.29 times more likely to be infected with opportunistic parasites. Conclusion: Despite the advent of combination ART and preventive treatment of opportunistic infections, intestinal parasites remain very prevalent and associated with diarrhea among patients with HIV in Ouagadougou.

Opportunistic and other intestinal parasites infections among HIVpositive patients in the era of combination antiretroviral therapy and preventive treatment in Ouagadougou, Burkina Faso

Opportunistic and other intestinal parasites infections among HIVpositive patients in the era of combination antiretroviral therapy and preventive treatment in Ouagadougou, Burkina Faso

Misdiagnosed HIV infection in pregnant women initiating universal ART in South Africa.

Introduction: Rapid diagnostic tests (RDTs) are the primary diagnostic tools for HIV used in resource-constrained settings. Without a proper confirmation algorithm, there is concern that false-positive (FP) RDTs could result in misdiagnosis of HIV infection and inappropriate antiretroviral treatment (ART) initiation, but programmatic data on FP are few. Methods: We examined the accuracy of RDT diagnosis among HIV-infected pregnant women attending public sector antenatal services in Cape Town, South Africa. We describe the proportion of women found to have started on ART erroneously due to FP RDT results based on pre-ART viral load (VL) testing and enzyme-linked immunosorbent assay (ELISA). Results: We analysed 952 consecutively enrolled pregnant women diagnosed as HIV infected based on two RDTs per local guideline and found 4.5% (43/952) of pre-ART VL results to be <50 copies/ml. After excluding 6 women who had detectable virus on subsequent VL measurements, ELISA was performed on the 37 remaining women. Of these, 3/952 (0.3%) HIV RDT diagnoses were found to be FP. We estimate that using ELISA to confirm all positive RDTs would cost $1110 (uncertainty interval $381–$5382) to identify one patient erroneously initiated on ART, while it costs $3912 for a lifetime of antiretrovirals with VL monitoring for one person. Conclusions: Compared to the cost of confirming the RDT-based diagnoses, the cost of HIV misdiagnosis is high. While testing programmes based on RDT should strive for constant quality improvement, where resources permit, laboratory confirmation algorithms can play an important role in strengthening the quality of HIV diagnosis in the era of universal ART.

Brief Report: IL-1β Levels Are Associated With Chronic Multisite Pain in People Living With HIV.

The pathophysiology of chronic pain experienced by people living with HIV (PLWH) in the current antiretroviral treatment era is poorly understood. We sought to investigate the relationship between inflammation and chronic pain in PLWH. We hypothesized that, among PLWH who have undetectable HIV viral loads, those with chronic multisite pain (CMP) would have higher levels of circulating pain-related inflammatory markers than those without chronic pain. This study was conducted at the University of Alabama at Birmingham's Center for AIDS Research Network of Integrated Clinical System site. We compared inflammatory markers in 70 PLWH with CMP and 70 PLWH without chronic pain. Custom multiplex human inflammatory assays were completed on banked plasma specimens to measure cytokines commonly associated with chronic inflammatory pain: interleukin 1β (IL-1β), eotaxin, IL-15, IL-6, tumor necrosis factor α, and leptin. Logistic regression models were built using group status (CMP vs no pain) as the outcome variable, with each cytokine as independent variables and age, sex, substance use, and prescribed opioid medications as covariates. Participants were mostly men (71%); 53% were 50 years or older. The most common sites of pain were low back (86%), hands/feet (81%), and knee (66%). Median CD4 T-cell count was 676 cells per milliliter. IL-1β was significantly higher in the CMP group than in the individuals without chronic pain (odds ratio: 1.35, 95% confidence interval: 1.01 to 1.82, P < 0.05). Eotaxin, IL-15, IL-6, tumor necrosis factor α, and leptin were not significantly different between groups. We found that PLWH who also have CMP have significantly higher levels of IL-1β than PLWH who do not have any pain. Future work on the role of IL-1β on chronic pain pathogenesis in this population may inform novel approaches to chronic pain management.

Highlights of This Issue

In the era of effective antiretroviral treatment, HIV-infected individuals experience increased longevity and a higher chronic disease burden. Coghill and colleagues used US surveillance data to model overall mortality in people with HIV and cancer to distinguish whether mortality was simply due to the added individual effects of each disease or higher than expected. For cancers of the lung, breast, colorectum, anus, and Hodgkin and Non-Hodgkin lymphomas, HIV-infected cancer patients experienced excess mortality, beyond that expected based on the effects of HIV and cancer separately. This excess mortality suggests that HIV may contribute to cancer progression and highlights the importance of cancer prevention in this population.Elevated keratinocyte cancer risk has been observed during iatrogenic immunosuppression, but relationships of many immune-related conditions with keratinocyte cancer have not been studied. Yanik and colleagues used Medicare claims to identify 47 immune-related conditions in &gt;1,000,000 keratinocyte cancer cases and corresponding controls. The authors identified elevated keratinocyte cancer risk with solid organ transplantation, non-Hodgkin lymphoma, and numerous other conditions, e.g., granulomatosis with polyangiitis and autoimmune hepatitis. Associations likely result from direct immunosuppressive effects or immunosuppressive treatment. Most conditions were more positively associated with cutaneous squamous cell carcinoma than basal cell carcinoma, indicating a tighter link between immune disturbances and squamous cell carcinoma.In this large population(n = 3,262) of early stage colorectal cancer (CRC), Caan and colleagues demonstrate patients in the overweight range have superior survival because they have adequate muscle mass, an important predictor of better survival, but adiposity levels not high enough to increase risk. Thus, the authors challenge that the observed association between overweight and lower mortality is due to methodological biases alone and provide a biologically compelling explanation for the obesity paradox in CRC. The study demonstrates that the presence of sarcopenia is highly prevalent (42%) among those with non- metastatic CRC, and is likely occult since it occurs across stage and BMI levels.Germline variants associated with breast cancer risk discovered among women of European ancestry may not generalize to other racial/ethnic populations. In this study Feng and colleagues tested 74 breast cancer risk variants and conducted fine-mapping in 6,522 breast cancer cases and 7,643 controls of African ancestry. Seven markers in six regions (3p24, 12p11, 14q13, 16q12/FTO, 16q23, 19p13) were identified to better represent the underlying risk association, whereas signals independent of the index variant were observed in another two regions (11q13, 16q12/TOX3). Epigenomic annotation revealed that many of the risk alleles lie in regions with biological functionality.

Changes in Fertility at the Population Level in the Era of ART in Rural Malawi.

Introduction:HIV reduces fertility through biological and social pathways, and antiretroviral treatment (ART) can ameliorate these effects. In northern Malawi, ART has been available since 2007 and lifelong ART is offered to all pregnant or breastfeeding HIV-positive women.Methods:Using data from the Karonga Health and Demographic Surveillance Site in Malawi from 2005 to 2014, we used total and age-specific fertility rates and Cox regression to assess associations between HIV and ART use and fertility. We also assessed temporal trends in in utero and breastfeeding HIV and ART exposure among live births.Results:From 2005 to 2014, there were 13,583 live births during approximately 78,000 person years of follow-up of women aged 15–49 years. The total fertility rate in HIV-negative women decreased from 6.1 [95% confidence interval (CI): 5.5 to 6.8] in 2005–2006 to 5.1 (4.8–5.5) in 2011–2014. In HIV-positive women, the total fertility rate was more stable, although lower, at 4.4 (3.2–6.1) in 2011–2014. In 2011–2014, compared with HIV-negative women, the adjusted (age, marital status, and education) hazard ratio was 0.7 (95% CI: 0.6 to 0.9) and 0.8 (95% CI: 0.6 to 1.0) for women on ART for at least 9 months and not (yet) on ART, respectively. The crude fertility rate increased with duration on ART up to 3 years before declining. The proportion of HIV-exposed infants decreased, but the proportion of ART-exposed infants increased from 2.4% in 2007–2010 to 3.5% in 2011–2014.Conclusions:Fertility rates in HIV-positive women are stable in the context of generally decreasing fertility. Despite a decrease in HIV-exposed infants, there has been an increase in ART-exposed infants.

Prevalence and Factors Associated with Hazardous Alcohol Use Among Persons Living with HIV Across the US in the Current Era of Antiretroviral Treatment.

Hazardous alcohol use is associated with detrimental health outcomes among persons living with HIV (PLWH). We examined the prevalence and factors associated with hazardous alcohol use in the current era using several hazardous drinking definitions and binge drinking defined as ≥5 drinks for men versus ≥4 for women. We included 8567 PLWH from 7 U.S. sites from 2013 to 2015. Current hazardous alcohol use was reported by 27% and 34% reported binge drinking. In adjusted analyses, current and past cocaine/crack (odd ratio [OR] 4.1:3.3-5.1, p<0.001 and OR 1.3:1.1-1.5, p<0.001 respectively), marijuana (OR 2.5:2.2-2.9, p<0.001 and OR 1.4:1.2-1.6, p<0.001), and cigarette use (OR 1.4:1.2-1.6, p<0.001 and OR 1.3:1.2-1.5, p<0.001) were associated with increased hazardous alcohol use. The prevalence of hazardous alcohol use remains high in the current era, particularly among younger men. Routine screening and targeted interventions for hazardous alcohol use, potentially bundled with interventions for other drugs, remain a key aspect of HIV care.

Experiences of patients with HIV/AIDS receiving mid- and long-term care in Japan: A qualitative study

PurposeIn the era of antiretroviral treatment (ART), treatment of HIV has become more manageable, and most patients with HIV benefit from long-term therapy in Japan. The aim of this qualitative study was to examine the experiences of patients with HIV/AIDS receiving mid- and long-term care in Japan. MethodsA qualitative study was performed using semi-structured interviews at an outpatient clinic of a university hospital in the Greater Tokyo area. A total of 31 Japanese patients with HIV who had been receiving treatment for at least a year were interviewed in Japanese. Data from these interviews were analyzed by ‘content analysis’ (Krippendorff, 1980). ResultsThe data were organized into the following seven themes: “feelings toward diagnosis of HIV infection”; “perceptions and behavior after diagnosis of HIV”; “attitudes toward HIV therapy”; “fear and hope for the future”; “feelings toward professional support”; “life changes after HIV therapy”; and “struggles in relationships with others”. ConclusionsSome participants accepted themselves as HIV-positive, some did not when they were diagnosis. This difference of reaction had effect on attitudes toward HIV therapy. But all participants continued mid- and long-treatments owing to feeling well and receiving support from professionals. Additionally, it found that patients were felt stigma of HIV-positive similarly to another Asian countries. Therefore, we should provide the entire Japanese society with knowledge about HIV/AIDS and be early and constant intervention by professional teams after being infected.

Abstract C84: Utilization of cervical cancer screening services by women living with HIV enrolled in primary care at the Moore Clinic of Johns Hopkins Hospital: A 10-year retrospective cohort study

Abstract Background: Due to their compromised immune function, which elevates their risk of disease, women living with HIV (WLWH) represent an important high-risk subgroup for cervical precancer and cancer. However, there is limited information on cervical cancer screening utilization by WLWH in the current antiretroviral treatment era. This retrospective cohort study explores frequency of screening, screening intervals, and the risk factors associated with utilization of cervical cancer screening services by 544 WLWH enrolled in clinical care for at least 18 months at Johns Hopkins between 2005-2014. Understanding utilization and the significant factors associated with underscreening of WLWH, can inform interventions to improve screening adherence in this high-risk group. Methods: Pap tests, clinical and socio-demographic covariates were obtained by merging a pathology database with a clinical cohort database. The primary outcome of interest was the receipt of Pap testing in the study period. Frequency of screening and screening intervals were described from study entry (defined as first clinic visit after January 1, 2005) to exit (December 31, 2014 or last time seen at Johns Hopkins). Results: The cohort was primarily black (79%), median age of 41 years (IQR: 34-48) and median follow-up of 5.7 years (IQR: 3.7-7.9). At entry, median CD4 count and HIV viral load were 307 cells/ul (IQR: 510-127), and 7712 copies/ml (IQR: 400-53693) respectively. Current smoking (57%), injection drug use (26%) and obesity or overweight (48.5%) were all common at entry. A substantial proportion of these women (21%) were never screened during the study, despite being in care. Median follow-up among these never-screened women was 4.7 years (IQR: 3.2-6.3). Among the 79% of women who were screened at least once, there was variation in frequency of screening. Some of these women received only one (21%), or two (18%) Pap tests, while others had three (15%), four (13%) and five or more (32%) Pap tests. Among this group of ever-screened participants, the median interval between Pap tests was 11.3 months (IQR: 6.2-17.2). Women who only had one Pap during the study had a much longer average time from entry to Pap (49.5 months, IQR: 18.4-62.4), than the time between Pap tests for women who had 2,3, 4, and 5 or more Pap tests (17.6, 14.8, 12.4, 10.1 months, respectively), p&amp;lt;0.001. Clinical and socio-demographic factors associated with Pap test utilization are currently being explored, and will be included in the meeting presentation. Conclusion: These findings enhance our knowledge of cervical cancer screening utilization among a high-risk group of HIV-infected, primarily minority, women. They demonstrate that in spite of the recommendation for annual cervical cancer screening of WLWH, even when enrolled in clinical care, some WLWH are not screened. Citation Format: Sally Peprah, Jenell Coleman, Anne Rositch, Christopher VandenBussche, Richard Moore, Amber D'Souza. Utilization of cervical cancer screening services by women living with HIV enrolled in primary care at the Moore Clinic of Johns Hopkins Hospital: A 10-year retrospective cohort study. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C84.

HIV as a Cause of Immune Activation and Immunosenescence.

Systemic immune activation has emerged as an essential component of the immunopathogenesis of HIV. It not only leads to faster disease progression, but also to accelerated decline of overall immune competence. HIV-associated immune activation is characterized by an increase in proinflammatory mediators, dysfunctional T regulatory cells, and a pattern of T-cell-senescent phenotypes similar to those seen in the elderly. These changes predispose HIV-infected persons to comorbid conditions that have been linked to immunosenescence and inflamm-ageing, such as atherosclerosis and cardiovascular disease, neurodegeneration, and cancer. In the antiretroviral treatment era, development of such non-AIDS-defining, age-related comorbidities is a major cause of morbidity and mortality. Treatment strategies aimed at curtailing persistent immune activation and inflammation may help prevent the development of these conditions. At present, the most effective strategy appears to be early antiretroviral treatment initiation. No other treatment interventions have been found effective in large-scale clinical trials, and no adjunctive treatment is currently recommended in international HIV treatment guidelines. This article reviews the role of systemic immune activation in the immunopathogenesis of HIV infection, its causes and the clinical implications linked to immunosenescence in adults, and the therapeutic interventions that have been investigated.

Prevalence and Factors Associated with Hazardous Alcohol Use Among Persons Living with HIV Across the US in the Current Era of Antiretroviral Treatment

Prevalence and Factors Associated with Hazardous Alcohol Use Among Persons Living with HIV Across the US in the Current Era of Antiretroviral Treatment

CD4:CD8 ratio comparison between cohorts of HIV-positive Asians and Caucasians upon commencement of antiretroviral therapy.

In the era of effective antiretroviral treatment (ART) CD4:CD8 ratio is proposed as a potential marker for HIV-positive (HIV+) patients at increased risk for non-AIDS comorbidities. The current study aims to compare CD4:CD8 ratio between Asian and Caucasian HIV+ patients. HIV+ patients from the Australian HIV Observational Database (AHOD) and the TREAT Asia HIV Observational Database (TAHOD) meeting specific criteria were included. In these analyses Asian and Caucasian status were defined by cohort. Factors associated with a low CD4:CD8 ratio (cutoff <0.2) prior to ART commencement, and with achieving a normal CD4:CD8 ratio (>1) at 12 and 24 months post ART commencement were assessed using logistic regression. There were 591 patients from AHOD and 2,620 patients from TAHOD who met the inclusion criteria. TAHOD patients had a significantly (P<0.001) lower odds of having a baseline (prior to ART initiation) CD4:CD8 ratio greater than 0.2. After 12 months of ART, AHOD patients were more than twice as likely to achieve a normal CD4:CD8 ratio compared to TAHOD patients (15% versus 6%). However, after adjustment for confounding factors there was no significant difference between cohorts in the odds of achieving a CD4:CD8 ratio >1 (P=0.475). We found a significantly lower CD4:CD8 ratio prior to commencing ART in TAHOD compared to AHOD even after adjusting for confounders. However, after adjustment, there was no significant difference between the cohorts in odds of achieving normal ratio. Baseline CD4+ and CD8+ counts seem to be the main driver for this difference between these two populations.

Trends of and factors associated with live-birth and abortion rates among HIV-positive and HIV-negative women

Little is known about fertility choices and pregnancy outcome rates among HIV-infected women in the current combination antiretroviral treatment era. We sought to describe trends and factors associated with live-birth and abortion rates among HIV-positive and high-risk HIV-negative women enrolled in the Women's Interagency HIV Study in the United States. We analyzed longitudinal data collected from Oct. 1, 1994, through Sept. 30, 2012, through the Women's Interagency HIV Study. Age-adjusted rates per 100 person-years live births and induced abortions were calculated by HIV serostatus over 4 time periods. Poisson mixed effects models containing variables associated with live births and abortions in bivariable analyses (P < .05) generated adjusted incidence rate ratios and 95% confidence intervals. There were 1356 pregnancies among 2414 women. Among HIV-positive women, age-adjusted rates of live birth increased from 1994 through 1997 to 2006 through 2012 (2.85-7.27/100 person-years, Ptrend < .0001). Age-adjusted rates of abortion in HIV-positive women remained stable over these time periods (4.03-4.29/100 person-years, Ptrend= .09). Significantly lower live-birth rates occurred among HIV-positive compared to HIV-negative women in 1994 through 1997 and 1997 through 2001, however rates were similar during 2002 through 2005 and 2006 through 2012. Higher CD4+ T cells/mm3 (≥350 adjusted incidence rate ratio, 1.39 [95% CI 1.03-1.89] vs <350) were significantly associated with increased live-birth rates, while combination antiretroviral treatment use (adjusted incidence rate ratio, 1.35 [95% CI 0.99-1.83]) was marginally associated with increased live-birth rates. Younger age, having a prior abortion, condom use, and increased parity were associated with increased abortion rates among both HIV-positive and HIV-negative women. CD4+ T-cell count, combination antiretroviral treatment use, and viral load were not associated with abortion rates. Unlike earlier periods (pre-2001) when live-birth rates were lower among HIV-positive women, rates are now similar to HIV-negative women, potentially due to improved health status and combination antiretroviral treatment. Abortion rates remain unchanged, illuminating a need to improve contraceptive services.

The High Cost of HIV-Positive Inpatient Care at an Urban Hospital in Johannesburg, South Africa.

BackgroundWhile most HIV care is provided on an outpatient basis, hospitals continue to treat serious HIV-related admissions, which is relatively resource-intensive and expensive. This study reports the primary reasons for HIV-related admission at a regional, urban hospital in Johannesburg, South Africa and estimates the associated lengths of stay and costs.Methods and FindingsA retrospective cohort study of adult, medical admissions was conducted. Each admission was assigned a reason for admission and an outcome. The length of stay was calculated for all patients (N = 1,041) and for HIV-positive patients (n = 469), actual utilization and associated costs were also estimated. Just under half were known to be HIV-positive admissions. Deaths and transfers were proportionately higher amongst HIV-positive admissions compared to HIV-negative and unknown. The three most common reasons for admission were tuberculosis and other mycobacterial infections (18%, n = 187), cardiovascular disorders (12%, n = 127) and bacterial infections (12%, n = 121). The study sample utilized a total of 7,733 bed days of those, 55% (4,259/7,733) were for HIV-positive patients. The average cost per admission amongst confirmed HIV-positive patients, which was an average of 9.3 days in length, was $1,783 (United States Dollars).ConclusionsEven in the era of large-scale antiretroviral treatment, inpatient facilities in South Africa shoulder a significant HIV burden. The majority of this burden is related to patients not on ART (298/469, 64%), and accounts for more than half of all inpatient resources. Reducing the costs of inpatient care is thus another important benefit of expanding access to ART, promoting earlier ART initiation, and achieving rates of ART retention and adherence.

Aging With HIV in the Era of Antiretroviral Treatment: Living Conditions and the Quality of Life of People Aged Above 50 Living With HIV/AIDS in Switzerland.

The aim of this cross-sectional study was to identify the living conditions and the quality of life of people aged more than 50 who were living with HIV in Switzerland. Participants were consecutively sampled through different HIV-specific sites. Seventy-two HIV-positive persons filled in an anonymous standardized questionnaire, either paper-pencil or online. Descriptive and inferential statistics were calculated. Quality of life was rated quite high (M = 14.9, SD = 4.14). The multivariate regression analyses showed that mental and physical health problems, long-term living with HIV, having a high degree of needed support, and financial problems decreased quality of life, and perceived available social support was an important predictor in maintaining quality of life. In addition to current offers to support mental health and social networks, efforts to integrate people of working age into the labor market and efforts to reduce stigma and the social marginalization of older HIV-positive people should be fostered.

Unintended pregnancy, contraceptive use, and childbearing desires among HIV-infected and HIV-uninfected women in Botswana: across-sectional study.

BackgroundLittle is known about the impact of knowledge of HIV serostatus on pregnancy intention and contraceptive use in high-HIV-burden southern African settings in the era of widespread antiretroviral treatment availability.MethodsWe analyzed interview data collected among 473 HIV-uninfected and 468 HIV-infected pregnant and recently postpartum women at two sites in southern Botswana. Participants were interviewed about their knowledge of their HIV status prior to pregnancy, intendedness of the pregnancy, contraceptive use, and future childbearing desires.ResultsThe median age of the 941 women was 27 years, median lifetime pregnancies was 2, and 416 (44 %) of pregnancies were unintended. Among women reporting unintended pregnancy, 36 % were not using a contraceptive method prior to conception. Among contraception users, 81 % used condoms, 13 % oral contraceptives and 5 % an injectable contraceptive. In univariable analysis, women with unintended pregnancy had a higher number of previous pregnancies (P = <0.0001), were less educated (P = 0.0002), and less likely to be married or living with a partner (P < 0.0001). Thirty-percent reported knowing that they were HIV-infected, 48 % reported knowing they were HIV-uninfected, and 22 % reported not knowing their HIV status prior to conception. In multivariable analysis, women who did not know their HIV status pre-conception were more likely to report their pregnancy as unintended compared to women who knew that they were HIV-uninfected (aOR = 1.7; 95%CI: 1.2-2.5). After controlling for other factors, unintended pregnancy was not associated with knowing one’s HIV positive status prior to conception (compared with knowing one’s negative HIV status prior to conception). Among women with unintended pregnancy, there was no association between knowing their HIV status and contraceptive use prior to pregnancy in adjusted analyses. Sixty-one percent of women reported not wanting any more children after this pregnancy, with HIV-infected women significantly more likely to report not wanting any more children compared to HIV-uninfected women (aOR = 3.9; 95%CI: 2.6-5.8).ConclusionsThe high rates of reported unintended pregnancy and contraceptive failure/misuse underscore an urgent need for better access to effective contraceptive methods for HIV-uninfected and HIV -infected women in Botswana. Lower socioeconomic status and lack of pre-conception HIV testing may indicate higher risk for unintended pregnancy in this setting.

Adult life expectancy trends in the era of antiretroviral treatment in rural Uganda (1991-2012).

To estimate the impact of antiretroviral therapy (ART) on population-wide adult life expectancy. A population-based open cohort study with repeated HIV status measurements and registration of vital events in Southwestern Uganda (1991-2012). Nonparametric survival analysis techniques are used for estimating trends in the adult life expectancy of the general population (aged 15 and above), the adult life expectancy by HIV status, and the adult life expectancy deficit. The life expectancy deficit is estimated as the difference between overall life expectancy and life expectancy of the HIV-negative population. All estimates are disaggregated by sex. Between 1991-1993 and 2009-2012, population-wide adult life expectancy increased from 39.3 [95% confidence interval (CI): 35.9-42.8] to 56.1 years (95% CI: 54.0-58.5) in women, and from 38.6 (95% CI: 35.4-42.1) to 51.4 years (95% CI: 49.2-53.7) in men. Most of the adult life expectancy gains coincide with the introduction of ART in 2004; as evidenced by an increase in the adult life expectancy of people living with HIV between 2000-2002 and 2009-2012 of 22.9 and 20.0 years for women and men, respectively. Over the whole period of observation, the adult life expectancy deficit associated with HIV decreased from 16.1 (95% CI: 12.7-19.8) to 6.0 years (95% CI: 4.1-7.8) among women, and from 16.0 (95% CI: 12.1-19.9) to 2.8 years (95% CI: 1.2-4.6) among men. Population-wide life expectancy increased substantially, largely driven by reductions in HIV-related mortality. Women have gained more adult life years than men since the introduction of ART, but the burden of HIV in terms of the life years lost is still larger for women than it is for men.

Lung cancer in HIV-infected patients in the combination antiretroviral treatment era.

The advent of combination antiretroviral treatment (cART) has been followed by a decrease in HIV-associated morbidity and mortality, but also by an apparent increase in the incidence of non-AIDS-defining cancers (NADCs). The risk of lung cancer is substantially higher in HIV-infected patients than in the general population, in part due to aging and tobacco use, and it is the most frequent NADC. The management of lung cancer in HIV-infected patients has some peculiarities that need to be taken into account. This review focuses on the epidemiology, risk factors, and clinical management of lung cancer in HIV-infected patients. In addition, screening tools and future perspectives are also discussed.

Does gender or mode of HIV acquisition affect virological response to modern antiretroviral therapy (ART)?

Previous UK studies have reported disparities in HIV treatment outcomes for women. We investigated whether these differences persist in the modern antiretroviral treatment (ART) era. A single-centre cohort analysis was carried out. We included in the study all previously ART-naïve individuals at our clinic starting triple ART from 1 January 2006 onwards with at least one follow-up viral load (VL). Time to viral suppression (VS; first viral load < 50 HIV-1 RNA copies/mL), virological failure (VF; first of two consecutive VLs > 200 copies/mL more than 6 months post-ART) and treatment modification were estimated using standard survival methods. Of 1086 individuals, 563 (52%) were men whose risk for HIV acquisition was sex with other men (MSM), 207 (19%) were men whose risk for HIV acquisition was sex with women (MSW) and 316 (29%) were women. Median pre-ART CD4 count and time since HIV diagnosis in these groups were 298, 215 and 219 cells/μL, and 2.3, 0.3 and 0.3 years, respectively. Time to VS was comparable between groups, but women [adjusted hazard ratio (aHR) 2.32; 95% confidence interval (CI) 1.28-4.22] and MSW (aHR 3.28; 95% CI 1.91-5.64) were at considerably higher risk of VF than MSM. Treatment switches and complete discontinuation were also more common among MSW [aHR 1.38 (95% CI 1.04-1.81) and aHR 1.73 (95% CI 0.97-3.16), respectively] and women [aHR 1.87 (95% CI 1.43-2.46) and aHR 3.20 (95% CI 2.03-5.03), respectively] than MSM. Although response rates were good in all groups, poorer virological outcomes for women and MSW have persisted into the modern ART era. Factors that might influence the differences include socioeconomic status and mental health disorders. Further interventions to ensure excellent response rates in women and MSW are required.